Patient-appraised couple emotion management and disease management among Chinese American patients with type 2 diabetes

Adaptation and psychometric assessment of the instrument "Partners of Adults with Type 1 Diabetes Distress Scale" in a Brazilian population

Objectives

To adapt the instrument "Partners of Adults with Type 1 Diabetes Distress Scale" (Partner-DDS) into Brazilian culture, and to evaluate the psychometric characteristics of the adapted version.

Methods

All the cultural adaptation steps of the measure's instruments were followed. The psychometric properties such as reliability (stability by test-retest; internal consistency), and convergent construct validity were performed.

Results

Of all 72 partners, 69.4% were male, mean age: 42.69 ± 14.09 years, mean of marriage duration: 14.74 ± 12.41 years, and mean schooling: 11.81 ± 3.91 years.The internal consistency of the instrument (Cronbach Alpha) was 0.90. The intra-class coefficient (stability) was 0.80 (0.72-0.84). The Spearman coefficient (convergent construct validity) between the Partner-DDS scale and the Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A) was 0.4273 (p < 0.0002).

Conclusions

The steps of the instruments' cultural adaptation were appropriately performed. The Brazilian version of the Partner- DDS scale demonstrates reliable psychometric properties for being used in POPWT1D distress evaluation in Brazil.

Innovation

The cultural adaptation of Partner-DDS scale into Brazilian Portuguese is a helpful innovation to assess the emotional burden in POPWT1D. This tool could be used to provide education and psychological support for this population.

Multiple sclerosis and mental health related quality of life: The role of defense mechanisms, defense styles and family environment

Background

Multiple sclerosis is a demyelinating chronic neurologic disease that can lead to disability and thus to deterioration of quality of life. Psychological parameters such as ego defense mechanisms, defense styles and family environment are important factors in the adaptation process, and as such they can play important roles in QoL. This study aims to assess the psychological factors as well as the clinical and demographic characteristics related to mental health quality of life (MHQoL).

Methods

This was an observational, cross-sectional study conducted in a sample of 90 people with MS in the years 2018-2020. All participants completed the following questionnaires: MSQoL-54, DSQ-88, LSI, FES-R, SOC, BDI-II, STAI. Disability was assessed using EDSS.

Results

In multiple linear regression, significant roles were played by depression (R2: 41.1%, p: 0.001) and, to a lesser extent, the event of a relapse (R2: 3.5%, p: 0.005), expressiveness (R2: 3.6%, p < 0.05) and image distortion style (R2: 4.5%, p: 0.032). After performing a hierarchical-stepwise analysis (excluding depression), the important factors were maladaptive defense style (R2: 23.7%, p: 0.002), the event of relapse (R2: 8.1%, p < 0.001), expressiveness (R2: 5.5%, p: 0.004) and self-sacrificing defense style (R2: 2.4%, p: 0.071).

Conclusion

Psychological factors play important roles in MHQoL of people with multiple sclerosis. Thus, neurologists should integrate in their practice an assessment by mental health specialists. Moreover, targeted psychotherapeutic interventions could be planned i to improve QoL.

The association between marital quality and diabetes mellitus: A systematic review

Background and Aims

Marital relationship and its quality are among the major psychological factors affecting the multiple aspects of a person's health status. Chronic diseases are also among the factors that affect various aspects of the lives of millions of people including their marital quality status. One of the most important underlying chronic diseases is diabetes. Since the correlation between diabetes mellitus and marital quality has been neglected, this systematic review, as the first one, aims to investigate the association between marital quality and diabetes mellitus.

Methods

A comprehensive search was conducted among three databases (Medline, Scopus, and Web of Science) until September 2021, which resulted in 189 articles. After assessing the studies based on the inclusion criteria, 14 studies were included.

Results

The included studies were divided into two general groups. The first group consisted of 3 articles examining the effect of factors related to diabetes on marital quality, and the second group included 11 articles studying the effect of marital quality on diabetes and its factors. In general, the articles investigating the impact of diabetes-related factors on marital quality showed that diabetes has negative impacts on levels of marital quality. Also, the articles investigating the impact of marital quality on diabetes-related factors, showed that higher marital quality is associated with a lower risk of developing diabetes, a better quality of life in patients with diabetes, and better adherence to diabetes care regimen. The results regarding diabetes management were conflicting. Gender was mentioned as an important modulator in some of the investigated relationships.

Conclusion

Marital quality remarkably influences diabetes-related factors and is itself affected by the condition resulting from diabetes in individuals with diabetes mellitus. However, further studies are required due to the limited number of studies investigating this correlation.

Identifying Barriers and Facilitators to Diet and Physical Activity Behaviour Change in Type 2 Diabetes Using a Design Probe Methodology

Treatment of Type 2 Diabetes (T2D) typically involves pharmacological methods and adjunct behavioural modifications, focused on changing diet and physical activity (PA) behaviours. Changing diet and physical activity behaviours is complex and any behavioural intervention in T2D, to be successful, must use an appropriate suite of behaviour change techniques (BCTs). In this study, we sought to understand the perceived barriers and facilitators to diet and PA behaviour change in persons with T2D, with a view to creating artefacts to facilitate the required behaviour changes. The Design Probe was chosen as the most appropriate design research instrument to capture the required data, as it enabled participants to reflect and self-document, over an extended period of time, on their daily lived experiences and, following this reflection, to identify their barriers and facilitators to diet and PA behaviour change. Design Probes were sent to 21 participants and 13 were fully completed. A reflective thematic analysis was carried out on the data, which identified themes of food environment, mental health, work schedule, planning, social support, cravings, economic circumstances and energy associated with diet behaviour. Similar themes were identified for PA as well as themes of physical health, weather, motivation and the physical environment.

Testing a Dimensional Versus a Typological Approach to the Communal Coping Model in the Context of Type 2 Diabetes

The impact of type 2 diabetes (T2D) is far reaching, influencing the lives of both patients and their families. The communal coping model argues that people cope with stress in the context of their relationships, including family relationships, and that coping responses are both cognitive and behavioral in nature. According to the model, communal coping exists along two continuous dimensions: (a) appraisal, which assesses whether people's cognitions are individual or shared, and (b) action, which pertains to whether people engage in sole or joint behavior to diminish the negative effects of their stress. Theoretically, the dimensions of communal coping cross to create four distinct types of coping. However, this typology has not been statistically tested in existing research, so one goal of this study was to test the typology. A second goal was to assess how the dimensions and types of communal coping are related to family cohesion and individual T2D outcomes. In partial support of the communal coping model, three types of coping emerged, and overall, coping together was beneficial for patient outcomes.

