Developing a conceptual framework for understanding illness and attitudes in older, urban African Americans with diabetes

Prevalence and Determinant Factors of Diabetes Distress in Community-Dwelling Elderly in Qom, Iran

Background:

Diabetes distress (DD) is common among the patients with type 2 diabetes (T2D), but few studies investigated this problem and its related factors in the elderly population. This study has focused on the prevalence rate of DD and its determinants in community-dwelling elderly in Qom, Iran.

Methods:

This study was cross-sectional. A total of 519 subjects community-dwelling with T2D participated in the study. Collected data contained sociodemographic information, some clinical variables (body mass index and duration of diabetes) knowledge, attitude, and self-efficacy. Participants' distress was measured via diabetes distress scale (DDS). The cut of 3 (≥3) was considered as the presence of distress. Also, the attitude, self-efficacy, and knowledge about diabetes were measured by questioner. Multiple logistic regression analysis was applied to detect predictors of DD.

Results:

The mean age of the participants was 68.38 ± 6.78 and 53.6% were female. Among the participants, 48.6% were identified with positive DD. According to the results of logistic regression analysis, being female (odds ration [OR] = 1.688, P = 0.009), being widowed or divorced (OR = 1.629, P = 0.027), being over-weight or obese (OR = 1.627, P = 0.027), and having less than 10 years in disease duration (OR = 1.721, P = 0.029), attitude (OR = 0.590, P < 0.001), and self-efficacy (OR = 0.658, P = 0.009) were identified as the independent predictors of DD. No significant association was found between DD and age, occupational status, education level, and knowledge (P > 0.05).

Conclusions:

The prevalence of DD is considerable among the elderly in Qom. It seems that more attention should be paid to the mental aspects of the patients with T2D specially in high risk groups.

Increasing Opportunities for Spiritual and Religious Supports to Improve HIV-Related Outcomes for Black Sexual Minority Men

Given the importance of spirituality and religion in the lives of many Black gay, bisexual, and other Black sexual minority men (SMM) and the need for additional resources to improve HIV outcomes within this population, research on how spiritual and religious support can promote HIV prevention and treatment among Black SMM is greatly needed. We conducted nine focus groups with 52 spiritual and religious Black SMM in Baltimore, Maryland, to explore opportunities for HIV-related programming that incorporates spiritual and/or religious supports. Thematic analysis of the focus group transcripts was conducted using an iterative constant comparison coding process. Participants expressed a desire for more spiritual/religious support in non-church-based settings and identified the use of peer supports, inclusion of prayer and gospel music, and messaging related to the ideas that God is love, the Bible says to treat yourself preciously, and taking care of your health can strengthen your relationship with God as ways in which this could be incorporated into HIV-related programming. Participants living with HIV identified the message of "keeping the faith" as important for maintaining their HIV treatment plans. Participants also expressed a need for parental supports to improve HIV-related outcomes for Black SMM and potentially expand opportunities for spiritual and religious support to Black SMM within the church. Spirituality and religion can influence HIV outcomes for Black SMM, and the strategies identified by Black SMM in this study could aid in designing culturally congruent HIV prevention and treatment programs situated in the community.

Utilizing the common sense model to explore African Americans' perception of type 2 diabetes: A qualitative study

Illness perceptions, which are likely influenced by patients' cultural contexts, are associated with disease self-management and adherence. African American patients perceptions of type 2 diabetes is not well understood and no known studies has used a comprehensive evidence-based theoretical framework to explore what AAs with type 2 diabetes know, believe, and think about type 2 diabetes. Understanding perceptions of an illness shared by a group of people will be useful in developing culturally-appropriate interventions targeted to the needs of the community. The purpose of this study is to explore African Americans' perceptions of type 2 diabetes based on the common sense model of illness and self-regulation. Using a phenomenology qualitative approach and purposive sampling, 40 African American men and women, age 45-60 years old with diagnosed type 2 diabetes at least one year prior, and who took at least one prescription diabetes medication, participated in six semi-structured 90-minute focus groups conducted in a private space. Qualitative content analysis was conducted to explore African Americans beliefs about type 2 diabetes. Participants expressed that historical issues, e.g., slavery, healthcare providers, the government, and God influenced how they developed diabetes. Participants reported a loss of autonomy, a change of their identity as an employee, a social individual and sexual person, as well as anger and frustration due to having diabetes. Diabetes made the African American family bonding experience of eating difficult, and the disease diminished their cultural experiences. Concerns about diabetes ranged from fear of death and amputations to the inability to prevent the disease among their children/grandchildren. Participants perceived that medications, faith in God, and positive thinking about survival helped control diabetes. Conclusions: Improved diabetes self-management and medication adherence may depend on the meaning African Americans attach to diabetes, available psychosocial support for managing diabetes, and African Americans experience with diabetes.

