(Mis)understanding in patient‐health care provider communication about total knee replacement

Objective

To examine whether communication factors affect health care provider and patient agreement on the need for, risks of, and benefits of joint replacement, and also whether degree of agreement predicts patient satisfaction and intent to follow treatment recommendations.

Methods

Health care providers (n = 27) and patients (n = 74) with severe osteoarthritis (OA) were recruited from clinics in Houston, Texas. Patients completed a baseline survey prior to the consultation. After the visit, patients and providers completed measures of the severity of the patient's OA, the expected benefits of total knee replacement (TKR), and concern about surgical complications. Patients also completed satisfaction and intent to adhere measures. Provider communication and patient participation were measured by patient self‐report and by observers' codings of audiorecordings of the consultations.

Results

Provider‐patient agreement was modest to poor regarding severity of the patient's OA and the expected benefits and risks of TKR. Providers and patients were more aligned on the patient's OA severity when providers used more partnership building but spent less time simply giving information. Differences between providers' and patients' concerns about surgery were greater when patients were less participatory, African American, or expressed lower trust in their doctors. Patient satisfaction and intent to adhere were predicted by provider‐patient agreement on the benefits of TKR.

Conclusion

Patients and providers often differ in their beliefs about the need for, risks of, and benefits of TKR, and these differences can affect patient satisfaction and commitment to treatment. Facilitating active patient participation might contribute to greater physician–patient agreement on the patient's concerns about OA and surgical interventions.     

Self‐monitoring of blood glucose changed non‐insulin‐treated Type 2 diabetes patients’ beliefs about diabetes and self‐monitoring in a randomized trial

Aims To determine whether differences in beliefs about diabetes and its treatment resulted from different intensities of self‐monitoring of blood glucose (SMBG) in non‐insulin treated patients with Type 2 diabetes in the Diabetes Glycaemic Education and Monitoring (DiGEM) trial. Methods Patients (n = 453) were randomized to usual care, less‐intensive SMBG and more intensive SMBG. Beliefs about diabetes were measured with a standard questionnaire (the revised Illness Perceptions Questionnaire; IPQ‐R). Changes in beliefs were analysed using analysis of covariance (ancova) with adjustment for baseline values. Mediation analyses assessed whether differences in behavioural outcomes between groups could be attributed to differences in beliefs. Results Completed questionnaires were returned by 339 patients (74.8%). Respondents were mean (± sd ) age 65.9 ± 10 years and with diabetes duration of 4.8 ± 4.7 years (median 36, range 1–384 months). Concerns about the consequences of diabetes increased in both self‐monitoring groups, relative to control subjects [P = 0.004; Cohen's d standardized effect size = 0.19 less intensive and d = 0.36 more intensive monitoring]. No other beliefs about diabetes differed between groups. Beliefs about the importance of self‐testing increased in both self‐monitoring groups relative to the usual‐care group (P < 0.001; d = 0.57 less intensive and d = 0.63 more intensive monitoring). Changes in psychological well‐being did not differ between groups, but control patients reported greater increases in general (P = 0.014) and specific (P < 0.001) dietary adherence than did patients in the self‐monitoring groups. These outcomes were not mediated by intervention‐related changes in beliefs. Conclusions Despite changes in some beliefs about diabetes differing between groups there were no corresponding changes in self‐reported health behaviours. This suggests that changes in illness beliefs resulting from SMBG do not cause changes in diabetes‐related health behaviours.     

Cross‐cultural comparison of predictors for self‐care behaviors in patients with type 2 diabetes

The aim of the present study was to evaluate how culture moderates the behavioral and psychosocial predictors of diabetes self‐care activities. Patients with type 2 diabetes were recruited in the outpatient department at two sites: Kyoto University hospital in Japan and the Christiana Care Health System in the USA. The data were collected by survey using questionnaires including questions on the frequency of self‐care activities, behavioral and psychosocial predictors, and other background information from 149 Japanese patients and 48 American patients. The cultural impact was observed by multiple regression analyses with interaction terms on the association between emotional support and self‐care activities in diet in female patients. The findings of the present study serve as an example of how cultural context can affect patients with diabetes, and lead to a better understanding of culturally sensitive behavioral intervention.     

