Exploratory Study: How Does the Spirituality of a Group of British People With Type 2 Diabetes Impact Their Coping and Self-management of Their Condition?
Conditions: Type 2 Diabetes
Sponsor: Natasha Duke

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Exploratory study:  how does the spirituality 
of a group of British people with Type 2 
Diabetes impact their coping and self-
management of their condition? 
Author: Natasha Duke 
Supervisors: Prof Andree Le May 
Dr Wendy Wigley 
 
ERGO No: 18602    IRAS No: 168308      
Date: 5 December 2016    Version V4 
 
This Proposal has been submitted as part of a 
Doctorate of Clinical Practice and has already been 
peer reviewed and passed by the Health Sciences 
Faculty at the University of Southampton 

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Contents 
 
1 
Introduction ....................................................................................................... 3 
2 
Aim and Objectives of Proposed Research ...................................................... 3 
3 
Type 2 Diabetes ................................................................................................ 4 
4 
Spirituality ......................................................................................................... 5 
5 
The Literature Review’s Key Themes ............................................................... 6 
5.1 
Limitations of the literature review ................................................................. 8 
5.2 
Literature review summary ............................................................................ 8 
6 
Research Design ............................................................................................ 11 
Figure 1:   Overall Research Design .................................................................. 13 
7 
The Constructivist Paradigm ........................................................................... 14 
8 
Methods considered for this study .................................................................. 15 
8.1 
Narratives .................................................................................................... 15 
8.2 
Biographic-Narrative-Interpretive Method ................................................... 16 
8.2.1 
The BNIM Interviews ............................................................................ 18 
8.2.2 
Sub-sessions ........................................................................................ 19 
8.2.3 
Training in interviewing ......................................................................... 19 
8.2.4 
Pilot interviews ...................................................................................... 20 
9 
Participation and Sample Size ........................................................................ 21 
9.1 
Inclusion/exclusion criteria .......................................................................... 21 
Table 1: Inclusion/ exclusion criteria for this study ............................................. 21 
9.2 
Recruitment ................................................................................................. 23 
9.3 
Recruitment Pack ........................................................................................ 24 
10 Data analysis .................................................................................................. 24 
10.1 
Reflexivity and bias .................................................................................. 25 
10.2 
Memos ..................................................................................................... 26 
10.3 
Transcription ............................................................................................ 26 
11 Ethical considerations ..................................................................................... 27 
11.1 
Consent ................................................................................................... 27 
11.2 
Storage of data: maintaining confidentiality and anonymity ..................... 28 
11.3 
Participants’ family or friends involvement ............................................... 28 
11.4 
Risks ........................................................................................................ 29 

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11.4.1 
Distress to participants/researcher .................................................... 29 
11.4.2 
Risky health behaviours .................................................................... 29 
12 Resources and costs ...................................................................................... 30 
13 Timetable ........................................................................................................ 30 
14 Dissemination ................................................................................................. 30 
15 References ..................................................................................................... 32 
16 Appendices ..................................................................................................... 46 
        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1 Introduction 
 
As an advanced nurse practitioner working in general practice within a predominantly 
white population in Hampshire, I care for people with Type 2 Diabetes (T2D).  In the 
clinics I run, some patients with T2D have revealed that their spiritual beliefs impact 
upon their self-management behaviours of diet and exercise; the extent to which 
they engage (or not) with treatment and their fears of disease progression.  This 
proposal outlines a study of people with T2D.  It seeks to understand if and how the 
spirituality of people with T2D impacts their coping and self-management of their 
condition. The results will be used to encourage clinicians to consider the spirituality 
of people with T2D when planning their care, thus giving holistic treatment. 
 
2 Aim and Objectives of Proposed Research 
 
It is known that poorly managed T2D leads to complications such as heart attack,  
kidney disease and blindness (Diabetes UK 2013; Hex et al. 2012). The current 
literature demonstrates that the spirituality of people with T2D does impact their 
coping and self-management of their condition, which will affect their risk of 
developing complications.  However, none of the studies have been with British 
participants.  It is not yet known if and how the spirituality of British people with T2D 
impacts their coping and self-management of their condition.  The aim of the 
proposed exploratory study is to discover if and how spirituality impacts the coping 
and self-management of T2D of a small group of British people, and in what ways it 
affects these areas.   
The objectives of this research will be to: 

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• explore if and how spirituality affects coping  
• explore if and how spirituality affects the self-management behaviours 
of diet and exercise 
The results will be used to make recommendations to clinicians caring for patients 
with T2D.  If clinicians have evidence that the spirituality of some British patients may 
influence their coping and self-management, then spiritual assessment can be 
promoted when negotiating healthcare treatment, thus giving greater individualised 
care. This is in line with guidance for patients with T2D from NICE [National Institute 
of Health Clinical Effectiveness] (2014 p8) that recommends ‘support of self-
management attitudes, beliefs, knowledge and skills’. 
 
 
3 Type 2 Diabetes 
 
T2D is a metabolic disorder characterised by high blood sugar and insulin 
resistance.  Micro-vascular, macro-vascular and neuropathic complications occur 
with poorly controlled T2D, such as stroke and peripheral nerve damage (Diabetes 
UK 2013).  The self-management behaviours of maintaining a healthy diet and doing 
exercise are key to reducing the risk of developing  these complications (NICE 
2014).  Research that identifies why and how people engage (or not) with self-
management behaviours will help to reduce disease complications (Diabetes UK, 
2005, 2013; Stride, 2008). 
 

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Obesity associated with physical inactivity in Britain is rising, and both of these are 
variable risk factors for T2D (Gatineau et al. 2014).  Diabetes is predicted to spend 
17% of the National Health Service [NHS] budget in 2035/2036, with T2D expending 
approximately 8 times more than other types of diabetes (Hex et al. 2012).  NHS 
England (2014) has stated that research should identify innovative ways to reduce 
disease complications and improve patients’ quality of life and health outcomes. 
Improvements in health outcomes may be made by focusing on physical, functional, 
social, emotional and spiritual well-being of an individual (Bredle et al. 2011; 
Fallowfield 2009; Peterson and Webb 2006).   This research project focuses on the 
latter. 
 
4 Spirituality 
 
In the United Kingdom [UK] 2011 Census (Office for National Statistics 2011) it was 
noted that Christian religious affiliation was falling, although other types of spiritual 
beliefs were rising. Contemporary spirituality has a different construct to religion, and 
people may consider themselves spiritual whilst having no religious affiliation  
(Swinton 2010).  Spirituality is now understood to be a concept relating to being 
human; may have nebulous boundaries, and is understood differently by different 
people.  Spirituality appears to be the product of human experience, reflection, 
reasoning and culture, forms part of the nature of being, and may (or may not)  
involve belief or worship of a Deity/deities (Cordova 2011; Harris 2008; Hjelm et al. 
2005; Polzer and Miles 2007; McSherry 2010). Religion on the other hand is defined 
as the belief and worship of a divine power (Oxford University Press 2014).  It is 
understood that spirituality and religion, although being different concepts, are 

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intricately linked (Swinton 2010 p27).  The British Humanist Association is committed 
to promoting non-religious beliefs of people, and welcomes the RCN definition of 
spirituality that includes ‘respect for privacy, dignity and religious and cultural beliefs, 
spending time with patients giving support and reassurance especially in a time of 
need and showing kindness, concern and cheerfulness when giving care’ (British 
Humanist Association 2015). 
 
It is documented that during suffering, illness or a life changing event  such as  being 
diagnosed with T2D,  spirituality comes to have a significant meaning for some 
individuals (Koenig 2004; Royal College of Nursing [RCN] 2011). T2D could be 
considered to involve illness and suffering (Rock 2010), even more so if the person 
has the complications of the disease (NICE 2014). The proposed research aims to 
find out if and how for some patients, their spirituality may impact how they cope with 
their T2D, and influences their approach to the self-management of their condition.  
 
5 The Literature Review’s Key Themes  
 
A literature review was undertaken to determine what was already known about T2D 
and spirituality.  The strengths, limitations, bias, and omissions of current research 
was considered, and how this sits within the national and international context 
(CASP UK 2013; Jesson and Lacey 2006).  Thirty-seven papers linking the concepts 
T2D and spirituality were retrieved and read (Appendix 1).  Analysis of these papers 
began by creating a ‘Mindmap’ identifying the themes (Appendix 2).  
Initially, the papers were separated into concepts of spirituality and religion as shown 
in the Mindmap.  However, twenty-four papers showed that while these two concepts 

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may differ they are most often inter-related.  Although being religious involved 
spirituality, spirituality may not involve religion (Swinton 2010).  
Nearly all the studies had been conducted in America.  Key themes emerged, and 
thirteen papers were analysed in depth (Appendix 3).  They revealed that: 
• spirituality and religion of people with T2D affects their self-management 
behaviours of diet and exercise (Polzer Casarez et al. 2010; Polzer and Miles 
2007). 
• Complementary alternative medicine and practices (CAMP) can be linked to 
spirituality.  In America diabetic people used CAMP more than non-diabetic 
people.  Their CAMP use affected their self-management behaviour of diet 
and also medicines adherence (Amirehsani 2011; Egede et al. 2002; Jones et 
al. 2006). 
• Ethnicity was related to spirituality.  For example, African Americans were 
more likely to use spiritual practices than White Americans (Polzer and Miles 
2007). Men from the former-Yugoslavia and Arabian cultures believed that 
supernatural factors and stress impact diabetes and have negative health 
effects (Hjelm et al. 2005). 
• Gender may affect spirituality.  Some studies identified that women were  
more likely to use spiritual practices than men (Decoster and Cummings 
2005; Jones et al. 2006; Lynch et al. 2012). 
• Coping styles can affect spirituality in complex ways, affecting self-
management of diet and exercise (Rovner et al. 2013).  This was evident in 
American Christians (Cordova 2011); Thai Buddhists (Thinganjana 2007); and 
Arabian Muslims in Sweden (Hjelm et al. 2005).   

