More support, services needed to match diabetes technology with underserved populations
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Disparities in diabetes care among underserved populations can be reduced with increased support, the right technology and “unlimited visits” with diabetes care and education specialists who understand patient needs, according to a speaker.
People with diabetes from underserved communities confront multiple barriers to receiving the care they need, such as difficulty accessing health care, a medical system designed for a different demographic, complex and stressful life situations, and a distrust of the health care system, Anne L. Peters, MD, professor of clinical medicine at Keck School of Medicine at the University of Southern California, Los Angeles, said during an online presentation during the virtual Association of Diabetes Care & Education Specialists annual meeting. Patients who work in low-paying jobs tend to also have lower levels of education and lower numeracy or health literacy skills, tend to be older and are less likely to adopt technology, Peters said.
“Underlying a lot of this is cultural differences,” said Peters, who works with patients with diabetes living in Beverly Hills, California, as well as patients living in the east side of Los Angeles. “Many people who do not want to accept what I have to say are more likely to accept it from people from their own culture, but I find it is hard to find ways in. Often, people’s lives are so stressful, and they are so distressed, that learning about the nuts and bolts of diabetes management is something that seems impossible to them.”
To confront such needs, solutions must be simple, have high benefit, and not disrupt a fragile system of existence, Peters said.
More than just technology
Technology alone for any person with diabetes —particularly a person struggling to make ends meet — does nothing to help their care, Peters said. Instead, technology such as a continuous glucose monitor combined with persistent, actualizable, incremental alterations in treatment can “change everything.”
The provider or diabetes care and education specialist must first realize that their solutions, no matter how well intentioned, may not help, Peters said. For example, labor-intensive jobs that are hard on hands can make fingerstick testing difficult.
“I had to step back and let the patient figure out the solution,” Peters said, referring to a patient who worked as a truck mechanic and had calloused fingers. “The patient’s solution was to take a belt with Velcro used to support the back and use it to support a glucose sensor. Then he was able to wear it when crawling under the trucks. An added problem was he was unable to give himself shots at work, so he could not dose for lunch, but at least having some CGM data made it easier to work with him. But clearly, my original assumptions about him were wrong, and I am willing to admit that happens all the time.”
Additionally, easy to access, culturally appropriate support is vital, Peters said.
“If people have trouble getting their medication, getting their Medicaid, there have to be people on the other side of a telephone that can provide culturally appropriate support, and they must be available 24/7 because these people are working all day long,” Peters said. “Many of the patients cannot just stop during the day and make a phone call.”
Similarly, device websites should reflect the faces and circumstances of people who use them, she said.
“I looked recently at the CGM websites, and they do now include more people of color; everyone in the pictures is not a non-Hispanic white person,” Peters said. “I was pleased at the improvement, but even if you show this, patients still see things that are not possible. It is beautiful to look at an Apple watch, but my patients do not even have smartphones. When they see this, they are immediately discouraged.”
Simple solutions needed
It is hard for patients to use the technology some take for granted, and simple, subsidized programs are needed to get devices and medications in the hands of people who need it.
“I have recently had a lot of patients who have fallen out of insurance and tried to get insulin, for example, using a patient assistance program,” Peters said. “All of those programs require a prescription from a health care provider. I get the need for checks and balances, but it can be hard to get things when you don’t have what I consider the fundamentals: a computer, an email address, a doctor to write a prescription. It gets harder as these things are stripped away.”
Peters also called for more access to diabetes care and education specialists who can work one-on-one with patients to navigate complex issues.
“I want all of my patients with diabetes to have unlimited visits with a diabetes care and education specialist, pharmacist or other health coach,” Peters said. “It is important to have educators who come from a similar background who understand what is going on and have family sessions, peer support sessions — whatever we can do to support people. We need to make it more normal to communicate with your health care team, and not something you do because you are really sick.”
Social workers and occupational therapists should be part of a care team to facilitate access to basic needs, and patients should also be screened for mental illness and referred to appropriate providers for help, Peters said.
“High-tech devices are great, but we need to support diversity, simplify and reduce language and literacy barriers,” Peter said.
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Peters A. Use of technology in underserved populations. Presented at: Association of Diabetes Care & Education Specialists Annual Meeting; Aug. 13 - 16, 2020; (virtual meeting).
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