Managing type 2 diabetes during the COVID-19 pandemic in Ghana: a qualitative study

Abstract

Background

The COVID-19 pandemic has impacted the lives of many including individuals living with chronic illnesses such as Type 2 Diabetes Mellitus (T2DM) in Ghana. This study aimed to explore how people living with T2DM managed their chronic condition during the COVID-19 pandemic.

Methods

This study employed the phenomenological approach where interviews were conducted among 10 participants at the Korle-Bu Teaching Hospital in Ghana. A semi-structured interview guide was used to explore the experiences of participants during the pandemic, focusing on participants’ perceptions about COVID-19 and diabetes management, adherence to treatment regimen during the pandemic, experiences of psychological distress, and coping strategies employed. The interviews were transcribed and analysed thematically.

Results

Four themes were identified related to participants’ experiences during the COVID-19 pandemic. These were (1) participants’ perceptions about COVID-19, (2) changes and challenges with diabetes management, (3) psychosocial impact of COVID-19, and (4) coping with diabetes care during the pandemic. Some participants perceived that having diabetes meant they would automatically get infected with COVID-19. All the participants reported experiencing challenges with their diabetes management during the pandemic though a few of them recorded improvements in diabetes management. Psychosocial effects reported were stigmatisation, fear, worry, and sadness, due to the ban on social gatherings. Notwithstanding these psychosocial challenges, participants indicated that maintaining diabetes care, engaging in recreational activities, support from family, and religious coping, were strategies used to lessen the COVID-19 psychological distress experienced.

Conclusion

Findings suggest that people with T2DM should be given psychological support and psychoeducation on appropriate coping skills during pandemics and other unexpected occurrences that could affect their diabetes management.

Background

People living with Type 2 Diabetes Mellitus (T2DM) were a typical example of people whose physical and mental health were at a higher risk during COVID-19 due to their susceptibility to serious illness [1, 2]. Pandemics like COVID-19 are known to have subtle negative impacts on the mental health of people who experience them [3, 4] and this impact on mental health can have short-term and long-term effects. COVID-19 was declared a pandemic in March 2020 [5], and to limit the spread of the infection, measures such as lockdown, isolation, social distancing, handwashing practices, the closure of educational institutions, workplaces, and entertainment venues [6, 7] were implemented. While these measures helped reduce the spread of the virus, they also caused significant disruptions in the daily routines of people living with T2DM due to difficulty maintaining a healthy lifestyle and increased sedentary lifestyle, potentially leading to new cases of diabetes [8,9,10]. Studies have shown a significant rise in the incidence rate of diabetes during the COVID-19 pandemic compared to the pre-pandemic period, with the incidence increasing from 4.85 per 1,000 people between 2017 and 2019 (pre-pandemic) to 12.48 per 1,000 people, between 2021 and 2022 [11].

Diabetes management recommends that people living with the condition maintain a balanced and healthy diet, engage in physical activity, monitor glycemic levels, adhere to medication schedule and attend clinic appointment. However, the changes in daily routines due to the pandemic undoubtedly led to challenges in managing diabetes, such as visits to hospitals for clinic reviews being halted or postponed, reduced physical activity, and difficulty refilling medications [12,13,14,15]. The fear of infection due to their increased risk of serious illness, coupled with disruptions in patients’ healthcare and self-care routines, created a unique set of challenges that negatively impacted both their mental health and diabetes management [16, 17].

A World Health Organization (WHO) report indicated that because of the COVID-19 pandemic, about 50% of nations experienced disruptions in healthcare management for non-communicable diseases, including diabetes, hypertension, stroke, and cardiovascular diseases [18]. In Ghana, the Ministry of Health, through the Ghana Health Service, enforced preventive measures during the pandemic. These included the prohibition of public gatherings, closure of schools and religious centres, and restrictions on entry for travellers to mitigate the spread of the infection. Additionally, specific regions of the country, namely Accra, Kumasi, and Kasoa, underwent a partial lockdown lasting approximately three weeks [19]. There were changes in healthcare services for people managing diabetes as outpatient services were completely shut down or halted, and specialist appointments and clinical reviews were extended to reduce contact hours [20, 21]. The teaching hospitals (major hospitals) faced difficulties in managing critically ill COVID-19 patients alongside patients with other conditions [22]. There was a reduction in clinic attendance as patients including those with T2DM were hesitant to go for reviews, even after the lockdown, due to the fear of getting infected with COVID-19 [20]. Amu et al. [23] reported that patients were advised to reduce their visits to hospitals unless their conditions were extremely critical.

The pandemic’s effect on self-care activities was another significant challenge for people with T2DM. Restrictions on movement and the closure of fitness centers and public spaces made it difficult for individuals to maintain physical activity routines. Additionally, disruptions to food supply chains and economic hardships resulted in poor dietary self-care, with many individuals struggling to maintain balanced nutrition essential for glycemic control [24, 25]. For instance, Shah et al. [26] reported that in India, the lockdown period led to an increased rate of hypoglycemia. Also, the disruption of diabetes care led to an increased risk of infection in diabetic foot ulcers, hospitalization, and amputation [27].

