Table 3 Barriers to diabetes management

Competing family needs

Family responsibilities were felt to be a barrier to healthy eating and time for self-care.

SM: “You can’t always be isolated from the foods normal people eat. For example within my family it is inconvenient for them to just cook for me and then also cook for the rest of the family.”

SW: “Foods need to be variety plus if we are living by them they are more likely to make healthy food for themselves, but that is not the case. We cook food for people that are not diabetes. I believe that to be the biggest problem.”

SW: “It’s different and difficult when women has diabetes than the men because the women always care for their families and children before they take care of them self…when you tell people you are diabetic they will make you feel very bad.”

Physical pain

Physical pain is distressing and often avoided.

LM: “The aspect of poking yourself…they gave me the insulin and that has been something that…first of all, the pills make me nauseous…but the poking was like a ceremony…it would take an hour…I would poke my belly, everywhere but I could not inject the needle, because I was in panic, I would feel horrible chills.”

SM: “…for me was poking my body or my finger that I hated and the biggest obstacle I have overcome to this day. They told me to measure it first thing in the morning and also when I'm about to go to sleep but I procrastinate when I get lazy from it and I really don't like poking my fingers. When I poke myself I start shaking and trembling.”

SM: “I have arthritis pain and that limits my ability to exercise.”

SM: “…for me I cannot move much, if I try to move I cannot reach even the nearest tree. I have pain in my thighs and I have no energy or endurance at all. From the pain in my joints I cannot move much.”

Lack of knowledge

Knowledge gaps and misinformation led to low adherence for some.

SM: “So even though the doctor gave me advice on how to take the medication even when I was fasting. I started to not follow the prescription as it was intended and I started to think hey you know may be I don't need to take the medication and I don’t want to make my disease worse.”

LM: “But, it depends a lot from you, to depend on you, you also need the information…if you don’t have the right information, that’s the point. They said, people from the town die for lack of information.”

LW: “The hard part is when we don’t understand, don’t know the symptoms.”

Food cravings and cultural customs

Food cravings identified as a barrier to healthy eating. Some cultural customs at times interfered with healthy eating or other self-care.

LW: “One has more cravings than ever, and one has to control the food intake, it is really hard when it is forbidden, it is when one wants to eat even more.”

LM: “In my case, the change has been horrible…it has been very difficult, I was used to have good food, and always to be served and to eat all my cravings. It has always been a wonder and joy of my life, and when I had to make changes in food; and it was very curios because a nurse came, and tells me, a little bite of food here and a little food there. I told her, are you joking to me? How do you think I will eat so few food? No, not even for the cat, no I… no, no, no, I like to eat a lot, not like a little here and there, I am not sick. Do I have like pneumonia?”

SM: “I know that even if we were given gym membership we will always have an obstacle against that because the thing is we don’t have a tradition that values exercise.”

SM: “But regardless of how they live, most Somali peoples eat similar food that lacks the proper nutrients. Most Somalis eat white rice with tomato sauce and a little bit of meat. This is what every mother knows. …It doesn’t matter if you give her EBT with full of money, doesn’t matter if you take them shopping to Walmart yourself. …This is the problem we have. It is not in our tradition to eat these kinds of healthy foods.”

Difficulties with changing habits

Staying in new routine may be as hard as starting one if motivation cannot be sustained—lack of discipline, lack of time, and competing priorities also may limit activity.

SM: “Then I started to make myself believe that I do not need to exercise and since I am fasting I started to stop it. Once I started to stop it then I got lazy.”

LM: “It is almost impossible for an individual to give full attention to his medication and also at the same time keep a job. Being diabetic by itself is a full-time job. You have to constantly check yourself and ask yourself is it going up, is it going down. It’s a constant struggle.”

SM: “Laziness and procrastination because I keep thinking to myself you will do later or sometimes I just don’t feel like doing it. Those were the biggest obstacles for me.”

SM: “I neglected myself in general to be honest. Because I focus my time on other things. From the time I get up 8 am or 9 am till 12 am, I find thing to be busy with such prayers going to the restaurant and doing other things. I also have exercise machine in my home so I really don’t have excuse but “negligence” as I call it.”

SM: “But when it was bad, I would pray Morning Prayer and then I would ride a bike or take a long walk. But when you start think you are ok, then you get complacent.”

LW: “I didn’t learn because I haven’t yet taken that continuously the medication, but I knew that… I am not much of, of taking medications every day or do something every day.”

Structural barriers

Structural barriers (e.g. cost and transportation) may be barriers to healthy activity

LM: “Us guys who work and have diabetes cannot afford to buy only foods that are for diabetic people since we have a whole family to feed and not everybody likes the same food. I don’t think some of us have the budget to buy fresh fruits and vegetables every day, whether you cook it yourself or have someone else cook it for you.”

SW: “Plus in Africa was walking everywhere all the time and here a barely do. I am always being driven to everywhere. Here my sugar got high and my pills have been increased.”