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

Comparison of Photographic Screening Methods for Diabetic Retinopathy – A Meta-analysis

INTRODUCTION

Diabetic Retinopathy (DR) is a leading cause of irreversible visual impairment and blindness in both developed and developing countries. Although the merits of DR screening are well recognized, significant variations in screening practices including imaging modality still exists.

PURPOSE

To evaluate and compare the sensitivity and specificity of mydriatic and non-mydriatic photographic screening methods using 7-Field fundus photography or dilated fundus examination (DFE) by an ophthalmologist as reference standard.

METHODS

A systematic review using PRISMA Guidelines was conducted by online search of MEDLINE, Web of Science, and other repositories of all available studies from 1990 until 2019. A total of 62 studies were included in the meta-analysis from a total of 406 suitable abstracts screened and 95 articles reviewed in full. Data were collected using a standardized extraction form independently, with all authors masked to others' search results.

RESULTS

For the detection of any DR (ADR), sensitivity ranged from 81% with single field to a maximum of 99% for 4-7 fields and wide-angle images. For detection of referable DR (RDR) sensitivity ranged from 76% for single field to 93% for wide-angle photography. Specificity was lowest at 91% for wide-angle images and greatest at 99% for three field photography. Study heterogeneity was noted to be significant, which was partly attributed to the range of DR classification between studies.

CONCLUSIONS

The sensitivity and specificity of DR screening are positively associated with number of photographic fields. Pooled estimates suggest non-mydriatic two-field photography may be sufficient for screening detection of ADR and RDR.

Effectiveness and Acceptability of a Nutrition Intervention Targeting Chinese Adult Immigrants With Type 2 Diabetes in Canada: A Study Using Mixed Methods Analysis

OBJECTIVES

Although culturally tailored diabetes treatment is recommended, there is a lack of relevant dietary resources for the Chinese population in Canada. In this study we assessed the feasibility and efficacy of a culturally tailored menu plan combined with nutrition education on clinical outcomes, diet quality and qualitative outcomes among Chinese immigrants with type 2 diabetes.

METHODS

Participants were 17 Chinese immigrants living with type 2 diabetes in Edmonton, Alberta, Canada. The design was a 12-week, single-arm intervention that included weekly nutrition education supported by a culturally tailored menu plan with mixed methods evaluation. Diet quality, clinical and other outcomes were assessed pre- and postintervention. One-on-one interviews were conducted postintervention to identify program feasibility and obstacles to adherence.

RESULTS

Waist circumference (mean ± standard deviation: -2.0±2.5 cm; p=0.004), total cholesterol (-21.4±28.2 mg/dL; p=0.007) and low-density lipoprotein cholesterol (-18.4±24.6 mg/dL; p=0.007) were decreased when compared with baseline. No significant change was detected in glycated hemoglobin. Postintervention, the Healthy Eating Index (p=0.01) and diabetes knowledge score (p=0.009) also increased. Participants reported that the program was culturally acceptable, easily understood and feasible to implement. Participants indicated the program helped them to improve their diabetes knowledge, adhere to the dietary guidelines, choose low glycemic index food and read food labels when shopping.

CONCLUSIONS

A flexible, culturally tailored menu plan was a feasible and effective tool for improving diabetes knowledge, diet quality and metabolic outcomes among Chinese immigrants with type 2 diabetes.

Development and evaluation of a new questionnaire to assess social cognitive factors of self-management in patients with type 2 diabetes: a psychometric study

Background

Self-care behaviors are essential to control blood sugar and to prevent mortality and complications of diabetes. The evidence suggests that social cognitive factors play a crucial role in adopting self-care behaviors. This study aimed to develop and examine the psychometric properties of the Diabetes Self-Management Questionnaire based on the social cognitive theory (DSMQ-SCT).

Methods

The present methodological cross-sectional study investigated 460 patients with T2DM referred to the Isfahan Endocrine and Metabolism Research Centre, Isfahan, Iran using the convenience sampling method. We assessed the reliability (internal consistency), content validity, convergent validity and construct validity. Construct validity was evaluated using exploratory factor analysis (calibration sample = 230) and confirmatory factor analysis (validation sample = 230).

Results

In the EFA with the varimax rotation, we extracted four factors that could explain 65.9% of the total variance of the DSMQ-SCT scale. The CFA exhibited a satisfactory fit level for the four-factor structure extracted from the EFA with the following measures. CFI: .971, IFI: .971, NFI: .942, TLI: .966, RMSEA: .046).Internal consistency was good (Cronbach's alpha coefficient for the whole scale: 0.88; the subscales: 0.85 to 0.92). The convergent validity showed significant negative correlations between DSMQ-SCT subscales and HbA1c.

Conclusion

DSMQ-SCT is a valid and reliable instrument to assess social cognitive factors associated with self-management behaviors in patients with T2DM. Therefore, this instrument can be used in both future research and clinical practices.

Clinicians' perceived barriers and enablers to the dietary management of adults with type 2 diabetes in primary care: A systematic review

BACKGROUND

Dietary management of type 2 diabetes is considered as a key remission and management strategy. This review explored clinicians' perceived barriers and enablers to the dietary management of adults with type 2 diabetes in primary care.

METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA were searched from 1980 to 26 June 2020.

RESULTS

Of 2021 records, 14 studies met the inclusion criteria, describing the 14 domains of the refined Theoretical Domains Framework. The data synthesised to the domains of environmental context and resources, intentions and beliefs about capabilities were considered most trustworthy, closely followed by knowledge, behavioural regulation and beliefs about consequences. Two-thirds of studies cited time for staff training or patient education as major constraints to type 2 diabetes management. Clinicians also identified lack of patient engagement and poor dietary adherence as issues. Despite this, clinician confidence about giving dietary advice to patients was high. With further exploration, knowledge gaps were apparent and feelings of despondency as a result of poor outcomes were visible.

CONCLUSIONS

This review revealed four clinician behaviours: (2) the perception of the dietitian; (2) the definition of a clinician qualified to give dietary advice; (3) clinician belief in dietary management as a treatment; and (4) clinician belief in a patient's capability to change dietary behaviour. These behaviours, if challenged and changed, have the potential to improve dietary management and outcomes for people with type 2 diabetes in primary care.

Doctors identify regulatory barriers for their patients with type 2 diabetes to access the nutritional expertise of dietitians

Diet is central to the management of type 2 diabetes (T2D) and better outcomes are achieved when the dietary intervention is delivered by a dietitian. Yet, many people with T2D never see a dietitian. It has been proposed that doctors prefer to provide the dietary advice themselves or rely on medication to treat their patients instead of referring them to a dietitian. This study aimed to collect the opinions and perspectives of doctors with regard to the dietary management of people with T2D in Australia. GPs and physicians treating people with T2D were recruited to participate in semistructured interviews conducted over the telephone. Inductive thematic analysis of content was conducted. Five GPs and seven physicians participated in the study. The qualitative analysis identified four main themes: the importance and role of diet in the management of T2D; the perceived value of dietetic care; access to dietetic services; and patients' motivation to consult a dietitian. All participants acknowledged the importance of diet in the treatment of T2D and all but one preferred to refer patients to a dietitian for nutritional management. Among the reported barriers to accessing dietetic services were: specialist physicians' lack of access to the national referral scheme for chronic conditions; patients' financial circumstances; and inadequacy of the number of subsidised sessions. It is important to facilitate and subsidise access to dietetic services through existing mechanisms by increasing the number of visits on the chronic disease management scheme and providing referral rights to specialist physicians.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Health-related quality of life and patient-reported outcome measures in NASH-related cirrhosis

BACKGROUND & AIMS

Non-alcoholic steatohepatitis (NASH) is known to have a negative impact on patients' health-related quality of life (HRQoL), even before progression to cirrhosis has occurred. The burden of NASH-related cirrhosis from the patient perspective remains poorly understood. Herein, we aimed to identify the burden of disease and HRQoL impairment among patients with NASH-related compensated cirrhosis.

