Access to diabetes self-management education: results of national surveys of patients, educators, and physicians

PURPOSE

To examine factors related to access to diabetes self-management education (DSME), including services delivered and sought; patient, physician, and program barriers to access; educator outreach and expansion efforts; and perceptions of alternative DSME delivery strategies.

METHODS

Internet surveys were completed by 1169 adults with diabetes (661 with prior DSME, 508 with no prior DSME) from a national community survey panel, 1871 educators who were AADE members, and 629 physicians (212 diabetes specialists, 417 primary care practitioners) from a national physician survey panel.

RESULTS

Physicians want patients to receive more self-management support, but some report that patients are told to do things with which the physician does not agree. Provider (physician and educator)-delivered DSME is more highly regarded among those who have received it than among those who have not received it. Physicians generally have positive perceptions of provider-delivered DSME, and educators see physicians as key to encouraging DSME use in patients. Some physicians are concerned about losing patients sent to DSME, and 11% of patients report changing physicians as a result of DSME. Most DSME programs have grown recently as a result of recruiting efforts and adding new programs/services; most programs plan more such efforts. Patients prefer traditional DSME sources/settings and are moderately accepting of media sources.

CONCLUSIONS

Additional efforts are required to guarantee that all people with diabetes receive the DSME they need. This will require increased referral by physicians, increased follow-through by patients, and increased availability of DSME in forms that make it appealing to patients and physicians.

Social support, quality of life, and self-care behaviors amongAfrican Americans with type 2 diabetes

PURPOSE

The purpose of this study was to examine social support and its relationship to diabetes-specific quality of life and self-care behaviors in African Americans with type 2 diabetes.

METHODS

The study followed a cross-sectional, observational design and recruited 89 African American adults, age 40 and older (mean = 60, SD = 10.5), diagnosed with type 2 diabetes. Participants completed measures assessing diabetes-specific quality of life, self-care behaviors (healthy eating, physical activity, self-monitoring of blood glucose, foot care, medication and/or insulin use), demographic background, and diabetes-related social support. Diabetes-related social support variables included amount of social support received, satisfaction with support, positive support behavior, negative support behavior, and primary source of support.

RESULTS

Stepwise regressions, controlling for demographic variables, were conducted to identify predictors of diabetes-specific quality of life and self-care behaviors from the diabetes-related social support variables. Satisfaction with support was a predictor for improved diabetes-specific quality of life (r = -.579, P < .001) and blood glucose monitoring (r = .258, P < .05). Positive support behavior was a predictor for following a healthy eating plan (r = .280, P < .05), spacing out carbohydrates evenly throughout the day (r = .367, P < .01), and performing physical activity at least 30 minutes per day (r = .296, P < .05). Negative support behavior was a predictor for not taking medication as recommended (r = -.348, P < .01).

CONCLUSIONS

Findings indicate that social support plays a role in diabetes-specific quality of life and self-management practices. Social support encompasses multiple dimensions that differentially influence specific diabetes health-related outcomes and behaviors.

The art and science of diabetes education: a culture out of balance

In the past 20 years, behavioral science has helped create a growing body of theoretically derived, evidenced-based approaches to diabetes patient education. Health care professionals in all disciplines are being required to demonstrate that their practice is evidence based. For diabetes educators, behavioral science is the source of much of that evidence. However, effective diabetes education involves a combination of art and science. Establishing a therapeutic alliance with patients is an art. Diabetes educators must have the interpersonal skills, values, and personal traits needed to cultivate relationships with patients that are characterized by trust, respect, and acceptance. They must feel and be able to express compassion, empathy, and warmth. However, if someone outside the field were reviewing diabetes education evaluation research, they would probably conclude that diabetes educators are interchangeable cogs in a wheel. The positive impact of the therapeutic alliance is well documented in the counseling, psychotherapy, education, and nursing literature. However, evidence to support the important role of the diabetes educator's values, interpersonal skills, and ability to establish a therapeutic alliance with patients is absent from that literature. Valid and reliable measures used to document the impact of interpersonal skills counselors and teachers could be used in diabetes education with little or no adaptation. The evidence and tools exist; we now need to determine if the will exists.

