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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

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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

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

Copyright copy Christopher K Rogers 2021

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

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

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

the PhD degree will inspire you to achieve your dreams and God-given

abilities

DEDICATION

I dedicate this dissertation to my mother Areh Howell my wife Latisha

Rogers and my three children Christian Anani and Christopher Jr

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

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

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

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

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

Process127

Social support147

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

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 10 Theme 3 and Corresponding Subthemeshelliphelliphelliphelliphelliphelliphelliphelliphelliphellip96

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

ABSTRACT

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

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

Key Words type 2 diabetes older adults underserved person-centered care

patient-centered care qualitative research

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

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)

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

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)

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

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

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

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

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

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

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

treatment and management care that is more effective for older adults living

in MUAs

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

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

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)

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

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)

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

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

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)

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

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)

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

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

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

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

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

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

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

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

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

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)

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

ldquono two patients have exactly the same set of experiences or respond to

treatment in the same wayrdquo (Pooley et al 2001 p 323)

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

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

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

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

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

multilevel interventions beyond disease-reduction to empower self-

management and optimize health outcomes and quality of life

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

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

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

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

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

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

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

(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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Theme Subthemes

Accessible services for older

adults

bull Health care services in older adultsrsquo

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

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

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

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

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

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

Theme Subthemes

Information sharing

and provider

communication

Informational Relational

bull Information from online to

help with diabetes self-

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

Theme Subthemes

Older adultsrsquo

diabetes self-

management

behavioral strategies

Physical

bull Monitoring blood

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)

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(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

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

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

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

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

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

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

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

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

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

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

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)

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

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)

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

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

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)

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

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

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

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

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-

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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

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Behan J Carmichael S Edeen R Gerry D Hoover M Hughes M

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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

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Berkowitz S A Delahanty L M Terranova J Steiner B Ruazol M P

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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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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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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

Environmental Health Perspectives 115(11) A534 httpswwwncbinlmnihgovpmcarticlesPMC2072858

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

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Carmen K L Dardess P Maurer M Sofaer S Adams K Bechtel C amp

Sweeney J (2013) Patient and family engagement A framework from understanding the elements and developing interventions and policies Health Affairs 32(2) 223-231 httpsdoiorg101377hlthaff20121133

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

evidence and equipment Diabetes Management (London England) 1(2) 191ndash199 httpsdoiorg102217dmt115

Cavanaugh K Huizinga M M Wallston K A Gebretsadik T Shintani

A Davis D Gregory R P Fuchs L Malone R Cherrington A Pignone M DeWalt D A Elasy T A amp Rothman R L (2008) Association of numeracy and diabetes control Annals of Internal Medicine 148(10) 737-746 httpsdoiorg1073260003-4819-148-10-200805200-00006

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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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

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Chentli F Azzoug S amp Mahgoun S (2015) Diabetes mellitus in elderly

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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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Clissett P Porock D Harwood R H amp Gladman RF J (2013) The

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Counsell S R Holder C M Liebenauer L L Palmer R M Fortinsky R

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Crabtree B F amp Miller W L (1992) Doing qualitative research Newbury

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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

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

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 (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

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and Laboratory Medicine 114(11) 1115-1118

Donabedian A (1992) The Lichfield Lecture Quality assurance in health

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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

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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

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

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

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

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

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

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

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

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

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

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

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-

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

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

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

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

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

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

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

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

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

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

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

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

Pew Research Center (2017a) Western Europe survey dataset httpswwwpewforumorgdatasetwestern-europe-survey-dataset

Pew Research Center (2017b) Technology use among seniors

httpswwwpewresearchorginternet20170517technology-use-among-seniors

Pew Research Center (2019a) Digital divide persists even as lower-income

Americans make gains in tech adoption httpswwwpewresearchorgfact-tank20190507digital-divide-persists-even-as-lower-income-americans-make-gains-in-tech-adoption

Pew Research Center (2019b) Mobile technology and home broadband

2019 httpswwwpewresearchorginternet20190613mobile-technology-and-home-broadband-2019

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-

19 outbreak say an outage would be a problem httpswwwpewresearchorgfact-tank20200331americans-turn-to-technology-during-covid-19-outbreak-say-an-outage-would-be-a-problem

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

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

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

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

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

2016 national summary tables httpswwwcdcgovnchsdataahcdnamcs_summary2016_namcs_ web_tablespdf

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

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

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

(2012) Food insecurity and glycemic control among low-income patients with type 2 diabetes Diabetes Care 35(2) 233-238 httpsdoiorg102337dc11-1627

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

research projects Education for Information 22(2) 63-75 httpsdoiorg103233EFI-2004-22201

Shojania K G amp Marang-van de Mheen P J (2020) Identifying adverse

events Reflections on an imperfect gold standard after 20 years of patient safety research BMJ Quality amp Safety 29(4) 265-270 httpdxdoiorg101136bmjqs-2019-009731

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

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

(2009) Modeling patient-centered communication Oncologist relational communication and patient communication involvement in breast cancer adjuvant therapy decision-making Patient Education and Counseling 77(3) 369-378 httpsdoiorg101016jpec200909010

Stoller E P (1993) Interpretations of symptoms by older people A health

diary study of illness behavior Journal of Aging and Health 5(1) 58-81 httpsdoiorg1011772F089826439300500103

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

reasons for lacking a usual source of care among working-age US

adults Public Health Reports (Washington DC 1974) 132(6) 660ndash668 httpsdoiorg1011770033354917735322

