Differences in perspectives regarding diabetes management between health care providers and patients

Differences in perspectives regarding diabetes management between health care providers and patients Abstract Chronic conditions such as type 2 diabetes are challenging to manage. This is often due to failure of both the practice of effective diabetes self-care management by the patient and inadequate intervention strategies and follow-up by the health care provider (HCP). The aims of the study are (i) to use a social marketing survey approach to understand the gaps in perceptions between patients with type 2 diabetes and HCPs on diabetes-related topics such as levels of awareness, use and satisfaction with community resources, and perceived barriers to self-management and (ii) to present the results of a public awareness campaign/diabetes management demonstration project (Cities for Life) on change in discordant views between HCPs and patients. The study was conducted as a separate sample pre–post quasiexperimental design study as part of a clinical-community program, Cities for Life in Birmingham, AL. The surveys were administered before (Wave 1 or W1 in 2012) and after (Wave 2 or W2 in 2013) implementation of the Cities for Life program. HCPs (n = 50 and 48) and patients with type 2 diabetes and prediabetes (n = 201 and 204) responded to surveys at W1 and W2, respectively. At both timepoints, HCPs and patients identified diabetes as a major health priority and stated education and information as the most valuable aspects of community-based programs (CBPs). Although 86% of HCPs reported recommending CBPs for lifestyle modification and that their patients frequently participated in CBPs (W1 = 70%; W2 = 82%), fewer patients reported participation (W1 = 31%; W2 = 22%). Patients frequently were not able to name any CBPs for diabetes prevention or treatment (W1 = 45%; W2 = 59%) despite a large proportion perceiving CBPs as valuable (W1 = 41%; W2 = 39%). A substantial percentage of patients reported receiving “a lot of support” from family/friends/or coworkers (W1 = 54%; W2 = 64%; p < .05), but HCPs believed that a much lower proportion of their patients received “a lot of support” (W1 = 0%, W2 = 10%, p < .05). Patients and HCPs independently reported patients’ lack of motivation as one of the main barriers to better diabetes care. HCPs and patients reported discordant views regarding two important aspects of diabetes self-management: the use of community resources and the degree of social suppor t received by patients. HCPs overestimated the patients’ use of community resources, and underestimated the patients’ degree of social support. Trans-disciplinary interventions to address patients’ lack of motivation and to engage social support networks may improve communication and mutual understanding about the role and benefits of community resources in diabetes and other chronic disease self-management. Implications Practice: Explicit motivational language from health care team members about the benefits of lifestyle modifications and self-management, accompanied by community engagement and family-focused interventions may reduce patient barriers to optimal diabetes care. Policy: Policymakers who want to improve diabetes prevention and reduce diabetes-related health complications should explore policies that provide sufficient support and funding for sustainable, accessible, and patient-centered community resources for self-management. Research: Future studies should further explore what factors contribute to the patients’ “lack of motivation” and what types of social support or other interventions that incorporate social, cultural, and economic issues empower patients with chronic conditions, including diabetes, and improve patient outcomes. INTRODUCTION Chronic disease management requires multiple strategies and recommendations to which patients need to adhere. These include lifestyle modifications, adherence to medication management, and regular interactions with health care professionals. Type 2 diabetes is a condition where both self-management and medical treatment are important. Blood glucose level control is just one of many treatment goals for individuals with diabetes. In addition, individuals should manage their blood pressure and lipid levels, engage in regular physical activity, monitor their diet, and ensure they receive regular assessments of their kidneys, eyes, and peripheral nerves. Several studies have reported that poor diet and exercise regimen adherence are significant barriers to improved health among patients with type 2 diabetes [1]. Not surprisingly, the full set of self-management activities required to manage chronic conditions such as diabetes can overwhelm many people. Primary care providers play an important role in educating and supporting patients in the self-management of diabetes. However, patients need self-care support and education outside of the medical office, and providers have insufficient time during infrequent visits and may not be aware of available community resources. These challenges have a negative effect on delivery of care[1]; however, the studies on patient and provider perspectives about optimal diabetes care and support are limited. A recent systematic literature review identified only two previous studies that reported perceived barriers for diabetes care from both patient and provider perspectives [2]. The review results underscore the need to investigate barriers from the patient and provider perspective in order to facilitate patient–provider conversations and mutual agreement of treatment goals and care plans. Previous studies targeted either providers or patients and were not concurrent in nature, thus making it difficult to compare the perspectives of the providers and the patients within the same context [3]. In addition to good care, the patient is central in the day-to-day management of the disease and requires support from family, neighborhood, organizations, and communities. A great number of effective interventions are available for improving diabetes care and self-management delivered at personal, practice, and community levels. Yet the number of longitudinal, investigational studies exploring changes in the concurrent perceptions of patients and providers due to such interventions is limited. In addition, most previous studies have been cross sectional in nature with very few pre–post studies that concurrently explore patient and provider perceptions over time. Even though some interventional studies have demonstrated that improved patient–provider communication and patient engagement in clinical decisions can improve clinical outcomes, the evidence on how to overcome barriers to care and enhance mutual agreements is still limited. In addition, while the importance of social and family support is highlighted in the patient responses in previous studies, none of the studies explored providers’ perspectives on the role of family members, friends, spiritual peers, or colleagues of patients with diabetes in self-care support and education. The primary objective of this work was to help understand the perceptions of patients with type 2 diabetes or prediabetes and that of health care providers (HCPs) on diabetes-related topics such as levels of awareness about available support for self-management, use and satisfaction with community resources, and barriers to self-management. A secondary objective was to explore whether an intervention in the form of a public awareness campaign/diabetes management demonstration project (Cities for Life) may lead to a change in providers’ and patients’ views. This work was conducted as part of Cities for Life, a clinical-community diabetes management partnership led by the American Academy of Family Physicians Foundation (AAFP), and was implemented in Birmingham, AL, from 2011–2013. The main goal of the Cities for Life partnership was to help community groups and primary care providers create an environment that facilitates and encourages healthy lifestyles, diabetes prevention, and self-management. METHODS Overall study description and survey development This was a separate pre–post samples design study that utilized a social marketing survey method for data collection. The study employed a model for integrating qualitative and quantitative methods in health education research proposed by Steckler et al. [4]. Based on this model, we engaged experts in the field of diabetes care and community-based diabetes support to develop the quantitative questionnaires in an iterative fashion, utilizing the qualitative data from two categories of focus groups: (i) the project team and experts in the field and (ii) patients and HCPs. The Cities for Life team conducted four focus groups of six to eight participants each. Participants included patients at risk for diabetes and people living with type 2 diabetes, community members, and HCPs (primary care physicians and nurse practitioners). These individuals either lived or worked in the greater Birmingham area. The objective was to understand the challenges for patients, community members, and HCPs when addressing type 2 diabetes. Focus group participants were also presented with pilot survey questions intended to assess the extent of diabetes as a public health issue as well as the importance of self-management, education, and community involvement. The project team used the data collected via qualitative methods (focus groups, expert panels) in the development of final quantitative survey instruments. The effects of the public awareness campaign were evaluated by the authors based on the survey data at the end of the program. The baseline HCP questionnaire consisted of 55 items, including a series of questions related to the following domains: respondent demographics, level of awareness of diabetes in the community, importance of diabetes as a public health issue, treatment and diabetes management practices, recommendations for diabetes self-management, perceived level of support for diabetes patients, awareness of resources in the community, and awareness of these resources’ utilization and value. The postsurvey included eight additional questions about the Cities for Life program (see Provider Survey Questionnaire in Supplementary Material AppendixA). The baseline patient questionnaire consisted of 59 questions related to the following domains: respondent demographics, health awareness and priority, diabetes awareness and importance as a public health issue, diabetes management, community resources, and programs for diabetes. The postsurvey included six additional questions asking about the Cities for Life program (see Patient Survey Questionnaire in Supplementary Material AppendixB). The questionnaires included skip patterns and a combination of response scales including multiple-response choice, dichotomous yes/no, and open-ended options. The AAFP institutional review board (IRB) approved the study. Survey administration methodology The surveys were administered at two time points in the study with presurvey (Wave 1, W1) available from April 16 to May 17, 2012, before the implementation of Cities for Life program; and postsurvey (Wave 2, W2) available from May 16 to July 01, 2013, at the end of implementation period. The survey results for two audiences are included in this report: HCPs and patients in the Birmingham, AL, metropolitan area. HCP surveys were administered via the Internet in W1 and by Internet and phone in W2. The phone survey administration was added in W2 as a supplemental recruitment strategy to collect responses from HCP nonresponsive to the initial online survey. Patient surveys were administered via phone in both waves. Patients were recruited from market research client lists via phone after screening for eligibility. Burson–Marsteller, a global public relations and communications firm, provided existing patient and HCP market research panels for the study. Random digit dialing for patients was performed until the targeted sample size was reached. The participants received nominal compensation for this study via mailed check. Survey samples The study was conducted as a separate sample pre–post quasiexperimental design study. This design was selected as most feasible to examine the targeted groups of participants while eliminating the possibility of duplicate respondents in both waves. Patients were included if they were diagnosed with type 2 diabetes or prediabetes and were being treated based on the results of eligibility screening. HCPs were included if they were board-certified or board-eligible physicians, nurse practitioners, or physician assistants working in family, geriatric, or general internal medicine. Intervention As mentioned earlier, the Cities for Life partnership developed and delivered a community awareness and engagement campaign. The primary goal of the campaign was to raise awareness about type 2 diabetes and connect people at risk for and with type 2 diabetes to existing community resources for diabetes management. The community partnership consisted of convening a network of community leaders and organizations that came together to provide diabetes-related social support for patients. Cities for Life established the program’s community component through the development and activation of a Steering Committee. Committee members included representatives from University of Alabama at Birmingham (UAB) Department of Family and Community Medicine, UAB’s Diabetes Research and Training Center’s Community Engagement Core, and UAB HealthSmart and YMCA of Greater Birmingham. With guidance from the Steering Committee, the Community Action Team (CAT) of more than 80 local community organizations was established that connected people living with or at risk for diabetes to community resources to help them manage their disease. Specifically, the CAT conducted the following activities: • Distributed program materials (brochures, posters, etc.) about Cities for Life and about community resources available for people living with and at risk for diabetes. • Encouraged people to use these resources by listing program information and resources on community bulletin boards, organization websites, in newsletters, on social media channels and other sources. • Provided information about organization events and/or resources to the Steering Committee to include on a free public community resources website (www.mydiabetesconnect.com). • Participated in Cities for Life events and other local events to raise awareness about diabetes. In addition to the social support function, the network also provided information on community resources for diabetes management available to patients and increased awareness though local events. Cities for Life representatives set up displays, distributed educational materials, networked with event attendees, and spoke during the events. The Cities for Life team utilized materials developed by the American Diabetes Association and local community-based programs (CBPs) and created original educational and promotional materials. Original Cities for Life materials were developed as a collaborative effort by the project team and Steering Committee. To complement the event activities, Cities for Life representatives participated in media interviews and disseminated social media posts on Facebook and Twitter. The detailed description of the Cities for Life campaign events is provided in Supplementary Material AppendixC. To raise awareness of the program and its goals, the team regularly contacted local media to reach the general community and implemented an integrated community support campaign to raise awareness of diabetes, link community resources and family medicine practices, and build partnerships to enhance community resources. The campaign featured promotion of the program, development and launch of the www.mydiabetesconnect.com website, and collaboration among community organizations. Cities for Life developed relationships with target print, television, radio, and online media outlets throughout the duration of the program to keep them updated on program activities. Several spokespeople were trained and available for interviews based on the need of the outlet. In addition, Cities for Life included a practice-based pilot study of telephone-based nonprofessional patient navigation to promote linkages between the primary care offices and community programs for patients with or at risk for type 2 diabetes. Six primary care practices and 179 patients participated in the pilot; the results of that study are reported elsewhere [5]. A full evaluation report on the Cities for Life program is available upon request. Data analysis Descriptive statistics of survey responses were computed separately for patients and HCPs for each wave. Descriptive statistics for separate survey administration waves and changes/differences in pre- and postsamples are presented as W1 (baseline) and W2 (end of study). The differences in the audience responses and pre–post measures were assessed using column proportions z-tests. These z-tests were used instead of t-tests to provide standardization to the data. The z-tests were appropriate for the types of data collected including Likert scale questions because the test is comparing one Likert scale item to another to determine significance in proportions, only few Likert scale-type questions were included in this report, and the analysis only focused on reporting the distribution of responses for individual questions and not the average scores. An α level of .05 was used for all comparisons. No correction to the α level was performed because the various z-tests were independent of each other. Only significant differences are noted in the text. RESULTS Sample overview The study included 50 and 48 HCP and 201 and 204 patients in W1 and W2 respectively. The HCP were predominantly primary care physicians or nurse practitioners (Table 1). In addition to having type 2 diabetes or prediabetes, the majority of patients reported having at least one other chronic condition (W1 = 79%; W2 = 74%). The sociodemographic and lifestyle characteristics of patients are presented in Table 2. Table 1 Health care provider characteristics Characteristics W1 (n = 50) W2 (n = 48) Methodology Online Online (n = 42); phone (n = 6) Profession/degree n (%)  Physician 44 (88) 45 (94)  Nurse practitioner 6 (12) 3 (6) Specialty n (%)  Family medicine 20 (46) 14 (31)  Geriatric medicine 0 5 (11)a  General internal medicine 24 (55) 26 (58) Years in practice post-training (mean, SD) 14.3 (11.0) 12.4 (11.2) Percent of time spent in direct patient care (mean, SD) 91.9 (16) 84.9 (22) Practice type n (%)  Solo practice 9 (18) 10 (21)  Group practice: 2 to 4 physicians 10 (20) 11 (23)  Group practice: 5 to 9 physicians 10 (20) 9 (19)  Group practice: 10 or more physicians 21 (42) 18 (38) Characteristics W1 (n = 50) W2 (n = 48) Methodology Online Online (n = 42); phone (n = 6) Profession/degree n (%)  Physician 44 (88) 45 (94)  Nurse practitioner 6 (12) 3 (6) Specialty n (%)  Family medicine 20 (46) 14 (31)  Geriatric medicine 0 5 (11)a  General internal medicine 24 (55) 26 (58) Years in practice post-training (mean, SD) 14.3 (11.0) 12.4 (11.2) Percent of time spent in direct patient care (mean, SD) 91.9 (16) 84.9 (22) Practice type n (%)  Solo practice 9 (18) 10 (21)  Group practice: 2 to 4 physicians 10 (20) 11 (23)  Group practice: 5 to 9 physicians 10 (20) 9 (19)  Group practice: 10 or more physicians 21 (42) 18 (38) aSignificantly different between W1 and W2 at p < .05 level. View Large Table 1 Health care provider characteristics Characteristics W1 (n = 50) W2 (n = 48) Methodology Online Online (n = 42); phone (n = 6) Profession/degree n (%)  Physician 44 (88) 45 (94)  Nurse practitioner 6 (12) 3 (6) Specialty n (%)  Family medicine 20 (46) 14 (31)  Geriatric medicine 0 5 (11)a  General internal medicine 24 (55) 26 (58) Years in practice post-training (mean, SD) 14.3 (11.0) 12.4 (11.2) Percent of time spent in direct patient care (mean, SD) 91.9 (16) 84.9 (22) Practice type n (%)  Solo practice 9 (18) 10 (21)  Group