Self-management of diabetes and associated comorbidities in rural and remote communities: a scoping review

Outcome measures after attending a specialist-led diabetes mellitus model of care in regional Victoria, Australia

BACKGROUND

Providing diabetes mellitus care to regional Australia remains a significant challenge due to limited access, workforce and travel. While primary care is essential, some patients require specialised care that necessitates adapted models of care.

AIMS

The study assessed the effect on diabetes mellitus metrics in patients attending a multidisciplinary centre in regional Victoria. We assessed changes in HbA1c over 6 months. Secondary outcomes included biometrics, drug combinations, insulin initiation and the proportion achieving diabetes care targets.

METHODS

We performed a longitudinal cohort study for all adult patients receiving multidisciplinary diabetes care at South West Healthcare between 1 July 2020 and 30 June 2022. Participants who had followed up over 6 months at three-monthly intervals (V1, V2 and V3) were included, excluding haemodialysis or transplant care or failure to attend three visits.

RESULTS

We assessed 90 participants with a balanced demographic with a generally low comorbidity burden. There was a significant decrease in HbA1c at 3 months (OR = -1.2 (95% CI: -1.6 to -1.1), P < 0.001) and 6 months (OR = -1.8 (95% CI: -2.2 to -1.5), P < 0.001) for all groups. Attendance within the cohort significantly increased for multidisciplinary services, including optometry, cDNE, dietetics and podiatry, but no change in drug regimens or insulin initiation.

CONCLUSION

This study highlights the impact of an adapted model of care for diabetes mellitus at South West Healthcare, focusing on a regional population. Among 90 patients over 6 months, there was a significant reduction in HbA1c levels and improved multidisciplinary engagement. This approach has successfully increased access to specialist and multidisciplinary diabetes care in rural areas.

Evaluating the impact of the Piki te Ora extended primary care team on clinical outcomes in type 2 diabetes patients: a retrospective study

Introduction Type 2 diabetes (T2D) is a significant health issue in New Zealand with a disproportionate effect for Māori. To address inequities and optimise care, Te Korowai Hauora o Hauraki, an Iwi Māori health provider, established the 'Piki te Ora service' to support its five rural clinics by providing culturally safe, multidisciplinary support for patients with T2D. Aim This study aimed to undertake a service review, describing and evaluating the available clinical data, of the Piki te Ora service. Methods Patients enrolled in the Piki te Ora service between January 2021 and March 2024 were invited to have their data (sociodemographic, HbA1c, cholesterol and blood pressure) included in the review. Frequency and mode of health care/patient contact were also explored. Results A total of 112 patients were contacted and 64 (mean age 58years, 62.5% Māori) consented to data review. Over 6months, patients in the Piki te Ora service were contacted an average of 9.5 times, with phone calls being the predominant mode of contact. Median HbA1c levels significantly decreased by 16.0mmol/mol at 6months post enrolment in the Piki te Ora service (P =0.011) but no significant changes were observed in cholesterol or blood pressure. Discussion The Piki te Ora service appears to provide effective support for T2D management, particularly glycaemic control, however more clinical data is needed to evaluate its effectiveness. Its flexible and accessible approach, including free consultations, may enhance care accessibility, especially for economically deprived patients.

Factors influencing type 2 diabetes self-management practices in rural Bangladesh: a qualitative investigation

Introduction

Type 2 diabetes mellitus (T2DM) is a prevalent, chronic health condition of global significance, with low- and middle-income countries (LMICs) disproportionately affected. Diabetes self-management practices (DSMP) are the gold-standard treatment approach, yet uptake remains challenge in LMICs.

Purpose of the study

This study aimed to explore the barriers to and facilitators of DSMP and preferences for intervention design and delivery in Bangladesh, an LMIC, with prevalent T2DM.

Methods

Sixteen qualitative focus group discussions (FGDs) with adults with T2DM and their caregivers were conducted in rural Bangladesh to explore preferences, barriers, and facilitators for community DSMP-related intervention programs. Data were thematically analyzed using a deductive theoretical domains framework (TDF) underpinned by the socio-ecological model.

Results

Overall, 117 participants (n = 58 with T2DM and n = 59 caregivers) were included in the analysis. Five overarching themes were identified, including (i) implementation of DSMP, (ii) community spirit and interconnectedness, (iii) environmental influences, (iv) healthcare professionals' role in DSMP, and (v) government support. Key barriers to DSMP identified for T2DM patients include knowledge implementation gaps, cultural practices, limited resources, and financial constraints. Facilitators include motivation, support from family and peers, and religious practices. Rural Bangladeshis prefer programs delivered at community clinics, viewing them as reliable, culturally appropriate central 'hubs' to assemble.

