Diabetes self-management education (DSME) is a critical element of diabetes care (Funnell et al. 2009). A vast number of studies have shown that DSME (Ellis et al. 2004; Norris, Engelgau & Narayan 2001; Norris et al. 2002) including nutrition education (NE) (Pastors et al. 2002; Shabbidar, Fathi & Shirazifard 2006) significantly improves health outcomes.

Planning tailored diabetes education programmes is only possible if one has a thorough understanding of the target group. A comprehensive needs assessment is thus crucial (Muchiri, Gericke & Rheeder 2009; Glazier et al. 2006 Brown et al. 2002). Determination of the education needs of the target population(s) is one of the DSME standards stipulated by organisations dealing with diabetes (International Diabetes Federation 2009; Funnell et al. 2009).

Qualitative studies have increasingly been used to assess the needs and preferences for education of the target group as well as evaluating education programmes (Benavides- Vaello et al. 2004; Dye, Haley-Zitlin & Willoughby 2003). Focus groups in particular have been used successfully in developing or adapting diabetes self-management interventions, especially in low-income populations and minority groups (Vincent et al. 2006; Rosal et al. 2004). The informal style of focus groups is conducive to identifying barriers to care, exploring health beliefs, identifying education needs and in gathering information to improve intervention programmes (Blancard et al. 1999; Benavides-Vaello et al. 2004). The synergy promoted by the group interaction produces ideas and statements which could not be generated with other types of methods (Rabiee 2004; Kidd & Parshall 2000). Respondents can qualify, clarify and build upon responses, thus conveying more thoughtful and in-depth information (Benavides-Vaello et al. 2004; Kidd & Parshall 2000).

Benavides-Vaello et al. (2004), in a study based on focus groups with Mexican Americans with type 2 diabetes, found that participants were able to identify specific diabetes topics and issues requiring attention. The results were used in planning a targeted education programme. Blancard et al. (1999) found knowledge deficits and financial problems to be the major factors affecting diabetes self-management amongst African Americans with type 2 diabetes. The study also identified group education, hospital setting and clinicians as ‘experts’ as desirable characteristics of an education programme. Similarly, other studies have obtained views of and preferences for education as well as factors that could influence education and ultimately diabetes self-management (Dye et al. 2003; Brown & Hanis 1999; Vincent et al. 2006; Two-Feathers et al. 2007; Rosal et al. 2004).

Education that is culturally relevant (Brown et al. 2002; Anderson-Loftin et al. 2002) and tailored to the needs and abilities (Clark et al. 2004; Two Feathers et al. 2007) of the patient has been shown to be effective in improving health outcomes. In sub-Saharan Africa there is a paucity of data or literature on structured, tailored NE programmes targeting individuals with diabetes mellitus. In addition, views of healthcare providers on the education needs of their diabetic patients have received little attention. There is therefore a need to establish the needs and preferences of individuals with diabetes for NE, in order to plan targeted education programmes.

Nutrition education: Any set of learning experiences designed to facilitate the voluntary adoption of eating and other nutrition-related behaviours conducive to health and well-being (America Dietetic Association, 1996).

Needs: In this study needs are perceived or observed problems and issues of concern or interest related to diabetes and diet.

Diabetes self-management education: Ongoing process of facilitating the knowledge, skill and ability necessary for diabetes self-care (Funnell et al. 2009).

Convenience purposive sampling of diabetic patients was undertaken. All patients attending the clinics during the study period and who met the inclusion criteria were invited to take part if they were able and willing to discuss their diabetes in a group. They were individually approached during their monthly clinic visits by the principal investigator and field worker. All health professionals who met the inclusion criteria (16 in all) were requested to participate in the study.

Four to 10 diabetic patients participated in each focus group that was held at the CHCs. FGDs were conducted until no new information emerged from consequent groups (Fouche 2005; Rabiee 2004), and a total of five FGDs were held with 31 participants. Debriefing between the research team (principal investigator, moderator, field worker and one other investigator) was done after each focus group to discuss and clarify any issues arising (Speziale & Carpenter 2007; Kidd & Parshall 2000).

Self-administered questionnaires with a total of 14 open-ended questions (two of which also included a closed-ended question) were used with the health professionals. The questions addressed adherence to dietary recommendations by patients, barriers and facilitators to dietary adherence of patients, and recommendations for an NE programme.