practice: 2 to 4 physicians 10 (20) 11 (23)  Group practice: 5 to 9 physicians 10 (20) 9 (19)  Group practice: 10 or more physicians 21 (42) 18 (38) Characteristics W1 (n = 50) W2 (n = 48) Methodology Online Online (n = 42); phone (n = 6) Profession/degree n (%)  Physician 44 (88) 45 (94)  Nurse practitioner 6 (12) 3 (6) Specialty n (%)  Family medicine 20 (46) 14 (31)  Geriatric medicine 0 5 (11)a  General internal medicine 24 (55) 26 (58) Years in practice post-training (mean, SD) 14.3 (11.0) 12.4 (11.2) Percent of time spent in direct patient care (mean, SD) 91.9 (16) 84.9 (22) Practice type n (%)  Solo practice 9 (18) 10 (21)  Group practice: 2 to 4 physicians 10 (20) 11 (23)  Group practice: 5 to 9 physicians 10 (20) 9 (19)  Group practice: 10 or more physicians 21 (42) 18 (38) aSignificantly different between W1 and W2 at p < .05 level. View Large Table 2 Patient participant characteristics Characteristics W1 (n = 201) W2 (n = 204) Age, years, mean (SD) 67 (11) 66 (12) Gender  Male (n, %) 63 (32) 78 (38)  Female (n, %) 137 (69) 126 (62) Diagnosis (n, %)  Prediabetes 17 (9) 21 (10)  Type 2 diabetes 184 (92) 183 (90) Eat meals out (n, %)  Less frequently than once a week 68 (34) 58 (28)  Once per week 66 (33) 58 (28)  Several times per week 48 (24) 68 (33)  Once per day 10 (5) 8 (4)  More than once per day 9 (5) 11 (5)  Don’t know 0 1 (0.5) Exercise frequency (n, %)  Less frequently than once a week 53 (26) 70 (34)  Once per week 31 (15) 32 (16)  Several times per week 75 (37) 67 (33)  Once per day 33 (16) 20 (10)  More than once per day 6 (3) 11 (5)  Don’t know 3 (2) 4 (2) Characteristics W1 (n = 201) W2 (n = 204) Age, years, mean (SD) 67 (11) 66 (12) Gender  Male (n, %) 63 (32) 78 (38)  Female (n, %) 137 (69) 126 (62) Diagnosis (n, %)  Prediabetes 17 (9) 21 (10)  Type 2 diabetes 184 (92) 183 (90) Eat meals out (n, %)  Less frequently than once a week 68 (34) 58 (28)  Once per week 66 (33) 58 (28)  Several times per week 48 (24) 68 (33)  Once per day 10 (5) 8 (4)  More than once per day 9 (5) 11 (5)  Don’t know 0 1 (0.5) Exercise frequency (n, %)  Less frequently than once a week 53 (26) 70 (34)  Once per week 31 (15) 32 (16)  Several times per week 75 (37) 67 (33)  Once per day 33 (16) 20 (10)  More than once per day 6 (3) 11 (5)  Don’t know 3 (2) 4 (2) View Large Table 2 Patient participant characteristics Characteristics W1 (n = 201) W2 (n = 204) Age, years, mean (SD) 67 (11) 66 (12) Gender  Male (n, %) 63 (32) 78 (38)  Female (n, %) 137 (69) 126 (62) Diagnosis (n, %)  Prediabetes 17 (9) 21 (10)  Type 2 diabetes 184 (92) 183 (90) Eat meals out (n, %)  Less frequently than once a week 68 (34) 58 (28)  Once per week 66 (33) 58 (28)  Several times per week 48 (24) 68 (33)  Once per day 10 (5) 8 (4)  More than once per day 9 (5) 11 (5)  Don’t know 0 1 (0.5) Exercise frequency (n, %)  Less frequently than once a week 53 (26) 70 (34)  Once per week 31 (15) 32 (16)  Several times per week 75 (37) 67 (33)  Once per day 33 (16) 20 (10)  More than once per day 6 (3) 11 (5)  Don’t know 3 (2) 4 (2) Characteristics W1 (n = 201) W2 (n = 204) Age, years, mean (SD) 67 (11) 66 (12) Gender  Male (n, %) 63 (32) 78 (38)  Female (n, %) 137 (69) 126 (62) Diagnosis (n, %)  Prediabetes 17 (9) 21 (10)  Type 2 diabetes 184 (92) 183 (90) Eat meals out (n, %)  Less frequently than once a week 68 (34) 58 (28)  Once per week 66 (33) 58 (28)  Several times per week 48 (24) 68 (33)  Once per day 10 (5) 8 (4)  More than once per day 9 (5) 11 (5)  Don’t know 0 1 (0.5) Exercise frequency (n, %)  Less frequently than once a week 53 (26) 70 (34)  Once per week 31 (15) 32 (16)  Several times per week 75 (37) 67 (33)  Once per day 33 (16) 20 (10)  More than once per day 6 (3) 11 (5)  Don’t know 3 (2) 4 (2) View Large Community resource awareness Data on detailed responses to the patient and HCP survey questions included in this report are presented in Table 3. At the baseline, awareness about the 16 types of various community resources was higher among patients as compared with HCPs in the following areas: diabetes publications such as books and magazines, grocery stores with healthy food options, pharmacies that provide help to patients, local government programs, and patient groups organized for helpful activities. Compared with the patients, HCPs were more aware of weight loss programs and workplace exercise programs. The patient and HCP awareness levels in W2 did not differ from baseline. Table 3 Survey responses Survey questions, n (%) unless notes otherwise HCP W1 (n = 50) HCP W2 (n = 48) Patients W1 (n = 201) Patients W2 (n = 204) In your opinion, do you believe your community provides people living with diabetes with enough local support to manage your condition?  Yes 12 (30) 13 (36) 89 (44) 72 (35)  No 14 (35) 12 (33) 84 (42) 92 (45)  Don’t know 14 (35) 11 (31) 28 (14) 40 (20) Overall, how valuable do you find the programs in your community are at possibly helping people reduce the risk of or manage type 2 diabetes?  1 – Not at all valuable 0 1 (3) 37 (23) 22 (16)  2 0 2 (6) 4 (3) 10 (7)  3 0 1 (3) 7 (4) 5 (4)  4 3 (9) 2 (7) 3 (2) 1 (1)  5 5 (15) 4 (13) 18 (11) 15 (11)  6 8 (24) 4 (13) 5 (3) 5 (4)  7 6 (18) 5 (16) 6 (4) 11 (8)  8 8 (24) 4 (13) 14 (9) 10 (7)  9 3 (9) 2 (7) 9 (6) 3 (2)  10 – Extremely valuable 0 3 (10) 42 (26) 41 (30)  Don’t know 0 3 (10) 14 (9) 13 (10) What types of treatment does your physician recommend for the management of your diabetes? NA NA  Prescription medication 180 (91) 173 (85)  Over-the-counter medication 17 (9) 19 (9)  Healthier eating habits 154 (78) 167 (82)  Exercising 155 (78) 160 (79)  Other 18 (9) 22 (11) Do your patients with prediabetes or type 2 diabetes typically participate in the community programs you recommend? NA NA  Yes, most do 2 (6) 5 (18)  Yes, some do 23 (64) 18 (64)  No 5 (14) 2 (7)  Don’t know 6 (17) 3 (11) Do you participate in any of these types of programs [programs “are you aware of” that are designed to help patients, like you, manage their diabetes]? NA NA  Yes 63 (31) ¤ 45 (22)  No 135 (67) 147 (72)  Don’t know 3 (2) 12 (6) Among prediabetes and type 2 diabetes patients who do not adhere to community programs, why do you think they have difficulty with adherence? NA NA  They cannot afford them 1 (13) 1 (7)  They say they do not have time 0 2 (14)  They say they have too many other commitments/stress in their lives at this time 1 (13) 1 (7)  They lack transportation 0 0  They are not personally motivated 3 (38) 8 (57)  Do not understand the importance of using these programs and how it can help them manage diabetes 3 (38) 1 (7)  Other 0 0  Don’t know 0 1 (7) What strategies do you use to “motivate” prediabetes or type 2 diabetes patients to follow through with the recommendations you make? NA NA  I emphasize the possible complications that can occur if their type 2 diabetes is not properly managed, like blindness, loss of limbs, kidney disease, etc. 43 (86) 40 (83)  I tell them to seek support from family, friends and/or community programs 27 (54) 22 (46)  I tell them that diabetes is chronic disease that can be self-managed 31 (62) 33 (69)  I provide literature or information about diabetes 27 (54) 24 (50)  I provide lists of resources available through community organizations, such as the Alabama Department of Public Health’s Diabetes Program 10 (20) 10 (21)  I provide information from national organizations (NIH, CDC, ADA) 14 (28) 7 (15) I tell them to keep a diary (for diet, exercise, medication or other daily needs) 32 (64) 33 (69)  My office calls or sends email or text reminders for between visit care (self-test blood glucose, adherence to medication regimens) 7 (14) 9 (19)  Other than making a recommendation of what step to take, I don’t really use any tactics to motivate my patients to follow through 3 (6) 3 (6)  Other tactic 0 1 (2) How much support do your prediabetes or type 2 diabetes patients get from their family and friends to help them reduce the risk of or manage their condition? NA NA  They get a lot of support 0 5 (10) ¤  They get some support 46 (92) 39 (81)  They don’t get any support 2 (4) 2 (4)  Don’t know 2 (4) 2 (4) How much support, if any, do you get from your family, friends, or co-workers to help you manage or live with diabetes? NA NA  I get a lot of support 108 (54) 130 (64) ¤  I get some support 61 (30) 46 (23)  I don’t get any support 30 (15) 26 (13)  Don’t know 2 (1) 2 (1) Would you consider yourself to be… NA NA  Obese 24 (12) 17 (8)  Overweight 110 (55) 100 (49)  At a proper weight 63 (31) 84 (41) ¤  Underweight 3 (2) 3 (2)  Don’t know 1 (0.5) 0 What percent of the type 2 diabetes patients in your practice are…? Please make sure your total sums to 100%. Your best estimate is fine; mean (SD) NA NA  Obese (BMI ≥ 30 kg/m2) 41.6 (24.4) 46.6 (23.1)  Overweight (BMI = 25–29.9 kg/m2) 32.6 (17.0) 32.0 (14.9)  Normal weight (BMI = 18.5–24.9 kg/m2) 22.5 (16.3) 17.5 (13.9)  Underweight weight (BMI < 18.5 kg/m2) 3.3 (4.0) 3.92 (5.0) When thinking of a coordinated care approach to reducing the risk of and managing type 2 diabetes, who should be responsible for leading this coordinated care? Please select all who you feel should be responsible NA NA  Myself 40 (80) 37 (77)  Clinical care coordinator (usually an RN) 18 (36) 17 (35)  Certified diabetes educator 20 (40) 18 (38)  Case manager 6 (12) 7 (15)  Physician assistant or nurse practitioner 9 (18) 17 (35)  Community organizations, for example, the American Diabetes Association 8 (16) 5 (10)  Family and friends 14 (28) 19 (40)  The person living with type 2 diabetes 31 (62) 33 (69)  Another physician (i.e., endocrinologist) 10 (20) 21 (44) ¤  Other 0 0 What type of “physician” is primarily responsible for the management of your diabetes? NA NA  Primary care physician (general practice, family practice, or internal medicine) 165 (82) 157 (77)  Diabetes specialist 23 (11) 36 (18)  Endocrinologist 10 (5) 10 (5)  I do not see a physician 2 (1) 1 (0.5)  Other 1 (0.5) 0 How often are you visiting this “physician” for the management of your diabetes? NA NA  More frequently than once a month 8 (4) 5 (3)  Once a month 17 (9) 15 (7)  Once every 3 months 111 (56) 117 (58)  Once every 6 months 54 (27) 59 (29)  Once a year 4 (2) 4 (2)  Less frequently than once a year 4 (2) 3 (2)  Don’t know 0 0 Which of the following health care professionals do you currently see or talk to for the management of your diabetes? The interaction could be in person, over the phone, or via email. NA NA  Diabetes counselor or educator  Nurse care manager 39 (19) 28 (14)  Physician assistant 32 (16) 33 (16)  Other 73 (36) 68 (33)  None of these 83 (41) 101 (50)  Don’t know 1 (0.5) 0 Specifically, in your community, which of the following programs are you aware of that are available to help people possibly manage their prediabetes or type 2 diabetes?  National Diabetes Education Program 14 (35) 8 (22) 80 (40)a 50 (25)  Cities for Life 0 5 (14) ¤ 12 (6) 12 (6)  Defeat Diabetes 1 (3) 2 (6) 22 (11) 18 (9)  Alabama Cooperative Extension Systemb 3 (8) 0 32 (16) 29 (14)  United Against Diabetes 2 (5) 2 (6) 29 (14) 21 (10)  The Alabama Diabetes Prevention and Control Program 7 (18) 9 (25) 41 (20) 30 (15)  Southeastern Diabetes Education Services 6 (15) 1 (3) 15 (8) 12 (6)  I Decide to Fight Diabetes 1 (3) 2 (6) 18 (9) 16 (8)  Steps to a Healthier US—Alabama 3 (8) 4 (11) 27 (13) 26 (13)  YMCA of Birmingham, YMCA Diabetes Prevention Program 22 (55)c 16 (44)a 72 (36) ¤ 52 (26)  American Diabetes Association, Alabama 26 (65) 24 (67) 124 (62) 110 (54)  Other 0 0 6 (3) 7 (3)  None of these 7 (18) 3 (8) 38 (19) 52 (26)a  Don’t know 0 2 (6) 4 (2) 16 (8) ¤ Survey questions, n (%) unless notes otherwise HCP W1 (n = 50) HCP W2 (n = 48) Patients W1 (n = 201) Patients W2 (n = 204) In your opinion, do you believe your community provides people living with diabetes with enough local support to manage your condition?  Yes 12 (30) 13 (36) 89 (44) 72 (35)  No 14 (35) 12 (33) 84 (42) 92 (45)  Don’t know 14 (35) 11 (31) 28 (14) 40 (20) Overall, how valuable do you find the programs in your community are at possibly helping people reduce the risk of or manage type 2 diabetes?  1 – Not at all valuable 0 1 (3) 37 (23) 22 (16)  2 0 2 (6) 4 (3) 10 (7)  3 0 1 (3) 7 (4) 5 (4)  4 3 (9) 2 (7) 3 (2) 1 (1)  5 5 (15) 4 (13) 18 (11) 15 (11)  6 8 (24) 4 (13) 5 (3) 5 (4)  7 6 (18) 5 (16) 6 (4) 11 (8)  8 8 (24) 4 (13) 14 (9) 10 (7)  9 3 (9) 2 (7) 9 (6) 3 (2)  10 – Extremely valuable 0 3 (10) 42 (26) 41 (30)  Don’t know 0 3 (10) 14 (9) 13 (10) What types of treatment does your physician recommend for the management of your diabetes? NA NA  Prescription medication 180 (91) 173 (85)  Over-the-counter medication 17 (9) 19 (9)  Healthier eating habits 154 (78) 167 (82)  Exercising 155 (78) 160 (79)  Other 18 (9) 22 (11) Do your patients with prediabetes or type 2 diabetes typically participate in the community programs you recommend? NA NA  Yes, most do 2 (6) 5 (18)  Yes, some do 23 (64) 18 (64)  No 5 (14) 2 (7)  Don’t know 6 (17) 3 (11) Do you participate in any of these types of programs [programs “are you aware of” that are designed to help patients, like you, manage their diabetes]? NA NA  Yes 63 (31) ¤ 45 (22)  No 135 (67) 147 (72)  Don’t know 3 (2) 12 (6) Among prediabetes and type 2 diabetes patients who do not adhere to community programs, why do you think they have difficulty with adherence? NA NA  They cannot afford them 1 (13) 1 (7)  They say they do not have time 0 2 (14)  They say they have too many other commitments/stress in their lives at this time 1 (13) 1 (7)  They lack transportation 0 0  They are not personally motivated 3 (38) 8 (57)  Do not understand the importance of using these programs and how it can help them manage diabetes 3 (38) 1 (7)  Other 0 0  Don’t know 0 1 (7) What strategies do you use to “motivate” prediabetes or type 2 diabetes patients to follow through with the recommendations you make? NA NA  I emphasize the possible complications that can occur if their type 2 diabetes is not properly managed, like blindness, loss of limbs, kidney disease, etc. 43 (86) 40 (83)  I tell them to seek support from family, friends and/or community programs 27 (54) 22 (46)  I tell them that diabetes is chronic disease that can be self-managed 31 (62) 33 (69)  I provide literature or information about diabetes 27 (54) 24 (50)  I provide lists of resources available through community organizations, such as the Alabama Department of Public Health’s Diabetes Program 10 (20) 10 (21)  I provide information from national organizations (NIH, CDC, ADA) 14 (28) 7 (15) I tell them to keep a diary (for diet, exercise, medication or other daily needs) 32 (64) 33 (69)  My office calls or sends email or text reminders for between visit care (self-test blood glucose, adherence to medication regimens) 7 (14) 9 (19)  Other than making a recommendation of what step to take, I don’t really use any tactics to motivate my patients to follow through 3 (6) 3 (6)  Other tactic 0 1 (2) How much support do your prediabetes or type 2 diabetes patients get from their family and friends to help them reduce the risk of or manage their condition? NA NA  They get a lot of support 0 5 (10) ¤  They get some support 46 (92) 39 (81)  They don’t get any support 2 (4) 2 (4)  Don’t know 2 (4) 2 (4) How much support, if any, do you get from your family, friends, or co-workers to help you manage or live with diabetes? NA NA  I get a lot of support 108 (54) 130 (64) ¤  I get some support 61 (30) 46 (23)  I don’t get any support 30 (15) 26 (13)  Don’t know 2 (1) 2 (1) Would you consider yourself to be… NA NA  Obese 24 (12) 17 (8)  Overweight 110 (55) 100 (49)  At a proper weight 63 (31) 84 (41) ¤  Underweight 3 (2) 3 (2)  Don’t know 1 (0.5) 0 What percent of the type 2 diabetes patients in your practice are…? Please make sure your total sums to 100%. Your best estimate is fine; mean (SD) NA NA  Obese (BMI ≥ 30 kg/m2) 41.6 (24.4) 46.6 (23.1)  Overweight (BMI = 25–29.9 kg/m2) 32.6 (17.0) 32.0 (14.9)  Normal weight (BMI = 18.5–24.9 kg/m2) 22.5 (16.3) 17.5 (13.9)  Underweight weight (BMI < 18.5 kg/m2) 3.3 (4.0) 3.92 (5.0) When thinking of a coordinated care approach to reducing the risk of and managing type 2 diabetes, who should be responsible for leading this coordinated care? Please select all who you feel should be responsible NA NA  Myself 40 (80) 37 (77)  Clinical care coordinator (usually an RN) 18 (36) 17 (35)  Certified diabetes educator 20 (40) 18 (38)  Case manager 6 (12) 7 (15)  Physician assistant or nurse practitioner 9 (18) 17 (35)  Community organizations, for example, the American Diabetes Association 8 (16) 5 (10)  Family and friends 14 (28) 19 (40)  The person living with type 2 diabetes 31 (62) 33 (69)  Another physician (i.e., endocrinologist) 10 (20) 21 (44) ¤  Other 0 0 What type of “physician” is primarily responsible for the management of your diabetes? NA NA  Primary care physician (general practice, family practice, or internal medicine) 165 (82) 157 (77)  Diabetes specialist 23 (11) 36 (18)  Endocrinologist 10 (5) 10 (5)  I do not see a physician 2 (1) 1 (0.5)  Other 1 (0.5) 0 How often are you visiting this “physician” for the management of your diabetes? NA NA  More frequently than once a month 8 (4) 5 (3)  Once a month 17 (9) 15 (7)  Once every 3 months 111 (56) 117 (58)  Once every 6 months 54 (27) 59 (29)  Once a year 4 (2) 4 (2)  Less frequently than once a year 4 (2) 3 (2)  Don’t know 0 0 Which of the following health care professionals do you currently see or talk to for the management of your diabetes? The interaction could be in person, over the phone, or via email. NA NA  Diabetes counselor or educator  Nurse care manager 39 (19) 28 (14)  Physician assistant 32 (16) 33 (16)  Other 73 (36) 68 (33)  None of these 83 (41) 101 (50)  Don’t know 1 (0.5) 0 Specifically, in your community, which of the following programs are you aware of that are available to help people possibly manage their prediabetes or type 2 diabetes?  National Diabetes Education Program 14 (35) 8 (22) 80 (40)a 50 (25)  Cities for Life 0 5 (14) ¤ 12 (6) 12 (6)  Defeat Diabetes 1 (3) 2 (6) 22 (11) 18 (9)  Alabama Cooperative Extension Systemb 3 (8) 0 32 (16) 29 (14)  United Against Diabetes 2 (5) 2 (6) 29 (14) 21 (10)  The Alabama Diabetes Prevention and Control Program 7 (18) 9 (25) 41 (20) 30 (15)  Southeastern Diabetes Education Services 6 (15) 1 (3) 15 (8) 12 (6)  I Decide to Fight Diabetes 1 (3) 2 (6) 18 (9) 16 (8)  Steps to a Healthier US—Alabama 3 (8) 4 (11) 27 (13) 26 (13)  YMCA of Birmingham, YMCA Diabetes Prevention Program 22 (55)c 16 (44)a 72 (36) ¤ 52 (26)  American Diabetes Association, Alabama 26 (65) 24 (67) 124 (62) 110 (54)  Other 0 0 6 (3) 7 (3)  None of these 7 (18) 3 (8) 38 (19) 52 (26)a  Don’t know 0 2 (6) 4 (2) 16 (8) ¤ ADA, American Diabetes Association; BMI, body mass index; CDC, Centers for Disease Control and Prevention; HCP, health care providers; NA, not applicable; NIH, National Institutes of Health; RN, registered nurse. aSignificant difference between patients and providers in W2. ¤Significant difference within the same group between W1 and W2. bAgricultural program, not related to diabetes. cSignificant difference between patients and providers in W1. View Large Table 3 Survey responses Survey questions, n (%) unless notes otherwise HCP W1 (n = 50) HCP W2 (n = 48) Patients W1 (n = 201) Patients W2 (n = 204) In your opinion, do you believe your community provides people living with diabetes with enough local support to manage your condition?  Yes 12 (30) 13 (36) 89 (44) 72 (35)  No 14 (35) 12 (33) 84 (42) 92 (45)  Don’t know 14 (35) 11 (31) 28 (14) 40 (20) Overall, how valuable do you find the programs in your community are at possibly helping people reduce the risk of or manage type 2 diabetes?  