METHODS

This targeted literature review sought first to identify the humanistic burden of disease from the perspective of patients with diagnosed NASH-cirrhosis and, secondly, to identify generic or disease-specific patient-reported outcome measures (PROMs) used to assess the impact of NASH-cirrhosis. Searches were conducted in bibliographical databases, grey or unpublished literature, liver disease websites, support group websites and online blogs. A quality assessment of specific PROMs was conducted.

RESULTS

Patients with NASH-cirrhosis are reported to suffer from lower HRQoL than patients with non-cirrhotic NASH and the general population with respect to physical health/functioning, emotional health and worry, and mental health. Thirteen PROMs were identified, of which 4 were liver-disease specific: CLDQ, CLDQ-NAFLD, LDQoL and LDSI. The most commonly used measures do not comply with current industry or regulatory standards for PROMs and/or are not validated for use in a cirrhotic NASH population.

CONCLUSIONS

Patients with NASH-cirrhosis have lower HRQoL and poorer physical health than patients with non-cirrhotic NASH. However, the literature lacked detail of the everyday impact on patients' lives. Currently, a number of PROMs are available to measure the impact of the disease in patients with chronic liver conditions. The lack of studies that include qualitative insights in this population mandates further exploration and research.

LAY SUMMARY

It is not well understood how having non-alcoholic fatty liver disease (NAFLD)-related cirrhosis affects a person's everyday wellbeing and quality of life. Some research has been done with patients who have early stages of liver disease but not people with cirrhosis. We found that patients with NAFLD-related cirrhosis tended to have poorer health than patients without cirrhosis. But there was not very much information from patients themselves and there were no tools or questionnaires just for this group of patients.

Positive health beliefs are associated with improvement of glycated hemoglobin and lipid profiles in Mexican patients with type 2 diabetes mellitus: a cross-sectional study

BACKGROUND

Health beliefs are relevant to consider in patients with type 2 diabetes since disease control depends mainly on the patient's behaviour. The aim of this study was to assess the association between health beliefs and glycated hemoglobin levels in Mexican patients with type 2 diabetes.

METHODS

An analytical cross-sectional study was conducted, and 336 patients were included. Fasting blood levels of glycated hemoglobin, glucose, cholesterol; triglycerides, high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c) were measured. Body fat percentage, weight, height; waist circumference, and systolic and diastolic blood pressures were also obtained. A previously validated self-administered questionnaire was used to assess the health beliefs with regards to non-pharmacological treatment. Health beliefs were classified as positive, neutral, and negative.

RESULTS

The average age of patients was 54.7 ± 8.5 years, with a higher proportion of females (69%). The questionnaire had a good internal consistency with a Cronbach's alpha score of 0.83. More than 90% of patients attributed a health benefit to diet and exercise, 30 to 40% experienced barriers, and more than 80% had a perception of complications associated to uncontrolled diabetes. Patients with positive health beliefs had lower HbA1c levels (8.2 ± 1.7%) compared to those with neutral (9.0 ± 2.3%), or negative (8.8 ± 1.8%; p = 0.042). The LDL-c levels were lower (p = 0.03), and HDL-c levels were higher (0.002) in patients with positive heath beliefs.

CONCLUSIONS

Positive health beliefs are associated with better metabolic control indicators in patients with type 2 diabetes.

Association Between Perceived Barriers to Diabetes Self-management and Diabetic Retinopathy in Asian Patients With Type 2 Diabetes

Importance

A patient’s perceived barriers to diabetes self-management (DSM) may affect his or her risk of diabetic retinopathy (DR); however, few studies have examined this association.

Objective

To examine the association between perceived barriers to DSM and the severity spectrum of DR in Asian patients with type 2 diabetes.

Design, Setting, and Participants

A cross-sectional clinic-based study, the Singapore Diabetes Management Project, was conducted from December 28, 2010, to March 20, 2013, at the Singapore National Eye Centre, a tertiary eye care institute. After excluding patients with type 1 diabetes and ungradable fundus images, 361 participants were included in the analyses. Statistical analysis was conducted from July 20 to September 8, 2017.

Exposure

The degree of perceived barriers to DSM was assessed using a 23-item questionnaire comprising items about knowledge of DSM, access to care, and confidence in health care professionals. Rasch analysis was used to optimize the scale’s psychometric properties, with lower scores indicating a higher degree of self-perceived barriers.

Main Outcomes and Measures

Diabetic retinopathy was graded from 2-field retinal images into categories of no DR (Early Treatment Diabetic Retinopathy Study levels 10-15; n = 154), mild to moderate DR (levels 20-43; n = 112), and severe DR (levels ≥53 and/or presence of clinically significant macular edema; n = 95) using the modified Airlie House classification system of DR. Multinomial logistic regression models were used to assess the association between perceived barriers and severity of DR in the worse-affected eye.

Results

Among the 361 participants (105 women and 256 men; mean [SD] age, 57 [8] years), a greater magnitude of perceived barriers to DSM was independently associated with higher odds of having any DR (odds ratio, 1.32; 95% CI, 1.06-1.66), mild to moderate DR (odds ratio, 1.30; 95% CI, 1.01-1.68), and severe DR (odds ratio, 1.36; 95% CI, 1.03-1.79). This association was independent of diabetes control (hemoglobin A1c, blood pressure, and lipid levels), presenting visual acuity, and socioeconomic indicators.

Conclusions and Relevance

These results suggest that greater perceived barriers to DSM are independently associated with severity of DR. Although longitudinal data are needed, these findings suggest that evidence-based interventions to reduce patient-, practitioner-, and system-related barriers to diabetes care may help reduce the risk of DR.

Attitudes towards, facilitators and barriers to the provision of diabetes self-care support: A qualitative study among healthcare providers in Ghana

STATEMENT OF THE PROBLEM

Self-care support provided by healthcare providers (HCPs) is critical to diabetes self-care. However, a number of barriers prevent HCPs from providing self-care support to people with diabetes. We explored attitudes towards, barriers and facilitators of the provision of diabetes self-care support among Ghanaian HCPs.

METHODS

Fourteen semi-structured interviews were conducted among HCPs recruited from three diabetes clinics in Tamale, Ghana. All interviews were digitally recorded and transcribed verbatim. Transcripts were coded and analysed thematically.

RESULTS

HCPs reported a sense of responsibility and urgency to provide self-care education to diabetes patients; while believing it was the patients' responsibility to self-care for their diabetes condition. Accordingly, HCPs perceived their role to be limited to information sharing rather than behaviour change interventions. Facilitators to the provision of self-care support included patients' motivation, and team work among healthcare professionals. Barriers that hindered self-care support included language barriers and poor inter-professional collaboration. Furthermore, HCPs discussed that they felt inadequately trained to provide self-care support. Healthcare-system-related barriers were inadequate office space, lack of professional development programmes, high patient numbers, inadequate staff numbers, inadequate health insurance and a lack of sufficient supplies and equipment in the hospital.

