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Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes
Accepted Manuscript Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes Maryam Sina, Jonathan Graffy, David Simmons PII: DOI: Reference:
S0168-8227(17)30671-X https://doi.org/10.1016/j.diabres.2018.04.031 DIAB 7346
To appear in:
Diabetes Research and Clinical Practice
Received Date: Accepted Date:
28 April 2017 17 April 2018
Please cite this article as: M. Sina, J. Graffy, D. Simmons, Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes, Diabetes Research and Clinical Practice (2018), doi: https:// doi.org/10.1016/j.diabres.2018.04.031
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Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes Maryam Sina a, Jonathan Graffy b and David Simmons*a a
School of Medicine; Western Sydney University, Campbelltown, NSW. Australia Primary Care Unit, Dept of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR b
*Corresponding author: Professor David Simmons, Macarthur Clinical School, School of Medicine, Western Sydney University, Locked Bag 1797, Campbelltown NSW 2751, AUSTRALIA Email: [email protected] TEL: (61+2) 4620 3899 FAX: (61+2) 4620 3890
Aims To determine which barriers to care are associated with type 2 diabetes complications in an area in rural East England. Methods 3,649 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 selfreported complications were assessed using logistic regression. Results
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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. Keywords Type 2 diabetes, complications, psychological, health services 1. Introduction Diabetes requires self-management, education, monitoring and timely interventions if needed. Despite increasing numbers of efficacious medications, the majority of the patients do not meet all the goals for important components of care such as levels of blood glucose, lowdensity lipoprotein cholesterol and blood pressure [1, 2], thereby leading to poor health outcomes [1, 3]. Previous studies have largely examined contributory factors to sub-optimal risk reduction from two perspectives: treatment delivery by attending health care professionals and self-care by patients [4, 5]. The former largely involves health service (systems) barriers such as insufficient health care professional knowledge and skills, nonadherence to guidelines and clinical inertia, poor patient-provider interaction/communication,
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and lack of effective operational management systems for individualized treatment [4]. Patient factors are multi-tiered, and involve psychological and physical factors which are unique to individual patients [4, 6]. People with type 2 diabetes, particularly with an associated amputation, impaired vision or other complications are more likely to be hospitalised [7] and to have more difficulties in their day to day living (as shown by studies using the EQ5D) than those with diabetes but no complications or without diabetes [8]. We hypothesised that among people with type 2 diabetes, those with self-reported complications would experience more barriers to care than those without complications. The objective of this study was to determine the most common patient-identified barriers and evaluate any association with self-reported diabetes complications in a rural area in England.
2. Subjects and methods 2.1. Recruitment Individuals with diabetes were recruited via postal invitation letters from 62 general practices in Cambridgeshire and neighbouring areas in Essex and Hertfordshire. General practices searched their registers for patients with pre-existing T2DM for at least 12 months, excluding those with type 1 diabetes, dementia or psychotic illnesses, as previously reported [9]. Invitations included an information sheet, a Barriers-to-Diabetes-Care Survey (BDCS) and an invitation to a linked trial of peer support [9], although questionnaire completion was requested whether or not the recipient intended to enter the trial. Two reminders were sent during follow-up and recruitment was augmented by community-based posters, mail-outs to
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hospital clinic patients and through Diabetes UK membership. The BDCS was self-completed by patients and returned in stamped addressed envelopes.
2.2. The Barriers-to-Diabetes-Care Survey (BDCS) We have previously identified 33 categories of perceived barriers to diabetes care through an in-depth, interview-based anthropological study among a multi-ethnic cohort of New Zealand urban community [10]. The 33 categories were then validated against open questions from a household survey [10], and used in both the USA and elsewhere in New Zealand [11, 12]. Further external validation has been derived from a systematic review of barriers to diabetes management identified similar categories based on patients’ adherence, attitudes and beliefs, health literacy, culture/language, financial resources and co-morbidity [4]. The questions have subsequently been used in closed question format in Australia [13], adapted from an American Diabetes Association questionnaire, itself based upon the prior validation work [6, 14]. Briefly, the survey includes 33 close-ended items representing five major barriers domains: physical-health (e.g. co-morbid conditions, side effects of medication); systems (e.g. finance and transport); educational (e.g. knowledge of diabetes); psychological (personal behaviour e.g. self-efficacy, motivation, health beliefs); and psychosocial (relationships with others e.g. community and family support). The survey additionally asked for demographic characteristics and information related to diabetes including duration of diabetes and self-care behaviours. Presence of any diabetes related complications were assessed by the question: “Have you any complications from your diabetes?” Individuals who indicated experience of complications were asked to record the types of complications towards the end of the survey, where participants are given options of “eyes”, “foot”, “legs”, “kidneys”, “heart”, and “other” along with commentary sections to describe the complications.
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2.3. Data handling and statistical analysis Specific barriers were determined based on the responses (“yes”, “no”, “don’t know”). These barriers were further grouped into five categories and were analysed as categorical variables (presence vs. absence vs. not being sure of the barriers). Statistical tests to compare differences between groups were two-tailed with significance level taken at P < 0.05. Twoway t-test was carried out for continuous variables and Chi-squared test was used for categorical variables. Continuous variables were shown as mean ± standard deviations and categorical variables were shown as percentages of the samples specified for each category (N). Multifactorial logistic regressions were carried out through two steps to assess independent association of each barrier group, as well as specific components of each group, on the outcome variable: any self-reported diabetes related complications. In the first step, all associations were adjusted for age, disease duration in years, gender, glucose monitoring, insulin treatment, blood pressure and cholesterol lowering tablet. In the second step, other barriers were added to the first multifactorial models. All statistical analyses were performed using SAS version 9.4 [15]. Ethics approval was received from the Cambridgeshire REC2 Committee.
