Employing user-centered design and education sciences to inform training of diabetes survival skills

Background

Patients newly diagnosed with diabetes mellitus (diabetes), who require insulin must acquire diabetes "survival" skills prior to discharge home. COVID-19 revealed considerable limitations of traditional in-person, time-intensive delivery of diabetes education and survival skills training (diabetes survival skills training). Furthermore, diabetes survival skills training has not been designed to meet the specific learning needs of patients with diabetes and their caregivers, particularly if delivered by telehealth. The objective of the study was to identify and understand the needs of users (patients newly prescribed insulin and their caregivers) to inform the design of a diabetes survival skills training, specifically for telehealth delivery, through the application of user-centered design and adult learning and education principles.

Methods

Users included patients newly prescribed insulin, their caregivers, and laypersons without diabetes. In semi-structured interviews, users were asked about experienced or perceived challenges in learning diabetes survival skills. Interviews were audio-recorded and transcribed. Investigators performed iterative rounds of coding of interview transcripts utilizing a constant comparative method to identify themes describing the dominant challenges users experienced. Themes were then mapped to adult learning and education principles to identify novel educational design solutions that can be applied to telehealth-based learning.

Results

We interviewed 18 users: patients (N = 6, 33 %), caregivers (N = 4, 22 %), and laypersons (N = 8, 44 %). Users consistently described challenges in understanding diabetes survival skills while hospitalized; in preparing needed supplies to execute diabetes survival skills; and in executing diabetes survival skills at home. The challenges mapped to three educational strategies: (1) spiral learning; (2) repetitive goal directed practice and feedback, which have the potential to translate into design solutions supporting remote/virtual learning; and (3) form fits function organizer, which supports safe organization and use of supplies to execute diabetes survival skills independently.

Conclusion

Learning complex tasks, such as diabetes survival skills, requires time, repetition, and continued support. The combination of a user-centered design approach to uncover learning needs as well as identification of relevant adult learning and education principles could inform the design of more user-centered, feasible, effective, and sustainable diabetes survival skills training for telehealth delivery.

A core outcome set for trials evaluating self-management interventions in people with severe mental illness and coexisting type 2 diabetes

BACKGROUND

People with severe mental illness (SMI), such as schizophrenia, have higher rates of type 2 diabetes and worse outcomes, compared to those without SMI and it is not known whether diabetes self-management interventions are effective for people who have both conditions. Research in this area has been impeded by a lack of consensus on which outcomes to prioritise in people with co-existing SMI and diabetes.

AIMS

To develop a core outcome set (COS) for use in effectiveness trials of diabetes self-management interventions in adults with both type 2 diabetes and SMI.

METHODS

The COS was developed in three stages: (i) identification of outcomes from systematic literature review of intervention studies, followed by multi-stakeholder and service user workshops; (ii) rating of outcomes in a two-round online Delphi survey; (iii) agreement of final 'core' outcomes through a stakeholder consensus workshop.

RESULTS

Seven outcomes were selected: glucose control, blood pressure, body composition (body weight, BMI, body fat), health-related quality of life, diabetes self-management, diabetes-related distress and medication adherence.

CONCLUSIONS

This COS is recommended for future trials of effectiveness of diabetes self-management interventions for people with SMI and type 2 diabetes. Its use will ensure trials capture important outcomes and reduce heterogeneity so findings can be readily synthesised to inform practice and policy.

Mobile-Based and Cloud-Based System for Self-management of People With Type 2 Diabetes: Development and Usability Evaluation

Background

As the use of smartphones and mobile apps is increasing, mobile health (mHealth) can be used as a cost-effective option to provide behavioral interventions aimed at educating and promoting self-management for chronic diseases such as diabetes. Although many mobile software apps have been developed for this purpose, they usually lack a theoretical foundation and do not follow the guidelines suggested for evidence-based practice. Therefore, this study aimed to develop a theory-based self-management app for people with type 2 diabetes and provide an app based on a needs assessment analysis.

Objective

This paper describes the development and usability evaluation of a cloud-based and mobile-based diabetes self-management app designed to help people with diabetes change their health behavior and also enable remote monitoring by health care providers.