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• ‘Emotion-based coping’ styles were used mostly used by women resulting in 
poorer T2D control, whereas ‘problem-based coping’ was used mostly by 
men, who had better T2D control (Decoster and Cummings 2005; Harris 
2008; Hart and Grindel 2010; Lynch et al. 2012; Newlin et al. 2003; Rovner et 
al. 2013). 
 
5.1 Limitations of the literature review 
The transferability of American studies to a British context should be applied with 
caution.  The healthcare provision of American people with T2D is funded differently 
than in Britain. In America healthcare costs are usually financed by the individual’s 
insurance, the employer, or the government (Rosenthal 2013; US Government 
2014a, 2014b). All medicines, any services (such as a blood test or kidney scan), 
and every doctor’s visit will be paid for by the patient, or the organisation.  Patients 
with T2D on low incomes in America may have no insurance, and spiritual practices 
and CAMP were used as an alternative, or alongside prescribed medicines 
(Amirehsani 2011; Bhattacharya 2012; Popoola 2005; Utz et al. 2006).  By contrast, 
in Britain people with T2D receive the healthcare and medicines free at point of 
access/care. Thus the transferability of these studies to a British context is restricted.   
 
5.2 Literature review summary 
Koenig et al. (2012) have identified that in many diseases/conditions spirituality can 
be related positively to mental and physical health. However, the study by King et al 
(2013) found that those who had a spiritual view of life in the absence of a religious 
framework were more vulnerable to mental disorder.  The review by Quinn et al. 

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(2001) found  a belief in God may give individuals a better sense of self-control with 
managing T2D, or have a negative health impact if people believe that God 
fatalistically determines their health, and they abandon their self-management.  The 
research by Polzer and Miles (2007) found three groups: one group saw God as 
helping them to perform good T2D self-management; another group believed 
although God did this they were submissive to his will, and any positive outcomes 
were attributed to God.  The third group believed if they had enough faith God would 
heal them, and they did not perform good diabetic self-management.  Polzer 
Casarez et al. (2010) found that for participants with T2D, some used spiritual 
practices to help their self-management; others used spiritual practices and self-
management towards healing, but another group used spiritual practices as healing 
from diabetes, and did not engage in self-management. In other studies (Lundberg 
and Thrakul 2013; Hjelm et al. 2005) participants engaged in self-management, 
despite believing it their fate or divine will to have T2D.  Participants’ perception of 
T2D causality centred on the disease being hereditary, caused by stress, or the 
divine will (Hart and Grindel 2010; Lundberg and Thrakul 2013; Meetoo and Meetoo 
2005). Whilst spirituality may give participants comfort, hope, meaning, and strength 
in adversity, the lack of self-management in others will lead to diabetic complications 
(Polzer and Miles 2007).  
Much of the American literature focussed on African-Americans (Jones et al. 2006; 
Polzer Casarez et al. 2010; Polzer and Miles 2007; Rovner et al. 2013), because 
they are considered a spiritual people, with complex religious and spiritual 
frameworks that influence the individual, family and society (Mattis and Jagers 2001; 
Polzer and Miles 2007). Other studies compared White Americans with African 
Americans (Decoster and Cummings, 2005; Harris, 2008; Hart and Grindel, 2010).   

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In the British census (Office for National Statistics 2013) the only voluntary question 
asked ‘What is your religion?’, of which 7% of the population declined to answer.  
The Census showed 59% of the population described themselves as Christian, 25% 
as having no religion, and 5% as Muslim. In England and Wales, 93% of Christians 
are White British, with the same number for those who reported no religion.  Thirty-
eight percent of Muslims report their ethnicity as Pakistani. Muslims usually fast at 
Ramadan, and this can have significant effects on those with T2D.  
 
Figure 1: Religion by age in England and Wales in 2011.  Office of National Statistics. 
 
The number of people reporting no religion in Britain has increased across all age-
groups, especially in the 20-24 and 40-44 year age groups.  Middle age is the time 
when T2D is likely to occur.  Although religious affiliation has fallen since the last 
Census in 2001, spirituality is rising (Crabtree 2012; King et al. 2013).  The 

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spirituality of American people may be different to that of Britons, and studies need 
to identify how spirituality influences British population (King et al. 2013). 
Although the literature review showed the spirituality of Americans affected their self-
management of T2D, it is not known how the spirituality of British people influences 
diabetes self-management. In addition, the religiousness and spirituality of the British 
appears to be changing.  
This literature review led to the refinement of the research question. The literature 
demonstrated that spirituality is unique to individuals, and can impact their coping 
and self-management of T2D.  The key themes of spirituality, self-management, 
coping and ethnicity of people with T2D were considered within a British context, and 
the planned research question is: 
 ‘How does the spirituality of a group of British people with T2D impact their coping 
and self-management of their condition?’   
Once the question had been refined, the design for the study was considered.  
 
6 Research Design  
 
To answer the research question, a constructivist approach will be used.  Following 
ethical approval it is planned to recruit participants for the study from diabetes clinics 
and GP Surgeries in Hampshire.  This location has been chosen for pragmatic 
reasons regarding gaining permissions for recruitment of participants.  I have contact 
with the Consultant Medical Diabetologist in the Community Diabetes Team, and 
also various Surgeries in Hampshire.  Two Surgeries and the Consultant have 
already given written permission to recruit from their clinics through a Nurse, myself 

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or via a poster in their premises.  The Community Diabetes Nurse or I will ask 
patients if they are interested in taking part in diabetes research, and if so, a 
Recruitment Pack will be given to them for their consideration. If they choose to 
participate, the Pack will ask them to sign the enclosed Consent Form that will be 
stored securely by the clinic, and the Form collected by myself.  If participants 
respond to a Clinic poster, they will choose where to have the Recruitment pack sent 
(to their home or their GP Surgery where they can collect it). The Pack will request 
for the signed Consent Form to be returned to myself via a self-addressed envelope.   
After written consent has been gained, I will contact participants to arrange recorded 
interviews in a location chosen by each participant. The Recruitment Pack will have 
advised participants that their contextual data will include their living situation (living 
alone or with family/partner); date of T2D diagnosis; current age; glycated 
haemoglobin (hba1c) blood test; body mass index and current pharmacological 
therapy. This data will be collected from the GP/Community Clinic to contextualize 
the qualitative data.  These measurements will reveal how well a participant is 
managing their T2D.  For example, a high ‘hba1c’ reveals that they do not have good 
control of their condition.  During the interviews the coping mechanisms of the 
participant may reveal factors as to why their ‘hba1c’ is high.  The interviews will be 
transcribed by myself, where I will reflexively immerse myself in all data, seeking 
embedded themes and patterns which I will discuss with my Supervisors. 
After the thesis is written up, dissemination will be by letters to participants involved, 
publishing in peer-reviewed journals, teaching of colleagues, and presentations at 
conferences. Further research can be planned in line with the findings of this 
research.  Figure 1 below shows the stages of the research design. 

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Figure 1:   Overall Research Design 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Research Question and Research Design 
Ethical approval 
Collect contextual data and interview participants 
Analysis – Thesis - Submission 
Feedback to Participants 
Publish – Conference presentation – Plan further research 
Recruit participants 

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7 The Constructivist Paradigm 
 
When seeking new knowledge, researchers need to establish what perspective they 
are using; they need to locate which paradigm to use (Bowling 2009).  This research 
follows a constructivist approach.    
This paradigm is underpinned by the principle that people develop their own 
understandings and meanings of the world in which they live (Guba and Lincoln 
1994). These meanings may be multiple and varied, and may be related to social 
and historical factors – hence the term ‘social constructivism’ (Creswell 2007; Lincoln 
and Guba 2005). This paradigm seeks to understand the participants’ subjective 
meanings to their experiences. The theories, background, values, experience and 
knowledge of researchers also influence what is observed and analysed.  
Constructionism posits that individuals ‘construct their own reality’  and the 
researcher interprets the data, so ‘there are multiple interpretations’, which is why it 
may also be referred to by some as interpretivism (Barney et al. 2007).  
This paradigm is helpful when seeking to understand the lives of people that are part 
of a social group (e.g. a group of patients with T2D). It has the potential to reveal rich 
data about if and how the spirituality of participants with T2D influences the self-
management of their condition.  As such, it is planned to use this paradigm for this 
study. 
 