3. Results Overall, 21,961 individuals were contacted. Of 3,871 (17.6%) responses, individuals who supplied blank responses for having diabetes (n = 70), no response for having complications (n = 89) and those with type 1 diabetes (n = 63) were further removed yielding the final Barriers-to-Care sample of 3,649 (16.6%) participants. 94.3% of patients were under GP care alone. Characteristics of the participants are summarised in Table 1, which compares those with and without self-reported diabetes-related complications. Compared with those who reported no complications, those with self-reported complications were significantly older,
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more likely to smoke, have been diagnosed for longer and were more likely to monitor their glucose, to inject insulin and to use medications to control their diabetes (P-value < 0.05).
(Table 1 here)
3.1. Frequencies of reported barriers Frequencies of reported barriers to diabetes care in individuals with and without complications are presented in Table 2. Of the five main categories, the most frequently reported categories were related to psychological barriers (e.g. lack of willingness to exercise) (64.5%), psychosocial barriers (particularly where others not knowing more about diabetes was a barrier) (61.2%), health systems barriers (31.8%), educational barriers (28.8%) and physical barriers (26.7%). (Table 2 here)
3.2. Barriers associated with reported complications The associations between barriers and any diabetes related complications are presented in Table 2. In the main categories ‘physical barriers’ (particularly presence of comorbidities), ‘systems barriers’ and ‘psychological barriers’ were significantly more likely to be associated with self-reported T2DM complications. In the systems barriers category, financial difficulties, absence of some required services, feeling public should bear more financial responsibility for their care and not having a local diabetes service were significantly associated with diabetes related complications. In the psychological category, feeling worried/afraid or ashamed about their diabetes and lack of readiness to exercise were significantly associated with any diabetes complications.
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4. Discussion In our study, we have demonstrated the associations of various barriers with self-reported complications in patients with T2DM, the first such survey in England. Physical barriers, while being the least frequently reported overall in our survey, perhaps not surprisingly, were significantly associated with self-reported complications (OR = 3.3). While this may reflect the consequences of diabetes complications, other co-morbidities may also be more common. For example, pain is a common comorbidity in patients with diabetes, and non-specific pain has been shown to influence HbA1c control with diabetes in a black population group [16]. Previous studies have identified adverse effects to be associated with combined medication usage, total burden of medications and complex medication schedules in simultaneously managing several chronic conditions [17]. Additionally, other symptomatic comorbidities may also be demanding on patients’ finance and time, or debilitate patients, rendering certain tasks more challenging [18]. Kerr et al demonstrated that diabetes patients with severe symptomatic conditions and/or conditions which are considered to be unrelated to diabetes, had the highest burden in both prioritising self-care management and diabetes self-treatment that they needed to undertake [19]. There is evidence that the preference and needs of patients with multiple conditions can be addressed through coordinated care in an organised environment such as the “medical home” [20]. In the UK, general practices are already expected to offer this, but time pressure and variable levels of skill lead to patients often receiving inconsistent care [21]. Therefore, inconsistent service could be associated with diabetes complications, as in the current study, where over 55% of patients with T2DM had comorbidities. Perhaps, individualised treatment regimens tailored to address these comorbidities may be an effective measure in improving awareness and adherence to diabetes management tasks and reducing related complications.
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Some of the systems barriers, such as those relating to limitations in the organisation of diabetes services and long distances to diabetes services were also strongly associated with excess complications. This may suggest that issues relating to the structure and delivery/accessibility of diabetes care programs remain important even in an area with relatively good access to primary care. The association between long distances to diabetes related services and complications of T2DM can be a barrier of particular importance to rural populations, since diabetes care requires access to regular follow-up [22]. Elsewhere, patients in rural areas with complications that impede their mobility are less likely to seek continuous care due to lack of adequate transport and fewer treatment options [23], leading to more severe complications. Therefore, interventions with multiple strategies targeting clinicians and health systems (e.g. developing telemedicine system), rather than focusing solely on conventional patient-oriented strategies, could be a beneficial approach for this population group. Psychological barriers are reflective of how individuals process incoming information regarding their health thereby affecting the subsequent disease related behaviours [24]. Having a poor psychological state such as worry, shame or fear has previously been associated with poor self-care behaviours and more severe health outcomes [25, 26]. In particular, insulin treatment is associated with a high degree of anxiety and shame, as insulin treatment is often associated with a sense of failure [27]. Other sources of anxiety around insulin treatment include injection phobia and fear of hypoglycaemia [28]. Therefore, psychological-based interventions, such as group sessions focusing on coping skills, behaviour skills and interpersonal skills, are recommended [29]. A web-based system could be designed to address the group-sessions, since having access to diabetes care could also be a barrier [30].
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Consistent with previous studies [31-33], we also found that individuals with reduced selfefficacy (e.g. lack of readiness to exercise) are more likely to report any complications. Lack of support from others and having a feeling that others are holding diabetes against them influence patients’ perception of their conditions, resulting in an overall lack of awareness for self-care [24]. Although we did not measure diabetes distress in this postal survey [34], this has been shown to impact on HbA1c among patients with T2DM in the USA and Europe [35, 36]. There are a number of limitations to the analyses and interpretation of the survey data presented here. Due to the cross-sectional nature of our study, we cannot assign a causal relationship between these barriers and complications; however, there is evidence from a randomised controlled study that addressing barriers may help in that study, providing psychological support to the elderly led to better glycaemic control and functionality [37]. The associations are based on self-reported complications, which may be over or under reported if the patients have limited knowledge of which comorbidities are diabetes related. Conversely, some patients failed to provide proper descriptions of their complications by selecting the “don’t know” option in the questionnaire. We were unable to factor in the effects of some important phenotypic characteristics such as socioeconomic status, health insurance status, body mass index and measured HbA1c levels due to lack of such information. However, we have included other important confounders such as age, sex, insulin, blood pressure and cholesterol treatment to reflect their diabetes state. Rural populations may experience different barriers than those of urban regions [38]. Another limitation is that since our study is based in a defined region of rural England that lacks ethnic diversity, barriers to care among non-majority groups are likely to be greater [23].
