Improving Rehabilitation for People With Type 2 Diabetes: Experiences From a Qualitative Study in a Municipal Setting

ABSTRACT

Background

Individuals with type 2 diabetes (T2D) who have lower levels of education and income face an elevated risk of decreased participation in and adherence to diabetes rehabilitation programmes.

Aim

This study investigated how diabetes rehabilitation could be improved by revamping the organisation of the healthcare system and accommodating the actual needs of people with diabetes. It explored current diabetes rehabilitation interventions from the perspectives of healthcare professionals, managers and people living with T2D in a Danish municipality with a high proportion of people with low incomes and low levels of education.

Methods

The research is based on empirical investigations in a municipality in Denmark. Seven individual qualitative interviews with people living with T2D, 5 individual qualitative interviews with healthcare professionals were conducted and 2 focus groups with managers and physiotherapists, respectively. The data analysis was inspired by Malterud's systematic text condensation. A hermeneutic–phenomenological interpretative approach was taken.

Results

Three main categories were found: (1) The target group, (2) The municipality's efforts and (3) The organisational level. Based upon the analysis, the article discusses how both social relations and the municipal rehabilitation programmes are essential if diabetes rehabilitation is to be successful. For rehabilitation to be successful, intervention must be translated into everyday life.

Conclusion

Despite the dedicated efforts within the rehabilitation programme, individuals with T2D encountered challenges in altering their daily routines and habits. Healthcare professionals faced difficulties translating their diabetes expertise into tangible lifestyle changes for participants in the municipality's rehabilitation programmes. The fundamental importance of fostering supportive social relations both at home and within the community cannot be overstated for successful and effective rehabilitation.

1. Background

The incidence of type 2 diabetes (T2D) is on the rise worldwide [1, 2]. Globally, an estimated 462 million individuals are living with T2D, which corresponds to 6.3% of the population [3]. In Denmark, the number of affected people is 322,000, corresponding to 5.5% of the population. Comorbidities are common and are at risk of affecting well‐being significantly. The risk of complications increases the worse the blood sugar is regulated. At the time of diagnosis, 35% of the patients have comorbidities [4]. The high prevalence of diabetes is expensive for society. Calculations show that in 2011, the disease costs 31.8 billion DKK annually (in Denmark) [5]. The cost is expected to have increased in line with the number of diabetes cases over the past ten years [6]. Rehabilitation has been suggested as an effective strategy in diabetes management [7], and since 2005, there has been an increased focus on rehabilitation programmes targeting people with T2D in Denmark. Like many other European healthcare systems, in its reform efforts, the Danish healthcare system has targeted the care of chronic medical conditions [8] and the treatment of chronic conditions has become increasingly preventive and rehabilitative. Treatment of T2D in Denmark is regulated by the National Clinical Guidelines, National Recommendations [9], and Disease Management Programmes (DMP) [10]. The DMPs describe the local organisation, the division of tasks, and the overall content of rehabilitation interventions, all based on national guidelines and recommendations.

The Danish healthcare system is publicly financed [11, 12]. It encompasses five regions responsible for hospitals and general practitioners, and 98 municipalities that are responsible for rehabilitation programmes and care in both private homes and nursing homes.

The first diabetes‐specific DMPs were launched in 2008 and have been revised more recently. In a collaborative effort between each of the five regions and the municipalities, a DMP has been developed [13, 14, 15, 16, 17]. These programmes, aligned with national recommendations and guidelines, delineate referral pathways and advocate high‐quality municipal rehabilitation initiatives catering to individuals with T2D. However, it is worth noting that individuals with lower levels of education and income are at heightened risk of developing T2D [18], further complicating their engagement and continuity within these programmes [19].