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8 Methods considered for this study 
To understand how participants’ spirituality influences their self-management, rich 
and descriptive data will be sought and therefore a qualitative approach is thought to 
be the most appropriate.  Different methodologies were considered, and for 
participants to reveal their beliefs, reasons for actions and how they managed their 
T2D on a day to day basis. Phenomenology, grounded theory and the narrative 
method were all deliberated upon.  Grounded theory was not chosen, as the aim was 
not to produce a theory (Strauss and Corbin 1999).  The aim of the research is not to 
understand a phenomena as in phenomenological research (Moustakas 1994; van 
Manen 1990) but to have insight into how participants’ spirituality impacts their 
coping and self-management  of T2D.  Therefore it is considered that a narrative 
approach is most appropriate method for this research. 
 
8.1 Narratives  
There is no clear agreement as to the definition of narrative and it does not fit into to 
one scholarly area (Reissman 1993 p17).  In narrative research, Czarniawska (2004 
p17) describes it as a ‘spoken or written text giving an account of an event/action or 
series of events/actions, chronologically connected’. Creswell states ‘the inquirer 
focuses on the stories told from the individual and arranges these stories in 
chronological order’ (2007 p76).  Labov (1997) likewise agrees with chronological 
sequencing, and assumes all narratives are about past events.    
Narratives are unique to time, place and person and evolve as the person transitions 
through life, and as such a story cannot be told exactly the same twice. In most 
narrative research, the narrative is influenced by the questions the researcher asks, 

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and in a sense becomes a partner influenceing the telling of the story and the 
direction in which it flows.  These narratives or descriptions of a series of events that 
impact the individual are studied to describe the experience of being human.  
Pinnegar and Daynes (2007) state that ‘narrative’ can be used to describe both the 
method and the phenomena of the study. In describing qualitative inquiry methods 
Creswell (2007 p55) states the narrative method is best for ‘capturing the detailed 
stores of life experiences of a single life or the lives of a small number of people’. 
Illness narratives are useful for ‘studying the world of biomedical reality, but also the 
illness experience and its social and cultural underpinnings’ (Hyden 1997 p1) and the 
identity of being a person with an illness (such as T2D) (Hyden 2010).  Narrative 
research has been used to understand what it is like living with T2D (Bhattacharya 
2013; Browne et al. 2013; Snow et al. 2013). 
Wengraf (2015 per comm) states narrative methods are both psychodynamic and 
socio-biographic in approach, and concerned with the ‘inner and outer worlds’ that 
the participant inhabits. In telling their stories participants express their conscious 
concerns and their unconscious cultural and societal beliefs.  In my proposed 
research the use of narrative will help to reveal how the participant’s spirituality may 
impact their approach to diabetic self-management and coping.   
 
8.2 Biographic-Narrative-Interpretive Method    
For this research the biographical-narrative interpretive method [BNIM] will be used. 
This is a method of conducting and analysing biographic narrative interviews 
(Chamberlayne et al. 2002; Rosenthal 2010;Wengraf 2015 per comm) and has been 
previously used for understanding self-management of T2D (Gomersall et al. 2012).  

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BNIM has also been used to understand the lives of those with other chronic 
illnesses, diseases or conditions (Curtin and Clarke 2005; Campbell-Green and 
Poland 2006; Sallinen et al. 2009; Thetford et al. 2013; Hughes 2014; Milne 2014).  
The study by Graham (2012) also used BNIM, in which he analysed recreational 
drug use and found two distinct types of emptiness: ‘deficient’ emptiness and a 
perceived ‘spiritual’ emptiness.   
In BNIM the ‘context’ is important, and Wengraf (2004 p8-9, 306) refers to the 
context as having ‘hard facts’ which are part of ‘objective knowledge’. In my 
proposed study, the ‘context’ would be their living situation (living alone or with a 
family/partner); date of diagnosis of T2D; current age; hba1c blood test; body mass 
index and current pharmacological therapy (bio-statistical markers).  Also their 
address and phone  number will be recorded, so that the researcher can contact 
them. These are part of the context of their ‘lived life’ (Wengraf  2004  p232), and 
can be verified by medical records kept by their Surgery/Clinic.  Contextual data 
involving bio-statistical T2D markers will be collected, anonymised, and stored 
securely in accordance with the Data Protection Act (1998). 
The ‘told story’ (Wengraf 2004  p232) covers the participant’s narrative of what has 
happened to them, and may include stories about their initial diagnosis; what it is like 
living with T2D; how they cope with self-management of T2D, and how their 
spirituality may have  influenced their approach to self-management of T2D.   This 
data will anchor the lived experience of managing T2D within the historical and 
biological context, aiding triangulation (Denzin 1970). 
The BNIM narratives will be solely concerned with listening to how the participants 
cope and self-manage T2D, and how their beliefs may impact this. Participants will 

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be offered a sequence of interviews (known as ‘sub-sessions’) that will be recorded 
(Wengraf 2004 Chapter 6). Participants will have been informed in their information 
guide prior to giving consent that interviews will be recorded, transcribed, names 
anonymised, and the data stored in a locked secure location in accordance with the 
Data Protection Act (1998)  and the University of Southampton Ethics and Research 
Governance policy (University of Southampton 2015). 
 
 
8.2.1 The BNIM Interviews 
 
BNIM involves a series of interviews.  All interviews are referred to as ‘sub-sessions’.  
In the first interview, there are two sub-sessions. The first sub-session is followed 
after a short break by a second sub-session, which will expand on topics raised in 
the first sub-session (Wengraf 2004 Chapter 6).  The third sub-session takes place 
around one month later. Sub-sessions may vary dramatically in length, but each 
interview commonly lasts 30 – 120 minutes (Wengraf 2015 per comm). Throughout 
all the interviews, I will ensure that the participant is happy to proceed, not 
emotionally distressed, and at the end of interviews will be thanked.  Potential 
emotional distress is discussed later in this proposal.  
Wengraf (2004 p189) does not specify the ideal location for interviews, only that it 
should be free from interruption, distractions and comfortable.   The participant will 
be asked to choose the location of interviews, which could be in their own home or 
the University.  If the participant chooses the University, the relevant permissions will 
be sought.   

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8.2.2 Sub-sessions 
 
In the first sub-session, the participant is asked a carefully constructed single 
question aimed at inducing a narrative (Appendix 4); this question has been 
formulated from consideration of the research question, and email discussion with 
Wengraf. No further questions, only active listening skills are utilised to enable 
spontaneous gestalt, whilst notes are made by the researcher.  A break of around 
fifteen minutes allows the participant to rest, whilst notes that the researcher has 
made are constructed to form the questions asked in the second sub-session. These 
are narrative-based topic questions, and must be asked in the order that the 
participant raised them in the first sub-session, and use the phrases used by the 
participant. At the end of second sub-session, the interview finishes.   
The participant will be advised that the interviewer may contact them for a second 
interview (the third sub-session) which is likely to be within one month.  If analyses of 
the previous two sub-sessions raises further questions, or the research question has 
not been answered, the participant is contacted for a third sub-session. Here further 
narrative questions, as well as non-narrative questions may be asked that relate to 
the research question.  If the participant has not yet talked about their spirituality and 
how or if it impacts self-management of T2D, it is in the third sub-session that this 
will be asked about (Appendix 4). 
 
8.2.3 Training in interviewing 
 

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 The Research Governance Framework (Department of Health [DH] 2008) 
recommends specific training if researchers are conducting qualitative interviews.  I 
have attended training on qualitative interviewing through the Faculty of Health 
Sciences, and have completed the online ‘Epigeum Ethics of Research module’, and 
also understand the policies regarding safety of ‘lone interviewing’ in participants’ 
homes (University of Southampton 2010).   
I am also in contact with previous researchers who have used BNIM  (Chamberlayne 
et al. 2002; Wengraf 2004, Milne 2014) and have a detailed guide of how to use this 
method (Wengraf 2015 per comm).  In addition, I will attend a five day BNIM 
intensive training residential course in London in November 2015, which will include 
follow on support from Wengraf. 
 
