Type 2 diabetes patients' and providers' differing perspectives on medication nonadherence: a qualitative meta-synthesis

Preference for a Novel Oral Alternative to Parenterally Administered Medications

Background

Rani Therapeutics is developing a robotic pill (RP), an oral drug delivery platform called RaniPill™ that can deliver a number of biotherapeutics with high bioavailability; eliminating the need for injections. While patients in general prefer oral to injectable therapies, preference for a more frequent oral regimen compared to a less frequent injectable regimen is unknown. Two marketing surveys were conducted to gather data on preference for oral versus injectable therapies. A clinical study gathered data on participant preference for oral pills vs injections before and after swallowing a Mock-RP capsule.

Methods

A total of 1689 adults taking injections (mean duration 3-7 years) to treat endocrine or inflammatory conditions were anonymously surveyed online for their preference to administer/prescribe medications orally via the RP. In the clinical study, 150 participants currently taking injections for chronic conditions evaluated the swallowability of a Mock-RP and completed a questionnaire regarding their preferences.

Results

Majority of respondents surveyed stated they would be willing to convert to an oral alternative over their current parenteral therapy regardless of drug or disease. In the clinical study, all participants were able to swallow the Mock-RP and 91% indicated their preference for the oral route versus their current parenteral route of drug administration. Survey respondents and those in the clinical study using frequent injections were more willing to select a once-daily capsule compared to those injecting infrequently. Even study participants who inject infrequently (≥monthly: 80%) would prefer a once-daily pill over their injection regimen.

Conclusion

Patients taking injections and prescribing physicians strongly prefer oral dosing to parenteral administration of biologics even if dosing frequency with the oral option, such as the RP, is increased.

Risk factors for prediabetes in community-dwelling adults: A generalized estimating equation logistic regression approach with natural language processing insights

The global prevalence of prediabetes is expected to reach 8.3% (587 million people) by 2045, with 70% of people with prediabetes developing diabetes during their lifetimes. We aimed to classify community-dwelling adults with a high risk for prediabetes based on prediabetes-related symptoms and to identify their characteristics, which might be factors associated with prediabetes. We analyzed homecare nursing records (n = 26,840) of 1628 patients aged over 20 years. Using a natural language processing algorithm, we classified each nursing episode as either low-risk or high-risk for prediabetes based on the detected number and category of prediabetes-symptom words. To identify differences between the risk groups, we employed t-tests, chi-square tests, and data visualization. Risk factors for prediabetes were identified using multiple logistic regression models with generalized estimating equations. A total of 3270 episodes (12.18%) were classified as potentially high-risk for prediabetes. There were significant differences in the personal, social, and clinical factors between groups. Results revealed that female sex, age, cancer coverage as part of homecare insurance coverage, and family caregivers were significantly associated with an increased risk of prediabetes. Although prediabetes is not a life-threatening disease, uncontrolled blood glucose can cause unfavorable outcomes for other major diseases. Thus, medical professionals should consider the associated symptoms and risk factors of prediabetes. Moreover, the proposed algorithm may support the detection of individuals at a high risk for prediabetes. Implementing this approach could facilitate proactive monitoring and early intervention, leading to reduced healthcare expenses and better health outcomes for community-dwelling adults.

Evaluating the impact of a discharge pharmacy in the emergency department on emergency department revisits and admissions

IMPORTANCE

Medication nonadherence leads to worse health outcomes, increased healthcare service utilization, and increased overall healthcare costs.

OBJECTIVE

To determine whether a discharge pharmacy located in the Emergency Department (ED) reduces ED revisits and hospitalizations.

DESIGN

This is a cohort study where we extracted data from our electronic medical records with adult encounters between 12/2019-10/2021. For the purpose of this study, we defined a revisit to the ED as within 7 days and an admission within 30 days from prior initial ED visit.

SETTING

The University of Chicago Medicine is an academic medical center located in Chicago's South Side.

PARTICIPANTS

Between dates of 12/2019-11/2021, we had 78,660 adult distinct encounters. We created 5 different groups: no medications prescribed, ED discharge pharmacy only, e-prescriptions to outside pharmacies, combination of ED pharmacy and e-prescription sent elsewhere, and printed prescriptions with or without any e-prescriptions.

EXPOSURE

Our ED pharmacy is located within the adult ED, serving only patients seen and discharged from the adult ED.

MAIN OUTCOME(S) AND MEASURE(S)

Our primary endpoint is to evaluate if prescribing and dispensing prescriptions from only our ED pharmacy is associated with decreased ED revisits within 7 days and reduced hospitalizations within 30 days of initial ED visit.

RESULTS

When comparing patients who received prescriptions only from the ED discharge pharmacy, patients who received no prescriptions were 31.6% (P < 0.001) more likely to revisit our ED, and patients who received e-prescriptions sent to other pharmacies were 10.4% (P = 0.017) more likely to revisit. Patients who received e-prescriptions from other pharmacies were 29.2% (P < 0.001) more likely to be hospitalized and mixture of e-prescriptions were 59.5% (P < 0.001) more likely to be hospitalized compared to the ED pharmacy only group.

CONCLUSIONS AND RELEVANCE

We believe having a pharmacy providing medications to patients being discharged from the ED reduces barriers like cost, transportation, and pharmacy access patients face trying to fill prescriptions at their local pharmacy. All of these reductions in barriers provides an easier and more convenient method for patients to obtain their medications at discharge from the ED, reducing the risk of a repeat ED visit and subsequent hospital admission.

Adherence to newer second-line oral antidiabetic drugs among people with type 2 diabetes-A systematic review

The adherence to oral antidiabetic drugs (OADs) among people with type 2 diabetes (T2D) is suboptimal. However, new OADs have been marketed within the last 10 years. As these new drugs differ in mechanism of action, treatment complexity, and side effects, they may influence adherence. Thus, the aim of this study was to assess the adherence to newer second-line OADs, defined as drugs marketed in 2012-2022, among people with T2D. A systematic review was performed in CINAHL, Cochrane Trials, Embase, PubMed, PsycINFO, and Scopus. Articles were included if they were original research of adherence to newer second-line OADs and reported objective adherence quantification. The quality of the articles was assessed using JBI's critical appraisal tools. The overall findings were reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and summarized in a narrative synthesis. All seven included articles were European retrospective cohort studies investigating alogliptin, canagliflozin, dapagliflozin, empagliflozin, and unspecified types of SGLT2i. Treatment discontinuation and medication possession ratio (MPR) were the most frequently reported adherence quantification measures. Within the first 12 months of treatment, 29%-44% of subjects on SGLT2i discontinued the treatment. In terms of MPR, 61.7%-94.9% of subjects on either alogliptin, canagliflozin, dapagliflozin, empagliflozin or an unspecified SGLT2i were adherent. The two investigated adherence quantification measures, treatment discontinuation and MPR, suggest that adherence to the newer second-line OADs may be better than that of older OADs. However, a study directly comparing older and newer OADs should be done to verify this.

Sulforaphane Ameliorates High-Fat-Diet-Induced Metabolic Abnormalities in Young and Middle-Aged Obese Male Mice

Type 2 diabetes (T2D) is still a fast-growing health problem globally. It is evident that chronic insulin resistance (IR) and progressive loss of β-cell mass and function are key features of T2D etiology. Obesity is a leading pathogenic factor for developing IR. The aim of the present study was to determine whether sulforaphane (SFN), a natural compound derived from cruciferous vegetables, can prevent (prevention approach) or treat (treatment approach) obesity and IR in mouse models. We show that dietary intake of SFN (0.5 g/kg of HFD) for 20 weeks suppressed high-fat diet (HFD)-induced fat accumulation by 6.04% and improved insulin sensitivity by 23.66% in young male mice. Similarly, dietary provision of SFN (0.25 g/kg) significantly improved blood lipid profile, glucose tolerance, and insulin sensitivity of the middle-aged male mice while it had little effects on body composition as compared with the HFD group. In the treatment study, oral administration of SFN (40 mg/kg) induced weight loss and improved insulin sensitivity and plasma lipid profile in the diet-induced-obesity (DIO) male mice. In all three studies, the metabolic effects of SFN administration were not associated with changes in food intake. In vitro, SFN increased glucose uptake in C2C12 myotubes and increased fatty acid and pyruvate oxidation in primary human skeletal muscle cells. Our results suggest that SFN may be a naturally occurring insulin-sensitizing agent that is capable of improving the metabolic processes in HFD-induced obesity and IR and thereby may be a promising compound for T2D prevention.

Contextual factors for the successful implementation of self-management interventions for chronic diseases: A qualitative review of reviews

OBJECTIVES

To identify and describe the most relevant contextual factors (CFs) from the literature that influence the successful implementation of self-management interventions (SMIs) for patients living with type 2 diabetes mellitus, obesity, COPD and/or heart failure.

METHODS

We conducted a qualitative review of reviews. Four databases were searched, 929 reviews were identified, 460 screened and 61 reviews met the inclusion criteria. CFs in this paper are categorized according to the Tailored Implementation for Chronic Diseases framework.

RESULTS

A great variety of CFs was identified on several levels, across all four chronic diseases. Most CFs were on the level of the patient, the professional and the interaction level, while less CFs were obtained on the level of the intervention, organization, setting and national level. No differences in main themes of CFs across all four diseases were found.

DISCUSSION

For the successful implementation of SMIs, it is crucial to take CFs on several levels into account simultaneously. Person-centered care, by tailoring SMIs to patients' needs and circumstances, may increase the successful uptake, application and implementation of SMIs in real-life practice. The next step will be to identify the most important CFs according to various stakeholders through a group consensus process.

