Title: Patient Factors and Perceived Barriers in Attending Diabetes Education Programs

First Author: Enza Gucciardi, MHSc PhD, School of Nutrition, Ryerson University, Toronto, Canada

Co-authors:

Vivian Wing-Sheung Chan, HBSc, PhD (c), Department of Psychology, University of Waterloo, Waterloo, Canada;Brian Kam Chuen Lo, BASc, School of Nutrition, Ryerson University, Toronto, Canada;Mariella Fortugno, BASc, School of Nutrition, Ryerson University, Toronto, Canada;Stacey Horodezny, BAA RD, Trillium Health Centre, Toronto, Canada Susan Swartzack, BScN MPA RN, Mississauga Halton Local Health Integration Network, Toronto, Canada;

Corresponding Author Contact Information:

Enza Gucciardi, PhDAssistant Professor School of Nutrition, Ryerson University350 Victoria Street Toronto, Ontario, M5B 2K3Phone: 416-979-5000 ext. 2728Fax: 416-979-5204egucciar@ryerson.ca

Acknowledgement of Financial Support

No financial support was provided for the completion of this study.

Word Count: 4580

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Abstract

Objective: This study aimed to explore patient utilization of and barriers to attending diabetes

education programs (DEPs) in Southern Ontario, Canada.

Method: Internet questionnaires were completed by 221 individuals living with diabetes in the

Peel-Halton regions of Ontario.

Results: Approximately 67% of respondents attended a DEP. The majority of them reported

gaining a better understanding and ability in managing diabetes. However, regular DEP follow-

up was relatively low. Reasons for finding DEP visits unhelpful include lack of DEP awareness,

insufficient individualized services, and unwelcoming staff. Common reasons for individuals

never attending a DEP include diabetes education provided by primary care physicians (PCPs),

lack of DEPs promotion from PCPs, patients’ high level of confidence in diabetes self-

management, and inconvenient DEP locations and operational times. Most participants relied on

their PCPs for managing diabetes, but PCPs were not frequently providing comprehensive

diabetes self-management support.

Conclusions: DEP utilization appears to improve patients’ perception of their ability to manage

the disease. Creating better partnerships between PCPs and DEPs could improve DEP referrals

and patient participation in DEPs. Delivering more accessible and patient-oriented services could

improve patient retention at DEPs.

Key words: attendance, diabetes self-management education, diabetes education programs, patient satisfaction, and Diabetes Mellitus

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Introduction

Diabetes Mellitus is a chronic illness that requires a lifelong commitment to complex lifestyle

modifications involving nutrition management, a physically active lifestyle, regular self-

monitoring of blood glucose, and adherence to medications and/or insulin therapy (1). Proper

management of these lifestyle modifications has been shown to reduce the risk and progression

of diabetes complications (2-7). In order for patients to manage their diabetes effectively, they

must become experts in the management of their illness. However, achieving and sustaining

effective management is challenging, and only about half of Canadians living with diabetes are

able to meet the recommended target for glycemic control (<7% Hemoglobin A1c [HbA1c])

(8). As a result, diabetes self-management education (DSME), which is primarily delivered at

diabetes educations programs (DEPs), is recommended by clinical practice guidelines as a

valuable resource that teaches patients the skills to actively participate in the management of

their illness and supports their efforts (1). DSME is intended to identify patients’ management

issues, priorities, goals, and barriers, as well as develop management plans and problem-solving

skills for optimal management of the illness (9;10).

Despite the documented benefits of DSME in improving self-care behaviours (3-7;11),

glycemic control, lipid profiles, and blood pressure, which reduce both the risk and progression

of diabetes complications (11-16) while lowering health care costs (12;13) and improving

quality of life (3;6), the literature suggests that DSME delivered by DEPs is underutilized in

both Canada (14;15) and the United States (16-21). Studies in Ontario suggest that 25 to 30% of

individuals with diabetes participate in DSME (14;15), and figures from the United States found

that only one-third to one-half of diabetes patients participate in DSME (16-21).