Methods

The development of this mHealth solution comprises 3 phases. Phase I: feature extraction of the Android apps that had a user rating of 4 stars or more and review of papers related to mHealth for diabetes self-management were performed followed by seeking expert opinions about the extracted features to determine the essential features of the app. Phase II: design and implementation included selecting which behavioral change and structural theories were to be applied the app and design of the website. Phase III: evaluation of the usability and user experience of the mobile app by people with diabetes and the portal by health care providers using the User Experience Questionnaire.

Results

The developed mobile app includes modules that support several features. A person’s data were entered or collected and viewed in the form of graphs and tables. The theoretical foundation of behavioral intervention is the transtheoretical model. Users were able to receive customized messages based on the behavioral change preparation stage using the Kreuter algorithm. The clinician’s portal was used by health care providers to monitor the patients. The results of the usability evaluation revealed overall user satisfaction with the app.

Conclusions

Mobile- and cloud-based systems may be an effective tool for facilitating the modification of self-management of chronic care. The results of this study showed that the usability of mobile- and cloud-based systems can be satisfactory and promising. Given that the study used a behavioral model, assessment of the effectiveness of behavior change over time requires further research with long-term follow-up.

An Effective Model of Diabetes Care and Education: The ADCES7 Self-Care Behaviors™

PURPOSE

The ADCES7 Self-Care Behaviors^™ (ADCES7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the Association of Diabetes Care and Education Specialists (ADCES) that at the cornerstone of diabetes self-management education and support, the ADCES7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The ADCES7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management as well as diabetes self-management education and support, ADCES has evaluated the ADCES7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and ADCES's vision and expansion beyond diabetes to refresh the ADCES7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.

Determinants of Physical Health Self-Management Behaviours in Adults With Serious Mental Illness: A Systematic Review

Behavioural interventions can support the adoption of healthier lifestyles and improve physical health outcomes, but it is unclear what factors might drive success of such interventions in people with serious mental illness (SMI). We systematically identified and reviewed evidence of the association between determinants of physical health self-management behaviours in adults with SMI. Data about American Association of Diabetes Educator's Self-Care Behaviours (AADE-7) were mapped against the novel Mechanisms of Action (MoA) framework. Twenty-eight studies were included in the review, reporting evidence on 104 determinant-behaviour links. Beliefs about capabilities and beliefs about consequences were the most important determinants of behaviour, especially for being physically active and healthy eating. There was some evidence that emotion and environmental context and resources played a role in determining reducing risks, being active, and taking medications. We found very limited evidence associated with problem solving, and no study assessed links between MoAs and healthy coping. Although the review predominantly identified evidence about associations from cross-sectional studies that lacked validated and objective measures of self-management behaviours, these findings can facilitate the identification of behaviour change techniques with hypothesised links to determinants to support self-management in people with SMI. Systematic Review Registration: PROSPERO, registration CRD42018099553.

An Effective Model of Diabetes Care and Education: Revising the AADE7 Self-Care Behaviors®

PURPOSE

The AADE7 Self-Care Behaviors^® (AADE7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the American Association of Diabetes Educators (AADE) that, at the cornerstone of diabetes self-management education and support, the AADE7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The AADE7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management, as well as in diabetes self-management education and support, AADE has evaluated the AADE7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and AADE's vision and expansion beyond diabetes to refresh the AADE7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.

Determining minimum set of features for diabetes mobile apps

Purpose

Interest in mobile health applications (apps) for diabetes self-care is growing. Mobile health is a promising new treatment modality for diabetes, though few smartphone apps have been designed based on a proper study and prioritization. The aim of this study was to determine a minimum set of features for diabetes mobile apps.

Methods

This study was conducted in three steps: 1.A review of the literature to collect all available features, 2. Assessing the validity of suggested features by Content Validity Index (CVI) and Content Validity Ratio (CVR), 3. Examining the importance of features by Friedman test.

Results

We retrieved all features of available mobile apps for type 2 diabetes, which are suggested and discussed in literature and compiled as a single list comprising of 33 features. Then, a survey of expert's opinion produced a set of 23 final minimum features which includes all types of tracking, mealtime tagging, food database, diet management, educational materials, healthy coping, reducing risks, problem solving, Email, color coding, alerts, reminder, target range setting, trend chart view, logbook view, numerical indicators view, customizable theme, preset notes, and custom notes. According to the mean rank which indicates the priority of each feature, the most important one was blood glucose tracking (with 16.71 mean rank) and the least important feature was the numerical indicators like such as standard deviation or average (with 6.50 mean rank).

