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

Participants' and Health Care Providers' Insights Regarding a Web-Based and Mobile-Delivered Healthy Eating Program for Disadvantaged People With Type 2 Diabetes: Descriptive Qualitative Study

BACKGROUND

Healthy eating is a key element of type 2 diabetes (T2D) self-management. Digital interventions offer new avenues to reach broad audiences to promote healthy eating behaviors. However, acceptance of these interventions by socioeconomically disadvantaged people (eg, those with lower levels of education and income or from ethnic minority groups) has not yet been fully evaluated.

OBJECTIVE

This study aimed to investigate the acceptability and usability of EatSmart, a 12-week web-based and mobile-delivered healthy eating behavior change support program, from the perspective of intervention participants living with T2D and health care providers (HCPs) involved in diabetes care.

METHODS

This study used a qualitative descriptive design. Overall, 60 disadvantaged adults with T2D, as determined by receipt of either a HealthCare Card or a pension or benefit as the main source of income, were recruited. Data from participants regarding their experiences with and perceptions of the program and longer-term maintenance of any behavior or attitudinal changes were collected through a web-based self-report survey with open-ended questions administered 12 weeks after baseline (54/60, 90%) and semistructured telephone interviews administered 36 weeks after baseline (16/60, 27%). Supplementary semistructured interviews with 6 HCPs involved in diabetes care (endocrinologists, accredited practicing dietitians, and diabetes nurse educators) were also conducted 36 weeks after baseline. These interviews aimed to understand HCPs' views on successful and unsuccessful elements of EatSmart as a technology-delivered intervention; any concerns or barriers regarding the use of these types of interventions; and feedback from their interactions with patients on the intervention's content, impact, or observed benefits. All data from the surveys and interviews were pooled and thematically analyzed.

RESULTS

In total, 5 key themes emerged from the data: program impact on food-related behaviors and routines, satisfaction with the program, reasons for low engagement and suggestions for future programs, benefits and challenges of digital interventions, and cultural considerations. Results showed that EatSmart was acceptable to participants and contributed positively to improving food-related behaviors. Most participants (27/43, 63%) mentioned that they enjoyed their experience with EatSmart and expressed high satisfaction with its content and delivery. The educational and motivational content was considered the most useful part of the program. Benefits discussed by intervention participants included gaining health knowledge and skills, positive changes in their food purchasing and cooking, and eating greater quantities and varieties of fruits and vegetables. HCPs also described the intervention as beneficial and persuasive for the target audience and had specific suggestions for future tailoring of such programs.

CONCLUSIONS

The findings suggested that this digitally delivered intervention with supportive educational modules and SMS text messages was generally appealing for both participants and HCPs. This intervention medium shows promise and could feasibly be rolled out on a broader scale to augment usual diabetes care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19488.

Effects of a theory-based training program with follow-up home visits on self-management behavior, glycemic index, and quality of life among Iranian patients with type 2 diabetes mellitus

Background

Uncontrolled diabetes is an important public health problem that endangers the quality of life of patients. Promoting self-management through well-planned training is an essential strategy to control diabetes effectively. This study aimed to examine the effects of a training program based on social cognitive theory (SCT) on self-management behavior, glycemic index, and quality of life among patients with type 2 diabetes mellitus.

Methods

This is a quasi-experimental study with a pretest–posttest design. The statistical population included 106 adults with type 2 diabetes mellitus assigned to the intervention and control groups [n₁ = n₂ = 53], who received services from two urban health centers. A multi-method, SCT-based training program consisting of six 60–80-min sessions was run, followed by 2–3 follow-up home visits [once a month for each participant] for the intervention group. The data were collected before and three months after the intervention and were analyzed in SPSS 19.

Results

Before the intervention, there was no significant difference between the two groups regarding the main variables. After the intervention, there was a significant increase in the intervention group's mean scores of knowledge, self-efficacy, social support, outcome expectations, self-regulation, self-management behavior, glycemic index, and quality of life. There were no significant changes in these constructs in the control group after the intervention. The regression analysis results indicated that social cognitive theory and self-management could explain the variance in quality of life [adjusted R-squared = 0.476].