The role of spousal support for dietary adherence among type 2 diabetes patients: a narrative review

Healthy eating is key to successful management of type 2 diabetes (T2D). As discussed in this narrative review, there are strong indications that spousal support is an important element affecting dietary adherence in T2D. To provide a synthesized review of this evidence, Google Scholar and PubMed were searched, 28 relevant studies were selected, and the results were narratively summarized. A framework for information synthesis was developed which categorized results into three major themes: how gender roles and spousal dynamics function in spousal support for dietary adherence, the role of race and ethnicity in the influence of spousal support on dietary adherence, and the extant interventional work specifically targeting spousal support for T2D. The reviewed studies indicate that gender role performance is the principal factor in the relationship between spousal support and dietary adherence in T2D, though race and ethnicity also contribute. Despite this evidence, interventions that specifically target spousal support to improve dietary adherence in T2D have had limited efficacy. A better understanding of the relationship between spousal support and dietary adherence, as well as a subsequent utilization of this information to create targeted and effective interventions, would be of great benefit to the field of diabetes management.

Biculturalism in couple support for diabetes care in U.S.-born Chinese Americans

Support in couples living with type 2 diabetes is associated with better health outcomes but support provision in collectivistic cultures has received limited research attention. To address this gap, we focused on couple dynamics and support in type 2 diabetes in U.S.-born Chinese Americans. Acculturation processes, particularly biculturalism, that is, the capacity to enact habits and practices from both the heritage and U.S. mainstream culture, were explored. Employing interpretive phenomenological methods, we conducted multiple narrative interviews with each of 15 couples regarding illness challenges and couple responses. Interviews were conducted in varied contexts, including with the couple, and in group interviews with people with diabetes or spouses. The unit of analysis was the couple, and narrative themes within the text were explored within the context of holistic couple summaries. We identified three key aspects of couple support: (i) Assisting with the diabetes treatment regimen; (ii) Moderating social and contextual factors that impede diabetes care; and (iii) Providing relational care and empathy for living with this challenging chronic condition. Support reflecting cultural maintenance of Chinese beliefs and practices include other directedness, family centeredness, and concerns for harmony and balance. Bicultural support patterns were also apparent in spousal communication that was both indirect and direct, and relationships marked by both interdependence and respect for independence or autonomy, reflecting both Chinese and U.S. cultural orientations, respectively. Working clinically with second and third generation Chinese immigrants requires clinical assessment of and responsiveness to couples' acculturation levels and bicultural skills.

Family and Couple Variables Regarding Adherence in Type 2 Diabetes Patients in the Initial Stages of the Disease

This study analyzed which family and couple variables predicted adherence to standard care treatment, in patients recently diagnosed with type 2 diabetes. The sample comprised 224 dyads assessed during the first year of diagnosis (T1) and 4 months later (T2). The results showed that family stress, dyadic adjustment, family coping, and positive support assessed by patients at T1 predicted medication adherence and glucose monitoring at T2. Positive support and dyadic adjustment, assessed by partners at T1, predicted patients' adherence to glucose monitoring and diet at T2. This study highlights the important role of the partner in patient`s adherence. Therefore, standard care in type 2 diabetes should be offered in the context of the dyad.

US Ethnic Group Differences in Family Member Support for People With Diabetes in the 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) Study

Purpose

The purpose of the study was to describe the perceptions of family members (FM) and people with diabetes (PWD) regarding the frequency and helpfulness of FM support for PWD, including differences among US ethnic groups.

Methods

The US 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) substudy was a survey of independent samples of 238 adult FM and 540 adult PWD. Outcome measures included ratings by FM and PWD of the frequency and perceived helpfulness of 7 FM support behaviors and composite scores for frequency and helpfulness.

Results

Ratings of individual FM support behaviors were strongly correlated between FM and PWD but significantly different among behaviors. FM and PWD reported most frequent support for listening, assisting, and doing activities with PWD and reporting PWD was doing poorly least frequently. Both groups reported listening, assisting, and reporting PWD was doing well as most helpful; reporting PWD was doing poorly was least helpful. PWD rated support and helpfulness of most behaviors lower than FM. Composite measures of support frequency and helpfulness were strongly correlated for both FM and PWD. Ethnic minority PWD and FM reported most support behaviors as more frequent and more helpful than non-Hispanic white Americans.

Conclusions

FM more frequently engage in the support behaviors they view as most helpful, but PWD perceive support to be less frequent and less helpful than FM. FM support differs across ethnic groups, with ethnic minorities reporting higher support frequency and helpfulness. Diabetes care providers should consider ethnic group differences in FM support for PWD.

Self-management of gestational diabetes among Chinese migrants: A qualitative study

BACKGROUND

Gestational diabetes mellitus is one of the most common complications of pregnancy. Women with Gestational diabetes are at increased risk of serious health outcomes, such as pre-eclampsia, obstructed labor, and the development of Type 2 diabetes later in life. Chinese migrants, the third largest cultural group in Australia, are more likely to develop Gestational diabetes than Australian-born women. However, to date, Gestational diabetes self-management has not been investigated in this population.

AIM

To explore the understanding and self-management experiences of Gestational diabetes among Chinese migrants.

METHODS

Data were collected through individual semi-structured face-to-face interviews. Participants were recruited from the antenatal clinic at the Royal Prince Alfred Hospital. Interviews were audio-recorded, transcribed verbatim and thematically analyzed.

FINDINGS

Although the majority of participants demonstrated a good understanding of Gestational diabetes, some did not understand the principles behind healthcare advice and faced challenges in self-management. Confusion about self-monitoring of blood glucose and fear of insulin were also evident. Participants relied on both formal and informal sources of information. Some had difficulty obtaining adequate support. Cultural influences on self-management included meeting family needs, Chinese diet and use of Chinese medicines.