Insulin detemir: a new option for the treatment of diabetes

PURPOSE

To highlight the pharmacology, clinical data, and practical application for the use of insulin detemir, a new long-acting insulin analog in the treatment of type 2 diabetes.

DATA SOURCES

Published clinical, pharmacokinetic, and pharmacodynamic studies of insulin detemir, as well as contemporary studies and reviews about the management of patients with type 2 diabetes.

CONCLUSIONS

Insulin therapy, if titrated appropriately, is the most physiological and effective intervention for lowering blood glucose and may help preserve beta-cell function in patients with type 2 diabetes. Insulin detemir, in comparative clinical trials, has been shown to provide effective glycemic control and a consistent blood glucose-lowering response for up to 24 h, a decreased incidence of nocturnal hypoglycemia, and less weight gain than other basal insulin formulations.

IMPLICATIONS FOR PRACTICE

Insulin therapy is often met with resistance from both patients and healthcare providers because of concerns about its effectiveness, hypoglycemia, injections, and weight gain. Insulin detemir, designed to closely mimic basal insulin secretion, may help overcome some of the barriers to effective diabetes management, i.e., hypoglycemia and weight gain, and lead to better outcomes.

Economics of diabetes mellitus

The increasing prevalence of diabetes and prediabetes makes the cost of diabetes care a pressing concern. Nurses in all settings play a critical role in helping to reduce the cost of diabetes not only for individual patients but ultimately for the health care system. This article focuses on four main issues related to the economic impact of diabetes for patients and health systems: (1) overall estimates of the direct and indirect costs of diabetes and its associated complications, (2) the impact of cost on diabetes care and health outcomes, (3) the ways in which federal- and state-mandated insurance for persons with diabetes is being used to promote more cost-effective and high-quality diabetes care, and (4) the use of cost-effectiveness analysis to evaluate interventions designed to prevent diabetes or diabetes-related complications.

A study of certified diabetes educators: influences and barriers

PURPOSE

There were 2 related goals for this study. The first purpose was to describe the structure (type, staffing, and number of educational sessions provided), process (preferred learning approaches), and outcome measures commonly used to provide patient education. The second purpose was to identify the influences, resources, and constraints that affect and alter the attitudes and practices of diabetes educators.

METHODS

A 30-item questionnaire that addressed 4 areas--demographics, practice characteristics, education program structure, and educational processes--was mailed to a sample of American Association of Diabetes Educators members. Three hundred sixty-one registered nurse and registered dietician certified diabetes educators completed the questionnaire and were included in the final analysis.

RESULTS

This survey indicated that this group of certified diabetes educators has incorporated new research findings and innovative teaching methods into their practices. They experience few barriers and tend to make changes in their attitudes and practices based on scientific and experiential evidence. The 3 most highly rated influences on these changes were related to patient responses to their teaching, followed by continuing education conferences and new research findings.

CONCLUSIONS

Based on these findings, providing continuing education that first and foremost incorporates experience-based examples of effective strategies supported by research published in professional journals appears to have the most influence on the practice of educators.

Barriers to achieving optimal glycemic control in a multi-ethnic society: a US focus

The increasing prevalence of diabetes is particularly apparent in certain ethnic groups, such as African and Hispanic Americans. These groups generally also have poorer glycemic control and outcomes. To better understand the issues surrounding these problems and possible methods to overcome them we performed a literature review from the past 15 years on barriers to glycemic control with a focus on US data. The literature reveals that barriers may be inherent (eg, genetic, cultural, and language/communication) or acquired (eg, those associated with changes in lifestyle and socioeconomic factors). Healthcare interventions that take into consideration cultural and population-specific characteristics can reduce the prevalence and severity of diabetes and its resulting complications. Implementing such strategies will require suitable education for patients and providers, the availability of culturally-sensitive, patient-centered healthcare teams, the creation of collaborative relationships between providers and patients, better use of community resources, and assistance for patients to make informed decisions about available treatment options. There is also evidence suggesting that at the same level of glucose control Hispanics and African Americans have the same degree of complications as whites; therefore, good control is essential for the future well-being of all patients. Addressing these issues may help to decrease the ethnic disparities that currently exist in diabetes care.