The study was conducted in a Danish municipality with approximately 60,000 inhabitants. In 2020, the overall prevalence of people living with T2D per 100,000 inhabitants was 4500 for Denmark as a whole, whereas the estimate for this municipality was 6175 [20]. Likewise, the incidence rate of T2D was 400 in the municipality compared to 325 in Denmark as a whole [21]. Furthermore, nearly 10% of people living in the municipality have prediabetes, undiagnosed diabetes, poorly controlled diabetes, or potentially sub‐controlled diabetes [22]. In a routine national health survey from 2021, the population in the municipality, compared to the average Danish population, scored unfavourably on numerous health indicators, such as being overweight or obese, being a daily smoker and living with a chronic illness. The decline in health within the municipality can be attributed to urbanisation, which triggers local socio‐demographic shifts. These changes involve the migration of young individuals away from the municipality to urban areas, while vulnerable populations either remain or relocate to the area [23]. Thus, a relatively high proportion of the population has a low income or low levels of education.

1.1. Rehabilitation Programmes—Content and Challenges in Participation

The rehabilitation centre in the municipality offers a range of health‐promoting interventions to encourage physical activity, reduce smoking, promote weight loss and improve self‐management for people living with T2D. People are referred to diabetes rehabilitation programmes by general practitioners and healthcare professionals in hospitals. All those with T2D referred to the rehabilitation centre are offered an initial start‐up meeting with a health professional—usually a physiotherapist. The intervention lasts up to 12 weeks and consists of patient education and exercise sessions, mostly in groups, once or twice weekly. Throughout the programme, healthcare professionals encourage participants to continue their altered behaviour patterns post‐intervention, and an individual meeting at the end of the programme is scheduled to facilitate the process of perseverance with new habits. The rehabilitation centre aims to provide value‐based diabetes programmes of coordinated, person‐centred quality diabetes care for adults with T2D [24]. However, enrolment in and perseverance with the programmes are low. Amongst people referred to the programmes, there was an 18% decline from the initial start‐up visits at the rehabilitation centre. Amongst those participating in the initial start‐up visit, 26% declined further exercise sessions. Furthermore, people participating in exercise‐based diabetes rehabilitation more regularly cancelled their exercise sessions (29%) compared to the average person with other diseases or injuries (19%) coming to the centre. Of those attending exercise sessions, 20% dropped out before completing the 12‐week exercise programme. An internal report from the rehabilitation centre (unpublished) indicates that most people with T2D decline or drop out of the programme without further explanation, while comorbidities and lack of motivation and interest are other main reasons.

1.2. Aim

The disparity in referral rates, participation and persistence within rehabilitation presents a multifaceted issue. This study aimed to investigate how diabetes rehabilitation could be improved. The focus was on opportunities and barriers regarding referral, participation and persistence within diabetes rehabilitation. The study explored current diabetes rehabilitation interventions from the perspectives of healthcare professionals, managers and people living with T2D in a Danish municipality with a high proportion of people with low incomes and low levels of education.

2. Methods

2.1. Sampling Procedures and Recruitment for Interviews

Participants involved (1) people living with T2D, (2) healthcare professionals and (3) municipal managers. People with T2D were recruited through the rehabilitation centre in the municipality. People living with T2D were purposively sampled with the help of a professional at the rehabilitation centre. Originally, the study's target group was vulnerable adults (> 18 years of age) with T2D who were expected to be recruited through the municipality diabetes rehabilitation programme. However, only two individuals in vulnerable circumstances were interested in participating. Later, only one of the two took part in an interview. Therefore, the healthcare professionals in the rehabilitation centre were asked to invite people with T2D who had already participated in the activities at the centre if they would participate, regardless of their vulnerability status.

We assumed that vulnerable people would be included in the sample. However, at the time of the investigation, the enrolment of vulnerable individuals was far too low. In hindsight, we realise that we should have employed a different methodological strategy earlier in the process. In short, we aimed at a purposive strategy but ended up with a convenience strategy [25] Nevertheless, we gained valuable insights into the barriers and opportunities for those participating in the municipal programmes.

2.2. Data Collection

From January to March 2022, 14 interviews were conducted: seven individual, in‐depth qualitative interviews with people living with T2D, five individual in‐depth qualitative interviews with healthcare professionals, and two focus groups of municipal managers and physiotherapists, respectively [26, 27, 28].

