Personal barriers to diabetes care: lessons from a multi-ethnic community in New Zealand

All-cause, premature, and cardiovascular death attributable to socioeconomic and ethnic disparities among New Zealanders with type 1 diabetes 1994-2019: a multi-linked population-based cohort study

BACKGROUND

New Zealand (NZ) research into type 1 diabetes mellitus (T1DM) mortality can inform policy and future research. In this study we aimed to quantify the magnitude to which ethnicity and socioeconomic disparities influenced mortality at the population level among people with Type 1 diabetes (T1DM) in Auckland, New Zealand (NZ).

METHODS

The cohort data were derived from the primary care diabetes audit program the Diabetes Care Support Service (DCSS), and linked with national primary care, pharmaceutical claims, hospitalisation, and death registration databases. People with T1DM enrolled in DCSS between 1994-2018 were included. All-cause, premature, and cardiovascular mortalities were estimated by Poisson regression models with adjustment for population-level confounders. The mortality rates ratio (MRR) was standardized against the DCSS type 2 diabetes population. Mortality rates were compared by ethnic group (NZ European (NZE) and non-NZE) and socioeconomic deprivation quintile. The population attributable fraction (PAF) was estimated for ethnic and socioeconomic disparities by Cox regression adjusting for demographic, lifestyle, and clinical covariates. The adjusted slope index inequality (SII) and relative index of inequality (RII) were used to measure the socioeconomic disparity in mortalities.

RESULTS

Overall, 2395 people with T1DM (median age 34.6 years; 45% female; 69% NZE) were enrolled, among whom the all-cause, premature and CVD mortalities were 6.69 (95% confidence interval: 5.93-7.53), 3.30 (2.77-3.90) and 1.77 (1.39-2.23) per 1,000 person-years over 25 years. The overall MRR was 0.39 (0.34-0.45), 0.65 (0.52-0.80), and 0.31 (0.24-0.41) for all-cause, premature and CVD mortality, respectively. PAF attributable to ethnicity disparity was not significantly different for mortality. The adjusted PAF indicated that 25.74 (0.84-44.39)% of all-cause mortality, 25.88 (0.69-44.69)% of premature mortality, 55.89 (1.20-80.31)% of CVD mortality could be attributed to socioeconomic inequality. The SII was 8.04 (6.30-9.78), 4.81 (3.60-6.02), 2.70 (1.82-3.59) per 1,000 person-years and RII was 2.20 (1.94-2.46), 2.46 (2.09-2.82), and 2.53 (2.03-3.03) for all-cause, premature and CVD mortality, respectively.

CONCLUSIONS

Our results suggest that socioeconomic disparities were responsible for a substantial proportion of all-cause, premature and CVD mortality in people with T1DM in Auckland, NZ. Reducing socioeconomic barriers to management and self-management would likely improve clinical outcomes.

Understanding barriers to diabetes eye screening in a large rural general practice: an audit of patients not reached by screening services

Introduction Diabetes is a leading cause of blindness in New Zealanders, yet a significant proportion of patients with diabetes are not reached by diabetes eye screening. Aim Our study audited patients with diabetes in a large New Zealand rural general practice, to identify addressable barriers preventing patients from attending diabetes eye screening. Methods All patients who had missed a diabetes eye screening appointment at the Dargaville Hospital Eye Screening Clinic between 2018 and 2021 were identified. Demographic information, laboratory and disease status data were recorded and analysed. Semi-structured telephone interviews were undertaken with 66 patients exploring barriers to diabetes eye screening. Descriptive statistical analysis was performed on quantitative data and a thematic analysis on qualitative results. Results One-hundred and fifty-four (27%) of 571 patients invited to screening missed at least one appointment; of these, 66 (43%) were interviewed. Quantitative analysis suggested Māori patients were less likely to be reached, with a 20% higher number of missed appointments than European patients and a higher glycated haemoglobin (HbA1c). Māori patients reported greater barriers to attending eye screening. Common barriers identified by participants were transport, work and family commitments, financial, health and lack of appointment reminders. Discussion Increased barriers for Māori patients could explain the reduced ability of the screening service to reach Māori patients. In order to address inequity and increase overall screening rates, diabetes eye screening and primary care services need to improve the booking system, facilitate transport to screening, engage patients and their whānau and build trust.

Ethnic differences in metabolic achievement between Māori, Pacific, and European New Zealanders with type 2 diabetes

AIMS

To compare variations in metabolic target achievement by ethnicity (Europeans, Māori and Pasifika) among patients with type 2 diabetes (T2DM) in Auckland, New Zealand (NZ) between 1994 and 2013.

METHODS

32,237 patients were enrolled. Adjusted marginal difference (European as reference) of systolic blood pressure (SBP), body mass index (BMI), HbA1c and total cholesterol, alongside the proportion achieving metabolic targets were estimated using multivariable mixed effect models at baseline, 1-, 2-, 3-, 4-, and 5-years, adjusted for covariates.

RESULTS

Compared with Europeans, Māori and Pasifika had continuously, significantly higher HbA1c (by 0.3% (+3.5 mmol/mol) and 0.6% (+6.8 mmol/mol) respectively and BMI (+1.5 and +0.3 kg/m² respectively) but lower SBP (-1.8 and -3.4 mmHg respectively) and TG (-0.03 and -0.34 mmol/L respectively), and insignificantly TC (+0.004 and +0.01 respectively), by 5-years of follow-up. While 49% Europeans were within target HbA1c, this was achieved by only 30% Māori and 27% Pasifika. Conversely, 41% Europeans, 46% Māori and 59% Pasifika achieved the SBP target (all P < 0.0001).

CONCLUSIONS

Managing hyperglycemia appears to be more challenging than treating hypertension and dyslipidemia among Māori and Pasifika. New anti-hyperglycemia treatments, addressing health literacy, socioeconomic and any cultural barriers to management and self-management are urgently needed to reduce these disparities.

What we need as we get older: needs assessment for the development of a community geriatrics service in an Australian context

Background

The aim of this study was to inform the development of a Community Geriatrics Service (CGS) that addressed the healthcare and social needs of community dwelling older people in an Australian context.

Methods

Stakeholders (N = 108) took part in a ‘needs assessment’ involving 30-min semi-structured interviews with general practitioners (GPs; N = 49), and three 2-h focus groups (community engagement meetings; N = 59) with older people, informal caregivers, allied healthcare workers, and nursing home directors. Data were transcribed and thematically coded, mapped to source and weighted to the frequency that the theme was raised across sources.

Results

Five themes informing CGS development and delivery emerged: active health conditions (management of behavioural and psychological symptoms of dementia, falls, multimorbidity, and other relevant conditions), active social challenges (patient non-compliance, need for aged care social workers, caregiver stress, elder abuse, social isolation, and stigma), referrals (availability of specialists, communication, specialist input, and advance care directives), access (lack of transport options, and inaccessibility of local geriatrics clinics and specialists), and awareness (lack of awareness, knowledge, and resources).

Conclusions

The CGS will need to address access, referral processes and health system navigation, which were perceived by stakeholders as significant challenges. These findings warrant the development of a CGS with an integrated approach to aged care, pertinent for the health and social needs of the elderly.

Learning from the experience of peer support facilitators and study nurses in diabetes peer support: A qualitative study

OBJECTIVES

We report on the experiences of peer support facilitators and study nurses who participated in a large trial of peer support for type 2 diabetes. The support was led by volunteer peer support facilitators, who were trained in overcoming barriers to diabetes care, motivational interviewing, listening skills and setting up and running group support sessions. There is currently a distinct lack of qualitative evidence on what works in peer support.

METHODS

The peer support facilitators and study nurses completed open-answer questionnaire items on what worked well and less well, problems encountered and how they were resolved, group dynamics and suggestions for improvement. We also collected data from end-of-study meetings. Inductive thematic analysis was used to allow the emergent themes to be strongly based in the data.Findings: We find that process factors, peer support facilitator and peer characteristics, their relationships with each other and group dynamics are all fundamental for effective peer support. Sustaining and ending support also emerged as a key theme.

