© 2015 Ohio Valley Philosophy of Education Society

DRESSING DIVERSITY: POLITICS OF DIFFERENCE AND THE CASE OF SCHOOL UNIFORMS

Samantha Deane Loyola University Chicago

In The New York Times parenting blog, Motherlode, Debra Monroe

writes about “the dynamic that makes public school democratic—a place to confront the humanity of others,” because she is concerned with what schooling teaches children about diversity and difference.1 This paper begins with a similar assumption and concern; I too think schools ought to be places where children learn to confront the humanity and difference of others, and I am concerned with how children are taught to do so. Through an analysis of school uniform policies and theories of social justice, I argue not that children consciously experience school uniforms as uniforming, but that school uniforms and their foregoing policies assume that confronting strangers—an imperative of living in a democratic polity—is something that requires seeing sameness instead of recognizing difference. Imbuing schooling with a directive that says schools ought to be places where children learn to confront the humanity of others requires that we ask questions about how educational policies teach children to deal with human difference. Broadly speaking, uniform policies undergird the assumption that a child’s capacity to confront difference is unimportant.2

To consider the ways in which school uniform policies unjustly teach children to disregard difference so that they can reasonably participate in public and school life, this paper engages in a rich conversation about social justice. Fundamentally, social justice is about recognizing grave injustices between individual persons and groups of people living in, or being prevented from living in, the world. The works of John Rawls, Iris Marion Young, and Nancy Fraser represent three common theoretical constructs for dealing with social justice. Rawls comes from a social contract position and constructs a floating theory of justice based on a Kantian self that ultimately addresses injustices by way of redistribution.3 Young aligns herself with critical theory, founds her critique in the messiness of the “real world,” and tackles injustice by

1 Debra Monroe, “When Elite Parents Dominate Volunteers, Children Lose.” Motherlode (blog), New York Times (January 19, 2014), http://nyti.ms/19EIwRF. 2 I am purposefully not differentiating between public and private schooling, because all schooling situated in a democratic context ought to teach children to confront the humanity of others. Moreover, children are a part of the larger “public” in a Deweyan sense. 3 John Rawls, Justice as Fairness: A Restatement, ed. Erin Kelly (Cambridge, MA: Harvard University Press, 2001).

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advocating for a politics of difference.4 All the while, Fraser works out a bivalent conception of social justice that bridges the divide between the spheres of distribution and recognition.5 Rawls’s Justice as Fairness: A Restatement is the theoretical backdrop against which this paper employs Young’s Justice and the Politics of Difference and Fraser’s “Social Justice in the Age of Identity Politics: Redistribution, Recognition, and Participation” to speak to the ways in which diversity can and should be “undressed,” and therefore, “addressed” by children in school.

To “address” diversity, the first section of this paper will focus on the language of school uniform policies. Policy makers tell us that school uniform policies are meant to: minimize disruptive behavior, remove socioeconomic tension, and maintain high academic standards.6 There is nothing unjust about wanting to reduce socioeconomic difference, nor valuing high academic standards. What is unjust is that these policies do not remove socioeconomic difference, nor cure disruptive behavior. School uniform policies dress difference; they do not address it. Accordingly, in an attempt to “undress” difference, and, perhaps, “redress” the injustice of school uniform policies, the second section of this paper argues that schools ought to be places where children are confronted with the humanity of others. The argument is that removing uniforms should not be a mere undressing that leaves children to deal with difference and humiliation on their own, but that we must redress the injustice by philosophically resituating schooling. Finally, the concluding section will sketch out what it might mean to philosophically resituate schools and to think of school life as a reflection of city life where, “the public is heterogeneous, plural, and playful, a place where people witness and appreciate the diverse cultural expressions that they do not share and do not fully understand.”7 Schools in this vision are not apolitical sanctuaries where children develop into perfect rational subjects; rather, schools are messy, vibrant, lively, worlds where children both constitute and come to know the diverse world and public(s) that surround them.

Dressing Diversity: The School Uniform Policy

A policy bulletin from Los Angeles states: “The Los Angeles Unified School District believes that appropriate student dress contributes to a

4 Iris Marion Young, Justice and the Politics of Difference (Princeton, NJ: Princeton University Press, 1990). 5 Nancy Fraser, “Social Justice in the Age of Identity Politics: Redistribution, Recognition, and Participation.” Tanner Lecture Series, Stanford University (April 30– May 2, 1996), http://tannerlectures.utah.edu/_documents/a-to-z/f/Fraser98.pdf. 6 David L. Brunsma, “School Uniforms in Public Schools,” National Association of Elementary School Principals (January/February 2006), 50. 7 Young, Politics of Difference, 241.

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productive learning environment.”8 While a policy from Pitt County states: “The implementation of school uniforms will help minimize disruptive behavior, promote respect for oneself and others, build school/community spirit, and, more significantly, help to maintain high academic standards.”9 Most school uniform policies echo these sentiments. They appear to originate from a genuine desire for students to succeed academically, and/or a need to improve behavior and safety. Yet, the history of asking students to appear one way or another is a story of mingled concerns about academic achievement, juvenile delinquency, gender appropriateness, race relations, and gang affiliation.10 Ines Dussel historically situates these concerns within a broad trend toward institutional organization and control of people who pivot around the “axis of difference.”11 According to Dussel, “such policies were tied to the disciplining of ‘unruly’, ‘savage’, ‘untamed’ bodies, that is, the bodies of those who were not able to perform self‐regulation or self‐government: women, Black, Indian, poor classes, immigrants, toddlers or infants.”12 In Young’s language, the victims of cultural imperialism are frozen “into a being marked as other,” while the dominant group occupies a universal “unmarked” position.13 The impetus to uniform is at once entangled in a project to mark or dress difference and to extend the “universalized” position to the “other.”14 The policy trend toward institutional control vis-à-vis school uniform policies is enmeshed in the desire for definition and regulation of student’s personal bodies and is a means to regulate and define children’s relationships with one another.