CONCLUSION

HCPs attitudes were generally favourable towards supporting self-care, albeit with a focus on information provision rather than behaviour change. Training in effective strategies for providing self-care support are needed, and better use of the resources that are available.

Samoan migrants' perspectives on diabetes: A qualitative study

ISSUE ADDRESSED

The Samoan community in Australia has one of the highest rates of diabetes in Australia. We explored the experiences and perceptions of Samoan patients living with diabetes and their family members.

METHODS

Semi-structured interviews were conducted with adults from a Samoan background living in Australia who had diabetes and their family members. Participants were recruited from a single general practice with a high proportion of Pacific Islander patients, through self-response to waiting room flyers. Inductive thematic analysis was conducted using a constructivist-grounded theory approach. This qualitative project was part of the developmental phase of a larger project aiming to promote healthy lifestyles and decrease diabetes in the Samoan community in Sydney, Australia.

RESULTS

Twenty participants, aged 36-67 years, were interviewed. The majority was men (n = 13) and all were migrants to Australia. Participants reported a range of barriers to early detection and self-management of diabetes, including dietary practices common within their culture and the role of church and religion. They identified that pride in their heritage and role within families could be a barrier to care but also provided an opportunity for health promotion.

CONCLUSIONS

The cultural factors which influence the risk and management of diabetes in the Samoan community in Australia can be the barriers to health change but also provide opportunities for culturally targeted diabetes education and health promotion. SO WHAT?: These findings will inform the development of approaches for the prevention and management of diabetes within the Samoan-Australian community. These include health-promotion initiatives which take into account the role of cultural dietary practices, diabetes stigma, cultural pride and working with churches.

Comparison of self-care in non-cardiac diabetic patients

BACKGROUND

In general, the majority of diabetic patients suffering from a lack of capability in controlling different aspects of self-care have likely been prone to cardiovascular disease. To reduce the economic burden in societies and the rate of death on one hand, and improve life expectancy, on the other hand, it seems necessary to emphasize self-care training in diabetic patients. The purpose of this study was to determine comparison of self-care in cardiac and non-cardiac diabetic patients.

METHODS

This descriptive-analytic study was carried out with 136 diabetic participants selected using random sampling and divided into two groups of 68 non-cardiac diabetic patients. Data were collected using a demographic and diabetic patient's self-management questionnaire (DSMQ). For the analysis of the data, SPSS16 was employed to check the significance test at the level of P<0.05.

RESULTS

In this study, twenty-eight (41.2%) and forty (58.8%) of the participants in each group were male and female, respectively. Their ages spanned from (61.35±13.34) in non-cardiac diabetic group to (65.94±8.74) in cardiac diabetic participants. There were significant differences between two groups, specifically in patients with cardiac diabetic disease in different aspects, for instance, including glucose monitoring (F=4.977, P=0.027, η²=0.036), diet control (F=9.125, P=0.003, η²=0.064), physical activity (F=22.954, P=0.0001, η²=0.146) and health care awareness (F=31.366, P=0.0001, η²=0.19).

CONCLUSION

According to DSMQ questionnaire in the present study, glucose monitoring, diet control, physical activity, and health care awareness in diabetic patients with heart disease were significantly reported to have been better than the other group with no cardiac problem. Due to insufficient self-care in diabetic patients and some consequences such as poor health, heart disease as one of the complications of diabetes, hospital re-admission and heavy costs, the therapeutic team should be alerted to self-care training.

Primary care physician perspectives on barriers and facilitators to self-management of type 2 diabetes

Objectives

To assess physician perspectives on perceived barriers and facilitators to type 2 diabetes self-management (DSM) in a primary care setting.

Methods

The study utilized survey methodology to measure perspectives of primary care physicians on DSM and the challenges they face in managing patients with poor glycaemic stability. Demographic and practice site-related information of the physicians were also collected.

Key findings

Of the 21 physicians who responded (53.8% response rate), 71.2% were aged 50 years or older, 54.2% had ≥25 years of clinical experience, and 50% practiced in an urban setting. The physicians examined 5–60 patients with type 2 diabetes per week (mean = 20), and over 75% of them spent &lt;20 min on face-to-face visits. Approximately, 95% of physicians considered self-care activities such as regular moderate exercise, following a recommended diet, regular blood glucose testing, proper insulin administration and adherence to oral medication as extremely important. Practice-related aspects such as patient–physician communication, patient health literacy and patient follow-up were unanimously considered extremely important, and performance on these measures was rated positively. Interestingly, 66% of physicians felt responsible to some extent for their patient's failure to reach type 2 DSM goals. Physician perceived barriers that contributed to clinical inertia included cost of medications, lack of patient motivation and knowledge, non-compliance with diet and medications, polypharmacy and lack of time and social support.

Conclusions

The study results underscore the importance of DSM in the overall management of type 2 diabetes. Addressing the challenges faced by physicians may result in better self-management and improved clinical outcomes in type 2 diabetes population.

Type 1 diabetes self-management: developing a web-based telemedicine application

BACKGROUND

Self-management skills are essential for patients with diabetes mellitus to minimise the risks of complications from their condition. The aim of this research was to develop a web-based application for self-management of type 1 diabetes, suitable for use by patients, their carers and physicians.

METHOD

The study was comprised of two phases, the first being analysis of the kind of information and capabilities required by potential users of the system. Based on the results derived from the first phase of the study, the system prototype was designed and then evaluated using the 'think aloud' method and a standard questionnaire. The application was designed for use by patients, their carers and physicians. Patients could enter the level of blood glucose, insulin and activities on a daily basis, and physicians were able to supervise a patient's health status from a distance.

RESULTS

Users were generally satisfied with the final version of the system. People with a wide range of literacy skills were able to use the system effectively.

CONCLUSION

Patients or their carers could use the web-based application as a log book by entering the level of blood glucose and insulin doses on a regular basis, and as an educational resource to improve self-management skills. Physicians could use the system at any time convenient to them to support patients by giving medical advice. Further research is needed to report the effectiveness of the system in practice.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Barriers and facilitators to diabetes self-management in a primary care setting - Patient perspectives

BACKGROUND

Diabetes self-management (DSM) is a key element in the overall management of type-2 diabetes (T2DM). Identifying barriers and facilitators to DSM and addressing them is a critical step in achieving improved health outcomes in this population.

OBJECTIVE

To assess patient reported barriers and facilitators to self-management of T2DM in a primary care setting.

METHODS

This cross sectional study combined patient survey data with electronic medical record (EMR) data. Patients (age≥18 years) with a recorded diagnosis of T2DM (ICD-9 code: 250. xx) and having ≥2 physician visits were identified from a physician group's EMR database. Patients were grouped based on their A1C levels: <7, 7-9, and >9. Information on demographics, knowledge of diabetes, attitudes, health beliefs, and level of self-management was collected through survey administration. Survey responses were linked to the EMR data, and additional patient information was extracted.

