Personal models of diabetes in relation to self-care, well-being, and glycemic control. A prospective study in adolescence

Improving glycaemic control in children and adolescents: which aspects of therapy really matter?

In paediatric diabetes, the concept of intensive therapy in the post-Diabetes Control and Complications Trial period has become subverted by a pharmaco-technological paradigm at the expense of other aspects of care such as goal-setting and psychosocial support. This review examines which patients benefit most from intensive therapy in terms of glycaemic control (HbA1c). It also reviews published controlled trial and observational data relating to the impact of various insulin types and delivery systems on glycaemic control and canvasses the literature dealing with the impact of patient support, philosophy of care, goal setting and treating team dynamic on HbA1c. Taking into account the characteristics of those patients who benefit most from intensive therapy, the quantum of HbA1c change and the persistence of changes that have been reported in selected and non-selected patient groups, it appears that there is a clear hierarchy in aspects of therapy that improve glycaemic control for children and adolescents with Type 1 diabetes. Prime issues appear to be patient support, team cohesion and goal setting. The reported glycaemic benefits achieved by an isolated emphasis upon a pharmaco-technological paradigm are limited in children and adolescents. It appears that only after the prime issues have been first considered will the potential benefits of the insulin types and regimens then be realized.

Illness perception and cardiovascular risk factors in patients with type 2 diabetes: cross-sectional questionnaire study

AIM. To investigate illness perception in patients with type 2 diabetes mellitus and its association with the degree of control over relevant cardiovascular risk factors. METHODS. A cross-sectional questionnaire-based study was performed from June 2007 to March 2008. A stratified random sample of 46 Croatian general practitioners was asked to select, using systematic sampling, the first 6 patients with type 2 diabetes mellitus aged > or =18 years who visited them for consultation during the study period. Data on 250 patients included patient illness perception assessment (Brief Illness Perception Questionnaire, IPQ), cardiovascular risk factors, and socio-demographic data. RESULTS. The patients' mean age was 63.0+/-10.9 years and mean duration of diabetes was 9.3+/-7.8 years. The patients' illness perception assessment on an 11-point (0 to 10) scale showed the highest median scores (interquartile range): 10 (8 to 10) for "timeline" and 8 (7 to 9) for "treatment control," followed by 7 (5 to 8) for "personal control," 7 (5 to 9) for "understanding," 5 (3 to 7) for "consequences," 6 (4 to 7) for "concern," and 5 (2 to 7) for "emotional response." The lowest score was 3 (1 to 5) for "identity." Multivariate logistic regression showed that the Brief IPQ item "concern" (P<0.001) was a significant predictor of body mass index; "personal control" (P<0.001) and "concern" (P=0.048) were significant predictors of fasting blood glucose; "treatment control" (P=0.009) was a significant predictor of total cholesterol; and "understanding" (P=0.010) was a significant predictor of blood pressure. CONCLUSION. As patients' beliefs seem to be associated with the degree of control over cardiovascular risk factors, they should be included in routine clinical assessments.

A cost-effectiveness analysis of a community pharmacist-initiated disease state management service for type 2 diabetes mellitus

Objective

To conduct an economic evaluation of a community pharmacy-delivered disease state management (DSM) service for type 2 diabetes mellitus.

Setting

The study was a parallel groups design, with control and intervention groups matched on demographic and diabetes-related characteristics, and was conducted in New South Wales, Australia. Three different settings were included — rural and metropolitan community pharmacy settings and hospital diabetes clinics.

Method

A cost-effectiveness analysis of the specialised service was conducted. The economic perspective adopted in the present analysis is that of the healthcare sector in general, taking into account the viewpoint of both the Commonwealth Government of Australia and the New South Wales State Government.

Key findings

Glycosylated haemoglobin (HbA1c) levels decreased by 0.46% (P = 0.02) in the intervention group compared with a change of 0.03% (P = 0.81) in the control group after 9 months. To obtain the 0.43% (95% confidence interval (CI) 0.34-0.52) reduction in HbA1c achieved by the specialised service, the cost to the healthcare sector was $A383 (Australian dollars; 95% CI $A46.16–717.46) per patient per 9 months.

Conclusion

This service has resulted in a significant reduction in HbA1c which should translate into improved health outcomes long term, since each 1% reduction in HbA1c has been associated with reductions in risk of 21% from any endpoint related to diabetes. Given the annual costs for the management of each patient with diabetes in Australia, the additional $A383 invested in the first 9 months of this service is likely to result in a saving to the healthcare system long term.

Perceived control and involvement in self care in patients with colorectal cancer

AIM

This paper reports the qualitative findings from a mixed methods study which explored patients' understandings of perceived control in relation to their self care during chemotherapy for colorectal cancer.

BACKGROUND

A greater degree of patient involvement in self care is increasingly being encouraged; however, little is known about how factors such as perceived control influence patients' active involvement in self care.

DESIGN

Qualitative, longitudinal study.

METHODS

Semi structured interviews were conducted with 11 patients before and after six months of chemotherapy treatment for colorectal cancer in a Scottish cancer centre between March 2005-June 2006. The interviews, conducted as part of a larger study, explored patients' understandings of their perceived control over managing treatment-related side effects and how this influenced their attitudes toward, and role preferences in, self care.