The psychological toll of the pandemic on people with T2DM was considerable. The fear of contracting COVID-19 and the disruptions to their healthcare routines led to increased anxiety, stress, poor sleep, and depression [28, 29]. These psychological issues are particularly concerning for T2DM patients because mental health problems can exacerbate diabetes complications. Ephraim et al. [30] reported that people living with diabetes in Ghana experienced some sense of worry and fear of not being able to manage their condition if infected with COVID-19. Similarly, within the Ghanaian context, people living with chronic illness were stigmatized by their community, and the ban on social gatherings stripped them of their social support, causing them to experience psychological distress [22].

The impact of COVID-19 on treatment regimens and the mental health of people living with T2DM worldwide cannot be overemphasized. The disruptions to healthcare services, coupled with the psychological stress of living through a global health crisis, created significant challenges for managing diabetes effectively. However, the impact of the pandemic on the illness management and mental health of diabetes patients varied due to the varying duration of the lockdowns, halting or extension of clinic reviews, alternative facilities available to patients, medication refills, reduction in social support, and changes in self-care activities [21, 31,32,33,34,35], all of which determined the coping strategies used by patients during this challenging period.

In Ghana, it is probable that people with T2DM experienced disruptions in healthcare delivery and self-care routines due to the fear of infection. These disruptions may not only have exacerbated diabetes management challenges, but also heightened the psychological distress of individuals, which may have worsened their health outcomes. Despite evidence of increased anxiety and stress among this population, there is little understanding of how T2DM patients in Ghana navigated these difficulties and what coping strategies they employed during the pandemic. Thus, it is important to gain a better understanding to offer the needed support to patients during pandemics. For instance, healthcare providers and policymakers could design more resilient systems that would better support patients in managing their diabetes care. This study therefore investigated the experiences of people with T2DM during the COVID-19 pandemic in Ghana and the coping strategies they employed to manage their treatment regimen while preventing COVID-19 infections. It explored self-care management activities during the pandemic and the impact of the pandemic on the treatment regimen and mental health of patients.

Method

Research design and setting

The phenomenological approach was used to explore the lived experiences of people with T2DM in Ghana during the COVID-19 pandemic. This approach aids in exploring a phenomenon from the perspective of those who experienced it, and the meaning of their experience [36]. A semi-structured interview schedule was used to gather in-depth information about how the participants made sense of their experiences without making general assumptions [37]. This study was conducted at the Korle-Bu Teaching Hospital (KBTH) in the Accra metropolis. This hospital is a premier healthcare facility and a tertiary hospital located in Accra, the capital of Ghana. The hospital has 21 clinical and diagnostic departments and three centres of excellence. Participants were recruited from the National Diabetes Management and Research Centre (NDRC), a unit of the Department of Medicine. This Centre has a team of consultants, doctors, assistant physicians, dieticians, optometrists, nurses, and psychologists providing holistic treatment to patients with diabetes. This setting was chosen because it was situated in a ‘hotspot’ region (Accra) for COVID-19 infection and therefore, the rate of infection may have impacted patients directly or indirectly in terms of their diabetes management.

Participants

Ten participants were purposively and conveniently sampled for in-depth interviews to explore their experiences during the COVID-19 pandemic [38]. These sampling approaches were used as they allowed the researchers to select participants who were able to provide the information necessary to achieve the objectives of the study. Participants selected met the following inclusion criteria: 1) ≥ 40 years old and 2) diagnosed with diabetes for more than two years before the start of the COVID-19 pandemic. Participants with severe mental disorders or cognitive impairments as well as those who had changed their medication less than 6 months before the study were excluded from participating in the study.

Fifteen [15] patients were approached but 12 agreed to participate in the study. These prospective participants were screened for eligibility and though all of them qualified to be tested, by the tenth participant, the researcher had reached saturation, and no new information was obtained [39]. This was determined based on the fact that after the eight participants, responses became repetitive. This might have been due to the fact that participants had the same condition and were receiving care at the same health centre, and thus were reporting similar experiences. Out of the 10 participants, 5 were male and the remaining 5 were females. They were aged between 49 and 68 years, with an average age of 54 years; and their duration of diabetes diagnosis was between 3 and 23 years. Half of the participants interviewed had tertiary education and more than half of them were married. Most of the participants interviewed were Christians. Participants’ information is presented in Table 1.

Table 1 Demographic characteristics of participants

Measures

Semi-structured interview guide

A semi-structured interview guide was developed to explore the experiences of people living with T2DM during the COVID-19 pandemic. The guide was in four parts which focused on questions relating to (1) participants’ perceptions of COVID-19, (2) diabetes self-care management in the wake of the COVID-19 pandemic, (3) participants’ fears and anxieties about COVID-19, and (4) the coping strategies employed. Each of these parts had several questions with probes which served as prompts to elicit in-depth information from participants. Demographic information was also obtained from the participants. Some of the questions asked during the interview included: “How have you been managing your treatment of diabetes since the outbreak of COVID-19”? “How have you coped with any anxieties and fears related to the COVID-19 pandemic” and “Generally, have you faced any difficulties in the period of pandemic with regard to your health”?

Ethics considerations

Ethics approval was obtained first, from the Ethics Committee for Humanities (ECH 156/20–21) at the University of Ghana and second, from the Korle-Bu Teaching Hospital Institutional Review Board (KBTH-IRB 00039/2021) which permitted data collection at the National Diabetes and Research Centre (NDRC) in KBTH. The researchers observed the following key ethical principles; confidentiality, anonymity, voluntary participation, and written informed consent. COVID-19 protocols were also observed.