Conclusions

The findings support the effectiveness of the multi-method, SCT-based educational intervention in improving self-management behaviors, glycemic index, and quality of life among patients with type 2 diabetes mellitus. It is suggested that the quality of type 2 diabetes care programs should be promoted. However, further research is needed to evaluate the long-term outcomes.

Nutritional Literacy Among Uninsured Patients With Diabetes Mellitus: A Free Clinic Study

Objective

Evaluate nutrition literacy in uninsured subjects with diabetes mellitus (DM) who presented to free diabetes management classes. 

Design 

This single-site, cross-sectional observational study recruited thirty subjects from a free clinic for uninsured patients to attend diabetes mellitus, self-management classes. Before starting the classes, DM care-related data were collected, and subjects were administered the Nutrition Literacy Assessment Instrument (NLit). The assessment covers six subscales in nutrition and categorizes results into three possible categories: the likelihood of poor nutrition literacy (NLit Score ≤ 44), the possibility of poor nutrition literacy (NLit Score- 45-57), and the likelihood of good nutrition literacy (NLit score ≥ 58). 

Results 

Median glycated haemoglobin (HbA1c) was 7.45% for study participants. The mean NLit score was 38.1 (SD ± 9.4), correlating with a likelihood of poor nutrition literacy. All participants had either likelihood or the possibility of poor nutrition literacy based on the NLit Assessment. There were no participants who scored in the range of likelihood of good nutrition literacy. Subjects who scored in the range of likelihood of poor nutrition literacy had a significantly higher mean HbA1c (8.6 %) than those who scored in the possibility of poor nutrition literacy (6.9 %, p=0.005).

Conclusions

Poor nutrition literacy is associated with worse glycemic control among uninsured subjects with diabetes mellitus.

Identifying Patient Strengths Instruments and Examining Their Relevance for Chronic Disease Management: A Systematic Review

INTRODUCTION

Most health care focuses on patients' deficits to encourage behavior change. A strengths-based approach, which relies on identifying patient strengths, has great potential to facilitate behavior change for chronic disease management. Little is known about instruments used to assess patient strengths. We conducted a systematic review to identify validated instruments that assess personal strengths by using a theory elaboration approach.

METHODS

We searched 8 databases including Web of Science, Cumulative Index of Nursing and Allied Health (CINAHL), and PsycINFO (through July 2019) to identify peer reviewed, English-language studies that described strength-based instruments. Thereafter, we evaluated the validity and reliability of the instruments according to 18 Scientific Advisory Committee of the Medical Outcome Trust (SACMOT) criteria, and used an inductive, iterative editing process to identify constructs measured by the instruments.

RESULTS

We identified 26 instruments that met our inclusion criteria. The instruments were validated in various clinical and nonclinical populations. Only 4 instruments met most of the SACMOT criteria for validation. We extracted 91 unique constructs that fell into 3 domains: inner strengths (49), external strengths (13), and personality constructs (29).

CONCLUSION

A limited number of reliable and valid instruments are available to assess strengths for the adult population, particularly for clinical populations. Internal strengths can be leveraged to improve patient health; however, the development and validation of additional instruments to capture personal strengths is necessary to examine the multilevel influence of external strengths on individual behaviors and well-being.

Salutogenic model of health to identify turning points and coping styles for eating practices in type 2 diabetes mellitus

BACKGROUND

It is important for people with Type 2 Diabetes Mellitus (T2DM) to eat healthily. However, implementing dietary advice in everyday life is difficult, because eating is not a distinguishable action, but a chain of activities, embedded in social practices and influenced by previous life experiences. This research aims to understand why and how eating practices are developed over the life-course by investigating influential life experiences - turning points - and coping strategies for eating practices of people with T2DM.

METHODS

The Salutogenic Model of Health guided the study's objective, study design and analysis. Seventeen interviews were performed and analysed based on the principles of interpretative phenomenological analysis. Narrative inquiry and the creation of timelines and food boxes were used as tools to facilitate reflection on turning points and eating practices.