School uniform policies are not merely concerned with what one wears, but are a part of how we organize schools and the students therein. These policies are an attempt to make schools safer and better, to regulate what happens, and who affiliates with whom. A District of Columbia uniform policy hints at these underlying tensions by taking measures to define what “uniform” means within the policy: “The term ‘uniform,’ for the purposes of a mandatory uniform policy, is defined as clothing of the same style and/or color and

8 Jim Morris, “Student Dress Codes/Uniforms,” Los Angeles Unified School District Policy Bulletin, BUL-2549.1 (December 2009), 1. 9 Ibid. 10 Wendell Anderson, “School Dress Codes and Uniform Policies,” Policy Report (ERIC Clearinghouse on Education Management), no. 4 (2002), 4. Anderson briefly captures this history in the synopsis of his policy report. 11 Ines Dussel, “When Appearances Are Not Deceptive: A Comparative History of School Uniforms in Argentina and the United States (Nineteenth–Twentieth Centuries),” Paedagogica Historica 41, no. 1–2 (2005): 191. 12 Ibid. 13 Young, Politics of Difference, 123. 14 To this point, Dussel, notes that elite, private, “preppy” school dress was extended down, as it were, to public mass schooling and has become the school uniform we are familiar with today, e.g. khaki pants and Oxford shirts.

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standard look, as agreed upon by the school community.”15 Nonetheless, a definition of “uniform” does little to draw attention away from the fact that the policy is asking all children to appear the same. The concluding advice from a US Department of Education policy report for drafting a uniform policy reads: “when they are justified by a school’s circumstances, wisely conceived in collaboration with the community, and coupled with appropriate interventions, dress codes and school uniforms may positively influence school climate, student behavior, and academic success. However, it is critical to keep such polices in proper perspective and avoid overestimating or exaggerating their potential benefits.”16 This hesitant endorsement of school uniform policies manages to advise caution about drawing specific cause-and-effect relationships between school uniforms and academic gains, and in the same instance, it glosses over the historical and philosophical significance of asking students to uniformly dress their difference. Standardizing how students appear may give the school an air of control over the schooling environment, but in doing so, these policies tell students that when and where appearances differ, danger lurks.

Addressing Diversity: Social Justice and the School Uniform Policy

Claims for social justice, more often than not, stem from one of two directions; summed up by references to distribution or recognition, social injustices are either rectified by redistributing wealth/social goods, or by recognizing and valuing difference. Redistributive claims generally follow the logic of John Rawls’ theory of justice and utilize some version of an “original position.” The policy logic, or reasoning behind, school uniform policies broadly appeals to logic derived from a distributional ethic, which finds its ideal articulation of the student in the rational, reasoning, and regulated self. The problem with this ideal articulation and the distributional ethic is best illustrated by evaluating the ways in which Rawls’ theory of social justice informs the rationale of school uniform policies.

Rawls’s theory of justice and the school uniform policy share a similar objective: thinly constructed reasoning parties. In Justice as Fairness Rawls develops the “original position” whereby parties can agree to the terms of society and justice without conceding “differences in life prospects.”17 That is to say, difference or diversity is an essential consideration in Rawls’ project. In an effort to deal with the mandates of diversity, the fact of pluralism, Rawls adopts and builds upon the Kantian deontological self to describe the sort of people contracting in the original position. Accordingly, the original position

15 “District of Columbia Public Schools: Notice of Final Rule Making,” (District of Columbia Register, vol. 56, no. 33, Chapter B24, Section B2408, August 2009), 3. 16 Anderson, “School Dress Codes,” 4, my emphasis. 17 Rawls, Justice as Fairness, 6.3–6.4, 12.2.

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imbues these intrinsically worthy subjects with neutrality and structural impartiality, both of which ensure that they are representative of any person from society. Placed behind the “veil of ignorance,” the parties are situated symmetrically and on this undifferentiated plane they do not claim a social class, racial or sexual orientation, a comprehensive conception of the good, or any other distinguishing factor.18 Rawls states, “the parties are artificial persons, merely inhabitants of our device of representation: they are characters who have a part in the play of our thought experiment.” 19 In consequence the representatives in the original position are, admittedly, non-real characters with limited knowledge, or “complicated amnesia.”20 Moreover, it is the “complicated amnesia,” or the “veil of ignorance” that gives the parties the ability to be impartial and, more importantly, rational.

It is true that Rawls works to construct a thin consensus in the public about society’s basic structures because he wants to leave open the ability to construct individually defined thick lives; however, the parties of the original position are abstracted to such an extent that a monological position ensues. Michael Sandel summarizes the problem aptly: “The notion that not persons but only a single subject is to be found behind the veil of ignorance would explain why no bargaining or discussion can take place there.”21 The “veil of ignorance” removes the parties’ “thickness” so that they can reason together. The problem is that a truly pluralistic or diverse society will not be the product when a single subject conceives the definitions of justice. What’s more, the agreement of like-minded parties does not necessitate actual participation—it merely requires appearance. Uniform policies are theoretically similar. They function as a “veil of ignorance” for children who are too poor, too brown, or too different from one another to be members of the same school. Uniform policies imply that children in uniform are freed from any context that might impose a restraint on reason. Under a “veil of ignorance” children are not asked to think about why their classmate is poor, or brown; they are required to show up. Rawls’ theory of justice constructs thin, uniform, rational people (students) who can operate in the political sphere (school) as a way to achieve some kind of overlapping consensus (standard academic achievement). I believe it is clear that these thinly constituted people are both objectionable and impractical; nonetheless, Young helps draw out the unwelcome side affects of favoring the impartial subject and proposes an alternative solution.

Young approaches justice from within the messy, situated context of the world. Her argument for a politics of difference highlights the fact that theories of distributive justice have monopolized the conversation about what justice entails in the era of modern political philosophy, such that “displacing 18 Ibid., 23.3, 25.3. 19 Ibid., 23.4. 20 Michael J. Sandel, Liberalism and the Limits of Justice (Cambridge, UK: Cambridge University Press, 1982), 105. 21 Ibid., 132.

