Group Versus Individual Diabetes Education for Persons With Experience of Homelessness in Canada.

PURPOSE: The purpose of the study was to explore various forms of diabetes self-management education (DSME), including group and individual sessions, for persons with lived experiences of homelessness (PWLEH) in Canada. METHODS: A qualitative descriptive study using open-ended interviews with health care and homeless sector service providers was utilized to serve those experiencing homelessness in 5 cities across Canada. NVivo qualitative data analysis software was used to facilitate thematic analysis, focusing on variations in DSME for PWLEH. RESULTS: We conducted interviews with 96 unique health and social care providers. Four themes were identified through focused coding of interviews. First, the use of a harm reduction approach during diabetes education tailored to PWLEH considered patients' access to food, medications, and supplies and other comorbidities, including mental health and substance use disorders. The second theme related to the unsuitability of the curriculum in mainstream diabetes education in a group setting for PWLEH. Third, the role of group education in community building is to create supportive relationships among members. The final theme was the importance of trust and confidentiality in DSME, which were most easily maintained during individual education, compared to group formats. CONCLUSIONS: Overall, PWLEH experience unique challenges in managing diabetes. DSME adapted to these individuals' unique needs may be more successful and could be delivered in both individual and group settings.

Lessons learned from a virtual Community-Based Participatory Research project: prioritizing needs of people who have diabetes and experiences of homelessness to co-design a participatory action project.

In Community-Based Participatory Research (CBPR), people with shared lived experiences (co-researchers) identify priority needs and work collaboratively to co-design an action-oriented research advocacy project. For this to occur, academic researchers must build mutually respectful partnerships with co-researchers by establishing trust. In the context of the COVID-19 pandemic, our objective was to virtually assemble a group of co-researchers (people with diverse but relevant experiences of homelessness and diabetes) and academic researchers who engaged in the CBPR process to identify a project that would address the difficulties of diabetes management while experiencing homelessness. Co-researchers were recruited to the committee from community homeless-serving organizations. Six co-researchers, one peer researcher and three academic researchers from Calgary, Alberta met virtually for bi-weekly committee meetings, from June 2021 to May 2022 to explore barriers to diabetes management and to complete a priority-setting exercise to determine the focus of our collective project. After reflecting on our virtual CBPR experience we present lessons learned related to: i) technical challenges and logistical considerations, ii) meeting virtually and building rapport, iii) driving engagement, and iv) challenges of transitioning from virtual to in-person meeting format. Overall, the process of conducting a CBPR project virtually to engage a group of co-researchers during a pandemic presents its challenges. However, a virtual CBPR project is feasible and can lead to meaningful experiences that benefit all group members, both from the community and academia.

In Community-Based Participatory Research (CBPR), we value peoples' lived experiences as knowledge and believe that it can help in the design of research projects. In these projects, people with similar lived experiences work with researchers to design a research advocacy project that will make meaningful changes in their community. Trust and respect between all team members are essential for working well together. Establishing trust and respect can be difficult, especially when done virtually. We virtually convened a committee and completed a CBPR project. Our group consisted of seven people with lived experience of diabetes and homelessness and three academic researchers in Calgary, Alberta. We met every two weeks between June 2021 and May 2022 to explore possible topics for our CBPR project, which we narrowed down to their top priority. As we reflected on our experience of working together, we came up with four categories of lessons learned: i) technical challenges, ii) building rapport, iii) driving engagement, and iv) challenges of transitioning from virtual to in-person meeting format. While our experience presented its challenges, we found working virtually to create a CBPR project is possible and can be meaningful for all group members.

The Development of a Conceptual Framework for Providing Tailored Diabetes Care for Individuals Experiencing Homelessness: A Qualitative Study.

Homelessness results in barriers to effective diabetes self-management. Programs targeting individuals facing homelessness have refined strategies to address these barriers. We sought to develop a framework to characterize these strategies that could help multidisciplinary providers to better support these individuals. Semi-structured interviews were conducted with a purposive sample of health and social care providers working in diabetes or homelessness in five Canadian cities (n=96). Interview transcripts were analyzed through qualitative thematic analysis. Providers described three groups of approaches that enabled care for this population. Person-centered provider behaviours: This included tailoring care plans to accommodate individuals' situational constraints. Lower-barrier organizational structure: Providers developed specialized organizational processes to increase accessibility. Bridging to larger care systems: Strategies included providing access to support workers. Across diverse program structures, similar approaches are used to enhance diabetes care for individuals who are experiencing homelessness, highlighting tangible opportunities for mainstream services to better engage with this population.

Developing and evaluating a SAFER model to screen for diabetes complications among people experiencing homelessness: a pilot study protocol.

BACKGROUND: Diabetes management combined with housing instability intersects, forcing individuals to triage competing needs and critical stressors, such as safety and shelter, with fundamental diabetes self-management tasks like attending healthcare appointments to screen for the complications of diabetes, leaving individuals overwhelmed and overburdened. We aim to address this disjuncture found within our current healthcare delivery system by providing point-of-care screening opportunities in a more patient-centered approach. METHOD: We describe a pilot study of a novel clinical intervention which provides timely, comprehensive, and accessible screening for diabetes complications to people experiencing homelessness. We will assess the reach, effectiveness, adoption, implementation, and maintenance, as per the RE-AIM framework, of a SAFER model of care (i.e., screening for A1C, feet, eyes, and renal function). A trained nurse will provide this screening within a homeless shelter. During these encounters, eligible participants will be screened for microvascular complications (neuropathy, nephropathy, retinopathy) and have their A1C measured, all at the point of care, using bedside tools and novel technology. Effectiveness, our primary objective, will be evaluated using a pre-post design, by comparing the rate of completion of full microvascular screening during the study period with individuals' own historical screening in the 2-year period prior to enrollment. The other domains of the RE-AIM framework will be assessed using process data, chart reviews, patient surveys, and qualitative semi-structured interviews with service providers and participants. This study will be conducted in a large inner-city homeless shelter within a major urban Canadian city (Calgary, Canada). DISCUSSION: Currently, screening for diabetes complications is often inaccessible for individuals experiencing homelessness, which places heavy burdens on individuals and, ultimately, on already strained emergency and acute care services when complications go undetected at earlier stages. The SAFER intervention will modify the current standard of care for this population in a way that is less fragmented, more person-focused, and timely, with the goal of ultimately improving the rate of screening in an acceptable fashion to identify those requiring specialist referral at earlier stages.

