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Litterbach E, Holmes-Truscott E, Gray S, Halliday J, Scibilia R, Skinner T, Speight J. "I feel like I'm being talked to like an equal": Diabetes language matters to adults with diabetes, a mixed-methods study. Diabet Med 2024:e15424. [PMID: 39150048 DOI: 10.1111/dme.15424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/28/2024] [Accepted: 07/29/2024] [Indexed: 08/17/2024]
Abstract
AIM To explore reactions to and preferences for words/phrases used in communications about diabetes among adults with diabetes and parents of children with diabetes. METHODS Eligible adults (aged 18+ years) living with diabetes, or parenting a child with diabetes, were recruited via social media to complete an online cross-sectional, mixed-methods survey. Study-specific items were used to examine 22 commonly used diabetes words/phrases in terms of participants' cognitive perceptions ('helpful', 'respectful', 'accurate', 'harmful', 'judgmental' and 'inaccurate') and emotional reactions ('optimistic', 'motivated', 'supported', 'understood', 'offended', 'blamed', 'distressed' and 'angry'). Open-ended questions invited further feedback on (non-)preferred language and its impact(s). Data were analysed using descriptive statistics and inductive thematic analysis. RESULTS Participants (N = 865) included adults with diabetes (type 1: n = 519; type 2: n = 180, other types: n = 48) and parents of children with diabetes (n = 118). Words/phrases most commonly associated with negative perceptions/emotional responses were 'non-compliant' (60% judgmental; 47% felt blamed) and '…good/bad' (54% judgmental; 43% blamed). Positive perceptions were reported for 'managing diabetes' (73% helpful, 47% felt understood), 'person with diabetes' (72% respectful; 49% understood), '…within/outside target range' (60% helpful, 44% understood), and 'condition' (58% respectful; 43% understood). Participants' qualitative responses illuminated perceptions, experiences and impacts across five themes: (1) accuracy and simplicity; (2) identity; (3) blame, judgement and stigma; (4) respect and trust and; (5) support, hope and feeling understood. Themes were consistent across diabetes types. CONCLUSIONS These findings provide novel evidence into (non-)preferred, and potential (negative and positive) impacts of, commonly used diabetes words/phrases, supporting the international #LanguageMatters movement.
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Affiliation(s)
- Eloise Litterbach
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Shikha Gray
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Victoria, Australia
| | - Jennifer Halliday
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | | | - Timothy Skinner
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Victoria, Australia
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
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Hughes AS. Diabetes, Insulin & Politics: 28 Years of Stigma, Innovation, and Ableism. HEALTH COMMUNICATION 2024:1-4. [PMID: 38982620 DOI: 10.1080/10410236.2024.2375145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
Nearly 3 decades after my type 1 diabetes diagnosis, I wrote this essay to document my journey. Through childhood and teen years where I experienced emotional abuse in clinic and felt the deepest of fears. Then in college, when I realized my voice mattered and I could elevate the voices of others with diabetes. During grad school, I began meeting with legislators and understanding how health policy works. I am now a health psychologist focused on improving health equity for people with diabetes and disabilities. Importantly, my research findings highlight how the U.S. medical system is not equipped to support people with diabetes. In this essay I also highlight key people in the diabetes and disability community who have served as lighthouses on my journey and continue to shine light across my path.
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Affiliation(s)
- Allyson S Hughes
- Department of Primary Care, Ohio University Heritage College of Osteopathic Medicine
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3
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George S, Kim MY, Naik AR, Lewis BE. Examining Inclusive Language in Clinical Narratives in Medical Biochemistry Textbooks to Model Equitable Patient-Centered Care in Preclinical Undergraduate Medical Education. MEDICAL SCIENCE EDUCATOR 2024; 34:581-587. [PMID: 38887417 PMCID: PMC11180134 DOI: 10.1007/s40670-024-02015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 06/20/2024]
Abstract
Purpose When healthcare professionals use biased or stigmatizing language to describe people or conditions, it can impact the quality of care or erode the patient-physician relationship. It is not clear where healthcare professionals acquire biased and stigmatizing language in practice. This study focuses on examining language in educational materials used in training of medical students. Specifically, medical biochemistry textbooks were examined as they are often a first exposure to clinical narratives and communication standards. The aim of this project is to investigate whether medical biochemistry textbooks, widely recommended in preclinical UME, model inclusive language communication in clinical narratives. Methods To determine if educational materials follow inclusive writing guidelines, we conducted a modified document analysis on a sample of medical biochemistry textbooks when clinical scenarios were described. Three independent researchers separately reviewed the textbooks, coded the language using NVivo, and generated themes. Results Our results show that medical biochemistry textbooks contain language which is not in alignment with the best practices for inclusive language. Our analysis mapped codes to two primary themes of language misalignment. The first theme, "clinical language" (n = 92), included the following codes: difficult patient, general negative descriptive language, patient as failure, and questioning patient credibility. The second primary theme, "identity-first labeling" (n = 251), included 21 codes. Conclusion This study provides early evidence that the language used in medical biochemistry textbooks to describe people and conditions is not in alignment with inclusive language recommendations. This can reinforce the way future healthcare professionals speak to and about their patients.
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Affiliation(s)
- Sarah George
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309 USA
| | - Min Young Kim
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309 USA
| | - Akshata R. Naik
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309 USA
| | - Brianne E. Lewis
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309 USA
- Department of Foundational Sciences, Central Michigan University College of Medicine, Mount Pleasant, MI 48859 USA
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Choo JWS, Moosa AS, Koh JWM, Ng CJ, Tan NC. Empowering patients in primary care: a qualitative exploration of the usability and utility of an online diabetes self-management tool. BMC PRIMARY CARE 2024; 25:111. [PMID: 38605357 PMCID: PMC11010383 DOI: 10.1186/s12875-024-02358-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/30/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Despite the potential advantages of Internet-based diabetes self-management education, its adoption was not widespread among Singapore's public primary care clinics (polyclinics). An interactive online tool was thus developed to help educate patients with Type 2 diabetes mellitus (T2DM), and was now ready for user testing before implementation. AIM To explore the perceived utility and usability of the educational tool in patients with suboptimally-controlled T2DM in a Singapore primary care setting. METHODS In-depth interviews were used to gather qualitative data from multi-ethnic Asian adults who had suboptimally-controlled T2DM. A total of 17 IDIs were conducted between April 2022 to March 2023, audio-recorded, transcribed, and analyzed to identify emergent themes via thematic analysis. RESULTS Regarding utility, users found the educational tool useful because it provided them with information that was comprehensive, accessible, reliable, and manageable. Regarding usability, the majority of users reported that the educational tool was easy to use, and suggested ways to improve navigational cues, visual clarity, readability and user engagement. CONCLUSION Participants generally found the educational tool useful and easy to use. A revised educational tool will be developed based on their feedback and implemented in clinical practice.
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Affiliation(s)
| | - Aminath Shiwaza Moosa
- SingHealth Polyclinics, Singapore, Singapore
- SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
| | | | - Chirk Jenn Ng
- SingHealth Polyclinics, Singapore, Singapore
- SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
| | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore, Singapore
- SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
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5
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Dickinson JK, Posesorski RE, Djiovanis SG, Brady VJ. Impact of Negative or Stigmatizing Messages on Diabetes Outcomes: An Integrative Review. Sci Diabetes Self Manag Care 2024; 50:167-178. [PMID: 38454649 DOI: 10.1177/26350106241232644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
PURPOSE The purpose was to determine if negative or stigmatizing language and messaging have an impact on diabetes distress, outcomes, or care behaviors in people with diabetes. Since 2012, when the first language position statement was published, the way health care professionals talk to people with diabetes has been an ongoing topic of discussion. However, there have been no recent literature reviews evaluating the impact of problem language on outcomes among people with type 1 and type 2 diabetes. METHODS An integrative review was conducted using 4 electronic databases: CINAHL, Embase, Web of Science, and Medline (Ovid). Studies reporting on diabetes, language, stigma, diabetes distress, glycemic outcomes, and self-care behaviors were included. RESULTS The review included 9 studies, all of which were of high quality. The impact of negative or stigmatizing language on self-care behaviors was the most commonly addressed outcome. Whereas some studies revealed no change, others reported a decrease in self-care behaviors by people with diabetes who had negative perceptions of provider messages. Actual or perceived use of negative or stigmatizing language is linked to higher A1C. Four studies reported an association between messages and diabetes distress. CONCLUSIONS Negative/stigmatizing language has both an immediate and long-term effect on people with diabetes. The inconsistent approaches to studying language in diabetes makes it challenging to compare outcomes and identify themes. Future research is needed to identify effective interventions to change the messages in diabetes.
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Stark JE, Cole J. Evaluation of Author Instructions for Inclusive Language Guidance in Highly Cited English Language Medical Journals. J Gen Intern Med 2024; 39:272-276. [PMID: 37670067 PMCID: PMC10853092 DOI: 10.1007/s11606-023-08390-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Diversity, equity, and inclusion (DEI) are at the core of publication ethics, and language around DEI has been shown to affect patient outcomes. Inclusive language is an important piece of effective communication and is one way to demonstrate and foster a welcoming, respectful, and accessible environment. Non-inclusive terminology in research may represent implicit bias, which is not typically corrected through introspection; thus, a systematic approach is needed in scientific writing. The prevalence of inclusive language guidance in leading medical journals is currently unknown. OBJECTIVE Investigators assess the prevalence and quality of inclusive language guidelines in author instructions in highly cited English language medical journals. DESIGN A cross-sectional review of author instructions from a convenience sample of 100 highly cited medical journals was completed in January 2023. SUBJECTS Each journal's author instructions were reviewed for presence of inclusive language guidelines for manuscript submissions. MAIN MEASURES Guidelines that included specific examples of inclusive language were defined as "strong." Author instructions were also reviewed for the Sex and Gender Equity in Research (SAGER) checklist, and each journal's publisher and impact factor (IF) were recorded. KEY RESULTS The 100 journals reviewed had an IF range of 3.0-202.7 with a median IF = 19.5 (IQR 11.95, 38.68), and 28 unique publishers were represented. Inclusive language guidance was provided in 23% of medical journals reviewed. Of those, 20 (86.9%) provided strong guidance. Seven journals also recommended use of the SAGER checklist. CONCLUSION Significant gaps still exist in ensuring use of inclusive language in medical journals.
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Affiliation(s)
- Jennifer E Stark
- Veterans Healthcare System of the Ozarks, 1100 North College Avenue, Fayetteville, AR, 72703, USA.
| | - Jennifer Cole
- Veterans Healthcare System of the Ozarks, 1100 North College Avenue, Fayetteville, AR, 72703, USA
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Speight J, Holmes-Truscott E, Garza M, Scibilia R, Wagner S, Kato A, Pedrero V, Deschênes S, Guzman SJ, Joiner KL, Liu S, Willaing I, Babbott KM, Cleal B, Dickinson JK, Halliday JA, Morrissey EC, Nefs G, O'Donnell S, Serlachius A, Winterdijk P, Alzubaidi H, Arifin B, Cambron-Kopco L, Santa Ana C, Davidsen E, de Groot M, de Wit M, Deroze P, Haack S, Holt RIG, Jensen W, Khunti K, Kragelund Nielsen K, Lathia T, Lee CJ, McNulty B, Naranjo D, Pearl RL, Prinjha S, Puhl RM, Sabidi A, Selvan C, Sethi J, Seyam M, Sturt J, Subramaniam M, Terkildsen Maindal H, Valentine V, Vallis M, Skinner TC. Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations. Lancet Diabetes Endocrinol 2024; 12:61-82. [PMID: 38128969 DOI: 10.1016/s2213-8587(23)00347-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 12/23/2023]
Abstract
People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.
