A Randomized Controlled Trial to Improve Unmet Social Needs and Clinical Outcomes Among Adults with Diabetes.

BACKGROUND: Adults with type 1 or type 2 diabetes often face financial challenges and other unmet social needs to effective diabetes self-management. OBJECTIVE: Whether a digital intervention focused on addressing socioeconomic determinants of health improves diabetes clinical outcomes more than usual care. DESIGN: Randomized trial from 2019 to 2023. PARTICIPANTS: A total of 600 adults with diabetes, HbA1c ≥ 7.5%, and self-reported unmet social needs or financial burden from a health system and randomized to the intervention or standard care. INTERVENTION: CareAvenue is an automated, e-health intervention with eight videos that address unmet social needs contributing to poor outcomes. MEASURES: Primary outcome was HbA1c, measured at baseline, and 6 and 12 months after randomization. Secondary outcomes included systolic blood pressure and reported met social needs, cost-related non-adherence (CRN), and financial burden. We examined main effects and variation in effects across predefined subgroups. RESULTS: Seventy-eight percent of CareAvenue participants completed one or more modules of the website. At 12-month follow-up, there were no significant differences in HbA1c changes between CareAvenue and control group (p = 0.24). There were also no significant between-group differences in systolic blood pressure (p = 0.29), met social needs (p = 0.25), CRN (p = 0.18), and perceived financial burden (p = 0.31). In subgroup analyses, participants with household incomes 100-400% FPL (1.93 (SE = 0.76), p < 0.01), 201-400% FPL (1.30 (SE = 0.62), p < 0.04), and > 400% FPL (1.27 (SE = 0.64), p < 0.05) had significantly less A1c decreases compared to the control group. CONCLUSIONS: On average, CareAvenue participants did not achieve better A1c lowering, met needs, CRN, or perceived financial burden compared to control participants. CareAvenue participants with higher incomes achieved significantly less A1c reductions than control. Further research is needed on social needs interventions that consider tailored approaches to population subgroups. CLINICAL TRIALS REGISTRY: ClinicalTrials.gov ID NCT03950973, May 2019.

Food Insecurity Prevalence and Risk Factors at a Large Academic Medical Center in Michigan.

Importance: Health care systems are increasingly adopting methods to screen for and integrate food insecurity and other social risk factors into electronic health records. However, there remain knowledge gaps regarding the cumulative burden of food insecurity in large clinical settings, which patients are most at risk, and the extent to which patients are interested in social assistance through their health care system. Objective: To evaluate the 5-year prevalence and associated risk factors of food insecurity among adult primary care patients, and to examine factors associated with patients' interest in social assistance among those with food insecurity. Design, Setting, and Participants: This cross-sectional analysis of a retrospective cohort study took place at a tertiary care academic medical center (encompassing 20 primary care clinics) in Michigan. Participants included adult patients who completed screening for social risk factors between August 1, 2017, and August 1, 2022. Data analysis was performed from November 2022 to June 2023. Exposure: Food insecurity was assessed using the Hunger Vital Sign. Main Outcomes and Measures: The primary outcome was patients' interest in social assistance, and associated factors were examined using multivariate logistic regression models, adjusting for patients' demographic and health characteristics. Results: Over the 5-year period, 106 087 adult primary care patients (mean [SD] age, 52.9 [17.9] years; 61 343 women [57.8%]) completed the standardized social risk factors questionnaire and were included in the analysis. The overall prevalence of food insecurity was 4.2% (4498 patients), with monthly trends ranging from 1.5% (70 positive screens) in August 2018 to 5.0% (193 positive screens) in June 2022. Food insecurity was significantly higher among patients who were younger, female, non-Hispanic Black or Hispanic, unmarried or unpartnered, and with public health insurance. Food insecurity was significantly associated with a higher cumulative burden of social needs, including social isolation, medical care insecurity, medication nonadherence, housing instability, and lack of transportation. Only 20.6% of patients with food insecurity (927 patients) expressed interest in social assistance. Factors associated with interest in social assistance including being non-Hispanic Black, unmarried or unpartnered, a current smoker, and having a higher burden of other social needs. Conclusions and Relevance: In this retrospective cohort study, the overall prevalence of food insecurity was 4.2%, of whom approximately 1 in 5 patients with food insecurity expressed interest in assistance. This study highlights ongoing challenges in ensuring all patients complete routine social determinants of health screening and gaps in patients' interest in assistance for food insecurity and other social needs through their health care system.