Conclusions

The present study is the first step towards the development of our mobile apps for people with type II diabetes, and highest the essential features that are required for an optimal self-care comprehensively.

Pharmacotherapeutic empowerment and its effectiveness in glycemic control in patients with Diabetes Mellitus

AIMS

To develop an intervention and evaluate its effectiveness in pharmacotherapeutic empowerment of patients with type 2 diabetes mellitus (T2DM).

METHOD

This is an intervention study with before and after evaluation. The intervention was conducted between 2015 and 2016 with users of the Unified Health System (SUS) in Brazil. The study was divided into six stages: initial evaluation, three individual patient-pharmacist meetings every 15 days over 6 weeks, clinical discussion between pharmacists, and final evaluation. At each meeting with the patient, specific themes for empowerment were addressed using educational booklets and pharmaceutical care. Clinical and laboratory evaluations and questionnaires on self-efficacy (IMDSES), self-care (QAD) and distress (PAID-5) were conducted before and three months after the intervention.

RESULTS

47 patients completed the intervention. Glycated hemoglobin of patients had a median reduced from 7.0% to 6.6% after the intervention (p = 0.02). There was a significant difference (p < 0.01) in the reduction in total cholesterol, fasting glycemia, creatinine and blood pressure. Participants showed significant improvements (p < 0.01) in scores related to self-efficacy and self-care and less distress related to T2DM.

CONCLUSION

The results of the study suggest that the strategy developed is effective in promoting the empowerment of T2DM patients, improved glycemic control and self-care.

Self-management of type 2 diabetes in gulf cooperation council countries: A systematic review

Aims

This study aimed to systematically review intervention studies on self-management of type 2 diabetes in Gulf Cooperation Council (GCC) countries to determine the most effective self-management strategies for individuals with type 2 diabetes in this region.

Methods

A search strategy was developed using multiple databases: Medline and Embase (via Ovid), CINAHL (via EBSCO), and PubMed. Study and intervention characteristics, intervention structure, content, cultural adaptation, and outcomes were extracted from the included studies. To be included in the review the studies should have met the following criteria: have examined the effectiveness of at least one intervention involving a type 2 DSME programme, have involved participants over 18 years old diagnosed with type 2 diabetes, have taken place to in a GCC country, have a study design that was observational, quasi-experimental or controlled, have reported at least one individual and have a quantitative outcome. A narrative data synthesis was used to describe the studies and comment on their methodological quality.

Results

Of the 737 retrieved papers, only eight met the inclusion criteria. Only one study was a randomised controlled trial. A statistically significant improvement in HbA1c was reported in five of the eight studies. There was a significant improvement in physical activity levels as reported in four of the eight studies. Only three studies referred to aspects of cultural design or adaptation of the intervention implemented.

Conclusions

Self-management interventions may have a positive impact on HbA1 levels in patients with type 2 diabetes in the GCC area. A greater emphasis placed on culturally appropriate self-management programmes may improve the effectiveness of self-management interventions for adults with type 2 diabetes in the GCC.

[Adaptation and validation of the SMP-T2D questionnaire in Spanish for evaluating self-management of high blood pressure and type 2 diabetes: PAG-DT2+HTA]

BACKGROUND

High blood pressure is one of the most common chronic conditions worldwide. It affects one in every 3 adults over 40, while one in 10 suffers from diabetes. For both diseases, adherence to pharmacological treatment is over 30%, and self-management, which takes into account diet and physical activity, is still unknown, as there is no tool available to measure self-management. Therefore, the object of this study was to adapt and validate the Spanish version of the self-management profile for type 2 diabetes (SMP-T2D) questionnaire in patients with type 2 diabetes and high blood pressure among users of first level care in the social security institution of Mexico.

METHODS

The SMP-T2D was adapted to Spanish by translation into Spanish, and being used only in patients with high blood pressure and type 2 diabetes-hypertension. A convergent and discriminatory validation was performed. Patients over 50 years old with high blood pressure were include. Those that did not complete the questionnaire or give informed consent were rejected.