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Affiliation(s)
- Jane Speight
- School of Psychology and Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC, Australia.
| | - Elizabeth Holmes-Truscott
- School of Psychology and Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC, Australia
| | | | - Renza Scibilia
- Diabetogenic, Melbourne, VIC, Australia; JDRF International, New York, NY, USA
| | - Sabina Wagner
- Department of Prevention, Health Promotions & Community Care, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Asuka Kato
- Department of Health and Social Behavior, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Victor Pedrero
- Faculty of Nursing, Universidad Andrés Bello, Santiago, Chile
| | - Sonya Deschênes
- School of Psychology, University College Dublin, Dublin, Ireland
| | | | - Kevin L Joiner
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Shengxin Liu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Ingrid Willaing
- Department of Prevention, Health Promotions & Community Care, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Copenhagen, Denmark; Institute of Public Health, Department of Health Services Research, University of Copenhagen, Copenhagen, Denmark
| | - Katie M Babbott
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bryan Cleal
- Department of Prevention, Health Promotions & Community Care, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Jane K Dickinson
- Department of Health Studies & Applied Educational Psychology, Teachers College Columbia University, New York, NY, USA
| | - Jennifer A Halliday
- School of Psychology and Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC, Australia
| | - Eimear C Morrissey
- Health Behavior Change Research Group, School of Psychology, University of Galway, Galway, Ireland
| | - Giesje Nefs
- Department of Medical Psychology, Radboudumc, Nijmegen, Netherlands; Center of Research on Psychological Disorders and Somatic Diseases, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands; Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, Netherlands
| | - Shane O'Donnell
- Birmingham Law School, University of Birmingham, Birmingham, UK
| | - Anna Serlachius
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Per Winterdijk
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, Netherlands
| | - Hamzah Alzubaidi
- College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
| | - Bustanul Arifin
- Faculty of Pharmacy, Universitas Hasanuddin, Makassar, Indonesia
| | | | | | - Emma Davidsen
- Department of Prevention, Health Promotions & Community Care, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Mary de Groot
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Maartje de Wit
- Medical Psychology, Amsterdam Public Health, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | | | - Richard I G Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Karoline Kragelund Nielsen
- Department of Prevention, Health Promotions & Community Care, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Tejal Lathia
- Department of Endocrinology, Apollo Hospitals, Navi Mumbai, India
| | | | | | - Diana Naranjo
- Department of Pediatrics, Division of Endocrinology, Stanford School of Medicine, Palo Alto, CA, USA
| | - Rebecca L Pearl
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
| | - Suman Prinjha
- Leicester Diabetes Centre, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rebecca M Puhl
- Department of Human Development & Family Sciences, College of Liberal Arts & Sciences, University of Connecticut, Storrs, CT, USA
| | | | - Chitra Selvan
- Department of Endocrinology, Ramaiah Medical College, Bengaluru, India
| | - Jazz Sethi
- The Diabesties Foundation, Ahmedabad, India
| | - Mohammed Seyam
- Faculty of Medicine, Al-Quds University, Abu Dis, Palestine
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Mythily Subramaniam
- Institute of Mental Health Singapore, Singapore; Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Helle Terkildsen Maindal
- Department of Prevention, Health Promotions & Community Care, Copenhagen University Hospital-Steno Diabetes Center Copenhagen, Copenhagen, Denmark; Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Michael Vallis
- Department of Family Medicine, Dalhousie University, Halifax, NS, Canada
| | - Timothy C Skinner
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC, Australia; La Trobe Rural Health School, La Trobe University, Flora Hill, VIC, Australia; Department of Psychology, University of Copenhagen, Copenhagen, Denmark
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Dickinson JK, Bialonczyk D, Reece J, Kyle TK, Close KL, Nadglowski J, Johnson K, Garza M, Pash E, Chiquette E. Person-first language in diabetes and obesity scientific publications. Diabet Med 2023; 40:e15067. [PMID: 36786059 DOI: 10.1111/dme.15067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
AIMS We aimed to quantify the use of person-first language (PFL) among scholarly articles focusing on diabetes or obesity. METHODS PFL and condition-first language (CFL) terms for diabetes and obesity (e.g. diabetic, obese) were identified from existing guidelines and a review of the literature. Exact phrase literature searches were conducted between 2011 and 2020 and results were categorised as PFL, CFL or both. RESULTS Among diabetes articles, 43% used PFL, 40% used CFL and 17% contained both. Among obesity articles, 0.5% used PFL, 99% used CFL and 0.2% used both. The use of PFL increased by 3% per year for diabetes articles, compared to 117% for obesity articles. The rate of adoption of PFL in diabetes articles was unchanged in 2018-2020 compared to the 3 years prior. CONCLUSIONS While the use of person-first language in diabetes articles had increased over the review period, its rate of adoption has started to slow. Conversely, the use of PFL in obesity articles is nascent and increasing.
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Affiliation(s)
| | | | - Jessica Reece
- North Carolina Biotechnology Center, Durham, North Carolina, USA
| | | | | | | | | | - Matthew Garza
- The diaTribe Foundation, San Francisco, California, USA
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Schöps AM, Skinner TC, Fosgerau CF. Time to move beyond monological perspectives in health behavior change communication research and practice. Front Psychol 2023; 14:1070006. [PMID: 37342636 PMCID: PMC10278534 DOI: 10.3389/fpsyg.2023.1070006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 03/06/2023] [Indexed: 06/23/2023] Open
Abstract
Chronic disease self-management and health behavior change programs are becoming increasingly important to health service delivery to prevent the development of chronic disease and optimize health outcomes for those who suffer from it. To train people to deliver these programs effectively, we need to understand both the what and how of program delivery. While there is an abundant literature on what, and a merging evidence about what techniques to use, such as goals setting and self-monitoring, the literature on how programs should be delivered is less well developed. This paper reviews emerging research in this area and identifies an underlying monological approach. We argue that this currently dominant model cannot address the key issues in this area. By considering the theoretical framework of Dialogism, we introduce the method of Conversation Analysis to the field of behavior change interventions. Extensive research into health communication has endeavored to show the importance of language and the organization of interactions. We demonstrate and discuss how a monological approach to interventions prevents exploration of what professionals do to deliver intervention content. In doing so, we show that techniques do not account for how successfully an intervention is delivered.
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Affiliation(s)
- Antje Maria Schöps
- Department of Nordic Studies and Linguistics, University of Copenhagen, Copenhagen, Denmark
| | - Timothy Charles Skinner
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- Department of Psychology, La Trobe University, Bendigo, VIC, Australia
- Centre for Behavioural Research in Diabetes, Melbourne, VIC, Australia
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Borglit T, Krogsgaard M, Theisen SZ, Juel Rothmann M. Assessment of a support garment in parastomal bulging from a patient perspective: a qualitative study. Int J Qual Stud Health Well-being 2022; 17:2039428. [PMID: 35174778 PMCID: PMC8925919 DOI: 10.1080/17482631.2022.2039428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Trine Borglit
- Department of Surgery, Zealand University Hospital, Koege, Denmark
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People with type 2 diabetes' experiences of emotional support in Australian general practice: a qualitative study. BJGP Open 2022; 6:BJGPO.2022.0079. [PMID: 36109020 PMCID: PMC9904790 DOI: 10.3399/bjgpo.2022.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/24/2022] [Accepted: 09/09/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Diabetes distress, experienced by up to 40% of people with type 2 diabetes (T2D), is the negative emotional response to the burden of living with and managing diabetes. It is associated with suboptimal glycaemia and diabetes self-management. Research indicates that people with diabetes do not recall being asked about emotional distress by healthcare professionals. AIM To explore the experiences, needs, and expectations of people with T2D regarding emotional support received in Australian general practice. DESIGN & SETTING Exploratory qualitative study in Victoria, Australia. METHOD Semi-structured interviews were undertaken to explore emotional health and support received in general practice in 12 adults with T2D who primarily attend general practice. Interviews were audio-recorded, transcribed verbatim, and analysed using the framework approach. RESULTS The following three major themes were identified: (1) Beneath the surface of diabetes care; (2) Importance of GP-patient relationship; and (3) Communication counts. Participants experienced diabetes care as focused primarily on medical management rather than the emotional aspects of living with T2D. While people's experiences of diabetes care in general practice primarily focused on physical health, the GP care beyond the presenting complaint has an essential role in identifying emotional issues and enabling support. Emotional issues were more likely to be discussed and acknowledged by the GP where there was a long-standing relationship between GP and patient. CONCLUSION Pre-existing positive GP-patient relationships and supportive communication enable people with 2TD to raise emotional issues as part of diabetes care.
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Alzubaidi H, Namara KM, Samorinha C, Saidawi W, Versace VL, Speight J. Type 2 Diabetes Stigma Assessment Scale (DSAS-2): Cultural and linguistic adaptation and psychometric assessment of the Arabic version. Prim Care Diabetes 2022; 16:703-708. [PMID: 35965209 DOI: 10.1016/j.pcd.2022.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 06/21/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
Abstract
AIMS To culturally and linguistically adapt the Type 2 Diabetes Stigma Assessment Scale (DSAS-2) into Arabic and assess its psychometric properties. METHODS Following forward-backward translation of the DSAS-2, the Content Validity Index (CVI) was assessed. Cognitive debriefing and pilot testing were conducted with adults with T2DM. The Arabic DSAS-2 was included in a multi-center, cross-sectional study (N = 327) Arabic-speaking adults with type 2 diabetes. Psychometric analyses included exploratory and confirmatory factor analysis (EFA/CFA), internal consistency reliability, and convergent validity. RESULTS The Arabic DSAS-2 was considered appropriate, with an excellent CVI (0.98). Unforced EFA revealed a satisfactory three-factor structure, indicating the same subscales as the original instrument ('Treated differently', 'Blame and judgment', 'Self-stigma'). EFA for three factors showed good indicators (KMO=0.924; Bartlett's test of sphericity χ2 = 4063.709, df=171, p < 0.001). Internal consistency was satisfactory for both the three-factor structure (α = 0.91, α = 0.88, and α = 0.88, respectively) and the single factor (α = 0.94). CFA results were inconclusive. Although fit indices improved for the single-factor model, compared to the three-factor, they remained inadequate. The total scale demonstrated satisfactory convergent validity with self-esteem. CONCLUSIONS The Arabic DSAS-2 has excellent reliability and acceptable validity, supporting a three-factor structure as well as the use of a total score.
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Affiliation(s)
- Hamzah Alzubaidi
- Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, United Arab Emirates; Sharjah Institute for Medical Research, University of Sharjah, PO Box 27272, Sharjah, United Arab Emirates.
| | - Kevin Mc Namara
- School of Medicine, Deakin University, 75 Pigdons Rd, Waurn Ponds, Victoria 3216, Australia; Centre for Population Health Research, Deakin University, Burwood, Victoria 3125, Australia.
| | - Catarina Samorinha
- Sharjah Institute for Medical Research, University of Sharjah, PO Box 27272, Sharjah, United Arab Emirates.
| | - Ward Saidawi
- Sharjah Institute for Medical Research, University of Sharjah, PO Box 27272, Sharjah, United Arab Emirates.
| | - Vincent L Versace
- School of Medicine, Deakin Rural Health, Deakin University Faculty of Health, 75 Pigdons Rd, Waurn Ponds, Victoria 3216, Australia.
| | - Jane Speight
- Deakin University, School of Psychology, Geelong, Victoria, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia.