DISCUSSION

Given the increasing interest in peer support, these findings will be useful to those interested in running groups in the future. Training programmes should help peer support facilitators develop confidence whilst emphasising that peer support ideally entails an equal, democratic dynamic. More attention is needed on to how to end groups appropriately.

Living with type 2 diabetes mellitus in the Kingdom of Tonga: a qualitative investigation of the barriers and enablers to lifestyle management

BACKGROUND

Despite the increasing prevalence of Type 2 Diabetes Mellitus (T2DM) in the Kingdom of Tonga, little is known of non-communicable disease experiences among adults living in this location. This investigation aimed to explore the barriers and enablers to healthy lifestyle in a group of men and women living with T2DM residing in this Pacific Island nation.

METHODS

This qualitative study consisted of three semi-structured focus groups (n = 16), conducted at the only Tongan Public Hospital located at Nuku'alofa, capital of Tonga (north coast of the island of Tongatapu). Discussions were audio-recorded, transcribed, cross-checked for consistency, and entered into a word processing document for analysis. Thematic analysis was employed to synthesise results.

RESULTS

Four main themes were identified: (1) Knowledge and Support; (2) Fear and Motivation; 3) Physical and Psychological Environment; and (4) Faith and Culture.

CONCLUSIONS

The qualitative findings from this study will assist the future development and information dissemination of culturally appropriate lifestyle-related for men and women living with T2DM in the Kingdom of Tonga. The need for collaboration between practitioners at the hospital, the church, family members, and local traditional healers is important if the lifestyle-related needs and wants of this group of people are to be met.

Predictors of self-monitoring of blood glucose among noninsulin-treated patients with type 2 diabetes in a primary care setting in Hong Kong: A cross-sectional study

Objectives:

The current study aimed to examine the relationship between patient characteristics (internal psychological, external psychological, internal physical, external physical, and educational) and self-monitoring of blood glucose among noninsulin-treated patients with type 2 diabetes in a local primary care setting.

Methods:

This was a cross-sectional study, in which data were collected by a structured questionnaire. Correlational and multivariate multiple regression analyses were performed. Three hundred seventy-four noninsulin-treated patients with type 2 diabetes were eligible and completed the questionnaire in August 2019. The response rate was 93.5%. The respondents’ self-reported self-monitoring of blood glucose adherence was the main outcome measure.

Results:

In predicting self-monitoring of blood glucose adherence, the current regression model accounted for 12.3% of the variance (Adjusted R² = 0.123, p < 0.05), with internal psychological factors and educational factors being significant. External psychological factors, external physical factors, and internal physical factors were found to be statistically nonsignificant.

Conclusion:

The findings highlighted the facilitating role of internal psychological factors and educational factors in SMBG adherence in noninsulin-treated type 2 diabetic patients. Among these factors, the education aspect was relatively strongly associated with increased SMBG adherence. With adequate patient education on diabetes and SMBG, the increased literacy would possibly strengthen patients’ internal psychological factors and motivate them to uptake SMBG practice. Implications from the current findings suggested that further research on different SMBG parameters is warranted to fill the knowledge gap in structuring an individualized and targeted SMBG protocol for better diabetic care.

Barriers to Diabetes Self-Management in a Subset of New Zealand Adults with Type 2 Diabetes and Poor Glycaemic Control

BACKGROUND

Despite the fact that there is an increasingly effective armoury of medications to treat diabetes, many people continue to have substantially elevated blood glucose levels. The purpose of this study was to explore what the barriers to diabetes management are in a cohort of people with diabetes and poor glycaemic control.

METHODS

Qualitative semistructured interviews were carried out with 10 people with diabetes who had known diabetes and a recent HbA1c of >11.3% (100 mmol/mol) to explore their experiences of barriers to diabetes self-management and glycaemic control.

RESULTS

Barriers to diabetes management were based around two key themes: biopsychosocial factors and knowledge about diabetes. Specifically, financial concerns, social stigma, medication side effects, and cognitive impairment due to hyperglycaemia were commonly reported as barriers to medication use. Other barriers included a lack of knowledge about their own condition, poor relationships with healthcare professionals, and a lack of relevant resources to support diet and weight loss.

CONCLUSION

People with diabetes with poor glycaemic control experience many of the same barriers as those reported elsewhere, but also experience issues specifically related to their severe hyperglycaemia. Management of diabetes could be improved via the increased use of patient education and availability of locally relevant resources.

Outcomes of a church-based lifestyle intervention among Australian Samoans in Sydney - Le Taeao Afua diabetes prevention program

AIMS

To evaluate the effectiveness of a culturally adapted, church-based lifestyle intervention among Australian Samoans living in Sydney.

METHODS

This was a prospective, pre-post study of a church-wide education and support programme delivered by Community Coach Facilitators and Peer Support Facilitators to prevent, and promote self-management of, Type 2 diabetes. Participants completed questionnaires, anthropometric and HbA1c measurements before and 3-8 months after the intervention. The primary outcome was HbA1c.

RESULTS

Overall, 68/107(63.5%) participants completed both before and after intervention data collection (mean age 48.9 ± 14.2 years; 57.2% female). HbA1c dropped significantly between baseline and follow-up among participants with known diabetes (8.1 ± 2.4% (65 mmol/mol) vs 7.4 ± 1.8% (57 mmol/mol); p = 0.040) and non-significantly among participants with newly diagnosed diabetes (8.0 ± 2.1% (64 mmol/mol) vs 7.1 ± 2.3 (54 mmol/mol); p = 0.131). Participants with no diabetes increased their weekly moderate and vigorous physical activity (316.1 ± 291.6mins vs 562.4 ± 486.6mins; p = 0.007) and their diabetes knowledge also improved post-intervention (42.0 ± 13.5% to 61.3 ± 20.2%; p < 0.001). There were no significant reductions in blood pressure, BMI or waist circumference at follow-up.

CONCLUSIONS

A structured, church-based, culturally tailored lifestyle intervention showed a number of improvements in diabetes risk among Samoans in Sydney. The intervention however, requires a more rigorous testing in a larger randomised controlled trial over a longer time period.

'Diabetes is a gift from god' a qualitative study coping with diabetes distress by Indonesian outpatients

Background

More than two-thirds of patients diagnosed with type 2 diabetes mellitus (T2DM) in Indonesia encounter medical-related problems connected to routine self-management of medication and the social stigma related to T2DM. The current study aims to explore distress and coping strategies in Indonesian T2DM outpatients in a Primary Healthcare Centre (PHC) in Surabaya, East Java, Indonesia.

Methods

We conducted a qualitative study using two different data collection methods: focus group discussions and in-depth interviews. The guideline of interviews and discussions were developed based on seventeen questions derived from the DDS17 Bahasa Indonesia (a Bahasa Indonesia version of the Diabetes Distress Scale questionnaire), which covered physician distress domain, emotional burden domain, regimen distress domain and interpersonal distress domain.

Results

The majority of the 43 participants were females and aged 50 or older. Our study discovered two main themes: internal and external diabetes distress and coping strategies. Internal diabetes distress consists of disease burden, fatigue due to T2DM, fatigue not due to T2DM, emotional burden (fear, anxiety, etc.) and lack of knowledge. Internal coping strategies comprised spirituality, positive attitude, acceptance and getting more information about T2DM. External diabetes distress was evoked by distress concerning healthcare services, diet, routine medication, monthly blood sugar checks, interpersonal distress (family) and financial concern. External coping strategies included healthcare support, traditional medicine, vigilance, self-management, social and family support and obtaining information about health insurance.

Conclusion

Our study shows that for Indonesian T2DM-patients, spirituality and acceptance are the most common coping mechanisms for reducing DD. Furthermore, our study revealed an overall positive attitude towards dealing with T2DM as well as a need for more information about T2DM and potential coping strategies. Finally, an important finding of ours relates to differences in DD between males and females, potential DD associated with health services provision and the specific challenges faced by housewives with T2DM.