COMPAR-EU Recommendations on Self-Management Interventions in Type 2 Diabetes Mellitus

Self-management interventions (SMIs) offer a promising approach to actively engage patients in the management of their chronic diseases. Within the scope of the COMPAR-EU project, our goal is to provide evidence-based recommendations for the utilisation and implementation of SMIs in the care of adult individuals with type 2 diabetes mellitus (T2DM). A multidisciplinary panel of experts, utilising a core outcome set (COS), identified critical outcomes and established effect thresholds for each outcome. The panel formulated recommendations using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, a transparent and rigorous framework for developing and presenting the best available evidence for the formulation of recommendations. All recommendations are based on systematic reviews (SR) of the effects and of values and preferences, a contextual analysis, and a cost-effectiveness analysis. The COMPAR-EU panel is in favour of using SMIs rather than usual care (UC) alone (conditional, very low certainty of the evidence). Furthermore, the panel specifically is in favour of using ten selected SMIs, rather than UC alone (conditional, low certainty of the evidence), mostly encompassing education, self-monitoring, and behavioural techniques. The panel acknowledges that, for most SMIs, moderate resource requirements exist, and cost-effectiveness analyses do not distinctly favour either the SMI or UC. Additionally, it recognises that SMIs are likely to enhance equity, deeming them acceptable and feasible for implementation.

Tensions in caring for chronic patients' medication adherence: A qualitative study in Cyprus

Medication adherence (MA) to recommended treatment is a multi-faceted problem and an ongoing challenge for healthcare providers (HCPs) to monitor. This qualitative study with 10 HCPs in Cyprus aims to explore HCPs' perceptions and strategies used on addressing medication non-adherence (MNA) in patients with chronic conditions. Two main themes emerged from the analysis reflecting the ways that HCPs described their reactions to MNA of their patients: (1) "Relying on information provision to improve MA" and (2) "Trying to understand patients' perspective." HCPs reported empathizing with patients and engaging in discussions to understand patients' perspective and reasons for MNA, so as to explore alternative solutions. Simultaneously, some HCPs reflected that the techniques used to improve MA are solely centered around information on medication and side-effects. HCPs experienced an internal conflict between providing patient-centered care versus using directive approaches to improve MA. Findings suggest how HCPs could thoroughly address patients' individual barriers.

Psychosocial Facilitators and Barriers to Type 2 Diabetes Management in Adults: A Meta-Synthesis

BACKGROUND

Globally, the cases of type 2 diabetes are increasing, and this is largely attributed to lifestyle changes. Though diabetes is primarily a metabolic disease determined by biological factors, psychosocial aspects play a crucial role in its progression and management. However, the literature on psychosocial dimensions of diabetes management is minuscule and scattered.

OBJECTIVE

This synthesis sought to understand the psychosocial facilitators and barriers to type 2 diabetes management and coping among adults.

METHODS

We have adopted a meta-synthesis to review available qualitative studies using Pub- Med and Scopus databases. Based on inclusion criteria, we have chosen 24 studies published between 2010 and 2023. We have considered studies across countries, among which 63% of the studies included were from Western countries, and most have employed qualitative descriptive design. The selected studies were analyzed thematically using a deductive framework.

RESULTS

Six themes emerged as the psychosocial barriers and facilitators of managing and coping with type 2 diabetes: 1) cognitive-emotional factors, 2) faith, 3) constraints to behavioural change, 4) social constraints and support, 5) healthcare provider-patient relationship, and 6) awareness. Further, a conceptual framework was developed from the synthesis.

CONCLUSION

The patients' experiences evident from this synthesis signify the crucial role of psychosocial factors in diabetes management and coping. This evidence emphasizes the need for integrated care so that psychosocial aspects are addressed by healthcare providers and behavioural health professionals, which may lead to the promotion of facilitators and the minimization of barriers.

Clinical impact of an integrated e-health system for diabetes self-management support and shared decision making (POWER2DM): a randomised controlled trial

AIMS/HYPOTHESIS

There is a lack of e-health systems that integrate the complex variety of aspects relevant for diabetes self-management. We developed and field-tested an e-health system (POWER2DM) that integrates medical, psychological and behavioural aspects and connected wearables to support patients and healthcare professionals in shared decision making and diabetes self-management.

METHODS

Participants with type 1 or type 2 diabetes (aged >18 years) from hospital outpatient diabetes clinics in the Netherlands and Spain were randomised using randomisation software to POWER2DM or usual care for 37 weeks. This RCT assessed the change in HbA1c between the POWER2DM and usual care groups at the end of the study (37 weeks) as a primary outcome measure. Participants and clinicians were not blinded to the intervention. Changes in quality of life (QoL) (WHO-5 Well-Being Index [WHO-5]), diabetes self-management (Diabetes Self-Management Questionnaire - Revised [DSMQ-R]), glycaemic profiles from continuous glucose monitoring devices, awareness of hypoglycaemia (Clarke hypoglycaemia unawareness instrument), incidence of hypoglycaemic episodes and technology acceptance were secondary outcome measures. Additionally, sub-analyses were performed for participants with type 1 and type 2 diabetes separately.

RESULTS

A total of 226 participants participated in the trial (108 with type 1 diabetes; 118 with type 2 diabetes). In the POWER2DM group (n=111), HbA1c decreased from 60.6±14.7 mmol/mol (7.7±1.3%) to 56.7±12.1 mmol/mol (7.3±1.1%) (means ± SD, p<0.001), compared with no change in the usual care group (n=115) (baseline: 61.7±13.7 mmol/mol, 7.8±1.3%; end of study: 61.0±12.4 mmol/mol, 7.7±1.1%; p=0.19) (between-group difference 0.24%, p=0.008). In the sub-analyses in the POWER2DM group, HbA1c in participants with type 2 diabetes decreased from 62.3±17.3 mmol/mol (7.9±1.6%) to 54.3±11.1 mmol/mol (7.1±1.0%) (p<0.001) compared with no change in HbA1c in participants with type 1 diabetes (baseline: 58.8±11.2 mmol/mol [7.5±1.0%]; end of study: 59.2±12.7 mmol/mol [7.6±1.2%]; p=0.84). There was an increase in the time during which interstitial glucose levels were between 3.0 and 3.9 mmol/l in the POWER2DM group, but no increase in clinically relevant hypoglycaemia (interstitial glucose level below 3.0 mmol/l). QoL improved in participants with type 1 diabetes in the POWER2DM group compared with the usual care group (baseline: 15.7±3.8; end of study: 16.3±3.5; p=0.047 for between-group difference). Diabetes self-management improved in both participants with type 1 diabetes (from 7.3±1.2 to 7.7±1.2; p=0.002) and those with type 2 diabetes (from 6.5±1.3 to 6.7±1.3; p=0.003) within the POWER2DM group. The POWER2DM integrated e-health support was well accepted in daily life and no important adverse (or unexpected) effects or side effects were observed.

CONCLUSIONS/INTERPRETATION

POWER2DM improves HbA1c levels compared with usual care in those with type 2 diabetes, improves QoL in those with type 1 diabetes, improves diabetes self-management in those with type 1 and type 2 diabetes, and is well accepted in daily life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03588104.

FUNDING

This study was funded by the European Union's Horizon 2020 Research and Innovation Programme (grant agreement number 689444).

Exploring the barriers and enablers of diabetes care in a remote Australian context: A qualitative study

OBJECTIVE

This qualitative study explored the current barriers and enablers of diabetes care in the Indian Ocean Territories (IOT).

METHODS

A constructivist grounded theory approach that incorporated semi-structured telephone interviews was employed. Initial analysis of the interview transcripts used a line-by-line approach, to identify recurring themes, connections, and patterns, before they were re-labelled and categorised. This was followed by axial coding, categorisation refinement, and mapping of diabetes triggers in the IOT.

PARTICIPANTS AND SETTING

The IOT, consisting of Christmas Island and the Cocos (Keeling) Islands, are some of the most remote areas in Australia. When compared with mainland Australia, the prevalence of type 2 diabetes in the IOT is disproportionately higher. There were no known cases of type 1 diabetes at the time of the study. Like other remote communities, these communities experience difficulties in accessing health services to prevent and manage diabetes. Twenty health care professionals and health service administrators in the IOT took part in semi-structured telephone interviews held during April-June 2020. Participants included GPs, nurses, dietitians, social and community services workers, school principals, and administrators. The interview questions focused on their perceptions of the current diabetes care in place in the IOT and their views on the challenges of providing diabetes care in the IOT.

RESULTS

We identified four main barriers and two main enabling factors to the provision of effective diabetes care in the IOT. The barriers were: (i) societal influences; (ii) family; (iii) changing availability of food; (v) sustainability and communication. The two main enablers were: (i) tailoring interventions to meet local and cultural needs and values; and (ii) proactive compliance with the medical model of care.

CONCLUSION

Due to the cultural and linguistic diversity within the IOT, many of the identified barriers and enablers are unique to this community and need to be considered and incorporated into routine diabetes care to ensure successful and effective delivery of services in a remote context.

An adapted model of cost-related medication nonadherence among older adult patients with chronic diseases: an Iranian qualitative study

BACKGROUND

Following the rapid aging of population, some concerns have emerged regarding increasing demand for health care services and the consequent increase in health costs. Besides, older adult patients with chronic disease are more prone to show cost-related medication non-adherence (CRN) to cope with their medication costs. The objective of this qualitative study was to develop an adopted conceptual framework on the contextual determinants that affect the CRN in older adult patients with chronic diseases.

METHODS

Problem-centered, semi-structured, in-depth, and face-to-face interviews, were conducted with healthcare informants in Iran, from Sep. 2021 to Feb. 2022. Collected data were analyzed using deductive and inductive analytic approaches and content analysis methodology was used to develop the model. This study applies to the COREQ checklist.

RESULTS

Fifteen informants, including 8 (60%) males, with mean ± SD age of 44.4 ± 9.7 years, entered into the study. Based on the data analysis performed on the information obtained from the interview with 3 subgroups of geriatricians, health policymakers, and pharmacists, six major themes identified as determinants: 1) socio-economic factors, 2) health system-related factors, 3) healthcare provider-related factors, 4) medication-related factors, 5) disease-related factors, and 6) patient-related factors. There were also 23 minor themes which were matched with the aforementioned six major themes.