Data analysis was done using Krueger’s framework approach (Rabiee 2004). Framework analysis uses a thematic approach, in which the themes are allowed to develop both from the research questions and the narratives of the participants (Rabiee 2004). The transcribed text and text from the health professionals’ responses were read through several times by the principal investigator to make sense of the whole data, before breaking it into parts. Next data were coded and then grouped according to their meaning to form categories. Frequency, extensiveness and intensity of participants’ comments (Rabiee 2004) were used to isolate the major categories. Making connections between the categories (abstraction) identified the most important themes from the data. Citations from the participants were used to demonstrate the link between the data and results.

‘diabetes is caused by the pancreas, when the pancreas is unable to break down the food’ (Gp 3, P6/8).

‘I was confused because I grew up not eating sugar’ (Gp 2, P4/10).

‘it is caused by family problems or your own problems that you do not share with others’ (Gp 4, P3/4).

‘while the heart is pumping because of the problems you have diabetes easily gets you’ (Gp 3, P2/8).

The following participants’ comments illustrate their awareness of management strategies:

‘it needs one to eat the proper foods’ (Gp 1, P1/5).

‘you are not supposed to be seated all the time, you should walk some distance’ (Gp 4, P2/4).

‘you have to take your medication and not to be too much stressed’ (Gp 3, P2/8).

In two focus groups participants seemed to believe there could be a cure for their condition, and that the current treatment is not effective, as illustrated by the following comments:

‘a grant and medicine that can help treat this disease’ (Gp 3, P1/8).

‘we would appreciate if they could make medicine that will make us better’ (Gp 2, P4/10).

‘we wish they could add something to the treatment of this illness that could help us’ (Gp 3, P2/8).

‘We are not supposed to eat oily and fatty foods; we may eat fruits, beans and vegetables’ (Gp 2, P2/10).

‘If you use sugar it must be just little, even salt’ (Gp 4, P4/4).

‘You must eat smaller amount of food’ (Gp 1, P3/5).

‘You should eat a lot of vegetables’ (Gp 5, P1/4).

The recommendations for limiting alcohol intake and drinking adequate water were not strongly emphasised, as each was mentioned by one participant only.

Limiting sugar and fat intake was considered important, as indicated by the reported food choices and past dietary changes. All the groups mentioned having reduced fat in cooking and reducing sugar intake:

‘I used to use a lot of oil in cooking but now I boil all my vegetables and use a little oil in cooking other foods’ (Gp 5, 4/4).

‘We no longer use oil, we cook with water’ (Gp 4, P3/4).

‘I do not use sugar anymore’ (Gp 2, P5/10).

Despite the reported reduction in fat intake, the use of saturated fats and high-fat products was identified in two of the focus groups:

‘I use full cream milk’ (Gp 5, P3/4).

‘I use a little Holsum [palm oil] in cooking’ (Gp 5, P2/4).

‘I use some butter after boiling the vegetables’ (Gp 4, P3/4).

Three focus groups indicated that they reduced food portion sizes; however, the participants expressed feeling hungry due to small portions:

‘I stopped eating a lot, at first I would feel hungry but now I am getting used’ (Gp 2, P6/10).

‘I like brown pap [stiff sorghum porridge] but it does not make me full as I have to eat a small amount’ (Gp 1, P4/5).

There seemed to be confusion concerning meal frequency and portion sizes, as expressed in the following comments by participants:

‘We are supposed to eat very little at a time within a short period, sometimes when you are supposed to eat you are still full and that causes sugar to go high’ [Gp 2, P3/10].

‘I may eat now and within a short time I want to eat again so I can have energy to do chores’ (Gp 4, P2/4).

‘I used to eat in the mornings and the next time I will eat at one o’clock or evening, now I have to eat because you cannot stay with an empty stomach’ (Gp 1, P3/5).

‘We are not supposed to eat to our full stomachs’ (Gp 2, P2/10).

Eating balanced meals seemed not to be an important aspect, as none of the groups mentioned consuming a combination of all food groups. Starchy foods were the most commonly mentioned as being consumed, followed by milk, fruits and meat. Vegetables seemed not to be consumed regularly. Legumes (apart from peanut butter spread) were not mentioned in any of the groups:

‘Most of the times I eat porridge’ (Gp 4, P2/4).

‘Supper I will eat pap [stiff maize meal porridge] or rice with meat or sometimes vegetables or milk’ (Gp 3, P3/8).

‘I eat mabela [sorghum] meal, at lunch I eat brown bread; I also sometimes eat apple for snacks’ (Gp 1, P5/5).

