“You always have a high sugar if you don’t communicate”: A qualitative secondary analysis of ‘Diabetes Together’ process evaluation data from couples in South Africa
PMCID: PMC11864531
PMID: 40009621
Abstract
Type 2 Diabetes Mellitus (T2D) can negatively impact relationships which may affect health and disease management. This can be moderated by positive communication between partners. Our aims were first, to identify ways in which couples’ communication and T2D impact each other. Second, we aimed to explore how improving couples’ communication may enhance self-management for people living with T2D (PLWD) and their partners in South Africa. We conducted secondary data analysis of qualitative interview and focus group data from an intervention pilot study designed to improve T2D self-management – ‘Diabetes Together’. 14 PLWD and their partners took part in two diabetes self-management workshops, including communication skills training, and were offered two couples counselling sessions. Inductive thematic and dyadic analysis explored how T2D and couples’ communication were connected, and how participants perceived the impact of couples’ communication skills training. Findings were compared to data collected from qualitative interviews with intervention-naive participants. We generated four themes linking couples’ communication and T2D: tone of discussions; listening; openness; and being informed about T2D. Participants described that T2D can create negative moods and stress (both from the disease and its management) and this can make communication challenging. They reported that negative communication styles can create stress worsening T2D and making it harder to manage. Participants felt that positive communication could ease stress, enable problem-solving and support behaviour change, which may improve T2D management. Couples reported that communication skills training helped them to address communication-related issues in their relationships. This included managing negative moods, changing communication styles and developing skills to discuss, listen and collaborate on improving T2D self-management. PLWD and their partners perceived that T2D and couples’ communication can affect one another positively and negatively. Equipping couples with effective communication skills may empower them to manage T2D more effectively.
Full Text
As a chronic and complex condition, Type 2 Diabetes Mellitus (T2D) can negatively impact relationships which then affect health and disease management [1]. In a systematic review of 29 studies exploring the links between familial relationships and diabetes management, marriage quality was found to affect how people living with diabetes (PLWD) felt and behaved in managing their diabetes, both positively and negatively [2]. Those experiencing high marital stress showed worse blood glucose control. PLWD experienced nagging, arguing, critical comments and overprotective approaches by the partner as unsupportive. Unresolved conflicts between partners were linked with poor management of diabetes. On the other hand, PLWD who experienced higher marital satisfaction had higher diabetes-related satisfaction and felt diabetes had fewer negative impacts on their daily lives [2].
Open and supportive communication between partners can facilitate a collaborative approach to managing chronic disease. “Communal coping”, a model of dyadic coping, can reduce disease-associated distress and improve outcomes [3]. In an umbrella review of how families, including intimate partners, influence T2D self-management, emotional support was identified alongside practical support in facilitating better outcomes [4]. Emotional support included understanding each other’s feelings, openly communicating needs and being motivated for lifestyle changes together. In a longitudinal study of couples from the USA where one partner was experiencing a chronic condition, researchers explored how the degree of open communication and dyadic coping was connected to the relational wellbeing of the couple [5]. When couples saw the condition as a shared problem they could manage together, they discussed it more often. They used more dyadic coping strategies, which led to more satisfaction with their relationship, greater emotional closeness and higher sexual satisfaction [5].
Other research highlights the need to ensure discussions are explicit. Being clear about what the problems are, how each partner feels about them, and what solutions are desirable or preferable for each, is important to enable effective communal coping [1,6].
Couples’ communication and T2D affect one another but these effects may vary according to gender and cultural background. Research in the USA found that preferences of language used to describe diabetes self-management varied between partners and PLWD, and between male and female PLWD [7,8].
There is limited research on the topic of couples’ communication and T2D from low- and middle-income country settings. Notably, over half of the 29 studies in a systematic review of familial relationships and diabetes management were based in the USA with only 2 from middle- or low-income countries (Botswana and China) [2].
We recently piloted a prototype couples-focused intervention designed to improve self-management of T2D in Cape Town, South Africa. This intervention included couples’ communication skills training and couples’ counselling designed to enhance discussions about diabetes and enable a collaborative approach to its management [9]. We have already reported that the communication skills training was highly valued by participants and that most couples reported that their communication improved following the workshop [10].