1 – Not at all valuable 0 1 (3) 37 (23) 22 (16)  2 0 2 (6) 4 (3) 10 (7)  3 0 1 (3) 7 (4) 5 (4)  4 3 (9) 2 (7) 3 (2) 1 (1)  5 5 (15) 4 (13) 18 (11) 15 (11)  6 8 (24) 4 (13) 5 (3) 5 (4)  7 6 (18) 5 (16) 6 (4) 11 (8)  8 8 (24) 4 (13) 14 (9) 10 (7)  9 3 (9) 2 (7) 9 (6) 3 (2)  10 – Extremely valuable 0 3 (10) 42 (26) 41 (30)  Don’t know 0 3 (10) 14 (9) 13 (10) What types of treatment does your physician recommend for the management of your diabetes? NA NA  Prescription medication 180 (91) 173 (85)  Over-the-counter medication 17 (9) 19 (9)  Healthier eating habits 154 (78) 167 (82)  Exercising 155 (78) 160 (79)  Other 18 (9) 22 (11) Do your patients with prediabetes or type 2 diabetes typically participate in the community programs you recommend? NA NA  Yes, most do 2 (6) 5 (18)  Yes, some do 23 (64) 18 (64)  No 5 (14) 2 (7)  Don’t know 6 (17) 3 (11) Do you participate in any of these types of programs [programs “are you aware of” that are designed to help patients, like you, manage their diabetes]? NA NA  Yes 63 (31) ¤ 45 (22)  No 135 (67) 147 (72)  Don’t know 3 (2) 12 (6) Among prediabetes and type 2 diabetes patients who do not adhere to community programs, why do you think they have difficulty with adherence? NA NA  They cannot afford them 1 (13) 1 (7)  They say they do not have time 0 2 (14)  They say they have too many other commitments/stress in their lives at this time 1 (13) 1 (7)  They lack transportation 0 0  They are not personally motivated 3 (38) 8 (57)  Do not understand the importance of using these programs and how it can help them manage diabetes 3 (38) 1 (7)  Other 0 0  Don’t know 0 1 (7) What strategies do you use to “motivate” prediabetes or type 2 diabetes patients to follow through with the recommendations you make? NA NA  I emphasize the possible complications that can occur if their type 2 diabetes is not properly managed, like blindness, loss of limbs, kidney disease, etc. 43 (86) 40 (83)  I tell them to seek support from family, friends and/or community programs 27 (54) 22 (46)  I tell them that diabetes is chronic disease that can be self-managed 31 (62) 33 (69)  I provide literature or information about diabetes 27 (54) 24 (50)  I provide lists of resources available through community organizations, such as the Alabama Department of Public Health’s Diabetes Program 10 (20) 10 (21)  I provide information from national organizations (NIH, CDC, ADA) 14 (28) 7 (15) I tell them to keep a diary (for diet, exercise, medication or other daily needs) 32 (64) 33 (69)  My office calls or sends email or text reminders for between visit care (self-test blood glucose, adherence to medication regimens) 7 (14) 9 (19)  Other than making a recommendation of what step to take, I don’t really use any tactics to motivate my patients to follow through 3 (6) 3 (6)  Other tactic 0 1 (2) How much support do your prediabetes or type 2 diabetes patients get from their family and friends to help them reduce the risk of or manage their condition? NA NA  They get a lot of support 0 5 (10) ¤  They get some support 46 (92) 39 (81)  They don’t get any support 2 (4) 2 (4)  Don’t know 2 (4) 2 (4) How much support, if any, do you get from your family, friends, or co-workers to help you manage or live with diabetes? NA NA  I get a lot of support 108 (54) 130 (64) ¤  I get some support 61 (30) 46 (23)  I don’t get any support 30 (15) 26 (13)  Don’t know 2 (1) 2 (1) Would you consider yourself to be… NA NA  Obese 24 (12) 17 (8)  Overweight 110 (55) 100 (49)  At a proper weight 63 (31) 84 (41) ¤  Underweight 3 (2) 3 (2)  Don’t know 1 (0.5) 0 What percent of the type 2 diabetes patients in your practice are…? Please make sure your total sums to 100%. Your best estimate is fine; mean (SD) NA NA  Obese (BMI ≥ 30 kg/m2) 41.6 (24.4) 46.6 (23.1)  Overweight (BMI = 25–29.9 kg/m2) 32.6 (17.0) 32.0 (14.9)  Normal weight (BMI = 18.5–24.9 kg/m2) 22.5 (16.3) 17.5 (13.9)  Underweight weight (BMI < 18.5 kg/m2) 3.3 (4.0) 3.92 (5.0) When thinking of a coordinated care approach to reducing the risk of and managing type 2 diabetes, who should be responsible for leading this coordinated care? Please select all who you feel should be responsible NA NA  Myself 40 (80) 37 (77)  Clinical care coordinator (usually an RN) 18 (36) 17 (35)  Certified diabetes educator 20 (40) 18 (38)  Case manager 6 (12) 7 (15)  Physician assistant or nurse practitioner 9 (18) 17 (35)  Community organizations, for example, the American Diabetes Association 8 (16) 5 (10)  Family and friends 14 (28) 19 (40)  The person living with type 2 diabetes 31 (62) 33 (69)  Another physician (i.e., endocrinologist) 10 (20) 21 (44) ¤  Other 0 0 What type of “physician” is primarily responsible for the management of your diabetes? NA NA  Primary care physician (general practice, family practice, or internal medicine) 165 (82) 157 (77)  Diabetes specialist 23 (11) 36 (18)  Endocrinologist 10 (5) 10 (5)  I do not see a physician 2 (1) 1 (0.5)  Other 1 (0.5) 0 How often are you visiting this “physician” for the management of your diabetes? NA NA  More frequently than once a month 8 (4) 5 (3)  Once a month 17 (9) 15 (7)  Once every 3 months 111 (56) 117 (58)  Once every 6 months 54 (27) 59 (29)  Once a year 4 (2) 4 (2)  Less frequently than once a year 4 (2) 3 (2)  Don’t know 0 0 Which of the following health care professionals do you currently see or talk to for the management of your diabetes? The interaction could be in person, over the phone, or via email. NA NA  Diabetes counselor or educator  Nurse care manager 39 (19) 28 (14)  Physician assistant 32 (16) 33 (16)  Other 73 (36) 68 (33)  None of these 83 (41) 101 (50)  Don’t know 1 (0.5) 0 Specifically, in your community, which of the following programs are you aware of that are available to help people possibly manage their prediabetes or type 2 diabetes?  National Diabetes Education Program 14 (35) 8 (22) 80 (40)a 50 (25)  Cities for Life 0 5 (14) ¤ 12 (6) 12 (6)  Defeat Diabetes 1 (3) 2 (6) 22 (11) 18 (9)  Alabama Cooperative Extension Systemb 3 (8) 0 32 (16) 29 (14)  United Against Diabetes 2 (5) 2 (6) 29 (14) 21 (10)  The Alabama Diabetes Prevention and Control Program 7 (18) 9 (25) 41 (20) 30 (15)  Southeastern Diabetes Education Services 6 (15) 1 (3) 15 (8) 12 (6)  I Decide to Fight Diabetes 1 (3) 2 (6) 18 (9) 16 (8)  Steps to a Healthier US—Alabama 3 (8) 4 (11) 27 (13) 26 (13)  YMCA of Birmingham, YMCA Diabetes Prevention Program 22 (55)c 16 (44)a 72 (36) ¤ 52 (26)  American Diabetes Association, Alabama 26 (65) 24 (67) 124 (62) 110 (54)  Other 0 0 6 (3) 7 (3)  None of these 7 (18) 3 (8) 38 (19) 52 (26)a  Don’t know 0 2 (6) 4 (2) 16 (8) ¤ Survey questions, n (%) unless notes otherwise HCP W1 (n = 50) HCP W2 (n = 48) Patients W1 (n = 201) Patients W2 (n = 204) In your opinion, do you believe your community provides people living with diabetes with enough local support to manage your condition?  Yes 12 (30) 13 (36) 89 (44) 72 (35)  No 14 (35) 12 (33) 84 (42) 92 (45)  Don’t know 14 (35) 11 (31) 28 (14) 40 (20) Overall, how valuable do you find the programs in your community are at possibly helping people reduce the risk of or manage type 2 diabetes?  1 – Not at all valuable 0 1 (3) 37 (23) 22 (16)  2 0 2 (6) 4 (3) 10 (7)  3 0 1 (3) 7 (4) 5 (4)  4 3 (9) 2 (7) 3 (2) 1 (1)  5 5 (15) 4 (13) 18 (11) 15 (11)  6 8 (24) 4 (13) 5 (3) 5 (4)  7 6 (18) 5 (16) 6 (4) 11 (8)  8 8 (24) 4 (13) 14 (9) 10 (7)  9 3 (9) 2 (7) 9 (6) 3 (2)  10 – Extremely valuable 0 3 (10) 42 (26) 41 (30)  Don’t know 0 3 (10) 14 (9) 13 (10) What types of treatment does your physician recommend for the management of your diabetes? NA NA  Prescription medication 180 (91) 173 (85)  Over-the-counter medication 17 (9) 19 (9)  Healthier eating habits 154 (78) 167 (82)  Exercising 155 (78) 160 (79)  Other 18 (9) 22 (11) Do your patients with prediabetes or type 2 diabetes typically participate in the community programs you recommend? NA NA  Yes, most do 2 (6) 5 (18)  Yes, some do 23 (64) 18 (64)  No 5 (14) 2 (7)  Don’t know 6 (17) 3 (11) Do you participate in any of these types of programs [programs “are you aware of” that are designed to help patients, like you, manage their diabetes]? NA NA  Yes 63 (31) ¤ 45 (22)  No 135 (67) 147 (72)  Don’t know 3 (2) 12 (6) Among prediabetes and type 2 diabetes patients who do not adhere to community programs, why do you think they have difficulty with adherence? NA NA  They cannot afford them 1 (13) 1 (7)  They say they do not have time 0 2 (14)  They say they have too many other commitments/stress in their lives at this time 1 (13) 1 (7)  They lack transportation 0 0  They are not personally motivated 3 (38) 8 (57)  Do not understand the importance of using these programs and how it can help them manage diabetes 3 (38) 1 (7)  Other 0 0  Don’t know 0 1 (7) What strategies do you use to “motivate” prediabetes or type 2 diabetes patients to follow through with the recommendations you make? NA NA  I emphasize the possible complications that can occur if their type 2 diabetes is not properly managed, like blindness, loss of limbs, kidney disease, etc. 43 (86) 40 (83)  I tell them to seek support from family, friends and/or community programs 27 (54) 22 (46)  I tell them that diabetes is chronic disease that can be self-managed 31 (62) 33 (69)  I provide literature or information about diabetes 27 (54) 24 (50)  I provide lists of resources available through community organizations, such as the Alabama Department of Public Health’s Diabetes Program 10 (20) 10 (21)  I provide information from national organizations (NIH, CDC, ADA) 14 (28) 7 (15) I tell them to keep a diary (for diet, exercise, medication or other daily needs) 32 (64) 33 (69)  My office calls or sends email or text reminders for between visit care (self-test blood glucose, adherence to medication regimens) 7 (14) 9 (19)  Other than making a recommendation of what step to take, I don’t really use any tactics to motivate my patients to follow through 3 (6) 3 (6)  Other tactic 0 1 (2) How much support do your prediabetes or type 2 diabetes patients get from their family and friends to help them reduce the risk of or manage their condition? NA NA  They get a lot of support 0 5 (10) ¤  They get some support 46 (92) 39 (81)  They don’t get any support 2 (4) 2 (4)  Don’t know 2 (4) 2 (4) How much support, if any, do you get from your family, friends, or co-workers to help you manage or live with diabetes? NA NA  I get a lot of support 108 (54) 130 (64) ¤  I get some support 61 (30) 46 (23)  I don’t get any support 30 (15) 26 (13)  Don’t know 2 (1) 2 (1) Would you consider yourself to be… NA NA  Obese 24 (12) 17 (8)  Overweight 110 (55) 100 (49)  At a proper weight 63 (31) 84 (41) ¤  Underweight 3 (2) 3 (2)  Don’t know 1 (0.5) 0 What percent of the type 2 diabetes patients in your practice are…? Please make sure your total sums to 100%. Your best estimate is fine; mean (SD) NA NA  Obese (BMI ≥ 30 kg/m2) 41.6 (24.4) 46.6 (23.1)  Overweight (BMI = 25–29.9 kg/m2) 32.6 (17.0) 32.0 (14.9)  Normal weight (BMI = 18.5–24.9 kg/m2) 22.5 (16.3) 17.5 (13.9)  Underweight weight (BMI < 18.5 kg/m2) 3.3 (4.0) 3.92 (5.0) When thinking of a coordinated care approach to reducing the risk of and managing type 2 diabetes, who should be responsible for leading this coordinated care? Please select all who you feel should be responsible NA NA  Myself 40 (80) 37 (77)  Clinical care coordinator (usually an RN) 18 (36) 17 (35)  Certified diabetes educator 20 (40) 18 (38)  Case manager 6 (12) 7 (15)  Physician assistant or nurse practitioner 9 (18) 17 (35)  Community organizations, for example, the American Diabetes Association 8 (16) 5 (10)  Family and friends 14 (28) 19 (40)  The person living with type 2 diabetes 31 (62) 33 (69)  Another physician (i.e., endocrinologist) 10 (20) 21 (44) ¤  Other 0 0 What type of “physician” is primarily responsible for the management of your diabetes? NA NA  Primary care physician (general practice, family practice, or internal medicine) 165 (82) 157 (77)  Diabetes specialist 23 (11) 36 (18)  Endocrinologist 10 (5) 10 (5)  I do not see a physician 2 (1) 1 (0.5)  Other 1 (0.5) 0 How often are you visiting this “physician” for the management of your diabetes? NA NA  More frequently than once a month 8 (4) 5 (3)  Once a month 17 (9) 15 (7)  Once every 3 months 111 (56) 117 (58)  Once every 6 months 54 (27) 59 (29)  Once a year 4 (2) 4 (2)  Less frequently than once a year 4 (2) 3 (2)  Don’t know 0 0 Which of the following health care professionals do you currently see or talk to for the management of your diabetes? The interaction could be in person, over the phone, or via email. NA NA  Diabetes counselor or educator  Nurse care manager 39 (19) 28 (14)  Physician assistant 32 (16) 33 (16)  Other 73 (36) 68 (33)  None of these 83 (41) 101 (50)  Don’t know 1 (0.5) 0 Specifically, in your community, which of the following programs are you aware of that are available to help people possibly manage their prediabetes or type 2 diabetes?  National Diabetes Education Program 14 (35) 8 (22) 80 (40)a 50 (25)  Cities for Life 0 5 (14) ¤ 12 (6) 12 (6)  Defeat Diabetes 1 (3) 2 (6) 22 (11) 18 (9)  Alabama Cooperative Extension Systemb 3 (8) 0 32 (16) 29 (14)  United Against Diabetes 2 (5) 2 (6) 29 (14) 21 (10)  The Alabama Diabetes Prevention and Control Program 7 (18) 9 (25) 41 (20) 30 (15)  Southeastern Diabetes Education Services 6 (15) 1 (3) 15 (8) 12 (6)  I Decide to Fight Diabetes 1 (3) 2 (6) 18 (9) 16 (8)  Steps to a Healthier US—Alabama 3 (8) 4 (11) 27 (13) 26 (13)  YMCA of Birmingham, YMCA Diabetes Prevention Program 22 (55)c 16 (44)a 72 (36) ¤ 52 (26)  American Diabetes Association, Alabama 26 (65) 24 (67) 124 (62) 110 (54)  Other 0 0 6 (3) 7 (3)  None of these 7 (18) 3 (8) 38 (19) 52 (26)a  Don’t know 0 2 (6) 4 (2) 16 (8) ¤ ADA, American Diabetes Association; BMI, body mass index; CDC, Centers for Disease Control and Prevention; HCP, health care providers; NA, not applicable; NIH, National Institutes of Health; RN, registered nurse. aSignificant difference between patients and providers in W2. ¤Significant difference within the same group between W1 and W2. bAgricultural program, not related to diabetes. cSignificant difference between patients and providers in W1. View Large Importance of CBPs At baseline, a larger proportion of patients (44%) than HCPs (30%) believed that the community provides patients with enough support to manage their condition. In addition, significantly more HCPs (35%) “do not know” whether there is enough support for diabetes management provided by their community as compared with14% of patients (p < .05). At baseline, 41% of patients and 33% of HCPs found CBPs valuable for helping with diabetes self-management. When asked about the most valuable aspect of the CBPs in an open-ended question (“What are the most valuable aspects of the programs in your community designed to help you possibly manage your prediabetes or type 2 diabetes?”), a substantial proportion (38%) of HCPs believed that awareness, education, and information are the most valuable aspects of CBPs. Nearly half (45%) of the patients, however, were not sure of the most valuable aspect of CBPs. Recommendations and uptake of lifestyle modification Patients reported that although their HCPs recommended prescription medications most frequently (W1 = 91%; W2 = 85%), they also received HCP’s recommendations for exercise (W1 = 78%; W2 = 79%) and healthier eating habits (W1 = 78%; W2 = 82%). Most HCPs reported that they recommended CBPs to their patients (W1 = 90%; W2 = 78%) as well as physical activity and dietary counseling, among other diabetes prevention and management strategies. Some HCPs did not recommend any programs for diabetes management to their patients (W1 = 10%; W2 = 19%). The majority of HCPs reported that some of their patients typically participate in CBPs (W1 = 64%; W2 = 64%), and fewer HCPs reported that most of their patients typically participate in CBPs (W1 = 6%; W2 = 18%). A small proportion of HCPs reported their patients do not participate (W1 = 14%; W2 = 7%), and some HCPs did not know about their participation (W1 = 17%; W2 = 11%). However, most patients reported that they do not participate in community programs (W1 = 67%; W2 = 72%), while fewer do participate (W1 = 31%; W2 = 22%). The HCPs, when asked about why their patients who do not adhere to community programs have difficulty with adherence, reported that the top reasons are that patients are not personally motivated (W1 = 38%; W2 = 57%) and the patients do not understand the importance of these programs (W1 = 37%; W2 = 7%). The top strategy reported by the HCPs for increasing patient motivation regarding recommendations was that the HCPs emphasized the possible complications of diabetes (W1 = 86%; W2 = 83%), followed by suggestions to keep a journal for diet, exercise, and other self-management activities. In addition, HCPs informed patients that diabetes is a chronic disease that can be self-managed (W1 = 62%; W2 = 69%). About half (W1 = 50%; W2 = 54%) of HCPs reported providing literature or some form of information about diabetes to patients, and fewer (W1 = 20%; W2 = 21%) reported providing a list of local CBPs. Importance of support Over half of the patients (W1 = 54%; W2 = 64%; p < .05) reported that they received a lot of support from their families and friends including emotional support (W1 = 73%; W2 = 76%), encouragement (W1 = 63%; W2 = 66%), and reminders (W1 = 49%; W2 = 52%). Few patients (W1 = 15%; W2 = 13%) reported that they do not get any support. Among patients in either wave, 68% reported that most of their family, friends, and coworkers understand their needs for self-management. The providers reported only a small proportion of their patients receive a lot of support (W1 = 0%; W2 = 10%; p < .05) and a small proportion (W1 = 4%; W2 = 4%) do not get any support. Barriers to improved self-management Patients and HCPs independently reported patients’ lack of motivation as a significant barrier to better diabetes care. Lack of motivation was the second most common reason reported by the patients for (a) not seeking more information about diabetes management (W1 = 25%; W2 = 23%), (b) increasing amount of exercise (W1 = 37%; W2 = 40%), and (c) achieving healthier diet (W1 = 33%; W2 = 35%). Lack of motivation was the third top barrier for having regular interactions with HCPs (W1 = 13%; W2 = 12%) as reported by the patient. The HCPs, however, reported that the lack of patient motivation was the top barrier to having regular interactions with their patients (W1 = 80%; W2 = 71%). Patients reported that the top three barriers for having regular interactions with HCPs were “I feel I already know a lot; am making a great effort” (W1 = 48%; W2 = 56%), “I go to the doctor enough. I do not want to spend more time visiting a physician” (W1 = 31%; W2 = 25%), and lack of personal motivation. Patients reported that their top barrier to exercising was “medical problems” that inhibit them from doing many exercises (W1 = 46%; W2 = 54%). The top three patient-reported barriers to having a healthier diet were “I feel I already am making a great effort” (W1 = 38%; W2 = 35%), lack of personal motivation, and “healthy food is too expensive” (W1 = 31%; W2 = 31%). When asked about how easy or hard it is to implement the steps that the HCPs recommended for their diabetes management, patients predominantly reported that they find items related to formal medical care and monitoring (lowering blood pressure, lowering cholesterol, regularly checking their blood sugar levels, visiting the physician regularly for monitoring of their diabetes, and regular checkups with an eye doctor) were easy to implement. The following items were hard to implement: (i) self-management and behavioral modifications such as cardiovascular activity (running, biking, or swimming) and participating in a weight-loss program, (ii) seeking and getting community support and counseling, and (iii) using diabetes websites (e.g., American Diabetes Association) for recipes and other tips. Detailed information is presented in Fig. 1. Fig 1 View largeDownload slide Patent responses and results on how easy or hard it is to implement the recommendations for better diabetes management. Fig 1 View largeDownload slide Patent responses and results on how easy or hard it is to implement the recommendations for better diabetes management. Health indicators About one half of all patient respondents believed they were overweight (W1 = 55%; W2 = 49%); one third believed they maintain “proper weight” (W1 = 31%; W2 = 41%; p < .05); and few identified themselves as obese (W1 = 12%; W2 = 8%). The