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Abstract

Higher rates of type 2 diabetes mellitus (T2DM) are found in rural populations and barriers lessen the ability of these individuals to effectively manage diabetes. By lessening potential barriers to self-care management, health professionals, especially occupational health nurses, can assist individuals confidently manage T2DM. In this article, the authors provide an overview of diabetes self-management barriers for rural populations and implications for health professionals who assist individuals with T2DM in the workplace.

Keywords

diabetes mellitus barriers to diabetes self-management

Barriers to Rural Workers’ Self-Management of Diabetes

Diabetes mellitus is a chronic disease that affects millions of Americans; 90% or more of those individuals with diabetes mellitus in the United States have type 2 diabetes mellitus (T2DM; Centers for Disease Control and Prevention [CDC], 2014). At least one fourth of the U.S. population live in rural areas and about two thirds of the nation’s counties are rural (Johnson, 2012). Furthermore, the prevalence of T2DM is higher in rural than urban areas (Logan, Guo, Dodd, Muller, & Riley, 2013). The United States Department of Agriculture (2013) defines rural as any area except incorporated municipalities or unincorporated areas with population greater than 50,000. However, some communities adjacent to urban areas are exempt from this population requirement if they are “rural in character,” underserved communities that are less densely populated with limited access to fresh healthy food and high rates of poverty and unemployment.

Rural communities have experienced robust job growth, with diverse industries and businesses that closely approximate those found in metropolitan areas. Rural areas have more work in services, trades, government organizations, and manufacturing than in agriculture (White House Rural Council, 2011). However, those individuals who live in rural areas encounter barriers to developing effective diabetes self-management behaviors (Ross, Benavides-Vaello, Schumann, & Haberman, 2015). These individuals depend on valuable occupational health programs (e.g., farming and agriculture, manufacturing, services, and trade) to improve health, lessen diabetes-associated complications, and enhance quality of life (Healthy People 2020, 2014). Therefore, the purpose of this article is to provide an overview of barriers to diabetes self-management among rural workers with T2DM. Implications for health professionals who assist individuals with T2DM in the workplace will be discussed.

Barriers to Diabetes Self-Management

Diabetes self-management includes eating healthy meals, exercising, monitoring blood glucose levels, taking medications, understanding psychological aspects of living with diabetes, using problem-solving skills to manage diabetes-related self-care challenges, and lessening risks of complications (Haas et al., 2013). Literature suggests lessening barriers is essential to diabetes self-management (Jones, Crabb, Turnbull, & Oxlad, 2014). Major barriers include an inadequate health system and communication interfaces, difficulty coping with diabetes, and managing diabetes within current social roles and contexts.

Inadequate Health System and Communication Interfaces

A common health system and communication interface barrier is brief office visits, with interactions between patients and health care providers inadequate to address self-care management. In one study of interactions between patients and health care providers, the median time for discussing diabetes self-care management (e.g., medications, blood sugar testing and values, foot problems) was 5.2 minutes (Kruse et al., 2013). Limited specialists, rapid turnover of specialists, and shortages of essential health care providers (i.e., registered nurses, nurse practitioners, primary care physicians, and dieticians) compound the problem. Inadequate contact with dieticians and busy practitioners during office visits limits time to review and develop a better understanding of heart healthy meal plans (Jones et al., 2014).

Rural individuals also encounter geographic challenges in accessing health care, requiring clients to travel farther for regularly scheduled appointments and emergency services. Inadequate numbers and distribution of health care providers and health care facilities, exacerbated by long travel distances, can contribute to fewer routine examinations, less early detection of complications, and worse health outcomes for rural clients with T2DM (White House Rural Council, 2011). Insufficient office visits and geographic challenges further highlight the importance of supplementing and supporting diabetes self-management in the workplace.