CONCLUSION

The final framework obtained in this qualitative study depicts CRN as an issue that is highly likely affected by six main determinants among older patients with chronic disease. Our findings emphasize that policymakers would focus on certain major themes and allocate resources to programs to improve medication therapy management in older adult patients.

Factors influencing medication adherence in multi-ethnic Asian patients with chronic diseases in Singapore: A qualitative study

Background: Poor medication adherence can lead to adverse health outcomes and increased healthcare costs. Although reasons for medication adherence have been widely studied, less is explored about factors affecting medication adherence for patients in non-Western healthcare setting and from Asian cultures. This study aimed to explore cultural perspectives on factors influencing medication adherence among patients with chronic diseases in a multi-ethnic Asian healthcare setting.

Methods: We conducted a qualitative study involving in-depth interviews with patients with chronic conditions purposively recruited from a community hospital in Singapore until data saturation was achieved. A total of 25 patients participated in this study. Interviews were transcribed and thematically analyzed. Themes were subsequently mapped into the World Health Organization (WHO) Framework of Medication Adherence.

Results: Participants commonly perceived that sides effects (therapy-related dimension), poor understanding of medication (patient-related dimension), limited knowledge of condition (patient-related dimension), forgetfulness (patient-related dimension) and language issues within a multi-ethnic healthcare context (healthcare team and system-related dimension) as the main factors contributing to medication adherence. Importantly, medication adherence was influenced by cultural beliefs such as the notion of modern medicines as harms and fatalistic orientations towards escalation of doses and polypharmacy (patient-related dimension). Participants made various suggestions to foster adherence, including improved patient-physician communication, enhanced care coordination across providers, use of language familiar to patients, patient education and empowerment on the benefits of medication and medication adjustment.

Conclusion: A wide range of factors influenced medication adherence, with therapy- and patient-related dimensions more pronounced compared to other dimensions. Findings demonstrated the importance of cultural beliefs that may influence medication adherence. Future efforts to improve medication adherence should consider a person-centered approach to foster more positive health expectations and self-efficacy on medication adherence, supplemented with routine reviews, development of pictograms and cultural competence training for healthcare professionals.

National Documentation and Coding Practices of Noncompliance: The Importance of Social Determinants of Health and the Stigma of African-American Bias

Patient records serve many purposes, one of which includes monitoring the quality of care provided that they can be analyzed through coding and documentation. Z-codes can provide additional information beyond a specific clinical disorder that may still warrant treatment. Social Determinants of Health have specific Z-codes that may help clinicians address social factors that may contribute to patients' health care outcomes. However, there are Z-codes that specify patient noncompliance which has a pejorative connotation that may stigmatize patients and prevent clinicians from examining nonadherence from a social determinant of health perspective. A retrospective cross-sectional study was performed to examine the associations of patient and encounter characteristics with the coding of patient noncompliance. Included in the study were all patients >18 years of age who were admitted to hospitals participating in the Vizient Clinical Data Base (CDB) between January 1, 2019 and December 31, 2019. Almost 9 million US inpatients were included in the study. Of those, 6.3% had a noncompliance Z-code. Use of noncompliance Z-codes was associated with the following odds estimate ratio in decreasing order: the presence of a social determinant of health (odds ratio [OR], 4.817), African American race (OR, 2.010), Medicaid insurance (OR, 1.707), >3 chronic medical conditions (OR, 1.546), living in an economically distressed community (OR, 1.320), male gender (OR, 1.313), nonelective admission status (OR, 1.245), age <65 years (OR, 1.234). More than 1 in 15 patient hospitalizations had a noncompliance code. Factors associated with these codes are difficult, if not impossible, for patients to modify. Disproportionate representation of Africa-Americans among hospitalizations with noncompliance coding is concerning and urgently deserves further exploration to determine the degree to which it may be a product of clinician bias, especially if the term noncompliance prevents health care providers from looking into socioeconomic factors that may contribute to patient nonadherence.

Routine healthcare disruptions: a longitudinal study on changes in self-management behavior during the COVID-19 pandemic

BACKGROUND

The outbreak of COVID-19 had a significant impact on routines and continuity of professional care. As frequent users of this professional care, especially for people with chronic diseases this had consequences. Due to barriers in access to healthcare, an even greater appeal was made on the self-management behaviors of this group. In the present study, we aim to investigate the extent to which self-management changed during the recent pandemic, and which factors contributed to these changes.

METHODS

The Dutch 'National Panel of people with Chronic Illness or Disability' was used to collect self-reported data of people with at least one chronic disease. Self-management was assessed with the Partners in Health questionnaire at two time points: before the crisis in 2018 and during the second wave of crisis in Autumn 2020. Paired t-tests were used to analyze changes in self-management. Potential associating factors on three levels - patient, organization and environment - were assessed in 2020 and their impact on self-management changes was tested with multinomial logistic regression.

RESULTS

Data from 345 panel members was available at two time points. In the majority of people, self-management behaviors were stable (70.7%). About one in seven experienced improved self-management (15.1%), and a similar proportion experienced deteriorated self-management (14.2%). Sex, physical disability, mental health and daily stressors due to COVID-19 (patient level), changes in healthcare access (organization level), and social support (environment level) were significantly associated with experienced changes in self-management.

CONCLUSIONS

People with chronic diseases experienced different trajectories of self-management changes during COVID-19. We need to be aware of people who seem to be more vulnerable to a healthcare crisis and report less stable self-management, such as those who experience mental health problems or daily stressors. Continuity of care and social support can buffer the impact of a healthcare crisis on self-management routines of people with chronic diseases.

Understanding strategies to improve medication adherence among persons with type 2 diabetes: A scoping review

AIMS

The objectives of this scoping review were to: (1) identify the target audience and contexts in which strategies to improve type 2 diabetes mellitus (T2DM) medication adherence have been used, (2) provide an overview of behaviour change techniques (BCTs) used, (3) describe the determinants of behaviour targeted by strategies and (4) to identify current gaps in strategies.

METHODS

A systemic search for articles related to T2DM, medication adherence and strategies was conducted in EMBASE, Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily using the OvidSP platform on 11 March 2021. All publications involving strategies to overcome medication non-adherence among adults with T2DM were included. Strategies were categorized according to the BCT taxonomy and the determinants of behaviour targeted by each strategy were classified by using the Theoretical Domains Framework (TDF).

RESULTS

The search identified 58 articles and 61 strategies. The BCT categories Antecedents and Natural consequences and BCTs Feedback on outcome(s) of behaviour, Adding objects to the environment and Information about health consequences were identified most frequently as components of strategies resulting in statistically significant improvement in medication adherence. Strategies targeting the TDF domains Reinforcement and Beliefs about Consequences most often resulted in statistically significant improvements in adherence measures.

CONCLUSIONS

The findings from this review identify BCTs and targeted behaviours with demonstrated success. Further exploration of the myriad of BCTs and the corresponding determinants of behaviour which were not accessed may be warranted for the development of future strategies to improve medication adherence in type 2 diabetes.

Looking at Diabetes-Related Distress through a New Lens: The Socio-Ecological Health Model

Diabetes-related distress (DRD) is defined as an emotional state experienced by people with diabetes (PWD) who are worried about their disease management, the emotional burden from the condition, and/or potential difficulties accessing care or support. The psychosocial aspect of diabetes management is a factor that directly influences patients’ well-being as well as the chronic management of the condition yet is not a primary clinical problem being addressed within the healthcare setting. This review advocates for a re-evaluation and subsequent adjustment of the current DRD screening methodology by implementing the five primary components (Intrapersonal, Interpersonal, Organizational, Community, and Public Policy) of the Socio-Ecological Model of Health (SEMH), bridging the gaps from a public-health perspective. We searched two electronic databases for studies published in the United States from 1995 to 2020 reporting the effects of social determinants of health (SDOH) on DRD. Articles that contained at least one of the five elements of the SEMH and focused on adults aged 18 years or older were included. SDOH, which include circumstances where individuals grow, work, and age, are highly influenced by external factors, such as the distribution of wealth, power, and resources. Current DRD screening tools lack the capacity to account for all major components of SDOH in a comprehensive manner. By applying the SEMH as a theory-based framework, a novel DRD screening tool addressing sex, ethnicity, and socioeconomic background should be implemented to better improve diabetes management outcomes. By exploring the relationships between each level of the SEMH and DRD, healthcare professionals will be better equipped to recognize potential stress-inducing factors for individuals managing diabetes. Further efforts should be invested with the goal of developing a novel screening tool founded on the all-encompassing SEMH in order to perpetuate a more comprehensive diabetes treatment plan to address barriers within the SDOH framework.

Factors affecting nonadherence to treatment among type 2 diabetic patients with limited health literacy: Perspectives of patients, their families, and healthcare providers

BACKGROUND

Treatment adherence is one of the behaviors associated with type 2 diabetes that predicts whether it will be successfully treated or develop complications and become uncontrolled. This study aimed to determine factors affecting nonadherence to treatment among diabetic patients with limited health literacy from the perspectives of patients, their families, and healthcare providers.

MATERIALS AND METHODS

This qualitative study with a content analysis approach was conducted on 84 eligible type 2 diabetes patients with limited health literacy and poor adherence to treatment, as well as their families and healthcare providers using a purposive sampling method, in Kerman city in 2021. Interviews were conducted using a semistructured interview guide with a broad, open-ended question to provide a general history of the disease separately. The interviewer asked participants to identify the perceived barriers to treatment nonadherence. Each interview lasted 45-60 min. MAXQDA version 20 and inductive content analysis were used to code and analyze extracted data.

RESULTS

Four major themes emerged from the patients' perspectives as "financial problems," "individual factors," "problems related to medication availability," and "healthcare providers' poor practices." Two major themes were classified from the perspective of patients' families as "financial problems" and "Individual factors," and four major themes were identified from the viewpoint of healthcare providers including "financial problems," "individual factors," "scarcity and medication availability," and "poor practice of the healthcare provider." These mentioned barriers were confirmed regarding treatment nonadherence among study participants.