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As most DEPs require a physician’s referral, primary care physicians (PCPs) are seen as

gatekeepers to DEP participation (22). Even though PCPs face barriers to caring for diabetes

patients, such as lack of time (23-26), knowledge (24-26) and resources to provide self-

management support for diabetes patients (24; 25), they are still not likely to refer all or most of

their patients to DEPs (24;27). A recent Canadian study found that less than one-half of PCPs

referred all their patients with diabetes to local DEPs; the reason most commonly reported by

PCPs was patients’ unwillingness to attend (24). In the U.S. literature, PCPs’ reasons for not

referring patients to DEPs include lack of awareness of existing programs, disagreement with

the content of DEPs, and concern of losing patients (28). Moreover, U.S. studies have found

that patient barriers to DEP attendance include accessibility issues (such as transportation

difficulties, inconvenient location, or program scheduling), long class hours, and high cost

(17;29;30). Patient attitudes, such as misunderstanding the seriousness of diabetes, lack of

motivation, denial or fear of the disease (29), scepticism concerning the benefits of DSME (31),

and greater priorities besides diabetes management (31), are also common barriers to attending

DEPs. Finally, the delivery structure of DSME, such as the lack of individualization, language

barriers, and culturally inappropriate programming, can affect the use of DEPs (17;30;32).

Research on patient perceptions of and barriers to attending DEPs has been primarily limited to

studies in the United States. Further exploration of these issues within a Canadian context is

necessary to identify appropriate strategies to improve the delivery of, access to, and use of

DSME in Canada. This research (a) describes the utilization patterns of DEPs; (b) explores

patient-perceived barriers to participating in DEPs; and (c) investigates patients’ perception of

their PCPs’ role in diabetes self-management care and support.

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Methods

The study was conducted between August and December 2008 in the Peel and Halton regions of

southern Ontario, Canada which includes the large suburban City of Mississauga and Town of

Oakville. Recruitment targeted both individuals with diabetes who were and were not using

DEPs in the Peel-Halton regions through flyers distributed in the community and word-of-mouth

by healthcare providers (physicians, nurses, dietitians, and pharmacists) who worked in DEPs or

in the community. Advertisements for the survey were also placed in local community

newspapers (i.e., the Mississauga News and the Oakville Beaver). Patients were given a

description of the survey and a consent form prior to participation. Questionnaires were

completed by participants using an Internet survey link (Survey Monkey) posted on the

Mississauga Halton Local Health Integrated Network’s (MH-LHIN) website.

Survey questions, developed in conjunction with the MH-LHIN Diabetes Education Task Group,

were based on a thorough literature review on the topic of patient utilization of DEPs. The

questionnaire incorporated both open and closed-ended questions. Variables included

demographic information, health conditions, relationship with family physicians, diabetes self-

management skills, acceptance of DSME, frequency in using DEPs, and barriers to using DEPs.

Other questions addressed the usefulness of DEPs and suggestions for improving DEP services.

All analyses were conducted using Statistical Package for Social Sciences (SPSS version 14.0,

IBM, Chicago, Illinois). Frequency counts and percentages were tabulated for all responses.

Open-ended questions and all “Other” responses were sorted into categories and themes by two

of the authors (VC and BL). Any discrepancies were resolved by the first author (EG).

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Results

Table 1 presents demographic information of the 221 respondents who completed the

questionnaire. More than a third (38.3%) were between 50 and 64 years old; most had type 2

diabetes (81.8%); many had lived with diabetes for at least 11 years (37.3%); less than one-fifth

had an annual household income greater than $100,000 (17.9%); and most had at least some high

school education (86.4%). On average, the respondents had 2.64 (SD=1.80) other health

conditions.

Diabetes Resources Used by Patients

The most common resources participants reported using for reliable diabetes and other medical

information were: family physicians (79.0%), diabetes centres (41.1%), pharmacists (30.4%),

endocrinologists (27.6%), the Internet (27.1%), and organizations such as the Canadian Diabetes

Association (22.9%).

Utilization Patterns of DEPs

Two-thirds of the participants had previously used DEP services (66.7%); a similar percentage of

participants were aware of the DEP in their region (64.5%). Participants had first attended DEPs

because they had recently been diagnosed with diabetes (67.9%), had poor glucose control

(9.3%), needed to start insulin treatment (7.9%), had experienced a change in diabetes treatment

(5.7%), or had an illness or infection (2.1%). Of these respondents, 38.1% attended regular

follow-up appointments, 32.4% attended only when they felt they needed to, and 29.5% had

attended just one appointment. The majority of these participants were referred by their regular

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family physicians (72.3%); others had been referred by a specialist or other health professional

(21.9%), a small number were self-referred (4.4%), or had been referred by a walk-in clinic

(1.5%). After attending a DEP, most participants reported a “much better” or “a little more”

understanding about the nature of diabetes (92.5%), as well as how to keep themselves healthy

(90.4%), and how to cope with their diabetes (88%), compared with their understanding before

their visit.