Inadequate monetary resources in many rural areas also contribute to inadequate health care systems and communication interfaces (Jessee & Rutledge, 2012). Health care expenses account for a significantly larger share of personal income for rural Americans compared with Americans who live in metropolitan areas. Hence, fewer rural families can afford the health care they need (White House Rural Council, 2011). Individuals with T2DM who have financial challenges commonly disengage from the community and are not routinely followed by health care providers (Jessee & Rutledge, 2012). Synthesized data underscore the importance of health care professionals working within their patients’ limited tangible resources when recommending diabetes self-care. Clients with T2DM report being unreceptive to suggestions by health care professionals who fail to recognize their financial problems (Stiffler, Cullen, & Luna, 2014).

Difficulty in Coping With Diabetes

Individuals also report experiencing a variety of emotional responses to a diagnosis of T2DM, including denial and fear of diabetes and resulting complications (Jones et al., 2014). Clients who reject their diagnoses of diabetes may feel “betrayed” by their own bodies and lose confidence in their abilities to implement therapeutic self-care behaviors. This fear and inability to accept diabetes is significant, commonly resulting in clients ignoring health care providers’ suggestions regarding how to successfully manage T2DM (Majeed-Ariss, Jackson, Knapp, & Cheater, 2015).

These feelings also are influenced by depression and other negative emotions. In a cross-sectional survey of 160 rural African American women with T2DM, 70% had scores suggestive of significant depressive symptomatology (Miller, 2011). An open-ended survey and thematic qualitative analysis of data from 7,228 individuals with T2DM, of whom 1,050 lived in rural areas, almost 500 respondents reported emotional reactions such as not accepting the diagnosis of diabetes, anxiety, fear, and depression (Stuckey et al., 2014).

Difficulty in Implementing Diabetes Self-Management Within Social Roles and Contexts

Diabetes self-management must be assessed within usual social roles and contexts. The demands of rural lifestyles with inflexible work responsibilities and multiple roles (e.g., parent, caregiver, and breadwinner) require commitments that contribute to ignoring T2DM and related treatment. Although individuals may understand the importance of checking capillary glucose and how to respond to elevated blood sugar, blood glucose may not be adequately monitored or treated because of competing responsibilities (Jones et al., 2014; Majeed-Ariss et al., 2015). Busy lifestyles may also affect whether individuals seek additional information and skills to effectively manage diabetes (Jones et al., 2014).

Individuals with T2DM also report cultural norms and preferences affect adherence to diabetes self-management; these clients want health professionals to understand these norms and their preferences when suggesting strategies for managing their disease. Dietary recommendations are commonly disregarded when suggestions are made without considering food and culture (Majeed-Ariss et al., 2015). Young rural African American women report they need most assistance with meal planning and exercise (Miller, 2011). Occupational norms associated with particular jobs (e.g., truck driving) also appear to influence T2DM self-management. In a survey of truck drivers employed by 13 companies, Angeles et al. (2014) reported that 96% had salt intake above the daily recommendation, approximately 32% smoked, and 48.4% were overweight.

Implications for Health Professionals

Knowledge of diabetes self-management barriers can assist health professionals to select the most appropriate interventions for those clients living in rural areas, especially for those individuals who receive care in the workplace. Individualized assessment of individuals with T2DM is essential because barriers can vary widely. These interventions overlap and are appropriate for addressing more than one barrier.

Improving Health Systems and Communication Interfaces

In addressing health systems and communication interfaces, clinicians should be non-judgmental, provide empathy, and motivate those clients who live daily with T2DM. Clients who engage motivating health professionals and view their providers as partners in decision making are more likely to follow treatment regimens (Stiffler et al., 2014). In providing effective communication interfaces, telephone health coaching can motivate and facilitate decision making in individuals with T2DM. Health coaches typically have a health care background (e.g., occupational health nurses) and use relationship building, active listening, goal setting, and questioning to address participants’ personal agendas regarding lifestyle behaviors to improve physical and psychosocial health (Lawson et al., 2013).

