Psychosocial correlates of glycemic control: the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study

Gender invariance in the relationship between social support and glycemic control

BACKGROUND

Social support (SS) is important in diabetes self-management; however, little is known about how different types of SS influence diabetes outcomes in men and women with type 2 diabetes mellitus (T2DM). Therefore, the aims of this study were to investigate the relationships between types of SS and glycemic control and self-care behaviors and assess whether the relationships differ by gender.

METHODS

Cross-sectional study of 615 adults from two primary care clinics in the southeastern U.S. Outcomes were hemoglobin A1c (HbA1c) extracted from the medical records, and self-management behaviors (general diet, specific diet, exercise, blood glucose testing, foot care) measured using the Summary of Diabetes Self-Care Activities (SDSCA). Independent variable was SS (emotional/informational, tangible, affectionate, positive social interaction) measured using the Medical Outcomes Study (MOS) SS Scale. Structural equation modeling (SEM) was used to understand pathways between SS and glycemic control based on a theoretical model.

RESULTS

Tangible support was significantly associated with self-care (r = 0.16; p = 0.046) and affectionate support was marginally associated with glycemic control (r = 0.15; p = 0.08) for both men and women. Using SEM to test gender invariance, there was no statistically significant difference in the meaning of SS between men and women. However, unique invariances in responses occurred, including a stronger relationship between tangible support and self-care for women (r = 0.24; p = 0.061).

CONCLUSIONS

Of the four components of SS, tangible and affectionate support had the strongest influence on glycemic control. While affectionate support will improve glycemic control in both men and women, tangible support will improve self-care management, particularly in women.

Inequalities in Glycemic Control in Youth with Type 1 Diabetes Over Time: Intersectionality Between Socioeconomic Position and Race and Ethnicity

BACKGROUND

Racial/ethnic health inequities have been well-documented among youth and young adults with type 1 diabetes (T1D), yet little is known about how socioeconomic position (SEP) intersects with the risk marker of race/ethnicity to predict inequities in longitudinal glycemic control.

PURPOSE

To identify patterns of SEP, race/ethnicity, and clinical characteristics that differentiate hemoglobin A1c (HbA1c) trajectories among youth and young adults after T1D diagnosis.

METHODS

The SEARCH for Diabetes in Youth cohort includes youth with diabetes diagnosed from 2002 to 2006 and 2008 who were followed through 2015. We analyzed data from 1,313 youth and young adults with T1D with ≥3 HbA1c measures. Classification tree analysis identified patterns of baseline demographic, SEP, and clinical characteristic that best predicted HbA1c trajectories over an average of 8.3 years using group-based trajectory modeling.

RESULTS

Two HbA1c trajectories were identified: Trajectory 1 (77%) with lower baseline HbA1c and mild increases (from mean 7.4% to 8.4%) and Trajectory 2 (23%) with higher baseline HbA1c and major increases (from 8.5% to 11.2%). Race/ethnicity intersected with different SEP characteristics among non-Hispanic white (NHW) than in non-whites. Public health insurance predicted high-risk Trajectory 2 membership in non-whites, whereas parental education, household structure, diagnosis age and glucose checking frequency predicted membership for NHW youth and young adults. Two characteristics, race/ethnicity and parental education alone identified 80% of the Trajectory 2 members.

CONCLUSIONS

Race/ethnicity intersects with multiple SEP and clinical characteristics among youth and young adults with T1D, which is associated with particularly high risk of poor long-term glycemic control.

Socioeconomic inequalities in mortality, morbidity and diabetes management for adults with type 1 diabetes: A systematic review

Aims

To systematically review the evidence of socioeconomic inequalities for adults with type 1 diabetes in relation to mortality, morbidity and diabetes management.

Methods

We carried out a systematic search across six relevant databases and included all studies reporting associations between socioeconomic indicators and mortality, morbidity, or diabetes management for adults with type 1 diabetes. Data extraction and quality assessment was undertaken for all included studies. A narrative synthesis was conducted.

Results

A total of 33 studies were identified. Twelve cohort, 19 cross sectional and 2 case control studies met the inclusion criteria. Regardless of healthcare system, low socioeconomic status was associated with poorer outcomes. Following adjustments for other risk factors, socioeconomic status was a statistically significant independent predictor of mortality in 9/10 studies and morbidity in 8/10 studies for adults with type 1 diabetes. There appeared to be an association between low socioeconomic status and some aspects of diabetes management. Although only 3 of 16 studies made adjustments for confounders and other risk factors, poor diabetes management was associated with lower socioeconomic status in 3/3 of these studies.

Conclusions

Low socioeconomic status is associated with higher levels of mortality and morbidity for adults with type 1 diabetes even amongst those with access to a universal healthcare system. The association between low socioeconomic status and diabetes management requires further research given the paucity of evidence and the potential for diabetes management to mitigate the adverse effects of low socioeconomic status.

Household composition and psychological health: Results of the Second Diabetes Attitudes, Wishes and Needs (DAWN2) study

AIMS

1) To explore the effect of household composition on the psychological health of adults with diabetes by comparing those living with other adult(s) including a partner with those living with neither partner nor other adult(s); 2) to examine potential mediation of social support in the association between household composition and psychological health.

METHODS

The study is part of the DAWN2 study conducted in 17 countries. The population comprised 8596 people with diabetes (PWD). Multiple regression models (linear and binary) were applied.