CONCLUSION

Study findings revealed different factors of treatment nonadherence among diabetic patients with limited health literacy. Therefore, these factors should be considered in tailoring promotive educational and supportive interventions. Considering the importance of adherence to treatment patients, planning empowerment family-based interventions focusing on health literacy improvement seems necessary.

Potential influences of religiosity and religious coping strategies on people with diabetes

Diabetes is a significant health issue that threatens patients’ overall wellbeing and quality of life. Critical public health concerns center on creating the best approach for diabetes management. Patients and caregivers have different approaches to diabetes management; however, this and the associated physiological, physical and mental health issues remain challenging. This review explores the potential influences of religiosity and religious coping strategies on people with diabetes. This study used a literature review approach to investigate how religiosity and religious coping strategies can influence the effective management of diabetes among patients. Based on the literature search, the researchers were able to identify and cite published papers that were analyzed using the descriptive-narrative analysis. An important goal of the descriptive-narrative analysis was to provide descriptions of the selected literature and take implications from the literature. The results of studies reviewed show some religious coping strategies for managing chronic diseases such as diabetes. The studies did establish a relationship between religiosity and diabetes management and suggest that religious coping strategies could positively impact the management of diabetes; however, they reported some adverse effects. Hence, we propose a pathway for the development of religion-oriented interventions and support framework for the management of diabetes.

Experiences of barriers to self-monitoring and medication-management among Indian patients with type 2 diabetes, their primary family-members and physicians

OBJECTIVES

This study explored the subjective accounts of the main barriers to self-monitoring of blood-glucose (SMBG) and medication-management among Indian patients with type 2 diabetes (T2DM), their primary family-members (PFMs) and physicians.

METHODS

Using convenience sampling, patients with T2DM, their PFMs, and physicians, residing in a South Indian capital city, were recruited for semi-structured, audio-recorded interviews. Thematic analysis was used to analyze the data.

RESULTS

Fifty patients (female = 14; mean age = 42.5 years) and their PFMs (female = 38; mean age = 39 years), and 25 physicians (female = 4; mean age = 49.8 years) were recruited. Three superordinate themes were identified: (i) complex medication-regimen: confusion, forgetting and reduced motivation, (ii) family recommendations of alternative therapies due to the social pressures of avoiding stigma, intrusiveness and being misrepresented for injecting insulin, and (iii) an expensive illness: choosing to spend money on only medication.

DISCUSSION

Implications of the findings highlight the need to (i) train physicians in communication and empathy skills, (ii) empower patients to communicate their barriers to physicians through triadic communication models and question-prompt lists, (iii) educate communities on the benefits of insulin for managing T2DM to reduce stigma, and (iv) equip communities with information about health insurance to address the financial toll of T2DM management.

Goals of cure: Perspectives on the concept of cure in type 2 diabetes

RATIONALE, AIMS AND OBJECTIVES: Type 2 diabetes (T2D) is an archetypical chronic condition of significant prevalence. Yet the concept of cure in the context of T2D reveals an interplay between the medical imagination and clinical realities that can shift the course of a patient's care. There are two domains in which cure is sociologically constructed: the professional domain occupied by clinicians treating people with T2D, and the lay domain occupied by T2D patients. Lay epistemologies of cure tend to be focused on modifying the experience of having T2D, while professional epistemologies tend to focus on modifying the disease through medical treatment. The objective of this study is to explore the role of the concept of cure in the context of type 2 diabetes, a model for chronic disease.

METHODS

Through surveys and interviews of T2D patients, providers and researchers at an urban academic medical centre, I explore the perspectives and attitudes each group have towards the concept of cure in T2D. Semi-structured interviews of T2D professionals and patient surveys consisting of free response questions and Likert scale items were thematically analysed for perspectives on cure in T2D.

RESULTS

Sixteen T2D patients met inclusion criteria and consented to the survey and ten T2D professionals were interviewed. Cure is conceived of heterogeneously both within and between epistemologies. Patients carry hopes of cure predicated on eliminating the unpleasant experiences of T2D and its treatments, while T2D professionals tend to avoid invoking the concept of cure, at least to patients, on grounds of clinical uncertainty. However, the concept of cure is a significant motivator of treatment in both lay and professional epistemologies.

CONCLUSION

Different viewpoints on cure in T2D present an opportunity for shared meaning and decision making between patients and their providers that can frame the best possible outcome for patient care.

Perceptions of patients on factors affecting diabetes self-management among type 2 diabetes mellitus (T2DM) patients in Fiji: A qualitative study

Introduction

Optimal glycemic control can be achieved when patients are adherent to self-management behaviours such as healthy diet, physical activity, monitoring of blood glucose, reducing the risk factors, ability to solve problems and healthy coping. In light of limited studies conducted, this study aimed to explore patient's perceptions on factors affecting diabetes self-management among Type 2 Diabetes Mellitus (T2DM) patients of Labasa, Fiji.

Materials and methods

A qualitative study was employed to obtain data using semi-structured interviews conducted amongst T2DM patients attending clinics in 3 randomly selected health facilities in Labasa, Fiji from 15^th March to 5^th April 2021. Non probability purposive sampling was used to recruit 30 T2DM patients. The data was collected using semi-structured open ended questionnaires. Thematic analysis was used for data analysis. This was done by closely examining the transcribed data to identify common themes such as ideas, topic and pattern that come up repeatedly, followed by reviewing themes, defining it and naming them.

Result

Five themes emerged including; awareness on diabetes, perceptions towards diabetes mellitus, social support and diabetes self-management, challenges in diabetes self-management, and cultural beliefs and practices. The findings of the study demonstrated lack of knowledge and attitude towards definition of diabetes and its complications. The self-management practices amongst patients were insufficient. There was poor financial support and lack of social support among patients.

Conclusion

The results of this study highlighted various factors such as poor knowledge of diabetes and its complications, inadequate family support, financial burden and strong cultural beliefs and social norms affecting diabetes self-management. This study informs the need to identify the factors affecting diabetes self-management among T2DM patients.

Delivering the Diabetes Remission Clinical Trial (DiRECT) in primary care: Experiences of healthcare professionals

OBJECTIVE

The Diabetes Remission Clinical Trial (DiRECT) used a formula total diet replacement programme followed by structured weight loss maintenance to induce and sustain weight loss and remission of type 2 diabetes (T2D) in 36% of participants after 2 years. Nurses and dietitians delivering DiRECT in 22 primary care practices in Tyneside and Scotland provided behavioural support to participants. Participant experiences with DiRECT highlighted the key role of support by healthcare professionals (HCPs). We evaluated HCPs' experiences with DiRECT.

RESEARCH DESIGN AND METHODS

Healthcare professionals delivering DiRECT were interviewed at 12 months, while general practices (GPs) were sent an implementation questionnaire. The interviews were analysed thematically. The questionnaires were analysed using frequencies and a narrative synthesis.

RESULTS

Healthcare professionals representing 11 of 22 intervention practices were interviewed and 10 of 22 GPs completed questionnaires. HCPs' initial concerns over perceived potential negative intervention effects, particularly withdrawing anti-diabetes and anti-hypertensive medications, were barriers to engagement. Trust of HCPs towards the research team and perceived credibility of the study facilitated engagement and adoption. Ongoing support by research dietitians was key to the management of participants. Involvement in DiRECT inspired more focus on behaviour modification in the treatment of other people living with T2D in routine practice.

CONCLUSIONS

Diabetes Remission Clinical Trial was considered highly appropriate for the management of T2D in primary care when supported by trained dietitians. Addressing limitations, including varying training needs of HCPs may improve intervention scale-up and tailoring to clinical contexts.

Patient Adherence to Health Care Provider Recommendations and Medication among Free Clinic Patients

Patient adherence is vital for the quality of health care outcomes and treatment efficacy, and reduces the economic burden on the healthcare system. The purpose of this study was to examine factors associated with levels of general adherence among uninsured free clinic patients. This was a cross-sectional study using a convenience sample of free clinic patients aged 18 years and older who spoke English and/or Spanish. Descriptive statistics and multiple regression were performed to understand sociodemographic characteristics and factors associated with higher levels of general adherence. A higher level of general adherence were significantly associated with younger age (P < .01), levels of adherence to lifestyle recommendations (P < .01), and medication (P < .01). Having attended health education classes and having a primary care provider were not associated with levels of general adherence.This study suggested that a lower level of general adherence exists among elderly patients of the free clinic. In this light, providers need to consider unique strategies to enhance the provider-patient relationship by understanding patient's characteristics and providing sufficient information and explanation for treatment and medication.

The experiences of people with type 2 diabetes in communicating with general practitioners in China - a primary care focus group study

BACKGROUND

With the implementation of health care reforms in China, primary care is on a journey to provide care for most patients with type 2 diabetes. While Chinese general practitioners (GPs) have described challenges in communication with diabetes patients in their daily practice, little is known about patients' experiences in communicating with their GPs.

METHODS

Five focus groups (of 4-5 participants each) were used to explore views from patients with type 2 diabetes. Purposive sampling was used to recruit a spread of participants from general practices in Guangzhou city, China. Focus groups were audio-recorded, transcribed, and thematically analyzed using the Framework Method.

RESULTS

Ten males and 12 female patients from five general practices participated in focus group discussions, with a mean age of 57.3 years and 7.3 years of diabetes duration. Five main themes emerged: patients' understanding about diabetes, diabetes medication, communication with GPs, physician-patient relationships, and healthcare systems and context. Patients generally searched for information on the internet, but they weren't always sure if it was trustworthy. Several communication needs were described by diabetes patients, such as explanation of blood glucose monitoring, medication information support, communication in the risk of diabetes complications and cardiovascular disease, and language barriers. Communication was frequently brief and not tailored to their concerns, and some described being scolded or panicked by GPs. Participants acknowledged the pressures within the health system, such as short consultation times, an incoherent GP-hospital interface and high demand.

