Barriers to appropriate diabetes management among homeless people in Toronto

Abstract

Background: Homeless people are more likely to have chronic medical conditions and to encounter barriers to health care than the general population. In this study we identify barriers to appropriate disease management among homeless adults with diabetes mellitus in Toronto.

Methods: People with diabetes were surveyed at homeless shelters in Toronto. Information was obtained on demographic characteristics, diabetes history, access to health care, substance abuse and mental illness. Participants' descriptions of the difficulties they experienced in managing their diabetes were analysed qualitatively. Hemoglobin A1c levels were used to assess adequacy of glycemic control.

Results: Fifty people completed the survey (response rate 83%). Of the respondents 82% were male and 64% were white. Type 2 diabetes had been diagnosed in 86%, with 62% of all participants taking oral agents alone and 28% taking insulin alone. Overall, 72% of the participants reported experiencing difficulties managing their diabetes: the most common were related to diet (type of food at shelters and inability to make dietary choices, reported by 64%) and scheduling and logistics (inability to get insulin and diabetic supplies when needed and inability to coordinate medications with meals, reported by 18%). Although alcohol use, cocaine use and mental health problems were common, few respondents cited these issues as barriers to diabetes management. According to Canadian Diabetes Association guidelines, glycemic control was inadequate in 44% of the people tested.

Interpretation: In Toronto, most homeless adults with diabetes report difficulties managing their disease, and poor glycemic control is common.

Fig. 1: Distribution of hemoglobin A_1c levels in a group of homeless adults in Toronto with type 2 diabetes mellitus (white bars) and in a population-based sample of adults in the United States with type 2 diabetes¹³ (black circles).