title: Meso level influences on long term condition self-management: stakeholder accounts of commonalities and differences across six European countries.
abstract: BACKGROUND
  European countries are increasingly adopting systems of self -care support (SMS) for long term conditions which focus on enhancing individual, competencies, skills, behaviour and lifestyle changes. To date the focus of policy for engendering greater self- management in the population has been focused in the main on the actions and motivations of individuals. Less attention has been paid to how the broader influences relevant to SMS policy and practice such as those related to food production, distribution and consumption and the structural aspects and economics relating to physical exercise and governance of health care delivery systems might be implicated in the populations ability to self- manage. This study aimed to identify key informants operating with knowledge of both policy and practice related to SMS in order to explore how these influences are seen to impact on the self-management support environment for diabetes type 2.
  
  
  METHODS
  Ninety semi-structured interviews were conducted with key stakeholder informants in Bulgaria, Spain, Greece, Norway, Netherlands and UK. Interviews were transcribed and analysed using thematic and textual analysis.
  
  
  RESULTS
  Stakeholders in the six countries identified a range of influences which shaped diabetes self-management (SM). The infrastructure and culture for supporting self- management practice is viewed as driven by political decision-makers, the socio-economic and policy environment, and the ethos and delivery of chronic illness management in formal health care systems. Three key themes emerged during the analysis of data. These were 1) social environmental influences on diabetes self-management 2) reluctance or inability of policy makers to regulate processes and environments related to chronic illness management 3) the focus of healthcare system governance and gaps in provision of self-management support (SMS). Nuances in the salience and content of these themes between partner countries related to the presence and articulation of dedicated prevention and self- management policies, behavioural interventions in primary care, drug company involvement and the impact of measures resulting from economic crises, and differences between countries with higher versus lower social welfare support and public spending on shaping illness management.
  
  
  CONCLUSIONS
  The results suggest reasons for giving increasing prominence to meso level influences as a means of rebalancing and improving the effectiveness of implementing an agenda for SMS. There is a need to acknowledge the greater economic and policy challenging environment operating in some countries which act as a source of inequality between countries in addressing SMS for chronic illness management and impacts on people's capacity to undertake self-care activities.
authors.affiliation: NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton Highfield Campus, University Road, Southampton, SO17 1BJ, UK. a.e.rogers@soton.ac.uk.
authors.forename: Anne
authors.initials: A
authors.lastname: Rogers
authors.affiliation: NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton Highfield Campus, University Road, Southampton, SO17 1BJ, UK. i.i.vassilev@soton.ac.uk.
authors.forename: Ivaylo
authors.initials: I
authors.lastname: Vassilev
authors.affiliation: School of Nursing, University of Navarra, Navarra, Spain. mnavarta@unav.es.
authors.forename: Maria J Jesús
authors.initials: MJ
authors.lastname: Pumar
authors.affiliation: Department of Sociology, University of National and World Economy, Sofia, Bulgaria. elka.todorova@me.com.|Department of Economic and Social Geography, Bulgarian Academy of Sciences, Sofia, Bulgaria. elka.todorova@me.com.
authors.forename: Elka
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authors.lastname: Todorova
authors.affiliation: School of Nursing, University of Navarra, Navarra, Spain. m.c.Portillo-Vega@soton.ac.uk.
authors.forename: Mari Carmen
authors.initials: MC
authors.lastname: Portillo
authors.affiliation: Department of Nursing Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway. i.c.foss@medisin.uio.no.
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authors.affiliation: Scientific Institute for Quality in Healthcare, Radboud University Medical Centre, Radboud, Netherlands. Jan.Koetsenruijter@radboudumc.nl.
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authors.lastname: Koetsenruijter
authors.affiliation: Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, Greece. ratsika@staff.teicrete.gr.
authors.forename: Nikoleta
authors.initials: N
authors.lastname: Ratsika
authors.affiliation: Funducaion Educacion, Salud Y Sociedad, Murcia, Spain. manuelserranogil@gmail.com.
authors.forename: Manuel
authors.initials: M
authors.lastname: Serrano
authors.affiliation: Department of Nursing Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway. i.a.r.knutsen@medisin.uio.no.
authors.forename: Ingrid A Ruud
authors.initials: IA
authors.lastname: Knutsen
authors.affiliation: Scientific Institute for Quality in Healthcare, Radboud University Medical Centre, Radboud, Netherlands. Michel.Wensing@radboudumc.nl.
authors.forename: Michel
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authors.affiliation: Department of Sociology, University of National and World Economy, Sofia, Bulgaria. proukova@bas.bg.|Department of Economic and Social Geography, Bulgarian Academy of Sciences, Sofia, Bulgaria. proukova@bas.bg.
authors.forename: Poli
authors.initials: P
authors.lastname: Roukova
authors.affiliation: Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, Greece. evridiki.patelarou@kcl.ac.uk.
authors.forename: Evridiki
authors.initials: E
authors.lastname: Patelarou
authors.affiliation: NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton Highfield Campus, University Road, Southampton, SO17 1BJ, UK. a.kennedy@soton.ac.uk.
authors.forename: Anne
authors.initials: A
authors.lastname: Kennedy
authors.affiliation: Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, Greece. lionis@galinos.soc.med.uoc.gr.
authors.forename: Christos
authors.initials: C
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mesh_terms: D000328:Adult; D002908:Chronic Disease; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D005060:Europe; D006291:Health Policy; D054625:Healthcare Disparities; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D009042:Motivation; D011787:Quality of Health Care / Q000458:organization & administration*; D012648:Self Care / Q000379:methods* / Q000523:psychology*; D012931:Social Environment; D012944:Social Support