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Although the survey was undertaken at the same time as delivering an invitation into a study, many responses concurrently declined trial participation, suggesting less bias than a study solely among trial participants. The 17% response rate, while fairly common in mail surveys, remains low and it is unclear how representative this study was of patients in the area. We did attempt to maximise the follow up with three mail outs as recommended by Dillman [39], but clearly this was insufficient. In conclusion, we have described several important barriers to diabetes self-care among patients with T2DM living in a rural area of England, and shown how these are related to self-reported diabetes related complications. Interventions could include care coordination or “Diabetes educators” trained in addressing more than glycaemic issues alone as well as online programs. It reinforces the need for holistic care and poses a particular challenge for UK general practice, where most patients with T2DM receive their care. Further research is needed to develop different approaches and test whether these improve diabetes outcomes.
Acknowledgements We thank participating general practices, Daniel Holmen, Caroline Taylor, Kim Mercer, Kevin Baker, James Brimicombe, the RAPSID Patient Committee (Peter Robins, Phillip Jones, Liz Carvlin, Roger Smith), the Primary Care Research Network – East of England and the Eastern Diabetes Research Network for their input. We thank Peers for Progress for financial support and collaboration. Funding sources We thank Peers for Progress for funding this work. Conflicts of Interest Authors have no conflict of interest
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Table1. Descriptive characteristics of the Barriers-to-Care study population. Characteristics
Age (years) (mean) Age > 60 (%) Male (%) Duration (years) How long since last seeing HCP (month) Glucose Monitoring (%) Diabetes tablets (%) Injects insulin (%) Blood pressure lowering tablets (%) Cholesterol Lowering Tablets (%) Smoker (%)
No complications n = 2,208 64.1 ± 10.0 71.4% 58.7 7.4 ± 6.2 3.4 ± 3.0 42.5 74.1 11.0 68.4 74.0 7.5
Any complications n = 1,441 66.8 ± 9.3 81.3% 64.8 10.5 ± 7.9 3.3 ± 3.0 57.5 78.1 26.1 74.9 79.0 8.9
P-value
<0.001 <0.001 <0.001 <0.001 0.17 0.005 0.003 0.007 <0.001 0.64 0.12
HCP = Health care professional; Variables are expressed as mean ± standard deviations unless otherwise specified; P-values < 0.05 are considered significant.
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Table 2. Frequencies a n (%) of reported barriers b and the association of those barriers with diabetes complications Barriers No OR (95%CI) P-value OR (95%CI) Any complications complications (Crude) (Adjusted*) (n = 2,208) (n = 1,441)
P-value
OR (95%CI) (Adjusted**)
P-value
Lack of Education
568 (26.0)
483(34.5)
1.6 (1.3, 1.8)
<0.001
1.6 (1.4, 1.9)
<0.001
1.2 (1.0, 1.4)
0.13
Lack of knowledge about diabetes Lack of knowledge about diabetes service
408 (18.7) 340 (15.5)
355 (25.3) 280 (19.6)
1.4 (1.2, 1.7) 1.3 (1.1, 1.6)
<0.001 0.001
1.7 (1.4, 2.0) 1.4 (1.2, 1.8)
<0.001 <0.001
1.2 (1.0, 1.5) 1.0 (0.8, 1.2)
0.09 0.71
Physical Barriers Other health conditions (Presence of co-morbidity) Physical effects of treatment (Dissatisfaction with diabetes medications)
369 (18.3) 314 (14.3)
604 (43.7) 583 (41.4)
3.6 (3.0, 4.2) 5.3 (4.5, 6.3)
<0.001 <0.001
3.8 (3.1, 4.5) 5.4 (4.5, 6.6)
<0.001 <0.001
3.3 (2.7, 4.0) 4.8 (3.9, 5.9)
<0.001 <0.001
110 (5.5)
109 (7.9)
1.6 (1.2, 2.0)
0.002
1.5 (1.1, 2.1)
0.007
1.1 (0.8, 1.6)
0.46
Systems b Lack of personal finance (Inability to afford having diabetes) Lack of general access (Lack of accessibility to diabetes team) Lack of range of services (Absence of some services needed) Physician appointment system/staffing (Dissatisfaction with organization of the services) Healthcare system (Feeling public should bear more financial responsibility for their care) Lack of physical access (Not having vicinity of diabetes service)
580 (27.4) 326 (15.4)
582 (41.7) 372 (26.7)
1.9 (1.7, 2.3) 2.1 (1.7, 2.5)
<0.001 <0.001
1.9 (1.6, 2.3) 2.0 (1.7, 2.5)
<0.001 <0.001
1.6 (1.3, 2.0) 1.7 (1.3, 2.1)
<0.001 <0.001
76 (3.5)
97 (6.8)
2.0 (1.5, 2.8)
<0.001
2.2 (1.5, 3.1)
<0.001
