Barriers and facilitators to primary care management of type 2 diabetes in Shijiazhuang City, China: a mixed methods study

BACKGROUND

The prevalence of type 2 diabetes (T2DM) in China is over 10%, affecting around 114 million people. Despite the inclusion of T2DM in the National Basic Public Health Service Program (NBPHSP), most people with T2DM experience challenges in achieving optimal management targets. This study aimed to identify barriers and facilitators of diabetes management from the perspectives of primary health care (PHC) service providers and recipients.

METHODS

This mixed-methods study was conducted in Shijiazhuang City, Hebei Province, China. A quantitative PHC facility assessment survey was conducted in all administrative districts and qualitative in-depth interviews were conducted in one district to government officials, medical staff, patients with T2DM, and their family members. Interviews were thematically analyzed, and all findings were synthesized using Michie's COM-B theory.

RESULTS

A total of 197 village/community level PHC facilities and 66 township/street level PHC facilities answered the survey, and 42 in-depth interviews were conducted. The key facilitators stemmed from the NBPHSP policy, which standardized the basic infrastructure, medical equipment, and medication for the PHC facilities, provided training on NCD prevention and control, and compensated the PHC workers. However, we identified a detrimental cycle among PHC providers characterized by inadequate capacity, overwhelming workloads, insufficient income, limited career development opportunities, and challenges in attracting young talents. Although patients were covered by the national medical insurance schemes, they experienced capability constraints primarily driven by low education levels, advanced age, low health literacy, and a proliferation of misinformation. These factors influenced patients' motivation to be actively engaged in care and contributed to inertia to intensify treatment and achieve their clinical management goals.

CONCLUSION

This study identifies several major facilitators and barriers from the perspectives of both PHC providers and patients with T2DM. Our findings suggest there are substantial opportunities to strengthen the NBPHSP, including improving the capacity and the income level of the PHC providers, attracting and retaining skilled health workers in rural areas, supporting patients to improve their health literacy and take a more active role in their health care, and improving access to high-quality care through digital health approaches.

TRIAL REGISTRATION

ClinicalTrials.gov (record NCT02726100, 03/22/2016).

A Systematic Review of Dietary Interventions for Cancer Survivors and Their Families or Caregivers

Family or caregiver engagement has the potential to support healthy dietary changes among cancer survivors. However, little is known about these family- or caregiver-involved dietary interventions and their effects. This systematic review aimed to identify the behavior change techniques (BCTs) used in dietary interventions for cancer survivors and their families or caregivers and to synthesize intervention effects on dietary and health outcomes. Following the PRISMA guidelines, we conducted systematic searches in three databases and identified 12 trials (16 peer-reviewed manuscripts) for inclusion in this review. Data were extracted from these manuscripts and the BCT taxonomy was used to identify the BCTs. A total of 38 BCTs were identified from 12 trials, 13 of which were used in at least half of the 12 trials. Ten studies reported significant intervention effects on health outcomes (e.g., adiposity) and six suggested significant improvements in dietary behaviors (e.g., fruit and vegetable intake). Overall, this review found that family- or caregiver-involved interventions for cancer survivors significantly improved dietary and health outcomes. Future research should identify BCTs particularly for dietary changes and develop effective dyadic strategies to facilitate diet-related interactions between survivors and their families or caregivers to enhance their engagement in healthy diets.

Perception of self-management and glycaemic control in people with type 2 diabetes receiving insulin injection therapy: A qualitative study

AIM

The aim of this study was to explore the experience of self-management and glycaemic control in Chinese people with type 2 diabetes receiving insulin injection therapy.

METHODS

A qualitative descriptive design was adopted with individual, semi-structured interviews. Participants were selected by purposive sampling. All face-to-face interviews were conducted between December 2020 and January 2021. The interviews were audio recorded and transcribed verbatim. Content analysis was used to analyse the interview data.

RESULTS

A total of 27 participants were recruited and individually interviewed. Three themes were generated: integrating insulin injection therapy into daily self-management; experiencing uncertainty when coping with suboptimal glycaemic control; and self-management programmes for optimal diabetes control.

CONCLUSION

All of our findings increase the understanding of self-management and glycaemic control in people with T2D receiving insulin injection therapy. Healthcare professionals should recognise the unmet needs of this cohort to promote their diabetes management. Appropriate and effective self-management programmes should be developed and implemented to alleviate the negative impacts of insulin injection therapy on diabetes management with consideration of cultural and personal context.

