Opportunities for Interventions That Address Socioeconomic Barriers to Type 2 Diabetes Management: Patient Perspectives

Abstract

Purpose

The purpose of the study was to explore patient perspectives on socioeconomic barriers related to diabetes self-management and interventions to address these barriers.

Methods

Focus groups (n = 8) were conducted with a diverse sample of adults with type 2 diabetes (T2D; n = 53). Researchers used a semistructured moderator guide; focus groups were audio recorded and transcribed verbatim. Researchers employed the constant comparison method for qualitative content analysis and utilized Atlas.ti (Version 8.1.1) to digitalize the analytic process.

Results

Findings revealed 3 primary themes: (1) Existing food and nutrition resources are insufficient to support healthy eating for diabetes; (2) healthy eating is critical for diabetes management, but socioeconomic circumstances make doing so challenging; and (3) participants supported several broad categories of preferred intervention strategies. First, they endorsed lifestyle intervention informed by socioeconomic status (SES; eg, focusing on food resource management, sensitive health coaching and nutritional counseling). Next, they expressed enthusiasm for group-based learning opportunities, such as cooking classes and support groups with similar SES peers. Finally, they suggested healthy food access resources.

Conclusions

Participant suggestions should be incorporated into intervention development. Ultimately, these interventional strategies should be tested and refined to help improve health for individuals with type 2 diabetes.

In the United States in 2018, 26.9 million people of all ages, or 8.2% of the population, had diagnosed diabetes.¹ Type 2 diabetes (T2D) accounted for 90% to 95% of all diabetes cases.¹ In 2017, the total direct and indirect estimated costs of diagnosed diabetes was $327 billion.¹ Among adults, prevalence varied significantly by education level, which is an indicator of socioeconomic status (SES). Specifically, 13.3% of adults with less than a high school education had diagnosed diabetes versus 9.7% of those with a high school education and 7.5% of those with more than a high school education.¹ Research suggests people who have limited income and/or experience poverty also have higher rates of T2D.^2–4

In addition to associations with diabetes prevalence, socioeconomic barriers such as food insecurity, housing insecurity,⁵ and decreased access to medications and health care negatively impact diabetes self-management and glycemic control.^6–8 Socioeconomic disparities such as these are key reasons that recently released Healthy People 2030 goals include stronger emphasis on addressing social determinants of health as key objectives.⁹

Although the associations between socioeconomic barriers and worse diabetes outcomes are clear, how best to intervene is not. Several interventions to assist patients with T2D who experience these socioeconomic barriers have been proposed. These include interventions to address food insecurity (eg, food pantry programs,^10,11 medically tailored meals,¹² fruit and vegetable prescription programs¹³), medication assistance programs, and diabetes education and lifestyle intervention.

However, recent studies of interventions to address socioeconomic barriers to diabetes self-management and support have been less effective than hoped. For example, a randomized controlled trial based in food banks that provided food boxes and diabetes self-management support classes for individuals with food insecurity found no differences in diabetes self-management outcomes, including A1C.¹⁰ Similarly, no significant changes in A1C were detected at 12 months in a randomized controlled trial exploring the use of a diabetes self-management intervention for low-income adults with diabetes (n = 145) delivered by a community health worker.¹⁴ Another study evaluated the impact of referral to a program that sought to link patients with unmet health-related social needs (eg, those related to food, medications, transportation, housing, utilities, employment, and elder-care services) to community resources. This study found that the program had modest improvements on blood pressure and lipids but no effect on glycemic control.¹⁵ Finally, another study showed no relationship between use of the USDA Supplemental Nutrition Assistance Program (SNAP) and glycemic control among Medicare beneficiaries.¹⁶

One strategy to improve intervention design is enhanced involvement of participants.^17–21 As supported by the theory of acceptability, which specifically highlights the importance of qualitative methods that engage members of the priority audience during the developmental phase,^22–24 the key contribution of the present study is to obtain patient perspectives on several commonly proposed types of interventions and solicit their ideas for how these interventions could be implemented alone or in combination. To this end, this article presents patient perspectives on socioeconomic barriers related to diabetes self-management and interventions to address these barriers.

