Perceived Usefulness of Continuous Glucose Monitoring Devices at the Workplace: Secondary Analysis of Data From a Qualitative Study

Abstract

Background:

Previous research suggests that psychosocial working conditions may detrimentally affect diabetes self-management behavior at work, including self-monitoring of glucose levels. We aimed to better understand the potential usefulness of continuous glucose monitoring devices at the workplace according to employees with diabetes.

Methods:

We carried out secondary analyses of data from a qualitative study, which sought to explore potential barriers to and solutions for effective diabetes self-management at work. Interviews were carried out in face-to-face contact or by telephone and were transcribed and content-analyzed using MaxQDA. The used topic guide did not specifically inquire after continuous glucose monitoring devices, but views on the suitability of those devices at the workplace repeatedly emerged from the interviews. Data from 25 employed adults with diabetes mellitus type 1 or type 2 on insulin therapy were included.

Results:

The major perceived improvements associated with the use of continuous glucose monitoring devices pertained to their time-saving application that allowed for an increased frequency of glucose level assessments and for socially covert glucose measurement. The socially less noticeable way of monitoring glucose level was specifically perceived as beneficial, as employees with diabetes believed their illness would thereby attract less attention. Fewer or shorter interruptions as well as the reliability of integrated alarm systems were perceived to increase concentration at work and workability.

Conclusions:

Continuous glucose monitoring devices were perceived to facilitate glucose management at the workplace, which may exert positive effects on compliance as well as functioning at work. Further research would be of interest to statistically confirm our findings in occupational samples.

Monitoring and adjustment of blood glucose levels represent a cornerstone of diabetes self-management. Adequate and consistent glucose monitoring in everyday life is however highly contingent upon contextual factors, some of which relate to individuals’ working conditions.^1-5 It has been suggested, for instance, that time pressure, a high workload, or poor decision authority related to one’s tasks or breaks may impair self-directed glucose management in terms of delayed or even omitted glucose monitoring.⁶ Also, many employees with diabetes may deliberately aim at running higher than optimal glucose levels to maintain their workability and to avoid hypoglycemic events.^1,6,7 In addition, traditional glucose monitoring procedures, that is, by finger prick, can be associated with anxiety of pain⁸ or an indisposition towards performing such self-management activities in the presence of colleagues and supervisors.^2-4

To improve the glucose monitoring process and experience, various types of continuous glucose monitoring (CGM) devices, which assess interstitial glucose levels, have been developed during the past two decades.⁹ Some features of those CGM devices may be particularly useful for employees with insulin-dependent diabetes, irrespective of the type of diabetes.¹⁰ For example, real-time CGM (rtCGM) devices allow for swift glucose monitoring (ie, within seconds) and calibration with one’s own blood is only required about twice a day.^11,12 Also, an alarm function will signal whenever glucose levels leave a predefined range.¹³ A new device using an intermittently scanned glucose monitoring (isCGM) system has recently been registered for some European countries and the USA.^9,14,15 Compared to rtCGM systems, isCGM devices offer the advantage that calibration with one’s own blood is not required at all. However, isCGM systems lack an integrated alarm.^9,16,17 International studies showed that patients are satisfied with both types of CGM devices^13,18 and that they seem to facilitate glucose monitoring as compared to blood glucose management in patients’ everyday life (eg, pain due finger prick is not experienced).^14,17,19

With regard to the potential merits of CGM in occupational settings, a recent study has shown that the utilization of a CGM device was associated with a reduction of diabetes-related absenteeism.²⁰ Another study conducted by Pickup et al²¹ has examined the benefits of CGM as perceived by users and suggested that those technologies are perceived to have the advantage of reducing the social attention for (or visibility of) diabetes at the workplace. In the latter study, findings were derived from qualitative analyses of patients’ responses to a single open-ended question, which was included in a short online survey. While that study provided important initial insights, its approach to data collection (ie, written responses) does not facilitate in-depth understanding of the perceived benefits or challenges associated with CGM use. Collection of qualitative data based on personal interviewing is superior in this respect. Such approaches allow gaining a more complete understanding of people’s attitudes, experiences and perspectives. Specifically, the social interaction during interviewing enables the interviewer to gain an understanding and interpretation of what is being said as well as hidden meanings.²² We aimed to provide such qualitative data on the perceived usefulness (or uselessness) of CGM devices at the workplace according to employees with diabetes. Such research is urgently needed in light of evidence suggesting that working conditions may impair blood glucose monitoring.^1,4,6,7

Methods

We drew on qualitative data from a previous study, which specifically addressed the potential contribution of working conditions to adequate diabetes self-management at work.¹ Briefly, 30 participants with diabetes mellitus type 1 (DMT1) or diabetes mellitus type 2 (DMT2) were recruited through a diabetes clinic (n = 17), physicians (n = 6), diabetes support groups (n = 6), and private contacts (n = 1). To be eligible, participants had to be in employment. We also ensured that at least five patients of each sex and for each type of diabetes were recruited.