The importance of health belief models in determining self‐care behaviour in diabetes

Patients’ self‐care behaviours have a major role in diabetes management. Diabetes education provides the required knowledge, but despite this, self‐care is often suboptimal. The degree to which patients follow advice as regards the various self‐care behaviours is determined by their health beliefs (Illness Representations or Personal Models) of diabetes. Psychometric studies have tried to categorize and measure the beliefs about illness that influence patients to adhere to treatment recommendations in diabetes. Various models have been proposed to explain the relationship between beliefs and behaviour. Leventhal's Self‐Regulatory Model, which takes account of the emotional as well as the objective rational response to illness, currently seems to offer the best system for identifying the determinants of patient self‐care behaviour. A review of interventions indicates those based on psychological theory offer professionals the best chance of maximizing their patients’ contribution to diabetes self‐management and achieving improved outcomes, both glycaemic and psychosocial. Studies designed specifically to modify illness representations are now being undertaken. This brief review aims to summarize developments in this area of psychological theory over the last 20 years and the implications for promoting better self‐care behaviour in diabetes.     

Self‐care versus self‐harm: piercing,tattooing, and self‐injuring in eating disorders

Eating disordered patients seem to have a love–hate relationship with their bodies. Why do some decorate their bodies by means of tattooing and piercing, while others deliberately injure themselves and make parts of their body unattractive? We have explored this question in 101 eating‐disordered patients by means of self‐reporting questionnaires about the presence and characteristics of tattooing, piercing and self‐injuring as well as the underlying motives. Furthermore, we studied the co‐occurrence of impulsive behaviours as well as personality traits. In our patient sample, 11.9 per cent had one or more tattoos, 25.7 per cent a piercing and 64.9 per cent showed some form of self‐injurious behaviour (SIB). Tattooing and piercing are clearly driven by esthetical reasons, whereas SIB can have various explanations. All three behaviours were significantly more often linked to substance (ab)use. With respect to personality traits, piercing was positively linked to extraversion (positive affectivity) and openness, and negatively to conscientiousness. SIB, on the contrary, was positively linked to neuroticism (negative affectivity) and conscientiousness, and negatively to extraversion and openness. Tattooing did not show significant correlations with particular personality traits (probably due to the small number of tattooed patients). In summary, piercing and tattooing seem to reflect more self‐care, and might protect some patients against more self‐harm. Copyright © 2005 John Wiley & Sons, Ltd and Eating Disorders Association.     

Variation in perceptions of treatment and self‐care practices in elderly with osteoarthritis: a comparison between African American and white patients

Objective

To compare elderly African American and white patients with osteoarthritis of the knee or hip with respect to their perceptions of the efficacy of traditional and complementary treatments and their self‐care practices.

Methods

An observational, cross‐sectional study design using structured questionnaires was employed.

Results

The sample consisted of 593 patients (44% African American and 56% white). The 2 groups were comparable with respect to age, disease severity or functional status, and comorbidities. African Americans were more likely than whites to report lower educational level and household income. African Americans were also more likely than whites to perceive various traditional and complementary care modalities as efficacious. However, they were less likely than whites to perceive joint replacement therapy as efficacious (odds ratio 0.52, 95% confidence interval 0.28–0.98). African American patients were more likely than white patients to rely on self‐care measures for their arthritis.

Conclusion

African American and white patients with osteoarthritis of the knee or hip differ with respect to their perceptions of traditional and complementary treatments for arthritis and their self‐care practices.

     

The effect of peer support groups on self‐care for haemophilic patients with HIV in Japan

Experienced peer support groups (EPSG) are expected to improve self‐care and complement professional health care for haemophilic patients, even those living in inconvenient clinical setting. However, these benefits have not been verified quantitatively. The structural equation modelling (SEM) was used to evaluate the effects of contact with EPSG on self‐care for haemophilic patients in the Japanese clinical settings. Factors affecting self‐care were compared between groups with and without EPSG contact. Self‐reported questionnaires were mailed to 652 haemophilic patients with HIV in Japan (September 2005–January 2006). SEM demonstrated significant associations between EPSG contact, self‐care scores and other social and individual factors. The total effect of EPSG contact on self‐care was calculated. The structural differences between models were analysed in a multi‐group analysis. Of the 257 respondents (response rate, 39.4%), 109 reported having contact with an EPSG (EPSG+ group) and 139 reported no contact (EPSG? group). EPSG contact was significantly associated with better self‐care. In the multi‐group analysis, the total effect of inconvenient access to medical services on self‐care in the EPSG+ group was 10% of that in the EPSG? group and was significantly associated with poor illness‐related knowledge and high anxiety level only in the EPSG? group. In the EPSG+ group, patient age was strongly associated with self‐care than in the EPSG? group. These findings suggest that EPSG contact may alleviate inconvenience in medical services. Factors associated with self‐care differed between groups. Health care professionals must carefully assess self‐care behaviours and service accessibility based on these results.     