RESULTS

The Spanish version of the SMP-T2D was called PAG-DT2+HTA, and was applied to 145 people with hypertension: 54.4% with hypertension only, and 43.6% with hypertension and type 2 diabetes. Mean age was 66.14 years (SD=10.78), with 34.7% women and 65.3% men. Internal consistency by α-Cronbach for the questionnaire was 0.561 (P=.000). The correlation between the PAG-DT2+HTA and Morisky-Green was significant. The ability to discriminate between people with and without education and with and without economic means was obtained.

CONCLUSION

The Spanish version of SMP-T2D (PAG-DT2+HTA) that measures self-management in type 2 diabetes, can be used to measure self-management in people with type 2 diabetes-hypertension.

What is diabetes distress and how can we measure it? A narrative review and conceptual model

BACKGROUND

Diabetes distress is the negative emotional impact of living with diabetes. It has tangible clinical importance, being associated with sub-optimal self-care and glycemic control. Diabetes distress has been operationalized in various ways and several measures exist. Measurement clarity is needed for both scientific and clinical reasons.

OBJECTIVES

To clarify the conceptualization and operationalization of diabetes distress, identify and distinguish relevant measures, and evaluate their appropriateness for this purpose.

RESULTS

Six measures were identified: Problem Areas in Diabetes (PAID) scale, Diabetes Distress Scale (DDS); Type I Diabetes Distress Scale (T1-DDS), Diabetes-specific Quality of Life Scale-Revised (DSQoLs-R) 'Burden and Restrictions-Daily Hassles' sub-scale, Well-being Questionnaire 28 (W-BQ 28) 'Diabetes Well-being' sub-scale, and Illness Perceptions Questionnaire-Revised (IPQ-R) 'Emotional Representations' sub-scale. Across these measures a broad spectrum of diabetes distress is captured, including distress associated with treatment regimen, food/eating, future/complications, hypoglycemia, social/interpersonal relationships, and healthcare professionals. No single measure appears fully comprehensive. Limited detail of the qualitative work informing scale design is reported, raising concerns about content validity.

CONCLUSIONS

Across the available measures diabetes distress is seemingly comprehensively assessed and measures should be considered in terms of their focus and scope to ensure the foci of interventions are appropriately targeted.

A core outcome set for evaluating self-management interventions in people with comorbid diabetes and severe mental illness: study protocol for a modified Delphi study and systematic review

Background

People with diabetes and comorbid severe mental illness (SMI) form a growing population at risk of increased mortality and morbidity compared to those with diabetes or SMI alone. There is increasing interest in interventions that target diabetes in SMI in order to help to improve physical health and reduce the associated health inequalities. However, there is a lack of consensus about which outcomes are important for this comorbid population, with trials differing in their focus on physical and mental health. A core outcome set, which includes outcomes across both conditions that are relevant to patients and other key stakeholders, is needed.

Methods

This study protocol describes methods to develop a core outcome set for use in effectiveness trials of self-management interventions for adults with comorbid type-2 diabetes and SMI. We will use a modified Delphi method to identify, rank, and agree core outcomes. This will comprise a two-round online survey and multistakeholder workshops involving patients and carers, health and social care professionals, health care commissioners, and other experts (e.g. academic researchers and third sector organisations). We will also select appropriate measurement tools for each outcome in the proposed core set and identify gaps in measures, where these exist.

Discussion

The proposed core outcome set will provide clear guidance about what outcomes should be measured, as a minimum, in trials of interventions for people with coexisting type-2 diabetes and SMI, and improve future synthesis of trial evidence in this area. We will also explore the challenges of using online Delphi methods for this hard-to-reach population, and examine differences in opinion about which outcomes matter to diverse stakeholder groups.

Trial registration

COMET registration: http://www.comet-initiative.org/studies/details/911. Registered on 1 July 2016

Challenges to developing diabetes self-management skills in a low-income sample in North Carolina, USA

High rates of diabetes diagnosis and poor diabetes outcomes are particularly significant in low-income, socially disadvantaged populations. Although many social and economic predictors of poor self-management outcomes are known, few studies have examined how these elements impact the ability to develop self-management capacities in low-income populations. This article presents new insights into low-income women's challenges and successes to becoming more adept self-managers. Interview data were collected in 2012 with a sample of low-income, middle-age women with type II diabetes recruited from a non-profit medical clinic serving low-income clients in North Carolina, United States. Data were analysed using a grounded theory approach. Developing self-management skills within disadvantaged life contexts involved negotiating three related, overlapping sub-processes: negotiating access to care systems, negotiating disruptions to diabetes self-management patterns, and negotiating self-care knowledge. Developing diabetes self-management skills is a long and arduous process. Data and analysis presented here help explain how disadvantaged life contexts can impact self-managers' efforts to develop self-management skills and why continued support is important for reducing and preventing future problems. These initial findings suggest that future studies and intervention development on the topic are warranted.

