Assessing sources of support for diabetes self-care in urban and rural underserved communities

Family Support and Type 2 Diabetes Self-management Behaviors in Underserved Latino/a/x Patients

BACKGROUND

Latino/a/x families experience persistent Type 2 diabetes mellitus (T2DM) disparities, including higher rates of diagnosis and mortality due to disease complications than their non-Hispanic White counterparts. Though greater social support is associated with improved disease outcomes for Latino/a/x patients with diabetes, research has yet to identify the specific pathways through which social support, and specifically family support, influences self-management.

PURPOSE

This study tested a theoretical model highlighting the mechanisms and pathways linking social support and physical health. Specifically, self-efficacy and depression were tested as psychological pathways connecting family support to diabetes self-management behaviors and diabetes morbidity in Latino/a/x patients with T2DM.

METHODS

Data from 177 patients were analyzed using structural equation modeling. Measures included diabetes-specific family support needed and received, depressive symptoms, self-efficacy in diabetes management, diabetes self-management behaviors, health appraisal, and hemoglobin A1c.

RESULTS

Greater diabetes-specific family support was significantly associated with more frequent engagement in diabetes self-management behaviors, both directly (p < .001) and through diabetes self-efficacy's partial mediation of this relationship (p = .013). Depression was not significantly associated with either family support (support received, p = .281; support needed, p = .428) or self-management behaviors (p = .349).

CONCLUSIONS

Family support and diabetes self-efficacy may be important modifiable psychosocial factors to target via integrated care interventions aimed at supporting Latino/a/x patients with T2DM. Future research is needed to test empirically based, culturally adapted interventions to reduce T2DM-related health disparities in this population.

The mediating/moderating role of cultural context factors on self-care practices among those living with diabetes in rural Appalachia

Background

The aim of this study was to examine whether cultural factors, such as religiosity and social support, mediate/moderate the relationship between personal/psychosocial factors and T2DM self-care in a rural Appalachian community.

Methods

Regression models were utilized to assess for mediation and moderation. Multilevel linear mixed effects models and GEE-type logistic regression models were fit for continuous (social support, self-care) and binary (religiosity) outcomes, respectively.

Results

The results indicated that cultural context factors (religiosity and social support) can mediate/moderate the relationship between psychosocial factors and T2DM self-care. Specifically, after adjusting for demographic variables, the findings suggested that social support may moderate the effect of depressive symptoms and stress on self-care. Religiosity may moderate the effect of distress on self-care, and empowerment was a predictor of self-care but was not mediated/moderated by the assessed cultural context factors. When considering health status, religiosity was a moderately significant predictor of self-care and may mediate the relationship between perceived health status and T2DM self-care.

Conclusions

This study represents the first known research to examine cultural assets and diabetes self-care practices among a community-based sample of Appalachian adults. We echo calls to increase the evidence on social support and religiosity and other contextual factors among this highly affected population.

Trial registration

US National Library of Science identifier NCT03474731. Registered March 23, 2018, www.clinicaltrials.gov.

New model of integrated care for uncontrolled type 2 diabetes in a retrospective, underserved adult population in the USA: a study protocol for an effectiveness and cost-effectiveness analysis

INTRODUCTION

Type 2 diabetes prevalence is increasing in the USA, especially in underserved populations. Patient outcomes can be improved by providing access to specialty care within Federally Qualified Health Centers, possibly improving the cost-effectiveness of diabetes care.

METHODS AND ANALYSIS

A new model of diabetes care based on multidisciplinary teams of clinical fellows, supported by an endocrinologist for underserved adult populations, is presented. The study uses a retrospective, non-randomised cohort of patients with diabetes who visited the community clinic between 1 January 2012 and 31 December 2018. A quasi-experimental method to analyse the causal evidence of the effect of the new model is presented. Discontinuity regression is used to compare two interventions, the intervention by a Clinical Fellow Endocrinology Programme and usual care by a primary care physician. Patients are referred to the Clinical Fellow Endocrinology Programme in case of uncontrolled diabetes (glycated haemoglobin (HbA1c)≥9%). The regression discontinuity design allows the construction of a treatment group for patients with an HbA1c equal or above the threshold in comparison with a control group for patients with an HbA1c below the threshold. The patient outcomes and cost-effectiveness of the new model are analysed. Regression models will be used to assess the differences between treatment and control groups.

ETHICS AND DISSEMINATION

Quantitative patient data are received by the study team in a de-identified format for analysis via an institutional review board-approved protocol. The quantitative study has been approved by the Houston Methodist Research Institute Institutional Review Board, Houston, Texas, USA. Anticipated results will not only provide evidence about the impact of patient outcomes in underserved diabetic populations, but also give an idea of the cost-effectiveness of the new model and whether or not cost savings can be attained for patients, third-party payers and society. The results will help set up evidence-based policy guidelines in diabetes care. Results will be disseminated through papers, conferences and public health/policy fora.

Relative Contribution of Individual, Community, and Health System Factors on Glycemic Control Among Inner-City African Americans with Type 2 Diabetes

BACKGROUND

Health disparities disproportionately impact inner-city African Americans; however, limited information exists on the contribution of individual, community, and health system barriers on diabetes outcomes in this population.

METHODS

A cross-sectional study collected primary data from 241 inner-city African Americans with type 2 diabetes. A conceptual framework was used to specify measurements across the individual level, such as age and comorbidities; community level, such as neighborhood factors and support; and health system level such as access, trust, and provider communication. Based on current best practices, four regression approaches were used: sequential, stepwise with forward selection, stepwise with backward selection, and all possible subsets. Variables were entered in blocks based on the theoretical framework in the order of individual, community, and health system factors and regressed against HbA1c.

