Self-reported perceptions of adults with diabetes regarding their care and health in the time of COVID-19 pandemic in a Swiss region: a cross-sectional study

DOI: https://doi.org/https://doi.org/10.57187/s.3578

Introduction

During the COVID-19 pandemic, many countries imposed lockdowns to contain and prevent virus spread [1]. In addition, the majority of high-income countries established various other preventive measures, such as social distancing, quarantines, restrictions on large events and mass gatherings, school closures, and mandates on working from home. Similar measures were implemented in Switzerland, even in the absence of strict and general lockdowns. In some countries, the pandemic was associated with increased incidence of stress, anxiety, and depression, as well as reduced levels of exercise and frequent snacking among the population [2–5]. Weight gain was reported in several countries [6–8], including Switzerland, with a 3 kg increase in body weight over the pandemic reported in all age groups [9]. This pandemic period was even more stressful for people living with diabetes, being classified as high risk for developing more severe forms of COVID-19. Reduction in physical activity [2, 10–16], weight gain [2, 12, 16], difficulties in diabetes management, and reduced access to medications and specialised care providers have all been reported in this population [10–12, 14, 17–19]. Together, these changes resulted in the deterioration of glucose control and adverse metabolic outcomes [10, 12, 20]. Stress, depression and anxiety also increased in patients living with diabetes, contributing to difficulties in the daily care routine [2, 14, 16].

In countries with easy and comprehensive access to care, including Switzerland, limited data is available other than for the paediatric population [21]. Therefore, we aimed to assess the perception of adults with diabetes on their care and health during the COVID-19 pandemic in the canton of Vaud, Switzerland, using data from the CoDiab-VD cohort. To achieve this, we aimed to describe the effects of the pandemic on various aspects of diabetes care, in particular relating to cancellation or postponement, changes in daily diabetes management, and psychosocial burden, and to explore factors associated with six COVID-19 outcomes related to these domains.

Methods

Study population and data sources

We used cross-sectional data from the 2021 follow-up survey of the CoDiab-VD cohort [22]. This cohort of people living with diabetes was recruited through community pharmacies in 2011–12 and 2017. The group was followed up annually until 2017, and then every 2 years, by postal questionnaires sent to participants' homes [23, 24]. The inclusion criteria at recruitment were being a noninstitutionalised adult (≥18 years) with a diagnosis of diabetes of any type for at least one year, and living in the canton of Vaud, Switzerland. Individuals with cognitive impairment or poor French proficiency and women with gestational diabetes were excluded from the study. Among the 1033 participants recruited in 2011–12 (n = 519) and 2017 (n = 514), 714 were still registered in the cohort in 2021 and were sent the follow-up questionnaire. The attrition of the cohort from 2011–2012 was due to 15 lost to follow-up, 232 drop-outs, and 72 deaths.

Core questions addressed different aspects of diabetes and diabetes care, as well as participants’ characteristics [24]. In addition, questions relating to the COVID-19 pandemic were added to two subsections, the first regarding the experiences of diabetes care during the pandemic, and the second concerning COVID-19 infection and vaccination, and the psychosocial burden of the pandemic.

Measurements

For the present study, data collected in the questionnaire section related to COVID-19 and that on participants’ characteristics was used. The variables are briefly described in table 1 and detailed (questions and response modalities) in table S1 in the appendix for the COVID-19 section; information on the core questions are published elsewhere [24].

Statistical analyses

First, descriptive analysis was conducted to present the characteristics of the participants and the results of the COVID-19 section of the questionnaire. Continuous parameters and parameters measured through a Likert scale were summarised with their mean and standard deviation (SD), while categorical variables were summarised with their relative frequency (percentage).

To further investigate themes in the COVID-19 section, we used principal component analysis (PCA) [25] to reduce the number of considered outcomes. Principal component analysis is a data-reduction technique that investigates the underlying structure of scales including several items, allowing a large amount of data to be summarised using a smaller set of components. The aim of principal component analysis was to aggregate items measuring the same dimension and reduce the number of variables included in the multivariable analyses, without overlooking important information. Eigenvalues higher than one and scree plots were used to determine the number of components to be considered in each analysis. Decisions to aggregate items measuring the same component were supported by correlation analysis and calculation of Cronbach’s alpha [26]. Usual thresholds and procedures were used [27]. We performed principal component analysis on each of the three scales included in the subsection “Worries about the pandemic and its consequences,” and on the scale in the section “Information technology (IT) tools” (for details, see table S2 in the appendix). Thus, we obtained five components (identified in brackets): a single component summarising the six aspects of the pandemic causing concern for respondents (Concerns about the pandemic); a single component summarising the six aspects of life impacted by the pandemic (Impact of the pandemic); two different components summarising feelings about the pandemic (one including three general questions on loneliness (Loneliness), and one including two questions relating to diabetes (Loneliness related to diabetes); and a final component summarising three questions about IT use (Comfortable with IT). The first four components were used as outcomes, and the final component was used as an independent variable for further analyses.

