Abstract and Introduction
Introduction
Diabetes affects approximately one in 10 persons in the United States†and is a risk factor for severe COVID-19,[1] especially when a patient’s diabetes is not well managed.[2] The extent to which the COVID-19 pandemic has affected diabetes care and management, and whether this varies across age groups, is currently unknown. To evaluate access to and use of health care, as well as experiences, attitudes, and behaviors about COVID-19 prevention and vaccination, a nonprobability, Internet-based survey was administered to 5,261 U.S. adults aged ≥18 years during February–March 2021. Among respondents, 760 (14%) adults who reported having diabetes currently managed with medication were included in the analysis. Younger adults (aged 18–29 years) with diabetes were more likely to report having missed medical care during the past 3 months (87%; 79) than were those aged 30–59 years (63%; 372) or ≥60 years (26%; 309) (p<0.001). Overall, 44% of younger adults reported difficulty accessing diabetes medications. Younger adults with diabetes also reported lower intention to receive COVID-19 vaccination (66%) compared with adults aged ≥60 years§ (85%; p = 0.001). During the COVID-19 pandemic, efforts to enhance access to diabetes care for adults with diabetes and deliver public health messages emphasizing the importance of diabetes management and COVID-19 prevention, including vaccination, are warranted, especially in younger adults.
During February–March 2021, among 8,475 eligible U.S. adults, 5,261 (62.1%) completed the COVID-19 Outbreak Public Evaluation Initiative nonprobability, Internet-based survey administered by Qualtrics LLC. ¶ Respondents answered questions on demographic characteristics, attitudes and beliefs about COVID-19, and access to and use of medical care (including health care or telemedicine visits, delayed care, and loss of health insurance) since March 2020. The Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human participants research. This activity was also reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.**
Among the 5,261 respondents, 760 (14%) who reported having diabetes currently managed by regular medications or treatment were included in the analyses.††Demographic characteristics, experiences, attitudes, and behaviors related to the pandemic and health care access and use were assessed among these 760 persons. Demographic variables included age, sex, race/ethnicity, household income, education attainment, employment status, U.S. Census region,§§ urban/rural classification,¶¶ and health insurance status. Experiences, attitudes, and behaviors related to the pandemic included knowing someone who had received a positive test result for SARS-CoV-2 or who had died from COVID-19, perception of being at risk for severe COVID-19, vaccination intention, and composite measures of support for*** and adherence to recommended COVID-19 prevention behaviors†††(e.g., wearing a mask, physical distancing, avoiding gatherings, and practicing hand hygiene). Regarding health care access and use, respondents reported whether they had delayed or avoided medical care because of concerns related to COVID-19,§§§ and whether their ability to access care or medications for diabetes was easier, harder, or unaffected as a consequence of the pandemic.
Weighted percentages and 95% CIs were calculated by age group (18–29, 30–59, and ≥60 years). CIs were calculated using a logit model. Significant differences (defined as p-values<0.05) among age groups were assessed using chi-square tests; statistical differences between groups were determined by nonoverlapping CIs only where chi-square tests were significant. Quota sampling and survey weighting were employed to match the U.S. Census Bureau’s 2019 American Community Survey population estimates for sex, age, and race/ethnicity of the general population. Analyses were conducted using the R survey package (version 3.29) and R software (version 4.0.2; R Foundation).
By age group, respondent characteristics varied by income, education, employment status, U.S. Census region, urban/rural classification, health insurance status, and diagnosed mental health conditions (all p<0.05) (Table 1). Adults aged 18–29 years (younger adults) less commonly reported having health insurance (77%), compared with those aged 30–59 years (91%) and ≥60 years (97%; p<0.001). Diagnosed mental health conditions, including depression, anxiety, and posttraumatic stress disorder, were more commonly reported among younger adults (86%) and adults aged 30–59 years (64%) than among adults aged ≥60 years (32%) (p<0.001).
A larger proportion of younger adults with diabetes reported not knowing someone who had received a positive SARS-CoV-2 test result (90%) than did adults aged 30–59 years (69%) or ≥60 years (57%) (p<0.001) (Table 2). Both groups of adults aged <60 years were more likely to believe they were not at high risk for severe COVID-19 (94% [18–29 years], 76% [30–59 years]) than were adults aged ≥60 years (52%) (p<0.001). Younger adults reported the lowest support for COVID-19 prevention guidelines (28%) and COVID-19 prevention behaviors (30%), compared with adults aged 30–59 years (62% and 64%, respectively; p<0.001) and ≥60 years (51% and 72%, respectively; p<0.001). A lower proportion of younger adults reported that they intended to be vaccinated (66%) than did those aged ≥60 years (85%) (p<0.001).
Younger adults with diabetes reported having the lowest percentage of in-person health care appointments (53%), compared with those aged 30–59 years (76%) and ≥60 years (85%) (p<0.001) (Table 3). Both groups of adults aged <60 years were more likely to report delayed health care (87% [18–29 years], 63% [30–59 years]) than were adults aged ≥60 years (26%) (p<0.001). Approximately two thirds of adults aged 18–29 years (66%) and 30–59 years (69%) with diabetes reported that their access to diabetes care was unaffected, whereas 91% of older adults reported that their access to diabetes care was unaffected (p<0.001). Adults with diabetes aged <60 years were less likely to report unaffected access to diabetes medications (44% [18–29 years], 72% [30–59 years]), than were adults aged ≥60 years (96%) (p<0.001).
Among all respondents with diabetes, 28%, 33%, and 17% of those aged 18–29 years, 30–59 years, ≥60 years, respectively, reported that their health care was disrupted because of personal concerns that the health care system might be overwhelmed (p = 0.001). The most common reason for disruption in care among younger adults was concern about becoming infected with SARS-CoV-2 (44%), which did not significantly differ from that of adults aged ≥30 years (31% [30–59 years], 27% [≥60 years]; p = 0.151). Concerns about the cost of medical care did not differ significantly across the three age groups.