’In the morning two slices of bread with some peanut butter and tea with low fat milk, around ten o’clock pap or bread, sometimes with fish, an apple around 2 o’clock, then supper brown or white pap’ (Gp 5, P4/4).

Fruits especially apples were regarded as important snack foods, but many participants (four groups) expressed problems in having adequate fruits:

‘we eat snacks like apples when they are available, when we have money’ (Gp 4, P1/8).

‘we are unable to buy enough foods like fruits’ (Gp1, P2/5).

‘I eat apples (green) sometimes; I do not eat every day because I do not have money’ (Gp 2, P1/10).

Consumption of starchy foods that were higher in fibre appeared to be important in all the groups. However, it was noted that the higher-fibre options were interchangeably used with the lower-fibre options by some participants:

‘I normally use brown bread’ (Gp 3, P3/8).

‘I now eat mabele [sorghum] porridge’ (Gp 4, P2/4).

‘I eat Jungle Oats in the morning’ (Gp 1, P3/5).

‘I eat brown or white pap [stiff maize meal porridge], sometimes brown rice’ (Gp 5, P3/5).

Misconceptions about the role of food were identified in three focus groups, as indicated by the following statements:

‘you must give yourself less food hence a lot of people die and become blind due to diabetes (Gp 1, P1/5).

‘it is dangerous because it needs you to eat’ (Gp 3, P4/8).

‘hence we lose weight because we cannot just eat anything’ (Gp 4, P2/4).

The health professionals were asked their views of their patients’ adherence to dietary recommendations with regard to proportions, following or not following recommendations (closed-ended question), and areas they found easy or difficult to adhere to (open-ended questions). A summary of the health professionals’ views about the patients’ adherence to dietary recommendations appears in Table 3. Five indicated that half of the patients did not adhere to dietary recommendations, whilst three indicated the majority did not adhere to recommendations per se.

Eight barriers to following dietary recommendations were identified (Table 4). Some of the barriers mentioned were similar amongst the patients and health professionals, whilst others differed.

The social context was another barrier cited by the two groups. Family meal arrangements was seen as a barrier, either due to the fact that some patients were not in charge of food purchasing or preparation, or their condition was viewed as needing different foods.

Health professionals viewed social functions (ceremonies) and cultural beliefs as precipitators or underlying forces to inappropriate dietary practices. This was not cited in the patient group.

Barriers related to self-care were cited by both the patients and health professionals, with some aspects being similar whilst others differed. Denial of disease and use of other remedies was mentioned as common by both groups. Self-care barriers cited only by patients included helplessness from lack of control despite perceived adherence, forgetting to eat, and the belief that dietary change is difficult. ‘Cravings and temptation’ was the only barrier mentioned by health professionals only.

Barriers related to perceived effects of the required dietary changes emerged from the patient group. Two of the focus groups indicated that special foods were needed, and three groups indicated that the foods were tasteless and the diet restrictive. Hunger was cited as related to the disease as well as to the requirement to eat small food portions, and therefore seen as a barrier.

Access to appropriate foods and the cost of these were barriers identified by both groups, and were associated with the physical environment. Participants cited the high cost of foods and unavailability of healthy foods in the local markets as impediments to dietary compliance.

The patients (four groups) indicated that the education they were offered at the clinic was not comprehensive and was too generalised as it was offered to them together with patients with other conditions. Health professionals cited poor understanding of the disease and diet due to low literacy levels as a barrier to adherence to dietary recommendations.

A summary of the facilitators to following dietary recommendations as expressed by the patients and health professionals appears in Table 5.

Health professionals recommended formation of support groups (peer groups), as they felt that this would facilitate appropriate self-care through sharing experiences.

The recommendations for an NE programme as suggested by the patients and health professionals are summarisd in Table 6. Both groups’ recommended topics related to the disease and diet. The patient group was not explicit with respect to nutrition topics. The health professionals gave a wide range of nutrition topics, including balanced diet, portion-size control, meal distribution, starches and the role of food in the management of the disease.

The patients perceived the health professional as the best person to deliver the education. Most of the health professionals indicated that the health professional or community worker in conjunction with a peer would be best suited to offer the education. They viewed the health professional or community worker as an authority figure that would motivate participation in the NE, whilst a peer would influence learning through sharing experiences.

The patients viewed the clinic as the best venue for receiving the education, and weekdays as the suitable time to receive the education. However, they were vague concerning the frequency of meetings. The health professionals gave a wide range of suggestions for frequency of meetings, with the majority (n = 5) indicating once per week. However, only one gave the reason for this suggestion: ‘they do not like coming often due to finances’.