Community-Based Culturally Tailored Education Programs for Black Communities with Cardiovascular Disease, Diabetes, Hypertension, and Stroke: Systematic Review Findings

BACKGROUND

Community-based culturally tailored education (CBCTE) programs for chronic diseases may reduce health disparities; however, a synthesis across chronic diseases is lacking. We explored (1) the characteristics and outcomes of CBCTE programs and (2) which strategies for culturally appropriate interventions have been used in CBCTE programs, and how they have been implemented.

METHODS

A systematic review was conducted by searching three databases to identify empirical full-text literature on CBCTE programs for Black communities with cardiovascular disease, hypertension, diabetes, or stroke. Studies were screened in duplicate, then data regarding study characteristics, participants, intervention, and outcomes were extracted and analyzed. Cultural tailoring strategies within programs were categorized using Kreuter and colleagues' framework.

RESULTS

Of the 74 studies, most were conducted in the USA (97%) and delivered in one site (53%; e.g., church/home). CBCTE programs targeted diabetes (65%), hypertension (30%), diabetes and hypertension (1%), cardiovascular disease (3%), and stroke (1%). Reported program benefits included physiological, medication-related, physical activity, and literacy. Cultural tailoring strategies included peripheral (targeted Black communities), constituent-involving (e.g., community informed), evidential (e.g., integrated community resources), linguistic (e.g., delivered in community's dialect/accent), and sociocultural (e.g., integrated community members' religious practices).

CONCLUSIONS

CBCTE programs may have beneficial outcomes, but a small sample size limited several. The strategies identified can be adopted by programs seeking to culturally tailor. Future interventions should clearly describe community members' roles/involvement and deliver programs in multiple locations to broaden reach.

TRIAL REGISTRATION

PROSPERO CRD42021245772.

Effects of family-based diabetes self-management education and support programme on support behaviour amongst adults with type 2 diabetes in Western Ethiopia

Support from family and peers may enhance the outcomes of diabetes management. This study reported the preliminary effect of a family-based diabetes self-management education and support (DSMES) programme on the perceived support status of people with diabetes and the family's caregiver support behaviour amongst dyads living in Western Ethiopia. A 1:1 two-armed pilot randomised controlled trial (RCT) was conducted. A total of 76 dyads were recruited using the convenience sampling method and randomly assigned to either intervention or control groups. The control group continued the usual care, whereas the intervention group continued the usual care and additionally received a 12-h social cognitive theory (SCT)-guided, family-supported DSMES programme in the community. Generalised estimating equations models were computed to test the preliminary effects of the DSMES programme on the outcomes. P-value < 0.05 was set as statistically significant. The pilot RCT shows a statistically significant between-group difference in the changes in support needed at T1 (d = 0.88) and T2 (d = 1.35) and support received at T1 (d = 0.88) and T2 (d = 1.44). The DSMES programme has outperformed usual care with a medium effect size at T1 (d = 0.54) and a large effect size at T2 (d = 0.97) on the family's supportive behaviour. Although the intervention group was not statistically significant at T1 (d = 0.43), a large effect size was obtained at T2 (d = 0.97) on the family's non-supportive behaviour. A SCT-guided, family-supported DSMES programme produced a promising positive effect on enhancing the support needed and support received from their family/friends, and it also improved the family's supportive behaviour. Thus, family support could be incorporated into DSMES programmes for diabetes management in Western Ethiopia. The trial was registered by the Chinese Clinical Trial Registry ( http://www.chictr.org.cn ); Registration number: ChiCTR2000040292.

Religion, spirituality and improved glycemic control among people with type 2 diabetes: A systematic review

OBJECTIVE

This systematic review investigates the association between measures of religiosity or spirituality (R/S) and glycemic control in patients with type 2 diabetes.

METHODS

A systematic literature review was conducted for all English language articles published between 1966 and August 2022 in six relevant databases: PubMed, PSYCHinfo, CINAHL, ATLA, Scopus, Sociological Abstracts, and the Cochrane Central Register of Controlled Clinical Trials. Search terms for religious variables included, "religion", "religiosity", "spirituality", "religious attendance". Search terms for diabetes outcomes included, "diabetes", "hemoglobin A1c", "blood glucose", "glycemic control." The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

A total of 758 studies examining correlations between R/S and glycemic control were screened from relevant databases. Forty studies were evaluated for eligibility and inclusion. Eight studies were selected and analyzed. Three studies showed positive associations, two studies showed positive and neutral associations, two studies showed positive and negative associations, and one study showed a neutral association. Limitations included small sample sizes and heterogeneity of study designs.