Procedure

The ethics approval letter from the KBTH Institutional Review Board was taken to the Medical Department and the National Diabetes Management and Research Centre, where the researchers further sought permission to recruit participants for the study. The second Researcher (GG-M, a student) conducted the interviews. Data collection began with the researcher approaching patients in the waiting area of the clinic to explain the purpose of the study and solicit their participation. Prospective participants were screened for eligibility, and those who qualified were interviewed. Participants were interviewed in English or Asante Twi, depending on which language they were comfortable communicating in. The interviews were audio recorded with the permission of the participants, and the duration of the interviews was between 25 and 45 min. Data collection lasted for four weeks.

Data analysis

Data was analyzed using thematic analysis which involved six steps [40]. First, the interviews were transcribed, and the researcher (GG-M) familiarized herself with the data by reading and re-reading the transcripts. Second, codes were formed from the data by organising raw data in a meaningful segment. Third, subthemes were generated from the codes by assembling codes with similarities. The generated subthemes were then reviewed by all the researchers to eliminate overlaps. Fourth, the researchers reviewed the subthemes with their codes to ensure they were appropriate and then categorized the subthemes into main themes. Fifth, themes and subthemes were re-defined and re-named to give them meaning. The sixth and final step in this analysis was producing a report based on the final representation of the results, accompanied by narratives from the transcripts.

Reflexivity and trustworthiness

In qualitative research, the researcher is the main instrument for data collection and analysis that can be possibly influenced by his/ her opinions, biases, and experiences [41]. It is therefore important for a researcher to consciously mitigate personal biases and judgments to maintain objectivity in the research.

Every researcher involved in this study has encountered individuals who live with diabetes. Two researchers (MAP and KOA) have specifically conducted studies involving diabetes management, thus gaining insight into the strict treatment regimens these individuals follow. Additionally, the researcher (GG-M), completed her practicum at a diabetes centre, leading to her familiarity with their management protocols and daily routines. Despite the collective experience of the researchers with diabetes patients, they consciously set aside their preconceptions when approaching this research. The study was approached with a fresh perspective, treating each participant as if they had no prior knowledge of their condition. Throughout the interviews, the researchers maintained an open-minded stance, ensuring that the data collected remained uninfluenced by their personal experiences or opinions.

In this study, trustworthiness was maintained, by ensuring credibility, transferability, dependability, and confirmability [41]. The researchers gave a detailed description of the phenomena under study. Using an appropriate qualitative method, conducted in-depth interviews which were transcribed and analyzed thoroughly. Personal beliefs and assumptions of the researchers were acknowledged and set aside in order to be objective during data collection and interpretation. The initial coding of transcripts was done by the second researcher (GG-M) and then evaluated by the other researchers MAP and KOA. The researchers then developed the subthemes and themes, peer-reviewing them throughout the process to reduce subjectivity. The researchers provided findings directly from the data by supporting the various themes and subthemes with quotes from the transcripts to ensure they were grounded in data.

Result

Analysis of transcripts yielded four themes, each with their sub-themes. These were: 1) Perception about COVID-19, 2. Challenges and changes in diabetes treatment, 3) Psychosocial impact of COVID-19, and 4) Coping with diabetes care during the pandemic. Themes and subthemes are presented in Table 2, and pictorial representation of the themes, subthemes and samples of quotes are also presented in Fig. 1.

Table 2 Summary of themes and subthemes

Fig. 1

A pictorial representation of the main themes, subthemes and samples of quotes

Perceptions of COVID-19

This theme reflected the perception of COVID-19 among participants living with Type 2 Diabetes. They reported their thoughts about the disease, COVID-19, the heightened risks associated with being part of a vulnerable group, their beliefs regarding the origins and persistence of the virus, and the importance of preventive measures to mitigate its spread. Subthemes within this theme included: (1) Vulnerability of weak immune systems, (2) Varying beliefs about COVID-19, and (3) “Protocols are for protection”.

Vulnerability of weak immune systems

Information about COVID-19 and its effect on the health of individuals who are infected was well known to participants. They were also aware that people with compromised immune systems were known to be at a higher risk of getting infected, severely being affected, and having a high rate of mortality. This was expressed vividly by some participants as follows:

Okay, what I heard was that for those of us who have diabetes our immune systems are not as strong as those who do not have diabetes. So when you get COVID and someone without diabetes gets COVID too, you will die faster than the person because of your immune system (P.4, female, 46 years).

From my understanding, if you are diabetic, you are very prone to get COVID-19 because your immune system is low. I was also made to understand that with that disease [COVID-19] and diabetes, they are very close. If you are diabetic, it is easy for you to get the virus and die (P.7, Male, 40 years).

These quotes reflected participants’ heightened awareness of the potential health complications associated with contracting COVID-19, due to their pre-existing medical condition (diabetes). It indicated the education participants had received and their knowledge and awareness about being a vulnerable population. While some participants believed that having diabetes automatically meant being infected with COVID-19, others understood their illness increased their susceptibility to severe COVID-19 infection or mortality.