The Types of Trust Involved in American Muslim Healthcare Decisions: An Exploratory Qualitative Study

Trust in physicians and the healthcare system underlies some disparities noted among minority populations, yet a descriptive typology of different types of trust informing healthcare decisions among minority populations is limited. Using data from 13 focus groups with 102 American Muslims, we identified the types and influence of trust in healthcare decision-making. Participants conveyed four types of trust implicating their health-seeking behaviors-(I) trust in allopathic medicine, (II) trust in God, (III) trust in personal relationships, and (IV) trust in self. Healthcare disparity research can benefit from assessing how these types of trust are associated with health outcomes among minority populations so as to inform intervention programs that seek to enhance trust as a means to improve community health.

Honor Thy Parents: An Ethnic Multigroup Analysis of Filial Responsibility, Health Perceptions, and Caregiving Decisions

The present study explores patterns of parity and disparity in the effect of filial responsibility on health-related evaluations and caregiving decisions. Participants who identified as White, Black, Hispanic, or Asian/Pacific Islander read a vignette about an older man needing medical care. They were asked to imagine that they were the man's son and answer questions regarding their likelihood of hiring a health care advocate (HCA) for services related to the father's care. A multigroup (ethnicity) path analysis was performed, and an intercept invariant multigroup model fits the data best. Direct and indirect effect estimation showed that filial responsibility mediated the relationship between both the perceived severity of the father's medical condition and the perceived need for medical assistance and the likelihood of hiring an HCA only for White and Hispanic participants, albeit differently. The findings demonstrate that culture and ethnicity affect health evaluations and caregiving decision making.

The role of religion and spirituality in coping with type 2 diabetes: a qualitative study among Black men

Religion and spirituality are instrumental to coping with health; however, there is limited literature on the use of religion and spirituality among Black men with type 2 diabetes. The purpose of this study is to explore how Black men use religion or spirituality to cope with diabetes management. We conducted in-depth interviews with 30 Black men recruited from a diabetes clinic in Atlanta, Georgia as part of a larger study. This article reports on data from 12 of the 30 Black men who reported the use of religion and spirituality as a coping strategy for diabetes management. The following coping strategies were reported: prayer and belief in God, keeping me alive, turning things over to God, changing my unhealthy behaviors, supplying my needs, reading the Bible, and religious or spiritual individuals helping me. Healthcare professionals and researchers involved in diabetes management among Black men should consider these findings in their efforts.

'Diabetes is nothing': the experience of older Singaporean women living and coping with type 2 diabetes

PURPOSE

The purpose of this study was to describe, through qualitative methods, the experiences and ways of coping of older Singaporean Chinese women with type 2 diabetes.

METHODS

Using a qualitative approach, 10 Singaporean Chinese women between the ages of 60-69 described their experiences of living and coping with type 2 diabetes. Data were collected via semi-structured interviews and analysed using thematic analysis.

RESULTS

Three themes were identified in the analysis: (i) Living with diabetes; (ii) Coping with diabetes; and (iii) Caring for the self in diabetes.

CONCLUSIONS

Findings indicate that women living and coping with diabetes confront numerous issues. In order to help these patients initiate and sustain lifestyle modifications, healthcare providers are encouraged to be empathetic and supportive and an understanding of the coping strategies used will ensure that effective coping strategies are utilised. Furthermore, diabetes education for family members will assist them to provide essential, ongoing support for the patient.

The influence of mistrust, racism, religious participation, and access to care on patient satisfaction for African American men: the North Carolina-Louisiana Prostate Cancer Project

OBJECTIVE

The purpose of this study was to explore whether a particular combination of individual characteristics influences patient satisfaction with the health care system among a sample of African American men in North Carolina with prostate cancer. Patient satisfaction may be relevant for improving African American men's use of regular care, thus improving the early detection of prostate cancer and attenuating racial disparities in prostate cancer outcomes.