We then carried out exploratory multivariable analyses to identify factors associated with six COVID-19-related outcomes: (1.) diabetes care cancelled or postponed (1 yes vs 0 no); (2.) physical activity management (1 more difficult vs 0 neither more difficult nor easier, and easier); (3.) loneliness related to diabetes (1 sometimes and often lonely vs 0 never and rarely lonely); (4.) concerns about the pandemic (continuous range, 1 not concerned to 3 very concerned); (5.) impact of the pandemic (continuous range, 1 not impacted to 3 much impacted); and (6.) loneliness (continuous range, 1 never felt lonely to 4 often felt lonely). Loneliness related to diabetes was recorded as a binary outcome because of the underrepresentation of certain score categories. Logistic regressions were used for binary outcomes, and linear regressions were used for continuous outcomes. For all models, a stepwise backward-forward selection of variables was performed, based on the Akaike information criterion [28]. Akaike information criterion was preferred to the Bayesian information criterion because of its less conservative power of selection. Statistical significance tests applied to the estimated coefficients of the models guided the variable selection process. While statistical significance indicates the presence of an association between variables, it is important to note that the strength of the association is not solely determined by statistical significance. Rather, the inclusion of variables in the models was based on their contribution to model fit, as assessed by the Akaike information criterion. In addition to estimating associations through regression models, precision was considered by providing confidence intervals for relevant estimates, where applicable. Stepwise variable selection, while commonly employed for model building, has inherent limitations that must be taken into consideration. The selected variables reflect statistical associations rather than direct causal relationships. The variables included in the models differed for analyses on binary or continuous outcomes. For binary outcomes, the small number of cases did not allow the inclusion of all candidate variables in the logistic regression model, because of insufficient statistical power. Therefore, we selected variables based on expert knowledge for the three binary outcomes (for details, see table S3 in the appendix). For continuous outcomes, we tested all variables selected in the models. Regarding multicollinearity, we computed independence and correlation tests, as well as the variance inflation factor, to identify possible collinear explanatory variables. Assumptions of the linear models have been inspected and are met. For each logistic model, we measured the goodness of fit with the Hosmer-Lemeshow test, the McFadden pseudo-R squared, and the McFadden adjusted pseudo-R squared. For both types of regression model, we considered all patients with complete data. The number of observations is the same for all outcomes. No imputation was made for missing data.

All statistical analyses were performed using Stata 17 [29] and the R statistical environment version 4.1.3 [30], with a significance level set at 5%.

Ethical approval

The protocol of the CoDiab-VD study was approved by the Ethics Committee of Research on Human Beings of the Canton of Vaud (CER-VD, protocol numbers 151/11 and PB_2017_00232). CoDiab-VD is registered with ClinicalTrials.gov, identifier NCT01902043. Written informed consent was obtained from all participants, and data were kept confidential.

Results

In late October 2021, the follow-up questionnaire was sent to the 714 participants still enrolled in CoDiab-VD; of these participants, 566 (79.3%) completed and returned the self-administered paper-based questionnaire before the end of January 2022 and were included in the analyses.

Characteristics of the respondents

Respondents’ characteristics are presented in table 2. Briefly, the mean age was approximately 70 years, men were more represented (57%) than women, and a third of the study participants lived alone. Type 2 diabetes was predominant (73%), and most respondents were taking antidiabetic medications, including injected medications (62%). 

COVID-19 and diabetes care

A tenth of participants reported having had diabetes-related care cancelled or postponed (table 3) during the pandemic, the majority of which were consultations with healthcare professionals (diabetologists, general practitioners, or other professionals). Outpatient or inpatient procedures were rarely cancelled or postponed (data not illustrated). According to the respondents, this cancellation or postponement had few negative effects on their physical and mental well-being; three-quarters reported not having been impacted at all in terms of their physical well-being, and two-thirds reported not having been impacted at all in terms of their mental well-being. Access to diabetes-specific medications or materials was reported as no more difficult during the COVID-19 pandemic than before (table 3). 

Concerning the daily management of diabetes since the beginning of the pandemic, no striking differences were reported in the difficulty of performing daily management routines, following an appropriate diet, or taking medications. In contrast, being physically active was reported as more difficult by 16% of the respondents (table 3).