CONCLUSIONS

Key issues from the patients' perspective for the development of primary care based management of diabetes in China were identified. People with type 2 diabetes require more access to trustworthy diabetes information and wish for better channels of communication with their GPs. Strategies may be required to improve GPs' communication skills with their patients that also consider the context of the wider health system environment in China.

Barriers to Prevention and Treatment of Type 2 Diabetes Mellitus Among Outpatients in Belarus

Objectives

This study aimed to determine the main barriers and reasons for non-adherence to preventive measures and treatment for type 2 diabetes mellitus among outpatients in Belarus.

Methods

An anonymous questionnaire survey was conducted with 814 adults aged 18 years and over who visited outpatient health care units and hospitals in Belarus. The questionnaire was developed to analyze the perceived barriers that limit adherence to preventive measures and treatment for type 2 diabetes.

Results

The proportion of respondents who reported doing daily physical activity was 53.2%, and 46.6% consumed at least 400 grams of fruit and vegetables per day. Among the 42.8% of respondents with a prescribed treatment for type 2 diabetes mellitus, 50.1% sometimes forgot to take their medicine. The specific barriers to treatment most frequently identified by survey respondents were “Financial situation” (23.5% of respondents), and “Fear of side effects” (25.2%). Those for lifestyle instructions were “Insufficient knowledge” (29.3%), “Financial situation” (27.9%), and “Lack of motivation” (21.7%).

Conclusions

The study revealed that the main barriers to adherence were insufficient knowledge of diabetes and its treatment and an underestimation of the role of behavioral risk factors in health, combined with financial difficulties. We recommend that physicians should take a patient-centered approach to raising awareness of behavioral risk factors for type 2 diabetes mellitus, and suggest that the importance of adhering to preventative measures and treatment should be promoted in consultations in Belarus.

Determinants of Poor Treatment Adherence among Patients with Type 2 Diabetes and Limited Health Literacy: A Scoping Review

Prevention of complications and successful control of diabetes require preventive and therapeutic measures. Patients' nonadherence to medication and diet regimens and healthcare protocols is associated with significant therapeutic and economic consequences. The present scoping review aims to identify determinants of poor treatment adherence among patients with type 2 diabetes and limited health literacy in 2021. This scoping review was conducted in five stages: designing a research question, searching and extracting related studies, selecting related studies, tabulating information, and reporting results. Data were collected from six foreign electronic databases (Embase, Science Direct, PubMed, Google Scholar, Scopus, and Web of Science) and four Iranian electronic databases (MagIran, SID, IranDoc, and IranMedex) using keywords "Type 2 diabetes", "barriers", "treatment", "medication", "adherence", "non-adherence", "limited adherence", and "limited health literacy" from January 2010 to November 2021. From an initial 146 articles, 18 articles were eligible for review. Eighteen studies involving 3925 patients with T2DM from eight countries were included. The prevalence of nonadherence ranged from 42% to 74.3%. Barriers to treatment adherence, which were common among the articles, included economic problems, poor communication with healthcare team, lack of family support, lack of knowledge, misconceptions, and limited health literacy. The results of the present study provided modifiable and nonmodifiable factors affecting treatment adherence among patients with type 2 diabetes. Modifiable factors are essential by performing appropriate interventions with the target group and health professionals.

Individual, healthcare professional and system-level barriers and facilitators to initiation and adherence to injectable therapies for type 2 diabetes: A systematic review and meta-ethnography

AIMS

To review and synthesise the contemporary qualitative evidence, relating to the individual, healthcare professional and system-level barriers and facilitators to injectable therapies in people with type 2 diabetes, and evaluate (using an intersectional approach to explore the diverse perspectives of different identities) whether views have changed with treatment and guideline advancements.

METHODS

A meta-ethnography approach used. Eight databases searched from the years 2006 (GLP-1 analogues introduced) to February 2021. Study selection (using a pre-defined inclusion criteria), quality appraisal and data extraction, conducted independently by two reviewers.

RESULTS

Screened 7143 abstracts, assessed 93 full-text papers for eligibility and included 42 studies-using data from 818 individuals with type 2 diabetes and 160 healthcare professionals. Studies covered a diverse range of views from healthcare professionals and individuals, including those relating to older adults and people from ethnic migrant backgrounds, and 10 studies rated moderate to strong research value. Key themes abstracted: barriers (physical/psychological/social) and facilitators (motivation/capability/opportunity).

CONCLUSIONS

The first synthesis of contemporary qualitative data to adopt an intersectionality approach and explore diverse views relating to barriers and facilitators that influence engagement with injectable treatments for type 2 diabetes. A model is presented to help patients, health practitioners and policy makers identify barriers and facilitators and understand the complex interplay of physical, psychological and social factors involved when prescribing injectable therapies. Despite advances in injectable treatments and guidelines, findings highlight the many barriers that still exist and show how strongly held culturally-specific health beliefs of people from diverse socio-economic and ethnic backgrounds can become substantial obstacles to treatment.

Medication Adherence Among Geriatric Patients with Chronic Diseases in Riyadh, Saudi Arabia

BACKGROUND

Medication non-adherence is a common and significant public health problem, especially among the geriatric population. This study's objective was to measure medication adherence and associated factors among geriatric patients with chronic diseases.

METHODS

A cross-sectional study targeted outpatient geriatrics who suffer from chronic diseases at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia. Telephone interviews were utilized to collect data from participants using a structured questionnaire and the GMAS validated instrument scale (General Medication Adherence Scale) intended to measure important determinants impacting adherence: patient behaviour, cost, comorbidity, and pill burden.

RESULTS

A total of 422 patients were assessed for medication adherence. The Mean overall score for GMAS was 29.9±3.1 out of 33. (64.9%) of the patients had a high level of medication adherence. The patients had a high adherence on the domain of patient behavior related non-adherence (PBNA) (13.5±1.9) out of 15, a high adherence on the domain of additional disease and pill burden (ADPB) (11.2±1.4) out of 12, and good to high adherence on the cost-related non-adherence (CRNA) (5.25±1.1) out of 6.

CONCLUSION

The geriatric population with chronic diseases in our study had a good level of adherence to medication if compared with other international figures. To promote better medication adherence, patients must have a good understanding of their disease and strong beliefs about the medications prescribed.

Discriminating Low to High Adherent Type 2 Patients with Diabetes by Glycosylated Hemoglobin A1c, Eating Self-Efficacy and Other Psychosocial Determinants: Difference Between Patient and Physician Adherence Models

OBJECTIVE

Develop individual discriminant models using clinical and psychosocial variables for physicians and patients with diabetes based on their perceptions of patient adherence.

METHODS

This was a cross-sectional research design utilizing a discriminant analysis approach. Type 2 patients on treatment for diabetes for at least 2 years prior to research were selected. Clinical data were obtained from patient records, and psychosocial variables were collected by survey instruments filled out by patients. A final sample of 200 patients was recruited.

RESULTS

We found a positive correlation between patient and physician assessment of patient adherence behaviors. Greater adherence efforts were associated with lower HbA1c. Better quality of the patient-physician relationship was linked to better patient adherence. Increased HbA1c, longer therapy duration and higher BMI described low patient adherence for physicians. Lower HbA1c, female gender and fewer difficulties in marital adjustment characterized high adherence for patients. Dietary self-efficacy as well as emotional and social isolation discriminated mid-level adherers in both models.

CONCLUSION

This research confirmed that patients and physicians perceived and judged patients' adherence behaviors differently. Physicians and patients associated different clinical and psychological factors with low and high adherence. Further research is recommended to clarify how the quality of the physician-patient as well as the patient-spouse relationship affect dietary efficacy and patient adherence. A randomized, controlled clinical trial approach is recommended to establish the effectiveness of interventions aiming to improve dietary self-efficacy on adherence outcomes.

Cost-Related Medication Nonadherence (CRN) on Healthcare Utilization and Patient-Reported Outcomes: Considerations in Managing Medicare Beneficiaries on Antidepressants

Background: Many patients face a financial burden due to their medications, which may lead to poor health outcomes. The behaviors of non-adherence due to financial difficulties, known as cost-related medication non-adherence (CRN), include taking smaller doses of drugs, skipping doses to make prescriptions last longer, or delaying prescriptions. To date, the prevalence of CRN remains unknown, and there are few studies about the association of CRN on self-reported healthcare utilization (Emergency room (ER) visits and outpatient visits) and self-reported health outcomes (health status and disability status) among older adults taking antidepressants. Objectives: The objectives were to 1) examine the CRN prevalence, and 2) determine the association of CRN on self-reported healthcare utilization and self-reported health outcomes. Methods: This study was a cross-sectional study of a sample of older adults from the Medicare Current Beneficiary Survey (MCBS) who reported having used antidepressants in 2017. Four logistic regressions were implemented to evaluate the association of CRN, and self-reported healthcare utilization and self-reported health outcomes. Results: The study identified 602 participants who were Medicare beneficiaries on antidepressants. The prevalence of CRN among antidepressant users was (16.61%). After controlling for covariates, CRN was associated with poorer self-reported outcomes but not statistically significant: general health status [odds ratio (OR): 0.67; 95% confidence interval (CI): 0.39-1.16] and disability status (OR: 1.34; 95% CI: 0.83-2.14). In addition, CRN was associated with increased outpatient visits (OR: 1.89; 95% CI: 1.19-3.02), but not associated with ER visits (OR: 1.10; 95% CI: 0.69-1.76). Conclusion: For Medicare beneficiaries on antidepressants, CRN prevalence was high and contributed to more outpatient visits. The healthcare provider needs to define the reasoning for CRN and provide solutions to reduce the financial burden on the affected patient. Also, health care providers need to consider the factors that may enhance patient health status and healthcare efficiency.

