How do we know? Reflections on qualitative research in diabetes.

E ach of us brings to our clinical encounters worldviews and behaviors shaped by a variety of cultural and psychoso-cial factors. In addition to having some of their views shaped in childhood, health care providers bring to their encounters a professional worldview that influences the way they interpret diabetes, explain its causes and progression, understand its symptoms, and orchestrate methods of treatment. This professional perspective may also differentiate providers from patients with respect to diabetes management goals and expectations. Although differences in perspective are not inherently problematic, they frequently become so when patients do not meet the goals and expectations of their health care providers. In these instances, patients are likely to be labeled "noncompliant," a pejorative term that implies a moral failure to behave appropriately. Our analysis of this blaming behavior is that it stems from the belief on the part of health care providers that the correct view of diabetes and its management is that of the clinicians. At the same time, there is an expectation that when they, as authoritative experts, make recommendations , the patient receiving those recommendations has an obligation to carry them out (1). The problem with understanding another's behavior as a moral issue is that it seldom leads to in-depth exploration of the reasons for the behavior or a rational approach to changing it. We have learned that we can better understand the behavior of patients if we take the time to ask them about the psy-chosocial contexts in which they care for their diabetes (rather than by making judgments about their self-care behaviors). The choices that patients make appear quite sensible if one understands the demand characteristics of their environment. For example, in a recent study of Latinos with diabetes (2), our focus group research highlighted the pressure that Latino women feel to put the priorities of their family ahead of their own. Making dietary modifications to care for ones diabetes in such a milieu is extraordinarily difficult. Blaming such patients for being noncompliant with recommendations regarding diet and exercise only adds to their difficulties. As behavioral scientists, we have been grappling with how best to learn from patients about the experience of having diabetes and of having to engage in a self-management regimen that impinges on such essential phenomena as family relationships , food preferences, level of physical activity, and beliefs about health and illness. We value research that helps us …