CONCLUSION

To assist Chinese women with Gestational diabetes to better self-manage their condition, there is a need for clinicians to: (1) provide more effective diabetes education to ensure clear understanding of self-management principles; (2) actively elicit and respond to women's confusion and concerns; (3) provide women with adequate practical support; and (4) develop greater cultural awareness.

Explicating the Appraisal Dimension of the Communal Coping Model

The communal coping model argues that people cope with stress in the context of their relationships and that coping responses are both cognitive and behavioral in nature. However, the cognitive dimension of the model (appraisal) has not been explicated in extant research. The purpose of this study is to fill that gap by conceptualizing the appraisal dimension of communal coping in the context of families managing one member's type 2 diabetes. Analysis of interviews with individuals with type 2 diabetes and their family members (N = 28) revealed that appraisal consists of problem ownership and perceived problem influence and that appraisals are influenced by knowledge of the disease and changing health status. Theoretical and practical implications are discussed.

The Relationship between Burden and Depression in Spouses of Chronic Kidney Disease Patients

The purpose of the present study was to investigate the burden and depression in spouses of patients with chronic kidney disease (CKD). The interrelation between burden and depression in family caregivers has been pointed out by previous researches in several chronic diseases and researchers agree that they clearly go together and one cannot talk about one without considering the other. More particularly, in the present study, the caregiver burden, the depression, anxiety, and also health-related quality of life and demographic factors of spouses of patients with CKD were examined, using self-report questionnaires. Participants were 50 spouses of patients with CKD, 29 of whom were dialysis dependent and 21 were not dialysis dependent. Group differences were examined for participants. Results confirm the interrelation between caregiver burden and depression in spouses. The increased perceived burden related to higher levels of depression. Low levels of caregiver burden, depression, anxiety, and satisfactory quality of life were found in spouses, with no differences between them relevant to whether the patients were dialysis dependent or not. All the above parameters interrelated. Implications for the findings and future research directions are discussed.

"I don't have to explain, people understand": Acceptability and Cultural Relevance of a Mobile Health Lifestyle Intervention for Filipinos with Type 2 Diabetes

BACKGROUND

Filipino Americans have the highest risk for obesity-related type 2 diabetes and related complications compared with all major Asian American subgroups. Identifying effective interventions to improve Filipino health outcomes are needed to reduce this health disparity.

OBJECTIVE

To assess the acceptability and cultural relevance of the PilAm Go4Health program - a culturally adapted mobile health weight-loss lifestyle intervention including virtual social networking for Filipino Americans with type 2 diabetes.

DESIGN SETTING PARTICIPANTS

Qualitative semi-structured post-program interviews explored perceptions of 45 Filipino Americans with type 2 diabetes in Northern California regarding their perceptions of the acceptability and cultural relevance of PilAm Go4Health. Participants' mean age was 57.6 years. Sixty-seven interviews were recorded, transcribed, and thematically analyzed by four independent coders.

RESULTS

Over half (n=26, 57.8%) of the respondents found that a culturally tailored intervention program enhanced their engagement. All (n=45) of the respondents felt that mobile health technology promoted their self-efficacy. A majority of the respondents (n=29, 64.4%) expressed that they progressed from despair to self-efficacy as a result of their participation in the intervention. More than one-fourth of the participants (n=13, 28.8%) discussed that the intervention needed further cultural tailoring.

CONCLUSIONS

Overall, PilAm Go4Health - a mobile health weight-loss lifestyle intervention - was acceptable and culturally relevant for Filipino Americans with type 2 diabetes. Findings may help inform clinician and researchers on effective intervention strategies for diabetes self-management when designing interventions for diverse populations.

Acculturation and bicultural efficacy effects on Chinese American immigrants' diabetes and health management

The primary goal of this study was to examine effects of bicultural efficacy, or perceived confidence in dealing with bicultural acculturation stressors, on type 2 diabetes management and health for first-generation, Cantonese-speaking, Chinese American immigrants (N = 162) recruited for a larger community-based diabetes intervention study (Chesla et al. in Res Nurs Health 36(4):359-372, 2013. doi: 10.1002/nur.21543 ). The current study also tested whether a new Bicultural Efficacy in Health Management (BEFF-HM) scale is a more robust predictor of diabetes and health outcomes than proxy (years in the U.S.) and general acculturation measures. Hierarchical regression analyses of cross-sectional data revealed that high BEFF-HM was significantly related to positive outcomes on five of six diabetes and health measures as hypothesized after accounting for participant characteristics, proxy and general acculturation measures, and social support. Proxy and general acculturation measures failed to predict any study outcome supporting our secondary hypothesis that BEFF-HM is a better predictor of Chinese American immigrants' diabetes and health management. An immigrant-focused research approach advances understanding of acculturation and bicultural efficacy effects on health by identifying key acculturation domains for study.

Patients' and Spouses' Contribution Toward Adherence to Self-Care Behaviors in Type 2 Diabetes

This article focuses on patients' and partners' variables regarding adherence to self-care, in recently diagnosed patients with Type 2 diabetes. One hundred four patients and partners were included. Instruments answered were Family Inventory of Life Events and Changes (family stress), Family Crisis Oriented Personal Evaluation Scales (family coping), Revised Dyadic Adjustment Scale (dyadic adjustment), Multidimensional Diabetes Questionnaire (partner support) and Hospital Anxiety and Depression Scale (psychological morbidity). Results showed adherence to diet to be positively predicted by patient dyadic adjustment and patient positive support and negatively by partner depression and partner negative support. Adherence to exercise was predicted by patient's family stress and negatively by partner anxiety. Adherence to glucose monitoring was predicted by partner positive support. Psychological variables were not associated with adherence to foot care. Finally, positive partner support moderated the relationship between family stress and dyadic adjustment in patients. The results emphasize the need to treat the patient in the context of the dyad. Future research should focus on partners' specific instrumental behaviors that promote patients' self-care behaviors.

Ethnic differences in family member diabetes involvement and psychological outcomes: results from the second Diabetes Attitudes, Wishes and Needs (DAWN2) study in the USA

OBJECTIVE

To assess differences among USA ethnic groups in psychological status of adult family members (FMs) and their involvement with the diabetes of another adult.