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the distributive paradigm” is part of accepting her theory of justice as recognition of difference.22 For Young the distributive paradigms pose a large- scale problem in the sense that the “ideal of impartiality or logic of identity” infiltrates every aspect of civic life. The logic of identity is problematic because of the intrinsic desire for unity. As such, “The logic of identity seeks to reduce the plurality of particular subjects, their bodily, perspectival experience, to a unity, by measuring them against the unvarying standard of universal reason.”23 The reverence deferred to universal reason is part of the project of moral ethics, which defines impartiality as necessary for the capacity to reason. The Kantian deontological ideal is to find a point of view that everyone can agree to, or see from, irrespective of their particular difference. School uniform polices strive for the same ideal. The hope is that if kids are all wearing the same clothing, no one will notice another’s socioeconomic status, or speak from their particular position. The ideal of impartiality creates a dichotomy between the “universal and the particular, public and private, and reason and passion” to the extent that the civic public, the terrain of schooling, becomes the place of universal reason.24 Much like the problem identified by Sandel’s reading of Rawls’ original position, universal reason requires agreement of abstracted parties, not dialogue with those who are differently situated. Furthermore, if the terrain of schooling is a place of universal reason it is no wonder that the “either-or thinking” of dichotomies reigns. Children are either uniformed or partial, uniformed or needy, uniformed or irrational.

Young pointedly explains that the “ideal of impartiality” is flat out impossible, because it requires expelling the aspects of difference that do not fit. In fact, “no one can adopt a view that is completely impersonal and dispassionate.”25 Additionally, my sense of imbeddedness defines my “social location” to the degree that I cannot enter someone else’s location. Nevertheless, if it is possible to strip myself of my location, what then is the purpose of having a location?26 Requiring the removal of particularity for uniformity, whether for moral cohesion or universal reason, is an affected wish. People do not have to be the same to get along; rather, it is possible for people to be both partial and have reasonable associations with each other. Young argues, “If one assumes instead that moral reason is dialogic, the product of discussion among differently situated subjects all of whom desire recognition and acknowledgement from the others, then there is no need for a universal point of view to pull people out of egoism.”27 Thus, the ideal of impartiality is not a necessity, and should not be a desire since it is a fanciful fiction. Instead,

22 Young, Politics of Difference, 15. 23 Ibid., 99. 24 Ibid., 97. 25 Ibid., 103. 26 Ibid., 105. 27 Ibid.,106.

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if we grant that differently situated people can and should have a voice to discuss what matters to them, we will see their differences shed new light on relevant issues and aspects of justice.

School uniform policies, like the “ideal of impartiality,” create unjust expectations of neutrality on behalf of students, and in removing the space for actual conversation, depoliticize difference. In contrast, the recognition of difference presumes that “blindness to difference disadvantages groups whose experience, culture, and socialized capacities differ from those of privileged groups”28 and that “assimilation always implies coming to the game late.”29 As reflected in school uniform policies, the ideal of impartiality, in its blindness to difference, disadvantages students who are asked to assimilate by removing the space for conversation about difference. Moreover, no child should feel like they are coming to the game late, especially in a learning environment. Recognition of difference should be an essential function of schooling to the extent that any language of assimilation finds no purchase. Writ large, Young’s solution may appear obvious at this point, but it is worth stating explicitly: “A democratic public should provide mechanisms for the effective recognition and representation of the distinct voices and perspectives of those of its constituent groups that are oppressed or disadvantaged.”30 The solution writ small in, say, a school system, should mimic the same sentiments. Requiring student to wear uniforms is not the problem: the problem is the reason for requiring uniforms.

A unique answer to Young’s demand to displace the distributive is Nancy Fraser’s mixing of the distributive paradigm with recognition. Fraser starts by noting that the distributive paradigm has a certain theoretical heft—at some point various groups or individuals have appealed to their common humanity, the original position, or impartial reason out of necessity, perceived or actual. With the weightiness of the distributive paradigm in mind, Fraser erects a “bivalent axis” of social justice she calls a “two pronged” approach. The bivalent axis of social justice is best thought of as a spectrum within which a pendulum can swing from distinctly distributional problems to those characterized as distinctly recognition-based, but where neither is ever the singular answer.31 The pendulum is always in motion. According to Fraser, “A bivalent conception treats distribution and recognition as distinct perspectives on, and dimensions of, justice, while at the same time encompassing both of them within a broader overarching framework.” This does not mean that either claim, distribution or recognition, is subsumed into the other.32 Instead, Fraser locates their shared normative core as a “parity of participation.”33 As she explains, “According to this norm, justice requires social arrangements that 28 Ibid., 164. 29 Ibid. 30 Ibid., 184. 31 Fraser, “Age of Identity Politics,” 22. 32 Ibid., 24. 33 Ibid., 30.

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permit all (adult) members of society to interact with one another as peers.”34 In other words, justice both of the distributional and recognition varieties, stems from the supposition that each member of society has equal dignity and ought to have the means to interact with one another in the public sphere.

Fraser’s “parity of participation,” relies on an understanding of the imbricated nature of culture and the economy. To say that justice spans a continuum from distribution to recognition is also to say that the economy and culture are institutions that make up our shared social world.35 The conditions for this parity of participation require a form of legal equality, and preclude “forms and levels of material inequality, [and] cultural patterns that systematically depreciate some categories of people.”36 People within this framework are thickly defined and contextually situated. They have both objective being that requires some kind of material position, and an intersubjective status that mandates recognition. The objective condition is, thus, most often rectified by redistribution, whereas the intersubjective condition is nullified by recognition. Fraser takes a decidedly rooted stance in a turn toward the pragmatic and recommends that answers to the injustice fit the practical situation. The pragmatic approach is the tool by which we ought to deploy the bivalent pendulum, which is always seeking the normative ideal, parity of participation. In every case the remedy of an injustice should be tailored to the harm, and in all cases the goal is to create, maintain, and reimagine a space for equal participation of each person or group of people.