RESULTS

People living with 'other adult(s) but no partner' experienced significantly lower well-being, higher diabetes distress and worried more frequently about hypoglycaemic events than those with a partner or those not co-habiting with another adult. However, participants living with 'other adult(s) but no partner' were more empowered compared to the other household composition groups. The association between household composition and psychological health was not mediated by diabetes-specific social support.

CONCLUSIONS

The study indicates the psychological vulnerability of respondents living without a partner but with other adult(s). Appropriate support interventions must be developed and tested in order to enhance psychological health in people with diabetes living with other adults such as adult children, but with no partner.

Factors associated with high stress levels in adults with diabetes mellitus attending a tertiary diabetes care center, Chennai, Tamil Nadu, India

OBJECTIVE

We aimed to determine perceived stress levels among adults aged >20 years with type 2 diabetes mellitus (DM) in a tertiary care diabetes center, Chennai, Tamil Nadu, India, assess their association with sociodemographic and clinical characteristics and assess the possible risk factors for stress and coping strategies.

METHODS

A mixed-methods (triangulation design) study with quantitative methodology (survey) and qualitative methodology (interviews) was carried out. Stress levels were assessed among type 2 DM patients attending a diabetes clinic using a 5-point perceived stress scale-10. One-on-one interviews were carried out with 376 participants with DM having high/very high stress levels to understand the reasons for perceived stress and explore their coping mechanisms.

RESULTS

The prevalence of high/very high stress was 35% among DM patients. Age 30-40 years, working in professional jobs, and lack of physical activity were factors significantly associated with stress. The perceived major stress inducers were related to family, work, financial issues, and the disease itself.

CONCLUSIONS

This study showed high levels of stress in more than one-third of DM patients. Potential solutions include regular, formal assessment of stress levels in the clinic, providing integrated counseling and psychological care for DM patients, and promoting physical activity.

The effect of peer support in adults with insulin pump-treated type 1 diabetes: a pilot study of a flexible and participatory intervention

AIM

The aim of this study was to explore the effects of a flexible and participatory peer support intervention in a clinical setting for adults with type 1 diabetes treated with an insulin pump, focusing on enhancing diabetes-specific social capital. The key questions were as follows: 1) what effects are appropriate to expect, according to participants? and 2) to what extent did these effects occur?

METHODS

Two peer support intervention programs were conducted in a diabetes specialist clinic (N=30). A participatory and adaptable approach allowed flexibility in the content of peer support meetings, which were facilitated by a diabetes nurse. Individual interviews explored participants' perception of effects of the intervention. Interview data were analyzed qualitatively. Participants (n=27) completed a baseline and postintervention questionnaire that included items assessing diabetes empowerment, diabetes distress, diabetes-specific social support, and diabetes loneliness. HbA1c levels were compared before and after the intervention.

RESULTS

Participants experienced enhanced diabetes-specific social capital, diabetes motivation, awareness of personal diabetes practices, and serenity and openness in life with diabetes. They also became more aware of treatment and support possibilities. Negative effects included feeling sad or upset after the meetings or feeling different than and not as well-controlled as other participants. Quantitative analyses showed enhanced social support, decreased eating distress and trends toward enhanced diabetes empowerment, decreased diabetes loneliness, and decreased diabetes distress (powerlessness). We found fewer positive and/or negative outcomes among participants who felt no need for peer support or felt that the group was not a unit or that important issues were not addressed.

CONCLUSION

The study indicated that flexible and participatory peer support can strengthen diabetes-specific social capital and improve participants' well-being and diabetes empowerment. Awareness of participants' incentives for attending peer support, as well as the risk of people feeling isolated within peer support groups, is essential to creating effective diabetes-specific social support.

Predictor effect of Locus Of Control (LOC) on self-care activities and metabolic control in individuals with type 2 diabetes

Background

Previous studies have examined the role of individuals’ personal characteristics in diabetes management and used the locus of control theory to assess adherence to a diabetes management regimen. These studies have emphasized that having internal locus of control may be a protective factor in diabetes management.

Objective

The purpose of this study is to determine the predictor effect of locus of control on self-care activities and A1c level.

Method

The study is descriptive and relational. Researchers used a Diabetes Self-Care Activities Scale and a Locus of Control Scale to collect data. The study sample consisted of 129 individuals with type 2 diabetes.

Results

The average score of locus of control of individuals with diabetes was 10.26, and the frequency of self-care activities in the past week was 2.9 days. A weak but statistically significant negative relation was found between the locus of control level and self-care activities of individuals with diabetes, which had no effect on A1c. It was determined that locus of control predicts 19% of self-care activities.

Conclusion

According to the study results, having internal locus of control had positive effects on self-care activities. Training and planning activities to improve internal locus of control can improve diabetes management.

Help or Hindrance? How Family and Friends Influence Chronic Illness Self-Management among Older Adults

We contribute to knowledge about older adults with chronic illnesses by identifying positive and negative influences of family and friends on self-management. Thirteen focus groups were conducted in upstate New York with 84 African American and White men and women, 65 years old or older, with arthritis, diabetes, and/or heart disease. Specific positive and negative social network influences are discussed in the areas of disease management (medication management, dietary activities, physical activity, and health care appointments); decision-making about the illness; and psychosocial coping. Overall, we found many more positive than negative social network influences, and more negative influences from family members than from friends. We discuss differences between influences of family members versus friends, and point out a few suggestive differences by gender and race. We conclude with limitations of the study as well as implications for the design of self-management interventions involving family members and friends.