1.5 (1.0, 2.1)
0.06
72 (3.3)
107 (7.5)
2.4 (1.8, 3.3)
<0.001
2.9 (2.1, 4.1)
<0.001
2.0 (1.4, 3.0)
0.001
85 (3.9)
103 (7.3)
2.0 (1.5, 2.7)
<0.001
2.1 (1.5, 3.0)
<0.001
1.2 (0.8, 1.7)
0.34
103 (4.7)
75 (5.2)
1.1 (0.8, 1.5)
0.42
1.6 (1.2, 2.2)
<0.001
1.6 (1.1, 2.1)
0.002
158 (7.3)
193 (13.6)
2.0 (1.6, 2.5)
<0.001
1.7 (1.5, 2.4)
<0.001
1.5 (1.1, 2.0)
0.003
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Psychological Barriers b Priorities (Lack of willingness to look after their diabetes) Health belief (Inability to look after their diabetes) No symptom (Lack of willingness to look after if symptom worse) Lack of time (Patients do not have enough time for diabetes) Lack of time (Diabetes team do have not enough time for their diabetes) Psychological state (Feeling worried, afraid or ashamed of their diabetes) Lack of motivation (Lack of willingness to look after their diabetes fully from today) Self-efficacy (Lack of readiness to exercise) Self-efficacy (lack of Readiness to change diet) Psychosocial Barriers b Lack of support (Pressure from others not to look after) Lack of support (Others should know more about diabetes) Prejudice/discrimination (Feel others are holding diabetes against them) Lack of Family support (Family not helping to look after diabetes) Family Demands (Family demands hinder care behaviour) Lack of social support (Lack of
1,324 (60.1) 13.0 (0.6)
1,030 (71.7) 12 (0.8)
1.7 (1.5, 2.5) 1.4 (0.6, 3.1)
<0.001 0.38
1.8 (1.5, 2.1) 1.5 (0.6, 3.4)
<0.001 0.38
1.3 (1.1, 1.5) 1.0 (0.4, 2.5)
0.01 0.97
103 (4.7)
111 (7.8)
1.8 (1.3, 2.3)
<0.001
1.9 (1.4, 2.6)
<0.001
1.3 (0.9, 1.8)
0.18
289 (13.3)
198 (14.0)
1.1 (0.9, 1.3)
0.38
1.0 (0.8, 1.3)
0.87
0.9 (0.7, 1.1)
0.23
191 (8.8)
135 (9.5)
1.1 (0.9, 1.4)
0.49
1.2 (0.9, 1.6)
0.16
0.8 (0.6, 1.1)
0.21
96 (4.4)
105 (7.4)
1.8 (1.4, 2.4)
<0.001
2.1 (1.5, 2.9)
<0.001
1.1 (0.7, 1.6)
0.63
274 (12.5)
266 (18.6)
1.6 (1.3, 1.9)
<0.001
2.1 (1.7, 2.6)
<0.001
1.5 (1.2, 2.0)
<0.001
83 (3.8)
81 (5.8)
1.6 (1.1, 2.1)
0.006
1.4 (0.9, 2.0)
0.06
1.2 (0.8, 1.8)
0.33
928 (42.5)
787 (55.2)
1.7 (1.5, 2.0)
<0.001
1.8 (1.5, 2.1)
<0.001
1.4 (1.2, 1.7)
<0.001
1.4, (1.2, 1.7)
0.013
1.7 (1.4, 2.0)
<0.001
1.2 (0.9, 1.5)
0.16
351 (16.1)
296 (20.8)
1,320 (60.1)
915 (63.9)
1.2 (1.0, 1.4)
0.016
1.2 (1.0, 1.4)
0.014
1.0 (0.8, 1.2)
0.80
103 (4.7)
75 (5.2)
1.1 (0.8, 1.5)
0.42
1.3 (0.9, 1.8)
0.19
0.8 (0.6, 1.2)
0.36
818 (37.4)
618 (43.3)
1.3 (1.2, 1.5)
<0.001
1.3 (1.1, 1.6)
0.001
1.2 (1.0, 1.4)
64 (2.9)
77 (5.4)
1.9 (1.4, 2.7)
<0.001
1.9 (1.3, 2.8)
0.001
1.2 (0.8, 1.9)
0.08 0.37 478 (21.9)
297 (20.8)
0.9 (0.8, 1.1)
0.39
1.1 (0.9, 1.3)
0.29
1.0 (0.8, 1.3)
0.81
96 (4.4)
75 (5.2)
1.2 (0.9, 1.6)
0.24
1.5 (1.1, 2.2)
0.016
1.1 (0.7, 1.6)
0.68
189 (8.8)
167 (12.0)
1.4 (1.2, 1.8)
0.001
2.1 (1.6, 2.8)
<0.001
1.0 (0.7, 1.3)
0.86
17
support in community or at work) Communication-language (Ability to speak or understand diabetes team) Communication-attitude (Uncomfortable speaking with diabetes team) Dissatisfied with diabetes team Dissatisfied with diabetes education and care
133 (6.1)
145 (10.2)
1.7 (1.4, 2.2)
<0.001
1.5 (1.0, 2.1)
0.052
1.1 (0.8, 1.5)
0.63
77 (3.5)
63 (4.4)
1.3 (0.9, 1.8)
0.13
1.5 (1.0, 2.1)
0.052
0.8 (0.5, 1.3)
0.36
146 (6.7) 187 (8.5)
152 (10.7) 167 (11.7)
1.7 (1.3, 2.1) 1.5 (1.2, 1.9)
<0.001 <0.001
1.7 (1.3, 2.2) 1.8 (1.4, 2.3)
<0.001 <0.001
1.1 (0.9, 1.5) 1.0 (0.7, 1.4)
0.36 0.96
a
Frequency (%) is calculated based on number of respondents with each barrier. b Each category includes all components listed. *All reported values are adjusted for age, disease duration in years, gender, glucose monitoring, insulin treatment, blood pressure and cholesterol tablets usage. **Adjusted for other barriers in addition to age, disease duration in years, gender, glucose monitoring, insulin treatment, blood pressure and cholesterol tablets usage.
18
Highlights
A comprehensive framework can be used to describe barriers to care People with diabetes in England face a multitude of barriers to self-care and clinical care and these are more common when they have diabetes related complications Psychological barriers were the most frequent barriers for those with and without complications Psychological barriers were more common in those with self-reported diabetes complications than those without complications.