RESULTS

A total of 2100 surveys were administered (700 in each A1C category) of which 210 responses were received (10% response rate). Mean age was 63.7 years ( ±11.79), 108 (51.4%) were males, and 197 (93.8%) were Caucasian. Age (X² = 15.73, p < 0.01), insurance status (X² = 12.03, p < 0.05), referral to an endocrinologist (X² = 6.17, p < 0.05), level of self-management (X² = 12.01, p < 0.05) and willingness to use insulin (X² = 9.8, p < 0.01) were associated with glycemic variability. Level of self-management (X² = 33.04, p < 0.01) and referral to an endocrinologist (X² = 11.11, p < 0.01) were associated with readiness to change DSM behavior. Better self-management, older age, lower willingness to use insulin, and 'less than graduate level' education were significant predictors of glycemic stability.

CONCLUSIONS

Self-management behavior of patients with T2DM is strongly associated with glycemic stability. Interventions directed towards improving self-management in this population may result in improved clinical outcomes.

Psychosocial barriers to healthcare use among individuals with diabetes mellitus: A systematic review

PURPOSE

To conduct a systematic review regarding psychosocial barriers to healthcare use in individuals with diabetes mellitus, using a well-established model of health-service use as a theoretical framework.

METHODS

We used database-specific controlled vocabularies and additional free text terms, and conducted searches via MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, OVID Journals. Included studies were rated according to the UK National Institute for Health and Care Excellence (NICE) criteria. A narrative data synthesis was conducted, using the Andersen model and developing categories from the included studies.

PRINCIPAL RESULTS

In total, 2923 studies were identified, and 15 finally included. We identified barriers according to the main categories "population characteristics", "norms and values", and "healthcare services" on a contextual and individual level, as well as "health status". Frequently reported barriers were "socioeconomic status", and "physician characteristics". Ethnic minorities were frequently analysed and may have specific barriers, e.g. "cultural beliefs" and "language".

MAJOR CONCLUSIONS

We identified a broad range of barriers to healthcare use in individuals with diabetes mellitus. However, the number of studies is low. Further research is needed to analyse barriers in more detail considering special subgroups.

Higher body mass index and lower intake of dairy products predict poor glycaemic control among Type 2 Diabetes patients in Malaysia

This cross-sectional study was designed to determine factors contributing to glyceamic control in order to provide better understanding of diabetes management among Type 2 Diabetes patients. A pre-tested structured questionnaire was used to obtain information on socio-demographic and medical history. As a proxy measure for glycaemic control, glycosylated haemoglobin (HbA1c) was obtained as secondary data from the medical reports. Perceived self-care barrier on diabetes management, diet knowledge and skills, and diet quality were assessed using pretested instruments. With a response rate of 80.3%, 155 subjects were recruited for the study. Mean HbA1c level of the subjects was 9.02 ± 2.25% with more than 70% not able to achieve acceptable level in accordance to WHO recommendation. Diet quality of the subjects was unsatisfactory especially for vegetables, fruits, fish and legumes as well as from the milk and dairy products group. Higher body mass index (BMI), poorer medication compliance, lower diet knowledge and skill scores and lower intake of milk and dairy products contributed significantly on poor glycaemic control. In conclusion, while perceived self-care barriers and diet quality failed to predict HbA1c, good knowledge and skill ability, together with appropriate BMI and adequate intake of dairy products should be emphasized to optimize glycaemic control among type 2 diabetes patients.

Understanding Financial Barriers to Care in Patients With Diabetes

Purpose

The purpose of this study was to better understand the impact that financial barriers have on patients with diabetes and the strategies that they use to cope with them.

Methods

A secondary analysis was conducted of 24 interviews with patients who had either type 1 or type 2 diabetes and perceived financial barriers, which were previously undertaken for a larger grounded theory study. Semistructured interviews were undertaken either face-to-face or by telephone. Data analysis was performed by 3 reviewers using inductive thematic analysis. Sampling for the original study continued until data saturation was achieved.

Results

The predominant aspects of care to which participants described financial barriers were medications, diabetes supplies, and healthy food. A variety of strategies are used by these patients. Participants described that their health care providers had the potential to either play an important supporting role; or alternatively, that they could also worsen the impacts of financial barriers.

Conclusions

Patients with diabetes experience financial barriers to various aspects of their care. While they use a variety of strategies to overcome their barriers, their health care providers can play a particularly important role in helping them manage these important barriers that impact their care and outcomes. Providers should ask patients about the existence of financial barriers, and employ strategies to mitigate against their impact.

Risk of type 2 diabetes: health care provider perceptions of prevention adherence

The aim of the current study was to describe health care providers' perceptions as to why individuals may or may not follow recommendations for reducing risk of developing type 2 diabetes. A grounded theory research design guided data collection and analysis. Data were collected from 16 health care providers through semi-structured interviews. Results demonstrated that health care providers perceived prevention adherence as related to individual characteristics of the patient and activities of the provider. Specifically, providers described assessment of patient-based characteristics associated with behavior, context, and traits. In addition, providers discussed giving attention to the patient-provider relationship and helping the patient incorporate small lifestyle changes. Providers might utilize social cognitive theory to understand personal and socio-structural aspects of adherence. In addition, providers should focus assessment and relationship building efforts on factors that support self-efficacy.

Design and development of a scale of perceived barriers to self-care in patients with type 2 diabetes mellitus: an exploratory factor analysis

Introduction

Despite the importance of perceived barriers against self-care in diabetic patients, the role of this factor is rarely addressed in the improvement of self-care behaviors of Iranian patients. The lack of appropriate instruments that fit demographic properties of Iranian society is one reason. The aim of this study was to develop and validate the scale of perceived barriers to self-care in patients with type 2 diabetes mellitus.

Methods

This cross-sectional study conducted on 400 patients with type 2 diabetes who were covered by the health centers in Isfahan (Iran) in 2015. A 22-item, researcher-made instrument was designed; the face and content validities of the instrument were examined through obtaining the opinions of an expert panel before administering the instrument in the study. Also, the exploratory factor analysis was used to investigate the instrument’s validity. Cronbach’s alpha was employed to measure its internal consistency (reliability). To examine the validity of the final scale, the mean scores of perceived barriers in patients with appropriate and inappropriate self-care behaviors were compared.

Results

The research sample was comprised of 240 women (60%) and 160 men (40%). The mean value of the content validity index was 0.84. The results of factor analysis confirmed the validity of the 11 items and 3 factors of the developed scale. The factor loading ranged from 0.46 to 0.78. These three factors together explained 40.28% of the total variance. The overall reliability coefficient of the instrument was 0.79, ranging from 0.82 to 0.93 for three factors.

Conclusion

According to the results, the developed scale was a valid and reliable instrument for examining the barriers perceived by the patients. The findings of this research can help health policy makers in planning to facilitate the self-care behaviors as the most vital factor in diabetes control.