Fraser’s pragmatic answer, and its normative assumption, is not radically divergent from Young’s grounding in critical social theory whereby she defines a “politics of difference.” Young’s politics of difference, after all, takes that differently situated people can have a discussion that leads to moral reason and just social structures.37 The distinction between Fraser’s parity of participation and Young’s politics of difference rests on how equality is imagined to function. For Fraser the norm “parity of participation” holds that each person’s voice has equal weight or worth within political discourse. Conversely, Young notes that the groups who are “oppressed and disadvantaged” are those for whom mechanisms of recognition must be appropriated.38 The distinction lies in the fact that Fraser’s “parity of participation” necessarily strives toward structural equality, as opposed to merely “mitigating the influence of current biases,” as Young puts it.39 Thus, Fraser’s bivalent conception is an excellent tool to help us think about the

34 Ibid. 35 As Fraser aptly characterizes the argument, the answer does not lie in statements like: “it’s the culture stupid,” nor its counterpart “it’s the economy stupid,” 39–41. 36 Ibid., 31. 37 Young, Politics of Difference, 106. 38 Ibid., 192–225. 39 Ibid., 198.

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pointed experience of injustice, but Young’s normative politics of difference is a fuller norm to reach toward.

Conclusion: Redressing Diversity, City Life as School Life

Employing Fraser’s bivalent continuum, we can say that school uniform policies are attempts to organize children who may be experiencing both distributional and recognition related injustices, but because the policies appeal to a logic of identity and distributional ethic, school uniform policies operate at the expense of a politics of difference. Following Fraser, a pragmatic remedy for the injustice of uniforming children in school requires that we rearticulate the value of “bringing children together in a common space.”40 An assumption of this paper is that the value of schooling is manifest in more than narrowly defined achievement or the acceptance of socialized roles. Rather, because education is always answering a question about what it means to be human,41 the value of bringing children together in a common space is evidenced when they learn how to recognize and speak from places of personal difference. The “dynamic that makes public schools democratic” is the activity of engaging children and their humanity. Higgins and Knight Abowitz ask, “What might it mean to think of the classroom not as a room within an institution that is already public, but as a space in which teachers and learners make public?”42 It means that we must see children and their teachers, and the school at large, as a public making project. Democratic schooling demands that we see children as full of vigorous and playful humanity. It requires that we engage with children as partial, situated members of the public.

Young imagines an alternative form of social relations—public— where a politics of difference prevails as analogous to city life.43 Young’s imaginative view of city life highlights democratic modes of being and is one way to think about what it might mean to envision the school as forever “becoming” public. In Young’s parlance, “By ‘city life’ I mean a form of social relations which I define as the being together of strangers. In the city persons and groups interact with spaces and institutions they all experience themselves as belonging to, but without those interactions dissolving into unity or commonness.”44 Each day an encounter with the city on the train, in the park, at a restaurant, or in a building requires that we find ways to live together. The persistent encounter with difference forces city dwellers to recognize that

40 Chris Higgins and Kathleen Knight Abowitz, “What Makes a Public School Public? A Framework for Evaluating the Civic Substance of Schooling,” Educational Theory 61, no. 4 (2011), 369. 41 Gert J. J. Biesta, Beyond Learning: Democratic Education for a Human Future (Boulder: Paradigm, 2006), 2. 42 Higgins and Knight Abowitz, “Public School,” 379. 43 Young, Politics of Difference, 226–27. 44 Ibid., 237.

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people are just differently situated, or socially located beings, with whom they can have a partial dialogue. Recognition of our relationally defined being is the foundation for meaningful conversation about justice and the bivalent structures, cultural and economic, which shape our shared world. Democracy is premised on the human ability to engage in dialogue, to plan consequences, and to generate publics. Moreover, democracy is a human endeavor that requires people to think about each other from the inside out, a dynamic Young sees in expressions of city life.45

Extending Young and Fraser into the school, which is a vital and political part of city life, requires that we imbue children with the capacity to converse with and about difference. It is unjust and naïve to believe a student’s capacity for confronting difference is any less than a typical member of a city. City living implies a form of social relations that requires “a being together of strangers,” but it does so no more than school living ought to, if schools do have “the dynamic that makes them democratic.”46 Moreover, the school is an institution each child can belong to; it is a place where they ought to be given the opportunity to come together as a public of strangers to workout the problems of associated living. By appealing to a “veil of ignorance” or logic of impartiality school uniform policies unjustly teach children to rid themselves of emotion, race, and gender so that they can reason.47 All this logic does is perpetuate the idea that you cannot reason while emotional, that race and reason cannot be articulated together, and that gender affects who is rational and when. In my evaluation, social justice requires that we facilitate “a politics of difference” and foster a “bivalent approach” toward the axes of injustice to support children in their growth. The “dynamic that makes school democratic” only works when children are trusted with difference, diversity, and strangeness—at least to the extent that we trust members of a city with the same.

45 Martha C. Nussbaum, Not for Profit: Why Democracy Needs the Humanities (Princeton, NJ: Princeton University Press, 2010). 46 Young, Politics of Difference, 237; see also Monroe, “When Elite Parents Dominate.” 47 For more on ritualization and gender and school uniforms see: Allison Happel, “Ritualized Girl: School Uniforms and the Compulsory Performance of Gender,” Journal of Gender Studies 22, no. 1(2013): 92–95.

Understanding the nutrition care needs of patients newly diagnosed with type 2 diabetes: a need for open communication and patient-focussed consultations

Lauren BallA,C, Ruth DavmorA, Michael LeverittB, Ben DesbrowA, Carolyn EhrlichA

and Wendy ChaboyerA

AMenzies Health Institute Queensland, Griffith University, Gold Coast 4222, Qld, Australia. BSchool of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane 4072, Qld, Australia.

CCorresponding author. Email: [email protected]

Abstract. Patients who are newly diagnosed with type 2 diabetes mellitus (T2DM) commonly attempt to modify their dietary intake after receiving nutrition care from primary health professionals. Yet, adherence to dietary recommendations is rarely sustained and factors influencing adherence are poorly understood. This study exploredT2DMpatients’ experiences of dietary change and their views on how primary health professionals can best support long-term maintenance of dietary change.Apurposive sample of 10 individuals recently diagnosedwithT2DMparticipated in three individual semi-structured qualitative telephone interviews: at baseline, then at 3 and 6 months after recruitment. Interview questions were modified from the initial interview inorder to investigate emergingfindings.A two-step data analysis process occurred throughcontent analysis of individual interviews andmeta-synthesis of findings over time. Participants initiallymadewide-ranging attempts to improve dietary behaviours, butmost experienced negative emotions from the restraint required tomaintain a healthy diet. Participants felt confused by the conflicting advice received from health professionals and other sources such as friends, family, internet and diabetes organisations. Participants frequently reported feeling rushed and not heard in consultations, resulting in limited ongoing engagement with primary healthcare services. These findings suggest that there is opportunity for primary health professionals to enhance the dietary support provided to patients by: acknowledging the challenges of sustained improvements in dietary intake; open communication; and investing in patient relationships through more patient-focussed consultations.

