Using focus groups to plan and evaluate diabetes self-management interventions for Mexican Americans

Overweight and obesity in south central Uganda: A population-based study

Obesity is a rapidly growing global health challenge, but there are few population-level studies from non-urban settings in sub-Saharan Africa. We evaluated the prevalence of overweight (body mass index (BMI)>25 kg/m2), obesity (BMI>30 kg/m2), and associated factors using data from May 2018 to November 2020 from the Rakai Community Cohort Study, a population-based cohort of residents aged 15 to 49 living in forty-one fishing, trading, and agrarian communities in South Central Uganda. Modified Poisson regression was used to estimate adjusted prevalence risk ratios (PRR) and 95% confidence intervals (CI) in 18,079 participants. The overall mean BMI was 22.9 kg/m2. Mean BMI was 21.5 kg/m2 and 24.1 kg/m2 for males and females, respectively. The prevalence of overweight and obesity were 22.8% and 6.2%, respectively. Females had a higher probability of overweight/obesity (PRR: 4.11, CI: 2.98-5.68) than males. For female participants, increasing age, higher socioeconomic status, residing in a trading or fishing community (PRR: 1.25, CI 1.16-1.35 and PRR: 1.17, CI 1.10-1.25, respectively), being currently or previously married (PRR: 1.22, CI 1.07-1.40 and PRR: 1.16, CI 1.01-1.34, respectively), working in a bar/restaurant (PRR: 1.29, CI 1.17-1.45), trading/shopkeeping (PRR: 1.38, CI 1.29-1.48), and reporting alcohol use in the last year (PRR: 1.21, CI 1.10-1.33) were risk factors for overweight/obese. For male participants, increasing age, higher socioeconomic status, being currently married (PRR: 1.94, CI 1.50-2.50), residing in a fishing community (PRR: 1.68, CI 1.40-2.02), working in a bar/restaurant (PRR: 2.20, CI 1.10-4.40), trading/shopkeeping (PRR: 1.75, CI 1.45-2.11), or fishing (PRR: 1.32, CI 1.03-1.69) increased the probability of overweight/obesity. Non-Muslim participants, male smokers, and HIV-positive females had a lower probability of overweight/obese. The prevalence of overweight/obesity in non-urban Ugandans is substantial. Targeted interventions to high-risk subgroups in this population are needed.

Adapting a Family-Focused Diabetes Prevention Program for a Federally Qualified Health Center: A Qualitative Report

PURPOSE

The purpose of the study was to explore the needs of high-risk Latinx/Hispanic women with a history of gestational diabetes who were patients at a Federally Qualified Health Center (FQHC) in anticipation of a future family-based program.

METHODS

Six focus group studies were conducted in partnership with El Rio Community Health Center, an FQHC in Tucson, Arizona. Thirty-nine women participated, each identified as Latinx/Hispanic, self-reported a history of gestational diabetes or prediabetes, and had at least 1 child aged 8 to 13. Three investigators independently reviewed transcripts from the focus groups to identify themes that reflected thematic saturation from participants' responses. Data coding and results were discussed as a group and any differences were collectively adjudicated.

RESULTS

All participants had a family member with diabetes and worried about their and their immediate family members' risk for developing the disease. The possible benefits of participating in a lifestyle prevention program were universally recognized, but multiple barriers to participation were described, including scheduling conflicts, access to childcare, transportation, and the need to involve additional family members to reinforce program objectives.

CONCLUSIONS

There is a strong willingness to participate in a diabetes prevention program among respondents, but to be successful, interventions must be tailored to specific needs and challenges. Trying to apply existing prevention curricula with low-income Latinx/Hispanic populations may not be successful without adaptations.