Methodology

Research Design

The qualitative data collection method used in this study was semistructured focus groups. The rationale for selecting this method is severalfold. Researchers wanted both to observe participants’ response to moderator questions and observe how focus group participants responded to the views of other participants. Furthermore, the investigators wanted to offset the power dynamic that typically privileges the clinician as the “one who knows” in a clinical setting, which they worried would be reproduced in a one-on-one interview. Because the focus group participants outnumber the focus group moderator, this shifts the power dynamic and allows participants to feel more confident in sharing their perspectives.^25–27

Details of study participants have been previously reported,²⁸ but in brief, participants were adults age ≥18 years with T2D who received care within a clinical network in eastern Massachusetts (n = 53). The practices from which participants were recruited were selected to have socioeconomic diversity in the patient population they served and included both community health centers and academic hospital-based practices. Participants were recruited at random from a registry of adults though an electronic health record review. Eligible participants were contacted up to 5 times. Participants were invited to attend 1 of 8 focus groups, depending on their availability, and all focus groups were held at a clinic with which the participants were already familiar.

The overall study these data come from had 2 primary aims: to examine patient perspectives on multidisciplinary coordinated diabetes care²⁸ and on socioeconomic barriers to diabetes care and interventions to address these barriers. Data on both topics were collected during the same focus groups and analyzed using similar methods. Results regarding multidisciplinary care have been previously published.²⁸ The specific contribution of this study is to report perspectives on socioeconomic barriers to T2D management and interventions to address them; data from the study on this topic have not been previously published.

Procedures and Data Collection

After agreeing to participate in the study, descriptive data about the participant were collected from the electronic health record. These data included demographics and recent A1C and blood pressure measurements. Researchers conducted 8 focus groups with 4 to 9 participants in each focus group from December 2014 to March 2015. Focus groups lasted approximately 90 minutes. One facilitator (SAB) led all focus groups. This facilitator was an internal medicine physician with master’s-level training in research methods, including qualitative research, specifically focus group and semistructured interview methods. The facilitator was also a practicing primary care physician who provided primary care to low-income individuals with T2D. The facilitator used a semistructured moderator guide. This guide was developed using an iterative process, including feedback from nurses, physicians, psychologists, and dietitians.²⁸ It was subsequently refined after a pilot focus group (this session was not analyzed).²⁸ The moderator guide had 2 primary areas of emphasis: perspectives on multidisciplinary coordinated diabetes care and perspectives on socioeconomic barriers to T2D management. Open-ended questions and prompts regarding socioeconomic barriers were drawn from conceptual models relating socioeconomic barriers to chronic disease management.^29,30 Example moderator guide questions include “What are your biggest obstacles/challenges to living with and taking care of your diabetes?” and “What strategies do you use for coping with the costs of managing diabetes when money is tight?” The study protocol was approved by the Human Research Committee at Partners HealthCare (Protocol No. 2014P001254). All participants provided verbal informed consent. At the end of each focus group, participants were debriefed.

Theoretical Framework for Analysis

Researchers employed the constant comparison method³¹ framed by the constructivist theory for this analysis.^32,33 Constructivism is built on the premise of a social construction of reality. One of the advantages of this approach is the close collaboration between the researcher and the participant while enabling participants to tell about their experiences. It is through this discourse that participants are able to describe their views of reality, and this enables the researcher to better understand the participants’ actions.³⁴ This approach is particularly well suited to the goals of this project given that researchers sought to understand what interventional strategies were perceived by participants as being most useful to help them better manage diabetes. The social constructivist perspective suggests that people are always developing meanings and understandings in social, cultural, and historical contexts. From this perspective, people construct, form, and negotiate subjective, complex understandings of food, eating, and health through their personal experiences and interactions with other people and their contextual environment.³⁵

Analysis

All focus group sessions were audio recorded and transcribed verbatim by a professional transcription company within a few weeks of the focus group. Transcripts were analyzed in their entirety. Using the constant comparison coding method, data were coded in various increments depending on context of the quotation. The first round of coding included inductive free coding where the coders developed and attached codes that arose from the transcripts. An example of an inductive code would be “strategy to eat well,” indicating where participants discussed a strategy for healthful eating. Researchers then created a codebook based on this first round of inductive coding and then added deductive codes to the codebook, which included predetermined a priori codes (based on the research questions, literature, and researchers’ prior understanding of the topic). An example of a deductive code was “cost of food” and was attached to quotations where participants discussed the cost of food. Together, the coders defined each inductive and deductive code to ensure mutual understanding for a code and collapsed redundant codes. For example, the codes “fast food” and “convenience food” and “processed food” were collapsed because they all referred to convenient, quick, high-calorie/fat/sodium, on-the-go food choices. Using this coding strategy, codes were then constructed into a hierarchical code system, which led to development of categories. Researchers utilized Atlas.ti (Version 8.1.1) to digitize the analytic process. As is the standard in qualitative research,³⁶ coders double coded 20% of the transcripts so that >80% concordance was achieved.³¹ The research team calculated descriptive statistics (means and frequency distributions) from the electronic health record to describe the sample of focus group participants. These data were analyzed using SAS Version 9.3.