The interviews with people living with T2D were conducted in the rehabilitation centre; individual interviews and focus groups with healthcare professionals and managers were performed at their workplaces. The individual interviews lasted approximately 60 min, and the focus groups lasted 90 min each. All interviews were conducted in Danish. All interviews and focus group discussions were recorded digitally and transcribed verbatim by two student assistants.

Two project members (EMA and MKN) conducted the individual interviews. Two project members (JT, LLJ) were the interviewer and observer, respectively, during the focus groups with managers. One project member was present during the focus group with physiotherapists (EMA). All interviews were carried out with physical presence.

The researchers had different backgrounds. Three were experienced qualitative researchers and two experienced quantitative researchers. One was a trained nurse, two were occupational therapists, one was a physiotherapist and one was an anthropologist. In the group, one of the members was attached to the municipality from which the project benefited. Three of the researchers have worked in depth with rehabilitation. All in all, the different backgrounds of the researchers complemented each other and created reflexivity in the process.

A standardised interview guide was used for all the interviews with people with T2D. Questions focused on how diabetes influenced people's everyday lives, their contact with a general practitioner, nurse, or hospital, and their views on using the municipality rehabilitation programmes. Questions also explored whether people with T2D felt their needs were being met. The standardised interview guide for healthcare professionals concentrated on their practice relating to interventions for people with T2D and people with T2D in vulnerable circumstances. Furthermore, there were questions concerning what interventions they felt were successful and their suggestions for the improvement of interventions they felt were currently less successful.

The interview guide for the focus groups with managers and physiotherapists focused on their knowledge of and experiences with interventions in the municipality related to T2D. The guide also investigated the challenges faced by vulnerable people living with T2D and their experiences with referral and cross‐sectoral collaboration.

2.3. Data Analysis

We used an interpretive hermeneutic‐phenomenological approach aiming in this way to gain an in‐depth understanding of people's lived experiences and how individuals make sense and meaning [29].

One of the strengths and main characteristics of qualitative studies is to be able to ask “why” [25]. People can describe and explain why they act as they do, i.e. the meaning of their lives [25]. The data analysis was inspired by Malterud's systematic text condensation and followed four steps [30, 31]. In the first step, transcriptions were read without theoretical understandings or preunderstandings to get an overall impression of the data. The next step was to find units of meaning expressed by the participants interviewed that were relevant to the aim of the study. In the third step, meaningful topics were condensed and coded. In step four, the findings were synthesised and passed from condensation to description and categories. Finally, these categories were related to the aim of the study. Three main categories were found: The target group, the municipality's efforts, and the organisational level.

To familiarise themselves with the transcribed data, all authors read through the entire material individually. During the analysis process, we met and revisited the material, reaching common clarifications of meaningful units and concepts. The analysis was conducted based on the authors' joint discussions of each step in the analysis process. As a final step, the meaningful topics were held up against the aim of the study and topics with no connection to the aim were eliminated. To obtain transparency the checklist standards for reporting Qualitative Research (SRQR) was used [32].

2.4. Ethics

Following the General Data Protection Regulation and National Guidelines, written consent was obtained from participants, and they were informed that they could withdraw from the study at any time. They were all guaranteed anonymity. The municipality has also been anonymised. Data were stored and handled following national guidelines [33]. In Denmark, this kind of research does not require approval from an ethical committee. Data use and protection were legally based on informed consent from participants, following General Data Protection Regulation, article 6, litra a. GDPR.DK. Databeskyttelsesforordningen. 2024 [34].

3. Results

3.1. Study Participants

Seven people living with T2D participated in the interviews: four men and three women. They had a median age of 64 (range 50–69) (Table 1). Seven healthcare professionals working with people with T2D participated in the interviews and focus groups. The healthcare professionals were two physiotherapists, one occupational therapist, one GP, one health consultant and two nurses, one of whom specialised in diabetes treatment. Four managers from the municipality participated: the heads of the health and care department, the public health department and the rehabilitation centre, plus the group leader of health care professionals at the rehabilitation centre.

