title: Barriers and enablers to the delivery of psychological care in the management of patients with type 2 diabetes mellitus in China: a qualitative study using the theoretical domains framework.
abstract: BACKGROUND
  China has the largest number of type 2 diabetes mellitus (T2DM) cases globally and individuals with T2DM have an increased risk of developing mental health disorders and functional problems. Despite guidelines recommending that psychological care be delivered in conjunction with standard T2DM care; psychological care is not routinely delivered in China. Community Health Centre (CHC) doctors play a key role in the management of patients with T2DM in China. Understanding the behavioural determinants of CHC doctors in the implementation of psychological care recommendations allows for the design of targeted and culturally appropriate interventions. As such, this study aimed to examine barriers and enablers to the delivery of psychological care to patients with T2DM from the perspective of CHC doctors in China.
  
  
  METHODS
  Two focus groups were conducted with 23 CHC doctors from Shenzhen, China. The discussion guide applied the Theoretical Domains Framework (TDF) that examines current practice and identifies key barriers and enablers perceived to influence practice. Focus groups were conducted with an interpreter, and were digitally recorded and transcribed. Two researchers independently coded transcripts into pre-defined themes using deductive thematic analysis.
  
  
  RESULTS
  Barriers and enablers perceived by doctors as being relevant to the delivery of psychological care for patients with T2DM were primarily categorised within eight TDF domains. Key barriers included: CHC doctors' knowledge and skills; time constraints; and absence of financial incentives. Other barriers included: societal perception that treating psychological aspects of health is less important than physical health; lack of opinion leaders; doctors' intentional disregard of psychological care; and doubts regarding the efficacy of psychological care. In contrast, perceived enablers included: training of CHC doctors in psychological skills; identification of afternoon/evening clinic times when recommendations could be implemented; introduction of financial incentives; and the creation of a professional role (e.g. diabetes educator), that could implement psychological care recommendations to patients with T2DM.
  
  
  CONCLUSIONS
  The utilisation of the TDF allowed for the comprehensive understanding of barriers and enablers to the implementation of psychological care recommendations for patients with T2DM, and consequently, has given direction to future interventions strategies aimed at improving the implementation of such recommendations.
authors.affiliation: School of Primary Health Care, Monash University, Building 1/270 Ferntree Gully Road, Notting Hill, Victoria, 3168, Australia. Anna.Chapman@monash.edu.|RDNS Institute, St Kilda, Victoria, Australia. Anna.Chapman@monash.edu.
authors.forename: Anna
authors.initials: A
authors.lastname: Chapman
authors.affiliation: School of Primary Health Care, Monash University, Building 1/270 Ferntree Gully Road, Notting Hill, Victoria, 3168, Australia.|International Institute for Primary Health Care Research, Shenzhen City, Guangdong Province, People's Republic of China.
authors.forename: Hui
authors.initials: H
authors.lastname: Yang
authors.affiliation: School of Primary Health Care, Monash University, Building 1/270 Ferntree Gully Road, Notting Hill, Victoria, 3168, Australia.|International Institute for Primary Health Care Research, Shenzhen City, Guangdong Province, People's Republic of China.
authors.forename: Shane A
authors.initials: SA
authors.lastname: Thomas
authors.affiliation: School of Primary Health Care, Monash University, Building 1/270 Ferntree Gully Road, Notting Hill, Victoria, 3168, Australia.
authors.forename: Kendall
authors.initials: K
authors.lastname: Searle
authors.affiliation: School of Primary Health Care, Monash University, Building 1/270 Ferntree Gully Road, Notting Hill, Victoria, 3168, Australia.|RDNS Institute, St Kilda, Victoria, Australia.|International Institute for Primary Health Care Research, Shenzhen City, Guangdong Province, People's Republic of China.
authors.forename: Colette
authors.initials: C
authors.lastname: Browning
mesh_terms: D002681:China; D003924:Diabetes Mellitus, Type 2 / Q000523:psychology*; D019468:Disease Management; D005260:Female; D017144:Focus Groups; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D009042:Motivation; D024382:Professional Role; D011613:Psychotherapy; D036301:Qualitative Research
keywords: China; Evidence-based practice; Guideline implementation; Psychological care; Theoretical domains framework; Type 2 diabetes mellitus