CONCLUSION

Involvement in religious and spiritual practices may be associated with improved glycemic control in patients with type 2 diabetes. Specific mechanisms for associations may be partially explained by more effective self-management practices, increased positive social contacts, and regular community support. Further research is needed to clarify these associations.

'I accept his manhood is on life-support': A qualitative understanding of the impact of diabetes on sexual relationships among men and women living with type 2 diabetes and their partners in South Africa

AIMS

To explore the impact of diabetes on sexual relationships among men and women living with type 2 diabetes People living with type 2 diabetes (PLWD) and their partners in Cape Town, South Africa.

METHODS

As part of a larger study developing an intervention to improve type 2 diabetes mellitus (T2DM) self management, we conducted in-depth individual interviews with 10 PLWD and their partners without diabetes about experiences living with T2DM, between July 2020 and January 2021. We used inductive thematic analysis.

RESULTS

Both PLWD and partners felt that their sexual relationships and desires changed post-diagnosis, in ways beyond biomedical issues. Although couples' reports on the quality of their sexual relationships were concordant, most participants had not communicated their sexual desires and concerns with each other, causing unhappiness and fears of disappointing or losing their partner. Participants felt uninformed about sexual dysfunction but had not discussed this with their healthcare provider, leading to increased anxiety.

CONCLUSION

PLWD and their partners need more informational support to increase their understanding of diabetes-associated sexual dysfunction and to decrease fears and anxiety. Strengthening communication within couples on sexual issues may empower them to find solutions to problems experienced. This may improve couples' relationships and quality of life, and indirectly result in better self management of T2DM.

The Effect of Attitude to Death on Self-Management in Patients With Type 2 Diabetes Mellitus During the COVID-19 Pandemic

This study was conducted to examine the effect of attitude to death on self-management in patients with Type 2 Diabetes Mellitus during the COVID-19 pandemic. This study was carried out in a descriptive and correlational type with the participation of n = 103 type 2 diabetes mellitus patients registered in the Internal Medicine Unit at a University Hospital. Personal Information Form, Death Attitude Profile-Revised (DAP-R), Diabetes Self-Management Questionnaire and Fear of COVID-19 Scale were used in data collection. According to the results of the study, it was determined that diabetes patients' fear of COVID-19 increased their fear of death and self-management. Similarly, neuropathy and nephropathy developed in these patients. In addition, it was determined that the diabetic patients who worked 6-7 days a week outside the home had higher levels of fear. It was found that those with high fear were more attentive to social distancing, wearing masks and hand sanitizer use. Staying at home is also not always possible for patients with chronic diseases, and people struggle with COVID-19 by working in crowded workspaces. It is necessary to recognize the struggle of patients with chronic diseases and provide social, economic and psychological support.

eDECIDE a web-based problem-solving interventions for diabetes self-management: Protocol for a pilot clinical trial

Background

In the US, diabetes affects 13.2% of African Americans, compared to 7.6% of Caucasians. Behavioral factors, such as poor diet, low physical activity, and general lack of good self-management skills and self-care knowledge are associated with poor glucose control among African Americans. African Americans are 77% more likely to develop diabetes and its associated health complications compared to non-Hispanic whites. A higher disease burden and lower adherence to self-management among this populations calls for innovative approaches to self-management training. Problem solving is a reliable tool for the behavior change necessary to improve self-management. The American Association of Diabetes Educators identifies problem-solving as one of seven core diabetes self-management behaviors.

Methods

We are using a randomized control trial design. Participants are randomized to either traditional DECIDE or eDECIDE intervention. Both interventions run bi-weekly over 18 weeks. Participant recruitment will take place through community health clinics, University health system registry, and through private clinics. The eDECIDE is an 18-week intervention designed to deliver problem-solving skills, goal setting, and education on the link between diabetes and cardiovascular disease.

Conclusion

This study will provide feasibility and acceptability of the eDECIDE intervention in community populations. This pilot trial will help inform a powered full-scale study using the eDECIDE design.

Barriers and facilitators in dietary and physical activity management of type 2 diabetes: Perspective of healthcare providers and patients

BACKGROUND AND AIMS

Type 2 diabetes (T2DM) is a chronic disease that requires continuous management and daily self-care activities. The purpose of the study was to identify the barriers and facilitators in dietary and physical activity management of T2DM by patients.

METHOD

Two focus group discussions with patients with T2DM (n = 12) and interviews with healthcare providers (HCPs, n = 15) were done, to identify the barriers and facilitators experienced by patients towards lifestyle management in T2DM. Data were analyzed using qualitative data analysis software Atlas ti. version 8.

