The impact of the COVID-19 pandemic on lifestyle behavior and accessibility to routine health care among people with type 2 diabetes mellitus: a qualitative study in urban slums of Hyderabad, India

The impact of the COVID-19 pandemic on lifestyle behavior and accessibility to routine health care among people with type 2 diabetes mellitus: a qualitative study in urban slums of Hyderabad, India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of the COVID-19 pandemic on lifestyle behavior and accessibility to routine health care among people with type 2 diabetes mellitus: a qualitative study in urban slums of Hyderabad, India Sudhir RaJ Thout, Nanda Kishore Kannuri, Aalok Khandekar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8493135/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Coronavirus disease (COVID-19) disproportionately impacted marginalized social groups globally, disrupting care access and the delivery of essential services. Few studies have qualitatively examined the experiences of individuals with type 2 diabetes mellitus (T2D) during the COVID-19 pandemic. This study aimed to qualitatively explore the experiences and perspectives of the urban poor with T2D, regarding the impact of the COVID-19 crisis on lifestyle behaviors, diabetic care, and self-management practices. Methods Individual, semi structured interviews about the experiences of patients with T2D on the implications of COVID-19 on lifestyle behaviors and routine diabetes care were conducted across two urban slums in Hyderabad, India. Guided by the framework of the Explanatory Model Interview Catalogue (EMIC), 25 semi structured interviews were conducted among purposively selected adults aged above 20 years with T2D, with participant recruitment facilitated by two female front-line community health workers. In addition, one focus group discussion of community health workers and four key informant interviews of healthcare providers ( n = 4; 2 Medical officer, 1 Nurse NCD coordinator, 1 Health supervisor) who treated patients with T2D from two Urban Primary Health Centres (UPHC) were conducted. All interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis. Results Three main themes based on the EMIC Framework were: “Increased psychosocial distress” which captures the participants experiences of socio-economic hardships, and psychological well-being and experiences of social stigma and discrimination; “COVID-19 disruptions in routine healthcare services”, which highlights challenges in accessing to healthcare and diabetes care services; “Greater awareness about diabetes complications and management”, which describes the enhanced awareness of diabetes self-care practices, improved disease management and increased engagement in routine health check-ups and uptake of diabetes health screening among individuals with T2D. Conclusions The study’s results can support the development of effective community-based interventions aimed to improve the availability and integration of health care services for people with T2D at the community level. Such interventions can enhance on improving continuity in delivery of diabetes care and overcoming health inequities during future public health emergencies in India. Qualitative study COVID-19 impact type 2 diabetes urban poor patients’ perspective healthcare service urban slum Introduction The prevalence of type 2 diabetes (T2D) mellitus is rising globally, and individuals with T2D from urban slum residents often experience difficulties in managing their disease conditions (1). The severity of COVID-19 infection and chronic health conditions such as type 2 diabetes was strongly connected (2). The COVID-19 pandemic disproportionately impacted on people with T2D living in urban slum settings, those who are poorly educated and migrants of low socioeconomic status further impacting their ability to effectively self-manage their condition (3). Despite growing evidence on the clinical risks associated with COVID-19 and T2D, there remains limited understanding of how the pandemic influenced the everyday experiences, and access to healthcare among socially marginalized groups with pre-existing condition such as T2D. In this paper, we seek to understand the experiences of individuals with T2D during the COVID-19 pandemic, focusing on maintaining lifestyle behavior, self-care practices and access to health care. Background Type 2 diabetes mellitus (T2D), a major non-communicable disease (NCD), is a serious public health concern in India. T2D affects individuals’ functional capacities and quality of life, leading to significant morbidity and premature mortality ( 4 ). Etiology of Diabetes is multifactorial and includes genetic factors coupled with environmental influences, obesity associated with rising living standards, steady urban migration, and lifestyle changes. All these factors resulted in a rapid increase in the prevalence of T2D among poorly educated and migrants of low socioeconomic status ( 5 – 7 ). Rapid social transition due to globalization and a galloping economy of India, both pose patients with T2D health challenges due to changing lifestyles, unhealthy diets, and sedentary habits resulting in an elevated Body Mass Index (BMI) and fasting plasma glucose ( 8 ). Some studies from India have shown that T2D is becoming more prevalent in urban slums, especially among marginalized groups living below poverty line and lack standard livelihood amenities ( 9 – 11 ). Apart from knowledge, and skills needed to perform self-care, make lifestyle changes, coordinated efforts from the healthcare team, patients, families and other partners including a favourable environment to successfully manage the disease are essential for effective management of diabetes ( 12 ). COVID-19 resulted in unprecedented number of mortality and morbidity disproportionately impacted people with certain chronic conditions, including the T2D ( 13 ). We first begin by discussing the impact of COVID-19 on the residents of Hyderabad and urban poor living in slum settlements selected for our study, as a way to contextualize and better understand the impact of the COVID-19 pandemic on socially disadvantaged patients with T2D. Unfolding of the COVID-19 pandemic in the city of Hyderabad Hyderabad is one of the fastest growing metropolises in south-central India, with population of more than 9 million residents ( 14 ), and is capital city of the state of Telangana. Hyderabad is known for its historic legacy and cultural diversity. With an output of US $ 74 billion, Hyderabad has the fifth-largest urban economy in India ( 15 ). Hyderabad like other metropolitan cities were most affected by COVID-19. The cities have been epicentre of COVID-19 pandemic and impact has been profoundly different on different segments of the population ( 16 ). The state has been in a lockdown since March 22, 2020, with streets have gone empty, shops are closed, people are hardly coming out. COVID-19 pandemic and the lockdown affected every individual living in the city adversely. The imposition of lockdown restrictions by the Government, the poor communities particularly daily bread winners were forced to stay indoors, which made their life more miserable most owing to their un-preparedness of their livelihood. First index case in Hyderabad was detected on 2nd March 2020 and to 53% of total cases in the state soon in a little over 7 months. There were 23 deceased, 305 cases recovered and 68,413 were confirmed cases of COVID-19 till 31st October 2020. The peak of the five wave of COVID-19 was between July to September 2020 and reported 47,228 cases and the second wave saw the Greater Hyderabad Municipal Corporation (GHMC) limits record 47,214 cases of Covid-19. The Director of Public Health and Family Welfare’s office, Telangana government, has released a COVID bulletin at scheduled times (mostly twice a day) reporting number of COVID-19 infection cases, tests, recovery cases and outlines precautionary measures for the public that urged vulnerable age groups, including children under 10 years, pregnant women, and individuals above 60 years, to refrain from unnecessary outdoor activities. The government have enacted a range of COVID-19 containment measures including school and workplace closures, stay-at-home orders, and travel restrictions. The Indian Council of Medical Research (ICMR) guidelines were implemented for containment measures, with 94 containment zones in Hyderabad city being identified as high-risk areas as of October 2020 and has barricaded these zones with police patrols to block entry and exit points to contain the virus. Restriction of public movement inside zones, deployment of rapid response teams to map cases, contact tracing, and marking of buffer zones were some of the exercises which were carried out. The Health and Sanitation, and Disaster Management and Monitoring departments, were the main monitoring bodies involved in the COVID-19 management in Hyderabad. Telangana state government also leveraged technology-based solutions such as Arogyasetu App and other means for contact tracing and breaking the cycle of virus ( 17 ). The lockdown in Hyderabad have impacted on employment across and the segments of the workforce such as most vulnerable groups, less educated low–wage workers, and those with casual employment such as temporary contracts, self-employed ( 18 ). A study conducted from city-based International Crops Research Institute in Semi-Arid Tropics (ICRISAT) showed many people suffered from unemployment, loss of income, food insecurity ( 19 ). Many people experienced in reduction of household income and to mitigate the impact on food security, availed credit from formal and informal sources ( 20 ). The multiple economic activities involving workforce participation and related higher population density, itis no surprise that they are the most affected by the COVID-19 crisis in India as well. The poor and vulnerable, including migrant workers and urban poor, have suffered from the dual blows of lost income and weak social protection coverage. The pandemic has also laid bare gender-based imbalances in public and private life in urban areas of Hyderabad city ( 21 ). The poor and vulnerable, including migrant workers and urban poor, have suffered from the dual blows of lost income and weak social protection coverage. The Telangana government also ensured minimum food supply, the migrants in the form of ‘packages’ that included provision of dry ration (12 kg of rice or wheat flour) and one-time cash transfer of Rs 500 per person ( 22 ). In addition, appeals were made to land-lords to not collect on rent and defer the same ( 23 ). The role of government has been crucial in combating the pandemic, by ensuring the health and hygiene-related facilities, providing adequate clean water, adequate sanitation, and sewerage facilities, cleaning the city, maintaining quarantine centres and public health care institutions, etc., and improving public distribution system especially among the urban poor and other deprived sub-groups, can help to control the spread of COVID-19 infection. COVID-19 and Slums The COVID-19 pandemic has been increasing concern over the impact on large urban slums, where viral transmission is aided by increased population density, manifested as more frequent person-to-person contact, crowded housing, unsanitary and unhygienic conditions ( 24 ). The impact of COVID-19 was devastating in slum settlements of the cities due to poor infrastructure, unavailability of medical equipment and high-density population ( 25 ). In India, such as like other big cities, Hyderabad recorded 250 to 300 COVID-19 cases every day in the second wave. The two selected slum areas, namely Damodar Sanjeevaiah Nagar and Sapota Bagh were severely affected with high infection rate and deaths which was similar to that of the other sites of the city. Damodar Sanjeevaiah Nagar is a slum settlement in Hyderabad, about 700 houses concentrated with packed concrete houses, with densely living conditions and many residents do have water taps within their homes. There is multiple entry points exist into the settlement with many narrow lanes and by-lanes with sewage water flowing drains. Multiple problems like sanitation, roads and lack access to civic amenities are some of the problems dogging the slum dwellers. Sapota Bagh slum lies in south of Hyderabad, has a high densely populated settlement of about 900 houses. This is a slum with poor population, located beside a high-income neighbourhood. The two slums were vulnerable to the COVID-19 transmission, since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing is limited within the premises. Further, the people in these two slums are socio-economically poor, low levels of formal education, lack awareness and low accessibility to basic amenities compared to other people of the urban environment. The other factors such as space constraints and overcrowding in slums and tenements make physical distancing and self-quarantine impractical. People with pre-existing comorbidities in these slums have faced COVID-19 vulnerability. Almost all residents are economically vulnerable and lost livelihood during COVID-19 responses, since most of them are informal workers, such as vendors, auto drivers, home maids, factory workers, small shop owners and labourers etc. who earn daily wages, and this daily income is used for subsistence. The COVID-19 pandemic fundamentally disrupted the routine healthcare system. As a result, health care system was confronted with the challenge of addressing a backlog of cases and NCD complications resulting from lack