Hinder för diabetesbehandling hos vuxna personer i hemlöshet - en kvalitativ studie
Project number : 272452
Created by: Martin Hammar, 2019-06-19
Last revised by: Martin Hammar, 2019-06-19
Project created in: FoU i Västra Götalandsregionen

PublishedPublished

1. Översiktlig projektbeskrivning

Engelsk titel

Barriers to diabetes management among homeless adults in Gothenburg city, Sweden – a qualitative study

Populärvetenskaplig sammanfattning av projektet

Bakgrund

Hemlösa personer är en särskilt utsatt grupp i samhället. De löper högre risk att dö i förtid är resten av befolkningen. En vanlig dödsorsak är hjärt- och kärlsjukdom, särskilt hos de äldre patienterna.

Internationella studier har visat att kontrollen av diabetes mellitus typ 2 är sämre hos dessa personer och risken för allvarliga komplikationer är förhöjd. Hemlösa personer upplever ofta unika hinder och svårigheter för att behandla och kontrollera sin sjukdom, exempelvis svårigheter att få tillgång till sjukvård, ekonomiska svårigheter att köpa mediciner och även svårigheter att följa ordinationer. Dock är inga studier av detta genomförda i Sverige.

Syfte

Denna kvalitativa intervjustudie skall undersöka och beskriva vilka hinder som hemlösa personer upplever för att kunna kontrollera och behandla sin diabetes mellitus typ 2 i Göteborg.

Metod

För att bäst besvara frågeställningen i denna studie används en kvalitativ metodik. Ett stategisk urval på preliminärt 10 informanter görs bland patienter med känd diabetes mellitus typ 2 på Närhälsan vårdcentral för hemlösa i Göteborg.. De tillfrågas om de vill delta i studien av läkare, sjuksköterska eller fotterapeut. Skriftlig och muntlig information ges och de som tackar ja får skriva på formellt samtycke. Individerna intervjuas med fokus på deras upplevda hinder för att behandla diabetes mellitus typ 2. Intervjuerna spelas in på band och skrivs ut i text som sedan analyseras och presenteras i skriftlig text.

Vetenskaplig sammanfattning av projektet

Bakgrund

Hemlösa personer är en särskilt utsatt grupp i samhället. De löper högre risk att dö i förtid är resten av befolkningen. En vanlig dödsorsak är hjärt- och kärlsjukdom, särskilt hos de äldre patienterna.

Internationella studier har visat att kontrollen av diabetes mellitus typ 2 är sämre hos dessa personer och risken för allvarliga komplikationer är förhöjd. Hemlösa personer upplever ofta unika hinder och svårigheter för att behandla och kontrollera sin sjukdom, exempelvis svårigheter att få tillgång till sjukvård, ekonomiska svårigheter att köpa mediciner och även svårigheter att följa ordinationer. Dock är inga studier av detta genomförda i Sverige.

Syfte

Denna kvalitativa intervjustudie skall undersöka och beskriva vilka hinder som hemlösa personer upplever för att kunna kontrollera och behandla sin diabetes mellitus typ 2 i Göteborg.

Metod

För att bäst besvara frågeställningen i denna studie används en kvalitativ metodik. Ett stategisk urval på preliminärt 10 informanter görs bland patienter med känd diabetes mellitus typ 2 på Närhälsan vårdcentral för hemlösa i Göteborg.. De tillfrågas om de vill delta i studien av läkare, sjuksköterska eller fotterapeut. Skriftlig och muntlig information ges och de som tackar ja får skriva på formellt samtycke. Individerna intervjuas med fokus på deras upplevda hinder för att behandla diabetes mellitus typ 2. Intervjuerna spelas in på band och skrivs ut i text som sedan analyseras och presenteras i skriftlig text.

