Authors:

Abstract

Introduction: People of lower socioeconomic status (SES) are at higher risk of developing diabetes complications because they face more difficulties in taking care of their disease. People with another ethnic background than Danish are at particular high risk. The Western part of Aarhus, Denmark, is a community with a high proportion of vulnerable citizens, primarily people of low SES and/or another ethnic background, living with type 2 diabetes where it is urgent to improve diabetes management. During a two-year project, a diabetes-nurse employed in the municipality health center offered a tailored, person-centred intervention in collaboration with general practitioners. 

Methods: Using mixed methods, the aim was to (a) study how the integrated care model and diabetes-nurse work to support vulnerable citizens and (b) measure the effect of tailoring interventions to the individual. Quantitatively, the study uses data on patient outcomes, e.g. HbA1c levels, process measures, e.g., participation in program activities, and patient reported outcomes, e.g., SF12 (n=40). Qualitatively, the study uses ethnographic observations, e.g., shadowing health care professionals, and interviews with nurses (n=3), citizens (n=14) and GP's (n=3) to zoom in on experiences and experienced outcome, cross-sectoral cooperation, challenges, opportunities, and sustainability by shadowing the daily work of the diabetes-nurse.

Highlights: The diabetes-nurse used three main drivers to support this diverse groups of citizens living with complex social and health related issues. (1) Relational work: build trust to actually start addressing diabetes-related issues. (2) Person-centred: start with the most pressing issues defined by the citizens themselves, thereby often dealing with issues unrelated to diabetes (3) Engaging the local community: take advantage of the community health center being placed within the citizens' neighborhood. Citizens highlight that they value the relationship with the diabetes-nurse and that all their complex social and health related issues are managed by one health care professional who proactively guide them through the health care system. Preliminary quantitative results show that the average HbA1c levels decreased by 10 mmol/mol and that the proportion of citizens who experienced good well-being and high quality of life increased from 41% to 74%.

Conclusions: Supporting vulnerable citizens with diabetes alongside other complex medical, social and cultural issues is challenging. This project used a model of integrated care where a diabetes-nurse used a relational and patient-centered approach to help vulnerable citizens improve their diabetes self-care and clinical outcomes.

Implications for applicability/transferability, sustainability, and limitations

The project initially struggled with patient recruitment. The project is unable to document longer-term effects. Future studies are needed about the extent to which new habits and care outcomes are maintained. Covid-19 influenced the intervention in terms of citizens' motivation and participation in program activities.