When participants were asked about the frequency with which they experienced episodes of hyperglycaemia or hypoglycaemia compared to the pre-pandemic period, few reported having had more frequent episodes of hyperglycaemia (6%) or hypoglycaemia (4%) during the COVID-19 period. Because of hyperglycaemia, approximately 1% had to seek emergency care, and 0.4% required hospitalisation. For hypoglycaemia, these proportions were similar, with approximately 1% seeking emergency care and 0.2% being hospitalised (table 3).

COVID-19 infection and vaccination

Since the beginning of the pandemic, 11.8% of the respondents (n = 552) had had a positive COVID-19 test using PCR or rapid antigen testing at the time of the survey (October 2021 – January 2022); and 12 of these 65 respondents had been hospitalised due to COVID-19. Vaccination was very common, with more than 90% of respondents having received at least one dose; two-thirds of the 35 unvaccinated individuals did not intend to receive the vaccine (table 3).

Concerns about the pandemic and its consequences

When participants reported the level of stress or worry they had felt about the pandemic on a scale from 0 (not at all) to 10 (very), one-third had not been worried (0–3, 33.2%), one-third had been somewhat worried (4–6, 31.9%), and one-third had been very worried (7–10, 34.9%) (table 3).

The participants were most concerned about the restrictions on their social life and the risks to their health (figure 1A). Aspects of their lives more impacted by the pandemic were social life, hobbies, and lifestyle (figure 1B). In terms of loneliness related to diabetes, fewer than 10% of the respondents reported often or sometimes missing someone to talk about their condition, or feeling alone with their diabetes since the beginning of the pandemic (figure 1C).

Figure 1Concerns about the pandemic and its consequences.

Use of telemedicine

One in six respondents had consulted a healthcare professional remotely during the pandemic. The main types of consultations were conducted by phone (n = 69) or email (n = 22), followed by SMS (n = 10) and video (n = 5). Most remote consultations were with a general practitioner (n = 42) or a diabetologist (n = 42); other healthcare professionals were less frequently consulted remotely, including diabetes nurses (n = 8), dieticians (n = 3), psychologists/psychiatrists (n = 10), and others (n = 13). Approximately 60% of the participants generally felt comfortable using a computer, two-thirds felt comfortable using a touch screen, and two-thirds felt comfortable searching for information on the internet (data not illustrated).

Factors associated with COVID-19-related outcomes

Multivariable analyses of the three binary outcomes are presented in table 4:

Diabetes-related care cancelled or postponed: having more diabetes-related complications, a higher anxiety (GAD-7) score, and having had remote consultations were all significantly associated with cancelled or postponed diabetes care.

Physical activity management: variability in blood glucose values, having had remote consultations, and having received dietary advice significantly increased the odds of having more difficulties in physical activity management. In contrast, a higher score in the physical component of the short-form 12 (SF-12) (physical component summary [PCS]) and having received physical activity advice decreased the odds of having increased difficulty in managing physical activity.

Loneliness related to diabetes:Higher scores in the mental and physical components of the SF-12 (mental component summary [MCS] and PCS), higher scores of diabetes-related quality of life (ADDQoL), and being comfortable using IT tools all decreased the odds of feeling lonely about one's diabetes. 

Table 5 presents multivariable analyses of the three continuous outcomes:

Concerns about the pandemic: depression, financial hardship, and variability in blood glucose values were all significantly associated with an increase in the level of concern, whereas better physical component summary scores were associated with lower levels of concern.

Impact of the pandemic:As with concerns, depression, financial hardship, and variability in blood glucose values were associated with an increased reported impact of the pandemic on participants’ lives, while better physical component summary and ADDQoL scores were associated with a lower impact.

Loneliness: having depression, being physically active, and receiving home care services were all significantly associated with a greater feeling of loneliness. Conversely, factors associated with reduced feelings of loneliness included living with someone as well as better mental component summary, physical component summary, and ADDQoL scores.

No association was found between the six COVID-19-related outcomes and age, sex, or type of diabetes.

Discussion

Our results suggest that people living with diabetes included in the CoDiab-VD cohort were not strongly affected by the COVID-19 pandemic in terms of their health and care. Indeed, access to diabetes care remained almost unchanged, with few consultations postponed or cancelled, and no reported increase in difficulty accessing diabetes-related treatment or materials. Additionally, most participants did not experience any increased difficulty in managing their diabetes during the pandemic, except for being physically active, which was more difficult for 16% of them. Few respondents reported a change in blood glucose values, and very few patients experienced more frequent episodes of hypoglycaemia or hyperglycaemia or were hospitalised due to diabetes. The aspects that concerned the greatest proportion of respondents were risks to their health and restrictions on their social life. The aspects most impacted by the pandemic were social life, hobbies, and lifestyle. However, few people felt excluded or isolated during the pandemic period.

