A qualitative analysis of the needs and wishes of people with type 2 diabetes and healthcare professionals for optimal diabetes care

. 2022 Jun 23;39(9):e14886. doi: 10.1111/dme.14886

Quotes pertaining to knowledge and skills (COM‐B header Capability)
More knowledge, information and skills	“Because I really went untreated with my diabetes for a long time because I did not realise just how serious it was” (aged 46, 6 years since diagnosis) “Maybe even a short video of something that you can be recommended to watch, maybe somebody who's had amputations, or gangrene in the feet, or something that's going to shock you into action” (aged 52, 13 years since diagnosis) “I just found I was hitting my head against the wall sometimes trying to get information. (…) When your diabetes is a little bit hard to control or is anything other than the norm, there was nowhere to go to get general information” (aged 56, 5 years since diagnosis) “For that whole time, I've never been given the tools to control it myself” (aged 47, 5 years since diagnosis) “Because really, I had no idea of what to avoid. I just thought sugar was sugar. I had no idea that fruit could affect your sugar. I had no idea that carbohydrates turn to sugars. (…) And it all comes back to, like I said, education. I was uneducated on the whole food and the values of food” (aged 46, 6 years since diagnosis) “Information when you need it would be great. It could be phone, it could be in person, it could be chat room” (aged 64, 13 years since diagnosis) “I just think in general, we have got all this new technology and there's got to be better ways to get the information across” (aged 56, 5 years since diagnosis)	“And, I think that's still lacking, unfortunately, I think there's just not enough information out there for people to say – if you get in early, these are the things that you can achieve” (specialist HCP, 19 years' experience) “If you have got the skills and you can give them those skills and the knowledge to back it all up and to help them make those changes then you can actually get some very good results” (specialist HCP, 11 years' experience).” “A lot of patients would come on who are quite educated people, but they'd essentially been diagnosed with diabetes and put on medications and never been given any of the dietary advice or lifestyle advice (…) no one had ever told them that if they changed their diet and did some exercise, that their diabetes control would be better” (specialist HCP, 12 years' experience) “They do not want to be told what they already know (…) It might almost be useful for the patients to have a little form that they fill in before they see us to say, ‘Which of these things do you think you would like more information about today?’ and tick the box” (specialist HCP, 6 years' experience) “I think, there’s a lot of education we do that you don’t actually have to be a person to do it so I think we could actually get away with a lot more education as videos, like, training videos and stuff which can provide the basics of all the diabetes education and then you come in and see for the specific stuff” (specialist HCP, 11 years’ experience)

Quotes pertaining to knowledge and skills (COM‐B header Capability)

Main themes

PWD quotes

HCPs quotes

More knowledge, information and skills

“Because I really went untreated with my diabetes for a long time because I did not realise just how serious it was” (aged 46, 6 years since diagnosis)

“Maybe even a short video of something that you can be recommended to watch, maybe somebody who's had amputations, or gangrene in the feet, or something that's going to shock you into action” (aged 52, 13 years since diagnosis)

“I just found I was hitting my head against the wall sometimes trying to get information. (…) When your diabetes is a little bit hard to control or is anything other than the norm, there was nowhere to go to get general information” (aged 56, 5 years since diagnosis)

“For that whole time, I've never been given the tools to control it myself” (aged 47, 5 years since diagnosis)

“Because really, I had no idea of what to avoid. I just thought sugar was sugar. I had no idea that fruit could affect your sugar. I had no idea that carbohydrates turn to sugars. (…) And it all comes back to, like I said, education. I was uneducated on the whole food and the values of food” (aged 46, 6 years since diagnosis)

“Information when you need it would be great. It could be phone, it could be in person, it could be chat room” (aged 64, 13 years since diagnosis)

“I just think in general, we have got all this new technology and there's got to be better ways to get the information across” (aged 56, 5 years since diagnosis)

“And, I think that's still lacking, unfortunately, I think there's just not enough information out there for people to say – if you get in early, these are the things that you can achieve” (specialist HCP, 19 years' experience)

“If you have got the skills and you can give them those skills and the knowledge to back it all up and to help them make those changes then you can actually get some very good results” (specialist HCP, 11 years' experience).”

“A lot of patients would come on who are quite educated people, but they'd essentially been diagnosed with diabetes and put on medications and never been given any of the dietary advice or lifestyle advice (…) no one had ever told them that if they changed their diet and did some exercise, that their diabetes control would be better” (specialist HCP, 12 years' experience)

“They do not want to be told what they already know (…) It might almost be useful for the patients to have a little form that they fill in before they see us to say, ‘Which of these things do you think you would like more information about today?’ and tick the box” (specialist HCP, 6 years' experience)

“I think, there’s a lot of education we do that you don’t actually have to be a person to do it so I think we could actually get away with a lot more education as videos, like, training videos and stuff which can provide the basics of all the diabetes education and then you come in and see for the specific stuff” (specialist HCP, 11 years’ experience)