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

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

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

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

Watson R Bryant J Sanson-Fisher R Mansfield E amp Evans T J (2018) What is a timely diagnosis Exploring the preferences of Australian health service consumers regarding when a diagnosis of dementia should be disclosed BMC Health Services Research 18(1) 612 httpsdoiorg101186s12913-018-3409-y

Weinert C (1987) A social support measure PRQ85 Nursing Research

36(5) 273ndash277 Wen L K Shepherd M D amp Parchman M L (2004) Family support diet

and exercise among older Mexican Americans with type 2 diabetes Diabetes Education 30(6) 980-993 httpsdoiorg101177014572170403000619

Wen L S amp Tucker S (2015) What do people want from their health care

A qualitative study Journal of Participatory Medicine 7 e10 httpsparticipatorymedicineorgjournalevidenceresearch20150625what-do-people-want-from-their-health-care-a-qualitative-study

Wheeler K Crawford R McAdams D Robinson R Dunbar V G amp

Cook C B (2007) Inpatient to outpatient transfer of diabetes care perceptions of barriers to postdischarge followup in urban African American patients Ethnicity amp Disease 17(2) 238ndash243

White R O Wolff K Cavanaugh K L Rothman R (2010) Addressing

health literacy and numeracy to improve diabetes education and care Diabetes Spectrum 23(4) 238-243 httpsdoiorg102337diaspect234238

Williams J S Walker R J Smalls B L Hill R amp Egede L E (2016)

Patient-centered care glycemic control diabetes self-care and quality of life in adults with type 2 diabetes Diabetes Technology amp Therapeutics 18(10) 644-649 httpsdoiorg101089dia20160079

Wolff J L amp Roter D L (2008) Hidden in plain sight Medical visit

companions as a resource for vulnerable older adults Archives of

Internal Medicine 168(13) 1409-1415 httpsdoiorg101001archinte168131409

Wolff J L amp Roter D L (2011) Family presence in routine medical visits A

meta-analytical review Social Science amp Medicine 72(6) 823-831 httpsdoiorg101016jsocscimed201101015

Wolinsky F D amp Marder W D (1982) Spending time with patients The

impact of organizational structure on medical practice Medical Care 20(10 1051-1059

World Health Organization (WHO) (2018) Global health estimates 2016

Deaths by cause age sex by country and by region 2000-2016 httpwwwwhointnews-roomfact-sheetsdetailthe-top-10-causes-of-death

Wu A W Cavanaugh T A McPhee S J Lo B amp Micco G P (1997)

To tell the truth Ethical and practical issues in disclosing medical mistakes to patients Journal of General Internal Medicine 12(12) 770-775 httpsdoiorg101046j1525-1497199707163x

Wunderlich G S amp Norwood J L (Eds) (2006) Food insecurity and

hunger in the United States An assessment of the measure Washington DC The National Academies Press httpswwwnapeducatalog11578food-insecurity-and-hunger-in-the-united-states-an-assessment

Wysocki A Cheh V amp Sigalo N (2019) Patterns of care and home health

utilization for community-admitted Medicare patients Mathematica Policy Research httpsaspehhsgovsystemfilespdf261016ComAdmitpdf

Yakaryılmaz F D amp Oumlztuumlrk Z A (2017) Treatment of type 2 diabetes

mellitus in the elderly World Journal Diabetes 8(6) 278-285 httpsdoiorg104239wjdv8i6278

Yap A F Thirumoorthy T amp Kawn Y H (2016) Medication adherence in the elderly Journal of Clinical Gerontology and Geriatrics 7(2) 64-67 httpsdoiorg101016jjcgg201505001

Yawn B Goodwin M A Zyzanski S J amp Stange K C (2003) Time use

during acute and chronic illness visits to a family physician Family Practice 20(4) 474-477 httpsdoiorg101093fampracmg425

Yeh G Y Eisenberg D M Davis R B amp Phillips R S (2002) Use of

complementary and alternative medicine among persons with diabetes mellitus Results of a national survey American Journal of Public Health 92(10) 1648-1852 httpsdoiorg102105ajph92101648

Zaugg S D Dogbey G Collins K Reynolds S Batista C Brannan G

amp Shubrool J H (2014) Diabetes numeracy and blood glucose control Association with type of diabetes and source of care Clinical Diabetes 32(4) 152-157 httpsdoiorg102337diaclin324152

Zelko E Klemenc-Ketis Z amp Tusek-Bunc K (2016) Medication adherence

in elderly with polypharmacy living at home A systematic review of existing studies Journal of the Academy of Medical Sciences of Bosnia and Herzegovina 28(2) 129-132 httpsdoiorg105455msm201628129-132

Zhang J Yang L Wang X Dai J Shan W amp Wang J (2020) Inpatient

satisfaction with nursing care in a backward region A cross-sectional study from northwestern China BMJ Open 10(9) e034196 httpsdoiorg101136bmjopen-2019-034196

Zhang X Bullard K M Gregg E W Beckles G L Williams D E

Barker L E Albright A L amp Imperatore G (2012) Access to health care and control of ABCs of diabetes Diabetes Care 35(7) 1566-1571 httpsdoiorg102337dc12-0081

Zolkefli Y (2018) The ethics of truth-telling in health-care settings The

Malaysian Journal of Medical Sciences MJMS 25(3) 135ndash139 httpsdoiorg1021315mjms201825314