Varying beliefs about COVID-19

Participants held varying beliefs about COVID-19 due to the various conspiracy theories and information that emerged about the pandemic when it began. In this study, some participants viewed the pandemic from a religious perspective, while others held the view that people in some parts of the world were more vulnerable to the infection than others from other parts of the world, such as Ghana. As some reported,

The truth is that, if COVID will go it is all up to God. Whether it will stay forever or not, everyone is just saying. But for me, I saw life to be one that, meant man cannot do much except God (P.1, Female, 49 years).

You know over there, their low temperate zone- it was easier for them to catch it. But when it came here, it was confusing at first because we thought the climate here made it not possible to get it, but it still came. I almost did not believe it till I heard doctors advising people with diabetes (P.8, male, 61 years).

One participant, however, was of the view that the pandemic, like some other pandemics, was going to “stay” forever but could eventually be prevented. As he reported,

For me, I saw that it’s going to stay with us forever. This disease is not going to go. Since it’s a virus and it is spreading, there’s no way it’s going to go. It is just like malaria and HIV when it started, we now have medications that will prevent them (P.7, Male, 40 years).

Participants’ perception of COVID-19, shaped their beliefs regarding the pandemic. Some participants viewed the pandemic through a religious lens, believing that only divine intervention could end it, while others believed, similar to previous pandemics, it would dissipate with the availability of medications. Regardless of the different beliefs they held, participants’ beliefs also influenced their reactions to the pandemic, including how they chose to protect themselves.

“Protocols are for protection”

Participants reported the COVID-19 preventive measures were beneficial to them, given their heightened susceptibility to COVID-19. These protocols were deemed essential as they represented the primary mode for reducing their risk of infection, especially in the absence of a cure. The excerpts below reflect this.

Well, it was difficult for me to adhere to the protocols because we were not used to them. But later I saw that no, if I don’t do that it will rather disturb me since I am vulnerable like they say (P.9, Female, 67 years).

The other day I cautioned someone without a nose mask in a car and she told me that ‘I am the one who is afraid so I should wear mine’. So, someone may contract it but may not die but if I contract it, I will die because of my sickness. So, I will take caution before it is too late for me (P.2, Female, 68 years).

Protecting themselves by following the preventive measures and maintaining health behaviours was seen as important, as several (seven) participants reported they had the duty to protect themselves by strictly observing all the protocols. Also, participants reported it was their responsibility to ensure people around them observed the protocols too. Unfortunately, not all participants could consistently follow the COVID-19 preventive protocols because they felt they had no choice. As one participant indicated,

I still went to the market to sell. I go around with my phone cards to get some coins. So, during the 3 weeks of lockups in Kasoa [a suburb of the central Region of Ghana], I didn’t observe [the protocols] because I had to force myself to get my daily bread. It was a decision I had to make because I could have died from hunger then (P.8, male, 61 years).

Despite being aware that disregarding the protocols increased his risk, this participant had a difficult choice of adhering to the lockdown and not being able to earn an income to feed himself or breaking the rules to be able to feed himself. From his report, he chose to prioritize going out to earn an income to meet his daily meals as a person managing diabetes.

Thus, the emergence of COVID-19 and its preventive measures led to participants making some pertinent decisions as well as lifestyle changes. These changes may have had positive or negative effects on the lives of the participants, especially their diabetes management.

Challenges and changes in diabetes treatment

This theme reflects the varied effects of the pandemic on the health of individuals living with Type 2 Diabetes (T2D). Participants in the study reported both positive and negative impacts from their experiences during the pandemic. The three subthemes under this theme are (1) Disruption of self-care routines, (2) Changes in clinical reviews, and (3) Improvement in management.

Disruption in self-care routines

People with T2D are expected to manage their glycemic levels by taking their medications as prescribed, monitoring their glucose levels, engaging in physical exercise, and adhering to a dietary plan. However, all 10 participants reported they had had a disruption in their self-care routines. This was as a result of how challenging their diabetes management had become, due to the COVID-19 pandemic, and the measures to curb infection rates in Ghana. The excerpt below illustrates some disruptions in their self-care routine.

There were times in the morning for instance I took yam [starch tuber-like potato], which increased my sugar level. But that is the only thing available. If it was plantain, my sugar level would have gone down. I took yam in the morning. In the afternoon, there was nothing, so I took rice. Rice also raises my sugar level. All these foods are not good for me (P.8, Male, 61 years).

First, I used to go to the gym as I said earlier, it was every Saturday morning for training. When the lockdown happened, the gym I was going to shut down. After the ban, one has still not been able to open and that is the one close to me too. So the lockdown affected my training and after the lockdown, I became too lazy to go back to the gym (P.6, female, 53 years).

Since COVID started till now, last month was when I checked my sugar, it had gone up to 8.5. I was not happy with myself at all because I could not tell what led to that 8.5. I had been recording around 4 even sometimes 3.8 …I am very careful because if you joke with your sugar level it will joke with you (P.9. female, 63 years).

The COVID-19 pandemic disrupted the daily self-care routines of participants, which were essential for managing their health condition. Restrictions such as lockdowns and social distancing measures hindered physical activities, as participants sought to avoid crowded places.

Not only were participants’ self-care routines disrupted, but additionally, most of them had their clinical appointment dates/ or processes changed, while a few skipped their appointments out of fear of being infected. This is reflected in the next subtheme.