METHODS

This descriptive correlation study examined relationships of individual characteristics that influence patient satisfaction using data from 505 African American men from North Carolina, who prospectively enrolled in the North Carolina-Louisiana Prostate Cancer Project from September 2004 to November 2007. Analyses consisted of univariate statistics, bivariate analysis, and multiple regression analysis.

RESULTS

The variables selected for the final model were: participation in religious activities, mistrust, racism, and perceived access to care. In this study, both cultural variables, mistrust (p=<.0001, F=95.58) and racism (p=<.002, F=5.59), were significantly negatively associated with patient satisfaction and accounted for the majority of the variability represented by individual characteristics.

CONCLUSION

Mistrust and racism are cultural factors that are extremely important and have been negatively associated with patient satisfaction and decreased desires to utilize health care services for African American men. To overcome barriers in seeking health care services, health care providers need to implement a patient-centered approach by creating a clinical environment that demonstrates cultural competence and eliminating policies, procedures, processes, or personnel that foster mistrust and racism.

The influence of social networks on patients' attitudes toward type II diabetes

Social networks are increasingly recognized as important determinants of many chronic diseases, yet little data exist regarding the influence of social networks on diabetes. We surveyed diabetic patients to determine how social networks affect their overall level of concern regarding diabetes and its complications. We adapted a previously published instrument and surveyed 240 diabetic patients at two primary care practices. Patients recorded the number of family and friends who had diabetes and rated their level of concern about diabetes on a scale of 0% (no concern) to 100% (extremely concerned). Our primary outcome variable was patients' level of concern (<75% or ≥75%). We developed logistic regression models to determine the effect of disease burden in patients' social networks on expressed level of concern about diabetes. We received 154 surveys (64% response rate). We found that for each additional family member with diabetes, patients expressed a greater level of concern about diabetes (AOR 1.5; 95% CI 1.2-2.0) and its potential complications (AOR 1.4; 95% CI 1.1-1.7). Similarly, patients with an increased number of friends with diabetes expressed greater concern about diabetes (AOR 1.5; 95% CI 1.2-1.9) and its complications (AOR 1.3; 95% CI 1.1-1.7). Patients with a higher prevalence of diabetes within their social networks expressed greater concern about diabetes and diabetic complications. Determining disease burden within patients' social networks may allow physicians to better understand patients' perspectives on their disease and ultimately help them achieve meaningful behavioral change.

Chronic illness self-care and the family lives of older adults: a synthetic review across four ethnic groups

The purpose of this paper is to integrate the literature on family and social ties among older ethnic minority men and women with the literature on chronic illness self-care among elders in these groups, in order to increase understanding of social influences on self-care behavior, raise questions for future research, and inform culturally appropriate interventions to maximize the health-promoting potential of social relationships. The paper presents demographic and chronic illness prevalence information, and then summarizes literature about patterns of chronic illness self-care behaviors for older African-Americans, Latinos, Asian-Americans, and American Indians in the U.S. For each group, the sociological literature about residential, cultural, and socioeconomic patterns, family lives, and other social ties is then reviewed, and the self-care literature that has accounted for these patterns is discussed. Finally, six themes are outlined and related questions are identified to further illuminate the social context of older adults' chronic illness self-care.

Exploring the role of spirituality in self-management practices among older African-American and non-Hispanic White women with chronic conditions

OBJECTIVE

The purpose of this study was to examine the role of spirituality in the self-management of chronic illness among older women with chronic conditions.

METHODS

A sample of 41 African-American and non-Hispanic White women, of age 66 and older, participated in the process of self-care study. Data were collected from semi-structured interviews and analysed for common themes using the Grounded Theory method.

RESULTS

Audiotaped and transcribed interviews identified four categories that emerged to suggest the influence of spirituality in behavioural change and disease management: (1) God's involvement in illness management; (2) prayer as a mediator; (3) spirituality as a coping mechanism; and (4) the combination of conventional and spiritual practices.