providers reported that almost half of the patients in their clinic are obese (W1 = 42%; W2 = 46%), 32% (both waves) are overweight, and a smaller proportion of their patients maintain “proper weight” (W1 = 22%; W2 = 17%). Diabetes care and chronic disease management Patients indicated that among medical professions, primary care providers are primarily responsible for their diabetes management (W1 = 82%; W2 = 77%). The HCPs state that they are responsible for leading coordinated diabetes care (W1 = 80%; W2 = 77%), with the majority of HCPs indicating that the person living with type 2 diabetes is equally responsible for their health or self-management (W1 = 62%; W2 = 69%). Regarding the discussion about diabetes prevention, when asked “Who typically initiates this discussion about reducing the risk of type 2 diabetes?”, providers indicated that they, not the patients, initiate the discussion most of the time (W1 = 100%; W2 = 90%; p < .05). In terms of the frequency of patient visits to HCPs, most patients reported visiting their HCP every 3 months (W1 = 56%; W2 = 58%), about one third visit every 6 months or less (W1 = 27%; W2 = 29%), and few patients visit every month or more frequently (W1 = 13%; W2 = 9%). A small proportion of patients visit their HCPs once a year or less (W1 = 4%, W2 = 3%). Most of the HCPs reported that they see their patients with controlled diabetes every 3 months (W1 = 66%; W2 = 56%), and some see their patients with controlled diabetes every 6 months (W1 = 26%; W2 = 29%). The majority of HCPs see patients with an A1c between 7 and 8.9 every 3 months (W1 = 76%; W2 = 73%) and see patients with an A1c 9 and higher every month (W1 = 44%; W2 = 56%) to every 3 months (W1 = 42%; W2 = 29%). Over half of the patients (W1 = 51%; W2 = 59%) reported that they visit or talk to a diabetes counselor or educator, nurse care manager, or other health care professional about the management of their diabetes. Among those, the proportion of patients who visit or talk to these health care professionals once every 3 months increased significantly from W1 to W2 (W1 = 32%; W2 = 51%; p < .05). The proportion of those patients who visit or talk to these other health care professionals once a month (W1 = 18%; W2 = 7%), more frequently than once a month (W1 = 7%; W2 = 8%), or less than once a year (W1 = 9%; W2 = 6%) did not change significantly. Awareness and perspectives on Cities for Life Twelve (6%) of the patients in either W1 or W2 were aware of Cities for Life. Of those who were familiar, patients most frequently reported hearing about the program from others or in their doctor’s office. As compared with no providers at W1, five HCPs (14%) were familiar with the program in W2. Out of those, three HCPs recommended Cities for Life to their patients and reported that two of their patients participated. DISCUSSION Awareness of available CBPs Diabetes is a major public health condition and a chronic condition that poses a significant burden on patients, families, health systems, and the economy. It is largely recognized that self-management is an important aspect of diabetes prevention and effective management. In spite of widespread recognition of community organizations in many areas of health promotion, they have been underutilized as an approach to diabetes prevention and management. From this perspective, diabetes is predominantly a clinical issue instead of a clinical issue combined with public health, population, and community dimensions [6]. Thus, it is important to understand the perspectives of both patients and health care professionals who deliver care to patients with diabetes and other chronic conditions on the role of self-management and CBPs. To our knowledge, this is the first study to assess perceptions, beliefs, attitudes, and self-reported behaviors related to diabetes self-management and the role of CBPs concurrently among HCPs and patients with type 2 diabetes or prediabetes. In addition, this study expands on the growing body of evidence regarding the effectiveness of public awareness initiatives. Overall, we found that awareness of available community resources and CBPs that provide services for patients with diabetes was somewhat low among HCPs and patients. Interestingly, the awareness of different types of resources differed between the HCPs and the patients with the HCPs being more aware of major formal and structured types of programs, such as weight loss and diabetes counseling, while the patients were more aware of unstructured and variable resources such as magazines, grocery stores, parks, and local support groups. This suggests that the patients are seeking resources for self-management from a broader range of community resources and amenities than the HCPs were aware. This assumption may also be supported by our findings that significantly more patients than HCPs believe that their community provides enough support for their diabetes management. This further illustrates that HCPs may not be aware of the amount of support the patients may have access to in their communities, or that HCPs and patients may even have different interpretations of “community support,” or what is sufficient or “enough.” Overall, many patients and providers believe that there is not enough support provided by communities. Recent evidence indicates that creating and supporting infrastructure for promoting self-management within communities may reduce chronic diseases, promote healthy lifestyles, reduce disparities, and reduce costs of health care [7]. Recommendation versus utilization Another key area of discordance between HCPs and patients was related to the high level of HCPs’ recommendation of, versus actual low patient participation in, CBPs for diabetes self-management. The differences related to adherence to management recommendations between HCPs and patients have been previously reported [8, 9]. Multiple studies describe the barriers to diabetes management that negatively affect patients’ ability to carry out recommendations successfully [1, 2]. Earlier studies postulated that the patients’ inability to implement HCP’s recommendation may be due to their inability to recall the recommendations. In our study, the patients’ reports on recommendations received for exercise and healthier eating habits align very closely with providers’ reports on recommendations provided. Patients’ lack of recollection may not be sufficient to explain nonadherence to management recommendations. Barriers and motivations Several recent literature reviews on barriers and facilitators to managing chronic conditions, such as diabetes, have concluded that patients experience multiple barriers that the HCPs either are unaware of or may not find as important [2, 8, 10]. The results of our study corroborate previous findings and expand on the understanding of differences in how patients and HCPs perceive barriers to improved care [2]. Previously reported HCP’s perspective on patient barriers highlighted the lack of patient education and understanding of diabetes, its complications, or the importance of self-management [8, 11]. In our study, the patients reported that they already know a lot about diabetes and diabetes management, though we did not assess their knowledge objectively. Our study finds that patients struggle with internal and external barriers to lifestyle change, including lack of motivation. The lack of patient motivation was similarly recognized by HCPs and patients. Motivational interviewing (MI) and Open Questions, Affirmation, Reflective Listening, and Summary Reflections (OARS) technique have been recently recognized as effective in increasing personal motivation and patient adherence to chronic disease management and behavioral modifications [12, 13]. These strategies are recommended for inclusion in the provider training and provider–patient communications; however, it is important to further explore what factors contribute to the patients’ “lack of motivation” or else MI will not be effective. Lack of motivation and other psychosocial and external barriers may also be addressed by implementing team-based or coordinated care models that include strategies such as collaborative goal setting, collaborative problem solving, enhancing motivation and self-efficacy, and continuing support [14]. In addition, it appears that patients’ perceptions of the common recommendation that “patients need to be educated” may in fact create barriers to seeking appropriate support. Future studies should explore the balance between the need for patients to be educated, and when patients report that they are educated enough, whether they would benefit from other strategies to reach their diabetes care goals [15]. Taken together, the lack of patient awareness of available resources and low patient motivation and engagement in initiation of discussions about diabetes with HCPs, combined with a perception that the patients feel educated enough, may indicate that patient empowerment among participants in this study is low. Social support Although the importance of social and family support is highlighted in the patient responses in previous studies, the evidence on the effects of family and social support is conflicting. Family support has been found to be associated with both positive and negative health outcomes. Most of the studies summarized in the recent literature review on barriers and facilitators to managing multiple chronic conditions by Koch et al. [16] explored lack of social and family support as one of the key barriers to optimal chronic disease care. The review presented five studies on family support that reported negative impact of family members on patients’ attempts to initiate or sustain healthy lifestyle. In the review by Miller and DiMatteo [17] on effects of social support on adherence to diabetes management, specifically, the evidence showed positive association between social support and positive outcomes. Overall, we found that most of the patients viewed the role of their family in their diabetes management as important and positive and most reported receiving “a lot” of support from their family, friends, and coworkers. The HCPs, however, believed only a small proportion of their patients receive a lot of support and only a few do not get any support, thus underestimating the proportions of patients with and without strong social support networks. It is important to note that ~15% of patients reported they do not have any support. Given the evidence of negative association of lack of support and patient outcomes, it may be beneficial if HCPs regularly inquired about the level of patient support and identified those who may benefit from seeking additional support. Given the emerging evidence on the positive effects of family-focused interventions (including behavioral family systems therapy, family social support training programs, peer support, and problem-solving group interventions), future research and clinical practice need to focus on the tactics that empower family members, friends, coworkers, and employers in supporting behavioral change in patients with type 2 diabetes [17, 18]. Future research should explore the types of social support interventions that incorporate social, cultural, and economic issues. Future interventions should also consider an active role that family members and friends can play in reducing barriers to diabetes self-management, in particular in areas where patients report the most challenges, such as exercise, weight loss, and community support access. Potential for closing the gap HCPs and patients often report discordant views regarding diabetes management [19]. Patients often struggle with motivation for behavior change. Explicit motivational language from HCPs about the benefits of lifestyle modification and medications, accompanied by community engagement, may help to close the gap in perceptions and reduce barriers. Even though mass media and other awareness campaigns have been used successfully to change health behavior [20], the results of our study did not find much change in perceptions over the course of 1 year. However, this was not surprising as it is known that most successful awareness programs are long term in duration, multicomponent, target episodic rather than chronic behavior and are well supported by policy and availability and access to crucial support services [20, 21]. More research is needed to explore effective ways to utilize public awareness campaigns and community engagement in supporting diabetes self-management. It is important to note that the results of our study need to be interpreted with caution due to several limitations. The patients who responded to our survey may have received health care services from nonparticipating HCPs and thus may not have the same views as the patients of participating HCPs. As mentioned earlier, the campaign was relatively short and broad and did not specifically target the survey participants who may or may not have been exposed to the campaign during the implementation period. Nonetheless, the purpose of the work was indeed to assess the effect of the campaign on a larger segment of the population, not only on people who were certainly exposed to the campaign, thus reducing possible selection bias. Several sociodemographic characteristics of the participants such as race, ethnicity, economic, or educational background were not available as a part of the survey, and the responses may be not representative of the patients from these groups. Whatever changes we observed over time have limited generalizability for establishing cause and effect in such a complex system because the results may not be fully attributed to the Cities for Life campaign. Moreover, we believe that behavioral changes take more than an awareness campaign. The broad range of public messages, activities, and events that Cities for Life included may be a limiting factor in terms of its focus and impacts. It may be necessary for the program managers to work with the community leaders on establishing and maintaining a specific and focused scope for similar programs. Overall, the public awareness campaigns for diabetes management may benefit from more rigorous project and evaluation designs, program monitoring, and targeted interventions informed by the patient and provider perceptions and preferences collected during baseline assessments. Given the important role that the CBPs play in diabetes support, it may be beneficial to establish and evaluate patient-centered collaborative programs that directly involve community services and improve utilization and effectiveness of those CBPs which patients find valuable. Future research studies need to explore which aspects of a public awareness campaign could be effective in closing the perception gaps and supporting patients with diabetes in their self-care. SUPPLEMENTARY MATERIAL Supplementary material is available at Translational Behavioral Medicine online. Compliance with Ethical Standards Primary Data: The authors have full control of all primary data, and they agree to allow the journal to review their data if requested. The findings reported in this work have not been previously published, and the manuscript is not being simultaneously submitted elsewhere. The data were previously presented as a poster at the American Diabetes Association 74 Scientific Session, San Francisco, CA, June 13–17, 2014. Conflict of Interest: N.Y. Loskutova: research support from Sanofi US, Merck, Eli Lilly and Shire; A.G. Tsai: research support from Sanofi US and Nutrisystem, Inc.; M. Harrington: research support from Sanofi US; T.J. Turner: research support from Sanofi US; W.D. Pace: research support from Sanofi US, Shire, Mallinckrodt, Novartis Pharmaceuticals Corporation, Merck, Pfizer, Inc. J.K. Carroll, E. Callen, and K. Ajayi declare they have no conflict of interest. Ethical Approval: All procedures performed in this study involving human participants were in accordance with the ethical standards of the AAFP IRB and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants in this study. No animals were used in this study. Acknowledgments We are extremely grateful to the City of Birmingham, including the University of Alabama at Birmingham and study participants, members of the Community Action Team (CAT), Mayor William Bell Sr., and City Councilor Jay Roberson (District 7). Special thanks to our Steering Committee members, whose hard work and dedication made this program possible. We thank the AAFP National Research Network for providing essential support and expertise. The Cities for Life project is made possible with support from Sanofi US. Sanofi US was not involved in the study design, data analysis, and interpretation or reporting of this work. References 1. Peyrot M , Rubin RR , Lauritzen T , Snoek FJ , Matthews DR , Skovlund SE . Psychosocial problems and barriers to improved diabetes management: Results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study . Diabet Med . 2005 ; 22 ( 10 ): 1379 – 1385 . Google Scholar CrossRef Search ADS PubMed 2. Pun SPY , Coates V , Benzie IFF . Barriers to the self-care of type 2 diabetes from both patients’ and providers’ perspectives: Literature review . J Nurs Healthc Chronic Illn . 2009 ; 1 (1) : 4 – 19 . Google Scholar CrossRef Search ADS 3. Marrero DG , Ard J , Delamater AM et al. Twenty-first century behavioral medicine: A context for empowering clinicians and patients with diabetes: A consensus report . Diabetes Care . 2013 ; 36 ( 2 ): 463 – 470 . Google Scholar CrossRef Search ADS PubMed 4. Steckler A , McLeroy KR , Goodman RM , Bird ST , McCormick L . Toward integrating qualitative and quantitative methods: An introduction . Health Educ Q . 1992 ; 19 ( 1 ): 1 – 8 . Google Scholar CrossRef Search ADS PubMed 5. Loskutova NY , Tsai AG , Fisher EB et al. Patient navigators connecting patients to community resources to improve diabetes outcomes . J Am Board Fam Med . 2016 ; 29 ( 1 ): 78 – 89 . Google Scholar CrossRef Search ADS PubMed 6. Glasgow RE , Wagner EH , Kaplan RM , Vinicor F , Smith L , Norman J . If diabetes is a public health problem, why not treat it as one? A population-based approach to chronic illness . Ann Behav Med . 1999 ; 21 ( 2 ): 159 – 170 . Google Scholar CrossRef Search ADS PubMed 7. Green LW , Brancati FL , Albright A ; Primary Prevention of Diabetes Working Group . Primary prevention of type 2 diabetes: Integrative public health and primary care opportunities, challenges and strategies . Fam Pract . 2012 ; 29 ( suppl 1 ): i13 – i23 . Google Scholar CrossRef Search ADS PubMed 8. 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Smith DE , Heckemeyer CM , Kratt PP , Mason DA . Motivational interviewing to improve adherence to a behavioral weight-control program for older obese women with NIDDM. a pilot study . Diabetes Care . 1997 ; 20 ( 1 ): 52 – 54 . Google Scholar CrossRef Search ADS PubMed 13. Knight KM , McGowan L , Dickens C , Bundy C . A systematic review of motivational interviewing in physical health care settings . Br J Health Psychol . 2006 ; 11 ( pt 2 ): 319 – 332 . Google Scholar CrossRef Search ADS PubMed 14. Peyrot M , Rubin RR . Behavioral and psychosocial interventions in diabetes: A conceptual review . Diabetes Care . 2007 ; 30 ( 10 ): 2433 – 2440 . Google Scholar CrossRef Search ADS PubMed 15. Osborn CY , Bains SS , Egede LE . Health literacy, diabetes self-care, and glycemic control in adults with type 2 diabetes . Diabetes Technol Ther . 2010 ; 12 ( 11 ): 913 – 919 . Google Scholar CrossRef Search ADS PubMed 16. Koch G , Wakefield BJ , Wakefield DS . Barriers and facilitators to managing multiple chronic conditions: A systematic literature review . West J Nurs Res . 2015 ; 37 ( 4 ): 498 – 516 . Google Scholar CrossRef Search ADS PubMed 17. Miller TA , Dimatteo MR . Importance of family/social support and impact on adherence to diabetic therapy . Diabetes Metab Syndr Obes . 2013 ; 6 : 421 – 426 . doi: 10.2147/DMSO.S36368 . Google Scholar CrossRef Search ADS PubMed 18. Fry-Bowers EK , Maliski S , Lewis MA , Macabasco-O’Connell A , DiMatteo R . The association of health literacy, social support, self-efficacy and interpersonal interactions with health care providers in low-income Latina mothers . J Pediatr Nurs . 2014 ; 29 ( 4 ): 309 – 320 . Google Scholar CrossRef Search ADS PubMed 19. Simmons D , Lillis S , Swan J , Haar J . Discordance in perceptions of barriers to diabetes care between patients and primary care and secondary care . Diabetes Care . 2007 ; 30 ( 3 ): 490 – 495 . Google Scholar CrossRef Search ADS PubMed 20. Wakefield MA , Loken B , Hornik RC . Use of mass media campaigns to change health behaviour . Lancet . 2010 ; 376 ( 9748 ): 1261 – 1271 . Google Scholar CrossRef Search ADS PubMed 21. Randolph W , Viswanath K . Lessons learned from public health mass media campaigns: Marketing health in a crowded media world . Annu Rev Public Health . 2004 ; 25 : 419 – 437 . Google Scholar CrossRef Search ADS PubMed © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