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13
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Svedbo Engström M, Johansson UB, Leksell J, Linder E, Eeg-Olofsson K. Implementing the Digital Diabetes Questionnaire as a Clinical Tool in Routine Diabetes Care: Focus Group Discussions With Patients and Health Care Professionals. JMIR Diabetes 2022; 7:e34561. [PMID: 35612885 PMCID: PMC9178456 DOI: 10.2196/34561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/27/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Diabetes Questionnaire is a digital patient-reported outcome and experience measure for adults living with diabetes. The Diabetes Questionnaire is intended for use in routine clinical visits in diabetes care and to enable patient perspectives to be integrated into the Swedish National Diabetes Register. The Diabetes Questionnaire was developed on the basis of patients' perspectives, and evidence for its measurement qualities has been demonstrated. Patients receive an invitation to complete the questionnaire before clinical visits, and the patient and health care professional (HCP) can discuss the findings, which are instantly displayed during the visit. Implementation processes for new tools in routine care need to be studied to understand the influence of contextual factors, the support needed, and how patients and HCPs experience clinical use. OBJECTIVE The aim of this study was to describe patients' and HCPs' experiences of initiating the use of the digital Diabetes Questionnaire as a clinical tool in routine diabetes care, supported by a structured implementation strategy involving initial education, local facilitators, and regular follow-ups. METHODS In this qualitative study, semistructured focus group discussions were conducted 12 months after the use of the Diabetes Questionnaire was initiated. Participants were diabetes specialist nurses and physicians (20 participants in 4 groups) at hospital-based outpatient clinics or primary health care clinics and adults with type 1 or type 2 diabetes (15 participants in 4 groups). The audiotaped transcripts were analyzed using inductive qualitative content analysis. RESULTS The results revealed 2 main categories that integrated patients' and HCPs' experiences, which together formed an overarching theme: While implementation demands new approaches, the Diabetes Questionnaire provides a broader perspective. The first main category (The Diabetes Questionnaire supports person-centered clinical visits) comprised comments expressing that the digital Diabetes Questionnaire can initiate and encourage reflection in preparation for clinical visits, bring important topics to light during clinical visits, and broaden the scope of discussion by providing additional information. The second main category (The process of initiating the implementation of the Diabetes Questionnaire) comprised comments that described differences in engagement among HCPs and their managers, challenges of establishing new routines, experiences of support during implementation, thoughts about the Diabetes Questionnaire, need to change local administrative routines, and opportunities and concerns for continued use. CONCLUSIONS The Diabetes Questionnaire can broaden the scope of health data in routine diabetes care. While implementation demands new approaches, patients and HCPs saw potential positive impacts of using the questionnaire at both the individual and group levels. Our results can inform further development of implementation strategies to support the clinical use of the questionnaire.
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Affiliation(s)
- Maria Svedbo Engström
- School of Health and Welfare, Dalarna University, Falun, Sweden.,Center for Clinical Research Dalarna, Uppsala University, Falun, Sweden
| | - Unn-Britt Johansson
- Sophiahemmet University, Stockholm, Sweden.,Department of Clinical Sciences and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Janeth Leksell
- Department of Medical Sciences, Clinical Diabetology and Metabolism, Uppsala University, Uppsala, Sweden
| | - Ebba Linder
- Swedish National Diabetes Register, Center of Registers Västra Götaland, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Swedish National Diabetes Register, Center of Registers Västra Götaland, Gothenburg, Sweden.,Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Sahlgrenska University Hospital, Gothenburg, Sweden
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14
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Abstract
Caitríona Cox and Zoë Fritz argue that outdated medical language that casts doubt, belittles, or blames patients jeopardises the therapeutic relationship and is overdue for change
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Affiliation(s)
- Caitríona Cox
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Zoë Fritz
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
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15
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Søholm U, Broadley M, Zaremba N, Divilly P, Nefs G, Mahmoudi Z, de Galan B, Pedersen-Bjergaard U, Brennan A, Pollard DJ, McCrimmon RJ, A Amiel S, Hendrieckx C, Speight J, Choudhary P, Pouwer F. Investigating the day-to-day impact of hypoglycaemia in adults with type 1 or type 2 diabetes: design and validation protocol of the Hypo-METRICS application. BMJ Open 2022; 12:e051651. [PMID: 35105572 PMCID: PMC8808414 DOI: 10.1136/bmjopen-2021-051651] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Hypoglycaemia is a frequent adverse event and major barrier for achieving optimal blood glucose levels in people with type 1 or type 2 diabetes using insulin. The Hypo-RESOLVE (Hypoglycaemia-Redefining SOLutions for better liVEs) consortium aims to further our understanding of the day-to-day impact of hypoglycaemia. The Hypo-METRICS (Hypoglycaemia-MEasurement, ThResholds and ImpaCtS) application (app) is a novel app for smartphones. This app is developed as part of the Hypo-RESOLVE project, using ecological momentary assessment methods that will minimise recall bias and allow for robust investigation of the day-to-day impact of hypoglycaemia. In this paper, the development and planned psychometric analyses of the app are described. METHODS AND ANALYSIS The three phases of development of the Hypo-METRICS app are: (1) establish a working group-comprising diabetologists, psychologists and people with diabetes-to define the problem and identify relevant areas of daily functioning; (2) develop app items, with user-testing, and implement into the app platform; and (3) plan a large-scale, multicountry study including interviews with users and psychometric validation. The app includes 7 modules (29 unique items) assessing: self-report of hypoglycaemic episodes (during the day and night, respectively), sleep quality, well-being/cognitive function, social interactions, fear of hypoglycaemia/hyperglycaemia and work/productivity. The app is designed for use within three fixed time intervals per day (morning, afternoon and evening). The first version was released mid-2020 for use (in conjunction with continuous glucose monitoring and activity tracking) in the Hypo-METRICS study; an international observational longitudinal study. As part of this study, semistructured user-experience interviews and psychometric analyses will be conducted. ETHICS AND DISSEMINATION Use of the novel Hypo-METRICS app in a multicountry clinical study has received ethical approval in each of the five countries involved (Oxford B Research Ethics Committee, CMO Region Arnhem-Nijmegen, Ethikkommission der Medizinischen Universität Graz, Videnskabsetisk Komite for Region Hovedstaden and the Comite Die Protection Des Personnes SUD Mediterranne IV). The results from the study will be published in peer review journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT04304963.
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Affiliation(s)
- Uffe Søholm
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Natalie Zaremba
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Patrick Divilly
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Giesje Nefs
- Department of Medical Psychology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Noord-Brabant, The Netherlands
- Diabeter, National treatment and research center for children, adolescents and adults with type 1 diabetes, Rotterdam, Netherlands
| | - Zeinab Mahmoudi
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Digital Therapeutics, Novo Nordisk A/S, Søborg, Denmark
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Division of Endocrinology and Metabolic Disease, Maastricht, Limburg, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology & Nephrology, Endocrine Section, Nordsjællands Hospital, Hillerød, Hillerød, Denmark
- Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| | - Alan Brennan
- School of Health & Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel John Pollard
- School of Health & Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Stephanie A Amiel
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Christel Hendrieckx
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Pratik Choudhary
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Diabetes Research Centre, University of Leicester, UK LE5 4PW, Leicester, UK
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Steno Diabetes Center Odense (SDCO), Odense, Denmark
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16
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Schmitt A, Kulzer B, Ehrmann D, Haak T, Hermanns N. A Self-Report Measure of Diabetes Self-Management for Type 1 and Type 2 Diabetes: The Diabetes Self-Management Questionnaire-Revised (DSMQ-R) – Clinimetric Evidence From Five Studies. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 2:823046. [PMID: 36994332 PMCID: PMC10012087 DOI: 10.3389/fcdhc.2021.823046] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 12/17/2021] [Indexed: 11/13/2022]
Abstract
AimsMeasurement tools to evaluate self-management behavior are useful for diabetes research and clinical practice. The Diabetes Self-Management Questionnaire (DSMQ) was introduced in 2013 and has become a widely used tool. This article presents a revised and updated version, DSMQ-R, and evaluates its properties in assessing self-management practices in type 1 diabetes (T1D) and type 2 diabetes (T2D).MethodsThe DSMQ-R is a multidimensional questionnaire with 27 items regarding essential self-management practices for T1D and T2D (including diabetes-adjusted eating, glucose testing/monitoring, medication taking, physical activity and cooperation with the diabetes team). For the revised form, the original items were partially amended and the wording was updated; eleven items were newly added. The tool was applied as part of health-related surveys in five clinical studies (two cross-sectional, three prospective) including a total of 1,447 people with T1D and T2D. Using this data base, clinimetric properties were rigorously tested.ResultsThe analyses showed high internal and retest reliability coefficients for the total scale and moderate to high coefficients for the subscales. Reliability coefficients for scales including the new items were consistently higher. Correlations with convergent criteria and related variables supported validity. Responsiveness was supported by significant short to medium term changes in prospective studies. Significant associations with glycemic outcomes were observed for DSMQ-R-assessed medication taking, glucose monitoring and eating behaviors.ConclusionsThe results support good clinimetric properties of the DSMQ-R. The tool can be useful for research and clinical practice and may facilitate the identification of improvable self-management practices in individuals.
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Affiliation(s)
- Andreas Schmitt
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Diabetes Center Mergentheim (DZM), Bad Mergentheim, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- *Correspondence: Andreas Schmitt,
| | - Bernhard Kulzer
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Diabetes Center Mergentheim (DZM), Bad Mergentheim, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
| | - Dominic Ehrmann
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Diabetes Center Mergentheim (DZM), Bad Mergentheim, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
| | - Thomas Haak
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Diabetes Center Mergentheim (DZM), Bad Mergentheim, Germany
| | - Norbert Hermanns
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Diabetes Center Mergentheim (DZM), Bad Mergentheim, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
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17
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Beverly EA, Hughes AS, Saunders A. Examination of Health Care Providers' Use of Language in Diabetes Care: A Secondary Qualitative Data Analysis. Clin Diabetes 2022; 40:434-441. [PMID: 36385976 PMCID: PMC9606549 DOI: 10.2337/cd21-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purpose of this secondary qualitative data analysis was to assess the frequency and context of stigmatizing language used by health care providers (HCPs). The authors conducted content and thematic analysis of in-depth face-to-face and telephone interviews with HCPs in southeastern Ohio. Participants frequently used labeling language, such as "diabetic" and "noncompliant," as well as language with negative connotations, such as "control," "testing," and "regimen." These findings offer a real-world glimpse of how HCPs communicate about people with diabetes in this region of the country.