Patient-perceived barriers to attending DEPs

Approximately 6% of participants indicated that the DEP was not helpful. These respondents

cited the lack of specific tailoring of the program to their needs (33.3%), perceived insensitivity

on the part of care providers (22.2%), perceived futility of the service (22.2%), the sense that

attendance was not a priority (11.1%), or the feeling that their disease was not severe enough to

make attendance worthwhile (11.1%) (Figure 1).

Reasons for never attending a DEP as reported by study participants are listed in Table 2 and

include: receiving diabetes education from family physicians (48.4%), lack of information about

DEPs from PCPs (32.3%), already having enough information and support to self-manage their

diabetes (21.0%), unsuitable hours of DEP operation (11.3%), lack of parking (6.5%), and long

waiting lists (6.5%) (Table 2).

Reported Diabetes Care Provided by Physicians

Most patients reported that they had a regular family physician (98.5%), whom they had visited

in the previous 6 months (91.3%). When patients were asked to describe their relationships with

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their family doctors in the past 12 months, they stated that their physicians “most of the time” or

“almost always” provided information or details about medications and lab results (71%), asked

patients if they had checked their feet or blood pressure regularly (54.9%), informed patients on

how often they should have their eyes examined (50.3%), asked what the patient would like to

discuss about diabetes in the visits (46%), set goals with the patients to manage their diabetes

(41.5%), or asked patients how their work, family, or social situations influenced self-

management of their diabetes (27%).

Discussion

Of the participants in our study, 66.7% attended a DEP. This percentage is high compared to

other reported usage of DEPs in Ontario (25 to 30%) (14;15), and in the U.S. (33 to 50%) (16-

21;33). Most respondents attended a DEP when they were first diagnosed with diabetes, had poor

glucose control, or needed to start insulin. These three circumstances demonstrate patients’ needs

for self-management education or re-education on self-care practices. Supporting this finding, a

Canadian study also found that patients who were recently diagnosed with diabetes were more

likely to attend a DEP (15). Similarly, Peyrot et al. (28) found that patients also used DEPs

when they wanted to know more about their diabetes, when their diabetes worsened, when they

started a new medication, or when they had a new physician.

The objectives of DSME according to the Canadian Diabetes Association 2008 Clinical Practice

Guidelines for the Prevention and Management of Diabetes is “to increase the individual’s

involvement in, confidence with and motivation to control their diabetes, its treatment and its

effects on their lives” (1). It is promising to observe that the majority of the DEP participants in

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our study reported that they gained a better understanding of diabetes and increased their ability

to manage and cope with their disease after their DEP visit(s). However, 6% of patients in our

study were either dissatisfied with the DEP services in their region or felt that the service was not

helpful or necessary. Although efforts have been made to advocate for patient-centered care

through clinical practice guidelines recommending that DSME be customized according to each

patient’s needs and concerns (1), a small proportion of patients’ education needs are not being

met. Previous research suggests that DSME needs to be tailored to patients’ individual needs in

terms of age, culture, insulin use, co-morbidity, type of patient care, health literacy level, and

physical limitations, in order to increase patient use of DSME (17;29;34).

Other patient reasons for not attending DEPs, such as the perceived futility of DEP services, the

low priority accorded to DSME, and low perceived severity of the disease, are common factors

identified in the literature for DEP attrition (35). According to the Health Belief Model, when

patients do not consider the severity or consequences of diabetes to be of much importance, they

are unlikely to change any health-related behaviours, including the use of self-management

programs (36-39). Furthermore, patients’ lack of confidence in the benefits of DSME has also

been identified as a barrier in attending DEPs (31). These factors could be addressed by PCPs

before making a DEP referral, in order to influence patient perceptions and increase

participation in DEPs. PCPs can discuss with patients the benefits of DSME, as well as the

severity and progressive nature of diabetes, in order to encourage patients to engage in lifestyle

modifications that will help them to manage the disease. Furthermore, DEPs need to assess the

needs of their patients to ensure that programs are relevant, appropriate, and timely based on

patients’ diabetes knowledge and existing self-management skills. For example, PCPs should

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assess patients’ knowledge of diabetes before referring them to DEPs and communicate this

information to the diabetes educators who provide DEP services, so that patients are not being

given redundant information.