Practice context also affects diabetes care for primary care clients. In a randomized clinical trial of 522 clinicians and staff members (both rural and urban), those practices with an effective work culture significantly improved diabetes care (e.g., HbA1c, foot examinations, lipid levels, eye examinations, renal screening), using either continuous quality improvement or self-directed approaches toward delivering quality chronic care to their clients. These findings highlight effective internal work relationships (e.g., teamwork) in providing effective diabetes self-management strategies for individuals with T2DM (Dickinson et al., 2015).

In examining best practices for educating rural individuals with T2DM, literature suggests lifestyle modifications, motivational and nutritional counseling, and education for providers are most effective in reducing glycosylated hemoglobin (HbA1c) values in clients with T2DM. In emphasizing lifestyle modifications, information about exercise, weight, heart healthy eating, and smoking cessation should be transmitted via a variety of formats (e.g., verbally, in writing, by video). Motivational counseling can be provided via face-to-face contact, group sessions, phone, and postcards to provide encouragement while reflecting on real life experiences and problem solving. Nutritional counseling that emphasizes portion control, how to choose low-fat foods, and heart healthy cooking adaptations is beneficial. Written materials about desirable HbA1c, blood pressure, and lipid values should be provided routinely to individuals with T2DM. Provider education should emphasize the American Diabetes Association Standards of Care; providers’ health care delivery systems should be redesigned to highlight these standards and related services (e.g., reminders of yearly eye examinations, scheduled physical examinations by health care providers at least every 6 months) are essential (Maez, Erickson, & Naumuk, 2014). Health care providers must continuously review the literature for strategies to provide effective diabetes education.

In overcoming tangible barriers to diabetes self-management (e.g., inadequate financial resources), supplemental mechanisms (e.g., letters, emails, text messages, and phone calls) for providing this information must be implemented in conjunction with face-to-face contacts (Labhardt, Balo, Ndam, Manga, & Stoll, 2011). Telephone health lines, telemedicine case management (e.g., televideo educator visits), and web-based models (available at workplaces, libraries, and churches) have been used successfully (Massey, Appel, Buchanan, & Cherrington, 2010). Prerecorded telephone calls with automated health education or routine telephone calls by nurses based on individuals’ responses during phone interactions are also supported (Schillinger, Handley, Wang, & Hammer, 2009). Other beneficial tools include automated appointments and medication refills and computerized T2DM interventions (Mallow, Theeke, Barnes, Whetsel, & Mallow, 2014).

Health advisors (e.g., peer advisors, community health workers) who live in the community and share workplaces can provide valuable information about T2DM. Trusting relationships are built between individuals with T2DM and these advisors because of their shared backgrounds. In contrast to coaching by health care personnel, these unlicensed advisors work in collaboration with health care providers to offer diabetes education and nutritional counseling (using protocols and following training), social support, and connections to community resources. Health advisors commonly meet initially face-to-face (e.g., clinic setting, workplace) and then by telephone with outcomes including improvements in client HbA1c, blood pressure, weight, and blood lipids as well as fewer emergency room visits and hospitalizations (Collinsworth, Vulimiri, Snead, & Walton, 2014). Research emphasizes that management support for health advisor programs result in the most successful programs that achieve tangible outcomes (Brace et al., 2015; Sidebar 1).

Effectively Coping With Diabetes

Of course, assessment and appropriate referral for counseling and treatment of depression and other negative emotions is essential. Support by caring and compassionate family, friends, co-workers, and health care professionals can positively influence adaptive coping. In a study of 74 workers with T2DM, focus group participants reported they needed social and psychological support to successfully manage their disease, both physically and emotionally. Strategies to better incorporate diabetes into both their work and personal lives are essential (Fukunaga, Uehara, & Tom, 2011). Other research emphasized the importance of employers, administrators, and supervisors who support workplace prevention programs designed for workers to learn about diabetes and healthy self-management behaviors (Brown et al., 2015).