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S0168-8227(17)30671-X https://doi.org/10.1016/j.diabres.2018.04.031 DIAB 7346
To appear in:
Diabetes Research and Clinical Practice
Received Date: Accepted Date:
28 April 2017 17 April 2018
Please cite this article as: M. Sina, J. Graffy, D. Simmons, Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes, Diabetes Research and Clinical Practice (2018), doi: https:// doi.org/10.1016/j.diabres.2018.04.031
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes Maryam Sina a, Jonathan Graffy b and David Simmons*a a
School of Medicine; Western Sydney University, Campbelltown, NSW. Australia Primary Care Unit, Dept of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR b
*Corresponding author: Professor David Simmons, Macarthur Clinical School, School of Medicine, Western Sydney University, Locked Bag 1797, Campbelltown NSW 2751, AUSTRALIA Email: [email protected] TEL: (61+2) 4620 3899 FAX: (61+2) 4620 3890
Aims To determine which barriers to care are associated with type 2 diabetes complications in an area in rural East England. Methods 3,649 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 selfreported complications were assessed using logistic regression. Results
1
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. Keywords Type 2 diabetes, complications, psychological, health services 1. Introduction Diabetes requires self-management, education, monitoring and timely interventions if needed. Despite increasing numbers of efficacious medications, the majority of the patients do not meet all the goals for important components of care such as levels of blood glucose, lowdensity lipoprotein cholesterol and blood pressure [1, 2], thereby leading to poor health outcomes [1, 3]. Previous studies have largely examined contributory factors to sub-optimal risk reduction from two perspectives: treatment delivery by attending health care professionals and self-care by patients [4, 5]. The former largely involves health service (systems) barriers such as insufficient health care professional knowledge and skills, nonadherence to guidelines and clinical inertia, poor patient-provider interaction/communication,
2
and lack of effective operational management systems for individualized treatment [4]. Patient factors are multi-tiered, and involve psychological and physical factors which are unique to individual patients [4, 6]. People with type 2 diabetes, particularly with an associated amputation, impaired vision or other complications are more likely to be hospitalised [7] and to have more difficulties in their day to day living (as shown by studies using the EQ5D) than those with diabetes but no complications or without diabetes [8]. We hypothesised that among people with type 2 diabetes, those with self-reported complications would experience more barriers to care than those without complications. The objective of this study was to determine the most common patient-identified barriers and evaluate any association with self-reported diabetes complications in a rural area in England.
2. Subjects and methods 2.1. Recruitment Individuals with diabetes were recruited via postal invitation letters from 62 general practices in Cambridgeshire and neighbouring areas in Essex and Hertfordshire. General practices searched their registers for patients with pre-existing T2DM for at least 12 months, excluding those with type 1 diabetes, dementia or psychotic illnesses, as previously reported [9]. Invitations included an information sheet, a Barriers-to-Diabetes-Care Survey (BDCS) and an invitation to a linked trial of peer support [9], although questionnaire completion was requested whether or not the recipient intended to enter the trial. Two reminders were sent during follow-up and recruitment was augmented by community-based posters, mail-outs to
3
hospital clinic patients and through Diabetes UK membership. The BDCS was self-completed by patients and returned in stamped addressed envelopes.
2.2. The Barriers-to-Diabetes-Care Survey (BDCS) We have previously identified 33 categories of perceived barriers to diabetes care through an in-depth, interview-based anthropological study among a multi-ethnic cohort of New Zealand urban community [10]. The 33 categories were then validated against open questions from a household survey [10], and used in both the USA and elsewhere in New Zealand [11, 12]. Further external validation has been derived from a systematic review of barriers to diabetes management identified similar categories based on patients’ adherence, attitudes and beliefs, health literacy, culture/language, financial resources and co-morbidity [4]. The questions have subsequently been used in closed question format in Australia [13], adapted from an American Diabetes Association questionnaire, itself based upon the prior validation work [6, 14]. Briefly, the survey includes 33 close-ended items representing five major barriers domains: physical-health (e.g. co-morbid conditions, side effects of medication); systems (e.g. finance and transport); educational (e.g. knowledge of diabetes); psychological (personal behaviour e.g. self-efficacy, motivation, health beliefs); and psychosocial (relationships with others e.g. community and family support). The survey additionally asked for demographic characteristics and information related to diabetes including duration of diabetes and self-care behaviours. Presence of any diabetes related complications were assessed by the question: “Have you any complications from your diabetes?” Individuals who indicated experience of complications were asked to record the types of complications towards the end of the survey, where participants are given options of “eyes”, “foot”, “legs”, “kidneys”, “heart”, and “other” along with commentary sections to describe the complications.
4
2.3. Data handling and statistical analysis Specific barriers were determined based on the responses (“yes”, “no”, “don’t know”). These barriers were further grouped into five categories and were analysed as categorical variables (presence vs. absence vs. not being sure of the barriers). Statistical tests to compare differences between groups were two-tailed with significance level taken at P < 0.05. Twoway t-test was carried out for continuous variables and Chi-squared test was used for categorical variables. Continuous variables were shown as mean ± standard deviations and categorical variables were shown as percentages of the samples specified for each category (N). Multifactorial logistic regressions were carried out through two steps to assess independent association of each barrier group, as well as specific components of each group, on the outcome variable: any self-reported diabetes related complications. In the first step, all associations were adjusted for age, disease duration in years, gender, glucose monitoring, insulin treatment, blood pressure and cholesterol lowering tablet. In the second step, other barriers were added to the first multifactorial models. All statistical analyses were performed using SAS version 9.4 [15]. Ethics approval was received from the Cambridgeshire REC2 Committee.
3. Results Overall, 21,961 individuals were contacted. Of 3,871 (17.6%) responses, individuals who supplied blank responses for having diabetes (n = 70), no response for having complications (n = 89) and those with type 1 diabetes (n = 63) were further removed yielding the final Barriers-to-Care sample of 3,649 (16.6%) participants. 94.3% of patients were under GP care alone. Characteristics of the participants are summarised in Table 1, which compares those with and without self-reported diabetes-related complications. Compared with those who reported no complications, those with self-reported complications were significantly older,
5
more likely to smoke, have been diagnosed for longer and were more likely to monitor their glucose, to inject insulin and to use medications to control their diabetes (P-value < 0.05).