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Affiliation(s)
- Elizabeth A. Beverly
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH
- Ohio University Diabetes Institute, Athens, OH
| | - Allyson S. Hughes
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH
- Ohio University Diabetes Institute, Athens, OH
| | - Amy Saunders
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH
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18
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Skovlund SE, Nicolucci A, Balk-Møller N, Berthelsen DB, Glümer C, Perrild H, Kjær P, Nørgaard LM, Troelsen LH, Pietraszek A, Hessler D, Kaplan S, Ejskjær N. Perceived Benefits, Barriers, and Facilitators of a Digital Patient-Reported Outcomes Tool for Routine Diabetes Care: Protocol for a National, Multicenter, Mixed Methods Implementation Study. JMIR Res Protoc 2021; 10:e28391. [PMID: 34477563 PMCID: PMC8449301 DOI: 10.2196/28391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/01/2021] [Accepted: 06/04/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND There is growing evidence that digital patient-reported outcome (PRO) questionnaires and PRO-based decision support tools may help improve the active engagement of people with diabetes in self-care, thereby improving the quality of care. However, many barriers still exist for the real-world effectiveness and implementation of such PRO tools in routine care. Furthermore, limited research has evaluated the acceptability, feasibility, and benefits of such tools across different health care settings. OBJECTIVE This study aims to evaluate the acceptability, feasibility, and perceived benefits of the Danish digital PRO diabetes tool in different health care settings in Denmark and to determine the factors affecting its implementation. Furthermore, the study evaluates the psychometric characteristics of the Danish PRO Diabetes Questionnaire and the validity of the scoring algorithms for dialogue support. The objective of this study is to guide the ongoing optimization of the PRO diabetes tool, its implementation, and the design of future randomized controlled effectiveness studies. METHODS We designed a multicenter, mixed methods, single-arm acceptability-feasibility implementation study protocol to contribute to the real-world pilot test of a new digital PRO diabetes tool in routine diabetes care. The use of the tool involves two main steps. First, the people with diabetes will complete a digital PRO Diabetes Questionnaire in the days before a routine diabetes visit. Second, the health care professional (HCP) will use a digital PRO tool to review the PRO results together with the people with diabetes during the visit. The PRO diabetes tool is designed to encourage and support people to take an active role for the people with diabetes in their own care and to expedite the delivery of person-centered, collaborative, and coordinated care. RESULTS A multicenter pilot study protocol and psychometrically designed digital data collection tools for evaluation were developed and deployed as part of a national evaluation of a new digital PRO diabetes intervention. A total of 598 people with diabetes and 34 HCPs completed the study protocol by April 1, 2021. CONCLUSIONS A large-scale, mixed methods, multicenter study for evaluating the use of the nationally developed PRO Diabetes Questionnaire in routine care across all health care sectors in Denmark by using the RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) model as a framework has been designed and is ongoing. This study is expected to provide new important and detailed information about the real-world acceptability, perceived relevance, and benefits of the PRO diabetes tool among a large heterogeneous population of people with diabetes in Denmark and HCPs in different care settings. The results will be used to further improve the PRO tool, design implementation facilitation support strategies, and design future controlled effectiveness studies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/28391.
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Affiliation(s)
- Søren Eik Skovlund
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Nina Balk-Møller
- PRO Secretariat, National Health Data Authority, Copenhagen, Denmark
| | - Dorthe B Berthelsen
- Department of Rehabilitation, Municipality of Guldborgsund, Nykoebing F, Denmark
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Charlotte Glümer
- Center for Diabetes, Copenhagen Municipality, Copenhagen, Denmark
| | - Hans Perrild
- Department of Endocrinology, Frederiksberg-Bisbebjerg Hospital, Copenhagen, Denmark
| | - Pernille Kjær
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Lise Havbæk Troelsen
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Anna Pietraszek
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Danielle Hessler
- Department of Family & Community Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Sherrie Kaplan
- School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Niels Ejskjær
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
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19
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Waller K, Furber S, Bauman A, Allman-Farinelli M, van den Dolder P, Hayes A, Facci F, Franco L, Webb A, Moses R, Cook R, Gugusheff J, Owen K, Colagiuri S. Effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management for people with type 2 diabetes. A randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2021; 104:1736-1744. [PMID: 33334634 DOI: 10.1016/j.pec.2020.11.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Determine the effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management behaviors for Australian adults with type 2 diabetes. METHODS Using intention to treat analysis and generalized estimating equations, this randomized controlled trial of 395 adults determined change in HbA1c at 3 and 6 months between the intervention and control group. Secondary outcomes included change in nutrition, physical activity, blood lipid profile, body mass index, quality of life, self-efficacy, medication taking and program acceptability. RESULTS No significant difference was observed between the intervention or control group for HbA1c at 3 months (P = 0.23) or 6 months (P = 0.22). Significant improvements were seen in consumption of vegetables at 3 months (P < 0.001) and 6 months (P = 0.04); fruit at 3 months (P = 0.046) and discretionary sweet foods at 3 months (P = 0.02). No other significant effects seen. The intervention demonstrated high rates of acceptability (94.0%) and minimal withdrawal (1.5%). CONCLUSIONS DTEXT was an acceptable text message intervention that improved some nutritional behaviors in people with type 2 diabetes, but did not significantly improve HbA1c or other outcomes. Further research is required to optimize DTEXT. PRACTICE IMPLICATIONS DTEXT provides an acceptable, feasible form of self-management support that may complement existing diabetes care.
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Affiliation(s)
- Karen Waller
- Health Promotion Service, Illawarra Shoalhaven Local Health District, Warrawong, Australia; School of Health and Society, University of Wollongong, Keiraville, Australia.
| | - Susan Furber
- Health Promotion Service, Illawarra Shoalhaven Local Health District, Warrawong, Australia; School of Public Health and Community Medicine, University of NSW, Kensington, Australia
| | - Adrian Bauman
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | - Paul van den Dolder
- Ambulatory and Primary Health Care, Illawarra Shoalhaven Local Health District, Warrawong, Australia
| | - Alison Hayes
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Franca Facci
- Integrated Chronic Disease Management Stream, Illawarra Shoalhaven Local Health District, Warrawong, Australia
| | - Lisa Franco
- Health Promotion Service, Illawarra Shoalhaven Local Health District, Warrawong, Australia
| | - Alison Webb
- Illawarra Shoalhaven Diabetes Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Robert Moses
- Illawarra Shoalhaven Diabetes Service, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Rebecca Cook
- Health Promotion Service, Illawarra Shoalhaven Local Health District, Warrawong, Australia
| | - Jessica Gugusheff
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Epidemiology and Evidence, NSW Ministry of Health, St Leonards, Australia
| | - Katherine Owen
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Stephen Colagiuri
- Boden Collaboration of Obesity, Nutrition, Exercise and Eating Disorders. University of Sydney, Sydney, Australia; WHO Collaborating Centre on Physical Activity, Nutrition and Obesity. University of Sydney, Sydney, Australia
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20
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J S, T C S, T D, T B, G K, C L, R S, G J. Our language matters: Improving communication with and about people with diabetes. A position statement by Diabetes Australia. Diabetes Res Clin Pract 2021; 173:108655. [PMID: 33422586 DOI: 10.1016/j.diabres.2021.108655] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/04/2021] [Indexed: 11/22/2022]
Abstract
The words used about diabetes affect the physical and emotional health of people living with diabetes. They also affect how individuals and society view people living with, or at risk of, diabetes. People with diabetes, their families, and people at risk of diabetes, need and deserve communications that are clear and accurate, respectful and inclusive, and free from judgement and bias. The aim of this position statement is to help bring about positive change in the language used about diabetes. It is based on 30+ years of research into the experiences of people with diabetes. Changing thelanguage of diabetes can make a powerful and positive difference to the emotional well-being, self-care and health outcomes of people affected by diabetes. It also affects community and government support for funding diabetes care, prevention and research. Diabetes Australia encourages everyone communicating about diabetes, or about people affected by diabetes, to choose and use their words carefully to support all people affected by diabetes. This position statement is intended as a guide for people working in healthcare, the media, government and policy, academia, industry, as well as employers and the community. It may also be helpful for the family and friends of people with diabetes.
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Affiliation(s)
- Speight J
- Deakin University, School of Psychology, Geelong, Victoria, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia.
| | - Skinner T C
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia; La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia; University of Copenhagen, Psychology, Copenhagen, Denmark
| | - Dunning T
- Deakin University, School of Nursing, Geelong, Victoria, Australia
| | - Black T
- Diabetes Australia, Canberra, ACT, Australia
| | - Kilov G
- University of Melbourne, Parkville, Victoria, Australia; Launceston Diabetes Clinic, Launceston, Tasmania, Australia
| | - Lee C
- Diabetes Australia, Canberra, ACT, Australia
| | - Scibilia R
- Diabetes Australia, Canberra, ACT, Australia
| | - Johnson G
- Diabetes Australia, Canberra, ACT, Australia
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Coates E, Amiel S, Baird W, Benaissa M, Brennan A, Campbell MJ, Chadwick P, Chater T, Choudhary P, Cooke D, Cooper C, Cross E, De Zoysa N, Eissa M, Elliott J, Gianfrancesco C, Good T, Hopkins D, Hui Z, Lawton J, Lorencatto F, Michie S, Pollard DJ, Rankin D, Schutter J, Scott E, Speight J, Stanton-Fay S, Taylor C, Thompson G, Totton N, Yardley L, Zaitcev A, Heller S. Protocol for a cluster randomised controlled trial of the DAFNE plus (Dose Adjustment For Normal Eating) intervention compared with 5x1 DAFNE: a lifelong approach to promote effective self-management in adults with type 1 diabetes. BMJ Open 2021; 11:e040438. [PMID: 33462097 PMCID: PMC7813353 DOI: 10.1136/bmjopen-2020-040438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/23/2020] [Accepted: 12/15/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION The successful treatment of type 1 diabetes (T1D) requires those affected to employ insulin therapy to maintain their blood glucose levels as close to normal to avoid complications in the long-term. The Dose Adjustment For Normal Eating (DAFNE) intervention is a group education course designed to help adults with T1D develop and sustain the complex self-management skills needed to adjust insulin in everyday life. It leads to improved glucose levels in the short term (manifest by falls in glycated haemoglobin, HbA1c), reduced rates of hypoglycaemia and sustained improvements in quality of life but overall glucose levels remain well above national targets. The DAFNEplus intervention is a development of DAFNE designed to incorporate behavioural change techniques, technology and longer-term structured support from healthcare professionals (HCPs). METHODS AND ANALYSIS A pragmatic cluster randomised controlled trial in adults with T1D, delivered in diabetes centres in National Health Service secondary care hospitals in the UK. Centres will be randomised on a 1:1 basis to standard DAFNE or DAFNEplus. Primary clinical outcome is the change in HbA1c and the primary endpoint is HbA1c at 12 months, in those entering the trial with HbA1c >7.5% (58 mmol/mol), and HbA1c at 6 months is the secondary endpoint. Sample size is 662 participants (approximately 47 per centre); 92% power to detect a 0.5% difference in the primary outcome of HbA1c between treatment groups. The trial also measures rates of hypoglycaemia, psychological outcomes, an economic evaluation and process evaluation. ETHICS AND DISSEMINATION Ethics approval was granted by South West-Exeter Research Ethics Committee (REC ref: 18/SW/0100) on 14 May 2018. The results of the trial will be published in a National Institute for Health Research monograph and relevant high-impact journals. TRIAL REGISTRATION NUMBER ISRCTN42908016.
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Affiliation(s)
- Elizabeth Coates
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Stephanie Amiel
- Department of Diabetes, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Wendy Baird
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Mohammed Benaissa
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield, UK
| | - Alan Brennan
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | | | - Tim Chater
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Pratik Choudhary
- Department of Diabetes, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Debbie Cooke
- Department of Diabetes, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Cindy Cooper
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Elizabeth Cross
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Mohammad Eissa
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield, UK
| | - Jackie Elliott
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Carla Gianfrancesco
- Diabetes Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Tim Good
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield, UK
| | - David Hopkins
- General and Emergency Medicine, King's College London, London, UK
| | - Zheng Hui
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Daniel John Pollard
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - David Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Elaine Scott
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Jane Speight
- The Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
| | | | - Carolin Taylor
- Diabetes Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Nikki Totton
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Lucy Yardley
- Academic Unit of Psychology, University of Southampton, Southampton, UK
| | - Aleksandr Zaitcev
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield, UK
| | - Simon Heller
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
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Patient decision aids in clinical practice for people with diabetes: a scoping review. Diabetol Int 2020; 11:344-359. [PMID: 33088642 DOI: 10.1007/s13340-020-00429-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
Background People with diabetes need to make regular choices that influence their long-term morbidity and mortality. Patient decision aids are validated tools and when used collaboratively between healthcare professionals, patients and carers, can help guide value-based discussions which encourage choices that are well informed and personally relevant. Objective To explore the use and effect of patient decision aids in the management of diabetes. Method A scoping review design was used. Medline, ProQuest, PsycINFO, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases were searched for peer-reviewed articles published between January 1998 and December 2018. Results Patient decision aids are not commonly or widely used in diabetes management. They offer a suitable adjunct to practice within the domains of healthcare knowledge, active participation, and communication, and shared decision-making between patients and healthcare professionals. Conclusion Patient decision aids can offer a simple and easy-to-use method to potentially improve diabetes health literacy, through the process of shared decision-making and two-way conversations. However, there are current limitations on using them to positively influence clinical outcomes or long-term changes in self-care behaviors within the management of diabetes. Further research to explore the validity of using patient decision aids long term in these areas is required.