of care during the pandemic ( 26 , 27 ). Most studies have shown that the impact of COVID-19 on routine diabetes care led to a number of challenges for patients. Some of the challenges were, missed follow-up visits, difficulties in obtaining routine medications and undiagnosed new cases and complications ( 28 ). Furthermore, outpatient services and inpatient care volumes were reduced due to the cancellation of elective procedures at many healthcare facilities ( 29 ). It is well documented that the pandemic disproportionately affected socioeconomically disadvantaged slum-dwellers. The studies have underscored the devastating impact of chronic conditions particularly on T2D patients who relied on public Primary Healthcare Centres (PHCs) for continuity of care, in access to medications, leading to worsening of diabetes symptoms ( 30 ). Even so, according to the current evidence, there is scant research focusing on the changes in lifestyle behavioral, diabetes management practices, and health care accessibility for urban poor individuals with T2D during the COVID-19 period in India. The current study therefore is important as it captures the intersection of COVID-19 pandemic and the burden of T2D on people with lower a socioeconomic status in the study area. This article therefore asks: what are the experiences of urban poor individuals with T2D and how did they navigate COVID-19? And by extension, what lessons does this hold for improving diabetic care and service delivery? Methods Research design and methodology This qualitative study applied the methodology of the Explanatory Model Interview Catalogue (EMIC), to explore and understand how COVID-19 impacts individuals living with T2D in aspects of lifestyle behavior, routine diabetes care and challenges on the management of T2D in Hyderabad, India. EMIC is a semi structured interview framework that elucidates the experience of illness from the perspective of patients based on three distinct components: the experience of the illness, the meaning of the illness, and the behaviors resulting from it. The research team The research team has previous experience with qualitative methods, and the first author has background in public health and was a young researcher with previous experience working in urban communities in multiple studies and training in conducting interviews. The second and third authors have extensive experience in community based qualitative research projects; each contributing relevant perspectives to the study. Setting and recruitment The study was conducted in two urban slum areas of Sapota Bagh and Damodar Sanjeevaiah Nagar, situated in east of Hyderabad city, the capital of the state of Telangana State in south-central India. These sites were purposely selected based on their geographic spread, to ensure covering a diverse population group within the city’s lower socioeconomic strata but broadly representative of the urban region of Hyderabad. Hyderabad is a mega city and one of the fastest growing metropolises which is further expected to be home to about 19 million residents by 2041 ( 31 ). According to Slum Free City Plan of Action 2013 Report, Hyderabad is home to 1,476 slums with a total population of 1,951,207 people and 84% of the slum households are below the poverty line. Individuals with T2D aged above 20 years, with a wide range of illness experiences, duration of T2D at least two years, and without any severe cognitive impairment were chosen through purposive sampling method. Care was taken to include participants, and represent maximum variety by age, gender, ethnicity, literacy, stage and severity of diabetes, level of family support, and socioeconomic status. The Initial participants were selected with the assistance of two female front-line community health workers. Subsequently snowball sampling was used to identify the next set of participants. Twenty-five semi structured interviews (15 male, and 10 female) with the self-reported prior diagnosis T2DM patients, who sought heath care from a public Primary Health Facility (some also consult private doctors) were conducted face-to-face manner at their homes. In addition, four key informant interviews with healthcare providers (2 Medical officer, 1 Nurse NCD coordinator, 1 Health supervisor) interviews who treated patients with T2D from two Urban Primary Health Centres (UPHC) and one focus group discussion with community health workers associated with study sites were conducted within the UPHC premises. Interviews Participant recruitment and interviews were conducted between late August 2021 and July 2023. All participants were informed about the study aims and data collection process and gave written consent for their participation prior to the administration of the questionnaire. Also, the voluntary nature of their participation, the possibility of withdrawing at any time and the confidentiality of the data were explained before the interviews. Written informed consent was obtained. The interviews lasted approximately 50 minutes, (minimum and maximum duration: 23 min; 78 mins). All the interviews were conducted by the lead author (ST) using the local language. Interview Guide An standard semi structured interview guide was developed based on the framework of the “Explanatory Model Interview Catalogue” (EMIC) ( 32 ). The interview guide focused on exploring the implications of COVID-19 on lifestyle behaviors and routine diabetes care using a cultural lens, which provides a comprehensive understanding of multiple factors that affect diabetes self-management within the social context of poverty. The term “emic” reflects the focus on culturally grounded explanatory models of illness, while “catalogue” denotes the plurality, thereby distinguishing the priority of locally adapted perspectives within the framework. The EMIC based semi structured interview guide was pilot tested, translated into the Telugu and Hindi local language and refined across different slum settings to ensure validity and reliability. Widely framed and open-ended questions were focused on to understand how COVID-19 impacts individuals with T2D and how patients are stigmatised as carriers of COVID-19, and concerns related COVID-19 in relation to NCD’s; and assessed the following domains: Explore disadvantaged patients with T2D challenges during COVID-19 pandemic Assess the impact of COVID-19 crisis that had changes in daily life Explore implications on diabetes care in accessing to healthcare services and medicines, and social support during the COVID-19 pandemic Assess the social benefits and healthcare services that are provided in reducing the impact of COVID-19 The interviews began with a short questionnaire to collect socio-demographic and disease-related data. Interview guides were developed to contain key questions tailored for each key informant that were intended to understand the process and challenges of healthcare provision towards diabetes care services, while the focus group discussion sought to capture the experiences of community health workers in providing diabetes care at community level. Focus group discussion commenced with a clear explanation to the participants of the study's objectives and confidentiality was assured. Medical officers in charge at the UPHC, Nursing NCD coordinator in charge of NCD care provision at the UPHC, and Health supervisor in responsible for community health workers at the UPHC were interviewed. Interviews with participant were conducted in the preferred language, either Telugu or Hindi, the main local language. Data were collected by the first author (ST), who met the participants for the first time for the study. Each interview session commenced with a clear explanation to the participants of the study’s objectives and confidentiality was assured. Saturation was deemed to have been achieved when no new themes emerged from the sample size. All data were safely stored on protected computers. Data analysis All the audio recorded semi structured interviews, focus group discussion and key informant interviews were transcribed into English. The English transcripts were loaded into qualitative software NVivo ( 33 ) and analysed by the first author (ST) using qualitative thematic analysis, which incorporated coding, analysing (categorising) and reporting patterns (themes) ( 34 ). Translations of the transcripts were made following the principles described by Chen & Boore ( 35 ). The transcribed data were read carefully multiple times, searching for original expressions related to the research questions. The derived codes were further sorted into sub-themes based on inter-connections and associations. These sub-themes were organized into meaningful clusters of main themes and compared across participant groups to inform the interpretation of the data. These were then validated by authors NK and AK. Finally, each theme was clearly defined and described after which relevant quotes were systematically selected and placed them under appropriate themes to ensure that they reflected the qualitative data. The research team maintained a reflexive stance throughout the data analysis process to minimize potential biases that could influence the interpretation of the findings. Results This study holistically attempted to understand the challenges, difficulties, and expectations of patients with T2D on lifestyle behaviour, management of diabetes and healthcare services during the COVID-19 pandemic. Of the participants ( n = 25), there were 15 men and 10 women. In Table. 1, we illustrated the socio-demographic characteristics of participants. Our analysis of the interviews and focus groups revealed three themes: (a) Increased psychosocial distress (b) COVID-19 disruptions in routine healthcare services and (c) Greater awareness about diabetes complication and management, are presented in Table 2 . Table 1 Socio-demographic characteristics of patients with type 2 diabetes (n = 25) Characteristic Number Gender Male 15 Female 10 Age (years) 40–50 6 > 50 19 Religion Hindu 12 Muslim 8 Christian 5 Caste Schedule Caste 13 Schedule Tribe 2 Other Backward Caste 10 Education status Below 8th class 19 8th-10th class 4 10th and above 2 Income (per month) INR > 30,000 1 INR 20,000–30,000 6 INR < 10,000 18 INR- Indian National Rupees Table 2 Codebook structure and themes Themes Sub-themes Codes Increased psychosocial distress Socio-economic challenges Livelihood losses and declined earning during the pandemic Psychosocial well-being Pervasive fear of contracting the contracting COVID-19 Social stigma and discrimination Stigma and discrimination associated with COVID-19 COVID-19 disruptions in routine health-care services Healthcare access and diabetic care services Closure of routine healthcare services and hindered NCD services at public health system Treatments at private hospital as an alternative Greater awareness of diabetes complications and management Increased awareness Opportunity to increase awareness towards diabetes education and knowledge Necessity for proactive management and self-care practices Increased routine check-ups and uptake of diabetes health screening Understanding on the importance of medical care for their treatment process and advice Active participation being made by patients in counseling sessions on improving lifestyle In the themes below, quotations are followed by the individual participant number (e.g., IP1 refers to interview person 1 in the study) and age. Theme 1: Increased Psychosocial Distress Socioeconomic challenges According to our analysis, widespread livelihood losses experienced by individuals with T2D in the pandemic wave were profound and pervasive. Lockdowns and restrictions on economic activities led to steep declines in income. Participants were therefore forced to dip into their savings, cut back on food, borrow money, and liquidate assets to make ends meet. Despite some revival of economic activities after the lockdowns ended, job losses and wage reductions persisted, particularly affecting those employed in the informal sector. The following quotes from our participants highlight these findings: “The financial burden was high due to declined earnings and debits resulting from the COVID-19 crisis. Earlier, my wife was a household servant, but no earnings during the pandemic. We did cut down the food to manage the treatment costs of diabetes complex condition that was badly suffering.” (Mr. KS, 59 years old) “I had stopped going for regular checkups and not buying medicine since the pandemic’s beginning. The saving was used to safeguard spending on food, as I wanted to avoid the hungriness which was a major concern in my household conditions.” (IP1, 62 years old) “Actually, I am suffering with severe diabetes complications since 3 years and for this I saved some of money for having better treatment in private hospital. COVID has hit us hard losing employment of my son. We had shortage for food supplies and pay for hand loans. So, I have prioritized for family wellbeing and could not have treatment for my disease.” (IP2, 45 years old) Psychosocial well-being The pervasive fear of contracting the virus, coupled with the looming threat of job loss or reduced income in urban poor individuals with T2D, has brought devastating consequences, including heightened levels of stress, anxiety, and other mental health issues. Those with T2D have endured discrimination and stigma associated with COVID-19, both within their communities and from healthcare providers, leading to obstacles in accessing healthcare services and perpetuating their social isolation. Our analysis revealed that with fear