Patient empowerment: reflections on the challenge of fostering the adoption of a new paradigm

Diabetes is a self-managed illness in which the decisions most affecting the health and well being of patients are made by the patients themselves. Many of these decisions involve routine activities of daily living (e.g., nutrition, physical activity). Effective diabetes care requires patients and health care professionals to collaborate in the development of self-management plans that integrate the clinical expertise of health care professionals with the concerns, priorities and resources of the patient. Collaborative diabetes care requires a new "empowerment" paradigm that involves a fundamental redefinition of roles and relationships of health care professionals and patients. The challenges of fostering the adoption of a new paradigm differ substantially from those associated with the introduction of new technology. Those challenges are discussed in this paper.

Developing a new generation of ongoing: Diabetes self-management support interventions: a preliminary report

PURPOSE

The study examined the feasibility, acceptability, and potential impact of an innovative, community-based, ongoing self-management intervention aimed at enhancing and sustaining self-care behaviors over the long term among urban African Americans with type 2 diabetes.

METHODS

Sixty-two African American men and women completed the study. Participants were invited to attend 24 weekly, consecutive, diabetes self-management support/ education groups. The flow of the weekly group sessions was guided by questions and concerns of the patients. Baseline and 6-month follow-up metabolic functioning, lipid profiles, cardiovascular functioning, and self-care behaviors were assessed.

RESULTS

Ninety percent (n = 56) of the sample attended at least 1 session; 40% attended at least 12 or more sessions. Paired t tests found significant improvements in body mass index (P < .001), total cholesterol (P < .01), high-density lipoprotein (P < .05), and low-density lipoprotein (P < .001). Significant increases were also found for self-care behaviors (P < .05).

CONCLUSIONS

Preliminary evidence suggests that participation in this weekly problem-based, self-management support intervention can yield diabetes-related health benefits.

Implementing an empowerment-based diabetes self-management education program

Diabetes educators are challenged to develop culturally appropriate, integrated, behaviorally based, effective education programs. This article describes the intervention used in a problem-based educational program for urban African Americans with diabetes. The intervention consisted of six 2-hour, weekly group educational and data collection sessions. No lectures were used, and the content was determined by participants' questions and concerns. Culturally tailored written educational materials were also provided.

Empowerment and Self-Management after Weight Loss Surgery

The bariatric surgery health-care professional team are often frustrated and discouraged when patients are unwilling or unable to follow their advice to achieve ideal outcomes after obesity surgery. The acute care model that suffices for other types of surgery is inadequate after a surgery that requires chronic life-long behavioral changes. Practical interventions that facilitate collaborative relationships and foster patient-centered practices are the key to giving up feeling responsible for the choices that patients make, by being responsible to them, and achieving better outcomes.

Evaluating a problem-based empowerment program for African Americans with diabetes: results of a randomized controlled trial

OBJECTIVE

The objective of this study was to evaluate the impact of a problem-based empowerment patient education program specifically tailored for urban African Americans with type 2 diabetes.

RESEARCH DESIGN AND METHODS

The study used a randomized controlled trial (RCT) pretest/post-test design with repeated measures. Patients were randomly assigned to either a six-week intervention group or a six-week wait-listed control group. After completing the six sessions, patients were invited to participate in one of two follow-up conditions; attend a monthly support group or receive a monthly phone call from a nurse. Assessment measures included HbA1C, lipids, blood pressure, weight, self-management behavior and psychosocial adaptation.

RESULTS

Both control and intervention patients showed a broad array of small-to-modest positive changes during the six-week RCT. These gains were maintained or improved upon during the one-year follow-up period. For patients in the two follow-up conditions, a positive correlation was seen between the number of follow-up contacts and their one-year HbA1C values.

CONCLUSIONS

We believe that results of this study can be attributed to volunteer bias, study effects (ie, providing study data on several occasions to patients and their physicians during the one-year study period), and impact of the interventions. However, the study design does not allow us to examine the relative impact of these three factors on the patient improvements seen over the one-year study period.