DISCUSSION

Older women with various chronic illnesses defined 'spirituality' in a broad, holistic way, and the findings suggest that spirituality played a part in documenting the self-management process. Knowledge of spirituality and the role it plays in illness management may assist public health gerontologists in designing effective and culturally appropriate self-management programmes.

Foot care education and self management behaviors in diverse veterans with diabetes

The objective of this study was to examine differences in self-reported diabetes foot care education, self management behaviors, and barriers to good foot care among veterans with diabetes by race and ethnicity. Data was collected using the Veterans Health Administration Footcare Survey, a validated tool that assessed demographic, general health, diabetes and foot self-care information, barriers to foot self-care, receipt of professional foot care, and satisfaction with current care. We mailed surveys to a random sample of patients with diabetes from eight VA medical centers. Study participants were 81% White; 13% African American; 4% Asian, and 2% American Indian and Pacific Islanders. The majority of respondents felt that they did not know enough about foot self-care. There were large gaps between self-reported knowledge and actual foot care practices, even among those who reported "knowing enough" on a given topic. There were significant differences in self-reported foot care behaviors and education by race and ethnicity. These findings document the need for culturally-specific self-management education to address unique cultural preferences and barriers to care.

The relationship between health literacy and knowledge improvement after a multimedia type 2 diabetes education program

OBJECTIVE

Multimedia diabetes education programs (MDEP) have the potential to improve communication and education of those with low health literacy. We examined the effect of a MDEP targeted to patients with low literacy on knowledge and assessed the association between literacy and knowledge improvement.

METHODS

We showed the MDEP to 190 patients recruited from clinics at a federally qualified health center and an academic health center. We measured diabetes knowledge before and after viewing the MDEP.

RESULTS

Seventy-nine percent of patients had adequate literacy, 13% marginal, and 8% inadequate literacy. Patients across all literacy levels had significant increases in knowledge scores after viewing the MDEP (p-value<0.001). Patients with inadequate literacy learned significantly less after the MDEP (adjusted beta-coefficient=-2.3, SE=0.70) compared to those with adequate literacy.

CONCLUSIONS

A MDEP designed for those with low literacy significantly increased diabetes knowledge across literacy levels. However, the MDEP did not overcome the learning gap between patients with low and high literacy.

PRACTICE IMPLICATIONS

A literacy appropriate MDEP may be an effective way to teach patients about diabetes. Combining the MDEP with other education methods may improve comprehension and learning among those with low literacy. Research is needed to identify which characteristics of low-literate patients influence the ability to learn health information. Identifying these factors and incorporating solutions into a diabetes education intervention may help bridge the learning gap related to literacy status.

Outcomes of an intervention to reduce uncertainty among African American women with diabetes

Poor adjustment to diabetes in older African American women may result from uncertainty, stemming from a lack of information about self-care activities, a complexity of self-care activities, comorbid conditions, and a lack of resources. This study evaluated a telephone intervention to reduce uncertainty (through problem-solving strategies, information, cognitive reframing, and improved patient-provider communication)--namely, to measure its effects on diabetes self-care and psychosocial adjustment. Sixty-eight older African American women were randomly assigned to an experimental group and a control group. The experimental group received the intervention for 4 weeks, and the control group received usual care. Psychosocial adjustment and self-care were measured in all participants at baseline and 6 weeks postbaseline. The experimental group reported increased participation in exercise (self-care component; p < .001) and improvement in psychosocial adjustment (p < .001). Thus, reducing the uncertainty related to diabetes self-care improves self-care exercise, as well as psychosocial adjustment.

Coping styles, well-being, and self-care behaviors among African Americans with type 2 diabetes

PURPOSE

The purpose of this study was to describe how coping styles among African Americans with type 2 diabetes relate to diabetes appraisals, self-care behaviors, and health-related quality of life or well-being.

METHODS

This cross-sectional analysis of baseline measures from 185 African Americans with type 2 diabetes enrolled in a church-based randomized controlled trial uses the theoretical framework of the transactional model of stress and coping to describe bivariate and multivariate associations among coping styles, psychosocial factors, self-care behaviors, and well-being, as measured by validated questionnaires.

