The burden of chronic diseases including type two diabetes mellitus (T2D) is increasing rapidly, especially in low- and middle-income countries. In high-income countries, evidence shows that T2D disproportionally affects socio-economically disadvantaged and vulnerable populations, which makes it an important contributor to inequality. Self-management is an essential and effective strategy for people with T2D, but is poorly adopted in vulnerable groups and low-resource settings. Research on self-management support interventions has been focused on the general population of high-income countries, ignoring the populations that need it the most. The objective of this study is to identify the motivational mechanisms that determine self-management outcomes in vulnerable and socio-economic disadvantaged populations living in suburbs in Sweden, an urban slum in South-Africa, and a rural area in Uganda.
The study is based on self-determination theory and hypothesizes that higher intrinsic motivation leads to better self-management which will improve physical and psychological outcomes. Moreover, increase of intrinsic motivation happens through fulfillment of the basic psychological needs which are perceived autonomy, competence and relatedness. In the same framework, we hypothesize that higher psychological adjustment – which refers to the absence of mental distress and the ability to cope with change – leads to better self-management and related outcomes.
The study builds on an ongoing cluster-randomized experimental trial evaluating the effectiveness of a context-appropriate community intervention to enhance self-management for people with T2D called SMART2D. The aim of this new proposal is to identify the motivational mechanisms that explain the effect of the intervention in the SMART2D trial. More specifically, this new proposal will assess the mediating role of perceived autonomy, perceived relatedness, perceived competence, intrinsic motivation, and psychological adjustment. Quantitative data on these psychological factors will be collected through the SMART2D project. To determine the mediating effect of these latent variables, a structural equation model will be developed and tested. We will use multi-group structural equation modelling to test the model across the three different sites. This new project will also collect additional qualitative data through semi-structural interviews with the people at risk for or with T2D to further explain the differences across the three study settings.
This study will inform us on how self-management support interventions need to be developed when targeting populations in disadvantaged or under-resourced areas, in order to make care more equal and inclusive.