RESULTS

Patients fell into one of two groups: 'high' or 'low' perceived controllers. High-perceived controllers were more likely to view their active involvement in self care positively, as being necessary in managing treatment-related effects and were less likely to rely on nurses to take overall responsibility for the management of treatment-related side effects. Low-perceived controllers were less likely to believe in the importance or necessity of their active involvement in self care and more likely to perceive nurses as being the ones responsible for the management of treatment-related side effects.

CONCLUSIONS

Perceived control during treatment for cancer influences patients' perceptions toward, and role preferences in, self care.

RELEVANCE TO CLINICAL PRACTICE

Clinical interventions designed to enhance involvement in self care would benefit from focussing on enhancing patients' perceived control and understanding their role preferences in self care. Patients with different understandings of perceived control may require different help and support to encourage their involvement in self care.

General practitioners trained in motivational interviewing can positively affect the attitude to behaviour change in people with type 2 diabetes. One year follow-up of an RCT, ADDITION Denmark

OBJECTIVE

To examine whether training GPs in motivational interviewing (MI) can improve type 2 diabetic patients' (1) understanding of diabetes, (2) beliefs regarding prevention and treatment, and (3) motivation for behaviour change.

METHODS

A randomized controlled trial including 65 GPs and 265 type 2 diabetic patients. The GPs were randomized in two groups, one with and one without MI training. Both groups received training in target-driven intensive treatment of type 2 diabetic patients. The intervention was a 1(1/2)-day residential course in MI with (1/2)-day follow-up twice during the first year. The patient data stemmed from previously validated questionnaires.

MAIN OUTCOME MEASURES

The Health Care Climates Questionnaire assesses the patient-doctor relationship and type of counselling. The Treatment Self-Regulation Questionnaire assesses the degree to which behaviour tends to be self-determined. The Diabetes Illness Representation Questionnaire assesses beliefs and understanding of type 2 diabetes. The Summary of Diabetes Self Care Activities assesses the extent of various self-care activities related to type 2 diabetes.

RESULTS

The response rate to our questionnaires was 87%. Patients in the intervention group were significantly more autonomous and motivated in their inclination to change behaviour after one year compared with the patients from the control group. Patients in the intervention group were also significantly more conscious of the importance of controlling their diabetes, and had a significantly better understanding of the possibility of preventing complications.

CONCLUSION

MI improved type 2 patients' understanding of diabetes, their beliefs regarding treatment aspects, their contemplation on and motivation for behaviour change. Whether our results can be sustained long term and are clinically relevant in terms of changes in risk profile advocates further research.

The importance of health belief models in determining self-care behaviour in diabetes

Patients' self-care behaviours have a major role in diabetes management. Diabetes education provides the required knowledge, but despite this, self-care is often suboptimal. The degree to which patients follow advice as regards the various self-care behaviours is determined by their health beliefs (Illness Representations or Personal Models) of diabetes. Psychometric studies have tried to categorize and measure the beliefs about illness that influence patients to adhere to treatment recommendations in diabetes. Various models have been proposed to explain the relationship between beliefs and behaviour. Leventhal's Self-Regulatory Model, which takes account of the emotional as well as the objective rational response to illness, currently seems to offer the best system for identifying the determinants of patient self-care behaviour. A review of interventions indicates those based on psychological theory offer professionals the best chance of maximizing their patients' contribution to diabetes self-management and achieving improved outcomes, both glycaemic and psychosocial. Studies designed specifically to modify illness representations are now being undertaken. This brief review aims to summarize developments in this area of psychological theory over the last 20 years and the implications for promoting better self-care behaviour in diabetes.

Factors influencing diabetes self-management in Chinese people with type 2 diabetes

Patients with diabetes must incorporate a complicated regimen of self-management into their daily lives (e.g., taking medication, diet, exercise). Diabetes self-management (DSM) is the cornerstone for controlling diabetes and preventing diabetic complications. The purpose of this study was to test a model describing the effects of individual and environmental factors on DSM in a sample of patients with diabetes in Beijing, China. Survey data were gathered from a convenience sample of 201 Chinese adults with type 2 diabetes during outpatient visits. Data were analyzed using structural equation modeling. Model fit indices indicated a good fit to the data. In the final model, belief in treatment effectiveness and diabetes self-efficacy were proximate factors affecting DSM. Knowledge, social support, and provider-patient communication affected self-management indirectly via beliefs and self-efficacy. The findings provide a theoretical basis to direct the development of interventions for improving DSM in Chinese individuals with diabetes.

Making diabetes self-management education culturally relevant for Filipino Americans in Hawaii

PURPOSE

The purpose of this study was to identify the cultural values, traditions, and perceptions of diabetes risk and self-care among Filipino Americans in Hawaii with type 2 diabetes that facilitate or impede engagement in diabetes self-management behaviors and education classes.