Health care providers should assess the availability and quality of perceived and actual support for individuals with diabetes, offering support by telephone, mobile applications, and Internet resources. Social networks, composed of family, friends, and co-workers, have been used successfully to provide emotional support (Mallow et al., 2014; McEwen & Murdaugh, 2014). Co-workers may support each other via telephone calls (e.g., adapting recipes to meet food likes and dislikes). Previously discussed health advisors, familiar with community values and beliefs, work within local networks (e.g. the workplace) offering encouragement and concrete examples of diabetes self-management (Cummings et al., 2013; Sidebar 2).

Promoting Diabetes Behaviors Within Social Roles and Contexts

In promoting positive diabetes behaviors within client social roles and contexts, health professionals should assist clients to find ways to incorporate self-management into busy lifestyles. Therefore, occupational health nurses should encourage individuals with T2DM to talk about their roles and activities to enable them to routinely incorporate daily diabetes self-management into their personal and work lives. Because goals set by individuals with T2DM may indicate a readiness for behavior change, engage individuals, co-workers, families, and friends to set realistic goals and identify potential solutions to problems they encounter in their work and personal lives. Subsequent success in self-managing diabetes mellitus will build confidence and may lessen future complications. Videotaped stories and group discussions to examine common diabetes self-management problems commonly identified in the workplace also appear to be useful as springboards for discussing how these issues apply to clients’ own lives (Williams et al., 2014).

Workplace health promotion programs may lessen the incidence of diabetes and its associated complications by encouraging adoption of healthy lifestyle behaviors such as exercise and healthy eating, and preventing risky behaviors such as smoking (Audrey & Procter, 2015; Barham et al., 2011; Rolando et al., 2013). For those on glycemic agents that increase the risk of hypoglycemia, offering flexible meal times, time for self-monitoring of blood glucose, storage/disposal of needles, and time for health care appointments are essential for workers with T2DM (Lee, Koh, Chui, & Sum, 2011).

Health care professionals who provide education about practical dietary strategies and incorporate culture beliefs/preferences for individuals with T2DM are more likely to improve health outcomes (Brown et al., 2011). Providing information about healthy meal plans that individuals can easily adapt to cultural preferences and eating away from home (e.g., at work), such as the plate method, is valuable (UCSF Medical Center, 2014). Identifying fresh fruits and vegetables that are available in rural areas can be challenging and knowing about appropriate lower cost dried, frozen, or canned foods is important. With expansion of roles in rural communities in which two or more individuals in a single household may work outside the home, providing information to the individual primarily responsible for preparing meals is beneficial (e.g., wife or spouse, person assigned to prepare meals in an all-male household, person assigned to prepare meals in an all-female household). Internet kiosks in communities (e.g., rural grocery stores, malls, or churches) and workplaces (e.g., gyms; meeting, break, and lunch rooms) can provide information on heart healthy behaviors (McIlhenny et al., 2011).

Other strategies include engaging in broad-based partnerships and collaborations with key representatives of rural communities to address barriers. Partnerships with local government commissions, planners, and executives; hospital and health care providers; community-based organizations; faith organizations; school districts; and park and recreation departments can collaborate to implement environmental policies and strategies. Gap analysis and assessment of existing health care resources can provide long-term visions for the community. Key representatives of the community can incorporate opportunities for heart healthy lifestyles into new development designs (e.g., safe walking areas; Barnidge et al., 2013) using federal monies to establish and renovate parks and open spaces (White House Rural Council, 2011; Sidebar 3).

Conclusion

In conclusion, health professionals are important in assisting individuals with T2DM who live in rural areas to manage significant barriers that affect self-care. Strategies should focus on lessening barriers concerning inadequate health system and communication interfaces, coping with T2DM, and implementing self-care management behaviors within current social roles and situations.

Sidebar 1: Strategies for Managing Inadequate Health Systems and Communication Interfaces

Clinicians should be non-judgmental, provide empathy, and motivate those who live daily with T2DM.

Telephone health coaching is useful in motivating workers with T2DM and facilitating their decision making.

Health practices encouraged by health care providers at offices or clinics with better work cultures can improve diabetes self-management care.

Lifestyle modifications, motivational and nutritional counseling, and education for providers can contribute to lowering glycosylated hemoglobin (HbA1c) values.

