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Table 3 Themes identified and representative quotes from in-depth interviews

From: A web-based intervention to support self-management of patients with type 2 diabetes mellitus: effect on self-efficacy, self-care and diabetes distress

Theme/subtheme

Representative quotes

1) Barriers and facilitators of website use:

Barriers to website use

Patient-related barriers

a) Competing health concerns

“Being 4 cancers in my life”. [3B53, 78-year old woman]

“it’s not just diabetes that I deal with”. [2B16, 37-year old woman]

b) Competing life concerns

“I think for me, health issues surround migraines and fatigue. By the time I was home and had any free time, there wasn’t a lot there. And then life style and other stresses the business and other stresses the business…” [2B16, 37-year old woman]

c) Lack of motivation

“It’s a me thing, as opposed to a site thing”. [2B09, 47-year old woman]

“Laziness”. [3B52, 65-year old woman]

d) Frustration with diabetes

“Part of it is, when you see the blood sugar is really high, I already know it’s high. I’m not taking the medication. So to log the fact that they are high, ends up making you more frustrated. So why do that”. [2B09, 47-year old woman]

e) Futility regarding diabetes

Sometimes I think no matter what I do it’s not going to matter because you read about this… they all end up on dialysis… they all, you know…” [2B09, 47-year old woman]

Website-related barriers

f) Login and password requirement

“I keep forgetting my password”. [3B27, 58-year old woman]

“The ability to change the password is good as well… Because I think that helps in returning, otherwise I would always go back and find your original email”. [2B16, 37-year old woman]

g) Limited computer and/or internet access

“I didn’t have too much time to look at it ’cause I don’t have a computer at home [3B39, 67-year old man]

“I wish I can have a mobile like app”. [3A10, 52-year old woman]

“on the road for work and limited web access”. [1A13, 47-year old man]

h) Onerous nature of data entry to use logs

“Um, but cause I did go in and I did try and do the tracking and I think cause I thought that was on an ongoing basis was the most useful part of it. But it was kind of a pain in the neck to use it… and kind of a pain in the ass getting where I wanted to go. I put some information and I wanted to delete it and I don’t know if I ever succeeded in getting rid of it”. [2B01, 48-year old man]

Facilitators of website use

i) Perceived reliability of information

“It has to be really, really tuned in or connected to the latest developments either at [hospital name] or the world… With tons of information by real authorities. If I had a diabetic questions, I thought you guys might answer it, I would consider this to be an authoritative source”. [2B01, 48-year old man]

j) Reminders, prompts of new content

“Actually love getting the reminders, I really do. In this day in age everybody is busy, but I’m really good about it. The day I get the reminder, I find time to go in, I read the blogs… As I said, if you told me there was something new under a certain heading, I would definitely go in. I just like the reminders, in this fast paced world you don’t always have time for things and the last thingyou think about is yourself. So I think the reminders are a great thing, and I always look”. [3B09, 61-year old woman]

k) Increasing comfort with internet use

“Slowly I got used to [the internet] and since that time I utilize the possibility to look after whatever is interesting to me”. [3B53, 78-year old woman]

“I starting writing a lot of emails to lawyers and the public trustee so I’m kind of used to no, more so than before, tracking stuff online. Kind of going paperless is neat”. [2B01, 48-year old man]

2) Patterns of use of the website, including role of blog in driving site traffic

a) Goal-directed use

“And that’s kind of how I use the tool. It’s not as much a “Do I go in daily and read a new section each day?” No, it’s when I have a specific concern that I hone in on it to a degree”. [2B09, 47-year old woman]

“Right, so there are a lot of places [in the website to which] you can go. But if those places don’t impact you… For example, if you don’t have high blood pressure, if it doesn’t impact you, you are less likely to go back to it. Then when it impacts you, then you know the resource is there”. [2B09, 47-year old woman]

b) Use in context of current concern

“Because the bottom of my toes is not sensitive and the side of my foot is not sensitive. So I looked up this website and tried to find out what could I do and is there any kind of help that I could find”. [3B52, 65-year old woman]

 -Motivation for repeated use

“The foot complication is the one I usually look up”. [3B52, 65-year old woman]

 -To gage urgency

“I would look something to see if I thought if it was urgent”. [3B13, 54-year old woman]

“Now, I have to say yesterday in desperation I actually tried to look up some medication information on this website…” [2B09, 47-year old woman]

c) Role of blog in driving site traffic:

“When new blogs coming up then I read it. Not always at once, but still eventually”. [3B53, 78-year old woman]

 Dual roles of blog

“‘Ask the Expert’ should remain open all the time… And maybe it’s not just ‘Ask the Expert’; maybe it’s ‘Ask someone’. So you need an ‘Ask the Expert’ section and ‘Ask the Fellow Patient’ section”. [2B09, 47-year old woman]

 i) Opportunity for anonymous request for information

“It provides an opportunity where people however anonymous they want to be and it might be something someone could be shy asking a heath care practitioner meanwhile go ahead and ask on something like that. So in that sense, I think that’s useful”. [2B16, 37-year old woman]

 ii) Fostering a sense of community

“It’s interesting because people will come with a question through [the blog, such as] “Well, this worked for me”, or “This will work for everyone.” It is a sort of communal sense and conversation”. [3B53, 78-year old woman]

