Innovations in Providing Diabetes Care for Individuals Experiencing Homelessness: An Environmental Scan

Peer and lay health work for people experiencing homelessness: A scoping review

Homelessness poses complex health obstacles for individuals and communities. Peer and lay health worker programs aim to increase access to health care and improve health outcomes for PEH by building trust and empowering community-based workers. The scope and breadth of peer and lay health worker programs among PEH has not been synthesized. The primary objective of this scoping review is to understand the context (setting, community, condition or disease) encompassing peer and lay health worker programs within the homelessness sector. The secondary objective is to examine the factors that either facilitate or hinder the effectiveness of peer and lay health worker programs when applied to people experiencing homelessness (PEH). We searched CINHAL, Cochrane, Web of Science Core Collection, PsycINFO, Google Scholar and MEDLINE. We conducted independent and duplicate screening of titles and abstracts, and extracted information from eligible studies including study and intervention characteristics, peer personnel characteristics, outcome measures, and the inhibitors and enablers of effective programs. We discuss how peer and lay health work programs have successfully been implemented in various contexts including substance use, chronic disease management, harm reduction, and mental health among people experiencing homelessness. These programs reported four themes of enablers (shared experiences, trust and rapport, strong knowledge base, and flexibility of role) and five themes of barriers and inhibitors (lack of support and clear scope of role, poor attendance, precarious work and high turnover, safety, and mental well-being and relational boundaries). Organizations seeking to implement these interventions should anticipate and plan around the enablers and barriers to promote program success. Further investigation is needed to understand how peer and lay health work programs are implemented, the mechanisms and processes that drive effective peer and lay health work among PEH, and to establish best practices for these programs.

Pilot trial results of D-HOMES: a behavioral-activation based intervention for diabetes medication adherence and psychological wellness among people who have been homeless

Introduction

People living with type 2 diabetes who experience homelessness face a myriad of barriers to engaging in diabetes self-care behaviors that lead to premature complications and death. This is exacerbated by high rates of comorbid mental illness, substance use disorder, and other physical health problems. Despite strong evidence to support lay health coach and behavioral activation, little research has effectively engaged people living with type 2 diabetes who had experienced homelessness (DH).

Methods

We used community engaged research and incremental behavioral treatment development to design the Diabetes HOmeless MEdication Support (D-HOMES) program, a one-on-one, 3 month, coaching intervention to improve medication adherence and psychological wellness for DH. We present results of our pilot randomized trial (with baseline, 3 mo., 6 mo. assessments) comparing D-HOMES to enhanced usual care (EUC; brief diabetes education session and routine care; NCT05258630). Participants were English-speaking adults with type 2 diabetes, current/recent (<24 mo.) homelessness, and an HbA1c‗7.5%. We focused on feasibility (recruitment, retention, engagement) and acceptability (Client Satisfaction Questionnaire, CSQ-8). Our primary clinical outcome was glycemic control (HbA1c) and primary behavioral outcome was medication adherence. Secondary outcomes included psychological wellness and diabetes self-care.

Results

Thirty-six eligible participants enrolled, 18 in each arm. Most participants identified as Black males, had high rates of co-morbidities, and lived in subsidized housing. We retained 100% of participants at 3-months, and 94% at 6-months. Participants reported high satisfaction (mean CSQ-8 scores=28.64 [SD 3.94] of 32). HbA1c reduced to clinically significant levels in both groups, but we found no between group differences. Mean blood pressure improved more in D-HOMES than EUC between baseline and 6 mo. with between group mean differences of systolic -19.5 mmHg (p=0.030) and diastolic blood pressure -11.1 mmHg (p=0.049). We found no significant between group differences in other secondary outcomes.

Conclusion

We effectively recruited and retained DH over 6 months. Data support that the D-HOMES intervention was acceptable and feasible. We observe preliminary blood pressure improvement favoring D-HOMES that were statistically and clinically significant. D-HOMES warrants testing in a fully powered trial which could inform future high quality behavioral trials to promote health equity.