Russia's Denial of Health Care as a Weapon of War in Occupied Ukrainian Territories.

This Viewpoint discusses Russia's mandate that Ukrainian citizens adopt Russian nationality and acquire Russian passports as a precondition for gaining access to health care.

Implementing integrated hypertension and diabetes management using the World Health Organization's HEARTS model: protocol for a pilot study in the Guatemalan national primary care system.

BACKGROUND: The HEARTS technical package was developed by the World Health Organization to address the implementation gap in cardiovascular disease prevention in low- and middle-income countries. Guatemala is a middle-income country that is currently implementing HEARTS. National authorities in Guatemala are interested in exploring how hypertension and diabetes management can be integrated in HEARTS implementation. The objective of this study is to conduct a feasibility and acceptability pilot trial of integrated hypertension and diabetes management based on HEARTS in the publicly funded primary care system in Guatemala. METHODS: A single-arm pilot trial for 6 months will be carried out in 11 Ministry of Health primary care facilities starting in September 2023. A planned sample of 100 adult patients diagnosed with diabetes (n = 45), hypertension (n = 45), or both (n = 10) will be enrolled. The intervention will consist of HEARTS-aligned components: Training health workers on healthy-lifestyle counseling and evidence-based treatment protocols, strengthening access to medications and diagnostics, training on risk-based cardiovascular disease management, team-based care and task sharing, and systems monitoring and feedback, including implementation of a facility-based electronic monitoring tool at the individual level. Co-primary outcomes of feasibility and acceptability will be assessed using an explanatory sequential mixed-methods design. Secondary outcomes include clinical effectiveness (treatment with medication, glycemic control, and blood pressure control), key implementation outcomes (adoption, fidelity, usability, and sustainability), and patient-reported outcome measures (diabetes distress, disability, and treatment burden). Using an implementation mapping approach, a Technical Advisory Committee will develop implementation strategies for subsequent scale-up planning. DISCUSSION: This trial will produce evidence on implementing HEARTS-aligned hypertension and diabetes care in the MOH primary care system in Guatemala. Results also will inform future HEARTS projects in Guatemala and other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT06080451. The trial was prospectively registered on October 12, 2023.

The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness.

Introduction: Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH. Methods: We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions). Results: In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing. Discussion: The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.

Torture beyond carceral settings against individuals from marginalized communities: the important role for clinical documentation.

Historically, torture often was understood as physical and/or psychological pain inflicted by governmental agents on an individual who is detained or imprisoned in governmental custody. As defined by the United Nations Convention Against Torture (UNCAT), however, torture is increasingly recognized as occurring in settings far beyond carceral settings.

A very low-carbohydrate diabetes prevention program for veterans with prediabetes: a single-arm mixed methods pilot study.