Overcoming obstacles: collaboration for change

Effective diabetes care requires a partnership between prepared, proactive practice teams and informed, activated patients. Diabetes education helps to overcome many of the barriers to effective self-management by enabling people with diabetes to make informed decisions about their day-to-day self-care. Both psychosocial and health outcomes have been improved through a variety of training programmes; however, education must be coupled with ongoing self-management support if these benefits are to be sustained. The principal goal of diabetes education has undergone a major shift over the past few years--evolving from primarily didactic interventions, focused on encouraging patients to adhere to the prescribed therapy, towards more interactive learning that supports people in making informed, self-directed decisions.

Patient empowerment

Patient empowerment is defined as helping people to discover and use their own innate ability to gain mastery over their diabetes (Funnell MM, Anderson RM. Diabetes Educ. 1991;17:37-41). While you cannot empower a patient, nurses can use strategies that will assist patients in this process. These include providing education for informed decision-making, assisting patients to weight costs and benefits of various treatment options, setting self-selected behavioral goals, and providing information about the importance of their role in self-management (Funnell et al. Diabetes Educ. 2003;29:454-464). The skills needed by nurses include asking questions in order to understand the patients' fears, concerns, and priorities, listening to responses, and educating and supporting patients for on-going self-management.

Self-management support for insulin therapy in type 2 diabetes

PURPOSE

The purpose of this article is to describe the self-management support that can be provided by diabetes educators for type 2 diabetes patients who are transitioning from therapy with oral hypoglycemic agents to insulin.

METHODS

The role of the diabetes educator in patient education and self-management support during all aspects of insulin therapy is discussed. Phases during which support may be especially important include the decision-making process, initiation, and maintenance.

RESULTS

Although some patients make the decision fairly easily, the introduction of insulin therapy is likely to raise many issues and questions for many type 2 diabetes patients. The more reluctant patients may experience psychological insulin resistance, a syndrome where insulin therapy is viewed as a threat or failure, which can affect health professionals as well. The diabetes educator can provide support and approaches to help diminish this resistance and make the transition to insulin therapy easier and more effective for patients with type 2 diabetes.

CONCLUSIONS

Education and ongoing self-management support are needed for informed decision making and the initiation and maintenance of insulin therapy. Therefore, diabetes educators have a critical role to play during both the decision-making process and the safe transition to insulin therapy.

Type 2 diabetes: treat to target

Traditionally, practitioners have reserved insulin therapy for patients with type 2 diabetes until diet, exercise, and treatment with oral agents have failed to maintain glycemic control. Increasing evidence, however, supports advancing insulin therapy earlier in treating diabetes, not only to normalize glycemic control and emulate normal physiologic insulin secretion, but also to delay or prevent disease-associated comorbidity.

Implementing practical interventions to support chronic illness self-management

BACKGROUND

Self-management support (SMS) is the area of disease management least often implemented and most challenging to integrate into usual care. This article outlines a model of SMS applicable across different chronic illnesses and health care systems, presents recommendations for assisting health care professionals and practice teams to make changes, and provides tips and lessons learned. Strategies can be applied across a wide range of conditions and settings by health educators, care managers, quality improvement specialists, researchers, program evaluators, and clinician leaders. Successful SMS programs involve changes at multiple levels: patient-clinician interactions; office environment changes; and health system, policy, and environmental supports. PATIENT-CLINICIAN INTERACTION LEVEL: Self-management by patients is not optional but inevitable because clinicians are present for only a fraction of the patient's life, and nearly all outcomes are mediated through patient behavior. Clinicians who believe they are in control or responsible for a patient's well-being are less able to adopt an approach that acknowledges the central role of the patient in his or her care.

SUMMARY AND CONCLUSIONS

Self-management should be an integral part of primary care, an ongoing iterative process, and patient centered; use collaborative goal setting and decision making; and include problem solving, outreach, and systematic follow-up.

Diabetes update: from the American Diabetes Association: preventing type 2 diabetes with weight loss and exercise

Modest changes in diet and physical activity helped participants in the NIH's Diabetes Prevention Program reduce their risk of developing Type 2 diabetes by a whopping 58%.