8.2.4 Pilot interviews 
 
Before interviewing participants, pilot interviews will be undertaken.  The BNIM 
training course will include, this but in addition one pilot interview will be conducted 
with a chosen nursing colleague, involving the three sub-sessions (Wengraf 2004 
p187).  I plan to ask a nursing colleague (who supports patients with T2D) to consent 
to giving an interview, in which they would talk about having a health problem and 
how their beliefs may impact their management of this condition.  Although their 
health problem is not T2D,  this pilot interview will enable me to further develop 
confidence in specific  interviewing skills; identify potential challenges that may occur 
from possible conflicts due to being a nurse as well as a researcher; assist in 
becoming confident with recording equipment; and aid development of reflexivity 
skills through the use of ‘memo’ writing (Wengraf 2004  p209–211).  Details of memo 

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writing is given in Section 9.2 of this proposal.  Discussion and feedback will be 
given to the Supervision team to identify further learning that may be gleaned from 
this process.   
9 Participation and Sample Size 
Wengraf (2004 p96) states in BNIM research ‘deliberate or purposeful selection’ of 
participants is used. Sample sizes are small, and may only involve one participant, 
who may serve as a critical case to illustrate a specific example - such as in the case 
of someone with mental challenges living in a complex society (Angrosino 1994).   
Factors influencing the planned sample size for this doctoral study are that BNIM 
inquiry is labour intensive involving 3 interviews for each participant, and each sub-
session may last up to 2 hours.  In exploratory qualitative studies seeking depth of 
analysis, it is considered 6-8 participants will yield considerable data (de Munck and 
Sobo 1998; Gomersall et al. 2012; Wengraf 2004), and therefore 6 participants will 
be recruited.   
9.1 Inclusion/exclusion criteria 
For participants to be included in this study, the following criteria will apply. 
Table 1: Inclusion/ exclusion criteria for this study 
 
Inclusion Criteria 
Speak English 
Have had T2D at least 6 months* 
Have read the Participant Information Sheet, explaining this study is regarding 
T2D, spirituality, coping and self-management 

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Gives consent to access their records stored on Clinic database 
Gives consent to recorded interviews 
Must be over 18 years old 
 
 
 
Exclusion Criteria 
Not speak English 
Have had T2D less than  6 months* 
Have read the Participant Information Sheet, and decided they are not 
comfortable talking about their T2D, or spirituality, or coping or their self-
management 
Not consenting to data collection from Clinic records 
Clinic records have not been kept (e.g. is a new patient to their GP) 
Consent is withdrawn from the study (which could be any stage) 
Under 18 years old 
 
* Participants should not be newly diagnosed with T2D, or may still be in the phase 
of shock or denial (Peel et al. 2004), and not able to tell how they cope with the day 
to day management of their condition.   
 

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9.2 Recruitment 
I will be recruiting from places where I am not known to the participants, and will 
present myself as a doctoral student from the University of Southampton.  Although I 
will not hide the fact I am a nurse, it will not be disclosed unless the participant 
directly asks about this.  If participants know I am a nurse, this could lead to them 
asking questions about how they should manage their T2D, which is not appropriate 
for this study. 
Two Hampshire based GP surgeries (Alma Road Surgery and Stoneham Lane 
Surgery) and a Community Clinic (Southern Health NHS Foundation Trust (SHFT)) 
have given email permission to recruit.  Participants will be recruited either: 
• Via a recruitment poster at the GP surgery or Community Clinic. The poster 
will have details of how to contact me via email or my mobile phone, and there 
are ‘tear off slips’ with these details on each poster (Appendix 5). 
• through a Diabetes Nurse asking patients if they would like to be involved in a 
diabetes research study, and if they are interested giving a Recruitment Pack 
to patients  
• through me opportunistically recruiting patients at a regular diabetes 
educational class, run as part of the usual NHS for treatment of T2D (National 
Institute of Health and Clinical Excellence  2014 p8) 
• SHFT have a database of diabetic patients who have already consented to be 
contacted as participants for research. The Consultant Diabetologist from 
SHFT has agreed for these patients to be contacted via email to inform them 
of this research. Any patients with T2D who are interested in the study would 
contact me via phone or email. 

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9.3 Recruitment Pack  
A 'Recruitment Pack’ will include an Information Sheet and a Consent Form 
(Appendix 6) given to people who may be interested in the study.  The pack will 
either be given at one of the identified sites, or mailed to the participant if they have 
responded via a poster, and include a stamped envelope to return the Pack to me.  
The Information Sheet will invite patients to participate in research on how the self-
management of T2D is impacted by peoples’ beliefs.  It will advise up that up to three 
30-120 minute recorded interviews inviting them to talk about their experience of 
T2D and spirituality will be requested, at a location of their choice; and their blood 
tests of hba1c, current age, age of T2D diagnosis, body mass index and 
pharmacological therapy will be accessed from their Clinic records. It will be made 
clear that involvement or non-involvement in the study will not affect their T2D 
treatment in any way.  
 
10 Data analysis 
 
Mauthner and Doucet (1998 p112) have commented that ‘the use of technology 
conveys an air of scientific objectivity onto what remains a fundamentally subjective, 
interpretive process’.  I do not consider it necessary to use a computer software 
programme to aid analysis (Mauthner and Doucet 2003).   
Data from the transcribed interviews will be analysed to code for patterns/themes. 
Thematic field analysis involves the researcher looking ‘at the presentation and 
process of telling the story and thus can discover the structure of its construction’ 
(Wengraf per comm 2015). This involves identifying the patterns of the ‘lived life’ (i.e. 
familial setting, the date and age at their diagnosis of T2D, their bio-statistical 

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markers such as blood serum hba1c,  body mass index and pharmacological 
therapy) and the ‘told story’ and the relationship between them, and understanding 
how these answer the research question.   
The transcript, thematic analysis and the interpretive process and interpretation will 
be discussed with the Supervision team to compare the researcher's analysis with 
that of the Supervision team. 
 
10.1 Reflexivity and bias 
Bias may occur when data are filtered through the understanding of the 
researcher(s) (Stern 2004). Hand (2013 p18) states that the researcher must 
consider their identity and position to disclose their ‘values, assumptions, prejudice, 
and influence’ and how this may influence the research. In this study, I will use 
reflexivity to consider my nursing background and personal spirituality and the extent 
to which this may or may not impact on the study (Anderson 2013; Mauthner and 
Doucet 2013). 
Reflexivity entails the researcher being aware of their own effect on the processes 
and outcomes of research, based on the premise that it is impossible to separate the 
researcher from the new knowledge being generated (Anderson 2013).  Given that 
data analysis can be seen as a method of sorting and organising data through 
various techniques, I will consider how to  immerse myself in the data and be 
reflexive (Mantzoukas 2005).  
I bring my experience as a nurse supporting patients with T2D, as well as 
experiences of listening to how patients’ spirituality has supported them or been a 
source of conflict for them in their self-management of T2D.  My own understandings 

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of spirituality have been developed from growing up in Hong Kong, and the influence 
of Buddhism (Melton 2014). As a Christian, I have a quiet faith, and have always 
been interested in how spirituality may or may not influence myself and other people.  
I am not interested in expressing my own personal views on spirituality or T2D, and 
will not discuss this with patients.  I am interested in hearing the voice of an 
individuals’ experience and what it means to them. 
 
10.2   Memos 
 
As advised by Wengraf  (2004 p210–212), I will write reflexive memos during 
interview, post interview and during transcribing. A reflexive journal will be kept 
(Jasper 2005) and engagement with the Supervisors will occur throughout this 
process. Immediately after each interview, I will spend 30-60 minutes writing memos 
in a free-associative flow writing down everything that can be remembered about the 
interview (e.g. feelings, processes, gestures).  This ensures as much of the interview 
is remembered as possible.  After memo writing, the recorded interview is listened to 
later, and memos are again written.   
 
10.3   Transcription 
 
Transcription is a complex part of qualitative research involving the writing down of 
the spoken discourse. It is acknowledged that the written account does not entirely 
capture the mental, social, and cultural components of the individual (Kowell and 
O’Connell 2013).  Although the University does not offer transcription training, 
sources explaining how to do this will be utilised ( McLellan et al. 2003; Kowell and 

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27 
 
O’Connell 2013; University of Essex 2015). Interviews will be transcribed verbatim by 
myself as soon as possible after the interview, to ensure data is still freshly in mind 
(Wengraf 2004).  It is expected each interview will take around 5-8 hours to 
transcribe.  
 
11 Ethical considerations 
This study will adhere to the ethical  principles of autonomy, non-maleficence, and 
beneficence (Beauchamp and Childress 2001; University of Southampton 2012).  
The participants’ well-being is of paramount importance, and will be considered at all 
stages throughout all interviews.  Participants will be reminded at each interview that 
they may withdraw their consent at any stage.  A thank-you letter will be sent to each 
participant after their interview.  
 
11.1  Consent 
 
Participants will have received a Recruitment Pack.  If participants choose to 
participate in the study, they will be requested to sign a Consent Form to be returned 
to me.  If they have been recruited by a Clinic, the signed Consent Forms will be 
securely stored by the Clinic, and I will collect the Consent Forms weekly.  If the 
participant has responded to a Poster and calls or emails me, a Recruitment Pack 
will be posted to their chosen address (i.e. home address or Clinic address) with a 
stamped addressed envelope to return the Consent Form to my home address. 
 

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11.2   Storage of data: maintaining confidentiality and anonymity 
 
Patients’ identity will be protected, and  personal data will comply with the Data 
Protection Act (GOV.UK 1998) and Research Data Management Policy (University 
of Southampton 2015b).  Data will be stored in a locked filing cabinet within my 
home office. My computer is password protected with antivirus software installed. 
Participants’ names will be anonymised by the substitution of a participant number. 
 
11.3    Participants’ family or friends involvement 
In my diabetes clinics, some patients attend with their partner.  T2D can be an 
emotive condition to discuss, and patients may need support (Kadirvelu et al. 2012; 
The Patients Association 2015).  In addition the partner may add information that is 
helpful, such as a difficulty the patient had encountered with their treatment, or ask 
additional questions that are pertinent.  
In this study, I will not encourage the presence of another person, as it is possible 
they may interject and interrupt the narrative of the participant, potentially impacting 
the gestalt (Wengraf 2004 p125).  If the participant wishes to include a significant 
person (family member or friend), I will explain how questions or comments by the 
other person may change the quality of the answers that the participant gives.  
However, it is important that the participant feels relaxed, and if the participant still 
wishes to have another person present, this will be consented to.  Details of the 
person (such as verbal consent, name and relationship to the participant) will be 
recorded.  Any interview involving another person will be discussed with the 
Supervisory team and Wengraf, and analysed to see if the interview is still suitable 
for BNIM analysis. 