RESULTS

In the final adjusted model across all four approaches, individual-level factors like age (β = - 0.05; p < 0.001); having 1-3 comorbidities (β = - 2.03; p < 0.05), and having 4-9 comorbidities (β = - 2.49; p = 0.001) were associated with poorer glycemic control. Similarly, male sex (β = 0.58; p < 0.05), being married (β = 1.16; p = 0.001), and being overweight/obese (β = 1.25; p < 0.01) were associated with better glycemic control. Community and health system-level factors were not significantly associated with glycemic control.

CONCLUSION

Individual-level factors are key drivers of glycemic control among inner-city African Americans. These factors should be the key targets for interventions to improve glycemic control in this population. However, community and health system factors may have indirect pathways to glycemic control that should be examined in future studies.

Inequalities and factors associated with adherence to diabetes self-care practices amongst patients at two public hospitals in Gauteng, South Africa

BACKGROUND

Self- management is vital to the control of diabetes. This study aims to assess the diabetes self-care behaviours of patients attending two tertiary hospitals in Gauteng, South Africa. The study also seeks to estimate the inequalities in adherence to diabetes self-care practices and associated factors.

METHODS

A unique health-facilities based cross-sectional survey was conducted amongst diabetes patients in 2017. Our study sample included 396 people living with diabetes. Face-to-face interviews were conducted using a structured questionnaire. Diabetes self-management practices considered in this study are dietary diversity, medication adherence, physical activity, self-monitoring of blood-glucose, avoiding smoking and limited alcohol consumption. Concentration indices (CIs) were used to estimate inequalities in adherence to diabetes self-care practices. Multiple logistic regressions were fitted to determine factors associated with diabetes self-care practices.

RESULTS

Approximately 99% of the sample did not consume alcohol or consumed alcohol moderately, 92% adhered to self-monitoring of blood-glucose, 85% did not smoke tobacco, 67% adhered to their medication, 62% had a diverse diet and 9% adhered to physical activity. Self-care practices of dietary diversity (CI = 0.1512) and exercise (CI = 0.1067) were all concentrated amongst patients with higher socio-economic status as indicated by the positive CIs, whilst not smoking (CI = - 0.0994) was concentrated amongst those of lower socio-economic status as indicated by the negative CI. Dietary diversity was associated with being female, being retired and higher wealth index. Medication adherence was found to be associated with older age groups. Physical activity was found to be associated with tertiary education, being a student and those within higher wealth index. Self-monitoring of blood glucose was associated with being married. Not smoking was associated with being female and being retired.

CONCLUSION

Adherence to exercising, dietary diversity and medication was found to be sub-optimal. Dietary diversity and exercise were more prevalent among patients with higher socio-economic status. Our findings suggest that efforts to improve self- management should focus on addressing socio-economic inequalities. It is critical to develop strategies that help those within low-socio-economic groups to adopt healthier diabetes self-care practices.

Individual-, Community-, and Health System-Level Barriers to Optimal Type 2 Diabetes Care for Inner-City African Americans: An Integrative Review and Model Development

PURPOSE

The purpose of this integrative review is (1) to elucidate the unique barriers faced by inner-city African Americans for type 2 diabetes (T2DM) care; (2) to identify effective interventions/programs for optimal T2DM care at the individual, community, and health systems levels; and (3) to integrate 2 behavioral models and 1 social ecological model for framing interventions for inner-city African American to optimize T2DM care.

METHODS

PRISMA guidelines were followed to systematically search PubMed, PsychInfo, and CINAHL. Integration of models was based on underlying principles of social ecological models.

RESULTS

The search returned 1183 articles. Forty-six articles were synthesized after applying inclusion criteria. Multiple barriers for the individual level, community level, and health system level were identified. Major barriers include lack of knowledge, lack of social support, and self-management support. Interventions identified in this review show that among inner-city African Americans with T2DM, the focus is placed at the health systems level, with very limited focus toward addressing individual- and community-level barriers. Final synthesis includes development of a new integrated model that explains barriers to care across multiple levels.

CONCLUSIONS

These findings highlight the fragmentation that may be occurring between policy, research, and practice for achieving health equity and addressing health disparities for T2DM care among inner-city African Americans. The new model is an important step in the pursuit of equity in T2DM by specifying the complex barriers that occur across multiple levels. The application of this model using the 2017 National Standards for Diabetes-Self Management Education and Support are discussed.

Cross-cultural adaptation of the Chronic Illness Resources Survey in Japanese patients with diabetes

AIM

The Chronic Illness Resources Survey (CIRS) is a tool for assessing multiple levels of resources for self-management in people with chronic illnesses. This study aimed to examine the reliability and validity of the Japanese version of the CIRS (CIRS-J) among patients with diabetes.

METHODS

This study included 102 Japanese patients with diabetes. Patients completed the CIRS-J on two occasions with additional measurements, including the multidimensional scale of perceived social support (MSPSS), the summary of diabetes self-care activities (SDSCA), and the perceived health competence scale (PHCS). The construct validity, internal consistency reliability, and test-retest reliability were evaluated.

RESULTS

Factor analysis resulted in six factors. The Cronbach's α coefficient was 0.82, indicating a high internal consistency. The intraclass correlation coefficient was 0.87, indicating that the CIRS-J is stable over time. The CIRS-J showed a positive moderate association with MSPSS, SDSCA, and PHCS, with a correlation coefficient value ranging from .34 to .44.