Zuchowski J L Chrystal J G Hamilton A B Patton E W Zephyrin L

C Yano E M amp Cordasco K M (2017) Coordinating care across health care systems for veterans with gynecologic malignancies A qualitative analysis Medical Care 55(Suppl 7 Suppl 1) S53ndashS60 httpsdoiorg101097MLR0000000000000737

Zwaan L amp Singh H (2020) Diagnostic error in hospitals Finding forests

not just the big trees BMJ Quality amp Safety 29(12) 961ndash964 httpsdoiorg101136bmjqs-2020-011099

APPENDICES

Appendix A

Pre-Screening Questionnaire

PRE-SCREENING QUESTIONNAIRE 1 What is your age _______________ [Enter Age in Years] 2 Has a doctor nurse or other health professional ever told you

that you had type 2 diabetes

Donrsquot know Not sure 3 Do you live in one of the following locations

Camden New Jersey

Garfield New Jersey

4 Do you speak English

No 5 Has a doctor nurse or other health professional ever told you

that you had any of the following Alzheimerrsquos disease dementia delirium or other cognitive impairment disorder

Donrsquot know Not sure

6 About how many times in the past 12 months have you seen a doctor nurse or other health professional for your type 2 diabetes

Number of times

Living Situation

7 What is your living situation today

I have a steady place to live

I have a place to live today but I am worried about losing it in the future

I do not have a steady place to live (I am temporarily staying with others in a hotel in a shelter living outside on the street on a beach in a car abandoned building bus or train station or in a park)

8 Think about the place you live Do you have problems with any of the following

CHOOSE ALL THAT APPLY

Pests such as bugs ants or mice

Lead paint or pipes

Lack of heat

Oven or stove not working

Smoke detectors missing or not working

Water leaks

None of the above

9 Within the past 12 months you worried that your food would run out before you got money to buy more

Often true

Sometimes true

Never true

10 Within the past 12 months the food you bought just didnt last and you didnt have money to get more

Often true

Sometimes true

Never true

Transportation

11 In the past 12 months has lack of reliable transportation kept you from medical appointments meetings work or from getting to things needed for daily living

Utilities

12 In the past 12 months has the electric gas oil or water company threatened to shut off services in your home

Already shut off

Financial Strain

13 How hard is it for you to pay for the very basics like food housing medical care and heating Would you say it ishellip

Very hard Somewhat hard Not hard at all

Family and Community Support

14 If for any reason you need help with day-to-day activities such as bathing preparing meals shopping caring for children or dependents managing finances etc do you get the help you need

I dont need any help I get all the help I need I could use a little more help I need a lot more help

15 How often do you feel lonely or isolated from those around you

Never Rarely Sometimes Often Always

THANK YOU Thank you very much for answering these questions

Appendix B

Site Permission Letter (Template)

CompanyInstitution Letterhead

Institutional Review Board for Human Subjects Research

400 South Orange Ave

South Orange NJ 07079

Insert Date

Dear Seton Hall IRB

On behalf of Insert Name of Facility I am writing to grant permission for

Christopher Rogers a doctoral student at Seton Hall University in the School

of Health and Medical Sciences to conduct his research titled

ldquoUnderstanding Older Adults Living in Medically Underserved Areas

Perspectives Regarding Type 2 Diabetes Care Receivedrdquo We understand

that Christopher Rogers will post recruitment fliers and recruit up to 20 of our

residents and conduct interviews at Insert Name of Facility during the period

of October 2019 to May 2020 Individualsrsquo participation will be voluntary and

at their own discretion The Insert Name of Facility reserves the right to

withdraw from the study at any time if our circumstances change We are

happy to participate in this study and contribute to this important research

Sincerely

Signature

Appendix C

Seton Hall University IRB Approval

Appendix D

Recruitment Flyer

Appendix E

Demographic Survey

DEMOGRAPHICS 1 What is your sex

Female 2 Which one or more of the following would you say is your raceethnicity

Black or African American

American Indian or Alaska Native

Pacific Islander

Hispanic Latinoa or Spanish origin

Donrsquot know Not sure 3 Are youhellip

Married

Divorced

Widowed

Separated

Never married

A member of an unmarried couple

4 What is the highest grade or year of school you completed

Never attended school or only attended kindergarten

Grades 1 through 8 (Elementary)

Grades 9 through 11 (Some high school)

Grade 12 or GED (High school graduate)

College 1 year to 3 years (Some college or technical school)

College 4 years or more (College graduate) 5 What is your present religion if any

Christian (Catholic Anglican Methodist Orthodox etc)

Muslim (Sunni Shia etc)

Jewish

Buddhist

Atheist (do not believe in God)

Agnostic (not sure if there is a God)

Something else [TEXT BOX (SPECIFY) __________]

Nothing in particular

HEALTH

6 Would you say that in general your health is

Excellent

Very good

7 Have you ever experienced any of these health problems during

the past 12 months

Severe Arthritis Rheumatism or other Bone or Joint diseases

Severe Asthma Bronchitis Emphysema Tuberculosis or other Lung problems

HIV AIDS

Blindness Deafness or Severe Visual or Hearing impairment

High Blood Pressure or Hypertension

Heart Attack or other Serious Heart trouble

Severe Hernia or Rupture

Severe Kidney or Liver disease

Lupus Thyroid disease or other Autoimmune disease

Multiple Sclerosis Epilepsy or other Neurological disorders

Chronic Stomach or Gall Bladder trouble

Stroke

8 How old were you when a doctor or other health professional first

told you that you had diabetes or sugar diabetes

_______________ [Enter Age in Years]

Less Than 1 Year

Donrsquot know Not sure 9 Are you now taking insulin

Donrsquot know Not sure 10 Are you now taking diabetic pills to lower your blood sugar