Conclusion

Barriers to and facilitators of DSMP were identified, and preferences for intervention design and delivery for implementing DSMP were explored. The findings provide a foundation for the critical need to implement programs that improve DSMP in Bangladesh, with the potential to translate to other LMIC settings.

Attendance at, and experiences of, urban hospital outpatient appointments: informing a new model of care for urban-dwelling Aboriginal and Torres Strait Islander patients

Objectives To compare outpatient attendance rates for Aboriginal and Torres Strait Islander ('Aboriginal') and non-Aboriginal patients at a large metropolitan health service in Melbourne, Australia, and to describe the barriers and enablers experienced by urban-dwelling Aboriginal patients in attending hospital outpatient appointments. Methods This study used a mixed-method approach. Proportions of referred patients who booked and attended outpatient appointments were extracted from a health service database. Aboriginal versus non-Aboriginal cohorts were compared using chi-squared tests. Eleven patients, one parent of a patient and two community nurses were interviewed by telephone to investigate perceived barriers and enablers to attending outpatient appointments among Aboriginal patients. Results Outpatient referrals were greater among Aboriginal than non-Aboriginal people; however, referrals were significantly less likely to result in an outpatient clinic booking and attendance for Aboriginal compared to non-Aboriginal people. Interview participants reported several barriers to attending appointments, related to logistical, quality of care and cultural factors. Suggested facilitators to make appointment attendance easier included: provision of transport support, improving clinic scheduling, utilising a variety of appointment reminder formats, providing food in waiting rooms, flexible appointment timing options, outreach services, access to Aboriginal support workers, improving communication and relationships with Aboriginal people, cultural awareness training for staff and the provision of culturally appropriate spaces. Conclusion Some barriers faced by Aboriginal patients in attending hospital outpatient appointments in urban areas can be addressed through implementation of enablers suggested by participants. Data have informed the development of a tailored, inclusive, culturally and consumer-focused appropriate hospital outpatient service model of care.

Barriers and enablers to structured care delivery in Australian rural primary care

OBJECTIVE

The primary aim of this study was to explore the barriers and enablers to structured care delivery in rural primary care, reflecting on Australian research findings.

DESIGN

CINAHL and Scopus databases were searched in August 2021. Inclusion criteria included English language, full-text studies, published since 2011, reporting on the barriers and enablers to the delivery of structured care within rural and remote primary care. Structured care was conceptualised as care that was organised, integrative and planned.

FINDINGS

A total of 435 studies were screened. Thirty-four met the inclusion criteria. Barriers to the provision of structured care related to workforce shortages, limited health care services and health care professional capacity, cultural safety and competency, limited resourcing, insufficient knowledge and education, geographical isolation, inadequate care coordination, unclear roles and responsibilities and poor health professional-patient relationships.

DISCUSSION

Health care system and geographical barriers and enablers encountered in rural areas are complex and multidimensional. Identification of the specific challenges to structured care delivery highlights the need for a focussed review of workforce supply and distribution challenges as well as the investigation of system integration, leadership, governance and funding reform that would be required to support rural primary care.

Leisure and Leisure Education as Resources for Rehabilitation Supports for Chronic Condition Self-Management in Rural and Remote Communities

The potential of leisure (enjoyable free time pursuits) to be a resource for chronic condition self-management (CCSM) is well-established. Because leisure pursuits are often self-determined, they have the potential to allow people to not only address self-management goals (e.g., managing symptoms through movements or stress-reducing activities) but meet important psychosocial needs (e.g., affiliation, sense of mastery) as well as support participation in a range of meaningful life situations. In this “Perspective” piece, we advocate for the ways leisure and leisure education can be resources for rehabilitation professionals to support CCSM, especially in rural and remote communities. In particular, we focus on aspects of the Taxonomy of Everyday Self-Management Strategies [TEDSS (1)] to highlight ways that embedding leisure and leisure education into supports for CCSM can strengthen rehabilitation services offered to rural and remote dwelling adults living with chronic conditions. Recognizing the breadth of leisure-related resources available in rural and remote communities, we recommend the following strategies to incorporate a focus on leisure-based self-management within rehabilitation services: (a) enhance the knowledge and capacity of rehabilitation practitioners to support leisure-based CCSM; (b) focus on coordinated leadership, patient navigation, and building multi-sectoral partnerships to better link individuals living with chronic conditions to community services and supports; and (c) educate individuals with chronic conditions and family/carers to develop knowledge, skills, awareness and confidence to use leisure as a self-management resource.