Changes to clinical reviews

Anxieties surrounding the pandemic led some participants to avoid attending clinical reviews, particularly at facilities such as the Korle-Bu Teaching Hospital (the study site), which was designated as a COVID-19 isolation centre.

Yes, it [COVID-19] changed it [diabetes management]. I was not coming, I avoided coming to the clinic for one year. I had my appointments, but I did not come. That was when my daughter told me that the COVID- you cannot tell who has it. It could even be that the doctor/nurse you are going to see has some of the COVID-19. So I did not come (P.3, female, 52 years).

For some participants also, the processes for their clinical appointment were truncated as they simply saw a nurse, collected their prescriptions, and departed from the clinic. Thus, their clinic visits did not entail comprehensive routine examinations, including glucose monitoring, ketone testing, and blood pressure checks, or even consultations with doctors.

The change that happened was that when COVID-19 was severe, I remember when I came, I did not even get to see the doctor because they said I had no issue. When you came for review, they were not checking your sugar level. Whether it is high or low they were not doing it. They were not checking the urinal or anything. They will just write medication and give you 6 months. So that is what we have been doing for the past year (P.10, Male, 67 years).

Other participants also lamented about how their monthly clinical appointments had now been prolonged to three months or even six months in some cases.

It was during COVID-19 that the schedule was from monthly to six months.… but six months is a long time so you consume a lot of food that will raise your sugar level and you won’t even know it (P.3, female, 52 years).

I had some soreness with my foot… nothing pricked me, but the thing was swelling, so I noticed there was something wrong with the tissue. I reported to a pharmacy… I came to see the doctor for proper medication after 4 months of treating the sore on my own (P.2, Female, 68 years).

Though participants reported challenges with their self-care routines and clinical appointments, the effect of COVID-19 was not all negative. Participants reported some positive effects that COVID-19 had had on their diabetes management.

Improvement in self-management

Some participants acknowledged that the lockdown during the initial period of COVID-19 in Ghana, gave them enough time to take good care of themselves and improve their diabetes management. Thus, they were quick to report the positive impact that the pandemic had on their health. One participant for instance had been non-adherent with his treatment regimen until the emergence of the pandemic and its preventive measures, which forced him to resolve to be adherent with his treatment regimen.

It has also helped me to now take control of my health, you know as I speak to you, I wouldn’t have requested to see a specialist at the diabetic clinic, I wouldn’t have because I would have been busy or on a work trip, you know. So, the impact is positive like I said. For me, the pandemic has given me much time to make resolutions and take proper care of my diabetes (P.5, Male, 46 years).

Another participant reported the pandemic gave him enough time to adhere to a good dietary plan and maintain his other treatment regimens.

Before COVID-19 sometimes when I’m busy my diet changed. I can be so busy I don’t take my breakfast. Sometimes I’ll wait till when it’s 2 o’clock before I take lunch. Sometimes after I take lunch then that’s all. So, the lockdown was of great help to me because I got time to rest, exercise and manage my diet well. After all, I was at home. I also told myself this is the time to eat well and get some good records of my sugar level, and it has helped me a lot (P.7, Male, 40 years).

Amidst the disruptions caused by the pandemic, the lockdown period provided participants with a valuable opportunity to dedicate ample time to themselves and focus more on adhering to their treatment regimen. With their usual activities temporarily halted, participants were able to prioritize their healthcare routines, even though this did not necessarily take away the negative impact the pandemic was having on them.

Psychosocial impact of COVID-19

Participants reported the impact of COVID-19 on their mental health as they struggled to live with the pandemic amidst managing their diabetes. Juggling their diabetes self-care and preventing the infection of COVID-19, put a toll on the participants both psychologically and socially. This theme had the following subthemes (1) Emotional distress of COVID-19, (2) Stigmatized as a diabetes patient.

Emotional distress of COVID-19

Concerning the impact of COVID-19 on their mental health, most participants mentioned experiencing emotional distress at the onset of COVID-19 in Ghana and when parts of the country were under lockdown. The common distress expressed among these participants were uncertainties, worry, and sadness, though the cause of worry for each participant was different. One participant expressed his worry in the narrative below:

For example, even after the lockdown here, my trip to India was canceled because of the COVID-19 situation there. Not only that but other work appointments were cancelled, and it was tough on me. I’m a single man so my work is all I have. At a point I left my hair [unkempt], and people were wondering what was happening. But I’d even forgotten I needed to shave and barber all because I was stressed (P.5, male, 46 years).

I was disturbed, I kept asking myself, are we ever going to go back? How long will we stay home? So, it got me to think a lot…. yes, it affected my sleep a little. My husband was even complaining about why I was over worrying (P.4, female, 46 years).

I mostly end my day sitting in a lounge with my friends. We meet to discuss all manner of things. You know, as retired people this is one of the ways to keep us going. During COVID-19 we could not meet as we used to meet. After 2 weeks, I realized I had lost something that kept me going. I felt sad and lonely and maybe it is also because I live alone (P.8, male,61 years).

Going about their daily routines and socializing with friends gave participants a sense of purpose and belongingness, but this was unexpectedly taken away by the COVID-19 restrictions and ban on social gatherings by the government, to curb the spread of infection and prevent deaths. For instance, participant 8, being a retired person and living alone, had nothing to occupy him, save his social interactions with his friends. Hence, these COVID-19 restrictions had a great impact on his psychological well-being, and this was also obvious for other participants as depicted in the quotes above.