Typ av projekt

Forskningsprojekt

MeSH-termer för att beskriva typ av studier

checked Kvalitativ forskning (Qualitative Research)


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MeSH-termer för att beskriva ämnesområdet

information Added MeSH terms
Diabetes Mellitus, Type 2
A subclass of DIABETES MELLITUS that is not INSULIN-responsive or dependent (NIDDM). It is characterized initially by INSULIN RESISTANCE and HYPERINSULINEMIA; and eventually by GLUCOSE INTOLERANCE; HYPERGLYCEMIA; and overt diabetes. Type II diabetes mellitus is no longer considered a disease exclusively found in adults. Patients seldom develop KETOSIS but often exhibit OBESITY.
Diabetes Mellitus
A heterogeneous group of disorders characterized by HYPERGLYCEMIA and GLUCOSE INTOLERANCE.
Homeless Persons
Persons who have no permanent residence. The concept excludes nomadic peoples.

Projektets delaktighet i utbildning

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2. Projektorganisation och finansiering

Arbetsplatser involverade i projektet

information Added workplaces
Regioner - Västra Götalandsregionen - Närhälsan - Övriga Vårdverksamheter - Närhälsan vårdcentral hemlösa workplace verified by Västra Götalandsregionen on 2018-02-27

Tutor

Bledar Daka
Specialistläkare i allmänmedicin, Närhälsan FoU-centrum Göteborg och Södra Bohuslän, Sahlgrenska akademin, Närhälsan Ekmanska vårdcentral (Göteborg), Enheten för Allmänmedicin

3. Processen och projektets redovisning

Detaljerad projektbeskrivning

Introduction

Homeless people represent a disadvantaged group in our society. Little is known about the health status of this group in Sweden. In Europe and North America, diabetes mellitus type 2 among homeless adults are more likely to be poorly controlled than in the general population and the risk for complications is higher. Homeless adults are also more likely to encounter barriers to health care than rest of the population.

Background

Mortality and homelessness

In Europe and North America homeless adults have a higher risk of premature death than the rest of the population (1-4). Information on causes of death in this population is sparse, but a few studies has identified various causes including infectious diseases, ischemic heart disease, alcohol and drug misuse, and external factors such as injuries, unintentional overdoses and violence (1, 3-5). However, homelessness itself is considered as an individual risk factor for mortality (2).

The mortality ratios reported vary between studies and countries, but are typically 2–5 times the age-standardized general population (6). In a Swedish study from 2011 indicated that both homeless men (relative risk 3.1) and women (relative risk 2.5) had excess mortality compared with the general population (3).

Homelessness and CVD

In an 11-year  nationwide study of 15 100 homeless and marginally housed individuals in Canada, the age-standardized mortality rates due to all cardiovascular causes were 61% to 71% higher than in the general population, and 63% to 80% higher for ischemic heart disease specifically (4). In a study from Boston, USA on mortality among homeless adults, heart disease was the second-leading cause of death among individuals 45 years of age or older, with mortality rates 2- to 3-fold higher than in similarly aged adults in the general population (5).

The high risk of CVD in homeless populations has multiple contributing reasons, including late presentation to care, competing psychosocial priorities, and a high burden of CVD risk factors (7).

Diabetes and homelessness

Diabetes is a complex chronic condition that requires access to integrated and comprehensive health care, which may be challenging for populations experiencing homelessness. Internationally the prevalence of diabetes mellitusSTRONG type 2 among homeless people is similar to the rest of the population (8-10). However, the disease is often poorly controlled and the risk for complications are higher (9, 11-15).

Studies have reported multiple barriers to adequate control of the disease. In a study from Toronto, Canada 72% of the participants reported experiencing difficulties managing their diabetes (12). The most commonly reported barriers were related to diet (type of food at shelters and inability to make dietary choices, reported by 64%) and scheduling and logistics (inability to get insulin and diabetic supplies when needed and inability to coordinate medications with meals, reported by 18%).

There are also general barriers to adequate management of chronic medical conditions that are related to the unique circumstances of homelessness. In some countries homeless people lack health insurances and therefore have difficulties accessing primary and preventive care (7).  However, evidence from Canada suggests that homeless people experience difficulties meeting health care needs even within a system of universal health insurance (16).  Homeless patients may also feel unwelcome in traditional health care settings, prompting intense emotional responses that negatively affect their desire to seek further care (17). Studies also show that homeless people have multiple barriers to medication adherence (18, 19).