Patient perspectives on peer support for adults with type 1 diabetes: a need for diabetes-specific social capital

AIM

To explore the function of peer support from the perspective of adults with type 1 diabetes in Denmark.

METHODS

The study population consisted of 20 adults with type 1 diabetes. The sample was diverse in relation to educational background, age, sex, and cohabitation status. Inspired by action research, several methods and perspectives on peer support were explored and tested. Workshops and group and individual interviews were performed. Systematic text condensation was used to analyze data, supplemented with theory-based interpretive analysis.

RESULTS

Adults with type 1 diabetes found peer support highly relevant to reduce a burdensome feeling of diabetes-specific loneliness. Peer support showed potential to create diabetes-specific social capital not only by creating reciprocal social support between peers but also, more importantly, by creating space for genuine trust and a feeling of communality. There was a widespread feeling of the pervasive impact of diabetes on daily life and thus the relevance of discussing all aspects of life. However, participants perceived peer support as particularly relevant in relation to big changes in life, for example, in family life, at work, or through treatment events such as getting an insulin pump.

CONCLUSION

Peer support programs focusing on creating and establishing diabetes-specific social capital using participatory approaches seem highly relevant among adults with type 1 diabetes. Content, methods, and effects of peer support need further exploration in collaboration with adults with type 1 diabetes.

Type 1 diabetes and living without a partner: psychological and social aspects, self-management behaviour, and glycaemic control

AIMS

(1) To investigate the association between cohabitation status and psychological aspects of living with diabetes (diabetes distress, diabetes empowerment, quality of life), self-management behaviours, and glycaemic control and (2) to explore whether potential associations are mediated by social support.

METHODS

Cross-sectional survey of 2419 adult outpatients with type 1 diabetes from a specialized diabetes clinic in Denmark. Stepwise multiple regression gender-stratified analyses assessed the association between cohabitation status and the variables of interest and the influence of social support.

RESULTS

Significant associations existed between living without a partner and low quality of life, low diabetes empowerment and HbA1c for both men and women. For women, living without a partner was significantly associated with higher diabetes distress and poor self-management behaviours. All associations were mediated by social support to varying degrees.

CONCLUSIONS

Social network and social support are related to important diabetes outcomes in type 1 diabetes. Living without a partner indicates a need for support to prevent poorer diabetes outcomes. Women appear more susceptible to living without a partner in terms of psychosocial diabetes outcomes and glycaemic control. Generally, social support is a mediator in the association between cohabitation status and diabetes outcomes, but social support, as well as cohabitation status, are also independently associated with poorer diabetes outcomes. Assessment of cohabitation status as an indicator of psychosocial capabilities and glycaemic control may be useful in diabetes care and support.

Smoking is associated with impaired long-term glucose metabolism in patients with type 1 diabetes mellitus

BACKGROUND AND AIMS

Smoking is known to negatively influence glucose metabolism both in healthy subjects and in patients with diabetes. The aim of this study was to compare glycemic control in patients with type 1 diabetes mellitus who were smokers with those who did not smoke during a prospective long-term follow-up.

METHODS AND RESULTS

In a single center, 763 patients with type 1 diabetes mellitus were included, 160 (21.0%) of them were smokers. Patients were treated with intensive insulin therapy according to existing guidelines. Glucose control was monitored quarterly, diabetes related complications and cardiovascular risk factors were assessed at least once a year. Glucose control in smokers was significantly worse than in non-smokers at baseline and during follow-up (mean HbA1c during 5047 patient-years of follow-up 7.9 ± 1.3% in smokers and 7.3 ± 1.1% in non-smokers, p < 0.001) despite a higher insulin dosage in smokers (0.71 ± 0.30 U/kg vs. 0.65 ± 0.31 U/kg in non-smokers, p = 0.046). HDL cholesterol was lower in smokers at baseline (1.53 ± 0.45 vs. 1.68 ± 0.51 in non-smokers, p = 0.048). Diabetes related complications tended to occur with a higher frequency in smokers, with a significant difference in macroalbuminuria (9.8% vs. 4.8% in non-smokers, p = 0.047).

CONCLUSION

Smoking is associated with worse glucose control in patients with type 1 diabetes mellitus despite the same treatment strategies as in non-smokers. Hyperglycemia, therefore, may contribute to an earlier incidence of diabetes related complications in these patients, in addition to direct toxic effects of smoking.

Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial

BACKGROUND

Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes.

OBJECTIVE

To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels.

DESIGN

A 6-month randomized, controlled trial. (ClinicalTrials.gov registration number: NCT01125956)

SETTING

Philadelphia Veterans Affairs Medical Center.

PATIENTS

African American veterans aged 50 to 70 years with persistently poor diabetes control.

INTERVENTION

118 patients were randomly assigned to 1 of 3 groups: usual care, a peer mentoring group, and a financial incentives group. Usual care patients were notified of their starting HbA(1c) level and recommended goals for HbA(1c). Those in the peer mentoring group were assigned a mentor who formerly had poor glycemic control but now had good control (HbA(1c) level ≤7.5%). The mentor was asked to talk with the patient at least once per week. Peer mentors were matched by race, sex, and age. Patients in the financial incentive group could earn $100 by decreasing their HbA(1c) level by 1% and $200 by decreasing it by 2% or to an HbA(1c) level of 6.5%.