Coping with diabetes stress among adults in rural Dominican Republic: "I don't think about it"

OBJECTIVES

As type 2 diabetes prevalence increases across Latin America, understanding local approaches to coping with diabetes stress is essential to providing care that incorporates patients' values and preferences. This study explored a local phenomenon, "no le doy mente" (I don't think about it), used by adults with type 2 diabetes in the Dominican Republic to cope with diabetes stress.

METHODS

We conducted 19 qualitative in-depth interviews with adults with type 2 diabetes (10 men, 9 women) recruited from one rural clinic. Using an inductive analytic approach including iterative coding, memos, and matrices, we identified reasons, strategies, and perceived benefits of not thinking about type 2 diabetes among participants.

RESULTS

Participants described not thinking about diabetes as an active process to maintain a sense of normalcy despite significant life changes following diagnosis. They avoided thinking about diabetes by staying busy, proactively managing type 2 diabetes through diet and medication, and turning to their faith. Participants perceived that enacting no le doy mente helped to protect their overall health and well-being.

DISCUSSION

Future research should investigate provider perceptions of no le doy mente to align patient and provider communication and mindfulness-based stress reduction as a way to support people with type 2 diabetes avoid dwelling on negative thoughts about diabetes.

How I see is how I feel. Identification of illness perception schema and its association with adaptation outcomes in multiple sclerosis - a 5-year prospective study

The aim of the study was to assess the role of illness perception in adaptation to chronic disease among patients with relapsing-remitting multiple sclerosis (RRMS). The differences between the obtained configurations of the illness perception components during four measurements and the model of predictions of the values of adaptation indicators, i.e. depression, anxiety and quality of life during subsequent measurements, were analyzed. Illness representation was assessed at baseline via the Illness Representation Questionnaire–Revised. The adaptation indicators–anxiety, depression (measured by HADS) and quality of life (measured by MSIS-29) were measured at baseline and three more times over a five-year period. The k-means cluster analysis (with two-way and repeated measures ANOVA) was conducted in a group of 90 patients (48.89% women and 51.11% men). Subsequently, the mean values of depression, anxiety, physical and psychological quality of life were compared between the clusters using the Kruskall-Wallis test. Finally, a cross-lagged panel modeled for HADS and MSIS-29 subscales in each measurement occasion (T1-T4). Three different illness perception clusters (Anxious, Realistic and Fatalistic Illness Perception named AIP, RIP and FIP) were composed which differentiated the depression, anxiety, quality of life level and age. FIP showed the lowest adaptation outcomes with small differences between AIP and RIP. It was also significantly characterized by the highest age. The positive adaptation indicators were related to the RIP cluster. The model presented rather satisfactory fit (χ²(48) = 81.05; CFI = .968; TLI = .925; SRMR = .050) with slightly inflated RMSEA = .087 (90%CI .053-.120). Based on initial measurements of individual characteristics, it was possible to predict the functioning of patients after several years. For patients with AIP, the covariance of anxiety and depression was significant, for patients with RIP–depression and anxiety, and for patients with FIP–depression. In addition, each of the variables was a predictor of subsequent measurements in particular time intervals, illustrating the dynamics of changes. Results highlight that illness perceptions formed at the beginning of RRMS are important for the process of adaptation to the disease. Moreover, they showed the differences between the adaptation outcomes supporting the idea that a cognitive representation might be important for the level of psychological functioning.

Patients' attitudes and intentions towards taking medical advice for type 2 diabetes mellitus: a theory of planned behaviour analysis

PURPOSE

A key component of effective diabetes care is understanding patients' perceptions about diabetes management. Patients' attitudes and intentions towards taking medical advice may predict the outcomes for effective diabetes care. This study aims to measure participants' attitudes, beliefs and intentions towards following medical advice to manage their diabetes using the Theory of Planned Behaviour (TPB). The domains of the TPB are correlated with clinical measures of diabetes to determine if these attitudes and intentions are predictive of better diabetes control.

METHODS

A pilot study was conducted. A 34-item survey was designed using the Theory of Planned Behaviour (TPB) framework and administered via mail by four general practice clinics. Included participants (N = 104; response rate 29.5%) had a diagnosis of type 2 diabetes and were taking medication for glycaemic control. Scores for each domain of the TPB survey were correlated with participants' clinical indicators for diabetes: HbA1c, blood pressure, lipid profile, cholesterol, and kidney health (eGFR and albumin: creatinine ratio) and BMI.

RESULTS

Participants surveyed generally reported positive attitudes and intention to follow medical advice. Medical advice was perceived to be beneficial and useful by the majority. However, in general, there was no correlation between positive intentions and improved clinical indicators of disease. Clinical indicators did not improve with duration of illness. The burden of illness is likely a mitigating factor for positive intention as participants perceive medical advice as difficult and inconvenient to follow.

CONCLUSIONS

Patients' individual capacity to implement medical advice should be addressed in shared-decision making models to potentially improve patient outcomes towards therapeutic targets.

Why do patients struggle with their medicines?-A phenomenological hermeneutical study of how patients experience medicines in their everyday lives

Why do so many people struggle with their medicines despite decades of research on medicines taking? Research into how people experience medicines in their everyday life remains scarce with the majority of research in this area of focusing on whether or not people take their medicines as prescribed. Hence, this study used a phenomenological hermeneutical qualitative design to gain a deeper understanding of individuals’ perspectives on the lived experience of medicine-taking. Findings from this study highlight five main themes where participants experience medicines as: 1) life-saving and indispensable, 2) normal and a daily routine, 3) confusing and concerning, 4) unsuitable without adjustment, and 5) intrusive and unwelcome. These results can be the basis for mutually agreed prescribing through a co-creative approach that aims at enhancing open and honest dialogues between patients and healthcare professionals in partnership about medicines.

Differential Cost-Sharing Undermines Treatment Adherence to Combination Therapy: Evidence from Diabetes Treatment

INTRODUCTION

The objective of this study was to measure the influence of differences in out-of-pocket (OOP) costs for type 2 diabetes (T2D) medications on within-patient adherence behavior towards combination drug therapy regimens.

METHODS

This was an observational, retrospective, paired sample study in patients with T2D using longitudinal pharmacy data from the 2009-2014 Medical Expenditure Panel Survey (MEPS) augmented with socio-demographic factors. We took a within-patient approach to minimize confounding effects by including patients who maintained the same number of diabetes drug classes over 2 years of MEPS. For each patient, we selected the most and least costly drug classes in the second year and examined their corresponding adherence behavior measured by medication possession ratio. The primary hypothesis tested the significance of the correlation between magnitude of the OOP cost difference and behavioral response in adherence.

RESULTS

Analysis included 1189 patients representing over 4.2 million US residents with T2D. A significant negative correlation (p < 0.001) was observed between the differences of OOP costs and adherence to the most and least costly medications compared within patients. Reduction in adherence to the most costly medication was generally observed when the difference in OOP costs was greater than $33/month. A greater variability in adherence was observed when the cost difference exceeded $2.39/month as compared to other cost difference ranges (p < 0.001), indicative of choices being made.

CONCLUSIONS

As OOP costs increased, adherence variability increased initially until a cost threshold, beyond which the adherence to the more costly medication decreased. In addition to OOP cost, adherence was also influenced by type of medication and self-perception of health. Given the complex correlation between OOP costs and adherence to medication, we suggest a careful approach to cost-sharing in the current insurance drug design and relevant insurance policies.

Factors influencing diabetes self-management in adults: an umbrella review of systematic reviews

OBJECTIVE

The objective of this review was to identify and describe the factors influencing diabetes self-management in adults by summarizing the available evidence concerning their types, categories, and relative importance.

INTRODUCTION

A wide range of factors, acting simultaneously, influence diabetes self-management and interfere with its actual application by patients. There is a variety of systematic reviews of these factors; however, a more thorough examination of their influences was lacking.

INCLUSION CRITERIA

Systematic reviews of qualitative or quantitative literature focusing on factors influencing adult diabetes self-management in general or on individual behaviors (ie, management of oral antidiabetic medication and insulin injections, self-monitoring of blood glucose, foot care, healthy eating, regular exercise, and smoking cessation) will be included.

METHODS

We performed an extensive search of 11 bibliographic databases, including gray literature, up to June 2019. Quantitative and qualitative findings were summarized separately and labeled according to their types (eg, facilitator/barrier, strength and direction of association), categories (eg, demographic, social), and frequency of occurrence.

RESULTS

We identified 51 types of factors within 114 systematic reviews, which mostly addressed medication-taking behavior. Thirty-two (62.7%) factors were reported in both qualitative and quantitative literature. The predominant influences were psychological factors and behavioral attributes/skills factors. The most frequently reported facilitators of diabetes self-management were motivation to diabetes self-management, a favorable attitude to diabetes self-management, knowledge about the disease, medication and behaviors associated with diabetes self-management, skills, and self-efficacy/perceived behavioral control. The predominant barriers were the presence of depression, and polypharmacy or drug regimen complexity. The demographic factor of female sex was frequently reported for its negative influence on diabetes self-management, whereas older age was a positive factor. The social/cultural and physical environment were the least-studied categories. Other factors such as social support from family, friends, or networks; interventions led by health professionals; and a strong community environment with good social services favoring diabetes self-management were reported as major facilitators of diabetes self-management.

CONCLUSIONS

Essential components of interventions to promote effective diabetes self-management should aim to help adults manage the effects of specific factors related to their psychological and practical self-management experience. Screening for depression, in particular, should become an integral part of the support for adult diabetes self-management, as depression is a particular obstacle to the effectiveness of diabetes self-management. Future studies should more deeply examine the influence of factors identified in the sociocultural and physical environment categories. Research should properly consider and invest efforts in strengthening social support and innovative community care approaches, including pharmacist- and nurse-led care models for encouraging and improving adult diabetes self-management. Finally, researchers should examine non-modifiable factors - age, sex, or socioeconomic status - in the light of factors from other categories in order to deepen understanding of their real-world patterns of action on adult diabetes self-management.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018084665.

