Method/ Study Design

Few published studies exist on the KAPs of adult male T2DM patients in Saudi Arabia. Among the published studies, a majority have applied a quantitative methodology, which is a positivist approach to research. The positivist approach makes use of existing theory to establish the research hypotheses that are tested and wholly or partially confirmed or refuted. In this regard, the approach assumes that human behaviour is passive and influenced by the external environment (Dash, 2005), and observations can be made from an objective viewpoint (Rubin &Babbie, 2011). On the contrary, social reality is complex and comprises multiple layers, with a single phenomenon having multiple interpretations (Dash, 2005). Therefore, an anti-positivist approach, interpretive, is preferable to facilitate an assessment of the unexplored dimensions of self-care and self-management practices of adult male T2DM patients in Saudi Arabia. Interpretive emphasises on the role of humans as social actors and asserts that humans interpret their social roles according to the meanings that they attach to the roles (Dash, 2005). In this case, the grounded theory approach was used in this study and the analysis of collected data was going progressively to determine the themes, which emerged (Silverman et al., 1990).

The goal of the grounded theory was to make the theoretical assertions, which will be verified and examined. Moreover, they will be inductive as well as conductive (Strauss & Corbin, 1998). The progress aims to enable the clarification of attitudes, perceptions, and behavious concedering to processing of the main opinion and concerns on the subject (Bluff, 2005). The choice of a qualitative methodology using grounded theory for this study was mainly due to the inability of the positivist approach to identify and provide tentative explanations for various social and psychological processes, for instance, those that adult male Saudis develop to self-manage T2DM, and to take into account the socio-cultural environment in which the processes occur. In the context of human behaviour, a quantitative methodology would be deficient in documenting the emotions of patients after disease diagnosis and during self-care and self-management. Additionally, the quantitative approach cannot account for the meanings, motivations and actions of the patients in their daily self-management practices (Coventry et al., 2014).

Importantly, the qualitative methodology is highly compatible with the researcher’s role as a health care provider. One of the overarching aims of the researcher is to improve public health outcomes by enhancing the capability of diseased populations to cope effectively though education. Public health specialists are well positioned in the integrated health care system and have a crucial role of enhancing the KAPs of patients with T2DM (Bluff, 2005). The researcher applied grounded theory in an attempt to interpret the responses of the study participants to explain how meanings are derived in the day-to-day self-management and self-care practices by linking patterns and relationships that explain the social process (Dey, 1999). Further, the application of grounded theory yields in-depth information that helps to identify, explain, and understand the psychosocial processes involved in the management of T2DM by adult Saudi males in their socio-cultural settings. The information obtained is crucial to derive accurate interpretations of the behaviours of the participants in their natural settings. This emphasizes the ability of qualitative research to yield in-depth information about human behaviours, which may not be conveyed quantitatively.

The researcher’s role is to investigate, in a social context, human behaviours, interactions, and experiences and the thought processes about them (Glaser &

Strauss, 1967).

The actions of individuals are a response to thoughts and interpretations of a phenomenon. In particular, self-management of T2DM is an individual process in which patients individually process and interpret the disease. On one hand, the actions of the patients result from the meanings they hold about the situation while, on the other hand, the situation gets its meanings from the interpretations and definitions of the patients. Among adult Saudi males, self-management and self-care is congruent with the meanings that they hold about T2DM. The past plays a crucial role in the formulation of meanings although it has a partial influence on the present actions. In this case, T2DM management is a process in which a patient actively participates by determining their actions. Based on the definition of the situation and the meanings attached to T2DM, the patients may self-determine to manage or not manage the disease. Therefore, the researcher must get close to the patients to establish their definition of the situation and the meanings for their self-management

actions. Consequently, this will facilitate explanations of the meanings and social symbols of diabetes management from the patients’ socio-cultural settings.

The main aim of grounded theory is to generate theory while addressing prior knowledge and ideas, as well as the selection, coding, and data analysis. This research utilised the grounded theory approach formulated by Strauss and Corbin (1998) and various tools were used including theoretical sampling, constant comparison, coding, and theoretical saturation. The study used the constructivist ground theory. The grounded theory methodology employs purposive sampling using theoretical sampling whereby the selection of the study participants is based on their ability to provide information for generating and developing theory (Glaser & Strauss, 1967). Through theoretical sampling, participants are not recruited at once, but the evaluation of the T2DM among the participants was accessed to ensure the participants was in deed suffuring from T2DM. This was done by evaluation the knowledge of the participants of T2DM and uses them to develop the themes (Sbaraini et al, 2011). Evidently, theoretical sampling and data analysis are simultaneous processes that result in refined and saturated categories.

The categories are termed as saturated when no new data can be obtained from the participants (Strauss & Corbin, 1998).

In using grounded theory, the process of data collection includes the constant comparison (Glaser & Strauss, 1967; Strauss & Corbin, 1998). The researcher constantly compares the interview transcription data from the first interview with the data from subsequent interviews. According to Boeije (2002) and Strauss and Corbin (1998) a constant comparison can be continually obtained from coded data where the themes were extracted based of theory. Besides enabling the researcher to observe the actions of the participants and the interactions in the social settings, constant comparison analysis acts as a guide for subsequent interviews. Hence, this study utilised constant comparative analysis to code themes that emerged from data (Becker, 1998; Silverman et al., 1990). The results of constant comparison analysis facilitate refining and exhausting categories, which results in the generation of either formal or substantive theory (Strauss & Corbin, 1998). While formal theories involve the examination of phenomena in various situational contexts to elaborate or modify existing theory, substantive theory emanates from the examination of a phenomenon in one

situational context (Strauss & Corbin, 1998). The study adopted the substantive approach to theory generation by evaluating the KAPs of adult male Saudis with T2DM.

The theory is developed around a core category, which denotes the overarching theme from which the other themes arise. The prime mover or the main concern in this study was self-management and self-care among adult male patients with T2DM in Saudi Arabia. In this regard, grounded theory represented the theory of how the adult male T2DM patients continually deal with self-care and self-management as influenced by their KAPs and those of health care providers in primary health care facilities. In conducting the study, the researcher deduced that T2DM management actions occur in the social context of Saudi males, and these actions are a reflection of the nature and individual experiences of the disease. The research assessed the pattern of behaviour, including the actions and interactions, which develop among the participants while managing T2DM as influenced by various socio-cultural factors.