Data were collected by qualitative interviews based on a topic guide. The topic guide addressed participants’ working conditions, their diabetes self-management behavior and how the former may affect the latter.¹ The topic guide did not specifically inquire about CGM systems. Experiences with those devices at the workplace and views regarding their usefulness were however frequently expressed and thus emerged as secondary findings and are reported in this paper. The topic guide was not modified to improve insights into the use of any CGM device, since the scope of this theme only became evident during formal data analysis addressing the original research question.

Interviews were digitally recorded, transcribed literally and content-analyzed using the MaxQDA 12 software package. Briefly, each broad topic included in the guide was taken as an overarching category (deductive coding), which was then refined based on the analyzed transcripts (inductive coding) (XQN, PVE, AL). Those analyses yielded a distinct category labeled “change requests—new practical therapy systems.” This category formed the basis to address the specific research question of the present study and was further supplement by reanalyses of all transcripts related to expressed views about CGM systems (JS). In the present analysis only interviews from participants who reported to practice insulin therapy requiring regularly blood glucose control as part of their diabetes management were included (N = 25). Two interviews were excluded because of poor recording quality and three interviews were excluded because participants were not on insulin treatment requiring regular self-monitoring of blood glucose.

Results

Table 1 summarizes characteristics of the study population. Briefly, the sex distribution was almost balanced and the age ranged between 24 and 64 years (mean = 44.7, SD = 11.3). Eighteen participants (75%) reported to have been diagnosed with DMT1 and the remainder reported DMT2. Diabetes diagnoses had been made on average 15.2 years ago (SD = 10.4) and 48% of the participants reported at least one diabetes complication. Participants from diverse occupational contexts were included with varying perceptions of their overall work stress.

Table 1.

Characteristics of the Study Population (ie, Workers With Insulin-Dependent Diabetes, N = 25).

Sociodemographics	Female sex, n (%)	14 (56.0)
	Age in years, mean (SD), min-max	44.7 (11.3), 24-64
	Married, n (%)	12 (48.0)
	High education level, n (%)a	16 (64.0)
Occupational data	Years in current job, mean (SD), min-max	15.5 (13.2), 0-37
	Working full-time (as opposed to part-time), n (%)	19 (76.0)
	Employed (as opposed to self-employed), n (%)	22 (88.0)
	Job with leadership responsibility	11 (45.83)
	Work stress (1-10), mean (SD), min-maxb	6.3 (2.4), 1-10
Diabetes-related data	Diabetes disclosed at work, n (%)	24 (96.0)
	Type 1 diabetes present (as opposed to type 2), n (%)	18 (75.0)
	Years since diabetes diagnosis, mean (SD), min-max	15.2 (10.4), 2-41
	At least one diabetes complication, n (%)c	12 (48.0)

^aHigh level of school education (ie, “Abitur” or “Fachhochschulreife” versus lower degrees or no formal degree).

^bWe measured overall work stress by a numeric rating scale ranging from 0 (low stress) to 10 (high stress).

^cMeasured by self-reported hypertension, myocardial infarction, stroke, circulatory disorders at the legs, retinopathy, polyneuropathy, and nephropathy.

In total, 8 participants initiated a discussion about the usefulness of CGM devices without any prior probing by the interviewer. Participants expressed that glucose monitoring at work was achieved more conveniently when CGM devices were used as compared to traditional blood glucose control (see quote a in Table 2). Important aspects in the context of the work environment seemed to be that measurements could be taken in a quick and time-saving way—by inspecting the display of a CGM system or scanning the sensor (in case on a isCGM systems)—and that comprehensive data was attained (eg, the potential trend over time) (see quote a in Table 2). This was in particular perceived as beneficial during stressful situations at work or when there appeared to be no time for a break (see quote b).

Table 2.

Quotes From the Interviews.