Posters and pamphlets were mentioned by the patients and health professionals as materials suitable for use in NE. Pamphlets were seen as materials that were useful even for those without diabetes, and for use at home with the help of family members.

Health professionals viewed participatory methods such as discussions and demonstrations as the best teaching methods.

The patients and health professionals made other recommendations, e.g. inclusion of family members in the NE and punctuality of the educators. The patients also recommended education specific to diabetes and a competent educator. The health professionals recommended use of the local language or an interpreter, and inclusion of motivational activities such as competitions.

The results are discussed as per the study objectives, namely the current understanding of diabetes and its management, the self-reported current dietary practices and perceived dietary adherence, the factors that could impact the NE (barriers and facilitators to dietary compliance), and recommendations for content and preferred education approaches for the NE programme.

Inadequate intake of fruits and vegetables in this study population confirms a problem identified by other studies in developed (Nelson, Reiber & Boyko 2002) as well as developing countries (Badruddin et al. 2002).

Absence of support in the social environment can cause difficulties for diabetic patients when coping with illness in everyday life (Albright, Parchman & Burge 2001). Family dietary behaviour was seen as a challenge due to family food preferences, food selection and preparation. Patients expressed reluctance by family members to make dietary changes since they were considered to be only for the diabetic person. This result is similar to other studies in different cultures (Jazayeri & Pipelzadeh 2006; Carbone et al. 2007; Wen, Parchman & Shepherd 2004; Albarran et al. 2006; Shultz et al. 2001; Vijan et al. 2005). Notably, social functions such as ceremonies were a barrier cited only by the health professionals. Although these may not be seen as an issue by the patients, this information forms a platform for exploring this barrier with the patients. Some studies have indicated that patients find it difficult to adhere to their diet during special occasions (Vijan et al. 2005).

The physical environment was seen as a barrier to accessibility and availability of healthful foods. This relates to the distant location of those supermarkets and/or grocery stores with a variety of and appropriate products, high cost of healthy foods in the local shops (Albarran et al. 2006; Marcy et al. 2011) and inconsistent availability of water that discourages gardening. This is an important finding since geographical areas such as neighbourhoods can influence the ability of the target audience to implement nutrition messages received (Viswanath & Bond 2007).

Barriers that have also been identified in other studies include generalised and incomprehensive education (Nagelkerk, et al. 2006; Vincent et al. 2006; Albarran et al. 2006), feeling hungry, small food portion sizes (Vijan et al. 2005, Shultz et al. 2001), taste of the food, restrictive diet (Dye et al. 2003), forgetting to eat and inadequate knowledge of the disease and diet (Nagelkerk et al. 2006; Nthangeni et al. 2001).

Three key facilitators to following dietary recommendations emerged from the two groups of participants: family support, health professionals’ support, and knowledge obtained through education. These findings have been reported in other studies (Chlebowy, Hood & LaJoie 2010) with diabetic patients and indicate that patients in this study value education. Carbone et al. (2007), in a study of perspectives of Latino patients and their health care providers about diabetes self-management, found similar results about support by family and health professionals. A review by Gallant (2003) reported a modest positive relationship between social support and chronic disease self-management, especially in diabetes. Dietary behaviour was indicated to be particularly susceptible to social influences. Other studies have also shown a positive relationship between social support and self-care behaviours (Albright et al. 2001; Wen et al. 2004). This finding has important implications in planning care for this study population.

Overall, the family was seen both as a barrier and facilitator to dietary self-management by the two groups of participants, a result also identified by Carbone et al. (2007).

A surprising finding concerning topics for the NE is that the majority of the patients strongly emphasised topics related to the disease, whilst they were not explicit on topics to do with diet, as indicated by statements such as ‘any information that can help us feel better’, and ‘more about food’. This finding could be attributed to the fact that the patients perceived themselves as more deficient in knowledge about the disease than about diet. In addition, the fact that many suggested provision of grants or food parcels to help them follow dietary recommendations may be an indication that food insecurity was seen as the major issue that needed to be addressed.

The patients also found it difficult to recommend preferred teaching methods. Other studies using focus groups have also found an inability of patients to articulate the content of an education programme (Benavides-Vaello et al. 2004; Blancard et al. 1999). The study by Benavides-Vaello et al. (2004) found that patients who had not been exposed to diabetes education found it difficult to define what they needed to know and how best they could learn. This could be true for this study population, who indicated that they were offered education together with other chronic disease patients.

