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2023 HSR&D/QUERI National Conference Abstract

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4100 — Understanding Diabetes Distress in Veterans with Type 2 Diabetes: Findings from an Explanatory Sequential Mixed-Methods Study

Lead/Presenter: Allison A Lewinski,  COIN - Durham
All Authors: Lewinski AA ((Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System; School of Nur), Crowley, MJ (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System; Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Duke University School of Medicine) Jeffreys, AS (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System) Coffman, CJ (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System; Department of Biostatistics and Bioinformatics, Duke University School of Medicine) Whitfield, CL (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System) Howard, T (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System) Shapiro, A (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System) McConnell, E (School of Nursing, Duke University; Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Health Care System) Tanabe, P (School of Nursing, Duke University; Division of Hematology, Department of Medicine, Duke University School of Medicine) Barcinas, S (Department of Educational Leadership, Policy, and Human Development, College of Education, North Carolina State University) Roman Jones, J (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System) Bosworth, HB (Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System; School of Nursing, Duke University; Department of Population Health Sciences, Duke University School of Medicine; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine)

Objectives:
Diabetes Distress (DD, i.e., regimen, emotional, interpersonal, clinician) in Veterans with diabetes mellitus type 2 (T2DM) and is associated with poor glycemic control, poorer diet and exercise, and more T2DM complications. The specific aim of this analysis was to describe how, and to what extent, differences exist in how Veterans describe DD in the context of T2DM self-management. We were particularly interested in noting differences by A1C ( < 9 or ? 9), medication use (insulin, no insulin), and severity of DD (low, moderate, high).

Methods:
Mixed-methods analysis of data collected from: (1) surveys with Veterans (n = 210) on DD, depression, empowerment, diabetes stigma, self-management behaviors; and (2) in-depth interview data from Veterans (n = 36) with questions focused on DD in the context of living with, and self-managing, T2DM. We assessed severity of DD by the Diabetes Distress Scale. First, we completed a descriptive analysis of interview transcripts using thematic analysis guided by the DD domains (regimen, emotional, interpersonal, clinician). Second, we integrated quantitative and interview data using matrices to examine the presence of qualitative descriptive themes by our variables of interest.

Results:
Mean age was 63 years (SD 10.2); 15% female; 69% non-white; 56% on insulin; mean A1c 8.9% (SD 2.0); mean DD score was 2.0 (SD 0.9), indicating moderate distress. When we integrated the quantitative data with the interview data, we noted that the presence of themes within each domain of DD varied by A1C, medication use, and severity of DD. Mixed methods analysis of the interview data indicated that all participants described regimen distress regardless of A1C level, medication use, and severity of DD. Descriptions of regimen distress included a general sense of overwhelm and frustration as well as distress and pain around blood glucose monitoring. Regarding emotional distress and medication use, Veterans who did not use insulin described a fear of the future with T2DM, whereas Veterans who used insulin described frustrations and embarrassment in regards to mental and physical changes from T2DM. Regarding emotional distress and severity of DD, those Veterans with moderate and high DD described distress particularly around maintaining a T2DM-friendly diet. Regarding clinician-related distress and A1C levels, Veterans with an A1C ? 9 described more clinician-related distress than those with A1C < 9; this distress was centered on lack of communication and frustration with medication changes. We noted a new domain of distress, the lifetime nature of T2DM, in our descriptive analysis. Regarding the lifetime nature of T2DM, Veterans who used insulin were more likely to feel that T2DM was controlling their lives and would be their cause of death. However, Veterans who did not use insulin feared future consequences of T2DM and felt a “sense of impending doom” about T2DM.

Implications:
DD, as a whole and by domain, is experienced differently by Veterans based upon A1C, medication use, and DD severity.

Impacts:
Identifying causes of DD in Veterans can help inform clinical decision-making and the provision of clinical and social resources to support the Veteran in T2DM self-management.