TABLE 1.

Characteristics for study participants of people living with T2D (n = 7).

Gender, n (%)
Male	5 (71)
Female	2 (29)
Age, years, median (range)	64 (50–69)
Living status, n (%)
Alone	2 (29)
Married	3 (43)
With someone	2 (29)
Education level, n (%)
Secondary education	3 (43)
Vocational education	4 (57)
Duration (years) of T2D diagnosis, median (range)	2 (0–11)

Abbreviation: T2D, type 2 diabetes.

3.2. Main Categories and Topics

Three main categories were identified: (1) The target group, (2) The municipality's efforts and (3) The organisational level.

In relation to the first main category, the target group, two meaningful topics emerged from the analysis: (a) difficulties in changing lifestyle and habits and (b) the enrolment of people in vulnerable circumstances suffering from T2D. In relation to the second category, the municipality's efforts, two meaningful topics emerged: (a) current activities and (b) barriers and facilitators related to rehabilitation. Concerning the third category, the organisational level, two meaningful topics emerged: (a) referral and (b) the improvement of interdisciplinary and cross‐sectoral cooperation.

3.2.1. Main Category 1: The Target Group—Difficulties in Changing Lifestyle and Habits and the Enrolment of People in Vulnerable Circumstances Suffering From T2D

People with T2D who participated in the rehabilitation programme explained that they found it difficult to translate the knowledge gained from the programmes into their everyday lives. People expressed that receiving a diagnosis required considerable effort, as it entailed adopting new approaches to lifestyle management. While many attempted to adhere to healthier practices, they struggled to muster the necessary determination and often felt they required a motivational push to initiate change:

It has been a struggle for me. I feel the disease has meant that I've had to change everything, food and so on.

Furthermore, they encountered difficulty in relinquishing many enjoyable aspects of life, such as preferred foods and beverages:

I have to avoid orange juice and all those different kinds of juices […], but I do like them…

Generally, the interviewed people with T2D found habits hard to break, as daily routines were deeply ingrained within the fabric of their lives, intertwined with familial and social networks.

The healthcare professionals also stressed that individuals with T2D may possess knowledge about how to manage their condition, but transitioning from knowledge to action presents a significant challenge. Numerous barriers were experienced by healthcare professionals, such as financial constraints, geographical limitations and comorbidities. Nonetheless, to truly recognise the necessity for lifestyle and habit changes, individuals with T2D must effectively apply their knowledge in their daily lives.

Asked if people in vulnerable positions were able to translate knowledge into everyday life, one of the health professionals replied:

I don't know. Very few at least, if any at all. I think maybe some might be able to do it for a short period. Trying it out, like. But you won't know what to buy if you don't have the resources and the money. So you just buy what you usually do. At least that's what I hear people say.

Overall, the healthcare professionals indicated that reaching individuals in vulnerable circumstances posed considerable difficulty, including the challenge of attracting them to organised meetings and activities.

A significant discussion point in the focus group with the municipality managers focused on enrolling people in vulnerable circumstances. One of the managers commented:

Well, our internal discussions have concerned the fact that we probably don't see the most vulnerable patients. Some of our patients are more vulnerable than others, but we probably don't see the ones we want to get hold of …. They just don't reach us.

The managers discussed why people with T2D in vulnerable circumstances did not participate in rehabilitation. They suggested that the reasons might be financial, such as not being able to afford transport to the rehabilitation centre. Another reason might be a lack of personal resources, such as not being motivated to take the bus to the centre. Regarding preventive home visits, reluctance to allow nurses or other healthcare workers into their homes was also cited as a potential reason.

About preventive home visits, one of the municipal managers said:

So the person says “Well, that's fine”, and we make a deal that she [the home nurse] will pay a visit, but in the end, she [the home nurse] isn't allowed in [to the patient's home]. So in this case, it's not about transport. But what is it, then? Is it something else? No matter what we do, we still represent a municipality that comes knocking at your door.