The health professionals suggested a range of topics related both to the disease and diet, most of which reflected the problems identified in the dietary practices and knowledge of the patients.

Patients envisioned a programme at the clinic, since this was seen as a familiar and accessible site. They also preferred group education as they could learn from each other. This finding has also been reported in other studies (Brown & Hanis 1999; Dye et al. 2003). The health professionals concurred with the group education format, although most suggested a combination of both individual and group delivery as each has unique potential in enhancing learning. A combination of the two approaches is supported in interventions to promote diabetes self-management (Brown 1999).

Knowledgeable educators such as a health professional and specific but comprehensive education were indicated as desirable characteristics of the programme by the patients. This finding has been cited in other studies (Brown & Hanis 1999; Rosal et al. 2004; Vincent et al. 2006). The health professionals also indicated that inclusion of a peer educator would further enhance learning, which is also supported by other studies (Vincent et al. 2006).

Written material, especially pamphlets, were seen as useful reinforcements of knowledge at home with the help of family. This finding has been observed in other studies (Brown & Hanis 1999; Vincent et al. 2006). A notable finding is the recommendation to include family members in the education, a suggestion also articulated by the health professionals. This finding is consistent with other studies with type 2 diabetic patients (Brown & Hanis 1999; Vincent et al. 2006).

The small convenient sample used in this study may not be representative of the population, and this may limit the generalisability of the results.

The use of interviews with the health professionals, as planned initially, would have given deeper insight into the issues at hand than the open-ended questionnaires. This is because with interviews one is able to probe and clarify issues (Greef 2005; Babbie et al. 2001). However, work schedules and limited staff at the clinics made it difficult to arrange for interviews. Open-ended questionnaires provided an alternative method where the health professionals could provide their views at their convenience.

In the exploration of dietary practices the reported dietary changes were not quantitatively verified. The reporting on dietary intake was mainly on the type of foods and frequency of consumption, and not the exact amounts of foods or drinks consumed. Thus the reported reduction in intake of sugar, fats and salt and portion sizes could be subjective. However, since the objective of the study was to gain insight into the nutritional issues that warrant intervention, qualitative analysis of dietary practices was deemed sufficient.

Participants in this study showed interest in an NE programme, and gave specific recommendations including the clinic as the preferred site, group education, a competent educator, provision of pamphlets and inclusion of family members. The health professionals’ input complemented the recommendations by the patients.

The planned NE programme should address the knowledge gaps and dietary practice problems and include strategies to address the barriers. It should also incorporate the suggestions for an NE programme as well as facilitators to dietary adherence.

Albright, T.L., Parchman, M. & Burge, S.K., 2001, ‘Predictors of self-care behaviour in adults with type 2 Diabetes: An RRNeST Study’, Family Medicine 33(5), 354–360.

American Dietetic Association, 1996, ‘Nutrition education for the public’, Journal of the American Dietetic Association 96(11), 1183–1187.

Anderson-Loftin, W., Barnett, S., Sullivan, P., Bunn, P.S. & Tavakoli, A., 2002, ‘Culturally competent dietary education for southern rural African Americans’, Diabetes Educator 28(2), 245–257. http://dx.doi.org/10.1177/014572170202800210

Babbie, E.R., Mouton, J., Vorster, P. & Prozesky, B., 2001, The practice of social research, Oxford University Press, Cape Town.

Badruddin, N., Basit, A., Hydrie, M.Z.I. & Hakeem, R., 2002, ‘Knowledge, attitudes and practices of patients visiting a diabetes care unit’, Pakistan Journal of Nutrition 1(20), 99–102.

Benavides-Vaello, S., Garcia , A.A., Brown, S.A. & Winchell, M., 2004, ‘Using focus groups to plan and evaluate diabetes self-management interventions for Mexican Americans’, Diabetes Educator 30(2), 238–256. http://dx.doi.org/10.1177/014572170403000217

Blancard, M.A., Rose, L.E., Taylor, J., McEntee, M.A. & Latchaw, L.L., 1999, ‘Using focus groups to design a diabetes education program for an African American population’, Diabetes Educator 25(6), 917–925. http://dx.doi.org/10.1177/014572179902500609

Brown, S.A. & Hanis C.L., 1999, ‘Culturally competent diabetes education for Mexican Americans: The Starr Country study’, Diabetes Educator 25(2), 226–236. http://dx.doi.org/10.1177/014572179902500208

Brown, S.A., 1999, ‘Interventions to promote diabetes self-management: state of art science’, Diabetes Educator 25(6), S52–S61.