Quotes pertaining to physical and social environment (COM‐B header Opportunity)
Social support—Family, friends and other PWD	“I've got support from my family, and my partner, she supports, obviously, my healthiness, she's been through some pretty hard times with me” (aged 34, 15 years since diagnosis) “I have family. I have neighbours. I have friends who all support in one way or another” (aged 64, 8 years since diagnosis) “This might seem a bit intrusive, but somebody that comes and knocks on your door three times a week, or whatever, and says, “Righto, let us go for a walk” (aged 52, 13 years since diagnosis) “It's good to hear other people, not just from medical staff but what's working for them and what's not working, because not all the time what the medical profession give you is useful for you” (aged 46, 6 years since diagnosis) “But, listening to them, motivates you, it helps you think it's possible.” (aged 70, 21 years since diagnosis)	“Patients have got good supports around them, their family, GPs, good team and they are using those to address what they need to address and make changes that they need to change and having the support to maintain them” (…) So, it's engaging the family in amongst that to say well, if you need to be healthier, we are going to be healthier, we are going to make whole family changes from diet, exercise, lifestyle, all those sorts of stress management plans” (specialist HCP, 10 years' experience) “Finding out what sort of support they have got around them to help motivate them between because obviously we are only seeing them once every three months, so kind of finding what sources of support they have got at home to help them with their daily motivation or asking them if they want to bring in a partner or children or anything into the consultation to help them remember information that helps when doing those things” (specialist HCP, 8 years' experience)
Community resources	“Like community meetings where you can talk to people who have lost weight, got foot issues, GP issues, with somebody with the authority to say somebody needs attention here, who can take notes and follow up” (aged 70, 21 years since diagnosis) “I actually think that regular group community sessions you can go to that are facilitated where you can get ideas (…) Where you have got professionals who are going to listen, at least somebody representing from the clinic or something, that's going to sit there and prepare to cop it.” (aged 47, 5 years since diagnosis) Another interviewee from the same focus group: “See, that would be part of a wellness centre, too” (aged 60, 30 years since diagnosis)	“Whether or not there's community resources that are available that might help them to tackle some of those lifestyle factors. Ways of engaging their families to support them, so often when we are talking with type 2 diabetes and from my perspective it seems a lot of it is about lifestyle modification.” (specialist HCP, 10 years' experience) “Some people have discussed with me a wish that there were more social groups to talk with other people with diabetes and share their experiences and feel a bit more normal in their experiences with diabetes (…) Other community groups who might – it's a potential place for support to help people emotionally and peer support to make those changes or work through the frustrations of doing those things initially to look after themselves” (specialist HCP, 10 years' experience)

Quotes pertaining to physical and social environment (COM‐B header Opportunity)

Main themes

PWD quotes

HCPs quotes

Social support—Family, friends and other PWD

“I've got support from my family, and my partner, she supports, obviously, my healthiness, she's been through some pretty hard times with me” (aged 34, 15 years since diagnosis)

“I have family. I have neighbours. I have friends who all support in one way or another” (aged 64, 8 years since diagnosis)

“This might seem a bit intrusive, but somebody that comes and knocks on your door three times a week, or whatever, and says, “Righto, let us go for a walk” (aged 52, 13 years since diagnosis)

“It's good to hear other people, not just from medical staff but what's working for them and what's not working, because not all the time what the medical profession give you is useful for you” (aged 46, 6 years since diagnosis)

“But, listening to them, motivates you, it helps you think it's possible.” (aged 70, 21 years since diagnosis)

“Patients have got good supports around them, their family, GPs, good team and they are using those to address what they need to address and make changes that they need to change and having the support to maintain them” (…) So, it's engaging the family in amongst that to say well, if you need to be healthier, we are going to be healthier, we are going to make whole family changes from diet, exercise, lifestyle, all those sorts of stress management plans” (specialist HCP, 10 years' experience)

“Finding out what sort of support they have got around them to help motivate them between because obviously we are only seeing them once every three months, so kind of finding what sources of support they have got at home to help them with their daily motivation or asking them if they want to bring in a partner or children or anything into the consultation to help them remember information that helps when doing those things” (specialist HCP, 8 years' experience)

Community resources

“Like community meetings where you can talk to people who have lost weight, got foot issues, GP issues, with somebody with the authority to say somebody needs attention here, who can take notes and follow up” (aged 70, 21 years since diagnosis)

“I actually think that regular group community sessions you can go to that are facilitated where you can get ideas (…) Where you have got professionals who are going to listen, at least somebody representing from the clinic or something, that's going to sit there and prepare to cop it.” (aged 47, 5 years since diagnosis) Another interviewee from the same focus group: “See, that would be part of a wellness centre, too” (aged 60, 30 years since diagnosis)

“Whether or not there's community resources that are available that might help them to tackle some of those lifestyle factors. Ways of engaging their families to support them, so often when we are talking with type 2 diabetes and from my perspective it seems a lot of it is about lifestyle modification.” (specialist HCP, 10 years' experience)

“Some people have discussed with me a wish that there were more social groups to talk with other people with diabetes and share their experiences and feel a bit more normal in their experiences with diabetes (…) Other community groups who might – it's a potential place for support to help people emotionally and peer support to make those changes or work through the frustrations of doing those things initially to look after themselves” (specialist HCP, 10 years' experience)