Most of the participants experienced COVID-19-related fears and uncertainties due to their vulnerability to its infection and the possibility of serious illness or death should they get infected with the virus.

Yeah, COVID-19 brought me a lot of fear at the beginning. A sickness that was killing people at that rate is something to fear. I could not tell where and how I could get infected, and if I would survive it, so it made me restrict myself from a lot of things (P.9, female, 63 years).

I had to be admitted to the hospital for one week, I think. I was very afraid all the time I was in the hospital… anytime the doctors asked for a lab test to be done, I got so anxious and when the results were in, I always wanted to find out what was in the result because I wanted to know if COVID-19 test was part of it. I have not lived in fear like that before (P.7, male, 40 years).

While some participants lived in fear, others were able to overcome their fears so that instead of fretting, they chose to take precautions to protect themselves by staying home. As one participant reported:

I do not think about COVID-19 because they told us that because of our diabetes, we should not think a lot, because it is not good for your health. Thinking too much can affect your health. So, after some time, I was not thinking of COVID-19 at all. Also, I do not go out a lot, so I was not scared (P.2, female, 68 years).

Stigmatized as a diabetes patient

The knowledge that most people dying from COVID-19 infection were individuals living with chronic illnesses such as diabetes, hypertension, cardiovascular disease, etc., led to some form of stigmatization in society. For some participants whose family members and other individuals were aware of their condition, these persons made them (participants) feel unwelcome in their presence, causing participants to isolate themselves or feel isolated.

The first time I got back from the diabetic clinic when COVID-19 started, I did not like how my family treated me. It’s like they are coming close but giving some distance too. They were afraid I would get COVID-19 and transmit it to them. So, I stayed in my room no matter what was happening to me, I was sad (P.2, female, 68 years).

I was not attending anything not because I didn’t want to, but because the way some people behaved when I was around them made me sad. I decided not to go to any gathering in the area because I was at risk, but they rather made me feel like I was bringing something to them. (P.6, female,53 years).

This stigmatization affected one participant to the extent that her diabetes care was negatively impacted, resulting in increased gylcemic levels.

I told you my grandchildren had been restricted from me and so I was a bit sad and lonely and that affected my routine. I wasn’t doing the right thing. I was not even coming out to the yard to stretch like I used to do. It disturbed my management and today I am still trying to get the sugar to go down (P.9. female, 63 years).

Coping with diabetes care during the pandemic

As a result of changes in work routines, social interactions, and healthcare accessibility for COVID-19 treatment, participants had to adjust their lifestyles to align with the demands of the pandemic era. They recounted their strategies for maintaining both physical and mental wellbeing amidst these changes, recognizing the need to manage their diabetes. The subthemes which culminated into this theme are (1) maintaining diabetes care, (2) psychosocial coping during the pandemic.

Maintaining diabetes care

According to the participants, their awareness that diabetes makes them susceptible to serious illness or death propelled them to engage in healthy behaviours such as monitoring their blood sugar and blood pressure levels. Additionally, they made conscious efforts to engage in some form of physical activity to control their glycemic levels, while coping with the restrictions of the pandemic.

We have all the machines. The BP machine and the sugar machine so I was controlling my diabetes even though I was not coming to the clinic. Every week we check. Even my daughter wished it was more than once a week, but I am afraid of the needle, so I do it once. I knew since I was doing what I was supposed to do, there was no way I had to be afraid of getting COVID-19 (P.3, female,52 years).

If I don’t engage in physical activity, my blood sugar fluctuates. So, after some time I realized I was doing more harm to myself by being affected by the COVID restrictions. So, I decided to engage in physical activities so I could cope well. So, I started a small garden behind my house and that kept me active in the mornings and it helped me (P. 8, male, 61 years).

Psychosocial coping in the pandemic

To maintain good glycemic levels for physical health and sound mental health during the COVID-19 pandemic, participants used different coping strategies, such as engaging in activities to feel relaxed, and helped them to cope as best as they could. Some participants reported engaging in recreational activities as depicted in the extracts below:

I love to sing and dance. This helped to take the pressure away from me. It is something that helps me. I am also a chorister, so I sing praises a lot. All these helped me to relax- forget about all the scary and sad things that were happening during the pandemic (P. 1, female, 49 years).

I did watch a lot of videos on interesting topics, and it helped me relax. I also have a very big screen, so I love to watch movies, these are what kept me calm when we were on lockdown (P.5, male, 46 years).

Other participants reported coping through religious means. They reported praying to God as a means of dealing with their fear of COVID-19 and also praying for God’s protection against the deadly virus. This gave them hope and calmed them down during this challenging period of their lives.

I had faith and prayed all the time when this COVID started that nothing can come and add up to my diabetes, as I am there right now my only hope is God, that He will protect me and my family. I have faith in God (P.1, female, 49 years).

As a Christian when you pray you feel okay and encouraged so we were praying. Because this thing only God knows when it will go for things to become normal (P.8, male, 61 years).

I prayed that God would continue to have mercy and rescue us. Doing that helped me not to be afraid because I believed God was protecting me (P.10, male, 67 year).