Results

Fifty-three adults, with an average age of 59 years (range: 33–84), participated across the 8 focus groups. Participants were primarily non-Hispanic white (70%), 43% were women, 63% had high school diploma or lower education, and 43% had Medicaid health insurance. Table 1 presents descriptive characteristics of the focus group participants.

Table 1.

Participant demographics (N=53)

	Mean (SD), or %
Age, years	59.4 (12.0)
Female	43
Race/ethnicity
Hispanic/Latinx	11
Non-Hispanic White	70
Non-Hispanic Black	15
Asian/other/multiple	4
Health Insurance
Private	23
Medicare	34
Medicaid	43
Education
< High School Diploma	7
High School Diploma	56
> High School Diploma	37
Mean systolic blood pressure, mmHg	130.7 (13.8)
Mean diastolic blood pressure, mmHg	75.2 (8.8)
Hemoglobin A1c	7.8% (1.7%)
	[62 mmol/mol (18.6 mmol/mol)]
LDL Cholesterol, mg/dL	89.5 (26.7)

LDL = low density lipoprotein. Hemoglobin A1c and LDL cholesterol results were obtained from the electronic health record, using the information most recent, with regard to when the focus group occurred, over the previous 18 months. Mean systolic and diastolic blood pressure represent the mean of up to 3 blood pressure readings.

Qualitative findings revealed 3 primary themes: (1) Existing food and nutrition resources are insufficient to support healthy eating for diabetes; (2) healthy eating is critical for diabetes management, but socioeconomic circumstances make doing so challenging; and (3) there is support for interventions to address socioeconomic barriers to T2D management. This section elaborates on these themes.

1. Existing food and nutrition resources are insufficient to support healthy eating for diabetes.

Two primary categories support this theme. First, participants expressed frustration when discussing existing food security resources, such as the USDA SNAP. Participants suggested these resources were insufficient to support healthy eating and that the time and effort required to enroll in SNAP often outweighed the value of the benefits received. One participant shared:

Oh, I get food stamps. They give me $166 a month. And that’s not enough for all the stuff that you need to buy. You know, you have to go buy the bargains, and you know hopefully there is stuff there in the bargains section that you can buy that you can have. But most of the times it’s not … and it’s just so hard.

In response to their experience with enrolling in SNAP, participants suggested “it was such a pain” and “it’s awful” and that it took substantial effort to enroll. One participant elaborated with her experience in enrolling for SNAP:

Like, I don’t understand. And I had to jump through hoops to get it. I had to get paperwork to prove that my when my ex-husband was [incarcerated] and proof of the last payment I got from him from child support…. What did they expect you to buy with $17?

Participants also shared that food banks or pantries can be helpful for emergencies but infrequently have healthy foods that are good for people with diabetes. One explained:

Now I went to a food pantry twice. I waited an hour and a half to get in there. I got 1 paper bag full…. It’s better than nothing, but they gave me cereal, bread, potatoes, all carbs and it really wasn’t good…. I mean I’m grateful ‘cause there are people out there that really need that, but they don’t give you vegetables or anything like that.

As a second supporting category to this theme, participants suggested they had mixed experiences with nutrition counseling. Some participants’ experiences with nutrition education were positive, and this primarily centered around the nutrition educator taking time with the appointment and offering concrete tips for healthful eating and weight management. In response to “tell me more about your experience with the dietitian you mentioned,” participants shared:

I did see a dietician, I think, when I first started. I learned how to weigh my food, read food labels, and I lost a lot of weight and my levels went really down.