METHODS

This qualitative study used 2 rounds of semistructured focus groups and interviews. Participants included 15 patients with type 2 diabetes recruited from a large health-maintenance organization in Hawaii and 7 health care and cultural experts recruited from the community. The taped and transcribed focus groups and interviews were coded thematically. Participants evaluated example materials for diabetes self-management education (DSME) with Filipino Americans.

RESULTS

Several aspects of Filipino American culture were identified as central to understanding the challenges of engaging in self-management behaviors and DSME: (1) undertaking self-management while prioritizing the family and maintaining social relationships, (2) modifying diet while upholding valued symbolic and social meanings of food, (3) participating in storytelling in the face of stigma associated with diabetes, and (4) reconciling spiritual and biomedical interpretations of disease causality and its management. Respondents also emphasized the role of several qualitative aspects of perceived risk (eg, dread, control) in moderating their behaviors. Participants suggested ways to make DSME culturally relevant.

CONCLUSIONS

Awareness of cultural values and qualitative aspects of perceived risk that influence Filipino Americans' engagement in diabetes self-care behaviors and classes may help to improve teaching methods, materials, and recruitment strategies.

Translational research: essential contributions from interpretive nursing science

Translating research into practice is a central priority in the National Institutes of Health Roadmap. Nurse scientists must reevaluate how proposed research fits within and contributes not only to the development of new knowledge, but to the translation of that knowledge to the care of diverse communities and populations. Key barriers to the translation of evidence based practices in health programs and initiatives have been identified in the health services and nursing literature. Contributions that interpretive research approaches enable in addressing those barriers are articulated.

Using the common sense model to design interventions for the prevention and management of chronic illness threats: from description to process

In this article, we discuss how one might use the common sense model of self-regulation (CSM) for developing interventions for improving chronic illness management. We argue that features of that CSM such as its dynamic, self-regulative (feedback) control feature and its system structure provide an important basis for patient-centered interventions. We describe two separate, ongoing interventions with patients with diabetes and asthma to demonstrate the adaptability of the CSM. Finally, we discuss three additional factors that need to be addressed before planning and implementing interventions: (1) the use of top-down versus bottom-up intervention strategies; (2) health care interventions involving multidisciplinary teams; and (3) fidelity of implementation for tailored interventions.

Características da dieta nas diferentes fases da evolução do diabetes melito tipo 1

A importância da terapia nutricional no tratamento do diabetes melito tem sido enfatizada desde os primórdios de seu conhecimento, quando era a única intervenção efetiva. No diabetes tipo 1, a dieta adequada é fundamental em conseqüência de sua conjugação com a utilização da insulina exógena. A ingestão energética adequada, para obtenção de peso normal mantém o anabolismo, assegurando crescimento e desenvolvimento, assim como diminui a resistência à insulina. O uso correto dos micro e macronutrientes é de fundamental importância. O conhecimento do metabolismo dos carboidratos e sua relação com a elevação glicêmica, em seus aspectos qualitativos e quantitativos é enfatizada por possibilitar um bom controle, principalmente no período pós-prandial. É comentada também a correta utilização de proteínas para prevenir ou tratar nefropatia e gorduras para evitar a dislipidemia, obesidade e doença cardiovascular. Sacarose e edulcorantes artificiais devem ser utilizados com critérios. A aderência ao tratamento, entretanto, é fundamental para obtenção das metas desejadas.

Facilitating narrative medical discussions of type 1 diabetes with computer visualizations and photography

OBJECTIVE

Patient-centered approaches to medicine suggest the need for physicians to become more aware of concerns and needs expressed in patient narratives. However, patients and physicians have different goals and discourse styles during consultations. We attempt to bridge these differences by providing patients with ways to collect, visualize, and describe behavioral and biomedical data.

METHODS

We describe an intervention where individuals with type 1 diabetes photograph health-related behaviors. These images and blood glucose records are displayed in computer visualizations and used during patient-physician interviews.

RESULTS

Qualitative analyses of interview data with patients who photographed their lives suggest the range of difficulties associated with diabetes self-management. The visualizations helped them articulate concerns about stress, peer relations, and unhealthy routines.

CONCLUSION

Interventions that combine biomedical and biopsychosocial data during patient-physician consultations may be beneficial for patients, helping them reflect on correlations between behaviors and health. Physicians are provided with contextual evidence to better understand patient issues around diabetes management.

PRACTICE IMPLICATIONS

We suggest that this and similar interventions could be used as an occasional diagnostic to help patients articulate stories of their health-related practices. Annotated archives of photographs and glucose data may also be useful tools for sharing diabetes experiences with newly diagnosed patients.

Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND): process modelling of pilot study

OBJECTIVE

To determine the effects of a structured education program on illness beliefs, quality of life and physical activity in people newly diagnosed with Type 2 diabetes.

METHODS

Individuals attending a diabetes education and self-management for ongoing and newly diagnosed (DESMOND) program in 12 Primary Care Trusts completed questionnaire booklets assessing illness beliefs and quality of life at baseline and 3-month follow-up, metabolic control being assessed through assay of HbA1c.