The most common reasons for participants’ never attending a DEP, include already receiving

diabetes education from their PCPs, a lack of DEP information received from PCPs, high patient

confidence in their existing self-management skills, and accessibility barriers of the DEP (i.e.,

hours of operation, lack of parking, and long waiting lists). These findings are similar to those

found in the U.S. literature (29-31). Our previous study examining referral practices and factors

influencing referrals by PCPs to DEPs in the same geographic region identified similar

accessibility barriers as reported by PCPs (24). To some extent, the reasons why PCPs did not

refer patients to DEPs in the previous study overlap with patients’ own reasons for non-

attendance in the current study, which include PCPs providing patients with diabetes education,

long waiting lists, and inconvenient locations and times of services (24). Our results also support

the common U.S. finding that patients’ perceptions of receiving adequate education from PCPs

and having enough information and support to self-manage the disease is a major reason for not

participating in DSME (28;31). When patients felt a high level of confidence in managing their

disease, they tended not to recognize the additional benefits of DSME (17;40). Despite the

benefits reported for those who use DSME, some individuals may be managing well and meeting

their glycemic target, and therefore they do not see any further benefits in participating in

DSME. However, further research is warranted to examine physiological data to verify whether

those who are confident in their management and feel that they do not need to attend DEPs are

within the recommended clinical targets for diabetes. Overall, there appears to be a need for

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better promotion of DEPs to PCPs. Developing partnerships with PCPs can better serve patients

by increasing access to a multidisciplinary care team, which is recommended for all individuals

with diabetes by the Canadian practice guidelines (1).

Although the majority of our study participants relied on their PCPs for diabetes information and

almost half did not attend a DEP because they were already receiving DSME from their PCP, the

provision of comprehensive diabetes self-management support from PCPs appears to be

infrequent. When describing their relationship with their PCPs, most study participants reported

receiving details about medications and lab results frequently, while only about half of

participants stated that PCPs make inquiries about blood pressure or feet checks and suggest

regular eye examinations most of the times or most always. Furthermore, only about a quarter

of the participants had the opportunity to discuss how their work, family or social life affected

their diabetes self-management with their PCPs or how to set self-management goals. These

findings are not surprising; as mentioned, the literature strongly substantiates that PCPs are

unable to provide the highest level of care for patients with diabetes and deliver education and

lifestyle-modification strategies necessary for chronic disease management (27;41-43). This is in

part due to their lack of time to assess complex cases and limited knowledge of insulin starts and

adjustments (24). Effective management of diabetes requires a high degree of patient

commitment to self-management, and thus ongoing self-management education, training, and

support is critical. Therefore, patients solely relying on their PCP for DSME are likely not

receiving the full range of services and resources that would facilitate effective diabetes self-

management.

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A limitation of this study is the small sample size, as this study was conducted in a specific

region in Ontario, thereby limiting the generalizability of the results to all Canadians living with

diabetes. In particular, caution should be taken when interpreting patients’ reasons for not

finding DEPs helpful, as they represent only 6% of the sample population. Although greater

distribution of the methods of recruitment and the use of incentives would have increased our

sample size to obtain a more representative sample of our target population, there is no reason to

assume this region of Ontario is different from other culturally mixed urban centers in Canada.

Furthermore, we were not able to estimate a response rate, given the type of recruitment efforts

used (i.e., through DEPs, internet and regular mail). Non-response bias is a possible limitation to

our study as we could not compare respondents with non-respondents due to the type of

recruitment efforts used and to participant anonymity.

Another limitation of our study was that our survey was conducted in English only, and thus we

were not able to assess the utilization patterns and barriers to using DEPs among non-English-

speaking patients in the region. For instance, issues such as language and cultural tailoring were

less identified as barriers in our study, but often reported in the literature (35;44;45). However, it

is worth noting that half of our sample was not born in Canada, so we were able to capture a

proportion of immigrant Canadians, who on average tend to have higher rates of diabetes than

those born in Canada (12;13;46). Future research in this area can contribute to a better

understanding of DEP usage by surveying a larger and more representative population, including

non-English speakers, to further validate our findings. Also, using qualitative approaches can

provide comprehensive data on patient-perceived barriers that may not be reflected in researcher-

designed surveys. In addition, a more complete understanding of DEP patterns of utilization in

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Canada can be achieved by also assessing Canadian PCP and diabetes educators’ perspectives on

DEP utilization.