However, other participants shared less positive experiences with nutrition counseling:

Yeah, she put a nutritionist [doctor nutrition referral] but she just showed me the basic, and I skip all her appointment after that ‘cause … it’s the same thing, same questions…. Now you can just google everything and you get everything, so yeah, the nutritionist didn’t work for me.

Another participant shared about his mixed experiences with nutrition education:

I tell you I’ve had a good experience and a bad one. I had a nutritionist and she just said … do this, do that. See this. Just read that. And you’ll be fine and I said okay. And then I went to main campus and they had one there and she was excellent…. The only thing is … I’m on Medicare and I could only be allowed 3 visits with her.

Participants also mentioned challenges with following a recommended meal plan that does not accommodate their lifestyle and their struggles with a nutrition educator truly understanding how difficult it is to eat healthfully on a budget for people with diabetes. Participants suggested their experience with nutrition education included a lack of sensitivity to socioeconomic challenges of healthy eating, challenges with following diet recommendations, and difficulty sustaining behavior change in the context of socioeconomic stressors.

2. Healthy eating is critical for diabetes management, but socioeconomic circumstances make doing so challenging.

The first supporting category for this theme was that participants suggested that mental health, comorbidities, and family needs can lead to stress, which can exacerbate challenges of healthful eating. One participant explained:

I’m stressed and depressed because of everything I’ve been through. So being depressed some days, I’m not so into it [healthy eating]. And I don’t care what I eat. Or some days I don’t eat all day, and the depression because of everything I’ve been through.

Participants suggested transportation can be challenging related to cost of gas and comorbidities, such as neuropathy and retinopathy, which compromise mobility and ability to drive. Participants also shared struggles with cooking at home. Some felt that having other family around made it more difficult to adhere to a strict diet, whereas others made comments about affording healthy foods. They also suggested that accommodating their family members’ diet restrictions and food preferences make it challenging for them to follow their own healthy diabetes diet. For example, one participant shared:

It’s not easy to stay healthy. So, I got 3 kids, so you know, kids they not liking vegetables every day, they’re not liking fruits every day. They want their pasta. They want like their carbohydrates…. I’m working full time, mom full time, and cook for myself and cook for my kids and cook for my husband. It’s just like, it’s not easy. And it costs money too…. So, you know, I have to forage other places to get food.

Additionally, participants shared that the cost of healthy eating is a key barrier to diabetes management. They shared struggles with grocery shopping on a budget:

People tell you to eat fish, and you can’t. Chicken and pork is the only thing you can really afford if you’re on if you’re on medium income. And no fresh anything. No vegetables. No fruits. Not when your income is like mine.

Participants lamented that the cost of food has increased, as had the cost of gas and rent, and discussed challenges with the logistics of eating healthy foods beyond the high cost of these foods. They discussed lack of access to grocery stores that carry affordable healthy foods. The cost of healthful foods caused participants to make tough decisions about how to balance finances between medications, healthy food, and other competing interests and to continue to eat healthy meals. Participants shared:

I’m on 2 different insulins. And I pay $375 for each one and the test strips are free and the lancets are free…. My thing is the food. I mean it’s so hard … I get a lot of cucumbers because they’re 2 for a dollar, so I get a lot of cucumbers and I’ll like dip that in hummus at night time when I want a snack instead of a bag of chips. … But the cost of the food is very … food stamps only gives me $17 a month and that really doesn’t cut it.

Finally, another barrier to healthy eating included challenges with finding time to cook at home and therefore overconsuming fast, processed, convenient foods that are high in refined carbohydrate, sodium, fat, and sugar. Participants suggested their busy work schedules make it difficult to eat healthy meals:

You do a 12, 13, 14 hour day you start at like 4, 5 in the morning. You get home at 7 o’clock at night. You’re not thinking healthy…. I don’t know how many times I did it, and I know it’s wrong. Go by Burger King and, you know, give me the dollar menu. Give me 4 hamburgers because I hadn’t really had anything to eat all day.

Finally, participants also shared the shame, embarrassment, and stigma they feel about having diabetes and low/limited income. One participant shared:

So, we couldn’t afford it [eating healthy meals] so my doctor told me just like get food stamps. I was ashamed first, but she said you have to go.

