Journal of Community & Public Health Nursing
Open Access

Diabetes is a priority in public health, with a prevalence rate of more than 425 million people worldwide and an annual mortality rate of 1.6 million [1,2]. As part of the 2030 Agenda for Sustainable Development Goals (SDG), the United Nations has announced a goal to reduce the premature mortality rate caused by chronic diseases, including diabetes, by one-third. This global effort aims to diagnose diabetes early, improve the quality of life for patients, and prevent or reduce the human and social health costs associated with complications through appropriate monitoring [3,4]. Worldwide diabetes-related health care costs exceed $700 billion per year [1]. In the United States in 2017, the total estimated care costs associated with diabetes were $327 billion [5]. As of 2018, about 34.2 million people, or 10.5% of the total U.S. population, have diabetes. However, the prevalence of diabetes, and subsequent complications of this disease, are strongly influenced by demographic, social, and economic factors, which contribute to health disparities among medically underserved multi-ethnic minorities in the United States [6,7].

The burden of diabetes-related health costs and complications is disproportionally higher in low and middle-income countries around the globe. In particular, individuals in Southeast Asia, the Western Pacific, Africa, and the Middle East develop diabetes earlier than those in other regions and are more likely to experience premature death from diabetes and diabetes-related complications [1,8]. Also, when individuals in this region migrate to a host country to form minority groups, these populations tend to have a higher incidence, prevalence, morbidity, and mortality than the host country population. This trend is most often caused by poverty, lack of access to health care, language barriers, changed lifestyles, adaptation, and genetic predisposition [9- 12].

These circumstances cause medically underserved migrant populations to experience social exclusion as well as administrative and financial hurdles. Furthermore, these challenges create a vicious circle of limited access, insufficient preventive interventions and routine health care, and increased risk of communicable and noncommunicable diseases in these populations [13]. Access to medical care has declined further as a result of the Coronavirus Disease 2019 (COVID-19) pandemic, which has had a more significant impact on the social determinants of health in high-risk people with diabetes and vulnerable populations of minorities [14]. The spread of COVID-19 has required coordination of communication strategies, particularly among vulnerable multi-ethnic populations, and a transition to culturally appropriate healthcare approaches [14]. Therefore, evidencebased telehealth intervention platform, structured monitoring, and improvement of health care access in the primary care setting can be an essential format for long-term intervention in medically underserved multi-ethnic groups.

Individuals with diabetes from medically underserved multiethnic groups face additional barriers that impact the ability to manage their disease effectively. Such barriers include different socio-cultural norms, poverty, stigma, social exclusion, language, cultural differences, financial challenges, and lack of legal status [13]. As a result of these barriers, this population tends to ignore their diabetes, leading to serious complications secondary to poor glycemic control. Therefore, lifestyle changes, frequent interventions, and structured monitoring in such a population with a high prevalence of diabetes require considerable medical expenditures, time, and a culturally competent approach that must utilize teamwork. Failure to cooperate in delivering structured monitoring and culturally competent care by providers, organizations, and targeted systems can lead to adverse health events and poor-quality outcomes in multi-ethnic patients. Furthermore, studies show that providing comprehensive and structured care in this population has been challenging due to weak quality patient-provider interactions and low engagement in patient partnerships [15-19].

Despite these challenges, telehealth platforms have emerged as one of the methods to monitor and interact with diabetic patients. Telehealth approaches have the potential to meet these factors in a culturally competent manner, to empower patients, improve outcomes, and save money in a comprehensive, personalized system [20-22]. Also, due to the COVID-19 pandemic, low-income, multi-ethnic populations with diabetes have experienced more challenges and vulnerabilities related to in-person care. Structured telehealth interventions, then, have the potential to improve self-management of diabetes in medically underserved populations. In light of this, the purpose of this integrative literature review is to provide a basis for developing an evidence-based practice platform through telehealth interventions to support the effective management of diabetes in medically underserved populations in the community.