Diabetes care provided by national standards can improve patients' self-management skills: A qualitative study of how people with type 2 diabetes perceive primary diabetes care

BACKGROUND

The increasing incidence of type 2 diabetes mellitus [T2DM] has resulted in extensive research into the characteristics of successful primary diabetes care. Even if self-management support and continuity are increasingly recognized as important, there is still a need for deeper understanding of how patients' experiences of continuity of care coincide with their needs for self-management and/or self-management support.

OBJECTIVE

To gain a deeper understanding of how people with T2DM perceive Swedish primary diabetes care and self-management support.

METHODS

This qualitative study used focus groups as the means for data collection. Participants were identified through a purposive sampling method differing in age, sex, diabetes duration and latest registered glycated haemoglobin level. Twenty-eight participants formed five focus groups. Qualitative content analysis was applied to interview transcripts.

RESULTS

The main theme emerging from the focus group data was that diabetes care provided by national standards improved self-management skills. Two themes that emerged from the analysis were (a) the importance of a clarification of structures and procedures in primary diabetes care and (b) health-care staff 'being there' and providing support enables trust and co-operation to enhance self-management.

CONCLUSIONS

Individual patients' self-management resources are strengthened if the importance of providing relational continuity, management continuity and informational continuity is considered. Patients also need assistance on 'how' self-management activities should be performed.

PATIENT CONTRIBUTION

Prior to the study, one pilot focus group was conducted with patients to obtain their perspectives on the content of the planned focus groups; thus, patients were involved in both planning and conduct of the study.

Collaborative care model for diabetes in primary care settings in Qatar: a qualitative exploration among healthcare professionals and patients who experienced the service

BACKGROUND

Diabetes mellitus is highly prevalent and associated with huge economic burden globally. The conventional care and management of diabetes mellitus is highly fragmented and complex, warranting the need for a comprehensive Collaborative Care Model (CCM). Little is known about the perception of patients with diabetes and their healthcare providers about CCM, its barriers and facilitators. This study aimed to explore the value of CCM in diabetes care at a primary healthcare (PHC) setting from the perspective of patients with diabetes and healthcare professionals (HCPs), in an effort to expand our current knowledge on collaborative care in diabetes at primary care level for the purpose of quality improvement and service expansion.

METHODS

Using an exploratory case study approach, semi-structured interviews were conducted among patients and HCPs who encountered CCM in Qatar during 2019 and 2020. The semi-structured interviews were transcribed verbatim and the data were analysed and interpreted using a deductive-inductive thematic analysis approach.

RESULTS

Twelve patients and 12 HCPs at a diabetes clinic participated in one-to-one interviews. The interviews resulted in five different themes: the process and components of collaborative care model (four subthemes), current organizational support and resources (three subthemes), impact of collaborative care model on diabetes outcomes (three subthemes), enablers of collaborative care model (three subthemes), and barriers to collaborative care model (three subthemes). The participants indicated easy access to and communication with competent and pleasant HCPs. The patients appreciated the extra time spent with HCPs, frequent follow-up visits, and health education, which empowered them to self-manage diabetes. HCPs believed that successful CCM provision relied on their interest and commitment to care for patients with diabetes. Generally, participants identified barriers and facilitators that are related to patients, HCPs, and healthcare system.

CONCLUSIONS

The providers and users of CCM had an overall positive perception and appreciation of this model in PHC settings. Barriers to CCM such as undesirable attributes of HCPs and patients, unsupportive hospital system, and high workload must be addressed before implementing the model in other PHC settings.

Patients' preferences for once-daily oral versus once-weekly injectable diabetes medications: The REVISE study

AIMS

To understand patient preferences for once-daily oral versus once-weekly injectable type 2 diabetes mellitus (T2DM) medication administration profiles, and reasons for their preferences.

MATERIALS AND METHODS

The REVISE study, a cross-sectional online survey of 600 participants with T2DM (United Kingdom, n = 300; United States, n = 300), elicited general preferences for once-daily oral versus once-weekly injectable diabetes medications, and reasons for the preference. Participants then viewed two videos describing the administration procedures for injectable dulaglutide and oral semaglutide, based on the product instructions for use. Thereafter, participants indicated their preference for a once-weekly injectable or a once-daily oral medication based on the video descriptions. Participants who switched preferences were asked to identify the reasons influencing their decision.

RESULTS

The participants were predominantly male (n = 349; 58.2%), with a mean (SD) age of 64 (11.3) years. Nearly all (n = 557; 92.8%) were taking an oral T2DM medication, and 158 (26.3%) were using an injectable. Initially, 76.5% (n = 459; 95% confidence interval [CI] 73.1-79.9) preferred a once-daily oral and 23.5% a once-weekly injectable (n = 141; 95% CI 20.1-26.9; P < 0.0001). After viewing the videos describing the product-specific administration, the proportions of participants preferring each option were not statistically different (oral semaglutide administration description (n = 315; 52.5%; 95% CI 48.5-56.5; dulaglutide administration description (n = 285; 47.5%; 95% CI 43.5-51.5; NS, P = 0.2207). The most common reason for switching preferences was the timing and steps of administration.

CONCLUSION

Several treatment-related characteristics, including route, frequency and complexity of the treatment, play a role in patients' preferences for T2DM treatments and should be considered during treatment selection.

Exchanges in a Virtual Environment for Diabetes Self-Management Education and Support: Social Network Analysis

BACKGROUND

Diabetes remains a major health problem in the United States, affecting an estimated 10.5% of the population. Diabetes self-management interventions improve diabetes knowledge, self-management behaviors, and clinical outcomes. Widespread internet connectivity facilitates the use of eHealth interventions, which positively impacts knowledge, social support, and clinical and behavioral outcomes. In particular, diabetes interventions based on virtual environments have the potential to improve diabetes self-efficacy and support, while being highly feasible and usable. However, little is known about the patterns of social interactions and support taking place within type 2 diabetes-specific virtual communities.

OBJECTIVE

The objective of this study was to examine social support exchanges from a type 2 diabetes self-management education and support intervention that was delivered via a virtual environment.

METHODS

Data comprised virtual environment-mediated synchronous interactions among participants and between participants and providers from an intervention for type 2 diabetes self-management education and support. Network data derived from such social interactions were used to create networks to analyze patterns of social support exchange with the lens of social network analysis. Additionally, network correlations were used to explore associations between social support networks.

RESULTS

The findings revealed structural differences between support networks, as well as key network characteristics of supportive interactions facilitated by the intervention. Emotional and appraisal support networks are the larger, most centralized, and most active networks, suggesting that virtual communities can be good sources for these types of support. In addition, appraisal and instrumental support networks are more connected, suggesting that members of virtual communities are more likely to engage in larger group interactions where these types of support can be exchanged. Lastly, network correlations suggest that participants who exchange emotional support are likely to exchange appraisal or instrumental support, and participants who exchange appraisal support are likely to exchange instrumental support.

CONCLUSIONS

Social interaction patterns from disease-specific virtual environments can be studied using a social network analysis approach to better understand the exchange of social support. Network data can provide valuable insights into the design of novel and effective eHealth interventions given the unique opportunity virtual environments have facilitating realistic environments that are effective and sustainable, where social interactions can be leveraged to achieve diverse health goals.

Self-Care Management of Patients with diabetes: nurses' perspectives

PURPOSE

To explore nurses' experiences of providing education on self- care management to patients with diabetes.

METHODS

A qualitative phenomenological study using semi-structured interview on all nine certified diabetic nurse educators in the main hospital and health centres in Brunei. Prolonged engagement with participants and data, and member checking were employed to ensure thematic analysis was trustworthy.

RESULTS

Three main themes emerged; 1) Factors of effective teaching strategies that emphasizes on assessing patients' knowledge and education level to provide individualised instructional plan, which need to follow latest ministerial guidelines and effective pedagogy; 2) Barriers to provide effective education including psychological, financial, and lack of familial support, 3) Overcoming barriers through parallel health education and counselling, referring to medical social worker and non-governmental organizations, and inclusion of family members and carers in plan of care.

CONCLUSION

Diabetic nurse educator plays a crucial role to ensure patient with diabetes achieved competency and compliance with long term self-care management. Nurses' need to ensure psychological preparedness and patient literacy assessment when designing individualised health education session. While identifying and addressing key barriers for each patient to ensure effectiveness of management plan and improve quality of life. More research are still needed to explore experiences and innovation solutions from nurses in different parts of the world to better inform policymakers and improve organisational and national guidelines for management of patients with diabetes.

Exploring perceptions, attitudes and beliefs of Thai patients with type 2 diabetes mellitus as they relate to medication adherence at an out-patient primary care clinic in Chiang Mai, Thailand

Background

Within the sphere of diabetes self-management, much emphasis has been placed on medication adherence. There has been a shift in thinking about medication adherence, moving from “compliance” and historically paternalistic models of care, to seeking better ways of characterizing dynamic and complex relationships that determine medication adherence and diabetes control. This study sought to understand the relationship between patient’s attitudes and medication adherence for oral anti-diabetics in Thailand.

Methods

In-depth interviews of patients with type 2 diabetes mellitus, taking oral anti-diabetic drugs, at the out-patient clinic run by the Department of Family Medicine, Chiang Mai University between May and December 2016. Thematic analysis followed the WHO framework for medication adherence in chronic disease to explore patient’s attitudes and their influence on medication compliance.

Results

Of 24 patients, 9 were men. The mean age was 62 years (SD 8.9 years). 67% had high compliance. Four themes were identified as important factors related to medication adherence: attitudes toward disease, attitudes toward treatment, attitudes toward family support and attitudes toward health care team. Specifically, symptoms at diagnosis, understanding and acceptance in taking medication, the presence of family support and the perception of concern by the doctor relate to improved medication compliance.