Differences in perspectives regarding diabetes management between health care providers and patients

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Abstract

Abstract Chronic conditions such as type 2 diabetes are challenging to manage. This is often due to failure of both the practice of effective diabetes self-care management by the patient and inadequate intervention strategies and follow-up by the health care provider (HCP). The aims of the study are (i) to use a social marketing survey approach to understand the gaps in perceptions between patients with type 2 diabetes and HCPs on diabetes-related topics such as levels of awareness, use and satisfaction with community resources, and perceived barriers to self-management and (ii) to present the results of a public awareness campaign/diabetes management demonstration project (Cities for Life) on change in discordant views between HCPs and patients. The study was conducted as a separate sample pre–post quasiexperimental design study as part of a clinical-community program, Cities for Life in Birmingham, AL. The surveys were administered before (Wave 1 or W1 in 2012) and after (Wave 2 or W2 in 2013) implementation of the Cities for Life program. HCPs (n = 50 and 48) and patients with type 2 diabetes and prediabetes (n = 201 and 204) responded to surveys at W1 and W2, respectively. At both timepoints, HCPs and patients identified diabetes as a major health priority and stated education and information as the most valuable aspects of community-based programs (CBPs). Although 86% of HCPs reported recommending CBPs for lifestyle modification and that their patients frequently participated in CBPs (W1 = 70%; W2 = 82%), fewer patients reported participation (W1 = 31%; W2 = 22%). Patients frequently were not able to name any CBPs for diabetes prevention or treatment (W1 = 45%; W2 = 59%) despite a large proportion perceiving CBPs as valuable (W1 = 41%; W2 = 39%). A substantial percentage of patients reported receiving “a lot of support” from family/friends/or coworkers (W1 = 54%; W2 = 64%; p < .05), but HCPs believed that a much lower proportion of their patients received “a lot of support” (W1 = 0%, W2 = 10%, p < .05). Patients and HCPs independently reported patients’ lack of motivation as one of the main barriers to better diabetes care. HCPs and patients reported discordant views regarding two important aspects of diabetes self-management: the use of community resources and the degree of social suppor t received by patients. HCPs overestimated the patients’ use of community resources, and underestimated the patients’ degree of social support. Trans-disciplinary interventions to address patients’ lack of motivation and to engage social support networks may improve communication and mutual understanding about the role and benefits of community resources in diabetes and other chronic disease self-management. Implications Practice: Explicit motivational language from health care team members about the benefits of lifestyle modifications and self-management, accompanied by community engagement and family-focused interventions may reduce patient barriers to optimal diabetes care. Policy: Policymakers who want to improve diabetes prevention and reduce diabetes-related health complications should explore policies that provide sufficient support and funding for sustainable, accessible, and patient-centered community resources for self-management. Research: Future studies should further explore what factors contribute to the patients’ “lack of motivation” and what types of social support or other interventions that incorporate social, cultural, and economic issues empower patients with chronic conditions, including diabetes, and improve patient outcomes. INTRODUCTION Chronic disease management requires multiple strategies and recommendations to which patients need to adhere. These include lifestyle modifications, adherence to medication management, and regular interactions with health care professionals. Type 2 diabetes is a condition where both self-management and medical treatment are important. Blood glucose level control is just one of many treatment goals for individuals with diabetes. In addition, individuals should manage their blood pressure and lipid levels, engage in regular physical activity, monitor their diet, and ensure they receive regular assessments of their kidneys, eyes, and peripheral nerves. Several studies have reported that poor diet and exercise regimen adherence are significant barriers to improved health among patients with type 2 diabetes [1]. Not surprisingly, the full set of self-management activities required to manage chronic conditions such as diabetes can overwhelm many people. Primary care providers play an important role in educating and supporting patients in the self-management of diabetes. However, patients need self-care support and education outside of the medical office, and providers have insufficient time during infrequent visits and may not be aware of available community resources. These challenges have a negative effect on delivery of care[1]; however, the studies on patient and provider perspectives about optimal diabetes care and support are limited. A recent systematic literature review identified only two previous studies that reported perceived barriers for diabetes care from both patient and provider perspectives [2]. The review results underscore the need to investigate barriers from the patient and provider perspective in order to facilitate patient–provider conversations and mutual agreement of treatment goals and care plans. Previous studies targeted either providers or patients and were not concurrent in nature, thus making it difficult to compare the perspectives of the providers and the patients within the same context [3]. In addition to good care, the patient is central in the day-to-day management of the disease and requires support from family, neighborhood, organizations, and communities. A great number of effective interventions are available for improving diabetes care and self-management delivered at personal, practice, and community levels. Yet the number of longitudinal, investigational studies exploring changes in the concurrent perceptions of patients and providers due to such interventions is limited. In addition, most previous studies have been cross sectional in nature with very few pre–post studies that concurrently explore patient and provider perceptions over time. Even though some interventional studies have demonstrated that improved patient–provider communication and patient engagement in clinical decisions can improve clinical outcomes, the evidence on how to overcome barriers to care and enhance mutual agreements is still limited. In addition, while the importance of social and family support is highlighted in the patient responses in previous studies, none of the studies explored providers’ perspectives on the role of family members, friends, spiritual peers, or colleagues of patients with diabetes in self-care support and education. The primary objective of this work was to help understand the perceptions of patients with type 2 diabetes or prediabetes and that of health care providers (HCPs) on diabetes-related topics such as levels of awareness about available support for self-management, use and satisfaction with community resources, and barriers to self-management. A secondary objective was to explore whether an intervention in the form of a public awareness campaign/diabetes management demonstration project (Cities for Life) may lead to a change in providers’ and patients’ views. This work was conducted as part of Cities for Life, a clinical-community diabetes management partnership led by the American Academy of Family Physicians Foundation (AAFP), and was implemented in Birmingham, AL, from 2011–2013. The main goal of the Cities for Life partnership was to help community groups and primary care providers create an environment that facilitates and encourages healthy lifestyles, diabetes prevention, and self-management. METHODS Overall study description and survey development This was a separate pre–post samples design study that utilized a social marketing survey method for data collection. The study employed a model for integrating qualitative and quantitative methods in health education research proposed by Steckler et al. [4]. Based on this model, we engaged experts in the field of diabetes care and community-based diabetes support to develop the quantitative questionnaires in an iterative fashion, utilizing the qualitative data from two categories of focus groups: (i) the project team and experts in the field and (ii) patients and HCPs. The Cities for Life team conducted four focus groups of six to eight participants each. Participants included patients at risk for diabetes and people living with type 2 diabetes, community members, and HCPs (primary care physicians and nurse practitioners). These individuals either lived or worked in the greater Birmingham area. The objective was to understand the challenges for patients, community members, and HCPs when addressing type 2 diabetes. Focus group participants were also presented with pilot survey questions intended to assess the extent of diabetes as a public health issue as well as the importance of self-management, education, and community involvement. The project team used the data collected via qualitative methods (focus groups, expert panels) in the development of final quantitative survey instruments. The effects of the public awareness campaign were evaluated by the authors based on the survey data at the end of the program. The baseline HCP questionnaire consisted of 55 items, including a series of questions related to the following domains: respondent demographics, level of awareness of diabetes in the community, importance of diabetes as a public health issue, treatment and diabetes management practices, recommendations for diabetes self-management, perceived level of support for diabetes patients, awareness of resources in the community, and awareness of these resources’ utilization and value. The postsurvey included eight additional questions about the Cities for Life program (see Provider Survey Questionnaire in Supplementary Material AppendixA). The baseline patient questionnaire consisted of 59 questions related to the following domains: respondent demographics, health awareness and priority, diabetes awareness and importance as a public health issue, diabetes management, community resources, and programs for diabetes. The postsurvey included six additional questions asking about the Cities for Life program (see Patient Survey Questionnaire in Supplementary Material AppendixB). The questionnaires included skip patterns and a combination of response scales including multiple-response choice, dichotomous yes/no, and open-ended options. The AAFP institutional review board (IRB) approved the study. Survey administration methodology The surveys were administered at two time points in the study with presurvey (Wave 1, W1) available from April 16 to May 17, 2012, before the implementation of Cities for Life program; and postsurvey (Wave 2, W2) available from May 16 to July 01, 2013, at the end of implementation period. The survey results for two audiences are included in this report: HCPs and patients in the Birmingham, AL, metropolitan area. HCP surveys were administered via the Internet in W1 and by Internet and phone in W2. The phone survey administration was added in W2 as a supplemental recruitment strategy to collect responses from HCP nonresponsive to the initial online survey. Patient surveys were administered via phone in both waves. Patients were recruited from market research client lists via phone after screening for eligibility. Burson–Marsteller, a global public relations and communications firm, provided existing patient and HCP market research panels for the study. Random digit dialing for patients was performed until the targeted sample size was reached. The participants received nominal compensation for this study via mailed check. Survey samples The study was conducted as a separate sample pre–post quasiexperimental design study. This design was selected as most feasible to examine the targeted groups of participants while eliminating the possibility of duplicate respondents in both waves. Patients were included if they were diagnosed with type 2 diabetes or prediabetes and were being treated based on the results of eligibility screening. HCPs were included if they were board-certified or board-eligible physicians, nurse practitioners, or physician assistants working in family, geriatric, or general internal medicine. Intervention As mentioned earlier, the Cities for Life partnership developed and delivered a community awareness and engagement campaign. The primary goal of the campaign was to raise awareness about type 2 diabetes and connect people at risk for and with type 2 diabetes to existing community resources for diabetes management. The community partnership consisted of convening a network of community leaders and organizations that came together to provide diabetes-related social support for patients. Cities for Life established the program’s community component through the development and activation of a Steering Committee. Committee members included representatives from University of Alabama at Birmingham (UAB) Department of Family and Community Medicine, UAB’s Diabetes Research and Training Center’s Community Engagement Core, and UAB HealthSmart and YMCA of Greater Birmingham. With guidance from the Steering Committee, the Community Action Team (CAT) of more than 80 local community organizations was established that connected people living with or at risk for diabetes to community resources to help them manage their disease. Specifically, the CAT conducted the following activities: • Distributed program materials (brochures, posters, etc.) about Cities for Life and about community resources available for people living with and at risk for diabetes. • Encouraged people to use these resources by listing program information and resources on community bulletin boards, organization websites, in newsletters, on social media channels and other sources. • Provided information about organization events and/or resources to the Steering Committee to include on a free public community resources website (www.mydiabetesconnect.com). • Participated in Cities for Life events and other local events to raise awareness about diabetes. In addition to the social support function, the network also provided information on community resources for diabetes management available to patients and increased awareness though local events. Cities for Life representatives set up displays, distributed educational materials, networked with event attendees, and spoke during the events. The Cities for Life team utilized materials developed by the American Diabetes Association and local community-based programs (CBPs) and created original educational and promotional materials. Original Cities for Life materials were developed as a collaborative effort by the project team and Steering Committee. To complement the event activities, Cities for Life representatives participated in media interviews and disseminated social media posts on Facebook and Twitter. The detailed description of the Cities for Life campaign events is provided in Supplementary Material AppendixC. To raise awareness of the program and its goals, the team regularly contacted local media to reach the general community and implemented an integrated community support campaign to raise awareness of diabetes, link community resources and family medicine practices, and build partnerships to enhance community resources. The campaign featured promotion of the program, development and launch of the www.mydiabetesconnect.com website, and collaboration among community organizations. Cities for Life developed relationships with target print, television, radio, and online media outlets throughout the duration of the program to keep them updated on program activities. Several spokespeople were trained and available for interviews based on the need of the outlet. In addition, Cities for Life included a practice-based pilot study of telephone-based nonprofessional patient navigation to promote linkages between the primary care offices and community programs for patients with or at risk for type 2 diabetes. Six primary care practices and 179 patients participated in the pilot; the results of that study are reported elsewhere [5]. A full evaluation report on the Cities for Life program is available upon request. Data analysis Descriptive statistics of survey responses were computed separately for patients and HCPs for each wave. Descriptive statistics for separate survey administration waves and changes/differences in pre- and postsamples are presented as W1 (baseline) and W2 (end of study). The differences in the audience responses and pre–post measures were assessed using column proportions z-tests. These z-tests were used instead of t-tests to provide standardization to the data. The z-tests were appropriate for the types of data collected including Likert scale questions because the test is comparing one Likert scale item to another to determine significance in proportions, only few Likert scale-type questions were included in this report, and the analysis only focused on reporting the distribution of responses for individual questions and not the average scores. An α level of .05 was used for all comparisons. No correction to the α level was performed because the various z-tests were independent of each other. Only significant differences are noted in the text. RESULTS Sample overview The study included 50 and 48 HCP and 201 and 204 patients in W1 and W2 respectively. The HCP were predominantly primary care physicians or nurse practitioners (Table 1). In addition to having type 2 diabetes or prediabetes, the majority of patients reported having at least one other chronic condition (W1 = 79%; W2 = 74%). The sociodemographic and lifestyle characteristics of patients are presented in Table 2. Table 1 Health care provider characteristics Characteristics W1 (n = 50) W2 (n = 48) Methodology Online Online (n = 42); phone (n = 6) Profession/degree n (%)  Physician 44 (88) 45 (94)  Nurse practitioner 6 (12) 3 (6) Specialty n (%)  Family medicine 20 (46) 14 (31)  Geriatric medicine 0 5 (11)a  General internal medicine 24 (55) 26 (58) Years in practice post-training (mean, SD) 14.3 (11.0) 12.4 (11.2) Percent of time spent in direct patient care (mean, SD) 91.9 (16) 84.9 (22) Practice type n (%)  Solo practice 9 (18) 10 (21)  Group practice: 2 to 4 physicians 10 (20) 11 (23)  Group practice: 5 to 9 physicians 10 (20) 9 (19)  Group practice: 10 or more physicians 21 (42) 18 (38) Characteristics W1 (n = 50) W2 (n = 48) Methodology Online Online (n = 42); phone (n = 6) Profession/degree n (%)  Physician 44 (88) 45 (94)  Nurse practitioner 6 (12) 3 (6) Specialty n (%)  Family medicine 20 (46) 14 (31)  Geriatric medicine 0 5 (11)a  General internal medicine 24 (55) 26 (58) Years in practice post-training (mean, SD) 14.3 (11.0) 12.4 (11.2) Percent of time spent