Quotes pertaining to physical and social environment (COM‐B header Opportunity) (cont.)
Holistic approach	“There was an article on picking GPs and dieticians who supported a holistic way of looking at you with your diabetes, that you do not focus on weight anymore, weight is just a side issue. The main thing is the wellness aspect, you want to feel good” (aged 60, 30 years since diagnosis) “Whether with the newly diagnosed, other services can kick in like, ‘Do you need to talk to somebody about how you are coping with this diagnosis with diabetes?’ Rather than, ‘you have got diabetes, give you a bit of script, off you go, we'll have a HbA1c in three months’. Maybe have access to easy recipes. Give the whole lot over to make that diagnosis a lot easier” (aged 60, 20 years since diagnosis) “Because that's what I found, being a diabetic and going to my GP, she just gives me this tablet and that's it” (aged 64, 13 years since diagnosis) “They should have had a more holistic approach to your care at that time” (aged 60, 20 years since diagnosis)	“We've got practice systems and employees, etcetera, databases and recall, but once the patient attends then, to listen and understand, I mean that's – living with diabetes is more than just numbers and glucose, it's about understanding how people live and how they apply all their knowledge of their diabetes to their own life and how sometimes it's difficult (…) We're trying to work out where are the patients in the time course of their illness, that is newly diagnosed, have they got complications, etcetera, where are they in their living space, in their psychology, their understanding of diabetes, and then trying to construct a plan, but using practice stuff” (primary HCP, 26 years' experience) “Education that there is something you can do if you make some lifestyle modifications, if you might be engaged in weight loss strategies, if you manage – stress and high sugars is very correlated to look after your mental health, look after stress levels, all those lifestyles and really support them in that” (specialist HCP, 10 years' experience)
More personalisation	“Obviously there's a lot of people out there, but it wasn't as personalised. Everyone's diabetes is different, and it's very painful or not painful, but just a hard thing to deal, with each case being different, my dad has got diabetes, and he's completely different to me” (aged 34, 15 years since diagnosis) “So different foods do different things to different people. And what people have got to remember and that is everyone from people like myself, right through to doctors that people are not always what is in the book. So, they cannot put everyone, ‘You're a diabetic. This is what you have got to do.’ It's not. Because it does not work for everyone” (aged 61, 19 years since diagnosis) “Exercise physiologists I find have helped me more so than the physios etcetera. You know, that can be helpful, so acknowledge the things that you can do, particularly when you have got joint limitations like I have.” (aged 70, 21 years since diagnosis)	“They're the ones that – it's about them, so you just – you need to be saying, ‘Well, what do you feel you need to help you get to your goal?’ Because you have to have goals. You have to have outcomes.” (primary HCP, 6 years' experience) “One of the things I noticed over at the hospital, was that, for the first ten minutes or so, they spoke only about what's been going on in your life. Tell us about cricket, you have been playing cricket, how's that going. Often, I'll know people from the last visit or the visit before, and how's it going, I know you were looking at changing your job, did you end up doing it?” (specialist HCP, 19 years' experience) “Having a medication regime that worked for the patient as well as giving them reasonable control of what works for them, I think, is something needs to be considered a little bit more ‘these are your options. You can either have this, this or this. These are the outcomes for all of these, which way would you like to go?’” (specialist HCP, 11 years' experience)

Quotes pertaining to physical and social environment (COM‐B header Opportunity) (cont.)

Main Themes

PWD Quotes

HCPs Quotes

Holistic approach

“There was an article on picking GPs and dieticians who supported a holistic way of looking at you with your diabetes, that you do not focus on weight anymore, weight is just a side issue. The main thing is the wellness aspect, you want to feel good” (aged 60, 30 years since diagnosis)

“Whether with the newly diagnosed, other services can kick in like, ‘Do you need to talk to somebody about how you are coping with this diagnosis with diabetes?’ Rather than, ‘you have got diabetes, give you a bit of script, off you go, we'll have a HbA1c in three months’. Maybe have access to easy recipes. Give the whole lot over to make that diagnosis a lot easier” (aged 60, 20 years since diagnosis)

“Because that's what I found, being a diabetic and going to my GP, she just gives me this tablet and that's it” (aged 64, 13 years since diagnosis)

“They should have had a more holistic approach to your care at that time” (aged 60, 20 years since diagnosis)

“We've got practice systems and employees, etcetera, databases and recall, but once the patient attends then, to listen and understand, I mean that's – living with diabetes is more than just numbers and glucose, it's about understanding how people live and how they apply all their knowledge of their diabetes to their own life and how sometimes it's difficult (…) We're trying to work out where are the patients in the time course of their illness, that is newly diagnosed, have they got complications, etcetera, where are they in their living space, in their psychology, their understanding of diabetes, and then trying to construct a plan, but using practice stuff” (primary HCP, 26 years' experience)

“Education that there is something you can do if you make some lifestyle modifications, if you might be engaged in weight loss strategies, if you manage – stress and high sugars is very correlated to look after your mental health, look after stress levels, all those lifestyles and really support them in that” (specialist HCP, 10 years' experience)

More personalisation

“Obviously there's a lot of people out there, but it wasn't as personalised. Everyone's diabetes is different, and it's very painful or not painful, but just a hard thing to deal, with each case being different, my dad has got diabetes, and he's completely different to me” (aged 34, 15 years since diagnosis)

“So different foods do different things to different people. And what people have got to remember and that is everyone from people like myself, right through to doctors that people are not always what is in the book. So, they cannot put everyone, ‘You're a diabetic. This is what you have got to do.’ It's not. Because it does not work for everyone” (aged 61, 19 years since diagnosis)

“Exercise physiologists I find have helped me more so than the physios etcetera. You know, that can be helpful, so acknowledge the things that you can do, particularly when you have got joint limitations like I have.” (aged 70, 21 years since diagnosis)

“They're the ones that – it's about them, so you just – you need to be saying, ‘Well, what do you feel you need to help you get to your goal?’ Because you have to have goals. You have to have outcomes.” (primary HCP, 6 years' experience)