Clinical trial registration

https://clinicaltrials.gov/study/NCT05258630?term=D-HOMES&rank=1, identifier NCT05258630.

Significance of fostering the mental health of patients with diabetes through critical time intervention

BACKGROUND

Critical time intervention (CTI) is an evidence-based model of practice that is time-limited and aims to provide support for most susceptible individuals during a transition period.

AIM

To examine the significance of fostering the mental health of diabetes patients through CTI using the scoping review methodology.

METHODS

As part of the scoping review process, we followed the guidelines established by the Joanna Briggs Institute. The search databases were Google Scholar, PubMed, Scopus, PsycINFO, Reference Citation Analysis (https://www.referencecitationanalysis.com/), and Cochrane Library. From these databases, 77 articles were retrieved with the aid of carefully selected search terms. However, 19 studies were selected after two reviewers appraised the full texts to ensure that they are all eligible for inclusion, while 54 papers were excluded.

RESULTS

This study revealed that diabetic patients who had experienced homelessness were at higher risk of being diagnosed with mental illness and that social support services are impactful in the management of the comorbidity of diabetes and mental health problems. In addition, this review reveals that CTI is impactful in enhancing the mental health of homeless patients during the transitional period from the hospital through social support services.

CONCLUSION

CTI is a promising intervention for alleviating mental health symptoms in homeless patients. Empirical studies are needed across the globe, involving both hospitalized and community-based patients, to determine how clinically effectively CTI is in managing the mental health of diabetics.

Group Versus Individual Diabetes Education for Persons With Experience of Homelessness in Canada

PURPOSE

The purpose of the study was to explore various forms of diabetes self-management education (DSME), including group and individual sessions, for persons with lived experiences of homelessness (PWLEH) in Canada.

METHODS

A qualitative descriptive study using open-ended interviews with health care and homeless sector service providers was utilized to serve those experiencing homelessness in 5 cities across Canada. NVivo qualitative data analysis software was used to facilitate thematic analysis, focusing on variations in DSME for PWLEH.

RESULTS

We conducted interviews with 96 unique health and social care providers. Four themes were identified through focused coding of interviews. First, the use of a harm reduction approach during diabetes education tailored to PWLEH considered patients' access to food, medications, and supplies and other comorbidities, including mental health and substance use disorders. The second theme related to the unsuitability of the curriculum in mainstream diabetes education in a group setting for PWLEH. Third, the role of group education in community building is to create supportive relationships among members. The final theme was the importance of trust and confidentiality in DSME, which were most easily maintained during individual education, compared to group formats.

CONCLUSIONS

Overall, PWLEH experience unique challenges in managing diabetes. DSME adapted to these individuals' unique needs may be more successful and could be delivered in both individual and group settings.

The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness

Introduction

Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH.

Methods

We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions).

Results

In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing.

Discussion

The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.

Pharmacists’ role in diabetes management for persons with lived experience of homelessness in Canada: A qualitative study

Introduction

Persons with lived experience of homelessness face many challenges in managing diabetes, including purchasing and storing medications, procuring healthy food and accessing healthcare services. Prior studies have found that pharmacy-led interventions for diabetes improved A1C, and lowered blood pressure and cholesterol in general populations. This study evaluated how select pharmacists in Canada have tailored their practices to serve persons with lived experiences of homelessness with diabetes.

Methods

We conducted a qualitative descriptive study using open-ended interviews with inner-city pharmacists in select Canadian municipalities (Calgary, Edmonton, Vancouver, and Ottawa). We used NVivo qualitative data analysis software to facilitate thematic analysis of the data, focusing on how pharmacists contributed to diabetes care for persons with lived experience of homelessness.

Results

These pharmacists developed diabetes programs after discovering an unmet need in the population. Pharmacists have the unique ability to see patients frequently, allowing tailored education and hands-on assistance with diabetes management. These pharmacists provided extra-ordinary care like financial and housing resources and many of them were uniquely embedded within other services for persons with lived experience of homelessness (i.e. housing and social work supports). Pharmacists reported struggling with balancing optimal medical care for individuals with the financial constraints of running a business.