of infection looming large and livelihoods threatened by job loss or reduced income, patients grappled with increased stress levels and anxiety. The following quotes from our participants illustrate these findings: “Financial insecurity due to job loss impacted a lot on my mental health condition and went through psychological distress in pandemic. I have taken hand loan to treat my illness at hospital and run the costs for daily need for food. High level of anxiety and distress issues that I’ve experienced, with negative experience from surroundings with no support.” (IP3, 50 years old) “My family were in distress conduction due to chances of acquiring me with COVID-19 condition. I have support from only children, as they were only earning. I have been with panic attacks with no proper sleep and low motivated in day-to-day life. I feel I don’t have any healthier lifestyle due to covid crisis and diabetes complex condition.” (IP4, 48 years old) Social stigma and discrimination Social stigma and discrimination associated with COVID-19, was prevalent both from within the community and external sources. Survivors of the virus faced social exclusion and were often shunned by neighbours and acquaintances. This discrimination experienced by urban poor individuals with T2D contributed to a reluctance to disclose symptoms or seek testing, as individuals feared being ostracized or stigmatized if they were diagnosed with COVID-19, as seen in the quotes below. “My family was very scared of me with diabetes disease, I was confined to my room, asked not to go out of homes for quarantine and our slum locked all sides with high security. As we are marginalized people, the government neglected not providing support and faced inequality as we are poor people.” (IP5, 68 years old) “Family tensions were high as we fought with each other's neighbours to gather food from subsidized shops. I was in critical diabetic condition with COVID symptoms and always been isolated in one room with no one to talk. Even my family has been isolated due to COVID infection and that stopped us buying essentials and reaching out in society.” (IP6, 47 years old) Theme 2: COVID-19 Disruptions in Routine Healthcare Services Healthcare access and diabetic care services According to our analysis, urban-dwelling individuals with T2D living in our two study sites faced challenges in care-seeking at primary care level. This was because barring a few services, such as antenatal care, newborn screening and child immunization, COVID-19 severely disrupted NCD services and other programmes at UPHCs. Out-patient services and face-to-face consultations for diabetes care at public primary care settings in their locality were halted during the COVID-19 outbreak. Many urban poor individuals with T2D therefore experienced difficulties in accessing routine care, which has led to discontinuation of their follow-up consultations, eventually leading to more severe complications. Lack of screening during the COVID-19 period has also led to many unidentified new diagnoses of T2D in this population group. Overall self-management, care-seeking, and access to essential medications and supplies were severely compromised. In cases of emergency, few individuals in our sample turned to private health facilities if they could afford them. Others were completely excluded, resulting in worsened health outcomes. As two participants expressed: “Our community was unable to go for treatment at our local public health centre, as health staff have told us that the services were closed for our people. People have treated and hospitalized at many unknown private clinics for their pre-existing health conditions. However, treatment was expensive at these private hospitals, so closing the services at public health centres resulted our people pushing it to poverty further.” (IP7, 51 years old) “Lifestyle behaviors and daily living conditions affected me, I did much worried about health concerns with no accessibility to free health care at government health centres within locality. With regard of this, I have missed medications, routine glucose tests, and follow-up medical check-ups, while we borrowed money to get hospital care at the private health care centres.” (IP8, 62 years old) Theme 3: Greater Awareness about Diabetes Complications and Management Increased awareness The COVID-19 pandemic has underscored the urgency of addressing the double burden of chronic conditions such as diabetes, leading to increased awareness and attention to diabetes management in the aftermath of the outbreak. For those with T2D, the severity of COVID-19 infection and chronic health conditions was strongly connected. This underscored the need for better self-care and disease management among urban poor individuals with T2D. Our data suggests that the pandemic has indeed resulted in greater awareness about diabetes and increased knowledge of treatment, control, and proper management of diabetes in this population group after the COVID crisis. The quotes below exemplify this finding. “When diabetes was diagnosed, I was 38 years old and was in complete denial. While in a pandemic lockdown, my family was worried about me contracting COVID, which was spreading too fast in our community. It was stressful due to pre-existing diabetes-related health problems. However, I had given time to listen and understand carefully on control measures of diabetes and diet related information. Moreover, I realized the importance of taking care of diabetes and learnt that unmanaged diabetes could result in serious complications in many ways." (IP9, 61 years old) “Diabetes education and awareness was increased in our community during Covid period. Many local community health workers during screening of Covid at home-visits talked about the benefits of gaining diabetes education that helped us to learn about the diabetes self-care including checking routine blood sugar levels, counting carbohydrates, taking insulin, and learning about seasonal healthy foods that are in access. The education during COVID time helped our community to make decision-making skills needed to manage diabetes successfully." (IP10, 47 years old). “Community health workers and health teams were frequently visited to our slums, which helped me gaining somewhat better knowledge on diabetic care and practices at home. I used to ask many questions and also could provide sufficient time to go to the facilities for treatment.” (IP11, 59 years old) Increased routine check-ups and uptake of diabetes health screening Our findings suggest that one long-term societal implication of COVID-19 crisis is that it has made significant difference in urban poor individuals’ with T2D healthcare seeking behaviors. One manifestation of this is in the form of increased visits for medical checks and uptake of diabetic health screening at public health centres after the COVID-19 pandemic in this population group. Enhanced knowledge and awareness about diabetes and its management among urban poor individuals with T2D and their communities underscored the importance of medical care and advice from healthcare teams. As medical officers noted: “The diabetes self-management education and treatment awareness was increased among patients during COVID-19 phase. This helped to think for managing care and they were motivated to change their lifestyle. The primary-care visits for diabetes screening to improve the blood glucose control increased. In addition, timely return of patients for routine check-ups and blood sugar control is seen high after post COVID-19 period. Patients were given sufficient time to take instructions and insight from health staff on understanding the treatment process for management of diabetes.” (Medical officer, 48 years old, PHC 1) “After the pandemic was controlled, the visits to the public healthcare centres by diabetes patients gone high number especially from slum residents. They wanted to improve their diabetic condition and preferred to have check-ups and diagnostic tests as well.” (Medical officer, 56 years old, PHC 2) Most healthcare providers including community health workers reported a noticeable change in overall behavior of urban poor individuals with T2D, with more frequent visits to UPHCs to have better diabetes treatment and reduce their disease burden after the COVID-19 pandemic. Healthcare providers also report more active participation of patients in counselling sessions on improving lifestyles including dietary modifications and taking necessary health precautions on diabetes management under the advice from healthcare providers and supported by community health workers. The following quotes from key informants illustrate these findings: “People from slum neighbourhoods are making frequent visits in short intervals to our health centres to have advice on improvising diabetes care and self-management behaviors. After the COVID-19 pandemic, diabetes patients are well-prepared to have positive change in behavior and attitude with better understanding to control the disease. There is active high participation of patients for our regular counselling sessions focused on decreasing risks, self-monitoring on blood glucose level, eating healthy foods, remaining physically active, taking medications, maintaining healthy behavior. This level of patient’s commitment and focus for lifestyle modification would be contributing to reduce their serious condition and complex nature of the disease.” (Nurse NCD coordinator, 56 years old, PHC2) “Though we faced many challenges during COVID-19 management, the diabetes patients engaged with our health workers in understanding their disease conditions and felt a necessity for diabetes care. The constant touch with health care workers in slums provided confidence on self-management of disease condition and trust in patients to go for regular screening which did not happen earlier times. This is a good advancement for patients for more diabetes care visits for low-income patients.” (Health supervisor, 49 years old, PHC1) “Patients who lived in slums had realized the importance of treatment for their diabetic health issues and were able to reach us ask for support to facilitate for visits to public health centres for their self-care diabetes practices with health staff. Also, many patients increased knowledge and awareness about diabetes education on managing diabetes while going for check-ups for NCDs related”. (FGD, community health workers) Discussion This study aimed to explore the impacts of the COVID-19 pandemic on urban poor individuals with T2D in two slums in the city of Hyderabad, India, to discover how the pandemic has affected their lifestyles and accessibility to routine chronic care provision at primary care level and also sought to understand longer-term implications of the pandemic for this population group. Understanding social effects of COVID-19 highlights ways in which the impacts of COVID-19 intersect with already existing social structures. We come to understand how socio-economically marginalized groups are rendered additionally vulnerable to the impacts of the pandemic. These are further compounded for population groups with pre-existing conditions such as T2D. The results of the study illustrated that the COVID-19 pandemic has presented severe challenges for individuals with T2D, impacting their ability to effectively self-manage their condition. Furthermore, disruptions in access to routine healthcare services have impacted the ability to receive necessary support and guidance from healthcare professionals. COVID-19 caused a wide range of consequences and a negative impact on psychosocial distress and severe disruptions in care-seeking for diabetes management. These findings were similar to studies done by Patel et al., Rashid et al., and Mehta et al. ( 3 , 36 , 37 ). Additionally, the findings showed that COVID-19 has greatly increased awareness on diabetes management in urban poor individuals with T2D. This long-term societal implication of COVID-19 shows that the pandemic has served as a catalyst for improving diabetes education and awareness, highlighting the importance of proactive management and self-care practices in mitigating the risks associated with chronic conditions in the aftermath of the crisis. Frequency of primary care diabetes visits has correspondingly increased for these urban-dwelling individuals with T2D, facilitating timely attention and treatment from healthcare providers. Our findings thus confirm that better educated patients on information related to diabetes management can contribute to better self-care and diabetes control among individuals. Similar studies have also been reported including patients who underwent training on diabetes management with better control of HbA1c and blood glucose than the remaining participants who did not undergo training ( 38 ). Research in Korea has shown also that the subjects had better HbA1c and blood glucose values after education ( 39 ). Research conducted in Brazil concluded that education should be part of routine care for diabetics and should be repeated periodically, every eight to twelve months ( 40 ). Thus, without discounting or diminishing the extreme suffering that the pandemic has wrought, we nonetheless want to highlight increased awareness regarding diabetes and its management as one positive outcome of the pandemic for this social group. We further suggest therefore that there is presently an opportunity for targeted public health interventions that can prepare and improve health care systems for future disruptions by addressing chronic conditions in