(Table 1 here)
3.1. Frequencies of reported barriers Frequencies of reported barriers to diabetes care in individuals with and without complications are presented in Table 2. Of the five main categories, the most frequently reported categories were related to psychological barriers (e.g. lack of willingness to exercise) (64.5%), psychosocial barriers (particularly where others not knowing more about diabetes was a barrier) (61.2%), health systems barriers (31.8%), educational barriers (28.8%) and physical barriers (26.7%). (Table 2 here)
3.2. Barriers associated with reported complications The associations between barriers and any diabetes related complications are presented in Table 2. In the main categories ‘physical barriers’ (particularly presence of comorbidities), ‘systems barriers’ and ‘psychological barriers’ were significantly more likely to be associated with self-reported T2DM complications. In the systems barriers category, financial difficulties, absence of some required services, feeling public should bear more financial responsibility for their care and not having a local diabetes service were significantly associated with diabetes related complications. In the psychological category, feeling worried/afraid or ashamed about their diabetes and lack of readiness to exercise were significantly associated with any diabetes complications.
6
4. Discussion In our study, we have demonstrated the associations of various barriers with self-reported complications in patients with T2DM, the first such survey in England. Physical barriers, while being the least frequently reported overall in our survey, perhaps not surprisingly, were significantly associated with self-reported complications (OR = 3.3). While this may reflect the consequences of diabetes complications, other co-morbidities may also be more common. For example, pain is a common comorbidity in patients with diabetes, and non-specific pain has been shown to influence HbA1c control with diabetes in a black population group [16]. Previous studies have identified adverse effects to be associated with combined medication usage, total burden of medications and complex medication schedules in simultaneously managing several chronic conditions [17]. Additionally, other symptomatic comorbidities may also be demanding on patients’ finance and time, or debilitate patients, rendering certain tasks more challenging [18]. Kerr et al demonstrated that diabetes patients with severe symptomatic conditions and/or conditions which are considered to be unrelated to diabetes, had the highest burden in both prioritising self-care management and diabetes self-treatment that they needed to undertake [19]. There is evidence that the preference and needs of patients with multiple conditions can be addressed through coordinated care in an organised environment such as the “medical home” [20]. In the UK, general practices are already expected to offer this, but time pressure and variable levels of skill lead to patients often receiving inconsistent care [21]. Therefore, inconsistent service could be associated with diabetes complications, as in the current study, where over 55% of patients with T2DM had comorbidities. Perhaps, individualised treatment regimens tailored to address these comorbidities may be an effective measure in improving awareness and adherence to diabetes management tasks and reducing related complications.
7
Some of the systems barriers, such as those relating to limitations in the organisation of diabetes services and long distances to diabetes services were also strongly associated with excess complications. This may suggest that issues relating to the structure and delivery/accessibility of diabetes care programs remain important even in an area with relatively good access to primary care. The association between long distances to diabetes related services and complications of T2DM can be a barrier of particular importance to rural populations, since diabetes care requires access to regular follow-up [22]. Elsewhere, patients in rural areas with complications that impede their mobility are less likely to seek continuous care due to lack of adequate transport and fewer treatment options [23], leading to more severe complications. Therefore, interventions with multiple strategies targeting clinicians and health systems (e.g. developing telemedicine system), rather than focusing solely on conventional patient-oriented strategies, could be a beneficial approach for this population group. Psychological barriers are reflective of how individuals process incoming information regarding their health thereby affecting the subsequent disease related behaviours [24]. Having a poor psychological state such as worry, shame or fear has previously been associated with poor self-care behaviours and more severe health outcomes [25, 26]. In particular, insulin treatment is associated with a high degree of anxiety and shame, as insulin treatment is often associated with a sense of failure [27]. Other sources of anxiety around insulin treatment include injection phobia and fear of hypoglycaemia [28]. Therefore, psychological-based interventions, such as group sessions focusing on coping skills, behaviour skills and interpersonal skills, are recommended [29]. A web-based system could be designed to address the group-sessions, since having access to diabetes care could also be a barrier [30].
8
Consistent with previous studies [31-33], we also found that individuals with reduced selfefficacy (e.g. lack of readiness to exercise) are more likely to report any complications. Lack of support from others and having a feeling that others are holding diabetes against them influence patients’ perception of their conditions, resulting in an overall lack of awareness for self-care [24]. Although we did not measure diabetes distress in this postal survey [34], this has been shown to impact on HbA1c among patients with T2DM in the USA and Europe [35, 36]. There are a number of limitations to the analyses and interpretation of the survey data presented here. Due to the cross-sectional nature of our study, we cannot assign a causal relationship between these barriers and complications; however, there is evidence from a randomised controlled study that addressing barriers may help in that study, providing psychological support to the elderly led to better glycaemic control and functionality [37]. The associations are based on self-reported complications, which may be over or under reported if the patients have limited knowledge of which comorbidities are diabetes related. Conversely, some patients failed to provide proper descriptions of their complications by selecting the “don’t know” option in the questionnaire. We were unable to factor in the effects of some important phenotypic characteristics such as socioeconomic status, health insurance status, body mass index and measured HbA1c levels due to lack of such information. However, we have included other important confounders such as age, sex, insulin, blood pressure and cholesterol treatment to reflect their diabetes state. Rural populations may experience different barriers than those of urban regions [38]. Another limitation is that since our study is based in a defined region of rural England that lacks ethnic diversity, barriers to care among non-majority groups are likely to be greater [23].
9
Although the survey was undertaken at the same time as delivering an invitation into a study, many responses concurrently declined trial participation, suggesting less bias than a study solely among trial participants. The 17% response rate, while fairly common in mail surveys, remains low and it is unclear how representative this study was of patients in the area. We did attempt to maximise the follow up with three mail outs as recommended by Dillman [39], but clearly this was insufficient. In conclusion, we have described several important barriers to diabetes self-care among patients with T2DM living in a rural area of England, and shown how these are related to self-reported diabetes related complications. Interventions could include care coordination or “Diabetes educators” trained in addressing more than glycaemic issues alone as well as online programs. It reinforces the need for holistic care and poses a particular challenge for UK general practice, where most patients with T2DM receive their care. Further research is needed to develop different approaches and test whether these improve diabetes outcomes.