CONCLUSION

This study showed preliminary support for the reliability and validity of the CIRS-J. The availability of this instrument will help identify the spectrum of resources available for Japanese people with diabetes in both research and practical settings.

Younger people with Type 2 diabetes have poorer self-care practices compared with older people: results from the Australian National Diabetes Audit

AIM

This cross-sectional study compares the self-care practices of younger and older people with Type 2 diabetes.

METHODS

Data were analysed from the Australian National Diabetes Audit (ANDA) including 2552 adults with Type 2 diabetes from Australian Diabetes Centres. Pre-specified demographic and clinical variables were obtained. Self-care variables (physical activity, following dietary recommendations, medication adherence and monitoring blood glucose levels) were compared in people ≤ 64 and > 64 years of age.

RESULTS

Mean age (± sd) of participants was 63 ± 13 years overall, 53 ± 9 years for the younger group and 73 ± 6 years for the older group. A greater proportion of younger people had HbA_1c levels > 53 mmol/mol (> 7.0%) (76% vs. 68%), reported difficulty following dietary recommendations (50% vs. 32%) and forgetting medications (37% vs. 22%) compared with older people (all P-values <0.001). A smaller proportion of younger compared with older people reported monitoring their blood glucose levels as often as recommended (60% vs. 70%, P < 0.001). Similar proportions of people aged ≤ 64 and > 64 years required insulin therapy (59% vs. 57%, P = 0.200). Younger age was associated with a twofold increase in the odds of not following the recommended self-care practices after adjustment for gender, smoking, insulin therapy, depression and allied health attendance (all P < 0.001).

CONCLUSIONS

Despite shorter diabetes duration, younger age was associated with worse glycaemic control and poorer diabetes self-care practices among people with Type 2 diabetes. Targeted strategies are required to optimize diabetes self-care practices and thereby glycaemic control.

Adherence to and factors associated with self-care behaviours in type 2 diabetes patients in Ghana

BACKGROUND

Previous research has failed to examine more than one self-care behaviour in type 2 diabetes patients in Ghana. The purpose of this study is to investigate adult Ghanaian type 2 diabetes patients' adherence to four self-care activities: diet (general and specific), exercise, self-monitoring of blood glucose (SMBG) and foot care.

METHODS

Consenting type 2 diabetes patients attending diabetes outpatient clinic appointments at three hospitals in the Tamale Metropolis of Ghana completed a cross-sectional survey comprising the Summary of Diabetes Self-Care Activities Measure, and questions about demographic characteristics and diabetes history. Height and weight were also measured. Multiple linear regression analyses were conducted to identify the factors associated with adherence to each of the four self-care behaviours.

RESULTS

In the last 7 days, participants exercised for a mean (SD) of 4.78 (2.09) days and followed diet, foot care and SMBG for a mean (SD) of 4.40 (1.52), 2.86 (2.16) and 2.15 (0.65) days, respectively. More education was associated with a higher frequency of reported participation in exercise (r = 0.168, p = 0.022), following a healthy diet (r = 0.223, p = 0.002) and foot care (r = 0.153, p = 0.037) in the last 7 days. Males reported performing SMBG (r = 0.198, p = 0.007) more frequently than their female counterparts.

CONCLUSION

Adherence to diet, SMBG and checking of feet were relatively low. People with low education and women may need additional support to improve adherence to self-care behaviours in this type 2 diabetes population.

Longitudinal Trends in Tobacco Availability, Tobacco Advertising, and Ownership Changes of Food Stores, Albany, New York, 2003-2015

Introduction

Frequency of visiting convenience and corner grocery stores that sell tobacco is positively associated with the odds of ever smoking and the risk of smoking initiation among youth. We assessed 12-year trends of tobacco availability, tobacco advertising, and ownership changes in various food stores in Albany, New York.

Methods

Eligible stores were identified by multiple government lists and community canvassing in 2003 (n = 107), 2009 (n = 117), 2012 (n = 135), and 2015 (n = 137). Tobacco availability (all years) and advertising (2009, 2012, and 2015) were directly measured; electronic cigarettes (e-cigarettes) were included in 2015.

Results

Percentage of stores selling tobacco peaked at 83.8% in 2009 and declined to 74.5% in 2015 (P for trend = .11). E-cigarettes were sold by 63.7% of tobacco retailers. The largest decline in tobacco availability came from convenience stores that went out of business (n = 11), followed by pharmacies that dropped tobacco sales (n = 4). The gain of tobacco availability mostly came from new convenience stores (n = 24) and new dollar stores (n = 8). Significant declining trends (P < .01) were found in tobacco availability and any tobacco advertising in pharmacies and in low (<3 feet) tobacco advertising in convenience stores and stores overall. Only one-third of stores that sold tobacco in 2003 continued to sell tobacco with the same owner in 2015.

Conclusion

The observed subtle declines in tobacco availability and advertising were explained in part by local tobacco control efforts, the pharmacy industry’s self-regulation of tobacco sales, and an increase in the state’s tobacco retailer registration fee. Nonetheless, overall tobacco availability remained high (>16 retailers per 10,000 population) in this community. The high store ownership turnover rate suggests that a moratorium of new tobacco retailer registrations would be an integral part of a multi-prong policy strategy to reduce tobacco availability and advertising.

Social support and lifestyle vs. medical diabetes self-management in the diabetes study of Northern California (DISTANCE)

BACKGROUND

In chronic illness self-care, social support may influence some health behaviors more than others.