Brown, S.A., Garcia, A., Koukezani, K. & Hanis, C.L., 2002, ‘Culturally competent diabetes self-management education for Mexican Americans: The Starr County Border Health Initiative’, Diabetes Care 25(2), 259–268. http://dx.doi.org/10.2337/diacare.25.2.259

Carbone, E.T., Rosal, M.C., Torres M. I., Goins, K.V. & Bermudez, I.I., 2007, ‘Diabetes self-management: perspectives of Latino patients and their health care providers’, Patient Education & Counseling 66, 202–210. http://dx.doi.org/10.1016/j.pec.2006.12.003

Chlebowy, D.O., Hood, S. & LaJoie, S., 2010, ‘Facilitators and barriers to self-management of type 2 diabetes among urban American adults: Focus group findings’, Diabetes Educator 36(6), 897–905. http://dx.doi.org/10.1177/0145721710385579

Clark, M., Hampson, S.E., Avery, H. & Simpson, R., 2004, ‘Effects of a tailored lifestyle self management intervention in patients with type 2 diabetes mellitus’, British Journal of Health Psychology 9(3), 365–379. http://dx.doi.org/10.1348/1359107041557066

Colleran, K.M., Starr B. & Burge, M.R., 2003, ‘Putting Diabetes to the Test. Analyzing glycemic control based on patients’ diabetes knowledge’, Diabetes Care 26(7), 2220–2221. http://dx.doi.org/10.2337/diacare.26.7.2220

Cox, R.H., Carpenter, J.P., Bruce, S.A., Poole, K.P. & Gaylord, C.K., 2004, ‘ Characteristics of low-income African-American and Caucasian adults that are important in self-management of type 2 diabetes’, Journal of Community Health 29(2), 155–577. http://dx.doi.org/10.1023/B:JOHE.0000016719.89848.b1

Department of Health, Directorate of Chronic Diseases, Disabilities & Geriatrics, 2005, National guideline: Management of diabetes type 1 and type 2 in adults at hospital level, Annexure 4, pp. 46–47, Depatment of Health, Pretoria.

Dye, C.J., Haley-Zitlin, V. & Willoughby, D., 2003, ‘Insights from older adults with type 2 diabetes: Making dietary and exercise changes’, Diabetes Educator 29(1), 116–127. http://dx.doi.org/10.1177/014572170302900116 dx.doi.org/10.1177/014572170302900116

Ellis, E.E., Speroff, T., Dittus, R.S., Brown, A., Pichert, J.W. & Elasy, T.A., 2004, ‘Diabetes patient education: A meta-analysis and meta-regression’, Patient Education & Counseling 52, 97–105. http://dx.doi.org/10.1016/S0738-3991(03)00016-8

Fouche, C.B., 2005, ‘Qualitative research designs’, in A.S. De Vos, H. Strydom, C.B. Fouche & C.S.L. Delport (eds.), Research at the grass root for the social sciences and human service professions, 3rd edn., pp. 263–273, Van Schaik Publishers, Pretoria.

Funnell, M.M., Brown, T.L., Childs, B.P., Haas, L.B., Hosey, G.M., Jensen, B. et al., 2009, ‘National standards for diabetes self-management education’, Diabetes care 32, suppl. 1, S87–S94. http://dx.doi.org/10.2337/dc09-S087

Gallant, M.P., 2003, ‘The influence of Social support on chronic illness self-management: A review and directions for research’, Health Education & Behaviour 30(2), 170–195. http://dx.doi.org/10.1177/1090198102251030

Glazier, R.H., Bajcar, J., Kennie, N.R. & Wilson, N.K., 2006, ‘A systematic review of interventions to improve diabetes care in socially disadvantaged populations’, Diabetes Care 29(7), 1675–1688. http://dx.doi.org/10.2337/dc05-1942

Golay, A., Lagger, G., Chambouleyron, M., Carrard, I. & Lasserre-M., 2008, ‘Therapeutic education of diabetic patient’, Diabetes/Metabolism Research & Reviews 24, 192–196. http://dx.doi.org/10.1002/dmrr.798

Greef, M., 2005, ‘Information collection: interviewing’, in A.S. De Vos, H. Strydom, C.B. Fouche & C.S.L Delport (eds.), Research at the grass root for the social sciences and human service professions, 3rd edn., pp. 286–313, Van Schaik Publishers, Pretoria.

