Background: Singapore is an urbanised Southeast Asian city-state facing a growing chronic disease burden and ageing population. A 2015 International Diabetes Federation report declared Singapore as having the second-highest proportion of diabetics among the world’s developed nations. The prevalence of Type 2 Diabetes Mellitus (T2DM) in the local population was 11.3% in 2010. This prevalence is expected to grow, with a study by Phan and colleagues (2014) projecting an increase in T2DM prevalence in Singapore’s adult population to 15.3% by 2050, and a disproportionate burden of T2DM among ethnic Indians and Malays in comparison with the Chinese.
 
Aims: This qualitative study sought to identify and explore the factors that influence T2DM prevention and management among T2DM patients in Singapore.
 
Methods: 53 in-depth interviews were conducted. Interviewees were purposively sampled. Interviews were with T2DM patients spanning across several categories: general population, lower socioeconomic status, and newly-diagnosed. Interviews were conducted in English, Malay, and Chinese. The average duration of each interview was 45 minutes. The resulting data were translated and transcribed into English and thematically analysed using QSR NVIVO 11.
 
Results: Of the 53 interviewees, 25 were T2DM patients from the general population, 21 were T2DM patients of low socioeconomic status, and 7 were newly diagnosed (defined as clinical diagnosis <1 year prior to interview). Interviewees’ ages ranged from 26 to 82 years of age. Of the 53 interviewees, 24 were female and 36 were male, with 25 Chinese, 15 Malay, 11 Indian, and 2 from other ethnic groups (e.g. Myanmarese, Filipino). 
 
•	Patient pathways: Several key patient pathways emerged from the data. The first pathway, reported by most patients, begins with diabetes diagnosis at a public-sector polyclinic during a routine check-up or screening, following which treatment and medication continued at the polyclinic, with preventive check-ups (e.g. eye screening) performed at a polyclinic or public hospital. The second key pathway, more common among low-income patients, begins with diagnosis at an acute hospital (either at a specialist outpatient clinic or during an unrelated hospitalisation), followed by treatment and medication follow-up at the hospital. A third pathway, which was more prevalent among patients with employer-based insurance coverage, was diagnosis by a private general practitioner (GP) or workplace doctor, following which treatment and medication continued with the private GP or workplace doctor in question. 
•	Healthcare system experiences and perspectives: Overall, patients reported positive experiences with the healthcare system. Patients’ concerns around public primary care included long waiting times, short doctor consultations, and limitations to Medisave withdrawal limits. However, public polyclinics were also perceived as accessible, convenient, and low-cost. Meanwhile, cost concerns around private primary care were also accompanied by reports of convenience and ability to use certain government subsidy schemes. Acute hospitals were spoken of highly, reported to have highly-qualified specialist physicians and offering good quality of care. 
•	Lifestyle factors: Many patients reported making positive changes to their diet, e.g. reduction of sugar and rice intake. Their willingness to make lifestyle changes was influenced strongly by family and social support, the experiences of others with T2DM and/or comorbid conditions, high personal motivation levels, an enabling environment, and low financial barriers to making changes. Time constraints, cost, and convenience were most commonly cited reasons for reluctance to change diets, while time constraints, physical mobility challenges, and lack of motivation were most frequently cited reasons for reluctance to increase physical activity. 
•	Adherence: Although most participants took many different medications, adherent participants were more likely to report supportive families and friends, high motivation to self-manage and self-monitor, better knowledge of diabetes and its complications, more proactive health-seeking behaviours (e.g. seeing a doctor regularly), independence and physical mobility, and more openness to lifestyle modification. Meanwhile, participants reporting low adherence were more likely to report low social and familial support, incompatibility of medication schedule with other commitments, and financial challenges. 
•	Human factors: Beyond healthcare factors, several individual-level factors emerged as strong impeding influences on patients’ healthcare-seeking behavior and ability to manage their T2DM and prevent complications. These included reported fear and denial of the disease, low levels of personal motivation to self-manage or change diet/exercise habits, unwillingness to change habits/preferences, and reluctance to rely on family and friends, and competing responsibilities (e.g. caring for grandchildren, securing employment). However, other individual-level factors, such as positive relationships with healthcare providers and trust and confidence in healthcare institutions, were found to facilitate patients’ self-care abilities and resilience. 

Discussion: This study’s findings present some of the key factors that influence T2DM prevention and management among T2DM patients and caregivers in Singapore. We found that factors influencing T2DM prevention and management fell into four broad categories: perspectives and experiences with the healthcare system, lifestyle factors, human factors, and medication adherence. Across categories, cost and financial constraints emerged as a major barrier to T2DM prevention and management, while convenience and the role of family/social support was highlighted as key facilitators. Alongside, across all three key patient pathways identified, accessibility and affordability were reported as major drivers of how T2DM patients move through the healthcare system. Beyond healthcare factors, several individual-level factors emerged as strong influences on patients’ lifestyle, healthcare-seeking behaviours, and adherence. This study therefore highlights the intersections between health systems and individual-level factors that contribute to T2DM prevention and management in Singapore, and highlights how both systems and individual-level factors affect patients across the entire spectrum of their experience with T2DM – from healthcare-seeking to lifestyle management. Further research considering the interactions and relationships between health systems factors and individual-level factors in the context of T2DM prevention and management is needed.

Factors influencing type 2 diabetes prevention and management in Singapore patients and caregivers: a qualitative study