RESULTS

Turning points for unhealthier eating were experiences that strongly disturbed the participants' emotional stability. These experiences included psychosocial trauma, physical health disorders, job loss, and smoking cessation. Turning points for healthier eating were experiences that significantly changed participants views on life and made participants reflective about the effects of current eating practices on future health and life goals. These turning points included confrontation with ill-health, becoming a parent, psychosocial therapy, and getting married. Notably, turning points for healthier eating seemed only to happen when life was relatively stress-free. All participants experienced turning points for healthier eating, yet, not all participants succeeded in improving their diets. Two coping styles were distinguished: active and passive coping. Active coping individuals were able to act in line with their personal intentions, whereas passive coping individuals could not. Differences between active and passive coping styles seemed to be explained by differences in available resources important for adapting and maintaining a healthy diet.

CONCLUSION

Disadvantaged childhood and later life adversities together with the inability to manage the mental stress explained the development unhealthier eating practices. All participants experienced turning points for healthier eating that caused eating to become a priority in their life. Yet, the fact that not all were able to eat as they intended, advocates for nutritional guidance for people with T2DM, with a greater emphasis on reflexivity, psycho-social well-being and social support.

Impact of Diabetes and Disease Duration on Work Status Among U.S. Older Adults

Objectives: To examine the effects of diabetes and disease duration on work status over a 9-year period. Method: Multinomial logistic regression models examined the probability of retirement and disability impeding work, using data from the Health and Retirement Study (n = 5,576). Results: Among participants who had retired in 2012, almost 14% had incident diabetes (4.91 mean years with diabetes, 95% confidence interval [CI] = [4.67, 5.15]). Approximately 22% of participants who reported a disability impeded labor force participation had prevalent diabetes (17.1 mean years with diabetes, 95%CI = [16.41, 17.71]). Only prevalent diabetes that indicated longer disease duration was associated with disability (relative risk ratio [RRR] = 1.83, 95% CI = [1.30, 2.57]). There was evidence of effect modification among Hispanics only (p = .02). Discussion: Diabetes increased risk of exiting the workforce due to disability, and mean disease duration was associated with changes. Disease management and workplace interventions may enable older adults to continue being productive should they choose to remain in the workforce.

Family behaviours that have an impact on the self-management activities of adults living with Type 2 diabetes: a systematic review and meta-synthesis

AIMS

To identify family behaviours that adults with Type 2 diabetes' perceive as having an impact on their diabetes self-management.

BACKGROUND

Research suggests that adults with Type 2 diabetes perceive that family members have an important impact on their self-management; however, it is unclear which family behaviours are perceived to influence self-management practices.

METHODS

This meta-synthesis identified and synthesized qualitative studies from the databases EMBASE, Medline and CINAHL published between the year 2000 and October 2016. Studies were eligible if they provided direct quotations from adults with Type 2 diabetes, describing the influence of families on their self-management. This meta-synthesis adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.

RESULTS

Of the 2606 studies screened, 40 were included. This meta-synthesis identified that adults with Type 2 diabetes perceive family behaviours to be either: 1) facilitators of diabetes self-management; 2) barriers to diabetes self-management; or 3) equivocal behaviours with the potential to both support and/or impede diabetes self-management. Seven sub-themes were identified within these themes, including: four facilitator sub-themes ('positive care partnerships'; 'family watchfulness'; 'families as extrinsic motivator' and 'independence from family'); two barrier sub-themes ('obstructive behaviours' and 'limited capacity for family support'); and one equivocal behaviours subtheme ('regular reminders and/or nagging').

CONCLUSION

While most family behaviours are unambiguously perceived by adults with Type 2 diabetes to act as facilitators of or barriers to self-management, some behaviours were perceived as being neither clear facilitators nor barriers; these were termed 'equivocal behaviours'. If the concept of 'equivocal behaviours' is confirmed, it may be possible to encourage the adult living with Type 2 diabetes to reframe these behaviours so that they are perceived as enabling their diabetes self-management.