The study took place in Cape Town, South Africa. Participants lived in low-income peri-urban settings with a predominantly black African and Coloured population. These settings face an array of challenges such as poverty, high rates of unemployment and inadequate infrastructure [11].
We conducted secondary analysis of qualitative data collected during pilot delivery of the prototype intervention ‘Diabetes Together’ [10].
Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S2Appendix).
Details are provided in previous papers [9,10] but, briefly, the intervention comprised two face-to-face, half-day workshops. A summary of modules is provided in Table 1, highlighting some sessions were held with the whole group, and for some the group was split by diabetes status (PLWD and partners) or by gender.
A core component of the communication skills module, the describe repeat method, was inspired by the speaker-listener technique [12] previously delivered in HIV-focused couples’ studies [13–15]. It helps couples talk about things that matter to either one of them and which they might find difficult to raise because they are upset, annoyed or worried about how the other person might respond. The technique was illustrated with pre-recorded exchanges between partners, one of which deteriorated into an argument. The second recording acted out the describe repeat method. Volunteer participants then performed a ‘live action’ role-play. Supporting information was provided in the handouts (Fig 1) with couples invited to practice the technique as part of their homework between workshops. This approach was presented again during the second workshop, inviting feedback from participants’ homework.
The initiator of the conversation (participant A on Fig 1) describes the issue to their partner (participant B). B then repeats back what they have heard in their own words. This gives an opportunity to verify what has been said and provides a pause before B responds to the content. A can then confirm B’s understanding or explain further if there has been a misunderstanding. Once B has fully understood the issue, they then take on the primary speaking role and describe their response to the issue. A then has an opportunity to repeat back to B what they have heard, and the process continues until both partners feel they have been adequately heard.
Sampling and recruitment are described elsewhere [10], but in brief, PLWD were approached at primary care diabetes clinics or contacted proactively following previous involvement in diabetes management studies with the Chronic Diseases Initiative for Africa (CDIA). Convenience sampling was used to ensure a minimum number of couples were available and in recognition of the challenges of recruitment during COVID.
Data were collected using interviews and Focus Group Discussions (FGDs) conducted during and after pilot delivery of the prototype intervention [10]. Participants were interviewed or attended FGDs after each of the two workshops, and for couples undergoing counselling, attended individual interviews after the final counselling session. Interviews were undertaken with individual participants. FGDs involved 3 or 4 couples at a time.
As previously described elsewhere, 14 couples attended the first workshop [10] on 12th February 2022. Of these, 12 completed the second workshop on 26th February 2022 and 12 contributed to at least one interview or focus group after one or both workshops. Two couples completed two couples counselling sessions (a median of 25.5 and 132.5 days after the second workshop, respectively) and a post-counselling interview (within a median of 28 days of the second counselling session). All participants were Black African (N=24) or Coloured (N=4) (see Table 2).
LL led analysis of the pilot data for this paper. Using Braun and Clarke’s 6 stages to guide thematic analysis [16], she read all interviews and FGD transcripts numerous times to become familiar with the data. She extracted all communication-related sections of text and applied inductive codes describing what the participants were saying. Once all pilot data had been coded, LL collated common topics and experiences into broader inductive themes. She analysed differences between subgroups, by diabetes status (PLWD; partners) and by gender (men; women).
Previous research inspired the approach to dyadic analysis [17]. Consideration of overlaps and contrasts in partners’ reports uncovered themes about the nature of couples’ relationships that would otherwise have remained invisible. The scope of dyadic analysis was limited because individual (and therefore couple) identifiers were not noted during FGD recordings. Comparison of within-couple comments was therefore only possible with data from the subset of couples who participated in post-workshop or post-counselling individual interviews. Where quotes from both partners in a couple were available for a specific code, these were compared and overlaps and contrasts between partners were noted. Communication codes described repeatedly or with emphatic statements by one partner but not mentioned by the other were also noted.
A selection of relevant quotes from intervention-naive participant data for each theme is summarised in S3 Appendix.