RESULTS

Among participants who were on average 59 years of age with 9 years of diagnosed diabetes, passive and emotive styles of coping were used most frequently, with older and less educated participants using more often passive forms of coping. Emotive styles of coping were significantly associated with greater perceived stress, problem areas in diabetes, and negative appraisals of diabetes control. Both passive and active styles of coping were associated with better diabetes self-efficacy and competence in bivariate analysis. In multivariate analysis, significant proportions of the variance in dietary behaviors and mental well-being outcomes (general and diabetes specific) were explained, with coping styles among the independent predictors. A positive role for church involvement in the psychological adaptation to living with diabetes was also observed.

CONCLUSIONS

In this sample of older African Americans with diabetes, coping styles were important factors in diabetes appraisals, self-care behaviors, and psychological outcomes. These findings suggest potential benefits in emphasizing cognitive and behavioral strategies to promote healthy coping outcomes in persons living with diabetes.

Variation in treatment preferences and care goals among older patients with diabetes and their physicians

BACKGROUND

Older persons with diabetes are heterogeneous with respect to life expectancy and frailty, and new guidelines recommend individualizing care.

OBJECTIVES

(1) To describe variation in the preferences of older patients with diabetes regarding aggressiveness of glycemic control and avoiding diabetic complications. (2) To determine correlates of patient preferences and physician treatment goals. (3) To assess whether physicians' goals were consistent with their patients' preferences.

RESEARCH DESIGN

Cross-sectional surveys and chart reviews in urban academic clinics.

SUBJECTS

: Four hundred seventy-three patients with diabetes age 65 or older and 64 physicians.

MEASURES

Patient preferences (utilities on a scale from 0 to 1, 0 = death, 1 = perfect health) for diabetic complications and intensity of treatment, and physician target treatment goals and ratings of aggressiveness of approach.

RESULTS

Eighty percent of the patients were African American, 63% were women, average age was 73.7 +/- 5.9 years and 26% expected to live 5 years or less. Patient preferences/utilities showed significant variation: blindness 0.39 (SD, 0.32), lower leg amputation 0.45 (0.34), conventional treatment 0.76 (0.27), and intensive insulin treatment 0.64 (0.32). Physicians' hemoglobin A1c goal was < or =7% in 69% of patients. Greater estimated patient life expectancy was consistently associated with higher patient utilities and was associated with physicians' willingness to use aggressive treatments. Physicians' treatment goals and approaches were associated with patients' utilities for treatment.

CONCLUSIONS

Older patients vary greatly in their preferences regarding diabetic complications and treatments. Acknowledging patient preferences, along with life goals and prognostic data, may improve quality of treatment decisions.

Depressive symptoms, cardiovascular risk, and diabetes self-care strategies in African American women with type 2 diabetes

This descriptive study examined depressive symptoms, cardiovascular risk, and diabetes self-care strategies in African American women (N = 45) with type 2 diabetes (T2D). All completed a questionnaire packet during structured interviews. Significant associations were found between two individual depressive symptoms and mean cardiovascular disease (CVD) risk scores, which suggest that in African American women with T2D, depressive symptoms may be correlated with a specific CVD profile and/or are unrecognized and/or unexpressed. Further analysis is warranted to determine the extent of this relationship in African American women with T2D.

The role of spirituality in the self-management of chronic illness among older African and Whites

This study used data from in-depth interviews collected from 88 African American and White men and women aged 65 years and older who reside in Allegheny County, Pennsylvania. The purpose of this study was to understand the role of spirituality in the self-management of chronic illness among this population. Thematic content analysis addressed two specific questions: (1) how do older adults use spirituality to help manage their chronic illness, and (2) are there any racial differences in the use of spirituality. Several core themes emerged from the linkage of spirituality and self-management: God: the healer, God: the enabler through doctors, faith in God, prayer as a mediator, spirituality as a coping mechanism, combining conventional medicine and spiritual practices, and empowering respondents to practice healthy eating habits. These results display racial differences in the use of spirituality in the self-management of chronic illness. African American elders were more likely than White elders to endorse a belief in divine intervention. White elders were more likely than African America elders to merge their spirituality in various self-management practices. Despite these differences, spirituality can play an integral part in a person's health and well-being of chronically ill elders.