The Starr County Border Health Initiative: Focus Groups on Diabetes Prevention in Mexican Americans

Purpose The purpose of the study was to conduct focus groups with Mexican Americans in an impoverished rural community on the Texas-Mexico border to identify current barriers to adopting healthier lifestyles and to obtain recommendations for diabetes prevention. Methods Three separate 2-hour focus groups were led by an experienced bilingual Mexican American moderator. Interviews included questions about cultural factors and barriers that influence lifestyle behaviors, aspects of previous diabetes self-management interventions that were helpful for motivating behavioral change, and recommendations for diabetes prevention. Results Twenty-seven participants attended a focus group session; each session involved 7 to 12 informants. Individuals were diagnosed with prediabetes or type 2 diabetes mellitus; most were female, foreign born, and Spanish speaking. Interviews documented the cultural importance of food. Informants raised priority issues for diabetes prevention, including the need to learn how to prepare healthier foods and track caloric intake. Major barriers to healthier lifestyles included high costs of healthy foods, fatigue from busy schedules and working multiple jobs, a cultural view that exercise is a waste of valuable time, and fear of deportation. Conclusions Cultural influences and barriers to implementing healthy lifestyles should be assessed regularly and strategies implemented to overcome them. Such factors may change as environmental, sociocultural, and political environments change.

A Systematic Review of Research on Culturally Relevant Issues for Hispanics With Diabetes

Purpose

The purpose of this review is to provide a description of current research on culturally relevant issues among Hispanics subgroups with diabetes throughout the United States.

Methods

A search of 2655 abstracts was conducted using Medline, PubMed, and Psychlit. Sixty articles were identified, and 33 were reviewed.

Results

Most studies focused on Mexican Americans, and little is known about the unique and shared health beliefs of different Hispanics subgroups within the United States. Personal models of illness varied across groups and were influenced by levels of acculturation. Definitions and treatments for susto varied considerably: Puerto Ricans did not identify it as a cause of diabetes. Patients'thoughts about God and diabetes differed, and little is known about how these thoughts affect diabetes self-management. There is also limited research on Hispanics' use of curanderos (folk healers) for diabetes-related care, and only some participants reported using alternative treatments in conjunction with standard medical care. There is limited evidence that fatalistic thinking is unique to Hispanic culture, and its relationship to diabetes self-management remains unclear.

Conclusions

More research is needed to determine how cultural factors influence Hispanics' approaches to diabetes self-management. Clinicians and educators would benefit from exploring cultural belief systems with patients, as they may enhance the patient-provider relationship and serve as tools in identifying appropriate treatment strategies.

A systematic review of research into black and ethnic minority patients' views on self-management of type 2 diabetes

CONTEXT

Eliciting patients' views of type 2 diabetes self-management provides insights on how policy and services might better support the needs of this population.

OBJECTIVE

To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self-management of type 2 diabetes.

SEARCH STRATEGY

A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free-text terms. Two relevant journals were also hand searched.

INCLUSION CRITERIA

Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self-management.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis.

MAIN RESULTS

Fifty-seven studies were included, of qualitative (n = 54), mixed-method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: 'Importance of identity'; 'Being understood by others' and 'Making sense of condition', all linked conceptually under the overarching theme 'Sense of self'. The quality of the studies varied.

DISCUSSION AND CONCLUSIONS

The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self-management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient-centred care and policies.

Lessons Learned From Using Focus Groups to Refine Digital Interventions

There is growing interest in applying novel eHealth approaches for the prevention and management of various health conditions, with the ultimate goal of increasing positive patient outcomes and improving the effectiveness and efficiency of health services delivery. Coupled with the use of innovative approaches is the possibility for adverse outcomes, highlighting the need to strategically refine digital practices prior to implementation with patients. One appropriate method for modification purposes includes focus groups. Although it is a well-established method in qualitative research, there is a lack of guidance regarding the use of focus groups for digital intervention refinement. To address this gap, the purpose of our paper is to highlight several lessons our research team has learned in using focus groups to help refine digital interventions prior to use with patients.

Culturally tailored diabetes prevention in the workplace: focus group interviews with Hispanic employees

PURPOSE

The purpose was to conduct focus groups with Hispanic employees to obtain input into adaptation of previous DSME interventions for use as a workplace diabetes prevention program.