Changing office practice and health care systems to facilitate diabetes self-management

Diabetes is a self-managed disease for which patients provide 99% of their own care. For patients to succeed as diabetes self-managers, they need office practices and health care systems that can prepare and support them in their diabetes self-management efforts over the long term. In order to provide effective diabetes education and ongoing support, office practices and health care systems will have to fundamentally redefine the roles of health professionals and patients with diabetes, and redesign practices and systems to allow for effective long-term self-management education and support. Although it is difficult for both people and systems to change, change is essential if we are going to provide self-management support for the majority of patients suffering from this serious chronic disease.

Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams

Self-management is an essential but frequently neglected component of chronic illness management that is challenging to implement. Available effectiveness data regarding self-management interventions tend to be from stand-alone programs rather than from efforts to integrate self-management into routine medical care. This article describes efforts to integrate self-management support into broader health care systems change to improve the quality of patient care in the Chronic Illness Care Breakthrough Series. We describe the general approach to system change (the Chronic Care Model) and the more specific self-management training model used. The process used in training organizations in self-management is discussed, and data are presented on teams from 21 health care systems participating in a 13-month-long Breakthrough Series to address diabetes and heart failure care. Available system-level data suggest that teams from a variety of health care organizations made improvements in support provided for self-management. Improvements were found for both diabetes and heart failure teams, suggesting that this improvement process may be broadly applicable. Lessons learned, keys to success, and directions for future research and practice are discussed.

Compliance and adherence are dysfunctional concepts in diabetes care

Recognizing that adherence and compliance are dysfunctional concepts is not a passing fad or the latest trend in behavioral approaches to diabetes care and education. Shifting from the acute-care/compliance-focused paradigm to an empowerment/collaborative approach requires a new vision of diabetes education and a new definition and enactment of the roles of educators and patients. Our practice is always an expression of our vision; therefore, if our vision is transformed, our practice will most likely change to reflect our vision. Eliminating the concepts of adherence and compliance makes it possible for our patients to discover and actualize their personal responsibility for their diabetes self-management. Also, it helps us to practice diabetes education as win-win collaboration among equals.

The Diabetes Empowerment Scale: a measure of psychosocial self-efficacy

OBJECTIVE

The purpose of this study was to assess the validity, reliability, and utility of the Diabetes Empowerment Scale (DES), which is a measure of diabetes-related psychosocial self-efficacy.

RESEARCH DESIGN AND METHODS

In this study (n = 375), the psychometric properties of the DES were calculated. To establish validity, DES subscales were compared with 2 previously validated subscales of the Diabetes Care Profile (DCP). Factor and item analyses were conducted to develop subscales that were coherent, meaningful, and had an acceptable coefficient alpha.

RESULTS

The psychometric analyses resulted in a 28-item DES (alpha = 0.96) with 3 subscales: Managing the Psychosocial Aspects of Diabetes (alpha = 0.93), Assessing Dissatisfaction and Readiness To Change (alpha = 0.81), and Setting and Achieving Diabetes Goals (alpha = 0.91). Consistent correlations in the expected direction between DES subscales and DCP subscales provided evidence of concurrent validity.

CONCLUSIONS

This study provides preliminary evidence that the DES is a valid and reliable measure of diabetes-related psychosocial self-efficacy. The DES should be a useful outcome measure for various educational and psychosocial interventions related to diabetes.

The influence of treatment modality and ethnicity on attitudes in type 2 diabetes

OBJECTIVE

The study examines diabetes attitude differences by treatment modality (insulin vs. no insulin), race/ethnicity, and the interaction of these two variables for people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were collected with the Diabetes Care Profile (DCP), an instrument that assesses psychosocial factors related to diabetes. Participants (n = 672) were recruited in the metropolitan Detroit, Michigan, area from 1993 to 1996. A total of 68% of these participants were African-Americans with type 2 diabetes, and 32% were Caucasians with type 2 diabetes. Analyses of covariance were performed to examine the effects of race/ethnicity, treatment, and their interaction for each DCP scale.