Additional keywords: chronic disease, general practice, primary care, nutrition therapy, nutritional management.

Received 28 April 2015, accepted 18 August 2015, published online 5 October 2015

Introduction

Type 2 diabetes mellitus (T2DM) is a lifestyle-related chronic disease and leading cause of morbidity andmortality in Australia (Australian Institute of Health andWelfare 2007). Over 5%of the Australian population has been diagnosed with T2DM, and an additional 0.9% is predicted to be diagnosed annually (Australian Bureau of Statistics (ABS) 2012). T2DM is typically diagnosed and managed in the primary healthcare setting, and patients with T2DM receive health care from a variety of primary health professionals (Diabetes Australia 2012). Importantly, the health outcomes of patients with T2DM are influenced by their dietary intake (Coppell et al. 2010). Therefore, facilitating patients to have a healthy dietary intake is a key component of T2DM management (Diabetes Australia, Royal Australian College of General Practitioners (RACGP) 2008; National Health and Hospitals Reform Commission 2009).

Patients who are newly diagnosed with T2DM commonly attempt to modify their dietary intake after receiving nutrition

care from primary health professionals (Castro-Sánchez and Avila-Ortiz 2013). In the first 6 months after diagnosis, patients often experience changes to their enjoyment of food while trying to follow a recommended diet, and most report only temporarily adherence to dietary recommendations (Castro-Sánchez and Avila-Ortiz 2013). The United Kingdom Prospective Diabetes Study was the largest clinical research study into diabetes management (n = 3867 participants), and has shown that establishing short-term optimal glycaemic control in the early stages after diagnosis reduces the risk of macro- and micro- vascular complications, as well as all-cause mortality 10 years after diagnosis (Murray et al.2010).Given the influenceofdietary intake on glycaemic control of patientswith T2DM, investigating ways to further support patients to maintain healthy dietary behaviours in the early stages after diagnosis is important.

Exploring patients’ experiences and perceptions is crucial to understanding how to provide patient-centred care. Patient- centred care is an approach to health care that meets the specific

Journal compilation � La Trobe University 2016 www.publish.csiro.au/journals/py

CSIRO PUBLISHING

Australian Journal of Primary Health, 2016, 22, 416–422 Research http://dx.doi.org/10.1071/PY15063

needs, values and beliefs of patients (McMillan et al. 2013) and is regarded as imperative to the optimal management of chronic disease, including T2DM (Holman and Lorig 2000). Many primary health professionals, such as GPs, practice nurses and dietitians, report providing ‘nutrition care’ to patients, referring to anypractice conducted to support patients to improve their dietary intake (Ball et al. 2010; Ball et al. 2012). Recent investigations into the nutrition care provided by primary health professionals indicate that patient-centred care is not always achieved, and this may be hindering the efficacy of nutrition care for chronic disease management (Ball et al. 2012; Ball et al. 2013; Ball et al. 2014). Given the importance of optimal dietary intake in T2DM self- management, it is necessary for primary health professionals to better understand the experiences, challenges and needs of patients attempting to improve their dietary behaviours in order to provide effective patient-centred nutrition care.

The aim of this study was to examine the perceptions of patientswho have been recently diagnosedwith T2DMregarding nutrition care provided by primary healthcare professionals. Specifically, the study explored patients’ experience of dietary change and their views on how primary health professionals could best support long-termmaintenance of dietary change. This understanding can be used to facilitate health professionals to provide nutrition care that addresses the needs and experiences of patients.

Methods

This study utilised a longitudinal, qualitative design to describe the perceptions and experiences of patients who have recently been diagnosed with T2DM. The study was approved by the Griffith University Human Research Ethics Committee (reference number PBH/09/14/HREC).

Participant recruitment

A purposive sample of individuals with T2DM (<4 months since diagnosis) was recruited via e-newsletters and social media pages of Diabetes Australia, and state branches of Diabetes New SouthWales,DiabetesQueensland,Diabetes SouthAustralia and Diabetes Tasmania. The sampling strategy aimed to recruit a combination of male and female, young and old, employed and unemployed/retired participants. Potential participants who contacted the research team were provided with a plain language

information sheet, before being asked to provide consent and attend an initial interview.

Data collection

Each participant was involved in three individual semi-structured telephone interviews; at baseline, and then at 3 and 6months after recruitment into the study.A semi-structured interviewguidewas developed for each round of interviews. Interviews included questions such as: ‘How has your recent diagnosis influenced your feelings about food?’; ‘Describe your interactions with health professionals regarding food and healthy eating’; and ‘At this moment, how could health professionals be most helpful in supporting you in healthy eating?’ Elaboration probing, clarification probing and attention probing were utilised to gain a deeper understanding of the participants’ perceptions (Liamputtong 2010). Interview questions were modified from the initial interview in order to investigate emerging findings (Thomson and Holland 2003).

All interviewswere conducted by one investigator (RD), were 30–60min in length and were digitally recorded and transcribed verbatim. Immediately after each interview, an entrywasmade in a reflective journal that outlined the impressions of the interview. Data collection and analysis were conducted concurrently; recruitment and data collection continued until data saturation was considered to have been achieved. In practical terms, saturation was considered to have been reached when no new responses and subsequent preliminary categoriesweredetectedas interviews progressed (Strauss and Corbin 2007).