in direct patient care (mean, SD) 91.9 (16) 84.9 (22) Practice type n (%)  Solo practice 9 (18) 10 (21)  Group practice: 2 to 4 physicians 10 (20) 11 (23)  Group practice: 5 to 9 physicians 10 (20) 9 (19)  Group practice: 10 or more physicians 21 (42) 18 (38) aSignificantly different between W1 and W2 at p < .05 level. View Large Table 1 Health care provider characteristics Characteristics W1 (n = 50) W2 (n = 48) Methodology Online Online (n = 42); phone (n = 6) Profession/degree n (%)  Physician 44 (88) 45 (94)  Nurse practitioner 6 (12) 3 (6) Specialty n (%)  Family medicine 20 (46) 14 (31)  Geriatric medicine 0 5 (11)a  General internal medicine 24 (55) 26 (58) Years in practice post-training (mean, SD) 14.3 (11.0) 12.4 (11.2) Percent of time spent in direct patient care (mean, SD) 91.9 (16) 84.9 (22) Practice type n (%)  Solo practice 9 (18) 10 (21)  Group practice: 2 to 4 physicians 10 (20) 11 (23)  Group practice: 5 to 9 physicians 10 (20) 9 (19)  Group practice: 10 or more physicians 21 (42) 18 (38) Characteristics W1 (n = 50) W2 (n = 48) Methodology Online Online (n = 42); phone (n = 6) Profession/degree n (%)  Physician 44 (88) 45 (94)  Nurse practitioner 6 (12) 3 (6) Specialty n (%)  Family medicine 20 (46) 14 (31)  Geriatric medicine 0 5 (11)a  General internal medicine 24 (55) 26 (58) Years in practice post-training (mean, SD) 14.3 (11.0) 12.4 (11.2) Percent of time spent in direct patient care (mean, SD) 91.9 (16) 84.9 (22) Practice type n (%)  Solo practice 9 (18) 10 (21)  Group practice: 2 to 4 physicians 10 (20) 11 (23)  Group practice: 5 to 9 physicians 10 (20) 9 (19)  Group practice: 10 or more physicians 21 (42) 18 (38) aSignificantly different between W1 and W2 at p < .05 level. View Large Table 2 Patient participant characteristics Characteristics W1 (n = 201) W2 (n = 204) Age, years, mean (SD) 67 (11) 66 (12) Gender  Male (n, %) 63 (32) 78 (38)  Female (n, %) 137 (69) 126 (62) Diagnosis (n, %)  Prediabetes 17 (9) 21 (10)  Type 2 diabetes 184 (92) 183 (90) Eat meals out (n, %)  Less frequently than once a week 68 (34) 58 (28)  Once per week 66 (33) 58 (28)  Several times per week 48 (24) 68 (33)  Once per day 10 (5) 8 (4)  More than once per day 9 (5) 11 (5)  Don’t know 0 1 (0.5) Exercise frequency (n, %)  Less frequently than once a week 53 (26) 70 (34)  Once per week 31 (15) 32 (16)  Several times per week 75 (37) 67 (33)  Once per day 33 (16) 20 (10)  More than once per day 6 (3) 11 (5)  Don’t know 3 (2) 4 (2) Characteristics W1 (n = 201) W2 (n = 204) Age, years, mean (SD) 67 (11) 66 (12) Gender  Male (n, %) 63 (32) 78 (38)  Female (n, %) 137 (69) 126 (62) Diagnosis (n, %)  Prediabetes 17 (9) 21 (10)  Type 2 diabetes 184 (92) 183 (90) Eat meals out (n, %)  Less frequently than once a week 68 (34) 58 (28)  Once per week 66 (33) 58 (28)  Several times per week 48 (24) 68 (33)  Once per day 10 (5) 8 (4)  More than once per day 9 (5) 11 (5)  Don’t know 0 1 (0.5) Exercise frequency (n, %)  Less frequently than once a week 53 (26) 70 (34)  Once per week 31 (15) 32 (16)  Several times per week 75 (37) 67 (33)  Once per day 33 (16) 20 (10)  More than once per day 6 (3) 11 (5)  Don’t know 3 (2) 4 (2) View Large Table 2 Patient participant characteristics Characteristics W1 (n = 201) W2 (n = 204) Age, years, mean (SD) 67 (11) 66 (12) Gender  Male (n, %) 63 (32) 78 (38)  Female (n, %) 137 (69) 126 (62) Diagnosis (n, %)  Prediabetes 17 (9) 21 (10)  Type 2 diabetes 184 (92) 183 (90) Eat meals out (n, %)  Less frequently than once a week 68 (34) 58 (28)  Once per week 66 (33) 58 (28)  Several times per week 48 (24) 68 (33)  Once per day 10 (5) 8 (4)  More than once per day 9 (5) 11 (5)  Don’t know 0 1 (0.5) Exercise frequency (n, %)  Less frequently than once a week 53 (26) 70 (34)  Once per week 31 (15) 32 (16)  Several times per week 75 (37) 67 (33)  Once per day 33 (16) 20 (10)  More than once per day 6 (3) 11 (5)  Don’t know 3 (2) 4 (2) Characteristics W1 (n = 201) W2 (n = 204) Age, years, mean (SD) 67 (11) 66 (12) Gender  Male (n, %) 63 (32) 78 (38)  Female (n, %) 137 (69) 126 (62) Diagnosis (n, %)  Prediabetes 17 (9) 21 (10)  Type 2 diabetes 184 (92) 183 (90) Eat meals out (n, %)  Less frequently than once a week 68 (34) 58 (28)  Once per week 66 (33) 58 (28)  Several times per week 48 (24) 68 (33)  Once per day 10 (5) 8 (4)  More than once per day 9 (5) 11 (5)  Don’t know 0 1 (0.5) Exercise frequency (n, %)  Less frequently than once a week 53 (26) 70 (34)  Once per week 31 (15) 32 (16)  Several times per week 75 (37) 67 (33)  Once per day 33 (16) 20 (10)  More than once per day 6 (3) 11 (5)  Don’t know 3 (2) 4 (2) View Large Community resource awareness Data on detailed responses to the patient and HCP survey questions included in this report are presented in Table 3. At the baseline, awareness about the 16 types of various community resources was higher among patients as compared with HCPs in the following areas: diabetes publications such as books and magazines, grocery stores with healthy food options, pharmacies that provide help to patients, local government programs, and patient groups organized for helpful activities. Compared with the patients, HCPs were more aware of weight loss programs and workplace exercise programs. The patient and HCP awareness levels in W2 did not differ from baseline. Table 3 Survey responses Survey questions, n (%) unless notes otherwise HCP W1 (n = 50) HCP W2 (n = 48) Patients W1 (n = 201) Patients W2 (n = 204) In your opinion, do you believe your community provides people living with diabetes with enough local support to manage your condition?  Yes 12 (30) 13 (36) 89 (44) 72 (35)  No 14 (35) 12 (33) 84 (42) 92 (45)  Don’t know 14 (35) 11 (31) 28 (14) 40 (20) Overall, how valuable do you find the programs in your community are at possibly helping people reduce the risk of or manage type 2 diabetes?  1 – Not at all valuable 0 1 (3) 37 (23) 22 (16)  2 0 2 (6) 4 (3) 10 (7)  3 0 1 (3) 7 (4) 5 (4)  4 3 (9) 2 (7) 3 (2) 1 (1)  5 5 (15) 4 (13) 18 (11) 15 (11)  6 8 (24) 4 (13) 5 (3) 5 (4)  7 6 (18) 5 (16) 6 (4) 11 (8)  8 8 (24) 4 (13) 14 (9) 10 (7)  9 3 (9) 2 (7) 9 (6) 3 (2)  10 – Extremely valuable 0 3 (10) 42 (26) 41 (30)  Don’t know 0 3 (10) 14 (9) 13 (10) What types of treatment does your physician recommend for the management of your diabetes? NA NA  Prescription medication 180 (91) 173 (85)  Over-the-counter medication 17 (9) 19 (9)  Healthier eating habits 154 (78) 167 (82)  Exercising 155 (78) 160 (79)  Other 18 (9) 22 (11) Do your patients with prediabetes or type 2 diabetes typically participate in the community programs you recommend? NA NA  Yes, most do 2 (6) 5 (18)  Yes, some do 23 (64) 18 (64)  No 5 (14) 2 (7)  Don’t know 6 (17) 3 (11) Do you participate in any of these types of programs [programs “are you aware of” that are designed to help patients, like you, manage their diabetes]? NA NA  Yes 63 (31) ¤ 45 (22)  No 135 (67) 147 (72)  Don’t know 3 (2) 12 (6) Among prediabetes and type 2 diabetes patients who do not adhere to community programs, why do you think they have difficulty with adherence? NA NA  They cannot afford them 1 (13) 1 (7)  They say they do not have time 0 2 (14)  They say they have too many other commitments/stress in their lives at this time 1 (13) 1 (7)  They lack transportation 0 0  They are not personally motivated 3 (38) 8 (57)  Do not understand the importance of using these programs and how it can help them manage diabetes 3 (38) 1 (7)  Other 0 0  Don’t know 0 1 (7) What strategies do you use to “motivate” prediabetes or type 2 diabetes patients to follow through with the recommendations you make? NA NA  I emphasize the possible complications that can occur if their type 2 diabetes is not properly managed, like blindness, loss of limbs, kidney disease, etc. 43 (86) 40 (83)  I tell them to seek support from family, friends and/or community programs 27 (54) 22 (46)  I tell them that diabetes is chronic disease that can be self-managed 31 (62) 33 (69)  I provide literature or information about diabetes 27 (54) 24 (50)  I provide lists of resources available through community organizations, such as the Alabama Department of Public Health’s Diabetes Program 10 (20) 10 (21)  I provide information from national organizations (NIH, CDC, ADA) 14 (28) 7 (15) I tell them to keep a diary (for diet, exercise, medication or other daily needs) 32 (64) 33 (69)  My office calls or sends email or text reminders for between visit care (self-test blood glucose, adherence to medication regimens) 7 (14) 9 (19)  Other than making a recommendation of what step to take, I don’t really use any tactics to motivate my patients to follow through 3 (6) 3 (6)  Other tactic 0 1 (2) How much support do your prediabetes or type 2 diabetes patients get from their family and friends to help them reduce the risk of or manage their condition? NA NA  They get a lot of support 0 5 (10) ¤  They get some support 46 (92) 39 (81)  They don’t get any support 2 (4) 2 (4)  Don’t know 2 (4) 2 (4) How much support, if any, do you get from your family, friends, or co-workers to help you manage or live with diabetes? NA NA  I get a lot of support 108 (54) 130 (64) ¤  I get some support 61 (30) 46 (23)  I don’t get any support 30 (15) 26 (13)  Don’t know 2 (1) 2 (1) Would you consider yourself to be… NA NA  Obese 24 (12) 17 (8)  Overweight 110 (55) 100 (49)  At a proper weight 63 (31) 84 (41) ¤  Underweight 3 (2) 3 (2)  Don’t know 1 (0.5) 0 What percent of the type 2 diabetes patients in your practice are…? Please make sure your total sums to 100%. Your best estimate is fine; mean (SD) NA NA  Obese (BMI ≥ 30 kg/m2) 41.6 (24.4) 46.6 (23.1)  Overweight (BMI = 25–29.9 kg/m2) 32.6 (17.0) 32.0 (14.9)  Normal weight (BMI = 18.5–24.9 kg/m2) 22.5 (16.3) 17.5 (13.9)  Underweight weight (BMI < 18.5 kg/m2) 3.3 (4.0) 3.92 (5.0) When thinking of a coordinated care approach to reducing the risk of and managing type 2 diabetes, who should be responsible for leading this coordinated care? Please select all who you feel should be responsible NA NA  Myself 40 (80) 37 (77)  Clinical care coordinator (usually an RN) 18 (36) 17 (35)  Certified diabetes educator 20 (40) 18 (38)  Case manager 6 (12) 7 (15)  Physician assistant or nurse practitioner 9 (18) 17 (35)  Community organizations, for example, the American Diabetes Association 8 (16) 5 (10)  Family and friends 14 (28) 19 (40)  The person living with type 2 diabetes 31 (62) 33 (69)  Another physician (i.e., endocrinologist) 10 (20) 21 (44) ¤  Other 0 0 What type of “physician” is primarily responsible for the management of your diabetes? NA NA  Primary care physician (general practice, family practice, or internal medicine) 165 (82) 157 (77)  Diabetes specialist 23 (11) 36 (18)  Endocrinologist 10 (5) 10 (5)  I do not see a physician 2 (1) 1 (0.5)  Other 1 (0.5) 0 How often are you visiting this “physician” for the management of your diabetes? NA NA  More frequently than once a month 8 (4) 5 (3)  Once a month 17 (9) 15 (7)  Once every 3 months 111 (56) 117 (58)  Once every 6 months 54 (27) 59 (29)  Once a year 4 (2) 4 (2)  Less frequently than once a year 4 (2) 3 (2)  Don’t know 0 0 Which of the following health care professionals do you currently see or talk to for the management of your diabetes? The interaction could be in person, over the phone, or via email. NA NA  Diabetes counselor or educator  Nurse care manager 39 (19) 28 (14)  Physician assistant 32 (16) 33 (16)  Other 73 (36) 68 (33)  None of these 83 (41) 101 (50)  Don’t know 1 (0.5) 0 Specifically, in your community, which of the following programs are you aware of that are available to help people possibly manage their prediabetes or type 2 diabetes?  National Diabetes Education Program 14 (35) 8 (22) 80 (40)a 50 (25)  Cities for Life 0 5 (14) ¤ 12 (6) 12 (6)  Defeat Diabetes 1 (3) 2 (6) 22 (11) 18 (9)  Alabama Cooperative Extension Systemb 3 (8) 0 32 (16) 29 (14)  United Against Diabetes 2 (5) 2 (6) 29 (14) 21 (10)  The Alabama Diabetes Prevention and Control Program 7 (18) 9 (25) 41 (20) 30 (15)  Southeastern Diabetes Education Services 6 (15) 1 (3) 15 (8) 12 (6)  I Decide to Fight Diabetes 1 (3) 2 (6) 18 (9) 16 (8)  Steps to a Healthier US—Alabama 3 (8) 4 (11) 27 (13) 26 (13)  YMCA of Birmingham, YMCA Diabetes Prevention Program 22 (55)c 16 (44)a 72 (36) ¤ 52 (26)  American Diabetes Association, Alabama 26 (65) 24 (67) 124 (62) 110 (54)  Other 0 0 6 (3) 7 (3)  None of these 7 (18) 3 (8) 38 (19) 52 (26)a  Don’t know 0 2 (6) 4 (2) 16 (8) ¤ Survey questions, n (%) unless notes otherwise HCP W1 (n = 50) HCP W2 (n = 48) Patients W1 (n = 201) Patients W2 (n = 204) In your opinion, do you believe your community provides people living with diabetes with enough local support to manage your condition?  Yes 12 (30) 13 (36) 89 (44) 72 (35)  No 14 (35) 12 (33) 84 (42) 92 (45)  Don’t know 14 (35) 11 (31) 28 (14) 40 (20) Overall, how valuable do you find the programs in your community are at possibly helping people reduce the risk of or manage type 2 diabetes?  1 – Not at all valuable 0 1 (3) 37 (23) 22 (16)  2 0 2 (6) 4 (3) 10 (7)  3 0 1 (3) 7 (4) 5 (4)  4 3 (9) 2 (7) 3 (2) 1 (1)  5 5 (15) 4 (13) 18 (11) 15 (11)  6 8 (24) 4 (13) 5 (3) 5 (4)  7 6 (18) 5 (16) 6 (4) 11 (8)  8 8 (24) 4 (13) 14 (9) 10 (7)  9 3 (9) 2 (7) 9 (6) 3 (2)  10 – Extremely valuable 0 3 (10) 42 (26) 41 (30)  Don’t know 0 3 (10) 14 (9) 13 (10) What types of treatment does your physician recommend for the management of your diabetes? NA NA  Prescription medication 180 (91) 173 (85)  Over-the-counter medication 17 (9) 19 (9)  Healthier eating habits 154 (78) 167 (82)  Exercising 155 (78) 160 (79)  Other 18 (9) 22 (11) Do your patients with prediabetes or type 2 diabetes typically participate in the community programs you recommend? NA NA  Yes, most do 2 (6) 5 (18)  Yes, some do 23 (64) 18 (64)  No 5 (14) 2 (7)  Don’t know 6 (17) 3 (11) Do you participate in any of these types of programs [programs “are you aware of” that are designed to help patients, like you, manage their diabetes]? NA NA  Yes 63 (31) ¤ 45 (22)  No 135 (67) 147 (72)  Don’t know 3 (2) 12 (6) Among prediabetes and type 2 diabetes patients who do not adhere to community programs, why do you think they have difficulty with adherence? NA NA  They cannot afford them 1 (13) 1 (7)  They say they do not have time 0 2 (14)  They say they have too many other commitments/stress in their lives at this time 1 (13) 1 (7)  They lack transportation 0 0  They are not personally motivated 3 (38) 8 (57)  Do not understand the importance of using these programs and how it can help them manage diabetes 3 (38) 1 (7)  Other 0 0  Don’t know 0 1 (7) What strategies do you use to “motivate” prediabetes or type 2 diabetes patients to follow through with the recommendations you make? NA NA  I emphasize the possible complications that can occur if their type 2 diabetes is not properly managed, like blindness, loss of limbs, kidney disease, etc. 43 (86) 40 (83)  I tell them to seek support from family, friends and/or community programs 27 (54) 22 (46)  I tell them that diabetes is chronic disease that can be self-managed 31 (62) 33 (69)  I provide literature or information about diabetes 27 (54) 24 (50)  I provide lists of resources available through community organizations, such as the Alabama Department of Public Health’s Diabetes Program 10 (20) 10 (21)  I provide information from national organizations (NIH, CDC, ADA) 14 (28) 7 (15) I tell them to keep a diary (for diet, exercise, medication or other daily needs) 32 (64) 33 (69)  My office calls or sends email or text reminders for between visit care (self-test blood glucose, adherence to medication regimens) 7 (14) 9 (19)  Other than making a recommendation of what step to take, I don’t really use any tactics to motivate my patients to follow through 3 (6) 3 (6)  Other tactic 0 1 (2) How much support do your prediabetes or type 2 diabetes patients get from their family and friends to help them reduce the risk of or manage their condition? NA NA  They get a lot of support 0 5 (10) ¤  They get some support 46 (92) 39 (81)  They don’t get any support 2 (4) 2 (4)  Don’t know 2 (4) 2 (4) How much support, if any, do you get from your family, friends, or co-workers to help you manage or live with diabetes? NA NA  I get a lot of support 108 (54) 130 (64) ¤  I get some support 61 (30) 46 (23)  I don’t get any support 30 (15) 26 (13)  Don’t know 2 (1) 2 (1) Would you consider yourself to be… NA NA  Obese 24 (12) 17 (8)  Overweight 110 (55) 100 (49)  At a proper weight 63 (31) 84 (41) ¤  Underweight 3 (2) 3 (2)  Don’t know 1 (0.5) 0 What percent of the type 2 diabetes patients in your practice are…? Please make sure your total sums to 100%. Your best estimate is fine; mean (SD) NA NA  Obese (BMI ≥ 30 kg/m2) 41.6 (24.4) 46.6 (23.1)  Overweight (BMI = 25–29.9 kg/m2) 32.6 (17.0) 32.0 (14.9)  Normal weight (BMI = 18.5–24.9 kg/m2) 22.5 (16.3) 17.5 (13.9)  Underweight weight (BMI < 18.5 kg/m2) 3.3 (4.0) 3.92 (5.0) When thinking of a coordinated care approach to reducing the risk of and managing type 2 diabetes, who should be responsible for leading this coordinated care? Please select all who you feel should be responsible NA NA  Myself 40 (80) 37 (77)  Clinical care coordinator (usually an RN) 18 (36) 17 (35)  Certified diabetes educator 20 (40) 18 (38)  Case manager 6 (12) 7 (15)  Physician assistant or nurse practitioner 9 (18) 17 (35)  Community organizations, for example, the American Diabetes Association 8 (16) 5 (10)  Family and friends 14 (28) 19 (40)  The person living with type 2 diabetes 31 (62) 33 (69)  Another physician (i.e., endocrinologist) 10 (20) 21 (44) ¤  Other 0 0 What type of “physician” is primarily responsible for the management of your diabetes? NA NA  Primary care physician (general practice, family practice, or internal medicine) 165 (82) 157 (77)  Diabetes specialist 23 (11) 36 (18)  Endocrinologist 10 (5) 10 (5)  I do not see a physician 2 (1) 1 (0.5)  Other 1 (0.5) 0 How often are you visiting this “physician” for the management of your diabetes? NA NA  More frequently than once a month 8 (4) 5 (3)  Once a month 17 (9) 15 (7)  Once every 3 months 111 (56) 117 (58)  Once every 6 months 54 (27) 59 (29)  Once a year 4 (2) 4 (2)  Less frequently than once a year 4 (2) 3 (2)  Don’t know 0 0 Which of the following health care professionals do you currently see or talk to for the management of your diabetes? The interaction could be in person, over the phone, or via email. NA NA  Diabetes counselor or educator  Nurse care manager 39 (19) 28 (14)  Physician assistant 32 (16) 33 (16)  Other 73 (36) 68 (33)  None of these 83 (41) 101 (50)  Don’t know 1 (0.5) 0 Specifically, in your community, which of the following programs are you aware of that are available to help people possibly manage their prediabetes or type 2 diabetes?  National Diabetes Education Program 14 (35) 8 (22) 80 (40)a 50 (25)  Cities for Life 0 5 (14) ¤ 12 (6) 12 (6)  Defeat Diabetes 1 (3) 2 (6) 22 (11) 18 (9)  Alabama Cooperative Extension Systemb 3 (8) 0 32 (16) 29 (14)  United Against Diabetes 2 (5) 2 (6) 29 (14) 21 (10)  The Alabama Diabetes Prevention and Control Program 7 (18) 9 (25) 41 (20) 30 (15)  Southeastern Diabetes Education Services 6 (15) 1 (3) 15 (8) 12 (6)  I Decide to Fight Diabetes 1 (3) 2 (6) 18 (9) 16 (8)  Steps to a Healthier US—Alabama 3 (8) 4 (11) 27 (13) 26 (13)  YMCA of Birmingham, YMCA Diabetes Prevention Program 22 (55)c 16 (44)a 72 (36) ¤ 52 (26)  American Diabetes Association, Alabama 26 (65) 24 (67) 124 (62) 110 (54)  Other 0 0 6 (3) 7 (3)  None of these 7 (18) 3 (8) 38 (19) 52 (26)a  Don’t know 0 2 (6) 4 (2) 16 (8) ¤ ADA, American Diabetes Association; BMI, body mass index; CDC, Centers for Disease Control and Prevention; HCP, health care providers; NA, not applicable; NIH, National Institutes of Health; RN, registered nurse. aSignificant difference between patients and providers in W2. ¤Significant difference within the same group between W1 and W2. bAgricultural program, not related to diabetes. cSignificant difference between patients and providers in W1. View Large Table 3 Survey responses Survey questions, n (%) unless notes otherwise HCP W1 (n = 50) HCP W2 (n = 48) Patients W1 (n = 201) Patients W2 (n = 204) In your opinion, do you believe your community provides people living with diabetes with enough local support to manage your condition?  