urban populations. Similar findings have been reported regarding the positive impact of COVID-19 pandemic on the PHCs in Qatar, by adapting new ways of delivering care for management of chronic conditions in patients with T2D thereby ensuring uninterrupted care delivery during pandemic ( 41 ). Similarly, studies from Malaysia and USA demonstrated improved medication adherence to glucose lowering medication and improvement in HbA1c levels among patients with T2D during the pandemic ( 42 , 43 ). The study has strengths and limitations. The strength of this qualitative study lies in its ability to provide experiences and deeper understanding surrounding chronic conditions of T2DM and challenges faced by urban-dwelling individuals with T2D during COVID-19 pandemic. A good rapport was developed through interaction between the interviewer and study participants, and a more open and candid discussion was possible. However, current results should be interpreted within the context of relevant limitations. The study emphasised in-depth exploration of urban-dwelling patients of two slums; thus, its finding cannot be generalized too broadly. Preconceptions of the phenomenon were possible because authors had worked for different research projects during the pandemic. Conclusion This study provides insights into the impact of the COVID–19 pandemic on urban poor individuals with T2D living in two urban slums in Hyderabad city. Our results demonstrate that the pandemic has led to increased psychosocial distress and disruptions in routine healthcare services in the public health system but had a positive impact in raising awareness of diabetes amongst urban-slum-dwelling individuals with T2D, who were rendered additionally vulnerable to the impact of the pandemic. This study reveals that COVID-19 served as a critical event that generated awareness about diabetes management among this population group. We thus call for increased diabetes education efforts in such populations, alongside the implementation of effective community-based interventions that are required to improve availability and integration of health services for diabetes at the community level. This study provides important insights for future strategies on improving continuity in delivery of diabetes care and overcoming health inequities during future public health emergencies. Further studies are warranted for developing more generalizable insights based on our findings. Abbreviations BMI Body Mass Index COVID-19 Coronavirus EMIC Explanatory Model Interview Catalogue GHMC Greater Hyderabad Municipal Corporation ICMR Indian Council of Medical Research ICRISAT International Crops Research Institute in Semi-Arid Tropics NCDs Non-communicable diseases PHCs Primary Healthcare Centres T2D Type 2 diabetes mellitus UPHC Urban Primary Health Centres Declarations Acknowledgements The authors wish to thank the participants for taking the time to share their experiences and perspectives and front-line community health workers who assisted with recruiting individuals with T2D in urban slums, Furthermore, the authors wish to thank the healthcare providers and local authorities. Author contributions ST, NK, and AK conceived the study idea. ST developed the interview guide in collaboration with NK and AK. ST conducted and transcribed the interviews. ST analysed the data with supervision from NK and AK. ST wrote the initial draft of the manuscript. All authors reviewed and approved the final draft of the manuscript. Funding This study received no funding. Data availability No datasets were generated or analysed during the current study. Ethical approval and consent to participate The study conducted with responsibility, integrity, meticulousness and accuracy, following the guidelines of the ethical procedures of s of the World Medical Association (WMA) and Helsinki Declaration II (44). The study was approved by the the Institutional Ethics Committee (IEC), Indian Institute of Technology (IIT) Hyderabad (IEC reference number IITH/IEC/2021/07/07). All informants gave written informed consent to participate and for results to be published. Consent for publication Not applicable. Competing interests The authors declare no competing interest Availability of data and materials Not applicable Author details 1 Department of Liberal Arts, Indian Institute of Technology Hyderabad, Hyderabad, India 2 The George Institute for Global Health, Hyderabad, India 3 Department of Anthropology, University of Hyderabad, Hyderabad, India References Uthman OA, Ayorinde A, Oyebode O, Sartori J, Gill P, Lilford R. Global prevalence and trends in hypertension and type 2 diabetes mellitus among slum residents: a systematic review and meta-analysis. BMJ open. 2022;12(2):e052393. Fatoke B, Hui AL, Saqib M, Vashisth M, Aremu SO, Aremu DO, et al. Type 2 diabetes mellitus as a predictor of severe outcomes in COVID-19—a systematic review and meta-analyses. BMC Infectious Diseases. 2025;25:719. Patel MR, Zhang G, Leung C, Song PX, Heisler M, Choe HM, et al. Impacts of the COVID-19 pandemic on unmet social needs, self-care, and outcomes among people with diabetes and poor glycemic control. 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Padmaja R, Nedumaran S, Jyosthnaa P, Kavitha K, Abu Hatab A, Lagerkvist C-J. COVID-19 impact on household food security in urban and peri-urban areas of Hyderabad, India. Frontiers in public health. 2022;10:814112. Kesar S, Abraham R, Lahoti R, Nath P, Basole A. Pandemic, informality, and vulnerability: Impact of COVID-19 on livelihoods in India. Canadian Journal of Development Studies/Revue canadienne d'études du développement. 2021;42(1-2):145-64. Patel V. Gender differential impact of COVID-19 on the urban India. Mr Ranjit S Chavan. 2020:1. LiveMint. Coronavirus: migrant workers in Telangana to get cash and rice. 2020. 2020 [Available from: https://www.livemint.com. Sapra I, Nayak BP. The protracted exodus of migrants from Hyderabad in the time of COVID-19. Journal of Social and Economic Development. 2021;23(Suppl 2):398-413. Sahasranaman A, Jensen HJ. Spread of COVID-19 in urban neighbourhoods and slums of the developing world. Journal of the Royal Society Interface. 2021;18(174):20200599. Patel A. Preventing COVID‐19 amid public health and urban planning failures in slums of Indian cities. World Medical & Health Policy. 2020;12(3):266-73. Lee M, You M. Avoidance of healthcare utilization in South Korea during the coronavirus disease 2019 (COVID-19) pandemic. International Journal of Environmental Research and Public Health. 2021;18(8):4363. Organization WH. The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. 2020. Gummidi B, John O, Jha V. Continuum of care for non-communicable diseases during COVID-19 pandemic in rural India: A mixed methods study. J Family Med Prim Care. 2020;9(12):6012-7. Nath A, Sudarshan KL, Rajput GK, Mathew S, Chandrika KRR, Mathur P. A rapid assessment of the impact of coronavirus disease (COVID- 19) pandemic on health care & service delivery for noncommunicable diseases in India. Diabetes Metab Syndr. 2022;16(10):102607. Singh K, Xin Y, Xiao Y, Quan J, Kim D, Nguyen T-P-L, et al. Impact of the COVID-19 pandemic on chronic disease care in India, China, Hong Kong, Korea, and Vietnam. Asia Pacific Journal of Public Health. 2022;34(4):392-400. Pradesh. GoA. Hyderabad metropolitan development plan 2031. Hyderabad; 2013. 2013 [Available from: Master Planning 2031 - Hyderabad Metropolitan Development Authority. . Weiss M. Explanatory Model Interview Catalogue (EMIC): Framework for comparative study of illness. Transcultural psychiatry. 1997;34(2):235-63. QSR International. NVivo qualitative data analysis software, version 12. 2018. Kyngäs H, Mikkonen K, Kääriäinen M. The application of content analysis in nursing science research: Springer; 2020. Chen HY, Boore JR. Translation and back‐translation in qualitative nursing research: methodological review. Journal of clinical nursing. 2010;19(1‐2):234-9. Mehta S, Puwar T, Patel Y, Patel M, Shah V, Patel K, et al. Understanding health-seeking behavior of people with diabetes during COVID-19 pandemic: a facility based cross-sectional study conducted in Ahmedabad, India. Clinical Diabetology. 2023;12(3):141-9. Rashid SF, Aktar B, Farnaz N, Theobald S, Ali S, Alam W, et al. Fault-lines in the public health approach to covid-19: recognizing inequities and ground realities of poor residents lives in the slums of Dhaka City, Bangladesh. 2020. Gagliardino JJ, Chantelot J-M, Domenger C, Ramachandran A, Kaddaha G, Mbanya JC, et al. Impact of diabetes education and self-management on the quality of care for people with type 1 diabetes mellitus in the Middle East (the International Diabetes Mellitus Practices Study, IDMPS). Diabetes research and clinical practice. 2019;147:29-36. Lee S-K, Shin D-H, Kim Y-H, Lee K-S. Effect of diabetes education through pattern management on self-care and self-efficacy in patients with type 2 diabetes. International journal of environmental research and public health. 2019;16(18):3323. Scain SF, Friedman R, Gross JL. A structured educational program improves metabolic control in patients with type 2 diabetes. The Diabetes Educator. 2009;35(4):603-11. Nuaimi ASA, Alam MT, Hassan M, Syed MA. Impact of COVID-19 restrictions on diabetes mellitus management in Qatari primary care settings. Discover Health Systems. 2024;3(1):2. Crowley MJ, Tarkington PE, Bosworth HB, Jeffreys AS, Coffman CJ, Maciejewski ML, et al. Effect of a comprehensive telehealth intervention vs telemonitoring and care coordination in patients with persistently poor type 2 diabetes control: a randomized clinical trial. JAMA internal medicine. 2022;182(9):943-52. Sim R, Chong CW, Loganadan NK, Hussein Z, Adam NL, Lee SWH. Impact of COVID-19 lockdown on glycemic, weight, blood pressure Control and medication adherence in patients with type 2 diabetes. Patient preference and adherence. 2023:2109-17. Association WM. WMA-The World Medical Association-WMA declaration of Helsinki–Ethical principles for medical research involving human subjects. World Medical Association. 2022. Additional Declarations No competing interests reported. Supplementary Files InterviewGuideT2DMpatients.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8493135","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":584480350,"identity":"164ee4e1-0e50-4ff9-ac74-07caafe9237b","order_by":0,"name":"Sudhir RaJ Thout","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIie3QMUvEMBTA8VcK7RLbNYeFfoUXbjiEw/sqLYIuDo43lJIQ6KT7fQxXtxyB3lJ0FVya3eFGBxVj8BzEnLjdkP9UmvejeQUIhQ6wDCIxfj5gHHFV4ZwkQNwJ8ZEEYomOpFKM26tzkiR/krSjjpCNZKuttq+8w18kXcvpctmWM1p3xwQfiqy8UfDSQDHzEVILMwya3a0cebIXy6rougdywn0XqyUTnV388ZsQhCMOBJWH5KabiPd2R+4did72EbvCRPC4wmFt10flSLz3K9RIxnvNbjfC/mQ8s+QSddFTL8nzC2N405ao01FVr6eLUg7MPDfzhY/8nh2m/5kPhUKh0I8+AH0gVb2lTxYyAAAAAElFTkSuQmCC","orcid":"","institution":"Indian Institute of Technology Hyderabad","correspondingAuthor":true,"prefix":"","firstName":"Sudhir","middleName":"RaJ","lastName":"Thout","suffix":""},{"id":584480351,"identity":"fe56d0b7-4ae8-4271-a75f-0ec5b8396346","order_by":1,"name":"Nanda Kishore Kannuri","email":"","orcid":"","institution":"University of Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Nanda","middleName":"Kishore","lastName":"Kannuri","suffix":""},{"id":584480352,"identity":"2a73e750-25e3-4017-a282-3d4278dd20f3","order_by":2,"name":"Aalok Khandekar","email":"","orcid":"","institution":"Indian Institute of Technology Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Aalok","middleName":"","lastName":"Khandekar","suffix":""}],"badges":[],"createdAt":"2026-01-01 04:53:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8493135/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8493135/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103221935,"identity":"f8bb4c59-36bb-4f0f-a63b-79a780b751f1","added_by":"auto","created_at":"2026-02-23 10:27:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":890858,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8493135/v1/5c66fd58-a277-43fc-a199-a8c98c6e72e4.pdf"},{"id":101777297,"identity":"ebd56ba9-b57e-4dbe-b5cc-c00d54ebc67c","added_by":"auto","created_at":"2026-02-03 14:13:27","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20510,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuideT2DMpatients.docx","url":"https://assets-eu.researchsquare.com/files/rs-8493135/v1/6ac878e3ba0f5fd4e26b76c6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of the COVID-19 pandemic on lifestyle behavior and accessibility to routine health care among people with type 2 diabetes mellitus: a qualitative study in urban slums of Hyderabad, India","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe prevalence of type 2 diabetes (T2D) mellitus is rising globally, and individuals with T2D from urban slum residents often experience difficulties in managing their disease conditions (1). The severity of COVID-19 infection and chronic health conditions such as type 2 diabetes was strongly connected (2).\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic disproportionately impacted on people with T2D living in urban slum settings, those who are poorly educated and migrants of low socioeconomic status further impacting their ability to effectively self-manage their condition (3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite growing evidence on the clinical risks associated with COVID-19 and T2D, there remains limited understanding of how the pandemic influenced the everyday experiences, and access to healthcare among socially marginalized groups with pre-existing condition such as T2D.