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Seton Hall University Seton Hall University
eRepository Seton Hall eRepository Seton Hall
Seton Hall University Dissertations and Theses (ETDs) Seton Hall University Dissertations and Theses
Spring 5-20-2021
Understanding Older Adults Living in Medically Underserved Understanding Older Adults Living in Medically Underserved
Areas Perspectives Regarding Type 2 Diabetes Care Received Areas Perspectives Regarding Type 2 Diabetes Care Received
Christopher Rogers christopherrogersstudentshuedu
Follow this and additional works at httpsscholarshipshuedudissertations
Part of the Community Health and Preventive Medicine Commons Endocrine System Diseases
Commons Endocrinology Diabetes and Metabolism Commons Geriatric Nursing Commons Geriatrics
Commons Gerontology Commons Health Communication Commons Health Services Administration
Commons Public Health and Community Nursing Commons Public Health Education and Promotion
Commons Quality Improvement Commons and the Quantitative Qualitative Comparative and Historical
Methodologies Commons
Recommended Citation Recommended Citation Rogers Christopher Understanding Older Adults Living in Medically Underserved Areas Perspectives Regarding Type 2 Diabetes Care Received (2021) Seton Hall University Dissertations and Theses (ETDs) 2865 httpsscholarshipshuedudissertations2865
UNDERSTANDING OLDER ADULTS LIVING IN MEDICALLY
UNDERSERVED AREAS PERSPECTIVES REGARDING TYPE 2
DIABETES CARE RECEIVED
BY
Christopher K Rogers
Dissertation Committee
Dr Michelle L DrsquoAbundo PhD MSH CHES (Chair)
Dr Genevieve Pinto Zipp PT EdD FNAP
Dr Felicia Hill-Briggs PhD ABPP
Submitted in partial fulfillment of the requirements for the degree of
Doctor of Philosophy in Health Sciences
Seton Hall University
2021
2
Copyright copy Christopher K Rogers 2021
All rights reserved
3
SETON HALL UNIVERSITY
School of Health and Medical Sciences
APPROVAL FOR SUCCESSFUL DEFENSE
Doctoral Candidate Christopher Rogers has successfully defended and
made required modifications to the text of the doctoral dissertation for the
PhD during the Spring Semester 2021
DISSERTATION COMMITTEE
(please sign and date beside your name)
Chair Michelle DrsquoAbundo (enter signature amp date) __________________________________ Committee Member Genevieve Pinto Zipp (enter signature amp date) __________________________________ Committee Member Felicia Hill-Briggs (enter signature amp date) __________________________________
Note The chair and any other committee members who wish to review
revisions will sign and date this document only when revisions have been
completed Please return this form to the Office of Graduate Studies where it
will be placed in the candidatersquos file and submit a copy with your final
dissertation to be bound as page number two
i
ACKNOWLEDGEMENTS
First I give honor to my Lord and Savior Jesus Christ Yeshua
Hamashiach the Son of the true and Living God Yahweh who has blessed
me with the knowledge strength and gifts that has enabled me to complete
the PhD degree
To my committee members Dr DrsquoAbundo Dr Zipp and Dr Hill-
Briggs thank you for your tutorage and guidance throughout this journey
To Dr DrsquoAbundo my Chair my passion for theoretically sound
qualitative research has grown exponentially under your leadership and
teaching Dr DrsquoAbundo encouraged me to think critically about my research
and meticulously guided me through the research process She was
responsive to my work responded to my emails in a timely manner meet with
me when necessary and did whatever she needed to do to ensure that I
continued to make progress Dr DrsquoAbundo I truly thank you and I appreciate
your guidance
To Dr Zipp you had a way of speaking clearly and directly to me to
make sure that I understood how to translate my research and my results in a
meaningful clear and yet impactful message to my audience Your
recommendations on how to provide clarity to my audience has been very
timely I truly thank you and I appreciate your guidance
ii
To Dr Hill-Briggs I thank you for teaching me your first-hand expertise
in behavior change and self-management of diabetes in lower socioeconomic
status groups Your thought-leadership expertise and grasp of the subject
matter was very apparent in your recommendations While at times your
recommendations may have been succinct when I applied your
recommendations to my research they were very extensive and exhaustive
It is clear to me how your recommendations and guidance provided greater
depth and insight into my research study I truly thank you and I appreciate
your guidance
I would like to thank Dr Terrence F Cahill former Chair of
Interprofessional Health Sciences and Health Administration and one of my
Committee Members prior to his retirement for his substantive contributions
early in the course of my dissertation research
I would also like to thank Dr Ning Zhang Associate Dean and
Professor for his guidance instruction and support in quantitative methods
for public health research
I am grateful for my mother Areh Howell for her continuous prayers
encouragement and support To my wife Latisha Rogers thank you for your
continuous prayers love encouragement and support And to my three
children Christian Anani and Christopher Jr thank you for your
understanding and patience with my PhD journey I hope that the fulfillment of
iii
the PhD degree will inspire you to achieve your dreams and God-given
abilities
iv
DEDICATION
I dedicate this dissertation to my mother Areh Howell my wife Latisha
Rogers and my three children Christian Anani and Christopher Jr
v
TABLE OF CONTENTS
ACKNOWLEDGEMENTShelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipi
DEDICATIONiv
LIST OF TABLESvi
LIST OF FIGURESvii
ABSTRACTviii
INTRODUCTION1
Problem Statement4
Purpose Statement6
Research Questions6
Overarching research questions7
Sub-questions7
Conceptual Framework7
Significance of the Study8
LITERATURE REVIEW11
Conceptual Orientation11
Donabedian Model of Care11
Structure14
Process14
Outcomes16
Epidemiology of Type 2 Diabetes in Older Adults19
vi
Social Determinants of Type 2 Diabetes20
Etiology of Type 2 Diabetes25
Insulin resistance26
Physiology of diagnosis of diabetes mellitus27
Treatment and Self-Management of Diabetes30
Pharmacological treatment30
Nonpharmacological treatment33
Self-management34
Self-management and the elderly39
Quality Improvement for Treatment and Management of Type 2
Diabetes42
Research on Individual Patient Preferences Needs Values and Goals
for Type 2 Diabetes Treatment and Management47
Why is Type 2 Diabetes Care for Older Adults Living in MUAs So
Complex51
Summary52
METHODOLOGY55
Aim of the Study55
Research Approach56
Participants and Sample58
Data Collection61
Study Procedures64
vii
Data Analysis66
Transcriptions66
Memo writing67
Initial coding67
Focused coding68
Sorting and diagramming themes68
Interpretation69
Consistency and Truth Value70
RESULTS73
Demographic Survey and Pre-Screening Results73
Demographics73
Health-related social needs76
Health status77
Interview Findings79
Types of health care providers80
Health care provider examinations81
Themes83
Care treatment and management83
Going to see different health care providers84
Thorough checkup85
The right diagnosis87
Listens and responds to problems and needs88
viii
Long-time doctor89
Taking the right medicine89
Accessible services for older adults91
Home health care92
Close health care services94
Spending time95
Information sharing and provider communication95
Information from online to help with diabetes self-care96
Information and recommendations to support diabetes
self-management97
Discussing things that interest the person99
Communication by telephone99
Attributes of health care providers101
Honest101
Trustworthy102
Smart102
Humorous102
Being there102
Smiles103
Caring103
Patient104
Social support104
ix
Family involvement in doctorrsquos appointments105
Financial assistance with diabetes care costs106
Community assistance with social services107
Family provides information for diabetes self-
management109
Older adultsrsquo diabetes self-management behavioral
strategies110
Monitoring blood sugar111
Taking diabetes medication regularly112
Managing comorbidities114
Exercising114
Healthy eating115
Regular doctor visits116
Diabetes education117
Prayer118
DISCUSSION IMPLICATIONS CONCLUSION120
Donabedian Model of Care as an Interpretation Framework120
Structure121
Accessible services for older adults122
Process127
Care treatment and management127
Information sharing and provider communication137
x
Attributes of health care providers145
Social support147
Older adultsrsquo diabetes self-management behavioral
strategies153
Limitations162
Implications for Care165
Future Research176
Conclusion178
REFERENCES180
APPENDICES233
Appendix A Pre-Screening Questionnaire233
Appendix B Site Permission Letter238
Appendix C Seton Hall IRB Approval240
Appendix D Recruitment Flyer242
Appendix E Demographic Survey244
Appendix F Interview Guide249
Appendix G Interview Protocol253
xi
LIST OF TABLES
Table 1 Clinical Attributes of Type 2 Diabetic Patientshelliphelliphelliphelliphelliphelliphelliphelliphellip25
Table 2 A1C Level and Average Blood Sugar Level Diabetes Diagnosis29
Table 3 Association Between Health Status and Recommended Glycemic
Goals in Older Adultshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip32
Table 4 Overview of the AADE7 Self-Care Behaviorshelliphelliphelliphelliphelliphelliphelliphelliphellip36
Table 5 Demographic Description of the Participantshelliphelliphelliphelliphelliphelliphelliphelliphellip75
Table 6 Health Care Providers Involved in Diabetes Treatment and
Management Carehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip80
Table 7 Health Care Provider Examinations Received by Older Adultshelliphellip82
Table 8 Theme 1 and Corresponding Subthemeshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip83
Table 9 Theme 2 and Corresponding Subthemeshelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip91
Table 10 Theme 3 and Corresponding Subthemeshelliphelliphelliphelliphelliphelliphelliphelliphelliphellip96
Table 11 Theme 4 and Corresponding Subthemeshelliphelliphelliphelliphelliphelliphelliphelliphelliphellip101
Table 12 Theme 5 and Corresponding Subthemeshelliphelliphelliphelliphelliphelliphelliphelliphelliphellip104
Table 13 Theme 6 and Corresponding Subthemeshelliphelliphelliphelliphelliphelliphelliphelliphelliphellip111
xii
LIST OF FIGURES
Figure 1 Conceptual Framework that Illustrates and Provides Examples of
the Donabedian Model of Care Domains Structure Process and
Outcomehelliphellip13
Figure 2 Identified Health-Related Social Needs of Participantshelliphelliphelliphelliphellip76
Figure 3 Participant Self-Reported Health Statushelliphelliphelliphelliphelliphelliphelliphelliphelliphellip77
Figure 4 Participant Diabetes Medication Usehelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip78
Figure 5 Conceptual Framework for Older Adults Living in MUAs
Preferences Desires and Values for Type 2 Diabetes Treatment and
Management Care Receivedhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip120
xiii
ABSTRACT
UNDERSTANDING OLDER ADULTS LIVING IN MEDICALLY
UNDERSERVED AREAS PERSPECTIVES REGARDING TYPE 2
DIABETES CARE RECEIVED
Christopher K Rogers
Seton Hall University
2021
Older adults with type 2 diabetes living in medically underserved areas
(MUAs) have unique health and social needs that must be taken into
consideration when supporting their type 2 diabetes treatment and
management care Effective treatment and management of type 2 diabetes
for older adults living in MUAs requires incorporating the preferences desires
needs values and goals of the person at the center of the care into hisher
care plan Shifting care to be conducive to the treatment and management
goals and plans co-created with older adults living in MUAs based on their
individual physical psychological social and spiritual preferences values
desires needs and goals requires health care systems to redesign and
restructure their services and roles to be more favorable to elderly adults
Utilizing a basic qualitative research study design semi-structured in-depth
xiv
interviews were conducted to understand the perspectives of older adults
living in MUAs regarding health care received in the treatment and
management of their type 2 diabetes Twelve older adults with type 2
diabetes living in MUAs recruited from senior housing facilities in two
designated MUAs participated in the study The constant comparative method
was used for qualitative data analysis NVivo 12 was used to organize the
emerging codes The Donabedian Model of Care was used as a conceptual
framework to guide this research study and provided a lens into which the
findings of the study were interpreted summarized and reported Six themes
emerged from the qualitative analysis care treatment and management
accessible services for older adults information sharing and provider
communication attributes of health care providers social support and older
adultsrsquo diabetes self-management behavioral strategies This study gave
older adults living in MUAs a voice that offered health care providers with a
better understanding of what is important to this vulnerable population in
treating and managing their type 2 diabetes This study provided a framework
for health care providers striving to deliver type 2 diabetes treatment and
management care to older adults living in MUAs that is holistic respectful and
individualized Incorporating the findings from this study into practice could
lead to greater empowerment and more effective treatment and management
care of type 2 diabetes for older adults living in MUAs
xv
Key Words type 2 diabetes older adults underserved person-centered care
patient-centered care qualitative research
1
Chapter I
INTRODUCTION
Chronic diseases are among the top causes of death in the United
States (US) (Centers for Disease Control and Prevention [CDC] 2019a)
Diabetes mellitus a major chronic disease is the seventh leading cause of
death globally and the eighth leading cause of death in high-income
countries (World Health Organization [WHO] 2018) More specifically
diabetes type 1 and type 2 combined is the seventh leading cause of death
in the US (CDC 2019a) and sixth leading cause of death for persons 65
years and over (Heron 2017)
Approximately 342 million people living in the United States (US)
have diabetes (CDC 2020) Of the 342 million adults with diabetes 115
million are adults aged 65 years and older with diagnosed diabetes and 29
million with undiagnosed diabetes (CDC 2020) This equates to more than
25 of the US population aged 65 and over as having diabetes (CDC 2020
Kirkman et al 2012a)
Approximately 90 of all diabetes occurrences worldwide are type 2
diabetes (WHO 2018) According to the King et al (1998) the majority of
people with diabetes in developed countries will be age 65 years and older by
2
2025 Among all US adult age groups the prevalence of type 2 diabetes is
the highest among adults aged 65 years and older (Bullard et al 2018)
However medically underserved older adults of lower socioeconomic status
suffer disproportionately from chronic disease health disparities namely type
2 diabetes (Carter et al 1996)
The characteristics of medically underserved areas (MUAs) are
associated with a disproportionate prevalence rate of type 2 diabetes (CDC
2018a) MUAs as designated by the Health Resources Services
Administration (HRSA) are disadvantaged populations disproportionately
affected by a shortage of primary care physicians high infant mortality high
poverty or a high elderly population (HRSA 2016) MUA designation involves
the application of a four-variable Index of Medical Underservice (IMU)
including percent of the population with incomes below poverty population-to-
primary care physician ratio infant mortality rate and percent elderly The
value of each of these variables for the service area is converted to a
weighted value according to established criteria (HRSA 2016) The four
values are summed to obtain the areas IMU score (HRSA 2016) The IMU
scale is from 0 to 100 where 0 represents completely underserved and 100
represents best served or least underserved (HRSA 2016) Each service
area found to have an IMU of 620 or less qualifies for designation as a
Medically Underserved Area (HRSA 2016)
3
Demographics and socioeconomic status for example age gender
raceethnicity educational attainment and income of MUAs are associated
with the global prevalence of type 2 diabetes (King et al 1998 WHO 2018)
Groups with the lowest levels of education and income experience the
greatest socioeconomic disparity in age-standardized prevalence of type 2
diabetes (CDC 2013) Studies show that adults living in MUAs attribute their
diabetes management problems to social factors such as lack of
transportation (Horowitz et al 2003) poor neighborhood characteristics
(Longnecker amp Daniels 2001 Wanko et al 2004) and food insecurity
(Seligman et al 2012)
Given the rise in the predicted probability of type 2 diabetes among the
worldrsquos elderly population and type 2 diabetes association to health
disparities poor health outcomes and lower quality of life for people living in
MUAs innovative interventions are needed to empower older adults with type
2 diabetes living in MUAs and their caregivers with instruction in self-
management and resources that will aid them in the day-to-day care of their
chronic disease
The primary goal of type 2 diabetes treatment and management in
older adults is to achieve a balance between targeted glucose levels and
blood pressure to prevent complications and comorbidities while avoiding
hypoglycemia (American Diabetes Association [ADA] 2021a) The starting
point for living well with type 2 diabetes and preventing further complications
4
is a rewarding interaction between the patient and the interdisciplinary care
team involved in treatment and management planning (ADA 2021a) This
treatment and management plan includes both pharmacological interventions
and nonpharmacological interventions such as self-management (Kaku
2010 Rodger 1991)
The American Diabetes Association (ADA) (2021a) recommends that
the treatment plan be created with the person based on their individual
physical psychological social and spiritual needs preferences values goals
and desired outcomes (ADA 2021a) Additionally the ADA (2021a)
recommends that the care management plan take into account the older
adultsrsquo type 2 diabetes self-management knowledge and skills caregiver
support socioeconomics health beliefs health knowledge cultural factors
and the presence or absence of coexisting chronic conditions An important
component to the collaborative treatment and management plan is for the
health care provider to foster a trusting relationship in which patients feel
valued trusted and psychologically safe (Tol et al 2015) Such a synergetic
relationship between the interdisciplinary health care team and patient that
takes into account the physical cognitive psychological and social aspects
of a person as well as his or her values beliefs goals desires and
preferences helps patients to (1) become active participants in their health
care (2) make smarter decisions regarding their health and (3) take control
of their own lives (Tol et al 2015)
5
Problem Statement
There is a shift in health care toward people with chronic conditions
receiving care that seeks to bring them to a state of wholeness in body mind
spirit and relationships (with other people and the environment) based entirely
on respecting their individual needs desires goals values and preferences
(Kogan et al 2016a) However because older adults with chronic conditions
who live in MUAs often face significant and unique health disparities that
complicate their treatment and management care plan (CDC 2018a ADA
2021a Philp et al 2017 Kirkman et al 2012a Northwood et al 2018)
health care could benefit from understanding this approach to care from the
perspectives of elderly persons living in these communities who have type 2
diabetes Holistic care that respects the unique needs goals desires values
and preferences of older adults with type 2 diabetes empowers and promotes
quality of life and self-management among this group of patients (Tol et al
2015)
Furthermore as described above previous research has highlighted
the importance of improving the health outcomes and quality of life of older
adults with type 2 diabetes through a collaborative treatment and
management care plan that is individualized and takes into consideration the
personrsquos needs preferences desires goals and values Similarly previous
research has described how the personrsquos role and perspectives are of
significant value in refining care processes and empowering them to
6
participate in their own care However there seems to be a lack of literature
on both of these approaches to care individualized for older adults with type 2
diabetes living in MUAs from their perspectives
In addition shifting care to be conducive to treatment and
management goals and plans co-created with type 2 diabetic older adults
living in MUAs based on their individual physical psychological social and
spiritual preferences values needs desires and goals requires health care
systems to redesign and restructure their services and roles to be more
propitious to this vulnerable group of elderly adults (Kogan et al 2016b)
There is a need for more research from the perspectives of older adults with
type 2 diabetes living in MUAs on the system- and provider-level
improvements that would facilitate individualized type 2 diabetes care
processes that increase patient empowerment for this population The
perspectives of what is important to older adults living in MUAs in treating and
managing their type 2 diabetes is essential to inform the design of care
delivery systems and processes that provides a foundation of support and
education for the elderly patient and motivates and empowers this vulnerable
population to become active decision-makers in their care
Purpose Statement
The purpose of this qualitative study is to understand older adults living
in medically underserved areas perspectives regarding health care received
in the treatment and management of their type 2 diabetes
7
Research Questions
Overarching research question What are the perspectives of older
adults living in medically underserved areas regarding health care received in
the treatment and management of their type 2 diabetes
Sub-questions
1 How do older adults living in medically underserved areas
experience the care they receive from their health care provider(s)
for treatment and management of their type 2 diabetes
2 What do older adults living in medically underserved areas prefer in
the care they receive for treatment and management of their type 2
diabetes
3 What do older adults living in medically underserved areas desire to
be incorporated into their treatment and management care in order
to improve their type 2 diabetes
4 What do older adults living in medically underserved areas value in
the care they receive for treatment and management of their type 2
diabetes
Conceptual Framework
The conceptual framework used to guide this qualitative research is
the Donabedian Model of Care (Donabedian 1980) This conceptual
framework was selected because it outlines the impact that structures
processes and outcomes have on treating and managing chronic diseases
8
with the aim to empower self-care and improve the quality of chronic disease
outcomes in older adults with type 2 diabetes living in MUAs
Therefore as applied to this research study Donabedianrsquos structure
process and outcome quality of care model was used to emphasize the value
each domain has on the perspectives of older adults living in MUAs regarding
health care received in the treatment and management of their type 2
diabetes These perspectives framed according to structures processes and
outcomes will provide unique information on the holistic (bio-psychosocial-
spiritual) treatment and management approach to delivering quality care that
is respectful and individualized allowing negotiation of care and offering
choice through a therapeutic relationship where older adults living in MUAs
are empowered to be involved in health decisions at whatever level is desired
by that individual who is receiving the care
Significance of the Study
As patient desires preferences needs goals and values increasingly
become drivers of individualized treatment plans and of patient engagement
and empowerment a clear understanding of the components of these
elements from the perspectives of the person at the center of the care could
facilitate the design of better type 2 diabetes disease treatment and
management systems and processes of care tailored towards older adults
living in MUAs This approach to care may result in improved patient
9
participation engagement empowerment and adherence leading to improved
health outcomes and health-related quality of life
When individualized type 2 diabetes care for older adults living in
MUAs is achieved health care professionals involved in diabetes treatment
and management care for older adults will ldquocenter consciousness and
intentionality on caring healing and wholeness rather than on disease
illness and pathologyrdquo (Watson 1988 p 179) This approach to care helps
health care professionals to ldquoacknowledge facilitate encourage and support
the person with diabetes in making informed decisions about their diabetes
self-managementrdquo (Australian Diabetes Educators Association 2015 p 4)
The value of understanding what is important in diabetes treatment
and management care from the perspective of older adults with type 2
diabetes living in MUAs may help providers deliver better holistic (bio-
psychosocial-spiritual) care that is respectful and individualized allowing
negotiation of care and offering choice through a therapeutic relationship
where older adults living in MUAs are empowered to be involved in health
decisions at whatever level is desired by that individual who is receiving the
care This approach to treatment and management care could empower and
promote health by supporting older adults with type 2 diabetes living in MUAs
in living a sustained quality of life over the course of their lifespan The
findings from this research will incorporate older adultsrsquo perspectives into
practice which could lead to greater empowerment and type 2 diabetes
10
treatment and management care that is more effective for older adults living
in MUAs
11
Chapter II
LITERATURE REVIEW
Conceptual Orientation
When defining the terms conceptual framework this research follows
and adapts the approach and usage of Jabareen (2009) as applied to
qualitative research Jabareen (2009) defined conceptual framework as a
ldquonetwork or ldquoa planerdquo of interlinked concepts that together provide a
comprehensive understanding of a phenomenon or phenomenardquo (p 51) A
conceptual framework is used to guide research and frame a study The
conceptual framework provides guidance in formulating the purpose of the
study the research questions and in qualitative research the interview guide
The conceptual framework also provides a lens into which the findings of the
study can be interpreted summarized and reported The Donabedian Model
of Care by Donabedian (1980) is a conceptual model that was used in this
study as a framework for examining the perspectives of older adults living in
MUAs regarding health care received in the treatment and management of
their type 2 diabetes
Donabedian Model of Care Avedis Donabedian a physician and
innovator of the study of quality in health care concluded that ldquoquality is a
property that medical care can have in varying degreesrdquo (p 3 1980) In other
12
words quality health care is a heterogeneous concept with multiple attributes
or characteristics that necessitates criteria and standards to judge its merit
(Donabedian 1980) Donabedian (1980) postulated that the attributes of
quality about medical care be assessed ldquoindirectly about the persons who
provide care and about the settings or systems within which care is providedrdquo
(p 3) As a result quality is defined and assessed based on ldquothe attributes of
these persons and settings and the attributes of the care itselfrdquo (Donabedian
1980 p 3)
Donabedian (1980) concluded that there is no singular definition that
captures the essence of ldquoquality medical carerdquo and that the differences in the
definition of quality ldquomay be almost anything anyone wishes it to be although
it is ordinarily a reflection of values and goals current in the medical care
system and in the larger society of which it is a partrdquo (2005 p 692)
Donabedian (1988) further explained that in defining quality ldquoseveral
formulations are both possible and legitimate depending on where we are
located in the system of care and on what nature and extent of our
responsibilities arerdquo (p 1743) Therefore instead of resting on a specific
definition of what ldquoquality medical carerdquo means Donabedian (1980) proposed
to begin with ldquothe simplest complete module of care the management by a
physician or any other primary practitioner of a clearly definable episode of
illness in a given patientrdquo (p 4) Donabedian (1980 1988) divided this
management into two domains the technical and the interpersonal which are
13
part of a larger group of coaxial concepts at which quality may be assessed
amenities of care contributions to care of the patient themselves as well as of
members of their families and care received by the community as a whole
The information from which inferences can be drawn about the quality of care
led to Donabedianrsquos (1980) groundbreaking model of care which proposes
using specific operational measures that express what quality is Donabedian
(1980) classified these more specific operational measures into three
domains structure process outcome (Figure 1)
Figure 1
Conceptual framework that illustrates and provides examples of the Donabedian Model of Care domains structure process and outcome
Note From ldquoThe definition of quality and approaches to its assessment Explorations in quality assessment and monitoring (Vol 1)rdquo by A Donabedian 1980 Ann Arbor MI Health Administration Press ldquoCriteria and standards for quality assessment and monitoringrdquo by A Donabedian 1986 Quality Review Bulletin 12(3) 99-108 (httpsdoiorg101016s0097-5990(16)30021-5) ldquoThe quality of care How can it be assessedrdquo by A Donabedian 1988 JAMA 260(12) 1743-1748 (httpsdoiorg101001jama260121743)
14
Structure Donabedian (1980) defines structures as the context or
attributes of the settings in which health care occurs These characteristics of
the providers of care are the fundamental components of an organization that
influence the kind of care that is provided (Donabedian 1980) The concept of
structure includes the human physical organizational financial and other
resources of the health care system and its environment (Donabedian 1980
1986) For example structures can include the organization of the medical
staff or nursing staff in a hospital the manner in which health care providers
conduct their work in individual or group practice quality improvement
strategies of a hospital or geographical accessibility of health care resources
available to a population of people within a defined territory (Donabedian
1980) Donabedian (1980) recommended that population characteristics such
as demographic social economic and location be taken into consideration
when designing structural features of health care Good structures frame the
manner in which quality of care is monitored and its findings are acted upon
(Donabedian 1980) Donabedian (1980) concluded that ldquogood structure that
is a sufficiency of resources and proper system design is probably the most
important means of protecting and promoting quality of carerdquo (p 82)
Process According to Donabedian (1980) ldquothe structural
characteristics of the settings in which care takes place have a propensity to
influence the process of care so that its quality is diminished or enhancedrdquo (p
84) That is care processes build upon the established structural components
15
of the organization The process domain depicts the elements of the care
delivery teamrsquos performance to maintain or improve the health of patients
Processes are defined by Donabedian (1980 1988) as actions done in giving
and receiving health care including those of patients families and health care
providers It includes patient engagement activities such as seeking care and
carrying it out and decision-making or expressing opinions about different
treatment methods as well as the practitionerrsquos activities in making a
diagnosis and recommending or implementing treatment (Donabedian 1980
1988) Donabedian (1980) distinguishes between the providerrsquos diagnostic
process and the therapeutic process The diagnostic process for example
includes the history that is taken the physical examination that is performed
and the laboratory tests that are ordered (Donabedian 1980) The therapeutic
process for example includes the performance of surgery the institution of
drug treatment supporting patientrsquos self-management respect for the
patientrsquos autonomy and use of enough time not rushing the patient
(Donabedian 1980) Donabedian describes a key component of the process
of health care as the management of the interpersonal relationship between
the provider and the patient (1982) Finally Donabedian (1980) emphasized
that the processes of care be ldquorelated to need and to sociodemographic and
residential characteristics of the clientsrdquo (p 95)
According to Donabedian (1980)
16
Elements of the process of care do not signify quality until their
relationship to desirable changes in health status has been
establishedhellipbut once it has been established that certain procedures
usedhellipare clearly associated with good results the mere presence or
absence of these procedures in these situations can be accepted as
evidence of good or bad quality (p 83)
Outcomes Outcome measures epitomize the impact of care and
sustainability of the organization Improving outcomes important to the
individual and society as a whole is the overarching goal of health care
(Donabedian 1980) Patient social demographic and residential differences
shape the current and future improvements in health care (Donabedian
1980) Outcomes are the current or future improvement effects on health
status quality of life knowledge behavior goals values and satisfaction of
patients and populations that can be attributed to antecedent health care
(Donabedian 1980 1986 1988) These include social and psychological
function in addition to physical and physiological aspects of performance
(Donabedian 1980) For example outcomes include preventable disease
morbidity mortality disability satisfaction with care restoration of physical
psychological and social function understanding of illness and the treatment
and management plan of care and adherence to the treatment and
management plan (Donabedian 1980)
In summary Donabedian (1980) states
17
The set of activitieshellipcalled the ldquoprocessrdquo of carehellipis the primary
object of assessment [however] the basis for the judgement of quality
is what is known about the relationship between the characteristics of
the medical care process and their consequences to the health and
welfare of individuals and of society according to the value placed
upon health and welfare by the individual and by society (p 79-80)
Jones and Meleis (1993) supported this view and the authors stated
that the evolution of the patientrsquos health through self-management can be
improved on increasing hisher empowerment Empowerment they say is
ldquoboth process and outcomerdquo (Jones amp Meleis 1993 p 8) Gibson (1991)
described empowerment as a ldquosocial process of recognizing promoting and
enhancing peoplersquos abilities to meet their own needs solve their own
problems and mobilize necessary resources to take control of their own livesrdquo
(p359) Gibson (1991) defined empowerment as simply ldquoa process of helping
people to assert control over the factors which affect their healthrdquo (p 358)
These processes that empower self-care and quality of life for people with
chronic disease as outlined by Donabedian in the 1980s and reemphasized in
the 1990s by Gibson (1991) and Jones and Meleis (1993) include (1) positive
interactions with onersquos health care team while receiving care (2) health care
professionals serving as a resource person and resource mobilizer who
facilitates access to both physiological psychological and social resources
that promote and support health and (3) coordination and communication
18
among various members of the health care team so that all involved are
working toward a common goal shaped by the patientrsquos values beliefs
fortitude and experience The outcome of the process of empowerment is
people experiencing improved health and well-being as described by
achieving the goals important to the individual (Jones amp Meleis 1993) which
is consistent with Donabedianrsquos outcome domain For example the outcome
of empowerment is employing the necessary knowledge and skills to self-
manage onersquos type 2 diabetes thus lowering onersquos risk for diabetes-related
complications such as hypertension
In conclusion each domain structure process and outcome is
influenced by the other and each is interdependent on the other (Donabedian
1988) The basis for judging quality health care are the goals and values
established by the individual The antecedent to this is the structural
capabilities for enhanced processes of care that make realization of good
health care possible According to Donabedian (1988) the triad approach to
health care quality improvement ldquois possible only because good structure
increases the likelihood of good process and good process increases the
likelihood of a good outcomerdquo (p 1745) Moore et alrsquos (2015) study showed
statistically significant correlations between the characteristics of the health
care setting (structure) and clinical processes performed in the health care
setting (process) and clinical processes performed in the health care setting
and the status of the patient following a given set of interventions (outcomes)
19
Donabedian (1980) underscored that the way patients view good care
is based on their needs and these patientrsquos perspectives are inseparable from
good structures processes and outcomes of health care Health care
treatment and management interventions directed at facilitating a connection
between structures processes and outcomes as well as research efforts to
understand the structures and processes of health care received in treating
and managing type 2 diabetes in older adults living in MUAs will shed further
light on models of care that respect the values needs goals and preferences
of this vulnerable population and that promote and empower self-
management
Epidemiology of Type 2 Diabetes in Older Adults
As the nationrsquos population of older adults continues to grow at a rapid
pace (United States Census Bureau 2017) the prevalence of type 2 diabetes
is expected to increase concurrently (Yakaryılmaz amp Oumlztuumlrk 2017) Among all
US adult age groups the prevalence of type 2 diabetes is the highest among
adults aged 65 years and older (Bullard et al 2018) In 2016 the overall
crude prevalence of diagnosed type 2 diabetes among US adults aged 65
years and older was 1962 (95 CI = 1854-2074 Bullard et al 2018)
With respect to the target population within New Jersey for this study in 2017
the crude rate of diagnosed diabetes among older adults aged 65 years and
older in Camden NJ was 266 (CI 174 383) and 259 (CI 173
368) in Bergen NJ (NJSHAD 2017) The number of cases of diagnosed
20
diabetes in those over 65 years of age is expected to increase 82 between
2005 and 2050 (Narayan et al 2006)
Those over age 65 years have higher rates of emergency department
visits for hypoglycemia a complication of type 2 diabetes compared to the
general adult population (Wang et al 2015) Older adults with diabetes have
higher rates of visual impairment (Leasher 2016) hearing impairment
(Bainbridge et al 2011) major lower extremity amputation (Li et al 2012)
and end-stage renal disease (Narres et al 2016) Death resulting from type 2
diabetes complications is significantly higher among the elderly (Kirkman et
al 2012b)
Social Determinants of Type 2 Diabetes
There are varying degrees of individual determinants that affect health
but research has established that social determinants of health (SDoH) also
known as health-related social needs (HRSNs) have a significant impact on
health namely type 2 diabetes SDoH stem from the unequal distribution of
power income goods and services across populations that impact onersquos
access to and equitable use of health care (Marmot et al 2008) SDoH
reflect the social factors and environmental conditions for example
education employment transportation leisure community neighborhood