Acknowledgements We thank participating general practices, Daniel Holmen, Caroline Taylor, Kim Mercer, Kevin Baker, James Brimicombe, the RAPSID Patient Committee (Peter Robins, Phillip Jones, Liz Carvlin, Roger Smith), the Primary Care Research Network – East of England and the Eastern Diabetes Research Network for their input. We thank Peers for Progress for financial support and collaboration. Funding sources We thank Peers for Progress for funding this work. Conflicts of Interest Authors have no conflict of interest
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[32] Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes care. 2001;24: pp. 561-87. [33] Krichbaum K, Aarestad V, Buethe M. Exploring the connection between self-efficacy and effective diabetes self-management. The Diabetes educator. 2003;29: pp. 653-62. [34] Aljasem LI, Peyrot M, Wissow L, Rubin RR. The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes. The Diabetes educator. 2001;27: pp. 393-404. [35] Leyva B, Zagarins SE, Allen NA, Welch G. The relative impact of diabetes distress vs depression on glycemic control in hispanic patients following a diabetes self-management education intervention. Ethnicity & disease. 2011;21: pp. 322-7. [36] Ascher-Svanum H, Zagar A, Jiang D, Schuster D, Schmitt H, Dennehy EB, et al. Associations between glycemic control, depressed mood, clinical depression, and diabetes distress before and after insulin initiation: an exploratory, post hoc analysis. Diabetes therapy. 2015;6: pp. 303-16. [37] Munshi MN, Segal AR, Suhl E, Ryan C, Sternthal A, Giusti J, et al. Assessment of barriers to improve diabetes management in older adults: a randomized controlled study. Diabetes care. 2013;36: pp. 543-9. [38] Vanasse A, Courteau J, Cohen AA, Orzanco MG, Drouin C. Rural-urban disparities in the management and health issues of chronic diseases in Quebec (Canada) in the early 2000s. Rural and remote health. 2010;10: pp. 1548. [39] Dillman DA. Mail and internet surveys: the tailored design method. New York: Wiley; 2007.
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Table1. Descriptive characteristics of the Barriers-to-Care study population. Characteristics
Age (years) (mean) Age > 60 (%) Male (%) Duration (years) How long since last seeing HCP (month) Glucose Monitoring (%) Diabetes tablets (%) Injects insulin (%) Blood pressure lowering tablets (%) Cholesterol Lowering Tablets (%) Smoker (%)
No complications n = 2,208 64.1 ± 10.0 71.4% 58.7 7.4 ± 6.2 3.4 ± 3.0 42.5 74.1 11.0 68.4 74.0 7.5
Any complications n = 1,441 66.8 ± 9.3 81.3% 64.8 10.5 ± 7.9 3.3 ± 3.0 57.5 78.1 26.1 74.9 79.0 8.9
P-value
<0.001 <0.001 <0.001 <0.001 0.17 0.005 0.003 0.007 <0.001 0.64 0.12
HCP = Health care professional; Variables are expressed as mean ± standard deviations unless otherwise specified; P-values < 0.05 are considered significant.
15
Table 2. Frequencies a n (%) of reported barriers b and the association of those barriers with diabetes complications Barriers No OR (95%CI) P-value OR (95%CI) Any complications complications (Crude) (Adjusted*) (n = 2,208) (n = 1,441)
P-value
OR (95%CI) (Adjusted**)
P-value
Lack of Education
568 (26.0)
483(34.5)
1.6 (1.3, 1.8)
<0.001
1.6 (1.4, 1.9)
<0.001
1.2 (1.0, 1.4)
0.13
Lack of knowledge about diabetes Lack of knowledge about diabetes service
408 (18.7) 340 (15.5)
355 (25.3) 280 (19.6)
1.4 (1.2, 1.7) 1.3 (1.1, 1.6)
<0.001 0.001
1.7 (1.4, 2.0) 1.4 (1.2, 1.8)
<0.001 <0.001
1.2 (1.0, 1.5) 1.0 (0.8, 1.2)
0.09 0.71
Physical Barriers Other health conditions (Presence of co-morbidity) Physical effects of treatment (Dissatisfaction with diabetes medications)
369 (18.3) 314 (14.3)
604 (43.7) 583 (41.4)
3.6 (3.0, 4.2) 5.3 (4.5, 6.3)
<0.001 <0.001
3.8 (3.1, 4.5) 5.4 (4.5, 6.6)
<0.001 <0.001
3.3 (2.7, 4.0) 4.8 (3.9, 5.9)
<0.001 <0.001
110 (5.5)
109 (7.9)
1.6 (1.2, 2.0)
0.002
1.5 (1.1, 2.1)
0.007
1.1 (0.8, 1.6)
0.46
Systems b Lack of personal finance (Inability to afford having diabetes) Lack of general access (Lack of accessibility to diabetes team) Lack of range of services (Absence of some services needed) Physician appointment system/staffing (Dissatisfaction with organization of the services) Healthcare system (Feeling public should bear more financial responsibility for their care) Lack of physical access (Not having vicinity of diabetes service)
580 (27.4) 326 (15.4)
582 (41.7) 372 (26.7)
1.9 (1.7, 2.3) 2.1 (1.7, 2.5)
<0.001 <0.001
1.9 (1.6, 2.3) 2.0 (1.7, 2.5)
<0.001 <0.001
1.6 (1.3, 2.0) 1.7 (1.3, 2.1)
<0.001 <0.001