Self‐management education for persons with arthritis: Managing comorbidity and eliminating health disparities

Objective

To compare short‐term and long‐term effectiveness of the Arthritis Self‐Help Course (ASHC) and the Chronic Disease Self‐Management Program (CDSMP) for persons with arthritis concerning health care use, health‐related quality of life, health behaviors, and arthritis self‐efficacy.

Methods

Forty‐eight workshops were randomized to the ASHC (n = 26) or CDSMP (n = 22). A total of 416 individuals, including 365 African Americans, participated. The mean age for each group was 64 years, mean years of education was 11.7, mean number of chronic conditions was 4, and 75–80% of participants in each group were female. Multivariate statistical tests were used to assess effectiveness within and between programs for all workshop participants and African Americans.

Results

At 4 months all ASHC participants including African Americans, had significant improvements (P ≤ 0.05) in self‐efficacy, stretching and strengthening exercises, aerobic exercises, and general health. All CDSMP participants had statistically significant improvements in self‐efficacy, disability, pain, and general health. African American CDSMP participants showed statistically significant improvements in general health. Trends toward improvement (P = 0.051–0.100) were shown in 5 variables among African American CDSMP participants and in 4 variables among all CDSMP participants. Statistically significant differences between the 2 programs at 4 months were seen in pain and disability in both groups. The CDSMP produced stronger results. Significant results at 1 year within and between programs were minimal for both groups.

Conclusion

When populations with arthritis and multiple comorbid conditions are targeted, the CDSMP may be most cost effective.     

Mental distress and health‐related quality of life among type 1 and type 2 diabetes patients using self‐monitoring of blood glucose: A cross‐sectional questionnaire study in Japan

Aims/Introduction

The present multicenter, cross‐sectional survey was initiated to evaluate self‐monitoring of blood glucose (SMBG)‐associated mental distress among patients with diabetes.

Materials and Methods

The survey was carried out in patients with type 1 diabetes and type 2 diabetes using SMBG recruited from 42 medical institutions. Profiles of Mood States 2 and diabetes therapy‐related quality of life questionnaires were used to evaluate mood status and health‐related quality of life. Two original questionnaires were also developed to evaluate SMBG ‘importance,’ ‘painfulness’ and ‘confidence’ among patients, and to evaluate physician attitudes to SMBG use.

Results

Questionnaires from 517 type 1 diabetes and 1,648 type 2 diabetes patients showed that 46.0% of type 1 diabetes and 37.5% of type 2 diabetes patients reported ‘painfulness,’ and that these patients reporting ‘painfulness’ showed significantly higher Profiles of Mood States 2 scores, lower diabetes therapy‐related quality of life scores and higher glycated hemoglobin compared with those not reporting ‘painfulness,’ whereas the number of their daily SMBG tests were comparable. Patients reporting ‘painfulness’ also reported that SMBG use was significantly less important. Whether or not patients recognized the importance of SMBG use was well correlated with the frequency of physicians checking patient diaries.

Conclusions

Type 1 diabetes and type 2 diabetes patients reporting ‘painfulness’ in SMBG use had more mental distress, lower health‐related quality of life and higher glycated hemoglobin regardless of their number of daily SMBG tests. The importance of SMBG use was recognized less by patients experiencing pain, and the importance of SMBG use was recognized more in medical institutions in which physicians regularly checked SMBG diaries to provide meaningful feedback to patients in clinical settings.     