housing shelter natural environment built environment social support or
social norms and attitudes that impact onersquos access to and equitable use of
health care (Marmot et al 2008)
21
There are a range of individual and population health factors that
influence type 2 diabetes risk treatment and management For type 2
diabetic patients social factors are key determinants in their ability to
successfully manage their condition and live a productive lifestyle
Demographics and socioeconomic status are associated with the global
prevalence of diabetes (King et al 1998 WHO 2018) Non-Hispanic Blacks
Hispanics and people of other or mixed race have higher age-standardized
prevalence of diabetes compared to Asians and White non-Hispanics (CDC
2013)
Groups with the lowest levels of education and income experience the
greatest socioeconomic disparity in age-standardized prevalence of diabetes
(CDC 2013) More specifically in 2014 the age-adjusted prevalence rates of
diagnosed diabetes among the general population of US adults with less
than a high school education was 129 compared to 67 for those with
greater than a high school education (CDC 2015b) In 2016 the prevalence
of type 2 diabetes in adults with less than a high school education rose to
1420 compared to 689 for adults with a high school diploma (Bullard et
al 2018) The age-standardized prevalence of diabetes among the general
population of US adults classified as poor (10 times the federal poverty
level) was 101 compared to 55 for those with high income (greater than
or equal to 40 times federal poverty level CDC 2013) Also people who
22
have diabetes have higher unemployment rates than non-diabetics (Robinson
et al 1989)
Physical environment factors such as transportation affect type 2
diabetes outcomes For example there is a link between limited or no
transportation access and successful follow-up care for diabetes
management (Wheeler et al 2007) Research has shown that the number of
visits made to the doctor is an independent predictor of glycemic control
(Zhang et al 2012) Diabetic adults who had a minimum of four visits in a
year to the doctors as per ADA recommendations had better glycemic
control compared to diabetic adults with no health care visits (Zhang et al
2012) This suggests that adequate transportation to the doctorrsquos is an
important factor in supporting ADA recommendations for glucose
management
Research has also demonstrated that there are racial and ethnic
disparities in diabetes care due to transportation issues (Kaplan et al 2013)
Further studies have also demonstrated an association between lack of
transportation and self-management of diabetes Musey et al (1995) showed
that 43 of low-income medically underserved African American patients with
diabetes hospitalized with a primary diagnosis of diabetic ketoacidosis
reported they stopped insulin therapy because of lack of money to purchase
insulin from the pharmacy and transportation barriers to the hospital These
findings are consistent with another study that showed adults living in MUAs
23
attribute their diabetes management problems to lack of transportation
(Horowitz et al 2003) Given the inequitable distribution of medical providers
in MUAs (Grumbach et al 1997) residents must travel far for care
(Rosenthal et al 2005) which presents barriers for individuals with limited or
no transportation
Additionally the built environment ndash the human places where people
live work worship play and more ndash has been a key factor impacting health
and health outcomes For example Dwyer-Lindgren et al (2017) showed that
differences in socioeconomic and racialethnic disparities amalgamated with
where a person lives affects health outcomes life expectancy at birth and
age-specific mortality risk Furthermore neighborhood characteristics of
MUAs such as no convenient accessible or nearby places to exercise or no
safe places to exercise are associated with an increased risk of developing
diabetes poor management of diabetes and adverse outcomes (Sigal
Kenny Wasserman amp Castaneda-Sceppa 2004 Wanko et al 2004)
Housing conditions a nexus between the built environment and health
disparities has been the focus of diabetes research Previous studies
demonstrated that unstable and poor housing is associated with the
increased risk of developing diabetes (Burton 2007) and the increased risk of
diabetes-related emergency department inpatient and outpatient visits
(Berkowitz et al 2018 Berkowitz et al 2015) Exposure to toxins lead paint
pest infestation and poor air quality in housing are associated with an
24
increased risk of developing diabetes poor management of diabetes and
adverse outcomes (Longnecker amp Daniels 2001 Remillard amp Bunce 2002
Bener et al 2001 Vasiliu et al 2006 Adamkiewicz et al 2014 Schootman
et al 2007)
In the literature a relationship between food insecurityndashno limited or
uncertain access to nutritionally adequate and safe foods at the household or
individual levels due to resource or other constraints (Bickel et al 2000
Wunderlich amp Norwood 2006)ndashand diabetes risk has been noted (Seligman amp
Schillinger 2010) Moderate and high levels of food insecurity among
racialethnic minorities individuals with less educational attainment and
individuals with low-income respectively are associated with higher odds of
type 2 diabetes (Seligman et al 2007) Horowitz et al (2004) showed that
access to healthy foods in MUAs severely prohibits diabetics from eating the
ADA recommended diet of foods low in fat and high in fibers
Recent research showed that a lack of money to buy healthy foods
lack of proper cooking facilitates not owning a stove and eating
microwavable foods are all barriers to optimal self-management in urban
adults with diabetes (Chan et al 2015) Seligman and colleagues (2012)
reported that type 2 diabetic adults living in MUAs who were food-insecure
had higher odds of poor glycemic control defined as a HbA1c ge85 (targeted
range for people with diabetes is usually less than 7) In a separate study
among low-income adults living in MUAs Seligman et al (2010) showed that
25
food insecurity is a barrier to diabetes self-management Other studies have
reported an association between food insecurity and low self-efficacy to
manage diabetes (Vijayaraghavan et al 2011 Lyles et al 2013) Pilkington
et al (2010) reported that out-of-pocket expenses for the management of
diabetes such as purchasing prescribed medication orthopedic shoes or
required mobility devices exacerbates food insecurity
Etiology of Type 2 Diabetes
Type 2 diabetes is attributable to clinical pathological and biochemical
defective changes of insulin secretion and insulin resistance (Rodger 1991)
There are pathogenetic processes and genetic defects of the pancreatic beta
cells that produces the onset of hyperglycaemia in patients with type 2
diabetes (Alberti amp Zimmet 1998) Table 1 provides clinical attributes for the
preponderance of type 2 diabetic patients
Table 1 Clinical Attributes of Type 2 Diabetic Patients
Age of onset Usually greater than 30 years
Body mass Obese
Plasma insulin Normal to high initially
Plasma glucagon High resistant to suppression
Plasma glucose Increased
Insulin sensitivity Reduced
Therapy Weight loss thiazolidinediones metformin sulfonylureas insulin
Note Clinical and chemical methods to diagnose type 2 diabetes From ldquoTextbook of medical physiology (11th ed)rdquo by A C Guyton amp J E Hall 2006 Philadelphia PA Elsevier Inc
26
In type 2 diabetes the plasma glucose concentrations breakdown
resulting in pathological defects to pancreatic islet beta cells that disable
insulin secretion and increase insulin resistance (Kaku 2010) Furthermore
physical and environmental factors such as obesity overeating lack of
exercise stress smoking alcohol drinking and aging exacerbates type 2
diabetes impaired insulin secretion and insulin resistance (Kaku 2010) The
combined effect of increases in visceral fat and decreases in muscle mass in
obese people gives rise to insulin resistance (Kaku 2010) Glucose
intolerance in obese people results from an increase in fat intake decrease in
starch intake increase in the consumption of simple sugars and decrease in
dietary fiber (Kaku 2010) Obese people have a 3- to 8-fold increase in the
risk of developing diabetes (Mokdad 2003)
Insulin resistance Prior to the onset of type 2 diabetes
hyperinsulinemia occurs which is an increase of plasma insulin concentration
in the blood (Guyton amp Hall 2006) In a counterbalance response there is
decreased sensitivity of pancreatic beta cells of the target tissues to the
metabolic effects of insulin a condition referred to as insulin resistance
(Guyton amp Hall 2006) The decrease in insulin sensitivity causes interference
of carbohydrate fat and protein metabolism raising blood glucose and
increasing insulin secretion (Guyton amp Hall 2006) Prolonged impaired insulin
secretion produces glucose toxicity and lipotoxicity (Kaku 2010) Left
27
untreated glucose toxicity and lipotoxicity decreases pancreatic beta cell
function affecting glucose regulation (Kaku 2010) As insulin resistance
develops and proliferates over a prolonged period of time moderate
hyperglycemia occurs after ingestion of carbohydrates giving rise to the early
stages of type 2 diabetes (Guyton amp Hall 2010) In the later stages of type 2
diabetes the body does not produce enough insulin to prevent severe
hyperglycemia because pancreatic islet cells become ldquoexhaustedrdquo and there
are prolonged defects in insulin secretion producing glucose insensitivity and
amino acid hypersensitivity of insulin release (Guyton amp Hall 2010 Ozougwu
et al 2013)
Physiology of diagnosis of diabetes mellitus Four main chemical
test of the urine and the blood are used to diagnose diabetes In contrast to a
normal person a person with diabetes will lose glucose in small to large
amounts given the stage of the disease and their intake of carbohydrates
(Guyton amp Hall 2006) As such a glucose in urine test can be used to
determine the amount of glucose in the urine to confirm diabetes (Guyton amp
Hall 2006)
As stated earlier ketoacidosis is a serious complication of diabetes In
early stages of diabetes small amounts of keto acids are produced (Guyton amp
Hall 2006) As prolonged and severe insulin resistance persist and the body
uses fat for energy excessive amounts of keto acids are produced giving rise
to diabetic ketoacidosis (Guyton amp Hall 2006) Keto acids can be detected
28
with a urine test (Guyton amp Hall 2006) Higher-than-normal keto acids in the
blood is a sign of out-of-control diabetes (Alberti amp Zimmet 1998)
Another method to diagnose diabetes is through fasting blood glucose
and insulin levels (Guyton amp Hall 2006) Evidence suggests that in a normal
person fasting blood glucose on awakening be between 70 and 100
mg100ml (Guyton amp Hall 2006) A fasting blood glucose above this level is a
sign of diabetes mellitus or at least pronounced insulin resistance (Guyton amp
Hall 2006)
Furthermore the glucose tolerance test is a medical test in which
glucose is ingested and a blood sample is drawn to measure blood glucose
levels (Guyton amp Hall 2006) When a fasting normal person ingest glucose
their glucose level rises from about 70 to 100 mg100 ml to 120 to 140
mg100 ml and falls back to normal range in 2 hours (Guyton amp Hall 2006) In
a person with diabetes upon ingestion of glucose their blood glucose level
will rise beyond the normal level of 140 mg100 ml to greater than 200
mg100 ml and fall back to below normal after 4-6 hours yet failing to fall
below the control level of 140 mg100 ml (Guyton amp Hall 2006 ADA 2016)
Finally the A1C test also known as the hemoglobin A1C HbA1C
glycated hemoglobin and glycosylated hemoglobin test is a blood test that
provides the average levels of blood glucose over the past three months
(ADA 2016) The A1C test is used to diagnosis type 2 diabetes or
29
prediabetes The A1C level percentage is the average blood glucose level in
milligrams per deciliter (mgdL) and millimoles per liter (mmolL ADA 2016)
Table 2 presents the associated A1C level average blood sugar level
and diabetes status An A1C level greater than 65 on two consecutive
occasions confirms diagnosis of diabetes (ADA 2016) A score above the
diagnostic threshold on two different tests (for example A1C and glucose
tolerance test) also confirms the disease (ADA 2016) In contrast if the
results of the two different tests conflict it is recommended that the test above
the diagnostic threshold be repeated (ADA 2016) For example glucose
tolerance test 140 mg100 ml and falls back to normal range within 25 hours
and A1C 57 repeat glucose tolerance test The recommendation is that the
test be repeated in 3-6 months (ADA 2016)
Table 2 A1C Level and Average Blood Sugar Level Diabetes Diagnosis
A1C Level Diagnosis Average Blood Sugar Level
Below 57 percent Normal Below 117 mgdL (65 mmolL)
57 percent to 64 percent
Prediabetes 117 mgdL (65 mmolL) to 137 mgdL (76 mmolL)
65 percent or above Diabetes 140 mgdL (78 mmolL) or above
From ldquoClassification and diagnosis of diabetesrdquo by American Diabetes Association 2016 (httpsdoiorg102337dc16-S005) ldquoeAGA1C conversion calculatorrdquo by American Diabetes Association nd (httpsprofessionaldiabetesorgdiaproglucose_calc)
30
Treatment and Self-Management of Diabetes
Pharmacological interventions and nonpharmacological interventions
such as self-management are the treatment approaches for type 2 diabetes
(Kaku 2010 Rodger 1991) The goal of both interventions is to prevent the
onset and progression of hyperglycemia dyslipidemia and cardiovascular
disorders such as hypertension (Rodger 1991 Kaku 2010) An essential
element in all pharmacological and nonpharmacological approaches that
guide type 2 diabetes clinical decisions and care is ensuring that treatment
and management recommendations reflect what is important to the person
and takes into consideration his or her physical mental emotional cultural
social and spiritual preferences needs and values (ADA 2021a)
Pharmacological treatment In persons with type 2 diabetes
pharmacological treatment focuses on drugs to increase insulin sensitivity or
to induce increased production of insulin by the pancreas (Guyton amp Hall
2006) The first goal of pharmacological treatment in persons with type 2
diabetes is to evaluate current medications known to stimulate hyperglycemia
(Rodger 1991) Medications that raise blood glucose level such as
epinephrine glucocorticoids thiazide diuretics salbutamol phenytoin niacin
and syrup additives should be avoided (Rodger 1991) In contrast evidence
suggest persons with type 2 diabetes be prescribed medicines that lower
blood glucose such as beta blockers salicylates ethyl alcohol and
phenylbutazone (Rodger 1991) Guidelines recommend prescribers look to
31
substitute medications that raise blood glucose for those that do not such as
replacing an angiotensin-converting-enzyme (ACE) inhibitor for thiazide
diuretic in persons with vascular complications in addition to type 2 diabetes
(Rodger 1991)
Clinical guidelines recommend that in persons with type 2 diabetes
dietary changes be the first approach to lower blood glucose levels (Rodger
1991) If blood glucose levels do not return to reasonable thresholds within 3
to 6 months pharmacotherapy in association with diet education and support
should be initiated (Rodger 1991)
In cases where pharmacotherapy is necessary to reduce
hyperglycemia in older adults with type 2 diabetes it is preferred that they are
prescribed medications with a low risk of hypoglycemia (ADA 2021b)
Avoidance of hypoglycemia in older adults is essential in order to prevent
cognitive decline (for example dementia) insulin deficiency requiring insulin
therapy and progressive renal insufficiency (ADA 2021b) Furthermore lipid-
lowering drugs and medicines that reduce the risk of cardiovascular events
and control blood pressure is warranted (Kirkman et al 2012)
Special care is required in prescribing older adults with diabetes
pharmacological therapy (ADA 2021b) Older adults are at an increased risk
for polypharmacy or the simultaneous use of multiple drugs to treat a single
ailment or condition (Parulekar amp Rogers 2018) Also pharmacological
therapy can complicate older adultsrsquo clinical cognitive and functional
32
heteromorphism (ADA 2021b) As such it is recommended that glycemic
goals in older adults be considered in light of their underlying chronic
conditions diabetes-related comorbidities physical or cognitive functioning
life expectancy and frailty (ADA 2021b Table 3)
Table 3 Association Between Health Status and Recommended Glycemic Goals in Older Adults
Health Status A1C Goal Fasting Glucose
Blood Pressure
Healthy (few chronic conditions good cognitive and physical function)
lt75 (58 mmolmol)
90-130 mgdL (50-72 mmolL)
lt14090 mmHg
Complications (multiple chronic conditions or 2 or more instrumental activities of daily living (ADL) impairments or mild-to-moderate cognitive impairment)
lt80 (64 mmolmol)
90-150 mgdL (50-83 mmolL)
lt14090 mmHg
Poor health (palliative care and end-of-life care moderate-to-severe cognitive impairment or 2 or more ADL dependencies
Avoid reliance on A1C
100-180 mgdL (56-100 mmolL)
lt15090 mmHg
From ldquoOlder adults Standards of medical care in diabetesmdash2021rdquo by American Diabetes Association 2021b (httpsdoiorg102337dc21-S012)
When medication is needed in older adults with type 2 diabetes
certain antihyperglycemic medication classes are preferred (ADA 2021b)
33
Before prescribing medication consideration of cost due to older adults
limited income is essential (ADA 2021b) It is also important to evaluate older
adultsrsquo ability to comply with supporting self-management regiments for
example blood glucose testing and insulin injection prior to prescribing a
certain antihyperglycemic medication since many of them struggle to main
adequate cognitive and physical functioning as they develop multiple medical
conditions (ADA 2021b) Once all factors have been considered the
following hypoglycemic agents for older adults are recommended metformin
thiazolidinediones insulin secretagogues incretin-based therapies sodium-
glucose contransporter 2 inhibitors and insulin therapy (ADA 2021b)
Metformin an orally administered drug used to treat high blood
glucose levels that are caused by type 2 diabetes is the principal agent for
older adults (ADA 2021b) Insulin therapy a cloudy or milky suspension of
insulin administered in the fat under the skin using a syringe insulin pen or
insulin pump is used in over 30 of the people with diabetes (CDC 2014) In
older adults clinical guidelines suggest that insulin therapy be used by
patients or caregivers that have good self-management ability and visual
motor and cognitive skills (ADA 2021b) Experts recommend that
pharmacological treatment be coupled with nonpharmacological treatment in
the form of education training and support (ADA 2021b Rodger 1991)
Nonpharmacological treatment Nonpharmacological treatment for
older adults emphasizes behavior change through diabetes self-management
34
educationtraining (DSMET) that leads to effective diabetes self-management
(American Association of Diabetes Educators [AADE] 2020 ADA 2021b) In
addition mathematical literacy (numeracy) and health literacy are important
for older adults achieving targeted blood sugar levels and improved health
outcomes (ADA 2021b Kirkman et al 2012a Cavanaugh 2011) With
respect to diabetes self-management a focus of this research the level of
diabetes self-management success for older patients or their caregivers is
dependent on having good visual physical and cognitive skills and the
presence or absence of coexisting chronic conditions (ADA 2021b) It is
important to make DSMET accommodations for older patients experiencing
impairments in visual motor and cognitive functioning (Kirkman et al 2012a)
Matching the diabetes treatment regimens with the self-management ability of
an older adult is essential (ADA 2021b) Individualized DSMET based on the
older adultrsquos medical cultural and social status may increase self-
management compliance (Kirkman et al 2012b) Continuous diabetes self-
management education and ongoing diabetes self-management support is
essential to experience the long-term benefits of nonpharmacological
treatment in older adults (ADA 2021b)
Self-management Self-management also called self-care has been
defined as ldquoactivities undertaken by individuals to promote health prevent
disease limit illness and restore health The critical component of this
definition is that [self-management] practices are lay initiated and reflect a
35
self-determined decision-making processrdquo (Stoller 1998 p 24) Self-
management has also been associated with patient behaviors patient
education and health promotion programs (Lorig amp Holman 2003) Effective
self-management behavior is a skill that is learned over the years through
experience (Majeed-Ariss et al 2013)
Self-management skills include problem solving decision making
resource utilization cultivating a patient-provider relationship action planning
and self-tailoring (Lorig amp Holman 2003) Self-management behaviors range
from recognizing and addressing symptoms information seeking utilizing
home medical supplies and equipment to manage diseases taking prescribed
and over-the-counter medications and implementing changes in activities (for
example eating healthier increasing physical activity or quitting smoking
Clark et al 1991 Dean 1986 Kart amp Engler 1994)
The American Association of Diabetes Educators (AADE 2020) has
defined 7 Self-Care Behaviors that provide a framework for person-centered
DSMET and care that affects clinical and health-related outcomes at the
individual and population levels The AADE7 Self-Care Behaviors (2020) are
as follows healthy coping healthy eating being active taking medication
monitoring reducing risk and problem solving (Table 4) These seven self-
care behaviors AADE (2020) suggests are essential processes of diabetes
management education and care to achieve desired health-related
outcomes and improved quality of life
36
Previous research has demonstrated positive associations between
each of the AADE7 Self-Care Behaviors respectively and clinical and health-
related outcomes For example through a two-arm randomized controlled trial
of low-income urban African Americans with type 2 diabetes and suboptimal
blood cholesterol blood pressure and blood sugar Hill-Briggs et al (2011)
demonstrated that a literacy-adapted intensive problem-solving based
diabetes self-management training was effective in improving clinical and
behavioral outcomes for intervention group participants In addition
medication adherence is associated with improved HbA1c control fewer
emergency department visits decreased hospitalizations lower out-of-pocket
medical costs increased physician trust and patientsrsquo feeling that their
physician listens and addresses their needs (Capoccia et al 2016 Polonsky
amp Henry 2016) Further previous research has highlighted how healthy
coping which Kent et al (2010) defined as ldquoresponding to a psychological
and physical challenge by recruiting available resources to increase the
probability of favorable outcomes in the futurerdquo is associated with better
quality of life decreases in diabetes-related distress better self-reported
health improved mental health and optimal glycemic control (Thorpe et al
2013 Kent et al 2010 Fisher et at 2007)
Table 4 Overview of the AADE7 Self-Care Behaviors
37
AADE7 Self-Care
Behaviors
Definition
Healthy Eating ldquoA pattern of eating a wide variety of high quality
nutritionally-dense foods in quantities that
promote optimal health and wellnessrdquo (AADE
2020 p 143) Nutrition and healthy eating
impacts blood glucose control Well-balanced
meals consist of non-starchy vegetables lean
meats fish and beans some low-fat dairy fruit
whole grains
Being Active ldquoBeing Active is inclusive of all types durations
and intensities of daily physical movement which
equates to bouts of aerobic or resistance
exercise training (structured or planned
ldquoexerciserdquo) as well as unstructured activitiesrdquo
(ADDE 2020 p 144) Examples include walking
swimming dancing or bike riding
Monitoring ldquoSelf-monitoring of blood glucose blood
pressure activity nutritional intake weight
medication feetskin mood sleep symptoms
like shortness of breath and other aspects of
self-carerdquo (AADE 2020 p 146)
Taking Medication ldquoFollowing the day-to-day prescribed treatment
with respect to timing dosage and frequency as
well as continuing treatment for the prescribed
durationrdquo (AADE 2020 p 144)
Problem Solving ldquoA learned behavior that includes generating a
set of potential strategies for problem resolution
selecting the most appropriate strategy applying
38
the strategy and evaluating the effectiveness of
the strategyrdquo (AADE 2020 p 148) Being
prepared for unexpected events that may disrupt
diabetes self-management or make it more
challenging
Healthy Coping ldquoA positive attitude toward diabetes and self-
management positive relationships with others
and quality of liferdquo which is ldquocritical for mastery of
the other six behaviorsrdquo (AADE 2020 p 141)
Examples include stress management avoiding
diabetes self-management burnout preventing
depression
Reducing Risks ldquoIdentifying risks and implementing behaviors to
minimize andor prevent complications or
adverse outcomes These include hypoglycemia
hyperglycemia diabetes-related ketoacidosis
hyperosmolar hyperglycemic state retinopathy
nephropathy neuropathy and cardiovascular
complicationsrdquo (AADE 2020 p 147)
From ldquoAn effective model of diabetes care and education Revising the AADE7 Self-Care Behaviorsrdquo by American Association of Diabetes Educators 2020 (httpsdoiorg1011770145721719894903) ldquoAADE 7 Self-
Care Behaviorsrdquo by Diabetes Association of Atlanta 2017 (httpdiabetesatlantaorgaade-7-self-care-behaviors)
Furthermore in order to be successful at self-management activities
individuals must be (1) knowledgeable about their disease and its treatment
to make informed decisions (2) perform the AADE7 Self-Care Behaviors
(2020) outlined above or in the case of elderly persons receive assistance
39
with activities and (3) apply skills necessary for maintaining adequate
psychosocial functioning (for example managing the feelings associated with
a deteriorating condition Clark et al 1991 ADA 2021b) Self-management
activities are undertaken with the guidance of a physician or other health care
professional (Clark et al 1991) The self-management of type 2 diabetes for
older adults is interdisciplinary including primary care physicians
endocrinologist nurses social workers psychologist dietitians podiatrist
and community health workers
Self-management and the elderly At the heart of self-management
practices for the elderly is taking into account the personrsquos values needs
preferences and goals (ADA 2018a) Self-management in old age involves a
variety of activities shaped by sociocultural and other social psychological
factors genetic physiological and biological characteristics (Stoller 1998)
Psychosocial aspects of self-management among the elderly necessitates
both intra- and interpersonal coping processes (Clark et al 1991) For
example the effects of social support can influence self-management
practices of older adults (Clark et al 1991)
Social support is a critical factor believed to mediate improved self-
management practices among the elderly (Clark et al 1991) Social support
has been conceptually categorized into four domains informational
(information provided advice suggestions) instrumental (the provision of
tangible aid or tangible goods and services) appraisal (communication of
40
information that gives a sense of social belonging) and emotional support
(the provision of empathy concern caring love trust or encouragement
Krause 1987 Weinert 1987 Valentiner et al 1994) Nicklett and Liang
(2010) demonstrated that older adults with increased social support increased
their likelihood of adherence to self-management regimens In a separate
study Wen et al (2004) examined the perceived level of all four domains of
social support on diabetes outcomes for older adults who lived with family
members and found that higher levels of perceived social support were
associated with higher levels of diabetes self-care management activities
(healthy eating and exercise)
Stoller (1993) found that elderly adults normalize their chronic disease
related symptoms by attributing them to the aging process As a result of this
normalization older people do not respond to their symptoms with self-
management behaviors (Stoller 1993) For example under half of
respondents studied by Stoller (1993) who experienced weakness dizziness
urination difficulties joint or muscle pain shortness of breath heart
palpitation or swelling indicated that their symptoms was not at all serious
and did not respond with self-care Thus elderly people do not necessarily
recognize and address their symptoms because they consider them outside a
disease framework (Stoller 1993 Stoller 1998)
Another factor that impacts older peoplersquos self-management behaviors
is that they frequently use medical terminology that does not always reflect
41
medicinersquos scientific guidelines (Stoller 1998) For example using
expressions such as ldquohigh bloodrdquo sugarrdquo ldquofallinrsquo outrdquo and ldquonervesrdquo to explain
complications is linguistically defined in terms of older adults lived
experiences (Stoller 1998) As a result provider self-care instructions often
result in contextual interpretations that lead to older patients
misunderstanding their physiciansrsquo directions and not self-managing their
disease (Stoller 1998)
Additionally Stoller (1998) reported that older adultsrsquo perceptions had
an impact on the symptom to self-management response relationship
Stollerrsquos (1993) research showed that older adults perceived their symptoms
on a scale from serious to benign and the degree to which they perceived
their symptoms affected their self-management response In a study by
Leventhal and Prohaska (1986) the authors reported that elderly adults who
associated their disease symptoms to aging were more likely to say they
would cope by (1) waiting and watching (2) accepting the symptoms (3)
denying or minimizing the threat or (4) postponing or avoiding medical
attention Finally Stoller (1993) concluded that the interpretation of symptoms
by older adults is influenced by situational factors Stoller (1993) explained
that variations in social settings social situations social stress and social
support impacts the degree to which older adults respond and address their
symptoms
42
In a meta-analysis by Norris et al (2002) the researchers found that
self-management interventions such as instruction in weight lossweight
management physical activity medication management and blood glucose
monitoring alone do not promote behavior changes that result in long-term
improvement in glycosylated hemoglobin Rather self-management is
dependent on multiple levels of influence for example applied behavior
interventions as well as social organizational community policy and
economic factors that work together to elicit behavior change and lifestyle
modification in individuals (Sallis amp Owen 2015 McLeroy et al 1988
Glasgow 1995)
Finally type 2 diabetes self-management abilities in older adults is
complicated because this population has higher rates of premature mortality
reduced functional status balance problems and muscle atrophy linked to
increased risk of falls and comorbidities such as coronary heart disease
stroke and hypertension (Kirkman et al 2012a) Additionally common
geriatric syndromes (for example polypharmacy cognitive impairment vision
and hearing impairment urinary incontinence injurious falls and persistent
pain) impact older adultsrsquo diabetes self-management abilities (Kirkman et al
2012a ADA 2021b) According to ADA (2021b) older adults should be
screened for these geriatric syndromes to ensure any ailments do not affect
diabetes self-management and quality of life
Quality Improvement for Treatment and Management of Type 2 Diabetes
43
The experiences and actions that impact health outcomes and health-
related quality of life of older adults with diabetes are affected by more than
just the disease process As stated above sustained quality of life and
lifespan proportional to healthy people is the goal of people with type 2
diabetes (Kaku 2010) In light of the rise in the predicted probability of
diabetes among the worldrsquos elderly population multilevel quality improvement
strategies targeting diabetes care coordination between health care systems
health care providers older adults and their caregivers could prove beneficial
(ADA 2021b Tricco et al 2012 Schmittdiel 2017) Care coordination should
aim to improve the efficiency of diabetes care for older adults and control for
geriatric syndromes (such as polypharmacy cognitive impairment vision and
hearing impairment urinary incontinence injurious falls and persistent pain)
that reduce older adults basic and instrumental activities of daily living that
may affect diabetes self-management and quality of life (ADA 2021b Tricco
et al 2012 Schmittdiel 2017) These are important goals that will aid this
population with day-to-day care of their chronic disease (ADA 2021b Tricco
et al 2012 Schmittdiel 2017)
At the center of health carersquos quest to improve diabetes care for
vulnerable older adults are quality improvement strategies designed to
mobilize individuals directly involved in the care process to examine and
improve the process with the goal of achieving a better outcome (Hayward et
al 2004) For example health care providers treatment and management
44
actionsinterventions aimed at facilitating improvements in patient health
status satisfaction or health behaviors This can be achieved primarily
through an individually care plan based on the personrsquos needs preferences
values and goals that involves pharmacological interventions and
nonpharmacological interventions such as self-management (Kaku 2010
Rodger 1991 ADA 2018a)
Evidence suggested that those directly involved in the care process
should construct an individualized tailored care plan that meets the individual
needs preferences values and goals of older adults and their caregivers
(ADA 2018a) Moreover quality improvement strategies targeted towards
ldquoredefining the roles of the health care delivery team and empowering patient
self-management are fundamental to the successful implementation of
[chronic care delivery models]rdquo that support pharmacological and
nonpharmacological interventions in older adults (ADA 2018a p S8) Holistic
system-level strategies that respect the values needs preferences and
goals of older adults living in MUAs with type 2 diabetes and that coordinate
quality physiological psychological and social care across provider and
practice settings are recommended to empower self-management and
improve health outcomes of older adults with type 2 diabetes (ADA 2018a)
Care delivery systems are situated in a unique position to optimize the
care of older adults with chronic diseases by implementing multilevel
interventions beyond disease-reduction that affect health outcomes and
45
quality of life for persons with type 2 diabetes (Hansen et al 2018) System-
level improvements requires centralized focused attention on improving the
quality of diabetes care through an individualized collaborative treatment and
management plan between the interdisciplinary health care team and the
older adult based on the personrsquos individual physical psychological social
and spiritual needs preferences values and goals (Wagner et al 2001
ADA 2018a) This approach to improving the quality of care for older people
with diabetes requires collaborative interdisciplinary health care teams (ADA
2018a) that
bull Provides care that is in accordance with evidence-based diabetes
guidelines (Fleming et al 2001)
bull Supports their patientrsquos performance with self-management tasks
(OrsquoConnor et al 2011)
bull Redesigns care processes of their delivery system to meet the
health status culture values and social context of the patient so as
to allow him or her to play an active role in their care plan (Feifer et
al 2007 Powers et al 2016)
bull Assess and address psychosocial emotional and socioeconomic
factors (Powers et al 2016)
bull Links patients to community resources to address their needs
(Tung amp Peek 2015)
46
Additionally in increasing the quality of diabetes care ADA (2021b)
recommends the care plans and goals take into account the older adults
bull living situation as it may affect diabetes management and support
bull type 2 diabetes self-management knowledge and skills
bull caregiver support
bull health beliefs
bull health knowledge and
bull the presence or absence of coexisting chronic conditions
For older adults with chronic conditions an active role with their health
care provider in deciding about and planning their care especially designed
to address the multilevel context of patient care could prove beneficial in
strengthening their (or their caregivers) type 2 diabetes self-management
practices From identifying older adults whose living situation and social
support networks (for example adult children caretakers) negatively affects
diabetes management and support to elderly patients who feel disrespected
after a care encounter and walk away less likely to comply with treatment
recommendations or older adults who need more community support to
overcome the barriers keeping them from managing their type 2 diabetes an
understanding of the multilevel processes that influence older adults type 2
diabetes outcomes will help providers deliver better quality health care that
facilitates shared decision-making and supports this vulnerable population in
maintaining self-management behaviors over the course of their life
47
Research on Individual Patient Preferences Needs Values and Goals
for Type 2 Diabetes Treatment and Management
The following section outlines previous research on type 2 diabetes
treatment and management goals and plans based on individual patient
preferences needs values and goals
Beverly et al (2014) conducted focus groups with adults 60 years of
age and older diagnosed with type 2 diabetes to explore their personal values
and preferences for diabetes care Two themes emerged representing older
adultsrsquo values and preferences for diabetes care 1) importance of an effective
physician-patient treatment relationship and 2) prioritizing quality of life in
diabetes care (Beverly et al 2014) With respect to effective physician-
patient treatment relationship participants valued a strong working
relationship with their diabetes physician a relationship in which they could
trust their physicianrsquos treatment decisions Relatedly ldquoolder adultsrsquo valued
physicians who encouraged them to be involved in their own care and
listened to their [diabetes] concernsrdquo (Beverly et al 2014 p 46) Older adults
expressed the following preferences to facilitate an effective physician-patient
treatment relationship a physician who knew them as a person an honest
physician a physician who understood their diabetes in the context of their
overall health seeing a diabetes specialist attending a clean organized
physician office and attending a physician office that is conveniently located
within their geographic proximity Furthermore older adults expressed the
48
following specific preferences for quality of life in diabetes care the ability to
choose the type and intensity of their diabetes treatment and shared
decision-making with their physician regarding end-of-life care
Lopez et al (2016) conducted a mixed-methods qualitative and
quantitative research study involving adult members aged 18 years and older
with self-reported type 2 diabetes residing in the United States who
participated in PatientsLikeMereg an online research network of patients The
study aimed to quantify and assess the utilization of various types of diabetes
management programs among a real-world sample of patients with type 2
diabetes in order to elucidate patient preferences for diabetes management
and support (Lopez et al 2016) Most respondents had goals of improving
diet (77) weight loss (71) and achieving stable blood glucose levels
(71) The most preferred type of support was dietweight-loss support
(62) Doctors or nurses (61) and dietitians (55) were the most preferred
sources of diabetes support
Mazurenko et al (2015) conducted a ldquoqualitative study examin[ing]
diabetic patientsrsquo experiences at one PCMH [patient-centered medical home]
setting using in-depth interviews to understand patientsrsquo perspectives of the
shared power and responsibility between patient and provider in their
diabetes carerdquo (p 61) The sample included type 2 diabetic adults 25 to 89
years of age of varying genders and racialethnic backgrounds who lived in a