Participants further shared how family and friends helped alleviate the stress and fear they had about getting infected with COVID-19 by keeping them company, helping them keep up with their diabetes management and strictly adhering to preventive protocols while resorting to their own COVID-19 remedies as family members. Some of the narratives are shown below:

Sometimes being home with the whole family was helpful. There are people to talk to and all. My family and I used to watch movies together and talk and laugh and I think that helped. Even though some things were taken away, my family was always there. Their company helped me to cope (P.4, female, 46 years).

They know about my diabetes, and they also heard about the woman whose husband infected her and she died instead. So, they all protected themselves. They were always in their nose mask when they are going out, but they were not going out anyhow too. They were also chewing some ginger and herbs. Everyone was doing it to help themselves. So, I will say they helped me (P.6, female, 53 years).

The results showed that as people living with diabetes, the participants put in measures to combat the distress that came with the pandemic. As reported above, knowing they were susceptible to the infection of COVID-19 which also made them vulnerable to death, participants resorted to their ways of coping in order to stay in good health.

Discussion

This study was conducted to explore the challenges in treatment regimens among people with diabetes during the COVID-19 pandemic. Findings showed that although there were some challenges and changes in participants’ treatment regimen and self-care, they still found ways of establishing routines to maintain good diabetes care.

Participants in the present study were well-informed about COVID-19 and its effect on people living with diabetes. The majority of them had received adequate knowledge concerning COVID-19 and its impact on their health. They were knowledgeable about the COVID-19 preventive measures, repercussions, causes, and documented death cases. For example, the majority of the participants perceived that because of their weak immune systems, they had higher chances of contracting COVID-19, compared to the general population. They were also aware of their vulnerability to severe illness and even death if they contracted COVID-19. This finding is consistent with an earlier study that showed older adults sought information concerning causes of COVID-19 and preventive measures, recorded cases, and death toll [42]. This information helped them to mitigate the risk of getting infected by complying with the COVID-19 preventive measures. Similarly, in the present study, participants’ knowledge of COVID-19 and their perception of it were sufficient to motivate compliance with preventive protocols. Like many parts of the world, in Ghana, there were continual reports and updates on infection and mortality rates (resulting from the pandemic), indicating that most of the victims had underlying health conditions [43]. Thus, participants adhered strictly to the COVID-19 safety protocols (to prevent infections) even though it was not an easy task for them. This finding also reflects a tenet of the health belief model which indicates that health behaviours are easily adopted when individuals think they are highly susceptible to an illness [44].

Findings showed that participants experienced changes in their self-care management during the COVID-19 pandemic, including alteration in their dietary intake, glucose monitoring, and decreased physical activity, which were consistent with existing literature [24,25,26]. Healthcare professionals also postponed clinic appointments and changed clinic review routines while participants themselves skipped their clinic appointments. Movement restrictions imposed as public health measures led to less physical activity, as participants could no longer engage in activities that were their main routines for physical exercise. The ban on social gatherings including the closure of gyms, led to decreased physical activities probably because participants had to avoid public spaces, which could raise their risk of infection. This finding is consistent with findings by Olausson et al. [44] and Hoseini et al. [45], who reported that people living with T2DM experienced a decrease in physical activities due to the closing down of exercise facilities.

Participants in the present study also reported experiencing changes in their dietary plan due to restricted access to food, changes in meal schedules, and limited options for food selection at home. They reported that these dietary shifts adversely impacted their blood glucose levels, resulting in poorer glucose management. Furthermore, they indicated that they did not monitor their glucose levels as frequently as recommended, due to the absence of monitoring devices at home. These changes in clinic schedules and movement restrictions during the pandemic hindered them from actively engaging in this self-care practice. Previous studies have reported similar findings where participants were not doing self-blood glucose monitoring, were eating less, made changes to meal timing, and increased their intake of carbohydrates and snacks, during the pandemic [46,47,48].

Participants reported skipping clinic appointments because of the changes in clinic review routines, which truncated their clinical care. It is probable that they did not see the need to visit the clinic if it was only to get a repeat prescription rather than the usual clinical observations and consultation with the doctor. This result is similar to the findings of Tagoe et al. [21] and Swaray et al. [20] who found changes in diabetes care delivery. Additionally, in the present study, participants reported the fear of COVID-19 infection, especially since their clinic was located in a COVID-19 treatment centre. In spite of the challenges the pandemic posed to their diabetes care, some participants used the opportunity to improve their diabetes management as they were spending more time at home (due to social restrictions), and therefore were more focused on their self-care routines. Also, it is probable that because participants knew they were vulnerable to the COVID-19 infection, they were keen on maintaining their health and thus, adhering to their treatment regimen. Researchers such as Grabowski et al. [48] also found that the pandemic had both positive and negative effects on the self-care practices of participants. Joensen et al. [29] also showed that participants who worried more about COVID-19 infection adhered to their medication intake and monitored their glucose levels frequently.