\u003c/p\u003e\n\u003cp\u003eIn this paper, we seek to understand the experiences of individuals with T2D during the COVID-19 pandemic, focusing on maintaining lifestyle behavior, self-care practices and access to health care.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eType 2 diabetes mellitus (T2D), a major non-communicable disease (NCD), is a serious public health concern in India. T2D affects individuals\u0026rsquo; functional capacities and quality of life, leading to significant morbidity and premature mortality (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Etiology of Diabetes is multifactorial and includes genetic factors coupled with environmental influences, obesity associated with rising living standards, steady urban migration, and lifestyle changes. All these factors resulted in a rapid increase in the prevalence of T2D among poorly educated and migrants of low socioeconomic status (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Rapid social transition due to globalization and a galloping economy of India, both pose patients with T2D health challenges due to changing lifestyles, unhealthy diets, and sedentary habits resulting in an elevated Body Mass Index (BMI) and fasting plasma glucose (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Some studies from India have shown that T2D is becoming more prevalent in urban slums, especially among marginalized groups living below poverty line and lack standard livelihood amenities (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Apart from knowledge, and skills needed to perform self-care, make lifestyle changes, coordinated efforts from the healthcare team, patients, families and other partners including a favourable environment to successfully manage the disease are essential for effective management of diabetes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). COVID-19 resulted in unprecedented number of mortality and morbidity disproportionately impacted people with certain chronic conditions, including the T2D (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe first begin by discussing the impact of COVID-19 on the residents of Hyderabad and urban poor living in slum settlements selected for our study, as a way to contextualize and better understand the impact of the COVID-19 pandemic on socially disadvantaged patients with T2D.\u003c/p\u003e\n\u003ch3\u003eUnfolding of the COVID-19 pandemic in the city of Hyderabad\u003c/h3\u003e\n\u003cp\u003eHyderabad is one of the fastest growing metropolises in south-central India, with population of more than 9\u0026nbsp;million residents (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and is capital city of the state of Telangana. Hyderabad is known for its historic legacy and cultural diversity. With an output of US\u003cspan\u003e$\u003c/span\u003e 74\u0026nbsp;billion, Hyderabad has the fifth-largest urban economy in India (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Hyderabad like other metropolitan cities were most affected by COVID-19. The cities have been epicentre of COVID-19 pandemic and impact has been profoundly different on different segments of the population (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The state has been in a lockdown since March 22, 2020, with streets have gone empty, shops are closed, people are hardly coming out. COVID-19 pandemic and the lockdown affected every individual living in the city adversely. The imposition of lockdown restrictions by the Government, the poor communities particularly daily bread winners were forced to stay indoors, which made their life more miserable most owing to their un-preparedness of their livelihood. First index case in Hyderabad was detected on 2nd March 2020 and to 53% of total cases in the state soon in a little over 7 months. There were 23 deceased, 305 cases recovered and 68,413 were confirmed cases of COVID-19 till 31st October 2020. The peak of the five wave of COVID-19 was between July to September 2020 and reported 47,228 cases and the second wave saw the Greater Hyderabad Municipal Corporation (GHMC) limits record 47,214 cases of Covid-19. The Director of Public Health and Family Welfare\u0026rsquo;s office, Telangana government, has released a COVID bulletin at scheduled times (mostly twice a day) reporting number of COVID-19 infection cases, tests, recovery cases and outlines precautionary measures for the public that urged vulnerable age groups, including children under 10 years, pregnant women, and individuals above 60 years, to refrain from unnecessary outdoor activities.\u003c/p\u003e \u003cp\u003eThe government have enacted a range of COVID-19 containment measures including school and workplace closures, stay-at-home orders, and travel restrictions. The Indian Council of Medical Research (ICMR) guidelines were implemented for containment measures, with 94 containment zones in Hyderabad city being identified as high-risk areas as of October 2020 and has barricaded these zones with police patrols to block entry and exit points to contain the virus. Restriction of public movement inside zones, deployment of rapid response teams to map cases, contact tracing, and marking of buffer zones were some of the exercises which were carried out. The Health and Sanitation, and Disaster Management and Monitoring departments, were the main monitoring bodies involved in the COVID-19 management in Hyderabad. Telangana state government also leveraged technology-based solutions such as Arogyasetu App and other means for contact tracing and breaking the cycle of virus (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe lockdown in Hyderabad have impacted on employment across and the segments of the workforce such as most vulnerable groups, less educated low\u0026ndash;wage workers, and those with casual employment such as temporary contracts, self-employed (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). A study conducted from city-based International Crops Research Institute in Semi-Arid Tropics (ICRISAT) showed many people suffered from unemployment, loss of income, food insecurity (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Many people experienced in reduction of household income and to mitigate the impact on food security, availed credit from formal and informal sources (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The multiple economic activities involving workforce participation and related higher population density, itis no surprise that they are the most affected by the COVID-19 crisis in India as well. The poor and vulnerable, including migrant workers and urban poor, have suffered from the dual blows of lost income and weak social protection coverage. The pandemic has also laid bare gender-based imbalances in public and private life in urban areas of Hyderabad city (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The poor and vulnerable, including migrant workers and urban poor, have suffered from the dual blows of lost income and weak social protection coverage. The Telangana government also ensured minimum food supply, the migrants in the form of \u0026lsquo;packages\u0026rsquo; that included provision of dry ration (12 kg of rice or wheat flour) and one-time cash transfer of Rs 500 per person (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In addition, appeals were made to land-lords to not collect on rent and defer the same (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The role of government has been crucial in combating the pandemic, by ensuring the health and hygiene-related facilities, providing adequate clean water, adequate sanitation, and sewerage facilities, cleaning the city, maintaining quarantine centres and public health care institutions, etc., and improving public distribution system especially among the urban poor and other deprived sub-groups, can help to control the spread of COVID-19 infection.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCOVID-19 and Slums\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic has been increasing concern over the impact on large urban slums, where viral transmission is aided by increased population density, manifested as more frequent person-to-person contact, crowded housing, unsanitary and unhygienic conditions (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The impact of COVID-19 was devastating in slum settlements of the cities due to poor infrastructure, unavailability of medical equipment and high-density population (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In India, such as like other big cities, Hyderabad recorded 250 to 300 COVID-19 cases every day in the second wave. The two selected slum areas, namely Damodar Sanjeevaiah Nagar and Sapota Bagh were severely affected with high infection rate and deaths which was similar to that of the other sites of the city. Damodar Sanjeevaiah Nagar is a slum settlement in Hyderabad, about 700 houses concentrated with packed concrete houses, with densely living conditions and many residents do have water taps within their homes. There is multiple entry points exist into the settlement with many narrow lanes and by-lanes with sewage water flowing drains. Multiple problems like sanitation, roads and lack access to civic amenities are some of the problems dogging the slum dwellers. Sapota Bagh slum lies in south of Hyderabad, has a high densely populated settlement of about 900 houses. This is a slum with poor population, located beside a high-income neighbourhood.\u003c/p\u003e \u003cp\u003eThe two slums were vulnerable to the COVID-19 transmission, since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing is limited within the premises. Further, the people in these two slums are socio-economically poor, low levels of formal education, lack awareness and low accessibility to basic amenities compared to other people of the urban environment. The other factors such as space constraints and overcrowding in slums and tenements make physical distancing and self-quarantine impractical. People with pre-existing comorbidities in these slums have faced COVID-19 vulnerability. Almost all residents are economically vulnerable and lost livelihood during COVID-19 responses, since most of them are informal workers, such as vendors, auto drivers, home maids, factory workers, small shop owners and labourers etc. who earn daily wages, and this daily income is used for subsistence.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic fundamentally disrupted the routine healthcare system. As a result, health care system was confronted with the challenge of addressing a backlog of cases and NCD complications resulting from lack of care during the pandemic (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Most studies have shown that the impact of COVID-19 on routine diabetes care led to a number of challenges for patients. Some of the challenges were, missed follow-up visits, difficulties in obtaining routine medications and undiagnosed new cases and complications (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Furthermore, outpatient services and inpatient care volumes were reduced due to the cancellation of elective procedures at many healthcare facilities (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). It is well documented that the pandemic disproportionately affected socioeconomically disadvantaged slum-dwellers. The studies have underscored the devastating impact of chronic conditions particularly on T2D patients who relied on public Primary Healthcare Centres (PHCs) for continuity of care, in access to medications, leading to worsening of diabetes symptoms (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEven so, according to the current evidence, there is scant research focusing on the changes in lifestyle behavioral, diabetes management practices, and health care accessibility for urban poor individuals with T2D during the COVID-19 period in India.\u003c/p\u003e \u003cp\u003eThe current study therefore is important as it captures the intersection of COVID-19 pandemic and the burden of T2D on people with lower a socioeconomic status in the study area.\u003c/p\u003e \u003cp\u003eThis article therefore asks: what are the experiences of urban poor individuals with T2D and how did they navigate COVID-19? And by extension, what lessons does this hold for improving diabetic care and service delivery?\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eResearch design and methodology\u003c/p\u003e \u003cp\u003eThis qualitative study applied the methodology of the Explanatory Model Interview Catalogue (EMIC), to explore and understand how COVID-19 impacts individuals living with T2D in aspects of lifestyle behavior, routine diabetes care and challenges on the management of T2D in Hyderabad, India. EMIC is a semi structured interview framework that elucidates the experience of illness from the perspective of patients based on three distinct components: the experience of the illness, the meaning of the illness, and the behaviors resulting from it.\u003c/p\u003e\n\u003ch3\u003eThe research team\u003c/h3\u003e\n\u003cp\u003eThe research team has previous experience with qualitative methods, and the first author has background in public health and was a young researcher with previous experience working in urban communities in multiple studies and training in conducting interviews. The second and third authors have extensive experience in community based qualitative research projects; each contributing relevant perspectives to the study.