Accessing Diabetes Specialty Care for Persons With Lived Experience of Homelessness in Canada: Challenges and Opportunities.

OBJECTIVES: Persons with lived experience of homelessness face many challenges in managing their diabetes, including purchasing and storing medications, procuring healthy food and accessing health-care services. Not only do these individuals have challenges in accessing primary care, they are also seen by diabetes specialists (endocrinologists, diabetes educators, foot- and eye-care specialists) less frequently. METHODS: We conducted a qualitative descriptive study using open-ended interviews of 96 health and social care providers across 5 Canadian cities (Calgary, Edmonton, Ottawa, Vancouver, Toronto). We used NVivo qualitative software to facilitate thematic analysis of the data, focussing on homelessness-related patient barriers to diabetes specialty care. RESULTS: Barriers identified included patients' competing priorities and previous negative experiences with specialists, long wait times from referral to appointment, difficulty in contacting patients and location of the clinics. Primary care providers were confident in managing diabetes in most patients and believed that patients were best served under their care. Other barriers included specialists' limited understanding of patients' complex social situations and medication coverage as well as out-of-pocket costs associated with some specialist care. Recommendations for improving access to diabetes specialty care for these medically and socially complex patients included holding diabetes specialty clinics at community health centres, providing physician-to-physician direct referrals, and selecting specialists with an interest in health of the homeless population. CONCLUSIONS: Barriers to diabetes specialty care for persons with lived experience of homelessness are due largely to the physical and social environment of the clinics. Innovative solutions may be implemented to address these challenges and improve access for this population.

Pharmacists' role in diabetes management for persons with lived experience of homelessness in Canada: A qualitative study.

Introduction: Persons with lived experience of homelessness face many challenges in managing diabetes, including purchasing and storing medications, procuring healthy food and accessing healthcare services. Prior studies have found that pharmacy-led interventions for diabetes improved A1C, and lowered blood pressure and cholesterol in general populations. This study evaluated how select pharmacists in Canada have tailored their practices to serve persons with lived experiences of homelessness with diabetes. Methods: We conducted a qualitative descriptive study using open-ended interviews with inner-city pharmacists in select Canadian municipalities (Calgary, Edmonton, Vancouver, and Ottawa). We used NVivo qualitative data analysis software to facilitate thematic analysis of the data, focusing on how pharmacists contributed to diabetes care for persons with lived experience of homelessness. Results: These pharmacists developed diabetes programs after discovering an unmet need in the population. Pharmacists have the unique ability to see patients frequently, allowing tailored education and hands-on assistance with diabetes management. These pharmacists provided extra-ordinary care like financial and housing resources and many of them were uniquely embedded within other services for persons with lived experience of homelessness (i.e. housing and social work supports). Pharmacists reported struggling with balancing optimal medical care for individuals with the financial constraints of running a business. Conclusion: Pharmacists are vital members of the diabetes care team for persons with lived experience of homelessness. Government policies should support and encourage unique models of care provided by pharmacists to improve diabetes management for this population.

Using concept mapping to prioritize barriers to diabetes care and self-management for those who experience homelessness.

BACKGROUND: Diabetes is a chronic medical condition which demands that patients engage in self-management to achieve optimal glycemic control and avoid severe complications. Individuals who have diabetes and are experiencing homelessness are more likely to have chronic hyperglycemia and adverse outcomes. Our objective was to collaborate with individuals experiencing homelessness and care providers to understand the barriers they face in managing diabetes, as a first step in identifying solutions for enhancing diabetes management in this population. METHODS: We recruited individuals with lived experience of homelessness and diabetes (i.e. clients; n = 32) from Toronto and health and social care providers working in the areas of diabetes and/or homelessness (i.e. providers; n = 96) from across Canada. We used concept mapping, a participatory research method, to engage participants in brainstorming barriers to diabetes management, which were subsequently categorized into clusters, using the Concept Systems Global MAX software, and rated based on their perceived impact on diabetes management. The ratings were standardized for each participant group, and the average cluster ratings for the clients and providers were compared using t-tests. RESULTS: The brainstorming identified 43 unique barriers to diabetes management. The clients' map featured 9 clusters of barriers: Challenges to getting healthy food, Inadequate income, Navigating services, Not having a place of your own, Relationships with professionals, Diabetes education, Emotional wellbeing, Competing priorities, and Weather-related issues. The providers' map had 7 clusters: Access to healthy food, Dietary choices in the context of homelessness, Limited finances, Lack of stable, private housing, Navigating the health and social sectors, Emotional distress and competing priorities, and Mental health and addictions. The highest-rated clusters were Challenges to getting healthy food (clients) and Mental health and addictions (providers). Challenges to getting healthy food was rated significantly higher by clients (p = 0.01) and Competing priorities was rated significantly higher by providers (p = 0.03). CONCLUSIONS: Experiencing homelessness poses numerous barriers to managing diabetes, the greatest of which according to clients, is challenges to getting healthy food. This study showed that the way clients and providers perceive these barriers differs considerably, which highlights the importance of including clients' insights when assessing needs and designing effective solutions.