Glucometer use and glycemic control among Hispanic patients with diabetes in southern Florida

BACKGROUND

Self-monitoring of blood glucose (SMBG) has been deemed a critical component of diabetes care in the United States. To be effective, patients must have some diabetes knowledge, glucometer proficiency, and an ability to take appropriate actions when certain readings are obtained. However, most patients take no action in response to out-of-range glucometer readings, and in many populations, SMBG practices are not associated with improved glycemic control. Thus, SMBG utilization is being reconsidered in other countries. Nonetheless, SMBG behaviors are increasingly recommended in the United States, where the Hispanic population represents the fastest-growing minority group and is disproportionately affected by suboptimal diabetes outcomes. Because a growing number of interventions aim to reduce diabetes disparities by improving glycemic control among minorities, it is essential to determine whether efforts should focus on SMBG practices. We present data on SMBG behaviors and glycemic control among participants from the Miami Healthy Heart Initiative (MHHI), a National Institutes of Health/National Heart, Lung, and Blood Institute-sponsored trial assessing a community health worker (CHW) intervention among Hispanic patients with poorly controlled diabetes.

OBJECTIVE

This study examined the effects of a CHW intervention on SMBG practices, glycosylated hemoglobin (HbA1c), and knowledge of appropriate responses to glucometer readings among Hispanic patients with diabetes.

METHODS

This study was an ancillary investigation within MHHI, a randomized, controlled trial in 300 Hispanic patients. Participants were intervention-group members who received 12 months of CHW support. Assessments were administered at baseline and poststudy to determine potential barriers to optimal health. Items from validated instruments were used to determine knowledge of appropriate responses to different glucose readings. These data were linked to HbA1c values. Means and frequencies were used to describe population characteristics and glucometer proficiency. Paired-sample t tests examined potential differences in HbA1c outcomes and SMBG practices. Qualitative data were collected from the CHWs who worked with study participants.

RESULTS

Our population was diverse, representing several countries. Mean HbA1c improved significantly, from 10% to 8.8% (P ≤ 0.001). SMBG practices did not change. At baseline, 96% of patients reported owning a glucometer and 94% reported knowing how to use it. However, quantitative assessments and qualitative data suggested that participants had suboptimal knowledge regarding actions that could cause an out-of-range reading or how to respond to certain readings.

CONCLUSIONS

SMBG behaviors were not associated with glycemic control in our sample. We conclude that a CHW intervention may improve glycemic control without improving SMBG practices. Future interventions may reconsider whether efforts should be directed toward improving SMBG behaviors.

A comparative study of the quality of care and glycemic control among ambulatory type 2 diabetes mellitus clients, at a Tertiary Referral Hospital and a Regional Hospital in Central Kenya

Background

Peripheral public health facilities remain the most frequented by the majority of the population in Kenya; yet remain sub-optimally equipped and not optimized for non-communicable diseases care.

Design and methodology

We undertook a descriptive, cross sectional study among ambulatory type 2 diabetes mellitus clients, attending Kenyatta National Referral Hospital (KNH), and Thika District Hospital (TDH) in Central Kenya. Systematic random sampling was used. HbA1c was assessed for glycemic control and the following, as markers of quality of care: direct client costs, clinic appointment interval and frequency of self monitoring test, affordability and satisfaction with care.

Results

We enrolled 200 clients, (Kenyatta National Hospital 120; Thika District Hospital 80); Majority of the patients 66.5 % were females, the mean age was 57.8 years; and 58 % of the patients had basic primary education. 67.5 % had diabetes for less than 10 years and 40 % were on insulin therapy. The proportion (95 % CI) with good glycemic was 17 % (12.0–22.5 respectively) in the two facilities [Kenyatta National Hospital 18.3 % (11.5–25.6); Thika District Hospital 15 % (CI 7.4–23.7); P = 0.539]. However, in Thika District Hospital clients were more likely to have a clinic driven routine urinalysis and weight, they were also accorded shorter clinic appointment intervals; incurred half to three quarter lower direct costs, and reported greater affordability and satisfactions with care.

Conclusion

In conclusion, we demonstrate that in Thika district hospital, glycemic control and diabetic care is suboptimal; but comparable to that of Kenyatta National Referral hospital. Opportunities for improvement of care abound at peripheral health facilities.

Low attendance at structured education for people with newly diagnosed type 2 diabetes: General practice characteristics and individual patient factors predict uptake

OBJECTIVE

The aims were to determine the association between individual and neighbourhood factors and attendance at structured education amongst people with newly diagnosed type 2 diabetes (T2DM).

METHODS

Multi-level analysis of questionnaire data from a prospective cohort of adults newly diagnosed T2DM. Setting was primary care, London, UK. Main outcome was attendance at structured education within 2 years.

RESULTS

Of 1790 people recruited, attendance data were available for 1626 (91%). Only 22.4% (n=365/1626) attended education. Attendance was independently associated with female gender (OR 1.28, 95% CI 1.05-1.46), lower HbA1c (OR 0.98 mmol/mol 95% CI 0.97-0.99) and non-smoker status (OR 1.36, 95% CI 1.07-1.55). General practice covariates, achievement of primary care targets for glycaemic control (OR 1.05, 95% C.I. 1.01-1.08) and recording of retinal screening (OR 0.96, 95% C.I. 0.93-0.99) were independently associated with attendance but unexplained general practice clustering accounted for 17% of the variance.

CONCLUSION

Education uptake is low amongst people with new onset T2DM. Attenders are more likely to be female, non-smokers with better HbA1c. General practices achieving glycaemic targets are more likely to have patients who attend education.

PRACTICE IMPLICATIONS

Strategies are needed to improve attendance at structured diabetes education particularly amongst hard to reach groups.

An Innovative Approach to Informing Research: Gathering Perspectives on Diabetes Care Challenges From an Online Patient Community

Background

Funding agencies and researchers increasingly recognize the importance of patient stakeholder engagement in research. Despite calls for greater patient engagement, few studies have engaged a broad-based online community of patient stakeholders in the early stages of the research development process.

Objective

The objective of our study was to inform a research priority-setting agenda by using a Web-based survey to gather perceptions of important and difficult aspects of diabetes care from patient members of a social networking site-based community.

Methods

Invitations to participate in a Web-based survey were sent by email to members of the PatientsLikeMe online diabetes community. The survey asked both quantitative and qualitative questions addressing individuals’ level of difficulty with diabetes care, provider communication, medication management, diet and exercise, and relationships with others. Qualitative responses were analyzed using content analysis.

Results

Of 6219 PatientsLikeMe members with diabetes who were sent survey invitations, 1044 (16.79%) opened the invitation and 320 (5.15% of 6219; 30.65% of 1044) completed the survey within 23 days. Of the 320 respondents, 33 (10.3%) reported having Type 1 diabetes; 107 (33.4%), Type 2 diabetes and taking insulin; and 180 (56.3%), Type 2 diabetes and taking oral agents or controlling their diabetes with lifestyle modifications. Compared to 2005-2010 National Health and Nutrition Examination Survey data for individuals with diabetes, our respondents were younger (mean age 55.8 years, SD 9.9 vs 59.4 years, SE 0.5); less likely to be male (111/320, 34.6% vs 48.4%); and less likely to be a racial or ethnic minority (40/312, 12.8% vs 37.5%). Of 29 potential challenges in diabetes care, 19 were categorized as difficult by 20% or more of respondents. Both quantitative and qualitative results indicated that top patient challenges were lifestyle concerns (diet, physical activity, weight, and stress) and interpersonal concerns (trying not to be a burden to others, getting support from family/friends). In our quantitative analysis, similar concerns were expressed across patient subgroups.