First, participants reported that poorly managed T2D can have a negative impact on communication between partners. Feeling irritable or tired due to disordered blood sugar and the stress of managing T2D, can create low moods in PLWD making it harder to talk calmly or share openly. This can leave partners feeling frustrated and unhappy. There is evidence of a relationship between diabetes and psychological disorders such as depression and anxiety that could make it difficult for PLWD to communicate easily and positively with those around them [18]. This is also consistent with work in the general population showing that higher sugar consumption over years is associated with common mental disorders [19]. These are likely to affect communication skills and style, particularly with spousal-type partners [20].
Second, negative communication styles were reported to negatively affect T2D management. This includes having a negative or aggressive tone, failing to listen and understand the other’s point of view, or refusing to share or discuss issues. Such negative approaches could raise stress levels or make it harder for PLWD to manage their condition and for partners to support them. Similar issues were identified in a broad review of how family interactions could impact the management of chronic conditions, including diabetes [21]. A range of studies showed that negative patient outcomes were associated with critical, overprotective and controlling communication styles.
Thirdly, participants felt that positive communication enhances T2D management. Having open and calm discussions and listening carefully to the other’s point of view can lead to a common understanding of issues, sharing of the burden and joint problem-solving. This was also found by the review of chronic conditions, showing better outcomes for patients were associated with supportive family interactions [21]. Positive communication may facilitate shared appraisal of the challenges an individual living with a chronic illness faces, enabling partners to collaborate more effectively to facilitate self-management including improving treatment adherence [22].
Finally, couples reported that communication skills training may improve communication styles and their management of T2D. The intervention provided communication skills training alongside efforts to increase knowledge about T2D and how it can be managed. Couples reported their workshop experiences led to more effective dyadic coping with the condition. This is in line with the optimised logic model for Diabetes Together [10], which incorporated part of a review of couples-based interventions for managing chronic physical illnesses [23]. The review recommended combining skills-based and relationship-focused training as both aspects were found to be effective in improving different outcomes.
There were some differences in how groups of participants described the links between T2D and communication within their relationships. Consistent with studies in the US, we found differences in language and preferences between genders of PLWD and their partners [7, 8]. We also saw some differences in communication between the genders irrespective of condition status. For example, gender affected the tone of discussions or the degree to which partners felt listened to: men were more often reported by themselves and their partners to be loud or domineering and this could be a barrier to calm discussions with both partners listening to each other. For diabetes status, PLWD were sometimes reported to struggle with being open about how their disease was affecting them or their fears about diabetes, while partners more often reported wanting and needing their partner to be more open. While lack of knowledge affected PLWD by creating fears and sadness, partners without a grounding of knowledge about how to manage diabetes were unable to offer effective support.
Limitations of this study included limited information power [24]. As this was a secondary data analysis, we were unable to ask follow-up questions specifically in relation to communication issues that arose, which limited the depth of data collected on the topic of communication. Secondly, interviews conducted after the intervention showed participants sometimes rehearsed messages from the workshops, potentially indicating participants were saying what they thought researchers wanted to hear. Incorporating analysis of interviews with intervention-naive couples enabled us to address this limitation and corroborate our findings. Thirdly, only two couples completed both couples’ counselling sessions offered and an interview afterwards due in part to resource constraints during the COVID pandemic. Data from these interviews contributed few direct quotes about communication. Finally, the lack of participant identifiers within the FGDs prevented more extensive dyadic analysis.