Southwestern state of the United States The researchers sought to
49
understand ldquohow do patients characterize the type of relationship they would
like to have with their physicianrdquo (Mazurenko et al 2015 p 63) Results
showed that patients would like their physician to make them feel
comfortablewelcomed cared for and listened to Patients also described that
ideally they would like their physician to take extra time to talk to them
specifically about non-medical topics other than health issues
Morrow et al (2008) conducted qualitative in-depth interviews with
adults over 55 years in age with diabetes and other morbid conditions andor
their caregivers when appropriate to ldquoinvestigate the life and health goals of
older adults with diabetes and examine the relationship if any between those
goals and diabetes self-managementrdquo (p 2) The researchers sought to
distinguish between participants life goals vs health goals ldquoHealth goals
were initially thought of as pertaining to improving treating or remaining
absent of illness while life goals encompassed all areas of a subjectsrsquo life they
deemed importantrdquo (Morrow et al 2008 p 420) Older adults expressed the
following life goals longevity improve or maintain physical functioning
spending time with family and maintaining independence Furthermore
participants described achieving their life goals in relation to diabetes self-
management goals citing changes in lifestyle behaviors such as diet
exercise and weight controlling sugar intake and avoiding diabetes related
complications Additionally older participants expressed the following goals
pertaining to improving diabetes self-management health care providersrsquo
50
responsiveness to their needs and ancillary resources both within and
outside of the health care system to assist with changing their lifestyle
behaviors and medication adherence such as pharmacist reading books
family and peers
Pooley et al (2001) conducted a qualitative study using in-depth
interviews with adults aged 50 years and older with type 2 diabetes ldquoto
explore the issues that they perceive as central to effective management of
diabetes primarily within a primary care settingrdquo (p 318) Patients expressed
a need to have sufficient time during consultations to ask questions receive
information and agree on a treatment and self-management plan in
accordance with their wishes Patients also expressed a preference for
continuity of care by having most of their diabetes care delivered through one
designated individual for example diabetes specialist nurse Furthermore
patients stated the importance of their practitioner creating an environment in
which they feel comfortable with raising their concerns and asking questions
Patients emphasized that they had good awareness of how their diabetes
affected them and how it should be managed Participants preferred an
environment in which they felt their views were listened to and taken
seriously that their provider is readily accessible when they needed advice
and that they valued two-way communication that is authentic Lastly patients
stressed a desire to have care tailored towards their individual needs because
51
ldquono two patients have exactly the same set of experiences or respond to
treatment in the same wayrdquo (Pooley et al 2001 p 323)
Why is Type 2 Diabetes Care for Older Adults Living in MUAs So
Complex
Older adults with type 2 diabetes living in MUAs have complex health
needs that make their treatment and management care more challenging and
complicated These challenges include
bull Lack of care planning that incorporates the preferences values
needs and goals of older adults and their families (ADA 2021b
Kirkman et al 2012a)
bull Side effects and adverse drug interactions from multiple
medications (ie polypharmacy ADA 2021b Kirkman et al
2012a)
bull Poor coordination between multiple care providers (Philp et al
2017)
bull Communication barriers including hearing language and
communication style (Kirkman et al 2012a)
bull Comorbidities and normalization of chronic disease related
symptoms (Kirkman et al 2021a)
bull Life expectancy in light of age gender raceethnicity and
underlying comorbidities and functional status (ADA 2021a
Kirkman et al 2012a)
52
One must also consider older adults living in MUAs social and
emotional experiences These include
bull social support system social isolation and loneliness (Hackett et
al 2020 Kirkman et al 2012a)
bull decreased mobility (ADA 2021b Northwood et al 2018 Kirkman
et al 2012a)
bull loss of independence (ADA 2021b) and
bull change in resources including food insecurity transportation needs
housing instability and financial insecurity (Northwood et al 2018)
Older adults specifically those with type 2 diabetes have unique
health and social needs that must be taken into consideration when
redesigning care processes There are no simple solutions for addressing the
fragmented systems of care that fail to account for the multilevel factors that
impact complications and premature death of type 2 diabetes among elderly
individuals Efforts to improve the health outcomes and quality of life for older
adults with type 2 diabetes will require tailored interventions that address an
individualrsquos social and physical environments the health care he or she
receives and the associated systems he or she accesses and individual-level
factors such as health behaviors
Summary
Where there is a negative interplay between treatment and
management goals and plans patientrsquos age cognitive abilities health beliefs
53
support systems social situation cultural factors comorbidities and
individual needs preferences values and goals these combine to deny the
person with diabetes a sense of personhood (ADA 2018a Clissett et al
2013) The demoralizing sense of personhood results from ldquocare practices
such as infantilization intimidation stigmatization and objectification which
create the lsquomalignant social psychologyrsquo where the individual is
depersonalized invalidated and treated as an objectrdquo (Clissett et al 2013 p
1496) When the person with diabetes is not respected and their personhood
(ie their physical psychological social and spiritual needs preferences
values and goals) is not included in their care treatment and management
plan they are less likely to exhibit self-care behaviors (Inzucchi et al 2012
Williams et al 2016)
Effective treatment and management of type 2 diabetes is a
partnership between the ldquopatientrdquo and health care provider Effective
treatment and management of type 2 diabetes requires incorporating the
preferences needs values and goals of the person at the center of the care
into hisher care plan These preferences needs values and goals are
physical psychological and social and it is critical for health care providers to
understand these factors when making treatment and management decisions
Improving providerrsquos awareness of how older adults living in MUAs define
their preferences needs values and goals in terms of health care received is
a crucial step in helping to design care delivery systems that individualize
54
multilevel interventions beyond disease-reduction to empower self-
management and optimize health outcomes and quality of life
55
Chapter III
METHODOLOGY
Aim of the Study
The provider-patient relationship remains at the heart of the patient
experience and diversity of perspective in the delivery of health care is what
may optimize patient outcomes Patientsrsquo perspectives of the health care
delivery system appear to contribute to their engagement in the care process
and ultimately the patient feeling empowered to participate in their own care
through self-management As patient preferences needs goals and values
increasingly become drivers of individualized treatment plans and of patient
engagement a clear understanding of the components of these elements
from the perspectives of the person at the center of the care could facilitate
the design of better type 2 diabetes disease treatment and management
systems and processes of care tailored towards older adults living in MUAs
This may result in improved patient participation engagement and
adherence leading to improved health outcomes and health-related quality of
life The purpose of this study is to understand older adults living in medically
underserved areas perspectives regarding health care received in the
treatment and management of their type 2 diabetes This study seeks
ultimately to incorporate the perspectives of older adults living in MUAs into
56
practice which could lead to greater patient empowerment and more effective
treatment and management of type 2 diabetes for this vulnerable population
Research Approach
A basic qualitative research study design was used to understand the
perspectives of older adults living in MUAs regarding health care received in
the treatment and management of their type 2 diabetes ldquoQualitative
Research is an umbrella concept covering several forms of inquiry that help
us understand and explain the meaning of social phenomena with as little
disruption of the natural setting as possiblerdquo (Merriam 1998 p5) In other
words qualitative research places the researcher a part of the participantsrsquo
process as the researcher collects and interprets data about the participantsrsquo
experiences in order to determine what is meaningful (Merriam 2009
Creswell 2013 Patton 2015 Charmaz 2008)
Qualitative research is used when a problem or issue needs to be
explored (Creswell 2013) This is needed to study a group of people to study
how things work to capture stories to understand peoplersquos perspectives and
experiences or to further explain how systems function and their
consequences (ie the events that occur as a result of the concept) for
peoplersquos lives (Creswell 2013 Patton 2015)
Basic qualitative research as a design is used when one of the five
traditional approaches (ie narrative research phenomenology grounded
theory ethnography or case study) to inquiry are not appropriate (Merriam
57
2009) The tradition most closely related to this study is grounded theory
because it is an interpretative approach aimed at describing and
understanding the social phenomena understudy (Charmaz 2008) However
grounded theory is typically used by sociologists as a general inductive
approach (Charmaz 2008) to build theory rather than health sciences
although grounded theory has been used more frequently in the field of
nursing research (Schreiber amp Stern 2001)
Furthermore the emphasis of the study will determine which
methodology is used (Cooper amp Endacott 2007) When the emphasis of the
study does not fit the distinguishing features of a specific qualitative tradition
a basic qualitative approach is selected (Cooper amp Endacott 2007) In the
case of this study while grounded theory design most closely aligns the
emphasis is not to build a theory (grounded theory) rather to explore the
older adultsrsquo perspectives regarding health care received in the treatment and
management of their type 2 diabetes Therefore instead of focusing this
study through the optics of one specific qualitative tradition the researcher
applied credibility strategies (Caelli et al 2003) to focus on understanding
older adultsrsquo experiences with health care received in the treatment and
management of their type 2 diabetes Hence a basic qualitative design fits
this studyrsquos purpose
Using a basic qualitative approach the researcher conducted semi-
structured in-depth interviews to understand the perspectives of older adults
58
living in MUAs regarding health care received in the treatment and
management of their type 2 diabetes The researcher used a semi-structured
in-depth interview guide with predetermined sequenced and logical
questions (Durdella 2018 Jamshed 2014 Morris 2015) to ask each
participant about their experiences preferences desires and values
regarding health care received in the treatment and management of their type
2 diabetes Questions were guided by the conceptual frame the Donabedian
Model of Care (1980) and aimed to understand the value each domain has
on the perspectives of older adults living in MUAs regarding health care
received in the treatment and management of their type 2 diabetes including
patient experiences and outcomes Probes were provided to ensure a
thorough understanding of the participantsrsquo perspectives (Durdella 2018
Guest et al 2013) Finally the researcher analyzed data using Donabedianrsquos
(1980) structure process and outcome quality of care conceptual frame
(Gale et al 2013)
Participants and Sample
This qualitative research study used the purposeful sampling strategy
Specifically a criterion sampling approach was used to identify a
homogeneous sample of individuals who met the specific criteria and had
experienced the phenomenon under study (Patton 2015 Creswell 2013)
This sampling approach produced a group of participants that provided
information-rich insights that contributed to the understanding of the
59
phenomenon (Creswell 2013) Participants enrolled in the study were older
adults 65 years of age or older diagnosed with type 2 diabetes English-
speaking did not have an identified cognitive diagnosis living in a MUA
experiencing one or more HRSNs and at least one visit in the past 12 months
to a doctor nurse or other health professional for type 2 diabetes Each
participant was screened using a pre-screening questionnaire (Appendix A) to
identify older adults living in MUAs with type 2 diabetes meeting the inclusion
criteria and experiencing the phenomenon under study Participants meeting
the inclusion criteria were invited to take part in a one-on-one in-person
interview Non-purposive snowball sampling was used to ask participants to
identify new people they know that met the inclusion criteria (Patton 2015)
Recruitment took place at four senior housing facilities in Camden
New Jersey and Garfield New Jersey two senior housing centers from each
area respectively Both Camden NJ and Garfield NJ are designated MUAs
according to HRSA (2016) The purpose of using geographical disparate sites
was to achieve what Shenton (2004) called ldquosite triangulationrdquo Site
triangulation is recruiting participants from several organizations ldquoso as to
reduce the effect on the study of particular local factors peculiar to one
institutionrdquo (Shenton 2004 p 66) In citing Dervinrsquos (1983) concept of ldquocircling
realityrdquo when explaining the purpose of site triangulation Shenton (2004)
suggested that the goal of site triangulation is to increase the diversity in
perspectives because this provides ldquoa better more stable view of lsquorealityrsquo
60
based on a wide spectrum of observations from a wide base of points in time-
spacerdquo (p 66) The Principal Investigator (PI) submitted a formal request to
each senior housing facility explaining the research study and asking
permission to recruit senior residents and conduct on-site one-on-one
interviews at a time and space agreed upon by the PI and the facility Senior
housing facilities agreeing to participate in the research study were asked to
sign a site permission letter (Appendix B)
Following IRB approval (Appendix C) the PI posted recruitment flyers
(Appendix D) throughout each senior housing facility that explained the
purpose of the study highlighted inclusion criteria and asked for participation
The recruitment flyer included the dates and times the PI would be on-site to
conduct in-person recruitment and administer the pre-screening
questionnaire At the time of recruitment the PI was on-site to discuss the
study with residents and for the residents to complete the pre-screening
questionnaire sign study consent and schedule one-on-one interviews
This research study required approximately 15 participants who met
the inclusion and exclusion criteria Instead of using g-power to calculate
sample size as with quantitative studies because this is a qualitative study
this research followed qualitative precedent and used saturation as the
criterion for determining sample size Glaser and Strauss (1967) define
saturation as ldquothe criterion for judging when to stop sampling the different
groups pertinent to a categoryhellipSaturation means that no additional data are
61
being found whereby the [researcher] can develop properties of the categoryrdquo
(p 61)
Additionally guidelines for the number of research participants to
recruit for qualitative research have been suggested in the literature Guest et
al (2006) suggested that saturation will be achieved within the first 12
participants interviewed While Patton (2015) does not give a specific sample
size for qualitative designs he cited several studies that conducted in-depth
interviews with sample sizes ranging from 1-10 Finally Crabtree and Miller
(1992) recommended sample sizes of 6-8 for homogeneous groups and 12-
20 for maximum variations As such since this qualitative study used
homogeneous groups to conduct in-depth one-on-one interviews as the data
collection method the sample size was approximately 15 older adults
meeting the inclusion criteria
Data Collection
The PI used ldquoa series of interrelated activities aimed at gathering good
information to answerhellipresearch questionsrdquo (Creswell 2013 p 146) Data
collection occurred in three steps First a paper-based pre-screening
questionnaire (Appendix A) was administered by the PI on-site at the senior
housing facilities The pre-screening questionnaire was developed using
questions from the CDCrsquos (2019) Behavioral Risk Factor Surveillance System
Survey (BRFSS) and the Centers for Medicare and Medicaid Servicesrsquo (nd)
Accountable Health Communities (AHC) Health-Related Social Needs
62
(HRSNs) Screening Tool The BRFSS is a national survey conducted since
1984 to measure adultrsquos health-related risk behaviors chronic health
conditions and use of preventive services (CDC 2019b) The AHC HRSNs
Screening Tool is designed to screen patients for social determinants of
health such as unmet housing and food needs (Billioux et al 2017)
The pre-screening tool had two sections that must be completed by
each participant to determine if they would be included in the study
background and HRSNs The background section asked for age type 2
diabetes status geographical location language spoken cognitive status
and health care access The second section asked if the participant was
experiencing one or more HRSNs in six (6) different domains housing
instability food insecurity transportation difficulties utility assistance needs
financial strain and lack of family and community support
An eleven-item paper-based researcher-administered demographic
survey (Appendix E) was provided to all participants at the start of the one-on-
one interviews The demographic survey was developed with questions from
the CDCrsquos 2019 BRFSS the CDCrsquos Health-Related Quality of Life Measures
survey (2018b) the CDCrsquos National Health and Nutrition Examination Survey
(2012) the National Comorbidity Survey (Kessler 2012) and the Western
Europe Survey (Pew Research Center 2017a) Demographics was used in
the Results section to describe the sample of participants interviewed The
demographic survey asked the participantrsquos gender raceethnicity education
63
attainment marital status spirituality quality of life years diagnosed with type
2 diabetes A1C level comorbidities prescribed oral hypoglycemic
medications and prescribed insulin injections
The primary method of data collection was one-on-one in-depth
interviews Older adultsrsquo perspectives regarding health care received in the
treatment and management of their type 2 diabetes draws out the
participantrsquos internal state hisher thoughts feelings and experiences about
the structure functioning and processes of the health care system regarding
their personal health care This made individual interviews best suited for this
study because interviews are most appropriate ldquowhen people tell stories they
select details of their experience from their stream of consciousnessrdquo to give
access and make understandable complex issues through their experiences
upon which the phenomenon is built (Seidman 2013 p 7) Given that health
care received is an individualized holistic approach to care that incorporates
various dimensions of a personrsquos well-being including their individual
expressions beliefs and preferences it is important to conduct individual
interviews to elicit detailed information about each older adultrsquos perspectives
on the structure functioning and processes of the health care they received
antecedent to improvements in health status quality of life and patient
satisfaction
All one-on-one interviews were conducted in-person to maintain
consistency between interviews A $15 gift card was provided to all
64
participants interviewed Interviews were recorded using a digital voice
recorder and transcribed verbatim Interviews took approximately 60 minutes
for each participant and utilized a semi-structured approach The in-depth
interviews utilized a semi-structured interview guide The interview guide
(Appendix F) questions were predetermined sequenced and logical allowing
for consistency over the concepts covered in the interview (Durdella 2018
Krueger amp Casey 2009 Corbin amp Strauss 2015) Questions were guided by
the conceptual frame the Donabedian Model of Care (1980) The interview
guide moved from general questions to focused questions (Durdella 2018
Krueger amp Casey 2009) The same questions were asked in each interview
(Corbin amp Strauss 2015) Participants were free to add anything to the
interview that they felt was relevant to the discussion (Corbin amp Strauss
2015)
Study Procedures
Subsequent to receiving IRB approval from Seton Hall University the
PI spoke to a designee from each senior housing facility to identify times
events and spaces to recruit participants and conduct the one-on-one
interviews Afterward the PI posted recruitment flyers throughout each of the
housing facilities and set-up a table in the residential hall to discuss the study
with potential participants and for participants to complete the pre-screening
survey and sign study consent If the participant met the inclusion criteria he
or she was scheduled for the in-person one-on-one interview After the
65
participant agreed to take part in the interview the PI assigned the individual
a participant number to maintain confidentiality The participant number was
used throughout the studyrsquos interview analysis and results phases to identify
the participants Participants were also given an option at the start of the
interview to be identified by a pseudonym instead of a participant number to
preserve anonymity The pseudonym was linked to the appropriate participant
number to ensure consistency and accuracy Additionally each senior
housing facility was assigned a site number to maintain confidentiality and to
identify participantsrsquo site location throughout the studyrsquos interview analysis
and results phases
The PI requested of the housing facilities that the space to conduct the
one-on-one interviews be private in order to maintain the privacy and
confidentiality of the participants and quite in order to reduce noise and
distractions On the day of the interview the PI began the conversation with
verbally confirming the participantrsquos identity with the assigned participant
number Next the participant signed the interview letter of consent Once the
letter of consent was signed the participant completed the researcher-
administered demographic survey The PI used the interview protocol
(Appendix G) to start the interview The PI asked the participant for verbal
permission to record the interview and if he or she consented the interview
began with the PI stating the purpose of the study defining treatment and
management and continuing with the interview guide questions (Appendix F)
66
After each interview was completed the PI began the transcription and data
analysis process
Data Analysis
Continued collection and analysis of data based on concepts derived
during the research process was the overall data analysis process for this
research study (Corbin amp Strauss 2015 Charmaz 2006 Creswell 2013)
The PI applied the constant comparative method Charmaz (2006) advises to
use constant comparative methods which allows the analyst to ldquomake
comparisons at each level of analytic workhellipfor example compare interview
statements and incidents within the same interview and compare statements
and incidents in different interviewsrdquo (p 54) As interviews were conducted
transcribed and analyzed concurrently the PI coded data in order to develop
emerging categories and subsequent themes (Creswell 2013 Charmaz
2008) The PI used QSR Internationalrsquos NVivo 12 (2018) qualitative data
analysis software to organize the emerging codes
Transcriptions All interviews conducted for this study were recorded
using a digital voice recorder After each interview was completed the PI
transcribed the data verbatim (ie recorded word for word exactly as said)
utilizing a transcription key to denote voice pitch and tone pauses and other
mannerisms (Creswell 2013) The PI proofread all transcriptions against the
digital voice recording and revised the transcript file accordingly (Creswell
2013) Each digital voice recording was listened to three times against the
67
transcript before it was considered final The transcripts were saved as a text
file rich text file with an rtf extension on a USB memory key and kept in a
locked secure physical site
Memo writing After the PI reviewed the transcript for accuracy the PI
read through the transcript several more times to gain familiarity with the data
and jotted down any preliminary words or phrases for codes in the margins for
future reference (Saldana 2009 Creswell 2013) Writing memos in the
margins allowed the PI to compose analytic notes to ldquoexplore check and
develop ideasrdquo (Charmaz 2008 p 166) that were used to hone the
development of categories (Charmaz 2006) All transcripts were imported
into NVivo 12 for organizing codes and themes developed
Initial coding The PI initiated coding by closely reading the data to
extract significant insights into the participants key experiences regarding
health care received in the treatment and management of their type 2
diabetes (Charmaz 2008) First impression codes emerged from the
perspective of older adults in order to develop categories and subsequent
themes (Saldana 2009 Creswell 2013) The PI coded word-by-word line-
by-line incident-by-incident using gerunds to help define the participantsrsquo
experiences in order to make connections between codes and to keep
categories and themes emerging (Saldana 2009 Charmaz 2008) In Vivo
Codes were used when the code was taken from the participantrsquos own
testimonies (Charmaz 2006 Saldana 2009) Constant comparative analysis
68
method was used to allow the PI to ldquomake comparisons at each level of
analytic workhellipfor example compare interview statements and incidents
within the same interview and compare statements and incidents in different
interviews (Charmaz 2006 p 54)
Focused coding Focused coding followed line-by-line initial coding
allowed the PI to capture synthesize and clarify the notable and recurring
initial codes (Charmaz 2006) In developing the focused codes the PI
maneuvered between interviews and observations and compared
participantsrsquo experiences actions and interpretations (Charmaz 2006) The
PI and Committee Chair coordinated to ensure agreement on the assignment
of focused codes to particular data (Saldana 2009) If focused codes were
not harmonized the PI and Committee Chair worked together to come to an
agreement The PI elevated the focused codes to preliminary categories
which underwent further refinement through saturation and memo writing
(Charmaz 2008 Creswell 2013) All focused codes were organized and
stored in NVivo 12 (2018)
Sorting and diagramming themes The PI sorted ordered and
refined piles of memos with categories in order to produce a written analytic
rendition of the participantsrsquo experiences regarding health care received in the
treatment and management of their type 2 diabetes (Corbin amp Strauss 2015)
The PI methodically codified the categories and created and refined
conceptual links in order to make comparisons between categories (Charmaz
69
2008) The PI used the conceptual frame Donabedian Model of Care (1980)
in order to understand the emerging categories and to diagram them into
themes (Creswell 2013) Diagrams helped the PI to ldquorevisehellipa category into
a more exacting form as a diagram illustrating the properties of a categoryrdquo
(Charmaz 2008 p 118) Diagramming provided the PI with a way of visually
representing the ldquostructural elements that shape and conditionrdquo (Charmaz
2008 p 118) the perspectives of older adults living in MUAs regarding health
care received in the treatment and management of their type 2 diabetes
Diagramming further helped the PI to ldquomove from micro to organizational
levels of analysis and to render invisible structural relationships and
processes visiblerdquo (Charmaz 2008 p 118) Diagrams provided a visual
representation of the categories and their relationships of the emerging
themes (Charmaz 2008) Themes were directly related to the research
questions under study and were agreed upon with the PIrsquos Committee
(Durdella 2018)
Interpretation
Sorting and diagramming helped with the final interpretation and
integration of the data needed to write the manuscript (Charmaz 2008)
Specifically the conceptual model helped the PI to explain the importance
each domain has on older adults living in MUAs preferences desires and
values regarding health care received in the treatment and management of
their type 2 diabetes Interpreting the data provided unique information on the
70
structures and processes of care that facilitate a holistic (bio-psychosocial-
spiritual) treatment and management approach to delivering quality diabetes
care that is respectful and individualized allowing negotiation of care and
offering choice through a therapeutic relationship where older adults living in
MUAs are empowered to be involved in health decisions at whatever level is
desired by that individual who is receiving the care
Consistency and Truth Value
Trustworthiness or the credibility process (Noble amp Smith 2015) is a
qualitative term used to judge the quality of a qualitative research study
(Patton 2015) While Long and Johnson (2000) and Creswell (2013) use
terms like validity and reliability to describe what constitutes good and quality
qualitative research Noble and Smith (2015) use terms like consistency
instead of reliability and truth value instead or validity Creswell (2013)
suggests that multiple strategies be used to ensure trustworthiness
Reliability in qualitative research has to do with consistency (Leung
2015) Consistency is achieved in qualitative research when the researcher
verifies the accuracy of the data ldquoin terms of form and context with constant
comparison either alone or with peersrdquo (Leung 2015 p 326) According to
Creswell (2013) ldquoreliability often refers to the stability of responses to multiple
coders of data setsrdquo (p 253) Consistency in this study was increased in
several ways First interviews were transcribed verbatim having utilized a
transcription key to differentiate participantsrsquo voice mannerisms (Creswell
71
2013) Next the transcripts were checked several times to ensure no
mistakes were made (Creswell 2013) Thirdly the PI ensured confirmability
by documenting the procedures for checking and rechecking assertations
findings and interpretations (Patton 2015) which Charmaz (2008) describes
as lsquoconstant comparative methodsrsquo Additionally the PI documented as
detailed in the preceding sections the logical process of the inquiry (Lincoln amp
Guba 1982) Lastly intercoder agreement was achieved by having the PIrsquos
Committee Chair review and agree on codes (Creswell 2013)
Truth value refers to the integrity and application of the methods that
is tools and processes assumed and the accuracy in which the
interpretations reflect the data (Leung 2015 Noble amp Smith 2015) Truth
value in this study was achieved in several ways First at the beginning of the
study the PI utilized a positionality statement to evaluate his systems of
values attitudes and beliefs in relationship to the phenomena under study
(Saldana 2009 Creswell 2013) To guide himself against the biases that
positionality lends itself to the PI used a conceptual frame to control for his
subjectivities (Saldana 2009) Secondly the interview guide was read and
checked by the PIrsquos Committee Chair and other Committee Members (Anney
2014) Furthermore the PI triangulated the data by recruiting participants
from several senior housing facilities in order to corroborate participantsrsquo
experiences (Shenton 2004 Creswell 2013) The PI also used rich thick
descriptions by providing detailed and sufficient information when writing
72
about actions processes or experiences using strong gerunds (Creswell
2013 Charmaz 2008) Finally the PI used member checking to ensure and
improve accuracy by sharing research findings with participants (Creswell
2013)
73
Chapter IV
RESULTS
The results presented in this chapter are delineated in two sections
The first section reports the demographic survey and pre-screening results
Demographics of the older adults are provided And lastly self-reported
HRSNs and health status of the older adults are provided
The second section reports the interview findings A description of the
types of health care providers involved directly in the type 2 diabetes
treatment and management care of the older adults are provided The health
provider examinations received by the older adults are reported And finally
section two concludes with six themes and their corresponding subthemes
that emerged during data analysis of the one-on-one interviews
Demographic Survey and Pre-Screening Results
Demographics
Table 5 presents descriptive characteristics for the participants The
participants included 12 older adults with type 2 diabetes (eight women and
four men) The mean age of the participants was 72 years with a range of 65
to 84 years old Of the participants 67 were minorities (six Black or African
American and two Hispanic Latinoa or Spanish origin) and the remaining
were White (33 or four) Five older adult participants graduated from high
74
school followed by some college or technical school (three older adults)
some high school (two older adults) and elementary (two older adults)
Twenty-five percent of the participants were either widowed or divorced
respectively 17 were either never married or separated respectively 8 a
member of an unmarried couple and one participantrsquos marital status is
unknown All participants reported their religion as Christianity Camden New
Jersey had the highest number of older adults participating (58) and the
remaining 42 of participants lived in Garfield New Jersey
75
Table 5
Demographic Description of the Participants
Participant Pseudonym Age Sex RaceEthnicity Marital Status Highest Level of Education Religion Location
Edward 70 Male Black or African American Widowed Grades 9 through 11 Christian Camden
Daisy 70 Female Black or African American Never married Grades 1 through 8 Christian Camden
Jacob 65 Male White Never married Grade 12 or GED Christian Camden
Leslie 79 Female Black or African American Separated Grade 12 or GED Christian Camden
Julie 66 Female Black or African American Divorced Grades 1 through 8 Christian Camden
Laura 71 Female Black or African American
A member of an unmarried couple College 1 year to 3 years Christian Camden
Josephine 72 Female Hispanic Latinoa or Spanish origin Separated College 1 year to 3 years Christian Camden
Tim 65 Male White Divorced Grade 12 or GED Christian Garfield
Jacqueline 75 Female Black or African American Widowed Grade 12 or GED Christian Garfield
Lucia 84 Female Hispanic Latinoa or Spanish origin Widowed Grades 9 through 11 Christian Garfield
Larry 73 Male White Grade 12 or GED Christian Garfield
Susan 70 Female White Divorced College 1 year to 3 years Christian Garfield
76
Health-Related Social Needs
Results in Figure 2 show the HRSNs of the participants Among the
older adults interviewed financial strain or onersquos ability to pay for the very
basics like food housing medical care and heating was most prevalent
(29) among the participants Twenty-six percent of the participants reported
needs associated with requiring help with activities of daily living (for example
bathing preparing meals or shopping) or feeling lonely or isolated
Figure 2
Identified Health-Related Social Needs of Participants
Nineteen percent of the participants indicated that they were food
insecure or at risk of food insecurity Unmet transportation or the lack of
77
transportation to get to any destinations for daily living was reported among
16 of the participants Unmet housing needs or poor housing quality was
reported among 7 of the participants Difficulty paying utility bills for
example electric gas oil or water was reported among 3 of the
participants
Health Status
Figure 3 displays the self-reported health status for older adults in this
study The mean duration of diabetes for reporting participants was 205
years The mean number of health care visits in the past 12 months to a
doctor nurse or other health professionals for type 2 diabetes was 215
years One participant reported visiting the health care provider 156 times or
three times per week in the past year On average participants reported
having two comorbidities Common comorbidities reported were hypertension
cardiovascular disease severe arthritis and severe kidney or liver disease
Figure 3
Participant Self-Reported Health Status
78
Note Self-reported health status box and whisker charts for duration of diabetes years health care provider visits for diabetes in the past 12 months and number of comorbidities
Figure 4 displays the type of medication diabetes insulin or pills taken
by the participants Ten of the twelve older adults interviewed were prescribed
diabetes medication As displayed in Figure 4 58 of the participants were
prescribed diabetes insulin or pills respectively And the remaining
participants 42 as highlighted in Figure 4 in the orange were not taking
diabetes insulin or pills respectively Of participants prescribed diabetes
medication 40 were prescribed both insulin and diabetic pills which
indicates disease severity
Figure 4
Participant Diabetes Medication Use
79
Furthermore participants were asked about their self-reported health
status Forty-two percent of the participants perceived their wellbeing as good
or fair respectively Eight percent of the participants self-reported their health
status as excellent or very good respectively
Lastly participants were asked to recall their last HbA1c level Ten of
the twelve participants did not know or was not sure of their last HbA1c level
The other two participants reported a HbA1c level of 55 and 99 respectively
Interview Findings
The second section reports the interview findings First the types of
health care providers involved directly in the type 2 diabetes treatment and
management care of the older adults are reported Next the health provider
80
examinations received by the older adults are described Presented lastly are
six themes and their corresponding subthemes that emerged during data
analysis of the one-on-one interviews
Types of Health Care Providers
Older adultsrsquo experiences involved interactions with an array of health
care providers involved directly in their treatment and management care
(Table 6)
Table 6 Health Care Providers Involved in Diabetes Treatment and Management Care
Health Care Providers Number Receiving Care Percent
Primary Care Provider 11 92
Podiatrist 8 67
Health Insurance Company 5 42
Optometrist 5 42
Nurse 4 33
Pharmacist 4 33
Endocrinologist 3 25
Home Health Aide 2 17
Social Worker 2 17
Medical Assistant 1 8
Nurse Practitioner 1 8
Note N = 12 for participantsrsquo receiving care from each health care provider
81
Eleven (92) of the older adults stated that they received their
diabetes care from a primary care provider (PCP) One participant stated she
received her primary diabetes care from a nurse practitioner In addition to a
PCP three (25) of the older adults stated they received specialized
diabetes care from an endocrinologist A total of eight (67) older adults
received care from a podiatrist Five (42) older adults stated their health
insurance company was involved in their care for example by providing
appointment reminders and medication management
Health Care Provider Examinations
Older adults cited an assortment of examinations they received from
their health care providers (Table 7) The health care provider examinations
that emerged are part of ADArsquos (2021c) recommended type 2 diabetes health
checks at initial follow-up or annual visits Although not all older adults in this