Conclusions

Lifestyle and interpersonal factors were particularly challenging for our online sample of adults with Type 1 or Type 2 diabetes. Our study demonstrates the innovative use of social networking sites and online communities to gather rapid, meaningful, and relevant patient perspectives that can be used to inform the development of research agendas.

No moment wasted: the primary-care visit for adults with diabetes and low socio-economic status

AIM

To better understand the type and range of health issues initiated by patients and providers in 'high-quality' primary-care for adults with diabetes and low socio-economic status (SES).

BACKGROUND

Although quality of care guidelines are straightforward, diabetes visits in primary care are often more complex than adhering to guidelines, especially in adults with low SES who experience many financial and environmental barriers to good care.

METHODS

We conducted a qualitative study using direct observation of primary-care diabetes visits at an exemplar safety net practice in 2009-2010. Findings In a mainly African American (93%) low-income population with fair cardiovascular control (mean A1c 7.5%, BP 134/81 mmHg, and low-density lipoprotein cholesterol 100 mg/dL), visits addressed a variety of bio-psychosocial health issues [median: 25 problems/visit (range 13-32)]. Physicians most frequently initiated discussions about chronic diseases, prevention, and health behavior. Patients most frequently initiated discussions about social environment and acute symptoms followed by prevention and health behavior.

CONCLUSIONS

Primary-care visits by diabetes patients with low SES address a surprising number and diversity of problems. Emerging new models of primary-care delivery and quality measurement should allow adequate time and resources to address the range of tasks necessary for integrating biomedical and psychosocial concerns to improve the health of socio-economically disadvantaged patients.

Effective intervention of self-care on glycaemia control in patients with type 2 diabetes

BACKGROUND

Diabetes is one of the most common diseases, which requires lifelong self-care to improve the quality of life.

OBJECTIVES

The current study aimed to determine the impact of self-care education programs on reducing HbA1c in patients with type 2 diabetes.

PATIENTS AND METHODS

The current experimental study was conducted on 138 female patients with type 2 diabetes in Zahedan city, Iran. The data were collected by a self-administered questionnaire which included items on demographics, awareness, beliefs, Self-care behaviors. Before the educational intervention, the (HbA1c) test check list was completed for the patients in both groups. Then the training was applied for the intervention group in five 60-minute educational sessions within one month. Three months following the training, the data collection based on the check list was repeated for both groups. Data were analyzed using SPSS software.

RESULTS

The mean scores of awareness, beliefs, Self-care behaviors of the educational group, were 46.6 ± 8.57, 46.5 ± 0.86 and 29.06 ± 10.02, respectively; and it was found that after the education, knowledge, attitude, and self-care scores increased significantly (P < 0.001 Before the training, the scores of self-care, beliefs, and awareness were less than average in the intervention and control groups. In addition, the levels of HbA1c in the patients were higher than the normal levels. Following the intervention, the mean of self-care and HbA1c of the intervention group significantly reduced as compared with those of the control group (P < 0.001).

CONCLUSIONS

Self-care training instructions led to improve knowledge, attitude, and performance of the subjects under study and also the average HbA1c. Therefore, the nurses and health care staff should be educated accordingly.

Association between diabetic ketoacidosis hospitalizations and driving distance to outpatient diabetes centres in adults with type 1 diabetes mellitus

OBJECTIVE

The purpose of this study was to assess the relationship between diabetic ketoacidosis (DKA) hospitalization and driving distance from home to outpatient diabetes care in adults with type 1 diabetes mellitus.

METHODS

We identified adults with type 1 diabetes using clinical and administrative databases living in Calgary, Alberta. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes were used to identify DKA hospitalizations, and geographic information systems were used to obtain road distance. Multivariate logistic regression was used to assess the association between driving distance (exposure) to diabetes care sites and the outcome of DKA hospitalization.

RESULTS

We identified 1467 patients (151 patients with DKA) with type 1 diabetes. Patients with DKA hospitalizations were younger (35.6 vs. 41.0 years), had shorter duration of diabetes (13.6 vs. 18.7 years) and higher glycated hemoglobin (9.2% vs. 8.4%). Driving distance from home to diabetes centre 1 (adjusted odds ratio 1.02 per 1 km; 95% confidence interval, 0.96 to 1.07), diabetes centre 2 (adjusted odds ratio 1.01; 95% confidence interval, 0.99 to 1.04) or closest general practitioner (adjusted odds ratio 0.9; 95% confidence interval, 0.63 to 1.25) was not associated with DKA hospitalization. Driving distance was also not associated with glycemic control.

CONCLUSIONS

Within a large urban city, driving distance to diabetes centres does not appear to be protective of DKA hospitalization. However, this work does not preclude the role of local travel distance and diabetes outcomes. More research is required to explore the role of other individual, neighbourhood and community factors that influence DKA hospitalization.

Diet and physical activity in the self-management of type 2 diabetes: barriers and facilitators identified by patients and health professionals

Aim To explore the views of individuals recently diagnosed with type 2 diabetes in relation to self-management of dietary intake and physical activity, and to compare these with the views of health professionals (HPs).

BACKGROUND

Diabetes education has become a priority area in primary and secondary care, and many education programmes are now embedded within a patient's care package. There are few contemporaneous explorations of patients' views about lifestyle self-management. Such research is vital in order to identify areas that require further support, refinement or enhancement in terms of patient education.

METHODS

Focus groups were held with patients recently diagnosed with type 2 diabetes (n = 16, 38% female, aged 45-73 years). In-depth semi-structured interviews were conducted with HPs (n = 7). Discussions focussed on self-management specifically in relation to making dietary and physical activity changes. All discussions were tape recorded, transcribed and analysed by emergent themes analysis using NVivo to manage the coded data. Findings Barriers were divided into six main categories: difficulty changing well-established habits, negative perception of the 'new' or recommended regimen, barriers relating to social circumstances, lack of knowledge and understanding, lack of motivation and barriers relating to the practicalities of making lifestyle changes. HPs generally echoed the views of patients. In conclusion, even against a background of diabetes education, recently diagnosed patients with type 2 diabetes discussed a wide range of barriers to self-management of diet and physical activity. The findings could help to provide HPs with a deeper understanding of the needs of recently diagnosed patients and may help refine current diabetes education activities and inform the development of educational resources.

Do patients and physicians agree on diabetes management? A study conducted in public healthcare centres in Brazil

OBJECTIVE

To explore to what extent patients with diabetes agree with their physicians on diabetes management and whether the agreement varies according to patients' socio-demographic characteristics.

METHODS

A cross-sectional study was conducted among patients with diabetes and their Family Health physicians in 108 healthcare centres in Belo Horizonte, Brazil. Patients and physicians were interviewed face-to-face using standard questionnaires. Physicians were unaware of which of their patients would be interviewed. Their responses were compared using descriptive statistics and Cohen's weighted kappa.

RESULTS

282 patient-physician pairs were included. Kappa coefficients were often low, the highest was found for presence of diabetic foot and the lowest for kidney disease. Physicians tended to overestimate patients' risk of diabetes complications and underestimate patients' adherence to all diabetes self-management activities as well as diabetes control. Moreover, the agreement rate regarding adherence to diet, foot care and medicine prescriptions was significantly higher among male, younger and higher educated patients.

CONCLUSION

Results indicate that physicians' recommendations are generally poorly apprehended by their patients, especially by the lower educated, compromising the goal of patient-centred care.