PURPOSE

Examine social support's association with seven individual chronic illness self-management behaviors: two healthy "lifestyle" behaviors (physical activity, diet) and five more highly skilled and diabetes-specific (medical) behaviors (checking feet, oral medication adherence, insulin adherence, self-monitored blood glucose, primary care appointment attendance).

METHODS

Using cross-sectional administrative and survey data from 13,366 patients with type 2 diabetes, Poisson regression models estimated the adjusted relative risks (ARR) of practicing each behavior at higher vs lower levels of social support.

RESULTS

Higher emotional support and social network scores were significantly associated with increased ARR of both lifestyle behaviors. Both social support measures were also associated with increased ARR for checking feet. Neither measure was significantly associated with other medical behaviors.

CONCLUSIONS

Findings suggest that social support diminished in importance as self-care progresses from lifestyle to more skilled "medical" behaviors.

An Ecological Perspective on Diabetes Self-care Support, Self-management Behaviors, and Hemoglobin A1C Among Latinos

Purpose

The purpose of this study was to examine the role of self, interpersonal (ie, family/friend), and organizational (ie, health care) support in performing diabetes-related self-management behaviors and hemoglobin A1C (A1C) levels among rural Latinos with type 2 diabetes.

Methods

Cross-sectional data from baseline interviews and medical records were used from a randomized controlled trial conducted in rural Southern California involving a clinic sample of Latinos with type 2 diabetes (N = 317). Self-management behaviors included fruit and vegetable intake, fat intake, physical activity, glucose monitoring, daily examination of feet, and medication adherence. Multivariate linear and logistic regression models were used to assess the relationships of sources of support with self-management behaviors and A1C.

Results

Higher levels of self-support were significantly associated with eating fruits and vegetables most days/week, eating high-fat foods few days/week, engaging in physical activity most days/week, daily feet examinations, and self-reported medication adherence. Self-support was also related to A1C. Family/friend support was significantly associated with eating fruits and vegetables and engaging in physical activity most days/week. Health care support was significantly associated with consuming fats most days/week.

Conclusions

Health care practitioners and future interventions should focus on improving individuals’ diabetes management behaviors, with the ultimate goal of promoting glycemic control. Eliciting family/friend support should be encouraged to promote fruit and vegetable consumption and physical activity.

Care plans and care planning in the management of long-term conditions in the UK: a controlled prospective cohort study

BACKGROUND

In the UK, the use of care planning and written care plans has been proposed to improve the management of long-term conditions, yet there is limited evidence concerning their uptake and benefits.

AIM

To explore the implementation of care plans and care planning in the UK and associations with the process and outcome of care.

DESIGN AND SETTING

A controlled prospective cohort study among two groups of patients with long-term conditions who were similar in demographic and clinical characteristics, but who were registered with general practices varying in their implementation of care plans and care planning.

METHOD

Implementation of care plans and care planning in general practice was assessed using the 2009-2010 GP Patient Survey, and relationships with patient outcomes (self-management and vitality) were examined using multilevel, mixed effects linear regression modelling.

RESULTS

The study recruited 38 practices and 2439 patients. Practices in the two groups (high and low users of written documents) were similar in structural and population characteristics. Patients in the two groups of practices were similar in demographics and baseline health. Patients did demonstrate significant differences in reported experiences of care planning, although the differences were modest. Very few patients in the cohort reported a written plan that could be confirmed. Analysis of outcomes suggested that most patients show limited change over time in vitality and self-management. Variation in the use of care plans at the practice level was very limited and not related to patient outcomes over time.

CONCLUSION

The use of written care plans in patients with long-term conditions is uncommon and unlikely to explain a substantive amount of variation in the process and outcome of care. More proactive efforts at implementation may be required to provide a rigorous test of the potential of care plans and care planning.

Multimorbidity and delivery of care for long-term conditions in the English National Health Service: baseline data from a cohort study

OBJECTIVES

Many patients with long-term conditions have multiple conditions. Current delivery of care is not designed around their needs and they may face barriers to effective self-management. This study assessed the relationships between multimorbidity, the delivery of care, and self-management.

METHODS

We surveyed 2439 patients with long-term conditions concerning their experience of the delivery of care and self-management in England in 2011. We assessed multimorbidity in terms of a count of long-term conditions and the presence of 'probable depression'. We explored the relationships between multimorbidity, patient experience of the delivery of care, and self-management

RESULTS

Neither measure of multimorbidity was a significant predictor of patients' experience of the delivery of care. Patients with multimorbidity reported higher levels of self-management behaviour, while the presence of depression was associated with less positive attitudes towards self-management.

CONCLUSIONS

The current data do not demonstrate a consistent impact of multimorbidity on patients' experience of care or on self-management. Further research is required to assess those types of multimorbidity that are associated with significant deficits, or to identify other aspects of care that might be problematic in the context of multiple conditions.

Understanding how self-management interventions work for disadvantaged populations living with chronic conditions: protocol for a realist synthesis

INTRODUCTION

Self-management programmes are complex interventions aimed at improving the way individuals self-manage chronic conditions, but there are questions about the overall impact of these programmes on disadvantaged populations, in terms of their capacity to engage with and receive the benefits from these initiatives. Given the increased resources being directed towards self-management initiatives, clinicians and policy makers need knowledge on how self-management interventions work for these populations. Most systematic reviews of self-management interventions do not consider the complex interactions between implementation contexts, intervention strategies, and mechanisms that influence how self-management interventions work in real life for disadvantaged groups.