Conclusions

Medication adherence in Thai patients with diabetes requires support from both the health care providers and the family. The patient’s perception of the doctor’s concern creates greater patient trust in the health care team. This trust, along with family support, helps deepen patients’ understanding of the disease, accept the chronic nature of their disease, and engenders a positive attitude towards taking medication that can improve medication adherence.

Medication non-adherence in patients with type 2 diabetes mellitus with full access to medicines

Purpose

The pharmacological treatment for Type 2 diabetes mellitus (T2DM) is continuous and adherence to medication is critical for disease control. Restricted access to medicines is one of the most important barriers to adherence to T2DM treatment. This study aimed to evaluate other factors for medication non-adherence by studying patients with full access to oral hypoglycemic agents.

Methods

Cross-sectional study with 300 patients receiving their medication without costs from a referral center for diabetes care in Crato, Ceará (Brazil). Participants were recruited from January to December 2017. Information was obtained by self-applied questionnaires, and the drugs used were confirmed in the prescription. Adherence to medication was determined by the Morisky Medication Adherence Scale (MMAS-4). Patient perceptions of drugs were assessed by the Beliefs about Medicines Questionnaire (BMQ).

Results

Only 22.7% of participants met the criterion of high adherence to medication. The most frequent characteristics in the low adherence group were married; hypertension; no regular physical activity; therapy based on the combination of two or more oral antidiabetic agents without insulin; low score in the BMQ necessity scale. Necessity score in BMQ increased with age and the number of medications used and decreased if the patient had family members with the same disease and had children.

Conclusions

Full access to medicines did not assure high adherence to pharmacological treatment of type 2 diabetes mellitus. Distinctive factors to medication non-adherence may be found and specific barriers should be considered when planning actions for improving adherence in such populations.

Patients' and Doctors' Beliefs about Treatment and Long-Term Adherence in Rheumatic Diseases

Objective:

The aim of this study was to explore the beliefs of rheumatologists and patients about treatment-related factors, long-term adherence, and their communication with regard to rheumatic diseases.

Methods:

In a multicentre, observational study conducted in Greece, a structured questionnaire was administered to 75 rheumatologists and 398 rheumatic patients from different regions. Five domains were investigated: i) effectiveness of treatment, ii) choice of treatment, iii) change of ineffective treatment, iv) long-term adherence, and v) the quality of communication between doctors and patients. Descriptive data, confidence intervals, t-tests and factor analysis were employed.

Results:

Examining the patients’ and rheumatologists’ beliefs and attitudes about treatment profiles and long-term adherence, a statistically significant convergence in their views on effectiveness and safety as the predominant factors concerning choice of treatment and long-term adherence was found. Although patients reported high trust to their doctors, a divergence of views is recorded regarding communication of the two parts. Statistically significant differences in the views between patients and rheumatologists were found with regards to access (p<0.001), time per visit (p<0.001), mutual understanding (p<0.001), and overall communication (p<0.001).

Conclusions:

Our study shows a great rate of agreement between patients and rheumatologists regarding the factors determining the efficacy, choice, switching and adherence to treatment while there was significant divergence in the views regarding the quality of communication between the two parts. Co-ordinated efforts are needed in order to improve the communication level between rheumatic patients and rheumatologists.

Adaptação e validação cultural de questionário de aconselhamento na diabetes do tipo 2

Objetivo

O objetivo do estudo é contribuir para a validação do Questionário de Avaliação dos Fatores Associados ao Aconselhamento na Diabetes do Tipo 2 (CSRBQ), que avalia os fatores psicossociais envolvidos na prestação de aconselhamento nutricional, de atividade física e de educação continuada (e.g., autoeficácia).

Método

Foi utilizada uma metodologia mista, com recurso a questionário e entrevistas individuais com profissionais de saúde. Primeiro foram feitas análises à sensibilidade e fiabilidade do instrumento numa amostra de 74 profissionais de saúde envolvidos diretamente na consulta de Diabetes do Tipo 2 (médicos e enfermeiros); posteriormente, foi feita uma análise facial do instrumento através da análise de conteúdo de 17 entrevistas individuais.

Resultados

A versão portuguesa do CSRBQ apresenta medidas descritivas e consistência interna aceitáveis para quase todas as escalas e, de um modo geral, foi bem aceite e interpretada pelos profissionais de saúde. A análise das entrevistas sugere a necessidade de ajustamento do questionário ao nível da sua organização e clarificação.

Conclusão

O CSRBQ pode oferecer informação relevante acerca das barreiras e facilitadores à prestação de aconselhamento pelos profissionais de saúde na diabetes do tipo 2.

Health Care Providers' Perspectives on Barriers and Facilitators to Care for Low-Income Pregnant Women With Diabetes

OBJECTIVE | Treatment of gestational diabetes mellitus and type 2 diabetes during pregnancy can improve maternal and neonatal outcomes; yet, self-care burdens for pregnant women with diabetes are high, particularly for low-income and minority women. Although prior studies have investigated patient-perceived barriers and facilitators to diabetes self-management during pregnancy, little work investigates the perspectives of health care providers (HCPs) on these factors. The objective of this study was to investigate HCPs' perspectives on patient barriers and facilitators to diabetes care during pregnancy. METHODS | In this qualitative investigation, focus groups were conducted using a semistructured interview guide designed to elicit HCPs' perceptions of patient barriers and facilitators to successful diabetes-related self-care. HCPs included physicians, nurses, health educators, and other personnel who care for low-income pregnant women with diabetes. Interviews were transcribed verbatim. Transcripts were analyzed using the constant comparative technique to identify themes and subthemes, using the Social Ecological Model as a theoretical framework. RESULTS | Participants (n = 29) identified barriers and facilitators to women's achievement of optimal diabetes self-care according to six levels (environment, access, institution, interpersonal, knowledge, and individual). Example subthemes included inflexible work schedule, poor access to medication and supplies, overburdened clinic, perceived patient "policing," and low health literacy. Individual factors included self-efficacy, motivation, and engagement. HCPs identified barriers, but not facilitators, for each theme. CONCLUSION | HCPs described facilitators and barriers to diabetes care at all levels of the Social Ecological Model. These data can inform interventions to dismantle barriers patients face and thus create meaningful health care interventions to improve outcomes for low-income pregnant women with diabetes.

Facilitating barriers: Contextual factors and self-management of type 2 diabetes in urban settings

Urban environments create unique challenges for the management of type 2 diabetes (T2D). City living is associated with unhealthy occupational, nutritional, and physical activity patterns. However, it has also been linked to behaviours that promote health, such as walking and cycling for transportation. Our research is situated at the intersection of these contradictory findings. We ask: What aspects of urban living impact the ability of those living with diabetes to reach optimal health? What contextual and structural factors influence how barriers are experienced in the everyday lives of those living with T2D? We conducted semi-structured interviews with 29 individuals living in Toronto and Vancouver. Interviews were recorded, transcribed, and systematically coded for themes and sub-themes. In addition to affirming readily acknowledged barriers to diabetes management, such as accessing healthy, culturally appropriate food and the cost of management, our findings suggest that the unpredictable nature of urban living creates barriers to routinizing self-management practices. As large, cosmopolitan centres with an abundance of activities on offer, cities pulls people away from home, making adherence to self-management recommendations more difficult. Moreover, our findings challenge commonly held assumptions about the mutually exclusive and static nature of barriers and facilitators. Public transit, a readily acknowledged facilitator of healthy living, can be experienced as a barrier to diabetes management. Participants report intentional non-adherence to their medication regimens for fear of hypoglycemia in subway or traffic delays. While the stimulating nature of cities promotes walkability, it produces barriers as well: participants partake in more restaurant eating than they would if they lived in a rural area and were home to cook their own meals. Understanding how barriers are experienced by people living with diabetes will help mitigate some of the unintended consequences associated with various contextual factors. We recommend that healthcare professionals acknowledge and support people with T2D in routinizing self-management and developing contingency plans for the unpredictability and complexity that urban living entails. We suggest further research be carried out to develop contextually-tailored municipal policies and interventions that will support self-management and improve outcomes for individuals living with T2D in urban settings.

Clinical pharmacists in diabetes management: What do minority patients with uncontrolled diabetes have to say?

OBJECTIVE

Clinical pharmacist support for patients with type 2 diabetes mellitus (T2DM) can optimize patient outcomes and medication adherence. However, there is limited understanding of what pharmacist roles patients perceive as most helpful in T2DM management interventions. This study describes experiences of minority patients with uncontrolled T2DM in terms of perceived pharmacist helpfulness and specific roles found to be most helpful within diabetes management.

DESIGN

A secondary analysis of a 2-year randomized, crossover trial was conducted.

SETTING AND PARTICIPANTS

This study included 244 African American and Hispanic adults with uncontrolled T2DM who received clinical pharmacist support within a team-based model.

OUTCOME MEASURES

The patients completed a mixed-methods survey regarding their experience with the intervention that included a general helpfulness rating on a 10-point unipolar Likert scale and described the support qualitatively, including their perception of the pharmacist roles. Thematic analysis guided coding of the responses.

RESULTS

One hundred forty-seven (60%) patients completed the survey and had at least 1 encounter with a clinical pharmacist. Of these, 108 (74%) were African American, 39 (27%) were Hispanic, and 101 (69%) were women. The median rating of clinical pharmacist helpfulness was 10 (very helpful). Only 10 (7%) participants rated pharmacist helpfulness as 1 (not at all helpful). "Medication education and management" was the most frequently perceived supportive role of the clinical pharmacists, followed by "non-medication-related patient education," "social support," and "care coordination." Miscommunication related to scheduling was the most common reason cited for not meeting with the clinical pharmacist.

CONCLUSION

This sample of minority patients with uncontrolled T2DM recognized many roles outlined within the American Pharmacists Association Medication Therapy Management framework. Patient experiences with clinical pharmacist T2DM support are crucial for developing effective programs, maximizing patient engagement, satisfying patient needs, and ensuring that a program's intended purpose aligns with the patient perspective.