PRACTICE IMPLICATIONS

Educational programmes need to incorporate strategies to improve the comprehension and effectiveness of physician-patient communication, especially with the most socially vulnerable groups.

Barriers and facilitators to effective type 2 diabetes management in a rural context: a qualitative study with diabetic patients and health professionals

Although effective type 2 diabetes management is essential for the prevention of complications, it is rarely carried out. Type 2 diabetes deaths in rural areas are higher than in metropolitan areas. A focus group (n = 8) and telephone interviews with patients (n = 10), and telephone interviews with health professionals (n = 18) in rural areas were conducted to examine this issue in a rural context. Inductive thematic analysis was used to generate 13 themes of barriers and facilitators to type 2 diabetes management at intrapersonal (denial of the illness, motivation, knowledge and skills and lack of time), interpersonal (stress and relationships), organisational (access to recommended foods, transport, health professionals, and exercise options) and societal (engagement and societal attitudes) levels of influence. Across all themes, participants highlighted the difficulty of maintaining management behaviours.

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

Objective

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

Design

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

Setting

A diabetes centre located in Abu-Dhabi, UAE.

Participants

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

Main outcome measures

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

Results

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

Conclusion

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

'Diabesity' down under: overweight and obesity as cultural signifiers for type 2 diabetes mellitus

Although overweight and obesity are increasingly seen as the key ‘risk factors’ for Type 2 diabetes mellitus (T2DM), the relationship between them is complex and not well understood. There are many ‘risk factors’ for T2DM, including ageing, genetics, previous gestational diabetes, a family history of the disease, etc. the interplay of which is not entirely clear. While weight gain is a common symptom of T2DM and the disease appears to be more prevalent among ‘obese’ people, individuals from a broad range of weights (including those considered ‘healthy’) can develop the disease. However, in recent years, the idea that fatness is the risk factor and/or central cause of T2DM has become increasingly prevalent and naturalized in popular, academic, and public health discourses in Australia. In these convergences, the complex etiology of the disease and limitations in current knowledge are blurred or reconstituted. To date, the potency of overweight and obesity as cultural signifiers for T2DM and its consequences has received little attention. Drawing on an analysis of government reports, journal articles, and media coverage published since 1998, this article sets out to trace and unpack some of the contours of these convergences, while recognizing their entanglement in earlier moralizing discourses, which continue to have considerable salience.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Using multiple measures of glycemia to support individualized diabetes management: recommendations for clinicians, patients, and payers

By the year 2030, the diabetes pandemic will likely affect more than 10% of the world's population. The personal, public health, and economic crises implicit in this trend call for decisive action. Yet, escalating dilemmas thwart full realization of current therapies. First, controversial studies, such as the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial, have amplified calls to individualize glycated hemoglobin (A1C) targets in the absence of adequate infrastructures for supporting personalized care. Second, costlier medications and technologies addressing more nuanced aspects of metabolic dysfunction are expanding options for diabetes management amidst growing disparities between "affordable" and "best" care. Third, common clinical quandaries, such as discrepancies between A1C and self-monitoring of blood glucose data, as well as misconceptions about long-term glycemic assessment, compound entrenched cycles of inadequate self-care, delayed intervention, and suboptimal glycemic outcomes. Because individual, clinical, and public policy responses to these conflicting forces are based largely on methodologies for glucose measurement, a panel of clinical experts from Europe and North America was convened to reexamine our glucose measuring tools and determine ways in which they can be better applied toward more purposeful processes of glycemic management. Among the main issues addressed were the need for caution in interpreting A1C for individual patients, the role of alternative biomarkers in identifying aspects of glycemic dysregulation not captured by A1C, and the value of using patients' own glucose data to consolidate therapeutic, educational, and behavior-change objectives.

Knowledge, attitudes, practices, and barriers reported by patients receiving diabetes and hypertension primary health care in Barbados: a focus group study

Background

Deficiencies in the quality of diabetes and hypertension primary care and outcomes have been documented in Barbados. This study aimed to explore the knowledge, attitudes and practices, and the barriers faced by people with diabetes and hypertension in Barbados that might contribute to these deficiencies.

Methods

Five structured focus groups were conducted for randomly selected people with diabetes and hypertension.

Results

Twenty-one patients (5 diabetic, 5 hypertensive, and 11 with both diseases) with a mean age of 59 years attended 5 focus group sessions.

Patient factors that affected care included the difficulty in maintaining behaviour change. Practitioner factors included not considering the "whole person" and patient expectations, and not showing enough respect for patients. Health care system factors revolved around the amount of time spent accessing care because of long waiting times in public sector clinics and pharmacies. Society related barriers included the high cost and limited availability of appropriate food, the availability of exercise facilities, stigma of disease and difficulty taking time off work.

Attendees were not familiar with guidelines for diabetes and hypertension management, but welcomed a patient version detailing a place to record results, the frequency of tests, and blood pressure and blood glucose targets. Appropriate education from practitioners during consultations, while waiting in clinic, through support and education groups, and for the general public through the schools, mass media and billboards were recommended.

Conclusions

Primary care providers should take a more patient centred approach to the care of those with diabetes and hypertension. The care system should provide better service by reducing waiting times. Patient self-management could be encouraged by a patient version of care guidelines and greater educational efforts.

Blood glucose control and quality of health care in non-insulin-treated patients with Type 2 diabetes in Spain: a retrospective and cross-sectional observational study

AIMS

To assess blood glucose control and quality of health care provided to non-insulin-treated patients with Type 2 diabetes mellitus in routine clinical practice in Spain.

METHODS

In this observational, retrospective, cross-sectional study, patients were grouped as either having good or suboptimal blood glucose control according to International Diabetes Federation or American Diabetes Association HbA(1c) goals. Clinical and socio-demographic data and compliance with the main standard level of care recommendations of the International Diabetes Federation were recorded during a routine visit. Correlates of glucose control were analysed by logistic regression.

RESULTS

Many patients were grouped as having suboptimal control under International Diabetes Federation (61.9%) or American Diabetes Association (45.0%) criteria. The mean number of accomplished International Diabetes Federation recommendations (7.3 out of 11) was higher for endocrinologists (than for internists or primary care physicians), and significantly more patients under their care were in the good glucose control group (than with primary care physicians). More recommendations were associated with blood glucose control using International Diabetes Federation than American Diabetes Association criteria, demanding higher quality of health care for achieving stricter goals. Some recommendations were poorly observed, particularly those concerning patients' education on diabetes, the prompt prescription of effective treatments and monitoring of complications. Diabetes complications were associated with being in the suboptimal control group. Patients' education on diabetes and HbA(1c) monitoring were associated with being in the good control group.

CONCLUSIONS

These results demonstrate the need for improvement in the management of patients with non-insulin-treated Type 2 diabetes in actual clinical practice in Spain. Such improvement would entail a stricter adherence to International Diabetes Federation recommendations.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical inertia in management of T2DM

Diabetes is highly prevalent and serious chronic debilitating disease and reported to be the fourth main cause of death in Europe. Despite extensive evidence of benefits of tight glycemic control, large proportions of people with diabetes do not achieve target glycemic control. One major reason for this is clinical inertia which is "recognising the problem but failure to act" by health care professionals in primary care. The key issues in the management of people with T2DM include early detection of problems, realistic goal setting, improved patient adherence, better knowledge and understanding of pharmacotherapeutic treatment options and prompt intervention. Health care professionals must need to overcome clinical inertia and need to intensify therapy in an appropriate and timely manner.