The knowledge, attitude and practice among diabetic patient in central region of Saudi Arabia

BACKGROUND

Diabetes mellitus is a common chronic disease with increasing prevalence world wide; it leads to devastating human, social and economic impact.

AIMS

this study were to determine the level of diabetes-related knowledge, attitude, and practice among adult diabetic patients in central region and finding correlation between knowledge, attitude and practice regarding diabetes.

METHOD

A descriptive study was conducted on 300 diabetic patients on internet using Monkey Survey from 7th to 24th April 2015. A questionnaire was filled out. SPSS version 22 was used for data analysis. Descriptive statistics were comprising percentages, and frequency in order to describe knowledge, attitude, and practice. Correlations between main outcomes variables were calculated by means of Pearson product-moment correlation coefficient (r) that measures the linear relationship between two variables. P-value ≤0.05 were regarded as statistically significant.

RESULTS

In the studied sample, 47% were age more than 45 years. About 71.4% of cases were females. The level of knowledge and attitude had 'good' in 73.6%, and 87.7% respectively but level of practice had poor in 45% of patients. There were good correlations between knowledge, attitude and practice. Significant positive linear correlation between knowledge and attitude (r = 0.503, P < 0.001), knowledge and practice (r = 0.337, P < 0.001), and statistically significant linear correlation between attitude and practice (r = 0.235, P < 0.001).

CONCLUSIONS

The overall knowledge and attitude were good, while diabetes-related practice were poor. However results indicate that an increase in knowledge will increase attitude, and practice. A better educational program on diabetes should be conducted to improve patients' attitude, and practice towards diabetes.

A Qualitative Exploration of Fijian Perceptions of Diabetes: Identifying Opportunities for Prevention and Management

Rates of diabetes are high in many communities of Pacific Island peoples, including people from Fiji. This qualitative study explores knowledge and attitudes towards diabetes among i-Taukei Fijians to facilitate the cultural tailoring of diabetes prevention and management programs for this community. Fijians aged 26 to 71 years (n = 15), residing in Australia, participated in semi-structured interviews; 53% (n = 8) were male. Interviews were audio-recorded, transcribed verbatim, then thematically analyzed. Diabetes is recognized as an important and increasing health problem requiring action in the i-Taukei Fijian community. Widespread support for culturally appropriate lifestyle interventions utilizing existing societal structures, like family networks and church groups, was apparent. These structures were also seen as a crucial motivator for health action. Intervention content suggestions included diabetes risk awareness and education, as well as skills development to improve lifestyle behaviors. Leveraging existing social structures and both faith and family experiences of diabetes within the Fijian community may help convert increased awareness and understanding into lifestyle change. Ongoing in-community support to prevent and manage diabetes was also regarded as important. We recommend building upon experience from prior community-based interventions in other high-risk populations, alongside our findings, to assist in developing tailored diabetes programs for Fijians.

Associations of different adherences in patients with type 2 diabetes mellitus

PURPOSE

The objective of our cross-sectional study is to explore the adherence behavior of patients with type 2 diabetes mellitus (T2DM) by examining the association between the various types of adherence. The success of diabetic therapy partly relies on patient motivation, psych-odemographic variables (self-efficacy, health literacy, and health locus of control [HLOC]), and adherence. The aim of our research was to explore the attitudes of T2DM patients toward medication and lifestyle therapy, thus gaining a deeper insight into the role of adherence-determining parameters in disease management.

PATIENTS AND METHODS

The sample for the present study consisted of 113 T2DM inpatients (75 women and 38 men) with a mean age of 60.56 years (SD=12.94, range: 20-85 years) diagnosed with T2DM for an average of 13 years (SD=8.23). Participants completed the Diabetes Adherence Questionnaire conceptualized by the research team in accordance with the mapping of psychological and psychosocial parameters. We examined the associations between variables using Spearman's rank correlation. Multivariate regression analysis was used to examine predictive variables for adherent behavior. In addition, we attempted to examine factors with a negative effect on adherence using factor analysis.

RESULTS

Based on our results, a high level of medication adherence negatively correlated with lifestyle adherence. Multivariate regression analysis showed that blood glucose monitoring adherence is mostly predicted by social-external HLOC, diabetes self-efficacy, and internal HLOC, while dietary adherence is predicted by the patient's self-efficacy and duration of the illness. Additionally, understanding and following the diabetes treatment were significantly associated with dietary adherence and high levels of patient self-efficacy, while health literacy was mostly predicted by internal HLOC.

CONCLUSION

Adherence to medication, diet, glucose monitoring, and physical exercise showed different levels in T2DM patients and were in association with psychodemographic factors.

Protocol for a randomised controlled trial to evaluate the effectiveness of the diabetes community exercise and education programme (DCEP) for long-term management of diabetes

INTRODUCTION

Type 2 diabetes is common in Māori and Pacific peoples and in those living in areas of high socioeconomic deprivation in New Zealand (NZ). People with type 2 diabetes often have multimorbidity, which makes their diabetes management more complex. The Diabetes Community Exercise and Education Programme (DCEP) is an interprofessional, patient-centred, whānau (family)-supported package of care specifically developed to engage with Māori and Pacific people and those living in deprived areas. We have previously demonstrated the feasibility and acceptability of the DCEP. This study aims to determine the effectiveness and cost-effectiveness of the DCEP through a pragmatic randomised controlled trial (RCT).

METHODS AND ANALYSIS

220 adults (age ≥35 years) with type 2 diabetes will be recruited from general practices in the lower South Island of NZ (Dunedin and Invercargill) to participate in an RCT. Participants will be randomised to intervention (DCEP) and control (usual care) groups. The DCEP participants will have their exercise goals agreed on with a physiotherapist and nurse and will attend two 90 min exercise and education sessions per week for 12 weeks. The primary outcome measure is blood glucose control (glycated haemoglobin). Secondary outcome measures include quality of life assessed using the Audit of Diabetes-Dependent Quality of Life questionnaire. Data will be collected at four time points: baseline, end of the 12-week intervention (3 months), 6 months postintervention (9 months) and 12 months after the intervention ends (15 months). We will also conduct a cost-effectiveness analysis and a qualitative process evaluation.

ETHICS AND DISSEMINATION

The study has been approved by the Health and Disability Ethics Committee, Ministry of Health (HDEC17/CEN/241/AM01). A key output will be the development of an evidence-based training package to facilitate implementation of the DCEP in other NZ regions.

TRIAL REGISTRATION NUMBER

ACTRN 12617001624370 p; Pre-results.

Development of an integrated, district-wide approach to pre-pregnancy management for women with pre-existing diabetes in a multi-ethnic population

BACKGROUND

Poor diabetes management prior to conception, results in increased rates of fetal malformations and other adverse pregnancy outcomes. We describe the development of an integrated, pre-pregnancy management strategy to improve pregnancy outcomes among women of reproductive age with diabetes in a multi-ethnic district.

METHODS

The strategy included (i) a narrative literature review of contraception and pre-pregnancy interventions for women with diabetes and development of a draft plan; (ii) a chart review of pregnancy outcomes (e.g. congenital malformations, neonatal hypoglycaemia and caesarean sections) among women with type 1 diabetes (T1D) (n = 53) and type 2 diabetes (T2D) (n = 46) between 2010 and 2015 (iii) interview surveys of women with T1D and T2D (n = 15), and local health care professionals (n = 13); (iv) two focus groups (n = 4) and one-to-one interviews with women with T1D and T2D from an Australian background (n = 5), women with T2D from cultural and linguistically diverse (CALD) (n = 7) and indigenous backgrounds (n = 1) and partners of CALD women (n = 3); and (v) two group meetings, one comprising predominantly primary care, and another comprising district-wide multidisciplinary inter-sectoral professionals, where components of the intervention strategy were finalised using a Delphi approach for development of the final plan.

