Original Research

Experiences of Veterans With Diabetes From Shared Medical Appointments

Fed Pract. 2015 May;32(5):40-45

References

1. Vouri SM, Shaw RF, Waterbury NV, Egge A, Alexander B. Prevalence of achievement of A_1c, blood pressure, and cholesterol (ABC) goal in veterans with diabetes. J Manag Care Pharm. 2011;17(4):304-312.

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Discussion

The purpose of this study was to analyze the veteran experience with diabetes self-management and identify motivating factors and barriers in a population that had attended a primary care SMA series. The focus group had several interesting findings. A person’s identity or self-worth can be disrupted by the experience of chronic illness. Chronic illness can be conceptualized as a threat to one’s sense of security and identity.¹⁵ This disruption of identity at various stages of diabetes duration, from new onset to living many years with this chronic illness, is illustrated in the study participants’ comments of negotiating, adapting, and integrating diabetes into their lives.

This outcome is similar to findings by Olshansky and colleagues in which individuals struggled with the transition of becoming “a person with diabetes” rather than a “diabetic person.”¹⁶ Olshansky and colleagues suggested emphasizing lifestyle changes as health-related benefits for all people, those with and without diabetes, as a strategy to deal with normalizing their new identity; this concept can be viewed as a form of empowerment.

Furthermore, veteran identity was found to be an important factor for driving behaviors in diabetes care. This layering or double identity of diabetes plus being a veteran can be particularly challenging. Several participants commented on Agent Orange exposure during their service time as the etiology of their diabetes. Some of the veterans placed more value on what other fellow veterans said vs what health care professionals said. A study of nonveteran insulin users found that narratives or sharing of life stories of diabetes to be beneficial to the described assault on personal identity.¹⁷

As only about one-third of participants had a support person for their diabetes in this focus group, veteran-only groups likely have additional benefits, especially for those without family support. An additional complication of diabetes self-management in the veteran population is a disproportionate prevalence of posttraumatic stress disorder, depression, and substance abuse comorbidities (including alcoholism).

Of interest in this focus group was the low rating of peer-led groups as a motivator for successful diabetes self-management, perhaps because this was not offered at VAPHCS. Support or peer-led groups provide ongoing opportunities to address at least 2 of the AADE 7 self-care behaviors—problem solving and healthy coping. A recent 6-month study compared peer coaches, financial incentives, or usual care to promote behaviors for improved glucose control in African American veterans.¹⁸ Weekly telephone interventions by the peer mentors reduced A_1c by 1.07% (95% confidence interval [CI], 1.84%-0.31%) compared with 0.45% (95% CI, 1.23%-0.32%) in the group with financial incentives. The authors suggest transitioning patients who achieve control from mentee to mentor roles to maintain the program’s sustainability.

Nearly all participants endorsed the SMAs as valuable for the expertise and education they offered as well as for the chance to meet regularly with a veteran diabetes cohort group for support. The SMAs could be viewed as an avenue for shared narratives that may assist individuals in understanding their experiences and adapting to their chronic illness.

Using social psychology interventions to change behaviors may be challenging in busy primary care settings and hampered when veterans perceive only pressure to do what their providers recommend in a controlled behavior fashion. Individuals in a SMA may be more apt to act in a self-determined manner when they feel they are in control and activities are done with volition and a choice consistent with their identity when supported by their fellow diabetic veterans. A previous survey of VA provider and student perceptions that used an SMA for diabetes education in a primary care setting also found benefits, but sustainability issues were identified, such as limited resources (space), organization issues with clinic structure redesign, and potential to alter long-standing patient-provider relationships.^19,20

An emphasis on A_1c goals may be appropriate, because this was the highest rated motivator in the focus group, although care should be taken to tailor care to the needs of the veteran. A veteran population may be even more driven by constant evaluation of their success in reaching target goals. Education may be useful about how A_1c relates to diabetes, such as self-monitoring of blood sugar, complications, and medications.

A study by Heisler and colleagues found that knowing A_1c values was useful to patients to assess their diabetes control but not sufficient to increase confidence or motivation.²¹ In this mail survey of patients with T2DM, where the VA was 1 of 5 sites, 66% did not know their last A_1c value, and only 25% accurately reported that value. The authors stated that it was unknown why VA respondents had significantly lower odds than did patients at the other sites of knowing their last A_1c value. This study’s focus group was anonymous, and participants were not asked whether they accurately knew their A_1c value or goal.