RESULTS

The four patient categories (two ethnicities by two treatment modalities) differed by age, years with diabetes, education, and sex distribution. Treatment modality had a significant effect on 6 of the 16 DCP scales (Control, Social and Personal Factors, Positive Attitude, Negative Attitude, Self-Care Ability, and Exercise Barriers). Ethnicity was a significant effect for three scales (Control, Support, and Support Attitudes). The interaction of race/ethnicity and treatment modality was a significant effect for two related attitude scales (Positive Attitude and Negative Attitude).

CONCLUSIONS

The results suggest that attitudes toward diabetes are similar for African-American and Caucasian patients with type 2 diabetes. The results also suggest that treatment modality has a greater effect on attitudes than either race/ethnicity or the interaction effect. However, Caucasian patients using insulin differed from the other patient groups by having the least positive and the most negative attitudes regarding diabetes.

Assessing the cultural relevance of an education program for urban African Americans with diabetes

PURPOSE

This study was conducted to assess the cultural relevance of an education program for urban African Americans with diabetes.

METHODS

A set of 12 videotape vignettes were developed for use in diabetes education for urban African Americans with diabetes. Focus groups and questionnaires were used to determine if patients and diabetes educators would find the materials stimulating, culturally appropriate, and useful.

RESULTS

The videotape and discussion guide were perceived as valuable by both healthcare professionals and patients.

CONCLUSIONS

This education program could be a valuable resource for diabetes educators who want to provide culturally sensitive and relevant diabetes education for urban African Americans with diabetes.

Diabetes patient education research: an integrative literature review

PURPOSE

The purpose of this study is to summarize the accumulated state of knowledge in the area of diabetes patient education research and highlight important issues that research has left unanswered.

METHODS

An integrative literature review was conducted on the topic of diabetes patient education between the years 1985 and 1998. Keywords used in the computerized search were diabetes mellitus, patient education, health education, research, and behavior change. The databases searched were MEDLINE, CINAHL, HealthSTAR, EMBASE, and CHID-HE. A total of 78 papers were reviewed.

RESULTS

Most studies lacked a theoretical framework and the majority of studies were conducted in an outpatient setting. HbA1c was the most frequently employed outcome measure, with little, if any, description of the interventions.

CONCLUSIONS

Much has been learned in terms of the effectiveness of diabetes education on improving knowledge. However, other topic areas and outcomes need further exploration.

Theory is the cart, vision is the horse: reflections on research in diabetes patient education

PURPOSE

In this paper, we examine the nature of vision and the role it plays in helping educators identify and use theories productively. We also discuss the role of theory in diabetes education and provide criteria for selecting appropriate theories.

METHODS

The vision of diabetes education developed at the Michigan Diabetes Research and Training Center was used to illustrate how our vision has influenced our use of educational and behavioral theories.

RESULTS

Both our vision and our theoretical assumptions should be articulated, discussed, debated, and studied.

CONCLUSIONS

Diabetes patient education research can systematically contribute to the development of a sound, coherent, and progressive body of knowledge that will truly serve diabetes patient education.

Care of the nursing-home resident with diabetes

Diabetes is a common and costly illness among elderly nursing-home residents. People with diabetes more often require skilled care, experience more frequent health problems and hospitalizations, and have longer nursing-home stays. This article provides information about recommendations for diabetes care in nursing homes, the current level of care, and strategies to improve the quality of care for residents with diabetes.

The third version of the Diabetes Attitude Scale

OBJECTIVE

The objective of this study was to develop a third version of the Diabetes Attitude Scale (DAS-3) that is congruent with current scientific knowledge about diabetes, has improved subscale internal reliability scores, and is shorter than the earlier versions of this instrument.

RESEARCH DESIGN AND METHODS

The second DAS was revised and rewritten by a panel of diabetes experts, including patients, associated with the University of Michigan Diabetes Research and Training Center. The revised version of the instrument was sent to physicians, nurses, dietitians, and patients with diabetes. Completed and usable questionnaires were obtained from 384 patients with diabetes, 321 physicians, 540 nurses, and 569 dietitians. The total number of surveys used for these analyses was 1,814.

