Opportunities for Interventions That Address Socioeconomic Barriers to Type 2 Diabetes Management: Patient Perspectives

Barriers and facilitators of self-management of diabetes amongst people experiencing socioeconomic deprivation: A systematic review and qualitative synthesis

BACKGROUND

The number of people living with diabetes is rising worldwide and a higher prevalence of diabetes has been linked to those experiencing socioeconomic deprivation. Self-management strategies are vital and known to reduce the risks of long-term complications amongst people living with diabetes. Lack of knowledge about self-care activity required to manage diabetes is a key barrier to successful self-management. Self-management interventions can be less effective in socioeconomically deprived populations which can increase the risk of exacerbating health inequalities. The purpose of this review is to identify and synthesise qualitative evidence on the barriers and facilitators of self-management of diabetes amongst people who are socioeconomically disadvantaged.

METHODS

MEDLINE, EMBASE, AMED, PsycINFO and CINAHL Plus were searched for qualitative studies concerning self-management of multiple long-term conditions amongst socioeconomically disadvantaged populations. Relevant papers which focused on diabetes were identified. Data were coded and thematically synthesised using NVivo.

FINDINGS

From the search results, 79 qualitative studies were identified after full-text screening and 26 studies were included in the final thematic analysis. Two overarching analytical themes were identified alongside a set of subthemes: (1) Socioeconomic barriers to diabetes self-management; healthcare costs, financial costs of healthy eating, cultural influences, living in areas of deprivation, competing priorities and time constraints, health literacy, (2) facilitators of diabetes self-management; lifestyle and having goals, support from healthcare providers, informal support.

DISCUSSION

Self-management of diabetes is challenging for people experiencing socioeconomic deprivation due to barriers associated with living in areas of deprivation and financial barriers surrounding healthcare, medication and healthy food. Support from healthcare providers can facilitate self-management, and it is important that people with diabetes have access to interventions that are designed to be inclusive from a cultural perspective as well as affordable.

PATIENT OR PUBLIC CONTRIBUTION

A patient advisory group contributed to the research questions and interpretation of the qualitative findings by reflecting on the themes developed.

Prioritizing Patient Experiences in the Management of Diabetes and Its Complications: An Endocrine Society Position Statement

Diabetes can be an arduous journey both for people with diabetes (PWD) and their caregivers. While the journey of every person with diabetes is unique, common themes emerge in managing this disease. To date, the experiences of PWD have not been fully considered to successfully implement the recommended standards of diabetes care in practice. It is critical for health-care providers (HCPs) to recognize perspectives of PWD to achieve optimal health outcomes. Further, existing tools are available to facilitate patient-centered care but are often underused. This statement summarizes findings from multistakeholder expert roundtable discussions hosted by the Endocrine Society that aimed to identify existing gaps in the management of diabetes and its complications and to identify tools needed to empower HCPs and PWD to address their many challenges. The roundtables included delegates from professional societies, governmental organizations, patient advocacy organizations, and social enterprises committed to making life better for PWD. Each section begins with a clinical scenario that serves as a framework to achieve desired health outcomes and includes a discussion of resources for HCPs to deliver patient-centered care in clinical practice. As diabetes management evolves, achieving this goal will also require the development of new tools to help guide HCPs in supporting PWD, as well as concrete strategies for the efficient uptake of these tools in clinical practice to minimize provider burden. Importantly, coordination among various stakeholders including PWD, HCPs, caregivers, policymakers, and payers is critical at all stages of the patient journey.

Nutrition and Physical Activity Interventions Provided by Nutrition and Exercise Practitioners for the General Population: An Evidence-Based Practice Guideline From the Academy of Nutrition and Dietetics and American Council on Exercise