These are sometimes called oral agents or oral hypoglycemic agents

Donrsquot know Not sure 11 What was your last A1C level

_______________ [Enter Value]

Appendix F

Interview Guide

Interview Guide The purpose of this study is to understand your perspectives regarding health care received in the treatment and management of your type 2 diabetes In terms of this study treatment is the use of medicine therapy or surgery to provide comfort and control or lessen the symptoms and complications of your type 2 diabetes Management focuses on improving your quality of life preventing the symptoms of type 2 diabetes side effects caused by treatment of type 2 diabetes and physical mental emotional cultural social and spiritual problems related to type 2 diabetes Interview Questions Section A Experience with care older adults receive 1 Please tell me about your experience managing your type 2 diabetes 2 Who is involved in managing your type 2 diabetes (Who did what

when and how)

bull How did insert nametitle of person involved participate physically mentally spiritually economically and socially

bull How is your health care provider involved in your type 2 diabetes treatment and management care (Who did what when and how) o Probe Health care provider (primary care doctor

endocrinologist nurse care coordinator dietician podiatrist community health workernavigator other specialists etc) Health insurance company (nurse care coordinator) Social worker Behavioral health counselor Pharmacist

3 Please comment on the resources you have available to you in support of your type 2 diabetes treatment and management care

bull Please comment on the resources your health care provider has provided to you in support of your type 2 diabetes treatment and management care o Probe Material resources (FacilitiesOfficesEnvironment

Equipment Money Information Technology) Human Resources (Number and qualifications of staff) Organizational structure (Administration Programs [health promotion and prevention])

4 Please give examples of the kind of care you have received from your health care providers for your type 2 diabetes

bull How has your health care provider o includedinvolvedengaged you in your type 2 diabetes

treatment and management care

o listened to you in the treatment and management of your type 2 diabetes

o communicated with you about the treatment and management of your type 2 diabetes

o demonstrated respectful and compassionate care in the treatment and management of your type 2 diabetes

o educatedinformed you about the treatment and management of your type 2 diabetes

Section B Preferences regarding care older adults receive 5 Ideally how would you like to work with your health care providers to

treat and manage your type 2 diabetes

bull For any preferences given ask o Why do you like that o Why is it better for you o How do you think it helpswould help you

6 What types of support from health care professionals would you like to receive that would give you a better quality of life

Section C Desires that could improve treatment and management care in older adults 7 What could help you improve your type 2 diabetes treatment and

management care

bull What could health care professionals do to help you improve your type 2 diabetes treatment and management care o How would this make you feel o How would this improve your type 2 diabetes care

Section D Values regarding care older adults receive 8 Please tell me what you like the most about the care you receive from

your health care providers for your type 2 diabetes

bull What makes the care special

bull How is it different 9 Please describe how health care professionals have been interested in

you as a person

bull Probe o How have health care professionals demonstrated that they

care about you a How does this help with your type 2 diabetes

management o How have health care professionals demonstrated concern

for the things that are important to you b How does this help with your type 2 diabetes

management

bull If not interested ask o How could they demonstrate interest

Section E Closing

10 Is there anything else you would like to share with me regarding your experience with your health care providers in treating and managing your type 2 diabetes

Appendix G

Interview Protocol

I Introduce myself a Introduction Hello and thank you for agreeing to be

interviewed My name is Christopher Rogers I am a doctoral student at Seton Hall University in the School of Health and Medical Sciences I am a health care professional and I am completing this interview for my dissertation research study as part of my graduation requirements for my PhD in Health Sciences My role is to talk to you about a number of important topics that I would like your input on I am interested in your viewpoint I am asking you because you are an older adult with type 2 diabetes living in [Camden NJ or Garfield NJ] You are the expert and I am here to learn from you Participation in this study is strictly voluntary I will be audio recording what you say and taking notes so I donrsquot miss anything important and so that I can go back and revisit the information if I need to If at any point in the interview you no longer want to continue please let me know There is no penalty if you decide you do not want to complete the study

II Introduce study a With the rapid growth in the older adult population and the

number of older adults with type 2 diabetes recent efforts in health care have focused on initiatives to improve the quality of life and health among older adults with type 2 diabetes Research is showing that incorporating the preferences goals desires and values of people into the treatment and management of their type 2 diabetes could help them to better self-manage their condition The purpose of this study is to understand your perspectives regarding health care received in the treatment and management of your type 2 diabetes I am focusing on older adults with type 2 diabetes to understand what is important to them in treating and managing their type 2 diabetes

III Orient to interview a This interview will be 1-1frac12 hours long b We will begin with a brief questionnaire c Then I will ask you some questions about your experiences with

the care you have received for type 2 diabetes your preferences regarding care desires to improve your care and your values regarding care

d I will be taking some notes as you talk and audio recording but I will take out all information that would identify you or this housing facility

e If at any point in the interview you no longer want to continue please let me know There is no penalty if you decide you do not want to complete the study

f Do you have any questions I can answer so far IV Consent

a Give participant consent form and keep one for self to go over b Focus on providing the participant with the purpose of the study

the costs and benefits confidentiality that the study is voluntary and contact information for questions or concerns

c Have participant sign one copy and keep this copy for my records Have participant keep one copy for himherself