Natasha Duke 
 
29 
 
 
11.4   Risks  
A Risk Assessment Form outlines possible risks to the participants and researcher, 
and measures that will be taken to address hazards (Appendix 7).  The key hazard 
identified is that of emotional or spiritual distress (McSherry and Ross 2002).  
 
11.4.1  Distress to participants/researcher 
My nursing role involves consultations with patients who may become distressed 
when discussing emotive subjects. As when nursing, if participants become 
unsettled or distressed during an interview, I would listen in an empathic non-
judgemental manner; ask if they are comfortable to continue with the interview, and 
ask if they would like to have a break or stop the interview. I would signpost them to 
further support arranged such as a counsellor, GP, or spiritual advisor (e.g. priest, 
rabbi, imam or any person they may identify).  There is also potential I may become 
unsettled by information disclosed.  If this occurs, support would be sought from the 
Supervisors. 
 
11.4.2 Risky health behaviours 
If the person disclosed issues that I know could seriously harm their health - such as 
dangerously incorrect use of insulin – they would be urged to contact their GP, or 
ask if they would like me to contact their GP, or the Diabetes Clinic on their behalf.  
In any of these instances, the Supervisors would be contacted for further advice. 
 

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30 
 
12  Resources and costs 
 
The recording equipment will be provided by the Faculty of Health Sciences, 
University of Southampton.  Costs such as letters, stamps and other consumables 
will be met by myself. 
 
13 Timetable 
 
I aim to spend 2 days a week on this study.  Work as an advanced nurse practitioner 
involves 3 days a week and enables me to self-fund this study. It is hoped to 
complete this research by October 2018.  
 
14 Dissemination 
It is an ethical obligation to ensure research findings are disseminated to the relevant 
bodies, such as the participants and health professionals (Yale Center for Clinical 
Investigation 2009).    At the culmination of this study, it is anticipated that the finding 
will 
• identify how the spirituality of people with T2D impacts their coping with their 
self-management 
• identify if and how the spirituality of people with T2D impacts their approach to 
their diet 
• identify if and how the spirituality of people with T2D impacts their approach to 
their exercise 

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31 
 
• if spirituality impacts patients’ self-management, to encourage clinicians to 
incorporate individual patient’s spirituality into their planned care 
 
It is planned the results of this research will be presented back to participants, 
presented at teaching settings/conferences and published in various peer reviewed 
journals. Journals will be those focused on clinical practice, T2D, and nursing.  
Participants will be sent a letter advising of the results of the research, and an offer 
will be made for me to visit them to discuss the findings if they wish this. 
 
 
 
 
 
 
 
 
 
 
 
 
 

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32 
 
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Natasha Duke 
 
44 
 
University of Southampton (2015) ERGO: Ethics and Research Governance Online. 
Available from: https://www.ergo.soton.ac.uk/ [Accessed 6 March 2015] 
 
University of Essex (2015) Create and Manage Data.Transcription. Available from: 
http://www.data-archive.ac.uk/create-manage/format/transcription [Accessed 6 
August 2015] 
US Government (2014a) Medicaid.gov.  Available from: http://www.medicaid.gov/. 
[Accessed 12 March 2015] 
US Government (2014b) Medicare.gov. Available from: http://www.medicare.gov 
/about-us/about-medicare.html. [Accessed 12 March 2015] 
Utz S, Steeves R, Wenzel J, Hinton I, Jones R, Andrews D, Muphy A and Oliver M 
(2006) “ Working Hard With It ” by Rural African Americans. Family and Community 
Health 29(3): 195–205 
Van Manen M (1990) Researching Lived Experience: Human Science for an Action 
Sensitive Pedagogy (SUNY Series, the Philosophy of Education). London Ontario: 
The University of Western Ontario 
Wengraf T (2004) Qualititative Reseach Interviewing. London: SAGE Publications 
Inc. 
 Wengraf (2015) The BNIM Short Guide and Detailed Manuals: Interviewing For Life-
Histories, Lived Situations And Personal Experience. Available from: 
tom@tomwengraf.com 

Natasha Duke 
 
45 
 
Yale Center for Clinical Investigation (2009) Beyond Scientific Publication: Strategies 
for Disseminating Research Findings. New Haven: Yale Center for Clinical 
Investigation  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Natasha Duke 
 
46 
 
 
 
 
 
 
16 Appendices 
 
Appendix 1:  Literature Review Adapted Prisma Diagram………………………..44 
Appendix 2:  Literature Review Mindmap…………………………………………..45 
Appendix 3:  Key Studies Analysed…………………………………………………46 
Appendix 4:  Questions for Participants…………………………………………….59 
Appendix 5:   Recruitment Poster……………………………………………………61 
Appendix 6a:  Recruitment Pack Participant Information Sheet…………………62 
Appendix 6b:  Recruitment Pack Consent Form…………………………………..68 
Appendix 7:  Risk Assessment Form……………………………………………….69 
 
 
 
 
 
 
 
 
 
 
 

Natasha Duke 
 
47 
 
 
 
 
Appendix 1: Adapted PRISMA 
 

45 
 
Appendix 2: Mindmap 

46 
 
Appendix 3: Key studies analysed 
1. 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Amirehsani 
(2011) 
 
(PhD 
Thesis) 
 
N=75 
 
Looks at spiritual, 
and 
complementary 
and alternative 
practices (CAMP) 
in Latino and 
Hispanic people, 
and notes how it 
impacts hba1c in 
diabetics.  
 
 
Cross sectional, 
correlational. 
Interviews. 
Leininger's culture 
care diversity and 
universality theory 
and sunrise 
enabler were used 
as the conceptual 
framework. 
 
Male and female in 
new emerging 
Latino and Hispanic 
area in North 
Carolina, America. 
 
67% female 
33% male. 
 
Religion was 
mostly Christian. 
 
 
Lower income Latino/Hispanic 
people are more likely to use 
CAMP and not inform doctor. 
Use CAMP because of belief in 
it; cheaper; difficulty with 
American healthcare system. 
Age and gender, and 
environmental context appear 
to impact cultural and social 
aspects; CAMP use; medical 
model of diabetes self-care, 
which all affect hba1c.  
 
45% trusted CAMP with 
prescriptions; 44% trusted 
prescriptions; 5% trusted CAMP 
only. Some participants adjusted 
prescription medicines the day 
they used CAMP.   
 
Participants wanted doctors to 
include faith-based remedies as 
part of their care. 
 
 
Specific identity of 
people group means 
findings may not be 
same to other non-
Latino/Hispanic 
people. Participants 
may give limited 
answers to White 
researchers. Hba1c 
only reported as 
either > or < than 
7%. 
 
As cross sectional, 
does not inform 
about changes over 
time, so cannot 
inform about how 
progressive nature 
of diabetes 
affects self-care.  
 
 
 

Natasha Duke 
 
47 
 
2. 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Decoster 
and 
Cummings 
(2005) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N=34 
 
Explored coping 
methods of 
American 
diabetics. 
Ascertained if this 
was influenced by 
gender or race, 
and analyzed 
coping with 
relation to 
diabetes. 
 
 
 
An exploratory 
research design 
using a mixed-
methodological 
approach, and 
interviews. 
 
American Black, 
and 
American Non-
Latino White. 
 
9 Black females,  
5 Black males 
 
15 White females,  
5 White males. 
 
No religion 
specified, although 
religious questions 
asked were related 
to Christianity (e.g. 
questions related 
to Bible study, or 
gospel music). 
 
 
 
 
 
 
 
Diabetic adults with type 2 
diabetes use different coping 
methods, influenced by race 
and gender.  Participants used 
either problem-focused or 
emotion-focused methods to 
cope with diabetes. 
 
Problem based = better control, 
emotion focused = worse 
control.  
 
Most common coping strategies 
were prayer, faith in God and 
pre-occupy the mind.  
 
 
 
 
 
 
 
 
 
 
 
 
Living in a large mid-
South city in 
America, results may 
be different for 
other types (e.g. 
rural American 
Blacks or American 
Whites). 
 
Samples not even – 
large amounts of 
females. 
 

Natasha Duke 
 
48 
 
3. 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Egede and 
Ellis (2010) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N=216 
 
Describes 
development and 
validation of the 
Diabetes Fatalism 
Scale (DFS) in 
adults with type 2 
diabetes. Three 
constructs: 
emotional 
distress; poor 
religious and 
spiritual coping; 
poor perceived 
self-efficacy. 
 
35 items were 
derived from focus 
groups, literature 
review, and expert 
opinion. Pilot 
tested. Analysis 
resulted in 12-item 
scale. Used to test 
the DFS's 
association with 
diabetes self-care, 
hbA1c and quality 
of life. Multiple 
linear regression 
used to assess DFS, 
hbA1c comorbidity 
and insulin use. 
 
American 
Black 61%. 
American  
White 39%. 
 
From South-East of 
America. 
 