RESULTS

Two hundred and thirty-six individuals attended the structured self-management education sessions, with 97% and 64% completing baseline and 3-month follow-up questionnaires. At 3 months, individuals were more likely to: understand their diabetes; agree it is a chronic illness; agree it is a serious condition, and that they can affect its course. Individuals achieving a greater reduction in HbA1c over the first 3 months were more likely to agree they could control their diabetes at 3 months (r=0.24; p=0.05), and less likely to agree that diabetes would have a major impact on their day to day life (r=0.35; p=0.006).

CONCLUSION

Pilot data indicate the DESMOND program for individuals newly diagnosed with Type 2 diabetes changes key illness beliefs and that these changes predict quality of life and metabolic control at 3-month follow-up.

PRACTICE IMPLICATIONS

Newly diagnosed individuals are open to attending self-management programs and, if the program is theoretically driven, can successfully engage with the true, serious nature of diabetes.

The impact of continuous subcutaneous insulin infusion on health-related quality of life in children and adolescents with type 1 diabetes

AIM

To study the impact of continuous subcutaneous insulin infusion (CSII) therapy on health-related quality of life in children and adolescents with type 1 diabetes.

METHODS

31 children and adolescents with poorly regulated type 1 diabetes (mean HbA1c 10.4%, SD 1.8), mean age 14.4 (1.5) y (range 9.7-17.1) and mean diabetes duration of 6.8 (3.2) y (range 1.3-14.6) were consecutively assigned to CSII therapy. Data for generic (CHQ-CF87) and diabetes-specific quality of life (DQOL) were obtained before initiating pump therapy and twice during 15 mo of treatment. HbA1c, BMI and episodes of severe hypoglycaemia and ketoacidosis were recorded over 15 mo prior to and 15 mo during pump therapy.

RESULTS

Analysis showed improvements on the family activity scale (p=0.041) and change in health score (p=0.042) (CHQ-CF87). Mean HbA1c decreased from 10.4% (1.8) to 9.0% (0.9) after 3 mo, increasing to 9.6% (1.2) after 15 mo. The number of overweight and obese children increased from 4 and 2 before CSII, to 6 and 3 after 15 mo (IOTF criteria). There was a reduction in severe hypoglycaemia episodes from 43.8 to 5.2 per 100 patient years, but no change in ketoacidosis episodes.

CONCLUSION

The degree of limitation experienced by families due to adolescents' general health and well-being was significantly reduced. Expected improvement in metabolic control and frequency of severe hypoglycaemia was observed.

Diabetes mellitus as a model of psychosomatic and somatopsychic interrelationships

The article reviews research on the problem of interrelationship between different physical and psychosocial factors in type 1 diabetes mellitus (DM1). The authors consider methodological principles of health-related quality of life (HRQoL) assessment in DM1 patients and stress the need for an integrated biopsychosocial approach to the management of the disease. DM1 is a chronic metabolic disease with an absolute requirement for insulin replacement therapy. The stress-inducing nature of DM1 is associated with its unexpected and dramatic manifestation in juvenile years, life-threatening nature of severe hypo-/hyperglycaemias and long-term complications, with the burden of diabetes self-management, threat of work disability, employment and career problems etc. These features of DM1 increase the likelihood of the development of anxiety and depressive disorders, which, in turn, may negatively influence the course of diabetes and in particular, diabetes self-care. This necessitates early diagnosis of emotional and behavioral disturbances in DM1 using self-report instruments as well as clinical assessment. Evidence suggests that active problem-focused coping behavior and adequate social support promote adherence to diabetes regimes and may act as a buffer against negative effects of the disease on HRQoL in DM1 patients. The core element in the HRQoL structure is personal disease picture (as opposed by objective clinical picture)--the cognitive-affective-behavioral complex reflecting the patient's personal perception of the disease. Examination of the personal disease picture and attitude towards the ailment in DM1 patients may help to improve understanding of the mechanisms of poor adjustment. Problems in disease adjustment can be detected also by diabetes-specific HRQoL assessment. The measures of HRQoL can be applied as screening instruments useful in increasing the effectiveness of patient-provider interactions and diabetes care.

The relationship between parental perceptions of diabetes and glycaemic control

AIM

To measure the relationship between perceived child competence, parental self-efficacy, and children's glycaemic control.

METHODS

Cross-sectional outpatient based questionnaire survey of 78 parents of children aged 6-12 years with insulin dependent diabetes mellitus, diagnosed for at least one year. Parental perceptions of their child's competence were assessed, together with parental perceptions of their own self-efficacy in managing their child's diabetes. Glycaemic control was assessed by the average annual HbA1C level.

RESULTS

The response rate was 64.5% (51 parents); 82% were mothers and the socioeconomic class and ethnicity spread was representative of the general population. The mean age of the children was 10 years and duration of diabetes 4.4 years. Poorer glycaemic control was associated with higher perceived child competence, together with lower perceived age of responsibility, lower perceived seriousness, and less frequent blood tests. Higher parental self-efficacy and higher perceived child competence predicted a higher level of normalisation, as did lower perceived seriousness, a lower perceived parental responsibility for management, and a less protective style of parenting.

CONCLUSION

Parents' perceptions of their children's diabetes are significantly related to glycaemic control; however, those who appear more competent at managing diabetes may overestimate their child's capabilities, leading to poorer glycaemic control.