The Impact of Social Support on Self-care of Patients With Diabetes: What Is the Effect of Diabetes Type? Systematic Review and Meta-analysis

Purpose This meta-analysis examined relationships between social support and self-care in type 1 (T1DM) and 2 diabetes mellitus (T2DM). Methods We searched for published and unpublished studies using the following databases: PubMed, Embase, PsycINFO, the Cochrane Library, and Medline. MeSH search terms included "diabetes mellitus," "social support," "caregiver," "self-care," "self-management," "self-care skills," and "coping behavior." Studies reporting correlations between social support and self-care were included. Results Initially, 2 095 studies were extracted. After eliminating duplicate and irrelevant studies, 28 studies involving 5 242 patients with diabetes were included. Of these, 22 studies examined T2DM subjects. Social support was significantly associated with self-care ( k = 28, r = .28, 95% CI: .21-.34, P < .001). Among the diabetes self-care types, the strongest effect was found for glucose monitoring ( k = 6, r = .21, 95% CI: .08-.33). The relationship between social support and self-care was stronger in T2DM ( k = 22, r = .30, 95% CI: .22-.37), relative to T1DM, samples ( k = 5, r = .22, 95% CI: .02-.38). Conclusion It was concluded that the overall effect size for social support on self-care was moderate, and its strength differed by ethnic majority within the sample, type of social support measures, and publication status.

Impact of Demographic, Socioeconomic, and Psychological Factors on Glycemic Self-Management in Adults with Type 2 Diabetes Mellitus

Diabetes mellitus (DM) is reported as one of the most complex chronic diseases worldwide. In the United States, Type 2 DM (T2DM) is the seventh leading cause of morbidity and mortality. Individuals with diabetes require lifelong personal care to reduce the possibility of developing long-term complications. A good knowledge of diabetes risk factors, including obesity, dyslipidemia, hypertension, family history of DM, and sedentary lifestyle, play an essential role in prevention and treatment. Also, sociodemographic, economic, psychological, and environmental factors are directly and indirectly associated with diabetes control and health outcomes. Our review intends to analyze the interaction between demographics, knowledge, environment, and other diabetes-related factors based on an extended literature search, and to provide insight for improving glycemic control and reducing the incidence of chronic complications.

Family and Community Influences on Diabetes-Related Dietary Change in a Low-Income Urban Neighborhood

Purpose

The purpose of this study is to explore the influence of the social environment, including family and community relationships, on diabetes-related dietary change behaviors in a low-income, predominantly African American community with limited access to healthy foods.

Methods

Study methods included interviews and focus groups with adults with diabetes and family members of individuals with diabetes in a low-income African American community. In this analysis, interview participants included 11 participants with diabetes, one with prediabetes, and 8 family members or close friends with diabetes. Information from 4 participants with diabetes and 6 with family members with diabetes was included from 6 focus groups. Transcripts were analyzed via thematic iterative coding influenced by social cognitive theory to understand the influence of family and community relationships on dietary change.

Results

Participants’ social environments strongly influenced diet-related behavioral change. Family members without diabetes provided reinforcements for dietary change for those with diabetes by preparing healthy food and monitoring intake, as well as by adopting dietary changes made by those with diabetes. Family and community members served as sources of observational learning about the potential impacts of diabetes and enhanced behavioral capability for dietary change among people with diabetes by providing dietary advice and strategies for making healthy choices.

Conclusions

This study demonstrates the ways in which family and community members can influence dietary change in people with diabetes. Interventions targeting diabetes management should incorporate families and communities as sources of information, learning, and support.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

The effect of sociostructural and collaborative decision-making on diabetes self-management

BACKGROUND

Diabetic self-management is important for controlling the diabetes complications and promoting health-related quality of life in these patients. The objective of this study was to examine a hypothetical model regarding influences of sociostructural determinants, collaborative decision-making and patient's beliefs system on diabetes self-management.