Conclusion

Pharmacists are vital members of the diabetes care team for persons with lived experience of homelessness. Government policies should support and encourage unique models of care provided by pharmacists to improve diabetes management for this population.

Developing and evaluating a SAFER model to screen for diabetes complications among people experiencing homelessness: a pilot study protocol

Background

Diabetes management combined with housing instability intersects, forcing individuals to triage competing needs and critical stressors, such as safety and shelter, with fundamental diabetes self-management tasks like attending healthcare appointments to screen for the complications of diabetes, leaving individuals overwhelmed and overburdened. We aim to address this disjuncture found within our current healthcare delivery system by providing point-of-care screening opportunities in a more patient-centered approach.

Method

We describe a pilot study of a novel clinical intervention which provides timely, comprehensive, and accessible screening for diabetes complications to people experiencing homelessness. We will assess the reach, effectiveness, adoption, implementation, and maintenance, as per the RE-AIM framework, of a SAFER model of care (i.e., screening for A1C, feet, eyes, and renal function). A trained nurse will provide this screening within a homeless shelter. During these encounters, eligible participants will be screened for microvascular complications (neuropathy, nephropathy, retinopathy) and have their A1C measured, all at the point of care, using bedside tools and novel technology. Effectiveness, our primary objective, will be evaluated using a pre-post design, by comparing the rate of completion of full microvascular screening during the study period with individuals’ own historical screening in the 2-year period prior to enrollment. The other domains of the RE-AIM framework will be assessed using process data, chart reviews, patient surveys, and qualitative semi-structured interviews with service providers and participants. This study will be conducted in a large inner-city homeless shelter within a major urban Canadian city (Calgary, Canada).

Discussion

Currently, screening for diabetes complications is often inaccessible for individuals experiencing homelessness, which places heavy burdens on individuals and, ultimately, on already strained emergency and acute care services when complications go undetected at earlier stages. The SAFER intervention will modify the current standard of care for this population in a way that is less fragmented, more person-focused, and timely, with the goal of ultimately improving the rate of screening in an acceptable fashion to identify those requiring specialist referral at earlier stages.

Using a community-based participatory research approach to meaningfully engage those with lived experience of diabetes and homelessness

INTRODUCTION

Participatory research is a study method that engages patients in research programs, ideally from study design through to dissemination. It is not commonly used in diabetes health services research. Our objectives were to describe the process and challenges of conducting a participatory research project and to highlight the experiences of both patient co-researchers and academic researchers.

RESEARCH DESIGN AND METHODS

We recruited people with lived experience of homelessness (PWLEH) and diabetes in Toronto, Canada to become patient co-researchers. They were asked to commit to attending biweekly meetings. We undertook two major research projects: concept mapping to choose a research focus; and photovoice to explore accessing healthy food while homeless. We used a convergent mixed-methods design to evaluate their experience.

RESULTS

A diverse group of eight PWLEH had an average attendance of 82% over 21 meetings-despite this success, we encountered a number of challenges of conducting this research: funding, ethics approval and recruitment were particularly difficult. Group members reported that participation improved their ability to self-advocate in their diabetes care and provided them with tangible skills and social benefits. Group members stated that they valued being involved in all aspects of the research, in particular knowledge translation activities, including advocating for nutritious food at shelters; presenting to stakeholders; and meeting with policymakers.

CONCLUSIONS

The use of participatory research methods enables academic researchers to support community members in pursuing research that is pertinent to them and which has a positive impact. In our study, co-researchers contributed in meaningful ways and also valued the experience.

Les défis de la gestion du diabète chez les personnes itinérantes : étude qualitative avec la méthode photovoix

CONTEXTE:

La recherche sur les défis de la prise en charge du diabète chez les personnes itinérantes qui en sont atteintes n’a pas tendance à prendre en considération le point de vue des personnes touchées. Nous avons utilisé une approche de recherche participative avec la communauté pour explorer ces défis.