METHODS

To address the need for better understanding of these mechanisms and to create context-relevant knowledge, we are conducting a realist synthesis of evidence on self-management interventions for disadvantaged populations living with chronic conditions. The primary research question is: What are the key mechanisms operating in chronic condition self-management interventions among disadvantaged populations? In this protocol, we outline the steps we will take to identify the programme theory for self-management interventions and candidate middle-range theories; to search for evidence in academic and grey literature; to appraise and extract the collected evidence; to synthesise and interpret the findings to generate key context-mechanism-outcome configurations and to disseminate results to relevant stakeholder and to peer-review publications.

DISSEMINATION

Understandings of how chronic conditions self-management interventions work among disadvantaged populations is essential knowledge for clinicians and other decision makers who need to know which programmes they should implement for which groups. Results will also benefit medical researchers who want to direct effort towards current gaps in knowledge in order to advance the self-management field. In addition, the study will make a contribution to the evolving body of knowledge on the realist synthesis method and, in particular, to its application to behaviour change interventions for disadvantaged populations.

Towards a conceptual model of diabetes self-management among Chinese immigrants in the United States

Background: Chinese immigrants have been disproportionally affected by type 2 diabetes. This paper presents the state of science regarding the factors that may influence diabetes self-management among Chinese immigrants in the US and the potential health outcomes. Design: Using Walker and Avant’s techniques, a search of the literature was conducted from CINAHL, PubMed, OVID, and Web of Science. Findings: Factors most relevant to diabetes self-management were grouped under five categories: socio-demographic characteristics, behavioral and psychological characteristics, social support, linguistic barriers, and cultural characteristics. Potential outcomes derived from improved diabetes self-management include quality of life, glycosylated hemoglobin, and blood pressure and other cardiovascular risk factors. Discussion: A conceptual model was provided to guide future research. Based on the review of the literature, specific research topics that need to fill the gaps in the literature were provided, including family-focused interventions for Chinese immigrant patients with diabetes and the effectiveness of these interventions to improve family functioning.

Relationship between objectively measured walkability and exercise walking among adults with diabetes

Little is known about the relationship between objectively measured walkability and walking for exercise among adults with diabetes. Information regarding walking behavior of adults with diabetes residing in 3 Upstate New York counties was collected through an interview survey. Walkability measures were collected through an environmental audit of a sample of street segments. Overall walkability and 4 subgroup measures of walkability were aggregated at the ZIP level. Multivariate logistic regression was used for analysis. Study participants (n = 208) were 61.0% female, 56.7% non-Hispanic White, and 35.1% African-American, with a mean age of 62.0 years. 108 participants (51.9%) walked for exercise on community streets, and 62 (29.8%) met the expert-recommended level of walking for ≥150 minutes/week. After adjustment for age, gender, race/ethnicity, education, BMI, physical impairment, and social support for exercise, walking any minutes/week was associated with traffic safety (OR 1.34, 95% CI 1.15–1.65). Walking ≥150 minutes/week was associated with overall walkability of the community (2.65, 1.22, and 5.74), as well as sidewalks (1.73, 1.12–2.67), street amenity (2.04, 1.12–3.71), and traffic safety (1.92, 1.02–3.72). This study suggests that walkability of the community should be an integral part of the socioecologic approach to increase physical activity among adults with diabetes.

Self-management activities in diabetes care: a systematic review

OBJECTIVE

To identify the range of self-management activities people diagnosed with diabetes engage in to manage their disease, the frequency of use, and whether self-management practices change over time.

METHODS

A systematic review of the literature was undertaken. Thirty-two studies identified through electronic databases met the inclusion criteria and were included in the review.

RESULTS

The study found that people living with diabetes undertake regular self-management activities and that compliance with medication regimes is high. Adherence, however, varied with respect to blood glucose testing, diet, physical activity and foot care. Levels of physical activity were not found to change over time. Evidence suggests that some people with diabetes modify their self-management practices in response to factors such as holidays.

CONCLUSIONS

The review suggests that the majority of people with diabetes self-manage, although there is variation in adherence to key self-management activities. How self-management practices change over time and whether this impacts on health outcomes is an area for future research.

Diabetes self-management in a low-income population: impacts of social support and relationships with the health care system

OBJECTIVES

This article reports on results of a qualitative study of social supports and institutional resources utilized by individuals living with diabetes in a high-poverty urban setting. The goal was to examine how access to social capital among low-income populations facilitates and impedes their self-efficacy in diabetes self-management.

METHODS

Semi-structured interviews were conducted with 34 patients with diabetes from a safety net primary care practice in Buffalo, New York.

RESULTS

Facilitators and barriers to successful self-management were identified in three broad areas: (1) the influence of social support networks; (2) the nature of the doctor-patient relationship; and (3) the nature of patient-health care system relationship. Patients' unmet needs were also highlighted across these three areas.

DISCUSSION

Participants identified barriers to effective diabetes self-management directly related to their low-income status, such as inadequate insurance, and mistrust of the medical system. It may be necessary for patients to activate social capital from multiple social spheres to achieve the most effective diabetes management.

Outcomes for type 2 diabetes mellitus patients with diverse regimens

AIMS AND OBJECTIVES

To compare the levels of self-care behaviour, social support and quality of life among type 2 diabetes mellitus patients who underwent three regimens: taking medicine, taking-medicine-while dieting and taking-medicine-while-dieting-with exercise.