“So, I think learning to develop your support systems is extremely important for a diabetic. And that having a forum where even if you don’t have a lot of people in your life that you can talk to about this, but having a forum where maybe you can go on and have an online community can be very helpful. Provided that they understand that any information that they read has to be verified”. [3B13, 58 year-old woman]

 -Social support

“For example, if you are feeling yourself alone and loneliness is not a very good thing health-wise. It leads to depression and everything else and if you feel that you have to communicate, and then communicate here”. [3B49, 46-year old man]

 -Though this was not a universal sentiment: others felt a lack of connection

“Sometimes with a blog it can be communal and it can be conversation, but it can also make people feel disconnected because: how comfortable are they in conversation?” [2B16, 37-year old woman]

 iii) However, tension between desire for online community and fear of ridicule, timidity

“Because we are afraid that we are putting a stupid question”. [3B53, 78-year old woman]

“I found at times, responding to other posts, that [I felt] shy about responding. But I did go ahead and do that even though I thought at times that’s not necessarily my usual style”. [2B16 37-year old woman]

“It might take time to catch on, because people who are feeling shy about it may need to see what other people do with it for quite a while”. [2B16, 37-year old woman]

“I think some people are shy about how they write.” [2B16, 37-year old woman]

“I’ve just never been interactive…” [3B09, 61-year old woman]

 iv) Other reasons for not contributing to the blog:

 -Nothing new to contribute

“But I’m not a poster. I read, I learn, I just don’t put my 2 cents in. [I don’t post because] I would say the same thing – why would I bother?” [3B09, 61-year old woman]

 -Reliability of content: Balance between evidence anecdote, trusted source versus patient centred

NO “I find for the most part it’s the blind leading the blind. I guess this one is being moderated but by and large you have a bunch of people who don’t know anything kind of spewing forth”. [3B13, 54-year old woman]

YES “However, the way this one is designed essentially it goes and it’s approved or reviewed before being posted in the first place. Which I think is a good style”. [2B16, 37-year old woman]

 -Perceived relevance to specific demographic population

“I don’t know what the ages are but I’m thinking a younger person would be more familiar with communication in a way that is not face to face, more so”. [2B16, 37-year old woman]

3) General feedback on website characteristics:

a) Accurate and comprehensive

In fact, what I noticed is that their seemed to be more than what I would have anticipated… [2B01, 48-year old man]

So there are lots of things on the website that really did help. So things like how to control the blood pressure and how to do all those other… there is lots of things that help. [2B09, 47-year old woman]

b) Easy to navigate

“The website itself is easy to navigate. And I think that list is very good and I’ve found that every time I have looked, [the answer] could typically could fall into one of those categories. The answer might not be there, but I know where to start to look”. [2B09, 47-year old woman]

c) But could be more relevant:

 -Want practical solutions

Maybe too many people are inundated with expert answers and not enough with real life answers. [3B09, 61-year old woman]

But that when you need it the most, that’s when I found it didn’t have everything I needed. It was still missing… the next piece; the next piece is what happens when you are in that mess? [3B49, 46-year old man]

Yeah, it combines that very practical app, ok so here is an endocrinologist talking about blah, blah, blah, new scientific in road into diabetes… ok, that’s great on an intellectual level… What does this mean on a practical level? For those that want to and can handle the scientific information, perfect. And those of us who can’t or don’t want to then there’s other things on the site. [3B13, 54-year old female]

What do you value about each type of information, the practical versus medical evidence based? 70 or 80 [percent of it practical] versus 30 and 20 for the medical. [3B53, 78-year old woman]

But nowhere does it tell you how to deal with it. So, what I’m looking for and what I was looking for in that peer support was other people in the same position who have found solutions to issues that typical websites don’t tell you [2B09, 47-year old woman]

4) Potential mechanism of impact of website on self-efficacy, behavior change and diabetes distress

a) Unanticipated pattern of use of DOC

“I actually I haven’t done it lately but when I first got this I searched a lot of stuff, I was interested so I did search. I printed it out I actually have some in a binder, which I have referred to on occasion. It’s nice to have something black and white that you can refer to. That’s why I like certain websites, because you can print it off and read it. I can search other references and I’ve done that. And I keep a binder and I refer to it when…” [3B09, 61-year old woman]

 -Print out

b) Unanticipated impact of reminder emails

“There were the reminders that you hadn’t visited the site in a while. [When I got those reminders], I said, I will answer it later…

This companion is a good reminder, I heard about it before but then let’s go back and check to make sure that I’m understanding properly…” [3B27, 58-year old woman]

“Constantly reminding me about the things that we need to be aware of. Most of us know but the Online Companion was a good reminder and got me thinking of things that I need to constantly do (some that we conveniently forget)”. [3B55, 58-year old woman]

c) Unanticipated role of DOC in “kickstarting” self-management behaviors

“Because of the recording of activity… I started… it guilted me into starting to record my activity and once I started recording it because also coming off of the Metformin, I started recording it there and then I switched to recording it in books and now I simply record it on the calendar”. [1A06, 62-year old woman]

  1. Abbreviations:
  2. St. Mike’s St. Michael’s Hospital, Toronto, ON, Canada.
  3. App application.
  4. DOC Diabetes Online Companion.