Spirituality in African Americans with diabetes: self-management through a relationship with God

The purpose of this study was to develop a theoretical model about how the spirituality of African Americans affects their self-management of diabetes. The sample consisted of 29 African American men and women, ages 40 to 75, with type 2 diabetes. The authors used a grounded theory design and collected data using minimally structured interviews. The method of analysis was constant comparison. The core concept identified was Self-Management Through a Relationship With God. Participants fell into one of three typologies: (a) Relationship and Responsibility: God Is in Background; (b) Relationship and Responsibility: God Is in Forefront: (c) Relationship and Relinquishing of Self-Management: God Is Healer. These typologies varied according to how participants viewed their relationship with God and the impact of this relationship on their self-management. The spirituality of these African Americans was an important factor that influenced the self-management of their diabetes.

Coping and psychosocial adaptation to Type 2 diabetes in older Blacks born in the Southern US and the Caribbean

Older Black men and women (n = 212) with Type 2 diabetes completed questionnaires. Spearman's rho correlation indicated that confrontive coping strategies supported effective psychosocial adaptation for persons originally from Haiti and Jamaica, while emotive coping strategies were related to ineffective psychosocial adaptation for persons originally from Barbados and to increased psychological distress for all participants. Women used more palliative coping; no gender differences were observed for psychosocial adaptation. Health care orientation, extended family relationships, and psychological distress domains distinguished Blacks born in Haiti from Blacks born in Barbados and Jamaica, the Southern US and Jamaica, and the Southern US, Barbados, and Jamaica. Findings from this study may aid in the development of interventions focused on improving diabetes self-management for older Blacks.

African Americans and diabetes: Spiritual role of the health care provider in self-management

How African Americans with type 2 diabetes perceive the spiritual role of health care providers (HCPs) and the effects of that role on self-management was explored using a qualitative descriptive analysis. The sample consisted of 29 African American men and women ages 40-75 with type 2 diabetes and 5 ministers of African American churches. A spiritual relationship with their health provider was important in helping participants manage their diabetes. Three typologies from a parent study were expanded with a focus in this extended study on the meaning ascribed to spiritual relationships with providers and the impact of these relationships on self-management. Care perceived as spiritual may be an important component of providing culturally sensitive health care to African Americans and may facilitate their self-management.

African American older adults coping with chronic health conditions

This study's purpose is to identify strategies used by community-dwelling African American elders to cope with their chronic health conditions. A focus group study of 28 African American elders with multiple chronic conditions was conducted. Data collection occurred during the last 4 months of 2003. The five focus groups were audiotaped and transcribed verbatim. Content analysis was performed on the data to ascertain coping strategies employed to manage daily life with chronic conditions. Categories of coping strategies identified are (a) dealing with it, (b) engaging in life, (c) exercising, (d) seeking information, (e) relying on God, (f) changing dietary patterns, (g) medicating, (h) self-monitoring, and (i) self-advocacy. This study expands nurses' knowledge of the repertoire of coping strategies used by African American elders to ameliorate the effects of their chronic health conditions. Study findings will be valuable for planning intervention studies aimed at promoting successful coping.

Self-management in African American women with diabetes

PURPOSE

This study describes demographic and medical characteristics, self-efficacy, locus of control, self-management defined by functional status, hemoglobin HbA1c outcomes, and the relationships among these variables based on age group differences (25-44 years, 45-64 years, and 65-84 years) in African American women with type 2 diabetes.

METHODS

Subjects (n = 75) in community medical practices were interviewed to complete a demographic and medical form, the Diabetes Self-efficacy Outcomes Expectancy Questionnaire (DSEQ), the Diabetes Locus of Control Scale, and the Medical Outcomes-Short Form 36 (SF-36). A venous blood sample was taken following the interview. Data were analyzed for the total sample and separately for age groups.

RESULTS

Scores on the self efficacy (DSEQ) and the locus of control (LOC) were above average for all 3 groups. Significant correlations were found among subscales of the LOC, SF-36, and HbA1c. HbA1c scores were abnormally high across groups. Significant group differences were found in duration of diabetes and number of medications used.

CONCLUSIONS

Despite high levels of internal locus of control and self-efficacy and scores indicating good mental, physical, emotional, and social health, self-management among the women was inadequate, as indicated by abnormally high HbA1c levels.