A nutritious diet and adequate physical activity vitally contribute to disease prevention, but most adults do not meet population-based dietary and physical activity recommendations. Qualified nutrition and exercise practitioners can address challenges to adopting healthy lifestyle behaviors by providing consistent, individualized, and evidence-based education and programming within their professional scopes of practice to improve client outcomes. The objective of this evidence-based practice guideline is to inform practice decisions for nutrition and exercise practitioners providing nutrition and physical activity interventions for adults who are healthy or have cardiometabolic risk factors, but no diagnosed disease. Evidence from a systematic review was translated to practice recommendations using an evidence-to-decision framework by an interdisciplinary team of nutrition and exercise practitioners and researchers. This evidence-based practice guideline does not provide specific dietary or physical activity recommendations but rather informs nutrition and exercise practitioners how they may utilize existing guidelines for the general population to individualize programming for a range of clients. This evidence-based practice guideline provides widely applicable recommendation statements and a detailed framework to help practitioners implement the recommendations into practice. Common barriers and facilitators encountered when delivering nutrition and physical activity interventions, such as adherence to professional scopes of practice; methods to support behavior change; and methods to support inclusion, diversity, equity, and access, are discussed. Nutrition and exercise practitioners can consistently provide individualized, practical, and evidence-based interventions by seeking to understand their clients' needs, circumstances, and values and by co-creating interventions with the client and their allied health team.

Adapting a cooking, food budgeting and nutrition intervention for a rural community of American Indians with type 2 diabetes in the North-Central United States

American Indian (AI) communities experience persistent diabetes-related disparities, yet few nutrition interventions are designed for AI with type 2 diabetes or address socio-contextual barriers to healthy eating. We describe our process of adapting the evidence-based Cooking Matters® program for use by AI adults with type 2 diabetes in a rural and resource-limited setting in the North-Central United States. We conducted three focus groups with AI adults with diabetes to (i) identify Cooking Matters® adaptations and (ii) gather feedback on appropriateness of the adapted intervention using Barrera and Castro's cultural adaptation framework. Transcripts were coded using an inductive, constant comparison approach. Queries of codes were reviewed to identify themes. Contextual considerations included limited access to grocery stores and transportation barriers, reliance on government food assistance and the intergenerational burden of diabetes. Adaptations to content and delivery included incorporating traditional and locally available foods; appealing to children or others in multigenerational households and prioritizing visual over written content. Our use of Barrera and Castro's framework adds rigor and structure to the cultural adaptation process and increases the likelihood of future intervention success. Other researchers may benefit from using this framework to guide the adaptation of evidence-based interventions in AI communities.

Changes in Food Insecurity and Changes in Patient-Reported Outcomes: a Nationally Representative Cohort Study

BACKGROUND

Cross-sectional studies have found that health-related quality of life and mental health are worse among food-insecure compared with food-secure individuals. However, how these outcomes change as food insecurity changes is unclear.

OBJECTIVE

To evaluate how common patient-reported health-related quality of life and mental health scales change in response to changes in food security.

DESIGN

Retrospective cohort study using data representative of the civilian, adult, non-institutionalized population of the USA.

PARTICIPANTS

Food insecure adults who completed the 2016-2017 Medical Expenditure Panel Survey.

MAIN MEASURES

Mental health, as measured by the mental component score of the Veterans Rand 12-Item Health Survey (VR-12) (primary outcome), along physical health (physical component score of the VR-12), self-rated health status, psychological distress (Kessler 6), depressive symptoms (PHQ2), and the SF-6D measure of health utility. We fit linear regression models adjusted for baseline outcome level, age, gender, race/ethnicity, education, health insurance, and family size followed by predictive margins to estimate the change in outcome associated with a 1-point improvement in food security.

KEY RESULTS

A total of 1,390 food-insecure adults were included. A 1-point improvement in food security was associated with a 0.38 (95%CI 0.62 to 0.14)-point improvement in mental health, a 0.15 (95%CI 0.02 to 0.27)-point improvement in psychological distress, a 0.05 (95%CI 0.01 to 0.09)-point improvement in depressive symptoms, and a 0.003 (95%CI 0.000 to 0.007)-point improvement in health utility. Point estimates for physical health and self-rated health were in the direction of improvement, but were not statistically significant.

CONCLUSIONS

Improvement in food insecurity was associated with improvement in several patient-reported outcomes. Further work should investigate whether similar changes are seen in food insecurity interventions, and the most useful scales for assessing changes in health-related quality of life and mental health in food insecurity interventions.