Sections
"[{\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref001\", \"pgph.0004089.ref002\", \"pgph.0004089.ref002\"], \"section\": \"1. Introduction\", \"text\": \"As a chronic and complex condition, Type 2 Diabetes Mellitus (T2D) can negatively impact relationships which then affect health and disease management [1]. In a systematic review of 29 studies exploring the links between familial relationships and diabetes management, marriage quality was found to affect how people living with diabetes (PLWD) felt and behaved in managing their diabetes, both positively and negatively [2]. Those experiencing high marital stress showed worse blood glucose control. PLWD experienced nagging, arguing, critical comments and overprotective approaches by the partner as unsupportive. Unresolved conflicts between partners were linked with poor management of diabetes. On the other hand, PLWD who experienced higher marital satisfaction had higher diabetes-related satisfaction and felt diabetes had fewer negative impacts on their daily lives [2].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref003\", \"pgph.0004089.ref004\", \"pgph.0004089.ref005\", \"pgph.0004089.ref005\"], \"section\": \"1. Introduction\", \"text\": \"Open and supportive communication between partners can facilitate a collaborative approach to managing chronic disease. \\u201cCommunal coping\\u201d, a model of dyadic coping, can reduce disease-associated distress and improve outcomes [3]. In an umbrella review of how families, including intimate partners, influence T2D self-management, emotional support was identified alongside practical support in facilitating better outcomes [4]. Emotional support included understanding each other\\u2019s feelings, openly communicating needs and being motivated for lifestyle changes together. In a longitudinal study of couples from the USA where one partner was experiencing a chronic condition, researchers explored how the degree of open communication and dyadic coping was connected to the relational wellbeing of the couple [5]. When couples saw the condition as a shared problem they could manage together, they discussed it more often. They used more dyadic coping strategies, which led to more satisfaction with their relationship, greater emotional closeness and higher sexual satisfaction [5].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref001\", \"pgph.0004089.ref006\"], \"section\": \"1. Introduction\", \"text\": \"Other research highlights the need to ensure discussions are explicit. Being clear about what the problems are, how each partner feels about them, and what solutions are desirable or preferable for each, is important to enable effective communal coping [1,6].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref007\", \"pgph.0004089.ref008\"], \"section\": \"1. Introduction\", \"text\": \"Couples\\u2019 communication and T2D affect one another but these effects may vary according to gender and cultural background. Research in the USA found that preferences of language used to describe diabetes self-management varied between partners and PLWD, and between male and female PLWD [7,8].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref002\"], \"section\": \"1. Introduction\", \"text\": \"There is limited research on the topic of couples\\u2019 communication and T2D from low- and middle-income country settings. Notably, over half of the 29 studies in a systematic review of familial relationships and diabetes management were based in the USA with only 2 from middle- or low-income countries (Botswana and China) [2].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref009\", \"pgph.0004089.ref010\"], \"section\": \"1. Introduction\", \"text\": \"We recently piloted a prototype couples-focused intervention designed to improve self-management of T2D in Cape Town, South Africa. This intervention included couples\\u2019 communication skills training and couples\\u2019 counselling designed to enhance discussions about diabetes and enable a collaborative approach to its management [9]. We have already reported that the communication skills training was highly valued by participants and that most couples reported that their communication improved following the workshop [10].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref011\"], \"section\": \"2.2 Setting\", \"text\": \"The study took place in Cape Town, South Africa. Participants lived in low-income peri-urban settings with a predominantly black African and Coloured population. These settings face an array of challenges such as poverty, high rates of unemployment and inadequate infrastructure [11].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref010\"], \"section\": \"2.3 Study design\", \"text\": \"We conducted secondary analysis of qualitative data collected during pilot delivery of the prototype intervention \\u2018Diabetes Together\\u2019 [10].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.s002\"], \"section\": \"2.3 Study design\", \"text\": \"Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S2Appendix).\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref009\", \"pgph.0004089.ref010\", \"pgph.0004089.t001\"], \"section\": \"2.4 Intervention\", \"text\": \"Details are provided in previous papers [9,10] but, briefly, the intervention comprised two face-to-face, half-day workshops. A summary of modules is provided in Table 1, highlighting some sessions were held with the whole group, and for some the group was split by diabetes status (PLWD and partners) or by gender.