MEASUREMENTS

Change in HbA(1c) level at 6 months.

RESULTS

Mentors and mentees talked the most in the first month (mean calls, 4; range, 0 to 30), but calls decreased to a mean of 2 calls (range, 0 to 10) by the sixth month. Levels of HbA(1c) decreased from 9.9% to 9.8% in the control group, from 9.8% to 8.7% in the peer mentor group, and from 9.5% to 9.1% in the financial incentive group. Mean change in HbA(1c) level from baseline to 6 months relative to control was -1.07% (95% CI, -1.84% to -0.31%) in the peer mentor group and -0.45% (CI, -1.23% to 0.32%) in the financial incentive group.

LIMITATION

The study included only veterans and lasted only 6 months.

CONCLUSION

Peer mentorship improved glucose control in a cohort of African American veterans with diabetes.

PRIMARY FUNDING SOURCE

National Institute on Aging Roybal Center.

Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial

BACKGROUND

Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes.

OBJECTIVE

To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels.

DESIGN

A 6-month randomized, controlled trial. (ClinicalTrials.gov registration number: NCT01125956)

SETTING

Philadelphia Veterans Affairs Medical Center.

PATIENTS

African American veterans aged 50 to 70 years with persistently poor diabetes control.

INTERVENTION

118 patients were randomly assigned to 1 of 3 groups: usual care, a peer mentoring group, and a financial incentives group. Usual care patients were notified of their starting HbA(1c) level and recommended goals for HbA(1c). Those in the peer mentoring group were assigned a mentor who formerly had poor glycemic control but now had good control (HbA(1c) level ≤7.5%). The mentor was asked to talk with the patient at least once per week. Peer mentors were matched by race, sex, and age. Patients in the financial incentive group could earn $100 by decreasing their HbA(1c) level by 1% and $200 by decreasing it by 2% or to an HbA(1c) level of 6.5%.

MEASUREMENTS

Change in HbA(1c) level at 6 months.

RESULTS

Mentors and mentees talked the most in the first month (mean calls, 4; range, 0 to 30), but calls decreased to a mean of 2 calls (range, 0 to 10) by the sixth month. Levels of HbA(1c) decreased from 9.9% to 9.8% in the control group, from 9.8% to 8.7% in the peer mentor group, and from 9.5% to 9.1% in the financial incentive group. Mean change in HbA(1c) level from baseline to 6 months relative to control was -1.07% (95% CI, -1.84% to -0.31%) in the peer mentor group and -0.45% (CI, -1.23% to 0.32%) in the financial incentive group.

LIMITATION

The study included only veterans and lasted only 6 months.

CONCLUSION

Peer mentorship improved glucose control in a cohort of African American veterans with diabetes.

PRIMARY FUNDING SOURCE

National Institute on Aging Roybal Center.

Assessment of self-reported self-esteem in healthy and diabetic children and adolescents in Greece

BACKGROUND

The aim of the present study was to evaluate any possible negative effect of diabetes on the self-esteem of children and adolescents with diabetes.

METHODS

Self-esteem was evaluated using the Culture-Free Self-Esteem Inventory (CFSEI-2) in 144 patients with Type 1 diabetes mellitus (T1DM; 7-18 years of age) treated in a diabetes center and compared against that of 136 healthy children and adolescents.

RESULTS

Self-esteem was correlated with age (P = 0.017), but not with diabetes (P = 0.886). The median CFSEI-2 score for both healthy and diabetic children was 22. There was no significant correlation between self-esteem and sex, body mass index (BMI), physical exercise, HbA1c or parental educational level. According to Spearman's rank correlation coefficient (r(s)), there was a significant association between age and self-esteem (r(s) = -0.15). Conversely, although BMI (r(s) = -0.09) and treatment duration (r(s) = -0.107) had a slight negative effect on self-esteem and the duration of physical exercise (r(s) = 0.11) and parental education (r(s) = 0.07) seemed to have a positive effect, the associations did not reach statistical significance.

CONCLUSIONS

Self-esteem in diabetic children is mainly affected by their age, level of physical activity and level of family support. These findings emphasize the need to discriminate between glycemic control and diabetic adjustment.

Different models to mobilize peer support to improve diabetes self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research

Much of diabetes care needs to be carried out by patients between office visits with their health care providers. Yet, many patients face difficulties carrying out these tasks. In addition, many adults with diabetes cannot count on effective support from their families and friends to help them with their self-management. Peer support programmes are a promising approach to enhance social and emotional support, assist patients in daily management and living with diabetes and promote linkages to clinical care. This background paper provides a brief overview of different approaches to mobilize peer support for diabetes self-management support, discusses evidence to date on the effectiveness of each of these models, highlights logistical and evaluation issues for each model and concludes with a discussion of directions for future research in this area.

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.

Socioeconomic status and the incidence of ESRD

BACKGROUND

Persons of low socioeconomic status (SES) may be at increased risk of end-stage renal disease (ESRD). This study examines the association between SES and incidence of ESRD caused by all primary renal diseases and caused by 3 diseases that differ in the availability of effective treatment: diabetes mellitus, lupus nephritis, and autosomal dominant polycystic kidney disease (ADPKD).