Personal models for diabetes in context and patients' health status

In a diverse sample of 452 adult diabetes patients, we investigated: (1) personal model dimensions for diabetes and expanded upon the literature by indexing fatalism, (2) the relationship between contextual factors and patients' beliefs about the seriousness and controllability of diabetes, and (3) the unique contribution of illness representation combinations to clinical outcomes when controlling for baseline disease severity. Major categories of predictors included patients' sociocultural characteristics, illness history (e.g., co-morbidities, diabetes complications) and recent physical symptoms. Illness representations were measured using the Personal Models of Diabetes Interview and questions that index fatalistic beliefs. Clinical outcome measures included patients' glycemic control (HbA1c) and the patient's physical and mental functions as measured by the SF-12. Analyses corroborated the literature by identifying seriousness and treatment effectiveness cognitive model dimensions for diabetes. Physical symptoms and other disease-related factors were strong predictors of patients' seriousness beliefs for diabetes, whereas sociocultural factors (education, ethnicity) best explained representations related to the controllability of diabetes (i.e., treatment effectiveness, fatalism). Seriousness beliefs were good indicators of actual glucose control, except for cases in which patients were more fatalistic and believed diabetes to be less serious. Although patients had medically consistent views of their diabetes, variations in personal models of diabetes were related to specific contextual factors and independently explained diabetes control.

Self-efficacy, outcome expectations, and diabetes self-management in adolescents with type 1 diabetes

The goal of this research was to develop and evaluate measures of adolescent diabetes management self-efficacy and outcome expectations that reflect developmentally relevant, situation-specific challenges to current diabetes regimens. Self-efficacy for diabetes management, expected outcomes of adherence, adherence to the diabetes regimen, and glycemic control were assessed in 168 adolescents (ages 10-16 years) with type 1 diabetes. Factor analyses indicated a single scale for self-efficacy and two distinct factors representing positive and negative outcome expectations. Reliability and predictive validity of the new scales were supported. In regression analyses, self-efficacy and the interaction of self-efficacy with expectations of positive outcomes were significantly associated with diabetes self-management adherence and glycemic control in older adolescents. The effect of self-efficacy was greatest when adolescents had stronger beliefs in the beneficial outcomes of adherence. These brief measures can be used to identify youths at risk of poor diabetes self-management. Interventions targeting self-efficacy may lead to improved diabetes self-management.

Personal characteristics and depression-related attitudes of older adults and participation in stages of implementation of a multi-site effectiveness trial (PRISM-E)

BACKGROUND

No study has assessed attitudes about depression and its treatment and participation at each step of recruitment and implementation of an effectiveness trial. Our purpose was to determine the association between personal characteristics and attitudes of older adults about depression with participation at each step of the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) treatment effectiveness trial.

METHODS

Information on personal characteristics and attitudes regarding depression and its treatment were obtained from all potential participants in PRISM-E.

RESULTS

Persons who reported better social support were more likely to complete a baseline interview, but were less likely to meet with the mental health professional carrying out the intervention. Attitudes about taking medicines were significantly associated with uptake of the intervention, but not with earlier phases of recruitment. Persons were much more likely to have a visit with the mental health professional for treatment of depression if they were willing to take medicine for depression but did not endorse waiting for the depression to get better [odds ratio (OR) = 3.16, 95% confidence interval (CI) = 1.48-6.75], working it out on one's own (OR = 5.18, 95% CI = 1.69-15.85), or talking to a minister, priest, or rabbi (OR = 2.01, 95% CI = 1.02-3.96).

CONCLUSION

Social support and other personal characteristics may be the most appropriate for tailoring recruitment strategies, but later steps in the recruitment and implementation may require more attention to specific attitudes towards antidepressant medications.

Applying the Transactional Stress and Coping Model to Sickle Cell Disorder and Insulin-Dependent Diabetes Mellitus: Identifying Psychosocial Variables Related to Adjustment and Intervention

This review paper examines the literature on psychosocial factors associated with adjustment to sickle cell disease and insulin-dependent diabetes mellitus in children through the framework of the transactional stress and coping (TSC) model. The transactional stress and coping model views adaptation to a childhood chronic illness as mediated by several psychosocial factors. This review examines the utility of the model in explaining adjustment in two different childhood diseases, identifies needed research and intervention targets, as well as highlights potential changes to the model. The major conclusions of this review suggest that, in addition to child-specific factors, family functioning is an area that interventions should address in sickle cell disease and insulin-dependent diabetes mellitus.

Disturbed eating attitudes, coping styles, and subjective quality of life in adolescents with Type 1 diabetes

OBJECTIVES

To evaluate coping styles and quality of life in youth with Type 1 diabetes with and without eating disorders and to identify relationships between these variables in each group.

METHODS

Adolescents were evaluated for eating disorders with a two-stage diagnostic procedure. Adolescents with and without eating disorders then provided data on coping styles and on subjective well-being.

RESULTS

Adolescents with Type 1 diabetes and disordered eating behavior reported more often blaming themselves and resorting to wishful thinking and poorer physical and psychosocial quality of life than do adolescents with Type 1 diabetes without disordered eating behavior. Specific coping strategies were also positively linked with quality of life and metabolic control.