RESULTS

The study resulted in a revised DAS with 33 items and five discrete subscales. The subscales were attitudes toward the following: 1) need for special training to provide diabetes care, 2) seriousness of type 2 diabetes, 3) value of tight glucose control, 4) pyschosocial impact of diabetes, and 5) attitude toward patient autonomy. Overall, the subscale reliabilities of the DAS-3 were superior to the earlier versions of the scale.

CONCLUSIONS

The DAS-3 is a valid and reliable general measure of diabetes-related attitudes and is most suitable for comparisons across different groups of health care professionals and/or patients. The DAS-3 is also suitable for the evaluation of patient and/or professional education programs if those programs focus on the specific topic areas measured by the five DAS-3 subscales.

The older adult with diabetes

Like their younger counterparts, older adults with diabetes need individualized treatment and educational programs based on personal glucose goals. Although most of the tools and therapies available to younger adults are also appropriate for the elderly, additional considerations and strategies are needed to meet the needs of this population for whom diabetes is a frequent and serious problem. To be effective, the therapeutic approach needs to take into consideration the aging process, other health problems, and the functional, psychosocial, cultural, and educational status of each patient. Along with these considerations, this article provides an overview of the treatment of diabetes for this age group and offers strategies for working with older adults.

The reliability and validity of a brief diabetes knowledge test

OBJECTIVE

To examine the reliability and validity of a brief diabetes knowledge test. The diabetes knowledge test has two components: a 14-item general test and a 9-item insulin-use subscale.

RESEARCH DESIGN AND METHODS

Two populations completed the test. In one population, patients received diabetes care in their community from a variety of providers, while the other population received care from local health departments. Cronbach's coefficient alpha was used to calculate scale reliability for each sample. To determine validity, patient group differences were examined. It was hypothesized that test scores would be higher for patients with type 1 diabetes, for patients with more education, and for patients who had received diabetes education.

RESULTS

The coefficient alpha s for the general test and the insulin-use subscale indicate that both are reliable, alpha > or = 0.70. In the community sample, patients with type 1 diabetes scored higher than patients with type 2 diabetes on the general test and the insulin-use subscale. In the health department sample, patients with type 1 scored higher than patients with type 2 on the insulin-use subscale. For both samples, scores increased as the years of formal education completed increased, and patients who received diabetes education scored higher than patients who did not.

CONCLUSIONS

Although the samples differed demographically, the reliability and validity of the test were supported in both the community and the health department samples. This suggests that the test is appropriate for a variety of settings and patient populations.

Participation in a diabetes education and care program: experience from the diabetes care for older adults project

There is very little reported information concerning the participation of older adults in diabetes education and care programs, factors related to their attendance, and the influence of attendance on program outcomes. In this study, which was part of a larger study of insulin therapy, subjects (> or = 65 years old) assigned to the intensive management group (n = 53) were provided with educational sessions during the 18-month study period. Data for this group were examined to determine factors that influenced enrollment and attendance. Attendance rates for individual participants averaged 72% during the first 6 months and 68% during the subsequent 12 months. Demographic factors, baseline knowledge test scores, and baseline glycosylated hemoglobin levels did not significantly influence participation. Greater distance from the clinic and shorter time using insulin were significantly related (P = .05) to attendance. Perceived benefits of the program included diabetes education (45%), glucose control (23%), and interacting with others who have diabetes (23%).

Screening, prevention, counseling, and treatment for the complications of type II diabetes mellitus. Putting evidence into practice

PURPOSE

To summarise current knowledge of interventions that should improve the care of patients with type II diabetes mellitus. Interventions lie within the realms of preventions, screening, and treatment, all of which are focused on office practice.

METHODS

Review of the literature by a multidisciplinary team involved in the care of patients with diabetes, followed by synthesis of the literature into a clinical care guideline. Literature was identified through consultation with experts and a focused MEDLINE search.