BACKGROUND

Diabetes treatment is a critical concern worldwide. However, studies on self-care behaviour, social support and quality of life based on diabetes patients' diverse regimens are few.

DESIGN

This study was a cross-sectional design.

METHODS

We enrolled 127 outpatients aged over 40 years who visited a metabolism clinic at a medical centre in Southern Taiwan. The Self-care Behaviour Scale, Social Support Scale and Quality of Life Scale were used to collect data.

RESULTS

The results indicated that patients with a combined regimen of taking-medicine-while-dieting-with-regular exercise had the highest score at the levels of social support, self-care behaviour and quality of life.

CONCLUSION

The study results could offer evidence-based knowledge for healthcare professionals to guide and promote social support, self-care behaviour and quality of life for people diagnosed with type 2 diabetes.

RELEVANCE TO CLINICAL PRACTICE

These findings will help healthcare professionals to establish appropriate nursing strategies for type 2 diabetes patients who need to exercise regularly as part of their daily care to enhance their self-care behaviour, social support and quality of life.

The impact of social support on outcomes in adult patients with type 2 diabetes: a systematic review

Diabetes is one of the fastest growing chronic diseases globally and in the United States. Although preventable, type 2 diabetes accounts for 90 % of all cases of diabetes worldwide and continues to be a source of increased disability, lost productivity, mortality, and amplified health-care costs. Proper disease management is crucial for achieving better diabetes-related outcomes. Evidence suggests that higher levels of social support are associated with improved clinical outcomes, reduced psychosocial symptomatology, and the adaptation of beneficial lifestyle activities; however, the role of social support in diabetes management is not well understood. The purpose of this systematic review is to examine the impact of social support on outcomes in adults with type 2 diabetes.

Relationships among self-efficacy, social support, social problem solving, and self-management in a rural sample living with type 2 diabetes mellitus

Self-management behaviors are important for control of type 2 diabetes mellitus. Therefore, determining factors that promote effective self-management behaviors may be significant for improving the well-being of patients with type 2 diabetes mellitus. This study examined relationships among self-efficacy, social support, social problem solving, and diabetes self-management behaviors. Further, this study evaluated whether social support and social problem solving were mediators of the relationship between self-efficacy and diabetes self-management behaviors in those living with type 2 diabetes mellitus. Using a cross-sectional, descriptive correlational design, data from a convenience sample of 152 rural people living with type 2 diabetes mellitus were examined. Findings indicated that self-efficacy was a strong predictor of diabetes self-management. The effect of social support on diabetes self-management differed among men and women in the sample. Social support and social problem solving were significantly associated with diabetes self-management in men. Neither social support nor social problem solving were mediators of the relationship between self-efficacy and diabetes self-management in this sample. These findings suggest that nurses need to consider implementing interventions to improve patients' self-efficacy and potentially influence diabetes self-management.

Diabetes and psychological profile of younger rural African American women with type 2 diabetes

PURPOSE

To describe diabetes self-care behaviors, diabetes-related distress, depressive symptoms, and diabetes-related needs among rural African American women with type 2 diabetes ages 21-50.

METHODS

A cross-sectional survey, including questionnaires and a single, open-ended question, was used to assess constructs of interest.

FINDINGS

Taking medication was the most frequently reported (5.5 days/week) self-care activity and exercise the least (3.0 days/week). Nearly half (44%) reported worrying about diabetes complications. Approximately one-third (31%) felt guilty about inconsistent self-care or fearful about living with diabetes. Seventy percent had a depression score suggestive of significant depressive symptomatology. Most diabetes-related concerns were about diet (34%) (i.e., what to eat), exercise (30%), taking medications (10%), and finances (8%).

CONCLUSIONS

Future research should explore specific diabetes self-care barriers/enablers and interventions should provide women with diabetes education, barrier management, and psychological support. Innovative delivery strategies are needed to provide this support in resource-limited rural communities.

Association between spirituality and depression in adults with type 2 diabetes

PURPOSE

The purpose of the study was to examine the association between spirituality and depression among patients with type 2 diabetes.

METHODS

This study included 201 adult participants with diabetes from an indigent clinic of an academic medical center. Participants completed validated surveys on spirituality and depression. The Daily Spiritual Experience (DSE) Scale measured a person's perception of the transcendent (God, the divine) in daily life. The Center for Epidemiologic Studies-Depression scale assessed depression. Linear regression analyses examined the association of spirituality as the predictor with depression as the outcome, adjusted for confounding variables.

RESULTS

Greater spirituality was reported among females, non-Hispanic blacks, those with lower educational levels, and those with lower income. The unadjusted regression model showed greater spirituality was associated with less depression. This association was mildly diminished but still significant in the final adjusted model. Depression scores also increased (greater depression risk) with females and those who were unemployed but decreased with older age and non-Hispanic black race/ethnicity.

CONCLUSIONS

Treatment of depression symptoms may be facilitated by incorporating the spiritual values and beliefs of patients with diabetes. Therefore, faith-based diabetes education is likely to improve self-care behaviors and glycemic control.

Predictors of poor glycaemic control during the initial five years post-diagnosis in rural adults with type 2 diabetes

OBJECTIVE

To identify factors predicting suboptimal glycaemic control in rural adults during the initial five years post-type 2 diabetes diagnosis.

DESIGN

Retrospective medical record audit. Quantitative study.

SETTING

Rural community-based primary health service, South Gippsland, Victoria, Australia.

PARTICIPANTS

Two hundred and seventy-two de-identified medical records randomly selected from the type 2 diabetes outpatient database.