Gwatkin, D., Guillot, M. & Heuveline, P., 1999, ‘The burden of disease among the global poor’, Lancet 354, 586–589. http://dx.doi.org/10.1016/S0140-6736(99)02108-X

Holmstrom, I. & Rosenqvist, U., 2005, ‘Misunderstanding about illness and treatment among patients with type 2 diabetes’, Journal of Advanced Nursing 49(2), 146–154. http://dx.doi.org/10.1111/j.1365-2648.2004.03274.x

International Diabetes Federation, 2009, ‘International standards for diabetes education’, 3rd edn., viewed 19 April 2012, from http://www.idf.org/files/docs/INTNL-STANDARDS-EN.pdf

International Diabetes Federation, 2011, ‘Types of diabetes’, viewed 19 April 2012, from http://www.idf.org/types-diabetes.

Jazayeri, S.M.H.M. & Pipelzadeh, M.H., 2006, ‘Barriers to diet self-care in outpatients with type 2 diabetes in Iran’, Pakistan Journal of Medical Sciences 22(4), 412–415.

Kidd, P.S. & Parshall, M.B., 2000, ‘Getting the focus and the group: Enhancing analytical rigor in focus group research’, Qualitative Health Research 10(3), 293. http://dx.doi.org/10.1177/104973200129118453

Levetan, B.N., Levitt, N.S. & Bonnici, F., 1997, ‘Hyperglycemic emergencies are a common problem’, South African Medical Journal 87, 368–370.

Lopez, K.A. & Willis, D.G., 2004, ‘Descriptive versus interpretive phenomenology: Their contributions to nursing knowledge’, Qualitative Health Research 14(5), 726–735. http://dx.doi.org/10.1177/1049732304263638

Marcy, T.R., Britton, M.L. & Harrison, D., 2011, ‘Identification of barriers to appropriate dietary behaviour in low-income patients with type 2 diabetes mellitus’, Diabetes Therapy 1(2), 1–11.

Moretele Local Municipality, 2008/2009, Reviewed integrated development plan (IDP), Moretele Local Municipality, Makapanstad.

Muchiri, J.W., Gericke, G. & Rheeder, P., 2009, ‘Elements of effective nutrition education for adults with diabetes mellitus in resource-poor settings: A review’, HealthSA Gesondheid 14(1), viewed 21 June 2011, from http://dx.doi.org/10.4102/hsag.v17i1.621

Nagelkerk, J., Reick, K. & Meengs, L., 2006, ‘Perceived barriers and effective strategies to diabetes self-management’, Journal of Advanced Nursing 54(2), 151–158. http://dx.doi.org/10.1111/j.1365-2648.2006.03799.x

Nelson, K.N., Reiber G. & Boyko E.J., 2002, ‘Diet and exercise among adults with type 2 diabetes: Findings from the third National Health and Nutrition Examination Survey (NHANES III)’, Diabetes Care 25(10), 1722–1728. http://dx.doi.org/10.2337/diacare.25.10.1722

Norlyk, A. & Harder, I., 2010, ‘What makes a phenomenological study phenomenological? An analysis of peer-reviewed empirical studies’, Qualitative Health Research 20(3), 420–431. http://dx.doi.org/10.1177/1049732309357435

Norris, S.L., Engelgau, M.M. & Narayan, K.V., 2001, ‘Effectiveness of self-management training in type 2 diabetes: A systematic review of randomized controlled trials’, Diabetes Care 24(3), 561–587.

Norris, S.L., Lau, J., Smith, S.J., Schmid, C.H. & Engelgau, M.M., 2002, ‘Self-management education for adults with type 2 diabetes: a meta-analysis of effect on glycemic control’, Diabetes Care 25(7), 1159–1171. http://dx.doi.org/10.2337/diacare.24.3.561

Nthangeni, G., Steyn, N.P., Alberts, M., Steyn, K., Levitt, N.S., Laubscher, R. et al., 2001, ‘Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services’, Public Health Nutrition 5(2), 329–338.