“One of the things I noticed over at the hospital, was that, for the first ten minutes or so, they spoke only about what's been going on in your life. Tell us about cricket, you have been playing cricket, how's that going. Often, I'll know people from the last visit or the visit before, and how's it going, I know you were looking at changing your job, did you end up doing it?” (specialist HCP, 19 years' experience)

“Having a medication regime that worked for the patient as well as giving them reasonable control of what works for them, I think, is something needs to be considered a little bit more ‘these are your options. You can either have this, this or this. These are the outcomes for all of these, which way would you like to go?’” (specialist HCP, 11 years' experience)

Quotes pertaining to physical and social environment (COM‐B header Opportunity) (cont.)
Support and encouragement from HCPs	“When they bring the next patient in, and they'll be like, ‘I forgot what [name deleted]’s problems were’. It's like you are in a deli with a ticket, it's like, ‘now serving number 15″ (aged 47, 20 years since diagnosis) “If we have got a good relationship that means there's good communications; they are keeping an eye on what's happening and they are showing an interest (…) To treat you as a partner, because it's a shared thing. They've got knowledge that you want, and you have got experience that only you can give them to let them know how to treat your individual case” (aged 61, 19 years since diagnosis) “For instance, I saw him this week, and he actually said, ‘You do eat well, it's partially your problems with movement.’ I guess he actually takes some of the guilt (…) We need the people who sort of say, ‘Well yeah, okay. You're doing well. But make sure you stay there.’” (aged 70, 21 years since diagnosis)	“It's also promoting honesty, making sure they feel honest and comfortable to really tell you what's going on. Because, we are not going to judge, we just want to be able to help them (…) It's not just a quick review of their BGLs, it's reinforcement, they are doing really well. Or, if they say they have lost weight, there's again, that motivational, ‘Keep going, that's fantastic’” (specialist HCP, 6 years' experience) “I'm doing a mini assessment on every single person who comes to clinic and then addressing needs as they arise and so I do get to know the patients a lot better. Then that rapport develops a lot easier, because they do see me at every single clinic, not just if there's a problem” (primary HCP, 5 years' experience) “Also encouraging the patient when positive changes are taken on board or actions, so always encouraging, it's very important to use appropriate language, and engagement” (primary HCP, 26 years' experience)
More coordination	“What would be really good is if we could get the different doctors to talk to each other. I've got a cardiologist, respiratory specialist, gastroenterology, orthopaedics, neurology. I've got so many and none of them speak to the other and consequently you get frustrated.” (aged 64, 8 years since diagnosis) “There's not one person that you go to for all of your diabetes assistance. You go to the GP to be prescribed a medication but your care plan, all your bits and pieces, are handled by the surgery nurse. There just does not seem to be any continuity. I think things are lost in translation. (…) To me, it's not logical” (aged 56, 5 years since diagnosis) “The technology can come into this too, because they do not necessarily have to all get together in one room. So, the fact that your health record is now going up on to the computer for all public hospitals to be able to see, is a really big step in the right direction” (aged 64, 8 years since diagnosis) “They say it's a lifestyle disease, and I hate the way you have to go to a chronic diseases unit with your diabetes. It sort of needs to be away from the hospital I reckon to have all this stuff with all the allied health professionals. I can just see it being more casual, and not a medical approach. A wellness centre.” (aged 60, 30 years since diagnosis)	“From a patient point of view, once they are first of all told that they have got diabetes it's very disjointed” (specialist HCP, 6 years' experience) “Of course there is communication issues. If your letter comes after two or three months, that's a communication issue, cause we do not know what the medications are” (primary HCP, 14 years' experience) “If it was well advertised and GPs knew that they could call and not have to wait for someone to get back to them, actually get an answer on the spot. So, if they had someone to call while the patient was with them to say, ‘I've got this patient. What do you think I should do?’ It would be quite useful” (specialist HCP, 12 years' experience) “That true case management I believe is the absolute success of this model of care, because they know that there's someone there and that person will go back to them the next date they are here or they'll deal with their issue on the spot if they can” (primary HCP, 5 years' experience) “We have obviously the same nurse every time. They see the same two GPs that do the diabetes clinic and they seem the same endocrinologist every time. So, I like our model from that perspective because they always see that” (primary HCP, 5 years' experience)

Quotes pertaining to physical and social environment (COM‐B header Opportunity) (cont.)

Main Themes

PWD Quotes

HCPs Quotes

Support and encouragement from HCPs

“When they bring the next patient in, and they'll be like, ‘I forgot what [name deleted]’s problems were’. It's like you are in a deli with a ticket, it's like, ‘now serving number 15″ (aged 47, 20 years since diagnosis)

“If we have got a good relationship that means there's good communications; they are keeping an eye on what's happening and they are showing an interest (…) To treat you as a partner, because it's a shared thing. They've got knowledge that you want, and you have got experience that only you can give them to let them know how to treat your individual case” (aged 61, 19 years since diagnosis)

“For instance, I saw him this week, and he actually said, ‘You do eat well, it's partially your problems with movement.’ I guess he actually takes some of the guilt (…) We need the people who sort of say, ‘Well yeah, okay. You're doing well. But make sure you stay there.’” (aged 70, 21 years since diagnosis)

“It's also promoting honesty, making sure they feel honest and comfortable to really tell you what's going on. Because, we are not going to judge, we just want to be able to help them (…) It's not just a quick review of their BGLs, it's reinforcement, they are doing really well. Or, if they say they have lost weight, there's again, that motivational, ‘Keep going, that's fantastic’” (specialist HCP, 6 years' experience)