RESULTS

Our literature review showed that a range of interventions, particularly multifaceted educational programs for women and healthcare professionals, significantly increased contraception uptake, and reduced adverse outcomes of pregnancy (e.g. malformations and stillbirth). Our chart-review showed that local rates of adverse pregnancy outcomes were similarly poor among women with both T1D and T2D (e.g. major congenital malformations [9.1% vs 8.9%] and macrosomia [34.7% vs 24.4%]). Challenges included lack of knowledge among women and healthcare professionals relating to diabetes management and limited access to specialist pre-pregnancy care. Group meetings led to a consensus to develop a district-wide approach including healthcare professional and patient education and a structured approach to identification and optimisation of self-management, including contraception, in women of reproductive age with diabetes.

CONCLUSIONS

Sufficient evidence exists for consensus on a district-wide strategy to improve pre-pregnancy management among women with pre-existing diabetes.

Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes

AIMS

To determine which barriers to care are associated with type 2 diabetes complications in an area in rural East England.

METHODS

3649 individuals with type 2 diabetes from 62 general practices were contacted via postal invitation which included a 33 item Barriers-to-Diabetes-Care Survey. Barriers were grouped into five priori major categories: educational, physical, psychological, psychosocial, and systems. The associations of reported barriers, both individually and as a group, with self-reported complications were assessed using logistic regression.

RESULTS

39.5% of participants had self-reported diabetes complications. Physical health barriers (OR = 3.3; 95%CI: 2.7, 4.0), systems barriers (OR = 1.6; 95%CI: 1.3, 2.0) and psychological barriers (OR = 1.3 (95%CI: 1.1, 1.5) were associated with diabetes complications. In subcategories, presence of comorbidities (OR = 4.8; 95%CI: 3.9, 5.9), financial difficulties (OR = 1.7; 95%CI: 1.3, 2.1), absence of services (OR = 2.0; 95%CI: 1.4, 3.0), feeling others should bear more financial responsibility for their care (OR = 1.6 (95%CI: 1.1, 2.1), no access to diabetes service (OR = 1.3; 95%CI: 1.1, 1.5), feeling worried about their diabetes (OR = 1.5; 95%CI: 1.2, 2.0) and lack of readiness to exercise (OR = 1.4; 95%CI: 1.2, 1.7) were associated with diabetes complications.

CONCLUSIONS

Barriers to self-care are significantly more common among those with, than those without, diabetes complications. Systematic identification and management of different barriers to self-care could help personalise care for those with diabetes related complications.

Implementing the Chronic Care Model for Improvements in Diabetes Care and Education in a Rural Primary Care Practice

Purpose

The purpose of this pilot study was to determine the impact of implementing elements of the chronic care model (CCM; decision support, self-management, and delivery system redesign) on providers' diabetes care practices and patient outcomes in a rural practice setting.

Methods

In this pilot study, 104 patients with type 2 diabetes and 6 providers in a rural primary care practice were involved in an intervention that included a certified diabetes educator (CDE) who educated and supported providers on diabetes management and adherence to the American Diabetes Association (ADA) Standards of Care over the year of the project. The CDE also provided diabetes self-management education (DSME) at the office site for 29 of the 104 patients who received their care in the practice. The following variables were evaluated: provider perceived barriers to care and adherence to ADA standards of care and patient A1C, blood pressure, cholesterol, knowledge, and empowerment levels.

Results

Provider adherence to ADA Standards of Care increased significantly across all process measures. Patients who received DSME at point of service in the primary care practice setting gained improvements in knowledge, empowerment, A1C, and high-density lipoprotein cholesterol levels.

Conclusions

Implementing systems to support decision support, selfmanagement education, and delivery system redesign has a positive influence on practices and patient outcomes in outlying rural communities.

Negative effects of diabetes-related distress on health-related quality of life: an evaluation among the adult patients with type 2 diabetes mellitus in three primary healthcare clinics in Malaysia

BACKGROUND

Patients with type 2 diabetes mellitus (T2D) often experienced change in life, altered self-esteem and increased feelings of uncertainty about the future that challenge their present existence and their perception of quality of life (QoL). There was a dearth of data on the association between diabetes-related distress (DRD) and health-related quality of life (HRQoL). This study examined the determinants of HRQoL, in particular the association between DRD and HRQoL by taking into account the socio-demographic-clinical variables, including depressive symptoms (DS) in adult patients with T2D.

METHODS

This cross-sectional study was conducted in 2012-2013 in three public health clinics in Malaysia. The World Health Organization Quality of Life-Brief (WHOQOL-BREF), 17-items Diabetes Distress Scale (DDS-17), and 9-items Patient Health Questionnaire (PHQ-9) were used to measure HRQoL, DRD and DS, respectively. The aim of this research was to examine the association between the socio-demographic-clinical variables and HRQoL as well as each of the WHOQOL-BREF domain score using multivariable regression analyses.

RESULTS

The response rate was 93.1% (700/752). The mean (SD) for age was 56.9 (10.18). The majority of the patients were female (52.8%), Malay (53.1%) and married (79.1%). About 60% of the patients had good overall HRQoL. The mean (SD) for Overall QoL, Physical QoL, Psychological QoL, Social Relationship QoL and Environmental QoL were 61.7 (9.86), 56.7 (10.64), 57.9 (11.73), 66.8 (15.01) and 65.3 (13.02), respectively. The mean (SD) for the total DDS-17 score was 37.1 (15.98), with 19.6% (136/694) had moderate distress. DDS-17 had a negative association with HRQoL but religiosity had a positive influence on HRQoL (B ranged between 3.07 and 4.76). Women, especially younger Malays, who had diabetes for a shorter period of time experienced better HRQoL. However, patients who were not married, had dyslipidaemia, higher levels of total cholesterol and higher PHQ-9 scores had lower HRQoL. Macrovascular complications showed the largest negative effect on the overall HRQoL (adjusted B = -4.98, 95% CI -8.56 to -1.40).

CONCLUSION

The majority of primary care adult with T2D had good overall HRQoL. Furthermore, the independent determinants for HRQoL had also concurred with many past studies. In addition, the researchers found that DRD had negative effects on HRQoL, but religiosity had positive influence on HRQoL. Appropriate support such as primary care is needed for adult patients with T2D to improve their life and their HRQoL.

TRIAL REGISTRATION

NMRR-12-1167-14158.

Effectiveness of a multidisciplinary team approach to the prevention of readmission for acute glycaemic events

AIMS

To describe the effect of a combined diabetes specialist/mental health team approach to prevent readmissions for acute glycaemic events among patients with diabetes.

METHODS

Consecutive patients with diabetes, readmitted to a single hospital for an acute glycaemic condition, were offered one or more diabetes (including assessment, education, medication, technology use and intensive support) and mental health (including assessment, training and therapies) interventions. The pilot service took place over 11 months, with the preceding 24 months and subsequent 8 months serving as control periods.

RESULTS

Of the 58 patients admitted, 50 had Type 1 diabetes and were from within the hospital catchment area, and were discharged home. Of these, 32 (64%) had a pre-existing mental health issue and 14 (28%) had a complex social situation. In all, 96% of patients were met as an inpatient by a team member, and 94% accepted at least one intervention. The mean ±sd number of admissions per patient/month dropped from 0.12 ± 0.10 to 0.05 ± 0.10 (P < 0.001) during the intervention, increasing, once the intervention ended, to 0.16 ± 0.36 (P = 0.002). The mean ± sd length of stay similarly decreased and increased (0.6 ± 0.9 to 0.2 ± 0.7 days; P < 0.001 to 0.006) to 0.6 ± 1.4 days (P = 0.003) per patient/month) across the three periods, as did the mean ±sd tariff paid per patient/month (₤258.0 ± 374.0 vs ₤92.1 ± 245.0 vs ₤287.3 ± 563.8; P < 0.001 and P = 0.018, respectively). The mean ± sd HbA1c level dropped from 99 ± 22 to 92 ± 24 mmol/mol (11.2 ± 4.2% vs 10.6 ± 4.3%; P = 0.014) but did not increase after the intervention [89 ± 26 mmol/mol (10.4 ± 4.5%)].