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Speight J, Hendrieckx C, Pouwer F, Skinner TC, Snoek FJ. Back to the future: 25 years of 'Guidelines for encouraging psychological well-being' among people affected by diabetes. Diabet Med 2020; 37:1225-1229. [PMID: 31661183 DOI: 10.1111/dme.14165] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2019] [Indexed: 01/01/2023]
Affiliation(s)
- J Speight
- School of Psychology, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - C Hendrieckx
- School of Psychology, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - F Pouwer
- School of Psychology, Deakin University, Geelong, Australia
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- STENO Diabetes Centre, Odense, Denmark
| | - T C Skinner
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- STENO Diabetes Centre, Copenhagen, Denmark
| | - F J Snoek
- Department of Medical Psychology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, The Netherlands
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Baptista S, Wadley G, Bird D, Oldenburg B, Speight J. Acceptability of an Embodied Conversational Agent for Type 2 Diabetes Self-Management Education and Support via a Smartphone App: Mixed Methods Study. JMIR Mhealth Uhealth 2020; 8:e17038. [PMID: 32706734 PMCID: PMC7407258 DOI: 10.2196/17038] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 03/18/2020] [Accepted: 03/29/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Embodied conversational agents (ECAs) are increasingly used in health care apps; however, their acceptability in type 2 diabetes (T2D) self-management apps has not yet been investigated. OBJECTIVE This study aimed to evaluate the acceptability of the ECA (Laura) used to deliver diabetes self-management education and support in the My Diabetes Coach (MDC) app. METHODS A sequential mixed methods design was applied. Adults with T2D allocated to the intervention arm of the MDC trial used the MDC app over a period of 12 months. At 6 months, they completed questions assessing their interaction with, and attitudes toward, the ECA. In-depth qualitative interviews were conducted with a subsample of the participants from the intervention arm to explore their experiences of using the ECA. The interview questions included the participants' perceptions of Laura, including their initial impression of her (and how this changed over time), her personality, and human character. The quantitative and qualitative data were interpreted using integrated synthesis. RESULTS Of the 93 intervention participants, 44 (47%) were women; the mean (SD) age of the participants was 55 (SD 10) years and the baseline glycated hemoglobin A1c level was 7.3% (SD 1.5%). Overall, 66 of the 93 participants (71%) provided survey responses. Of these, most described Laura as being helpful (57/66, 86%), friendly (57/66, 86%), competent (56/66, 85%), trustworthy (48/66, 73%), and likable (40/66, 61%). Some described Laura as not real (18/66, 27%), boring (26/66, 39%), and annoying (20/66, 30%). Participants reported that interacting with Laura made them feel more motivated (29/66, 44%), comfortable (24/66, 36%), confident (14/66, 21%), happy (11/66, 17%), and hopeful (8/66, 12%). Furthermore, 20% (13/66) of the participants were frustrated by their interaction with Laura, and 17% (11/66) of the participants reported that interacting with Laura made them feel guilty. A total of 4 themes emerged from the qualitative data (N=19): (1) perceived role: a friendly coach rather than a health professional; (2) perceived support: emotional and motivational support; (3) embodiment preference acceptability of a human-like character; and (4) room for improvement: need for greater congruence between Laura's words and actions. CONCLUSIONS These findings suggest that an ECA is an acceptable means to deliver T2D self-management education and support. A human-like character providing ongoing, friendly, nonjudgmental, emotional, and motivational support is well received. Nevertheless, the ECA can be improved by increasing congruence between its verbal and nonverbal communication and accommodating user preferences. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry CTRN12614001229662; https://tinyurl.com/yxshn6pd.
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Affiliation(s)
- Shaira Baptista
- The University of Melbourne, Melbourne, Australia.,The Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
| | - Greg Wadley
- The University of Melbourne, Melbourne, Australia
| | | | | | - Jane Speight
- The University of Melbourne, Melbourne, Australia.,The Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia
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- see Authors' Contributions,
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25
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deMolitor L, Dunbar M, Vallis M. Diabetes Distress in Adults Living With Type 1 and Type 2 Diabetes: A Public Health Issue. Can J Diabetes 2020; 44:549-554. [PMID: 32690277 DOI: 10.1016/j.jcjd.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 06/10/2020] [Accepted: 06/15/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Lisa deMolitor
- Nova Scotia Health Authority, Kentville, Nova Scotia, Canada.
| | - Margaret Dunbar
- Diabetes Care Program of Nova Scotia, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Michael Vallis
- Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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26
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Hansen UM, Olesen K, Willaing I. Diabetes stigma and its association with diabetes outcomes: a cross-sectional study of adults with type 1 diabetes. Scand J Public Health 2020; 48:855-861. [PMID: 32338563 DOI: 10.1177/1403494819862941] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims: The aim of this study was to investigate the relationship between diabetes stigma as experienced by adults with type 1 diabetes and diabetes outcomes using the novel, validated measure of the Type 1 Diabetes Stigma Assessment Scale. Methods: A total of 1594 adults with type 1 diabetes completed a questionnaire on socio-economic factors, psychosocial health, and diabetes stigma and these self-reported data were linked with data from electronic clinical records on glycaemic control, diabetes duration, age, and diabetes-related complications. Bivariate analyses and multivariate linear regressions were performed to assess the relationship between diabetes stigma as measured by three subscales, Identity concern, Blame and judgement, and Treated differently on the one hand, and patient characteristics and diabetes outcomes on the other. Results: Endorsement of the stigma statements ranged from 3.6-78.3% of respondents. Higher stigma scores in relation to Identity concern and Blame and judgement were significantly associated with being female, of lower age, lower diabetes duration, and having at least one complication. Those who reported higher levels of perceived stigma reported significantly higher levels of diabetes distress (β = 0.37 (95% CI: 0.33-0.40), 0.35 (95% CI: 0.30-0.39), 0.41 (95% CI: 0.35-0.46)), and HbA1c levels (β = 0.11 (95% CI: 0.02-0.21), 0.28 (95% CI: 0.16-0.40), 0.26 (95% CI: 0.14-0.42) for Identity concern, Blame and judgement, and Treated differently, respectively). Conclusions: The findings demonstrated that diabetes stigma is negatively associated with both diabetes distress and glycaemic control and should be considered part of the psychosocial burden of adults with type 1 diabetes.
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27
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Halliday JA, Speight J, Bennet A, Beeney LJ, Hendrieckx C. The Diabetes and Emotional Health Handbook and Toolkit for Health Professionals Supporting Adults With Type 1 and Type 2 Diabetes: Formative Evaluation. JMIR Form Res 2020; 4:e15007. [PMID: 32130112 PMCID: PMC7060499 DOI: 10.2196/15007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/08/2019] [Accepted: 10/22/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Health professionals have expressed unmet needs, including lacking the skills, confidence, training, and resources needed to properly attend to the psychological needs of people with diabetes. OBJECTIVE Informed by needs assessments, this study aimed to develop practical, evidence-based resources to support health professionals to address the emotional needs of adults with type 1 or type 2 diabetes. METHODS We developed a new handbook and toolkit informed by formative evaluation, including literature reviews, stakeholder consultation and review, and a qualitative study. In the qualitative study, health professionals participated in interviews after reading sections of the handbook and toolkit. RESULTS The literature review uncovered that psychological problems are common among adults with diabetes, but health professionals lack resources to provide related support. We planned and drafted resources to fill this unmet need, guided by stakeholder consultation and an Expert Reference Group (ERG). Before finalizing the resources, we implemented feedback received from stakeholders (ERG, health professionals, academics, and people with diabetes). The resulting resources were the practical, evidence-based Diabetes and Emotional Health handbook and toolkit. A total of 19 health professionals took part in the qualitative study about the handbook and toolkit. They viewed the resources favorably, felt empowered to support people with diabetes experiencing psychological problems, and felt motivated to share the resources with others. Some gave examples of how they had used the handbook in clinical practice. A perceived highlight was the inclusion of a process model outlining 7 steps for identifying and supporting people with emotional problems: the 7 A's model. With funding from the National Diabetes Services Scheme (NDSS), more than 2400 copies of Diabetes and Emotional Health have been distributed. It is freely available on the Web. The NDSS is an initiative of the Australian Government administered with the assistance of Diabetes Australia. CONCLUSIONS The new evidence-based resources are perceived by stakeholders as effective aids to assist health professionals in providing emotional support to adults with diabetes. The 7 A's model may have clinical utility for routine monitoring of other psychological and health-related problems, as part of person-centered clinical care.
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Affiliation(s)
- Jennifer A Halliday
- School of Psychology, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- Applied Health Psychology Research, Hornchurch, Essex, United Kingdom
| | - Andrea Bennet
- School of Psychology, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - Linda J Beeney
- Sydney Medical School, The University of Sydney, Sydney, Australia
- Diabetes & Medical Psychology Services, Normanhurst, Australia
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
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28
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Murphy ME, McSharry J, Byrne M, Boland F, Corrigan D, Gillespie P, Fahey T, Smith SM. Supporting care for suboptimally controlled type 2 diabetes mellitus in general practice with a clinical decision support system: a mixed methods pilot cluster randomised trial. BMJ Open 2020; 10:e032594. [PMID: 32051304 PMCID: PMC7045235 DOI: 10.1136/bmjopen-2019-032594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES We developed a complex intervention called DECIDE (ComputeriseD dECisIonal support for suboptimally controlleD typE 2 Diabetes mellitus in Irish General Practice) which used a clinical decision support system to address clinical inertia and support general practitioner (GP) intensification of treatment for adults with suboptimally controlled type2 diabetes mellitus (T2DM). The current study explored the feasibility and potential impact of DECIDE. DESIGN A pilot cluster randomised controlled trial. SETTING Conducted in 14 practices in Irish General Practice. PARTICIPANTS The DECIDE intervention was targeted at GPs. They applied DECIDE to patients with suboptimally controlled T2DM, defined as a glycated haemoglobin (HbA1c) ≥70 mmol/mol and/or blood pressure ≥150/95 mmHg. INTERVENTION The intervention incorporated training and a web-based clinical decision support system which supported; (i) medication intensification actions; and (ii) non-pharmacological actions to support care. Control practices delivered usual care. PRIMARY AND SECONDARY OUTCOME MEASURES Feasibility and acceptability was determined using thematic analysis of semi-structured interviews with GPs, combined with data from the DECIDE website. Clinical outcomes included HbA1c, medication intensification, blood pressure and lipids. RESULTS We recruited 14 practices and 134 patients. At 4-month follow-up, all practices and 114 patients were followed up. GPs reported finding decision support helpful navigating increasingly complex medication algorithms. However, the majority of GPs believed that the target patient group had poor engagement with GP and hospital services for a range of reasons. At follow-up, there was no difference in glycaemic control (-3.6 mmol/mol (95% CI -11.2 to 4.0)) between intervention and control groups or in secondary outcomes including, blood pressure, total cholesterol, medication intensification or utilisation of services. Continuation criteria supported proceeding to a definitive randomised trial with some modifications. CONCLUSION The DECIDE study was feasible and acceptable to GPs but wider impacts on glycaemic and blood pressure control need to be considered for this patient population going forward. TRIAL REGISTRATION NUMBER ISRCTN69498919.