Mental health plays a crucial role in diabetes management, as stress, anxiety, and depression can lead to fluctuations in blood sugar levels, complicating diabetes control [49]. Conversely, maintaining good mental health can improve adherence to treatment regimens and healthier lifestyle choices. However, in the present study, participants reported experiencing stigmatization and emotional distress, which adversely impacted their mental well-being. This finding is consistent with reports indicating that the pandemic had a psychological impact on people living with T2DM due to their vulnerability and challenges in managing their condition [28, 30]. Results from the present study showed that family and friends of the participants believed people with diabetes could easily transmit COVID-19, thereby leading to participants feeling stigmatized. This social stigmatization within participants’ communities led them feeling isolated and unsupported, which in some cases affected diabetes care. This finding suggests some of these participants were not receiving the social support they required. Sujan et al. [43] have also reported the lack of social support, which led to worries among people with diabetes during the pandemic. Additionally, the dissemination of information regarding infected cases and death toll, along with restrictions on movements, disruptions to daily routines, changes in diabetes self-care practices, and closure of outpatient departments (to focus on the treatment of COVID-19 infections), all induced worries, fear and anxiety for the participants [50, 51].

To alleviate the distress associated with the pandemic, participants reported employing various coping strategies, including improvising diabetes self-care practices, religious engagement, relaxation techniques, and family support, to mitigate the psychological distress they encountered. Iddi et al. [52] and Tiwari et al. [53] have also highlighted the use of recreational activities, meditation, and prayers as coping mechanisms during the pandemic. In like manner, many participants in the present study utilized relaxation activities such as watching television or engaging in hobbies as forms of self-distraction coping, to manage the stress induced by the pandemic effectively. Additionally, many participants reported that religious practices provided a source of hope for them as they engaged in spiritual activities, such as praying, to alleviate psychological distress. They added that family members, providing information about COVID-19 and encouraging adherence to diabetes management, also played a significant role in reducing their stress and anxiety levels [53]. Furthermore, recognizing their heightened risk during the pandemic, they found relief by adhering closely to their treatment regimens and feeling in control of their diabetes management offered a sense of relief and security, particularly amidst reduced attention from healthcare facilities towards diabetes care [51].

Limitations and strengths

This study investigated the experiences of people with T2DM during the COVID-19 pandemic and explored its effect on patients’ treatment regimen and mental health. Though the study produced interesting findings, these findings should be interpreted in the light of the following limitations. First, this is a qualitative study which tested a small number of participants compared to what would have been done in a quantitative study. Therefore, the findings of this study cannot be generalised to other diabetes patients. Second, this was a qualitative study and therefore, in as much as the researchers mitigate personal biases and judgments to ensure unbiased outcomes during research there could possibly and unknowingly have been some subjectivity in the collection and analysis of data. Third, the study focused on only people with T2DM, therefore the results can only be inferred to people with T2DM and not those with other types of diabetes or other health conditions which may have been impacted by the pandemic. Fourth, even though some participants reported poorer glycemic levels as a result of the pandemic, this could not be objectively ascertained as participants’ glycemic levels were not measured. This self-reported information could introduce recall bias or subjective interpretation, making it difficult to confirm the true extent of glycemic fluctuations. Therefore, future studies could use the quantitative methods and also test a large sample of patients, focusing on the different types of diabetes. This will also offer results from a more objective perspective and afford the possibility of generalising the result. Additionally, future studies could consider obtaining the glycemic levels of patients to objectively ascertain their diabetes control.

These limitations notwithstanding, this study sheds light on personal experiences and challenges faced by patients, providing rich qualitative data that helps to highlight gaps in diabetes care in Ghana, such as access to healthcare services, the psychological burden of the pandemic, and the barriers to maintaining glycemic control. The study tested patients who were managing their diabetes care during a pandemic, while preventing infection with COVID-19, rather than patients who were already infected with the virus. Thus, the study gives a different perspective from other studies conducted in Ghana in which T2DM patients tested were patients infected with COVID-19 [e.g. Ephraim et al. [30] and Hardy et al. [54]].

Clinical implications

This study has implications for clinical practice. Findings showed that the shift in medical attention with a greater focus on treating COVID-19 cases rather than diabetes (and other diseases) led to extended periods for clinical review which made some participants face challenges in their diabetes management. They experienced psychosocial distress and were worried about what the future held for them. First, during pandemics, people with chronic illnesses such as diabetes should still be given adequate attention both for their physical and mental health. Second, people with type 2 diabetes should have access to psychological support at the onset of a pandemic to address the psychological burdens related to managing their treatment during this time. Third, because the psychological distress from the pandemic can affect self-care management of diabetes it is important to offer post-pandemic tailored therapy to patients. Finally, adequate education must be given on the condition at hand while controlling false information, which can cause stigmatization and psychological distress.

Conclusion

This study investigated the experiences of people with type 2 diabetes during the COVID-19 pandemic in Ghana and the coping strategies they employed. Findings showed that as a vulnerable group, participants had the extra burden of managing their diabetes while protecting themselves from COVID-19 infections. They experienced psychosocial distress, which negatively influenced treatment adherence for some of them, while others reported managing their health condition better than they did before the pandemic. Amid these challenges, participants found the need to adopt coping strategies to mitigate the psychosocial distress from the COVID-19 pandemic. Findings suggest that people with type 2 diabetes should receive adequate attention during a pandemic and be offered psychological support to address any psychosocial burdens related to managing their diabetes treatment amidst protecting themselves from infection. Healthcare providers and policymakers can design more resilient systems that would better support patients with diabetes during pandemics.