Home self‐dilatation for esophageal strictures

Esophageal strictures secondary to caustic ingestion, head and neck radiation and at the anastomosis post‐esophagectomy tend to be refractory to one or several dilatations. One option for these strictures is home self‐dilatation. The aim of this study was to assess the efficacy and safety of home self‐dilatation for a refractory esophageal stricture. A retrospective chart review was performed of all patients from 1997 to 2009 that performed home self‐dilatation for an esophageal stricture. Patients with proximal strictures without tortuosity or a shelf proximal to the stricture were selected for self‐dilatation. The patients were taught self‐dilatation by the surgeon and an experienced nurse, and an appropriate sized Maloney dilator was provided to the patient and returned when no longer needed. There were 16 patients (11 male and 5 female) with a median age of 60 years (range 38–78). The stricture was related to the anastomosis after esophagectomy in 12 patients, caustic injury in 3 patients and cervical chemoradiotherapy in 1 patient. Prior to initiation of self‐dilatation patients had a median of four endoscopic dilatations. Self‐dilatation was done with a Maloney dilator ranging in size from 45 to 60 French. The median duration of self‐dilatation was 16 weeks. No patient had a perforation or complication related to self‐dilatation. No patient required stenting or repetitive endoscopic dilatations because of failure of self‐dilatation. Strictures recurred in two patients after cessation of self‐dilatation and both responded to endoscopic dilatation followed by additional self‐dilatation. Self‐dilatation effectively resolves refractory esophageal strictures. It was well tolerated, and there were no complications in this series. Home self‐dilatation should be considered the treatment of choice in appropriate patients with refractory esophageal strictures in the cervical esophagus.     

Individual and contextual factors associated with follow‐up use of diabetes self‐management education programmes: a multisite prospective analysis

Aims Although a considerable body of research supports the efficacy of diabetes self‐management education (DSME), these programmes are often challenged by high attrition rates. Little is known about factors influencing follow‐up use of DSME services, thus the aim of this study was to identify these factors. Methods In this multisite prospective analysis, adults with Type 2 diabetes (n = 268) who attended one of two diabetes management centres (DMCs) were followed over a 1‐year period from their initial visit. The influence of individual and contextual factors on the number of contacts with DMC providers was examined. Data were analysed within the context of the Health Behavioral Model of Health Services Utilization. Results In a multivariable negative binomial regression model, the number of contacts over 1 year was greater for those who were female, non‐smokers, unemployed, self‐referred to the DMC, lived closer to the DMC, had a lower body mass index, or had a longer known duration of diabetes. Follow‐up use of services differed significantly between the two sites. Provider contacts were greater at the centre that offered flexible hours of services and a variety of optional educational modules. Conclusions Healthcare professionals need to encourage ongoing use of DSME, particularly for individuals prone to lower follow‐up use of these services. Providing services that are accessible, convenient, and can easily fit into patients’ schedules may increase follow‐up use. Further exploration into how operations and delivery of these services influence utilization patterns is strongly recommended.     

Is diabetes‐specific health literacy associated with diabetes‐related outcomes in older adults?

Background: The present study examined the association between a measure of diabetes‐specific health literacy and three different Type 2 diabetes outcome indicators in a national sample of older adults. Methods: Data were taken from the Health and Retirement Study (HRS) 2003 Diabetes module and the HRS 2002 core wave. Analysis was performed on data from 1318 respondents aged 42–96 years [mean (±SD) 67.96 ± 8.65 years] who submitted responses on all relevant independent variable measures along with an HbA1c test kit. The index of diabetes‐specific health literacy was constructed from responses to 10 diabetes self‐care regimen items (α = 0.927). Results: Using a multivariate regression strategy to analyze weighted data, the diabetes‐specific health literacy index was significantly and positively associated with self‐graded assessment of diabetes self‐care (R² = 0.231). However, diabetes‐specific health literacy was not independently associated with the HbA1c level or the average number of days five recommended self‐management behaviors were practiced each week. Conclusions: No previous single study has focused on the relationship between diabetes‐specific health literacy and multiple diabetes‐related outcomes. The direct association of diabetes‐specific health literacy with patients’ assessment of their self‐care practice acumen is useful information for the design of effective patient intervention and/or communication strategies. Health literacy is a broad, multidimensional construct that bridges basic literacy skills and various health and illness contexts. Because it is so important to adults engaged in the self‐management of chronic illness, indicators of disease‐specific knowledge and/or understanding should be included in efforts to measure health literacy.     