study received each examination for example liver examination skin
examination and cognitive examination these results do suggest that some
health care providers may be aware of ADArsquos recommended components of
the comprehensive diabetes medical evaluation at initial follow-up and
annual visits As mentioned previously the ADA (2021b) recommends health
care providers screen older adults for geriatric syndromes for example
cognitive impairment to ensure any ailments do not affect diabetes self-
management and quality of life
82
Table 7 Health Care Provider Examinations Received by Older Adults
Examinations Number Receiving Care Percent
Blood glucose test 12 100
Foot examination 9 75
Eye examination 8 67
Physical examination 6 50
Cardiac examination 2 17
Kidney examination 2 17
Cognitive examination 1 8
Dental examination 1 8
Liver examination 1 8
Skin examination 1 8
Note N = 12 for participantsrsquo receiving examination from health care provider
All older adults interviewed described their experiences with their
health care providers monitoring their blood glucose Susan said ldquoI get blood
work done before I meets with the = Dr Doe = the doctor looks over the
blood work and adjusts my insulin if she needs tordquo Julie said
Just staying up on thingshellipYou know uh appreciating the blood tests
and uh attention that I do get where its you know noticeable and theyll
be able to stop it before it get started you know where it gets too
highhellip
83
Six (50) older adults discussed their experiences receiving a general
physical examination for example that included blood pressure
measurement and checking weight Nine (75) older adults discussed
receiving foot examinations from their health care providers Daisy described
her foot examinations ldquoUh they keep make sure my toenails is clipped and
my () you know if I got any problems with my feet they make sure you know I
get the stuff I needrdquo
Themes
The codes extracted from interviews were categorized and divided up
into six themes with subthemes that emerged during data analysis of the one-
on-one interviews
Care Treatment and Management
The older adults interviewed expressed their desires preferences and
values regarding care treatment and management as the first theme (Table
8) The six subthemes (Table 8) reflect what the participantsrsquo preferred
desired or valued as part of their treatment and management care that they
would like to receive
Table 8 Theme 1 and Corresponding Subthemes
Theme Subthemes
Care treatment and
management
bull Older adults going to see different health
care providers
84
bull Older adults receiving thorough health
checkup from doctor
bull Doctor making the right diagnosis in diabetes
bull Health care provider who listens and
responds to older adultsrsquo diabetes problems
and needs
bull Long-time doctor-person relationship
bull Older adults taking the right medicine
Going to See Different Health Care Providers Older adults
interviewed valued going to see different health care providers as identified in
Table 8 This involved a health care provider who provided links and referrals
for different providers and services for example community resources
diabetes education classes specialist and hospitals Several participants
valued a health care provider who consistently refereed them to a specialist
for their identified problems Jacqueline a participant with comorbidities said
ldquohellipshe told me that I need to get a foot doctor cause then there the ones to
check out the foot () to make sure that um () you know that everythings OK
with themrdquo
Laura explained how she valued her primary care doctor who was
responsible for her diabetes care asking her if she wanted a referral to a
mental health provider
hellipshe would call me at least once a week and check up on me and
say you know how are you doing Hows it going Do you need to
85
talk to somebody about this She said because we can arrange for
you to go and talk to someonehellipAnd she really wanted me to go and
talk to somebody because () mentally () in the beginning it was
tearing me up
Additionally participants valued a health care provider who tracks
referrals and follows through with them on the care plan from the specialist
Josephine said
hellipif I wanna go to uh a certain specialist she shell give me a referral
right away its all taken care of And shell ask me questions uh which
doctors have I gone to and I need to go to this doctor for this and this
and that
Older adults also valued the role their health insurance company has in
ensuring they received care from other health care providers More
specifically participants spoke about their health insurance company
encouraging them to speak with their physician for a referral to diabetes
classes Tim explained ldquohellipthey send me thing for classes if I want to take it
talk to my doctor to see if he can take this classhelliprdquo
Thorough Checkup Older adults interviewed valued receiving a
thorough checkup from their doctor to check their overall health This included
the physician conducting routine blood glucose test and monitoring
examining their blood pressure weight heart kidneys liver skin eyes feet
86
and teeth lipid testing to provide a detailed analysis of cholesterol and diet
and nutrition assessment Laura said
Shes so thorough with so many things to the point where Ima be
honest with you shes thorough I mean when I say thorough I mean
likehellipI had to go get my kidneys checked my heart checked uh at
every anything that had to do with diabetes I had to get done
dermatologist for my skin I mean
Edward an older adult in this study who reported multiple
comorbidities stated
hellipthey do the best they can to tell you where you going wrong at even
down far as your calcium your phosphorus and proteins and all of
that Whatever your body supposed to be functioning at they will make
sure that they keep a check on that
The older adults valued receiving a head-to-toe physical examination
to check their overall health Daisy said ldquoWell = Dr Jane Doe =hellipshe
checked everything to make sure my ankles wasnt swollen you know check
my heart yeaprdquo
Some participants expressed a desire for more components of a
thorough checkup Susan said ldquoI wanna go for my uh checkup my eye I find
therersquos a cataract and I make an appointment will go for my eyes and change
my glassesrdquo
87
The Right Diagnosis Older adults interviewed desired and valued a
health care provider who made the right diagnosis in diabetes an accurate
and timely diabetes diagnosis For example Laura described her experience
with her former doctor not making a timely and correct diabetes diagnosis
while her current doctor made an accurate and timely diabetes diagnosis at
her first appointment To illustrate this Laura said
I think when I was going to = Dr Clark = and I had been going to = Dr
Clark = all those years that she couldve told me that I had type 2
diabetes instead of constantly telling me that oh youre on the
borderline I will not I will not lie to you the very first time that I went to
= Dr Doe = and they did the blood thing she said youre a diabetic
type 2 diabetic From day one from day one and she said we have to
do something about this immediately She said Im surprised youre
still walking around
Another participant described her experience with her health care
provider not diagnosing her diabetes which she believed resulted in several
adverse health effects Julie said
I had an aneurysm () 2002 where I cant see out my right eye Um it
was caused by my doctor which he retired now was giving me
medicine for cholesterol but never checked me for diabetes I had a
couple car accidents and I lost this sight My blood vessels is gone in
my right eye where l cant see out my right eye And so () he said its
88
nothing he can do though Ill be blind forever So Im blind in one side
you know in my right eye
Listens and Responds to Problems and Needs Older adults
interviewed desired and valued a health care provider who proactively
listened and responded to their diabetes problems needs complications and
associated comorbidities so that they may receive the appropriate treatment
and management care Jacqueline said
hellipif Im having any problems especially with being under chemotherapy
um the doctors give me a lot of attention now because your numbers
can play around with you and they need to be more involved and
theyre showing me that theyre interested
Laura also stated
I like the fact that if I have a problem if theres if if anything like for
instance I have gout andhellipI called her yesterday and I said listen
what can I do about this gout You know what she told me She said
listen I want you to get some lemons and squeeze them in some water
and drink it because that kills the uric acid that causes gout
Other participants described how their health care provider listened to
them Jacob said ldquoUh he listens to me when I tell him something It seems
like I know he can listen he listens good to me and everything cause he
comes and see me every monthrdquo
89
Long-time Doctor Under the next subtheme older adult participants
communicated their desires preferences and values to have a long-time
doctor-person relationship Tim stated ldquoIve been with him for diabetes 15
years at least now Ive known him for a long time his good He knows my
namerdquo
Other participants described their desire for a constant doctor and not
one that frequently changed beyond their control For example Daisy said
I guess they just left and went somewhere else I guess you know You
never get to hear the truth you know So um but thats one thing I dont
really care for you know My first doctor when I first started going to =
Clinic = I had the same doctor for a long time = Dr Jane = Then she
left and went to = Hospital = and since she left () I then had three
different or four different doctors I just wish I can have a steady onehellip
Taking the Right Medicine The final subtheme which occurred
consistently throughout the interviews emphasized older adultsrsquo desires
preferences and values for taking the right medication Several participants
shared the sentiment of one participant who plainly stated ldquohellipa lot of times
they did prescribe medicine and Ive been under several medicines that it it
wasnt right for me It was terrible you know The side effects was horriblehellipI
need to get the right medicinerdquo (Josephine)
Edward preferred not to take his diabetes medication regularly
because of the adverse side effects and not doing so would help him to avoid
90
severe hypoglycemia and keep his glycemic levels within targeted ranges
Therefore Edward valued a doctor who supported his right not to take his
medication regularly Edward said
I ainrsquot taking nothing nowhellipAnd if I take my medicine I can assure you
that my sugar is gonna drophellipsohellipthatrsquos what actually made me stop
taking my medicine I said itrsquos time for me to stop Now I told my
doctor He said long as it donrsquot as long as your sugar stay down go
head go for it
Other participants valued health care providers that ensured their
medications are administered safely and accurately Julie said
helliphell give me uh uh stronger medicine Like one time I went and my
sugar was doing all right so () he dropped it he dropped the dosage
like from 500 to 5000 so he made it a little less But then eventually he
had to bring it back up cause it went back
Medication safety in polypharmacy to ensure the older adult was taking
the right medication was cited as an important topic for the older adults
interviewed Laura stated
I was on a lot of medication from = Dr Clark = I mean a lot of
medication from = Dr Clark = And = Dr Doe = took me off of
everything and put me on a very good regimen of medicationhellipI
stopped the needles and all of thathellip
91
Other participants valued their doctor ensuring they were taking the
right medication for their diabetes Jacqueline said
Well they make sure () the diabetes doctor will make sure that you
taken the right amount of insulin Depending on which your numbers
whether they should go up in your insulin or or should it go down in
your insulin () just to make sure that your numbers are in with that 65
where they really want you to be () for your um A1C But they they just
have a look at um () the whole scale to make sure that your medicine
that youre taking besides the insulin is all in accord with () to make
you better
Accessible Services for Older Adults
Older adults interviewed discussed the role of their health care
provider cultivating an atmosphere where they are able to get the right
services at the right time as the second theme (Table 9) The participants
highlighted three major subthemes as reflected in Table 9
Table 9 Theme 2 and Corresponding Subthemes
Theme Subthemes
Accessible services for older
adults
bull Health care services in older adultsrsquo
homes
92
bull Local health care services close to
older adultsrsquo home
bull Health care provider who spends
time with older adults
Home Health Care Older adults interviewed valued receiving health
care services in their home Jacob said ldquohellipthey [nurses] come to my home
Once in the morning I gohellipdown to the office on uh second floor here And
then at night she comes to my houserdquo
Older adults also valued a doctor visit to their home to diagnose and
treat illness(es) related to diabetes the feet and lower limbs and other
complications and comorbidities prescribe medications and patient
education Susan stated
hellipIrsquom happy = Dr Mark = comes to the building You know like cut the
nails because they going grow Yeah especially the toes The growing
on the side something itrsquos better now I likehellipstimulation for my feet
He gave me a prescription for the shoe place where I gohellipfor diabetic
shoes
Older adults also expressed their values for visitation from a nurse or
medical assistant to administer medication monitor blood glucose blood
pressure and general health and other general support Leslie described her
experiences with the medical assistant in her senior housing facility where
she lives
93
I like her cause she pays attention to me you know and everything like
that you know I like her Well she take my sugar and and you know
like that she takes my sugarhellipto see if itrsquos high or low andhellipthey come
like 3 times a dayhellip
Older adults interviewed also valued counseling locating community
resources and other medical social services support from social workers that
come to their home care from home health aides to help with basic personal
needs and activities of daily living dietary assessments and guidance on
meal planning from dietitians home delivery of medicine and medical
equipment transportation to and from a medical facility for treatment and
management care and home-delivered meals Josephine described her
experience receiving food education from a dietitian at the senior housing
facility
There was a lady here many years ago we had a group going it was
really nice And she would go and she would bring all kinds of um mats
with food and all kinds of like a puzzle something to work with And
she would ask us a lot of questions how did we do this And you know
what what to watch for And when we buy food you know watch for
the sugar intake and all kinds of stuff like that So she was very very
informative
94
Jacob said ldquoWell the health insurance I got is starting this month
theyre going tohellippay forhellipthese = Moms Meals = And this month Im going
to have diabetes dinners [delivered]hellipevery two weeks
Close Health Care Services Older adults desired and valued health
care services that were geographically close to their home This included
having health care providers and diabetes education programs located
nearby Tim emphasized ldquoYea really good everythings OK The doctors are
close I mean everything is closehelliprdquo Yet Tim also cited not participating in
diabetes classes that could help him improve his type 2 diabetes because
they were not located in his area
hellip= Insurance Company =hellipsend me thing for [diabetes] classes if I
want to take it talk to my doctor to see if he can take this class or
nothellipI havenrsquot been but Irsquom thinking about ithellipI say Irsquom take it take it
and then I donrsquothellipsometimes they ainrsquot [convenient] sometimes there in
different towns or whateverhelliprdquo
However Tim further stated ldquoI would probably take them [diabetes
classes]rdquo if they were located nearby
Other older adults discussed their values for health care providers
located in the area Susan said ldquohellipI like because she [doctor] in = City = now
closer than a longer time I had before a doctor in = Borough =rdquo Josephine
valued having her pharmacist located nearby stating ldquoYeah I have a good
95
pharmacisthellipits down the street I go get it [medicine] yeah I have no
problemrdquo
Spending Time Overall participants valued a health care provider
who spends time with them Edward said ldquoonce they get to know you know
know you they give you that extra [time] especially if they see you where you
uh fall off the trail athelliprdquo Additionally Larry said ldquoShell take time out to talk to
you you know what I mean talk to you you knowrdquo
On the other hand some participants described how their health care
provider always seemed to be in a hurry and therefore they desired their
health care provider to spend more time with them Daisy said
You just go in there and they say ldquohi you doingrdquo and then they read the
charts they got and ask you any questions you know but its not that
same kind of contact you know feeling between a doctor and a
patienthellipit dont seem like people have time no morehellip
Similarly older adults preferred their health care provider spend more
time than they did with them with Susan stating ldquoI think my diabetes [doctor]
couldrsquove checkup me like every two two months much oftenhelliprdquo
Information Sharing and Provider Communication
Information sharing and provider communication was a major theme
expressed by the older adults interviewed The four subthemes (Table 10)
have been categorized in two groups informational which reflects the ADA
(2020a) guidelines for what information should be discussed with the patient
96
at the initial and subsequent diabetes doctorrsquos visit and relational which
reflects the quality of the communication between the health care provider
and older adult
Table 10 Theme 3 and Corresponding Subthemes
Theme Subthemes
Information sharing
and provider
communication
Informational Relational
bull Information from online to
help with diabetes self-
care
bull Information and
recommendations from
health care provider to
support with diabetes
self-management
bull Discussing things
that interest the
person
bull Health care
provider
communication by
telephone
Information from Online to Help with Diabetes Self-Care Older
adults interviewed desired and valued information from online to help with
diabetes self-care Participants found social media useful in supporting
diabetes self-management Josephine explained
I look at Facebook a lot and uh a lot of times they have a lot of things
uh pertaining to diabetes Um () they have you know medicinehellipa lot
97
of times they have um () menus so I take it from there you know and
I write them downhellip
Older adults also valued mobile technology for example cellphones
tablets and iPads as a convenient way for getting information to help them
identify healthy foods to support with better managing their type 2 diabetes
Tim said ldquoOn my phonehellipsometimes I look up see what things like to eat and
stuff like thatrdquo Lucia concurred stating
Right I have the information I needhellipFrom my iPadhellipI read
sometimes uh you know uh on Facebook Irsquoll put uh uh about diabetic
and they give you um a list to follow and what you should eat and what
you shouldnrsquot eathellip
One participant described his desire to use his cellphone for diabetes
information Jacob said ldquoNo I havent used the phone I should try to get up
get some information on it [type 2 diabetes]rdquo
Information and Recommendations to Support Diabetes Self-
Management Older adults preferred and valued information and
recommendations from their health care provider to support with diabetes
self-management
Participants reported preferences for a health care provider who made
recommendations that will help them to control their blood glucose
Jacqueline stated
98
ldquohellipwith my um diabetes doctorhellipwhen Im asking her a question I want
something that I could deal withhellipif I tell her um ooh my sugar was
high this morning or something I want her to come back to me with
solutions as to um () what I could do to help that outhelliprdquo
Furthermore older adults interviewed preferred their health care
provider give them recommendations that will improve their self-management
behaviors Jacob said ldquohellipId like to have support where they canhelliptell
mehelliphow I can manage my diabetes and stuffrdquo
Additionally participants valued their health care provider
recommending diabetes activities workshops books and other free
resources that will enhance their self-care behaviors Laura said
hellipshes always recommending various things um activities
workshops books um that I could do for myself you know and I
appreciate thathellipshe made me aware of is that my uh = insurance
company =hellipI can get this book and I can order the diabetic socks
freehellipmy insurance will pay for it
Lastly many older adults valued a range of reminders they received
from their health care providers that were intended to promote better self-
management For example participants valued receiving reminders to take
their blood glucose with one participant stating that her nurse would remind
her to monitor her blood glucose three times a day Laura said ldquo= Peggy =
the nursehellipwas really good She washellipreally good you know cause
99
shehellipwould say did youhelliptake thehellipblood test and on the monitorhellipthree
times a dayhelliprdquo
Nearly all of the participating older adults valued reminders to eat
healthy Older adults stated that they were frequently reminded to avoid foods
with large amounts of sugar ldquoI like it because hes very concerned about me
and everything He usually tells me make sure you eat eat a good diet and
stay away from sugars and sodasrdquo (Jacob)
Discussing Things that Interest the Person Older adults
interviewed discussed their preferences for their health care providers
discussing things that interest them Daisy said ldquoBefore the doctor used to sit
there and talk with you and you know discuss things different things about
how you feel and everything they dont do that nowrdquo
Other participants expressed their values for their health care providers
discussing things that interest them Josephine stated
And shes interested in you Cause shell call me right away like like in
my blood or something shell call meI never had a doctor to call me
and tell me what was wrong with me And she stays up on that
Jacqueline also explained
hellipconversation communication show interest in what Im explaining to
them Um I like with my with my um diabetes doctor like the answers
shes gonna give me when Im asking her a question I want something
that I could deal withhellip
100
Communication by Telephone Older adults interviewed valued
receiving telephone calls from their health care providers regarding a range of
diabetes wellness topics for example checking on their physical health
emotional wellbeing medication refills blood sugar results and reminders
Jacqueline said
hellipthe doctor talks to me and they talk () call you up I like that part
where they call you on the phone to discuss () how where your
numbers are and what you should do to get them into the right spot
Laura shared an impactful story of how her diabetes doctor would call
her to check on her family and emotional wellbeing
I like the fact that they they really you know the other thing that really
touched my heart was the fact that = Dr Doe = has constantly kept up
and constantly shell call and ask me how hows your hows little =
John = Hows he doing You know what Im saying And that touched
me that that that really touched because a lot of doctors when cause
this is an 11 year old child that got shot through the neck that went out
through his brain He will never be what he was You know what Im
saying And um hes had four operations so far and um shes been
very good at kind of keeping me updated on what happens and
everything and I appreciate that that that means a lot to me you
know her and the nurse theyrsquore you know they keep me updated and
stuff and I appreciate that
101
While many participants valued telephone calls some participants
preferred more telephone calls from their health care providers for example
to see if they need new medication Lucia said ldquoWellhellipif they give you a call
once in a while () uh that would be you know something goodhellipjust to find
out how yoursquore doing and uh in case you need new medicationhelliprdquo
Attributes of Health Care Providers
Attributes of health care providers was a theme that emerged from the
older adults interviewed Older adults interviewed described a whole host of
qualities that they valued in their health care providers Table 11 presents the
eight subthemes that emerged from the overarching theme
Table 11 Theme 4 and Corresponding Subthemes
Theme Subthemes
Attributes of health care
providers
bull Honest
bull Trustworthy
bull Smart
bull Humorous
bull Being there for
the person
bull Smiles
bull Caring
bull Patient
Honest Several older adults valued an honest health care provider
Laura said ldquoI like the fact that they donrsquothelliptry to sugar coat nothing They
102
dont sugar coat it They give it to you right to your facehelliprdquo Julie said ldquoI know
hes gonna tell me whats good for merdquo
Trustworthy Older adults also valued a trustworthy health care
provider
ldquoRight I trust him yeah I dordquo (Larry)
ldquoI couldnrsquot do it without her put it that wayrdquo (Julie)
ldquoFeels good that I have someone I can trustrdquo (Jacob)
ldquoWell Irsquom uh glad I can always count on themrdquo (Lucia)
Smart Another quality that was valued by older adults is a health care
provider who has the broadest-possible knowledge of medicine Josephine
said ldquoShe shes very smart you know shes uh on top of things Shes very
on top of things you know yeahrdquo
Humorous Older adults interviewed also valued a health care
provider that is humorous Larry stated
I go there and what I do what I got to do and we talk he [podiatrist]
listens to me you know make cracks jokes and stuff like thathellipI just
go there ((laughs)) you know so he listens to me you know and crack
jokes all the time you know thats allhellipI like him
Being There Additionally participants valued a health care provider
who is there for them when they need them Julie said ldquohellipshes there for
mehelliprdquo Lucia said ldquohelliptheyrsquore always there if I need themhelliprdquo Josephine said
103
ldquoIm pretty sure if I need to know I can always go to you know my doctor
Like I said shes willing to help me out you know in any areas that I needrdquo
Smiles Other participants valued a health care provider that smiles
Daisy said
She was a people person you know You know you come in smiling
you know You know even if youre unhappy you got a smile you
know That makes you feel better you know Come in with the puss on
your face you know ((laughs)) thats kind of down you know But uh =
Dr Jane Doe = always had us long yeap
Caring Most older adults valued a caring and compassionate health
care provider Josephine said ldquoShes caring Shes very caring you know
Thats thats the most most important shes caringrdquo Jacob said
I like it because he comes over and talks to me about my diabetes and
does the blood test and everything on it I like it because hes very
concerned about me and everything He usually tells me make sure
you eat eat a good diet and stay away from sugars and sodas It helps
me a lot because he he shows that he cares and everything
Laura also expressed how her health care provider is caring by stating
I just feel like = Dr Doe = just has this way of making you feel like
youre the only person youre the most important person that she
cares about and that she wants it done correctly you know what Im
saying that she wants you to survive she wants you to be healthy
104
Patient Older adults also valued a patient health care provider Daisy
described her experience with the doctor being patient while checking her
blood pressure
Ah cause she always took a thing with my blood pressure for some
reason Cause shed say just sit there and relax Cause she said when
you get up fast it makes your blood pressure go up high I said that
dont make my blood pressure high its coming in this office that
((laughs)) makes my blood pressure high I said every time I come to
the doctor my blood pressure goes up But she always said sit there for
few minutes and then shed take it again you know So that extra care
Social Support
Social support was a theme identified by the older adults interviewed
Older adults in this study identified receiving social support from family
friends their health care provider and the community The four subthemes
(Table 12) have been categorized into two groups instrumental which reflects
tangible aid and services provided for older adults to support type 2 diabetes
self-management and informational which is advice suggestions reminders
and information given to older adults to support type 2 diabetes self-
management
Table 12 Theme 5 and Corresponding Subthemes
105
Theme Subthemes
Social support Instrumental
bull Family involvement in
doctorrsquos appointments
bull Financial assistance
with diabetes care costs
bull Community assistance
with social services
Informational
bull Family provides
information for
diabetes self-
management
Family Involvement in Doctorrsquos Appointments Older adults valued
involvement of family with scheduling and attending doctorrsquos appointments
Laura stated
hellipmy daughter = Mary = my oldest daughter shes a registered
nursehellipI was drinking water like gallons of it And she said Mom she
said theres something wrong youre not supposed to be drinking that
much water OK And I said but Im thirsty all the timehellipI was thirsty
and something else was wrong with me But it was all symptoms of
being a diabetic And by her being a registered nurse I went up to stay
with herhellipShe said what is doctor = Dr Clark = I said I dont knowhellip
she came down here she said I made you an appointment with
doctor another doctor at = Hospital = and were going now
Susan described support received from her daughter with attending
doctorrsquos visits to perform blood sugar test ldquoI get blood work done before I
meets with the = Dr Doe = the doctor looks over the blood work and adjusts
106
my insulin if she needs tohelliplike every 3 monthshellipmy daughter schedules me
because I do go for blood workhellipMy daughter always go go with me She
take me to herrdquo
Edward who reported multiple diabetes related comorbidities including
severe kidney disease referenced his girlfriend taking him to the hospital
because of complications
hellipmy kidneys had start to failhellipmy kidneys wasnrsquot producing that
water Ah the next thing I know I was in the congestive heart failure
They said if I hadnrsquot went to the hospital when I did I might not made it
Only thing I know all that day I wanted to sleep to sleep Finally about
6 7 orsquoclock that night my girlfriend told me you got to go to the doctor
Yoursquore going to the hospital
Financial Assistance with Diabetes Care Costs Older adults
interviewed valued financial assistance they received with diabetes care costs
from their health care providers family or friends Josephine said ldquoI have =
Financial Assistance Program = that helps me with my medicine you knowrdquo
Additionally Jacqueline valued receiving free insulin samples to help with the
costs of diabetes medicine
And if it wasnt for like some time with your diabetes doctor or the
primary [care doctor] they get samples from um () like the um people
that come in and drop off samples and things So theyll help you out
by giving you um () some of the insulin to overfray the cost
107
Susan valued receiving support from her podiatrist giving her free
diabetic socks and bandages to help heal diabetic wounds
Well = Dr Mark = uh he try uh he try bring me you know bandage
because I bandage cause my woman [home health aide] bandage my
leg Diabetic shoes and bandage He said he going bring me new
bandage because I I wrapping both my legs He said he going to bring
me bandages because I that way I donrsquot have to buy bandages he
going to bring the bandages
Daisy valued the use her friendrsquos blood glucose machine because she
did not have the money to buy one which created a barrier to her monitoring
her blood sugar Daisyrsquos friendrsquos blood glucose machine was free to use and
thus provided her with what she needed for diabetes self-care Daisy stated
I did [check A1C] when I had a [blood glucose] machine I had just got
another machine now my insurance company sent me a letter I think it
was last month said they no longer going pay for it seeing I just got it
So now theyre not going to pay for ithellipSo I havent checked it in a
whilehellipBut I can just about tell when its if its acting up you know then
Ill might use a friendsrsquo or something like that to take ithellipif Im not
feeling good my sugar is uphellipI can use a friends of mines machine
you know
Community Assistance with Social Services Older adults
interviewed described their desires preferences and values for receiving
108
community assistance with social services to support their HRSNs and
diabetes self-management For example older adults interviewed valued
having food at their senior housing facility to support a healthy diet Daisy who
reported experiencing food insecurity stated ldquoWell they have a food program
here so they give us food here you know once a month so () you know
thats good That helpsrdquo Susan said ldquoI have the congregant program They
serve meals that donrsquot have any seasonings in them no salt or anything so
itrsquos pretty diabetic friendly and eat lunch down here every dayrdquo
Further older adults cited their desires preferences and values
related to transportation assistance and their diabetes care Julie stated
So I can get where I had to go () without having to worry about how
Im going to get the money to get therehellipits nobody there to help you
uh senior citizens when we get um to the place where we have to be
certain place and being able to get there Thats the only support I
needhellipget to the doctors and stuff like that
Others discussed transportation support they received from social
services at their housing facility Leslie said
hellipthey [senior housing facility] take us places like like Wednesday
theyrsquoll take us wersquoll go I think wersquoll go to the big Walmart Wednesday
Then wersquoll go to maybe to the Shoprite or whatever that store is if we
want to go something like that you know Every Wednesday they take
you somewhere or something like thathellip
109
Additionally participants valued receiving social services supports that
help them to navigate and complete tasks associated with conducting routine
daily business For example one participant valued the social worker at the
senior housing facility helping her complete documents having to do with life
affairs Leslie who reported needing help with day-to-day activities described
how she valued the social services office in her senior housing facility
supporting her routine daily business
Well I have social services downstairs in the program I belong to And
they help me a lot like help me take care of say if I have a um I need
different papers or I need them to help me with paperwork and
everything like thathellip
Family Provides Information for Diabetes Self-Management Older
adults interviewed also spoke about how they valued their family providing
information to support diabetes self-management For example older adults
in this study valued receiving information from their family on programs that
teach healthy and easy to cook recipes for improved diabetes self-
management Tim said ldquoThey have programs [on balancing a diabetes diet]
that they I go to once in a while yea I mean just like I said she [girlfriend]
makes me she says I sign you uprdquo
Larry described how his girlfriend used her cellphone to provide him
with type 2 diabetes information to support with self-management ldquohellipIm not
computer literate you know my girlfriend is But as far as the phone goes I
110
just use it making uh phone calls basically thats allhellipmy girlfriend use the
phone sometimes to search type 2 diabetes informationrdquo
Additionally older adults in this study valued reminders that they
received from their family to help them with self-management for example
reminders to eat healthy Susan who reported food insecurity said ldquoShe
[daughter] put me on a diet She said she want me to stop eating out because
she want me to lose weight She said shersquos going to buy the foods for merdquo
Tim who reported food insecurity and being prescribed insulin and diabetic
pills explained how his girlfriend reminds him to take his medication and eat
healthy
She makes sure I take it She shes with me every day and she
teaching me making sure I take it morning and night in between like
she sometimes shes out She she watches me She sits there and
watches me Yea she reminds mind yea yea O when we go out to
dinner when we have lunch or something shell say you know Tim
cant eat that (you know stuff like that and) you shouldnt have thatrdquo
Older Adultsrsquo Diabetes Self-Management Behavioral Strategies
Older adultsrsquo diabetes self-management behavioral strategies were a
theme that emerged from the interviews The eight subthemes have been
categorized into three groups physical behavioral strategies for diabetes self-
management intellectual diabetes self-management behavioral strategies
and spiritual behavioral strategies for diabetes self-management (Table 13)
111
Table 13 Theme 6 and Corresponding Subthemes
Theme Subthemes
Older adultsrsquo
diabetes self-
management
behavioral strategies
Physical
bull Monitoring blood
sugar
bull Taking diabetes
medication
regularly
bull Managing
comorbidities
bull Exercising
bull Healthy eating
bull Regular doctor
visits
Intellectual
bull Diabetes
education
Spiritual
bull Prayer
Monitoring Blood Sugar As a diabetes self-management behavioral
strategy older adults frequented cited monitoring blood sugar to ensure they
achieved and maintained specific glycemic targets
I just you know try and watchhellipas far as you know sugar goeshelliptry and
watch my sugar levelhellipI got a meterhellipAnd I know uh certain level you
know I just try and get you know Sometimes itrsquos uh depends
sometimes itrsquos like 120 130 varies Uh I use it maybe () maybe once
a week (Larry)
112
Well at least once every three months I get a blood work done and
um she uh has me at least once a week I have to take my blood uh
what is it you know um () I have to take theYeah I have to take that
to see what it is And that and as long as it stays between uh I think itrsquos
one mine usually stays between 92 and 101 and that and shersquos very
pleased with that (Laura)
In addition monitoring blood sugar levels was also a behavioral
strategy that older adults conducted as a measure to reduce their risk for
diabetes complications Jacob said
hellipI have to take the sugar the insulin and stuff all the time and I have
to check my sugars all timehellipI know I have to manage it because I
know you can lose you can lose stuff from diabetes
Making sure my AC one whatever donrsquot get too high where it be out of
controlhellipI donrsquot want to get to the point where Irsquom be totally dependent
on someone to take care of me like go into a coma be in a hospital I
donrsquot want none of that I wanna keep going as Irsquom going (Julie)
Taking Diabetes Medication Regularly Taking diabetes medication
(insulin or an oral hypoglycemic agent) regularly as prescribed was a diabetes
self-management behavioral strategy emphasized by older adults Tim said
ldquohellipit keeps me doing my medicine I look back and I see I dont want to be like
113
this so and I do the medicine I do the meds and keep on try to keep on top of
it you knowrdquo
Jacqueline described her experience with diabetes numeracy or the
ability to understand and use math skills to adjust the amount of insulin she
takes
Depending on my um () my sugar test that tells me how much insulin
Im going to take () with my um experience with my diabetes doctor
they have me on like um a slide sliding scale that when my sugar is a
certain amount that I have to use a certain amount of insulinhellip
Other older adults shared their experiences with taking diabetes
medication regularly as a behavioral strategy to increase their success rates
in achieving blood sugar targets Daisy said