METHODS

From a list of interested Hispanic employees who attended a local health fair (n = 68), 36 were randomly selected to participate in focus groups held during supper mealtime breaks. An experienced bilingual moderator directed the sessions, using interview guidelines developed by the research team.

RESULTS

Participants' ages ranged from 22 to 65 years (mean = 50.4, n = 36, SD = 10.7), 7 males and 29 females attended, and 53% had type 2 diabetes mellitus (T2DM). Employees expressed a keen interest in diabetes classes and recommended a focus on preparing healthier Hispanic foods. Primary barriers to promoting healthier lifestyles were work schedules; many employees worked 2 part-time or full-time jobs. Administrators and direct supervisors of the employees were highly supportive of a workplace diabetes prevention program.

CONCLUSIONS

The consistent message was that a workplace program would be the ideal solution for Hispanic employees to learn about diabetes and healthy behaviors, given their busy schedules, family responsibilities, and limited resources. If found to be effective, such a workplace program would be generalizable to other service employees who have disproportionate diabetes rates.

Partnering With Families to Refine and Expand a Diabetes Intervention for Mexican Americans

PURPOSE

The purpose of this study was to refine and expand a culturally tailored individual-level diabetes self-management intervention to a family-level intervention.

METHODS

Using community-based participatory research principles, Mexican American adults (n = 12) with type 2 diabetes mellitus (T2DM) and family members (n = 12) in the United States-Mexico border region participated in 6 focus group interviews, conducted by bilingual, bicultural facilitators. Facilitators and barriers to T2DM management were identified. Transcripts were analyzed using qualitative content analysis.

RESULTS

Through an iterative analysis process, 5 categories represented participants with T2DM: (1) strategies my family can use to support our managing T2DM, (2) be sensitive to my challenges, (3) stop telling me what to eat or do, (4) how can we peacefully coexist, and (5) I feel supported. Categories identified by family members were (1) changing behaviors together, (2) sharing not controlling, (3) supporting positive behaviors, and (4) your behaviors frustrate me.

CONCLUSIONS

The family was reinforced as a major influence for successful T2DM management. Family support requires that families value and develop knowledge and skills for T2DM management. This family intervention builds on family assets and relationships, shifting from traditional externally motivated individual models to create a shared commitment to manage T2DM among Mexican American adults.

Perceptions of barriers in managing diabetes: perspectives of Hispanic immigrant patients and family members

PURPOSE

Hispanics show poorer self-management of type 2 diabetes than non-Hispanic whites. Although previous studies have reported socioeconomic and cultural barriers to diabetes self-management by Hispanics, little is known about perceived barriers to diabetes self-management from the perspectives of both Hispanics and their family members. The purpose of the study was to explore perceived barriers among Hispanic immigrants with diabetes and their family members.

METHODS

A qualitative study using 5 focus groups was conducted. A total of 73 Hispanic immigrants with type 2 diabetes (n = 36) and family members (n = 37) were recruited in the southeastern United States for a family-based intervention study of diabetes-self management. Participants were asked to describe their perceptions of barriers to self-management. The 5 sessions were audiotaped and transcribed, translated from Spanish into English, and analyzed using standard content analysis. Demographics, hemoglobin A1C levels, blood pressure, and body mass index (BMI) were obtained both for participants with diabetes and for their family members.

RESULTS

Barriers to diabetes self-management identified by participants with diabetes were in 3 major themes categorized as: suffering from diabetes, difficulties in managing the disease, and lack of resources/support. Two key themes emerged pertaining to family members: we can provide support and we lack knowledge.

CONCLUSIONS

Perceived barriers to diabetes self-management described by Hispanic immigrants with diabetes and family members indicate a lack of intervention strategies to meet their needs. Interventions should include culturally relevant resources, family support, and diabetes self-management skills education.