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Affiliation(s)
- Mark E Murphy
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Jenny McSharry
- Health Behaviour Change Research Group, School of Psycology, NUI Galway, Galway, Ireland
| | - Molly Byrne
- Health Behaviour Change Research Group, School of Psycology, NUI Galway, Galway, Ireland
| | - Fiona Boland
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Derek Corrigan
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Paddy Gillespie
- School of Business and Economics, National University of Ireland, Galway, Ireland
| | - Tom Fahey
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Susan M Smith
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
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29
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Swarna Nantha Y, Haque S, Paul Chelliah AA, Md Zain AZ, Kim Yen G. The Internal Realities of Individuals With Type 2 Diabetes: Mediators Influencing Self-Management Beliefs via Grounded Theory Approach. J Prim Care Community Health 2020; 11:2150132719900710. [PMID: 32009509 PMCID: PMC7257383 DOI: 10.1177/2150132719900710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/14/2020] [Indexed: 12/12/2022] Open
Abstract
Background: There has been an unabated rise in the prevalence of type 2 diabetes (T2D) worldwide. Although T2D is highly preventable, these trends suggest that a paradigm change is much needed in the way both clinicians and policy makers view what effective T2D strategies conventionally entail. Hence, it is becoming increasingly clear that T2D patients require more than just a pharmacological approach to their disease. Evidence indicate that culturally specific mediators can help foster better self-management practices. We intend to discover psychosocial mediators that influence and support self-management beliefs in T2D patients. Methods: We adopted the grounded theory approach to guide in-depth interviews with T2D patients and health care professionals (HCP) at a regional primary care clinic in Malaysia. Twenty-four T2D patients and 10 HCPs were recruited through purposive sampling method to examine the inner psychological narratives about how they perceive and what they believe beliefs about the disease. Two focus group discussions were also were conducted for data triangulation. Results: A functional framework for the psychosocial mediators influencing self-management beliefs in T2D patients was designed and characterized by 4 major processes: (1) health promotion, (2) personal expectations, (3) person-centered care, and (4) psychosocial support. The fulfillment of patients' personal expectations is central to better self-management beliefs. Conclusions: Positive emotional states are important in providing a positive environment to nurture self-management practices. A person-centered consultation that focuses on empathy and cultural sensitivities has the potential to foster behavioral change required to sustain self-care practices.
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Affiliation(s)
- Yogarabindranath Swarna Nantha
- Seremban Primary Health Care Clinic, Jalan Rasah, Seremban, Negeri Sembilan, Malaysia
- Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Shamsul Haque
- Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | | | | | - Gan Kim Yen
- Seremban Primary Health Care Clinic, Jalan Rasah, Seremban, Negeri Sembilan, Malaysia
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30
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O'Donnell S, Lewis D, Marchante Fernández M, Wäldchen M, Cleal B, Skinner T, Raile K, Tappe A, Ubben T, Willaing I, Hauck B, Wolf S, Braune K. Evidence on User-Led Innovation in Diabetes Technology (The OPEN Project): Protocol for a Mixed Methods Study. JMIR Res Protoc 2019; 8:e15368. [PMID: 31742563 PMCID: PMC6891827 DOI: 10.2196/15368] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/22/2019] [Accepted: 10/30/2019] [Indexed: 01/24/2023] Open
Abstract
Background Digital innovations in health care have traditionally followed a top-down pathway, with manufacturers leading the design and production of technology-enabled solutions and those living with chronic conditions involved only as passive recipients of the end product. However, user-driven open-source initiatives in health care are becoming increasingly popular. An example is the growing movement of people with diabetes, who create their own “Do-It-Yourself Artificial Pancreas Systems” (DIYAPS). Objective The overall aim of this study is to establish the empirical evidence base for the clinical effectiveness and quality-of-life benefits of DIYAPS and identify the challenges and possible solutions to enable their wider diffusion. Methods A research program comprising 5 work packages will examine the outcomes and potential for scaling up DIYAPS solutions. Quantitative and qualitative methodologies will be used to examine clinical and self-reported outcome measures of DIYAPS users. The majority of members of the research team live with type 1 diabetes and are active DIYAPS users, making Outcomes of Patients’ Evidence With Novel, Do-It-Yourself Artificial Pancreas Technology (OPEN) a unique, user-driven research project. Results This project has received funding from the European Commission’s Horizon 2020 Research and Innovation Program, under the Marie Skłodowska-Curie Action Research and Innovation Staff Exchange. Researchers with both academic and nonacademic backgrounds have been recruited to formulate research questions, drive the research process, and disseminate ongoing findings back to the DIYAPS community and other stakeholders. Conclusions The OPEN project is unique in that it is a truly patient- and user-led research project, which brings together an international, interdisciplinary, and intersectoral research group, comprising health care professionals, technical developers, biomedical and social scientists, the majority of whom are also living with diabetes. Thus, it directly addresses the core research and user needs of the DIYAPS movement. As a new model of cooperation, it will highlight how researchers in academia, industry, and the patient community can create patient-centric innovation and reduce disease burden together. International Registered Report Identifier (IRRID) PRR1-10.2196/15368
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Affiliation(s)
- Shane O'Donnell
- School of Sociology, University College Dublin, Belfield, Ireland
| | | | | | - Mandy Wäldchen
- School of Sociology, University College Dublin, Belfield, Ireland
| | - Bryan Cleal
- Diabetes Management Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Timothy Skinner
- Diabetes Management Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Institut for Psykologi, Københavns Universitet, Copenhagen, Denmark
| | - Klemens Raile
- Department of Paediatric Endocrinology and Diabetes, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tebbe Ubben
- AndroidAPS, Vienna, Austria.,#dedoc° Diabetes Online Community, Berlin, Germany
| | - Ingrid Willaing
- Diabetes Management Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | | | - Saskia Wolf
- #dedoc° Diabetes Online Community, Berlin, Germany
| | - Katarina Braune
- Department of Paediatric Endocrinology and Diabetes, Charité - Universitätsmedizin Berlin, Berlin, Germany
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31
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Bednarek M, Carr G. Diabetes coverage in Australian newspapers (2013-2017): A computer-based linguistic analysis. Health Promot J Austr 2019; 31:497-503. [PMID: 31520565 DOI: 10.1002/hpja.295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/25/2019] [Accepted: 09/10/2019] [Indexed: 11/09/2022] Open
Abstract
ISSUE ADDRESSED This study analysed diabetes coverage in 12 Australian metropolitan/national newspapers over a period of 5 years (2013-2017). It aimed to describe quantitative tendencies in diabetes coverage (amount of articles per newspaper and over time) and to identify potential discrepancies between diabetes coverage and societal prevalence of diabetes. The study addressed the following research questions, with a focus on language use: How frequent are mentions of different types of diabetes? How are people with diabetes referred to? How frequent and how distributed are mentions of Aboriginal and Torres Strait Islander people and matters? METHODS Data were collected in electronic format, manually classified and processed using a specialised software program, with a focus on quantitative analysis. RESULTS 577 articles were classified as news and 117 were classified as "non-news." The Australian Financial Review published the fewest items, followed by the NT News, while the West Australian and the Advertiser published the most. References to "type 2" appear slightly more frequent and more distributed than to "type 1" diabetes. The labelling of people with the noun diabetic/s occurs in about a quarter of the dataset. References to Aboriginal and Torres Strait Islander people or matters appear to be extremely rare in the analysed dataset. CONCLUSIONS Diabetes coverage does not fully align with incidence of diabetes among Australians, and problematic language practices such as the labelling of people as "diabetics" continue to occur. SO WHAT?: Given the agenda-setting function of the news media, new strategies may be needed to change how Australian metropolitan and national newspapers cover diabetes, especially in relation to incorporating Aboriginal and Torres Strait Islander voices and perspectives.
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Affiliation(s)
- Monika Bednarek
- Department of Linguistics, The University of Sydney, Sydney, Australia
| | - Georgia Carr
- Department of Linguistics, The University of Sydney, Sydney, Australia
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Skovlund SE, Lichtenberg TH, Hessler D, Ejskjaer N. Can the Routine Use of Patient-Reported Outcome Measures Improve the Delivery of Person-Centered Diabetes Care? A Review of Recent Developments and a Case Study. Curr Diab Rep 2019; 19:84. [PMID: 31420754 DOI: 10.1007/s11892-019-1190-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW In recent years, the recommendation for and use of patient-reported outcome measures (PROMs) in routine diabetes care has significantly increased. We review recent evidence and highlight key opportunities and challenges related to the active clinical use of PROMs to support person-centered diabetes care and focus areas for future research in the area. RECENT FINDINGS Recent pragmatic studies support that integration of multi-dimensional PROMs for diabetes in clinical care as part of a care improvement strategy can be acceptable for and valued by people with diabetes (PWD) and healthcare professionals (HCPs) and may improve multiple aspects of quality of care, including screening, medical care monitoring and decision support, individualization of self-management support and goal-setting, and broader benefits related to active patient participation and person-centred diabetes care. We identify multiple intervention, individual, and care setting characteristics, which influence acceptability, feasibility, implementation, and effectiveness of PROMs in routine care. Recent clinical PROM studies highlight the value of mixed methods research and systematic involvement of PWD, clinicians, and other stakeholders in the design and implementation of questionnaires for patient input in routine diabetes care. We identified a new significant trend towards participatory development of multi-dimensional PROMs with the aim of IT-enabled integration into routine diabetes care to facilitate multiple components of person-centered diabetes care and better clinical, quality of life, and cost outcomes. While results from large-scale randomized controlled studies are still limited, a growing number of pragmatic implementation studies support that user-centric PROM interventions have the potential to facilitate significant improvements in care for PWD.