In conclusion, people with T2D found it challenging to change their deeply ingrained daily routines, and healthcare professionals described that individuals in vulnerable circumstances were particularly difficult to engage in organised activities. Factors such as lack of financial or personal resources, low motivation and barriers to contact might contribute to their low enrolment in rehabilitation programmes.

3.2.2. Main Category 2: The Municipality's Efforts—Current Activities and Barriers as Well as Opportunities Related to Rehabilitation

The interviews conducted with individuals living with T2D highlighted the significance of personalised and adaptable rehabilitation approaches. It was emphasised that the focus should be on identifying strategies that are effective for each individual. Another notable finding was the pivotal role of positive interaction between individuals with T2D and healthcare professionals in fostering a successful rehabilitation process. Moreover, the involvement of key individuals in a person's daily life, such as spouses, friends and other significant family members, was deemed essential for implementing lifestyle changes effectively.

Furthermore, all participants expressed the need for more guidance on nutrition and dietary habits, recognising the importance of adjusting food choices to manage T2D effectively. Consequently, enhanced support from a dietitian was seen as a valuable improvement. As expressed by one participant:

I would have liked some sort of cooking course for people with diabetes (…), where we were told do this and that and learn how to make easy and healthy food.

People mostly requested more help concerning shopping, recipes and cooking classes. Also, they requested general information about what kind of help people living with T2D could get from the municipality. One participant said:

I need help applying for medical support, a podiatrist, a dentist, an optician, and an eye specialist.

Motivation to participate in rehabilitation was associated with good interaction with the healthcare professionals offering the courses. Similarly, a negative interaction did not motivate the participants to change their lifestyles. About good interaction, one person said:

I am quite okay with that [the doctor told her to reduce weight] because then I know someone's keeping an eye on me. I'm not just forgotten, which is what I felt like at the other place.

Involving a participant's family might facilitate lifestyle changes because the family is essential to their everyday life. For example, a man with T2D and his wife did training sessions together. It might also be a question of being with likeminded people with T2D, where people can support each other:

I would like something different, where you cook together and sit, talk, and eat. This is what it could be like.

The structured schedule of activities organised by the municipality posed challenges for certain individuals with T2D. This was particularly problematic for those in employment, as rehabilitation sessions often overlapped with working hours. Additionally, accessibility became an issue for individuals living far from the rehabilitation centre.

All healthcare professionals unanimously emphasised the relevance of having a dietitian on board. Moreover, they prioritised the relational dynamics not only between themselves and individuals with T2D but also amongst those living with T2D and others facing similar circumstances. The significance of being part of a supportive community of like‐minded individuals was underlined, providing a sense of camaraderie and mutual support. When rehabilitation teams functioned effectively, they served as a motivating force in their own right. Employing practices such as consistent documentation served to strengthen team cohesion and establish a lasting network. Ultimately, the communal or social dimension of the programmes offered by the municipality was deemed paramount.

Aligned with the preferences of individuals with T2D, healthcare professionals also advocated greater flexibility in the services provided by the municipality. As one healthcare professional put it:

It would be great if people had the opportunity to do some courses later in the day, so some of them could perhaps come in the late afternoon or evening.

Furthermore, if individuals with T2D in vulnerable circumstances could be encouraged to participate in rehabilitation, a more diversified range of options should be offered, not only in terms of content but also in terms of location. Additionally, it was suggested that certain rehabilitation activities for individuals with T2D could be conducted in their own homes. Implementing various pedagogical approaches could also help gain insights into what strategies are effective for different individuals.

The group of managers discussed whether T2D can be defined as a hidden disease. In this case, T2D would not, from the beginning, be regarded as an acute, chronic disease that leaves one disabled and in pain. On this basis, the managers discussed whether people with T2D might perhaps find it easier to make excuses not to change their lifestyles; they might just take T2D less seriously than other chronic diseases or social problems. Since T2D is not acute, the severity will first be shown in the long run.

