Content area
Abstract
Background: Racial and ethnic minorities are disproportionately affected with type 2 diabetes (T2D) in the United States. Tight diabetes control can prevent or delay complications of the disease. However, if the disease is uncontrolled, long-term complications of diabetes may result in blindness, renal disease, heart disease and stroke, and lower extremity amputation. Research shows that diabetes self-management education (DSME) has been an effective intervention in managing diabetes. Education represents a potentially effective solution to the pervasive problem of uncontrolled diabetes, yet is used relatively infrequently. Since DSME often requires a physician referral, the physician influences a patient's decision whether or not to attend DSME.
Purpose: This study evaluates differences in referral patterns to diabetes self-management education (high referring and low referring), and identifies specific factors related to improving access to DSME through culturally competent health care delivery.
Methods: Findings from this study are based on 16 semi-structured interviews with physicians, 32 semi-structured interviews with patients who have T2D, and 32 clinical observations. Interview transcripts and observation notes were analyzed in MAXQDA using the framework method combined with thematic content analysis.
Results: No overall differences with respect to high/low referring groups or patient race/ethnicity were found in this study.
All physicians considered diabetes education a very important part of diabetes treatment, but physician referral patterns to DSME varied. Physicians with low referrals to DSME did not infer that less education was occurring with the patient. Physicians reported that health system factors and reimbursement patterns contributed to DSME underutilization. Physicians also described how current health system metrics and practice patterns were not aligned to account for patient variation. Cultural and social needs are challenging to address in the treatment plan for patients with diabetes. Building relationships and rapport with patients led to discussions of understanding barriers to diabetes management.
Patients described the importance of relationships because they placed high levels of trust in their physician. Although supportive relationships and good physician communication skills were important, improved health effects were not always associated with improved communication skills. Nevertheless, patients reported that physicians communicated effectively to assess important values or circumstances for teaching them how to self-manage diabetes. Participants did not report cultural or religious ideas conflicting with their physicians’ education or recommendations. Most participants were aware of the diabetes self-management education program. The data suggest that patients’ decision to attend was influenced by their physician. Patients recommended renaming the program in such a way as to make it more appealing or attractive (e.g. health promotion for individuals with diabetes). Also, it is recommended to monitor the frequency and effectiveness of educational experiences of patients with diabetes and create patient report cards attributable to each primary care physician.
Conclusion: Physicians and patients recognize the importance of DSME. However, physician cultural competence was not found to improve participation in diabetes selfmanagement education even when physicians respond to patients’ specific needs. This qualitative study suggests that trust and building relationships remain important aspects of health care for patients with T2D. Health care organizations can potentially utilize knowledge from this study to shape the delivery of health care from the patient perspective, especially study of on-site diabetes education and providing patients with community resources.