I take my medicinehellipbefore I eathellipI take twice a day So one of my
pills I had to take uh my metformin I take twice a day So I take that in
the morning and then I take it when I eat my dinnerhellipI donrsquot
forgethellipBut basically my sugar is really its under you know it stays
the same its like under controlhellipBut I think if I didnt take the medicine
it might not would be you know
In addition older adults cited taking diabetes medication regularly as a
strategy to reduce the likelihood of diabetes complications or to prevent
diabetes complication from getting worse Lucia said ldquoWell all I do is take
114
medication all I do is take my pillhelliponce in a while I would get dizzyhellipbut the
medication helps me I take my medication every morningrdquo
Managing Comorbidities Managing comorbidities of diabetes such
as chronic kidney disease cancer or depression was a self-management
behavioral strategy emphasized by older adults Susan stated ldquoI got a
psychiatrist and taking pills for depressionrdquo Jacqueline said
I am a cancer patient also so Im currently under chemotherapy for the
next nine weeks And when you are getting steroids () and and chemo
it messes with your diabetes () it causes your numbers to go up So
therefore you have to control the insulin that you take
Larry who reported being diagnosed with severe kidney diseases
explained
I do have kidney problems okay I got a nephrologist and urologist So
I visit them maybe every three months or so Theyll take blood work
and uh () theyll uh () if its something is not right according to the
blood work theyll uh give me give me medication or maybe see uh
give me a () try to see a specialist something like that you know
Exercising Older adults discussed exercises such as walking
swimming and going to the gym as self-management behavioral strategies to
help control blood sugar levels promote weight loss and improve well-being
ldquoI do a lot of a lot of walkingrdquo (Larry)
115
ldquoI got this other health insurance its uh = Insurance Company = and
theyre going to they cover the uh SilverSneakers for gyms and stuff I
can go to the gym I want to try to go like maybe three days a weekrdquo
(Jacob)
ldquoTry to exercise as much as possiblehellipUh I go to uh um adult day care
center and we exercise therehellipexercising and stuff that it takes control
over the diabetes and keep it stablerdquo (Julie)
ldquoExercising is real important you know exercise you have to exercise
when you have diabeteshellipI decided to do swimmingrdquo (Laura)
Healthy Eating Eating healthy in order to keep blood sugar levels in
target ranges was a diabetes self-management behavioral strategy discussed
by older adults Jacqueline stated
ldquoI just got to be more attentive to my diet Once that is then I () you
know then I think Ill have a better control on my type 2 diabeteshellipDiet
is really important () with diabetes Ive found out like () with diabetes
() when I eat something and thats not really a good lay out for that
day I can notice how the sugar would go up () and then try something
else that um where it has less carbohydrates and then youll find that
you can control it a little bit better without um the starches
Julie also said ldquoBasically relaxing and trying to just take one day at a
time and hoping that you know by me eating the things I eat and exercising
and stuff that it takes control over the diabetes and keep it stablerdquo Laura said
116
I control my diabetes with my diethellipI decided to go to the classes that
taught me how to uh cook for myself what to eat what not to eat
when to eat because its important that you know when to eat when
you have diabeteshellipAnd um some of the soups that I were eating was
not good for my high blood blood pressure or my diabetes So I had to
stay away from them
Some participants stated their desire to have healthy foods available to
eat so that they can better self-manage their diabetes Josephine said
Uh its been a long time since Ive had diabeteshellipits been like
uncontrollablehellipMaybe its because of my what I eat too Sometimes I
dont have the right food for me to um () to you know to have a good
healthy meal you know I eat what I have So sometimes thats thats a
problemhellipI know you know what to do if I had the stuffhellipI know you
know what to eat and what not to eat you know but basically I eat
what I have
Regular Doctor Visits Older adults in this study discussed the
importance of regularly attending doctor visits as a strategy to manage their
type 2 diabetes Jacob said
I see my doctor all the timehellipprimary care doctor He does blood tests
and uh tells me to watch out for sugars and stuff and tells me just to
keep keep like dont eat a lot of starches and stuff And uh he told me
117
stay away from sodas and stuff He just tells me basically to eat right
and everything () exercise and stuff
Edward who reported multiple diabetes related comorbidities
discussed the importance of regularly attending doctor appointments as a
way to build his confidence to self-manage his diabetes
Do your doctorshellipyou donrsquot want to skip too many You donrsquot want to
skip too many appointmentshellipYou gotta have a little bit of confidence
in yourself Itrsquos just like anything else you do If you donrsquot have no self-
confidence or self-esteem for yourself most everything you do will be
negative Pull your self-esteem up have plenty of confidence I can
do I will do I have done all that you pretty much get away with it
Older adults also discussed the importance of visits to specialist
doctors for example eye doctor for examinations as an essential part of
diabetes self-management Daisy said ldquoI always go to doctor eye doctor once
a month I got a appointment for 18th uh this month I had to go at least once a
year cause of my diabetes you know () to keep trackrdquo
Diabetes Education Older adults interviewed valued various formats
of diabetes education as a self-management behavioral strategy For
example older adults valued peer group education as a source of intellectual
information to help learn self-management strategies to better control blood
glucose levels Jacqueline stated
118
hellipwhen youre talking to other people about diabetes and listening to
what their um () experiences are with diabetes you learn a lot
fromhellipseeing how other people are tolerating with their insulinhellipI think
that more like you when youre involved and like um focus groups and
um () just talking with other people that have the experience you you
learn a lothellipmaybe something that they dohellipgreat controls it a little
better than you do
Older adults also valued reading diabetes self-management education
information in print format Laura stated
And you have um the the my diabetic magazines that I get I get those
every month my diabetic magazines I get them every single month I
read themhellip And the best thing about the diabetic magazine is theyre
always giving you different ideas on on um exercising um how to keep
your eyes healthy you know how to keep your skin because when
youre diabetic your skins very very dry
Susan said ldquoI read my Polish book on my diabetes I know doctor says
I have to read it to know how to manage itrdquo
Prayer Prayer was an important spiritual diabetes self-management
behavioral strategy expressed by older adults interviewed Several older
adults described prayer as an integral part of diabetes health care and daily
life Josephine said ldquoI just keep on praying thats all Yeah I pray every day
about thisrdquo
119
Older adults in this study valued that their health care provider
speaking with them about their spiritual beliefs and encouraged them to pray
about their diabetes Laura stated ldquoAnd she [doctor] said you have to put it in
Gods hands and God will guide you and you have to pray about thisrdquo
Further older adults in this study also valued the role of prayer as a
source of strength in helping them to cope with their diabetes Lucia said
ldquohellipevery morning when I get up I say thank you God give me another day
and help with my illnesseshelliprdquo
A discussion of the findings is provided in chapter five
120
Chapter V
DISCUSSION IMPLICATIONS CONCLUSION
Donabedian Model of Care as an Interpretation Framework
The Donabedian Model of Care will be used as a lens to interpret the
data and understand the results The six themes and their subthemes that
emerged during data analysis correspond to two of the three domains which
reflect type 2 diabetes treatment and management care received by the older
adults living in MUAs in this study It is important to highlight that the majority
of the themes that emerged fit with the process domain which in light of the
purpose of this study aligns congruently since the process domain reflects
actions done in giving and receiving health care Figure 5 below displays
which themes correspond to each domain Outcomes reflect select
improvements in diabetes measures gleaned from the interviews and prior
literature
Figure 5
Conceptual Framework for Older Adults Living in MUAs Preferences Desires and Values for Type 2 Diabetes Treatment and Management Care Received
121
Note Conceptual framework that illustrates and provides examples of the Donabedian Model of Care used as a lens to interpret the themes and explain the findings Adapted from ldquoThe definition of quality and approaches to its assessment Explorations in quality assessment and monitoring (Vol 1)rdquo by A Donabedian 1980 Ann Arbor MI Health Administration Press ldquoCriteria and standards for quality assessment and monitoringrdquo by A Donabedian 1986 Quality Review Bulletin 12(3) 99-108 (httpsdoiorg101016s0097-5990(16)30021-5) ldquoThe quality of care How can it be assessedrdquo by A Donabedian 1988 JAMA 260(12) 1743-1748 (httpsdoiorg101001jama260121743) Structure
The first domain of the Donabedian Model of Care is structure These
characteristics of the providers of care are the fundamental components of an
organization and its environment that influence the kind of care that is
provided (Donabedian 1980) The concept of structure includes the human
physical organizational financial and other resources of the health care
system and its environment (Donabedian 1980 1986) The theme that is
associated with the structure domain is Accessible Services for Older Adults
122
Accessible Services for Older Adults Older adults living in MUAs
interviewed discussed the role of their health care provider cultivating an
atmosphere where they are able to get the right diabetes care at the right
time Findings from the interviews showed that older adults desire prefer and
value structure-related dimensions of care that are accessible For example
this qualitative studied highlighted that older adults living in MUAs valued
receiving convenient access to health care services in their home This
included receiving home health care to diagnose and treat illness(es) related
to diabetes dietary assessments and guidance on meal planning from
dietitians home delivery of medications and food and medical social services
support This is the first study to the authorrsquos knowledge to provide an
understanding of the characteristics and values of home health care for older
adults with type 2 diabetes living in MUAs These characteristics and values
are necessary to optimize the diabetes home health care that health care
providers offer to older adults living in MUAs
Previous research has reported that home health care services for
older adults is underutilized (Reckrey 2020 Wysocki et al 2019) This
research study demonstrates that older adults living in MUAs value diabetes
home health care services In addition as articulated by the older adults in
this study home health care services may prove beneficial for improving their
diabetes self-management skills and diabetes outcomes
123
Dietary counseling has been widely studied as being beneficial for type
2 diabetes (Evert et al 2019) However the results of the National Home and
Hospice Care Survey (CDC 2000 Jones et al 2012) showed that among
adults aged 65 years and over receiving home health care dietary counseling
and social services were less frequently received This finding is concerning
in light of this study which showed that 19 of the participants indicated that
they were food insecure or at risk of food insecurity and that older adults living
in MUAs valued receiving at-home dietary assessments and guidance on
meal planning from dietitians to support with their diabetes self-management
Given the importance of healthy eating for optimal diabetes self-management
it seems that dietary counseling would be a critical service that home health
care provides to older adults living in MUAs
It is also important to highlight that the older adults living MUAs in this
study valued home-delivered meals to support with a healthy diabetes diet
Previous research has been mixed when analyzing various outcomes of
adults (age gt 18 years) receiving home-delivered meals compared with those
who are not recipients of home-delivered meals For example Luscombe-
Marsh et al (2013) found no significant differences in weight loss between
older adults who received home-delivered meals compared to those older
adults who did not receive home-delivered meals Lee et al (2015) conducted
a study that showed older adults receiving home-delivered meals were
significantly less likely to report being food insecure compared to those older
124
adults who did not receive home-delivered meals In a randomized study
Edwards et al (1993) found that elderly receiving home-delivered meals were
less likely to have uncontrolled diabetes and hospitalizations compared to
older adults not receiving home-delivered meals In contrast Berkowitz et
alrsquos (2019) study found no significance differences of improvements in HbA1c
for adults when they received home-delivered meals compared to when they
did not receive home-delivered meals Despite these and other mixed
research findings on how home-delivered meals may contribute to health and
addressing HRSNs older adults with type 2 diabetes living in MUAs in this
study articulated that they valued receiving healthy home-delivered meals to
address food insecurity and support with diabetes self-management
In this study older adults living MUAs also desired and valued
diabetes health care services in close proximity to their home Provider
network accuracy and accessibility is a key component of the care continuum
to ensure patients have access to the right care when needed Provider
networks consist of contracted physicians hospitals and health systems
nonphysician professionals ancillary and therapeutic services and facilities
social services and supports and any other providers of care (Giovannelli et
al 2016 Busch amp Kyanko 2020 Segal 1999) The service area or the
geographic area in which the health insurance plan provides access to
hospital care and other health and social services is crucial to eliminating
barriers to care for patients especially those who require specialty care
125
physicians behavioral health care providers and social services support
Despite the advantages of an accurate and accessible provider networks that
are associated with better health outcomes and reduced mortality (Fields et
al 2016) underserved communities continue to face challenges with
accessible provider networks to address health disparities (Haeder et al
2019 Morelli 2017) Haeder (2019) found that older adults living in urban
communities had limited access to endocrinologists Nevertheless the
findings in this study show that older adults with type 2 diabetes living in
MUAs desired and valued a range of centrally located health and social care
providers in their community that can help them to improve their diabetes
outcomes These findings suggest the importance of ensuring strong provider
network access where health care and social services can be conveniently
accessed to facilitate improved diabetes outcomes for older adults living in
MUAs
In this study older adults with type 2 diabetes living in MUAs
discussed the importance of having a health care provider that spends time
with them Previous research in the US shows that in the late 1980s
physicians spent an average of 263 minutes with patients during an office
visit compared to 183 minutes in 1998 174 minutes in the early 2000s and
225 minutes in 2016 the latest year available (Mechanic et al 2001 Tai-
Seale et al 2007 Rui amp Okeyode 2016) On the other hand Yawn et al
(2003) found that primary care office visits lasted about 10 minutes While this
126
study did not do a quantitative analysis of the amount of time the physicians
of the older adults in this study spent with them older adults living in MUAs
with type 2 diabetes in this study valued a health care provider who spends
extra time with them and desired or preferred their health care provider to
spend more time than they did with them This perhaps suggest that 10 ndash
225 minutes is or is not long enough for the older adults with type 2 diabetes
living in MUAs in this study
Health care provider constraints on how much time they spend with
patients could have an impact on health outcomes Previous research has
shown that providers who spend less time with their patients are for example
prone to have more malpractice claims and have lower patient trust ratings
(Levinson et al 1997 Fiscella et al 2004) Similarly Zhang et al (2020)
found that only 227 of surveyed patients admitted to a tertiary hospital were
completely satisfied with the amount of time nurses spent with them In
contrast Lin et al (2001) research suggested that patients who feel that they
spent more time than anticipated with their health care provider are
significantly more satisfied with the visit which in-turn could positively impact
quality of care and type 2 diabetes outcomes (Narayan et al 2003 Alazri amp
Neal 2003)
Finally Donabedian (1980) has suggested that increasing the level of
and equalizing access to care is a key indicator and dimension of the
structures of quality of care Additionally Penchansky and Thomas (1981)
127
conceptualized the dimensions of access which includes geographically
accessible services and time spent with patient as important facilitating
factors to cultivate an atmosphere where persons are able to get the right
care at the right time These findings are consistent with other studies that
suggested key structure components such as the ability of people to reach
the services that they need and prefer and re-designing visits to allow
providers to spend more time with the patient are important organizational
facilitators in delivering care that is responsive to the individual preferences
values needs and desires of patients (Takane amp Hunt 2012 Wolinsky amp
Marder 1982)
Process
The second domain of the Donabedian Model of Care is process The
process domain depicts the elements of the care delivery teamrsquos performance
to maintain or improve the health of patients Processes are defined by
Donabedian (1980 1988) as the actions done in giving and receiving health
care including those of patients families and health care providers The
themes that are associated with the process domain are Care Treatment and
Management Information Sharing and Provider Communication Attributes of
Health Care Providers Social Support and Older Adultsrsquo Diabetes Self-
Management Behavioral Strategies
Care Treatment and Management Older adults living in MUAs in this
study discussed their desires preferences and values for diabetes treatment
128
and management care For example older adults living in MUAs valued
receiving diabetes treatment and management care from different health care
providers An interdisciplinary coordinated care team whereby health care
providers interact with each other for care planning to produce quality care
has been identified by Donabedian (1985) as an element in the process of
care
Yet challenges remain on the health care provider level with ensuring
patients are linked and refereed to interdisciplinary providers and services
and that the care is tracked and followed through by the originating health
care provider For example a qualitative study by Friedman et al (2016)
found the following barriers to interdisciplinary collaborative care when
interviewing health care providers lack of IT functionality availability of
community resources to address SDoH resistance from clinicians and health
care facilities and resistance from patients to care coordination Likewise
Zuchowski et al (2017) conducted a qualitative analysis to explore health
providersrsquo and administratorsrsquo perceptions of care coordination challenges
The authors found care coordination challenges to include providers not
working effectively together lack of role clarity deficiencies in care tracking
insufficient communication between internal and community providers
communication breakdown across internal systems delayed and deficient
patient records exchange and delays around authorizations (Zuchowski et
al 2017)
129
Nevertheless overcoming care coordination challenges leading to the
involvement of an interdisciplinary collaborative health care team that works
in partnership to meet the needs of older adults with chronic conditions is
associated with improved use of self-management strategies to control
symptoms decreased readmission rates lower total inpatient costs very high
satisfaction with care and helps prevent functional decline (Hoover et al
2017 Barnes et al 2012 Counsell et al 2000 Kresevic amp Holder 1998)
Further several studies have demonstrated patients perceive a cooperative
care team working together for ongoing health care management as a
beneficial part of their diabetes care (Alazri et al 2006 Lawton et al 2009)
Older adults living in MUAs in this study also valued receiving a
thorough checkup from their doctor to check their overall health It is
important to note that some of the components of a thorough checkup that
emerged are not part of the ADA (2021c) recommended guidelines for what
health checks should happen for patients with type 2 diabetes for example
liver examination skin examination and cognitive examination which
indicates some physicians are going beyond recommended guidelines to
provide comprehensive care for their patients This finding in this study is
similar to Oboler et alrsquos (2002) study that reported most adults in the US
valued a comprehensive annual physical examination that included blood
pressure measurement and a check of the heart lungs abdomen reflexes
prostate and vision Similarly in Duan et alrsquos (2020) study the authors found
130
that almost all respondents felt that their health care provider should conduct
a total body skin examination heart examination abdomen examination eyes
examination mouth examination and check their blood pressure
The above findings on adultsrsquo values and preferences for a thorough
and comprehensive exam are noteworthy in light of previous discussions
questioning the value of these physical examinations (Himmelstein amp Phillips
2016 Reynolds et al 2016 Mehrotra amp Prochazka 2015) Krogsboslashll et al
(2019) seem to concur considering their systematic review and meta-analysis
reported little or no effects of general health checkups on morbidity
hospitalization disability or worry In contrast a previous systematic review
and research reported that the benefits of a periodicannual physical
examination include improved physician-patient relationship better patient
disease detection and improved patient satisfaction health behaviors
attitudes clinical outcomes (eg blood pressure body mass index)
hospitalization disability and costs (Duan et al 2020 Hyman 2020
Boulware et al 2007 Prochazka et al 2005)
Donabedian (1985) described comprehensive treatment and
management care and the components that it entails for example the
diagnostic processmdashphysical examination and diagnostic test as a process-
related dimension of care to assessing and monitoring quality In addition the
components of a thorough checkup that older adults in this study valued are
131
part of ADArsquos (2021c) recommended type 2 diabetes health checks at initial
follow-up or annual visits
Older adults living in MUAs in this study desired and valued a health
care provider who makes the right diagnosis in diabetes an accurate and
timely diabetes diagnosis Unfortunately doctors misdiagnose patients at an
astounding rate (Zwaan amp Singh 2020 Shojania amp de Mheen 2020 Singh et
al 2017) Gunderson et alrsquos (2020) systematic review and meta-analysis
found that harmful diagnostic errors in hospitalized adults occurs in at least
07 of adult admissions According to the authors this equates to
approximately 249900 harmful diagnostic errors including common diseases
missed both cognitive and system-level (Gunderson et al 2020) Singh et al
(2014) found a rate of outpatient diagnostic errors of 508 or approximately
12 million US adults every year In Seidu et alrsquos (2014) study the authors
found that the prevalence of diagnostic errors in people with diabetes in
primary care was 74 Similarly Samuels et al (2006) reported that delayed
diabetes diagnosis occurred in more than 7 of incident cases for at least 75
years after the onset of disease
The previous data on diagnostic errors makes the finding of this study
regarding older adults living in MUAs desires and values for an accurate and
timely diabetes diagnosis essential The concept of timely diagnosis refers to
a more person-centered approach to disclose the diagnosis at the right time
for the patient with consideration for their unique circumstances and
132
preferences (Dhedhi et al 2014) In a survey of adults attending an
outpatient appointment at a hospital 92 of respondents preferred a timely
diagnosis with older adults (lt50 years of age) more likely to prefer a timely
diagnosis compared to younger adults (Watson et al 2018) Herman et al
(2015) reported that early diagnosis and treatment of glycemia and
cardiovascular risk factors in type 2 diabetes may reduce the run-up time
between diabetes onset and clinical diagnosis and to allow for immediate
multifaceted treatment More recently several articles have called for more
timely diagnosis of diabetes in older adults because this vulnerable
population is at a high risk for diabetes-related complications including
cardiovascular urinary cognitive sensory and extremity (LeRoith amp Halter
2020 LeRoith et al 2019 Ha amp Kim 2015 Chentli et al 2015)
Older adults living in MUAs with type 2 diabetes also described their
desires and values for a health care provider that listens and responds to their
problems and needs Peoplersquos perceptions about their health care provider
listening to them has been reported on in the literature although with mixed
findings In analyzing the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) survey results for patients receiving care
at a public safety-net hospital Indovina et al (2016) found that patients gave
a positive assessment of their doctors listening carefully to them roughly
865 of the time during their hospital stay In a more recent survey Tran et
al (2020) reported that approximately 93 of patients surveyed believed that
133
during the last consultation their doctor listened attentively while they talked
Tran et al (2020) and Indovina et alrsquos (2016) studies stand in somewhat
contrast to Zhang et alrsquos (2020) study which found that patients admitted to a
tertiary hospital were least satisfied with ldquoHow nurses listened to patient
worries and concernsrdquo (134) and with nursersquos lack of awareness of the
patientrsquos needs (96) In addition Ospina et alrsquos (2019) study which found
that on average clinicians interrupted patients seven out of every ten times
while listening to patients for 11 seconds before interrupting them
It seems then that there is little to no benefit in clinicians asking
patients about their needs only to briefly listen to their patientsrsquo responses
before interrupting (Phillips amp Ospina 2017) Moreover in Tran et alrsquos (2020)
study ldquoDoctor listens attentively while patient talksrdquo was significantly
associated with higher patientsrsquo satisfaction with doctorsrsquo communication
Furthermore Lee et al (2016) research showed that when health care
providers listen to and respond timely to patient needs there is a positive
impact on patient perception of care
Older adults with type 2 diabetes living in MUAs in this study further
desired preferred and valued a long-time doctor-person relationship a
constant doctor for diabetes care and not one that frequently changed beyond
onersquos control This finding underscores previous research by Mold et al
(2004) that found older adults with multiple complex chronic health
conditions benefit on health outcomes from a sustained continuous
134
relationship with their health care providers Unfortunately fragmented
relationships between health care providers and patients are all too common
In the study by Mold et al (2004) the authors found a statistically
significant association between older adultsrsquo voluntary or involuntary change
of physician and duration of relationship More specifically Mold et al (2004)
found that approximately 72 to 92 of older adults surveyed reported an
involuntary change in PCP at some point during the course of their 10-year
provider-patient relationship The doctor leftdiedretired or insurancecost
issues were cited as the highest reasons Older adults in urban areas were
more likely to involuntarily change PCPs for insurance reasons (Mold et al
2004) In other national studies researchers have reported that approximately
11 to 19 of adults experience clinician discontinuity over a 12-month
period (Stransky 2017 Smith amp Bartell 2004) Stansky (2017) also found that
adults who were unemployed or had a lower income respectively were more
likely to have a change in their usual source of care
The effects of long-time doctor-person relationship have been reported
on in the literature In a survey of physicians conducted by Hines et al (2017)
approximately 45 perceived long-term relationships (LTRs) with their
patients have a great impact on clinical outcomes 65 believed that LTRs
contribute to patient trust and 52 believed that LTRs are more likely to
cause a patient to follow a clinicianrsquos medical recommendations Moreover
Stransky (2018) found that persons who lost their health care providers were
135
more likely to forgo getting medical care and needed medications Nam et al
(2019) analyzed the effect of provider continuity on type 2 diabetes outcomes
and found that the average incidence of diabetic complications per patient
was lower with a higher provider continuity score Furthermore previous
studies have reported that longer patient-provider relationships are
associated with greater patient satisfaction more confidence in onersquos
physician and better communication with providers (Donahue et al 2005
Smith amp Bartell 2004 Mold et al 2004 Safran et al 2001)
Finally older adults with type 2 diabetes living in MUAs in this study
valued a doctor who ensured their medications were administrated safely and
accurately Older adults in this study also desired the right medications and
preferred medications that does not cause adverse side effects such as
hypoglycemia Polypharmacy was also an issue that the older adults in this
study valued their doctor addressing
De-intensification of diabetes medication treatment which is a
decrease or discontinuation of any antidiabetic drug without adding another
drug or a reduction in the total daily dose of insulin with or without adding a
drug without risk of hypoglycemia is recommended in elderly patients with
strict glycemic control at high risk of hypoglycemia (ADA 2021b Pirela amp
Garg 2019 Seidu et al 2019)
Maciejewski et al (2018) conducted a study that examined rates of
overtreatment and ldquodeintensificationrdquo of medication therapy for older adults
136
with diabetes The authors research suggested that overtreatment for
diabetes occurred in almost 11 of the older adults as indicative of having
had very low ongoing blood sugar levels (Maciejewski et al 2018)
Maciejewski et al (2018) research also showed that older adults over 75
years of age and low-income dually eligible under Medicare-Medicaid
respectively were significantly more likely to be overtreated for diabetes Of
the older adults who were overtreated approximately 14 received
reductions in diabetes medication refills within six months following the index
HbA1c (Maciejewski et al 2018) Treatment deintensification was significantly
more likely in urban areas compared to rural areas (Maciejewski et al 2018)
However older adults over 75 years of age were less likely to have their
medications de-intensified (Maciejewski et al 2018) Thus Maciejewski et
alrsquos (2018) study suggested that proper prescribing for older adults with
diabetes based on their needs may provide relief from unintended side effects
that results from glycemic levels out of targeted range
Furthermore some older adults in this study cited not taking diabetes
medication due to its adverse side effects and in doing so they would avoid
severe hypoglycemia This finding is consistent with previous studies that
show people with diabetes who take certain types of medications to lower
their blood sugar sometimes experience extreme hypoglycemia (Kalra et al
2013 Lipska et al 2013 Miller et al 2010) Vijayakumar et al (2020)
reported that approximately 30 of patients in their study had a decrease in
137
their diabetes medication fills 6-months after experiencing a hypoglycemia-
related encounter (ie emergency department visit observation stay or
hospital admission) Thus while not taking diabetes medication to avoid serve
hypoglycemia was preferred in this study physicians should work with their
older patients to personalize medication regiments to increase or decrease
drugs to control the side effects
Whether a patient is prescribed the right medication prescribed a
dosage as to prevent undue medication side effects or the elimination of
unnecessary medications these are measures of process from which
inferences are made about the effectiveness and efficiency of care
(Donabedian 1982) Safe medication administration by health care providers
including using specially trained nurses or pharmacists is associated with
significant improvements in glycemic control non-glycemic measures such as
low-density lipoprotein cholesterol triglycerides and systolic and diastolic
blood pressure and lower likelihood of polypharmacy and adverse events
related to it (Parulekar amp Rogers 2018 Davidson 2009 Al Mazroui et al
2009 Davidson 2007 Choe et al 2005 Krein et al 2004) Thus health
care providers should work with their older patients to personalize medication
regiments to increase or decrease drugs to control the side effects as
reflected by the desires preferences and values of the older adults with type
2 diabetes living in MUAs in this study
138
Information Sharing and Provider Communication Additionally
older adults living in MUAs in this study desired preferred and valued
information sharing and provider communication in the diabetes health care
they received The subthemes were categorized as informational and
relational The significance of interpersonal communication between the
doctor and patient in quality care has been well documented by Donabedian
(1988 1990) For example Donabedian (1982) highlighted instruction to the
patient on aspects of self-management as a dimension of process Previous
evidence highlighted that when patientrsquos values needs and preferences are
incorporated into cultivating communication for example sharing information
and making recommendations they become more active participants in their
care which may improve patient outcomes such as understanding and
adherence to medication regimens and overall satisfaction with care
(Teutsch 2003 Beck et al 2002 Mead et al 2014)
Informational subthemes reflected those processes of care described
in the ADArsquos (2020a) medical evaluation and assessment standards of
medical care For example the older adults in this study valued information
and recommendations from their health care provider intended to support with
optimal diabetes self-management According to ADArsquos (2020a) standards of
medical care in diabetes effective communication between the health care
provider and person with diabetes should ldquofoster a collaborative
relationshiphellip[and] use language that is strength based respectful and
139
inclusive and that imparts hoperdquo (pS38) In addition at each visit a doctor
should be evaluating diabetes self-management skills and barriers and
educating about self-care (ADA 2020a) The subthemes that emerged in this
study were consistent with ADArsquos (2020a) guidelines
Older adults in this study desired and valued information from online to
help with diabetes self-care Older adults in this study found social media and
mobile technology key to supporting optimal type 2 diabetes self-
management Luxford et al (2011) suggested that supportive information
technology are important facilitators that may improve care delivery focused
on meeting patientrsquos needs and preferences In addition technology
preferences of the person at the center of the care are important processes of
health care delivery to improve the health status (Donabedian 2003) Despite
this evidence older adults and underserved communities experience limited
access to technology and the internet as described below
While roughly four-in-ten older adults reports owning a smartphone
approximately 30 of adults earning less than $30000 a year do not own a
smartphone (Pew Research Center 2017b 2019a) A recent survey reported
that 15 of older adults in the US go online using their smartphone 15
used the internet or email to communicate with doctors or other medical
professionals while 52 searched online for health information (Pew
Research Center 2019b 2020) Even then older adults racial and ethnic
minorities and underserved communities are less likely to have broadband
140
access at home (Pew Research Center 2019c) Vaportzis et al (2017)
reported that older adults experience health-related barriers such as poor
eyesight and arthritis when using tablets or other technology equipment
Grindrod et al (2014) reported that older adults who have less experience
using apps for health information are often confused because of ambiguous
in-app symbols or the functionality may not be ldquoolder adultrdquo friendly or too
complex Pal et al (2013) conducted a systematic literature review that
showed computer-based diabetes self-management interventions had limited
effectiveness on glycemic control
Despite these limitations of technology use among older adults and
digital technology efficacy on diabetes control a recent study stated that older
adults are embracing the use of digital technology (Andrews et al 2019)
Access to digital technology including mobile health information and online
health services and tools has the potential to improve chronic disease
outcomes as highlighted in this study A recent survey reported that 52 of
older adults in the US searched online for health information (Pew Research
Center 2020) Kim and Song (2008) reported that adults with type 2 diabetes
who accessed a web site by using cellphones or computer internet services to
receive educational information for diabetes self-management had a
statistically significant decrease in HbA1c compared to adults who received in-
person educational information from the physician Similarly a randomized
controlled trial conducted by Kumar et al (2020) showed that using a mobile
141
application for health information on diabetes lifestyle modification and
medication management improved quality of life for intervention group
participants compared to the non-intervention group
The digital technology challenges highlighted above should be
addressed to ensure older adults get the full benefit of using digital
technology to support type 2 diabetes self-management In the meantime the
older adults living in MUAs in this study valued and desired the use of
smartphones and tablets to access health information from online to help with
diabetes self-management
Finally in this study older adults with type 2 diabetes living in MUAs
preferred and valued relational communication processes in their
relationships with health care providers For example older adults in this
study valued a health care provider that discusses things that interest them
ldquoRelational communication can be described as those identifiable verbal and
nonverbal behaviors that carry message value about the type of relationship
the communicators sharerdquo (Step et al 2009 p 3) Relational communication
reflects the quality of the communication between the health care provider
and the person at the center of care (Step et al 2009) Shay et al (2012)
found that positive physician relational communication is associated with
patients feeling that their physician understood their health care preferences