V Give demographic survey a Collect and file questionnaire

VI Pseudonym a ldquoWould you like to add a pseudonym or pretend name for you

because I wonrsquot use your name in the interview I will use the pretend name when going back through your interview and during writing the manuscriptrdquo

b Write pseudonym on the demographic survey if applicable VII Set up audio recorder

a Ensure that it is on and recording b Do I have your permission to continue with the interview and

record it c Say ldquothank you again for agreeing to be interviewed This is

[insert participant number and pseudonym if applicable] on [insert date and time]rdquo

d Proceed with interview guide Insert Interview Guide We have come to the end of our interview (turn off recorder) Post Interview Protocol

I Thank participant for their time a Thank you so very much for your participation in my study b Do you have any questions you would like me to answer

II Payment

a Ensure participant receives the $15 gift card b Ensure the participant signs and dates Gift Card Distribution

Log c Sign and date the Gift Card Distribution Log d File Gift Card Distribution Log

III Go over next steps for study a I will come back to share with you the research findings to

ensure and improve accuracy Would you be willing to be contacted to look over your transcript to ensure accuracy

b Confirm my contact information c Please feel free to contact me with questions or concerns

IV Thank the participant one final time and end conversation

Understanding Older Adults Living in Medically Underserved Areas Perspectives Regarding Type 2 Diabetes Care Received

Recommended Citation

tmp1620064866pdfD1_xa

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

ACKNOWLEDGEMENTS

the PhD degree

your guidance

abilities

DEDICATION

TABLE OF CONTENTS

DEDICATIONiv

LIST OF TABLESvi

LIST OF FIGURESvii

ABSTRACTviii

INTRODUCTION1

Problem Statement4

Purpose Statement6

Research Questions6

Sub-questions7

LITERATURE REVIEW11

Structure14

Process14

Outcomes16

Self-management34

Diabetes42

Complex51

Summary52

METHODOLOGY55

Aim of the Study55

Research Approach56

Data Collection61

Study Procedures64

Data Analysis66

Transcriptions66

Memo writing67

Initial coding67

Focused coding68

Interpretation69

RESULTS73

Demographics73

Health status77

Themes83

Thorough checkup85

Long-time doctor89

Home health care92

Spending time95

self-management97

Honest101

Trustworthy102

Smart102

Humorous102

Being there102

Smiles103

Caring103

Patient104

Social support104

management109

strategies110

Exercising114

Healthy eating115

Prayer118

Structure121

Process127

Social support147

strategies153

Limitations162

Future Research176

Conclusion178

REFERENCES180

APPENDICES233

LIST OF TABLES

LIST OF FIGURES

ABSTRACT

Chapter I

INTRODUCTION

chronic disease

2010 Rodger 1991)

Problem Statement

Purpose Statement

Research Questions

Sub-questions

diabetes

in MUAs

Chapter II

LITERATURE REVIEW

1980 p 3)

Figure 1

management

al 2012b)

et al 1989)

management

no transportation

et al 2007)

Body mass Obese

et al 2013)

Hall 2006)

(Rodger 1991)

Blood Pressure

lt75 (58 mmolmol)

90-130 mgdL (50-72 mmolL)

lt14090 mmHg

lt80 (64 mmolmol)

90-150 mgdL (50-83 mmolL)

lt14090 mmHg

100-180 mgdL (56-100 mmolL)

lt15090 mmHg

AADE7 Self-Care

Behaviors

Definition

whole grains

challenging

depression

symptoms

Glasgow 1995)

2018a) that

bull health beliefs

family and peers

Complex

2012a)

et al 2012a)

Summary

Chapter III

METHODOLOGY

Aim of the Study

Research Approach

(Gale et al 2013)

(p 61)

Data Collection

satisfaction

Study Procedures

and results phases

analysis process

Data Analysis

(Durdella 2018)

Interpretation

Chapter IV

RESULTS

Demographics

Table 5

Figure 2

participants

Health Status

Figure 3

Figure 4

Interview Findings

(Table 6)

Podiatrist 8 67

Optometrist 5 42

Nurse 4 33

Pharmacist 4 33

Social Worker 2 17

highhellip

Themes

on-one interviews

Theme Subthemes

Care treatment and

management

care providers

checkup from doctor

and needs

with themrdquo

tearing me up

Josephine said

and that

my heart yeaprdquo

my glassesrdquo

Laura also stated

namerdquo

head go for it

you better

Theme Subthemes

adults

she lives

facility

informative

problemrdquo

and older adult

Theme Subthemes

Information sharing

and provider

communication

self-management

that interest the

person

bull Health care

provider

communication by

telephone

self-management

Jacqueline stated

Jacqueline said

Theme Subthemes

providers

bull Honest

bull Trustworthy

bull Smart

bull Humorous

the person

bull Smiles

bull Caring

bull Patient

provider

Daisy said

blood pressure

Social Support

management

Theme Subthemes

Informational

information for

diabetes self-

management

Laura stated

take me to herrdquo

you know

healthy

Theme Subthemes

Older adultsrsquo

diabetes self-

management

Physical

medication

regularly

bull Managing

comorbidities

bull Exercising

bull Healthy eating

bull Regular doctor

visits

Intellectual

bull Diabetes

education

Spiritual

bull Prayer

a week (Larry)

it you knowrdquo

explained

(Jacob)

stay away from them

what I have

better than you do

about thisrdquo

Chapter V

literature

Figure 5

Neal 2003)

Marder 1982)

Process

al 2017)

studied

et al 1997)

diabetes control

outcomes

levels for patients

et al 2012)