Religion not 
identified. 
Higher scores= greater diabetes 
fatalism. Scores not significantly 
correlated with age, years of 
education, or diabetes duration. 
White Americans, men, those 
with government or no 
insurance, and those with 3+ 
comorbid conditions had 
significantly higher DFS scores.  
 
DFS was significantly correlated 
with self-management adjusting 
for demographics, comorbidity 
and insulin use, the DFS was 
independently associated with 
increased hbA1c. The DFS is a 
valid and reliable measure of 
diabetes fatalism.  
 
Diabetes fatalism is associated 
with self-care problems, poor 
glycaemic control, and 
decreased quality of life. 
 
 
 
 
 
Did not identify how 
recruitment 
occurred, so limits 
transferability. 
 
Participants were 
low income, so could 
be a confounding 
factor. 
 
Religion not 
identified, so limits 
transferability. 
 
Samples not even – 
large amounts of 
American Blacks. 
 
 
 

Natasha Duke 
 
49 
 
4. 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Harris 
(2008) 
 
PhD Thesis 
 
N=534 
 
Investigates if 
American 
diabetics in 
Eastern North 
Carolina using 
spirituality as a 
coping 
mechanism have 
better health 
conditions. 
 
Mailed survey.  
Analysed using 
multiple regression 
and multiple 
logistic regression. 
 
All were American: 
Black    69% 
White  28% 
Other     3% 
 
63% female 
37% male 
 
Christian 72% 
None         4% 
Other      14% 
No data   10% 
 
Participants using spirituality as 
a coping mechanism for their 
diabetes have significantly lower 
current mean hba1c. 
Males have significantly lower 
hba1c than females. 
 
American Blacks have 
significantly lower mean hba1c 
levels than other races.  
 
Higher educated have 
significantly lower mean hba1c 
levels (masters or doctoral 
degrees). 
 
Older participants (62 years to 
105 years) have significantly 
lower current mean A1c levels 
than younger. 
 
 
 
 
 
 
 
Relied upon self-
reporting of hba1c. 
 
Data limited to 6 
months, so 
longitudinal study 
would give greater 
validity. 
 
Samples not even – 
large amounts of 
females, and 
American Blacks. 
 

Natasha Duke 
 
50 
 
5 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Hjelm et al. 
(2005) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N=35 
 
Explored health 
and illness beliefs 
of middle-aged to 
older men from 
different cultural 
backgrounds, 
who were living 
in Sweden. 
 
 
 
 
 
 
 
Explorative design 
with focus group 
interviews. 
 
14 Arab males. 
 
10 former-
Yugoslavian males. 
 
11 Swedish males. 
Important health factors were 
being occupied/employed, 
income, and sexual functioning: 
participants believed that these 
affected their diabetes.  
 
Arabs and former Yugoslavians 
believed supernatural factors 
and stress have negative health 
effects. Some Arabs believed 
having diabetes may be Allah’s 
will for them, but demonstrated 
better health-seeking 
information.  
 
Although the former- 
Yugoslavians described health as 
‘the most important thing in 
life’, they had the least healthy 
lifestyle in terms of diet, 
exercise and smoking.  
 
Swedes focused on heredity 
factors, lifestyle and self-
management. 
 
 
 
Age was 39-78, so 
younger persons 
may have different 
outcomes. 
 
Small sample size. 
 
Used interpreters. 

Natasha Duke 
 
51 
 
6 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Hart and 
Grindel 
(2010) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N=119 
 
Examined 
relationship of 
illness 
representations, 
emotional 
distress, coping 
strategies and 
coping efficacy as 
predictors of 
hba1c in 
American 
diabetics from 
Georgia, America.  
Did not include 
spirituality. 
 
Descriptive, cross 
sectional, 
correlational 
design. Used Self-
Regulation Theory 
to analyse 
questionnaires. 
 
American White 
75%. 
American Black 
21%. 
Other 4%. 
 
55 male. 
64 female. 
 
Found good coping 
efficacy=better diabetes control. 
 
Psychosocial factors influence 
self-management, hba1c values 
and therefore diabetes 
outcomes. 
 
Coping efficacy accounted for 
9% in variance of self-
management. 
 
Illness accounted for 12% 
variance in self-management.  
 
 
Recruited from 
diabetes health care 
programs, or health 
appointments, which 
may mean 
participants are 
more focused than 
non-attenders. 
 
Was cross sectional, 
so cannot inform 
about how 
progressive nature 
of diabetes 
affects self-care. 
 
Samples not even: 
large amounts of 
American Whites. 
 
Majority were white 
and well educated, 
which affects 
transferability. 
 
 
 

Natasha Duke 
 
52 
 
7 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Jones et al. 
(2006) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N=68 
 
 
 
 
Focus groups  
explored the use 
of CAMP, religion 
and spirituality 
with diabetic 
American Blacks.   
 
Descriptive study in 
2 rural 
communities in 
Central Virginia, 
America.  
 
This study was part 
of a larger study to 
identify facilitators 
and barriers to self-
management of 
diabetes. 
 
Focus group 
sessions in 
community 
settings that  
described their use 
of CAMP.  
 
 
  
 
American Blacks 
 
39 female 
29 men. 
 
Protestant or 
Baptist 
American Blacks.  
 
 
 
Participants used prayer as a 
coping strategy; diet based 
therapy; and natural products. 
 
Women use CAMP more than 
men. 
 
These participants did not use 
CAMP as an alternative to 
prescription medicines, as in the 
Amirehsani (2011) study. 
 
Three groups emerged: 
 (1) Those who use prayer and 
faith  
(2) Those who believe God helps 
healthcare providers 
(3) Those who see a link 
between faith and treatment. 
 
 
 
 
Results may only 
apply to these 
specific groups 
(Protestant or 
Baptist Amercain 
Blacks).  

Natasha Duke 
 
53 
 
8 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Lundberg 
and Thrakul 
(2013) 
 
N= 48 
 
 
 
Qualitative study 
to assess how 
religion affects 
diabetic self-
management.  
 
Semi-structured 
interviews and 
observation.  
Health Belief 
Model and 
Keonig’s 
Theoretical Model 
analysed data. 
 
Thai women in 
Bangkok. 
 
19 Buddhist 
29 Muslim 
 
Religion is a way of coping: 
Buddhists accept fate and illness 
due to previous sins; Muslims 
believe Allah controls people’s 
health and he can heal.   
 
Religions can help and hinder 
self-management. Spiritual 
practices helped coping.  
 
Buddhists didn’t exercise whilst 
Muslims did exercise– but this 
seemed income related.  
 
Cultural factors affected diet – 
Buddhists eat lots of rice and 
found adaptation to a diabetic 
diet difficult. 
 
Family supported diet, exercise, 
medication, and doctor’s visits.   
 
 
 
 
 
 
Small sample size.  
 
Blood glucose data 
given by women was 
not accurate- so was 
not used, but raises 
concerns over other 
information given by 
participants.  
 
No previous data 
about religious 
practices before 
diagnosis.  
 
 
 
 
 
 

Natasha Duke 
 
54 
 
9 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Polzer and 
Miles 
(2007) 
 
N= 29 
 
 
Aimed to develop 
a theoretical 
model about how 
the spirituality of 
American Blacks 
affects their 
diabetic self-
management.  
 
Grounded theory, 
using minimally 
structured 
interviews, and 
constant 
comparison. 
 
Religious American 
Blacks.  
 
60% female 
40% male 
 
Included Christian 
Church 
Ministers. 
 
Participants fell into one of 
three typologies: 
(1) Relationship and 
Responsibility: God is in 
Background 
(2) Relationship and 
Responsibility: God is in 
Forefront 
(3) Relationship and 
Relinquishing of Self-
Management: God is Healer.  
 
These typologies varied 
according to how participants 
viewed their relationship with 
God, and this impacted their 
self-management.   Spirituality 
was linked to the denomination 
of church they attended.   
 
Group 1 had mean educational 
level of Batchelor’s degree. 
 
 
 
 
Sample size only 
included Protestant 
American Blacks.  
 
Age was >42 years, 
so findings may not 
apply to younger 
American Black 
religious diabetics. 

Natasha Duke 
 
55 
 
10 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Polzer 
Casarez et 
al. (2010) 
 
 
 
N=18 
 
Qualitative study 
showing 
American Blacks 
in Texas, America 
use spiritual 
orientations to 
help manage or 
cure diabetes. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Qualitative, 
descriptive 
approach with 
interviews.  
 
American Blacks 
 
4  males 
14 females 
 
Christian 
 
Black Christians found 3 
cohorts:  
(1) use spiritual practice aiding 
self-management 
(2) spiritual practice and self-
management towards healing; 
(3) spiritual practice as healing. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Small sample size. 
 
Samples not even – 
large amounts of 
females. 
 
Recruited only those 
> 40 years old, so 
limits transferability 
to younger diabetics. 
 
Recruited from 
Christian Churches, 
and senior citizens 
housing. Only 
persons interested 
in spirituality were 
likely to be 
recruited. 
 