Conclusion

Diabetes is a chronic and progressive disease that requires continuous self-management and

support, particularly given patients’ changing needs throughout the lifecycle. It is well

established that DSME benefits those living with diabetes and that long-term regular use is

crucial in effective management and reaching clinically recommended targets (47;48). This study

provides valuable insight into the utilization of DEPs and the reasons identified by patients for

not attending. In the Peel-Halton Region of Southern Ontario, the majority of those who were

surveyed attended DEPs and they are generally satisfied with the services. Those who did not

find DEPs helpful found DEPs lacking an individualized approach in meeting patients’ specific

needs, while those who never attended DEPs appear to be satisfied with the information they

were receiving from their PCPs. As patients mostly receive diabetes information from PCPs,

DEPs need to promote themselves to PCPs to increase PCPs’ awareness of the benefits of these

services.

The establishment of partnerships between DEPs and PCPs could increase patients’ access to and

support from a multidisciplinary team, as recommended for the management of diabetes by the

Canadian practice guidelines (1). The creation of such partnerships would also provide a

knowledge exchange opportunity by helping PCPs improve their own knowledge and confidence

in managing patients with diabetes and would encourage the referral of patients with more

complex needs to specialized care and education. DEPs need to enhance their efforts to increase

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the visibility, relevancy, and accessibility of their services within their local communities. Future

research should examine alternative strategies and models of care that overcome patient DEP

barriers. .

Acknowledgements

No acknowledgements to declare

Author Contributions

SJS, SH and EG contributed to the conception and design of the project. EG, VC and BL analyzed the data. EG, VC, BL and MF wrote the first draft of the manuscript. All authors reviewed the draft critically for important intellectual content and approved the final version to be published.

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References

(1) Canadian Diabetes Association. Clinical Practice Guidelines for the Prevention and

Management of Diabetes in Canada. Can J Diabetes 2008; 32 (suppl 1), S1–S201.

(2) Public Health Agency of Canada. Diabetes – Facts & Figures. 2003.

(3) Ellis SE, Speroff T, Dittus RS, et al. Diabetes patient education: a meta-analysis and

meta-regression. Patient Educ Couns 2004 Jan;52(1):97-105.

(4) Gary TL, Genkinger JM, Guallar E, et al. Meta-analysis of randomized educational and

behavioral interventions in type 2 diabetes. Diabetes Educator 2003 May;29(3):488-

501.

(5) Norris SL, Nichols PJ, Caspersen CJ, et al. The effectiveness of disease and case

management for people with diabetes. A systematic review. Am J Prev Med 2002

May;22(4 Suppl):15-38.

(6) Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in

type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care

2001 Mar;24(3):561-87.

(7) Norris SL, Lau J, Smith SJ, et al. Self-management education for adults with type 2

diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002

Jul;25(7):1159-71.

(8) Harris SB, Ekoe JM, Zdanowicz Y, et al. Glycemic control and morbidity in the

Canadian primary care setting (results of the diabetes in Canada evaluation study).

Diabetes Res Clin Pract 2005;70(1):90-7.

(9) Von KM, Gruman J, Schaefer J, et al. Collaborative management of chronic illness.

13

Ann Intern Med 1997;127(12):1097-102.

(10) Glasgow RE. Outcomes of and for diabetes education research. Diabetes Educator 1999

Nov;25(6 Suppl):74-88.

(11) Padgett D, Mumford E, Hynes M, et al. Meta-analysis of the effects of educational and

psychosocial interventions on management of diabetes mellitus. J Clin Epidemiol

1988;41(10):1007-30.

(12) Robbins JM, Thatcher GE, Webb DA, et al. Nutritionist visits, diabetes classes, and

hospitalization rates and charges: the Urban Diabetes Study. Diabetes Care 2008

Apr;31(4):655-60.

(13) Renders CM, Valk GD, Griffin SJ, et al. Interventions to improve the management of

diabetes in primary care, outpatient, and community settings: a systematic review.

Diabetes Care 2001 Oct;24(10):1821-33.

(14) Diabetes Complication Prevention Cooperative. Adult gap analysis for southern

Ontario 2001. Toronto, Canada; 2001.

(15) Shah BR, Booth GL. Predictors and effectiveness of diabetes self-management

education in clinical practice. Patient Educ Couns 2009 Jan;74(1):19-22.

