NJ. Verhoeff, W. Cheema, S. Mojdehi, H. Gad, D. Mumford, MR. Waniss, A. Orszag, A. Jain, P. Bapat, D. Budhram, A. Bakhsh, MI. Abuabat, LE. Lovblom, N. Ivers, et al. (2026). Barriers to Diabetic Ketoacidosis Prevention in Adults With Type 1 Diabetes: Implications for Education and Implementation of New Monitoring Technologies. Canadian journal of diabetes, 50(2), 72-81.e2. https://doi.org/10.1016/j.jcjd.2025.11.002

PubMed 41319796

[Abstract]
OBJECTIVES: Diabetic ketoacidosis (DKA) is a major acute complication whose prevention depends on patient knowledge and self-management skills. In this study we aimed to identify the patient-level barriers to effective DKA prevention behaviours.

METHODS: We conducted a qualitative study using a behavioural science lens and implementation science methods involving 3 independent, sequential focus groups. Informed by the Action, Actor, Context, Target, Time framework, 3 targeted behaviours were defined: testing ketone levels; acting upon ketone results; and seeking emergency medical care. Deductive coding was used to categorize barriers and enablers for each targeted behaviour using the Theoretical Domains Framework. This was followed by thematic analysis and then member checking of key findings.

RESULTS: Twenty-two participants (9 with type 1 diabetes, 1 caregiver, 12 health-care providers) contributed to 1 of 3 focus groups. Key barriers to engaging in the target behaviours were 1) a lack of understanding of the clinical relevance of ketones; 2) inability to retain necessary steps for ketone testing and a lack of access to supplies; 3) mental health challenges, sense of identity, and resistance to change; and 4) negative experiences with and fear of stigma from the health-care system. Key enablers included 1) reminders from clinicians and technologies; and 2) community supports and accessible resources.

CONCLUSIONS: Acknowledgment of specific barriers is essential to designing future simplified DKA prevention educational tools and for implementation of continuous ketone monitoring. In a subsequent step we aim to co-create a simplified DKA prevention infographic that addresses these barriers for individuals living with diabetes.