RESEARCH METHODS

Data are from the FM survey of the USA DAWN2 study, including 105 White non-Hispanics, 47 African Americans, 46 Hispanic Americans and 40 Chinese Americans. All FMs lived with and cared for an adult with diabetes. Analysis of covariance controlled for respondent and patient characteristics to assess ethnic group differences (P < 0.05). Multiple regression analyses identified significant (P < 0.05) independent correlates of psychological outcomes.

MAIN OUTCOME MEASURES

FM psychological outcomes measured include well-being, quality of life (QoL), impact of diabetes on life domains, diabetes distress, and burden.

CLINICAL TRIAL REGISTRATION

NCT01507116.

RESULTS

White non-Hispanics reported less diabetes burden and distress, more negative life impact, and lower well-being than FMs from ethnic minority groups. African Americans reported the highest well-being and lowest negative life impact, Chinese Americans reported the most diabetes burden, Hispanic Americans reported the highest distress. There were no ethnic group differences in QoL. Ethnic minority FMs reported having more involvement with diabetes, greater support success, and more access to a diabetes support network than White non-Hispanics. Higher FM diabetes involvement was associated with negative psychological outcomes, while diabetes education, support success and diabetes support network size were associated with better psychological outcomes. Potential limitations are the sample sizes and representativeness.

CONCLUSIONS

Minority ethnic FMs experienced both advantages and disadvantages in psychological outcomes relative to each other and to White non-Hispanics. Ethnic minority FMs had more involvement in diabetes care, support success and support from others, with the first associated with worse and the latter two with better psychological outcomes. Additional studies are needed with larger samples and broader representation of ethnic groups to better understand these associations and identify areas for intervention.

Spousal support in diabetes self-management among Korean immigrant older adults

The authors of the current article investigated domains of spousal support among diabetic Korean older adults and their spouses. Two focus groups were conducted with diabetic participants from the greater Los Angeles Korean community, and three were conducted with their spouses. In the focus groups, participants were asked to describe the spousal support given or received for diabetes self-management. Each group comprised four to nine participants. Focus groups were audiotaped, transcribed, and translated; two independent coders identified domains of spousal support. Content analysis identified six domains: diet, exercise, emotional support, medical regimen, communication with clinicians, and information. Diet was the most frequently described domain across all groups. Gender differences were noted in domains of information, communication, and medical regimen among diabetic participants. Both diabetic and spouse participants identified individualizing spousal support and recognizing diabetes management as teamwork as important elements of successful spousal support. Spousal support education for Korean older adults may have the greatest impact by incorporating these six domains, addressing gender differences, providing tips on individualizing support, and cultivating teamwork.

Couples with diabetes and health-care providers: a grounded theory of preferential relating

BACKGROUND

A collaborative health-care relationship is considered critical in managing chronic illness like diabetes. Poorly controlled diabetes can greatly diminish one's quality of life and lead to severe complications or even death.

RATIONALE

Understanding how to improve the relationship between patients and their providers supports improved diabetes health outcomes.

OBJECTIVE

We conducted a grounded theory study to examine the types of relationships that diabetic patients and their spouses prefer to form with their health-care providers.

RESULTS

The analysis of in-depth interviews with 18 diabetic couples reveals four major relationship preferences that differ by the nature of caregiving and decision-making power demonstrated by the physician.

CONCLUSION

Using illustrative examples, we show how the type of health-care relationship couples prefer is explained by their connection with one another and suggest implications for practitioners that expand current collaborative models of care.

Ethnic differences in psychological outcomes among people with diabetes: USA results from the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study

OBJECTIVE

To assess differences in psychological outcomes as well as risk and protective factors for these outcomes among several USA ethnic groups and identify correlates of these psychological outcomes among adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2 * ) study.

RESEARCH DESIGN AND METHODS

The core USA DAWN2 sample was supplemented by independent samples of specific ethnic minority groups, yielding a total of 447 White non-Hispanics, 241 African Americans, 194 Hispanics, and 173 Chinese Americans (n = 1055). Multivariate analysis examined ethnic differences in psychological outcomes and risk/protective factors (disease, demographic and socioeconomic factors, health status and healthcare access/utilization, subjective burden of diabetes and social support/burden). Separate analyses were performed on each group to determine whether risk/protective factors differed across ethnic groups.

MAIN OUTCOME MEASURES

Psychological outcomes include well-being, quality of life, impact of diabetes on life domains, diabetes distress, and diabetes empowerment.

CLINICAL TRIAL REGISTRATION

NCT01507116.

RESULTS

Ethnic minorities tended to have better psychological outcomes than White non-Hispanics, although their diabetes distress was higher. Levels of most risk and protective factors differed significantly across ethnic groups; adjustment for these factors reduced ethnic group differences in psychological outcomes. Health status and modifiable diabetes-specific risk/protective factors (healthcare access/utilization, subjective diabetes burden, social support/burden) had strong associations with psychological outcomes, especially diabetes distress and empowerment. Numerous interactions between ethnicity and other correlates of psychological outcomes suggest that ethnic groups are differentially sensitive to various risk/protective factors. Potential limitations are the sample sizes and representativeness.

CONCLUSIONS

Ethnic groups differ in their psychological outcomes. The risk/protective factors for psychological outcomes differ across ethnic groups and different ethnic groups are more/less sensitive to their influence. These findings can aid the development of strategies to overcome the most prominent and influential psychosocial barriers to optimal diabetes care within each ethnic group.

A study of a couple with type 2 diabetes: dyadic adjustment and psychological morbidity

OBJECTIVE

this study assessed dyadic adjustment and psychological morbidity in type 2 diabetic patients and their partners, focusing on the role of gender.

METHODS

214 diabetic patients and their partners participated in the cross-sectional study and were assessed on psychological morbidity (HADS) and marital adjustment (RDAS). Data was analyzed using dyadic analysis, a statistical process that studies the patient/partner dyads simultaneously.

RESULTS

results revealed that the negative relationship between dyadic adjustment and psychological morbidity in female patients was stronger than in male diabetic patients or in partners of male diabetic patients. On the other hand, the relationship between dyadic adjustment and psychological morbidity in partners of diabetic men was stronger than the same relationship in partners of diabetic women.