Introduction: All Veterans Affairs (VA) Medical Centers offer the MOVE! Weight Management Program to help patients achieve and maintain a healthy weight through a calorie-restricted, low-fat diet and increased physical activity. Yet, most MOVE! participants do not achieve clinically significant weight loss of ≥5%. A carbohydrate-restricted diet may help more Veterans to achieve ≥5% weight loss. Methods: This was a single-arm explanatory sequential mixed methods pilot study conducted in one VA health care system. Veterans with prediabetes and body mass index ≥25 kg/m2 were invited to participate in a group-based, virtual, very low-carbohydrate Diabetes Prevention Program (VLC-DPP) consisting of 23 sessions over 12 months. Participants were taught to follow a very low-carbohydrate eating pattern, defined as 20-35 grams of net carbohydrates per day. The primary outcomes were measures of feasibility and acceptability, including program uptake and session attendance. Secondary outcomes included change in weight, hemoglobin A1c, lipids, and patient-reported measures of food cravings, stress eating, perceived health status, and motivation. Interviews were conducted at 6 months to identify factors that facilitated or hindered participants' achievement of ≥5% weight loss. Results: Among 108 screened Veterans, 21 enrolled in the study (19%), and 18 were included in the analytic cohort. On average, participants attended 12.4/16 weekly sessions and 3.6/8 bimonthly or monthly sessions. At 12 months, mean percent weight loss was 9.4% (SD = 10.7) with 9 participants (50%) achieving ≥5% weight loss. Three factors facilitated achievement of ≥5% weight loss among 10/16 interviewees: (1) enjoyment of low-carbohydrate foods; (2) careful monitoring of carbohydrate intake; and (3) reduced hunger and food cravings. Three factors hindered achievement of ≥5% weight loss among 6/16 interviewees: (1) food cravings, particularly for sweets; (2) challenges with maintaining a food log; and (3) difficulty with meal planning. Conclusion: A VLC-DPP is feasible and acceptable and shows preliminary efficacy among Veterans with prediabetes. The program's weight loss effectiveness compared to standard MOVE! should be evaluated in a larger-scale trial. Such a program may be offered in addition to the standard MOVE! program to expand the menu of evidence-based lifestyle counseling options for Veterans. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04881890, identifier NCT04881890.

Economic burden, financial stress, and cost-related coping among people with uncontrolled diabetes in the U.S.

Granular information on material deprivation including financial and economic well-being among people with diabetes can better inform policy, practice and interventions to support diabetes management. The purpose of this study was to describe in-depth the state of economic burden, financial stress, and coping among people with high A1c. Data came from the 2019-2021 baseline assessment in an ongoing U.S. trial that addresses social determinants of health among people with diabetes and high A1c who report at least one financial burden or cost-related non-adherence (CRN) (n = 600). Mean age of participants was 53 years. Planning behaviors were the most common financial well-being behavior, while savings was least frequently endorsed. Nearly a quarter of participants report spending more than $300 per month out-of-pocket to manage all of their health conditions. Participants reported spending the most out-of-pocket on medications (52%), special foods (40%), doctor's visits (27%), and blood glucose supplies (22%). Along with health insurance, these were also the most cited as sources of financial stress and where assistance. Seventy-two percent reported high levels of financial stress. Maladaptive coping was evident through CRN, and less than half engaged in adaptive coping such as talking to a doctor about cost or using a resource to address their needs. Economic burden, financial stress, and cost-related coping are highly relevant constructs among people with diabetes and high A1cs. More evidence-generation is needed for diabetes self-management programs to address sources of financial stress, facilitate behaviors to enhance financial well-being, and address unmet social needs to alleviate economic burdens.

How do current police practices impact trauma care in the prehospital setting? A scoping review.

Objective: In the United States, police are often important co-responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive understanding of the mechanisms by which police response modifies time to in-hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement. Methods: PubMed, SCOPUS, and Criminal Justice Abstracts databases were utilized to identify articles. English-language, US-based, peer-reviewed articles published on or prior to March 30, 2022 were eligible for inclusion. Results: Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level. Conclusions: Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well-being, there remains a paucity of data examining and driving current practices.

Primary care providers' perceived barriers to obesity treatment and opportunities for improvement: A mixed methods study.