Search strategies

For the selection of literature for review, the following question developed in PICOT (Participant, Intervention, Comparison, Outcomes, Timing) format was used to determine the inclusion and exclusion criteria of the literature: In medically underserved populations with diabetes in the community (P), what is the effect of utilization of telehealth management (I), compared to usual diabetic care (C), on glycemic control (O) within the intervention period (T)?

Inclusion criteria for evidence search

Participants included all medically underserved adult populations with diabetes, including multi-ethnic minorities, underserved urban or rural area communities, ethnically diverse people, low-income adults, refugees, asylees, and immigrants who have type 2 diabetes. Intervention criteria include all types of telehealth or telemedicine programs for diabetes management in the community primary care settings. In terms of comparison, the inclusion criteria included all intervention studies that were compared with non-intervention, usual diabetes care group, and non-treatment groups. In terms of the criteria of outcomes, glycemic control, hemoglobin A1c levels, blood pressure, lipids, cholesterol levels, body mass index (BMI), waist circumference, albumin-to-creatinine ratio, compliance of selfmanagement, and qualitative descriptions from participants were included. For timing, the period of all telehealth programs and both pre and post-test until follow-up studies were included. In the study design, systematic reviews with meta-analysis, systematic reviews with network meta-analysis, randomized controlled trials (RCTs), quasiexperimental study, cross-sectional exploratory study, and protocol for the experimental study were included in the search. The language included only published studies in English, but the inclusion criteria in the research environment and settings were international.

Exclusion criteria for evidence search

The exclusion criteria for the literature search were as follows. All evidence for children with type I diabetes and women with gestation diabetes were excluded from this search. In telehealth practice, all the studies on continuous glucose monitoring devices, closed-loop systems, and artificial pancreas for type I and II diabetes were also removed. Among the telehealth interventions for adults with diabetes, evidence focusing on secondary and tertiary medical institutions was also excluded. Lastly, among telehealth interventions for diabetes management, studies focusing on patients with other chronic diseases as comorbid were also eliminated.

Keywords and search engines

This literature review was conducted using search databases, including the Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete, and PubMed. For the gray literature, a manual search was conducted through Google Scholar, the Clifton Fowler Library of Colorado Christian Library (CCU), and the American Diabetes Association Research site. Databases were searched for articles that were published in scholarly journals from 2009 to 2020. Medical Subject Headings (MeSH) were used to select search terms. Keywords to search for evidence were diabetes, diabetes mellitus, telehealth, telemedicine, glycemic control, hemoglobin A1c, medically underserved, multi-ethnic, culturally diverse, and migrants. The final thirteen studies were selected for analysis and integration, narrowed down according to inclusion and exclusion criteria from a total of 687 studies found in databases (Table 1).

Table 1: Study Selection.

Levels of Evidence

The purpose of the appraisal of this literature review was to evaluate and appraise the strengths, limitations, and value of evidence searched and narrowed down from databases to incorporate the best evidence for evidence-based implementation for diabetic patients through telehealth intervention. For this appraisal, the Johns Hopkins Nursing Evidence-Based Practice (EBP) Levels of evidence [24] was used for rating the levels and quality of evidence. The final thirteen pieces of literature were presented with rated levels and quality of evidence for this integrative literature review in Table 2. Article numbers presented in this table 2 were listed according to the alphabetical order of the author’s last names. The final thirteen studies included four systematic reviews and meta-analyses, five experimental studies with randomized controlled trials (RCTs), two quasi-experimental studies, one cross-sectional exploratory research, and one protocol for a randomized controlled trial study. The nine studies in the narrowed evidence appraised for the telehealth interventions were rated at level I, two studies at level II, one study at level III, and one study at level IV. Therefore, by integrating evidence of a high level of reviews and qualities, there was a possibility of showing effective evidence-based interventions and outcomes in projects based on substantial evidence (Table 2).

Table 2: Level and Strength of Evidence Summary.