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Adults with incident ESRD in the United States from January 1, 1996, to June 30, 2004 (N = 747,556).

PREDICTOR

SES, based on characteristics of the patient's ZIP code of residence.

OUTCOMES

Incidence of ESRD.

RESULTS

In all sex-race groups, the incidence of ESRD caused by all primary renal diseases was greatest in those in the lowest SES score quartile and decreased progressively with higher SES. For example, for white women, the incidence of ESRD was 388.9 per million in the lowest quartile of SES and 200.8 per million in the highest quartile of SES (relative risk, 1.92; 95% confidence interval, 1.89 to 1.95). However, this association differed among patients with primary renal diseases. There were strong associations between SES and ESRD caused by diabetes mellitus, weaker associations for ESRD caused by lupus nephritis, and generally no associations for ESRD caused by ADPKD. For example, for white women, relative risks of ESRD in the lowest compared with the highest SES quartile were 2.84 for ESRD caused by diabetes mellitus, 1.63 for ESRD caused by lupus nephritis, and 1.27 for ESRD caused by ADPKD.

LIMITATIONS

Use of an area-based measure of SES.

CONCLUSIONS

The strength of the association between SES and ESRD differs among patients with diabetes mellitus, lupus nephritis, and ADPKD, suggesting that socioeconomic factors act differently in the progression of chronic kidney disease in these conditions.

Diabetes treatments

With the aging of the population, physical inactivity, and growing rates of obesity, there has been a dramatic rise in the incidence of diabetes. Diabetes and its treatment is a holistic and dynamic experience, shaping many aspects of a person's life and well-being. Despite the biopsychosocial nature of this chronic disease, medications tend to be the principal intervention among medical professionals. Over the past fifteen years, however, diabetes researchers and clinicians have begun to develop interventions addressing the psychosocial aspects of diabetes. The majority of these interventions fall within the knowledge base and clinical abilities of social work practitioners. This paper systematically reviews psychosocial intervention studies with older adults, identifying and summarizing treatment protocols.

Executive summary. The State of the Science on Nursing Best Practices for Diabetes Self-Management

The State of the Science on Nursing Best Practices for Diabetes Self-Management.

The extended health belief model applied to the experience of diabetes in young people

OBJECTIVES

The experience of diabetes in young people was investigated within the theoretical framework of the extended health belief model (EHBM). It was anticipated that participant reports of high internal locus of control, high diabetes related empowerment, coping with hypoglycaemia, and diabetes related social support would be associated with good patient adherence to the self-care regime.

METHOD

118 participants aged 16-25 years with Type 1 diabetes mellitus were sent a set of questionnaires incorporating previously published scales measuring all variables of the EHBM.

RESULTS

High levels of family support and low locus of control beliefs in powerful others to control their diabetes reduce the young person's perception of severity and vulnerability to diabetes related complications. High internal locus of control beliefs and high levels of self-efficacy predicted the benefits of adhering to the self-care regime as outweighing the costs of doing so. Adherence to self-care regime was predicted by high levels of family support.

CONCLUSION

The final model explained 12% of the variance in the young person's adherence to diabetes self-care regime. It is proposed that the EHBM is an adequate model for understanding the socio-psychological factors present in the young person's appraisal of their diabetes, which, in turn, influences adherence to the diabetes self-care regime.

Effect of stress management training on glycemic control in patients with type 1 diabetes

AIMS

In this study, the effect of stress management training on glycemic control has been investigated in type 1 diabetic patients.

METHODS

The participants were 60 type 1 diabetic patients (aged 16-30). 30 Subjects attended in 3-month stress management training classes during which the prescribed insulin remained constant, but the remainder 30 ones did not. HbA1 from all patients were measured before and after the intervention. Besides, in order to assess the ways of coping, every patient completed a questionnaire and the scores were compared between two groups.

RESULTS

Trained patients showed significantly improved ways of coping. HbA1 changed from 11.7+/-2.9 and 10.9+/-2.1 before training to 8.5+/-1.7 and 10.3+/-2.1 after intervention in trained and control groups respectively and the changes were significant in study group (P<0.001). In addition, the difference between means of HbA1 of two groups was statistically significant at the end of the study (P<0.001).

CONCLUSIONS

Results show a clinically significant beneficial effect of stress management training on glycemic control among type 1 diabetic patient. It is recommended to consider this type of training as an addition to the treatment program in type 1 diabetic patient.

Glycemic control, self-care behaviors, and psychosocial factors among insulin treated diabetics: a test of an extended health belief model

The relations of diet adherence (DA) and self-monitoring of blood glucose (SMBG) to metabolic control, as measured with glycosylated hemoglobin A(tc) (GHbA(tc), and correlates of self-care were examines among a type I diabetic sample (n = 423). The Health Belief Model (HBM), supplemented by other factors (locus of control, self-efficacy, health value, and social support), was used as a theoretical model. In multiple regression analyses both DA (p<.01) and SMBG (p<.001). SMBG showed strong associations with self-efficacy in SMBG (p,.001) and net benefits of SMBG (p<.001). The revised models explained 14% and 21% of the variation in DA and SMBG, respectively. The results suggest that although perceived net benefits are important determinants of both SMBG and DA, DA is also related to diabetes support, whereas SMBG is more strongly related to perceived self-efficacy. Thus self-care regimen should be planned individually for diabetic patients.