Needs and preferences for nutrition education of type 2 diabetic adults in a resource-limited setting in South Africa

Diabetes self-management education is crucial in diabetes care. Education that is tailored to the needs of the patient is considered the most effective in improving health outcomes. Diet, a critical element of diabetes treatment, is reported as the most difficult to adhere to by both patients and health professionals. Tailored nutrition education (NE) could benefit diabetic individuals with low socio-economic status, who are amongst those noted to have poor health outcomes. This qualitative interpretive phenomenological study aimed to explore and describe the NE needs of adults with type 2 diabetes mellitus to guide development of a tailored NE programme for resource-poor settings. Participants were 31 non-insulin-dependent type 2 diabetic patients (convenience sample) and 10 health professionals. Focus group discussions using semi-structured questions were held with the diabetics, and open-ended self-administered questionnaires were used with the health professionals. Data analysis was done using Krueger’s framework approach. Disease-related knowledge deficits and inappropriate self-reported dietary practices, including intake of unbalanced meals, problems with food portion control and unsatisfactory intake of fruits and vegetables, were observed. Recommendations for the NE programme included topics related to the disease and others related to diet. Group education at the clinic, a competent educator and comprehensive education were indicated by the patients. Participation of family and provision of pamphlets were aspects recommended by patients and health professionals. Barriers that could impact the NE included financial constraints, food insecurity, conflict in family meal arrangements and access to appropriate foods. Support from family and health professionals and empowerment through education were identified as facilitators to following dietary recommendations by both groups of participants. Knowledge deficits, inappropriate dietary practices and barriers are issues that need addressing in an NE programme, whilst the suggestions for an NE programme and facilitators to dietary compliance need to be incorporated.Onderrig in die selfbestuur van diabetes is essensieel in diabetessorg. Onderrig wat spesifiek ooreenkomstig die behoeftes van die pasiënt aangepas is, word die mees doeltreffend in die verbetering van gesondheiduitkomste geag. Dieet, ’n kritiese element in diabetesbehandeling, word deur pasiënte en gesondheidpraktisyns as die moeilikste beskou om na te volg. Spesifiek beplande voedingonderrig kan tot voordeel van lae sosio-ekonomiese diabete wees wat deel van diegene wat swak gesondheiduitkomste toon, uitmaak. Die doel van hierdie kwalitatiewe interpreterende fenomologiese studie was om die voedingonderrigbehoeftes van volwassenes met tipe 2 diabetes mellitus te ondersoek en te beskryf ten einde die ontwikkeling van ’n voedingonderrigprogram wat op hulpbrondbeperkte omgewings afgestem is, te rig. Een en dertig nie-insulien afhanklike tipe 2 diabetes pasiënte (geriefsteekproef) en 10 gesondheidpraktisyns was  evalueer.  Fokusgroepbesprekings  deur  gebruikmaking  van  semi-gestruktureerde vrae, is met die diabete gehou. Self-geadministreerde oop-eindigende vraelyste is deur die gesondheidpraktisyns  voltooi.  Data-analise  is  volgens  Krueger  se  raamwerkbenadering gedoen. Siekteverwante kennisgapings en ontoepaslike self-gerapporteerde dieetpraktyke, insluitend ongebalanseerde maaltye, probleme met porsiekontrole en ontoereikende inname van groente en vrugte is gerapporteer. Aanbevelings vir die voedingonderrigprogram het onderwerpe verwant aan die siekte en die dieet ingesluit. Die pasiënte het groeponderrig by die kliniek, ’n bevoegde onderrigpraktisyn en omvattende onderrig verkies. Die pasiënte en die gesondheidpraktisyns het gesinsdeelname en die beskikbaarstelling van pamflette aanbeveel. Struikelblokke wat negatief op die voedingonderrigprogram kon inwerk, het finansiële beperkinge, voedselinsekuriteit, konflik met gesinsmaaltydreëlings en toegang tot  geskikte  voedsels  ingesluit.  Ondersteuning  van  die  gesin  en  gesondheidpraktisyns, sowel as bemagtiging deur kennis is as fasiliteerders ter bevordering van die navolging van dieetaanbevelings deur beide groepe deelnemers geïdentifiseer. Tekortkominge in kennis, ontoepaslike dieetpraktyke en struikelblokke is aspekte wat in ’n voedingonderrigprogram aangespreek behoort te word. Voorstelle wat vir die voedingonderrigprogram en fasiliteerders gemaak is vir dieetnavolging, behoort in die program ingesluit te word.