BACKGROUND: Primary care patients with obesity seldom receive effective weight management treatment in primary care settings. This study aims to understand PCPs' perspectives on obesity treatment barriers and opportunities to overcome them. STUDY DESIGN: This is an explanatory sequential mixed methods study in which survey data was collected and used to inform subsequent qualitative interviews. SETTINGS AND PARTICIPANTS: PCPs who provide care to adult patients in an academic medical center in the Midwestern US. METHODOLOGY: PCPs (n = 350) were invited by email to participate in an online survey. PCPs were subsequently invited to participate in semi-structured interviews to further explore survey domains. ANALYTIC APPROACH: Survey data were analyzed using descriptive statistics. Interviews were analyzed using directed content analysis. RESULTS: Among 107 survey respondents, less than 10% (n = 8) used evidence-based guidelines to inform obesity treatment decisions. PCPs' identified opportunities to improve obesity treatment including (1) education on local obesity treatment resources (n = 78, 73%), evidence-based dietary counseling strategies (n = 67, 63%), and effective self-help resources (n = 75, 70%) and (2) enhanced team-based care with support from clinic staff (n = 53, 46%), peers trained in obesity medicine (n = 47, 44%), and dietitians (n = 58, 54%). PCPs also desired increased reimbursement for obesity treatment. While 40% (n = 39) of survey respondents expressed interest in obesity medicine training and certification through the American Board of Obesity Medicine, qualitative interviewees felt that pursuing training would require dedicated time (i.e., reduced clinical effort) and financial support. CONCLUSIONS: Opportunities to improve obesity treatment in primary care settings include educational initiatives, use of team-based care models, and policy changes to incentivize obesity treatment. Primary care clinics or health systems should be encouraged to identify PCPs with specific interests in obesity medicine and support their training and certification through ABOM by reimbursing training costs and reducing clinical effort to allow for study and board examination.

Patient-Centered Outcomes After a Medication Adherence Intervention: a Pilot Study.

PRCIS: Self-determination theory (SDT) guided behavioral interventions are effective in improving several patient-centered metrics, including glaucoma-related distress. However, whether improvement in patient-centered metrics can drive an improvement in medication-taking behavior remains to be seen. OBJECTIVE: The 7-month Support, Educate, Empower (SEE) personalized glaucoma coaching program was previously shown to improve glaucoma medication adherence by 21 percent points. This study's goal was to assess the impact of the SEE program on self-determination theory (SDT) metrics and other patient-centered outcome measures. PARTICIPANTS AND METHODS: Glaucoma patients (≥40 y old, taking ≥1 medication) self-reporting poor medication adherence were recruited at the University of Michigan. Eight surveys (with 10 subscales) were completed before and after the 7-month SEE program. Three surveys assessed changes in SDT (Treatment Self-regulation Questionnaire, Healthcare-Climate Questionnaire, Perceived Competence) while the others assessed participants' Glaucoma Knowledge, Glaucoma Medication Self-efficacy, Glaucoma-related distress, Perceived benefits, confidence asking and getting questions answered. RESULTS: Thirty-nine participants completed the SEE program. Significant improvements were in 7 subscales, including all three SDT tenets of competence (mean change =0.9, SD =±1.2, adjusted P =0.0002), autonomy (0.5, ±0.9, 0.044), and relatedness ( P =0.002). Glaucoma-related distress (-2.0, ±3.2, 0.004), confidence in asking questions (1.1, ±2.0, 0.008), and confidence in getting questions answered (1.0, ±2.0, 0.009) also improved. Glaucoma-related distress was correlated with perceived competence ( r =-0.56, adjusted P =0.005), and an increase in perceived competence was associated with a decrease in glaucoma-related distress (ß=-0.43, 95% CI -0.67 - -0.20, adjusted P =0.007). CONCLUSIONS: The SEE program improved participants' autonomous motivation, perceived support, perceived competence, glaucoma-related distress, and competence. These results point to the promising potential of SDT-guided behavioral interventions in improving patient-centered metrics.

The Support, Educate, Empower personalized glaucoma coaching trial design.