3. There is support for interventions to address socioeconomic barriers to T2D management.

This theme is supported by participants’ description of 3 broad categories of preferred intervention strategies. First, they endorsed socioeconomic-informed lifestyle intervention such as focusing on food resource management, sensitive health coaching, and nutritional counseling. Participants indicated desire for skill building related to cooking diabetes-healthy food, education for eating healthy on a budget, or “on the go,” away-from-home, healthy, affordable meal ideas. One participant who suggested that traditional nutrition education “didn’t work for me” shared:

But it will be different idea if it was a nutritionist like somebody that can like teach you how to cook, exercise in just one [appointment].

Second, participants demonstrated enthusiasm for group-based learning opportunities, such as cooking classes and support groups conducted among peers with similar SES. Participants suggested they like to get to know one another and receive positive feedback from their peers about their food and nutrition habits, as exemplified in this exchange:

Participant A: I like to see people face-to-face.

Participant B: It’s nice to meet new people and to get new ideas. That makes ya feel good!

Participant A: But it’s good to exchange ideas and exchange information.

Within the focus group setting, participants shared personal stories and struggles with diabetes and provided support for one another. Participants mentioned their diabetes makes them feel “isolated” and “lonely” and separate from their family when it comes to food and eating. Participants indicated that group-based, peer-to-peer support may help mitigate sentiments of shame and embarrassment by normalizing the challenges of managing diabetes with limited resources. During the focus groups, participants commiserated on high cost of healthy foods but also shared suggestions for healthy eating on a budget, including use of coupons, meal preparation ahead of time, and buying in bulk. Participants exchanged ideas for buying in bulk:

Participant C: Exactly. I trade with my grand-kids…. But we will buy like the big batch of carrots and split it. You know what I mean?

Participant D: I buy 1 get 1 free, give 1 to my daughter, keep 1 for myself.

Finally, participants suggested provision of additional resources such as meal delivery programs, healthy food subsidies, and assistance in accessing food aid. Regarding programs to help access food aid resources, participants expressed interest but shared concerns about previous experiences and understanding of the process. For example, one participant said:

My primary care doctor suggested that [resource to access SNAP] a couple of times but I’m discouraged because I’m aware of what goes on in … that office area there and some of the people are really rude and I don’t want to be subject to something like that so I stay away.

Participants also indicated assistance to affordable fresh produce would help them eat healthier as exemplified here:

If I could afford them, I could sit down and have a plate just of vegetables and it wouldn’t bother me one bit. I enjoy vegetables. It’s you know, ‘cause I know they’re better for you.

Together, these key themes indicate participants’ sentiments about gaps in food and nutrition resources, barriers to healthful eating, and potential interventions to mitigate these gaps and barriers.

Discussion

The purpose of this study was to understand patient perspectives on socioeconomic barriers related to diabetes self-management and interventions to address them. The longer-term goal is to use these perspectives to identify opportunities for intervention specific to socioeconomic barriers to T2D management. Participants recognized the importance of diabetes self-management, particularly healthy eating; noted socioeconomic barriers to T2D management; and suggested interventions to help overcome these barriers, both inductively from the participants and deductively as specific responses to moderator guide questions. The interface of these 2 analytical techniques allows us to triangulate findings³¹ as a means to inform future interventions to address socioeconomic barriers to T2D management.

This study is consistent with and extends findings from prior work. Focus groups and interviews with socioeconomically disadvantaged adults have provided insight for development of food and nutrition community-based resources and programs.^37–40 Internationally, qualitative researchers have explored how socioeconomic factors impact diabetes management among adults with T2D in Australia^41,42 and Africa.^43,44 Findings suggest that multilevel approaches to diabetes care interventions are necessary to adequately address the myriad of socioeconomic barriers patients face. One US-based study examined financial barriers to care among patients with diabetes through phone and in-person one-on-one interviews and determined the importance of health care providers in supporting these patients.⁴⁵ This work contributes to this body of literature by focusing on interventions, as supported the participants’ perspectives, that can be developed to address socioeconomic barriers to T2D management.