CONCLUSIONS

The cost and long-term risks of hospitalization among patients with Type 1 diabetes and recurrent admissions can be reduced by a combined specialist diabetes/mental health team approach.

Impact of community based peer support in type 2 diabetes: a cluster randomised controlled trial of individual and/or group approaches

Background

Diabetes peer support, where one person with diabetes helps guide and support others, has been proposed as a way to improve diabetes management. We have tested whether different diabetes peer support strategies can improve metabolic and/or psychological outcomes.

Methods

People with type 2 diabetes (n = 1,299) were invited to participate as either ‘peer’ or ‘peer support facilitator’ (PSF) in a 2x2 factorial randomised cluster controlled trial across rural communities (130 clusters) in England. Peer support was delivered over 8–12 months by trained PSFs, supported by monthly meetings with a diabetes educator. Primary end point was HbA1c. Secondary outcomes included quality of life, diabetes distress, blood pressure, waist, total cholesterol and weight. Outcome assessors and investigators were masked to arm allocation. Main factors were 1:1 or group intervention. Analysis was by intention-to-treat adjusting for baseline.

Results

The 4 arms were well matched (Group n = 330, 1:1(individual) n = 325, combined n = 322, control n = 322); 1035 (79•7%) completed the mid-point postal questionnaire and 1064 (81•9%) had a final HbA1c. A limitation was that although 92.6% PSFs and peers were in telephone contact, only 61.4% of intervention participants attended a face to face session. Mean baseline HbA1c was 57 mmol/mol (7•4%), with no significant change across arms. Follow up systolic blood pressure was 2•3mm Hg (0.6 to 4.0) lower among those allocated group peer-support and 3•0mm Hg (1.1 to 5.0) lower if the group support was attended at least once. There was no impact on other outcomes by intention to treat or significant differences between arms in self-reported adherence or medication.

Conclusions

Group diabetes peer support over 8–12 months was associated with a small improvement in blood pressure but no other significant outcomes. Long term benefits should be investigated.

Trial Registration

ISRCTN.com ISRCTN6696362166963621

Emotional support for diabetes management: an international cross-cultural study

PURPOSE

The purpose of this study was to explore how emotional support emerged in interactions between peer supporters (PSs) and adults living with type 2 diabetes.

METHODS

Qualitative data were analyzed from 22 semistructured interviews with PSs in 3 settings: low-income Latinos in Chicago, middle-class Caucasians in the United Kingdom, and low-income African American women in North Carolina. Emotional support was defined as expressions of empathy, trust, and caring.

RESULTS

Across all sites, emotional support gradually emerged over time, was often combined with informational support, and was conveyed both implicitly (through nonverbal actions connoting emotional acceptance; eg, a walk together without discussion of problems) and explicitly (eg, by reassurance or discussion of stressors). Cross-site differences did appear regarding the strategies to address barriers to diabetes management (eg, PSs in North Carolina and Chicago reported providing support for social stressors) and the role of PSs (eg, PSs in Chicago reported providing directive support).

CONCLUSIONS

Across different settings and populations, emotional support for diabetes management evolved over time, was often integrated with informational support, and emerged through both implicit and explicit strategies that addressed varied context-specific stressors.

Changes in hospital admissions and inpatient tariff associated with a Diabetes Integrated Care Initiative: preliminary findings

BACKGROUND

The Diabetes Integrated Care Initiative (DICI) has tested whether hospital admissions and total amounts paid for inpatient care have declined through closer (integrated) working between primary, secondary and community diabetes services in Cambridgeshire.

METHOD

Poisson regression models were used to compare the percentage change in hospital admissions, and tariff paid, before and after each of 43 months (April 2007 - November 2010). East Cambridgeshire and Fenland (ECF) practices were divided into those fully (n = 10) and less (n = 7) "engaged" with the intervention defined by the extent of their uptake of intervention components between July 2009 and June 2010. Other parts of the county were "controls".

RESULTS

Among patients with diabetes in the fully engaged ECF practices, the monthly average hospital admission rate was 19.0% (13.9, 24.2) higher (7.7 hospital admissions per 1000 patients) and the monthly tariff paid was 28.8% (28.7, 28.9) higher (£19.60 per patient per month), at the time of introducing the DICI versus the pre-implementation period (April 2007 to June 2009). These differences, had dropped to 8.7% (1.9, 15.6) and 13.4% (13.2, 13.5) (£9.92 per patient per month) higher 12 months after introduction. Comparable reductions in the rate of increase were not seen among those without diabetes or in control areas.

CONCLUSION

During the DICI, patients with diabetes from "fully engaged" practices experienced increased hospitalization and amount paid for in-patient care, the extent of which trended downwards by 12 months. Further time is needed to monitor whether this trend is sustained.

The chronic care model and diabetes management in US primary care settings: a systematic review

Introduction

The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation.

Methods

We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: “chronic care model” (and) “diabet*.” We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies.

Results

The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies.

Conclusion

CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making.

Factors affecting the motivation of healthcare professionals providing care to Emiratis with type 2 diabetes

Objective

We aimed to identify facilitators of and barriers to healthcare professionals' motivation in a diabetes centre in the United Arab Emirates (UAE).

Design

A qualitative research approach was employed using semistructured interviews to assess perception of and attitudes regarding healthcare professionals' motivation in providing good quality diabetes care.

Setting

A diabetes centre located in Abu-Dhabi, UAE.

Participants

Healthcare professionals including specialist physicians, dieticians, podiatrists, health educators and nurses were recruited through purposive sampling.

Main outcome measures

After data collection, the audiotaped interviews were transcribed verbatim and subjected to content analysis.

Results

Nine semistructured interviews were conducted with healthcare professionals of various professional backgrounds. Important facilitators and barriers related to patient, professional, organization and cultural factors were identified. Barriers that related to heavy workload, disjointed care, lack of patient compliance and awareness, and cultural beliefs and attitudes about diabetes were common. Key facilitators included the patient's role in achieving therapeutic outcomes as well as compliance, cooperation and communication.

Conclusion

This qualitative study provides some unique insights about factors affecting healthcare professionals' motivation in providing good quality care. To improve the motivation of healthcare professionals in the management of diabetes and therefore the quality of diabetes care, several steps are needed. Importantly, the role of primary care should be reinforced and strengthened regarding the management of type 2 diabetes mellitus, privacy of the consultation time should be highly protected and regulated, and awareness of the Emirate culture and its impact on health should be disseminated to the healthcare professionals providing care to Emirates with diabetes. Also, greater emphasis should be placed on educating Emiratis with diabetes on, and involving them in, the management of their condition.

Testing a peer support intervention for people with type 2 diabetes: a pilot for a randomised controlled trial

BACKGROUND

People with Type 2 diabetes face various psycho-social, self-management and clinical care issues and evidence is mixed whether support from others with diabetes, 'peer support', can help. We now describe a 2 month pilot study of different peer support interventions.

METHODS

The intervention was informed by formative evaluation using semi-structured interviews with health professionals, community support groups and observation of diabetes education and support groups. Invitations to participate were mailed from 4 general practices and included a survey of barriers to care. Participants were randomized by practice to receive individual, group, combined (both individual and group) or no peer support. Evaluation included ethnographic observation, semi-structured interviews and questionnaires at baseline and post-intervention.

RESULTS

Of 1,101 invited, 15% expressed an interest in participating in the pilot. Sufficient numbers volunteered to become peer supporters, although 50% of these (8/16) withdrew. Those in the pilot were similar to other patients, but were less likely to feel they knew enough about diabetes (60.8% vs 44.6% p = 0.035) and less likely to be happy with the diabetes education/care to date (75.4% vs 55.4% p = 0.013). Key issues identified were the need to recruit peer supporters directly rather than through clinicians, to address participant diabetes educational needs early and the potential for group sessions to have lower participation rates than 1:1 sessions.