BACKGROUND: Glaucoma is a chronic disease that affects 3 million Americans. Glaucoma is most often asymptomatic until very late in its course when treatment is more difficult and extensive peripheral vision loss has already occurred. Taking daily medications can mitigate this vision loss, but at least half of people with glaucoma do not take their prescribed medications regularly. The purpose of this study is to improve glaucoma medication adherence among those with medically treated glaucoma and poor self-reported adherence using the Support, Educate, Empower personalized coaching program. METHODS/DESIGN: This study is a two-site randomized controlled trial enrolling 230 participants with poor self-reported glaucoma medication adherence. The trial has two arms, an intervention arm and a control arm. Participants in the intervention arm receive personalized glaucoma education and motivational interviewing-based coaching over 6 months from a trained non-physician interventionist for three in-person sessions with between visit phone calls for check-ins where current adherence level is reported to participants. Participants also can elect to have visual, audio, text or automated phone call medication dose reminders. Participants in the control arm continue usual care with their physician and receive non-personalized glaucoma educational materials via mail in parallel to the three in-person coaching sessions to control for glaucoma knowledge content. All participants receive a medication adherence monitor. The primary outcome is the proportion of prescribed doses taken on schedule during the 6-month period. The secondary outcome is glaucoma related distress. The exploratory outcome is intraocular pressure. DISCUSSION: The personalized education and motivational-interviewing-based intervention that we are testing is comprehensive in that it addresses the wide range of barriers to adherence that people with glaucoma encounter. Leveraging a custom-built web-based application to generate the personalized content and the motivational-interviewing-based prompts to guide the coaching sessions will make this program both replicable and scalable and can be integrated into clinical care utilizing trained non-physician providers. Although this type of self-management support is not currently reimbursed for glaucoma as it is for diabetes, this trial could help shape future policy change should the intervention be found effective.

Using Peer Support to Prevent Diabetes: Results of a Pragmatic RCT.

INTRODUCTION: High-contact structured diabetes prevention programs are effective in lowering weight and HbA1cs, yet their intensity level can create barriers to participation. Peer support programs improve clinical outcomes among adults with Type 2 diabetes, but their effectiveness in diabetes prevention is unknown. This study examined whether a low-intensity peer support program improved outcomes more than enhanced usual care in a diverse population with prediabetes. STUDY DESIGN: The intervention was tested in a pragmatic 2-arm RCT. SETTING/PARTICIPANTS: Participants were adults with prediabetes at three healthcare centers. INTERVENTION: Participants randomized to the enhanced usual care arm received educational materials. Participants in the Using Peer Support to Aid in Prevention and Treatment in Prediabetes arm were matched with a peer supporter: another patient who had made healthy lifestyle changes and was trained in autonomy-supportive action planning. Peer supporters were instructed to provide weekly telephone support to their peers on specific action steps toward behavioral goals for 6 months, then monthly support for 6 months. MAIN OUTCOME MEASURES: Changes in primary outcomes of weight and HbA1c and secondary outcomes of enrollment in formal diabetes prevention programs, self-reported diet, physical activity, health-specific social support, self-efficacy, motivation, and activation at 6 and 12 months were examined. RESULTS: Data collection occurred from October 2018 to March 2022, with analyses completed in September 2022. Among 355 randomized patients, in intention-to-treat analyses, there were no between-group differences in HbA1c or weight changes at 6 and 12 months. Using Peer Support to Aid in Prevention and Treatment in Prediabetes participants were more likely to enroll in structured programs at 6 (AOR=2.45, p=0.009) and 12 (AOR=2.21, p=0.016) months and to report eating whole grains at 6 (4.49, p=0.026) and 12 (4.22, p=0.034) months. They reported greater improvements in perceived social support for diabetes prevention behaviors at 6 (6.39, p<0.001) and 12 (5.48, p<0.001) months, with no differences in other measures. CONCLUSIONS: A stand-alone, low-intensity peer support program improved social support and participation in formal diabetes prevention programs but not weight or HbA1c. It will be important to examine whether peer support could effectively complement higher-intensity, structured diabetes prevention programs. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov, NCT03689530. Full protocol available at https://clinicaltrials.gov/ct2/show/NCT03689530.