However, no studies on barriers to health care among the homeless have ever been conducted in Sweden. Because of international differences in the organization of public health care and social care it is of great interest to study this in a Swedish context.

Homelessness in Sweden

In Sweden approximately 33 000 people are considered homeless (20). The definition of homelessness in Sweden has been described by the National Board of Health and Welfare and includes people who live in shelters and other emergency accommodation, but also people staying in treatment institutions or in some form of supported accommodation, often arranged by the social services. A person is also defined as homeless if they were

living with relatives or friends, or had subletting contracts shorter than three months.

In Gothenburg City almost 5 400 individuals are considered homeless, and about 1 000 of these are staying in shelters or other emergency accommodations.

Aim

The aim of the study is to describe the perceived barriers to the management of diabetes mellitus type 2 among homeless adults at a primary care health center in Gothenburg, Sweden.

Method

Research design and paradigm

The study will use a qualitative descriptive method as described by Sandelowski (21, 22). Qualitative description follows the tradition of qualitative research, i.e. an empirical method of investigation aiming to describe the informant's perception and experience of the world and its phenomena. Qualitative research is well suited for "why", "how" and "what" questions about human behavior, motives, views and barriers (23).

According to Sandelowski,  a qualitative descriptive approach is the method of choice when straight descriptions of phenomena are desired and design facilitates a “comprehensive summary of an event in the everyday terms of those events” (21). Others has described qualitative descriptive research studies as those that seek to discover and understand a phenomenon, a process, or the perspectives and worldviews of the people involved (24).

Study setting

In Sweden primary care is considered the first point of contact between a patient and the health care system and can cover illness prevention, health promotion, diagnosis, treatment, rehabilitation, and counseling. In Gothenburg there is a primary care health center exclusively for adults living in homelessness, where subjects will be invited to participate in this study.

Sampling of participants

Participants will be recruited from the primary care health center for the homeless described above. Inclusion criteria are: a) adults aged 18 years or older, b) diagnosed diabetes mellitus type 2 since at least 6 months, c) living in homelessness as defined by the National Board of Health and Welfare in Sweden, d) speaks and understands the Swedish language and e) have no clear active mental illness (such as mania or psychosis) or other conditions that will preclude ability to give informed consent.

The sampling of participants will be purposeful to get a variation in age, sex, duration of the diagnose and severity of the disease. The purpose is to ensure enough variations in the observations.

Participants will be chosen together with staff from the primary care health center for the homeless. The staff consists of two nurses, one podiatrist and three doctors who all have knowledge and experience working with patients with diabetes mellitus type 2. In respect of professional secrecy each staff member is encouraged to ask their patients, fulfilling the inclusion criteria, if they want to participate in the study. If the patient is interested he or she will be given a written information with more specific information about the study. If still interested he or she is informed that the researcher will contact them for booking an appointment for the interview at the primary care health center.

Data collection

Data will be collected using semi-structured face-to face interviews with one person at the time. This is chosen over focus groups since living in homelessness is a sensitive matter and that the self-management of a chronical medical condition also contains sensitive information regarding the way of life.

The interviews will be audio-recorded and transcribed into written text.

Data analyses

The interviews will be analyzed using Systematic Text Condensation which is an analytic strategy inspired by Giorgi and modified by Malterud (25). The procedure aims to identify and sort units of meaning and to condensate these into descriptions and concepts.

Ethical considerations

Informed consent will be obtained from all participants. Their participation is voluntary, and they can leave the study at any time. Participants will be guaranteed confidentiality and anonymity.

The researcher will pay close attention to the possible psychological consequences of participating in a study, particularly in qualitative research (26).

In case of new and unknown medical issues discovered during the interview the participants will be referred to the appropriate care.

Time line

Planning and preparing the project:         May – September 2019.

Interviewing study subjects:                    October 2019 – January 2020

Analyzing data:                                        January – March 2020

Writing article:                                         March-June 2020.

Budget

References

1.                         Nordentoft M, Wandall-Holm N. 10 year follow up study of mortality among users of hostels for homeless people in Copenhagen. BMJ. 2003;327(7406):81.