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref012\", \"pgph.0004089.ref013\", \"pgph.0004089.ref015\", \"pgph.0004089.g001\"], \"section\": \"2.4 Intervention\", \"text\": \"A core component of the communication skills module, the describe repeat method, was inspired by the speaker-listener technique [12] previously delivered in HIV-focused couples\\u2019 studies [13\\u201315]. It helps couples talk about things that matter to either one of them and which they might find difficult to raise because they are upset, annoyed or worried about how the other person might respond. The technique was illustrated with pre-recorded exchanges between partners, one of which deteriorated into an argument. The second recording acted out the describe repeat method. Volunteer participants then performed a \\u2018live action\\u2019 role-play. Supporting information was provided in the handouts (Fig 1) with couples invited to practice the technique as part of their homework between workshops. This approach was presented again during the second workshop, inviting feedback from participants\\u2019 homework.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.g001\"], \"section\": \"2.4 Intervention\", \"text\": \"The initiator of the conversation (participant A on Fig 1) describes the issue to their partner (participant B). B then repeats back what they have heard in their own words. This gives an opportunity to verify what has been said and provides a pause before B responds to the content. A can then confirm B\\u2019s understanding or explain further if there has been a misunderstanding. Once B has fully understood the issue, they then take on the primary speaking role and describe their response to the issue. A then has an opportunity to repeat back to B what they have heard, and the process continues until both partners feel they have been adequately heard.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref010\"], \"section\": \"2.5 Sampling and recruitment\", \"text\": \"Sampling and recruitment are described elsewhere [10], but in brief, PLWD were approached at primary care diabetes clinics or contacted proactively following previous involvement in diabetes management studies with the Chronic Diseases Initiative for Africa (CDIA). Convenience sampling was used to ensure a minimum number of couples were available and in recognition of the challenges of recruitment during COVID.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref010\"], \"section\": \"2.6 Data collection\", \"text\": \"Data were collected using interviews and Focus Group Discussions (FGDs) conducted during and after pilot delivery of the prototype intervention [10]. Participants were interviewed or attended FGDs after each of the two workshops, and for couples undergoing counselling, attended individual interviews after the final counselling session. Interviews were undertaken with individual participants. FGDs involved 3 or 4 couples at a time.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref010\", \"pgph.0004089.t002\"], \"section\": \"2.6 Data collection\", \"text\": \"As previously described elsewhere, 14 couples attended the first workshop [10] on 12th February 2022. Of these, 12 completed the second workshop on 26th February 2022 and 12 contributed to at least one interview or focus group after one or both workshops. Two couples completed two couples counselling sessions (a median of 25.5 and 132.5 days after the second workshop, respectively) and a post-counselling interview (within a median of 28 days of the second counselling session). All participants were Black African (N=24) or Coloured (N=4) (see Table 2).\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref016\"], \"section\": \"2.7 Data analysis\", \"text\": \"LL led analysis of the pilot data for this paper. Using Braun and Clarke\\u2019s 6 stages to guide thematic analysis [16], she read all interviews and FGD transcripts numerous times to become familiar with the data. She extracted all communication-related sections of text and applied inductive codes describing what the participants were saying. Once all pilot data had been coded, LL collated common topics and experiences into broader inductive themes. She analysed differences between subgroups, by diabetes status (PLWD; partners) and by gender (men; women).\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref017\"], \"section\": \"2.7 Data analysis\", \"text\": \"Previous research inspired the approach to dyadic analysis [17]. Consideration of overlaps and contrasts in partners\\u2019 reports uncovered themes about the nature of couples\\u2019 relationships that would otherwise have remained invisible. The scope of dyadic analysis was limited because individual (and therefore couple) identifiers were not noted during FGD recordings. Comparison of within-couple comments was therefore only possible with data from the subset of couples who participated in post-workshop or post-counselling individual interviews. Where quotes from both partners in a couple were available for a specific code, these were compared and overlaps and contrasts between partners were noted. Communication codes described repeatedly or with emphatic statements by one partner but not mentioned by the other were also noted.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.s003\"], \"section\": \"3.5 Secondary data analysis of data from intervention na\\u00efve participants\", \"text\": \"A selection of relevant quotes from intervention-naive participant data for each theme is summarised in S3 Appendix.