Synthesis of critically appraised literature

Of the thirteen pieces of literature included in this review, 12 studies were designed with a focus on glycemic control as a primary outcome in the adult population with diabetes through a variety of telehealth approaches in medically underserved communities in the United States. The other study investigated the willingness and readiness of the use of tele-technology in diabetic adults in Saudi Arabia’s public health setting [25]. One study [26], as a protocol for randomized controlled trials, suggested the possibility of improvement in glycemic control and the quality of life measured by hemoglobin A1c as a primary outcome in low-income patients with diabetes. The intervention periods for telehealth programs suggested in studies included in this literature review reported an intervention time frame ranging from 3 months to 5 years. In particular, the self-data upload platform for patients who used telehealth intervention methods of 3 and 6 months showed a significant decrease in hemoglobin A1c [27,28]. Telehealth approaches for diabetes management in medically underserved populations have improved access to health services and show beneficial results from patient-provider partnerships [29].

Characteristics of telehealth intervention programs in studies

In each study included in this review, the characteristics of telehealth interventions for diabetes management in medically underserved patients were reviewed and analyzed by dividing them into the program structures and intervention contents. Carter et al. [29] included a culturally competent health education portal and system of uploading self-measured biometric data in a nine-month telehealth self-management program. This intervention was provided for 30 minutes to the intervention group every other week by telehealth nurse visits. Davis et al. [27] provided 13 sessions of telecare intervention to the telecare group for 12 months and compared outcomes with the control group. The intervention included diabetes self-management education, the setting of individual and group goals at each session, and the completion of a recorded log. This program was provided by a nurse, dietician, and certified diabetes educator. Egede et al. [26,28] organized two studies by planning protocols and interventions for research on telehealth systems. They planned and intervened in the use of the Innovative FORA telehealth system for coastal low-income adults with type 2 diabetes. This intervention evaluated the effectiveness of technology-assisted case management (TACM) at 3 and 6 months. The blood glucose and blood pressure data that patients self-measured and transmitted to the FORA telehealth system were reviewed daily by the nurse case manager. Patients’ medications were titrated according to an algorithm. Patients received positive reinforcement and feedback in real-time.

In a systematic review with a meta-analysis conducted by Heitkemper et al. [30], they analyzed RCT studies that performed diabetes selfmanagement education through health information technology based on community primary health care settings for medically underserved populations with type 2 diabetes. The intervention contents used in the studies included in this review were internet-based applications, telehealth or telemedicine intervention, cell phone intervention, automated telephone, and computer software without the internet. McLendon et al. [31] provided diabetes self-management education (DSME) through a 12-month telehealth intervention for rural adults with hemoglobin A1c greater than 8%. In the Intervention contents, a public health clinical nurse specialist (PHCNS) performed nurse case management through the telehealth system and incorporated DSME. Also, the monthly telephone follow-up was performed by a bilingual nurse care manager. Saddik and Al-Dulaijan [25] conducted a survey at Saudi Arabia’s Ministry of National Guard Health Affairs (MNGHA) to investigate the willingness and readiness of telehealth use of adults with diabetes in the public health sector. This was not an experimental study that conducted an intervention.

This study reported the potential of active diabetes management to improve patient communication using telehealth technologies on selfmanagement of diabetes in public health.

Shea et al. [21] provided a telehealth nurse case management and home telemedicine unit system for five years of IDEATel (Informatics for Diabetes Education and Telemedicine) intervention for ethnically diverse and medically underserved patients with diabetes. The intervention group received a glucometer and blood pressure device to transfer the data to the clinical database. Patients also received regular and low-literacy versions of the American Diabetes Association (ADA)’s education web pages. Patients’ medications were titrated using intervention algorithms by nurse case managers under endocrinologist supervision. Weinstock et al. [22] analyzed the results of IDEATel interventions conducted in Shea et al.’s [21] study from a different angle and found the impact of telemedicine interventions every 4-6 weeks on the ethnic disparity in the low-income population. Welch et al. [33] integrated a type II diabetes medication electronic pillbox and remote home automated glucometer and blood pressure device into the telehealth intervention.

