Breaking the barriers to optimal glycaemic control--what physicians need to know from patients' perspectives.

Diabetes is a largely self-managed disease with a major psychosocial impact on the lives of patients and their families. Coping effectively with the stresses related to living with and having to manage diabetes on a daily basis is not a simple function of education, i.e., knowing "what is right for you." Clearly, knowledge is a prerequisite, but in no way a guarantee, of making the recommended changes in self-care necessary to achieve optimal glycaemic control. To understand patients' self-care behaviour, we need to take into account various psychological and social factors. Behavioural research findings underscore the role of attitudes and illness beliefs as determinants of patients' health behaviours. For example, misperceptions regarding the seriousness and controllability of diabetes can inhibit active participation of the patient in the treatment. A reluctance to start insulin therapy can be observed in patients with type 2 diabetes who have poor glycaemic control on maximum dosage of oral hypoglycaemic agents. This phenomenon of "psychological insulin resistance" clearly demonstrates how even irrational beliefs can impact health outcomes. Misconceptions about having to start insulin treatment ("now I am seriously ill") are often linked to negative emotions, e.g. anger and fear. Negativistic attitudes and low self-efficacy expectations are not uncommon among people with diabetes, precipitated and maintained by repeated experiences of failure to "master" the diabetes and achieve satisfactory diabetes control. Ultimately, cumulative negative experiences can result in a state of "learned helplessness" or "diabetes burnout." Relational conflicts and lack of social support can also seriously hamper patients' self-care behaviours. In addition, contextual factors such as financial barriers and difficulty with access to health care influence peoples' self-care behaviours. In diabetes care, a bio-psychosocial approach to the patient and his or her coping problems is warranted. Learning to understand the patient's perspective will help health care professionals communicate more effectively and tailor the treatment to the needs of the individual.