The impact of cognitive impairment in dementia on self‐care domains in diabetes: A systematic search and narrative review

Self‐management is integral to effective chronic disease management. Cognitive impairments (CogImp) associated with dementia have not previously been reviewed in diabetes mellitus (DM) self‐care. The aims of this study are to know (1) whether CogImp associated with dementia impact self‐care and (2) whether specific CogImp affects key DM self‐care processes. A systematic literature search with a narrative review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. This review examined studies published from January, 2000 to February, 2016 describing the relationship between cognition and DM self‐care domains in community dwelling older adults with dementia/CogImp. Eight studies met inclusion criteria. Decrements in all self‐care domains were associated with CogImp. Problem solving was related to reduced disease knowledge (OR 0.87, 95% CI = 0.49‐1.55), resulting in poorer glycemic control. Decision‐making impairments manifested as difficulties in adjusting insulin doses, leading to more hospital admissions. People without CogImp were better able to find/utilize resources by adhering to recommended management (OR 1.03, 95% CI = 1.02‐1.05). A lack of interaction with health care providers was demonstrated through reduced receipt of important routine investigation including eye examinations (ARR = 0.85, 95% CI = 0.85‐0.86), HbA1c testing (ARR = 0.96, 95% CI = 0.96‐0.97), and LDL‐C testing (ARR = 0.91, 95% CI = 0.901‐0.914). People without CogImp had better clinic attendance (OR 2.17, 95% CI = 1.30‐3.70). Action taking deficits were apparent through less self‐testing of blood sugar levels (20.2% vs 24.4%, P = 0.1) resulting in poorer glycemic control, self‐care, and more frequent micro/macrovascular complications. Persons with diabetes and CogImp, particularly in domains of learning, memory and executive function, were significantly impaired in all self‐care tasks.     

Symptoms of depression prospectively predict poorer self‐care in patients with Type 2 diabetes

Aims To examine prospectively the association of depression symptoms with subsequent self‐care and medication adherence in patients with Type 2 diabetes mellitus. Methods Two hundred and eight primary care patients with Type 2 diabetes completed the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS) and the Summary of Diabetes Self‐Care Activities (SDSCA) at baseline and at follow‐up, an average of 9 months later. They also self‐reported medication adherence at baseline and at a follow‐up. Results Baseline HANDS scores ranged from 0 to 27, with a mean score of 5.15 ± 4.99. In separate linear regression models that adjusted for baseline self‐care, patients with higher levels of depressive symptoms at baseline reported significantly lower adherence to general diet recommendations and specific recommendations for consumption of fruits and vegetables and spacing of carbohydrates; less exercise; and poorer foot care at follow‐up (β ranging from ?0.12 to ?0.23; P < 0.05). Similarly, each one‐point increase in baseline HANDS score was associated with a 1.08‐fold increase in the odds of non‐adherence to prescribed medication at follow‐up (95% confidence interval 1.001, 1.158, P = 0.047). Increases in depression scores over time also predicted poorer adherence to aspects of diet and exercise. Conclusions Depressive symptoms predict subsequent non‐adherence to important aspects of self‐care in patients with Type 2 diabetes, even after controlling for baseline self‐care. Although the relationship between symptoms of depression and poorer diabetes self‐care is consistent, it is not large, and interventions may need to address depression and self‐care skills simultaneously in order to maximize effects on diabetes outcomes.     

SELF‐EFFICACY IN RELATION TO LIMITED FLUID INTAKE AMONGST PORTUGUESE HAEMODIALYSIS PATIENTS

Self‐efficacy is a temporary and influenceable characteristic, related to situations and tasks, mediating health‐promoting behaviours. This study aimed to evaluate psychometric properties of a Portuguese version of the Fluid Intake Appraisal Inventory, and to describe self‐efficacy in relation to limited fluid intake amongst Portuguese haemodialysis patients. Respondents were recruited from three dialysis units, and 113 of 155 eligible patients gave their informed consent. The translated scale was distributed and collected by the head nurses. Interdialytic weight gain was calculated as percentage of dry weight. Satisfactory psychometric properties were estimated in the Portuguese context. The participants’ self‐efficacy in relation to low fluid intake was asymmetrically distributed; the majority had moderately to high self‐efficacy while some patients had very low self‐efficacy to limited fluid intake. There was a significant difference in self‐efficacy to fluid restrictions; patients with a weight gain of 3.5% or less presented higher self‐efficacy scores than did patients exceeding the cutoff point.     