CONCLUSIONS

Eating disorders and disordered eating behavior in adolescents with Type 1 diabetes seem to be associated with certain negative and avoidant coping strategies and with impeded physical and bio-psychosocial well-being.

Metabolic improvement after intervention focusing on personal understanding in type 2 diabetes

The aim of this study was to evaluate, whether an educational intervention, focusing on patients' personal understanding of their illness, was more effective than care given according to national guidelines for diabetes care.

METHODS

An intervention group (n = 44), with type 2 diabetes was compared with a control group (n = 60), with HbA1c as the primary outcome. The intervention included ten group sessions addressing themes related to the patients' personal understanding of their illness. The diabetes nurses involved were educated in theories about illness/wellness experiences and participated in group sessions where various caring strategies related to the patients' individual needs and understanding were reflected upon.

RESULTS

At 1-year follow-up the intervention group showed lower HbA1c levels (mean difference 0.94%; P < 0.001), lower triglycerides (mean difference 0.52 mmol/l; P = 0.002) and higher high-density lipoprotein (mean difference 0.15 mmol/l; P = 0.029) and treatment satisfaction than did the control group. The differences remained when adjusting for age, gender, body mass index or changed treatment during the intervention period. Within the intervention group, BMI and treatment satisfaction were also improved.

CONCLUSION

The intervention, which focused on patients' personal understanding of illness, was found to be effective in terms of metabolic control and treatment satisfaction.

Is the relationship between adherence behaviours and glycaemic control bi-directional at adolescence? A longitudinal cohort study

AIM

To analyse the change in adherence to diabetes treatment and its association with metabolic control from childhood to adolescence. The Tanner pubertal staging model was selected as a marker of developmental maturity.

METHODS

In a multicentre, longitudinal cohort study, 142 children with Type 1 diabetes completed a scale that assessed adherence to treatment and a test of diabetes knowledge at the beginning of the study (T0) and four years later (T4). HbA1c and clinical data were collected at T0 and at T4.

RESULTS

From T0 to T4, the mean HbA1c increased from 8.2 +/- 1.6 to 9.1 +/- 1.4% (P < 0.001). Among patients at pubertal stages 1-4, adherence did not decline from T0 to T4, whereas the HbA1c level increased and a positive correlation between adherence and the knowledge score was noted (r = 0.32; P < 0.02). Among adolescents at pubertal stage 5, the level of adherence decreased (P < 0.01) from T0 to T4 and the HbA1c level increased despite an increase in the knowledge score (P < 0.001), a negative correlation between HbA1c and adherence was found (r = -0.37; P = 0.001) and adherence at T4 significantly added to the prediction of HbA1c at T4.

CONCLUSIONS

In this longitudinal study, an initial worsening of glycaemic control as a result of puberty preceded worsening of adherence behaviours. Low levels of adherence become predictive of HbA1c degradation among pubertal stage 5 adolescents. These results suggest a potential bi-directional relationship between glycaemic control and adherence.

Promoting health in type 2 diabetes: nurse-physician collaboration in primary care

The purpose of this study is to examine effects of a nurse-physician collaborative approach to care of patients with type 2 diabetes and to determine possible effect sizes for use in computing sample sizes for a larger study. Forty patients from a family practice clinic with type 2 diabetes were randomly assigned to control or experimental groups. The control group received standard care, whereas the experimental group received standard care plus home visits from a nurse, as well as consultation with an exercise specialist and/or nutritionist. Follow-up continued for 3 months. Clinical end points included standard measures of diabetes activity as well as quality-of-life indicators. Focus group interviews were used to explore patients' responses to the program. Although findings were not statistically significant, a trend toward small to moderate positive effect sizes was found in glycosylated hemoglobin and blood pressure. Quality of life measures also showed a trend toward small to moderate, but nonsignificant, improvements in physical functioning, bodily pain, vitality, social and global functioning, energy, impact of diabetes, and health distress. Focus group interviews indicated a very positive response from patients, who expressed feelings of empowerment. In this study, patients treated with nurse-physician collaboration demonstrated small, but nonsignificant, improvements in blood chemistry after only 3 months. Physical and social functioning, energy, and bodily pain also showed a small improvement. Changes in awareness of effects of diabetes on health and an expressed sense of self-efficacy suggest that effects could be sustainable over the longer term.

Diabetes care credit system: a model for comprehensive and optimal diabetes care

OBJECTIVE

To introduce a "credit system," which empowers patients with diabetes to share in the implementation of guidelines with the health-care provider and provides credits for achievement of health variables considered essential for optimal diabetes care.

METHODS

We describe the credit system and the points offered for achievement of variables that assess lifestyle, glycohemoglobin, blood pressure, lipid values, measurement of urinary albumin, annual physical examination, dilated eye examination, foot examination, and electrocardiogram, use of antiplatelet therapy, and use of angiotensin receptor blocker (ARB) or angiotensin-converting enzyme (ACE) inhibitor therapy. The patient's knowledge of diabetes and nutrition was also assessed. Patients with diabetes mellitus were enrolled in the credit program during their scheduled office visits. Results were compared with those in a control group.