“I'm doing a mini assessment on every single person who comes to clinic and then addressing needs as they arise and so I do get to know the patients a lot better. Then that rapport develops a lot easier, because they do see me at every single clinic, not just if there's a problem” (primary HCP, 5 years' experience)

“Also encouraging the patient when positive changes are taken on board or actions, so always encouraging, it's very important to use appropriate language, and engagement” (primary HCP, 26 years' experience)

More coordination

“What would be really good is if we could get the different doctors to talk to each other. I've got a cardiologist, respiratory specialist, gastroenterology, orthopaedics, neurology. I've got so many and none of them speak to the other and consequently you get frustrated.” (aged 64, 8 years since diagnosis)

“There's not one person that you go to for all of your diabetes assistance. You go to the GP to be prescribed a medication but your care plan, all your bits and pieces, are handled by the surgery nurse. There just does not seem to be any continuity. I think things are lost in translation. (…) To me, it's not logical” (aged 56, 5 years since diagnosis)

“The technology can come into this too, because they do not necessarily have to all get together in one room. So, the fact that your health record is now going up on to the computer for all public hospitals to be able to see, is a really big step in the right direction” (aged 64, 8 years since diagnosis)

“They say it's a lifestyle disease, and I hate the way you have to go to a chronic diseases unit with your diabetes. It sort of needs to be away from the hospital I reckon to have all this stuff with all the allied health professionals. I can just see it being more casual, and not a medical approach. A wellness centre.” (aged 60, 30 years since diagnosis)

“From a patient point of view, once they are first of all told that they have got diabetes it's very disjointed” (specialist HCP, 6 years' experience)

“Of course there is communication issues. If your letter comes after two or three months, that's a communication issue, cause we do not know what the medications are” (primary HCP, 14 years' experience)

“If it was well advertised and GPs knew that they could call and not have to wait for someone to get back to them, actually get an answer on the spot. So, if they had someone to call while the patient was with them to say, ‘I've got this patient. What do you think I should do?’ It would be quite useful” (specialist HCP, 12 years' experience)

“That true case management I believe is the absolute success of this model of care, because they know that there's someone there and that person will go back to them the next date they are here or they'll deal with their issue on the spot if they can” (primary HCP, 5 years' experience)

“We have obviously the same nurse every time. They see the same two GPs that do the diabetes clinic and they seem the same endocrinologist every time. So, I like our model from that perspective because they always see that” (primary HCP, 5 years' experience)

Quotes pertaining to physical and social environment (COM‐B header Opportunity) (cont.)
Proactive assistance	“If you say, ‘Well, I think I'm edging the wrong way’, it needs to be addressed then, not later on when you are in trouble, and not when your eyes are gone, do you know what I mean? I mean, I'm listening to what she was saying, and she needs prompt eye care, regular eye care, because she's in trouble on her eyes, and she needs it” (aged 70, 21 years since diagnosis) “Simply be in a better position to contact the specialist and ask the question instead of the patient waiting six or nine months, that would be one good thing” (aged 61, 19 years since diagnosis) “The GP needs to be able to say something like, ‘This person needs to be seen fairly promptly, because she's in trouble’” (aged 70, 21 years since diagnosis) “I need that accountability as well. I think I find it more comfortable and satisfying that I know someone is there and if something suddenly happens then I'm able to get to help immediately (…) I think that's what people would get out of a technology‐based thing, is the comfort of knowing that if something goes wrong someone is there to pick up on it and so consequently, they would get help sooner” (aged 64, 8 years since diagnosis)	“But we do know that we need to get in early, in the early stages where you can reverse thing. We need to be able to focus on that” (specialist HCP, 19 years' experience) “Where probably at that early point when they are being started on oral medication that changing things like diet and exercise could actually make a bigger difference” (specialist HCP, 12 years' experience) “I could just check it at any time. That technology absolutely makes – and that's the centre obviously, if people own the Accu‐Chek guide, you can go in and they have linked it to their App. You can see their blood sugars whenever you want to look at them and can offer feedback whenever it's needed and people like that” (primary HCP, 5 years' experience) “We try to support the patient as best we can too, because diabetes management likes a bit of regularity and review and try to make sure people do not accidentally fall through the cracks” (primary HCP, 26 years' experience) “I'll give you a face‐to‐face Skype call, we'll have a quick chat ‘cause you still do need the face to face even with the technology because then you are still getting that personal care. No‐one wants to be just a number, so they still want a little bit of face to face but not necessarily having to come in every week” (specialist HCP, 11 years’ experience)

Quotes pertaining to physical and social environment (COM‐B header Opportunity) (cont.)