 
 
 
 
 
 

Natasha Duke 
 
56 
 
11 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Peyrot et al. 
(1999) 
 
N=118 
 
 
 
Compared type 1 
and type 2 
diabetics bio-
psycho-social 
risks, comparing 
emotion and 
problem based 
coping.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Paper 
questionnaire 
assessing hba1c 
and insulin 
injections;  stress- 
using Hassel’s 
scale; coping- using 
Wilson scale; and 
socio-demo- 
graphic data. 
 
Ethnicity not 
recorded, but 
recruited from 
Michigan hospital 
in America. 
 
83% female 
17% male. 
 
Religion not 
recorded. 
 
N= 57: Had type 1 
diabetes 
 
N= 61:  Had type 2 
Diabetes 
 
 
 
 
 
 
Relationship to stress, emotion, 
non-adherence to insulin are 
intertwined.   
 
Biological factors interact with 
psychosocial factors that impact 
hba1c.  Stress and coping affect 
hba1c.  
 
Psychosocial factors relating to 
hba1c are stronger in Type 1.  
 
Relationships of psychosocial 
factors and glycaemic control 
differ for transient and chronic 
control: stable psychosocial 
resources are linked to chronic 
control, and stress/adherence 
to transient control. 
 
Participants with 
Type 1 will have had 
disease much longer 
than Type 2, and this 
could be a 
confounding factor. 
 
Samples not even – 
large amounts of 
females. 
 
Type 2 were older 
and this could have 
affected coping 
style. 
 
Participants were 
drawn from hospital 
based clinic. By 
reason of actually 
attending hospital 
appointment, 
showed they already 
engaged well in 
treatment. 
 

Natasha Duke 
 
57 
 
12 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Rovner et 
al. (2013) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N=110 
 
Surveys analysed 
diabetic American 
Blacks, assessing 
present-time-
orientation, and 
future-time-
orientation with 
religiosity; as well 
as exercise; 
checking blood 
glucose and 
reading food 
labels. 
 
Paper 
questionnaire 
survey. x² analysis 
for categorical 
data, and one way 
analysis of variance 
for continuous 
data.  
 
American Blacks. 
 
80% female 
20% male. 
 
 
 
 
 
 
 
Time-orientation relates to 
participants’ focus on short or 
longer term consequences.   
 
Future-time-orientation 
participants related their 
current health behaviours with 
future disease progression.  
 
Participants engaging in exercise 
had significantly higher 
religiosity and future-time-
orientation, although clear 
reasons for this were not 
identified.  
 
 
Convenience 
sampling and older 
age group may 
influence findings.  
Samples not even – 
large amounts of 
females. 
 
Did not analyse type 
of religion, although 
it was implied it was 
Christian, as many 
participants 
attended church. 
 
Older participants’ 
future-time 
orientation could be 
influenced by other 
health concerns or 
impending demise. 
 
 
 
 
 

Natasha Duke 
 
58 
 
 
 
13 
Author 
N 
Summary 
Method 
Ethnicity 
Gender 
Religion 
Key Findings 
Limitations 
 
 
Thinganjana 
(2007) 
 
 
PhD 
Thesis 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N= 16 
 
Describes the 
lived experience 
of spirituality of 
Thai immigrants 
in the United 
States who are 
living with type 2 
diabetes. 
 
Descriptive 
phenomenological 
method. Open 
ended interviews.  
Analysed using 
Colaizzi's method 
(1978).  
 
 
Thai immigrants 
living in the 
Richmond 
Metropolitan 
Statistical Area, 
other cities of the 
State of Virginia, 
and New York City. 
 
4 male 
12 female. 
 
Buddhists. 
  
 
Five main themes:  
(1) Sequela of Diabetes 
(2) Coming to Terms with 
Diabetes 
(3) Managing Diabetes 
(4) Religion is Intertwined with 
Spirituality 
(5) Cultural Patterns. 
 
Spirituality is finding meaning 
and purpose in life; a sense of 
relatedness; understanding the 
fundamental nature of human 
life; and the indispensable 
expression of joy, happiness, 
soothing, calm, peace, security, 
hope and inner strength. 
 
Important for clinicians to 
understand beliefs other than 
their own. 
 
Results only applied 
to this specific group 
(Thai immigrants in 
America). 
 
Samples not even – 
large amounts of 
females. 

59 
 
 
Appendix 4  
QUESTIONS FOR PARTICIPANTS 
Version : V1 
Date: 12 November 2018 
Study Title: How does the spirituality of a group of British people with type 2 
diabetes impact their coping and self-management of their condition? 
ERGO Study ID number:  
Student: Natasha Duke 
Supervisors: Professor A Le May; Dr W Wigley 
 
Interviews 
Sub-sessions One and Two are on the same day, usually about 15 minutes apart.  
Sub-session Three is about one month later. 
Sub-session One:  
The ‘Single Question aimed at Inducing Narrative’ for Biographic-Narrative Interview 
Method sub-session one interview is: 
“As you know I’m researching people’s stories of living with type 2 diabetes.  
Please could you tell me your story from when you first became aware that 
you might have diabetes up to now.  You can start wherever you like.  Please 
take all the time you need.  I’ll listen first, I won’t interrupt.  I’ll just take some 
notes in case I have any further questions for after you’ve finished telling me 
about it all.” 
 
Sub-session Two:  
Questions may be asked only of topics that have been raised by the participant in 
Sub-session One; only in the order the participant raised them; only using the words 

Natasha Duke 
 
60 
 
and phrases used by the participant. No other questions may be asked unless they 
have been raised by the participant in Sub-session One.  Questions will be asked 
that induce narrative. 
 
Sub-session Three: 
This session allows the researcher to ask any questions related to the study, and do 
not have to induce narratives.  Questions to be asked, if these topics have not arisen 
in Sub-session One and Two include:  
• What is it that gives you strength to cope with the challenges in life? 
• Have any particular spiritual practices or religious beliefs help you cope with 
your diabetes? 
• Can you tell me about how having diabetes may have impacted your diet and 
exercise? 
 
Some further questions may arise from the answers the participant gives.  
The principles of BNIM will be used – any question will use the words and phrases 
used by the participant. 
 
 
 
 
 
 
 
 
 

Natasha Duke61 
 
 
                                                                                              Appendix 5 
Start date:                        Site: North Baddesley Surgery/Alma Road Surgery/Community Diabetes Clinic 
End date:                          
Version: v1                             
ERGO Study ID number:     
 
Do you have Type 2 Diabetes?    Would you like to tell us what it is like living with this condition? 
A lot of research focuses on the physical aspects of diabetes, but this study wants to listen to how diabetes affects people on a day 
to day basis, and what gives them strength and helps them cope with this condition.  I am a doctoral student from the University of 
Southampton, and would like to hear from you if you would like to be involved in this study. 
I will listen to you telling me what it is like living with diabetes, and ask you some questions to better understand how your beliefs 
may affect you managing your diabetes.  If you are happy, I will also conduct a second interview with you about one month later. 
You can decide where you would like to meet.  I can come to your home, but if you prefer we can meet at the University.  If you are 
interested, please contact Natasha Duke.  You can email me at:  nd2g13@soton.ac.uk, or call me on 07792 739 574.  There are 
‘tear off slips’ below with details that you can rip off to take the details home. 
 
 
 
 
 
 
 
Contact : Natasha Duke 
Email: 
nd2g13@soton.ac.uk 
Call: 07792 739574 
Contact : Natasha Duke 
Email: 
nd2g13@soton.ac.uk 
Call: 07792 739574 
Contact : Natasha Duke 
Email: 
nd2g13@soton.ac.uk 
Call: 07792 739574 
Contact : Natasha Duke 
Email: 
nd2g13@soton.ac.uk 
Call: 07792 739574 
Contact : Natasha Duke 
Email: 
nd2g13@soton.ac.uk 
Call: 07792 739574 
Contact : Natasha Duke 
Email: 
nd2g13@soton.ac.uk 
Call: 07792 739574 

Natasha Duke62 
 
 
Appendix 6a 
PARTICIPANT INFORMATION SHEET  
 
 
 
Version: V1 
Date: 12 November 2018 
Study Title: How does the spirituality of a group of British people with type 2 
diabetes impact their coping and self-management of their condition? 
ERGO Study ID number:  
Student: Natasha Duke 
Supervisors: Professor A Le May; Dr W Wigley 
---------------------------------------------------------------------------------------------------------------- 
 
1. Thank you for taking the time to read this information sheet.  Please 
read it carefully before deciding to take part in this research.  If you are 
happy to participate, please sign and date the consent form enclosed in 
this pack.  If you have received this Recruitment Pack from your GP or 
Diabetes Clinic, please give the signed Consent Form to Reception. If 
you have received this in the post, please return the signed Consent 
Form in the stamped envelope to the Researcher Natasha Duke.   
 
2. What is the research about? 
People with type 2 diabetes have to cope with managing their diabetes in a number 
of ways, e.g. managing their diet and exercise.  This study would like to explore what 
gives people strength and helps them cope with this in day to day life.  Research so 
far has shown that people use all sorts of ways to help them cope, and some people 
have found spiritual practices help them cope with having diabetes.   
Spiritual practices are unique to each person.  They could include prayer, meditation, 
complementary medicines or vitamin use, new age practices, spiritual healings, 

Natasha Duke63 
 
63 
 
massage, acupuncture, naturopathy, herbs, guided imagery, hypnotherapy and 
many others. Some people find their belief in God or gods helpful, and this gives 
them comfort and strength. 
 