Elevating the patient voice in contraceptive care quality improvement: A qualitative study of patient preferences for peripartum contraceptive care.

OBJECTIVE: Patient-centeredness is an important indicator of peripartum contraceptive care quality. Prior work demonstrates how care fragmentation, provider biases, and other factors sometimes undermine the patient-centeredness and quality of this care. To guide the design of future quality improvement interventions, we explored patient preferences for peripartum contraceptive care. STUDY DESIGN: For this qualitative study, we recruited a convenience sample of individuals receiving prenatal care at the study site and participating in an online survey about their experience of peripartum contraceptive care during February-July 2020. We conducted individual, in-depth, semistructured interviews to assess patients' preferences for peripartum contraceptive care. Using inductive and deductive qualitative content analysis, we evaluated interview data for patient preferences for peripartum contraceptive counseling and organized preferences into domains to inform future quality measurement. RESULTS: Interviews (lasting 7-26 min) included 21 postpartum individuals, who were largely White with high levels of formal education. Many participants described suboptimal care experiences characterized by insufficient information, inadequate centering of patient values, and, occasionally, disrespectful care. We identified four key themes describing patients' desire for (1) comprehensive, anticipatory information from one's peripartum provider; (2) counseling and decision-making that (a) prioritize patient preferences and values and (b) avoid pressure; (3) care that respects patient feelings and wishes; and (4) provider responsiveness to individual patient preferences regarding timing and frequency of counseling. CONCLUSIONS: We newly identify four key domains of patient preferences for peripartum contraceptive care. Additional research is needed to understand peripartum contraceptive care preferences among diverse patient populations. Future research should develop validated measures for evaluating the patient experience of peripartum contraceptive care at scale, as part of ongoing efforts to improve the quality and respectfulness of peripartum care. IMPLICATIONS: Patients want peripartum contraceptive care to provide comprehensive, anticipatory information; elicit and respond to their counseling and decision-making preferences; and demonstrate respect for their wishes.

Effects of COVID-19 shelter-in-place confinement on diabetes prevention health behaviors among US adults with prediabetes: A cross-sectional survey.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant lifestyle changes due to shelter-in-place confinement orders. The study's purpose was to assess if the COVID-19 pandemic affected self-reported diabetes prevention behaviors among American adults with prediabetes. As part of a randomized clinical trial among adults with prediabetes and overweight/obesity, questions were added to existing study surveys to assess the effect of the COVID-19 pandemic on diabetes prevention behaviors and stress. Survey responses were summarized using frequencies. 259 study participants completed seven COVID-19 survey questions from June 2020 to June 2021. Participants were 62.9% female, 42.5% White, 31.3% Black, 11.6% Asian, 8.1% Hispanic, and 6.6% Other. Over 75% of participants reported that the COVID-19 pandemic affected physical activity levels, with 82.1% of those affected reporting decreased physical activity; 70.3% reported that the pandemic affected their eating habits, with 61.7% of those affected reporting their eating habits became less healthy; 73.7% reported that the pandemic affected their level of stress, with 97.4% of those affected reporting that their level of stress had increased; 60% reported that the pandemic affected their motivation to adopt/maintain healthy habits, with 72.9% of those affected reporting their motivation decreased. A high percentage of study participants with prediabetes reported decreases in health promotion behaviors and increases in stress due to the COVID-19 pandemic. Consequently, the pandemic could lead to increased diabetes incidence. Strategies to improve diabetes prevention behaviors and address mental health concerns among those at-risk for diabetes are critical during and after the COVID-19 pandemic.

Attacks on Health Care Used as a Weapon of War in Ukraine and Globally: The Demand for Accountability.

In this Viewpoint, authors from Physicians for Human Rights and the Ukrainian Healthcare Center present findings from a joint report documenting the attacks on health care workers and facilities as a weapon of war in the Russian war with Ukraine.

Diabetes distress mediates the relationship between depressive symptoms and glycaemic control among adults with type 2 diabetes: Findings from a multi-site diabetes peer support intervention.