Yes 12 (30) 13 (36) 89 (44) 72 (35)  No 14 (35) 12 (33) 84 (42) 92 (45)  Don’t know 14 (35) 11 (31) 28 (14) 40 (20) Overall, how valuable do you find the programs in your community are at possibly helping people reduce the risk of or manage type 2 diabetes?  1 – Not at all valuable 0 1 (3) 37 (23) 22 (16)  2 0 2 (6) 4 (3) 10 (7)  3 0 1 (3) 7 (4) 5 (4)  4 3 (9) 2 (7) 3 (2) 1 (1)  5 5 (15) 4 (13) 18 (11) 15 (11)  6 8 (24) 4 (13) 5 (3) 5 (4)  7 6 (18) 5 (16) 6 (4) 11 (8)  8 8 (24) 4 (13) 14 (9) 10 (7)  9 3 (9) 2 (7) 9 (6) 3 (2)  10 – Extremely valuable 0 3 (10) 42 (26) 41 (30)  Don’t know 0 3 (10) 14 (9) 13 (10) What types of treatment does your physician recommend for the management of your diabetes? NA NA  Prescription medication 180 (91) 173 (85)  Over-the-counter medication 17 (9) 19 (9)  Healthier eating habits 154 (78) 167 (82)  Exercising 155 (78) 160 (79)  Other 18 (9) 22 (11) Do your patients with prediabetes or type 2 diabetes typically participate in the community programs you recommend? NA NA  Yes, most do 2 (6) 5 (18)  Yes, some do 23 (64) 18 (64)  No 5 (14) 2 (7)  Don’t know 6 (17) 3 (11) Do you participate in any of these types of programs [programs “are you aware of” that are designed to help patients, like you, manage their diabetes]? NA NA  Yes 63 (31) ¤ 45 (22)  No 135 (67) 147 (72)  Don’t know 3 (2) 12 (6) Among prediabetes and type 2 diabetes patients who do not adhere to community programs, why do you think they have difficulty with adherence? NA NA  They cannot afford them 1 (13) 1 (7)  They say they do not have time 0 2 (14)  They say they have too many other commitments/stress in their lives at this time 1 (13) 1 (7)  They lack transportation 0 0  They are not personally motivated 3 (38) 8 (57)  Do not understand the importance of using these programs and how it can help them manage diabetes 3 (38) 1 (7)  Other 0 0  Don’t know 0 1 (7) What strategies do you use to “motivate” prediabetes or type 2 diabetes patients to follow through with the recommendations you make? NA NA  I emphasize the possible complications that can occur if their type 2 diabetes is not properly managed, like blindness, loss of limbs, kidney disease, etc. 43 (86) 40 (83)  I tell them to seek support from family, friends and/or community programs 27 (54) 22 (46)  I tell them that diabetes is chronic disease that can be self-managed 31 (62) 33 (69)  I provide literature or information about diabetes 27 (54) 24 (50)  I provide lists of resources available through community organizations, such as the Alabama Department of Public Health’s Diabetes Program 10 (20) 10 (21)  I provide information from national organizations (NIH, CDC, ADA) 14 (28) 7 (15) I tell them to keep a diary (for diet, exercise, medication or other daily needs) 32 (64) 33 (69)  My office calls or sends email or text reminders for between visit care (self-test blood glucose, adherence to medication regimens) 7 (14) 9 (19)  Other than making a recommendation of what step to take, I don’t really use any tactics to motivate my patients to follow through 3 (6) 3 (6)  Other tactic 0 1 (2) How much support do your prediabetes or type 2 diabetes patients get from their family and friends to help them reduce the risk of or manage their condition? NA NA  They get a lot of support 0 5 (10) ¤  They get some support 46 (92) 39 (81)  They don’t get any support 2 (4) 2 (4)  Don’t know 2 (4) 2 (4) How much support, if any, do you get from your family, friends, or co-workers to help you manage or live with diabetes? NA NA  I get a lot of support 108 (54) 130 (64) ¤  I get some support 61 (30) 46 (23)  I don’t get any support 30 (15) 26 (13)  Don’t know 2 (1) 2 (1) Would you consider yourself to be… NA NA  Obese 24 (12) 17 (8)  Overweight 110 (55) 100 (49)  At a proper weight 63 (31) 84 (41) ¤  Underweight 3 (2) 3 (2)  Don’t know 1 (0.5) 0 What percent of the type 2 diabetes patients in your practice are…? Please make sure your total sums to 100%. Your best estimate is fine; mean (SD) NA NA  Obese (BMI ≥ 30 kg/m2) 41.6 (24.4) 46.6 (23.1)  Overweight (BMI = 25–29.9 kg/m2) 32.6 (17.0) 32.0 (14.9)  Normal weight (BMI = 18.5–24.9 kg/m2) 22.5 (16.3) 17.5 (13.9)  Underweight weight (BMI < 18.5 kg/m2) 3.3 (4.0) 3.92 (5.0) When thinking of a coordinated care approach to reducing the risk of and managing type 2 diabetes, who should be responsible for leading this coordinated care? Please select all who you feel should be responsible NA NA  Myself 40 (80) 37 (77)  Clinical care coordinator (usually an RN) 18 (36) 17 (35)  Certified diabetes educator 20 (40) 18 (38)  Case manager 6 (12) 7 (15)  Physician assistant or nurse practitioner 9 (18) 17 (35)  Community organizations, for example, the American Diabetes Association 8 (16) 5 (10)  Family and friends 14 (28) 19 (40)  The person living with type 2 diabetes 31 (62) 33 (69)  Another physician (i.e., endocrinologist) 10 (20) 21 (44) ¤  Other 0 0 What type of “physician” is primarily responsible for the management of your diabetes? NA NA  Primary care physician (general practice, family practice, or internal medicine) 165 (82) 157 (77)  Diabetes specialist 23 (11) 36 (18)  Endocrinologist 10 (5) 10 (5)  I do not see a physician 2 (1) 1 (0.5)  Other 1 (0.5) 0 How often are you visiting this “physician” for the management of your diabetes? NA NA  More frequently than once a month 8 (4) 5 (3)  Once a month 17 (9) 15 (7)  Once every 3 months 111 (56) 117 (58)  Once every 6 months 54 (27) 59 (29)  Once a year 4 (2) 4 (2)  Less frequently than once a year 4 (2) 3 (2)  Don’t know 0 0 Which of the following health care professionals do you currently see or talk to for the management of your diabetes? The interaction could be in person, over the phone, or via email. NA NA  Diabetes counselor or educator  Nurse care manager 39 (19) 28 (14)  Physician assistant 32 (16) 33 (16)  Other 73 (36) 68 (33)  None of these 83 (41) 101 (50)  Don’t know 1 (0.5) 0 Specifically, in your community, which of the following programs are you aware of that are available to help people possibly manage their prediabetes or type 2 diabetes?  National Diabetes Education Program 14 (35) 8 (22) 80 (40)a 50 (25)  Cities for Life 0 5 (14) ¤ 12 (6) 12 (6)  Defeat Diabetes 1 (3) 2 (6) 22 (11) 18 (9)  Alabama Cooperative Extension Systemb 3 (8) 0 32 (16) 29 (14)  United Against Diabetes 2 (5) 2 (6) 29 (14) 21 (10)  The Alabama Diabetes Prevention and Control Program 7 (18) 9 (25) 41 (20) 30 (15)  Southeastern Diabetes Education Services 6 (15) 1 (3) 15 (8) 12 (6)  I Decide to Fight Diabetes 1 (3) 2 (6) 18 (9) 16 (8)  Steps to a Healthier US—Alabama 3 (8) 4 (11) 27 (13) 26 (13)  YMCA of Birmingham, YMCA Diabetes Prevention Program 22 (55)c 16 (44)a 72 (36) ¤ 52 (26)  American Diabetes Association, Alabama 26 (65) 24 (67) 124 (62) 110 (54)  Other 0 0 6 (3) 7 (3)  None of these 7 (18) 3 (8) 38 (19) 52 (26)a  Don’t know 0 2 (6) 4 (2) 16 (8) ¤ Survey questions, n (%) unless notes otherwise HCP W1 (n = 50) HCP W2 (n = 48) Patients W1 (n = 201) Patients W2 (n = 204) In your opinion, do you believe your community provides people living with diabetes with enough local support to manage your condition?  Yes 12 (30) 13 (36) 89 (44) 72 (35)  No 14 (35) 12 (33) 84 (42) 92 (45)  Don’t know 14 (35) 11 (31) 28 (14) 40 (20) Overall, how valuable do you find the programs in your community are at possibly helping people reduce the risk of or manage type 2 diabetes?  1 – Not at all valuable 0 1 (3) 37 (23) 22 (16)  2 0 2 (6) 4 (3) 10 (7)  3 0 1 (3) 7 (4) 5 (4)  4 3 (9) 2 (7) 3 (2) 1 (1)  5 5 (15) 4 (13) 18 (11) 15 (11)  6 8 (24) 4 (13) 5 (3) 5 (4)  7 6 (18) 5 (16) 6 (4) 11 (8)  8 8 (24) 4 (13) 14 (9) 10 (7)  9 3 (9) 2 (7) 9 (6) 3 (2)  10 – Extremely valuable 0 3 (10) 42 (26) 41 (30)  Don’t know 0 3 (10) 14 (9) 13 (10) What types of treatment does your physician recommend for the management of your diabetes? NA NA  Prescription medication 180 (91) 173 (85)  Over-the-counter medication 17 (9) 19 (9)  Healthier eating habits 154 (78) 167 (82)  Exercising 155 (78) 160 (79)  Other 18 (9) 22 (11) Do your patients with prediabetes or type 2 diabetes typically participate in the community programs you recommend? NA NA  Yes, most do 2 (6) 5 (18)  Yes, some do 23 (64) 18 (64)  No 5 (14) 2 (7)  Don’t know 6 (17) 3 (11) Do you participate in any of these types of programs [programs “are you aware of” that are designed to help patients, like you, manage their diabetes]? NA NA  Yes 63 (31) ¤ 45 (22)  No 135 (67) 147 (72)  Don’t know 3 (2) 12 (6) Among prediabetes and type 2 diabetes patients who do not adhere to community programs, why do you think they have difficulty with adherence? NA NA  They cannot afford them 1 (13) 1 (7)  They say they do not have time 0 2 (14)  They say they have too many other commitments/stress in their lives at this time 1 (13) 1 (7)  They lack transportation 0 0  They are not personally motivated 3 (38) 8 (57)  Do not understand the importance of using these programs and how it can help them manage diabetes 3 (38) 1 (7)  Other 0 0  Don’t know 0 1 (7) What strategies do you use to “motivate” prediabetes or type 2 diabetes patients to follow through with the recommendations you make? NA NA  I emphasize the possible complications that can occur if their type 2 diabetes is not properly managed, like blindness, loss of limbs, kidney disease, etc. 43 (86) 40 (83)  I tell them to seek support from family, friends and/or community programs 27 (54) 22 (46)  I tell them that diabetes is chronic disease that can be self-managed 31 (62) 33 (69)  I provide literature or information about diabetes 27 (54) 24 (50)  I provide lists of resources available through community organizations, such as the Alabama Department of Public Health’s Diabetes Program 10 (20) 10 (21)  I provide information from national organizations (NIH, CDC, ADA) 14 (28) 7 (15) I tell them to keep a diary (for diet, exercise, medication or other daily needs) 32 (64) 33 (69)  My office calls or sends email or text reminders for between visit care (self-test blood glucose, adherence to medication regimens) 7 (14) 9 (19)  Other than making a recommendation of what step to take, I don’t really use any tactics to motivate my patients to follow through 3 (6) 3 (6)  Other tactic 0 1 (2) How much support do your prediabetes or type 2 diabetes patients get from their family and friends to help them reduce the risk of or manage their condition? NA NA  They get a lot of support 0 5 (10) ¤  They get some support 46 (92) 39 (81)  They don’t get any support 2 (4) 2 (4)  Don’t know 2 (4) 2 (4) How much support, if any, do you get from your family, friends, or co-workers to help you manage or live with diabetes? NA NA  I get a lot of support 108 (54) 130 (64) ¤  I get some support 61 (30) 46 (23)  I don’t get any support 30 (15) 26 (13)  Don’t know 2 (1) 2 (1) Would you consider yourself to be… NA NA  Obese 24 (12) 17 (8)  Overweight 110 (55) 100 (49)  At a proper weight 63 (31) 84 (41) ¤  Underweight 3 (2) 3 (2)  Don’t know 1 (0.5) 0 What percent of the type 2 diabetes patients in your practice are…? Please make sure your total sums to 100%. Your best estimate is fine; mean (SD) NA NA  Obese (BMI ≥ 30 kg/m2) 41.6 (24.4) 46.6 (23.1)  Overweight (BMI = 25–29.9 kg/m2) 32.6 (17.0) 32.0 (14.9)  Normal weight (BMI = 18.5–24.9 kg/m2) 22.5 (16.3) 17.5 (13.9)  Underweight weight (BMI < 18.5 kg/m2) 3.3 (4.0) 3.92 (5.0) When thinking of a coordinated care approach to reducing the risk of and managing type 2 diabetes, who should be responsible for leading this coordinated care? Please select all who you feel should be responsible NA NA  Myself 40 (80) 37 (77)  Clinical care coordinator (usually an RN) 18 (36) 17 (35)  Certified diabetes educator 20 (40) 18 (38)  Case manager 6 (12) 7 (15)  Physician assistant or nurse practitioner 9 (18) 17 (35)  Community organizations, for example, the American Diabetes Association 8 (16) 5 (10)  Family and friends 14 (28) 19 (40)  The person living with type 2 diabetes 31 (62) 33 (69)  Another physician (i.e., endocrinologist) 10 (20) 21 (44) ¤  Other 0 0 What type of “physician” is primarily responsible for the management of your diabetes? NA NA  Primary care physician (general practice, family practice, or internal medicine) 165 (82) 157 (77)  Diabetes specialist 23 (11) 36 (18)  Endocrinologist 10 (5) 10 (5)  I do not see a physician 2 (1) 1 (0.5)  Other 1 (0.5) 0 How often are you visiting this “physician” for the management of your diabetes? NA NA  More frequently than once a month 8 (4) 5 (3)  Once a month 17 (9) 15 (7)  Once every 3 months 111 (56) 117 (58)  Once every 6 months 54 (27) 59 (29)  Once a year 4 (2) 4 (2)  Less frequently than once a year 4 (2) 3 (2)  Don’t know 0 0 Which of the following health care professionals do you currently see or talk to for the management of your diabetes? The interaction could be in person, over the phone, or via email. NA NA  Diabetes counselor or educator  Nurse care manager 39 (19) 28 (14)  Physician assistant 32 (16) 33 (16)  Other 73 (36) 68 (33)  None of these 83 (41) 101 (50)  Don’t know 1 (0.5) 0 Specifically, in your community, which of the following programs are you aware of that are available to help people possibly manage their prediabetes or type 2 diabetes?  National Diabetes Education Program 14 (35) 8 (22) 80 (40)a 50 (25)  Cities for Life 0 5 (14) ¤ 12 (6) 12 (6)  Defeat Diabetes 1 (3) 2 (6) 22 (11) 18 (9)  Alabama Cooperative Extension Systemb 3 (8) 0 32 (16) 29 (14)  United Against Diabetes 2 (5) 2 (6) 29 (14) 21 (10)  The Alabama Diabetes Prevention and Control Program 7 (18) 9 (25) 41 (20) 30 (15)  Southeastern Diabetes Education Services 6 (15) 1 (3) 15 (8) 12 (6)  I Decide to Fight Diabetes 1 (3) 2 (6) 18 (9) 16 (8)  Steps to a Healthier US—Alabama 3 (8) 4 (11) 27 (13) 26 (13)  YMCA of Birmingham, YMCA Diabetes Prevention Program 22 (55)c 16 (44)a 72 (36) ¤ 52 (26)  American Diabetes Association, Alabama 26 (65) 24 (67) 124 (62) 110 (54)  Other 0 0 6 (3) 7 (3)  None of these 7 (18) 3 (8) 38 (19) 52 (26)a  Don’t know 0 2 (6) 4 (2) 16 (8) ¤ ADA, American Diabetes Association; BMI, body mass index; CDC, Centers for Disease Control and Prevention; HCP, health care providers; NA, not applicable; NIH, National Institutes of Health; RN, registered nurse. aSignificant difference between patients and providers in W2. ¤Significant difference within the same group between W1 and W2. bAgricultural program, not related to diabetes. cSignificant difference between patients and providers in W1. View Large Importance of CBPs At baseline, a larger proportion of patients (44%) than HCPs (30%) believed that the community provides patients with enough support to manage their condition. In addition, significantly more HCPs (35%) “do not know” whether there is enough support for diabetes management provided by their community as compared with14% of patients (p < .05). At baseline, 41% of patients and 33% of HCPs found CBPs valuable for helping with diabetes self-management. When asked about the most valuable aspect of the CBPs in an open-ended question (“What are the most valuable aspects of the programs in your community designed to help you possibly manage your prediabetes or type 2 diabetes?”), a substantial proportion (38%) of HCPs believed that awareness, education, and information are the most valuable aspects of CBPs. Nearly half (45%) of the patients, however, were not sure of the most valuable aspect of CBPs. Recommendations and uptake of lifestyle modification Patients reported that although their HCPs recommended prescription medications most frequently (W1 = 91%; W2 = 85%), they also received HCP’s recommendations for exercise (W1 = 78%; W2 = 79%) and healthier eating habits (W1 = 78%; W2 = 82%). Most HCPs reported that they recommended CBPs to their patients (W1 = 90%; W2 = 78%) as well as physical activity and dietary counseling, among other diabetes prevention and management strategies. Some HCPs did not recommend any programs for diabetes management to their patients (W1 = 10%; W2 = 19%). The majority of HCPs reported that some of their patients typically participate in CBPs (W1 = 64%; W2 = 64%), and fewer HCPs reported that most of their patients typically participate in CBPs (W1 = 6%; W2 = 18%). A small proportion of HCPs reported their patients do not participate (W1 = 14%; W2 = 7%), and some HCPs did not know about their participation (W1 = 17%; W2 = 11%). However, most patients reported that they do not participate in community programs (W1 = 67%; W2 = 72%), while fewer do participate (W1 = 31%; W2 = 22%). The HCPs, when asked about why their patients who do not adhere to community programs have difficulty with adherence, reported that the top reasons are that patients are not personally motivated (W1 = 38%; W2 = 57%) and the patients do not understand the importance of these programs (W1 = 37%; W2 = 7%). The top strategy reported by the HCPs for increasing patient motivation regarding recommendations was that the HCPs emphasized the possible complications of diabetes (W1 = 86%; W2 = 83%), followed by suggestions to keep a journal for diet, exercise, and other self-management activities. In addition, HCPs informed patients that diabetes is a chronic disease that can be self-managed (W1 = 62%; W2 = 69%). About half (W1 = 50%; W2 = 54%) of HCPs reported providing literature or some form of information about diabetes to patients, and fewer (W1 = 20%; W2 = 21%) reported providing a list of local CBPs. Importance of support Over half of the patients (W1 = 54%; W2 = 64%; p < .05) reported that they received a lot of support from their families and friends including emotional support (W1 = 73%; W2 = 76%), encouragement (W1 = 63%; W2 = 66%), and reminders (W1 = 49%; W2 = 52%). Few patients (W1 = 15%; W2 = 13%) reported that they do not get any support. Among patients in either wave, 68% reported that most of their family, friends, and coworkers understand their needs for self-management. The providers reported only a small proportion of their patients receive a lot of support (W1 = 0%; W2 = 10%; p < .05) and a small proportion (W1 = 4%; W2 = 4%) do not get any support. Barriers to improved self-management Patients and HCPs independently reported patients’ lack of motivation as a significant barrier to better diabetes care. Lack of motivation was the second most common reason reported by the patients for (a) not seeking more information about diabetes management (W1 = 25%; W2 = 23%), (b) increasing amount of exercise (W1 = 37%; W2 = 40%), and (c) achieving healthier diet (W1 = 33%; W2 = 35%). Lack of motivation was the third top barrier for having regular interactions with HCPs (W1 = 13%; W2 = 12%) as reported by the patient. The HCPs, however, reported that the lack of patient motivation was the top barrier to having regular interactions with their patients (W1 = 80%; W2 = 71%). Patients reported that the top three barriers for having regular interactions with HCPs were “I feel I already know a lot; am making a great effort” (W1 = 48%; W2 = 56%), “I go to the doctor enough. I do not want to spend more time visiting a physician” (W1 = 31%; W2 = 25%), and lack of personal motivation. Patients reported that their top barrier to exercising was “medical problems” that inhibit them from doing many exercises (W1 = 46%; W2 = 54%). The top three patient-reported barriers to having a healthier diet were “I feel I already am making a great effort” (W1 = 38%; W2 = 35%), lack of personal motivation, and “healthy food is too expensive” (W1 = 31%; W2 = 31%). When asked about how easy or hard it is to implement the steps that the HCPs recommended for their diabetes management, patients predominantly reported that they find items related to formal medical care and monitoring (lowering blood pressure, lowering cholesterol, regularly checking their blood sugar levels, visiting the physician regularly for monitoring of their diabetes, and regular checkups with an eye doctor) were easy to implement. The following items were hard to implement: (i) self-management and behavioral