….it is not an acute illness. It is much easier to get people to come if their illness is something they really feel here and now … So there may well be many excuses [for not participating in what the municipalities offer]

This is a basic premise for what we're dealing with here … it's something of an invisible disease.

In conclusion, encouraging individuals with T2D, who might take T2D less seriously than other chronic diseases or social issues, to participate in rehabilitation requires offering a diverse range of options tailored to individual needs and habits. Positive interactions between patients and healthcare professionals, along with the involvement of key individuals in patients' daily lives, were stressed. Guidance on nutrition, including help with shopping, recipes and cooking classes, was considered important, and the structured schedule and location of municipal activities posed challenges, particularly for employed individuals and those living far from rehabilitation centres.

3.2.3. Main Category 3: The Organisational Level—Referral and the Improvement of Interdisciplinary and Cross‐Sectoral Cooperation

The general experience of referral practice was that it did not follow a pattern. Some of the people with T2D were, for instance, referred very late in the course of their disease. They were predominantly referred by their GP or a nurse employed at the GP's clinic; outpatient wards at hospitals were not mentioned as playing a role in the referral. Some people with T2D felt that the healthcare professionals did not communicate with each other, which generated insecurity. For example, one comment was:

They don't talk together as they should.

The importance of communication amongst healthcare professionals in terms of creating a coherent process was also mentioned. A situation in which the GP wanted to stop treatment, though the person with T2D had not yet been in contact with the municipality nurse, is illustrated in the following quote from one of the participants:

The consultation nurse was afraid that I was entering no man's land.

It could cause serious problems if communication between the hospital consultant and municipality nurse did not work well, because important and relevant knowledge about people with T2D might be lost.

Parallel to the above, healthcare professionals called for improvements to interdisciplinary and cross‐sectional work. To their knowledge, there was no common understanding of what valid criteria might apply for referral. In other words, the question was who should be referred to rehabilitation and when. The healthcare professionals stressed that there was room for better cooperation in order to strengthen coherence between the two sectors: the GP and the municipality.

Asked if there might be some GPs who paid less attention to T2D than others, one healthcare professional replied:

I think that there are some GPs who may be less interested in T2D than others.

Regarding the organisation of efforts to help people with T2D in vulnerable circumstances, another healthcare professional suggested improved cooperation with the home nurse or a support contact person. In her words:

Call them and ask: How are you? And then again three months later maybe… Some patients would find it reassuring because they would feel that they were getting somewhere if they knew someone was keeping an eye on them or that there was some kind of structure around them.

Overall, the healthcare professionals pointed out that the referral practice was heterogeneous, i.e., there was no pattern as to whether and when the GP would refer a patient to diabetes rehabilitation.

The municipal managers also discussed referral practices. The procedure was that people with T2D should be referred by a GP or hospital doctor, but the municipal managers pointed out the shortage of GPs in the area and expressed uncertainty as to how well the diabetes programmes were followed. The group also considered the issue of people with T2D not consulting their GPs, especially people in vulnerable circumstances.

As one of the managers put it:

In other words, doctors are meant to refer [….], but doctors are different. Some rarely refer. Conversely, we have a few GPs who make a lot of referrals to diabetes rehabilitation.

Another manager added:

But there is a reason why we don't see the most vulnerable people—they just don't visit the doctor.

In conclusion, all municipality representatives agreed that there were different practices concerning referrals. Another important finding was that the people with T2D in vulnerable circumstances did not show up at the rehabilitation centre or at the GP's surgery. They were simply missing.