Limitations

resources

the response given

telephone support

complements

Future Research

strategies

diabetes care

Conclusion

outcomes

REFERENCES

APPENDICES

Appendix A

Camden New Jersey

Garfield New Jersey

Number of times

Living Situation

Lead paint or pipes

Lack of heat

Water leaks

None of the above

Often true

Sometimes true

Never true

Often true

Sometimes true

Never true

Transportation

Utilities

Already shut off

Financial Strain

Appendix B

Insert Date

Dear Seton Hall IRB

Sincerely

Signature

Appendix C

Appendix D

Recruitment Flyer

Appendix E

Demographic Survey

Pacific Islander

Married

Divorced

Widowed

Separated

Never married

Jewish

Buddhist

HEALTH

Excellent

Very good

the past 12 months

HIV AIDS

Stroke

Less Than 1 Year

_______________ [Enter Value]

Appendix F

Interview Guide

when and how)

management care

you as a person

management

Section E Closing

Appendix G

Interview Protocol

II Payment

ACKNOWLEDGEMENTS

the PhD degree

your guidance

abilities

DEDICATION

TABLE OF CONTENTS

DEDICATIONiv

LIST OF TABLESvi

LIST OF FIGURESvii

ABSTRACTviii

INTRODUCTION1

Problem Statement4

Purpose Statement6

Research Questions6

Sub-questions7

LITERATURE REVIEW11

Structure14

Process14

Outcomes16

Self-management34

Diabetes42

Complex51

Summary52

METHODOLOGY55

Aim of the Study55

Research Approach56

Data Collection61

Study Procedures64

Data Analysis66

Transcriptions66

Memo writing67

Initial coding67

Focused coding68

Interpretation69

RESULTS73

Demographics73

Health status77

Themes83

Thorough checkup85

Long-time doctor89

Home health care92

Spending time95

self-management97

Honest101

Trustworthy102

Smart102

Humorous102

Being there102

Smiles103

Caring103

Patient104

Social support104

management109

strategies110

Exercising114

Healthy eating115

Prayer118

Structure121

Process127

Social support147

strategies153

Limitations162

Future Research176

Conclusion178

REFERENCES180

APPENDICES233

LIST OF TABLES

LIST OF FIGURES

ABSTRACT

Chapter I

INTRODUCTION

chronic disease

2010 Rodger 1991)

Problem Statement

Purpose Statement

Research Questions

Sub-questions

diabetes

in MUAs

Chapter II

LITERATURE REVIEW

1980 p 3)

Figure 1

management

al 2012b)

et al 1989)

management

no transportation

et al 2007)

Body mass Obese

et al 2013)

Hall 2006)

(Rodger 1991)

Blood Pressure

lt75 (58 mmolmol)

90-130 mgdL (50-72 mmolL)

lt14090 mmHg

lt80 (64 mmolmol)

90-150 mgdL (50-83 mmolL)

lt14090 mmHg

100-180 mgdL (56-100 mmolL)

lt15090 mmHg

AADE7 Self-Care

Behaviors

Definition

whole grains

challenging

depression

symptoms

Glasgow 1995)

2018a) that

bull health beliefs

family and peers

Complex

2012a)

et al 2012a)

Summary

Chapter III

METHODOLOGY

Aim of the Study

Research Approach

(Gale et al 2013)

(p 61)

Data Collection

satisfaction

Study Procedures

and results phases

analysis process

Data Analysis

(Durdella 2018)

Interpretation

Chapter IV

RESULTS

Demographics

Table 5

Figure 2

participants

Health Status

Figure 3

Figure 4

Interview Findings

(Table 6)

Podiatrist 8 67

Optometrist 5 42

Nurse 4 33

Pharmacist 4 33

Social Worker 2 17

highhellip

Themes

on-one interviews

Theme Subthemes

Care treatment and

management

care providers

checkup from doctor

and needs

with themrdquo

tearing me up

Josephine said

and that

my heart yeaprdquo

my glassesrdquo

Laura also stated

namerdquo

head go for it

you better

Theme Subthemes

adults

she lives

facility

informative

problemrdquo

and older adult

Theme Subthemes

Information sharing

and provider

communication

self-management

that interest the

person

bull Health care

provider

communication by

telephone

self-management

Jacqueline stated

Jacqueline said

Theme Subthemes

providers

bull Honest

bull Trustworthy

bull Smart

bull Humorous

the person

bull Smiles

bull Caring

bull Patient

provider

Daisy said

blood pressure

Social Support

management

Theme Subthemes

Informational

information for

diabetes self-

management

Laura stated

take me to herrdquo

you know

healthy

Theme Subthemes

Older adultsrsquo

diabetes self-

management

Physical

medication

regularly

bull Managing

comorbidities

bull Exercising

bull Healthy eating

bull Regular doctor

visits

Intellectual

bull Diabetes

education

Spiritual

bull Prayer

a week (Larry)

it you knowrdquo

explained

(Jacob)

stay away from them

what I have

better than you do

about thisrdquo

Chapter V

literature

Figure 5

Neal 2003)

Marder 1982)

Process

al 2017)

studied

et al 1997)

diabetes control

outcomes

levels for patients

et al 2012)