Widening social inequalities in risk for sudden infant death syndrome

OBJECTIVES

In 1994, the US Public Health Service launched the "Back to Sleep" campaign, promoting the supine sleep position to prevent sudden infant death syndrome (SIDS). Studies of SIDS in the United States have generally found socioeconomic and race disparities. Our objective was to see whether the "Back to Sleep" campaign, which involves an effective, easy, and free intervention, has reduced social class inequalities in SIDS.

METHODS

We conducted a population-based case-cohort study during 2 periods, 1989 to 1991 and 1996 to 1998, using the US Linked Birth/Infant Death Data Sets. Case group was infants who died of SIDS in infancy (N = 21 126); control group was a 10% random sample of infants who lived through the first year and all infants who died of other causes (N=2241218). Social class was measured by mother's education level.

RESULTS

There was no evidence that inequalities in SIDS were reduced after the Back to Sleep campaign. In fact, odds ratios for SIDS associated with lower social class increased between 1989-1991 and 1996-1998. The race disparity in SIDS increased after the Back to Sleep campaign.

CONCLUSIONS

The introduction of an inexpensive, easy, public health intervention has not reduced social inequalities in SIDS; in fact, the gap has widened. Although the risk of SIDS has been reduced for all social class groups, women who are more educated have experienced the greatest decline.

Cost and benefits of a multidisciplinary intensive diabetes education programme

OBJECTIVES

To determine the cost and benefits of an intensive diabetes education programme for patients with prolonged self-management problems and to determine the inclusion criteria for optimal outcomes.

METHODS

Sixty-one participants of a multidisciplinary intensive diabetes education programme (MIDEP) were measured before they started the intervention (T0), and at 1-year follow-up (T1). Data on glycaemic control (HbA1c), diabetes-related distress (PAID) and costs were obtained. Changes over time were analysed and means at T0 and T1 were compared to a reference group of 230 non-referred consecutive outpatients. The number needed to treat (NNT), that is, the number of patients to be treated to achieve one successful case, was calculated for different baseline values of HbA1c and PAID to determine optimal inclusion criteria.

RESULTS

Diabetes-related costs decreased significantly and participants improved significantly in HbA1c and diabetes-related distress following MIDEP. HbA1c and distress reached the levels of the reference group. The T1 costs remained higher than in the reference group, but the reduction in costs outweighed the intervention costs. Including patients with baseline HbA1c>or=8.0% and/or PAID scores>or=40 would improve the NNT to achieve clinically relevant outcomes, while 76% of the patients matched these inclusion criteria.

CONCLUSIONS

MIDEP is effective in improving glycaemic control and diabetes-related distress for patients with prolonged self-management difficulties. Besides the immediate reduction in costs found in the present study, improved glycaemic control may reduce future costs of diabetic complications. Stricter inclusion criteria with respect to HbA1c and PAID scores may further improve the programme's efficiency.

Reliability and validity of the Chinese version of the Worry Scale

This article presents the findings on the development and validation of a Chinese version of the Worry Scale (WS), a measure of worry about hypoglycemia. A previously developed 16-item WS was back-translated and applied to 117 Chinese diabetic patients living in Hong Kong. An iterative process of factor and item analyses identified a unidimensional 10-item Chinese WS (WS-10), which accounted for 57.15% of the total variance. Cronbach's alpha was 0.91. Strong correlation was demonstrated between the WS-10 and WS with 16 items (r = 0.97, p = 0.000). Comparing the level of worry about hypoglycemia between Type 1 and Type 2 diabetic patients established a contrast-group validity of the WS-10 (p = 0.002). Criterion validity was established by correlating the WS-10 with the respondents' glycosylated hemoglobin (r = -0.29, p = 0.002). Test-retest reliability using intraclass correlation (ICC) was established, ICC(1, 1) = 0.68. As the clinical administration of this scale takes less than 5 min, the Chinese WS-10 offers a useful instrument to identify patients with high levels of worry about hypoglycemia for clinical and education interventions. It also provides public health nurses with a reliable and valid prepost measure of intervention effectiveness. The Chinese WS-10 will facilitate further research about the effects of worry concerning hypoglycemia on self-care behaviors with the Chinese populations.

Culture-specific diabetes care for Surinam South Asians with a low socio-economic position: who benefits?

The South Asians in The Netherlands have a high diabetes prevalence in combination with a low socio-economic position. A new, culture-specific type of care was developed. This intervention study investigates which patient characteristics are associated with success and whether those in the lowest socio-economic position have been reached. Before and after the end of the intensive guidance, the HbAlc of the patients (n=101) was measured. The following variables were significantly related to success (defined as a decrease in HbAlc > or = 0.8%): a high initial HbAlc, a low BMI and presence of complications. The average improvement in HbAlc was significant only in the group with a higher socio-economic position. Although the patients with the lowest socio-economic position did not sufficiently benefit from this intervention, an overall improvement was achieved in this poorly educated study population. The further improvements in the care after the completion of this study should be evaluated.