Predictors and variability of drug‐eluting vs bare‐metal stent selection in contemporary percutaneous coronary intervention: Insights from the PRISM study

Drug‐eluting stents (DES ) reduce risk of in‐stent restenosis after percutaneous coronary intervention (PCI ) but require dual antiplatelet therapy (DAPT ) for a longer term than bare‐metal stents (BMS ). Few studies have examined clinical predictors of DES vs BMS , and variability in provider selection between DES and BMS in clinical practice has not been well described. These insights can inform our understanding of current practice and may identify opportunities to improve decision‐making stent selection decinsion‐making. In a multicenter registry, 3295 consecutive patients underwent PCI by 158 interventional cardiologists across 10 US sites. Eighty percent of patients with treated with DES. Using hierarchical regression, diabetes mellitus, multivessel disease, health insurance, and white race were independently associated with greater DES use, whereas increasing age, history of hypertension, anticipated surgery, use of warfarin, lower hemoglobin, prior history of bleeding, and treatment of right coronary and left circumflex artery lesions as compared with PCI of left anterior descending artery were associated with lower likelihood of receiving DES . Adjusted rates of DES use across providers varied from 52.3% to 94.6%, and adjusted median odds ratio for DES selection was 1.69. DES selection appeared to reflect physicians’ attempts to balance benefits of DES against risks of prolonged DAPT . Nevertheless, marked residual variability in DES selection across providers persisted after adjusting for predictors of restenosis, bleeding, and other factors. Further studies are needed to better understand drivers of this variability and identify the impact of patient and provider preferences on stent selection at the time of PCI .     

Patient and provider perceptions of care for diabetes: results of the cross-national DAWN Study

Aims/hypothesis We assessed country-level and individual-level patterns in patient and provider perceptions of diabetes care. Methods The study used a cross-sectional design with face-to-face or telephone interviews of diabetic patients and healthcare providers in 13 countries from Asia, Australia, Europe and North America. Participants were randomly selected adults with type 1 or type 2 diabetes (n=5,104), and randomly selected diabetes-care providers, including primary-care physicians (n=2,070), diabetes specialist physicians (n=635) and nurses (n=1,122). Multivariate analysis was used to examine the relationships between outcomes and both country and respondent characteristics, and the interaction between these two factors. Results Providers rated chronic-care systems and remuneration for chronic care as mediocre. Patients reported that ease of access to care was high, but not without financial barriers. Patients reported moderate levels of collaboration among providers, and providers indicated that several specialist disciplines were not readily available to them. Patients reported high levels of collaboration with providers in their own care. Provider endorsement of primary prevention strategies for type 2 diabetes was high. Patients with fewer socio-economic resources and more diabetes complications had lower access (and/or higher barriers) to care and lower quality of patient–provider collaboration. Countries differed significantly for all outcomes, and the relationships between respondent characteristics and outcomes varied by country. Conclusions/interpretation There is much need for improvement in applying the chronic-care model to the treatment and prevention of diabetes in all of the countries studied. Each country must develop its own priorities for improving diabetes care and comparison with other countries can help identify strengths as well as weaknesses.     

Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study.

AIMS: To examine patient- and provider-reported psychosocial problems and barriers to effective self-care and resources for dealing with those barriers. METHODS: Cross-sectional study using face-to-face or telephone interviews with diabetic patients and health-care providers in 13 countries in Asia, Australia, Europe and North America. Participants were randomly selected adults (n = 5104) with Type 1 or Type 2 diabetes, and providers (n = 3827), including primary care physicians, diabetes specialist physicians and nurses. RESULTS: Regimen adherence was poor, especially for diet and exercise; provider estimates of patient self-care were lower than patient reports for all behaviours. Diabetes-related worries were common among patients, and providers generally recognized these worries. Many patients (41%) had poor psychological well-being. Providers reported that most patients had psychological problems that affected diabetes self-care, yet providers often reported they did not have the resources to manage these problems, and few patients (10%) reported receiving psychological treatment. CONCLUSIONS: Psychosocial problems appear to be common among diabetic patients worldwide. Addressing these problems may improve diabetes outcomes, but providers often lack critical resources for doing so, particularly skill, time and adequate referral sources.