Limitations

resources

the response given

telephone support

complements

Future Research

strategies

diabetes care

Conclusion

outcomes

REFERENCES

APPENDICES

Appendix A

Camden New Jersey

Garfield New Jersey

Number of times

Living Situation

Lead paint or pipes

Lack of heat

Water leaks

None of the above

Often true

Sometimes true

Never true

Often true

Sometimes true

Never true

Transportation

Utilities

Already shut off

Financial Strain

Appendix B

Insert Date

Dear Seton Hall IRB

Sincerely

Signature

Appendix C

Appendix D

Recruitment Flyer

Appendix E

Demographic Survey

Pacific Islander

Married

Divorced

Widowed

Separated

Never married

Jewish

Buddhist

HEALTH

Excellent

Very good

the past 12 months

HIV AIDS

Stroke

Less Than 1 Year

_______________ [Enter Value]

Appendix F

Interview Guide

when and how)

management care

you as a person

management

Section E Closing

Appendix G

Interview Protocol

II Payment

ACKNOWLEDGEMENTS

the PhD degree

your guidance

abilities

DEDICATION

TABLE OF CONTENTS

DEDICATIONiv

LIST OF TABLESvi

LIST OF FIGURESvii

ABSTRACTviii

INTRODUCTION1

Problem Statement4

Purpose Statement6

Research Questions6

Sub-questions7

LITERATURE REVIEW11

Structure14

Process14

Outcomes16

Self-management34

Diabetes42

Complex51

Summary52

METHODOLOGY55

Aim of the Study55

Research Approach56

Data Collection61

Study Procedures64

Data Analysis66

Transcriptions66

Memo writing67

Initial coding67

Focused coding68

Interpretation69

RESULTS73

Demographics73

Health status77

Themes83

Thorough checkup85

Long-time doctor89

Home health care92

Spending time95

self-management97

Honest101

Trustworthy102

Smart102

Humorous102

Being there102

Smiles103

Caring103

Patient104

Social support104

management109

strategies110

Exercising114

Healthy eating115

Prayer118

Structure121

Process127

Social support147

strategies153

Limitations162

Future Research176

Conclusion178

REFERENCES180

APPENDICES233

LIST OF TABLES

LIST OF FIGURES

ABSTRACT

Chapter I

INTRODUCTION

chronic disease

2010 Rodger 1991)

Problem Statement

Purpose Statement

Research Questions

Sub-questions

diabetes

in MUAs

Chapter II

LITERATURE REVIEW

1980 p 3)

Figure 1

management

al 2012b)

et al 1989)

management

no transportation

et al 2007)

Body mass Obese

et al 2013)

Hall 2006)

(Rodger 1991)

Blood Pressure

lt75 (58 mmolmol)

90-130 mgdL (50-72 mmolL)

lt14090 mmHg

lt80 (64 mmolmol)

90-150 mgdL (50-83 mmolL)

lt14090 mmHg

100-180 mgdL (56-100 mmolL)

lt15090 mmHg

AADE7 Self-Care

Behaviors

Definition

whole grains

challenging

depression

symptoms

Glasgow 1995)

2018a) that

bull health beliefs

family and peers

Complex

2012a)

et al 2012a)

Summary

Chapter III

METHODOLOGY

Aim of the Study

Research Approach

(Gale et al 2013)

(p 61)

Data Collection

satisfaction

Study Procedures

and results phases

analysis process

Data Analysis

(Durdella 2018)

Interpretation

Chapter IV

RESULTS

Demographics

Table 5

Figure 2

participants

Health Status

Figure 3

Figure 4

Interview Findings

(Table 6)

Podiatrist 8 67

Optometrist 5 42

Nurse 4 33

Pharmacist 4 33

Social Worker 2 17

highhellip

Themes

on-one interviews

Theme Subthemes

Care treatment and

management

care providers

checkup from doctor

and needs

with themrdquo

tearing me up

Josephine said

and that

my heart yeaprdquo

my glassesrdquo

Laura also stated

namerdquo

head go for it

you better

Theme Subthemes

adults

she lives

facility

informative

problemrdquo

and older adult

Theme Subthemes

Information sharing

and provider

communication

self-management

that interest the

person

bull Health care

provider

communication by

telephone

self-management

Jacqueline stated

Jacqueline said

Theme Subthemes

providers

bull Honest

bull Trustworthy

bull Smart

bull Humorous

the person

bull Smiles

bull Caring

bull Patient

provider

Daisy said

blood pressure

Social Support

management

Theme Subthemes

Informational

information for

diabetes self-

management

Laura stated

take me to herrdquo

you know

healthy

Theme Subthemes

Older adultsrsquo

diabetes self-

management

Physical

medication

regularly

bull Managing

comorbidities

bull Exercising

bull Healthy eating

bull Regular doctor

visits

Intellectual

bull Diabetes

education

Spiritual

bull Prayer

a week (Larry)

it you knowrdquo

explained

(Jacob)

stay away from them

what I have

better than you do

about thisrdquo

Chapter V

literature

Figure 5

Neal 2003)

Marder 1982)

Process

al 2017)

studied

et al 1997)

diabetes control

outcomes

levels for patients

et al 2012)