and values Furthermore past studies have demonstrated that positive
relational communication between the provider and person at the center of
142
care is associated with improved health behaviors fostering hope greater
emotional self-management adherence to self-care significant health and
psychological benefits including less anxiety and emotional distress greater
patient satisfaction reduction in health care disparities lower health care
costs and improved life expectancy (Epstein amp Street 2007 Step et al
2009 Burgoon et al 1987) In contrast negative relational communication is
associated with patient psychological distress feeling dehumanized and
despair (Thorne et al 2008)
Older adults in this study also valued receiving diabetes care
information from their health care provider by telephone The role of
synchronous versus asynchronous communication between the patient and
the provider is important due to the value of selecting the right method based
on patient preferences for the given clinical situation Synchronous
communication including the use of the telephone as a communication tool
for health care providers to interact with diabetic patients has been widely
studied
Becker et al (2017) conducted a randomized study evaluating the
effectiveness of telephone support and counseling on HbA1c control of elderly
people with type 2 diabetes Intervention group participants received 16
telephone support calls over four months (four calls per month) The control
group received their information through the mail The study demonstrated
mixed results At baseline the intervention group showed statistically
143
significant poor glycemic control compared to the control group Participants
receiving the telephone diabetes support and counseling showed statistically
significant reductions in the values of fasting blood glucose and HbA1c
Control group participants showed a reduction in fasting blood glucose
although not significant However there were no significant differences in
values for fasting blood glucose or HbA1c respectively between the
intervention and control groups Becker et alrsquos (2017) study demonstrated
that telephone support and counseling is an effective strategy of educating
elderly people with diabetes and will help achieve HbA1c optimal levels
In a separate study Ward et al (2018) evaluated the effectiveness of a
pilot program that for patients who received telephone-only versus mixed-
modalities (ie any combination of telephone videoconferencing and in-
person appointments) medication management and diabetes self-
management education from certified diabetes educators (CDE) The study
results showed that HbA1c was significantly improved in both groups (percent
change in HbA1c -12 for telephone-only versus -09 for mixed-modality) from
baseline to follow-up Participants in the telephone-only group had more
medication management interactions with the CDE compared to the mixed-
modality group 61 versus 37 The results from Ward et alrsquos (2018) study
demonstrated that receipt of telephone care for diabetes self-management
education has the potential to improve type 2 diabetes outcomes for adults
144
Walker et al (2011) conducted a randomized study involving low-
income urban adults to assess the effectiveness of a telephone versus print
intervention delivered by health educators to improve type 2 diabetes control
At one-year follow-up a statistically significant difference was observed in
that the telephone group had a mean HbA1c decline of 011 compared to a
mean HbA1c increase of 013 in the print group The statistically significance
difference remained after adjusting for baseline HbA1c sex age and insulin
use The results from Walker et alrsquos study (2011) is consistent with other
studies that show telephone diabetes care delivered by health care providers
has the potential to improve type 2 diabetes self-management for adults in
low-income communities
Other studies have shown mixed results for telephone diabetes care
impact on diabetes outcomes McFarland et al (2012) conducted a
nonrandomized parallel control-group study that showed no statistically
significant difference in mean HbA1c reduction from baseline to six months
follow-up for patients with poorly controlled type 2 diabetes who received
medication therapy management by a clinical pharmacy specialist either
through home telemonitoring versus telephone follow-ups between their face-
to-face visits Similar results were reported by Greenwood et al (2014) in
which adults receiving diabetes self-management support delivered via
telephone versus secure message had no significant difference in total mean
HbA1c from baseline to nine-month follow-up
145
Despite the mixed results on the effectiveness of telephone diabetes
care on diabetes outcomes telephone care may still have potential benefits
on diabetes outcomes The older adults living in MUAs in this study valued
receiving telephone care from their health care providers to support with type
2 diabetes self-management
Attributes of Health Care Providers Older adults living in MUAs in
this study highlighted a whole host of essential attributes that they valued in
their health care providers According to Donabedian (1982) the attributes of
health care providers are a fundamental process-related dimension of care in
the management of the interpersonal relationship between the practitioner
and the patient is a necessary conduit in the application of technical care and
contributes to health care quality
Older adults interviewed valued a caring health care provider Wen and
Tucker (2015) conducted a qualitative study that showed patients valued a
doctor who is caring and compassionate as well as having pleasant
interactions with other staff in the doctorrsquos offices However just over half
(57) of Americans say medical doctors care about their patientsrsquo best
interest all or most of the time (Pew Research Center 2019d)
Furthermore older adults living in MUAs in this study valued an honest
health care provider Physician honesty with patients is said to be associated
with reduced risk of misdiagnosis and improper or inadequate treatment
unnecessary worrying about the cause of a medical problem or complication
146
informed decision-making or increased trust in physicians (Zolkefli 2018 Wu
et al 1997)
However only about half (48) of Americans say medical doctors
provide fair and accurate information when making recommendations all or
most of the time (Pew Research Center 2019d) A study in Health Affairs
revealed that some physicians are not always honest with their patients The
authors of the study reported that 34 of physicians surveyed did not think
they should disclose serious medical errors to patients 20 said they did not
disclose an error within the previous year for fear of a malpractice claim and
slightly over 10 said they told their patients something that was not true
within the previous year (Iezzoni et al 2012) Failure of health care providers
being honest with the person at the center of the care about their condition
and prognosis can lead to the personrsquos false hope (Ngo-Metzger et al 2008)
Despite these disturbing pervious findings the older adults with type 2
diabetes living in MUAs in this study expressed that consideration for the
health care provider-person relationship indicates that honesty may lead to
the patient trusting treatment and management recommendations thereby
improving adherence and type 2 diabetes outcomes
Trust in their health care provider was another attribute valued by older
adults interviewed Chandra et al (2018) conducted a systematic literature
review that showed patient trust in the doctor-patient relationship is positively
associated with patient satisfaction and perceived quality of health care
147
services Physician trust has been associated with adherence to treatment
(Altice et al 2001) However previous research has shown mixed results in
the percentage of patients who trust their health care provider For example
Kao et al (1998) research showed that only 604 of the respondents
surveyed completely trusted their physician ldquoto put their medical needs above
all other considerations when treating their medical problemsrdquo An estimated
30 of the respondents completely trusted their health insurance company
ldquoto put their medical needs above all other considerationsrdquo while
approximately 10 of the respondents did not trust their health insurer at all
(Kao et al 1998) In 2012 only 34 of Americans expressed trust in the
leaders of the medical profession (Blendon et al 2014) In 2014 public trust
in the health care system was down to only 23 (Blendon et al 2014)
Health care provider behavior is key to garnering patient trust (Fiscella
et al 2004) Mistrust of the health care system is associated with not taking
medical advice not keeping a follow-up appointment postponing receiving
needed medical care and failing to fill a prescription (LaVeist et al 2009)
Building patient trust through onersquos behavior is essential to delivering care
that older adults with type 2 diabetes living in MUAs value
Social Support Social support was a theme that emerged from the
data The social support that emerged from the interviews was instrumental
and informational Older adults living in MUAs in this study discussed their
desires preferences and values for social support for diabetes care received
148
from family friends and peers health care providers and community For
example older adults living in MUAs in this study valued involvement of
family with scheduling and attending doctorrsquos appointments and providing
information to support diabetes self-management
Boise and White (2004) conducted a study that showed patients
preferred to incorporate their family into the care delivery process
Additionally studies have highlighted the value of family members supporting
self-management needs and preferences of patients (Institute of Medicine
2013) Pfaff and Markaki (2017) conducted a study that showed patients
valued supportive human resources such as family as important partners in
their care The ADA and the American Geriatrics Society have emphasized
the importance of including older adultsrsquo family and other caregivers as
partners involved in DSMET to increase the likelihood of successful self-
management behaviors (Kirkman et al 2012 Suhl amp Bonsignore 2006)
Despite the evidence supporting the inclusion of older adultsrsquo family and
friends in processes of care unfortunately the older adults interviewed in this
study did not identify social support through the inclusion of family and friends
as a process of care they received from their health care providers
This studyrsquos finding of older adults with type 2 diabetes living in MUAs
not identifying social support through the inclusion of their family and friends
as a process of care elicited by their health care providers is consistent with a
lack of health care providers involving family members in patient care
149
(Carmen et al 2013) In addition previous studies reported family member
accompaniment to older adultsrsquo medical visits occur approximately 20 to
60 of the time (Wolff amp Roter 2008 2011) Other studies have also shown
that family members lack clear instruction from providers on how they can
participate in the care of their elderly loved one (Belanger 2018 Li et al
2000)
To the contrary of previous research it is clear from this study that
older adults with type 2 diabetes living in MUAs valued involving family
members in care processes to help support with diabetes self-management
This finding is aligned with other studies that show a positive statistically
significant association between good family support and improved diabetes
self-management for people who live in urban areas as well as
improvements in HbA1c and other clinical outcomes (Ravi et al 2018
Pamungkas et al 2017)
Furthermore approximately 30 of the older adults in this study
reported financial strain or the inability to pay for very basics like medical
care or bills Older adults living in MUAs in this study valued financial
assistance they received with diabetes care costs from their health care
providers family or friends For example this study showed that older adults
with type 2 diabetes living in MUAs valued receiving financial assistance with
purchasing insulin and diabetes supplies
150
Older adults with diabetes may experience increased financial burden
and have lower economic resources compared to their middle-aged
counterparts (DeNavas-Walt amp Proctor 2015) For example it is estimated
that nearly 15 of older adults in the US live below the federal poverty line
(DeNavas-Walt amp Proctor 2015) According to the ADA (2018b) the average
per person cost of health care for adults aged 65 or older with diabetes is
$13239 per year which includes insulin and diabetes supplies This is 50
more than the per person health care cost of younger people (ADA 2018b)
The association between financial strain and diabetes processes of
care and outcomes for older adults have been reported in the literature
Assari et alrsquos (2017) studied showed no association between low
socioeconomic status and glycemic control in urban adults However Walker
et al (2021) reported a significant relationship between experiencing
increasing financial hardships with an increase in HbA1c for older adults with
diabetes which suggest that fewer financial hardships is associated with
better glycemic control Other studies showed a significant relationship
between the increased cost of diabetes medication and medication non-
adherence (Kang et al 2018 Berkowitz et al 2014)
These previous findings coupled with the findings of this study which
show older adultsrsquo living in MUAs value financial assistance with diabetes
care cost should spur health care providers to identify structure and process
strategies to address the ongoing financial strain of older adults with diabetes
151
living in MUAs This may aid this vulnerable population with achieving optimal
diabetes control
Lastly older adults in this study discussed a range of community social
services supports that they desire prefer and value to address their SDoH ndash
food and transportation ndash to support with diabetes self-care The Donabedian
Model of Care as originally constructed has served as a flexible framework
that has been used to conceptualize the health care system However the
framework does not take into consideration the SDoH beyond medical care
(Institute of Medicine 2001) Yet previous research has described how care
processes can be adapted to more effectively address the SDoH (Beck et al
2016)
Furthermore previous research has highlighted the value of identifying
and addressing SDoH within care that meets patientsrsquo needs preferences
desires and values (Pirhonen et al 2017 Garg et al 2013) However
according to a study published by Fraze et al (2019) approximately 24 of
US hospitals and 16 of US physician practices reported screening for
SDoH in view of the finding that 80 of hospitals and 33 of practices
reported no screening Screening for transportation needs and food insecurity
occurred with 740 and 398 of hospitals and 354 and 296 of
physician practices respectively (Fraze et al 2019) These screening results
coupled with the findings from this study underscore the need to increase
SDoH screening rates for older adults with type 2 diabetes living in MUAs
152
Screening this vulnerable population for SDoH so that the proper social
services support may be offered to address older adults with type 2 diabetes
living in MUAs unmet social needs may improve diabetes outcomes
For example according to Schroeder et alrsquos (2019) longitudinal cohort
study of older adults with type 2 diabetes those who were food secure were
significantly less likely to have an emergency department visit or
hospitalization compared to those who were food insecure In addition older
adults who were food secure had lower HbA1c levels (Schroeder et al 2019)
Bergmans et al (2019) conducted a study that examined the relationship
between food insecurity and diabetic morbidity among older adults When
controlling for covariates older adults who were food insecure had a 17
times higher odds of poor diabetes control compared to those who were food
secure (Bergmans et al 2019)
In addition support for transportation access may prove beneficial for
the diabetes outcomes of older adults such as reducing rescheduled or
missed appointments delayed care and missed or delayed medication use
For example rural low-income older adults with diabetes who had access to
transportation had significantly more diabetes care visits for routine care
compared to low-income younger people (Thomas et al 2018) Access to
and use of adequate public transportation is associated with more routine
chronic care visits compared to those who do not use public transportation
(Arcury et al 2005) In contrast Tierney et al (2000) found that primary care
153
visits and visits for medication refills declined when the state Medicaid payor
restricted payments for transportation for low-income inner-city adults Li et al
(2020) found no difference in the mode of transportation to primary care visits
and the level of satisfaction with primary care among older adults
The previous findings from the literature and the results from this study
that show older adults with type 2 diabetes living in MUAs desire prefer and
value receiving community assistance with social services to address their
unmet social needs suggest that processes that support greater access to
healthy and nutritious foods and transportation for this vulnerable population
may improve diabetes self-management outcomes
Older Adultsrsquo Diabetes Self-Management Behavioral Strategies
Lastly older adults living in MUAs in this study identified a range of self-
management behavioral strategies for diabetes control All of the physical
diabetes self-management behaviors that emerged from the interviews with
the older adults in this study are a part of the AADE (2020) seven self-care
behaviors essential for successful and effective diabetes self-management
Actions done by patients such as self-management tasks are processes of
care (Donabedian 1982) Self-management behavioral strategies for
diabetes control are associated with improvements in patient-reported
outcomes
For example older adults living in MUAs in this study discussed the
importance of taking diabetes medication regularly Adherence to diabetes
154
medications is associated with lower probability of hospitalization and
emergency department visits shorter length of stay in the hospital improved
glycemic control and better perceived quality of life (Curtis et al 2017
Capoccia et al 2016 Krass et al 2015 Khayyat et al 2019) Furthermore
with a medication possession ratio (MPR) of ge80 over the period of
observation defined as optimal adherence previous research has reported
that MPR ge80 for patients with diabetes have ranged from approximately
37 to 58 (Clifford et al 2014 Farr et al 2014 Cramer et al 2008) In
addition Rogers et al (2017) conducted a cross-sectional survey study that
showed patient experiences with medication adherence self-management
tasks (for example organizing taking and adjusting medications) were
associated with patient-reported outcomes of lower diabetes distress
improved general physical and mental health and medication adherence The
important concern to note here is that older adults with diabetes in
underserved communities have long struggled with medication adherence
and health care providers can assist this vulnerable population to become
more adherent to their diabetes medication by encouraging mail order
pharmacy use providing coaching on problem-solving skills to manage daily
barriers to medication adherence addressing polypharmacy linkages and
referrals to address SDOH building patient trust or involving family and
friends (Smaje et al 2018 Bailey et al 2012 Ramachandran et al 2020
155
Hill-Briggs 2003 Yap et al 2016 Zelko et al 2016 Hill-Briggs et al 2020
Polonsky amp Henry 2016)
Diabetes numeracy or the ability to use math calculations to adjust
medications based on onersquos blood glucose readings as cited by the older
adults living in MUAs in this study has important effects for diabetes
outcomes Nandyala et al (2018) reported that for every 1-point increase in
numeracy skills adults with type 2 diabetes were 19 times significantly more
likely to have optimal medication adherence Turrin and Trujillo (2019)
reported in their exploratory observational cross-sectional study that adults
with lower Diabetes Numeracy Test (DNT-15) scores were more likely to have
higher HbA1c scores compared to adults with higher DNT-15 scores (80
versus 75 p = 004) In a similar cross-sectional study higher diabetes-
related numeracy was significantly associated with lower HbA1c levels
(Osborn et al 2009) Higher diabetes-related numeracy has also been
reported to be associated with greater perceived self-efficacy for diabetes
self-care and greater diabetes knowledge (Cavanaugh et al 2008)
In addition to patientsrsquo individual diabetes-related numeracy skills
health care providers and the educational setting has played a pivotal role in
diabetes-related numeracy Zaugg et al (2014) reported that diabetic patients
who received care from diabetologistendocrinologists in a diabetes-focused
center had statistically significant better numeracy scores on the Diabetes
Numeracy Test compared to patients who received care from PCPs in
156
primary care facilities Zaugg et al (2014) further reported that taking diabetic
pills rather than insulin may make a positive difference in diabetic numeracy
levels for patients
Conversely there are several concerns to note about diabetes
numeracy In a study by Turrin and Trujillo (2019) older adults were
significantly more likely to have lower DNT-15 scores Osborn et al (2009)
reported that African Americans were significantly more likely to have lower
DNT-15 scores compared to Whites Other determinants of low DNT-15
scores included only attaining a high school diploma or GED or lower income
(Osborn et al 2009) Low health literacy in type 2 diabetic adults has also
been reported to be associated with lower diabetes-related numeracy
(Abdullah et al 2019 Al Sayah et al 2013 White et al 2010 Cavanaugh et
al 2009) And finally Zaugg et al (2014) reported no association between
higher numeracy scores and better glycemic control Health care providers
attention to diabetes numeracy in older adults living in MUAs may improve
medication adherence for this vulnerable population
Older adults living in MUAs in this study discussed the importance of
regularly attending doctor visits as a strategy to manage their type 2 diabetes
and build self-confidence to manage their diabetes This finding is interesting
in light of McCarlie et alrsquos (2003) study that suggested adults age 70 years
and older are more likely to miss their diabetes appointments compared to
157
younger people but this has not been further substantiated in other studies
(Diaz et al 2017 Low et al 2016)
Nevertheless previous research has suggested that consistent visits to
the doctors may lead to better glycemic control For example Karter et al
(2004) in their cross-sectional study reported that adults who attended all their
outpatient appointments for primary care and HbA1c measurements during a
1-year period had significantly better adjusted mean HbA1c Karter at alrsquos
(2004) study also reported that adults who missed less than 30 of their
medical appointments were more likely to practice daily self-management of
blood sugar and had better oral medication refill adherence Other studies
have reported a positive relationship between glycemic control and medical
appointment attendance (Alvarez et al 2018 Diaz et al 2017)
Even in light of the positive effect regularly attending doctorsrsquo visits has
on diabetes glycemic control whether or not someone attends their doctorrsquos
appointment may be extraneous to other factors independent of appointment-
keeping For example the literature has suggested that the following reasons
for non-attendance to diabetes appointments forgetfulness long wait times
lack of continuity and coordination between providers geographical location
financial difficulties and a dislike of health care providers (Akhter et al 2012
Ryu amp Lee 2017 Archibald amp Gill 1992 Campbell-Richards 2016
Heydarabadi et al 2017 Lawson et al 2005)
158
Notwithstanding the extraneous factors that are associated with
missed diabetes appointments and that must be acknowledged by health care
providers the older adults living in MUAs in this study discussed the
importance of regularly attending doctor visits as a strategy to manage their
type 2 diabetes and build self-confidence to manage their diabetes
Older adults living in MUAs in this study also valued group-based
training made up of their peers as a source for helping them to learn
strategies to better control their blood glucose levels Group-based peer self-
management education trainings for people with uncontrolled and controlled
diabetes has been explored previously and the results are promising for
improving diabetes health outcomes and lowering risk of diabetes
complications albeit a few noteworthy extraneous factors to consider (Tay et
al 2021 Odgers-Jewell et al 2017 Gatlin et al 2017 Patil et al 2016)
Debussche et al (2018) conducted a randomized controlled trial of
adults with type 2 diabetes in a low-income low-resource setting that
assessed the effects of a peer-led structured education group delivered in the
community on the primary outcome of mean change in HbA1c from baseline to
12 months Intervention group participants had a significant decrease in
HbA1c levels compared to control group participants who received
conventional care alone (percent change of -105 versus -015 p = 0006
Debussche et el 2018) Intervention group participantsrsquo diabetes knowledge
(eg problem-solving symptoms treatment and hypoglycemia management)
159
scores improved slightly compared to the control group although not
significant (Debussche et al 2018)
In Gambao Moreno et alrsquos (2019) randomized controlled trial of adults
the researchers conducted a 25-hour peer-to-peer diabetes self-
management program workshop once a week for six consecutive weeks that
showed no significant differences between intervention and control groups on
HbA1c change at 24 months follow-up However Gambao Moreno et alrsquos
(2019) research did report a statistically significance increase in overall self-
efficacy score for the intervention group Intervention group participants also
reported significantly lower medication consumption (number of drugs) and
emergency department visits over the study period compared to the control
group (Gambao Moreno et al 2019)
In Patil et alrsquos (2016) meta-analysis of diabetes self-management
peer-to-peer educational interventions the authors reported that significant
improvements in HbA1c were observed in the intervention group in studies
with predominantly minority participants Patil et al (2016) further highlighted
some noteworthy yet cautioning factors when considering the effectiveness of
diabetes self-management peer-to-peer educational interventions For
example the authors underscored that the diabetes peer support curriculum
should be culturally tailored to the needs preferences and values of the
participants (Patil et al 2016) The authors also reported that peer-to-peer
diabetes management or group education sessions are most effective for
160
those having poor self-management skills poor baseline diabetes support
and lower levels of health literacy (Patil et al 2016)
A review of the literature demonstrated that group-based self-
management education between peers may be effective in improving
glycemic control for people with diabetes Previous findings regarding group-
based peer diabetes self-management education are encouraging in light of
the older adults living in MUAs in this study valued this educational
mechanism as a diabetes self-management behavioral strategy
Another diabetes self-management behavioral strategy expressed by
older adults living in MUAs in this study was prayer Prayer for the older
adults interviewed was an action valued that gave them hope for a better
outcome helped them to cope with their type 2 diabetes and empowered
them with the strength to gain greater internal control over their type 2
diabetes Prayer has been identified as a complementary and alternative
medical treatment among persons with diabetes (Yeh et al 2002 Dham et
al 2006 Bell et al 2006)
Most physicians believe prayers could promote healing and positive
outcomes (Curlin et al 2007 Larimore et al 2002) In a related and
separate study most physicians believed they should pray with their patient
(Monroe et al 2003 Larimore et al 2002) However the researchers also
reported that most physicians donrsquot know if or when to engage their patients
about prayer (Monroe et al 2003 Larimore et al 2002) In a more recent
161
study approximately 21 of physicians reported praying with patients
(Robinson et al 2017) Yet nurses in faith-based settings are highly likely to
engage patients in prayer (Taylor et al 2018)
Previous research has shown how prayer over ones illness is
associated with more improved patient well-being happiness hope high self-
esteem and a greater sense of internal control over life (Koenig 2012) Olver
and Dutney (2012) conducted a randomized blinded study that showed
intercessory prayer was associated with a statistically significant improvement
in spiritual well-being as well as an improvement in emotional well-being
Hunt et al (2000) conducted a qualitative study in which participants with type
2 diabetes said prayer influences health by reducing stress and anxiety
promoting disease management and bringing healing power to medicines
When controlling for demographic medical and depression variables Ai et al
(2009) research showed that a one-unit increase in prayer frequency was
associated with nearly 15 times the likelihood of no-complication following
major heart surgery Ai et alrsquos (2009) finding is consistent with other studies
that showed certain positive effects of prayer on health outcomes (Miller amp
Thoresen 2003 Masters amp Spielmans 2007) Consideration to patientsrsquo
spiritual needs through prayer and thus providing spiritual care can
strengthen the patient-provider relationship (King amp Bushwick 1994 Phelps
et al 2012)
162
Roughly 19-90 of adults would like their physician to speak with
them about prayer although in several studies it depended on the
environment for example if it came during routine office visit in a
hospitalized setting or in a near-death scenario (Behan et al 2012 Mann et
al 2005 Masters amp Spielmans 2007 MacLean et al 2003 Larimore et al
2002)
Previous studies have highlighted how prayer is an important factor
that positively influenced self-management of type 2 diabetes (Gupta amp
Anandarajah 2014 Polzer amp Miles 2007 Samuel-Hodge et al 2000) For
older adults with type 2 diabetes living in MUAs in this study turning to prayer
was a source comfort in dealing with their diabetes and a source of strength
in empowering them to achieve better self-management
In conclusion health care providers can engage adults in managing
their care by discussing explaining supporting and building capacity for self-
management and self-care (Mead amp Bower 2002) Health care providerrsquos
instruction to the patient on characteristics of effective diabetes management
and self-care is a category of interpersonal process of care (Donabedian
1982) When health care providers engage patients on self-care behavioral
strategies to better control their diabetes they are more successful in carrying
out self-management tasks (Mead amp Bower 2002)
Limitations
163
There are several limitations worth mentioning in interpreting these
findings The sample was recruited from four senior housing facilities where
the residents are close-knit and the researcherrsquos ability to gain trust was an
important factor in recruitment and getting the participants to open-up during
the interviews The researcherrsquos study was exploratory in nature in an under-
studied population and so the ending sample size was purposefully small
A non-randomized sampling approach was used and the results may
not be generalizable Although this studyrsquos results are not generalizable to
other environments careful consideration was taken to achieve site
triangulation by recruiting from four senior housing facilities across two
geographical disparate locations In addition while generalizability may be a
limitation in this study in considering that the intent of this study was to fill a
gap in the literature by providing a voice to older adults living in MUAs
regarding their experiences desires preferences and values for type 2
diabetes treatment and management care received that may improve their
diabetes self-care and outcomes Therefore the results of this study may only
be applicable to similar populations who may share similar life experiences to
the older adults in this study based on their background socioeconomics or
resources
Furthermore recruitment was voluntary and recruitment may have
selected participants that were more motivated to share their experiences or
164
engage in medical care If this were the case this research would most likely
overestimate participants perspectives about the health care system
This study relied on self-reported data where each individual gave their
own perspectives on health care received that was not validated with the
participants health care providers Therefore this study is limited in its effect
to reflect how health care providers practicing in MUAs perceive the
processes of diabetes care they deliver contributes to improving diabetes self-
management and outcomes of older adults living in MUAs
Finally given the researcherrsquos lived experiences involving the plight
that health disparities have on chronic disease outcomes in MUAs and
potential opportunities to improve quality of care for this vulnerable
population this study may be limited due to social desirability tendencies in
the nature of the researcherrsquos positive follow-up questions asked and
responses given to participantsrsquo responses that may be similar to the
researcherrsquos own systems of values attitudes and beliefs in relationship to
the phenomena under study However the researcher took steps to guard
against social desirability bias prior to and throughout the interviews and
analysis by developing a positionality statement to evaluate and guard
against his own systems of values attitudes and beliefs in relationship to the
phenomena under study The researcher read and reflected on the
positionality statement prior to the start of the first interview throughout the
course of the interviews during data analysis and writing the studyrsquos results
165
In addition the researcher was proactive in asking participants to recall a
personal experience with their health care provider that would expound upon
the response given
Implications for Care
Results from this qualitative study are a step in the right direction
towards gaining a better understanding of older adults living in MUAs desires
preferences and values for individualized type 2 diabetes care that could
achieve quality outcomes To further center care on the needs desires and
preferences of older adults with type 2 diabetes living in MUAs health care
providers can act on lessons learned about what this population values in the
treatment and management care they receive
The older adults living in MUAs in this study reported that they value
their family providing information for diabetes self-management Thus health
care providers can ensure the inclusion of older adults living in MUAs
perspectives in their clinical operations by involving family in self-
management education and care Delivering diabetes care with family support
is an essential part of sustaining self-care behaviors and improving the health
outcomes of older adults with type 2 diabetes living in MUAs Future delivery
of diabetes care and self-management education in MUAs should focus on
older adultsrsquo family engagement in care
Additionally the older adults living in MUAs in this study valued
instrumental support received from family and friends with diabetes self-
166
management activities However there remains opportunities for
improvement with assisting older adults in achieving the AADE 7 Self-Care
Behaviors (2020) Individualized diabetes care plans should clarify and define
caregiver roles within DSMET based on the needs preferences desires and
values of older adults living in MUAs
For older adults living in MUAs that live in senior housing facilities
health care providers should take diabetes care education classes and
resources to their place of residence to ensure greater access to these
services Diabetes home health care services for older adults living in MUAs
that live in senior housing facilities should be comprehensive to include
visitation from a nurse or medical assistant to administer medication monitor
blood glucose blood pressure and general health and other generalsocial
services support as described by the older adults living in MUAs in this study
While home health care normally implies the delivery of medical care as seen
through this study older adults living in MUAs valued in-home dietary
assessments and guidance on meal planning from dietitians home delivery of
medicine and medical equipment and home-delivered diabetic-friendly
meals This finding is important because the older adults living in MUAs in this
study reported transportation problems with getting to the services they need
for example doctorsrsquo appointments or the grocery store Bringing health care
services into the homes of older adults living in MUAs may prove beneficial to
167
addressing transportation barriers to and from doctorrsquos appointments food
access and medication access
Furthermore older adults living in MUAs with type 2 diabetes valued
care that is affordable available and accessible Health care providers can
ensure their organizational structure is designed so that this population is able
to get the right services at the right time For example providers can ensure
they have the requisite resources such as technology to meet the needs of
older adults Providers can also encourage older adults living in MUAs to use
trusted web-based platforms or social media sites that can enhance their
diabetes self-management knowledge and behaviors Additionally systems of
care can ensure their services are geographically accessible by ensuring
older adults in MUAs can physically reach the providerrsquos location with ease or
able to receive services within the comfort of their home for example medical
care or home delivery of medications
Funding and policies that provide greater access to DSMET programs
for older adults in MUAs is warranted These programs should be tailored to
the needs preferences and values of older adults living in MUAs Bringing
DSMET programs close to the homes of older adults in MUAs especially
those that live in senior housing facilities may help reduce transportation
barriers that may be impediments to attendance Health care provider
referrals and linkages to DSMET programs may help to increase uptake of
168
evidence-based self-management programs that improve behaviors that
contribute to healthier outcomes among the elderly living in MUAs
The older adults living in MUAs in this study provided keen insights into
their diabetes self-management behavioral strategies Older adults living in
MUAs in this study were exhibiting several behavioral self-care strategies
recommended by the AADE (2020) Health care providers can act on this
information to better empower older adults living in MUAs with diabetes self-
care For example identification of older adults living in MUAs with low
diabetes numeracy may allow for the delivery of tailored diabetes education to
meet the personrsquos needs that could help to improve glycemic control
Older adults in this study valued the role of spirituality as an important
strategy in their diabetes self-care and daily life Health care providers can
benefit from education and training in spiritual care as a way to integrate
prayer into diabetes health care services that meet older adults living in
MUAsrsquo needs preferences and values
Older adults living in MUAs in this study discussed the value of
regularly attending doctor appointments as a strategy to manage their type 2
diabetes Providers could focus on strategies to remind older adults living in
MUAs about their appointments such as through telephone calls or text
messages or using the electronic health record to identify patients with
missed appointments that could be targeted for outreach Additionally health
care providers simply asking older adults living in MUAs if they have family
169
that can support with taking them back and forth to doctor appointments for
diabetes care may prove beneficial For those older adults living in MUAs