Supplemental mechanisms for providing information (e.g., letters, emails, text messages, and phone calls; telephone health lines; telemedicine case management; web-based models; prerecorded telephone calls with automated health education or nurse telephone monitoring; automated appointments and medication refills; and computerized interventions) are valuable.

Health advisors (e.g., peer advisors, community health workers) who live in the community and share workplaces can provide important information.

Sidebar 2: Strategies for Facilitating Coping With Diabetes

Assess and identify appropriate referrals for counseling and treatment of depression and other negative emotion.

Provide support (e.g., caring and compassionate family, friends, co-workers, health care professionals, and social networks) to improve adaptive coping with diabetes.

Collaborate with employers, administrators, and supervisors to develop workplace diabetes prevention programs and encourage healthy behaviors.

Assess the availability and quality of perceived and actual support for individuals with diabetes using telephone calls, mobile applications, and Internet resources.

Provide additional co-worker support via telephone calls (e.g., discuss recipes for healthy foods that take into account personal preferences).

Offer encouragement and provide concrete examples of diabetes self-management strategies, especially by health advisers who understand community culture.

Sidebar 3: Strategies for Implementing Diabetes Self-management Behaviors Within Current Social Roles and Contexts

Encourage workers to discuss roles and activities in their personal and work lives that could inhibit daily diabetes self-management behaviors.

Encourage individuals, co-workers, families, and friends to set realistic goals and identify potential solutions to problems related to diabetes self-management in their work and personal lives.

Examine common diabetes self-management problems in the workplace using videotaped stories and group discussions.

Facilitate adoption of healthy lifestyle habits (e.g., exercise, smoking cessation, healthy food choices based on cultural preferences and appropriate alternatives to fresh foods and vegetables) among individuals with T2DM and their families.

Offer flexible meal times, time for self-monitoring of blood glucose, storage/disposal of needles, and time off for health care appointments for individuals on glycemic agents associated with potential hypoglycemia.

Engage in broad-based partnerships and collaborations with key representatives of the local community to address barriers to T2DM self-management using gap analysis and assessment of existing health care resources, with a long-term vison for the community.

In Summary

Diabetes self-management is challenging for individuals with T2DM who work and live in rural areas.

Major barriers include inadequate health system and communication interfaces, difficulty coping with T2DM, and challenges incorporating self-management behaviors within social roles and contexts.

Health care professionals can assist individuals with T2DM to reduce barriers and achieve treatment goals by motivating them and viewing them as decision-making partners, providing information in a variety of formats.

Health care professionals should encourage family, friends, and co-workers to provide support; workers with T2DM should incorporate cultural norms and preferences in diabetes self-management; and both groups should engage others in broad-based partnerships and collaborations.

Footnotes

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Dr. Joan S. Grant is a Professor and Dr. Laura A. Steadman is an Assistant Professor at the University of Alabama at Birmingham, School of Nursing. Both are faculty in the Department of Nursing, Acute, Chronic & Continuing Care and care for clients who have type 2 diabetes mellitus and live in rural areas.

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Barriers to Diabetes Self-Management Among Rural Individuals in the Workplace

Abstract

Keywords

Barriers to Rural Workers’ Self-Management of Diabetes

Barriers to Diabetes Self-Management

Inadequate Health System and Communication Interfaces

Difficulty in Coping With Diabetes

Difficulty in Implementing Diabetes Self-Management Within Social Roles and Contexts

Implications for Health Professionals

Improving Health Systems and Communication Interfaces

Effectively Coping With Diabetes

Promoting Diabetes Behaviors Within Social Roles and Contexts

Conclusion

Sidebar 1: Strategies for Managing Inadequate Health Systems and Communication Interfaces

Sidebar 2: Strategies for Facilitating Coping With Diabetes

Sidebar 3: Strategies for Implementing Diabetes Self-management Behaviors Within Current Social Roles and Contexts

In Summary

Footnotes

Conflict of Interest

Funding

Author Biographies

References