CONCLUSIONS

Recruitment to a full trial of peer support within the existing study design is feasible with some amendments. Attendance emerged as a key issue needing close monitoring and additional intervention during the trial.

Should diabetes be commissioned through multidisciplinary networks, rather than Practice Based Commissioning?

AIMS

Diabetes is recognized as a complex, long term, largely asymptomatic condition requiring self management skills, a range of health care professionals and articulated health services. Diabetes Networks have been introduced to provide guidance from people with diabetes and local health professionals with different skills to ensure that diabetes care is well organized, sustainable and delivers quality care. We have considered the role of Diabetes Networks in the English setting.

METHODS

Drawing on studies of health service organization and health policy, we describe the context in which diabetes commissioning is currently occurring in England, the role of Diabetes Networks and key components for an effective Diabetes Network.

RESULTS

We have identified that Diabetes Networks are not currently mandatory and discovered policy approaches that are likely to work against safe, timely, integrated approaches to diabetes services with potentially harmful impacts on people with diabetes in the future. Practice Based Commissioning, where it sidelines Diabetes Networks, is a particular concern. We have identified key components of Diabetes Networks including explicit frameworks for leadership, membership, funding, decision making, communication and action.

CONCLUSIONS

Diabetes is a condition requiring collaboration between all involved. Diabetes Networks include patients and all relevant health professionals and should dictate what and how diabetes care should be commissioned within the local health economy.

Impact of patient level factors on the improvement of the ABCs of diabetes

OBJECTIVE

To determine which patient factors contribute to improvements in the ABCs of diabetes following a multi-faceted diabetes care intervention.

METHODS

A multi-level, cluster design, randomized controlled trial examined the effectiveness of a Chronic Care Model (CCM) intervention in an underserved community (n=119).

RESULTS

Improvements in glycemic control were experienced among older subjects (p=0.02), those with higher scores on the WHO-10 Quality of Well-Being Subscale 1 (p=0.05), and those in the CCM group (p=0.04). Insulin use was associated with greater improvements in SBP and DBP. Those taking insulin (p=0.07), and those more satisfied with their diabetes care and ready to make a behavior change (p=0.08) experienced larger improvements in Non-HDLc. Medication treatment intensification (TI) did not significantly impact the ABCs.

CONCLUSION

Psychosocial and sociodemographic factors explained more of the variation in the ABCs than TI, and are important contributors to clinical improvement.

PRACTICE IMPLICATIONS

Providers may be able to identify and intervene on patients who are at risk for developing diabetes complications and improve the consistency, quality, and effectiveness of patient care.

The New Zealand experience in peer support interventions among people with diabetes

BACKGROUND

Peer-to-peer support has the potential to assist people with diabetes, or at risk of diabetes.

OBJECTIVE

To review the development of diabetes peer support initiatives in New Zealand.

METHODS

A systematic review of diabetes peer support publications from New Zealand, supplemented by unpublished records from Diabetes New Zealand (DNZ, the national diabetes patient organization) and the two major regional initiatives in South Auckland and Waikato.

RESULTS

DNZ, which has 40 societies and 71 diabetes support groups, delivers a range of services to members and non-members. The membership is mainly older European New Zealanders with diabetes, with some Maori and associated societies for Pacific and Youth. While demand exists, no quantitative evaluation of health impact by these organizations has been undertaken. Other peer support groups have developed in South Auckland and Northland. Common themes that emerge relate to leadership, organization and balancing the different needs of people with diabetes at different stages (e.g. newly diagnosed versus others) and with different personal needs. In South Auckland and the Waikato, lay educators have been trained to provide 1:1 and group sessions for people with, or at high risk of, diabetes. A range of training, management, funding and organizational barriers existed in the implementation of these lay educator programmes. Conclusions. Peer-to-peer support and education programmes in diabetes have been considered useful in New Zealand. Knowledge regarding training, management and organization is nearing a level, which would allow formal evaluation of a strategy for both the prevention of diabetes and in supporting people with diabetes.

Ethnic and gender differences in psychosocial factors, glycemic control, and quality of life among adult type 2 diabetic patients

OBJECTIVE

To examine ethnic and gender differences in psychosocial factors, e.g., social support and acceptance of the disease, knowledge levels, perceived difficulty in adherence behaviors, and diabetes outcome (glycemic control and quality of life) in Type 2 diabetic patients.

METHODS

Data were collected via telephone interviews from 180 diabetic subjects (34% Hispanics, 27% Non-Hispanic whites, 18% African-Americans, and 20% Asian-Indians; 52% females) from 2 clinics. Hemoglobin A1c levels were obtained from patient charts.

RESULTS

Significant ethnic and gender differences existed in acceptance of the disease, in receiving social support, disease knowledge, perceived difficulty in self-management behaviors, glycemic control, and quality of life among Type 2 diabetic patients; differences were more pronounced by gender than by ethnicity. In general, social support and acceptance of the disease were high. However, perceived difficulty in self-management behaviors varied by racial/ethnic groups with self-monitoring of blood glucose perceived as most difficult by Hispanic respondents, dietary management was most difficult for non-Hispanic whites, while physical activity was the most difficult for African-Americans. Hispanic respondents had greatest severity of the disease (poorest metabolic control).

CONCLUSIONS

Ethnic and gender variations exist in social support, acceptance of diabetes, quality of life, and adherence behaviors. The outcomes of diabetes care can be improved if practitioners factor these differences in tailoring diabetes education and supportive care for individuals with Type 2 diabetes.

Characteristics and blood pressure management in patients with and without diabetes in primary care in rural Victoria

AIMS/HYPOTHESIS

This study tested whether diabetic hypertensive patients receive more intensive BP management than hypertensive patients without diabetes.

METHODS

A 12 month retrospective review of BP management was undertaken among 2460 hypertensive patients (335 with diabetes), aged 40-79 years from randomly selected general practices in rural Australia.

RESULTS

Prevalent diagnosed cardiovascular disease (CVD) was commoner among diabetic than non-diabetic patients (27.2% vs. 16.0%, OR 1.82 (1.39-2.39)). The proportion with a BP<130/80 mmHg was low (22.9% vs. 18.6%, p=.069, respectively). BP was monitored more closely among diabetic patients (e.g. quarterly BP measurements in 18.2% vs. 10.5% respectively, p<.001), was treated with more anti-hypertensive agents (1.5+/-1.0 vs. 1.0+/-1.0, p<001) and was more likely to be associated with other CVD medications. Achievement of non-diabetic BP targets was associated with living in the regional centre (vs. smaller rural town: 1.21 (1.02-1.43)) and CVD (1.54 (1.21-1.95)), but not the presence of diabetes (0.94 (0.73-1.19)).

CONCLUSIONS

In this population, hypertension is more aggressively monitored and treated among diabetic than non-diabetic patients, but largely due to their CVD and not to the level recommended in guidelines. Commencing anti-hypertensive treatment earlier (e.g. at diagnosis) and recommending more agents (e.g. in combination) may be needed to improve BP control among diabetic patients on a population basis.

Patient factors associated with attrition from a self-management education programme

OBJECTIVE

To examine utilization patterns of diabetes self-management training (DSME) and identify patient factors associated with attrition from these services at an ambulatory diabetes education centre (DEC).

METHODS

A retrospective medical chart review of first time visits (536) to the centre between 1 August 2000 and 31 July 2001 was conducted for patients with type 2 diabetes. Descriptive analyses were conducted to examine utilization patterns over a 1-year period. Multivariable logistic regression was used to identify patient factors associated with attrition from DSME and non-use of group education among new patients.

RESULTS

Almost 50% of new patients withdrew prematurely from recommended DSME services over the 1-year period, and only 24.8% attended group education. Patient variables such as being older than 65 years of age, primarily speaking English, or working full or part-time were associated with attrition from DSME and non-use of group education when compared with middle aged, non-English-speaking, and non-working patients.