\u003c/p\u003e\n\u003ch3\u003eSetting and recruitment\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in two urban slum areas of Sapota Bagh and Damodar Sanjeevaiah Nagar, situated in east of Hyderabad city, the capital of the state of Telangana State in south-central India. These sites were purposely selected based on their geographic spread, to ensure covering a diverse population group within the city\u0026rsquo;s lower socioeconomic strata but broadly representative of the urban region of Hyderabad.\u003c/p\u003e \u003cp\u003eHyderabad is a mega city and one of the fastest growing metropolises which is further expected to be home to about 19\u0026nbsp;million residents by 2041 (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). According to Slum Free City Plan of Action 2013 Report, Hyderabad is home to 1,476 slums with a total population of 1,951,207 people and 84% of the slum households are below the poverty line.\u003c/p\u003e \u003cp\u003eIndividuals with T2D aged above 20 years, with a wide range of illness experiences, duration of T2D at least two years, and without any severe cognitive impairment were chosen through purposive sampling method. Care was taken to include participants, and represent maximum variety by age, gender, ethnicity, literacy, stage and severity of diabetes, level of family support, and socioeconomic status. The Initial participants were selected with the assistance of two female front-line community health workers. Subsequently snowball sampling was used to identify the next set of participants.\u003c/p\u003e \u003cp\u003eTwenty-five semi structured interviews (15 male, and 10 female) with the self-reported prior diagnosis T2DM patients, who sought heath care from a public Primary Health Facility (some also consult private doctors) were conducted face-to-face manner at their homes. In addition, four key informant interviews with healthcare providers (2 Medical officer, 1 Nurse NCD coordinator, 1 Health supervisor) interviews who treated patients with T2D from two Urban Primary Health Centres (UPHC) and one focus group discussion with community health workers associated with study sites were conducted within the UPHC premises.\u003c/p\u003e\n\u003ch3\u003eInterviews\u003c/h3\u003e\n\u003cp\u003eParticipant recruitment and interviews were conducted between late August 2021 and July 2023. All participants were informed about the study aims and data collection process and gave written consent for their participation prior to the administration of the questionnaire. Also, the voluntary nature of their participation, the possibility of withdrawing at any time and the confidentiality of the data were explained before the interviews. Written informed consent was obtained. The interviews lasted approximately 50 minutes, (minimum and maximum duration: 23 min; 78 mins). All the interviews were conducted by the lead author (ST) using the local language.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInterview Guide\u003c/h2\u003e \u003cp\u003eAn standard semi structured interview guide was developed based on the framework of the \u0026ldquo;Explanatory Model Interview Catalogue\u0026rdquo; (EMIC) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The interview guide focused on exploring the implications of COVID-19 on lifestyle behaviors and routine diabetes care using a cultural lens, which provides a comprehensive understanding of multiple factors that affect diabetes self-management within the social context of poverty. The term \u0026ldquo;emic\u0026rdquo; reflects the focus on culturally grounded explanatory models of illness, while \u0026ldquo;catalogue\u0026rdquo; denotes the plurality, thereby distinguishing the priority of locally adapted perspectives within the framework. The EMIC based semi structured interview guide was pilot tested, translated into the Telugu and Hindi local language and refined across different slum settings to ensure validity and reliability. Widely framed and open-ended questions were focused on to understand how COVID-19 impacts individuals with T2D and how patients are stigmatised as carriers of COVID-19, and concerns related COVID-19 in relation to NCD\u0026rsquo;s; and assessed the following domains:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eExplore disadvantaged patients with T2D challenges during COVID-19 pandemic\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAssess the impact of COVID-19 crisis that had changes in daily life\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExplore implications on diabetes care in accessing to healthcare services and\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003emedicines, and social support during the COVID-19 pandemic\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAssess the social benefits and healthcare services that are provided in reducing the\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eimpact of COVID-19\u003c/p\u003e \u003cp\u003eThe interviews began with a short questionnaire to collect socio-demographic and disease-related data. Interview guides were developed to contain key questions tailored for each key informant that were intended to understand the process and challenges of healthcare provision towards diabetes care services, while the focus group discussion sought to capture the experiences of community health workers in providing diabetes care at community level. Focus group discussion commenced with a clear explanation to the participants of the study's objectives and confidentiality was assured. Medical officers in charge at the UPHC, Nursing NCD coordinator in charge of NCD care provision at the UPHC, and Health supervisor in responsible for community health workers at the UPHC were interviewed. Interviews with participant were conducted in the preferred language, either Telugu or Hindi, the main local language. Data were collected by the first author (ST), who met the participants for the first time for the study. Each interview session commenced with a clear explanation to the participants of the study\u0026rsquo;s objectives and confidentiality was assured. Saturation was deemed to have been achieved when no new themes emerged from the sample size. All data were safely stored on protected computers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll the audio recorded semi structured interviews, focus group discussion and key informant interviews were transcribed into English. The English transcripts were loaded into qualitative software NVivo (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and analysed by the first author (ST) using qualitative thematic analysis, which incorporated coding, analysing (categorising) and reporting patterns (themes) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Translations of the transcripts were made following the principles described by Chen \u0026amp; Boore (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The transcribed data were read carefully multiple times, searching for original expressions related to the research questions. The derived codes were further sorted into sub-themes based on inter-connections and associations. These sub-themes were organized into meaningful clusters of main themes and compared across participant groups to inform the interpretation of the data. These were then validated by authors NK and AK. Finally, each theme was clearly defined and described after which relevant quotes were systematically selected and placed them under appropriate themes to ensure that they reflected the qualitative data. The research team maintained a reflexive stance throughout the data analysis process to minimize potential biases that could influence the interpretation of the findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study holistically attempted to understand the challenges, difficulties, and expectations of patients with T2D on lifestyle behaviour, management of diabetes and healthcare services during the COVID-19 pandemic. Of the participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25), there were 15 men and 10 women. In Table. 1, we illustrated the socio-demographic characteristics of participants. Our analysis of the interviews and focus groups revealed three themes: (a) Increased psychosocial distress (b) COVID-19 disruptions in routine healthcare services and (c) Greater awareness about diabetes complication and management, are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of patients with type 2 diabetes (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCaste\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchedule Caste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchedule Tribe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Backward Caste\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelow 8th class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8th-10th class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10th and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome (per month)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u0026thinsp;\u0026gt;\u0026thinsp;30,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR 20,000\u0026ndash;30,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u0026thinsp;\u0026lt;\u0026thinsp;10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eINR- Indian National Rupees\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCodebook structure and themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIncreased psychosocial distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocio-economic challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLivelihood losses and declined earning during the pandemic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychosocial well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePervasive fear of contracting the contracting COVID-19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial stigma and discrimination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStigma and discrimination associated with COVID-19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOVID-19 disruptions in routine health-care services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthcare access and diabetic care services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClosure of routine healthcare services and hindered NCD services at public health system\u003c/p\u003e \u003cp\u003eTreatments at private hospital as an alternative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGreater awareness of diabetes complications and management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreased awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpportunity to increase awareness towards diabetes education and knowledge\u003c/p\u003e \u003cp\u003eNecessity for proactive management and self-care practices\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreased routine check-ups and uptake of diabetes health screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding on the importance of medical care for their treatment process and advice\u003c/p\u003e \u003cp\u003eActive participation being made by patients in counseling sessions on improving lifestyle\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the themes below, quotations are followed by the individual participant number (e.g., IP1 refers to interview person 1 in the study) and age.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Increased Psychosocial Distress\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eSocioeconomic challenges\u003c/h2\u003e \u003cp\u003eAccording to our analysis, widespread livelihood losses experienced by individuals with T2D in the pandemic wave were profound and pervasive. Lockdowns and restrictions on economic activities led to steep declines in income. Participants were therefore forced to dip into their savings, cut back on food, borrow money, and liquidate assets to make ends meet. Despite some revival of economic activities after the lockdowns ended, job losses and wage reductions persisted, particularly affecting those employed in the informal sector. The following quotes from our participants highlight these findings:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The financial burden was high due to declined earnings and debits resulting from the COVID-19 crisis. Earlier, my wife was a household servant, but no earnings during the pandemic. We did cut down the food to manage the treatment costs of diabetes complex condition that was badly suffering.\u0026rdquo; (Mr. KS, 59 years old)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I had stopped going for regular checkups and not buying medicine since the pandemic\u0026rsquo;s beginning. The saving was used to safeguard spending on food, as I wanted to avoid the hungriness which was a major concern in my household conditions.\u0026rdquo; (IP1, 62 years old)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Actually, I am suffering with severe diabetes complications since 3 years and for this I saved some of money for having better treatment in private hospital. COVID has hit us hard losing employment of my son. We had shortage for food supplies and pay for hand loans. So, I have prioritized for family wellbeing and could not have treatment for my disease.