The influence of social support on chronic illness self-management: a review and directions for research

A review of the empirical literature examining the relationship between social support and chronic illness self-management identified 29 articles, of which 22 were quantitative and 7 were qualitative. The majority of research in this area concerns diabetes self-management, with a few studies examining asthma, heart disease, and epilepsy management. Taken together, these studies provide evidence for a modest positive relationship between social support and chronic illness self-management, especially for diabetes. Dietary behavior appears to be particularly susceptible to social influences. In addition, social network members have potentially important negative influences on self-management There is a need to elucidate the underlying mechanisms by which support influences self-management and to examine whether this relationship varies by illness, type of support, and behavior. There is also a need to understand how the social environment may influence self-management in ways other than the provision of social support

Barriers to blood glucose monitoring in a multiethnic community

OBJECTIVE

We studied a multiethnic community to determine factors associated with blood glucose monitoring (BGM) and to determine the independent association between barriers to diabetes care and BGM.

RESEARCH DESIGN AND METHODS

A total of 323 participants (35.6% European, 32.2% Maori, and 32.2% Pacific Islander) from the South Auckland Diabetes Project (free of major complications by self-report) completed a qualitative survey to determine barriers to diabetes care. Five barriers to diabetes care categories were generated including internal psychological (self efficacy/health beliefs), external psychological (psychosocial environment), internal physical (comorbidities/side effects of treatment), external physical (finance/access to care), and educational (knowledge of diabetes/services) barriers.

RESULTS

Characteristics associated with BGM greater than or equal to twice weekly were female sex, HbA(1c) >8%, higher diabetes knowledge scores, and insulin use. Multivariate analyses demonstrated that those reporting external physical barriers (OR 0.47, 95% CI 0.26-0.84), external psychological barriers (0.55, 0.30-1.0), and internal psychological barriers (0.56, 0.32-1.0) were less likely to perform BGM independent of ethnicity, insulin use, age, sex, diabetes knowledge, and glycemic control. Further multivariate analyses demonstrated that those reporting external physical barriers, particularly related to personal finance, were less likely to perform BGM.

CONCLUSIONS

These data demonstrate that patient-reported barriers to diabetes care are associated with BGM, particularly in relation to financial, psychosocial, and self-efficacy issues. Understanding these barriers and overcoming them within the context of the patient's ethnic environment may lead to increased participation in self-care.

Sociodemographic determinants of glycaemic control in young diabetic patients in peninsular Malaysia

Recent studies have shown that good glycaemic control can prevent the development of diabetic complications in type 1 and type 2 diabetes. We wished to observe the glycaemic control in patients from different centres in Peninsular Malaysia and the factors that determine it. We recruited 926 patients with diabetes diagnosed before age 40 years from seven different centres, with proportionate representation from the three main ethnic groups. Clinical history and physical examination were done and blood taken for HbA1c and fasting glucose. The overall glycaemic control was poor with geometric mean HbA1c of 8.6% whilst 61.1% of the patients had HbA1c greater than 8%. Glycaemic control in patients with type 2 diabetes varied between various centres and ethnic groups, with the best control obtained in Chinese patients. Significant predictors of HbA1c in both type 1 and type 2 diabetes include access to nurse educators, ethnic background and WHR. In type 2 diabetes, use of insulin was a significant predictor, while in type 1 diabetes, household income was a significant predictor. Socioeconomic status did not have a significant effect in type 2 diabetes. There were no significant differences in the glycaemic control in patients with different educational status. In conclusion, glycaemic control in big hospitals in Malaysia was poor, and was closely related to the availability of diabetes care facilities and ethnic group, rather than socioeconomic status.

Stress coping and social support in glucose tolerance abnormality

We examined coping with stress, including social support, dealing with illness, and mood states, in a sample of 600 persons who underwent primary health-care screening. Subjects were not yet diagnosed as having glucose tolerance abnormality and considered themselves healthy before the examination. Although no significant differences on the existence and perception of social support were found, the utilization of social support was significantly and negatively correlated with the level of glucose tolerance abnormality. The results suggest that poor utilization of social support is associated with the onset of glucose tolerance abnormality.

Perception and utilization of social support in diabetic control

This study examined the influence of social support (perception and utilization) on diabetic control. Subjects were 178 patients with diabetes mellitus [insulin dependent diabetes mellitus (IDDM) = 26, non-insulin dependent diabetes mellitus (NIDDM)= 152]. HbA1c values was used as an indicator of diabetic control. Assessment of social support was performed using the Stress and Coping Inventory. HbA1c values were significantly related to the presence or absence of participation in a diabetic education program as well as scores on perception and utilization of social supports. The participation in the diabetic education program was not significantly associated with the two social supports, however, the two social support factors interacted significantly with one another. As for type of DM, these findings were stronger in IDDM patients. These results suggest that, in particular patients with NIDDM, although diabetes education is effective for decreasing HbA1c, a combination of the two social supports also decrease the HbA1c value, independent of diabetic education.

Development of the eating Attitude Inventory for Diabetes Mellitus

The authors examined the validity and reliability of the Eating Attitude Inventory for Diabetes Mellitus in a sample of 178 patients with diabetes mellitus. Reliability was supported by factor analysis, adequate internal consistency, and relatively high test-retest correlations. Validity was indicated by correlation with the Eating Attitudes Test designed for eating disorders. This inventory may be useful for assessing eating attitudes of patients with diabetes mellitus.