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Affiliation(s)
- Soren E Skovlund
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, DK-9000, Aalborg, Denmark.
| | | | - D Hessler
- Family & Community Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - N Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, DK-9000, Aalborg, Denmark
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Skinner T, Byrne M, Dickinson JK, Fisher L, Funnell M, Guzman S, Hendrieckx C, Hermanns N, Kanc K, Lloyd C, Mocan A, Nouwen A, Pouwer F, Saleh-Stattin N, Snoek F, Speight J, Sturt J, Vallis M, Wagner J, Willaing I, Young-Hyman D, Zoffmann V. Comment on the consensus report on the management of hyperglycaemia in Type 2 diabetes by the American Diabetes Association and the European Association for the Study of Diabetes. Diabet Med 2019; 36:911-912. [PMID: 30785642 DOI: 10.1111/dme.13934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- T Skinner
- University of Copenhagen, Denmark
- Steno Diabetes Centre Copenhagen, Denmark
| | - M Byrne
- School of Psychology, National University of Ireland, Galway, Ireland
| | - J K Dickinson
- Diabetes Education and Management, Teachers College Columbia University, New York, NY, USA
| | - L Fisher
- Family and Community Medicine, University of California San Francisco, San Francisco, LA, USA
| | - M Funnell
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - S Guzman
- Behavioural Diabetes Institute, San Diego, CA, USA
| | - C Hendrieckx
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
- Deakin University, Australia
| | - N Hermanns
- Jazindiabetes, (Diabetes & Me), Slovenia
| | - K Kanc
- Forschungsinstitut Diabetes-Akademie, Bad Mergentheim, Germany
| | - C Lloyd
- Open University, Milton Keynes, UK
| | - A Mocan
- Emergency Clinical County Hospital, Cluj-Napoca, Romania
| | - A Nouwen
- Middlesex University, London, UK
| | - F Pouwer
- University of Southern Denmark, Odense, Denmark
| | | | - F Snoek
- Amsterdam UMC, Amsterdam, Netherlands
| | - J Speight
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Victoria, Australia
- Deakin University, Australia
| | - J Sturt
- Florence Nightingale Faculty of Nursing and Midwifery, Kings College London, London, UK
| | - M Vallis
- Dalhousie University, Halifax, Canada
| | - J Wagner
- Behavioral Sciences and Community Health, University of Connecticut Health Center, Farmington, CT, USA
| | - I Willaing
- Steno Diabetes Centre Copenhagen, Denmark
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Joensen L, Fisher L, Skinner T, Doherty Y, Willaing I. Integrating psychosocial support into routine diabetes care: perspectives from participants at the Self-Management Alliance meeting 2016. Diabet Med 2019; 36:847-853. [PMID: 30315608 DOI: 10.1111/dme.13836] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2018] [Indexed: 01/09/2023]
Abstract
AIMS To identify challenges and solutions to integrating psychosocial support into routine diabetes care from the perspective of stakeholders with expertise in diabetes self-management education and support. METHODS Ninety-four people attended the annual international Diabetes Self-Management Alliance meeting in 2016, which included plenary sessions and workshops on self-management education, support and prevention. One workshop focused on how to integrate psychosocial support into routine diabetes care; this was run four times consecutively, allowing all conference participants to attend the workshops in groups of 20-25 people. RESULTS Challenges and solutions associated with integrating psychosocial support into routine diabetes care concern the patient-provider relationship, the healthcare system and the community. Challenges identified were: lack of time, skills and resources to deal with psychological well-being; a culture of patient blame and care expectations; the complexity of person-centred assessment of psychological issues; and the substantial healthcare system focus on productivity and biomedical indicators. Lack of involvement of local communities and of inclusion of social determinants of health were also highlighted as challenging. Solutions identified were more patient-provider dialogue; more training and better skills among care providers; system incentives for psychosocial outcomes; and targeting social determinants of health and involvement of family and peers. CONCLUSIONS From the perspective of international stakeholders with an expertise in diabetes self-management and support attending the conference in Denmark, substantial new incentives and systematic cultural changes are needed in healthcare systems to integrate psychosocial support into routine diabetes care, as recommended in international guidelines.
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Affiliation(s)
- L Joensen
- Department of Health Promotion, Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - L Fisher
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - T Skinner
- Department of Psychology, Faculty of Social Sciences, University of Copenhagen, Denmark
| | - Y Doherty
- Department of Psychological Medicine, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - I Willaing
- Department of Health Promotion, Steno Diabetes Center Copenhagen, Copenhagen, Denmark
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Villalba C, Jaiprakash A, Donovan J, Roberts J, Crawford R. Unlocking the Value of Literature in Health Co-Design: Transforming Patient Experience Publications into a Creative and Accessible Card Tool. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 11:637-648. [PMID: 29802539 DOI: 10.1007/s40271-018-0315-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND A wealth of peer-reviewed data exists regarding people's health experience, yet practical ways of using the data to understand patients' experiences and to inform health co-design are needed. OBJECTIVE This study aims to develop an applied and pragmatic method for using patient experience literature in co-design by transforming it into an accessible and creative co-design tool. METHOD A scoping literature review of the CINAHL, MEDLINE, PsycINFO and PubMed electronic databases was conducted from January 2011 through August 2016. Qualitative publications regarding the experience of living with diabetes in Australia were selected. The Results section of each paper was extracted and affinity analysis was applied to identify insights into the health experience. These insights were developed into a card tool for use in health co-design activities. RESULTS Thirteen relevant papers were identified from the review, and affinity analysis of the Results sections of these papers lead to the identification of 85 insights, from 'Shock of diagnosis' (Insight 1), to 'Delay seeking care' (Insight 9), to 'Assess the quality of care' (Insight 28), to 'Avoid or adapt habits' (Insight 78). Each insight was developed into an individual card, which included a high-level theme, insight, quote and a link back to the literature, together making up the Health Experience Insight Cards, Living with Diabetes Edition. CONCLUSIONS This was the first study to develop a method for transforming existing patient experience literature into a creative tool for health improvement. The Health Experience Insight Cards collate the diverse experiences of over 300 people living with diabetes in Australia, from 13 studies. Health improvement teams can use the 'Living with Diabetes Edition' cards or they can follow this pragmatic method to create their own cards focused on other health experiences to facilitate person-focused health improvements.
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Affiliation(s)
- Clare Villalba
- Medical and Healthcare Robotics, Queensland University of Technology, Brisbane, QLD, Australia
| | - Anjali Jaiprakash
- Medical and Healthcare Robotics, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Jared Donovan
- Design Lab, Creative Industries Faculty, Queensland University of Technology, Brisbane, QLD, Australia
| | - Jonathan Roberts
- Medical and Healthcare Robotics, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ross Crawford
- Medical and Healthcare Robotics, Prince Charles Hospital, Queensland University of Technology, Brisbane, QLD, Australia
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Abstract
Pharmacy data reveal that 70% of patients were missing one or more days worth of drops out of five. Adopting approaches to behavior change and management skills used for people with diabetes may provide insight to improve self-management of glaucoma. Every person who is diagnosed with a chronic health condition such as glaucoma has unique life circumstances that may present barriers to behavior change. An accurate diagnosis and a treatment plan are useless if patients do not use their prescribed eye drops. Active listening and effective communication can result in persons who are more engaged in their self-care behaviors. Collaborative communication using person-centered and strengths-based messages could help eye care providers identify challenges and concerns for people with glaucoma who are experiencing inconsistencies with their eye drops. In an atmosphere where patients can discuss their challenges with treatment recommendations without judgment or fear, they are more likely to trust their provider and therefore share their situation openly and honestly. This is accomplished by choosing language that communicates mutually-agreed-upon self-management goals and addresses and strengthens individual and clinical outcomes. The eye care professional is then seen by the patient as a resource who can empathize when setbacks occur and reinforce the patient's self-management goals. Open-ended questions and tell-ask-tell approaches for identifying barriers to care are keys to more effective communication and trusting relationships. This includes recognizing that glaucoma is associated with increased rates of anxiety or depression that may be an overlooked barrier to self-management. By adopting language recommendations from diabetes care and education, eye care practitioners may be better equipped to help people with glaucoma improve their self-care.
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Beeney LJ, Fynes-Clinton EJ. The Language of Diabetes Complications: Communication and Framing of Risk Messages in North American and Australasian Diabetes-Specific Media. Clin Diabetes 2019; 37:116-123. [PMID: 31057217 PMCID: PMC6468819 DOI: 10.2337/cd18-0024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
IN BRIEF Reducing the risk of diabetes complications requires the delivery of accurate and constructive information for people with diabetes to make informed self-management choices. This article reports on a study assessing the language and framing of risk messages about long-term complications featured in publications produced by North American and Australasian diabetes organizations. Findings highlight problems with the language, content, and framing of messages about risk of long-term diabetes complications presented by diabetes-specific media. These poorly communicated messages may be contributing to distorted perceptions of complications risk and diabetes distress and may interfere with optimal self-management.
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Affiliation(s)
- Linda J. Beeney
- Sydney Medical School, The University of Sydney, Sydney, Australia
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38
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Waller K, Furber S, Bauman A, Allman-Farinelli M, van den Dolder P, Hayes A, Facci F, Franco L, Webb A, Moses R, Colagiuri S. DTEXT - text messaging intervention to improve outcomes of people with type 2 diabetes: protocol for randomised controlled trial and cost-effectiveness analysis. BMC Public Health 2019; 19:262. [PMID: 30832638 PMCID: PMC6399841 DOI: 10.1186/s12889-019-6550-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/15/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Diabetes prevalence is rapidly increasing, with type 2 diabetes predicted to be the leading contributor of non-communicable disease in Australia by 2020. It is anticipated that rates of type 2 diabetes will continue to increase if factors such as overweight and obesity, low physical activity and poor nutrition are not addressed. The majority of Australians with type 2 diabetes do not meet the guidelines for optimal diabetes management, and access to diabetes education is limited. This highlights the need for new interventions that can reduce existing barriers to diabetes education, attain greater population reach and support self-management strategies for people with type 2 diabetes. Mobile phone text messages have shown promising results as an intervention for people with chronic disease. They have the ability to achieve high levels of engagement and broad population reach, whilst requiring minimal resources. There is however, no evidence on the effect of text messaging to improve the health of people with type 2 diabetes in Australia. METHODS/DESIGN This randomised controlled trial aims to investigate if a 6 month text message intervention (DTEXT) can lead to improvements in glycated haemoglobin (HbA1c) and diabetes self-management among Australian residents in New South Wales (NSW) with type 2 diabetes. Community dwelling adults (n = 340) will be recruited with the primary outcome being change in HbA1c at 6 months. Secondary outcomes include behaviour change for diabetes self-management, self-efficacy, quality of life and intervention acceptability. An economic evaluation will be conducted using a funder plus patient perspective. DISCUSSION This study will provide evidence on the effectiveness and cost effectiveness of a text message intervention to reduce HbA1c and enhance self-management of type 2 diabetes in the Australian population. If successful, this intervention could be used as a model to complement and extend existing diabetes care in the Australian health care system. TRIAL REGISTRATION The study has been registered with the Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617000416392 . Registered: 23 March 2017.
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Affiliation(s)
- Karen Waller
- Illawarra Shoalhaven Local Health District, Warrawong, Australia.
| | - Susan Furber
- Illawarra Shoalhaven Local Health District, Warrawong, Australia
| | | | | | | | | | - Franca Facci
- Illawarra Shoalhaven Local Health District, Warrawong, Australia
| | - Lisa Franco
- Illawarra Shoalhaven Local Health District, Warrawong, Australia
| | - Alison Webb
- Illawarra Shoalhaven Local Health District, Warrawong, Australia
| | - Robert Moses
- Illawarra Shoalhaven Local Health District, Warrawong, Australia
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39
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Latchman L. Putting People First. Home Healthc Now 2019; 37:116. [PMID: 30829789 DOI: 10.1097/nhh.0000000000000762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Lellieth Latchman
- Lellieth Latchman, RD, CDE, CDN, CPT, is a Nutrition Diabetes Educator, Norwalk Hospital Outpatient Diabetes Program, Norwalk Hospital, Norwalk, Connecticut
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40
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Habenicht AE, Gallagher S, O’Keeffe MC, Creaven AM. Making the leap and finding your feet: A qualitative study of disclosure and social support in university students with type 1 diabetes. J Health Psychol 2018; 26:260-269. [DOI: 10.1177/1359105318810875] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
University poses unique challenges surrounding disclosure for students living with type 1 diabetes, with implications for social support and self-management. Semi-structured interviews with students and peer interviewers living with type 1 diabetes explored university experiences of disclosure and social support. Thematic analysis identified three major themes: disclosure as a measured process, the need for lived experience for true understanding and personal growth and self-awareness. Findings emphasize the need to scaffold the university transition for individuals with type 1 diabetes as disclosure can elicit effective social support. In addition, the importance of lived experience suggests support from students with type 1 diabetes could considerably impact diabetes management.