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref018\", \"pgph.0004089.ref019\", \"pgph.0004089.ref020\"], \"section\": \"4. Discussion\", \"text\": \"First, participants reported that poorly managed T2D can have a negative impact on communication between partners. Feeling irritable or tired due to disordered blood sugar and the stress of managing T2D, can create low moods in PLWD making it harder to talk calmly or share openly. This can leave partners feeling frustrated and unhappy. There is evidence of a relationship between diabetes and psychological disorders such as depression and anxiety that could make it difficult for PLWD to communicate easily and positively with those around them [18]. This is also consistent with work in the general population showing that higher sugar consumption over years is associated with common mental disorders [19]. These are likely to affect communication skills and style, particularly with spousal-type partners [20].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref021\"], \"section\": \"4. Discussion\", \"text\": \"Second, negative communication styles were reported to negatively affect T2D management. This includes having a negative or aggressive tone, failing to listen and understand the other\\u2019s point of view, or refusing to share or discuss issues. Such negative approaches could raise stress levels or make it harder for PLWD to manage their condition and for partners to support them. Similar issues were identified in a broad review of how family interactions could impact the management of chronic conditions, including diabetes [21]. A range of studies showed that negative patient outcomes were associated with critical, overprotective and controlling communication styles.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref021\", \"pgph.0004089.ref022\"], \"section\": \"4. Discussion\", \"text\": \"Thirdly, participants felt that positive communication enhances T2D management. Having open and calm discussions and listening carefully to the other\\u2019s point of view can lead to a common understanding of issues, sharing of the burden and joint problem-solving. This was also found by the review of chronic conditions, showing better outcomes for patients were associated with supportive family interactions [21]. Positive communication may facilitate shared appraisal of the challenges an individual living with a chronic illness faces, enabling partners to collaborate more effectively to facilitate self-management including improving treatment adherence [22].\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref010\", \"pgph.0004089.ref023\"], \"section\": \"4. Discussion\", \"text\": \"Finally, couples reported that communication skills training may improve communication styles and their management of T2D. The intervention provided communication skills training alongside efforts to increase knowledge about T2D and how it can be managed. Couples reported their workshop experiences led to more effective dyadic coping with the condition. This is in line with the optimised logic model for Diabetes Together [10], which incorporated part of a review of couples-based interventions for managing chronic physical illnesses [23]. The review recommended combining skills-based and relationship-focused training as both aspects were found to be effective in improving different outcomes.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref007\", \"pgph.0004089.ref008\"], \"section\": \"4. Discussion\", \"text\": \"There were some differences in how groups of participants described the links between T2D and communication within their relationships. Consistent with studies in the US, we found differences in language and preferences between genders of PLWD and their partners [7, 8]. We also saw some differences in communication between the genders irrespective of condition status. For example, gender affected the tone of discussions or the degree to which partners felt listened to: men were more often reported by themselves and their partners to be loud or domineering and this could be a barrier to calm discussions with both partners listening to each other. For diabetes status, PLWD were sometimes reported to struggle with being open about how their disease was affecting them or their fears about diabetes, while partners more often reported wanting and needing their partner to be more open. While lack of knowledge affected PLWD by creating fears and sadness, partners without a grounding of knowledge about how to manage diabetes were unable to offer effective support.\"}, {\"pmc\": \"PMC11864531\", \"pmid\": \"40009621\", \"reference_ids\": [\"pgph.0004089.ref024\"], \"section\": \"4. Discussion\", \"text\": \"Limitations of this study included limited information power [24]. As this was a secondary data analysis, we were unable to ask follow-up questions specifically in relation to communication issues that arose, which limited the depth of data collected on the topic of communication. Secondly, interviews conducted after the intervention showed participants sometimes rehearsed messages from the workshops, potentially indicating participants were saying what they thought researchers wanted to hear. Incorporating analysis of interviews with intervention-naive couples enabled us to address this limitation and corroborate our findings. Thirdly, only two couples completed both couples\\u2019 counselling sessions offered and an interview afterwards due in part to resource constraints during the COVID pandemic. Data from these interviews contributed few direct quotes about communication. Finally, the lack of participant identifiers within the FGDs prevented more extensive dyadic analysis.\"}]"
Metadata
"{\"Data Availability\": \"This paper includes selected excerpts from the qualitative data collected and synthesized by the authors. Releasing full transcripts would not adhere to ethics and consent practices, and therefore further information is available only upon request. For those interested in accessing the interview transcripts, access requests can be directed to risethic@soton.ac.uk.\", \"Submission Version\": \"1\"}"