The meaning of insulin to Hispanic immigrants with type 2 diabetes and their families

PURPOSE

The purpose of this study was to explore the meaning of insulin among a sample of Hispanic immigrants with type 2 diabetes and their family members/significant others.

METHOD

Forty-three Hispanics with type 2 diabetes and their family members/significant others were recruited in the southeastern United States for a family-based intervention study on diabetes self-management. Focus groups were conducted in which participants with diabetes and family members were asked to describe their perceptions of insulin. The sessions were audiotaped and transcribed, translated from Spanish into English, and analyzed using standard content analysis. This article reports the findings as well as demographic information and hemoglobin A1C levels of participants.

RESULTS

The meaning of insulin was described by both Hispanic immigrants with type 2 diabetes and their family members/significant others. Participants' perceptions were categorized into three major themes: (1) negative perceptions of insulin therapy, (2) perceived barriers to insulin therapy, and (3) positive experiences with insulin emerged from qualitative data.

CONCLUSIONS

The Hispanic immigrants with diabetes and their family members/significant others in this study described perceptions and fears of insulin indicating a lack of understanding of the diabetes disease process and the progressive nature of diabetes. Strategies and further research are necessary to dispel negative perceptions and facilitate positive experiences with insulin for patients and family members/significant others.

The Diabetes Symptom Self-Care Inventory: development and psychometric testing with Mexican Americans

CONTEXT

Type 2 diabetes is prevalent throughout the world. In previous studies of Mexican Americans with type 2 diabetes, 95%-97% of those sampled reported having symptoms they believe were caused by diabetes and most self-treated their symptoms. To more accurately capture Mexican Americans' symptom prevalence and their self-treatments, the Diabetes Symptom Self-Care Inventory (DSSCI) was adapted from the Diabetes Self-Care Instrument.

OBJECTIVES

This article describes the modification process used to perfect the DSSCI for use in improving self-care among people with type 2 diabetes.

METHODS

This instrumentation study used qualitative and quantitative methods. The study was completed in four phases that used focus groups, cognitive interviews, and survey administration. Four convenience samples were drawn from community-dwelling Mexican American adults, aged 25-75 years, with type 2 diabetes in an urban area and a rural location in Texas.

RESULTS

Phase I: Seven focus groups (n=45) generated data for revising items. Phase II: Cognitive interviews with 16 participants were used to evaluate four revisions of the questionnaire. Phase III: Surveys were administered to 81 participants. Total number of symptoms on the DSSCI correlated with scores on the Centers for Epidemiological Studies-Depression scale (r=0.65, P<0.001), Illness Perception Questionnaire-Revised Diabetes Symptom subscale (r=0.57, P<0.001), and Audit of Diabetes-Dependent Quality of Life scale (r=-0.42, P<0.001). Minor revisions followed. Phase IV: Test-retest stability was demonstrated (n=44).

CONCLUSION

The DSSCI is a culturally relevant, sound measure of Mexican Americans' diabetes symptoms and the actions they take to address them.

The Limits of Self-Management: Community and Health Care System Barriers Among Latinos With Diabetes

Although numerous studies examine diabetes self-care, few regard ecological framework correlates such as community and institutional level factors as fundamental for understanding diabetes management for Latinos. This article addresses the dearth of research that exists regarding social contextual forces and diabetes management for Latinos. Given the scarcity of research on this topic, studies of non-Latino groups were reviewed to illustrate the importance of community and institutional influences on diabetes care. Consideration of fundamental correlates within the ecological framework may better discern the underlying rationale for inadequate diabetes self-management for individuals who live in impoverished communities.