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Abbott B, Zybutz C, Scott KM, Eberhard J, Widmer R. A review of the hours dedicated to oral health education in medical programmes across Australia. Intern Med J 2018; 48:1035-1040. [DOI: 10.1111/imj.14021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/07/2018] [Accepted: 03/16/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Bronwyn Abbott
- Discipline of Child and Adolescent Health; The University of Sydney; New South Wales Australia
| | - Cian Zybutz
- Discipline of Child and Adolescent Health; The University of Sydney; New South Wales Australia
| | - Karen M. Scott
- Discipline of Child and Adolescent Health; The University of Sydney; New South Wales Australia
| | - Joerg Eberhard
- Sydney Dental School; The University of Sydney; New South Wales Australia
| | - Richard Widmer
- Discipline of Child and Adolescent Health; The University of Sydney; New South Wales Australia
- Dental Department; The Children's Hospital at Westmead; Sydney New South Wales Australia
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42
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Call for Papers. J Health Psychol 2018. [DOI: 10.1177/1359105318763393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bassett AM, de Souza S, Williams R, Lempp H. Rheumatoid Arthritis Portrayal by UK National Newspapers 2011-2016: A Service User - Led Thematic Analysis of Language Used. BMC Rheumatol 2018; 2:5. [PMID: 30886956 PMCID: PMC6390613 DOI: 10.1186/s41927-018-0013-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/09/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND An important source of knowledge, beliefs, and attitudes about illness is the mass media. Research has established the often negative and emotive language utilised by journalists to report on physical and mental long-term illnesses. The limited amount of research on rheumatological conditions has largely focused on the extent of, and/or accuracy of media coverage. This is the first published study to examine systematically the language used by the United Kingdom (UK) popular press to specifically describe rheumatoid arthritis (RA). METHODS A patient and public involvement (PPI) approach, involving academics and service users with RA, was used to conduct the research. LexisNexis online repository of print media was searched for articles within a defined five year time frame, which included RA in the headline and/or lead paragraph of 15 UK national non-specialist newspapers. Resultant articles were uploaded to NVivo, and a realist perspective aided a thematic analysis of the data set. RESULTS A search of LexisNexis produced 413 newspaper articles, of which 147 met the inclusion criteria. Three themes emerged: (1) language used to describe RA; (2) language used to refer to those who live with RA and; (3) language used to report on potential new treatments for RA. Negative and emotive terms such as 'attack', 'painful', 'crippling', and 'agony' were the most frequently used to describe the experience of RA. People diagnosed with RA were often portrayed as 'sufferers' or 'victims', though neutral language was also deployed. 'Hope' and 'breakthrough' were the most reported terms for potential new treatments for RA. Across the three themes, tabloid and middle market newspaper articles applied more sensationalised language with attention grabbing headlines and news stories. By contrast, such emotive terminology was less apparent in broadsheets. CONCLUSIONS The media is a source of information about RA for the general population, but the quality of newspaper journalism about the condition requires improvement. The findings may act as a stimulus for a national public awareness initiative and/or social marketing campaign. How the language currently constructed to describe RA in the press is received by people with RA would be an important area for future research.
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Affiliation(s)
- Andrew Mark Bassett
- King’s College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ UK
| | - Savia de Souza
- King’s College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ UK
| | - Ruth Williams
- King’s College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ UK
| | - Heidi Lempp
- King’s College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ UK
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Abstract
OBJECTIVE The goal of this study was to understand how adults with diabetes experience the words used in diabetes care. METHODS This qualitative study guided by Critical Theory used two virtual and two in-person focus groups conducted by the same facilitator. A total of 68 focus group members participated. The facilitator transcribed and coded focus group data using individual responses as the unit of analysis. The facilitator used constant comparison to analyze responses and developed a research summary of themes that emerged. A second coder confirmed the themes originally identified, and participants provided feedback on the summary. RESULTS Many negative and stigmatizing words are used in diabetes care. Several themes emerged from the data, including judgment; fear and anxiety; labels, reminders, and assumptions; oversimplification and directives; misunderstanding, misinformation, and disconnection; and body language and tone. Participants reported experiencing negative diabetes-related words in the general public, with their health care providers (HCPs), and in the media. Participants made suggestions for HCPs to replace negative words; they raised a concern that current negative words will be replaced by others with similar negative connotations; and they said they would feel more like a partner in their care if HCPs stopped using these words. CONCLUSION The language used in diabetes care has an impact on people who live with the disease. Awareness is the first step in eradicating stigma in diabetes care. HCPs can improve patient-provider communication and contribute to a more positive experience for people living with diabetes by choosing words that empower.
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Affiliation(s)
- Jane K Dickinson
- Health & Behavior Studies Department, Teachers College Columbia University, New York, NY
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45
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Fuoco RE. People-Centered Language Recommendations for Sleep Research Communication. Sleep 2017; 40:3062257. [PMID: 28329207 DOI: 10.1093/sleep/zsx039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The growing embrace of patient-centered outcomes research (PCOR) in sleep medicine is a significant step forward for the field. In engaging and incorporating the unique perspectives of people with sleep disorders, PCOR enhances the relevance of findings and facilitates the uptake of research into practice. While centering research design around what matters most to people with sleep disorders is critical, research communication must be similarly people-centered. One approach is using "people-centered language" in both professional and public communications. People-centered language is rooted in sociolinguistic research demonstrating that language both reflects and shapes attitudes. People-centered language puts people first, is precise and neutral, and respects autonomy. By adhering to the language guidelines described in this article, sleep researchers will better serve the field's most important stakeholders.
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Dickinson JK, Guzman SJ, Maryniuk MD, O'Brian CA, Kadohiro JK, Jackson RA, D'Hondt N, Montgomery B, Close KL, Funnell MM. The Use of Language in Diabetes Care and Education. Diabetes Care 2017; 40:1790-1799. [PMID: 29042412 DOI: 10.2337/dci17-0041] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Language is powerful and can have a strong impact on perceptions as well as behavior. A task force, consisting of representatives from the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA), convened to discuss language in diabetes care and education. This document represents the expert opinion of the task force. The literature supports the need for a language movement in diabetes care and education. There are effective ways of communicating about diabetes. This article provides recommendations for language used by health care professionals and others when discussing diabetes through spoken or written words-whether directed to people with diabetes, colleagues, or the general public, as well as research questions related to language and diabetes.
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Affiliation(s)
- Jane K Dickinson
- Department of Health & Behavior Studies, Teachers College, Columbia University, New York, NY
| | - Susan J Guzman
- Clinical/Educational Services, Behavioral Diabetes Institute, San Diego, CA
| | | | - Catherine A O'Brian
- Department of Science and Practice, American Association of Diabetes Educators, Chicago, IL
| | - Jane K Kadohiro
- Diabetes Education and Support Consulting Services, Reno, NV
| | | | | | | | - Kelly L Close
- Close Concerns and The diaTribe Foundation, San Francisco, CA
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47
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Affiliation(s)
- R I G Holt
- Editor-in-Chief, Diabetic Medicine, University of Southampton, Southampton, UK
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - J Speight
- Associate Editor, Diabetic Medicine, University of Southampton, Southampton, UK
- Deakin University, School of Psychology, Geelong, Victoria, Australia
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- AHP Research, Hornchurch, UK
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48
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Dickinson JK, Guzman SJ, Maryniuk MD, O'Brian CA, Kadohiro JK, Jackson RA, D'Hondt N, Montgomery B, Close KL, Funnell MM. The Use of Language in Diabetes Care and Education. DIABETES EDUCATOR 2017; 43:551-564. [PMID: 29040034 DOI: 10.1177/0145721717735535] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Language is powerful and can have a strong impact on perceptions as well as behavior. A task force, consisting of representatives from the American Association of Diabetes Educators and the American Diabetes Association, convened to discuss language in diabetes care and education. The literature supports the need for a language movement in diabetes care and education. There are effective ways of communicating about diabetes. This article provides recommendations for language used by health care professionals and others when discussing diabetes through spoken or written words, whether directed to people with diabetes, colleagues, or the general public, as well as research questions related to language and diabetes.
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Affiliation(s)
| | | | | | | | | | | | - Nancy D'Hondt
- Ascension St John Providence Hospital and Medical Center, Detroit, Michigan
| | | | | | - Martha M Funnell
- Michigan Center for Diabetes Translational Research, Ann Arbor, Michigan
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49
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Murphy ME, Byrne M, Zarabzadeh A, Corrigan D, Fahey T, Smith SM. Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice. Implement Sci 2017; 12:115. [PMID: 28915897 PMCID: PMC5602930 DOI: 10.1186/s13012-017-0647-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 09/11/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Poorly controlled type 2 diabetes mellitus (T2DM) can be seen as failure to meet recommended targets for management of key risk factors including glycaemic control, blood pressure and lipids. Poor control of risk factors is associated with significant morbidity, mortality and healthcare costs. Failure to intensify medications for patients with poor control of T2DM when indicated is called clinical inertia and is one contributory factor to poor control of T2DM. We aimed to develop a theory and evidence-based complex intervention to improve appropriate prescribing and medication intensification in poorly controlled T2DM in Irish general practice. METHODS The first stage of the Medical Research Council Framework for developing and evaluating complex interventions was utilised. To identify current evidence, we performed a systematic review to examine the effectiveness of interventions targeting patients with poorly controlled T2DM in community settings. The Behaviour Change Wheel theoretical approach was used to identify suitable intervention functions. Workshops, simulation, collaborations with academic partners and observation of physicians were utilised to operationalise the intervention functions and design the elements of the complex intervention. RESULTS Our systematic review highlighted that professional-based interventions, potentially through clinical decision support systems, could address poorly controlled T2DM. Appropriate intensification of anti-glycaemic and cardiovascular medications, by general practitioners (GPs), for adults with poorly controlled T2DM was identified as the key behaviour to address clinical inertia. Psychological capability was the key driver of the behaviour, which needed to change, suggesting five key intervention functions (education, training, enablement, environmental restructuring and incentivisation) and nine key behaviour change techniques, which were operationalised into a complex intervention. The intervention has three components: (a) a training program/academic detailing of target GPs, (b) a remote finder tool to help GPs identify patients with poor control of T2DM in their practice and (c) A web-based clinical decision support system. CONCLUSIONS This paper describes a multifaceted process including an exploration of current evidence and a thorough theoretical understanding of the predictors of the behaviour resulting in the design of a complex intervention to promote the implementation of evidence-based guidelines, through appropriate prescribing and medication intensification in poorly controlled T2DM.
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Affiliation(s)
- Mark E. Murphy
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Molly Byrne
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Ireland
| | - Atieh Zarabzadeh
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Derek Corrigan
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
- HRB Centre for Primary Care Clinical Trials Network, Dublin, Ireland
| | - Susan M. Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
- HRB Centre for Primary Care Clinical Trials Network, Dublin, Ireland
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Abstract
This article discusses the effect of words on diabetes. People with diabetes are exposed to the language health care professionals (HCPs) use, in both speaking and writing, and those words may contribute to an already stressful illness experience. Language is a significant part of every person's context, and context shapes experience. There is evidence that words can affect responses to health-related situations and may even lead to a stress response. HCPs often discuss delivering diabetes care in an empowerment model, and so far that has not included using language that is consistent with the approach. Awareness is the first step toward identifying and changing the words HCPs use with people who have diabetes.
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Affiliation(s)
- Jane K Dickinson
- Teachers College Columbia University-Health & Behavior Studies, Steamboat Springs, CO
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