4. Discussion

This study aimed to investigate how diabetes rehabilitation could be improved. Related to the three main categories; (1) the target group, (2) the municipality's efforts and (3) the organisational level our results show the following. First, it is a challenge for the target group to change deeply ingrained daily routines. To attract vulnerable people living with T2D to take part in the municipality's rehabilitation programmes was another big challenge. Second, obtaining success with rehabilitation requires offering a diverse range of options tailored to individual needs. Positive interaction between patient and healthcare professional, as well as with key individuals in the patients' daily lives was also vital for success. Third, there were different practices concerning referrals. The vulnerable people living with T2D were not only missing in the municipality's rehabilitation programme but also at the GPs surgery. All in all, our findings regarding the significance of everyday life aspects are pervasive, i.e. including time, place, relation, and habits. Therefore, we include research in our discussion that draws on everyday life perspectives for lifestyle changes. One of the key findings of this study was that having good relationships with one's spouse, family members and friends was crucial for the success of diabetes rehabilitation. For any lifestyle changes to last, it was found to be important to apply what was learned in the rehabilitation centre to everyday life, especially at home. For instance, doing physical activities with one's spouse could significantly boost motivation. Similarly, receiving support from family members, such as changing diets together, could make it easier for individuals with T2D to adopt new habits. Being surrounded by people with similar goals seemed to increase motivation for change.

As pointed out by Thuesen and Swane, lifestyle changes are deeply rooted within everyday life, the social relations and significant others, and specific places as the scene for change. When the inner compass needs to be restored, as is often the case in rehabilitation, it always happens with someone, and in relation to someone and somewhere. Hence, rehabilitation practice should consider these aspects carefully [35]. When rehabilitation in the study primarily takes place in centres where various exercises are taught to help people with T2D learn new ways to use their bodies, it should also be recognised that for long‐term success, rehabilitation needs to extend into local communities and homes and include significant others.

The healthcare professionals emphasised the importance of the interaction between them as professionals and the participants in the rehabilitation centre. It was crucial that the interaction between people with T2D and healthcare professionals was positive and could develop over time. Sufficient time was needed to learn the life stories and values of the people living with T2D. If successful, healthcare professionals would be better equipped to assist individuals in changing habits and customs. However, rehabilitation also had to encourage new habits, and what was learned in the diabetes programme had to be applied to everyday life. Therefore, lessons from healthcare professionals, such as adopting new eating habits or physical exercises, should be incorporated into everyday practices at home. This effort can be referred to as ‘homework’, a concept developed by Grøn et al. [36]. In essence, this concept denotes the tasks that the healthcare system expects individuals living with a chronic disease and their families to carry out at home and in their daily lives [36].

The lifestyle change will unfold within a specific context involving family members, friends and others. It entails concrete activities or tasks to be carried out at home by individuals with T2D. Importantly, it is not solely the individuals with T2D or those with other chronic illnesses who must participate; it includes their social circle and significant others who will adapt to the new situation and participate in and support the homework [36]. Therefore, the homework is inherently social. Motivation to change habits is crucial when engaging in these tasks. Consequently, envisioning future aspirations and navigating new life situations despite living with a chronic disease becomes integral to imagining a better future. However, dilemmas may arise when completing such homework. It is not always clear what is most crucial or feasible regarding implementing new habits and care, and there may be discrepancies between the expectations of individuals at home and those of healthcare professionals.

The above is in line with H. A. Fritz. According to Fritz, it is challenging for people, in particular middle‐aged, low‐income women, with T2D to develop self‐management skills [37]. Pre‐existing routines must be changed, and the changes are tied to both habits and life situations [38, 39].

Another key issue highlighted in the analysis was the absence of individuals living with T2D who were in vulnerable circumstances and who participated in community courses [40, 41]. Attracting individuals in vulnerable circumstances is linked to the concept of homework: homework may not be feasible if one lacks a stable home, for example, and even if the person has a home, prioritising homework might still be unattainable. As noted by Schneider‐Kamp et al. [42], it is essential to consider the cultural and social resources of patients and their families. They found that a deficiency in cultural and social resources poses a significant barrier to effective communication between patients and healthcare professionals, contributing to health inequality [42]. This highlights the necessity for the healthcare system to address organisational health literacy, particularly concerning the organisation of the diabetes rehabilitation programme in terms of its content and delivery methods, as identified in this study.