Main Themes

PWD Quotes

HCPs Quotes

Proactive assistance

“If you say, ‘Well, I think I'm edging the wrong way’, it needs to be addressed then, not later on when you are in trouble, and not when your eyes are gone, do you know what I mean? I mean, I'm listening to what she was saying, and she needs prompt eye care, regular eye care, because she's in trouble on her eyes, and she needs it” (aged 70, 21 years since diagnosis)

“Simply be in a better position to contact the specialist and ask the question instead of the patient waiting six or nine months, that would be one good thing” (aged 61, 19 years since diagnosis)

“The GP needs to be able to say something like, ‘This person needs to be seen fairly promptly, because she's in trouble’” (aged 70, 21 years since diagnosis)

“I need that accountability as well. I think I find it more comfortable and satisfying that I know someone is there and if something suddenly happens then I'm able to get to help immediately (…) I think that's what people would get out of a technology‐based thing, is the comfort of knowing that if something goes wrong someone is there to pick up on it and so consequently, they would get help sooner” (aged 64, 8 years since diagnosis)

“But we do know that we need to get in early, in the early stages where you can reverse thing. We need to be able to focus on that” (specialist HCP, 19 years' experience)

“Where probably at that early point when they are being started on oral medication that changing things like diet and exercise could actually make a bigger difference” (specialist HCP, 12 years' experience)

“I could just check it at any time. That technology absolutely makes – and that's the centre obviously, if people own the Accu‐Chek guide, you can go in and they have linked it to their App. You can see their blood sugars whenever you want to look at them and can offer feedback whenever it's needed and people like that” (primary HCP, 5 years' experience)

“We try to support the patient as best we can too, because diabetes management likes a bit of regularity and review and try to make sure people do not accidentally fall through the cracks” (primary HCP, 26 years' experience)

“I'll give you a face‐to‐face Skype call, we'll have a quick chat ‘cause you still do need the face to face even with the technology because then you are still getting that personal care. No‐one wants to be just a number, so they still want a little bit of face to face but not necessarily having to come in every week” (specialist HCP, 11 years’ experience)

Quotes pertaining to emotions, evaluation and plans (COM‐B header Motivation)
Emotions and burden of living with diabetes	“Because sometimes it felt like you hit a wall. I've got diabetes. I'm terrified (…) It still gets a little bit confusing. The whole diabetes is frightening to start with and then some of the terminology, the way some health professionals talk, it adds to the whole fear of it” (aged 46, 6 years since diagnosis) “Hated in the beginning, pricking the fingers upwards of four times a day. I hate that with an absolute passion” (aged 47, 20 years since diagnosis) “I thought it is frustrating because you are being given this tag, ‘You're a diabetic’. He [husband with diabetes] was made to feel that he was a bad person because he allowed it to happen” (aged 64, 13 years since diagnosis) “’Have you looked at my file?’ Like, I was 153 [kilos] two years ago, so I've lost like 30‐odd kilos, and the first thing they say is, ‘You're obese.’ ‘Yeah. Thanks for that. (…) There's an assumption. There's no discussion about have you lost weight, or what is your diet, nothing. They just assume straight away” (aged 47, 5 years since diagnosis)	“The ones I meet are the ones who are struggling with accepting they have a new diagnosis, trying to make changes to very long‐standing habits and behaviours” (specialist HCP, 10 years' experience) “Diabetes distress is something that I see a lot of, the burden and stress and the diabetes type 1 and type 2 is well known to be correlated with depression and anxiety. (…) What's associated with diabetes distress is also the social impacts, the stigmas, the constant reminders that you have a disease” (specialist HCP, 10 years' experience) “Language is very important or dismissive language, saying, ‘you are fat’, or, ‘you are obese and you need to lose weight’, so shaming the patient or confronting the patient negatively I do not think is a healthy option” (primary HCP, 26 years' experience) “Tt's also promoting honesty, making sure they feel honest and comfortable to really tell you what's going on. Because, we are not going to judge, we just want to be able to help them.” (specialist HCP, 6 years' experience)
Beliefs and motivation to manage diabetes	“Didn't really believe it but then I had some really bad problems in 2007, 2008 and I was actually put in the care of a specialist endocrine doctor, who woke me up to how serious diabetes can be and then I lost a few toes and that really put me back on the straight and narrow” (aged 74, 45 years since diagnosis) “With the whole not understanding the food values and what not and you think you are doing the right thing and my sugars are actually going up, not going down. It comes back to that whole, why bother if it's not working?” (aged 46, 6 years since diagnosis) “I'm one of those people who struggles with discipline and motivation sometimes” (aged 52, 13 years since diagnosis) “I think too motivation – it has not worked with me really, motivation to keep on track” (aged 60, 20 years since diagnosis)	“They do not believe they can succeed. So, they do not believe there is a path that they can take that is going to do it” (primary HCP, 25 years' experience) “One aspect is giving them hope and opportunity and education early on and it's not death sentences. It's not like a blame situation, but it's treating them with compassion, but giving them hope that there are things they can do and also having the support and the self‐efficacy, that believe that they could do something and actually get a result and make a difference to their diabetes” (specialist HCP, 10 years' experience) “I think the missed part of that is still engaging patients. And encouraging them to change lifestyles. And I think involving them in their care” (primary HCP, 14 years' experience) “Maybe often trying to find a source of motivation. So, if people have children that they want to grow old for and want to be healthy and be able to do stuff with, a lot of the time that seems to be motivating for patients” (specialist HCP, 12 years' experience)

Quotes pertaining to emotions, evaluation and plans (COM‐B header Motivation)

Main Themes

PWD Quotes

HCPs Quotes

Emotions and burden of living with diabetes

“Because sometimes it felt like you hit a wall. I've got diabetes. I'm terrified (…) It still gets a little bit confusing. The whole diabetes is frightening to start with and then some of the terminology, the way some health professionals talk, it adds to the whole fear of it” (aged 46, 6 years since diagnosis)

“Hated in the beginning, pricking the fingers upwards of four times a day. I hate that with an absolute passion” (aged 47, 20 years since diagnosis)

“I thought it is frustrating because you are being given this tag, ‘You're a diabetic’. He [husband with diabetes] was made to feel that he was a bad person because he allowed it to happen” (aged 64, 13 years since diagnosis)