CONCLUSIONS

High DSME attrition rates indicate that retention needs to become a focus of programme policy, planning and evaluation to improve programme effectiveness. DSME tailored to the cultural and linguistic characteristics of the community, and convenient and accessible to working and older patients will potentially increase retention in and accessibility to these services.

Primary care management of diabetes in a low/middle income country: a multi-method, qualitative study of barriers and facilitators to care

BACKGROUND

The management of patients with diabetes mellitus is complex. Some research has been done in developed countries to attempt to determine the factors that influence quality of care of patients with diabetes: Factors thus far postulated are usually categorised into patient, clinician and organisational factors. Our study sought to discover the main barriers and facilitators to care in the management of diabetes in primary care in a low/middle income country.

METHODS

A qualitative study, based on reflexive ethnography using participant observation, semi-structured interviews of clinicians (10) and group interviews with paramedical staff (4) and patients (12) in three purposively sampled health centres, along with informal observation and discussions at over 50 other health centres throughout Tunisia. A content analysis of the data was performed.

RESULTS

Over 400 potential barriers or facilitators to care of patients with diabetes in primary care in Tunisia emerged. Overall, the most common cited factor was the availability of medication at the health centre. Other frequently observed organisational factors were the existence of chronic disease clinics and clinicians workload. The most commonly mentioned health professional factor was doctor motivation. Frequently cited patient factors were financial issues, patient education and compliance and attendance issues. There were notable differences in the priority given to the various factors by the researcher, physicians, paramedical staff and the patients.

CONCLUSION

We have discovered a large number of potential barriers and facilitators to care that may potentially be influencing the care of patients with diabetes within primary care in Tunisia, a low/middle income country. An appreciation and understanding of these factors is essential in order to develop culturally appropriate interventions to improve the care of people with diabetes.

Diabetes risk factors, diabetes and diabetes care in a rural Australian community

OBJECTIVE

To comprehensively describe diabetes-related risk factors, quality of care and patient-perceived barriers to care in a rural community.

DESIGN

Cross-sectional mail study, self-completed survey and retrospective chart review.

SETTING

Community and health services in Corryong, rural Victoria, Australia.

PARTICIPANTS

Ninety-seven patients with diabetes and 495 with other diseases in the mail study, 84 with diabetes in the self-completed survey and 101 diabetic patient chart reviews.

MAIN OUTCOME MEASURES

Self-reported lifestyle activities, uptake of health checks, metabolic measures and uptake of medication, and self-reported barriers to diabetes care.

RESULTS

Most residents without diabetes had recently had their blood pressure and cholesterol checked; 60.4% were trying to control their weight and 73.9% were exercising regularly (although only 30.7% to an adequate level). Those with diabetes reported a greater uptake of healthy living messages, and had a mean HbA1c of 7.3%, total cholesterol of 5.0 mmol L(-1); 12.9% had a diastolic blood pressure > or =85 mmHg. Foot checks were infrequent (18%). There was substantial room to increase antiplatelet, blood pressure, antihyperglycaemia and lipid-lowering therapy. Most patients reported psychological (84.5%) and educational (82.1%) barriers to care, with few perceiving physical barriers to care.

CONCLUSION

Living in a rural area with predominantly GP care can be associated with comparatively good metabolic control, although psycho-educational barriers are frequently present. In the wider community, risk factors for diabetes remain common, and the majority have been screened for components of the metabolic syndrome in the previous year.

Novel approaches to diabetes care: a population perspective

PURPOSE OF REVIEW

The purpose of this review is to outline the current state of diabetes in the United States and to explore novel, population-based approaches that involve the patient, provider and community, in the context of the health system, to improve diabetes care.

RECENT FINDINGS

Currently, there is sub-optimal delivery of diabetes processes and outcomes in the United States. The US healthcare system remains rooted in acute and episodic care, resulting in consistently low-quality healthcare, and is not equipped to handle the diabetes epidemic. Evidence demonstrates that models of chronic care are needed in order for system changes to occur. Recent studies that have implemented such models are beginning to demonstrate improvements in both process measures and clinical outcomes following interventions which incorporate a comprehensive approach to chronic illness care.

SUMMARY

Research over the past 5+ years demonstrates that a more comprehensive approach to diabetes care is needed. Only recently have studies been able to validate this concept, however. Applied research that strives to translate available knowledge and operationalize it in clinical and public health practice is needed in order for diabetes care to improve.

A case control study of diabetic patients who default from primary care in urban New Zealand

AIM

Diabetic patients defaulting from specialist care have worse metabolic control and complications than those attending regularly. We have compared the clinical characteristics of defaulters and more regular health care attenders on a population basis in a multi-ethnic community.

METHODS

We performed a 2:1 case control study of those defaulting from care for at least 10 months identified from a cross-sectional household survey of known diabetes in inner urban South Auckland, New Zealand. Thirty-seven cases and 52 controls with type 2 diabetes were examined (28 and 36 having retinal photography).

RESULTS

Defaulters were less likely to have been damaged by their diabetes (including less severe/proliferative retinopathy 16.7% vs. 0%, respectively, P<0.05), more likely to have worse foot care (95% vs. 79% poor nail or skin care, P<0.05) but had similar metabolic control as regular attenders. Most patients could either give no reason for default (40%) or claimed that their diabetes had gone (14%). Twenty-four (65%) reported that nothing could lead them to start attending for diabetes care.

CONCLUSION

We conclude that unlike those defaulting from specialist care, many, but not all, of those with diabetes defaulting from all care generally have comparable metabolic control and less complication than regular attenders. The patients had a range of attitudes to their diabetes suggesting that attracting such patients back into care, prior to a major clinical event or the development of symptoms, is unlikely without major effort.

Discordance in perceptions of barriers to diabetes care between patients and primary care and secondary care

OBJECTIVE

We sought to compare perceived barriers to diabetes care between people with diabetes and different health professional groups.

RESEARCH DESIGN AND METHODS

This was a cross-sectional, postal, open-questionnaire survey conducted in the Waikato district, New Zealand. A total of 3,890 individuals with diabetes participated, as well as 436 primary and secondary health professionals.

RESULTS

Barriers were reported in 69.7% of patients. Psychological barriers were most important (55.5%), followed by systems barriers (25.7%), and then knowledge as least important (15.3%). Psychological barriers were ranked first among general practitioners (91.0%), but systems barriers were ranked first by other health professionals (38.8-100%). General practitioner and patient barrier group rankings were similar (r(T) = 0.976, P < 0.05). Of specific barriers among individuals with diabetes, strictness of treatment regimen was the most frequently reported (42.3 vs. 0.1-16.8%) (P < 0.001) and 2.5 (95% CI 2.4-2.7)- to 3.4 (3.2-3.7)-fold more than the 2nd through 4th ranked barriers. Motivation was the most common specific barrier reported by general practitioners (86%), practice nurses (31.5%), and the diabetes team (85.7%). Practice and hospital nurse/dietitian rankings were most comparable with patients (r(T) = 0.457 and 0.466, respectively, both P < 0.05). A major area of patient-health professional discordance was the influence of other health problems, which was ranked 2nd among patients but 10th-18th among health professionals.

CONCLUSIONS

The most important barriers to diabetes care perceived by patients are psychological and particularly relate to the strictness of the regimen. Discordance between patients and different health professionals exists in the perception of the importance of different barriers to diabetes care.