Quotes
(a) Interview 2: R: Because that is just, it is like using a cell phone, you put it over the skin once and get an estimate. The estimate is shown immediately and whether it increases or decreases. And you get much more information than during normal capillary blood glucose monitoring, which does not take hours, but still much more demanding and, and more noticeable.
(b) Interview 2: R: Once in a while I indulge myself in the luxury and use the [brand name], and this is much easier to get an overview of the blood sugar levels and to counteract a fall or increase in blood sugar early, which is not possible with the usual way of measuring blood glucose, especially in stressful work situations.
(c) Interview 25: R: Well, I do not want to attract attention, like for example during a meeting, right? Instead, I have to focus on what’s actually going on in the conversation.
(d) Interview 20: R: That means, I can also trust it during a longer critical conversation, in case I did not receive a message. When I feel restless or nervous it is not a hypoglycemic event. And that’s the way it is. So it brings more confidence in your own body. And thus also better personal performance. And that I can concentrate better on other things. I: Hm, do I understand correctly that the sensor helps you to have more freedom and to be able to concentrate better on work? R: Exactly.
(e) R: I see those devices as an essential relief, which measure the permanent blood sugar, because then you really can react flexibly. And above all, the trend indicator. Now if I had, say, a sugar value of 80 . . . if the trend goes down, then I would eat something right away. If the tendency is rising, I would perhaps think again and then again maybe a few minutes later . . . or maybe again in half an hour to test again whether, or, and watch the device, that is relatively easy, if this trend continues to prevail upwards. Because otherwise at 80 . . . and the tendency is falling, I would eat immediately, so that it does not move into a hypo.
(f) Interview 4: R: Especially when I attend a meeting, then I don’t want to fiddle around with my test stripes and my work documents. (1) And then everybody watches me. So I always withdrew and went to the bathroom, (1) just to measure blood sugar.
(g) Interview 3: R: Because sometimes I think that’s quite good in a meeting for example. If you sit in a meeting, then I do not necessarily want to somehow get out my blood glucose meter and prick my finger. (1) And then everybody is watching.
(h) Interview 17: R: This is such a measuring system, which measures continuously and so you do not always have to prick your finger. It’s also very handy, when you’re busy at work and there’s a lot of work to do, then you do not have to dig out the meter and prick your finger. Since you can just scan the sensor, which is attached to the upper arm.
(i) Interview 3: R: I find this finger testing stupid. First of all, because you do not make your fingers look nicer, then you have some scars . . . or puncture marks.
(j) Interview 4: R: Now with the [brand name], yes, I can do it anywhere, anytime. Whether I’m sitting in the meeting, or elsewhere.
(k) Interview 25: R: Exactly. At work, that you do not even want to show it to everyone, right? Now I do that during a conversation.
(l) Interview 2: R: So [brand name], if I carry it, the sensor, I do that, I would say, ten to twelve times, because that’s really fast. With my usual (1) test device, with the pricking, four to eight times, so depending on how much I move around, depending on whether I have longer car rides ahead or not.

According to participants, the opportunity to monitor glucose levels in the working situation and not needing to interrupt their current task positively affected their functioning at work. Due to a quicker monitoring process, more time was spent on occupational tasks. Also, interruptions and absences were reduced, for example, in meetings, and less social attention was attracted to one’s diabetes (see quote c). In addition, interviewees mentioned that they were able to concentrate better on occupational tasks as they did not need to worry about their glucose level, in case they have a rtCGM system with an integrated alarm on which they can trust (see quote d).

Due to the convenient monitoring, any countermeasures could be well-timed, for example, early on or later when the projected trend is verified or the measurement is repeated (see quote e). Participants reported to dislike performing traditional blood glucose measurement because it requires the use of comparatively comprehensive equipment, such as test strips, needles and a reading device and because those procedures were time-consuming. Furthermore, many participants disliked performing finger pricks at work, for instance, to avoid work-related documents from having contact with blood (see quote f). In this context, the unwillingness to draw blood from the finger in social situations seemed also related to an uncomfortable feeling and possibly shame (see quote g). Conversely, a perceived main advantage of rtCGM systems was that finger pricks at work (for calibration purposes) could be largely avoided (eg, done before work) and that isCGM devices did not require any blood calibration (see quote h). This was further perceived as beneficial as skin problems (eg, due to puncture makers or scars) were reduced (see quote i) and because glucose monitoring by rtCGM or isCGM devices was less noticeable in social situations and can be carried out in the presence of colleagues or during contact with customers (eg, in business meeting or while being on the telephone) (see quotes j, k).

In the context of work, an easy and socially covert way to monitor one’s glucose level in stressful situations or when being around colleagues and supervisors may contribute to a higher compliance in terms of glucose level monitoring. Many participants reported that they had been monitoring their glucose level on an irregular basis when they had used traditional blood glucose approaches. By contrast, use of rtCGM or isCGM was perceived to contribute to more regular and more frequent assessments (see quote l).