76 (3.5)
97 (6.8)
2.0 (1.5, 2.8)
<0.001
2.2 (1.5, 3.1)
<0.001
1.5 (1.0, 2.1)
0.06
72 (3.3)
107 (7.5)
2.4 (1.8, 3.3)
<0.001
2.9 (2.1, 4.1)
<0.001
2.0 (1.4, 3.0)
0.001
85 (3.9)
103 (7.3)
2.0 (1.5, 2.7)
<0.001
2.1 (1.5, 3.0)
<0.001
1.2 (0.8, 1.7)
0.34
103 (4.7)
75 (5.2)
1.1 (0.8, 1.5)
0.42
1.6 (1.2, 2.2)
<0.001
1.6 (1.1, 2.1)
0.002
158 (7.3)
193 (13.6)
2.0 (1.6, 2.5)
<0.001
1.7 (1.5, 2.4)
<0.001
1.5 (1.1, 2.0)
0.003
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Psychological Barriers b Priorities (Lack of willingness to look after their diabetes) Health belief (Inability to look after their diabetes) No symptom (Lack of willingness to look after if symptom worse) Lack of time (Patients do not have enough time for diabetes) Lack of time (Diabetes team do have not enough time for their diabetes) Psychological state (Feeling worried, afraid or ashamed of their diabetes) Lack of motivation (Lack of willingness to look after their diabetes fully from today) Self-efficacy (Lack of readiness to exercise) Self-efficacy (lack of Readiness to change diet) Psychosocial Barriers b Lack of support (Pressure from others not to look after) Lack of support (Others should know more about diabetes) Prejudice/discrimination (Feel others are holding diabetes against them) Lack of Family support (Family not helping to look after diabetes) Family Demands (Family demands hinder care behaviour) Lack of social support (Lack of
1,324 (60.1) 13.0 (0.6)
1,030 (71.7) 12 (0.8)
1.7 (1.5, 2.5) 1.4 (0.6, 3.1)
<0.001 0.38
1.8 (1.5, 2.1) 1.5 (0.6, 3.4)
<0.001 0.38
1.3 (1.1, 1.5) 1.0 (0.4, 2.5)
0.01 0.97
103 (4.7)
111 (7.8)
1.8 (1.3, 2.3)
<0.001
1.9 (1.4, 2.6)
<0.001
1.3 (0.9, 1.8)
0.18
289 (13.3)
198 (14.0)
1.1 (0.9, 1.3)
0.38
1.0 (0.8, 1.3)
0.87
0.9 (0.7, 1.1)
0.23
191 (8.8)
135 (9.5)
1.1 (0.9, 1.4)
0.49
1.2 (0.9, 1.6)
0.16
0.8 (0.6, 1.1)
0.21
96 (4.4)
105 (7.4)
1.8 (1.4, 2.4)
<0.001
2.1 (1.5, 2.9)
<0.001
1.1 (0.7, 1.6)
0.63
274 (12.5)
266 (18.6)
1.6 (1.3, 1.9)
<0.001
2.1 (1.7, 2.6)
<0.001
1.5 (1.2, 2.0)
<0.001
83 (3.8)
81 (5.8)
1.6 (1.1, 2.1)
0.006
1.4 (0.9, 2.0)
0.06
1.2 (0.8, 1.8)
0.33
928 (42.5)
787 (55.2)
1.7 (1.5, 2.0)
<0.001
1.8 (1.5, 2.1)
<0.001
1.4 (1.2, 1.7)
<0.001
1.4, (1.2, 1.7)
0.013
1.7 (1.4, 2.0)
<0.001
1.2 (0.9, 1.5)
0.16
351 (16.1)
296 (20.8)
1,320 (60.1)
915 (63.9)
1.2 (1.0, 1.4)
0.016
1.2 (1.0, 1.4)
0.014
1.0 (0.8, 1.2)
0.80
103 (4.7)
75 (5.2)
1.1 (0.8, 1.5)
0.42
1.3 (0.9, 1.8)
0.19
0.8 (0.6, 1.2)
0.36
818 (37.4)
618 (43.3)
1.3 (1.2, 1.5)
<0.001
1.3 (1.1, 1.6)
0.001
1.2 (1.0, 1.4)
64 (2.9)
77 (5.4)
1.9 (1.4, 2.7)
<0.001
1.9 (1.3, 2.8)
0.001
1.2 (0.8, 1.9)
0.08 0.37 478 (21.9)
297 (20.8)
0.9 (0.8, 1.1)
0.39
1.1 (0.9, 1.3)
0.29
1.0 (0.8, 1.3)
0.81
96 (4.4)
75 (5.2)
1.2 (0.9, 1.6)
0.24
1.5 (1.1, 2.2)
0.016
1.1 (0.7, 1.6)
0.68
189 (8.8)
167 (12.0)
1.4 (1.2, 1.8)
0.001
2.1 (1.6, 2.8)
<0.001
1.0 (0.7, 1.3)
0.86
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support in community or at work) Communication-language (Ability to speak or understand diabetes team) Communication-attitude (Uncomfortable speaking with diabetes team) Dissatisfied with diabetes team Dissatisfied with diabetes education and care
133 (6.1)
145 (10.2)
1.7 (1.4, 2.2)
<0.001
1.5 (1.0, 2.1)
0.052
1.1 (0.8, 1.5)
0.63
77 (3.5)
63 (4.4)
1.3 (0.9, 1.8)
0.13
1.5 (1.0, 2.1)
0.052
0.8 (0.5, 1.3)
0.36
146 (6.7) 187 (8.5)
152 (10.7) 167 (11.7)
1.7 (1.3, 2.1) 1.5 (1.2, 1.9)
<0.001 <0.001
1.7 (1.3, 2.2) 1.8 (1.4, 2.3)
<0.001 <0.001
1.1 (0.9, 1.5) 1.0 (0.7, 1.4)
0.36 0.96
a
Frequency (%) is calculated based on number of respondents with each barrier. b Each category includes all components listed. *All reported values are adjusted for age, disease duration in years, gender, glucose monitoring, insulin treatment, blood pressure and cholesterol tablets usage. **Adjusted for other barriers in addition to age, disease duration in years, gender, glucose monitoring, insulin treatment, blood pressure and cholesterol tablets usage.
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Highlights
A comprehensive framework can be used to describe barriers to care People with diabetes in England face a multitude of barriers to self-care and clinical care and these are more common when they have diabetes related complications Psychological barriers were the most frequent barriers for those with and without complications Psychological barriers were more common in those with self-reported diabetes complications than those without complications.
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