A telehealth nurse interventionist provided the intervention in this program. The telehealth nurse interventionist provided minimal diabetes education every other week, and patient data and graphic reports were sent to each primary care provider. Wu et al. [34] included telehealth interventions for more than six months, including tele-education, tele-monitoring, tele-consultation, tele-case management, and tele-monitoring, as strategies in a study in which meta-analysis was performed through 19 randomized controlled trials. They demonstrated that more frequent interventions in patients with hemoglobin A1c above 9% were associated with improved glycemic control. Zhai et al. [35] reviewed the cost-effectiveness of telehealth intervention in patients with type 2 diabetes through meta-analysis. Telephone-based and internet-based interventions showed significant improvement in hemoglobin A1c levels (pooled difference in means= -0.53% and pooled difference in means= - 0.62%, respectively).

The telehealth solutions included in the thirteen studies used in this review introduce the comprehensive potential for patient-centered care by enhancing patient self-management and empowerment. In telehealth platforms used in most community primary care settings reported by the studies in this review, nurses, clinical nurse specialists, or certified diabetes educators provide intervention or programs with patient engagement and empowerment as telehealth interventionists or managers. Also, the interventions included in this review demonstrate success in achieving goals and improving interactions, medication adherence through remote monitoring, and communication between patients and telehealth providers [22]. The use of the telehealth platform in medically underserved populations with diabetes has been reviewed and integrated into this section by the literature to support the recommendations of evidence-based interventions with the outcome of effective glycemic control via improved hemoglobin A1c levels.

Best Practice Model Recommendations

The participant samples included in thirteen studies used in this review ranged from as little as 47 participants [29] to as many as 16,978 in a meta-analysis [32]. Hemoglobin A1c levels were the primary outcome for diabetes telehealth interventions, and these levels were significantly improved in all eleven studies. In particular, telehealth intervention for uncontrolled diabetic patients with hemoglobin A1c, which was higher than 9%, reported that endpoint hemoglobin A1c decreased to lower than 7% in glycemic control, resulting in a more significant outcome [29]. In medically underserved patients with diabetes, the telehealth interventions displayed care quality, care coordination with patient healthcare access, as well diabetes self-management compliance, which have been reported in most literature.

Care quality: telemonitoring and frequent data reporting

Best practice in telehealth methods presented in these studies is the use of telemonitoring, which provides medication compliance, frequency of blood glucose testing, and enhanced empowerment in lifestyle changes in terms of patient self-care quality. This telemonitoring practice procedure involves a process by which patients with diabetes upload or report biometric data, including their blood glucose from a home remote care unit device, and transmit or report it to a central telehealth system. Many studies have demonstrated that each patient’s efforts to measure and report this self-data make significant improvement in glycemic control [21,22,28,29,32,33]. The telemonitoring platform requires the establishment of a hubtype remote monitoring device. It needs Bluetooth compatibility that allows frequent reporting of biometric data, including blood glucose, to be placed on the individual patient's side. A better hemoglobin A1c level can be expected by reflecting the success of compliance and goal achievement [22]. Telemonitoring interventions with data transmission or reporting showed significant improvement in hemoglobin A1c levels, ranging from -0.22% to -2.28%, but differences are dependent on the intervention periods [21,29,33].

Healthcare access: patient interactions through telehealth manager

From this literature review, the best practice in terms of effective improvement of health care access has focused on motivating patients through patient interactions with telehealth managers or interventionists and regular reinforcement. Additionally, telehealth interventions improved care access through increased patient selfmanagement efficacy, generation of the care partnership between patient and provider, and active achievement of health goals [25,29,30,34]. Studies presenting interactions, including regular realtime two-way video visits between patients and telehealth managers, reported meaningful descriptive patient satisfaction with a decrease in hemoglobin A1C levels. These continued patient-provider interactions were designed as a practice platform in which self-measured blood glucose levels were reviewed for each video visit, drugs were adjusted according to the provider’s instructions if necessary, and mutual goals were set up again [21,22,28,29,32,33]. The interaction intervals of the studies included in this review were planned from as little as two weeks to as long as six weeks. For regular and robust reinforcement, most studies set up patient interaction intervals every two weeks, and intervention periods showed the most significant improvement in hemoglobin A1C at three or six months [28-30,32,33].

