Original Research

Experiences of Veterans With Diabetes From Shared Medical Appointments

Fed Pract. 2015 May;32(5):40-45

References

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After the focus groups, the research team used a formal debriefing tool to identify both initial impressions of possible discussion themes and group dynamics potentially influencing the content of the discussion; no significant communication or participation issues were identified.¹³ All research team members read the discussion notes and met to iteratively develop a simple codebook of global themes, using an approach of general inductive thematic content analysis.¹⁴

Two team members coded the notes, paying attention to the need to capture divergent or minority positions voiced by participants. Both coders worked toward consensus on code definitions through repeated discussions with each other and with the full research team. Codes were then used to sort and analyze about 180 comments made by participants during the focus groups. The Institutional Review Board of the VAPHCS approved the protocol for this study.

Results

Most participants in the diabetes focus group had type 2 diabetes mellitus (T2DM) and were male—1 female veteran participated (eTable).

After the initial analysis, all participants were mailed a letter summarizing themes and suggestions from the meeting (see Box). Responses to questions posted on the board and responded to by voting are included in Table 1. Weight gain was most commonly chosen as a barrier to self-management. The A_1c value was the highest rated motivator for self-management of diabetes, followed by face-to-face support from the care team and family support. Participants chose one-on-one appointments with the diabetes team and classes with instructors as the most helpful VA resources.

The final codebook resulted in 9 domains: diagnostic experience, what helps, perceived value of the SMA group, veteran identity, interaction with care providers, denial, fatalism, motivators, and barriers; each contained several related codes. Several themes emerged from the analysis of the focus group data for a desired experience of managing and coping with diabetes.

Identity as a Person With Diabetes

Participants were at various stages of their identity with a chronic illness. Over time, the veterans noted a transition from being a “diabetic person” to a “person living healthy with diabetes.” One veteran’s comment encapsulated the shift in diabetic identity over time: “[Initially] when looking up diabetes on the computer, there were scary things. It was very frightening, and I was thinking, oh, they’re going to cut off my legs. Years later you have more objectivity and control.”

When asked about advice for a person with a new diagnosis of diabetes, one participant stated, “Diabetes is a chronic thing, it’s not going to go away overnight. Don’t be afraid to experiment. Be patient.”

Some participants responded with denial, rejecting that they had diabetes or that they needed to make lifestyle changes. When asked how he felt when first diagnosed, one veteran stated, “I resisted endlessly. I wouldn’t take my face out of the food.” Many veterans expressed that the diagnosis of diabetes was similar to an assault on their identity.

One veteran with long-standing diabetes shared the following: “I got a giant plastic box, and every needle [I use] goes into the box. Every day I look at this huge pile of needles. It’s my sign of weakness. If I kick it…I won’t keep adding them [to the pile].”

Similarly another veteran stated, “I felt like a failure, not a winner, when I started taking insulin.” The A_1c test result was seen “like a hammer coming down,” an indication of the individual’s success or failure.

Identity as a Veteran

For some veterans in the focus group, the development of diabetes was considered to be service connected and related to chemical exposure to herbicides, including Agent Orange. One veteran emphasized, “This [diabetes] is ’cause of Agent Orange exposure.”

Another participant commented, “If you’ve served your country, you’re strong…[you think diabetes] can’t happen to you.” One participant explained, “Hearing it from [other veterans in focus group].... I don’t know if this was bred into me in the service. Probably. These guys have traversed the territory. I go to these guys for my answers. And hearing it from them, you could tell me everything I need to hear, and every one of these guys could tell me the exact same thing, and I would listen to them and not to [the clinical staff].”

Early Education

Another theme was a general desire for early information and education. Veterans suggested that information and self-management coaching when diagnosed with prediabetes would have been beneficial to reduce the risk of progression to diabetes. Many participants expressed regret that tools such as A_1cmonitoring were not available to them earlier: “I was also diagnosed borderline…that’s when I should have been hit by the 2 x 4...[they] should have done the A_1c every 6 months.” Some participants described feelings that early education and, as one put it, “more emphasis on the seriousness of it,” would have helped them prevent their diabetes from worsening or develop healthier habits for self-management earlier.