\u0026rdquo; (IP2, 45 years old)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePsychosocial well-being\u003c/h2\u003e \u003cp\u003eThe pervasive fear of contracting the virus, coupled with the looming threat of job loss or reduced income in urban poor individuals with T2D, has brought devastating consequences, including heightened levels of stress, anxiety, and other mental health issues. Those with T2D have endured discrimination and stigma associated with COVID-19, both within their communities and from healthcare providers, leading to obstacles in accessing healthcare services and perpetuating their social isolation. Our analysis revealed that with fear of infection looming large and livelihoods threatened by job loss or reduced income, patients grappled with increased stress levels and anxiety. The following quotes from our participants illustrate these findings:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Financial insecurity due to job loss impacted a lot on my mental health condition and went through psychological distress in pandemic. I have taken hand loan to treat my illness at hospital and run the costs for daily need for food. High level of anxiety and distress issues that I\u0026rsquo;ve experienced, with negative experience from surroundings with no support.\u0026rdquo; (IP3, 50 years old)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;My family were in distress conduction due to chances of acquiring me with COVID-19 condition. I have support from only children, as they were only earning. I have been with panic attacks with no proper sleep and low motivated in day-to-day life. I feel I don\u0026rsquo;t have any healthier lifestyle due to covid crisis and diabetes complex condition.\u0026rdquo; (IP4, 48 years old)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSocial stigma and discrimination\u003c/h2\u003e \u003cp\u003eSocial stigma and discrimination associated with COVID-19, was prevalent both from within the community and external sources. Survivors of the virus faced social exclusion and were often shunned by neighbours and acquaintances. This discrimination experienced by urban poor individuals with T2D contributed to a reluctance to disclose symptoms or seek testing, as individuals feared being ostracized or stigmatized if they were diagnosed with COVID-19, as seen in the quotes below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;My family was very scared of me with diabetes disease, I was confined to my room, asked not to go out of homes for quarantine and our slum locked all sides with high security. As we are marginalized people, the government neglected not providing support and faced inequality as we are poor people.\u0026rdquo; (IP5, 68 years old)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Family tensions were high as we fought with each other's neighbours to gather food from subsidized shops. I was in critical diabetic condition with COVID symptoms and always been isolated in one room with no one to talk. Even my family has been isolated due to COVID infection and that stopped us buying essentials and reaching out in society.\u0026rdquo; (IP6, 47 years old)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: COVID-19 Disruptions in Routine Healthcare Services\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eHealthcare access and diabetic care services\u003c/h2\u003e \u003cp\u003eAccording to our analysis, urban-dwelling individuals with T2D living in our two study sites faced challenges in care-seeking at primary care level. This was because barring a few services, such as antenatal care, newborn screening and child immunization, COVID-19 severely disrupted NCD services and other programmes at UPHCs. Out-patient services and face-to-face consultations for diabetes care at public primary care settings in their locality were halted during the COVID-19 outbreak. Many urban poor individuals with T2D therefore experienced difficulties in accessing routine care, which has led to discontinuation of their follow-up consultations, eventually leading to more severe complications. Lack of screening during the COVID-19 period has also led to many unidentified new diagnoses of T2D in this population group. Overall self-management, care-seeking, and access to essential medications and supplies were severely compromised. In cases of emergency, few individuals in our sample turned to private health facilities if they could afford them. Others were completely excluded, resulting in worsened health outcomes. As two participants expressed:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Our community was unable to go for treatment at our local public health centre, as health staff have told us that the services were closed for our people. People have treated and hospitalized at many unknown private clinics for their pre-existing health conditions. However, treatment was expensive at these private hospitals, so closing the services at public health centres resulted our people pushing it to poverty further.\u0026rdquo; (IP7, 51 years old)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Lifestyle behaviors and daily living conditions affected me, I did much worried about health concerns with no accessibility to free health care at government health centres within locality. With regard of this, I have missed medications, routine glucose tests, and follow-up medical check-ups, while we borrowed money to get hospital care at the private health care centres.\u0026rdquo; (IP8, 62 years old)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Greater Awareness about Diabetes Complications and Management\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eIncreased awareness\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic has underscored the urgency of addressing the double burden of chronic conditions such as diabetes, leading to increased awareness and attention to diabetes management in the aftermath of the outbreak. For those with T2D, the severity of COVID-19 infection and chronic health conditions was strongly connected. This underscored the need for better self-care and disease management among urban poor individuals with T2D. Our data suggests that the pandemic has indeed resulted in greater awareness about diabetes and increased knowledge of treatment, control, and proper management of diabetes in this population group after the COVID crisis. The quotes below exemplify this finding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When diabetes was diagnosed, I was 38 years old and was in complete denial. While in a pandemic lockdown, my family was worried about me contracting COVID, which was spreading too fast in our community. It was stressful due to pre-existing diabetes-related health problems. However, I had given time to listen and understand carefully on control measures of diabetes and diet related information. Moreover, I realized the importance of taking care of diabetes and learnt that unmanaged diabetes could result in serious complications in many ways.\" (IP9, 61 years old)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Diabetes education and awareness was increased in our community during Covid period. Many local community health workers during screening of Covid at home-visits talked about the benefits of gaining diabetes education that helped us to learn about the diabetes self-care including checking routine blood sugar levels, counting carbohydrates, taking insulin, and learning about seasonal healthy foods that are in access. The education during COVID time helped our community to make decision-making skills needed to manage diabetes successfully.\" (IP10, 47 years old).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Community health workers and health teams were frequently visited to our slums, which helped me gaining somewhat better knowledge on diabetic care and practices at home. I used to ask many questions and also could provide sufficient time to go to the facilities for treatment.\u0026rdquo; (IP11, 59 years old)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eIncreased routine check-ups and uptake of diabetes health screening\u003c/h2\u003e \u003cp\u003eOur findings suggest that one long-term societal implication of COVID-19 crisis is that it has made significant difference in urban poor individuals\u0026rsquo; with T2D healthcare seeking behaviors. One manifestation of this is in the form of increased visits for medical checks and uptake of diabetic health screening at public health centres after the COVID-19 pandemic in this population group. Enhanced knowledge and awareness about diabetes and its management among urban poor individuals with T2D and their communities underscored the importance of medical care and advice from healthcare teams. As medical officers noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The diabetes self-management education and treatment awareness was increased among patients during COVID-19 phase. This helped to think for managing care and they were motivated to change their lifestyle. The primary-care visits for diabetes screening to improve the blood glucose control increased. In addition, timely return of patients for routine check-ups and blood sugar control is seen high after post COVID-19 period. Patients were given sufficient time to take instructions and insight from health staff on understanding the treatment process for management of diabetes.\u0026rdquo; (Medical officer, 48 years old, PHC 1)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;After the pandemic was controlled, the visits to the public healthcare centres by diabetes patients gone high number especially from slum residents. They wanted to improve their diabetic condition and preferred to have check-ups and diagnostic tests as well.\u0026rdquo; (Medical officer, 56 years old, PHC 2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost healthcare providers including community health workers reported a noticeable change in overall behavior of urban poor individuals with T2D, with more frequent visits to UPHCs to have better diabetes treatment and reduce their disease burden after the COVID-19 pandemic. Healthcare providers also report more active participation of patients in counselling sessions on improving lifestyles including dietary modifications and taking necessary health precautions on diabetes management under the advice from healthcare providers and supported by community health workers. The following quotes from key informants illustrate these findings:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;People from slum neighbourhoods are making frequent visits in short intervals to our health centres to have advice on improvising diabetes care and self-management behaviors. After the COVID-19 pandemic, diabetes patients are well-prepared to have positive change in behavior and attitude with better understanding to control the disease. There is active high participation of patients for our regular counselling sessions focused on decreasing risks, self-monitoring on blood glucose level, eating healthy foods, remaining physically active, taking medications, maintaining healthy behavior. This level of patient\u0026rsquo;s commitment and focus for lifestyle modification would be contributing to reduce their serious condition and complex nature of the disease.\u0026rdquo; (Nurse NCD coordinator, 56 years old, PHC2)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Though we faced many challenges during COVID-19 management, the diabetes patients engaged with our health workers in understanding their disease conditions and felt a necessity for diabetes care. The constant touch with health care workers in slums provided confidence on self-management of disease condition and trust in patients to go for regular screening which did not happen earlier times. This is a good advancement for patients for more diabetes care visits for low-income patients.\u0026rdquo; (Health supervisor, 49 years old, PHC1)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Patients who lived in slums had realized the importance of treatment for their diabetic health issues and were able to reach us ask for support to facilitate for visits to public health centres for their self-care diabetes practices with health staff. Also, many patients increased knowledge and awareness about diabetes education on managing diabetes while going for check-ups for NCDs related\u0026rdquo;. (FGD, community health workers)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study aimed to explore the impacts of the COVID-19 pandemic on urban poor individuals with T2D in two slums in the city of Hyderabad, India, to discover how the pandemic has affected their lifestyles and accessibility to routine chronic care provision at primary care level and also sought to understand longer-term implications of the pandemic for this population group. Understanding social effects of COVID-19 highlights ways in which the impacts of COVID-19 intersect with already existing social structures. We come to understand how socio-economically marginalized groups are rendered additionally vulnerable to the impacts of the pandemic. These are further compounded for population groups with pre-existing conditions such as T2D.