Data analysis

A two-step data analysis process was used for this study. First, content analysis was used to analyse the verbatim transcripts because it allows an in-depth understanding of the participants’ nutrition care needs (Graneheim and Lundman 2004; Hsieh and Shannon 2005). Analysis of verbatim transcripts involved an iterative process of reading the transcripts to become familiar with the data, generating initial subcategories, searching for categories, reviewing the categories and, finally, labelling the categories (Graneheim and Lundman 2004; Hsieh and Shannon 2005). Triangular analysis was conducted by two investigators (LB andRD), who independently generated initial subcategories, and then compared and discussed to reach agreement. Second, a meta-synthesis approach was undertaken to synthesise and interpret the data across the three time points (Sandelowski and Barroso 2007). The process involved extracting the subcategories and interpreting them in order to identify higher order categories that transcend findings from each period. Regular meetings were held with the whole research team in which emerging findings were critically reviewed, ensuring that the identified and defined subcategories accurately reflected the data for transferability and credibility.

Results

Ten individuals participated in the study, each completing three interviews. The participants consisted of three males and seven females, and their ages ranged from 27 to 74 years. A summary of the three categories and subcategories that emerged from the analysis are displayed in Table 1.

What is known about the topic? * Patients newly diagnosed with type 2 diabetes commonly attempt to modify their dietary intake after receiving nutrition-related care. Adherence to dietary recommendations is rarely sustained and factors influencing adherence are poorly understood.

What does this paper add? * The results suggest that there is opportunity to enhance the dietary support provided to patients by investing in patient relationships through more patient-focussed consultations and open communication.

Nutrition care for type 2 diabetes mellitus Australian Journal of Primary Health 417

Adjusting to diagnosis

The first category encompassed the impact of being diagnosed with T2DM on participants’ perceptions about the food they eat and their broader dietary intake. The adjustment process involved considerable emotional adaptation, which occurred at different rates among participants. Initially, participants reported feeling shocked and surprised at being diagnosed with T2DM. Most considered their usual dietary intake to be healthy, and this added to the challengeof coming to termswith having a long-termhealth condition:

I’ve always considered [that] we ate healthy . . . It never entered my mind that I would have sugar diabetes. (Participant 7, Interview 1)

The diagnosis of T2DM appeared to have an immediate negative impact on participants’ views about dietary intake in general, particularly in social situations when others reacted to the news:

All the sad faces, they say, ‘Oh, you’ve got diabetes.’ People are now scared to cook for me. It’s actually intimidated them to think they can’t actually cook normal food. (Participant 8, Interview 1)

Three and six months after the initial interview, participants began to adapt to the diagnosis of T2DM, generally moving on from the initial shock and feelingmore in control, as the following statements from the same participant in successive interviews demonstrate:

I keep saying tomyself, ‘I’mnot depressed, I’mnot allowed to be depressed.’ I got so depressedwhen I was diagnosed, of course, and I don’t feel quite as black as that, but I don’t feel that I’m in control of myself at the moment, either. (Participant 7, Interview 2)

I’ve accepted it now, and just have a little swear and curse every now and then. It’s been a little bit easier lately, I’m handling it better. (Participant 7, Interview 3)

After adjusting to thediagnosis, participantswantedcontinued improvement in their management of T2DM, even beyond the goals suggested by their supporting health professionals:

The doctor said she was really happy with my BGL [blood glucose level] at 6.5, but I think maybe below 6 is better. I know it’s quite difficult, but I want to try anyway. (Participant 5, Interview 3)

Modifying dietary behaviours

The second category related to participants’ experiences of modifying their dietary behaviours in order to improve their blood glucose management and other health outcomes. These experiences ranged from logistical considerations of food preparation to broad emotional adaptation to having different dietary behaviours compared with before diagnosis.

Initially,wide-ranging attempts to improvedietary behaviours were undertaken by participants. Participants experienced an emotional impact of restricting their diet, as well as managing ongoing changes:

I’vemade somewholesale changes to theway I vieweating, what I eat and [now I pay] particular attention, like stuff like food labels . . .making sure I eat three meals a day and don’t skip meals. (Participant 2, Interview 1)

As time progressed, participants had differing experiences of sustaining dietary changes, with some finding that monitoring blood sugar levels provided useful feedback on food choices:

I’ve got to the stage now where I don’t think too much about the diet because . . . you’re just in the habit of eating healthy meals. I know now what I should be eating, and what are ‘sometimes’ foods. (Participant 2, Interview 2)

You know you’ve eaten the right thing because the [blood sugar] reading is lower. (Participant 6, Interview 2)

Table 1. Categories and subcategories emerging from the interviews

Category Definition Subcategories

Adjusting to diagnosis Impact of being diagnosed with T2DM on perceptions about food and dietary intake

*Shocked and surprised at being diagnosed with T2DM *Immediate negative views about dietary intake *Beginning to move on from the initial shock of diagnosis *Wanting continued improvement beyond suggested goals

Modifying dietary behaviours

Patient experiences of modifying their dietary behaviours in an attempt to improve management of blood glucose levels and other health outcomes, ranging from logistical considerations of food preparation to broad emotional adaptation to eating differently to before diagnosis

*Wide-ranging attempts to improve dietary behaviours *Emotional impact of restricting diet and managing ongoing changes

*Differing experiences of sustaining dietary changes *Maintaining a healthy dietary intake continues to be a challenge

*Monitoring blood sugar levels provides useful feedback on food choices

*Feeling aware of the consequences of not eating healthy foods Receiving support from

health professionals Experiences of interacting with health professionals and discussing food and dietary intake

*Receiving overwhelming, conflicting nutrition information *Receiving initial directives from dietitians is challenging *Ongoing engagement with primary care services is limited and not highly valued

*Feeling rushed and not heard in consultations

418 Australian Journal of Primary Health L. Ball et al.

However, formany participants,maintaining a healthy dietary intake continued to be a challenge as time progressed, mostly because it felt restrictive:

It’s a challenge . . . I’ve beenputting abitmore onmyplate, having a second serve of something . . . It’s the old habits . . . It’s not something I could maintain. (Participant 3, Interview 2)

I’m getting to the point where I’m cheesed off with always having to have diabetic biscuits and other things. You get bored with them. I’m feeling I’mhaving tomake a sacrifice that other people don’t have to. (Participant 9, Interview 3)

Despite the challenge of maintaining a healthy dietary intake, some participants reported feeling aware of the consequences of not eating healthy foods:

I can’t see myself drifting back to eating the same way as I was, because I know what the consequences are. (Participant 2, Interview 3)

Receiving support from health professionals

The third category related to participants’ experiences of receiving nutrition care from health professionals. Participants’ perceptions extended beyond the content of advice provided by health professionals to broader experiences of support and communication in healthcare consultations.