Spirituality and self-management of diabetes in African Americans

Attention to spirituality is especially important for nurses when providing care to African Americans. Spirituality is deeply embedded in their rich cultural heritage. For many African Americans, spirituality is intertwined into all aspects of life, including beliefs about health and illness. Therefore, it is imperative that nurses understand the relationship between African American spirituality, health, and self-management of illness to provide culturally competent care to African Americans. The purpose of this article is to summarize the research literature on African American spirituality, health, and self-management as it relates to Type 2 diabetes, an illness that involves complex self-care management. Recommendations for holistic nursing practice and research related to this literature are also identified.

Beliefs about health and diabetes in men of different ethnic origin

AIM

This paper reports the findings of a study exploring the health and illness beliefs of men with diabetes, who were from different cultural backgrounds and living in Sweden.

BACKGROUND

No studies have been reported that have focused on the beliefs about health and illness in men with diabetes mellitus of different ethnic origin. Beliefs may affect self-care and care-seeking behaviour.

METHOD

An explorative study design and purposive sampling procedure was used. Focus-group interviews were held with 35 men with diabetes and aged between 39 and 78 years. Fourteen participants were born in Arabic countries, 10 in former Yugoslavia and 11 in Sweden.

FINDINGS

Important factors for health were the ability to be occupied/employed and economically independent and, especially among Arabs and former Yugoslavians, sexual functioning. Swedes focused on heredity, lifestyle and management of diabetes, while non-Swedes claimed the influence of supernatural factors and emotional stress related to the role of being an immigrant and migratory experiences as factors related to development of diabetes and having a negative influence on health. Swedes and Arabs described health as "freedom from disease" in contrast to many former Yugoslavians who described health as "wealth and the most important thing in life". Knowledge about diabetes was limited among the men studied, but Arabs showed an active information-seeking behaviour compared with Swedes and former Yugoslavians. Non-Swedish respondents, particularly Arabs, had sought help from health care professionals to a greater extent than Swedes, who were more likely to use self-care measures.

CONCLUSION

Being occupied/employed and having knowledge about the body and management of diabetes are important for positive health development. There are dissimilarities in beliefs about health and diabetes that influence self-care behaviour and health care seeking. Men's cultural backgrounds and spiritual beliefs need to be considered in diabetes care.

Self-reported goals of older patients with type 2 diabetes mellitus

OBJECTIVES

New diabetes mellitus guidelines from the American Geriatrics Society promote the individualization of treatment goals and plans for patients aged 65 and older. Communicating with older patients about such complex medical decisions presents new challenges for providers. The self-reported healthcare goals, factors influencing these goals, and self-care practices of older patients with diabetes mellitus were explored.

DESIGN

Exploratory study involving semistructured interviews.

SETTING

Four clinics of a midwestern, urban academic medical center.

PARTICIPANTS

Patients aged 65 and older with type II diabetes mellitus (N=28).

MEASUREMENTS

Semistructured, one-on-one interviews were conducted. Interviews were audiotaped, transcribed, and evaluated for recurring themes using a grounded theory approach.

RESULTS

The majority of patients expressed their healthcare goals in a social and functional language, in contrast to the biomedical language of risk factor control and complication prevention, even when specifically asked about goals for diabetes mellitus care. Patient's predominant healthcare goals centered on maintaining their independence and their activities of daily living (71%). Medical experiences of friends and family (50%), social comparison with peers (7%), and medical professionals (43%) shaped patients' goals. Self-reported medication adherence and glucose monitoring was high, but more than one-quarter of patients failed to adhere to any dietary recommendations, and one-third failed to adhere to their exercise regimens.

CONCLUSION

As diabetes mellitus care recommendations for older patients grow more complex, providers could enhance their communication about such medical decisions by exploring patients' specific circumstances and reframing diabetes mellitus treatment goals in patients' own language. These may be crucial steps to developing successful individualized care plans.

Developing a new generation of ongoing: Diabetes self-management support interventions: a preliminary report

PURPOSE

The study examined the feasibility, acceptability, and potential impact of an innovative, community-based, ongoing self-management intervention aimed at enhancing and sustaining self-care behaviors over the long term among urban African Americans with type 2 diabetes.

METHODS

Sixty-two African American men and women completed the study. Participants were invited to attend 24 weekly, consecutive, diabetes self-management support/ education groups. The flow of the weekly group sessions was guided by questions and concerns of the patients. Baseline and 6-month follow-up metabolic functioning, lipid profiles, cardiovascular functioning, and self-care behaviors were assessed.