\u003c/p\u003e\u003cp\u003eThe results of the study illustrated that the COVID-19 pandemic has presented severe challenges for individuals with T2D, impacting their ability to effectively self-manage their condition. Furthermore, disruptions in access to routine healthcare services have impacted the ability to receive necessary support and guidance from healthcare professionals. COVID-19 caused a wide range of consequences and a negative impact on psychosocial distress and severe disruptions in care-seeking for diabetes management. These findings were similar to studies done by Patel et al., Rashid et al., and Mehta et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAdditionally, the findings showed that COVID-19 has greatly increased awareness on diabetes management in urban poor individuals with T2D. This long-term societal implication of COVID-19 shows that the pandemic has served as a catalyst for improving diabetes education and awareness, highlighting the importance of proactive management and self-care practices in mitigating the risks associated with chronic conditions in the aftermath of the crisis. Frequency of primary care diabetes visits has correspondingly increased for these urban-dwelling individuals with T2D, facilitating timely attention and treatment from healthcare providers. Our findings thus confirm that better educated patients on information related to diabetes management can contribute to better self-care and diabetes control among individuals. Similar studies have also been reported including patients who underwent training on diabetes management with better control of HbA1c and blood glucose than the remaining participants who did not undergo training (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Research in Korea has shown also that the subjects had better HbA1c and blood glucose values after education (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Research conducted in Brazil concluded that education should be part of routine care for diabetics and should be repeated periodically, every eight to twelve months (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThus, without discounting or diminishing the extreme suffering that the pandemic has wrought, we nonetheless want to highlight increased awareness regarding diabetes and its management as one positive outcome of the pandemic for this social group. We further suggest therefore that there is presently an opportunity for targeted public health interventions that can prepare and improve health care systems for future disruptions by addressing chronic conditions in urban populations. Similar findings have been reported regarding the positive impact of COVID-19 pandemic on the PHCs in Qatar, by adapting new ways of delivering care for management of chronic conditions in patients with T2D thereby ensuring uninterrupted care delivery during pandemic (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Similarly, studies from Malaysia and USA demonstrated improved medication adherence to glucose lowering medication and improvement in HbA1c levels among patients with T2D during the pandemic (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study has strengths and limitations. The strength of this qualitative study lies in its ability to provide experiences and deeper understanding surrounding chronic conditions of T2DM and challenges faced by urban-dwelling individuals with T2D during COVID-19 pandemic. A good rapport was developed through interaction between the interviewer and study participants, and a more open and candid discussion was possible. However, current results should be interpreted within the context of relevant limitations. The study emphasised in-depth exploration of urban-dwelling patients of two slums; thus, its finding cannot be generalized too broadly. Preconceptions of the phenomenon were possible because authors had worked for different research projects during the pandemic.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study provides insights into the impact of the COVID\u0026ndash;19 pandemic on urban poor individuals with T2D living in two urban slums in Hyderabad city. Our results demonstrate that the pandemic has led to increased psychosocial distress and disruptions in routine healthcare services in the public health system but had a positive impact in raising awareness of diabetes amongst urban-slum-dwelling individuals with T2D, who were rendered additionally vulnerable to the impact of the pandemic. This study reveals that COVID-19 served as a critical event that generated awareness about diabetes management among this population group. We thus call for increased diabetes education efforts in such populations, alongside the implementation of effective community-based interventions that are required to improve availability and integration of health services for diabetes at the community level.\u003c/p\u003e \u003cp\u003eThis study provides important insights for future strategies on improving continuity in delivery of diabetes care and overcoming health inequities during future public health emergencies. Further studies are warranted for developing more generalizable insights based on our findings.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations ","content":"\u003cp\u003eBMI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Body Mass Index\u003c/p\u003e\n\u003cp\u003eCOVID-19\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Coronavirus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEMIC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Explanatory Model Interview Catalogue\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGHMC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Greater Hyderabad Municipal Corporation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eICMR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Indian Council of Medical Research\u003c/p\u003e\n\u003cp\u003eICRISAT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Crops Research Institute in Semi-Arid Tropics\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNCDs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-communicable diseases\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHCs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Primary Healthcare Centres\u003c/p\u003e\n\u003cp\u003eT2D\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Type 2 diabetes mellitus\u003c/p\u003e\n\u003cp\u003eUPHC Urban Primary Health Centres \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the participants for taking the time to share their experiences and perspectives and front-line community health workers who assisted with recruiting individuals with T2D in urban slums, Furthermore, the authors wish to thank the healthcare providers and local authorities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eST, NK, and AK conceived the study idea. ST developed the interview guide in collaboration with NK and AK. ST conducted and transcribed the interviews. ST analysed the data with supervision from NK and AK. ST wrote the initial draft of the manuscript. All authors reviewed and approved the final draft of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study conducted with responsibility, integrity, meticulousness and accuracy, following the guidelines of the ethical procedures of s of the World Medical Association (WMA) and Helsinki Declaration II (44). The study was approved by the the Institutional Ethics Committee (IEC), Indian Institute of Technology (IIT) Hyderabad (IEC reference number IITH/IEC/2021/07/07). All informants gave written informed consent to participate and for results to be published.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Liberal Arts, Indian Institute of Technology Hyderabad,\u0026nbsp;Hyderabad, India\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eThe George Institute for Global Health, Hyderabad, India\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Anthropology, University of Hyderabad, Hyderabad, India\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUthman OA, Ayorinde A, Oyebode O, Sartori J, Gill P, Lilford R. 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Asia Pacific Journal of Public Health. 2022;34(4):392-400.\u003c/li\u003e\n\u003cli\u003ePradesh. GoA. Hyderabad metropolitan development plan 2031. Hyderabad; 2013. 2013 [Available from: Master Planning 2031 - Hyderabad Metropolitan Development Authority. .\u003c/li\u003e\n\u003cli\u003eWeiss M. Explanatory Model Interview Catalogue (EMIC): Framework for comparative study of illness. Transcultural psychiatry. 1997;34(2):235-63.\u003c/li\u003e\n\u003cli\u003eQSR International. NVivo qualitative data analysis software, version 12. 2018.\u003c/li\u003e\n\u003cli\u003eKyng\u0026auml;s H, Mikkonen K, K\u0026auml;\u0026auml;ri\u0026auml;inen M. The application of content analysis in nursing science research: Springer; 2020.\u003c/li\u003e\n\u003cli\u003eChen HY, Boore JR. Translation and back‐translation in qualitative nursing research: methodological review. 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Diabetes research and clinical practice. 2019;147:29-36.\u003c/li\u003e\n\u003cli\u003eLee S-K, Shin D-H, Kim Y-H, Lee K-S. Effect of diabetes education through pattern management on self-care and self-efficacy in patients with type 2 diabetes. International journal of environmental research and public health. 2019;16(18):3323.\u003c/li\u003e\n\u003cli\u003eScain SF, Friedman R, Gross JL. A structured educational program improves metabolic control in patients with type 2 diabetes. The Diabetes Educator. 2009;35(4):603-11.\u003c/li\u003e\n\u003cli\u003eNuaimi ASA, Alam MT, Hassan M, Syed MA. Impact of COVID-19 restrictions on diabetes mellitus management in Qatari primary care settings. Discover Health Systems. 2024;3(1):2.\u003c/li\u003e\n\u003cli\u003eCrowley MJ, Tarkington PE, Bosworth HB, Jeffreys AS, Coffman CJ, Maciejewski ML, et al. Effect of a comprehensive telehealth intervention vs telemonitoring and care coordination in patients with persistently poor type 2 diabetes control: a randomized clinical trial. JAMA internal medicine. 2022;182(9):943-52.\u003c/li\u003e\n\u003cli\u003eSim R, Chong CW, Loganadan NK, Hussein Z, Adam NL, Lee SWH. Impact of COVID-19 lockdown on glycemic, weight, blood pressure Control and medication adherence in patients with type 2 diabetes. Patient preference and adherence. 2023:2109-17.\u003c/li\u003e\n\u003cli\u003eAssociation WM. WMA-The World Medical Association-WMA declaration of Helsinki\u0026ndash;Ethical principles for medical research involving human subjects. World Medical Association. 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Qualitative study, COVID-19 impact, type 2 diabetes, urban poor, patients’ perspective, healthcare service, urban slum","lastPublishedDoi":"10.21203/rs.3.rs-8493135/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8493135/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eBackground\u003c/b\u003e Coronavirus disease (COVID-19) disproportionately impacted marginalized social groups globally, disrupting care access and the delivery of essential services. Few studies have qualitatively examined the experiences of individuals with type 2 diabetes mellitus (T2D) during the COVID-19 pandemic. This study aimed to qualitatively explore the experiences and perspectives of the urban poor with T2D, regarding the impact of the COVID-19 crisis on lifestyle behaviors, diabetic care, and self-management practices.\u003c/p\u003e \u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e Individual, semi structured interviews about the experiences of patients with T2D on the implications of COVID-19 on lifestyle behaviors and routine diabetes care were conducted across two urban slums in Hyderabad, India. Guided by the framework of the Explanatory Model Interview Catalogue (EMIC), 25 semi structured interviews were conducted among purposively selected adults aged above 20 years with T2D, with participant recruitment facilitated by two female front-line community health workers. In addition, one focus group discussion of community health workers and four key informant interviews of healthcare providers (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4; 2 Medical officer, 1 Nurse NCD coordinator, 1 Health supervisor) who treated patients with T2D from two Urban Primary Health Centres (UPHC) were conducted. All interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e Three main themes based on the EMIC Framework were: \u0026ldquo;Increased psychosocial distress\u0026rdquo; which captures the participants experiences of socio-economic hardships, and psychological well-being and experiences of social stigma and discrimination; \u0026ldquo;COVID-19 disruptions in routine healthcare services\u0026rdquo;, which highlights challenges in accessing to healthcare and diabetes care services; \u0026ldquo;Greater awareness about diabetes complications and management\u0026rdquo;, which describes the enhanced awareness of diabetes self-care practices, improved disease management and increased engagement in routine health check-ups and uptake of diabetes health screening among individuals with T2D.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusions\u003c/b\u003e The study\u0026rsquo;s results can support the development of effective community-based interventions aimed to improve the availability and integration of health care services for people with T2D at the community level. Such interventions can enhance on improving continuity in delivery of diabetes care and overcoming health inequities during future public health emergencies in India.\u003c/p\u003e","manuscriptTitle":"The impact of the COVID-19 pandemic on lifestyle behavior and accessibility to routine health care among people with type 2 diabetes mellitus: a qualitative study in urban slums of Hyderabad, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 14:12:57","doi":"10.21203/rs.3.rs-8493135/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2eac084-91fb-4ad6-9a0a-ef0e4224ef80","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T10:26:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 14:12:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8493135","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8493135","identity":"rs-8493135","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}