2.                         Morrison DS. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol. 2009;38(3):877-83.

3.                         Beijer U, Andreasson S, Agren G, Fugelstad A. Mortality and causes of death among homeless women and men in Stockholm. Scand J Public Health. 2011;39(2):121-7.

4.                         Hwang SW, Wilkins R, Tjepkema M, O'Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ. 2009;339:b4036.

5.                         Baggett TP, Hwang SW, O'Connell JJ, Porneala BC, Stringfellow EJ, Orav EJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-95.

6.                         Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014;384(9953):1529-40.

7.                         Baggett TP, Liauw SS, Hwang SW. Cardiovascular Disease and Homelessness. J Am Coll Cardiol. 2018;71(22):2585-97.

8.                         Bernstein RS, Meurer LN, Plumb EJ, Jackson JL. Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis. Am J Public Health. 2015;105(2):e46-60.

9.                         Arnaud A, Fagot-Campagna A, Reach G, Basin C, Laporte A. Prevalence and characteristics of diabetes among homeless people attending shelters in Paris, France, 2006. Eur J Public Health. 2010;20(5):601-3.

10.                       Scott J, Gavin J, Egan AM, Avalos G, Dennedy MC, Bell M, et al. The prevalence of diabetes, pre-diabetes and the metabolic syndrome in an Irish regional homeless population. QJM. 2013;106(6):547-53.

11.                       Lee TC, Hanlon JG, Ben-David J, Booth GL, Cantor WJ, Connelly PW, et al. Risk factors for cardiovascular disease in homeless adults. Circulation. 2005;111(20):2629-35.

12.                       Hwang SW, Bugeja AL. Barriers to appropriate diabetes management among homeless people in Toronto. CMAJ. 2000;163(2):161-5.

13.                       Axon RN, Gebregziabher M, Dismuke CE, Hunt KJ, Yeager D, Ana EJS, et al. Differential Impact of Homelessness on Glycemic Control in Veterans with Type 2 Diabetes Mellitus. J Gen Intern Med. 2016;31(11):1331-7.

14.                       Elder NC, Tubb MR. Diabetes in homeless persons: barriers and enablers to health as perceived by patients, medical, and social service providers. Soc Work Public Health. 2014;29(3):220-31.

15.                       White BM, Logan A, Magwood GS. Access to Diabetes Care for Populations Experiencing Homelessness: an Integrated Review. Curr Diab Rep. 2016;16(11):112.

16.                       Hwang SW, Ueng JJ, Chiu S, Kiss A, Tolomiczenko G, Cowan L, et al. Universal health insurance and health care access for homeless persons. Am J Public Health. 2010;100(8):1454-61.

17.                       Wen CK, Hudak PL, Hwang SW. Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med. 2007;22(7):1011-7.

18.                       Hunter CE, Palepu A, Farrell S, Gogosis E, O'Brien K, Hwang SW. Barriers to Prescription Medication Adherence Among Homeless and Vulnerably Housed Adults in Three Canadian Cities. J Prim Care Community Health. 2015;6(3):154-61.

19.                       Paudyal V, MacLure K, Buchanan C, Wilson L, Macleod J, Stewart D. 'When you are homeless, you are not thinking about your medication, but your food, shelter or heat for the night': behavioural determinants of homeless patients' adherence to prescribed medicines. Public Health. 2017;148:1-8.

20.                       Socialstyrelsen. Hemlöshet 2017 - omfattning och karaktär. Stockholm: Socialstyrelsen; 2017.

21.                       Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334-40.

22.                       Sandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77-84.

23.                       Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description - the poor cousin of health research? BMC Med Res Methodol. 2009;9:52.

24.                       Bradshaw C, Atkinson S, Doody O. Employing a Qualitative Description Approach in Health Care Research. Glob Qual Nurs Res. 2017;4:2333393617742282.

25.                       Malterud K. Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health. 2012;40(8):795-805.

26.                       Richards HM, Schwartz LJ. Ethics of qualitative research: are there special issues for health services research? Fam Pract. 2002;19(2):135-9.


Hinder för diabetesbehandling hos vuxna personer i hemlöshet - en kvalitativ studie, from FoU i Västra Götalandsregionen
http://www.researchweb.org/is/html/vgr/project/272452