without family to assist with attending doctor appointments health care
providers should explore and link older adults to community medical
assistance transportation When older adults living in MUAs regularly attend
their doctor appointments not only does it build confidence to self-manage
diabetes as highlighted in this study but it may also give clinicians
opportunities to evaluate medications and make appropriate adjustments
ensure timely treatment that delays diabetes complications and fosters a
trusting provider-patient relationship
Health care providers should recognize the importance of peer-to-peer
learning and reinforcement as opportunities for diabetes education and group
interactions within the office setting and in the community near the homes of
older adults living in MUAs In resource strapped communities like MUAs
where the health care system may have limited resources group-based peer
self-management education trainings might be an effective way of improving
diabetes outcomes for older adults living in MUAs
Health care providers also may aid older adults living in MUAs in
addressing social issues by providing in-depth intensive interventions
through redesigned structures and processes of diabetes care or in-house
programs Others may take an aggressive approach by referring older adults
with unmet HRSNs to public benefit programs or community-based resources
170
and closing the loop by following-up with patients to ensure their needs have
been resolved Other health care providers can provide financial assistance to
older adults living in MUAs who are in need by proactively offering free
diabetic supplies and medications Some older adults living in MUAs may be
hesitant to freely share their financial challenges with their health care
providers therefore screening for financial strain as part of standard of care
or in fact going-ahead to offer free diabetic supplies or medications may aid
older adults living in MUAs with achieving improved diabetes self-
management behaviors
The findings from this study revealed a host of attributes of health care
providers that older adults with type 2 diabetes living in MUAs value Creating
a culture where health care providers and their team exhibit compassion
honesty trustworthiness humor and healing in the care that they render can
improve the patient experience and contribute to quality of diabetes care for
older adults living in MUAs Balancing trustworthiness and honesty especially
when it may not be in the best interest of the health care provider can be a
challenging decision However the findings from this study provide further
justification of the importance that trustworthiness and honesty in the delivery
of diabetes care has on the health outcomes of older adults living in MUAs
Further a caring and compassionate health care provider as valued by the
older adults in this study may help older adults living in MUAs become
empowered in their diabetes self-care
171
Health care providers can redesign service delivery processes that
align with the type 2 diabetes care that older adults living in MUAs desire
prefer and value For example through this research the study results
highlight the value of ensuring older adults living in MUAs see the same
clinician in general practice as a matter of choice within a reasonable time
Yet coordination by health care providers involved in diabetes treatment and
management care across the care continuum is warranted as valued by the
older adults living in MUAs in this study Health care providers should include
physical psychological social emotional and spiritual well-being in
comprehensive diabetes care planning for older adults living in MUAs
It is clear from this study the older adults living in MUAs desired and
valued a comprehensive thorough checkup Perhaps physicians should
spend time communicating to older adults with type 2 diabetes living in MUAs
why they are not examining their heart kidneys liver or skin instead of
bypassing these body organs all together Clinicians may benefit from
including additional components into the physical exam of type 2 diabetic
older adults in order to improve patientrsquos perceptions of their health care
experience Timely diagnosis and referrals to consulting specialist and
diabetes educators is important for older adults living in MUAs Matching
older adults living in MUAs needs to existing community resources that can
promote diabetes care is especially important for this vulnerable population
and was valued by the older adults in this study Providers can ensure
172
continuity by timely follow-up on referrals tests and examinations Clear
workflows should be established to ensure coordination of services across
providers Health care providers serving MUAs should ask their older adult
patients with type 2 diabetes if they feel they are spending enough time with
them
Furthermore older adultsrsquo perspectives can help in designing
appropriate interventions to optimize medication evaluation and management
For example several participants described their experiences with
polypharmacy and the appreciation they had for their health care provider
when heshe took the appropriate steps to reduce or eliminate medications
The avoidance of severe hypoglycemia or rather the management of
hypoglycemia by clinicians is prudent for older adults living in MUAs Health
care providers should consider a comprehensive medication review as the
initial step to promote patient safety in older adults with diabetes living in
MUAs By focusing on medication excessive treatment or inadequate
treatment of the diabetes quality continuum health care providers can begin
to improve quality of diabetes care ensuring that older adults living in MUAs
get the care they need while avoiding adverse effects Effective treatment of
diabetes for older adults living in MUAs requires a personalized approach
based on individual risk and benefit
Older adults with type 2 diabetes living in MUAs can also benefit from
health care providers who gather information from them through active
173
listening The elicitation of older adults living in MUAs perspectives about their
health status allows clinicians and the person at the center of care to engage
in meaningful conversations thus setting the groundwork for person-
centered care and shared decision making From there providers can be
proactive in sharing information that addresses the older adultrsquos needs
desires preferences and values the older adultrsquos health condition and how
their own health behaviors impact their condition Where older adults are
making the right decisions and self-managing well health care providers
should consider using praise to encourage continued good behaviors
Older adults living MUAs in this study valued information sharing and
provider communication such as the lessons learned on how to monitor their
blood glucose from watching and speaking with their health care providers
Providers should consider being more proactive and explicit about
instructions in diabetes self-management while also considering the clinical
and functional characteristics of older adults their comorbidities and the
availability of supportive resources Reminders on proper diabetes self-care
while the older adult is in the providerrsquos office or away from the providerrsquos
office may empower older adults living in MUAs to be in charge of their own
health care and achieve glycemic control This can be achieved through in-
person health education by a member of the care team or through consistent
telephone support
174
Nearly all the older adults interviewed valued telephone
communication with their health care providers Providers can ensure their
operations are organized in ways that meet the preferences of older adults
for example by reviewing how telephone communications are handled
Telephone diabetes management as highlighted by the older adults living in
MUAs in this study can be just as effective as other communication
modalities of care in educating older adults with diabetes and empowering
behaviors to achieve targeted HbA1c levels
This study offers insights to support the idea that relational
communication and its associated benefits may be fostered by health care
providers discussing things about diabetes care that interest older adults
living in MUAs This creates an atmosphere where older adults living in MUAs
are encouraged to express concerns within the visit Relational
communication plays an important role in diabetes treatment and
management care for older adults living in MUAs and should be a focus in
building type 2 diabetes care delivery that is committed to supporting high
quality communication that meets the desires preferences and values of
older adults living in MUAs
A long-term doctor-person relationship was something desired
preferred and valued by the older adults living in MUAs in this study
Insurance and policies and programs are needed to reduce involuntarily
changes in health care providers and increase the number of older adults
175
living in MUAs with consistent care Where clinicians are leaving MUAs for
organizational factors beyond their control thus resulting in provider
instability health care organizations should work to correct these issues in an
effort to ensure the desires and preferences for continuity in provider-person
relationship is maintained for older adults with type 2 diabetes living in MUAs
When older adults living in MUAs are involuntarily assigned a new clinician
health care providers should be prompt and transparent with providing an
explanation as to why An expeditious and clear explanation may help to build
a stronger and trusting relationship between the older adult and new provider
This could potentially be useful to patient adherence and improved diabetes
self-management knowledge and skills
Older adults in this study frequently used the terms preferences and
values interchangeably which suggest they may not fully understand the
meaning of these terms Health care providers can overcome this in their
conversations with older adult patients by simply asking what is most
important to them in their diabetes care What is important to older adults with
type 2 diabetes living in MUAs can also help health care providers to identify
targeted outcomes While health care providers may not always discuss
desires preferences and values with their older adult patients this research
study underscores the importance of engaging in such a conversation
Finally health care providers should develop measures to monitor
structures processes and outcomes of diabetes care to ensure they meet
176
older adults living in MUAs needs desires preferences and values
Measurement approaches could include the use patient experience surveys
informed by qualitative studies such as this one or patient complaints and
complements
Future Research
Based on the study results there are several recommendations for
future research Qualitative studies often inform the development of concepts
that turn into constructs in a survey This is important given the
generalizability limitations described above Now with the findings of this
study the results could be generalizable to other populations of older adults
through the development of a quantitative survey to examine associations
among older adultsrsquo values desires and preferences for diabetes care and
social care or diabetes related outcomes and other health outcomes
The perspectives of health care providers (for example primary care
doctor endocrinologist nurse health insurance company pharmacist eye
doctor or social worker) on the role of values desires and preferences in type
2 diabetes care for older adults living in MUAs needs to be evaluated Also
future studies are needed that explore older adultsrsquo family and friends
specifically those who care for them perspectives regarding their desires
preferences and values for health care received in treatment and
management of diabetes care for their loved one
177
Future studies should explore older adults with type 2 diabetes living in
MUAs perspectives to better understand how financial hardship impacts
health outcomes and possible solutions to address barriers For those older
adults with type 2 diabetes living in senior housing facilities a qualitative
study is needed to understand how the health and social care services at their
place of residence can be strengthened and enhanced to better facilitate
improved outcomes Future studies should explore older adults living in MUAs
perspectives on diabetes deintensification and medication management
strategies
Older adults in this study valued their physician engaging them with
prayer Future studies to explore the perspectives of other health care
providers beyond the physician in engaging older adults living MUAs in prayer
about their diabetes self-management is important A quantitative study here
may be valuable also given the limited literature in this area
The findings from this study are exploratory and should be hypotheses
tested Future studies based on the results of this study should employ a
quasi-experimental study design and a holistic approach that focuses on
multilevel factors (access clinical care social support health behaviors
provider characteristics and provider-patient communication) to empower
diabetes self-care in older adults living in MUAs and proactive collaboration
between health care providers older adults and their family to manage
diabetes care
178
Conclusion
This research study provides a greater understanding of older adults
living in MUAs desires preferences and values regarding health care
received in the treatment and management of their type 2 diabetes As
underscored throughout this research study older adults living in MUAs
desired preferred and valued type 2 diabetes care that is
bull Interdisciplinary timely safe responsive and thorough
bull Accessible in or close to home or online to ensure the right
diabetes care at the right time
bull Communicative and recommendatory of empowering diabetes self-
management information
bull Honest and trustworthy with a smile and humor when needed
bull Aware competent and reactive to social circumstances And
bull Engaged on self-care behavioral strategies to empower better
control of blood sugar levels
This research study provides a framework for health care providers
striving to deliver type 2 diabetes treatment and management care to older
adults living in MUAs that is holistic respectful and individualized Health care
providers should be willing to embrace a cultural shift in the way that they
provide care Systems should be redesigned and restructured into innovative
models of care that are conducive to the physical cognitive psychological
179
spiritual and social needs desires preferences and values of older adults
living in MUAs in order to improve quality type 2 diabetes care
This research study gives older adults living in MUAs a voice that
offers health care providers with a better understanding of what is important
to this vulnerable population in treating and managing their type 2 diabetes
As underscored throughout the research inquiring about older adults living in
MUAs desires preferences and values for type 2 diabetes treatment and
management care are important steps towards improving quality of care for
this vulnerable population The themes and corresponding subthemes
gleaned from the interviews with the older adults living in MUAs provides
practical implications for care that when implemented in practice can improve
patient participation engagement adherence and self-management leading
to improved health outcomes and health-related quality of life This approach
to holistic collaborative diabetes care promotes health by supporting older
adults in living a sustained quality of life over the course of their lifespan
In conclusion this research study collected rich and detailed
information about the desires preferences and values for type 2 diabetes
treatment and management care received by older adults living in MUAs The
findings from this study could help health care providers prioritize structures
and processes of individualized treatment and management care to empower
and support older adults living in MUAs to achieve optimal type 2 diabetes
outcomes
180
181
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American Diabetes Association (2020a) Comprehensive medical evaluation
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Andrews J A Brown L J E Hawley M S amp Astell A J (2019) Older
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Assari S Moghani Lankarani M Piette J D amp Aikens J E (2017)
Socioeconomic Status and Glycemic Control in Type 2 Diabetes Race by Gender Differences Healthcare (Basel Switzerland) 5(4) 83 httpsdoiorg103390healthcare5040083
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Bailey G R Barner J C Weems J K Leckbee G Solis R
Montemayor D amp Pope N D (2012) Assessing barriers to medication adherence in underserved patients with diabetes in Texas The Diabetes Educator 38(2) 271-279 httpsdoiorg1011770145721711436134
Bainbridge K E Hoffman H J amp Cowie C C (2011) Risk factors for
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Barnes D E Palmer R M Kresevic D M Fortinsky R H Kowal J
Chren M M amp Landefeld C S (2012) Acute care for elders units produced shorter hospital stays at lower cost while maintaining
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Beck R S Daughtridge R amp Sloane P D (2002) Physician-patient
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Becker T A C de Souza Teixeira C R Zanetti M L Pace A E
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Behan J Carmichael S Edeen R Gerry D Hoover M Hughes M
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Belanger L Desmartis M amp Coulombe M (2018) Barriers and facilitators
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Bell R A Suerken C K Grzywacz J G Lang W Quandt S A amp
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Bener A Obineche E Gillett M Pasha M A H amp Bishawi B (2001) Association between blood levels of lead blood pressure and risk of diabetes and heart disease in workers International Archives of Occupational and Environmental Health 74(5) 375-378 httpsdoiorg101007s004200100231
Bergmans R S Zivin K amp Mezuk B (2019) Depression food insecurity
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Berkowitz S A Delahanty L M Terranova J Steiner B Ruazol M P
Singh R Shahid N N amp Wexler D J (2019) Medically tailored meal delivery from diabetes patients with food insecurity A randomized cross-over trail Journal of General Internal Medicine 34 396-404 httpsdoiorg101007s11606-018-4716-z
Berkowitz S A Kalkhoran S Edwards S T Essien U R amp Baggett T
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Berkowitz S A Meigs J B DeWalt D Seligman H K Barnard L S
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Berkowitz S A Seligman H K amp Choudhry N K (2014) Treat or eat
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Beverly E A LaCoe C L Gabbay R A (2014) Listening to older adultsrsquo
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Billioux A Verlander K Anthony S amp Alley D (2017) Standardized
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Blendon R J Benson J M amp Hero J O (2014) Public trust in physicians
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Boise L amp White D (2004) The familyrsquos role in person-centered care
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Boulware L E Marinopoulos S Phillips K A Hwang C W Maynor K
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Bullard K M Cowie C C Lessem S E Saydah S H Menke A Geiss
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Burgoon J K Pfau M Parrott R Birk T Coker R amp Burgoon M
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Burton A (2007) Built environment does poor housing raise diabetes risk
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Busch S H amp Kyanko K A (2020) Incorrect provider directories
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Caelli K Ray L amp Mill J (2003) lsquoClear as Mudrsquo Toward greater clarity in
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Campbell-Richards D (2016) Exploring diabetes non-attendance An inner
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Capoccia K Odegard P S amp Letassy N (2016) Medication adherence
with diabetes medication A systematic review of the literature The Diabetes Educator 42(1) 34-71 httpsdoiorg1011770145721715619038
Carmen K L Dardess P Maurer M Sofaer S Adams K Bechtel C amp
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Carter J S Pugh J A amp Monterrosa A (1996) Non-insulin-dependent
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Cavanaugh K L (2011) Health literacy in diabetes care explanation
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Cavanaugh K Huizinga M M Wallston K A Gebretsadik T Shintani
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Cavanaugh K Wallston K A Gebretsadik T Shintani A Huizinga M
M Davis D Gregory R P Malone R Pignone M DeWalt D Elasy T A amp Rothman R L (2009) Addressing literacy and numeracy to improve diabetes care Two randomized controlled trials Diabetes Care 32(12) 2149-2155 httpsdoiorg102337dc09-0563
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Charmaz K (2006) Constructing grounded theory A practical guide through
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Charmaz K (2008) Grounded theory as an emergent method In S N Hesse-Biber amp P Leavy Handbook of emergent methods (pp 155-170) New York NY Guilford Press
Chan J DeMelo M Gingras J amp Gucciardi E (2015) Challenges of
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Chandra S Mohammadnezhad M amp Ward P (2018) Trust and
communication in a doctor-patient relationship A literature review Journal of Healthcare Communications 3(3) 36 httpsdoiorg1041722472-1654100146
Chentli F Azzoug S amp Mahgoun S (2015) Diabetes mellitus in elderly
Indian Journal of Endocrinology and Metabolism 19(6) 744ndash752 httpsdoiorg1041032230-8210167553
Choe H M Mitrovich S Dubay D Hayward R A Krein S L amp Vijan S
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Clark N M Becker M H Janz N K Lorig K Rakowski W amp Anderson
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Clifford S Perez-Nieves M Skalicky A M Reaney M Coyne K S
(2014) A systematic literature review of methodologies used to assess medication adherence in patients with diabetes Current Medical Research and Opinion 30(6) 1071ndash1085 httpsdoiorg101185030079952014884491
Clissett P Porock D Harwood R H amp Gladman RF J (2013) The
challenges of achieving person-centered care in acute hospitals A qualitative study of people with dementia and their families
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International Journal of Nursing Studies 50 1495-1503 httpdxdoiorg101016jijnurstu201303001
Cooper S amp Endacott R (2007) Generic qualitative research A design for
qualitative research in emergency care Emergency Medicine Journal 24(12) 816-9 httpsdoiorg101136emj2007050641
Corbin J amp Strauss J (2015) Basics of qualitative research Techniques
and procedures for developing grounded theory (4th ed) Thousand Oaks CA Sage Publications
Counsell S R Holder C M Liebenauer L L Palmer R M Fortinsky R
H Kresevic D M Quinn L M Allen K R Covinsky K E amp Landefeld C S (2000) Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients A randomized controlled trial of acute care for elders (ACE) in a community hospital Journal of the American Geriatrics Society 48(12) 1572-1581 httpsdoiorg101111j1532-54152000tb03866x
Crabtree B F amp Miller W L (1992) Doing qualitative research Newbury
Park CA Sage Publications Cramer J A Benedict A Muszbek N Keskinaslan A amp Khan Z M
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Creswell J (2013) Qualitative inquiry and research design Choosing among
five approaches (3rd ed) Thousand Oaks CA Sage Publications Curlin F A Sellergren S A Lantos J D amp Chin M H (2007) Physicians
observations and interpretations of the influence of religion and spirituality on health Archives of Internal Medicine 167(7) 649ndash654 httpsdoiorg101001archinte1677649
193
Curtis S E Boye K S Lage M J amp Garcia-Perez L-E (2017) Medication adherence and improved outcomes among patients with type 2 diabetes American Journal of Managed Care 23(7) e208-e214
Davidson M B (2007) The effectiveness of nurse- and pharmacist-directed
care in diabetes disease management A narrative review Current Diabetes Reviews 3(4) 280ndash286 httpsdoiorg102174157339907782330058
Davidson M B (2009) How our current medical care system fails people with
diabetes Lack of timely appropriate clinical decisions Diabetes Care 32(2) 370ndash372 httpsdoiorg102337dc08-2046
Dean K (1986) Lay care in illness Social Science and Medicine 22(2) 275-
284 httpdxdoiorg1010160277-9536(86)90076-6 Debussche X Besanccedilon S Balcou-Debussche M Ferdynus C Delisle
H Huiart L amp Sidibe A T (2018) Structured peer-led diabetes self-management and support in a low-income country The ST2EP randomised controlled trial in Mali PloS one 13(1) e0191262 httpsdoiorg101371journalpone0191262
DeNavas-Walt C amp Proctor B D (2015) Income and poverty in the United
States 2014 Washington DC United States Census Bureau Dervin B (1983) An overview of sense-making Concepts methods and
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Dham S Shah V Hirsch S Banerji M A (2006) The role of
complementary and alternative medicine in diabetes Current Diabetes Reports 6(3) 251-258 httpsdoiorg101007s11892-006-0042-7
194
Dhedhi S A Swinglehurst D amp Russell J (2014) Timely diagnosis of dementia What does it mean A narrative analysis of GPs accounts BMJ Open 4(3) e004439 httpsdoiorg101136bmjopen-2013-004439
Diabetes Association of Atlanta (2017) AADE 7 Self-Care Behaviors
httpdiabetesatlantaorgaade-7-self-care-behaviors Diaz E G Medina D R Lopez A G amp Morera Porras O M (2017)
Determinants of adherence to hypoglycemic agents and medical visits in patients with type 2 diabetes mellitus Endocrinologia Diabetes y Nutricion (English ed) 64(10) 531-538 httpsdoiorg101016jendien201708015
Donabedian A (1980) The definition of quality and approaches to its
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Donabedian A (1982) The criteria and standards of quality Explorations in
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Donabedian A (1985) The methods and findings of quality assessment and
monitoring An illustrated analysis (Vol III) Ann Arbor MI Health Administration Press
Donabedian A (1986) Criteria and standards for quality assessment and
monitoring Quality Review Bulletin 12(3) 99-108 httpsdoiorg101016s0097-5990(16)30021-5
Donabedian A (1988) The quality of care How can it be assessed JAMA
260(12) 1743-1748 httpsdoiorg101001jama260121743 Donabedian A (1990) The seven pillars of quality Archives of Pathology
and Laboratory Medicine 114(11) 1115-1118
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Donabedian A (1992) The Lichfield Lecture Quality assurance in health
care Consumers role Quality in Health Care QHC 1(4) 247ndash251 httpsdoiorg101136qshc14247
Donabedian A (2003) An introduction to quality assurance in health care
New York NY Oxford University Press Donabedian A (2005) Evaluating the quality of medical care The Millbank
Quarterly 83(4) 691-729 httpsdoiorg101111j1468-0009200500397x
Donahue K E Ashkin E amp Pathman D E (2005) Length of patient-
physician relationship and patients satisfaction and preventive service use in the rural south a cross-sectional telephone study BMC Family Practice 6 40 httpsdoiorg1011861471-2296-6-40
Duan L Mukherjee E M amp Federman D G (2020) The physical
examination A survey of patient preferences and expectations during primary care visits Postgraduate Medicine 132(1) 102ndash108 httpsdoiorg1010800032548120201713618
Durdella N (2018) Qualitative dissertation methodology A guide for
research design and methods (1st ed) Thousand Oaks CA Sage Publications
Dwyer-Lindgren L Bertozzi-Villa A amp Stubbs R W (2017) Inequalities in
life expectancy among US counties 1980 to 2014 Temporal trends and key drivers JAMA Internal Medicine 177(7) 1003-1011 httpsdoiorg101001jamainternmed20170918
Edwards D L Frongillo E A Jr Rauschenbach B amp Roe D A (1993)
Home-delivered meals benefit the diabetic elderly Journal of the American Dietetic Association 93(5) 585-587 httpsdoiorg1010160002-8223(93)91824-a
196
Epstein R M amp Street R L (2007) Patient-centered communication in cancer care Promoting healing and reducing suffering National Cancer Institute httpscancercontrolcancergovsitesdefaultfiles2020-06pcc_monographpdf
Evert A B Dennison M Gardner C D Garvey W T Lau K MacLeod
J Mitri J Pereira R F Rawlings K Robinson S Saslow L Uelmen S Urbanski P B amp Yancy W S Jr (2019) Nutrition therapy for adults with diabetes or prediabetes A consensus report Diabetes Care 42(5) 731-754 httpsdoiorg102337dci19-0014
Farr A M Sheehan J J Curkendall S M Smith D M Johnston S S
amp Kalsekar I (2014) Retrospective analysis of long-term adherence to and persistence with DPP-4 inhibitors in US adults with type 2 diabetes mellitus Advances in Therapy 31(12) 1287ndash1305 httpsdoiorg101007s12325-014-0171-3
Feifer C Nemeth L Nietert P J Wessell A M Jenkins R G Roylance
L amp Ornstein S M (2007) Different paths to high-quality care Three archetypes of top-performing practice sites Annals of Family Medicine 5(3) 233-241 httpsdoiorg101370afm697
Fields B E Bigbee J L amp Bell J F (2016) Associations of provider-to-
population ratios and population health by county-level rurality Journal of Rural Health 32(3) 235-244 httpsdoiorg101111jrh12143
Fiscella K Meldrum S Franks P Shields C G Duberstein P
McDaniel S H amp Epstein R M (2004) Patient trust Is it related to patient-centered behavior of primary care physicians Medical Care 42(11) 1049-1055 httpsdoiorg10109700005650-200411000-00003
Fisher E B Thorpe C T Devellis B M amp Devellis R F (2007) Healthy
coping negative emotions and diabetes management A systematic review and appraisal The Diabetes Educator 33(6) 1080ndash1106 httpsdoiorg1011770145721707309808
197
Fleming B B Greenfield S Engelgau M M Pogach L M Clauser S
B amp Parrott M A (2001) The Diabetes Quality Improvement Project Moving science into health policy to gain an edge on the diabetes epidemic Diabetes Care 24(10) 1815-1820 httpsdoiorg102337diacare24101815
Fraze T K Brewster A L Lewis V A Beidler L B Murray G F amp
Colla C H (2019) Prevalence of screening for food insecurity housing instability utility needs transportation needs and interpersonal violence by US physician practices and hospitals Journal of the American Medical Association Network Open 2(9) e1911514 httpsdoiorg101001jamanetworkopen201911514
Friedman A Howard J Shaw E K Cohen D J Shahidi L amp Ferrante
J M (2016) Facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators perspectives Journal of the American Board of Family Medicine 29(1) 90ndash101 httpsdoiorg103122jabfm201601150175
Gale N K Gemma H Cameron E Rashid S amp Redwood S (2013)
Using the framework method for the analysis of qualitative data in multi-disciplinary health research BMC Medical Research Methodology 13(117) 1-8 httpsdoiorg1011861471-2288-13-117
Gamboa Moreno E Mateo-Abad M Ochoa de Retana Garciacutea L Vrotsou
K Del Campo Pena E Saacutenchez Perez Aacute Martiacutenez Carazo C Arbonies Ortiz J C Ruacutea Portu M Aacute Pintildeera Elorriaga K Zenarutzabeitia Pikatza A Urquiza Bengoa M N Meacutendez Sanpedro T Oses Portu A Aguirre Sorondo M B Rotaeche Del Campo R amp Osakidetza Active Patient Research Group (2019) Efficacy of a self-management education programme on patients with type 2 diabetes in primary care A randomised controlled trial Primary Care Diabetes 13(2) 122ndash133 httpsdoiorg101016jpcd201810001
Garg A Jack B amp Zuckerman B (2013) Addressing the social
determinants of health within the patient-centered medical home
198
Journal of the American Medical Association 309(19) 2001-2002 httpsdoiorg101001jama20131471
Gatlin T K Serafica R amp Johnson M (2017) Systematic review of peer
education intervention programmes among individuals with type 2 diabetes Journal of Clinical Nursing 26(23-24) 4212ndash4222 httpsdoiorg101111jocn13991
Gibson C H (1991) A concept analysis of empowerment Journal of
Advanced Nursing 16(3) 354-361 httpsdoiorg101111j1365-26481991tb01660x
Giovannelli J Lucia K amp Corlette S (2016) HealthPolicy Brief Network
Adequacy Health Affairs httpswwwhealthaffairsorgdo101377hpb20160728898461fullhealthpolicybrief_160pdf
Glaser B G amp Strauss A L (1967) The discovery of grounded theory
Strategies for qualitative research Piscataway NJ AldineTransaction Glasgow R E (1995) A practical model of diabetes management and
education Diabetes Care 18(1) 117-126 httpsdoiorg102337diacare181117
Greenwood D A Hankins A I Parise C A Spier V Olveda J amp Buss
K A (2014) A comparison of in-person telephone and secure messaging for type 2 diabetes self-management The Diabetes Educator 40(4) 516-525 httpsdoiorg1011770145721714531337
Grindrod K A Li M amp Gates A (2014) Evaluating user perceptions of
mobile medication management applications with older adults A usability study Journal of Medical Internet Research mHealth and UHealth 2(1) e11 httpsdoiorg102196mhealth3048
199
Grumbach K Vranizan K amp Bindman A B (1997) Physician supply and access to care in urban communities Health Affairs 16(1) 71-86 httpsdoiorg101377hlthaff16171
Guest G Bunce A amp Johnson L (2006) How many interviews are
enough An experiment with data saturation and variability Field Methods 18(1) 59-82 httpspsycnetapaorgdoi1011771525822X05279903
Guest G Namey E E amp Mitchell M L (2013) Collecting qualitative data
A field manual for applied research Thousand Oaks CA SAGE Publications Inc
Gunderson C G Bilan V P Holleck J L Nickerson P Cherry B M
Chui P Bastian L A Grimshaw A A amp Rodwin B A (2020) Prevalence of harmful diagnostic errors in hospitalised adults a systematic review and meta-analysis BMJ Quality amp Safety 29(12) 1008ndash1018 httpsdoiorg101136bmjqs-2019-010822
Gupta P S amp Anandarajah G (2014) The role of spirituality in diabetes
self-management in an urban underserved population A qualitative exploratory study Rhode Island Medical Journal (2013) 97(3) 31ndash35
Guyton A C amp Hall J E (2006) Textbook of medical physiology (11th ed)
Philadelphia PA Elsevier Inc Ha K H amp Kim D J (2015) Trends in the diabetes epidemic in Korea
Endocrinology and Metabolism (Seoul Korea) 30(2) 142ndash146 httpsdoiorg103803EnM2015302142
Hackett R A Hudson J L amp Chilcot J (2020) Loneliness and type 2
diabetes incidence Findings from the English Longitudinal Study of Ageing Diabetologia 63(11) 2329ndash2338 httpsdoiorg101007s00125-020-05258-6
200
Haeder S F (2019) Quality regulation Access to high-quality specialists for Medicare Advantage beneficiaries in California Health Services Research and Managerial Epidemiology 6 1-15 httpsdoiorg1011772333392818824472
Haeder S F Weimer D L amp Mukamel D B (2019) A knotty problem
Consumer access and the regulation of provider networks Journal of Health Politics Policy and Law 44(6) 937-954 httpsdoiorg10121503616878-7785835
Hansen F Berntsen G K R amp Salamonsen A (2018) ldquoWhat matters to
yourdquo A longitudinal qualitative study of Norwegian patientsrsquo perspectives on their pathways with colorectal cancer International Journal of Qualitative Studies on Health and Well-Being 13(1) 1548240 httpsdoiorg1010801748263120181548240
Hayward R A Hofer T P Kerr E A amp Krein S L (2004) Quality
improvement strategies Issues in moving from diabetes guidelines to policy Diabetes Care 27(Suppl 2) B54-B60 httpsdoiorg102337diacare27suppl_2B54
Health Resources amp Services Administration (HRSA) (2016) Medically
underserved areaspopulations httpwwwhrsagovshortagemua Herman W H Ye W Griffin S J Simmons R K Davies M J Khunti
K Rutten G E Sandbaek A Lauritzen T Borch-Johnsen K Brown M B amp Wareham N J (2015) Early detection and treatment of type 2 diabetes reduce cardiovascular morbidity and mortality A simulation of the results of the Anglo-Danish-Dutch Study of Intensive Treatment in People With Screen-Detected Diabetes in Primary Care (ADDITION-Europe) Diabetes Care 38(8) 1449ndash1455 httpsdoiorg102337dc14-2459
Heron M (2017) Deaths Leading causes for 2015 National Vital Statistics
Reports 66(5) Hyattsville MD National Center for Health Statistics
201
Heydarabadi A B Mehr H M amp Nouhjah S (2017) Why rural diabetic patients do not attend for scheduled appointments Results of a qualitative study Diabetes amp Metabolic Syndrome 11 Suppl 2 S989ndashS995 httpsdoiorg101016jdsx201707027
Hill-Briggs F (2003) Problem solving in diabetes self-management A model
of chronic illness self-management behavior Annals of Behavioral Medicine 25(3) 182-193 httpsdoiorg101207S15324796ABM2503_04
Hill-Briggs F Adler N E Berkowitz S A Chin M H Gary-Webb T L
Navas-Acien A Thornton P L amp Haire-Joshu D (2020) Social determinants of health and diabetes A scientific review Diabetes Care 44(1) 258-279 httpsdoiorg102337dci20-0053
Hill-Briggs F Lazo M Peyrot M Doswell A Chang Y-T Hill M N hellip
Brancati F L (2011) Effect of problem-solving-based diabetes self-management training on diabetes control in a low income patient sample Journal of General Internal Medicine 26(9) 972-978 httpsdoiorg101007s11606-011-1689-6
Himmelstein D U amp Phillips R S (2016) Should we abandon routine
visits There is little evidence for or against Annals of Internal Medicine 164(7) 498ndash499 httpsdoiorg107326M15-2097
Hines H G Avila C J Rudakevych T M Curlin F A amp Yoon J D
(2017) Physician perspectives on long-term relationships and friendships with patients A national assessment Southern Medical Journal 110(11) 679ndash684 httpsdoiorg1014423SMJ0000000000000723
Hoover C Plamann J amp Beckel J (2017) Outcomes of an interdisciplinary
transitional care quality improvement project on self-management and health care use in patients with heart failure Journal of Gerontological Nursing 43(1) 23-31 httpsdoiorg10392800989134-20160901-01
202
Horowitz C R Colson K A Hebert P L amp Lancaster K (2004) Barriers to buying healthy foods for people with diabetes Evidence if environmental disparities American Journal of Public Health 94(9) 1549-1554 httpsdoiorg102105AJPH9491549
Horowitz C R Williams L Bickell N A (2003) A community-centered
approach to diabetes in East Harlem Journal of General Internal Medicine 18(7) 542-548 httpsdoiorg101046j1525-1497200321028x
Hunt L M Arar N H amp Akana L L (2000) Herbs prayer and insulin Use
of medical and alternative treatments by a group of Mexican American diabetes patients The Journal of Family Practice 49(3) 216-223
Hyman P (2020) The disappearance of the primary care physical
examinationmdashlosing touch JAMA Internal Medicine 180(11) 1417-1418 httpsdoiorg101001jamainternmed20203546
Iezzoni L I Rao S R DesRoches C M Vogeli C amp Campbell E G
(2012) Survey shows that at least some physicians are not always open or honest with patients Health Affairs 31(2) 383-391 httpsdoiorg101377hlthaff20101137
Indovina K Keniston A Reid M Sachs K Zheng C Tong A
Hernandez D Bui K Ali Z Nguyen T Guirguis H Albert R K amp Burden M (2016) Real-time patient experience surveys of hospitalized medical patients Journal of Hospital Medicine 11(4) 251ndash256 httpsdoiorg101002jhm2533
Institute of Medicine (2001) Envisioning the National Health Care Quality
Report Washington DC The National Academies Press Institute of Medicine (2013) Best Care at Lower Cost The Path to
Continuously Learning Health Care in America Washington DC The National Academies Press
203
Inzucchi S E Bergenstal R M Buse J B Diamant M Ferrannini E Nauck M Peters A L Tsapas A Wender R Matthews D R American Diabetes Association (ADA) amp European Association for the Study of Diabetes (EASD) (2012) Management of hyperglycemia in type 2 diabetes A patient-centered approach Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) Diabetes Care 35(6) 1364-1379 httpsdoiorg102337dc12-0413
Jabareen Y (2009) Building a conceptual framework Philosophy
definitions and procedure International Journal of Qualitative Methods 8(4) 49-62 httpsdoiorg1011772F160940690900800406
Jamshed S (2014) Qualitative research method-interviewing and
observation Journal of Basic and Clinical Pharmacy 5(4) 87-88 httpsdoiorg1041030976-0105141942
Jones A L Harrris-Kojetin L amp Valverde R (2012) Characteristics and
use of home health care by men and women aged 65 and over National Health Statistics reports no 52 Hyattsville MD US Department of Health and Human Services National Center for Health Statistics httpswwwcdcgovnchsdatanhsrnhsr052pdf
Jones P S amp Meleis A I (1993) Health is empowerment Advances in
Nursing Science 15(3) 1-14 httpsdoiorg10109700012272-199303000-00003
Kaku K (2010) Pathophysiology of type 2 diabetes and its treatment policy
Japan Medical Association Journal 53(1) 41-46 Kang H Lobo J M Kim S amp Sohn M W (2018) Cost-related medication
non-adherence among US adults with diabetes Diabetes Research and Clinical Practice 143 24-33 httpsdoiorg101016jdiabres201806016