AIMS: Diabetes distress is positively associated with HbA1c and may mediate the relationship between depressive symptoms and HbA1c . This study examined these relationships in a geographically, socioeconomically, and ethnically diverse sample of adults with type 2 diabetes. METHODS: Using data from five US sites evaluating peer support for diabetes management (n = 917), Structural Equation Modeling (SEM) examined whether diabetes distress (four items from Diabetes Distress Scale) mediated the relationship between depressive symptoms (PHQ-8) and HbA1c . Sites compared interventions of varying content and duration with control conditions. Time from Baseline Assessment to Final Assessment varied from six to 18 months. Site characteristics were controlled by entering site as a covariate along with age, sex, education, diabetes duration, insulin use, and intervention/control assignment. RESULTS: Depressive symptoms, diabetes distress, and HbA1c were all intercorrelated cross-sectionally and from Baseline to Final Assessment (rs from 0.10 to 0.57; ps <0.05). In SEM analyses, diabetes distress at Final Assessment mediated the relationship between Baseline depressive symptoms and HbA1c at Final Assessment (indirect effect: b = 0.031, p < 0.001), controlling for Baseline HbA1c and covariates. Parallel analysis of whether depressive symptoms mediated the relationship between Baseline diabetes distress and HbA1c at Final Assessment was not significant. CONCLUSIONS: In this diverse sample, diabetes distress mediated the influence of depressive symptoms on HbA1c but the reverse, depressive symptoms mediating the effect of distress, was not found. These findings add to the evidence that diabetes distress is a worthy intervention target to improve clinical status and quality of life among individuals with type 2 diabetes.

Helping Patients With Chronic Conditions Overcome Challenges of High-Deductible Health Plans: Mixed Methods Study.

BACKGROUND: A growing number of Americans are enrolled in high-deductible health plans (HDHPs). Enrollees in HDHPs, particularly those with chronic conditions, face high out-of-pocket costs and often delay or forgo needed care owing to cost. These challenges could be mitigated by the use of cost-conscious strategies when seeking health care, such as discussing costs with providers, saving for medical expenses, and using web-based tools to compare prices, but few HDHP enrollees engage in such cost-conscious strategies. A novel behavioral intervention could enable HDHP enrollees with chronic conditions to adopt these strategies, but it is unknown which intervention features would be most valued and used by this patient population. OBJECTIVE: This study aimed to assess preferences among HDHP enrollees with chronic conditions for a novel behavioral intervention that supports the use of cost-conscious strategies when planning for and seeking health care. METHODS: In an exploratory sequential mixed methods study among HDHP enrollees with chronic conditions, we conducted 20 semistructured telephone interviews and then surveyed 432 participants using a national internet survey panel. Participants were adult HDHP enrollees with diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, or asthma. The interviews and survey assessed participants' health care experiences when using HDHPs and their preferences for the content, modality, and frequency of use of a novel intervention that would support their use of cost-conscious strategies when seeking health care. RESULTS: Approximately half (11/20, 55%) of the interview participants reported barriers to using cost-conscious strategies. These included not knowing where to find information and worrying that the use of cost-conscious strategies would be very time consuming. Most (18/20, 90%) interviewees who had discussed costs with providers, saved for medical expenses, or used web-based price comparison tools found these strategies to be helpful for managing their health care costs. Most (17/20, 85%) interviewees expressed interest in an intervention delivered through a website or phone app that would help them compare prices for services at different locations. Survey participants were most interested in learning to compare prices and quality, followed by discussing costs with their providers and putting aside money for care, through a website-based or email-based intervention that they would use a few times a year. CONCLUSIONS: Regular use of cost-conscious strategies could mitigate financial barriers faced by HDHP enrollees with chronic conditions. Interventions to encourage the use of cost-conscious strategies should be delivered through a web-based modality and focus on helping these patients in navigating their HDHPs to better manage their out-of-pocket spending.