RESULTS

Ninety percent (n = 56) of the sample attended at least 1 session; 40% attended at least 12 or more sessions. Paired t tests found significant improvements in body mass index (P < .001), total cholesterol (P < .01), high-density lipoprotein (P < .05), and low-density lipoprotein (P < .001). Significant increases were also found for self-care behaviors (P < .05).

CONCLUSIONS

Preliminary evidence suggests that participation in this weekly problem-based, self-management support intervention can yield diabetes-related health benefits.

Religious and cultural distance in beliefs about health and illness in women with diabetes mellitus of different origin living in Sweden

The study explored beliefs about health and illness in females with diabetes mellitus (DM) from different religious backgrounds living in Sweden. Swedes showed an active self-care behaviour and a healthy and controlled life-style. Ex-Yugoslavian Muslims emphasised enjoyment of life and a passive self-care attitude, lesser inclination to self-monitoring of blood glucose and preventive foot care. Arabs emphasised adaptation to DM and a lot of 'musts' concerning diet, and had a lower threshold for seeking care. They also emphasised being a believing Muslim, and although explaining the cause of DM as 'the will of Allah or God', in contrast to ex-Yugoslavians, they actively searched for information about management of DM. Cultural and religious distance are essential for understanding self-care practice and care-seeking behaviour, and need to be considered in the planning of diabetes care.

[Perspective of patients on type-2 diabetes and their relationship with primary care health professionals: a qualitative study]

AIM

The objective of this study is to investigate the perception that people with type 2 diabetes have about the disease and about their relationship with the primary healthcare professionals.

DESIGN

Qualitative research, carried out between September-November 2000.

SETTING

Primary healthcare center Barrio del Pilar from Madrid.

PARTICIPANTS

15 persons with type 2 diabetes. Variables considered to design the profiles of the interviewed were: age, gender, educational level, and time since diagnosis.

METHOD

Structural sampling and open interviews.

RESULTS

Patients express having scarce information regarding the consequences of diabetes. As diabetes is symptom free represents a difficulty for being perceived as a severe disease. The most valued aspects of the relationship with health professionals are that they provide with clear and tailored information, build a trust context, support changes and take account their perspectives and living circumstances.

CONCLUSIONS

It is essential to recognize how patients understand and shape the disease. Information provided by professionals have to be tailored to patients necessities, and take place in a trusting environment. Decisions related with diabetes management have to be aligned with patients perspectives. Effective communication could be considered as a useful tool to encourage adherence and improve healthcare quality.

Variations in the care of elderly persons with diabetes among endocrinologists, general internists, and geriatricians

BACKGROUND

The American Diabetes Association (ADA) clinical practice recommendations have been widely promoted, but they lack a geriatric-specific approach to care. We aimed to determine the style of care that endocrinologists, general internists, and geriatricians provided to their elderly patients with diabetes and to what extent these medical professionals adhered to the ADA standards.

METHODS

We performed a retrospective cohort study of a stratified sample of 531 diabetic patients aged 65 years and older from the endocrinology, general internal medicine, and geriatrics clinics of an urban academic medical center.

RESULTS

Patients of geriatricians were older, had higher comorbidity, and were more likely to be demented. The average number of diabetic complications was similar across the specialties, although patients of endocrinologists had higher prevalence of neuropathy and retinopathy compared with patients of geriatricians. Endocrinologists were more likely to use insulin, multiple types of insulin, and combined oral hypoglycemic and insulin therapies. Most patients had hemoglobin A1c measured, and average values were similarly high across specialties at 8.6%. Blood pressures were above 130/85 mm Hg in 85% of the patients. All specialties rarely measured urine microalbumin; geriatricians seldom performed fractionated cholesterol tests, and ophthalmology visits occurred in only half of the patients.

CONCLUSION

Endocrinologists had the most aggressive, complex diabetes treatment regimens, although geriatricians had older patients with more dementia and lower prevalence of microvascular complications. Average hemoglobin A1c levels and blood pressures were higher than recommended among patients of all three specialties. Screening for diabetic complications and hyperlipidemia was lower than advised.