RESULTS

The study enrolled 613 patients (303 male and 310 female patients), with a mean age of 59.91 +/- 13.57 years (range, 16 to 90). The control group consisted of 119 patients with diabetes (63 men and 56 women; mean age, 55.94 +/- 14.83 years) not participating in the credit system. One year after initiation of the program, analysis of the study group demonstrated high rates of implementation of guidelines: complete physical examination, 94%; foot examination, 89%; dilated eye examination, 77%; blood pressure less than 135/85 mm Hg, 78%; hemoglobin A1c less than 6%, 7%, and 8%, 26%, 58%, and 82%, respectively; serum triglycerides less than 200 mg/dL, 61%; low-density lipoprotein cholesterol less than 100 mg/dL, 49%; high-density lipoprotein cholesterol more than 35 mg/dL, 76%; use of antiplatelet therapy, 60%; quantitative urinary albumin screening, 74%; and use of ACE inhibitors or ARB, 44%. These rates of achievement of established variables for hemoglobin A1c, serum lipids, blood pressure, antiplatelet therapy, and measurement of urinary albumin were significantly higher than those in the control subjects.

CONCLUSION

The described credit system demonstrates an effective and practical means to implement and achieve the necessary guidelines and target variables that are intended to lead to optimal diabetes and cardiovascular outcomes.

Self-care behaviors for muscle pain

This investigation examined self-care behaviors for muscle pain because of the prevalence of musculoskeletal pain and the substitution of self-care for formal medical care. In Study 1, university students (N = 187) completed a retrospective questionnaire about self-care for muscle pain. In Study 2, muscle pain was experimentally induced in university students (N = 79) with subsequent measurement of self-care. In both studies, stretching and massaging were the most frequently performed behaviors, and consuming medication was the least frequently performed. In Study 1, the perceived effectiveness of behaviors and level of pain required to perform self-care accounted for 12% to 32% of the variance in behavior frequency. In Study 2, pain ratings and pain during activities were higher among those who performed self-care (ds = .59 to 1.00). These studies indicated that self-care behaviors are performed for both naturally occurring and experimentally induced muscle pain. However, both studies determined that the performance of self-care behaviors did not always correspond with current evidence of treatment effectiveness for muscle injuries. Unique opportunities for future investigations of self-care behavior models and interventions are permitted by muscle pain induction.

PERSPECTIVE

Self-care for pain reduction is an understudied behavior. This report describes 2 studies of self-care behaviors for naturally occurring and experimentally induced muscle pain. The most frequent types of self-care behaviors are similar for the types of pain, and the perceived effectiveness of behaviors and pain level influence performance of the behaviors.

Personal understandings of illness among people with type 2 diabetes

BACKGROUND

Professionals and patients understand the experience of illness from different worlds. Professionals' explanatory models focus on aetiology, diagnosis, pathophysiology and treatment, while patients' explanatory models are more focused on consequences and influences on daily life. The differences between patients and professionals in their understanding often result in conflicting expectations about treatment, priorities and outcomes of care.

AIM

The aim of this study was to describe personal understandings of illness among people with type 2 diabetes in Sweden.

METHOD

A sample of 44 patients, 47-80 years, diagnosed with type 2 diabetes within the last 2 years, was recruited from four health care centres. Narrative thematic interviews were used covering the areas of developing, coping with and living with diabetes. Qualitative content analysis was performed.

FINDINGS

The findings were formulated into six categories: image of the disease, meaning of the diagnosis, integration of the illness, space for the illness, responsibility for care and future prospects.

CONCLUSIONS

The findings demonstrate that patients' personal understanding of illness is an important complement to the traditional professional view of diabetes. They could serve as a foundation for development of health history interviewing, as well as development of systems of documentation. Patients' personal understandings of diabetes in their daily lives are considered to be an important shared source of information for planning meaningful care.

A developmental perspective on the challenges of diabetes education and care during the young adult period

There is increasing recognition that the patient education and care provided to young adults with chronic physical illnesses, including type 1 diabetes, is inattentive to the complex developmental issues facing the older adolescent transitioning into the young adult period [Pediatrics 110 (2002) 1307]. In this paper, we present a clinical perspective on the challenge of improving diabetes education and care during the young adult period focusing on the importance of the developmental changes-cognitive, social, emotional, educational, and familial-that occur during this transitional stage of life. This developmental perspective on young adulthood provides a conceptual framework to better understand the young adult's "readiness" for engagement in intensive medical therapy. We review factors such as the timing and context of diabetes care and education that may be important determinants of young adults' ultimate success in becoming independent managers of their health care during this difficult transition. Developmentally-based practice principles for the young adult period are presented which include: assessing the patient's expectation at transition, building the relationship, working with families, assessing barriers to care, and formulating treatment plans and goals.

The coping styles of adolescents with type 1 diabetes are associated with degree of metabolic control

OBJECTIVE

To systematically study the various coping styles in a population-based sample of adolescents with type 1 diabetes, exploring the association of different coping styles with metabolic control and adolescent self-reported diabetes-related quality of life.