‘Help, educate, encourage?’: Geographical variations in the provision and utilisation of diabetes education in New Zealand

In New Zealand, as elsewhere, it is argued that a diabetes epidemic is underway. With careful management from individuals and professionals and appropriate levels of education, it is possible to prevent many complications of diabetes. The overall objective of the paper is to evaluate the role and impact of Diabetes New Zealand (DNZ), the key voluntary sector provider of diabetes education and support services, with respect to four criteria: (i) the extent to which DNZ is reaching groups most at risk of diabetes; (ii) the degree to which it has encouraged levels of member involvement; (iii) whether voluntary group provision of education is that most preferred by members; and (iv) the extent to which members see the voluntary sector model as being effective in combating the growth of diabetes. A survey of members of six of the 41 affiliated societies of DNZ suggests that such organisations, although having a high proportion of older members, have generally failed to target more deprived groups. While the societies generally score more positively in encouraging member involvement and being perceived as effective by their members, they do not always utilise the preferred form of educational provision. However, there are significant contextual variations by urban-rural location and according to the organisational structure of the societies. Rural societies and those with decentralised organisational structures generally score highest on the above criteria. The results pose a problem for DNZ which, like many other voluntary sector organisations, is facing pressures of increased corporatisation and centralisation. We see this as an important challenge that DNZ needs to address if New Zealand is going to better cope with the emerging diabetes epidemic.

Quality of care in diabetic patients attending routine primary care clinics compared with those attending GP specialist clinics

AIM

To determine the impact on clinical outcomes of specialist diabetes clinics compared with routine primary care clinics.

METHODS

Observational study measuring clinical performance (process/outcome measures) in the primary care sector. A cohort of patients attending specialist diabetes clinics was compared with a control cohort of patients attending routine primary care clinics.

RESULTS

Patients seen in specialist diabetes clinics had a significantly higher HbA1c than patients in routine primary care clinics (mean difference 0.58%; P < 0.001) but there was no significant difference in rate of improvement with visits compared with primary care clinics. In contrast, patients seen in the routine primary care clinics had significantly higher cholesterol levels (mean difference 0.24 mmol/l; P < 0.001) compared with patients in specialist diabetes clinics and their improvement was significantly greater over time (mean difference 0.14 mmol/l per visit compared with 0.10 mmol/l; P < 0.006). Patients in routine primary care clinics also had significantly higher diastolic blood pressure (mean difference 1.6 mmHg; P < 0.007) but there was no difference in improvement with time compared with specialist diabetes clinics. Uptake of podiatry and retinal screening was significantly lower in patients attending routine primary care clinics, but this difference disappeared with time, with significant increases in uptake in the primary care clinic group. Weight increased in both groups significantly with time, but more so in the specialist clinic patients (mean increase 0.18 kg per visit more compared with routine clinic primary care patients; P < 0.001).

CONCLUSIONS

This study provides evidence that the provision of primary care services for patients with diabetes, whether traditional general practitioner clinics or diabetes clinics run by general practitioners with special interests, is effective in reducing HbA1c, cholesterol and blood pressure. However, the same provision of care was unable to prevent increasing weight or creatinine over time. No evidence was found that patients in specialist clinics do better than patients in routine primary care clinics.

Improving access to health care among New Zealand's Maori population

The health status of indigenous peoples worldwide varies according to their unique historical, political, and social circumstances. Disparities in health between Maoris and non-Maoris have been evident for all of the colonial history of New Zealand. Explanations for these differences involve a complex mix of components associated with socioeconomic and lifestyle factors, availability of health care, and discrimination. Improving access to care is critical to addressing health disparities, and increasing evidence suggests that Maoris and non-Maoris differ in terms of access to primary and secondary health care services. We use 2 approaches to health service development to demonstrate how Maori-led initiatives are seeking to improve access to and quality of health care for Maoris.

Initial validation of an instrument to identify barriers to self-management for persons with co-morbidities

OBJECTIVE

To develop and initially validate a questionnaire designed to assess barriers to self-management perceived by persons with multiple chronic medical conditions. We hypothesized that persons who reported increased barriers to self-management would also report lower general health status and a greater disease burden.

METHODS

A cross-sectional survey was done of Health Maintenance Organization members aged 65 years or older with varying numbers of chronic medical conditions. On the basis of a previous qualitative investigation, we have identified 13 domains representing potential barriers to self-management. We developed questions to assess each of these domains and, for each, calculated coefficients alpha and assessed correlation of that domain with self-reported general health status and disease burden.

RESULTS

Respondents reported an average of 5.9 chronic conditions. Eight domains demonstrated acceptable internal consistency in this population. Nine of 13 domains correlated significantly in the expected direction with health status and/or disease burden.

DISCUSSION

These results provide an encouraging first step in developing a tool that will be clinically useful in assessing and addressing barriers to medical self-management for persons with co-morbidities. Use of assessments such as this in clinical settings may facilitate appropriate and efficient care management and improved health outcomes for this growing and vulnerable patient population.

Rural Vincentians' (Caribbean) beliefs about the usage of non-prescribable medicines for treating Type 2 diabetes

AIMS

To explore beliefs among persons in St. Vincent, a rural Caribbean Community, regarding the usage of non-prescribable medicines for treating Type 2 diabetes.

METHODS

A phenomenological enquiry explored people's experiences and the manner in which they interpret these. One focus-group interview was conducted of persons attending a rural diabetes clinic in St Vincent to generate insights into the phenomenon. Analysis was undertaken using the four steps utilized in phenomenological studies of bracketing, intuiting, analysis and description. The findings result in deeper understanding and definition of the phenomenon.

RESULTS

A variety of non-prescribable, predominantly herbal and folk, medicines were commonly used as a means of self care in diabetes. Usage was underpinned by a system of lay beliefs about diabetes and beliefs in the treatment efficacy of folk medicine. A strong religious influence formed the basis of diabetes treatment and offered some symptom relief and therefore treatment satisfaction through spiritual revelations about remedies. Conventional medicines were taken in conjunction with non-prescribable treatments or else not at all.

CONCLUSIONS

Non-prescribable medicines were believed by participants to be efficacious. Conventional medication was perceived as an access to medical care. Study findings may be relevant to other rural populations with strong social and religious mores.

Factors affecting the quality of diabetes care in primary health care centres in Tunis

We have conducted a retrospective medical record review of a random sample of 580 patients with diabetes from 12 primary health care centres (PHCCs) in Greater Tunis. The aim was to assess the quality of diabetes care in PHCCs and to explore factors associated with quality of care. Data were collected concerning patient characteristics, health centre characteristics and process of care criteria. In our sample, recording of care varied significantly between the health centres for all of the process of care criteria studied. Factors significantly associated with improved recording of care were younger patient age (found in 5 of the 10 process of care criteria), use of the new medical records (8 of the 10 criteria), urban health centres (8 of the 10 criteria) and those centres with a doctor with a special interest in diabetes (7 of the 10 criteria). Gender and socio-economic status were not found to be associated with recording of care. The quality of diabetes care in Greater Tunis varies widely between PHCCs and a number of associated factors have been highlighted. A fuller understanding of quality of care within the context of the patients' environment is essential in order to develop appropriate health interventions.

Health literacy, social support, and health: a research agenda

Amid increased concerns about the adverse consequences of low health literacy, it remains unclear how health literacy affects health status and health service utilization. Moreover, studies have shown significant variation in individual adaptation to health literacy problems. This article proposes research hypotheses to address two questions: (1) What are the causal pathways or intermediate steps that link low health literacy to poor health status and high utilization of expensive services such as hospitalization and emergency care? (2) What impact does social support have on the relationships between health literacy and health service utilization? Empirical studies of health literacy are reviewed to indicate the limitations of current literature and to highlight the importance of the proposed research agenda. In particular, we note the individualistic premise of current literature in which individuals are treated as isolated and passive actors. Thus, low health literacy is considered simply as an individual trait independent of support and resources in an individual's social environment. To remedy this, research needs to take into account social support that people can draw on when problems arise due to their health literacy limitations. Examination of the proposed agenda will make two main contributions. First, we will gain a better understanding of the causal effects of health literacy and identify missing links in the delivery of care for patients with low health literacy. Second, if social support buffers the adverse effects of low health literacy, more effective interventions can be designed to address differences in individuals' social support system in addition to individual differences in reading and comprehension. More targeted and more cost-efficient efforts could also be taken to identify and reach those who not only have low health literacy but also lack the resources and support to bridge the unmet literacy demands of their health conditions.