MÉTHODES:

Nous avons recruté des cochercheurs ayant une connaissance expérientielle de l’itinérance et du diabète. Les chercheurs principaux leur ont offert une formation en recherche et ont préparé le terrain avec eux pour ce projet. Les cochercheurs ont collectivement choisi d’utiliser la méthode photovoix pour illustrer la difficulté de bien s’alimenter quand on est en situation d’itinérance et explorer en quoi cet écueil affecte plus largement la gestion du diabète. Après une formation en photographie et en éthique, les cochercheurs ont pris des photos en lien avec les objectifs du projet et rédigé des récits connexes au moyen de techniques de rédaction inspirée par des photos. Les chercheurs principaux ont analysé les photos et les récits, et ils en ont dégagé des thèmes qui se sont précisés lors de discussions de groupe.

RÉSULTATS:

Les 8 cochercheurs étaient atteints de diabète de type 2 (diagnostiqué de 18 mois à 23 ans auparavant) et avaient vécu en situation d’itinérance pendant des périodes allant de 8 mois à 12 ans. Nous avons dégagé 4 thèmes à partir de 17 photos et récits produits. L’itinérance affecte grandement la santé émotionnelle et mentale des personnes, ce qui nuit à leur capacité de bien gérer leur diabète. Les aliments servis dans les refuges sont rarement nutritifs ou appétissants. L’obtention d’une forme de logement peut faciliter la prise en charge du diabète en créant un environnement stable qui favorise l’autonomie, mais les coûts et le manque de connaissances sont des obstacles à la préparation de repas sains. L’itinérance complique aussi l’accès aux professionnels de la prise en charge du diabète et aux médicaments d’ordonnance.

INTERPRÉTATION:

Les images et les récits associés permettent de dresser un tableau frappant, complet et fidèle des défis auxquels sont confrontées les personnes en situation d’itinérance qui essaient de gérer leur diabète. Comprendre ces défis est la première étape qui permettra aux intervenants et aux décideurs de répondre aux besoins de cette population.

Using concept mapping to prioritize barriers to diabetes care and self-management for those who experience homelessness

BACKGROUND

Diabetes is a chronic medical condition which demands that patients engage in self-management to achieve optimal glycemic control and avoid severe complications. Individuals who have diabetes and are experiencing homelessness are more likely to have chronic hyperglycemia and adverse outcomes. Our objective was to collaborate with individuals experiencing homelessness and care providers to understand the barriers they face in managing diabetes, as a first step in identifying solutions for enhancing diabetes management in this population.

METHODS

We recruited individuals with lived experience of homelessness and diabetes (i.e. clients; n = 32) from Toronto and health and social care providers working in the areas of diabetes and/or homelessness (i.e. providers; n = 96) from across Canada. We used concept mapping, a participatory research method, to engage participants in brainstorming barriers to diabetes management, which were subsequently categorized into clusters, using the Concept Systems Global MAX software, and rated based on their perceived impact on diabetes management. The ratings were standardized for each participant group, and the average cluster ratings for the clients and providers were compared using t-tests.

RESULTS

The brainstorming identified 43 unique barriers to diabetes management. The clients' map featured 9 clusters of barriers: Challenges to getting healthy food, Inadequate income, Navigating services, Not having a place of your own, Relationships with professionals, Diabetes education, Emotional wellbeing, Competing priorities, and Weather-related issues. The providers' map had 7 clusters: Access to healthy food, Dietary choices in the context of homelessness, Limited finances, Lack of stable, private housing, Navigating the health and social sectors, Emotional distress and competing priorities, and Mental health and addictions. The highest-rated clusters were Challenges to getting healthy food (clients) and Mental health and addictions (providers). Challenges to getting healthy food was rated significantly higher by clients (p = 0.01) and Competing priorities was rated significantly higher by providers (p = 0.03).

CONCLUSIONS

Experiencing homelessness poses numerous barriers to managing diabetes, the greatest of which according to clients, is challenges to getting healthy food. This study showed that the way clients and providers perceive these barriers differs considerably, which highlights the importance of including clients' insights when assessing needs and designing effective solutions.