Self-management behavior among patients with diabetic retinopathy in the community: a structural equation model

PURPOSE

Diabetic retinopathy (DR) is an important, chronic complication of diabetes, requiring competent self-management that depends on adherence to behavioral regimens. This study attempted to identify factors influencing self-management behaviors and develop a model illustrating the interdependence of several factors associated with DR patients.

METHODS

In June-December 2012, 368 patients with DR completed questionnaires assessing self-management behavior, diabetes knowledge, health beliefs, social support, and treatment adherence. Structural equation modeling was used to test predicted pathways linking self-management behavior to diabetes knowledge, health beliefs, social support, and treatment adherence.

RESULTS

The results indicated that health beliefs, treatment adherence, and duration of diabetes each had a direct impact on diabetes self-management (p < 0.05). Diabetes knowledge only indirectly influenced diabetes self-management, through health beliefs. Social support had a direct impact on diabetes self-management (β = 0.35, p < 0.01), and an indirect influence on diabetes self-management, through treatment adherence (β = 0.77, p < 0.01).

CONCLUSION

Health beliefs, treatment adherence, and social support directly affect diabetes self-management, and diabetes knowledge indirectly affects diabetes self-management. This suggests that enhancing DR patients' health beliefs, treatment adherence, and social support would facilitate their diabetes self-management. Meanwhile, improved health education can strengthen diabetes knowledge, which in turn, can positively affect diabetes self-management.

Learning to do better: the transactional model of diabetes self-management integration

In this article I examine the process by which low-income (mostly minority) women develop the skills to integrate diabetes self-management into daily life and the conditions that affect the process. I present and describe a multimethod approach, including semistructured interviews, photo elicitation, time geographic diaries, and a standardized assessment which were used to collect data from 10 low-income women with type 2 diabetes, ages 40 to 64 years, between July and December 2012. I describe the grounded theory approach to data analysis which facilitated the development of the Transactional Model of Diabetes Self-Management (DSM) Integration. The model depicts the theorized process whereby low-income women accept aspects of diabetes education and training as congruent with their circumstances, act on them, and practice with them until they become integrated into daily life. Inquiry and practice play key roles in assimilating DSM. I discuss the study's implications for facilitating better health-management programs.

If it does not significantly change HbA1c levels why should we waste time on it? A plea for the prioritization of psychological well-being in people with diabetes

Despite improvements in pharmacological treatments and methods of care and care delivery, the burden of living with diabetes remains an ongoing challenge, as many people with diabetes are at increased risk of mental health disorders, psychological disturbances and functional problems associated with living with diabetes. Person-centred collaborative care that also meets the psychological needs of the individual is not available to many people with diabetes. The present article examines the role of psychological factors in the onset of diabetes and in relation to living with diabetes. It is argued that the pursuit of psychological well-being is worthy of individual attention in the care of people with diabetes and should not be contingent upon attainment of somatic indices of health. The barriers to attaining this goal are examined, including the costs of treating (or not treating) psychological problems in people with diabetes. Recommendations on how to improve diabetes care are offered, including psychological interventions that are both evidence-based and cost-effective.

Reducing the modifiable risks of cardiovascular disease in Turkish patients with type 2 diabetes: the effectiveness of training

Our goal was to reduce the number of modifiable risk factors for cardiovascular disease (CVD) through providing lifestyle adjustment training and counseling to patients with type 2 diabetes. In this pre-post intervention study, 139 patients with diabetes were provided with training to reduce the modifiable risks of CVD. One hundred three patients attended the post-training evaluation. Two phone counseling sessions were provided with 1-month intervals. Consumption of red meat and processed food decreased and water consumption, carrying on the recommended diet, and the frequency of exercise increased (p = .000), A1C decreased (p = .05), and the use of aspirin increased (p = .03). Thus, a contribution to the reduction of CVD risk factors in patients with type 2 diabetes was achieved. The training program for reducing CVD risk factors in patients with type 2 diabetes was effective in improving nutrition and lifestyle behaviors and decreasing glycemic control.