Limitations

resources

the response given

telephone support

complements

Future Research

strategies

diabetes care

Conclusion

outcomes

REFERENCES

APPENDICES

Appendix A

Camden New Jersey

Garfield New Jersey

Number of times

Living Situation

Lead paint or pipes

Lack of heat

Water leaks

None of the above

Often true

Sometimes true

Never true

Often true

Sometimes true

Never true

Transportation

Utilities

Already shut off

Financial Strain

Appendix B

Insert Date

Dear Seton Hall IRB

Sincerely

Signature

Appendix C

Appendix D

Recruitment Flyer

Appendix E

Demographic Survey

Pacific Islander

Married

Divorced

Widowed

Separated

Never married

Jewish

Buddhist

HEALTH

Excellent

Very good

the past 12 months

HIV AIDS

Stroke

Less Than 1 Year

_______________ [Enter Value]

Appendix F

Interview Guide

when and how)

management care

you as a person

management

Section E Closing

Appendix G

Interview Protocol

II Payment

ACKNOWLEDGEMENTS

the PhD degree

your guidance

abilities

DEDICATION

TABLE OF CONTENTS

DEDICATIONiv

LIST OF TABLESvi

LIST OF FIGURESvii

ABSTRACTviii

INTRODUCTION1

Problem Statement4

Purpose Statement6

Research Questions6

Sub-questions7

LITERATURE REVIEW11

Structure14

Process14

Outcomes16

Self-management34

Diabetes42

Complex51

Summary52

METHODOLOGY55

Aim of the Study55

Research Approach56

Data Collection61

Study Procedures64

Data Analysis66

Transcriptions66

Memo writing67

Initial coding67

Focused coding68

Interpretation69

RESULTS73

Demographics73

Health status77

Themes83

Thorough checkup85

Long-time doctor89

Home health care92

Spending time95

self-management97

Honest101

Trustworthy102

Smart102

Humorous102

Being there102

Smiles103

Caring103

Patient104

Social support104

management109

strategies110

Exercising114

Healthy eating115

Prayer118

Structure121

Process127

Social support147

strategies153

Limitations162

Future Research176

Conclusion178

REFERENCES180

APPENDICES233

LIST OF TABLES

LIST OF FIGURES

ABSTRACT

Chapter I

INTRODUCTION

chronic disease

2010 Rodger 1991)

Problem Statement

Purpose Statement

Research Questions

Sub-questions

diabetes

in MUAs

Chapter II

LITERATURE REVIEW

1980 p 3)

Figure 1

management

al 2012b)

et al 1989)

management

no transportation

et al 2007)

Body mass Obese

et al 2013)

Hall 2006)

(Rodger 1991)

Blood Pressure

lt75 (58 mmolmol)

90-130 mgdL (50-72 mmolL)

lt14090 mmHg

lt80 (64 mmolmol)

90-150 mgdL (50-83 mmolL)

lt14090 mmHg

100-180 mgdL (56-100 mmolL)

lt15090 mmHg

AADE7 Self-Care

Behaviors

Definition

whole grains

challenging

depression

symptoms

Glasgow 1995)

2018a) that

bull health beliefs

family and peers

Complex

2012a)

et al 2012a)

Summary

Chapter III

METHODOLOGY

Aim of the Study

Research Approach

(Gale et al 2013)

(p 61)

Data Collection

satisfaction

Study Procedures

and results phases

analysis process

Data Analysis

(Durdella 2018)

Interpretation

Chapter IV

RESULTS

Demographics

Table 5

Figure 2

participants

Health Status

Figure 3

Figure 4

Interview Findings

(Table 6)

Podiatrist 8 67

Optometrist 5 42

Nurse 4 33

Pharmacist 4 33

Social Worker 2 17

highhellip

Themes

on-one interviews

Theme Subthemes

Care treatment and

management

care providers

checkup from doctor

and needs

with themrdquo

tearing me up

Josephine said

and that

my heart yeaprdquo

my glassesrdquo

Laura also stated

namerdquo

head go for it

you better

Theme Subthemes

adults

she lives

facility

informative

problemrdquo

and older adult

Theme Subthemes

Information sharing

and provider

communication

self-management

that interest the

person

bull Health care

provider

communication by

telephone

self-management

Jacqueline stated

Jacqueline said

Theme Subthemes

providers

bull Honest

bull Trustworthy

bull Smart

bull Humorous

the person

bull Smiles

bull Caring

bull Patient

provider

Daisy said

blood pressure

Social Support

management

Theme Subthemes

Informational

information for

diabetes self-

management

Laura stated

take me to herrdquo

you know

healthy

Theme Subthemes

Older adultsrsquo

diabetes self-

management

Physical

medication

regularly

bull Managing

comorbidities

bull Exercising

bull Healthy eating

bull Regular doctor

visits

Intellectual

bull Diabetes

education

Spiritual

bull Prayer

a week (Larry)

it you knowrdquo

explained

(Jacob)

stay away from them

what I have

better than you do

about thisrdquo

Chapter V

literature

Figure 5

Neal 2003)

Marder 1982)

Process

al 2017)

studied

et al 1997)

diabetes control

outcomes

levels for patients

et al 2012)

Limitations

resources

the response given

telephone support

complements

Future Research

strategies

diabetes care

Conclusion

outcomes

REFERENCES

APPENDICES

Appendix A

Camden New Jersey

Garfield New Jersey

Number of times

Living Situation

Lead paint or pipes

Lack of heat

Water leaks

None of the above

Often true

Sometimes true

Never true

Often true

Sometimes true

Never true

Transportation

Utilities

Already shut off

Financial Strain

Appendix B

Insert Date

Dear Seton Hall IRB

Sincerely

Signature

Appendix C

Appendix D

Recruitment Flyer

Appendix E

Demographic Survey

Pacific Islander

Married

Divorced

Widowed

Separated

Never married

Jewish

Buddhist

HEALTH

Excellent

Very good

the past 12 months

HIV AIDS

Stroke

Less Than 1 Year

_______________ [Enter Value]

Appendix F

Interview Guide

when and how)

management care

you as a person

management

Section E Closing

Appendix G

Interview Protocol

II Payment

Documents

eRepository @ Seton Hall - Seton Hall University