(16) Irvine AA, Mitchell CM. Impact of community-based diabetes education on program

attenders and nonattenders. Diabetes Educator 1992 Jan;18(1):29-33.

(17) Chapko MK, Norman J, Bell-Hart M, et al. Increasing the utilization of outpatient

diabetes education programs. Diabetes Educator 1987;13(2):116-9.

(18) Brown SA. Effects of educational interventions in diabetes care: a meta-analysis of

findings. Nurs Res 1988 Jul;37(4):223-30.

(19) Anderson RM, Hiss RG, Stepien CJ, et al. The diabetes education experience of

14

randomly selected patients under the care of community physicians. Diabetes Educator

1994;20(5):399-405.

(20) Coonrod BA, Betschart J, Harris MI. Frequency and determinants of diabetes patient

education among adults in the U.S. population. Diabetes Care 1994 Aug;17(8):852-8.

(21) Graber AL, Davidson P, Brown AW, et al. Dropout and relapse during diabetes care.

Diabetes Care 1992 Nov;15(11):1477-83.

(22) Walters DJ, Toombs M, Rabuka LA. Strengthening the foundation: the physician's vital

role in primary health care in Canada. CMAJ 1994;150(6):839-49.

(23) College of Family Physicians of Canada. National Physician Survey. 2007. Ref Type:

Online Source

(24) Gucciardi E, Horodezny S, Swartzack S, et al. Primary care physician referral patterns

to diabetes education programs in Southern Ontario. Can J Diabetes 2011;35(3):262-

268.

(25) Brez S, Rowan M, Malcolm J, et al. Transition from specialist to primary diabetes care:

a qualitative study of perspectives of primary care physicians. BMC Fam Pract

2009;10:39.

(26) Blakeman T, Macdonald W, Bower P, et al. A qualitative study of GPs' attitudes to

self-management of chronic disease. Br J Gen Pract 2006 Jun;56(527):407-14.

(27) Harris SB, Petrella RJ, Lambert-Lanning A, et al. Lifestyle management for type 2

diabetes. Are family physicians ready and willing? Can Fam Physician 2004

Sep;50:1235-43.

(28) Peyrot M, Rubin RR, Funnell MM, et al. Access to diabetes self-management

education: Results of national surveys of patients, educators, and physicians. Diabetes

15

Educator 2009;35:246-63.

(29) Graziani C, Rosenthal MP, Diamond JJ. Diabetes education program use and patient-

perceived barriers to attendance. Fam Med 1999 May;31(5):358-63.

(30) Powell MP, Glover SH, Probst JC, et al. Barriers associated with the delivery of

Medicare-reimbursed diabetes self-management education. Diabetes Educator 2005

Nov;31(6):890-9.

(31) Maine Department of Health and Human Services. Diabetes Self-Management

Education Barrier Study. 2006.

(32) Corkery E, Palmer C, Foley ME, et al. Effect of a bicultural community health worker

on completion of diabetes education in a Hispanic population. Diabetes Care 1997

Mar;20(3):254-7.

(33) Robson T, Blackwell D, Waine C, et al. Factors affecting the use of dietetic services by

patients with diabetes mellitus. Diabet Med 2001 Apr;18(4):295-300.

(34) Rhee MK, Cook CB, El-Kebbi IM, et al. Barriers to diabetes education in urban

patients. Diabetes Educator 2005;31(3):410-7.

(35) Gucciardi E, DeMelo M, Offenheim A, et al. Factors contributing to attrition behavior

in diabetes self-management programs: a mixed method approach. BMC Health Serv

Res 2008;8:33.

(36) Harris SB, Linn MW. Health beliefs, compliance, and control of diabetes mellitus.

South Med J 1985;78(2):162-6.

(37) Becker MH, Maiman LA. Health beliefs, compliance, and control of diabetes mellitus.

Med Care 1975;13(1):10-24.

(38) Polly R. Diabetes health beliefs, self-care behaviors, and glycemic control among older

16

adults with non-insulin-dependent diabetes mellitus. Diabetes Educator

1992;18(4):321-7.

(39) Wooldridge KL, Wallston KA, Graber AL, et al. The relationship between health

beliefs, adherence, and metabolic control of diabetes. Diabetes Educator

1992;18(6):495-500.