This study also addressed referrals, which are a fundamental aspect of the organisation of the DMP [10]. One of the key findings of this study was that referrals appeared to be characterised by varying practices. We identified several problems related to referrals, indicating a need for improved interdisciplinary and cross‐sectoral collaboration. For instance, there was a lack of clear communication between different sectors, and there was no consensus on which criteria should be considered valid for referrals. Additionally, a shortage of GPs in the municipality posed a challenge. These issues are pivotal to the DMP as they contribute to establishing coherence and ensuring optimal conditions for assisting individuals living with T2D [10].

The results of this study indicate that diabetes rehabilitation might be improved to meet the needs of people with T2D, especially people in vulnerable circumstances. Changes in everyday life and lifestyle are challenging and require people with T2D to live healthier lives. Moreover, referrals of people needing rehabilitation services seem non‐standardised and must be approached more systematically

5. Strengths and Limitations of This Study

Individual interviews provide the researcher with the optimal opportunity to delve deeply into people's experiences and practices. The strength of the study lies in its inclusion of three distinct perspectives on rehabilitation within a municipal setting. This study offered insights into everyday life with a chronic disease from the individual's perspective. The interviews conducted with healthcare professionals provided a detailed view of how they implemented interventions in T2D rehabilitation. Additionally, healthcare professionals were able to share their experiences regarding whether the municipality adequately addressed the needs of individuals with T2D and concerning the cross‐sectorial setup and referral practices. All the informants were eager to share their experiences, leading to richly detailed interviews with examples. The focus groups with health care professionals provided empirical data about experiences and interpretations of clinical practice relating to people with T2D. Through the healthcare professionals' interactions and discussions, their agreements and disagreements, the study gained insight into the functioning and challenges of the rehabilitation programme [43].

In addition, the focus group with the managers concentrated on their leadership of various sections within the municipality and how they organised and managed the rehabilitation programme for individuals with T2D. All in all, this study gathered insights from different organisational perspectives through individual interviews and focus group discussions. These two interview methods complemented each other and significantly contributed to the study's objectives.

It is important to note that this study was conducted in a specific municipality; therefore, the results are rooted in this particular context. Consequently, these findings may not necessarily apply to other municipalities. Further research is warranted, particularly studies that involve comparisons between municipalities with similar or different characteristics.

We only did one focus group interview with managers. The study would have benefitted from more in‐depth individual interviews with managers.

In the same way, by including more vulnerable people living with T2D, the study would also have become more representative.

Another limitation of this study is that we were unable to conduct more than one interview with a GP. Initially, we had planned to conduct multiple interviews with GPs, but practical constraints unfortunately hindered this process. Insights from GPs regarding referrals and their knowledge of the municipality's rehabilitation programmes would have provided additional valuable perspectives on the referral practices of GPs within the municipality.

6. Conclusion

In general, it was challenging for individuals with T2D participating in the rehabilitation programmes to alter their daily routines and habits. Similarly, healthcare professionals found it difficult to translate their knowledge about diabetes into lifestyle changes amongst those participating in the rehabilitation programmes within the municipality. The study demonstrates that the support of social relations at home and in the community is crucial if rehabilitation is to be successful and effective. Simply possessing knowledge is not sufficient; individuals living with T2D must apply this knowledge to their everyday lives and personal contexts.

Furthermore, there is a need for improvement in the organisation of interdisciplinary and cross‐sectoral cooperation between the secondary and primary sectors. Additionally, a more systematic approach to referrals from GPs to the municipality is required.

Author Contributions

L.L.‐J. conceived the study. L.L.‐J. and M.K.N. did the project administration from Oct. 2021 to 31 Dec 2023. M.K.N., E.M.A., J.T. and L.L.‐J. contributed to the data curation and performed the formal analysis. M.K.N., E.M.A., J.T., D.B.B. and L.L.‐J. wrote the original draft. All authors contributed to the methodology, reviewing and editing the manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1

Appendix S2

Appendix S3

Appendix S4

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.