Glycaemic control and its determinants in diabetic patients in Ethiopia

A cross-sectional study was undertaken in which concentrations of glycated haemoglobins were measured in 102 diabetics seen at the outpatient clinic in Gondar, Ethiopia, between 26 January and 7 March, 1995. Mean HbA1, levels (standard deviations) were 5.35% (1.1) in non-diabetic controls, 12.0% (1.5) in 59 insulin-dependent diabetics, and 11.0% (2.0) in 43 non-insulin dependent outpatients. The majority of insulin-dependent mellitus (IDDM) (78%) and non-insulin-dependent mellitus (NIDDM) patients (77%) were poorly controlled (HbA1 > 10.8% in IDDM, and > 9.7% in NIDDM, respectively). Multiple linear regression analyses revealed that HbA1 levels were significantly positively associated with lower body mass index, duration of diabetes, a recent history of polydipsia, hypertension, and low income in NIDDM individuals. Whereas in IDDM patients lower age (or alternatively lower age at onset) was the only significant predictor. Whilst 49% of the model variance was explained by the predictors in NIDDM diabetics, only 9% were so in IDDM patients. Current fasting blood glucose level was marginally significant in NIDDM patients (r = 0.29; P = 0.058), but insignificant in IDDM individuals. This points towards the fluctuations in blood glucose levels experienced by IDDM patients in a setting where insulin supply is unreliable. It also confirms the doubts about the usefulness of fasting blood glucose values as a tool for assessing metabolic control.

Health related quality of life among insulin-dependent diabetics: disease-related and psychosocial correlates

This crossectional questionnaire study examined the associations of health factors and psychosocial factors with Health Related Quality of Life (HRQOL) in a sample of adult type I diabetic patients (n = 385). Health related quality of life was measured by the Finnish version of MOS SF-20. Psychosocial measures were general social support, diabetes-specific social support, diabetes locus of control (DCL), self-efficacy, diabetes health beliefs and self-care practices. In multivariate analyses, limitations in physical functioning showed strong associations with perceived health (beta = -0.33, P < 0.001), role functioning (OR = 38.54, 95% CL 10.73-139.56), social functioning (OR = 7.05, 95% CL 2.88-17.27) and pain (OR = 7.89, 95% CL 4.26-14.47), and was moderately associated to mental health (beta = -0.12, P < .01). Duration of diabetes and glycemic control were not related to HRQOL dimensions. Adequacy of social support was related to all HRQOL domains apart from pain and role functioning. The most important diabetes-related psychosocial factors were self-efficacy, and diabetes-related social support. Diabetes-specific factors were more important among those in good physical condition.

Foreign- and Swedish-born diabetic patients--a population-based study of prevalence, glycaemic control and social position

In this study foreign- and Swedish-born individuals with diabetes mellitus were compared regarding prevalence and characteristics. In a Swedish county 1,568 patients aged 20-64 years were identified, of whom 97.4% were included (143 foreign- and 1,384 Swedish-born) in the study of medical records. There was no difference in prevalence of diabetes (1.4% (95% CI 1.2-1.7%) vs 1.5% (95% CI 1.4-1.6%) but diagnosis at or after the age of 30 years was more common in foreign-born patients (p < 0.001). They were also less often treated with insulin (p < 0.001), had shorter duration of diabetes (p < 0.001), were more often classified as having a low social position in Sweden (p < 0.001) and less often controlled in specialized diabetes care departments (p < 0.001, 18% vs 43%). There was a higher occurrence of albuminuria among foreign-born women (p < 0.05). No differences were found in glycaemic control, but low social position was related to poor glycaemic control independent of being foreign- or Swedish-born, and it seems to be more important than place of birth.

Health-related quality of life in relation to metabolic control and late complications in patients with insulin dependent diabetes mellitus

To investigate important factors with respect to health-related quality of life (HRQOL) in patients with longstanding insulin dependent diabetes mellitus, a patient cohort was followed prospectively for 10 years. The degree of metabolic control and the presence of late complications was assessed and HRQOL was measured with a 61-item questionnaire (SWEDQUAL) in which reference values have been obtained in a population sample. The results indicate that diabetic patients (n = 108) experienced a quality of life as good as a general population. When patients were divided into four groups based on metabolic control, those with poor control (HbA1c > or = 9%) rated their physical and emotional functioning significantly lower than those with lower HbA1c values. Nearly 15% of the patients reported 1-5 hypoglycaemic episodes during the latest 6 months. Despite a lower HbA1c they rated their general health as being poorer than patients without severe hypoglycaemia. Of the 108 patients 39% appeared to be free from late complications of diabetes. These patients rated their general health as better than patients who already had developed late complications. We conclude that a satisfactory metabolic control with a minimum of hypoglycaemic episodes is desirable not only to prevent late complications but also because poor metabolic control seems to be one reason why diabetic patients experience a poorer quality of life.

Towards improving care for children with diabetes in Kuwait

Presents the results of a medical audit of the records of 199 children diagnosed as diabetic and admitted to Al-Amiri Hospital, Kuwait. Uses the measurement of glycosylated haemoglobin (HbA1) to indicate the levels of control achieved. Finds that the degree of glycaemic control compares favourably with studies done in other hospitals, but unfavourably with specialized diabetic clinics. Proposes that glycaemic control could be improved by provision of the services of specialized support staff such as dietitian, educator, psychologist and health visitor.