modifications such as cardiovascular activity (running, biking, or swimming) and participating in a weight-loss program, (ii) seeking and getting community support and counseling, and (iii) using diabetes websites (e.g., American Diabetes Association) for recipes and other tips. Detailed information is presented in Fig. 1. Fig 1 View largeDownload slide Patent responses and results on how easy or hard it is to implement the recommendations for better diabetes management. Fig 1 View largeDownload slide Patent responses and results on how easy or hard it is to implement the recommendations for better diabetes management. Health indicators About one half of all patient respondents believed they were overweight (W1 = 55%; W2 = 49%); one third believed they maintain “proper weight” (W1 = 31%; W2 = 41%; p < .05); and few identified themselves as obese (W1 = 12%; W2 = 8%). The providers reported that almost half of the patients in their clinic are obese (W1 = 42%; W2 = 46%), 32% (both waves) are overweight, and a smaller proportion of their patients maintain “proper weight” (W1 = 22%; W2 = 17%). Diabetes care and chronic disease management Patients indicated that among medical professions, primary care providers are primarily responsible for their diabetes management (W1 = 82%; W2 = 77%). The HCPs state that they are responsible for leading coordinated diabetes care (W1 = 80%; W2 = 77%), with the majority of HCPs indicating that the person living with type 2 diabetes is equally responsible for their health or self-management (W1 = 62%; W2 = 69%). Regarding the discussion about diabetes prevention, when asked “Who typically initiates this discussion about reducing the risk of type 2 diabetes?”, providers indicated that they, not the patients, initiate the discussion most of the time (W1 = 100%; W2 = 90%; p < .05). In terms of the frequency of patient visits to HCPs, most patients reported visiting their HCP every 3 months (W1 = 56%; W2 = 58%), about one third visit every 6 months or less (W1 = 27%; W2 = 29%), and few patients visit every month or more frequently (W1 = 13%; W2 = 9%). A small proportion of patients visit their HCPs once a year or less (W1 = 4%, W2 = 3%). Most of the HCPs reported that they see their patients with controlled diabetes every 3 months (W1 = 66%; W2 = 56%), and some see their patients with controlled diabetes every 6 months (W1 = 26%; W2 = 29%). The majority of HCPs see patients with an A1c between 7 and 8.9 every 3 months (W1 = 76%; W2 = 73%) and see patients with an A1c 9 and higher every month (W1 = 44%; W2 = 56%) to every 3 months (W1 = 42%; W2 = 29%). Over half of the patients (W1 = 51%; W2 = 59%) reported that they visit or talk to a diabetes counselor or educator, nurse care manager, or other health care professional about the management of their diabetes. Among those, the proportion of patients who visit or talk to these health care professionals once every 3 months increased significantly from W1 to W2 (W1 = 32%; W2 = 51%; p < .05). The proportion of those patients who visit or talk to these other health care professionals once a month (W1 = 18%; W2 = 7%), more frequently than once a month (W1 = 7%; W2 = 8%), or less than once a year (W1 = 9%; W2 = 6%) did not change significantly. Awareness and perspectives on Cities for Life Twelve (6%) of the patients in either W1 or W2 were aware of Cities for Life. Of those who were familiar, patients most frequently reported hearing about the program from others or in their doctor’s office. As compared with no providers at W1, five HCPs (14%) were familiar with the program in W2. Out of those, three HCPs recommended Cities for Life to their patients and reported that two of their patients participated. DISCUSSION Awareness of available CBPs Diabetes is a major public health condition and a chronic condition that poses a significant burden on patients, families, health systems, and the economy. It is largely recognized that self-management is an important aspect of diabetes prevention and effective management. In spite of widespread recognition of community organizations in many areas of health promotion, they have been underutilized as an approach to diabetes prevention and management. From this perspective, diabetes is predominantly a clinical issue instead of a clinical issue combined with public health, population, and community dimensions [6]. Thus, it is important to understand the perspectives of both patients and health care professionals who deliver care to patients with diabetes and other chronic conditions on the role of self-management and CBPs. To our knowledge, this is the first study to assess perceptions, beliefs, attitudes, and self-reported behaviors related to diabetes self-management and the role of CBPs concurrently among HCPs and patients with type 2 diabetes or prediabetes. In addition, this study expands on the growing body of evidence regarding the effectiveness of public awareness initiatives. Overall, we found that awareness of available community resources and CBPs that provide services for patients with diabetes was somewhat low among HCPs and patients. Interestingly, the awareness of different types of resources differed between the HCPs and the patients with the HCPs being more aware of major formal and structured types of programs, such as weight loss and diabetes counseling, while the patients were more aware of unstructured and variable resources such as magazines, grocery stores, parks, and local support groups. This suggests that the patients are seeking resources for self-management from a broader range of community resources and amenities than the HCPs were aware. This assumption may also be supported by our findings that significantly more patients than HCPs believe that their community provides enough support for their diabetes management. This further illustrates that HCPs may not be aware of the amount of support the patients may have access to in their communities, or that HCPs and patients may even have different interpretations of “community support,” or what is sufficient or “enough.” Overall, many patients and providers believe that there is not enough support provided by communities. Recent evidence indicates that creating and supporting infrastructure for promoting self-management within communities may reduce chronic diseases, promote healthy lifestyles, reduce disparities, and reduce costs of health care [7]. Recommendation versus utilization Another key area of discordance between HCPs and patients was related to the high level of HCPs’ recommendation of, versus actual low patient participation in, CBPs for diabetes self-management. The differences related to adherence to management recommendations between HCPs and patients have been previously reported [8, 9]. Multiple studies describe the barriers to diabetes management that negatively affect patients’ ability to carry out recommendations successfully [1, 2]. Earlier studies postulated that the patients’ inability to implement HCP’s recommendation may be due to their inability to recall the recommendations. In our study, the patients’ reports on recommendations received for exercise and healthier eating habits align very closely with providers’ reports on recommendations provided. Patients’ lack of recollection may not be sufficient to explain nonadherence to management recommendations. Barriers and motivations Several recent literature reviews on barriers and facilitators to managing chronic conditions, such as diabetes, have concluded that patients experience multiple barriers that the HCPs either are unaware of or may not find as important [2, 8, 10]. The results of our study corroborate previous findings and expand on the understanding of differences in how patients and HCPs perceive barriers to improved care [2]. Previously reported HCP’s perspective on patient barriers highlighted the lack of patient education and understanding of diabetes, its complications, or the importance of self-management [8, 11]. In our study, the patients reported that they already know a lot about diabetes and diabetes management, though we did not assess their knowledge objectively. Our study finds that patients struggle with internal and external barriers to lifestyle change, including lack of motivation. The lack of patient motivation was similarly recognized by HCPs and patients. Motivational interviewing (MI) and Open Questions, Affirmation, Reflective Listening, and Summary Reflections (OARS) technique have been recently recognized as effective in increasing personal motivation and patient adherence to chronic disease management and behavioral modifications [12, 13]. These strategies are recommended for inclusion in the provider training and provider–patient communications; however, it is important to further explore what factors contribute to the patients’ “lack of motivation” or else MI will not be effective. Lack of motivation and other psychosocial and external barriers may also be addressed by implementing team-based or coordinated care models that include strategies such as collaborative goal setting, collaborative problem solving, enhancing motivation and self-efficacy, and continuing support [14]. In addition, it appears that patients’ perceptions of the common recommendation that “patients need to be educated” may in fact create barriers to seeking appropriate support. Future studies should explore the balance between the need for patients to be educated, and when patients report that they are educated enough, whether they would benefit from other strategies to reach their diabetes care goals [15]. Taken together, the lack of patient awareness of available resources and low patient motivation and engagement in initiation of discussions about diabetes with HCPs, combined with a perception that the patients feel educated enough, may indicate that patient empowerment among participants in this study is low. Social support Although the importance of social and family support is highlighted in the patient responses in previous studies, the evidence on the effects of family and social support is conflicting. Family support has been found to be associated with both positive and negative health outcomes. Most of the studies summarized in the recent literature review on barriers and facilitators to managing multiple chronic conditions by Koch et al. [16] explored lack of social and family support as one of the key barriers to optimal chronic disease care. The review presented five studies on family support that reported negative impact of family members on patients’ attempts to initiate or sustain healthy lifestyle. In the review by Miller and DiMatteo [17] on effects of social support on adherence to diabetes management, specifically, the evidence showed positive association between social support and positive outcomes. Overall, we found that most of the patients viewed the role of their family in their diabetes management as important and positive and most reported receiving “a lot” of support from their family, friends, and coworkers. The HCPs, however, believed only a small proportion of their patients receive a lot of support and only a few do not get any support, thus underestimating the proportions of patients with and without strong social support networks. It is important to note that ~15% of patients reported they do not have any support. Given the evidence of negative association of lack of support and patient outcomes, it may be beneficial if HCPs regularly inquired about the level of patient support and identified those who may benefit from seeking additional support. Given the emerging evidence on the positive effects of family-focused interventions (including behavioral family systems therapy, family social support training programs, peer support, and problem-solving group interventions), future research and clinical practice need to focus on the tactics that empower family members, friends, coworkers, and employers in supporting behavioral change in patients with type 2 diabetes [17, 18]. Future research should explore the types of social support interventions that incorporate social, cultural, and economic issues. Future interventions should also consider an active role that family members and friends can play in reducing barriers to diabetes self-management, in particular in areas where patients report the most challenges, such as exercise, weight loss, and community support access. Potential for closing the gap HCPs and patients often report discordant views regarding diabetes management [19]. Patients often struggle with motivation for behavior change. Explicit motivational language from HCPs about the benefits of lifestyle modification and medications, accompanied by community engagement, may help to close the gap in perceptions and reduce barriers. Even though mass media and other awareness campaigns have been used successfully to change health behavior [20], the results of our study did not find much change in perceptions over the course of 1 year. However, this was not surprising as it is known that most successful awareness programs are long term in duration, multicomponent, target episodic rather than chronic behavior and are well supported by policy and availability and access to crucial support services [20, 21]. More research is needed to explore effective ways to utilize public awareness campaigns and community engagement in supporting diabetes self-management. It is important to note that the results of our study need to be interpreted with caution due to several limitations. The patients who responded to our survey may have received health care services from nonparticipating HCPs and thus may not have the same views as the patients of participating HCPs. As mentioned earlier, the campaign was relatively short and broad and did not specifically target the survey participants who may or may not have been exposed to the campaign during the implementation period. Nonetheless, the purpose of the work was indeed to assess the effect of the campaign on a larger segment of the population, not only on people who were certainly exposed to the campaign, thus reducing possible selection bias. Several sociodemographic characteristics of the participants such as race, ethnicity, economic, or educational background were not available as a part of the survey, and the responses may be not representative of the patients from these groups. Whatever changes we observed over time have limited generalizability for establishing cause and effect in such a complex system because the results may not be fully attributed to the Cities for Life campaign. Moreover, we believe that behavioral changes take more than an awareness campaign. The broad range of public messages, activities, and events that Cities for Life included may be a limiting factor in terms of its focus and impacts. It may be necessary for the program managers to work with the community leaders on establishing and maintaining a specific and focused scope for similar programs. Overall, the public awareness campaigns for diabetes management may benefit from more rigorous project and evaluation designs, program monitoring, and targeted interventions informed by the patient and provider perceptions and preferences collected during baseline assessments. Given the important role that the CBPs play in diabetes support, it may be beneficial to establish and evaluate patient-centered collaborative programs that directly involve community services and improve utilization and effectiveness of those CBPs which patients find valuable. Future research studies need to explore which aspects of a public awareness campaign could be effective in closing the perception gaps and supporting patients with diabetes in their self-care. SUPPLEMENTARY MATERIAL Supplementary material is available at Translational Behavioral Medicine online. Compliance with Ethical Standards Primary Data: The authors have full control of all primary data, and they agree to allow the journal to review their data if requested. The findings reported in this work have not been previously published, and the manuscript is not being simultaneously submitted elsewhere. The data were previously presented as a poster at the American Diabetes Association 74 Scientific Session, San Francisco, CA, June 13–17, 2014. Conflict of Interest: N.Y. Loskutova: research support from Sanofi US, Merck, Eli Lilly and Shire; A.G. Tsai: research support from Sanofi US and Nutrisystem, Inc.; M. Harrington: research support from Sanofi US; T.J. Turner: research support from Sanofi US; W.D. Pace: research support from Sanofi US, Shire, Mallinckrodt, Novartis Pharmaceuticals Corporation, Merck, Pfizer, Inc. J.K. Carroll, E. Callen, and K. Ajayi declare they have no conflict of interest. Ethical Approval: All procedures performed in this study involving human participants were in accordance with the ethical standards of the AAFP IRB and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants in this study. No animals were used in this study. Acknowledgments We are extremely grateful to the City of Birmingham, including the University of Alabama at Birmingham and study participants, members of the Community Action Team (CAT), Mayor William Bell Sr., and City Councilor Jay Roberson (District 7). Special thanks to our Steering Committee members, whose hard work and dedication made this program possible. We thank the AAFP National Research Network for providing essential support and expertise. The Cities for Life project is made possible with support from Sanofi US. Sanofi US was not involved in the study design, data analysis, and interpretation or reporting of this work. References 1. Peyrot M , Rubin RR , Lauritzen T , Snoek FJ , Matthews DR , Skovlund SE . Psychosocial problems and barriers to improved diabetes management: Results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study . Diabet Med . 2005 ; 22 ( 10 ): 1379 – 1385 . Google Scholar CrossRef Search ADS PubMed 2. Pun SPY , Coates V , Benzie IFF . Barriers to the self-care of type 2 diabetes from both patients’ and providers’ perspectives: Literature review . J Nurs Healthc Chronic Illn . 2009 ; 1 (1) : 4 – 19 . Google Scholar CrossRef Search ADS 3. Marrero DG , Ard J , Delamater AM et al. Twenty-first century behavioral medicine: A context for empowering clinicians and patients with diabetes: A consensus report . Diabetes Care . 2013 ; 36 ( 2 ): 463 – 470 . Google Scholar CrossRef Search ADS PubMed 4. Steckler A , McLeroy KR , Goodman RM , Bird ST , McCormick L . 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Barriers and facilitators to managing multiple chronic conditions: A systematic literature review . West J Nurs Res . 2015 ; 37 ( 4 ): 498 – 516 . Google Scholar CrossRef Search ADS PubMed 17. Miller TA , Dimatteo MR . Importance of family/social support and impact on adherence to diabetic therapy . Diabetes Metab Syndr Obes . 2013 ; 6 : 421 – 426 . doi: 10.2147/DMSO.S36368 . Google Scholar CrossRef Search ADS PubMed 18. Fry-Bowers EK , Maliski S , Lewis MA , Macabasco-O’Connell A , DiMatteo R . The association of health literacy, social support, self-efficacy and interpersonal interactions with health care providers in low-income Latina mothers . J Pediatr Nurs . 2014 ; 29 ( 4 ): 309 – 320 . Google Scholar CrossRef Search ADS PubMed 19. Simmons D , Lillis S , Swan J , Haar J . Discordance in perceptions of barriers to diabetes care between patients and primary care and secondary care . Diabetes Care . 2007 ; 30 ( 3 ): 490 – 495 . Google Scholar CrossRef Search ADS PubMed 20. Wakefield MA , Loken B , Hornik RC . Use of mass media campaigns to change health behaviour . Lancet . 2010 ; 376 ( 9748 ): 1261 – 1271 . Google Scholar CrossRef Search ADS PubMed 21. Randolph W , Viswanath K . Lessons learned from public health mass media campaigns: Marketing health in a crowded media world . Annu Rev Public Health . 2004 ; 25 : 419 – 437 . Google Scholar CrossRef Search ADS PubMed © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Translational Behavioral MedicineOxford University Press

Published: May 23, 2018

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