CONCLUSION

since gender is a moderator, it is important to attend to the different needs of female and male patients and the education of diabetic patients should be centered on the patient/partner dyad.

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

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

Gender differences in factors related to diabetes management in Chinese American immigrants

Chinese American women with type 2 diabetes (T2DM) are more vulnerable to poor diabetes outcomes than men because immigrant status, ethnicity, and economics intersect with gender to diminish disease management opportunities. We explored gender differences in factors associated with diabetes management at intake and after treatment with a behavioral intervention in first-generation Chinese American immigrants. A sample of 178 Chinese Americans with T2DM was enrolled in a single-cohort, repeated-measures delayed-treatment trial. Data were collected at baseline, 8, 16, 24, and 32 weeks with 6-week treatment provided after 16 weeks. Gender differences at baseline and gender by treatment interactions were noted. Women at baseline reported significantly worse depressive symptoms and general health. Significant gender by treatment interactions were observed for diabetes self-efficacy, bicultural efficacy, family instrumental support, and diabetes quality of life-satisfaction. Only women showed improvement, suggesting women benefited more from the intervention in psychosocial factors related to diabetes management.

Marital quality and health: a meta-analytic review

This meta-analysis reviewed 126 published empirical articles over the past 50 years describing associations between marital relationship quality and physical health in more than 72,000 individuals. Health outcomes included clinical endpoints (objective assessments of function, disease severity, and mortality; subjective health assessments) and surrogate endpoints (biological markers that substitute for clinical endpoints, such as blood pressure). Biological mediators included cardiovascular reactivity and hypothalamic-pituitary-adrenal axis activity. Greater marital quality was related to better health, with mean effect sizes from r = .07 to .21, including lower risk of mortality (r = .11) and lower cardiovascular reactivity during marital conflict (r = -.13), but not daily cortisol slopes or cortisol reactivity during conflict. The small effect sizes were similar in magnitude to previously found associations between health behaviors (e.g., diet) and health outcomes. Effect sizes for a small subset of clinical outcomes were susceptible to publication bias. In some studies, effect sizes remained significant after accounting for confounds such as age and socioeconomic status. Studies with a higher proportion of women in the sample demonstrated larger effect sizes, but we found little evidence for gender differences in studies that explicitly tested gender moderation, with the exception of surrogate endpoint studies. Our conclusions are limited by small numbers of studies for specific health outcomes, unexplained heterogeneity, and designs that limit causal inferences. These findings highlight the need to explicitly test affective, health behavior, and biological mechanisms in future research, and focus on moderating factors that may alter the relationship between marital quality and health.

Perceptions and management of psychosocial factors affecting type 2 diabetes mellitus in Chinese Americans

Diabetes has become a global pandemic and Chinese Americans are at least 60% more likely to develop type 2 diabetes than White Americans, despite having lower body weight, due to a combination of genetic and environmental factors. Because of the increased risk, it is vitally important to address the issues of treatment adherence and diabetes self-management in the Chinese American population. Many factors affect an individual's ability to manage diabetes, including cultural beliefs, immigration experience, language abilities/health literacy, educational background, employment, and accessibility of healthcare services. In treating Chinese American patients, these factors must be considered to determine appropriate treatment. Eastern cultural and individual beliefs differ greatly from Western beliefs and, therefore, may affect the presentation of the patients. If left unacknowledged, these differences might be misinterpreted by healthcare providers as merely treatment non-adherence or unwillingness to change. Suggestions for providing culturally competent healthcare are discussed.

The psychological well-being of couples experiencing a chronic illness: A matter of personal and partner illness cognitions and the role of marital quality

This study aimed to examine the effects of 75 cardiac patients’ and their spouses’ illness cognitions of acceptance and helplessness on their own and their partner’s psychological symptoms, as well as the impact of marital quality. Dyadic responses were examined with the Actor–Partner Interdependence Model, while PROCESS was used to examine possible conditional indirect effects. Patients’ and spouses’ cognitions were related to their partners’ symptoms through the partners’ cognitions. These relationships were not statistically significant at the higher levels of marital quality. Thus, there seems to be a flow of information between partners, while marital quality may impact self-regulation processes.

Testing the efficacy of culturally adapted coping skills training for Chinese American immigrants with type 2 diabetes using community-based participatory research

Chinese Americans demonstrate greater prevalence of diabetes than non-Hispanic whites and find standard diabetes care disregards their cultural health beliefs. Academic researchers and Chinatown agencies collaborated to culturally adapt and test an efficacious cognitive-behavioral intervention using community-based participatory research. Using a delayed-treatment repeated-measures design, 145 adult Chinese immigrants with Type 2 diabetes completed treatment. Immediate benefits of treatment were evident in the improvement (p < .05) in diabetes self-efficacy, diabetes knowledge, bicultural efficacy, family emotional and instrumental support, diabetes quality of life, and diabetes distress. Prolonged benefits were evident in all changed variables 2 months post-intervention. The CBPR approach enabled the development of a culturally acceptable, efficacious behavioral intervention, and provides a model for working with communities that demonstrate health disparities.

Acculturation, Dietary Acceptability, and Diabetes Management among Chinese in North America

Immigrants to a new country face many challenges when diagnosed with type 2 diabetes, a chronic disease with a complex treatment involving both medical and behavioral interventions. These challenges will depend upon the extent to which the patient has adapted to the new country's social and cultural norms, as well as individual factors such as age, education, and gender. This adaptation is termed acculturation. With respect to nutritional interventions for type 2 diabetes, uptake and adherence over the long term will depend upon overall health literacy, the cultural acceptability of the recommended diet. This review has focused on acculturation and its effects on diabetes management in ethnic Chinese in North America as an example of one populous minority and the challenges faced in adopting nutritional recommendations. Research directions and practical considerations are suggested.

Health communication with Chinese Americans about type 2 diabetes

PURPOSE

Chinese Americans are at high risk for type 2 diabetes and face some health disparities that can be attributed to language barriers, cultural differences, and access to care. The purpose of this article is to review current literature and establish best practices regarding health communication about type 2 diabetes for Chinese Americans. The authors reviewed clinical research literature from January 2000 to April 2011 to assess current knowledge about providing diabetes management guidance to Chinese Americans.