“’Have you looked at my file?’ Like, I was 153 [kilos] two years ago, so I've lost like 30‐odd kilos, and the first thing they say is, ‘You're obese.’ ‘Yeah. Thanks for that. (…) There's an assumption. There's no discussion about have you lost weight, or what is your diet, nothing. They just assume straight away” (aged 47, 5 years since diagnosis)

“The ones I meet are the ones who are struggling with accepting they have a new diagnosis, trying to make changes to very long‐standing habits and behaviours” (specialist HCP, 10 years' experience)

“Diabetes distress is something that I see a lot of, the burden and stress and the diabetes type 1 and type 2 is well known to be correlated with depression and anxiety. (…) What's associated with diabetes distress is also the social impacts, the stigmas, the constant reminders that you have a disease” (specialist HCP, 10 years' experience)

“Language is very important or dismissive language, saying, ‘you are fat’, or, ‘you are obese and you need to lose weight’, so shaming the patient or confronting the patient negatively I do not think is a healthy option” (primary HCP, 26 years' experience)

“Tt's also promoting honesty, making sure they feel honest and comfortable to really tell you what's going on. Because, we are not going to judge, we just want to be able to help them.” (specialist HCP, 6 years' experience)

Beliefs and motivation to manage diabetes

“Didn't really believe it but then I had some really bad problems in 2007, 2008 and I was actually put in the care of a specialist endocrine doctor, who woke me up to how serious diabetes can be and then I lost a few toes and that really put me back on the straight and narrow” (aged 74, 45 years since diagnosis)

“With the whole not understanding the food values and what not and you think you are doing the right thing and my sugars are actually going up, not going down. It comes back to that whole, why bother if it's not working?” (aged 46, 6 years since diagnosis)

“I'm one of those people who struggles with discipline and motivation sometimes” (aged 52, 13 years since diagnosis)

“I think too motivation – it has not worked with me really, motivation to keep on track” (aged 60, 20 years since diagnosis)

“They do not believe they can succeed. So, they do not believe there is a path that they can take that is going to do it” (primary HCP, 25 years' experience)

“One aspect is giving them hope and opportunity and education early on and it's not death sentences. It's not like a blame situation, but it's treating them with compassion, but giving them hope that there are things they can do and also having the support and the self‐efficacy, that believe that they could do something and actually get a result and make a difference to their diabetes” (specialist HCP, 10 years' experience)

“I think the missed part of that is still engaging patients. And encouraging them to change lifestyles. And I think involving them in their care” (primary HCP, 14 years' experience)

“Maybe often trying to find a source of motivation. So, if people have children that they want to grow old for and want to be healthy and be able to do stuff with, a lot of the time that seems to be motivating for patients” (specialist HCP, 12 years' experience)

Quotes pertaining to emotions, evaluations and plans (COM‐B header Motivation) (cont.)
Plans and goals	“What I have trouble with now, because I used to take the insulin before I went to bed because it was ideal. Now I take it with dinner, I keep forgetting it, so I'm used to putting it beside where I have my dinner, so I put it there, so I remember. I forget” (aged 72, 30 years since diagnosis) “I always took my blood sugars each morning and I quite often took my blood pressure as well. Do everything. I've just added in to it, it's the pulse oximeter. But it just means I do the whole lot. Stand on the scales. Have a shower. Come in, get dressed. Take my insulin. Go out, do the other measurements. Take my pills and then go with the day from there. So, it's just part of my normal routine” (aged 64, 8 years since diagnosis) “I'm just looking forward to getting rid of this ulcer so I can actually do something. I used to get up at four o'clock each morning and walk for a couple of kilometres just around my local neighbourhood and I used to really enjoy that” (aged 74, 45 years since diagnosis) “Just quality of life improvements, ease of life, I guess you could say, to make things easier for us. As I said, I started off initially injecting four times a day, I'm now down to two times a day. That's great. If I can get it to once a day, sign me up, I would love that. Just stuff that you are not constantly having to worry, and that you can just be normal” (aged 47, 20 years since diagnosis)	“Understanding your patients, how they live, talking to them about it, but also then also working with them about setting healthy goals, but that work for them, but some of the goals for patients might include more than just glucose, like weight management, psychological support, it might mean they might need education, and so it's about trying to get inside the patient's realm of living and understanding what is their needs now and in the future, both near and long‐term” (primary HCP, 26 years' experience) “You'd hope so because people know what their plan is and they know what their goals are, and if you have got family onboard, they are hopefully going to be more supportive” (specialist HCP, 8 years' experience) “If we could connect patients with technology that kept them aware of the goals and where they are in relationship to those goals” (primary HCP, 26 years' experience) “Motivational interviewing, you can write the smart goals, you can try and get them to make their own – obviously, it's their goals, they need to reflect and make their own journey, but it is hard” (specialist HCP, 6 years' experience) “As you said, there's no holidays. You have to be caring for yourself and monitoring and injecting if you have to take insulin” (specialist HCP, 10 years' experience)

Quotes pertaining to emotions, evaluations and plans (COM‐B header Motivation) (cont.)