The influence of daily routines on engaging in diabetes self-management

OBJECTIVE

In contrast to previous research concerning the importance of routines in occupational engagement, most of which have largely focused on the routines of children and families, in this study a qualitative methodology was used to understand how routines function in a specific occupation: diabetes self-management (DSM).

METHODS

Ten low-income women participated in a multiple-methods study that involved completing a time-geographic diary (TGD) and participating in a TGD interview.

RESULTS

Findings reveal that pre-existing routines must be changed so that they may better support engagement in DSM, and that such changes are tied to underlying habits and life situations. The experiences of study participants also showed that the distribution of daily occupations through time and across social spheres can be both supportive of and problematic for engaging in DSM. In addition, the structure and sequence of competing daily occupations influences the available time and opportunities for people to further develop their skills and become more adept self-managers.

CONCLUSIONS

The implications of these findings for occupational science and therapy are discussed.

Partnering with diabetes educators to improve patient outcomes

Diabetes is a chronic, progressive disease that affects millions worldwide. The paradigm of diabetes management has shifted to focus on empowering the person with diabetes to manage the disease successfully and to improve their quality of life. Diabetes self-management education is a collaborative process through which people with diabetes gain the knowledge and skills needed to modify their behavior and to self-manage successfully the disease and its related conditions. Diabetes educators are health care professionals who apply in-depth knowledge and skills in the biological and social sciences, communication, counseling, and pedagogy to enable patients to manage daily and future challenges. Diabetes educators are integral in providing individualized education and promoting behavior change, using a framework of seven self-care behaviors known as the AADE7 Self-Care Behaviors™, developed by the American Association of Diabetes Educators. The iterative process of promoting behavior change includes assessment, goal setting, planning, implementation, evaluation, and documentation. Diabetes educators work as part of the patient's health care team to engage with the patient in informed, shared decision making. The increasing prevalence of diabetes and the growing focus on its prevention require strategies for providing people with knowledge, skills, and strategies they need and can use. The diabetes educator is the logical facilitator of change. Access to diabetes education is critically important; incorporating diabetes educators into more and varied practice settings will serve to improve clinical and quality of life outcomes for persons with diabetes.

Social support strategies in adult patients with diabetes: a review of strategies in the USA and Europe

Improvement of adherence in patients with a chronic disease state such as diabetes can be facilitated through well-crafted social support strategies. Family and friends are support options for many individuals living with diabetes. A systematic search of three databases was conducted to evaluate literature published from 2006 to April 2013 regarding social support in adults with diabetes conducted in the USA and Europe. While various studies had different findings, the overall trend shows that social support can result in a positive influence on both the ability of the patient to initiate and sustain diabetes management that can potentially result in positive health outcomes. This appears true even when the patient has low psychosocial skills and a small social support network. Healthcare professional involvement also correlates with patient improvement in specific outcomes not overlapped by the patient's social network. Support facilitated by peers can be a viable option along with the multitude of electronic options to help with social support.

Educators’ Insights in Using Chronicle Diabetes

Purpose

Diabetes educators lack data systems to monitor diabetes self-management education processes and programs. The purpose of the study is to explore diabetes educator’s insights in using a diabetes education data management program: the Chronicle Diabetes system.

Methods

We conducted 1 focus group with 8 diabetes educators who use the Chronicle system in western Pennsylvania. The focus group was audiotaped and transcribed verbatim. Themes were categorized according to system facilitators and barriers in using Chronicle.

Results

Educators report 4 system facilitators and 4 barrier features. System facilitators include (1) ability to extract data from Chronicle for education program recognition, (2) central location for collecting and documenting all patient and education data, (3) capability to monitor behavioral goal setting and clinical outcomes, and (4) use of a patient snapshot report that automatically summarizes behavioral goal setting and an education plan. Barriers reported are (1) initially time-consuming for data entry, (2) Health Insurance Portability and Accountability Act privacy concerns for e-mailing or downloading report, (3) need for special features (eg, ability to attach a food diary), and (4) need to enhance existing features to standardize goal-setting process and incorporate psychosocial content.