METHODS

In a cross-sectional descriptive study from Dec 2010 to Mar 2010, 500 patients of Iranian adult patients with type II diabetes attended the outpatient diabetic clinics of the Shariati Hospital in Tehran were selected by convenience sampling. Data were collected by The Demographical Information, Social- Economical Status and Diabetic History Questionnaire and eleven self-reported scales of this research. Structural equation modeling (SEM) with LIZREL software applied for data analysis.

RESULTS

The modified model had a desirable fitness to the observed data. Patient's beliefs system directly influenced the diabetes self-management. Sociostructural determinants influenced diabetes self-management indirectly via collaborative decision-making and Patient's beliefs system. In addition, collaborative decision-making significantly influenced patient's beliefs system that thereby impacted diabetes self-management.

CONCLUSIONS

Sociostructural determinants, collaborative decision-making and patient's beliefs system are integrated and cooperatively affect on diabetes self-management. Comprehensive intervention schedules required to improve these agents for encouragement the type II diabetes self-management.

African Americans and Peripheral Arterial Disease: A Review Article

Peripheral arterial disease (PAD)—atherosclerosis of the abdominal aorta and arteries of the lower extremities—affects 12 million Americans. African Americans (AAs) are more than twice as likely as non-Hispanic whites to suffer from PAD. When compared to non-Hispanic whites with PAD, AAs with PAD have more severe disease and a greater reduction in walking distance, speed, and/or stair climbing. AAs with PAD are at increased risk for disease progression and worsening lower limb function. Reasons for the higher risk for disease progression have not been defined. One potential modifiable risk is a lower level of physical activity. Lower levels of physical activity are more common among African American seniors. Walking is a common type of physical activity. The benefits of walking therapy are only realized if the patient adheres to such therapy. Efforts are needed to increase walking in AAs with PAD. Additionally, risk factor management is key to reducing adverse events in AAs with PAD-yet few studies have targeted this high-risk group. In this paper, we discuss the management of PAD in AAs. Identifying current gaps will help to inform clinicians, researchers, and policy makers on next steps in identifying innovative approaches to increase home-based walking and reduce walking impairment in AAs with PAD.

The DISC (Diabetes in Social Context) Study-evaluation of a culturally sensitive social network intervention for diabetic patients in lower socioeconomic groups: a study protocol

Background

Compared to those in higher socioeconomic groups, diabetic patients in lower socioeconomic groups have less favourable metabolic control and experience more diabetes-related complications. They encounter specific barriers that hinder optimal diabetes self-management, including a lack of social support and other psychosocial mechanisms in their immediate social environments. Powerful Together with Diabetes is a culturally sensitive social network intervention specifically targeted to ethnic Dutch, Moroccan, Turkish, and Surinamese diabetic patients in lower socioeconomic groups. For ten months, patients will participate in peer support groups in which they will share experiences, support each other in maintaining healthy lifestyles, and learn skills to resist social pressure. At the same time, their significant others will also receive an intervention, aimed at maximizing support for and minimizing the negative social influences on diabetes self-management. This study aims to test the effectiveness of Powerful Together with Diabetes.

Methods/Design

We will use a quasi-experimental design with an intervention group (Group 1) and two comparison groups (Groups 2 and 3), N = 128 in each group. Group 1 will receive Powerful Together with Diabetes. Group 2 will receive Know your Sugar, a six-week group intervention that does not focus on the participants' social environments. Group 3 receives standard care only. Participants in Groups 1 and 2 will be interviewed and physically examined at baseline, 3, 10, and 16 months. We will compare their haemoglobin A1C levels with the haemoglobin A1C levels of Group 3. Main outcome measures are haemoglobin A1C, diabetes-related quality of life, diabetes self-management, health-related, and intermediate outcome measures. We will conduct a process evaluation and a qualitative study to gain more insights into the intervention fidelity, feasibility, and changes in the psychosocial mechanism in the participants' immediate social environments.

Discussion

With this study, we will assess the feasibility and effectiveness of a culturally sensitive social network intervention for lower socioeconomic groups. Furthermore, we will study how to enable these patients to optimally manage their diabetes. This trial is registered in the Dutch Trial Register: NTR1886