RESEARCH DESIGN AND METHODS

Of a total population of 116 adolescents with type 1 diabetes (age 13-18 years), 103 (89%) participated in the study, completing a questionnaire to obtain information on coping styles and perception of diabetes-specific quality of life. The mean age (+/-SD) was 14.9 +/- 1.6 years, diabetes duration 7.1 +/- 3.8 years, HbA(1c) 9.4 +/- 1.6%, and male-to-female ratio 52:51.

RESULTS

There was a significant correlation between higher HbA(1c) values and higher degree of mental (r = 0.25, P < 0.05) and behavioral (r = 0.33, P < 0.01) disengagement and aggressive coping (r = 0.33, P < 0.01). Stepwise multiple regression analyses indicated that greater use of aggressive coping (P < 0.05) and behavioral disengagement (P < 0.05) were significantly related to increase in HbA(1c). Greater use of active coping (P < 0.05) was significantly related to a decrease in HbA(1c). Partial correlation analysis showed that lower scores on diabetes-specific quality of life were significantly related to greater use of emotion-focused coping (r = -0.22 to -0.49). Stepwise multiple regression analyses showed that greater use of mental disengagement was significantly related to lower degree of perceived diabetes-related impact.

CONCLUSIONS

Poor metabolic control and lower degree of diabetes-related quality of life are associated with greater use of emotion-focused coping in adolescents with type 1 diabetes.

Effects of an empowerment-based psychosocial intervention on quality of life and metabolic control in type 2 diabetic patients

This study was aimed at determining impact of an empowerment-based psychosocial intervention on the patients' quality of life and glycemic control as compared to patients in standard care. Consecutively recruited type 2 diabetic patients, scheduled for their regular medical check-ups, were individually acquainted with empowerment-based principles and invited to participate in an empowering psychosocial course. The response rate was 35% giving a number of 73 patients who were treated in eight separate groups. The treated patients reported their quality of life to be improved after the course regarding its psychological and social aspects. Their glycemic control also improved and remained so after 3- and 6-month follow-up periods, still being in a category of poor control. Empowerment-based psychosocial intervention in type 2 diabetic patients was shown to favourably affect their quality of life and to improve their metabolic control, the latter in a modest degree. Better educated patients believing in internal health control and efficacy of diabetes treatment seemed to benefit the most. Further research is needed in order to highlight individual preferences for different educational approaches, as well as social and cultural factors affecting them.

Development, reliability and validity of the Diabetes Illness Representations Questionnaire: four studies with adolescents

AIMS

This article reports on the development and validity of a Diabetes-specific Illness Representations Questionnaire (DIRQ) to assess all five dimensions of an individual's perception of diabetes, for adolescents with Type 1 diabetes mellitus.

METHODS

There were two development studies. Study 1: participants (n = 115) completed a questionnaire assessing perceptions of the consequences of diabetes and the effectiveness of treatment, along with a questionnaire assessing self-care. Study 2: participants (n = 79) completed a questionnaire assessing their identity, timeline and causal beliefs, along with a diabetes self-efficacy and barriers to adherence questionnaire. Subsequently there were two validation studies. Study 3: participants (n = 44 adolescents and 28 parents) completed the DIRQ and questionnaires assessing their self-care and psychological well-being. Glycaemic control was assessed through retrieval of routine assay results. Study 4: participants (n = 70) completed the DIRQ and questionnaires to assess their psychological well-being, with glycaemic control assessed through retrieval of routine assay results.

RESULTS

The development studies suggest that the perceived consequences of diabetes consist of two subscales, perceived threat and perceived impact, and provide further support for the distinction between treatment effectiveness to control diabetes and treatment effectiveness to prevent complications. Along with the validation studies, the results indicate that the questionnaire scales showed good internal consistency and construct validity through their associations with measures of self-care and psychological well-being.

CONCLUSION

The data reported here suggest that the DIRQ has the potential to be a useful tool for clinical assessment and evaluating the impact of psycho-educational and medical interventions.

Behavioral science research in the prevention of diabetes : status and opportunities

Recent studies show diabetes can be prevented. Growing knowledge of its biological bases opens further prevention opportunities. This article focuses on behavioral science research that may advance these opportunities. An ecological model guides attention to how prevention research may be pursued at the individual, group, or community levels. Three key areas are reviewed: risk communication, screening, and preventive interventions. Research on diabetes risk communication is limited but suggests that many are relatively unaware of risks and may have misconceptions about the disease. Amid policy debates and research regarding the potential benefits and costs of screening, identification of diabetes may itself be risky in terms of psychological and social consequences. The Diabetes Prevention Program and other studies make clear that diabetes can be prevented, both by the combination of weight loss and physical activity and by medications. Research needs to address promoting these methods to individuals as well as to groups and even whole communities. Fundamental as well as applied research should address how risks of diabetes are understood and may be communicated; how to enhance benefits and minimize psychological and other risks of screening; how to promote healthy eating and weight loss, physical activity, and appropriate use of medications to prevent diabetes; and how to reduce socioeconomic and cultural disparities in all these areas.