The positive results we observed in terms of diabetes care might be explained by the strong recommendations made to people with diabetes to be very careful about their health, being considered at higher risk of severe COVID-19 infection than the general population [31]. This may explain the high rate of vaccination against COVID-19 observed (93.8%) in our cohort. Adequate diabetes control was reported by the participants, with consultations mostly maintained, including in-person and remote contact with health professionals; this was not the case reported in other countries [10–12, 14, 17]. We observed that individuals with more diabetes complications or those declaring more symptoms of anxiety had a higher risk of cancelled or postponed consultations. Conversely, having a remote consultation was also associated with an increased chance of having an in-person consultation cancelled or postponed, suggesting the need for remote consultation in times of health crisis. Remote care seems to be an appropriate alternative for people who need to avoid the establishment of a vicious circle from the absence of medical follow-up, reduced access to care, and consequent worsening of metabolic and mental health, as has been described in other studies [2, 14, 16].

Other surveys carried out with people living with diabetes have reported poorer diabetes control, greater weight gain, and more negative psychological and social effects during the pandemic than before [2, 10–15, 17, 20]. The results in our cohort were slightly different; in particular, participants did not report more glucose variability, occurrence of hyper- and hypoglycaemia, or hospitalisation for diabetes. This may be a result of the participant-reported lack of changes in diabetes self-management, medication use, appropriate diet, and the continued ease of access to diabetes medication or materials during the pandemic. Nevertheless, unlike the other self-management dimensions, physical activity was more difficult for one in six participants, which could be explained by the closure or restricted access to sports facilities during this period in Switzerland, or by participants’ fear of coming into contact with other people and being infected with SARS-CoV-2. Even with a partial reduction in physical activity, participants did not report worsening diabetes control. However, 16.1% of the participants reported weight gain, in line with other studies [32, 33].

Better self-perceived physical health, as measured with the SF-12 physical component summary, was associated with less difficulty in managing physical activity, lower levels of concerns about and impact of the pandemic, decreased loneliness and less risk of feeling lonely with one’s diabetes. This finding suggests that feeling in good physical health positively affects not only diabetes management but also how individuals experienced the pandemic in general. The effect of COVID-19 on health-related quality of life has been previously described, with mostly negative impacts observed in people living with diabetes [34]. Here, we show that better physical health seems to enable people to better cope with the pandemic.

The present study has two main strengths. First, it used data from a cohort with a diverse range of respondents living with diabetes, giving good heterogeneity in the sample. While the cohort was drawn from community pharmacies and designed to be representative of individuals with diabetes in the canton of Vaud, Switzerland, it is essential to acknowledge potential limitations in the representativeness of the sample. The sampling strategy, primarily through community pharmacies, may have introduced biases; although efforts were made to include a broad spectrum of individuals, caution is warranted in generalising the findings to the entire diabetic population in the region. Second, the questionnaire assessed various aspects of the participants’ experience of the pandemic, such as the management of diabetes and psychosocial burden. While interpreting these results, the following limitations should be considered: first, respondents had to recall their experiences over a very long period to answer the questions. Thus, we must consider that the survey was conducted at a single specific time and only reflects the patient’s perception at that time. Second, the cohort consists of adults with diabetes from a specific Swiss region, which may limit the generalisability of the present results. Third, since individuals unable to read French were not eligible for inclusion in the cohort, the interpretation of the present results is limited for people with migrant backgrounds who have not mastered French. Fourth, participants who willingly engaged in the cohort may possess higher health literacy, leading to a potential underrepresentation of individuals with lower health literacy or facing more significant health challenges; this could influence the generalisability of the findings. Finally, our data are self-reported and may therefore be prone to recall and desirability bias. However, since the importance of patient-reported experience measures has become increasingly recognised, self-reported data remain appropriate to assess how people living with diabetes experienced the COVID-19 pandemic [35].

Conclusions

Diabetes management among CoDiab-VD participants was not highly affected by the COVID-19 pandemic. Our results show that diabetes-related complications, depression, glucose variability, and financial insecurity were factors associated with access to care, self-management, and psychosocial burden during this period.

Maintenance of contact with healthcare professionals, psychological support, and the availability of remote consultations should be emphasised in crisis situations.

Data availability

CoDiab-VD metadata are available in a public, open-access repository, and data are available upon reasonable request through the repository (CoDiab-VD: Cohort of Patients with Diabetes in the Canton of Vaud [Switzerland]), https://doi.org/10.16909/dataset/18 [22].

Acknowledgments

The authors thank the respondents for their participation in the surveys and the people involved in the data collection.

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Appendix

The appendix is available in the pdf version of the article at https://doi.org/10.57187/s.3578