CONCLUSIONS

To improve health communication and dissemination of health information to Chinese Americans regarding diabetes and diabetes management, research scholars, health care providers, and diabetes educators can analyze current health messages by source, message, audience, channel, and destination characteristics. Extensive research has led to clear guidelines focusing on language-appropriate materials, an understanding of Chinese food beliefs and family practices, and the importance of culturally competent health care providers. However, many Chinese Americans are using Chinese foods and medicinal herbs with little communication between patients and providers about these practices. Although Chinese Americans are not a homogenous group, this article points to a set of cultural considerations that health care providers should address when working with Chinese Americans. By attending to various qualities of health messages, efforts at diabetes prevention and management may be greatly enhanced.

Young adult African American patients with type 2 diabetes: a high risk patient sub-group with few supports for good diabetes management

This study examined age differences in support, BMI, and HbA1c among African American patients with type 2 diabetes. Participants were 158 African American adults with type 2 diabetes. Average HbA1c was 1% higher among patients aged 20-49 than patients 60-77, and double the number of younger patients had a BMI ≥35 than older patients. Younger patients reported less trust in their physician and greater disagreement with recommendations. They reported relying less on partners, greater unresolved conflict with partners around diabetes, and less church involvement. The association between age and HbA1c was partially mediated by patients' trust of their physician.

Psychometric validation of a short acculturation scale for Korean immigrants

BACKGROUND

Acculturation has been identified as a determinant of health behavior and outcome among ethnic minorities. The high prevalence of lifestyle-related chronic diseases and risk factors among Korean immigrants calls for a valid short acculturation scale to use in clinical practice and health research settings.

OBJECTIVES

The aim of this study was to validate the psychometric properties of a short acculturation scale originally developed for Hispanics after translating the scale to Korean (SAS-K) to determine its suitability for use with Korean immigrants.

METHODS

A self-administered questionnaire was completed by 143 Korean immigrants with Type 2 diabetes aged 30-80 years from a Korean community in Southern California. Confirmatory factor analysis, criterion validity, and internal reliability were utilized to evaluate the psychometric properties of the SAS-K.

RESULTS

Using a second-order confirmatory factor analysis, a 3-factor structure, χ(51) = 121.49, p < .001 (comparative fit index = .950, standardized root mean squared residual = .055, root mean square error of approximation = .099), was confirmed. The SAS-K was associated positively with length of residence, age of arrival, and English proficiency. Reliability for the total SAS-K was .93. Cronbach's alpha coefficients for each subscale of the SAS-K ranged from .80 (Ethnic Social Relations) to .95 (Media).

DISCUSSION

The 12-item, easy-to-use SAS-K showed satisfactory reliability and validity and, thus, is an appropriate instrument for measuring acculturation in Korean immigrants. The short nature and ease of administration of the SAS-K make it an ideal choice for healthcare providers and researchers to assess acculturation levels quickly and easily and to further the development and use of more culture-appropriate interventions.

The role of acculturation in diabetes self-management among Chinese Americans with type 2 diabetes

AIMS

We sought to examine the acculturation level and its relationship with diabetes self-management among Chinese Americans with type 2 diabetes.

METHODS

We conducted a cross-sectional survey research study in a convenience sample of 211 Chinese Americans with type 2 diabetes. We measured acculturation and diabetes self-management and evaluated the association between acculturation and self-management behaviors after controlling participants' characteristics using structural equation modeling.

RESULTS

The majority of the participants was born outside the U.S. and had a low level of acculturation. Women and older individuals were less acculturated, and those who had higher social economic status and lived in the U.S. for a longer period were more acculturated. The results of the structural equation modeling demonstrated that acculturation was significantly associated with DM self-management, and more-acculturated individuals were more likely to perform DM self-management than less-acculturated ones after controlling demographic characteristics.

CONCLUSIONS

The results of this study indicated that Chinese Americans diagnosed with diabetes may benefit from acculturation to mainstream society probably because increased acculturation was associated with increased help seeking behaviors and increased use of professional services.

The impact of family behaviors and communication patterns on chronic illness outcomes: a systematic review

In general, social support from family members affects chronic illness outcomes, but evidence on which specific family behaviors are most important to adult patient outcomes has not been summarized. We systematically reviewed studies examining the effect of specific family member behaviors and communication patterns on adult chronic illness self-management and clinical outcomes. Thirty studies meeting inclusion criteria were identified, representing 22 participant cohorts, and including adults with arthritis, chronic cardiovascular disease, diabetes, and/or end stage renal disease. Family emphasis on self-reliance and personal achievement, family cohesion, and attentive responses to symptoms were associated with better patient outcomes. Critical, overprotective, controlling, and distracting family responses to illness management were associated with negative patient outcomes. Study limitations included cross-sectional designs (11 cohorts); however results from longitudinal studies were similar. Findings suggest that future interventions aiming to improve chronic illness outcomes should emphasize increased family use of attentive coping techniques and family support for the patient's autonomous motivation.

Social networks, social capital and chronic illness self-management: a realist review

BACKGROUND

Existing literature on the design of interventions and health policy about self-management have tended to focus on individual-centred definitions of self-care and there is growing recognition of the need to extend consideration beyond individual factors, which determine self-care, to examine wider influences such as the health service, the family and the wider social context.

AIMS

To explore the theoretical and empirical links between social networks, social capital and the self-care practices associated with chronic illness work and management in the context of people's everyday lives.

METHOD

A realist review method was used to search and appraise relevant quantitative and qualitative literature.

FINDINGS

The review findings indicate that social networks play an important part in the management of long-term conditions. We found that social networks tend to be defined narrowly and are primarily used as a way of acknowledging the significance of context. There is insufficient discussion in the literature of the specific types of networks that support or undermine self-care as well as an understanding of the processes involved. This necessitates shifting the emphasis of self-care towards community and network-centred approaches, which may also prove more appropriate for engaging people in socially and economically deprived contexts.