When participants were initially diagnosed with T2DM, they received an overwhelming amount of conflicting nutrition information. The information came from health professionals as well as dietary advice from friends, family, online sources and T2DM organisations:

I kept finding somuch controversy it mademyhead spin . . . They say you have protein, you have carbs, and you have your veggies and stuff. Well, then you read no meat, no animal protein, none of this . . . Who is right and who is wrong? I found it confusing. (Participant 2, Interview 1)

Participants found their initial interactions with dietitians to be challenging because of the direct, instructional nature of the nutrition care provided:

A few days after I was diagnosed, I went to a dietitian and she laid it all out . . . I wasn’t impressed. This woman was just there to purposefully lay down a diet . . . to put me in line and show me this, that and that. (Participant 1, Interview 1)

I’d had a nice lead-in with the educator and then, all of a sudden, I saw the dietitian and shewas laying down the law and I was thinking, ‘This is a bit of a turnaround!’ (Participant 2, Interview 2)

Participants found that aside from the support provided by dietitians, other health professionals, aswell as family and friends and online support, were helpful on occasions:

The diabetes educator . . . she handled me very well and I felt different when I came out of there . . . They put it in perspective, which is sort of what I needed. (Participant 2, Interview 1)

There’s one lady at work, her husband has type 2 diabetes and she tells me what she does with him, so yeah, that is really good. (Participant 3, Interview 2)

Overall, participants had limited ongoing engagement with primary healthcare services. This appeared to be a result of limited understanding about how the primary care system operated, and the role of different health professionals, as well as the limited value patients placed on the services provided in this setting:

TheGPgavemeoneof those ‘goand seefive people a year’ diabetes plans but I haven’t organised any of it . . . It’s not a big deal, it’s just something I probably need to tick off to keep everybody happy and then I can relax again for another year. (Participant 8, Interview 2)

I didn’t quite understand what diabetes educators did or the dietitians. (Participant 2, Interview 2)

Most participants thought that the support provided by primary health professionals had considerable room for improvement because they felt rushedandnotheard inconsultations, andbecause open communication was not always achieved:

They get you in there, they tell you you’ve got type 2 and you’ve got to make these changes, and it always feels like [they’re in] a rush to finish with you and get you out the back door and start with a new case. (Participant 2, Interview 3)

You’re talking to someone and they go, ‘Your half hour’s up, I’ve got another patient waiting’. Nobody has got the time to sit and take the time to talk. I find that very frustrating and annoying. You just start to say something and then you’ve got to leave.’ (Participant 1, Interview 3)

Differences in accommodating new dietary behaviours

The collective experiences of participants over time suggest that individuals have different experiences in accommodating new dietary behaviours after being diagnosed with T2DM. The experiences of participants in this study appeared to be influenced by contextual conditions such as immediate family support and responsibilities, confidence in existing food knowledge, and familiarity with health professionals and the healthcare system.

Three archetypical experiences were apparent in this study. First, some individuals appeared to take a factual and directive approach to adjusting to their diagnosis and modifying their dietary behaviours. In order to achieve this, they preferred clear instructions from health professionals and felt most comfortable eating in accordance with a predetermined plan. Positive feedback from continued healthy eating (such as improved blood glucose management and weight loss) outweighed the negative emotions felt from being restricted in their food choices, and this motivated continued adherence to the point of sustained improvement in dietary behaviours.

Second, some individuals appeared to take an adaptive approach to adjusting to their diagnosis, modifying their dietary behaviours and seeking support from health professionals. The initial shock of diagnosis reduced their confidence in making dietary choices, and they placed considerable importance on

Nutrition care for type 2 diabetes mellitus Australian Journal of Primary Health 419

guidance from health professionals and other sources of dietary information (such as family, friends, internet and diabetes organisations). Early improvements in dietary intake were not considered sustainable because of the negative emotional impact dietary restrictions had on their quality of life. However, over time, adjustments to dietary intake that were considered reasonable and achievable were made. These individuals perceived themselves as having made general improvements in their dietary behaviours that had positive impacts on blood glucose management and other health outcomes. However, these individuals also experienced regular occasions of making food choices that were not viewed as ideal, and risked having a poor dietary intake over time.

Third, some individuals experienced persistent negative emotions after diagnosis and did not makemeaningful adaptations to their dietary behaviours over time. These individuals felt overwhelmed by the conflicting information received from health professionals and other sources of dietary information, which caused them to withdraw from the experience of making dietary choices and receiving support. Improvements in blood glucose management and other health outcomes appeared to be a result of undereating and avoiding social eating situations, which was not identified in consultations with health professionals. These individuals perceived themselves as requiring considerably more support thanwhat they feltwas available, andwere frustratedby the lack of immediate success when following guidelines provided by primary health professionals.

Discussion This study contributes new information on patients’ experiences of dietary change after being diagnosed with T2DM and their views on howprimary health professionals can best support long- term maintenance of dietary change. Participants’ insights resulted in the generation of three categories: adjusting to diagnosis, modifying dietary behaviours and receiving support from health professionals. This information is important because of the relationship that exists between healthcare experiences, chronic disease self-management practices (including dietary behaviours) and healthcare outcomes (Sequist et al. 2012).

Participants in this study experienced challenges in adjusting to their recent diagnosis of T2DM; this had a direct negative impact on their views about their dietary intake. Being diagnosed with T2DM is recognised as a particularly alarming and emotional time for patients because it is viewed as a transformation point from a healthy person to one who is aware, frightened and sometimes embarrassed by having a long-term health condition (Histock et al. 2001; Hillson 2014). The impact of thediagnosis onparticipants’ attitude to foodwas considerable, including reduced confidence in what to eat, reduced enjoyment of eating, and feeling uncomfortable eatingwith others, including family, peers and friends. These factors have the potential to influence the effectiveness of nutrition care provided by primary health professionals, and health professionals should be aware of this when providing nutrition care to patients.