MAIN OUTCOME MEASURES

Demographic, biochemical, anthropometric, pharmacological, co-morbidity and lifestyle data during the first five years post-diabetes diagnosis were retrospectively collected. Univariate analysis was performed to identify variables associated with poor diabetes control (HbA1c ≥ 7%).

RESULTS

Independent predictors of poor glycaemic control in this rural cohort were elevated fasting glucose at diagnosis (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.31-2.97, P < 0.001), weight gain during the initial 2.5 years of diabetes (OR 1.33, 95% CI 1.11-1.59, P < 0.01), excessive body weight at diagnosis (OR 1.07, 95% CI 1.03-1.12, P < 0.001) and younger age at diagnosis (OR 0.94, 95% CI 0.88-1.00, P < 0.05). These variables combined explained 48% of the variation in HbA1c. Gender, body mass index, waist circumference and lifestyle factors at diagnosis were not significant predictors of diabetes control.

CONCLUSIONS

Young-middle-aged adults (≤58 years) with elevated fasting glucose (≥9.0 mmol L(-1) ) and excessive body weight (≥93.1 kg) at type 2 diabetes diagnosis and those unable to lose weight early in the course of the disease are more likely to experience a rapid deterioration in glucose control. Rural clinicians should target these individuals for aggressive diabetes management from the time of diagnosis.

Keys to successful diabetes self-management for uninsured patients: social support, observational learning, and turning points: a safety net providers' strategic alliance study

OBJECTIVE

To examine how medically uninsured patients who receive health care at federally qualified health centers and free clinics are able to successfully self-manage diabetes compared to patients who are less successful.

METHODS

Two distinct groups of patients with diabetes for 6 months or longer were enrolled: (1) successful, defined as those with glycated hemoglobin (HbA1c) of 7% or less or a recent improvement of at least 2% (n=17); and (2) unsuccessful, defined as patients with HbAlc of at least 9% (n=9) and without recent improvement. Patients were interviewed about enabling factors, motivators, resources, and barriers to diabetes self-management. Data from interviews, chart reviews, and clinician surveys were analyzed using qualitative methods and statistical techniques.

RESULTS

African Americans comprised 57.7% of the sample and whites 38.5% (N=26). No significant differences were detected between successful and unsuccessful groups in age, race, education, or employment status. Clinicians rated unsuccessful patients as having more severe diabetes and significantly lower levels of control than successful patients. Compared to unsuccessful patients, successful patients more often reported having friends or family with diabetes, more frequently sought information about the disease, used evidence-based self-management strategies, held more accurate perceptions of their own diabetes control, and experienced "turning point" events that motivated increased efforts in disease management.

CONCLUSIONS

Patients who successfully managed diabetes learned from diabetic family members and interpreted disease-related events as motivational turning points. It may be beneficial to incorporate social learning and motivational enhancement into diabetes interventions to increase patients' motivation for improved levels of self-management.

Design of a rural diabetes self-directed care program

This article describes a rural self-directed care program for adults with diabetes. The intervention consisted of coordinating with primary care clinics, six 2-hour facilitated educational peer groups, communication with physicians, referral tracking and follow-up, telephone support, and cooking demonstrations. The educators minimized lectures and they allowed content to emerge from participant questions and concerns. The program provided culturally tailored written educational materials. The author identifies theory and process issues for designing a diabetes self-directed care program in rural settings.

Racial differences in diabetes-related psychosocial factors and glycemic control in patients with type 2 diabetes

BACKGROUND

We examined whether diabetes-related psychosocial factors differ between African American and white patients with type 2 diabetes. We also tested whether racial differences in glycemic control are independent of such factors.

METHODS

Baseline glycosylated hemoglobin (HbA(1c)) and survey measures from 79 African American and 203 white adult participants in a diabetes self-management clinical trial were analyzed.

RESULTS

Several psychosocial characteristics varied by race. Perceived interference of diabetes with daily life, perceived diabetes severity, and diabetes-related emotional distress were higher for African Americans than for whites, as were access to illness-management resources and social support. Mean HbA(1c) levels were higher among African Americans than whites (8.14 vs 7.40, beta = 0.17). This difference persisted after adjusting for demographic, clinical, and diabetes-related psychosocial characteristics that differed by race (beta = 0.18). Less access to illness-management resources (beta = -0.25) and greater perceived severity of diabetes (beta = 0.21) also predicted higher HbA(1c).

DISCUSSION

Although racial differences in diabetes-related psychosocial factors were observed, African Americans continued to have poorer glycemic control than whites even after such differences were taken into account. Interventions that target psychosocial factors related to diabetes management, particularly illness-management resources, may be a promising way to improve glycemic control for all patients.

Enhancing community capacity to support physical activity: the development of a community-based indoor-outdoor walking program

The University at Albany Prevention Research Center, guided by a needs assessment in two underserved communities (one urban, one rural), initiated a pilot project that opened a public school for community walking in a rural setting. This study examined a 9-week program for potential barriers, benefits, influential factors, and the physical activity levels of program participants. Evaluation was based on daily logs, pedometer diaries, participant surveys, and focus groups. Results indicated that rural schools provide a useful resource for residents and increase participants' physical activity levels. A more comprehensive rural community walking program has been implemented as a result of these findings.