(40) Williamson AR, Hunt AE, Pope JF, et al. Recommendations of dietitians for

overcoming barriers to dietary adherence in individuals with diabetes. Diabetes

Educator 2000;26:272-9.

(41) Leeman J, Mark B. The chronic care model versus disease management programs: a

transaction cost analysis approach. Health Care Manage Rev 2006 Jan;31(1):18-25.

(42) Albisser AM, Harris RI, Sperlich M, et al. Getting referrals for diabetes education and

self-management training. Diabetes Educator 1999 Nov;25(6):959-4, 966.

(43) Graham RC, Dugdill L, Cable NT. Health professionals' perspectives in exercise

referral: implications for the referral process. Ergonomics 2005 Sep 15;48(11-14):1411-

22.

(44) Karter AJ, Ferrara A, Darbinian JA, et al. Self-monitoring of blood glucose: language

and financial barriers in a managed care population with diabetes. Diabetes Care

2000;23(4):477-83.

(45) Peyrot M, Rubin RR. Access to diabetes self-management education. Diabetes

Educator 2008;34:90-7.

(46) Creatore M, Moineddin R, Booth G, et al. Age- and sex-related prevalence of diabetes

mellitus among immigrants to Ontario, Canada. CMAJ 2010;182(8):781-9.

(47) Brown SA, Blozis SA, Kousekanani K, et al. Dosage effects of diabetes self-

17

management education for Mexican Americans: The Starr County Border Health

Initiative. Diabetes Care 2005;28:527-32.

(48) Goudswaard AN, Stolk RP, Zuithoff NPA, et al. Long-term effects of self-management

education for patients with type 2 diabetes taking maximal oral hypoglycemic therapy:

a randomized trial in primary care. Diabetic Med 2004;21:491-6.

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Tables

Table 1. Demographic characteristics

Characteristics n (%) or mean +/- (standard deviation)Sex (n=203)Male 104 (51.2)Female 99 (48.8)Age Group (n=206)18 to 34 Years 14 (6.8)35 to 49 Years 31 (15.0)50 to 64 Years 79 (38.3)65 to 74 Years 45 (19.8)75 to 84 Years 35 (17.0)84 Years of Age and Older 1 (1.0)Type of Diabetes (n=220)Type 1 Diabetes 30 (13.6)Type 2 Diabetes 180 (81.8)Pre-diabetes 7 (3.2)When first diagnosed with diabetes (n=217)Within one year 23 (10.6)1 to 5 years ago 62 (28.6)6 to 10 years ago 51 (23.5)11 or more years ago 81 (37.3)Mean Number of Other Health Problems (n=221) 2.64 +/- 1.80Annual Household Income (n=190)Under $20,000 25 (13.2)$20,000 to $29,999 20 (10.5)$30,000 to $39,999 17 (8.9)$40,000 to $59,999 29 (15.3)$60,000 to $79,999 15 (7.9)$80,000 to $99,999 20 (10.5)$100,000 and Over 34 (17.9)Highest Level of Education Reached (n=184)Less than high school 25 (13.6)Competed high school 54 (29.3)Completing undergraduate university or college degree 10 (5.4)Competed undergraduate university or college degree 78 (42.4)Completing post-graduate university degree 1 (0.5)Completed post-graduate university degree 16 (8.7)Country Born In (n=208)Canada 110 (52.9)Other 98 (47.1)

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Table 2. Reasons for never attending DEPs (Check all that applies) (n=62)

Reasons Frequencyn (%)

Your own doctor provides you with diabetes education 30 (48.4)Your doctor does not promote the diabetes centre 20 (32.3)Perceive enough information and support to self-management own diabetes

13 (21.0)

Time unsuitable (i.e., no evening and weekend appointments) 7 (11.3)Parking issues 4 (6.5)Long waiting list 4 (6.5)Diabetes not serious enough to visit a diabetes centre 3 (4.8)Program is not offered in a language you feel most comfortable in speaking

3 (4.8)

You are too ill to attend 3 (4.8)Location is hard to get to 3 (4.8)Diabetes education is a low priority for you 1 (1.6)

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Figures

Figure 1. Reasons for not finding DEP visit(s) helpful (n=9)

33%

22%

22%

11%

11%

Reasons for not finding DEP visit(s) helpful

DEP need independent/specific tailoringInsensitive interactions with professionalsPerceived futility of the serviceUnmotivated or not a priorityCondition is not considered as severe

21