Conclusions

Educators favor capabilities for documenting program requirements, goal setting, and patient summaries. Barriers that need to be overcome are the amount of time needed for data entry, privacy, and special features. Diabetes educators conclude that a data management system such as Chronicle facilitates the education process and affords ease in documentation of meeting diabetes self-management education standards and recognition requirements.

Relationships among self-efficacy, social support, social problem solving, and self-management in a rural sample living with type 2 diabetes mellitus

Self-management behaviors are important for control of type 2 diabetes mellitus. Therefore, determining factors that promote effective self-management behaviors may be significant for improving the well-being of patients with type 2 diabetes mellitus. This study examined relationships among self-efficacy, social support, social problem solving, and diabetes self-management behaviors. Further, this study evaluated whether social support and social problem solving were mediators of the relationship between self-efficacy and diabetes self-management behaviors in those living with type 2 diabetes mellitus. Using a cross-sectional, descriptive correlational design, data from a convenience sample of 152 rural people living with type 2 diabetes mellitus were examined. Findings indicated that self-efficacy was a strong predictor of diabetes self-management. The effect of social support on diabetes self-management differed among men and women in the sample. Social support and social problem solving were significantly associated with diabetes self-management in men. Neither social support nor social problem solving were mediators of the relationship between self-efficacy and diabetes self-management in this sample. These findings suggest that nurses need to consider implementing interventions to improve patients' self-efficacy and potentially influence diabetes self-management.

An empirical study of self-efficacy and social support in diabetes self-management: implications for home healthcare nurses

This pilot study was conducted to evaluate relationships among self-efficacy, social support, social problem solving, and diabetes self-management in people living with Type 2 diabetes mellitus. Self-efficacy, social support, and social problem solving were significantly correlated with diabetes self-management. These relationships indicate the importance of including interventions to promote self-efficacy, social support, and social problem solving in diabetes self-management programs.

Effects of depression and antidepressant use on goal setting and barrier identification among patients with type 2 diabetes

PURPOSE

The purpose of this study was to examine the effects of depression and antidepressant use on goal setting and barrier identification in patients with type 2 diabetes.

METHODS

In a large diabetes education network, 778 patients with type 2 diabetes were enrolled in the American Association of Diabetes Educators (AADE) Outcomes System as part of their routine diabetes education between 2005 and 2008. Self-reported depression, 7 self-identified behavior change goals, and 13 barriers to diabetes self-care were collected from the Diabetes Self-Management Assessment Report Tool (D-SMART(®)); antidepressant use was documented from the Diabetes Educator Tool (D-ET(®)). Multiple linear regression was used to evaluate the effects of depression or antidepressant use on the number of goals or the number of barriers while controlling for relevant covariates.

RESULTS

Among 778 patients (507 nondepressed, 181 depressed with antidepressant use, 90 depressed without antidepressant use), median age was 58, 60.9% were female, and 85.9% were Caucasian. Patients with and without depression had a similar number of self-identified behavior change goals, whereas patients with depression had 1 additional barrier to diabetes self-care compared with those without depression. In the depressed subgroup, antidepressant use had no association with the number of goals that the subjects set or the number of barriers they identified.

CONCLUSIONS

Among patients with type 2 diabetes, depression was associated with a slightly greater number of barriers, which may support the importance of depression screening and depression treatment in patients with diabetes.

Monitoring in diabetes self-management: issues and recommendations for improvement

The American Association of Diabetes Educators hosted a Monitoring Symposium during which 18 invited participants considered pre-set questions regarding how diabetes education can more effectively address barriers to monitoring for people with diabetes and related conditions. This report provides a summary of the moderated discussion and highlights the key points that apply to diabetes educators and other providers involved with diabetes care. The participating thought leaders reviewed findings from published literature and participated in a moderated discussion with the aim of providing practical advice for health care practitioners regarding monitoring for people with diabetes so that the overall health of this population can be enhanced. The discussants also defined monitoring for diabetes as including that done by the clinician or laboratory, as well as self-monitoring. The discussion was distilled into key points that apply to diabetes educators and other providers involved with diabetes care. Participants developed specific recommendations for a self-monitoring behavior and monitoring framework. People with diabetes benefit from instruction and guidance about self-monitoring and decision making that is based on monitored results and informed interactions with providers. Importantly, collaboration among the entire diabetes care community is needed to ensure that monitoring is performed and utilized to its fullest advantage. Going forward, it will be critical to mitigate barriers to diabetes self-management and training and to identify linkages and partnerships to address barriers to self-monitoring.

