Table 3.

COVID-19 impacts on self-management.

Theme	Subtheme and Illustrative Quotation
Increase in mental health symptoms made self-care difficult.	Depression Then there’s been quite a bit of depression too. Not necessarily depression that needs medication, but definitely some decreased moods just with patients not being able to see their loved ones, or see their friends, or get out and do anything. (Primary Care Provider)
	Anxiety We’ve seen more anxiety, a lot more anxiety, a lot more anxiety and depression as well. But I think it’s been, I would say, maybe 75/25 anxiety/depression for me because I only see women. I think women, especially women with young children or families, they’re taking this very seriously some of them. It’s really affecting them mentally because they’re the protectors of the children, and they can’t protect their children, and it’s really working their nerves very badly. (Primary Care Provider)
	General stress and wellbeing In general I think more folks were just feeling down. In general you could feel that they were stressed. A lot of their normal routine was disrupted, and they were not able to keep up with their families just because everyone was somewhat staying at home. So, I think it was definitely a time where people were just not feeling well. (Endocrine Specialty Clinician)
Financial challenges impacted self-care.	Job or insurance loss I think they had more challenges because a lot of people did lose jobs and it was a big challenge to go to doctors and paying copays and everything. They lost insurances too. That way I think they’re also having issues paying bills for their medical health. (Endocrine Specialty Clinician)
	New Expenses People who are not working their full hours, people who were having to pay for childcare that didn’t usually because the kids were in school … I think a lot of people were having to pinch a penny here or there, and if they weren’t really vested in doing [self-management] before, it was certainly one of the easier things to cut loose. (Primary Care Provider)
Restrictions disrupted self-care routines.	New family responsibilities The people who suffer the most are the same people who always suffer the most, women for sure, childcare. There was always kids in the background. They’re the ones for the most part stuck with childcare, and elder care, and everything else. (Endocrine Specialty Clinician)
	Reduced safe exercise space They’re not able to go to the gym for a long time … Some of them are even afraid to go out and walk which I kind of told them that hey, you can go outdoors without a mask if you’re not around other people it’s okay but some were not willing to do that initially so many patients have gained weight. (Endocrine Specialty Clinician)
	Reduced access to healthy food Of course, a lot of people are stress eating or tending to eat food because they really don’t want to go to the grocery store as often, so they’re not buying as many fresh fruits and vegetables. They’re tending to eat more processed, non-perishable foods. (Primary Care Provider)
	Increased availability of unhealthy food Their access to food ended up being worse because they were doing drive-thru rather than going to the grocery store. (Endocrine Specialty Clinician)
Restrictions allowed patients to prioritize self-care.	Improved diet They would say, “Yeah, it was great to be home with the kids, and I also cooked all the time, so I did well with my blood sugar monitoring and carb intake,” (Endocrine Specialty Clinician)
	Increased exercise I have occasional patients who now find themselves with more free time because of COVID. Maybe their work hours have been cut back or whatever, so they’re actually exercising more. (Primary Care Provider)
	More time for self-management A lot of my patients cut down on one to two hours of commuting a day into their office … they were able to check for the first time three times a day before they ate their meals and could decide how much insulin to give which, in an office environment, sometimes, they wouldn’t check before lunch because they didn’t want to do it or didn’t have time. (Primary Care Provider)
	Improved participation in care And that actually made my patients a little bit more participatory in their diabetes care because there was all these other setbacks meaning they couldn’t come in for routine bloodwork and evaluation in a clinic type setting. (Endocrine Specialty Clinician)
Clinical team utilized patient-centered strategies.	Prioritized lifestyle discussions With the gyms closing and now that they’re back open some people do feel comfortable to go back but some people are still saying “yeah, I’m still not feeling great about it” but then kind of having the discussion of “alright, I get it, I’m not going back to the gym either right now but it is still nice outside and you can walk” and then they’re like “oh yeah, I guess I could do that” … so having to make more of a conscious effort to go for a walk, to get up and move every hour or so to get some more steps in. (Primary Care Provider)
	Utilized telemedicine I would say in the patient who is pretty tech savvy and can upload their CGM or their pump, the virtual visits actually work quite well because we have all of the data in front of us so especially if they’re on a CGM, we can estimate their A1C just from that. In that population, I think it actually went pretty well. (Endocrine Specialty Clinician)
	Offered financial assistance We encouraged patients to apply for drug assistance, and sometimes helping them out with doing that. We directed them to clinics, pharmacies, clinics that have pharmacies for indigent patients that offer a drug program that they can access. All of that, and then we do have an active sampling system (Endocrine Specialty Clinician)