Pastors, J.G., Warshaw, H., Daly, A., Franz, M. & Kulkani, K., 2002, ‘The evidence for the effectiveness of medical nutrition therapy in diabetes management’, Diabetes Care 25(3), 608–613. http://dx.doi.org/10.2337/diacare.25.3.608

Persell, S.D., Keating, N.L., Landrum, M.B., Landon, B.E., Ayanian, J.Z., Borbas, C. et al., 2004, ‘Relationship of diabetes-specific knowledge to self-care activities, ambulatory preventive care and metabolic outcomes’, Preventive Medicine 39, 764–752. http://dx.doi.org/10.1016/j.ypmed.2004.02.045

Rabiee, F., 2004,’Focus-group interview and data analysis’, Proceedings of the Nutrition Society 63, 655–660. http://dx.doi.org/10.1079/PNS2004399

Roper, N.A., Bilous, R.W., Kelly, W.F., Unwin, N.C. & Connolly, V.M., 2001, ‘Excess mortality in a population with diabetes and the impact of material deprivation: Longitudinal, population based study’, British Medical Journal 322, 1389–1393. http://dx.doi.org/10.1136/bmj.322.7299.1389

Rosal, M.C., Goins, K.V., Carbone, E.T. & Cortes, D.E., 2004, ‘Views and preferences of low-literate Hispanics regarding education: Results of formative research’, Health Education & Behavior 31(3), 388–405. http://dx.doi.org/10.1177/1090198104263360

Shabbidar, S., Fathi, B. & Shirazifard, N.M., 2006, ‘Effects of clinical nutrition education on glycemic control outcomes in type 2 diabetes’, International Journal of Diabetes in Developing Countries 26(4), 165–169. http://dx.doi.org/10.4103/0973-3930.33181

Shaw, J.E., Sicree, R.A. & Zimmet, P.Z., 2010, ‘Global estimates of the prevalence of diabetes for 2010 and 2030’, Diabetes Research and Clinical Practice 87(1), 4–14. http://dx.doi.org/10.1016/j.diabres.2009.10.007

Shultz, J.A., Sprague, M.A., Branen, L.J. & Lambeth, S., 2001, ‘A comparison of views of individuals with type 2 diabetes mellitus and diabetes educators about barriers to diet and exercise’, Journal of Health Communication 6, 99–115. http://dx.doi.org/10.1080/108107301750254457

Speziale, H.J.S. & Carpenter, D.R., 2007, Qualitative research in nursing. Advancing the humanistic imperative, 4th edn., Lippincott Williams & Wilkins, Philadelphia.

Suhl, E. & Bonsignore, P., 2006, ‘Diabetes self-management education for older adults: General principles and practical application’, Diabetes Spectrum 19(4), 234–240. http://dx.doi.org/10.2337/diaspect.19.4.234

Sullivan, E.D. & Joseph, D.H., 1998, ‘Struggling with behaviour changes: a special case for clients with diabetes’, Diabetes Educator 24, 72–77. http://dx.doi.org/10.1177/014572179802400110

Two Feathers, J., Kieffer, E.C., Palmisano, G., Anderson, M., Guzman, N. & James S.A., 2007, ‘The development, implementation, and process evaluation of the REACH Detroit Partnership’s Diabetes’, Diabetes Educator 33(3), 509–520.

Van den Arend, I.J., Stolk R.P., Rutten, G.E. & Schrijvers, G.J., 2001, ‘Education integrated into structured general practice care for type 2 diabetic patients’ results in improvement of disease knowledge and self-care’, Diabetes Medicine 17(3), 190–197. http://dx.doi.org/10.1046/j.1464-5491.2000.00232.x

Vijan, S., Stuart, N.S., Fitzgard, J.T., Ronis, D.L., Hayward, R.A., Slater, S., & Hofer T.P., 2005, ‘Barriers to following dietary recommendations in type 2 diabetes’, Diabetes Medicine 22, 32–38. http://dx.doi.org/10.1111/j.1464-5491.2004.01342.x

Vincent, B., Clark, L., Marquez, L., Zimmer, L. & Sanchez, J., 2006, ‘Using Focus Groups to develop a culturally competent diabetes self-management program for Mexican Americans’, Diabetes Educator 32(1), 89–97. http://dx.doi.org/10.1177/0145721705284372

Viswanath, K. & Bond, K., 2007, ‘Social determinants and nutrition: Reflections on the role of communication’, Journal of Nutrition Education & Behaviour 39, S20–S24. http://dx.doi.org/10.1016/j.jneb.2006.07.008

Vorster, H.H. (ed.), 2001, ‘South African Food Based Dietary Guidelines’, South African Journal of Clinical Nutrition 14(3), Suppl. S1–S80.

Wen, L.K., Parchman, M.L. & Shepherd, M.D., 2004, ‘Family support and diet barriers among older Hispanic adults with type 2 Diabetes’, Family Medicine 36(6), 423–430.

Zimmet, P., 2003, ‘The burden of type 2 diabetes: are we doing enough?’, Diabetes & Metabolism 29(4), 6S9–6S18.