Self-care beliefs and behaviors in Ugandan adults with type 2 diabetes

PURPOSE

The purpose of this study was to describe illness beliefs and diabetes self-care behaviors of Ugandan adults with type 2 diabetes.

METHODS

A convenience sample of 340 adults with type 2 diabetes was recruited from 2 outpatient settings in Kampala, Uganda. Participants were interviewed by a nurse about diabetes self-care behaviors; had their weight, height, and waist and hip circumference measured; and shared with the interviewer the blood glucose and blood pressure values obtained during their clinic visit.

RESULTS

The majority of participants viewed diabetes as a serious, life-long condition that they had a good deal of control over; however, while 88% believed they could tell high blood glucose by the presence of symptoms, only 39% said they could detect low blood glucose by the presence of symptoms. Self-care challenges include limited access to appropriate food, diabetes medications, blood glucose testing equipment, and educational materials. Subjects reported significant negative psychosocial outcomes associated with having diabetes. Using selected indicators for metabolic syndrome, 87% had elevated blood pressure, and 67% had elevated blood glucose; 33.4% were overweight, and 18.7% were obese.

CONCLUSIONS

Results from this study highlight the challenges of diabetes self-care in resource-poor countries. Improving diabetes care will require systems-level interventions to provide access to basic resources as well as to social support and educational interventions.

Access to diabetes self-management education: results of national surveys of patients, educators, and physicians

PURPOSE

To examine factors related to access to diabetes self-management education (DSME), including services delivered and sought; patient, physician, and program barriers to access; educator outreach and expansion efforts; and perceptions of alternative DSME delivery strategies.

METHODS

Internet surveys were completed by 1169 adults with diabetes (661 with prior DSME, 508 with no prior DSME) from a national community survey panel, 1871 educators who were AADE members, and 629 physicians (212 diabetes specialists, 417 primary care practitioners) from a national physician survey panel.

RESULTS

Physicians want patients to receive more self-management support, but some report that patients are told to do things with which the physician does not agree. Provider (physician and educator)-delivered DSME is more highly regarded among those who have received it than among those who have not received it. Physicians generally have positive perceptions of provider-delivered DSME, and educators see physicians as key to encouraging DSME use in patients. Some physicians are concerned about losing patients sent to DSME, and 11% of patients report changing physicians as a result of DSME. Most DSME programs have grown recently as a result of recruiting efforts and adding new programs/services; most programs plan more such efforts. Patients prefer traditional DSME sources/settings and are moderately accepting of media sources.

CONCLUSIONS

Additional efforts are required to guarantee that all people with diabetes receive the DSME they need. This will require increased referral by physicians, increased follow-through by patients, and increased availability of DSME in forms that make it appealing to patients and physicians.

Where is the patient in diabetes performance measures? The case for including patient-centered and self-management measures

OBJECTIVE

Health policies are important determinants of clinician and patient behavior, and an important policy issue is what items are included in healthcare quality and performance measures. There is consensus that patient-centered care and self-management support are essential evidence-based components of good diabetes care. However, most major diabetes performance measures such as the National Committee for Quality Assurance (NCQA)/American Diabetes Association (ADA) Provider Recognition Program indexes have not included self-management or psychosocial items.

RESEARCH DESIGN AND METHODS AND RESULTS

We review the case for and propose a set of patient-centered, self-management indicators to be included as a standard part of diabetes quality indicators. The proposed indicators include: patient self-management goal(s), measures of health behaviors (e.g., healthy eating, medication taking, physical activity, and smoking status), quality of life, and patient-centered collaborative care. We discuss the evidence and the concerns about patient-report measures and summarize successful incorporation of such patient-centered measures in other countries and by the American Association of Diabetes Educators (AADE).

CONCLUSIONS

The adage that "what gets measured, gets done" applies to diabetes management and many other areas of healthcare. Inclusion of the proposed indicators in national diabetes performance measures would be consistent with Institute of Medicine (IOM), ADA, Centers for Disease Control (CDC), Diabetes Attitudes, Wishes, and Needs (DAWN), AADE, and Society of Behavioral Medicine (SBM) recommendations. Such action would enhance both the priority and delivery of quality, patient-centered care, and diabetes self-management support.