Due to the above-mentioned improvements related to glucose monitoring, participants expressed the wish to use the rtCGM or isCGM device on a daily basis. At the time of interviewing, the cost of these devices are not or only partly covered by health insurances in Germany and many of our participants recommended full coverage and to make devices accessible to all employees with insulin-dependent diabetes.

Discussion

Our qualitative study suggests that—in occupational contexts—employees with diabetes believe that CGM devices facilitate glucose monitoring. Main benefits were that the monitoring of glucose levels was perceived as convenient, more regular/more frequent, time-saving and socially covert. These findings are in line with the results from prior studies supporting the notion that the monitoring process of glucose level for patients with diabetes is simplified through CGM devices.^14,17,19 In keeping with a prior study by Pickup et al,²¹ we found that the opportunity to closely and conveniently monitor glucose levels and to be warned by an alarm if levels are inadequate was perceived to result in fewer interruptions of occupational tasks. More specifically, our study suggests that due to the omission of fingerprick CGM devices enable employees with diabetes to monitor their glucose levels directly at the workplace, for example, while performing work-related tasks. In addition, participants reported that CGM devices offer the benefit that one is able to assess glucose level in social situations, which was more problematic with traditional blood glucose measurement. This may not only improve the workability of employees with diabetes, but may also contribute to higher work satisfaction and better mental health.²³ In addition, participants stated that CGM devices contribute to a consistent glucose management in the occupational context. A main motive for increasing the frequency of glucose monitoring was the prevention of hypo- or hyperglycemia through a well-timed initiation of countermeasures. This notion is supported by a multicenter randomized controlled trial which found a significant reduction of time in hypoglycemia and hypoglycemic events when CGM devices were used (as compared to self-monitoring with traditional blood glucose measurement).¹⁹ The prevention of such events is an important motive for employees with diabetes since such an event attracts attention through being unable to continue working.⁷

In summary, earlier studies found that blood glucose monitoring at the workplace is influenced by working conditions, such as work processes, unhygienic workplaces or social interactions which may impair opportunities for consistent blood glucose monitoring.^4,6,7 In light of those findings, our study adds that employees report to experience improved glucose monitoring as well as better work performance and workability when using CGM devices. Implications may therefore include offering CGM devices to employees on a larger scale. For instance, physicians (eg, diabetologists and occupational physicians) could be encouraged to inform patients about CGM devices and their beneficial effects on glucose monitoring at the workplace. Moreover, employers may offer copayment or partial refund of the expenses of their employees for CGM devices, in case such expenses are not covered by health insurance schemes. This may not only lead to more consistent glucose monitoring and likely better glucose management (ie, administration of insulin when required) and thus an improved prognosis,²⁴ but also to improved workability and reduced diabetes-related absenteeism,²⁰ which benefits employees and employers alike.

Some methodological limitations of our study deserve mentioning. First, participants’ views on the usefulness of rtCGM and/or isCGM emerged as a secondary finding from 8 out of 25 interviews. Since neither the topic guide nor the standardized background questionnaire specifically inquired after the use of CGM devices, but only after diabetes management procedures, we do not know what proportion of the participants used isCGM, rtCGM, or blood glucose management or any combination of these approaches. Some participants mentioned to use any type of CGM device and some specified their device as rtCGM or isCGM. Therefore, it was not possible to analyze employees using rtCGM or isCGM separately. In addition, some participants might have used a CGM device, but did not mention it during the interview. As a consequence, we cannot rule out that only those participants that have made very positive experiences with CGM devices have raised this topic and that negative experiences were less likely to be reported. In the literature it appeared, for instance, that patients reported alarm-fatigue when using CGM devices,^13,25 but this theme did not emerge from our data. Second, background information concerning not only the types of device participants used had been useful, but also data on the duration of use or reasons for initiating use (eg, recommended by a physician because glycemic control was suboptimal), but such data were not collected. All participants included in the present analysis reported to have disclosed their diabetes to their supervisor and/or (close) colleagues. Therefore, there are no statements as to whether CGM devices would be useful to people who do not wish to disclose their condition at work. In this study, employees from diverse occupational backgrounds were included, but most of those occupations were characterized by low physical activity levels and regular working hours. Thus, further research to examine specific improvements in daily and work-related activities in different professional groups, but especially in physically demanding professions with poor job control, is needed.

Conclusion

CGM devices seem to facilitate glucose management at the workplace according to users and are perceived to exert positive effects on compliance and functioning at work.