As health personnel, we have a responsibility to meet the interests of all groups in the population and test out several approaches in order for health information to reach more people, thereby reducing social inequality in health (37). Investment in patient education in Norway is biased towards group-based self-management programmes, and apparently few objections are raised with regard to the fact that these programmes are not equally suitable for all groups. (38). Our study indicates that there is a need for new and different thinking, and for a focus that extends beyond individual factors in the training programmes.
Broader self-management programmes are suitable for reaching patients who are difficult to recruit to group-based programmes. Moreover, we need more knowledge regarding the wishes of non-participant patient groups. With the increasing prevalence of type 2 diabetes (1), the lack of self-management programmes constitutes a serious problem with regard to health, long-term complications and increased suffering. At a societal level, an inability to cope and inappropriate health behaviour push up treatment and follow-up costs. Awareness and attention to social health disparities is an important priority area for health policy (15), which unfortunately until now has received little attention in nursing science research.
The purpose of the study’s recruitment strategy via outpatient clinics in the specialist health service was to obtain a sample that included patients with a complex disease, who struggle to cope with their type 2 diabetes. In line with the statistics, a poor ability to cope and a complex disease are more frequent in population groups with a low socioeconomic status (24). It is generally difficult to recruit persons with a low economic status to participate in research (39). The picture portrayed by the sample in this study (Table 1) shows that one-quarter are disability pensioners or on sick leave, one-third live alone and have a lower than average income, and one in three report high comorbidity. By way of contrast, the proportion of disability pensioners in the Norwegian population in the age group 18–67 years is 9 per cent (40).
Altogether, 47.7 of study participants reported having a primary/lower secondary education, while the figure is slightly less than 30 per cent of the population among those who are 60 years and over (41). With this comparison, we believe that we can estimate to have obtained a sample that is in line with our intention. However, the representativity of the sample in relation to the total population with type 2 diabetes in Norway is somewhat uncertain. With regard to morbidity, data from the Norwegian Quality Improvement of Laboratory Examinations (NOKLUS) register show that 5.5 per cent have suffered a stroke (42), while the corresponding figure in this study is 5.3 per cent. The NOKLUS register is based on 16 223 Norwegian patients with type 2 diabetes. Other figures are difficult to compare. Although the percentage that has suffered a stroke is approximately the same as the percentage in the NOKLUS population, we cannot guarantee the representativity of the sample. Caution should therefore be exercised in making any generalisations.
The health condition of the informants in the study is based on self-reporting, which may represent a weakness in the study. Holseter and colleagues, however, find that self-reporting yields valid data when presenting health disparities, also when different social groups are compared (43). There are few respondents with an immigrant background in the study, which is probably attributable to the fact that the questionnaire was in Norwegian. The diabetes nurses who did the recruitment for the study confirmed that informants with another cultural background did not manage to complete the questionnaire due to language difficulties. The decision not to translate the questionnaire to minority languages was a joint decision by EU-WISE and was related to finances. We have thereby not included participants with another cultural background, who represent an important and exposed group with regard to type 2 diabetes, socioeconomic status and health behaviour (22). This constitutes a weakness in our study.
The results show that more than half of the informants have not participated in group-based self-management programmes, and that there is a selection bias in patient education programmes among people with type 2 diabetes. Participation is higher among women and persons with a higher education, while smokers and persons with high comorbidity have a lower participation rate. There are also higher odds of participation among patients who are physically active and therefore have better health behaviour. These findings are consistent with those from international studies, which show that certain groups fail to benefit from group-based self-management programmes on which there is a considerable focus today. Our study highlights a need for more knowledge on which programmes may suit those groups of patients who do not find existing ones attractive. The study also indicates a need for more targeted recruitment to existing programmes. In order to help equalise social health disparities, it seems to be important to pursue approaches that go beyond programmes that are clearly oriented towards the individual, thereby reaching more groups in the population.
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