As supported by the policy, systems, and environment framework for nutrition interventions^46,47 and the social-ecological model,⁴⁸ these findings suggest the importance of the relationship between health behaviors and individual, interpersonal, organizational, community, and social systems. The social-ecological model effectively links the complexities of health determinants and environmental influences on health.⁴⁹ Specific to nutrition guidelines, the 2015–2020 Dietary Guidelines for Americans also draws on the social-ecological model and suggests the importance of addressing multilevel approaches to health interventions. A key construct in this model includes the importance of addressing social and cultural norms because they influence health outcomes.⁵⁰ As supported by these frameworks, findings from this study suggest that individuals with T2D desire social, community, and interpersonal support (peer-to-peer coaching or group-based medical visits), individual support (food resource management-based nutrition education), and systems support (improved access to SNAP or other food aid benefits). With regard to diabetes self-management education and support, participants suggested that peer-to-peer education, coaching, and support groups specific to their socioeconomic circumstances would help reduce the stress of feeling lonely, isolated, and stigmatized for having T2D or experiencing socioeconomic challenges to managing T2D. Group-based or peer-to-peer education and support opportunities would not only address the aforementioned considerations, but the literature suggests that especially among minority,^51,52 immigrant,^53,54 and low-income populations, the community health worker or peer educator model for diabetes self-management education and support is especially effective.⁵⁵ Incorporating community health worker and/or peer-educator support would also address the concern supported by these findings that registered dietitians and/or nutrition professionals may not be aware of socioeconomic barriers to healthful eating and that time with registered dietitians is often limited by reimbursement/insurance coverage.

Participants perceived that healthy eating and cooking at home is time-consuming and more expensive than eating out. This perception suggests a need for nutrition education opportunities on food resource management.⁵⁶ Examples of nutrition education on food resource management include hands-on cooking classes,^57,58 grocery store or food-pantry-based education focused on meal planning,¹¹ and support in budgeting food resource dollars to maximize healthful food intake. Specific to improving healthy food access, participants in this study were interested in several opportunities for intervention. These may include: meal delivery services,¹² as suggested by comments about issues with transportation and time to prepare healthful meals; fruit and vegetable subsidy programs,^13,59–62 as suggested by comments related to high costs of fresh produce; or assistance with completing SNAP application materials, given that participants who had applied for SNAP complained of challenges in the process. Furthermore, because SNAP benefit amounts are often insufficient to support healthy diets, increasing SNAP benefit levels may be another approach.⁶³ Improving transportation opportunities may also improve access to healthy food,⁶⁴ as suggested by participants in this study who lived in areas where there were no affordable supermarkets.

In considering opportunities to combine multiple intervention strategies, supported by these findings and the aforementioned frameworks, several potentially innovative solutions arise. First, buying in bulk and preparing home-cooked meals are key strategies for food resource management and healthful eating.⁶⁵ Combining a peer-to-peer support and education model with group-based grocery shopping and/or group cooking could facilitate social interaction and hands-on-learning, and participants could gain a sense of pride and ownership to preparing their own meal either for on-site consumption or meals later in the week. Second, to address stress, participants in this study discussed that mindfulness practices,⁶⁶ including mindful eating,^67,68 could be incorporated into diabetes self-management support. Within the group-based medical visit or support group context, mindful eating may be effective at addressing stress and healthful eating and build social support among people with T2D who experience socioeconomic barriers to diabetes management. Finally, subsidized community-supported agriculture programs have been explored as potential ways to increase fresh produce consumption among people with low SES.^13,69

As is inherent to qualitative research, these findings are not necessarily generalizable beyond the experiences of this sample,^70,71 but these perspectives nevertheless provide a starting point for intervention development. A limitation of the study is that data collection included only 1 geographic location. Social determinants of health are greatly influenced by location-specific resources.

Implications for Diabetes Care and Education Specialists

Social determinants of health, such as education and income, are well established as predictors of poor diabetes outcomes. How best to intervene to address socioeconomic barriers to T2D management remains unclear, however. Findings from this study suggest intervention opportunities to mitigate the effects of adverse social determinants of health. This study has several implications for diabetes care and education specialists. First, participants commented on past experiences perceived as lacking in sensitivity to socioeconomic concerns. Understanding an individual’s social context is a key aspect of formulating an individualized treatment plan, and interactions with individuals should be sensitive to that context. This could be done using formal assessment of health-related social needs (eg, by using the PRAPARE⁷² or Accountable Health Communities⁷³ instruments to assess for health-related social needs) or by informal assessment as part of asking individuals about barriers and facilitators to enacting treatment plans. Next, participants’ perspectives should be included in developing, testing, and implementing interventions. Taken together, these steps will help increase both the patient-centeredness and the effectiveness of care.