Main Themes

PWD Quotes

HCPs Quotes

Plans and goals

“What I have trouble with now, because I used to take the insulin before I went to bed because it was ideal. Now I take it with dinner, I keep forgetting it, so I'm used to putting it beside where I have my dinner, so I put it there, so I remember. I forget” (aged 72, 30 years since diagnosis)

“I always took my blood sugars each morning and I quite often took my blood pressure as well. Do everything. I've just added in to it, it's the pulse oximeter. But it just means I do the whole lot. Stand on the scales. Have a shower. Come in, get dressed. Take my insulin. Go out, do the other measurements. Take my pills and then go with the day from there. So, it's just part of my normal routine” (aged 64, 8 years since diagnosis)

“I'm just looking forward to getting rid of this ulcer so I can actually do something. I used to get up at four o'clock each morning and walk for a couple of kilometres just around my local neighbourhood and I used to really enjoy that” (aged 74, 45 years since diagnosis)

“Just quality of life improvements, ease of life, I guess you could say, to make things easier for us. As I said, I started off initially injecting four times a day, I'm now down to two times a day. That's great. If I can get it to once a day, sign me up, I would love that. Just stuff that you are not constantly having to worry, and that you can just be normal” (aged 47, 20 years since diagnosis)

“Understanding your patients, how they live, talking to them about it, but also then also working with them about setting healthy goals, but that work for them, but some of the goals for patients might include more than just glucose, like weight management, psychological support, it might mean they might need education, and so it's about trying to get inside the patient's realm of living and understanding what is their needs now and in the future, both near and long‐term” (primary HCP, 26 years' experience)

“You'd hope so because people know what their plan is and they know what their goals are, and if you have got family onboard, they are hopefully going to be more supportive” (specialist HCP, 8 years' experience)

“If we could connect patients with technology that kept them aware of the goals and where they are in relationship to those goals” (primary HCP, 26 years' experience)

“Motivational interviewing, you can write the smart goals, you can try and get them to make their own – obviously, it's their goals, they need to reflect and make their own journey, but it is hard” (specialist HCP, 6 years' experience)

“As you said, there's no holidays. You have to be caring for yourself and monitoring and injecting if you have to take insulin” (specialist HCP, 10 years' experience)

Quotes pertaining to HCPs’ own burden and needs
HCPs' challenging work	“With some people it's very frustrating, they are trying and trying and trying, but they are not actually getting their sugars and they are not getting the control that they should be getting. So, a lot of that then is expectations and compassion and all that” (specialist HCP, 10 years' experience) “But we just do not seem to get the time to do it because we are too busy – we do not have the resources to be giving those basics when we are not there (…) We're relying on the GPs to provide the information and time constraints are such that they cannot do it. We do not see them. We will not see a new type 2 ‘cause our time constraints on an inpatient basis is there's just too many patients to see. So, they are not getting the education from us. We're saying ‘go to your GP’. GP cannot do it.” (specialist HCP, 11 years’ experience) “But then, the doctor is worried about being audited, and making sure that everything is being done correctly, otherwise Medicare will come in and say, ‘You've got to pay us back’. So, there's also that fear as well, I think, that you have done the plan properly” (primary HCP, 6 years' experience) “Even though we have tried to keep well‐educated, there's just a plethora of new treatment options and changes in the guidelines such that trying to keep up to date, for some patients, someone with diabetes particularly, is quite difficult. And changes in when do you use GLP‐1 versus insulin and what's the dose, what are the names of the agents, all these things. Because there's so many other diseases GPs manage” (primary HCP, 26 years' experience) “Particularly given GPs have to look after every other medical problem as well. The ones that do not have a special interest in diabetes aren't going to have read 130 pages on a diabetes management, I would not think” (specialist HCP, 12 years' experience) “Whereas in some areas I worked at, everyone is overweight, so I tell them, ‘You are overweight’. But, they say, ‘Everyone is like that, so that's normal’. It's a bit difficult” (primary HCP, 10 years' experience)

Quotes pertaining to HCPs’ own burden and needs

Main Themes

HCPs Quotes

HCPs' challenging work

“With some people it's very frustrating, they are trying and trying and trying, but they are not actually getting their sugars and they are not getting the control that they should be getting. So, a lot of that then is expectations and compassion and all that” (specialist HCP, 10 years' experience)

“But we just do not seem to get the time to do it because we are too busy – we do not have the resources to be giving those basics when we are not there (…) We're relying on the GPs to provide the information and time constraints are such that they cannot do it. We do not see them. We will not see a new type 2 ‘cause our time constraints on an inpatient basis is there's just too many patients to see. So, they are not getting the education from us. We're saying ‘go to your GP’. GP cannot do it.” (specialist HCP, 11 years’ experience)

“But then, the doctor is worried about being audited, and making sure that everything is being done correctly, otherwise Medicare will come in and say, ‘You've got to pay us back’. So, there's also that fear as well, I think, that you have done the plan properly” (primary HCP, 6 years' experience)

“Even though we have tried to keep well‐educated, there's just a plethora of new treatment options and changes in the guidelines such that trying to keep up to date, for some patients, someone with diabetes particularly, is quite difficult. And changes in when do you use GLP‐1 versus insulin and what's the dose, what are the names of the agents, all these things. Because there's so many other diseases GPs manage” (primary HCP, 26 years' experience)

“Particularly given GPs have to look after every other medical problem as well. The ones that do not have a special interest in diabetes aren't going to have read 130 pages on a diabetes management, I would not think” (specialist HCP, 12 years' experience)

“Whereas in some areas I worked at, everyone is overweight, so I tell them, ‘You are overweight’. But, they say, ‘Everyone is like that, so that's normal’. It's a bit difficult” (primary HCP, 10 years' experience)