MAIN RESULTS

An algorithm-based guideline for screening and treatment of the complications of diabetes was developed. The emphasis is on prevention of atherosclerotic disease, and prevention, screening, and early treatment of microvascular disease. Implementation of these practices has the potential to significantly improve quality of life and increase life expectancy in patients with type II diabetes mellitus.

Predictors of adherence to nutrition recommendations in people with non-insulin-dependent diabetes mellitus

The purpose of this study was to determine how the components of psychosocial adjustment to diabetes predict adherence to nutrition recommendations based on self-reported successful completion of contingency contracts. The relationships between the components of psychosocial adjustment and adherence to nutrition recommendations were examined in a convenience sample of patients with non-insulin-dependent diabetes mellitus participating in a contingency contracting intervention with nurses. Patients completed a standardized instrument, the Diabetes Care Profile, at the time they were enrolled into this randomized clinical trial. High and low levels of adherence to nutrition recommendations were identified by a median split of the number of contingency contracts completed for adherence to nutrition recommendations. Subjects who reported higher regimen adherence and a higher support ratio (received more diabetes-specific social support than desired) were significantly less likely to engage in contingency contracting for adherence to nutrition recommendations.

Differences in the impact of dietary restrictions on African Americans and Caucasians with NIDDM

African-American and Caucasian patients with non-insulin-dependent diabetes mellitus were surveyed to determine differences in self-reported dietary adherence. The relationship between dietary adherence and other psychosocial factors also was explored. The Diabetes Care Profile, an instrument designed to assess psychosocial factors related to diabetes, was completed by 178 patients. Correlation and regression analyses were used to examine the relationship between dietary adherence and 15 other scales in this instrument. Regression analyses revealed that selected scales were better at predicting dietary adherence for African Americans than for Caucasians. Self-care adherence was the most significant predictor of dietary adherence for African Americans while support was the most significant predictor for Caucasians. These findings suggest that cultural and social functions of food and diet should be examined and incorporated in the development of appropriate meal plans and educational interventions.

Development and validation of the Diabetes Care Profile

To determine the reliability and the validity of the Diabetes Care Profile (DCP), an instrument that assesses the social and psychological factors related to diabetes and its treatment, two studies with separate populations and methodologies were conducted. In the first study, the DCP was administered to, and physiologic measures collected from, individuals with diabetes being cared for in a community setting (n = 440). In the second study, the DCP and several previously validated scales were administered to individuals with diabetes receiving care at a university medical center (n = 352). Cronbach's alphas of individual DCP scales ranged from .60 to .95 (Study 1) and from .66 to .94 (Study 2). Glycohemoglobin levels correlated with three DCP scales (Study 1). Several DCP scales discriminated among patients with different levels of disease severity. The results of the studies indicate that the DCP is a reliable and valid instrument for measuring the psychosocial factors related to diabetes and its treatment.

Using focus groups to identify psychosocial issues of urban black individuals with diabetes

The purpose of this focus group research was to identify issues that could serve as topics for a series of educational videos portraying psychosocial issues of urban black individuals with diabetes. Four focus groups involving 34 black adults were conducted in the Detroit area. Psychosocial issues were identified and rated in order of priority by an expert panel. The major psychosocial issues identified were the importance of food and eating in the black culture, the necessity for learning more about diabetes and its complications, learning to interact effectively with healthcare providers and systems, and the need for help and support in managing psychosocial issues related to diabetes. Black individuals with diabetes face unique psychosocial challenges. Focus groups are an effective method for obtaining relevant, culturally specific, in-depth information about living with diabetes from patients who are members of minority groups.

Prostate cancer in African American men: increasing knowledge and self-efficacy

An educational and screening program for prostate cancer designed to increase knowledge and self-efficacy in African American men was provided in African American churches in a major midwestern city. Modeling was provided by trained lay educators who were African American men previously diagnosed and treated for prostate cancer and who could serve as role models of the desired behaviors. Pretests and posttests developed for this study and provided to the participants were the Prostate Cancer Screening Knowledge Inventory and the Prostate Cancer Screening Self-Efficacy Scale. Paired t tests demonstrated that after completing the church-based intervention, participants had significantly improved knowledge and self-efficacy scores related to prostate cancer screening.