"So We Adapt Step by Step": Acculturation experiences affecting diabetes management and perceived health for Chinese American immigrants

This study examines how acculturation affects type 2 diabetes management and perceived health for Chinese American immigrants in the U.S. Acculturation experiences or cultural adaptation experiences affecting diabetes management and health were solicited from an informant group of immigrant patients and their spouses (N = 40) during group, couple and individual interviews conducted from 2005 to 2008. A separate respondent group of immigrant patients and their spouses (N = 19) meeting inclusion criteria reviewed and confirmed themes generated by the informant group. Using interpretive phenomenology, three key themes in patients' and spouses' acculturation experiences were identified: a) utilizing health care, b) maintaining family relations and roles, and c) establishing community ties and groundedness in the U.S. Acculturation experiences reflecting these themes were broad in scope and not fully captured by current self-report and proxy acculturation measures. In the current study, shifting family roles and evaluations of diabetes care and physical environment in the U.S. significantly affected diabetes management and health, yet are overlooked in acculturation and health investigations. Furthermore, the salience and impact of specific acculturation experiences respective to diabetes management and perceived health varied across participants due to individual, family, developmental, and environmental factors. In regards to salience, maintaining filial and interdependent family relations in the U.S. was of particular concern for older participants and coping with inadequate health insurance in the U.S. was especially distressing for self-described lower-middle to middle-class participants. In terms of impact, family separation and relocating to ethnically similar neighborhoods in the U.S. differentially affected diabetes management and health due to participants' varied family relations and pre-migration family support levels and diverse cultural and linguistic backgrounds, respectively. Implications for expanding current conceptualizations and measures of acculturation to better comprehend its dynamic and multidimensional properties and complex effects on health are discussed. Additionally, implications for developing culturally-appropriate diabetes management recommendations for Chinese immigrants and their families are outlined.

Emerging models for mobilizing family support for chronic disease management: a structured review

OBJECTIVES

We identify recent models for programmes aiming to increase effective family support for chronic illness management and self-care among adult patients without significant physical or cognitive disabilities. We then summarize evidence regarding the efficacy for each model identified.

METHODS

Structured review of studies published in medical and psychology databases from 1990 to the present, reference review, general Web searches and conversations with family intervention experts. Review was limited to studies on conditions that require ongoing self-management, such as diabetes, chronic heart disease and rheumatologic disease.

RESULTS

Programmes with three separate foci were identified: (1) Programmes that guide family members in setting goals for supporting patient self-care behaviours have led to improved implementation of family support roles, but have mixed success improving patient outcomes. (2) Programmes that train family in supportive communication techniques, such as prompting patient coping techniques or use of autonomy supportive statements, have successfully improved patient symptom management and health behaviours. (3) Programmes that give families tools and infrastructure to assist in monitoring clinical symptoms and medications are being conducted, with no evidence to date on their impact on patient outcomes.

DISCUSSION

The next generation of programmes to improve family support for chronic disease management incorporate a variety of strategies. Future research can define optimal clinical situations for family support programmes, the most effective combinations of support strategies, and how best to integrate family support programmes into comprehensive models of chronic disease care.

Diet-specific family support and glucose control among Korean immigrants with type 2 diabetes

PURPOSE

The purpose of this study was to examine the influence of diet family support on glucose outcome in Korean immigrants with type 2 diabetes, taking into consideration patient gender.

METHODS

A total of 143 Korean immigrants with type 2 diabetes were recruited from a West Coast Koreatown. On completing questionnaires (demographic, health history, and the Diabetes Family Behavior Checklist-II [DFBC]), a participant was given a finger stick blood test for glycosylated hemoglobin (A1C). Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated after measurements were taken. Analyses assessed the independent associations of diet family support, gender, and diet family support by gender interactions with glucose outcome.

RESULTS

A higher level of diet family support was significantly associated with lower A1C, indicating the beneficial effect of diet family support on glucose control. Although the main effect of gender on A1C was not significant, the effect of the product term of family support and gender was, indicating that the significant beneficial impact of diet family support on A1C depends on gender. The impact is much more pronounced in men (B = -.516) than women (B = -.038).

CONCLUSIONS

Family support, specific to diet, is significantly associated with glucose outcomes in Korean immigrants with type 2 diabetes. That is, more perceived family support was associated with better glucose control. The positive impact of family support on glucose outcome was significantly stronger in men than in women, even after other factors were taken into consideration.

Efficacy of a child-centred and family-based program in promoting healthy weight and healthy behaviors in Chinese American children: a randomized controlled study

OBJECTIVE

To examine the efficacy of an interactive, child-centred and family-based program in promoting healthy weight and healthy lifestyles in Chinese American children.

DESIGN

A randomized controlled study of a culturally sensitive behavioral intervention.

SUBJECTS

Sixty-seven Chinese American children (ages, 8-10 years; normal weight and overweight) and their families.

MEASUREMENTS

Anthropometry, blood pressure, measures of dietary intake, physical activity, knowledge and self-efficacy regarding physical activity and diet at baseline and 2, 6 and 8 months after baseline assessment.

RESULTS

Linear mixed modeling indicated a significant effect of the intervention in decreasing body mass index, diastolic blood pressure and fat intake while increasing vegetable and fruit intake, actual physical activity and knowledge about physical activity.

CONCLUSION

This interactive child-centred and family-based behavioral program appears feasible and effective, leading to reduced body mass index and improved overweight-related health behaviors in Chinese American children. This type of program can be adapted for other minority ethnic groups who are at high risk for overweight and obesity and have limited access to programs that promote healthy lifestyles.

Cultural and family challenges to managing type 2 diabetes in immigrant Chinese Americans

OBJECTIVE

Although Asians demonstrate elevated levels of type 2 diabetes, little attention has been directed to their unique cultural beliefs and practices regarding diabetes. We describe cultural and family challenges to illness management in foreign-born Chinese American patients with type 2 diabetes and their spouses.

RESEARCH DESIGN AND METHODS

This was an interpretive comparative interview study with 20 foreign-born Chinese American couples (n = 40) living with type 2 diabetes. Multiple (six to seven) semistructured interviews with each couple in individual, group, and couple settings elicited beliefs about diabetes and narratives of care within the family and community. Interpretive narrative and thematic analysis were completed. A separate respondent group of 19 patients and spouses who met the inclusion criteria reviewed and confirmed the themes developed from the initial couples.

RESULTS

Cultural and family challenges to diabetes management within foreign-born Chinese American families included how 1) diabetes symptoms challenged family harmony, 2) dietary prescriptions challenged food beliefs and practices, and 3) disease management requirements challenged established family role responsibilities.