Previous studies investigating dietary changes after diagnosis with T2DM report that following initial dietary changes, patients often move into an accommodation-adaptation phase regarding their dietary intake (Castro-Sánchez and Avila-Ortiz 2013).

However, this finding was not apparent in all participants in the current study, even6months after recruitment into the study (up to 10 months after diagnosis). While some participants did report positive perceptions about their dietary intake as time progressed, many participants continued to experience negative emotions as a result of the restraint required to maintain a healthy diet, and the conflict between diet-related social activities and necessary self-management behaviours. The three archetypical experiences apparent in this study and the individual timelines in which participants adjusted to changes in dietary intake highlight the importance of flexible and tailored support for patients in the months after diagnosis.

Participants in this study reported that they have received an overwhelming amount of contradictory nutrition information from health professionals and other sources. A recent survey of Australian adults who self-identified as needing to improve their dietary behaviours suggested that nutrition information sources perceived as most trustworthy, credible and effective included dietitians, nutritionists and GPs, but the most frequently utilised sources were the internet, friends, family and magazines (Cash et al. 2014). The use of family as a source of information aligns with family systems theory, which conceptualises families as a system of interrelated parts that influence each other and contribute to the growth or detriment of others (Bowen 1966). Further, the participants in the current study reported limited ongoing engagement with health professionals such as dietitians and GPs, despite these sources being described in the recent survey as the most trusted, credible and effective (Cash et al. 2014). Further understanding about how patients decide which nutrition information sources to use is clearly required.

The support provided by primary health professionals to the participants in this study was generally reported as requiring significant improvement. Interestingly, the factors that weremost influential in patients’ experiences of receiving nutrition care appeared to be open communication, not feeling rushed andbeing genuinely supported, rather than any specific nutrition advice or approach. This appeared to be important for all participants but particularly those who experienced persistent negative emotions after diagnosis. Open communication and genuine support are considered critical for building relationships with patients with T2DM, and the way this is displayed is influenced by a health professional’s own personality and the emotions they are experiencing (Kowitt et al. 2015). Similar factors that influence patients’ experiences of health care have been identified in other Australian population groups, such as new mothers, whose perceptions of their healthcare quality were reduced when they felt unsupported and hurried in consultations (Corr et al. 2015). Collectively, this suggests that primary health professionals could enhance the delivery of their care by investing in patient relationships through longer, more patient-focussed consultations and open communication.

Study participants described situations in which health professionals provided nutrition care that did not meet their needs. FacilitatingAustralian primary healthcare professionals to provide nutrition care in a patient-centred manner is important to optimise self-management of T2DM and reduce the risk of complications. It has been suggested that compassion fatigue – a gradual lessening of compassion over time as a result of being regularly exposed to patients’problems– is occurring amongGPs

420 Australian Journal of Primary Health L. Ball et al.

and other primary health professionals in Australia (Shrestha and Joyce 2011). This lack of empathy from health professionals has been associated with significantly increased metabolic complications in patients with T2DM (Canale et al. 2012). Given this association, strategies to reduce compassion fatigue and subsequently enhance patient-centred care appear to warrant investigation, and may improve the self-management of patients with T2DM, including improved dietary intake and subsequent health outcomes (Lawson and Flocke 2009). Further, thefindings of this study provide additional support for the use of emerging workforce models in Australia to meet the challenges of chronic disease prevention and management. Recommendations for improvements to Australian primary care include greater self- management support through enrolment of patients with primary care teams, expansion of workforce capacity through greater training, and new categories of health workers, such as health assistants, who may receive special training to assist those in the community (Harris et al. 2008).

Participants had limited ongoing engagement with primary care services, reportedly because of limited understanding about how the system operated and the roles of different health professionals. Interestingly, a recent studyhas shown that patients with T2DM rarely attend all Medicare-subsidised dietetic appointments towhich they have access, despite an association of modestly greater reductions in weight and waist circumference observed in patients who attended more consultations (Spencer et al. 2013). Given that insufficient healthcare support is likely to affect patients’ health outcomes (Diabetes Australia, RACGP 2008), greater support for patients to ‘navigate’ the system and maintain engagement appearswarranted. This has been identified by the Australian Government as a priority for primary health care; however, implementation is yet to undergo evaluation (Australian Government 2013).

Despite the general negative emotions felt by T2DM patients regarding their experiences of dietary change and health care, a limitation of this study is that the actual changes to dietary intake were not investigated and therefore remain unclear in this population group. While many participants reported improved dietary intakes after diagnosis, confirmation of the usual changes in nutrient intakes warrants further investigation. This information will identify common areas in which patients may benefit from further support from primary health professionals to implement sustained healthy dietary behaviours. Further, this study explored participants’ experiences over a 6-month period following diagnosis with T2DM. The long-term experiences of dietary change and nutrition care have not been explored and warrant consideration.

In conclusion, this study explored patients’ experiences of dietary change and their views on how primary health professionals can best support long-term maintenance of dietary change. Three archetypical experiences of accommodating new dietary behaviours were apparent in this study. Most participants felt confused by the conflicting advice received from health professionals and other sources such as friends, family, internet and diabetes organisations. Participants frequently reported feeling rushed and not heard in consultations, resulting in limited ongoing engagement with primary care services. These results suggest that there is opportunity for primaryhealth professionals to enhance thedietary support provided to patients byacknowledging

the challenges of sustained improvements in dietary intake, and investing in patient relationships through more patient-focussed consultations and open communication.

Conflicts of interest

None declared.

Acknowledgements

The authors wish to thank Diabetes Australia, Diabetes New South Wales, Diabetes Queensland, Diabetes South Australia and Diabetes Tasmania for their support in disseminating information about the study to potential participants. The authors also thank the participants for sharing their views and experiences. This study was supported by a Griffith University New Researcher Grant.

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