Neighborhood mapping and evaluation: a methodology for participatory community health initiatives

OBJECTIVES

This paper describes the use of neighborhood mapping as a key element in an ecological study of a community-based urban infant mortality prevention program. We propose the use of neighborhood mapping in evaluation research to more fully examine the local context of community health programs. Mapping can be used to study community change and to describe community assets and structural, epidemiological, and social features of neighborhoods that may influence program implementation and outcomes.

METHODS

Data on physical features were collected by community residents during street-by-street neighborhood walkthroughs. Other data sources included program records, Census, birth certificate, and state and city data. Analytic methods included geo-coding, exploratory factor analysis to create spatial density indicators of neighborhood features at the Census block group level, and analysis of associations between neighborhood features and outcomes.

RESULTS

Point and chloropleth maps provide a powerful illustration of neighborhood features (e.g., vacant buildings), client distribution and participation, health outcomes, and change over time. Factor analysis indicated two salient clusters of non-residential land use: (1) legitimate daily usage (liquor stores and other businesses) and (2) non-legitimate daily use (houses of worship and vacant buildings). A composite scale was created to indicate overall risk related to physical neighborhood features.

CONCLUSIONS

Neighborhood mapping is a powerful tool that brings participants and residents into the research process. Moreover, it can improve understanding of the role of neighborhood ecology in program implementation and outcomes.

The views of dentists, nurses and nutritionists on the association between diabetes and periodontal disease: a qualitative study in a Latino community

OBJECTIVE

To interview health professionals in a Latino community about the association between diabetes and periodontitis, and provide a basis to develop interventions for them to promote oral health and good glycemic control among patients with diabetes.

METHODS

Five dentists, seven nurses and two nutritionists were interviewed about their practices relevant to oral health and diabetes, knowledge about the association, beliefs about Latinos, recommendations on reaching others in their fields, and barriers. The interviews were audiotaped, transcribed, and analyzed qualitatively.

RESULTS

Professionals identified policy, community and practice barriers for promoting diabetic control and oral health.

CONCLUSIONS

Producing a resource list, cross-educating professionals about diabetes and oral health, training professionals to better serve Latino patients, developing appropriate protocols for each profession regarding the association between diabetes and periodontitis, and educating the community about diabetic control, oral health and disease prevention were identified as potential strategies to improve oral health among Latino persons with diabetes.

Dosage effects of diabetes self-management education for Mexican Americans: the Starr County Border Health Initiative

OBJECTIVE

The objective of this study was to compare two diabetes self-management interventions designed for Mexican Americans: "extended" (24 h of education, 28 h of support groups) and "compressed" (16 h of education, 6 h of support groups). Both interventions were culturally competent regarding language, diet, social emphasis, family participation, and incorporating cultural beliefs.

RESEARCH DESIGN AND METHODS

We recruited 216 persons between 35 and 70 years of age diagnosed with type 2 diabetes >/=1 year. Intervention groups of eight participants and eight support persons were randomly assigned to the compressed or extended conditions. The interventions differed in total number of contact hours over the year-long intervention period, with the major difference being the number of support group sessions held. The same information provided in the educational sessions of the extended intervention was compressed into fewer sessions, thus providing more information during each group meeting.

RESULTS

The interventions were not statistically different in reducing HbA(1c); however, both were effective. A "dosage effect" of attendance was detected with the largest HbA(1c) reductions achieved by those who attended more of the extended intervention. For individuals who attended >/=50% of the intervention, baseline to 12-month HbA(1c) change was -0.6 percentage points for the compressed group and -1.7 percentage points for the extended group.

CONCLUSIONS

Both culturally competent diabetes self-management education interventions were effective in promoting improved metabolic control and diabetes knowledge. A dosage effect was evident; attending more sessions resulted in greater improvements in metabolic control.