3. Why have I been chosen? 
You have been invited to take part because you have type 2 diabetes. Anyone can 
take part as long as they:  
• have had type 2 diabetes for at least  6 months  
• are over 18 years old 
• speak English 
• are happy for details about their diabetes to be obtained from their GP’s or 
Diabetes Clinic computer records (e.g. their blood test results) 
• and have signed and dated a Consent Form 
 
4. What will happen to me if I take part? 
The researcher from the University of Southampton will contact you to find a time 
that is convenient for you to talk to her about what it is like living with type 2 diabetes.  
Most people would like to talk about this in their own home, but if you prefer it can 
take place at the University of Southampton.   
The interview is recorded on a small tape recorder, and the researcher will also take 
some notes.  There are 2 parts to the first interview, with a break of around 15 
minutes in the middle.  The interview can last for as long or a short as you like; the 
usual time is anything from around 30 minutes to 2 hours.  The researcher will then 
arrange to have a follow up interview about one month later.   

Natasha Duke64 
 
64 
 
If you decided not to continue with any interview at any stage, you can simply tell the 
researcher, and the interview will end.  
5. Are there any benefits to me taking part? 
There are no payments given for taking part in this research.  Most people take part 
in diabetes research because they would like to contribute to improving the lives of 
people with this condition. 
6. How do I know this study is safe? 
This study has already been examined internally by the Research and Governance 
Office at the University of Southampton, and externally examined by the NHS 
Research Ethics Committee, and has been deemed safe.  Your usual diabetes 
treatment will not be affected in any way by taking part in this study. 
7. Are there are risks to me if I take part?    
Some people may feel emotional discussing their experience of living with diabetes, 
If you wish to stop the interview at any stage, the interviewer will finish the interview.  
If you wished for the researcher to delete anything from the record, she will do this.  
8. Will what I say be confidential, and who will have access to my details?  
This study complies with the University of Southampton’s ethical guidelines for 
confidentiality.  All the names of the participants involved will be anonymised by a 
number (e.g. P1), and details will be kept in password protected computers, or 
locked filing cabinets.  No details in the study will refer to any person by name.  
Although it is unlikely, if something you said caused the researcher to be seriously 
concerned that your health was in danger, she would discuss this with you and about 
contacting your GP.  

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9. What information will you be collecting about me? 
In order to provide background information about your type 2 diabetes, the 
researcher will need to collect some information about your diabetes from your GP or 
Diabetes Clinic database.  These will include: 
• your living situation, i.e. if you are living alone or with a family/partner.  It will 
help this study to understand if you alone manage your diabetes, or if your 
family/partner help you with this, for example with cooking meals.  
• your date of diagnosis of type 2 diabetes  
• your age 
• your diabetes blood sugar test (called an ‘hba1c’ test) 
• your body mass index  
• medicines you are taking for type 2 diabetes 
 
10. What happens if I change my mind, and don’t want to be involved in the 
study anymore? 
You can withdraw from the study at any time.  You may stop an interview at any time 
if you don’t wish to continue.   
 
11. What happens if after I have taken part, I change my mind and don’t 
want you keeping information about me? 
If you change your mind about being involved in the study, you can withdraw your 
consent at any time.  You would need to contact the researcher or the University of 
Southampton to let them know (the address is given below).  In this case, all the 

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information about you will be deleted.   This will not affect your diabetes care with 
your Doctor or Nurse in any way.  
 
12. What will happen to the findings of this study? 
The results of this study will be published in health professional journals, discussed 
at health conferences, and used in the education of health professionals.  The aim of 
this is so that health professionals can give better, more holistic care to people with 
type 2 diabetes.  No identifiable data will be used that will link the information directly 
to you. 
 
13. Will I be told about the results of the research afterwards? 
Yes.  The researcher will arrange for a letter to be sent to you, to inform you of the 
outcomes of this research.  If you choose to participate in this research, but you do 
not wish to know about the results of the research (when it’s completed in around 2-3 
years), please let the University researcher know this. 
 
14. What are the benefits of this research? 
The aim of this study is for health professionals to have a greater understanding of 
the complexities of living with type 2 diabetes, and to be able to offer better 
consultations for people living with type 2 diabetes.  
 
 

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15. What happens if I have a concern, or I am unhappy with what the 
researcher is asking? 
If you have a concern about the study or wish to withdraw from it, you should contact 
Dr Wendy Wigley, who is one of the Supervisors of this study. 
• You can email Dr Wigley:  w.wigley@soton.ac.uk  
• or write to: Dr Wigley, Faculty of Health Sciences, Room 2030, Building 45, 
University of Southampton, SO17 1BJ.   
 
16. What can I do if I want to make a complaint about this study? 
If you have more than just a concern, and you wish to make a complaint about this 
study, then you can: 
• write to the Research Integrity and Governance Manager at the University of 
Southampton, Highfield SO17 1BJ  
• or email the Research Integrity and Governance Manager Trudi Bartlett at 
rgoinfo@soton.ac.uk  
• or call the Research Governance Office on 02380 595058. 
 
 
 
 
 
 
 
 
 
 

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Appendix 6b 
Study Title:  How does the spirituality of a group of people with type 2 diabetes, living in England, influence 
their coping and self-management of their condition?  Student: Natasha Duke.  Supervisors: Professor A Le 
May; Dr W Wigley. Version: v4.    ERGO No: 18602    IRAS No: 168308      Date: 12 November 2018 
Please initial each box, if you agree with the statements below. 
1.  I have read and understood the Participant Information 
Sheet (V3, 18 May 2016). 
 
2. I consent to interviews that will be recorded.  
I have opportunity to ask questions about the study. 
 
3.  I agree to take part in this research, and agree for   
 
 
information about me to be used for the purpose 
of this and future research only. 
 
4.  I understand my involvement is voluntary, and I can withdraw my  
consent at any time, and stop my involvement, and all information  
about me will be deleted. My legal rights will not be affected. 
 
5.  I understand if I am unhappy with any aspect of 
this study I may contact the University. 
 
6. I understand that relevant sections of my medical notes and data collected           
during the study, may be looked at by individuals from regulatory 
authorities or from the NHS Trust, where it is relevant to my taking part 
in this research.  I give permission for these individuals to have access to  
my records. 
 
Data Protection 
 
I understand that information collected about me during my participation in this study will be 
 
stored on a password protected computer and that this information will only be used for the 
 
purpose of this study. All files containing any personal data will be made anonymous. 
 
Name of Participant……………………………………………………………………………………………………. 
 
Signature of Participant……………………………………………………………………………………………… 
 
Date signed by Participant…………………………………………………………………………………………. 
 
Name of Researcher: Natasha Duke.  Signature of researcher……….……………………………… 
 
Date signed by Researcher…………………………………………………………………………………………. 
 
What to do with this form: see the Participant Information Sheet, page 1, paragraph 1 about what 
to do if you wish to take part in the research, and have signed this form. 
1 copy for participant 
1 for investigator 

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Appendix 7 
 
 
 
 
 
 
 
 
RISK ASSESSMENT OF POTENTIAL HAZARDS 
 
 
Version: v1.   Date: 12 November 2018 
 
ERGO Study ID number:  
 
Study Title: How does the spirituality of a group of British people with type 2 
diabetes impact their coping and self-management of their condition? 
Student: Natasha Duke 
Supervisors: Professor A Le May; Dr W Wigley 
 
 
Outline of study 
 
The Participants consenting for the 
study will have two interviews lasting 
approximately 30-120 minutes with the 
researcher that will be recorded.  The 
key questions asked will be as outlined 
in the Appendix 4: Questions for 
Participants 
 
 
 
Location 
 
 
 
 
 
 
 
 
 
 
 
 
 
Interviews: The Participant will choose 
whether the interview is at their home or 
the University.  The researcher will 
comply with the ‘Lone Working Policy’ of 
the University of Southampton. 

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Hazards 
 
The Participant may become upset or 
distressed. The researcher may be 
upset or distressed on hearing 
information disclosed.  
 
 
Who might be exposed to identified 
hazards 
 
 
Participants or researcher 
 
 
Planned measures to manage hazards 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The Participants will have already been 
advised that they will be asked about 
their experience of diabetes, and what 
gives them strength to cope via the 
Participant Information Sheet.   
 
If the Participant discloses their 
beliefs/spirituality/religion affects the 
management of their diabetes, the 
researcher will ask further questions 
about this.  There is potential for the  
Participant to become upset when 
discussing aspects of their diabetes,  
 

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Planned measures to manage hazards 
(continued) 
 
 
their beliefs, or how these influence 
their life.  If this occurs, the researcher 
will offer to stop the interview; to seek 
external support from the GP/spiritual 
support, or the source that the 
participant identifies (e.g. 
priest/rabbi/imam/other person or any 
other source identified by the 
Participant).  The researcher will 
arrange any follow up that the 
Participant identifies would be helpful. 
 
 
There is also potential the researcher 
could become unsettled by information 
disclosed.  If this occurs, the researcher 
would seek support from the 
supervisors. 
 
 
Risks adequately controlled? 
 
 
Yes 
 
 
 
 
 
 

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End of Appendices