Depressive symptomatology mediates the effect of socioeconomic disadvantage on HbA(1c) among rural African Americans with type 2 diabetes

OBJECTIVE

Rural African Americans with diabetes mellitus type 2 (T2D) represent a disadvantaged and understudied group who experience difficulties with maintaining glycemic control. Although mounting evidence has linked socioeconomic disadvantage to chronic disease morbidity, few studies have examined the mediating mechanisms that account for this effect. We hypothesized that rural African Americans' financial distress, community disadvantage, and educational attainment would predict glycemic control, indirectly, via effects on depressive symptoms.

METHODS

Predictions were tested using data from 192 rural African American adults with T2D and data from community support persons the participants nominated. Participants completed an in-home interview and provided a blood sample at a local laboratory. Levels of glycosylated hemoglobin (HbA(1c)) constituted the criterion variable.

RESULTS

Structural equation modeling analyses confirmed our hypotheses: financial distress, community disadvantage, and educational attainment demonstrated significant indirect effects on HbA(1c) via their influence on depressive symptoms.

CONCLUSIONS

The findings underscore the importance of targeting mental health in interventions to support glycemic control as well as tailoring interventions for individuals in difficult socioeconomic circumstances.

When is social support important? The association of family support and professional support with specific diabetes self-management behaviors

BACKGROUND

Social support is associated with better diabetes self-management behavior (SMB), yet interventions to increase family and friend support (FF support) have had inconsistent effects on SMB.

OBJECTIVE

To test whether FF support differentially affects specific SMBs and compare the influence of support from health professionals and psychological factors on specific SMBs to that of FF support.

DESIGN

Cross-sectional survey of people with diabetes recruited for a self-management intervention

PARTICIPANTS AND SETTING

One hundred sixty-four African-American and Latino adults with diabetes living in inner-city Detroit

MEASUREMENTS AND MAIN RESULTS

For every unit increase in FF support for glucose monitoring, the adjusted odds ratio (AOR) of completing testing as recommended was 1.77 (95% CI 1.21-2.58). FF support was not associated with four other SMBs (taking medicines, following a meal plan, physical activity, checking feet). Support from non-physician health professionals was associated with checking feet [AOR 1.72 (1.07-2.78)] and meal plan adherence [AOR = 1.61 (1.11-2.34)]. Diabetes self-efficacy was associated with testing sugar, meal plan adherence, and checking feet. Additional analyses suggested that self-efficacy was mediating the effect of FF support on diet and checking feet, but not the FF support effect on glucose monitoring.

CONCLUSIONS

The association between FF support and SMB performance was stronger for glucose monitoring than for other SMBs. Professional support and diabetes self-efficacy were each independently associated with performance of different SMBs. SMB interventions may need to differentially emphasize FF support, self-efficacy, or professional support depending on the SMB targeted for improvement.

The role of insulin analogs in type 2 diabetes in the rural community

OBJECTIVE

Type 2 diabetes is a progressive disease requiring constant monitoring of patients to ensure maintenance of glycemic goals and advancement of therapy when necessary. The challenges of treatment in rural areas may be different from those in urban areas. This review article will evaluate the barriers to treatment of type 2 diabetes and the role of insulin analogs in overcoming such barriers and in treating the disease, particularly with respect to rural communities.

RESEARCH DESIGN AND METHODS

A literature review of English language articles in the Medline Database was conducted to identify published articles through April 2008. Search terms included rural, diabetes, insulin, treatment, and treatment challenges/barriers and were used either alone or in various combinations with one another. Articles were included if they pertained to rural communities in the United States. Barriers related to treatment of type 2 diabetes and the role of insulin analogs in treatment and in overcoming such barriers, were examined.

RESULTS

Health-care providers and patients in rural areas face barriers both common to the general population and unique to the rural setting. Challenges include limited access to health care, lack of health-care resources, and lack of multidisciplinary staff.

CONCLUSIONS

A number of strategies exist, including simple, stepwise treatment algorithms for insulin therapy, to manage type 2 diabetes in rural populations effectively. Because this article focused on rural communities in the United States, barriers in other rural communities may not have been identified. Additionally, although Medline is one of the largest and most comprehensive databases of published medical literature, publications not in the Medline database have not been included in this analysis.

Diabetes and perioperative outcomes following cervical fusion in patients with myelopathy

STUDY DESIGN

Database study using the Nationwide Inpatient Sample administrative data from 1988 through 2004.

OBJECTIVE

To examine perioperative morbidity and mortality for patients diagnosed with myelopathy, with and without diabetes mellitus (DM) (and subclassifications) following cervical spinal fusion.

SUMMARY OF BACKGROUND DATA

DM has been associated with worse outcomes in a variety of orthopedic procedures including spinal surgery. Evidence that patients with DM have more complications following cervical fusion, specifically those treated for myelopathy, has been suggested within the literature but has been poorly explored.

METHODS

Data from 37,732 patients within Nationwide Inpatient Sample database (1988-2004) with diagnostic codes specifying the presence of myelopathy and who underwent cervical fusion were included in the analysis. Patients were compared on the basis of the presence of DM, type of DM, and whether DM was controlled or uncontrolled. Bivariate statistical analyses compared postoperative complication rates while multivariate statistics were used to determine likelihood of complications with DM.

RESULTS

Multivariate regression modeling outlined higher likelihoods of complications and hospital discharge variables with DM, particularly if it was diagnosed as uncontrolled disease. Fewer significant discrepancies in complications were noted in comparison of Type I versus Type II DM.

CONCLUSION

This nationally representative study of inpatients in the United States provides evidence that patients with DM who received cervical fusion secondary to myelopathy are associated with greater perioperative complications, nonroutine discharge, and increased total charges. Subanalyses suggest that uncontrolled DM is a significant associative factor in outcome.