Obesity stigma: a newly recognized barrier to comprehensive and effective type 2 diabetes management

PURPOSE

The purpose of this article is to increase awareness regarding the social problem of obesity stigma and its effects on persons with type 2 diabetes mellitus (T2DM). In addition, practical strategies to dispel stigma and improve diabetes care that nurse practitioners (NPs) can integrate into practice will be introduced.

DATA SOURCES

Thorough review of the literature was conducted including MEDLINE, PsycINFO and CINAHL, spanning the years 1994-2008.

CONCLUSIONS

Obesity and diabetes are both epidemics that demand immediate attention; however, obesity stigma can act as a barrier to ongoing management of both conditions. Obese patients with T2DM may feel responsible not only for their weight but also their diabetes. Therefore, NPs can employ specific counseling strategies that may be beneficial with T2DM obese patients to improve continuity of care while decreasing weight-related stigmatization.

IMPLICATIONS FOR PRACTICE

Negative attitudes toward obesity by healthcare professionals can act as a barrier to diabetes management. Primary care providers including NPs must begin through self-reflection to recognize their own attitudes regarding weight-stigma and how these attitudes may affect their patients. By implementing effective strategies to reduce weight bias, an environment conducive to diabetes and lifestyle modification management may prevent patients from forgoing care.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

The European EUCCLID pilot study on care and complications in an unselected sample of people with type 2 diabetes in primary care

BACKGROUND

European studies on quality of diabetes care in an unselected primary care diabetes population are scarce.

RESEARCH QUESTION

To test the feasibility of the set-up and logistics of a cross-sectional EUropean study on Care and Complications in patients with type 2 diabetes (T2DM) in Primary Care (EUCCLID) in 12 European countries.

METHOD

One rural and one urban practice from each country participated. The central coordinating centre randomly selected five patients from each practice. Patient characteristics were assessed including medical history, anthropometric measures, quality indicators, UKPDS-risk engine, psychological and general well-being.

RESULTS

We included 103 participants from 22 GPs in 11 countries. Central data and laboratory samples were successfully collected. Of the participants 54% were female, mean age was 66 years and mean duration of diabetes was 9.6 years. Besides, 18% were using insulin, 31% had a history of cardiovascular disease, mean HbA1c was 7.1% (range 6.6-8.0), mean systolic blood pressure was 133.7 mmHg (range 126.1-144.4) and mean total cholesterol was 4.9 mmol/l (range 4.0-6.2).

CONCLUSION

A European study on care and complications in a random selection of people with T2DM is feasible. There are large differences in indicators of metabolic control and wellbeing between countries.

[Diabetes immersion training as teaching method to medical practitioners]

This study evaluated the effectiveness of theoretical and practical teaching method in diabetes and doctors' position about feasibility of intensive blood glucose control. Forty-eight internal medicine or endocrinology residents participated in a two-day diabetes immersion course. The participants received training on self-blood glucose monitoring, techniques of insulin administration and carbohydrate counting. They were also instructed to behave as patients with diabetes and to follow individual medical prescription. They were assessed through questionnaires. In knowledge assessment, a significant increase of 12% was observed between the beginning and the end of the course (61.2% and 73.2%, respectively, with p < 0.0001). Before the course, 70.8% and 89.6% of the participants believed there were complications in performing carbohydrate counting and blood glucose monitoring, respectively. After the experience, 82.9% of them had difficulties in carbohydrate counting and 80.8% in self-monitoring; 40.4% took all medications prescribed and 36.1% monitored blood glucose correctly. These results show that the methodology of this course is an effective way to disseminate knowledge and that it contributes to doctors becoming more sensitive to daily problems faced by patients with diabetes melito concerning the acceptance of medical recommendations.

Family physician and endocrinologist coordination as the basis for diabetes care in clinical practice

BACKGROUND

To estimate the proportion of diabetic patients (DPts) with peripheral vascular disease treated at a primary health care site after an endocrinologist-based intervention, who meet ATP III and Steno targets of metabolic control, as well as to compare the outcome with the results of the patients treated by endocrinologists.

METHODS

A controlled, prospective over 30-months period study was conducted in area 7 of Madrid. One hundred twenty six eligible diabetic patients diagnosed as having peripheral vascular disease between January 2003 and June 2004 were included in the study. After a treatment period of three months by the Diabetes team at St Carlos Hospital, 63 patients were randomly assigned to continue their follow up by diabetes team (Group A) and other 63 to be treated by the family physicians (FP) at primary care level with continuous diabetes team coordination (Group B). 57 DPts from Group A and 59 from Group B, completed the 30 months follow-up period. At baseline both groups were similar in age, weight, time from diagnosis and metabolic control. The main outcomes of this study were the proportion of patients meeting ATP III and Steno goals for HbA1c (%), Cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, blood pressure, albumine-to-creatinine excretion ratio (ACR), body mass index (BMI), waist circumference (WC), anti-aggregation treatment and smoking status.

RESULTS

At the end of the follow up, no differences were found between the groups. More than 37% of diabetic patients assigned to be treated by FP achieved a HbA1c < 6.5%, more than 50% a ACR < 30 mg/g, and more than 80% reached low risk values for cholesterol, LDL cholesterol, triglycerides, diastolic blood pressure and were anti-aggregated, and 12% remained smokers. In contrast, less than 45% achieved a systolic blood pressure < 130 mm Hg, less than 12% had a BMI < 25 Kg.m-2 (versus 23% in group A; p < 0.05) and 49%/30% (men/women) had a waist circumference of low risk.

CONCLUSION

Improvements in metabolic control among diabetic patients with peripheral vascular disease treated at a primary health care setting is possible, reaching similar results to the patients treated at a specialized level. Despite such an improvement, body weight control remains more than poor in both levels, mainly at primary care level. General practitioner and endocrinologist coordination care may be important to enhance diabetes management in primary care settings.

TRIAL REGISTRATION

Clinical Trial number ISRCTN75037597.

The EUCCLID study: proposed European study on care and complications in people with type 2 diabetes in primary care

AIM

The EUCCLID study aims to compare the quality of type 2 diabetes (DM2) care and the prevalence of complications in primary care DM2 patients in Europe.

DESIGN

A cross-sectional survey consisting of three parallel studies: (1) study on actual clinical practice; (2) study on patient's perspective of diabetes care; (3) study on general practitioner's perspective of diabetes care.

METHODS

Patients will be randomly selected from a list of all patients known to the participating GPs with DM2 for whom the GP is the main diabetes care provider. Exclusion criteria will include people with type 1 diabetes mellitus, diabetes of pregnancy, serious mental illness, unable to complete a questionnaire in national language or unable to give written informed consent. Approximately 12,000 patients will be included. Participants will have a detailed medical history and anthropometric measurements, blood and urine will be collected and questionnaires will be taken. Endpoints will include quality indicators of clinical DM2 care, prevalence of diabetic complications, knowledge, attitudes, barriers and behaviour affecting good control in DM2 patients, quality of life and patients' satisfaction with diabetes care. We will also determine primary care physician's attitudes, behaviour and perception of barriers to deliver effective diabetes care.