Clinical outcomes: goal attainment and glycemic control

The goal of lowering hemoglobin A1c levels by improving clinical outcomes in diabetic patients has been suggested in almost all of the reviewed literature as the primary outcome to improve symptoms and minimize diabetic complications. It has been reported that diabetes management in a community primary care setting is more effective when telehealth interventions are used for self-monitoring habits and adherence to diet and exercise in low-income patients [26]. The results of the above interventions reflected that telehealth intervention can improve diabetes self-management habits and outcome monitoring in relation to glycemic control resulting from hemoglobin A1c levels [27].

Best practice recommendations

The best practices regarding telehealth infrastructure recommended through this literature review provide definite answers to the PICOT question presented before. The effectiveness of a telehealth care platform for medically underserved multi-ethnic patients with diabetes in the community primary care setting has been confirmed through an integrated literature review that increases care quality, promotes access to culturally competent medical services, and improves glycemic control as clinical outcomes. In medically underserved populations, it has been confirmed that diabetes care quality can be supported through frequent blood glucose data reporting and telemonitoring infrastructure [21,29]. Therefore, continued telemonitoring for this population is worth considering as an EBP intervention. This telemonitoring is a method of providing participants with Bluetooth glucometers that can transmit or report blood glucose data to the central telehealth system. Telehealth interactions can also be planned where the participants are taught how to use telehealth system, and self-measured blood glucose data is obtained, analyzed, and returned as feedback. Those interventions are expected to improve patient compliance with oral diabetic agents or insulin, blood glucose monitoring, and diabetes self-care quality.

Implications for advanced practice nursing

Improving healthcare access in the medically underserved multi-ethnic population with diabetes is expected to be a culturally competent approach through continuous patient interactions, regular reinforcement, and improved self-management efficiency through individual real-time interactive video visits between patients and telehealth managers. According to the best practice recommendations from the reviewed literature, many studies recommend providing an appropriate time interval of every other week to provide reinforcement for patients through telehealth visits. Also, the intervention periods in various studies were set up for 3-6 months for strong patient motivation. In addition, the intervention of bilingual interpreters, telehealth interventionists, and personalized feedback provided through advanced nurse case management offers the potential to improve healthcare access in multi-ethnic, vulnerable, or non-English speaking patients [30,32]. In order to improve the ultimate patient outcome, glycemic control, most of the researchers proceeded by attempting to improve hemoglobin A1c in the telehealth intervention group. Improving individual hemoglobin A1c can be a primary clinical outcome through telehealth intervention and a short-term goal set by patients. Also, if the patient sets goals focusing on self-measured blood glucose, outcomes of improved glycemic control and more detailed diabetes support according to self-diabetes management habits can be expected [22].

Through the telehealth platform development in the community, effective diabetic management in the primary health care setting can be expected using a meaningful transaction of patient relationships obtained from the interactions between patients and providers through advanced practice nursing with mutual goal set-up in medically underserved multi-ethnic populations.

There were several limitations in the literature reviewed. Some studies mentioned that it was difficult to show consistency in surveys and data collection as well as interpretation for participants in the community due to various circumstances. In addition, other studies report that medical care was hampered by limitations in technology, staff resources, and cost for case management.

The purpose of this integrative literature review was to examine a basis for developing an evidence-based practice platform through telehealth interventions to support effective management of diabetes in medically underserved populations and improve care access and glycemic controls as patient outcomes. Almost all telehealth intervention platforms for vulnerable populations in the community influenced glycemic control through improving care access and selfmonitoring compliance. Therefore, this literature review highlighted the evidence for the best telehealth practice model and recommendable interventions that could be implemented in community health practice based on comprehensive integration of the best relevant evidence. In medically underserved patients with diabetes, the telehealth interventions displayed care quality, care coordination with patient healthcare access, as well diabetes self-management compliance, which have been reported in most literature.