CONCLUSIONS

Culturally nuanced care with immigrant Chinese Americans requires attentiveness to the social context of disease management. Patients' and families' disease management decisions are seldom made independent of their concerns for family well-being, family face, and the reciprocal responsibilities required by varied family roles. Framing disease recommendations to include cultural concerns for balance and significant food rituals are warranted.

Glucose control in korean immigrants with type 2 diabetes

Despite the rising incidence of type 2 diabetes in Korean immigrants, little is known about glucose control in these individuals. This descriptive study examined factors influencing glucose control in Korean immigrants with type 2 diabetes. Participants were 143 Korean immigrants with type 2 diabetes who completed questionnaires, a finger stick blood test for glycosylated hemoglobin (HbA1c), and anthropometric measures. The mean HbA1c level was 7.6 % (SD = 1.5; range = 5.6 to 12.5). Less than half of the participants (41.3%) met the American Diabetes Association's goal of less than 7%. After adjusting for demographic and health variables, family diet support, waist-to-hip ratio (WHR), the duration of diabetes, the number of diabetic medications, and age significantly influenced glucose control. Findings support the positive role of family involvement in diabetes management. Patients with long-standing diabetes, higher WHR, and more diabetic medications deserve special attention because they tend to have higher HbA1c levels.

Spirituality and relationship: a holistic analysis of how couples cope with diabetes

This study explores how couples' spirituality and relationship processes holistically interact to inform diabetes management. Qualitative analysis of interviews with 20 heterosexual couples identified five spiritual coping styles based on the spiritual meaning they ascribed to the situation and the nature of their relationships with God and each other: (a) opportunists approach the illness as an opportunity for growth; (b) mutual problem solvers collaborate with their partners to respond to their disease; (c) individualistic problem solvers take personal responsibility for managing their disease; (d) accepters endure their disease; and (e) victims take a hopeless, discouraged approach. Results suggest that spirituality and couple communication and problem-solving patterns appear intertwined and integral to the practice of family therapy.

Predictors of increased body mass index in Chinese children

A longitudinal study design was used to examine factors related to change of body mass index (BMI) over a 1-year period in 307 Chinese children, aged 7 and 8 years, in Taiwan. Standardized instruments were used to measure the children's food intake, physical activity/inactivity, and physical fitness, as well as maternal BMI. Results suggested that a high baseline BMI, poor aerobic capacity, and a high maternal BMI were significantly correlated with increased BMI at 12 months' follow-up. A higher baseline BMI, an overweight mother, increased television viewing and computer time, and poorer aerobic capacity were identified as predictors for weight gain in children (F=207.67; P<.001; adjusted R(2)=0.752). These findings suggest that health care providers need to include the family in children's health care visits and incorporate an assessment of maternal weight status and children's BMI status, activity levels, and aerobic capacity into patient care and education.

Diabetic patients: Psychological aspects

This study was undertaken to consider the psychological aspect of diabetes with regard to improving clinical outcomes. The review was limited to literature reports on the causes, solutions, and treatments of some common psychological problems known to complicate diabetes management. A literature search was undertaken using Pub-Med, CINAHL, Proquest, Elsevier, Blackwell Synergy, Ovid, Ebsco, Rose net, and Google websites, including studies published in English journals between 1995 and 2006. Therefore about 88 articles were selected based on the inclusion criteria. In earlier studies, relatively little empirical research was found to substantiate the effect of psychological counseling in complicated diabetes. The greatest deficits were seen in areas of mental health, self-esteem parent impact, and family cohesion. There were some different factors, which influence the psychological aspect of diabetic patients, such as age, gender, place of living, familial and social support, motivation, energy, life satisfaction, and lifestyle. There are various types of solutions for coping with the psychological problems in diabetic clients. The most essential solution lies in educating the patients and healthcare providers on the subject. Before initiating each educational intervention, a thorough assessment would be crucial. Treatment plans may benefit from cognitive behavior therapy (CBT), behavior family therapy, improving family communication, problem-solving skills, and providing motivation for diabetic patients. Moreover, it seems that the close collaboration between diabetologists and psychologists would be fruitful.

Interventions for the family with diabetes

This article demonstrates that families can make a difference in diabetes outcomes and nurses can make a difference in how families organize and interact around the person with diabetes. Highlighted are key findings from the research on families and diabetes across different phases of the lifespan. Recommendations for general practice with families that might be adapted by nurses to different settings in which they care for families with diabetes are included.

Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy?

OBJECTIVE

Although prior research demonstrated that improving diabetes self-efficacy can improve self-management behavior, little is known about the applicability of this research across race/ethnicity and health literacy levels. We examined the relationship between diabetes self-efficacy and self-management behavior in an urban, diverse, low-income population with a high prevalence of limited health literacy.

RESEARCH DESIGN AND METHODS

We administered an oral questionnaire in Spanish and English to patients with type 2 diabetes at two primary care clinics at a public hospital. We measured self-efficacy, health literacy, and self-management behaviors using established instruments. We performed multivariate regressions to explore the associations between self-efficacy and self-management, adjusting for clinical and demographic factors. We tested for interactions between self-efficacy, race/ethnicity, and health literacy on self-management.

RESULTS

The study participants were ethnically diverse (18% Asian/Pacific Islander, 25% African American, 42% Latino/a, and 15% white), and 52% had limited health literacy (short version of the Test of Functional Health Literacy in Adults score <23). Diabetes self-efficacy was associated with four of the five self-management domains (P < 0.01). After adjustment, with each 10% increase in self-efficacy score, patients were more likely to report optimal diet (0.14 day more per week), exercise (0.09 day more per week), self-monitoring of blood glucose (odds ratio 1.16), and foot care (1.22), but not medication adherence (1.10, P = 0.40). The associations between self-efficacy and self-management were consistent across race/ethnicity and health literacy levels.

CONCLUSIONS

Self-efficacy was associated with self-management behaviors in this vulnerable population, across both race/ethnicity and health literacy levels. However, the magnitude of the associations suggests that, among diverse populations, further study of the determinants of and barriers to self-management is warranted. Policy efforts should be focused on expanding the reach of self-management interventions to include ethnically diverse populations across the spectrum of health literacy.