204
Kao A C Green D C Davis N A Koplan J P amp Cleary P D (1998) Patientsrsquo trust in their physicians Effects of choice continuity and payment method Journal of General Internal Medicine 13(10) 681-686 httpsdoiorg101046j1525-1497199800204x
Kaplan S H Billimek J Sorkin D H Ngo-Metzger Q amp Greenfield S
(2013) Reducing racialethnic disparities in diabetes The Coached Care (R2D2C2) Project Journal of General Internal Medicine 28(10) 1340-1349 httpsdoiorg101007s11606-013-2452-y
Kalra S Mukherjee J J Venkataraman S Bantwal G Shaikh S
Saboo B Das A K amp Ramachandran A (2013) Hypoglycemia The neglected complication Indian Journal of Endocrinology and Metabolism 17(5) 819-834 httpsdoiorg1041032230-8210117219
Kart C amp Engler C (1994) Predispositions to self-care Who does what for
themselves and why Journal of Gerontology 49(6) S301-S308 httpsdoiorg101093geronj496S301
Karter A J Parker M M Moffet H H Ahmed A T Ferrara A Liu J Y
amp Selby J V (2004) Missed appointments and poor glycemic control an opportunity to identify high-risk diabetic patients Medical Care 42(2) 110ndash115 httpsdoiorg10109701mlr00001090236465073
Kent D Haas L Randal D Lin E Thorpe C T Boren S A Fisher J
Heins J Lustman P Nelson J Ruggiero L Wysocki T Fitzner K Sherr D amp Martin A L (2010) Healthy coping Issues and implications in diabetes education and care Population Health Management 13(5) 227-233 httpsdoiorg101089pop20090065
Kessler R C (2002) National comorbidity survey 1990-1992 [Computer
file] Ann Arbor MI University of Michigan Survey Research Center httpswwwhcpmedharvardeduncsftpdirBaseline20NCSpdf
Khayyat S M Mohamed M Khayyat S Hyat Alhazmi R S Korani M
F Allugmani E B Saleh S F Mansouri D A Lamfon Q A Beshiri O M amp Abdul Hadi M (2019) Association between
205
medication adherence and quality of life of patients with diabetes and hypertension attending primary care clinics A cross-sectional survey Quality of Life Research 28(4) 1053-1061 httpsdoiorg101007s11136-018-2060-8
Kim H-S amp Song M-S (2008) Technological intervention for obese patients
with type 2 diabetes Applied Nursing Research 21(2) 84-89 httpsdoiorg101016japnr200701007
King D E amp Bushwick B (1994) Beliefs and attitudes of hospital inpatients
about faith health and prayer The Journal of Family Practice 39(4) 349-352
King H Aubert R E amp Herman W H (1998) Global burden of diabetes
1995-2025 Prevalence numerical estimates and projections Diabetes Care 21(9) 1414-1431 httpsdoiorg102337diacare2191414
Kirkman M S Briscoe V J Clark N Florez H Haas L B Halter J B
Huang E S Korytkowski M T Munshi M N Odegard P S Pratley R E amp Swift C S (2012a) Diabetes in older adults Diabetes Care 35(12) 2650ndash2664 httpsdoiorg102337dc12-1801
Kirkman M S Briscoe V J Clark N Florez H Haas L B Halter J B
Huang E S Korytkowski M T Munshi M N Odegard P S Pratley R E Swift C S amp Consensus Development Conference on Diabetes and Older Adults (2012b) Diabetes in older adults A consensus report Journal of the American Geriatrics Society 60(12) 2342ndash2356 httpsdoiorg101111jgs12035
Kogan A C Wilber K amp Mosqueda L (2016a) Person-centered care for
older adults with chronic conditions and functional impairment A systematic literature review Journal of the American Geriatrics Society 64(1) e1-e7 httpsdoi101111jgs13873
Kogan A C Wilber K amp Mosqueda L (2016b) Moving toward
implementation of person-centered care for older adults in community-
206
based medical and social service settings ldquoYou only get things done when working in concert with clients Journal of the American Geriatrics Society 64(1) e8-e14 httpsdoi101111jgs13876
Krass I Schieback P Dhippayom T (2015) Adherence to diabetes
medication A systematic review Diabetic Medicine 32(6) 725-737 httpsdoiorg101111dme12651
Krause N (1987) Understanding the stress process Linking social support
with locus of control beliefs Journal of Gerontology 42(6) 589ndash593 httpsdoiorg101093geronj426589
Krein S L Klamerus M L Vijan S Lee J L Fitzgerald J T Pawlow
A Reeves P amp Hayward R A (2004) Case management for patients with poorly controlled diabetes A randomized trial The American Journal of Medicine 116(11) 732ndash739 httpsdoiorg101016jamjmed200311028
Kresevic D amp Holder C (1998) Interdisciplinary care Clinics in Geriatric
Medicine 14(4) 787-798 Krogsboslashll L T Joslashrgensen K J amp Goslashtzsche P C (2019) General health
checks in adults for reducing morbidity and mortality from disease The Cochrane Database of Systematic Reviews 1(1) CD009009 httpsdoiorg10100214651858CD009009pub3
Krueger R A amp Casey M A (2009) Focus groups A practical guide for
applied research (4th ed) Thousand Oaks CA SAGE Publications Inc
Kumar D S Prakash B Chandra B J S Kadkol P S Arun V amp
Thomas J J (2020) An android smartphone-based randomized intervention improves the quality of life in patients with type 2 diabetes in Mysore Karnataka India Diabetes amp Metabolic Syndrome Clinical Research amp Reviews 14(5) 1327-1332 httpsdoiorg101016jdsx202007025
207
Larimore W L Parker M amp Crowther M (2002) Should clinicians
incorporate positive spirituality into their practices What does the evidence say Annals of Behavioral Medicine A publication of the Society of Behavioral Medicine 24(1) 69ndash73 httpsdoiorg101207S15324796ABM2401_08
LaVeist T A Isaac L A amp Williams K P (2009) Mistrust of health care
organizations is associated with underutilization of health services Health Services Research 44(6) 2093-2105 httpsdoiorg101111j1475-6773200901017x
Lawson V L Lyne P A Harvey J N amp Bundy C E (2005)
Understanding why people with type 1 diabetes do not attend for specialist advice A qualitative analysis of the views of people with insulin-dependent diabetes who do not attend diabetes clinic Journal of Health Psychology 10(3) 409ndash423 httpsdoiorg1011771359105305051426
Lawton J Rankin D Peel E amp Douglas M (2009) Patientsrsquo perceptions
and experiences of transitions in diabetes care A longitudinal qualitative study Health Expectations 12 138-148 httpsdoiorg101111j1369-7625200900537x
Leasher J L Bourne R R A Flaxman S R Jonas J B Keeffe J
Naidoo K Pesudovs K Price H White R A Wong T Y Resnikoff S Taylor H R amp Vision Loss Expert Group of the Global Burden of Disease Study Global estimates on the number of people blind or visually impaired by diabetic retinopathy A meta-analysis from 1990 to 2010 Diabetes Care 39(9) 1643-1649 httpsdoiorg102337dc15-2171
Lee J S Shannon J amp Brown A (2015) Characteristics of older
Georgians receiving Older Americans Act Nutrition Program Services and other home and community-based services Findings from the Georgia Aging Information Management System (GA AIMS) Journal of Nutrition in Gerontology and Geriatrics 34(2) 168-188 httpsdoiorg1010802155119720151031595
208
Lee T L Crouse M amp Gipson K (2016) No-pass zone Multidisciplinary
approach to responding to patient needs Journal of Nursing Care Quality 31(4) 327-334 httpsdoiorg101097NCQ0000000000000179
LeRoith D Biessels G J Braithwaite S S Casanueva F F Draznin B
Halter J B Hirsch I B McDonnell M E Molitch M E Murad M H amp Sinclair A J (2019) Treatment of Ddabetes in older adults An Endocrine Society clinical practice guideline The Journal of Clinical Endocrinology and Metabolism 104(5) 1520ndash1574 httpsdoiorg101210jc2019-00198
LeRoith D amp Halter J B (2020) Diagnosis of diabetes in older adults
Diabetes Care 43(7) 1373-1374 httpsdoiorg102337dci20-0013 Leung L (2015) Validity reliability and generalizability in qualitative
research Journal of Family Medicine and Primary Care 4(3) 324-327 httpsdoiorg1041032249-4863161306
Leventhal E A amp Prohaska T R (1986) Age symptom interpretation and
health behavior Journal of the American Geriatrics Society 34(3) 185-191
Levinson W Roter D L Mullooly J P Dull V T amp Frankel R M (1997)
Physician-patient communication The relationship with malpractice claims among primary care physicians and surgeons Journal of the American Medical Association 277(7) 553-559 httpsdoiorg101001jama2777553
Li H Stewart B J Imle M A Archbold P G amp Felver L (2000)
Families and hospitalized elders A typology of family care actions Research in Nursing amp Health 23(1) 3-16 httpsdoiorg101002(sici)1098-240x(200002)231lt3aid-nur2gt30co2-u
209
Li S A Zhang Y Ruan H Guerra E amp Burnette D (2020) The role of transportation in older adultsrsquo use of and satisfaction with primary care in China Journal of Transport amp Health 18 100898 httpsdoiorg101016jjth2020100898
Li Y Burrows N R Gregg E W Albright A amp Geiss L S (2012)
Declining rates of hospitalization for non-traumatic lower-extremity amputation in the diabetic population aged 40 years or older US 1988-2008 Diabetes Care 35 273-277 httpsdoiorg102337dc11-1360
Lin C-T Albertson G A Schilling L M Cyran E M Anderson S N
Ware L amp Anderson R J (2001) Is patientsrsquo perception of time spent with the physician a determinant of ambulatory patient satisfaction Archives of Internal Medicine 161(11) 1437-1442 httpsdoiorg101001archinte161111437
Lipska K J Warton E M Huang E S Moffet H H Inzucchi S E
Krumholz H M amp Karter A J (2013) HbA1c and risk of severe hypoglycemia in type 2 diabetes Diabetes Care 36(11) 3535-3542 httpsdoiorg102337dc13-0610
Lincoln Y S amp Guba E G (1982) Establishing dependability and
confirmability in naturalistic inquiry through an audit Paper prepared for presentation at the American Education Research Association Annual Meeting New York NY httpsfilesericedgovfulltextED216019pdf
Long T amp Johnson M (2000) Rigour reliability and validity in qualitative
research Clinical Effectiveness in Nursing 4(1) 30-37 httpsdoiorg101054cein20000106
Longnecker M P amp Daniels J L (2001) Environmental containments as
etiologic factors for diabetes Environmental Health Perspective 109(Suppl 6) 871-876 httpsdoiorg101289ehp01109s6871
210
Lopez J M S Katic B J Fitz-Randolph M Jackson R A Chow W amp Mullins C D (2016) Understanding preferences for type 2 diabetes mellitus self-management support through a patient-centered approach A 2-phase mixed-methods study BMC Endocrine Disorders 16(41) httpsdoiorg101186s12902-016-0122-x
Lorig K R amp Holman H (2003) Self-management education history
definition outcomes and mechanisms Annals of Behavioral Medicine 26(1) 1-7 httpsdoiorg101207S15324796ABM2601_01
Low S K Khoo J K Tavintharan S Lim S C amp Sum C F (2016)
Missed appointments at a diabetes centre Not a small problem Annals of the Academy of Medicine Singapore 45(1) 1ndash5
Luscombe-Marsh N Chapman J amp Visvanathan R (2013) Hospital
admissions in poorly nourished compared with well-nourished older South Australians receiving lsquoMeals on Wheelsrsquo Findings from a pilot study Australasian Journal on Ageing 33(3) 164-169 httpsdoiorg101111ajag12009
Luxford K Safran D G amp Delbanco T (2011) Promoting patient-centered
care A qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving patient experience International Journal for Quality in Health Care 23(5) 510-515 httpsdoiorg101093intqhcmzr024
Lyles C R Wolf M S Schillinger D Davis T C DeWalt D Dahlke A
R Curtis L amp Seligman H K (2013) Food insecurity in relation to changes in hemoglobin A1c self-efficacy and fruitvegetable intake during a diabetes educational intervention Diabetes Care 36(6) 1448-1453 httpsdoiorg102337dc12-1961
Maciejewski M L Mi X Sussman J Greiner M Curtis L H Ng J
Haffer S C amp Kerr E A (2018) Overtreatment and deintensification of diabetic therapy among Medicare beneficiaries Journal of General Internal Medicine 33(1) 34-41 httpsdoiorg101007s11606-017-4167-y
211
MacLean C D Susi B Phifer N Schultz L Bynum D Franco M
Klioze A Monroe M Garrett J amp Cykert S (2003) Patient preference for physician discussion and practice of spirituality Journal of General Internal Medicine 18(1) 38ndash43 httpsdoiorg101046j1525-1497200320403x
Majeed-Ariss R Jackson C Knapp P amp Cheater F M (2013) A
systematic review of research into black and ethnic minority patientsrsquo views on self-management of type 2 diabetes Health Expectations 18 625-642 httpsdoiorg101111hex12080
Mann J R McKay S Daniels D Lamar C S Witherspoon P W
Stanek M K amp Larimore W L (2005) Physician offered prayer and patient satisfaction International Journal of Psychiatry In Medicine 35(2) 161ndash170 httpsdoiorg1021902B0Q-2GW0-80L9-N3TK
Marmot M Friel S Bell R Houweling T A Taylor S amp Commission on
Social Determinants of Health (2008) Closing the gap in a generation Health equity through action on the social determinants of health Lancet (London England) 372(9650) 1661ndash1669 httpsdoiorg101016S0140-6736(08)61690-6
Masters K S amp Spielmans G I (2007) Prayer and health Review meta-
analysis and research agenda Journal of Behavioral Medicine 30 329-338 httpsdoiorg101007s10865-007-9106-7
Mazurenko O Bock S Prato C amp Bondarenko M (2015) Considering
shared power and responsibility Diabetic patientsrsquo experience with the PCMH care model Patient Experience Journal 2(1) 61-67 httpsdoiorg10356802372-02471056
McCarlie J Anderson A Collier A Jaap A McGettrick P MacPherson
N (2002) Who missed routine diabetic review Information from a district diabetes register Practical Diabetes International 19(9) 283-286 httpsdoiorg101002pdi397
212
McFarland M Davis K Wallace J Wan J Cassidy R Morgan T amp Venugopal D (2012) Use of home telehealth monitoring with active medication therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus Pharmacotherapy 32(5) 420-426 httpsdoiorg101002j1875-9114201101038x
McKenzie J F Pinger R F amp Seabert D M (2018) An introduction to
community amp public health (9th ed) Burlington MA Jones amp Bartlett Learning
McLeroy K R Bibeau D Steckler A amp Glanz K (1988) An ecological
perspective on health promotion programs Health Education Quarterly 15(4) 351-377 httpsdoiorg101177109019818801500401
Mead H Andres E amp Regenstein M (2014) Underserved patientsrsquo
perspectives on patient-centered primary care Does the patient-centered medical home model meet their needs Medical Care Research and Review 71(1) 61-84 httpsdoiorg1011771077558713509890
Mead N amp Bower P (2002) Patient-centered consultations and outcomes
in primary care A review of the literature Patient Education and Counseling 48(1) 51-61 httpsdoiorg101016s0738-3991(02)00099-x
Mechanic D McAlpine D D amp Rosenthal M (2001) Are patientsrsquo office
visits with physicians getting shorter New England Journal of Medicine 344(3) 198-204 httpsdoiorg101056NEJM200101183440307
Mehrotra A amp Prochazka A (2015) Improving value in health care--against
the annual physical The New England Journal of Medicine 373(16) 1485ndash1487 httpsdoiorg101056NEJMp1507485
Merriam S B (2009) Qualitative research A guide to design and
implementation (3rd ed) San Francisco CA John Wiley amp Sons
213
Merriam S B amp Tisdell E J (1998) Qualitative research A guide to design
and implementation (4th ed) San Francisco CA John Wiley amp Sons Miller M E Bonds D E Gerstein H C Seaquist E R Bergenstal R M
Calles-Escandon J Childress R D Craven T E Cuddihy R M Dailey G Feinglos M N Ismail-Beigi F Largay J F OConnor P J Paul T Savage P J Schubart U K Sood A Genuth S amp ACCORD Investigators (2010) The effects of baseline characteristics glycaemia treatment approach and glycated haemoglobin concentration on the risk of severe hypoglycaemia Post hoc epidemiological analysis of the ACCORD study BMJ 340 b5444 httpsdoiorg101136bmjb5444
Miller W R amp Thoresen C E (2003) Spirituality religion and health An
emerging research field The American Psychologist 58(1) 24-35 httpsdoiorg1010370003-066x58124
Mokdad A H Ford E S Bowman B A Dietz W H Vinicor F Bales V
S amp Marks J S (2003) Prevalence of obesity diabetes and obesity-related health risk factors 2001 Journal of the American Medical Association 289(1) 76-79 httpsdoiorg101001jama289176
Mold J W Fryer G E amp Roberts A M (2004) When do older patients
change primary care physicians The Journal of the American Board of Family Practice 17(6) 453ndash460 httpsdoiorg103122jabfm176453
Monroe M H Bynum D Susi B Phifer N Schultz L Franco M
MacLean C D Cykert S amp Garrett J (2003) Primary care physician preferences regarding spiritual behavior in medical practice Archives of Internal Medicine 163(22) 2751ndash2756 httpsdoiorg101001archinte163222751
Moore L Lavoie A Bourgeois G amp Lapointe J (2015) Donabedianrsquos
structure-process-outcome quality of care model Validation in an integrated trauma system The Journal of Trauma and Acute Care
214
Surgery 78(6) 1168-1175 httpsdoiorg101097TA0000000000000663
Morelli V (2017) An introduction to primary care in underserved populations
Definitions scope and challenges Primary Care Clinics in Office Practice 44(1) 1-9 httpsdoiorg101016jpop201609002
Morris A (2015) A practical introduction to in-depth interviewing Thousand
Oaks CA SAGE Publications Inc Morrow A S Haidet P Skinner J amp Naik A D (2008) Integrating
diabetes self-management with the health goals of older adults A qualitative exploration Patient Education Counseling 72(3) 418-423 httpsdoiorg101016jpec200805017
Musey V C Lee J K Crawford R Klatka M A McAdams D amp Phillips
L S (1995) Diabetes in urban African-Americans I Cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis Diabetes Care 18(4) 483-489 httpsdoiorg102337diacare184483
Nam J H Lee C Kim N Park K Y Ha J Yun J Shin D W amp Shin
E (2019) Impact of continuous care on health outcomes and cost for type 2 diabetes mellitus Analysis using National Health Insurance Cohort Database Diabetes amp Metabolism Journal 43(6) 776ndash784 httpsdoiorg104093dmj20180189
Nandyala A S Nelson L A Lagotte A E amp Osborn C Y (2018) An
analysis of whether health literacy and numeracy are associated with diabetes medication adherence HLRP Health Literacy Research and Practice 2(1) e15-e20 httpsdoiorg10392824748307-20171212-01
Narayan K M V Boyle J P Geiss L S Saaddine J B amp Thompson T
J (2006) Impact of recent increase in incidence on future diabetes burden Diabetes Care 29(9) 2114-2116 httpsdoiorg102337dc06-1136
215
Narayan K M V Gregg E W Fagot-Campagna A Gary T L Saaddine
J B Parker C Imperatore G Valdez R Beckles G amp Engelgau M M (2003) Relationship between quality of diabetes care and patient satisfaction Journal of the National Medical Association 95(1) 64-70
Narres M Claessen H Droste S Kvitkina T Koch M Kuss O amp Icks
A (2016) The incidence of end-stage renal disease in the diabetic (compared to the non-diabetic) population A systemic review PLoS One 11(1) e0147329 httpsdoiorg101371journal pone0147329
New Jersey Department of Health Center for Health Statistics New Jersey
State Health Assessment Data (NJSHAD) (2017) New Jersey Behavioral Risk Factor Survey (NJBRFS) Query Results for New Jersey Behavioral Risk Factor Survey Data - Diabetes - Crude Rate [online] httpnjgovhealthshad
Ngo-Metzger Q August K J Srinivasan M Liao S amp Meyskens Jr F L
(2008) End-of-life care Guidelines for patient-centered communication American Family Medicine 77(2) 167-174
Nicklett E J amp Liang J (2010) Diabetes-related support regimen
adherence and health decline among older adults Journal of Gerontology 65B(3) 390-399 httpsdoiorg101093geronbgbp050
Noble H amp Smith J (2015) Issues of validity and reliability in qualitative
research Evidence Based Nursing 18(2) 34-35 httpsdoiorg101136eb-2015-102054
Norris S L Lau J Smith S J Schmid C H amp Engelgau M M (2002)
Self-management education for adults with type 2 diabetes Diabetes Care 25(7) 1159-1171 httpsdoiorg102337diacare2571159
Northwood M Ploeg J Markle-Reid M amp Sherifali D (2018) Integrative
review of the social determinants of health in older adults with
216
multimorbidity Journal of Advanced Nursing 74(1) 45-60 doi101111jan13408 httpsdoiorg101111jan13408
NVivo qualitative data analysis software QSR International Pty Ltd Version
12 2018 Oboler S K Prochazka A V Gonzales R Xu S amp Anderson R J
(2002) Public expectations and attitudes for annual physical examinations and testing Annals of Internal Medicine 136(9) 652ndash659 httpsdoiorg1073260003-4819-136-9-200205070-00007
OConnor P J Bodkin N L Fradkin J Glasgow R E Greenfield S
Gregg E Kerr E A Pawlson L G Selby J V Sutherland J E Taylor M L amp Wysham C H (2011) Diabetes performance measures Current status and future directions Diabetes Care 34(12) 1651-1659 httpsdoiorg102337dc11-0735
Odgers-Jewell K Ball L E Kelly J T Isenring E A Reidlinger D P amp
Thomas R (2017) Effectiveness of group-based self-management education for individuals with Type 2 diabetes a systematic review with meta-analyses and meta-regression Diabetic medicine A Journal of the British Diabetic Association 34(8) 1027ndash1039 httpsdoiorg101111dme13340
Olver I N amp Dutney A (2012) A randomized blinded study of the impact of
intercessory prayer on spiritual well-being in patients with cancer Alternative Therapies in Health amp Medicine 18(5) 18-27
Osborn C Y Cavanaugh K Wallston K A White R O amp Rothman R
L (2009) Diabetes numeracy An overlooked factor in understanding racial disparities in glycemic control Diabetes Care 32(9) 1614-1619 httpsdoiorg102337dc09-0425
Ospina N S Phillips K A Rodriguez-Gutierrez R Castaneda-Guarderas
A Gionfriddo M R Branda M E amp Montori V M (2019) Eliciting the patients agenda- secondary analysis of recorded clinical
217
encounters Journal of General Internal Medicine 34(1) 36ndash40 httpsdoiorg101007s11606-018-4540-5
Ozougwu J C Obimba K C Belonwu C D amp Unakalamba C B (2013)
The pathogenesis and pathophysiology of type 1 and type 2 diabetes mellitus Journal of Physiology and Pathophysiology 4(4) 46-57 httpsdoiorg105897JPAP20130001
Pal K Eastwood S V Michie S Farmer A J Barnard M L Peacock
R Wood B Inniss J D amp Murray E (2013) Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus Cochrane Database of Systematic Reviews 2013(3) CD008776 httpsdoiorg10100214651858CD008776pub2
Pamungkas R A Chamroonsawasdi K amp Vatanasomboon P (2017) A
systematic review Family support integrated with diabetes self-management among uncontrolled type II diabetes mellitus patients Behavioral sciences (Basel Switzerland) 7(3) 62 httpsdoiorg103390bs7030062
Parulekar M S amp Rogers C K (2018) Polypharmacy and mobility In D X
Cifu H L Lew amp M Oh-Park (Eds) Geriatric Rehabilitation (pp 121-129) Elsevier Inc
Patil S J Ruppar T Koopman R J Lindbloom E J Elliott S G Mehr
D R amp Conn V S (2016) Peer support interventions for adults with diabetes A meta-analysis of hemoglobin A1c outcomes Annals of Family Medicine 14(6) 540ndash551 httpsdoiorg101370afm1982
Patton M Q (2015) Qualitative research amp evaluation methods (4th ed)
Thousand Oaks CA Sage Publications Penchansky R amp Thomas J W (1981) The concept of access Definition
and relationship to consumer satisfaction Medical Care 19(2) 127-140 httpsdoiorg10109700005650-198102000-00001
218
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Pew Research Center (2017b) Technology use among seniors
httpswwwpewresearchorginternet20170517technology-use-among-seniors
Pew Research Center (2019a) Digital divide persists even as lower-income
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Pew Research Center (2019b) Mobile technology and home broadband
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Pew Research Center (2019c) Internetbroadband fact sheet
httpswwwpewresearchorginternetfact-sheetinternet-broadband Pew Research Center (2019d) Findings at a glance Medical doctors
httpswwwpewresearchorgscience20190802findings-at-a-glance-medical-doctors
Pew Research Center (2020) Americans turn to technology during COVID-
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Pfaff K amp Markaki A (2017) Compassionate collaborative care An
integrative review of quality indicators in end-of-life care BMC Palliative Care 16(65) httpsdoiorg101186s12904-017-0246-4
Phelps A C Lauderdale K E Alcorn S Dillinger J Balboni M T Van
Wert M Vanderweele T J amp Balboni T A (2012) Addressing spirituality within the care of patients at end of life Perspectives of
219
patients with advanced cancer oncologists and oncology nurses Journal of Clinical Oncology 30(20) 2538-2544 httpsdoiorg101200JCO2011403766
Phillips K A amp Ospina N S (2017) Physicians interrupting patients
Journal of the American Medical Association 318(1) 93-94 httpsdoiorg101001jama20176493
Philp L Tugay K Hildon Z Aw S Jeon Y-H Naegle M Michel J-P
Namara A Wang N amp Hardman M (2017) Person-centred assessment to integrate care for older people World Health Organization httpswwwwhointageinghealth-systemsicopeicope-consultationICOPE-Global-Consultation-Background-Paper-2pdf
Pilkington F B Daiski I Bryant T Dinca-Panaitescu M Dinca-
Panaitescu S amp Raphael D (2010) The experience of living with diabetes for low-income Canadians Canadian Journal of Diabetes 34(2) 119-126 httpsdoiorg101016S1499-2671(10)42008-0
Pirela D V amp Garg R (2019) De-intensification of diabetes treatment in
elderly patients with type 2 diabetes mellitus Endocrine Practice 25(12) 1317ndash1322 httpsdoiorg104158EP-2019-0303
Pirhonen L Olofsson E H Fors A Ekman I amp Bolin K (2017) Effects
of person-centered care on health outcomes-ndashA randomized controlled trial in patients with acute coronary syndrome Health Policy 121 169-179 httpsdoiorg101016jhealthpol201612003
Polonsky W H amp Henry R R (2016) Poor medication adherence in type 2
diabetes Recognizing the scope of the problem and its key contributors Patient Preference and Adherence 10 1299ndash1307 httpsdoiorg102147PPAS106821
Polzer R L amp Miles M S (2007) Spirituality in African Americans with
diabetes Self-management through a relationship with God Qualitative Health Research 17(2) 176ndash188 httpsdoiorg1011771049732306297750
220
Pooley C G Gerrard C Hollis S Morton S amp Astbury J (2001) lsquoOh itrsquos
a wonderful practice you can talk to themrsquo A qualitative study of patientsrsquo and health professionalsrsquo views on the management of type 2 diabetes Health and Social Care in the Community 9(5) 318-326 httpsdoiorg101046j1365-2524200100307x
Powers M A Bardsley J Cypress M Duker P Funnell M M Fischl A
H Maryniuk M D Siminerio L amp Vivian E (2016) Diabetes self-management education and support in type 2 diabetes A joint position statement of the American Diabetes Association the American Association of Diabetes Educators and the Academy of Nutrition and Dietetics Diabetes Care 34(2) 70-80 httpsdoiorg102337diaclin34270
Prochazka A V Lundahl K Pearson W Oboler S K amp Anderson R J
(2005) Support of evidence-based guidelines for the annual physical examination a survey of primary care providers Archives of Internal Medicine 165(12) 1347ndash1352 httpsdoiorg101001archinte165121347
Ramachandran B Trinacty C M Wharam J F Duru O K Dyer W T
Neugebauer R S Karter A J Brown S D Marshall C J Wiley D Ross-Degnan D amp Schmittdiel J A (2020) A randomized encouragement trial to increase mail order pharmacy use and medication adherence in patients with diabetes Journal of General Internal Medicine 101007s11606-020-06237-8 Advance online publication httpsdoiorg101007s11606-020-06237-8
Ravi S Kumar S amp Gopichandran V (2018) Do supportive family
behaviors promote diabetes self-management in resource limited urban settings A cross sectional study BMC Public Health 18(1) 826 httpsdoiorg101186s12889-018-5766-1
Reckrey J M Yang M Kinosian B Bollens-Lund E Leff B Ritchie C
amp Ornstein K (2020) Receipt of home-based medical care among older beneficiaries enrollees in fee-for-service Medicare Health Affairs 39(8) 1289-1296 httpsdoiorg101377hlthaff201901537
221
Remillard R B J amp Bunce N J (2002) Linking dioxins to diabetes
Epidemiology and biologic plausibility Environment Health Perspective 110(9) 853-858 httpsdoiorg101289ehp02110853
Reynolds E E Heffernan J Mehrotra A amp Libman H (2016) Should
patients have periodic health examinations Grand rounds Discussion from Beth Israel Deaconess Medical Center Annals of Internal Medicine 164(3) 176ndash183 httpsdoiorg107326M15-2885
Robinson K A Cheng M R Hansen P D amp Gray R J (2017) Religious
and Spiritual Beliefs of Physicians Journal of Religion and Health 56(1) 205ndash225 httpsdoiorg101007s10943-016-0233-8
Robinson N Yateman N A Protopapa L E amp Bush L (1989)
Unemployment and diabetes Diabetic Medicine 6(9) 797-803 httpsdoiorg101111j1464-54911989tb01282x
Rodger W (1991) Non-insulin-dependent (type II) diabetes mellitus
Canadian Medical Association Journal 145(12) 1571-1581 Rogers E A Yost K J Rosedahl J K Linzer M Boehm D H Thakur
A Poplau S Anderson R T amp Eton D T (2017) Validating the patient experience with treatment and self-management (PETS) a patient-reported measure of treatment burden in people with diabetes Patient Related Outcome Measures 8 143-156 httpsdoiorg102147PROMS140851
Rosenthal M B Zaslavsky A amp Newhouse J P (2005) The geographic
distribution of physicians revisited Health Services Research 40(6) 1931-1952 httpsdoiorg101111j1475-6773200500440x
Rui P amp Okeyode T (2016) National ambulatory medical care survey
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222
Ryu J amp Lee T H (2017) The waiting game ndash why providers may fail to
reduce with times The New England Journal of Medicine 376 2309-2311 httpsdoiorg101056NEJMp1704478
Safran D G Montgomery J E Chang H Murphy J amp Rogers W H
(2001) Switching doctors Predictors of voluntary disenrollment from a primary physicians practice The Journal of Family Practice 50(2) 130ndash136
Saldana J (2009) The coding manual for qualitative researchers (1st ed)
Thousand Oaks CA Sage Publications Sallis J F amp Owen N (2015) Ecological models of health behavior In K
Glanz B K Rimer amp K Viswanath (Eds) Health behavior theory research and practice (5th ed pp 43-64) San Francisco CA Jossey-Bass
Samuel-Hodge C D Headen S W Skelly A H Ingram A F Keyserling
T C Jackson E J Ammerman A S amp Elasy T A (2000) Influences on day-to-day self-management of type 2 diabetes among African-American women Spirituality the multi-caregiver role and other social context factors Diabetes Care 23(7) 928ndash933 httpsdoiorg102337diacare237928
Samuels T A Cohen D Brancati F L Coresh J amp Kao W H (2006)
Delayed diagnosis of incident type 2 diabetes mellitus in the ARIC study The American Journal of Managed Care 12(12) 717ndash724
Schmittdiel J A Gopalan A Lin M W Banerjee S Chau C V amp
Adams A S (2017) Population health management for diabetes Health care system-level approaches for improving quality and addressing disparities Current Diabetes Reports 17(5) 31 httpsdoiorg101007s11892-017-0858-3
223
Schootman M Andresen E M Wolinsky F D Malmstrom T K Miller J P Yan Y amp Miller D K (2007) The effect of adverse housing and neighborhood conditions on the development of diabetes mellitus among middle-aged African Americans American Journal of Epidemiology 166(4) 379-387 httpsdoiorg101093ajekwm190
Schreiber R S amp Stern P N (Eds) (2001) Using grounded theory in
nursing New York NY Springer Publishing Company Inc Schroeder E B Zeng C Sterrett A T Kimpo T K Paolino A R amp
Steiner J F (2019) The longitudinal relationship between food insecurity in older adults with diabetes and emergency department visits hospitalizations hemoglobin A1c and medication adherence Journal of Diabetes and Its Complications 33(4) 289-295 httpsdoiorg101016jjdiacomp201811011
Segal S P (1999) Social work in a managed care environment
International Journal of Social Welfare 8 47-55 Seidman I (2013) Interviewing as qualitative research (4th ed) New York
NY Teachers College Press Seidu S Davies M J Mostafa S de Lusignan S amp Khunti K (2014)
Prevalence and characteristics in coding classification and diagnosis of diabetes in primary care Postgraduate Medical Journal 90(1059) 13ndash17 httpsdoiorg101136postgradmedj-2013-132068
Seidu S Kunutsor S K Topsever P Hambling C E Cos F X amp
Khunti K (2019) Deintensification in older patients with type 2 diabetes A systematic review of approaches rates and outcomes Diabetes Obesity amp Metabolism 21(7) 1668ndash1679 httpsdoiorg101111dom13724
Seligman H K Bindman A B Vittinghoff E Kanaya A M amp Kushel M
B (2007) Food insecurity is associated with diabetes mellitus results from the National Health Examination and Nutrition Examination
224
Survey (NHANES) 1999-2002 Journal of General Internal Medicine 22(7) 1018-1023 httpsdoiorg101007s11606-007-0192-6
Seligman H K Davis T C Schillinger D amp Wolf M S (2010) Food
insecurity is associated with hypoglycemia and poor diabetes self-management in a low-income sample with diabetes Journal of Health Care for the Poor and Underserved 21(4) 1227-1233 httpsdoiorg101353hpu20100921
Seligman H K Jacobs E A Lopez A Tschann J amp Fernandez A
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Seligman H K amp Schillinger D (2010) Hunger and socioeconomic
disparities in chronic disease New England Journal of Medicine 363(1) 6-9 httpsdoiorg101056NEJMp1000072
Shay L A Dumenci L Siminoff L A Flocke S A amp Lafata J E (2012)
Factors associated with patient reports of positive physician relational communication Patient Education and Counseling 89(1) 96-101 httpdxdoiorg101016jpec201204003
Shenton A K (2004) Strategies for ensuring trustworthiness in qualitative
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Shojania K G amp Marang-van de Mheen P J (2020) Identifying adverse
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Sigal R J Kenny G P Wasserman D H amp Castaneda-Sceppa C
(2004) Physical activityexercise and type 2 diabetes Diabetes Care 27(10) 2518-2539 httpdxdoiorg102337diacare27102518
225
Singh H Meyer A N amp Thomas E J (2014) The frequency of diagnostic errors in outpatient care estimations from three large observational studies involving US adult populations BMJ Quality amp Safety 23(9) 727ndash731 httpsdoiorg101136bmjqs-2013-002627
Singh H Schiff G D Graber M L Onakpoya I amp Thompson M J
(2017) The global burden of diagnostic errors in primary care BMJ Quality amp Safety 26 484-494 httpdxdoiorg101136bmjqs-2016-005401
Smaje A Weston-Clark M Raj R Orlu M Davis D amp Rawle M (2018)
Factors associated with medication adherence in older patients A systematic review Aging Medicine 1(3) 254-266 httpsdoiorg101002agm212045
Smith M A amp Bartell J M (2004) Changes in usual source of care and
perceptions of health care access quality and use Medical Care 42(10) 975ndash984 httpsdoiorg10109700005650-200410000-00006
Step M M Rose J H Albert J M Cheruvu V K amp Siminoff L A
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Stoller E P (1993) Interpretations of symptoms by older people A health
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Stoller E P (1998) Dynamics and processes of self-care in old age In M G
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Stransky M L (2017) Two-year stability and change in access to and
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226
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Stransky M L (2018) Unmet needs for care and medications cost as a
reason for unmet needs and unmet needs as a big problem due to health-care provider (dis)continuity Journal of Patient Experience 5(4) 258ndash266 httpsdoiorg1011772374373518755499
Suhl E amp Bonsignore P (2006) Diabetes self-management education for
older adults General principles and practical application Diabetes Spectrum 19(4) 234-240 httpsdoiorg102337diaspect194234
Tai-Seale M McGuire T G amp Zhang W (2007) Time allocation in primary
care office visits Health Services Research 42(5) 1871-1894 httpsdoiorg101111j1475-6773200600689x
Takane A K amp Hunt S B (2012) Transforming primary care practices in a
HawairsquoI island clinic Obtaining patient perceptions on patient centered medical home HawairsquoI Journal of Medicine amp Public Health 71(9) 253-258
Tay J Jiang Y Hong J He H amp Wang W (2021) Effectiveness of lay-
led group-based self-management interventions to improve glycated hemoglobin (HbA1c) self-efficacy and emergency visit rates among adults with type 2 diabetes A systematic review and meta-analysis International Journal of Nursing Studies 113 103779 httpsdoiorg101016jijnurstu2020103779
Teutsch C (2003) Patient-doctor communication The Medical Clinics of
North America 87(5) 1115-1145 httpsdoiorg101016s0025-7125(03)00066-x
Tierney W M Harris L E Gaskins D L Zhou X H Eckert G J Bates
A S amp Wolinsky F D (2000) Restricting Medicaid payments for transportation Effects on inner-city patientsrsquo health care The American Journal of the Medical Sciences 319(5) 326-333 httpsdoiorg10109700000441-200005000-00010
227
Thomas L V Wedel K R amp Christopher J E (2018) Access to
transportation and health care visits for Medicaid enrollees with diabetes The Journal of Rural Health 34(2) 162-172 httpsdoiorg101111jrh12239
Thorne S E Hislop T G Armstrong E-A amp Oglov V (2008) Cancer care
communication The power to harm and the power to heal Patient Education and Counseling 71(1) 34-40 httpsdoiorg101016jpec200711010
Thorpe C T Fahey L E Johnson H Deshpande M Thorpe J M amp
Fisher E B (2013) Facilitating healthy coping in patients with diabetes a systematic review The Diabetes Educator 39(1) 33ndash52 httpsdoiorg1011770145721712464400
Tol A Alhani F Shojaeazadeh D Sharifirad G amp Moazam N (2015) An
empowering approach to promote the quality of life and self-management among type 2 diabetic patients Journal of Education and Health Promotion 4(13) httpsdoiorg1041032277-9531154022
Tran T Q Scherpbier A J J A van Dalen J Do Van D amp Wright E P
(2020) Nationwide survey of patientsrsquo and doctorsrsquo perceptions of what is needed in doctor - patient communication in a Southeast Asian context BMC Health Services 20 946 httpsdoiorg101186s12913-020-05803-4
Tricco A C Ivers N M Grimshaw J M Moher D Turner L Galipeau
J Halperin I Vachon B Ramsay T Manns B Tonelli M amp Shojania K (2012) Effectiveness of quality improvement strategies on the management of diabetes A systematic review and meta-analysis Lancet 379(9833) 2252-2261 httpsdoiorg101016S0140-6736(12)60480-2
Tung E L amp Peek M E (2015) Linking community resources in diabetes
care A role for technology Current Diabetes Report 15(7) 614 httpsdoiorg101007s11892-015-0614-5
228
Turrin K B amp Trujillo J M (2019) Effects of diabetes numeracy on
glycemic control and diabetes self-management behaviors in patients on insulin pump therapy Diabetes Therapy 10(4) 1337-1346 httpsdoiorg101007s13300-019-0634-2
United States Census Bureau (2017) The nationrsquos older population is still
growing Census Bureau reports (Release Number CB17-100) httpswwwcensusgovnewsroompress-releases2017cb17-100html
Valentiner D P Holahan C J amp Moos R H (1994) Social support
appraisals of event controllability and coping An integrative model Journal of Personality and Social Psychology 66(6) 1094-1102 httpsdoiorg1010370022-35146661094
Vaportzis E Clausen M G amp Gow A J (2017) Older adults perceptions
of technology and barriers to interacting with tablet computer A focus group study Frontiers in Psychology 8(1687) 1-11 httpsdoiorg103389fpsyg201701687
Vasiliu O Cameron L Gardiner J Deguire P amp Karmaus W (2006)
Polybrominated biphenyls polychlorinated biphenyls body weight and incidence of adult-onset diabetes mellitus Epidemiology 17(4) 352-359 httpsdoiorg10109701ede000022055384350c5
Vijayakumar P Liu S McCoy R G Karter A J Lipska K J (2020)
Changes in management of type 2 diabetes before and after severe hypoglycemia Diabetes Care 43(11) e188-e189 httpsdoiorg102337dc20-0458
Vijayaraghavan M Jacobs E A Seligman H amp Fernandez A (2011)
The association between housing instability food insecurity and diabetes self-efficacy in low-income adults Journal of Health Care for the Poor and Underserved 22(4) 1279-1291 httpsdoiorg101353hpu20110131
229
Wagner E H Austin B T Davis C Hindmarsh M Schaefer J amp Bonomi A (2001) Improving chronic illness care Translating evidence into action Health Affairs 20(6) 64-78 httpsdoiorg101377hlthaff20664
Walker E A Shmukler C Ullman R Blanco E Scollan-Koliopoulus M
amp Cohen H W (2011) Results of a successful telephonic intervention to improve diabetes control in urban adults A randomized trial Diabetes Care 34(1) 2-7 httpsdoiorg102337dc10-1005
Walker R J Garacci E Campbell J A Harris M Mosley-Johnson E amp
Egede L E (2021) Relationship between multiple measures of financial hardship and glycemic control in older adults with diabetes Journal of Applied Gerontology 40(2) 162-169 httpsdoiorg10117707334648209115
Wang J Geiss L S Williams D E amp Gregg E W (2015) Trends in
emergency department visit rates for hypoglycemia and hyperglycemic crisis among adults with diabetes United States 2006-2011 PLoS One 10(8) e0134917 httpsdoiorg101371journal pone0134917
Wanko N S Brazier C W Young-Rogers D Dunbar V G Boyd B
George C D Rhee M K el-Kebbi I M amp Cook C B (2004) Exercise preferences and barriers in urban African Americans with type 2 diabetes The Diabetes Educator 30(3) 502ndash513 httpsdoiorg101177014572170403000322
Ward K Eustice R S Nawarskas A D amp Resch N D (2018)
Comparison of diabetes management by certified diabetes educators via telephone versus mixed modalities of care Clinical Diabetes 36(1) 44-49 httpsdoiorg102337cd17-0018
Watson M J (1988) New dimensions of human caring theory Nursing
Science Quarterly 1(4) 175ndash181 httpsdoiorg101177089431848800100411