RESULT

Three major themes were identified as barriers and facilitators viz., Personal barriers and facilitators, social barriers and facilitators, and barriers and facilitators related to the healthcare provider. Major barriers were denial of illness, low level of knowledge of the disease, excess use of gadgets, poor infrastructure, gender issues, and lack of time. Major facilitators identified were patient education and motivation, continuous counseling and regular follow-up, family and peer support, and recreational and indoor activities.

CONCLUSION

Based on the findings of the study, a multifaceted approach is required to address these barriers and facilitators. These findings will help in developing novel intervention strategies and making policy-level changes, which are required to improve diabetes self-management practices in people with T2DM.

The effectiveness of self-management programme based on multilevel social resources utilization in diabetes mellitus patients: A randomized controlled study

AIMS

This study aimed to test the effects of a novel diabetes self-management education (DSME) programme focused on multilevel social resources utilization on improving self-management behaviour, social resources utilization and haemoglobin A_lc (HbA_1c ) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A randomized controlled design was used. A total of 118 participants with T2DM from two communities were recruited through randomized sampling, and randomly assigned to the novel DSME group or the traditional DSME group. DSME focusing on multilevel social resources utilization was implemented in the novel DSME group. Data were collected at baseline (T₀ ), at the end of the intervention (T₁ ) and 3 months after the end of intervention (T₂ ) from 3 March to 16 November 2014.

RESULTS

Comparing these two groups, the participants in the novel DSME group reported significantly better improvement in self-management behaviour and social resources utilization at T₁ and T₂ (all p < 0.01). A significant difference was found in the mean improvement of HbA_1c level between the two groups at T₂ (p < 0.05).

CONCLUSIONS

The novel DSME programme focused on multilevel social resources utilization can effectively enhance T2DM patients' self-management behaviour and social resource utilization and lower HbA_1c levels. More importantly, the effects could last longer.

Community-based culturally tailored education programmes for black adults with cardiovascular disease, diabetes, hypertension and stroke: a systematic review protocol of primary empirical studies

INTRODUCTION

Chronic conditions and stroke disproportionately affect black adults in communities all around the world partly due to patterns of systemic racism, disparities in care, and lack of resources. Culturally tailored programmes can potentially meet the needs of the communities they serve, including black adults who may experience reduced access to postacute services. To address unequal care received by black communities, a shift to community-based programmes that deliver culturally tailored programmes may give an alternative to a healthcare model which reinforces health inequities. The objectives of this review are to: (1) synthesise key programme characteristics and outcomes of culturally tailored community-based (CBCT) programmes that are designed to improve health outcomes in black adults with cardiovascular disease, hypertension, diabetes, or stroke and (2) identify which of the five categories of culturally appropriate programmes from Kreuter and colleagues have been used to implement CBCT programmes.

METHODS AND ANALYSIS

This is a protocol for a systematic review that will search Medline, Embase and Cumulative Index to Nursing and Allied Health Literature databases to identify studies of CBCT programmes for black adults with cardiovascular disease, hypertension, diabetes, or stroke between 2000 and 2021. Two reviewers will assess each study based on the inclusion criteria and any disagreements will be resolved by a third reviewer. Data will be extracted using a customised data extraction form to identify programme characteristics and the strategies used to develop culturally appropriate programmes. AMSTAR will be used to evaluate the articles included in the study. The aggregated data will be presented through textual descriptions of programme characteristics and outcomes.

ETHICS AND DISSEMINATION

This systematic review protocol does not require ethics approval without the inclusion of human participants and will use studies that have previously obtained informed consent. The systematic review findings will be disseminated in a peer-reviewed journal and used to inform future research led by JF and HS.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42021245772.

Experiences of Urinary Incontinence Management in Older Women: A Qualitative Study

Introduction

Older women have various experiences regarding the management of urinary incontinence depending on the societies they live in and their cultural backgrounds. The present study aimed to determine older women's experiences in urinary incontinence management.

Methods

The present qualitative study employed a conventional content analysis approach and was conducted in Iran from 2019 to 2020. In this research, the data were collected through face-to-face unstructured in-depth interviews with 22 older women suffering from urinary incontinence selected via purposeful sampling. The interviews were continued until reaching the data saturation point. Data analysis was performed simultaneously with data collection. The interviews were recorded, transcribed, and analyzed through Graneheim and Lundman style content analysis, and data management was done using the MAXQDA software. In order to achieve the accuracy and validity of the study, the Four-Dimensions Criteria (FDC) by Lincoln and Guba, namely credibility, dependability, conformability, and transformability, were considered and used.

Results

This study was conducted on 22 older women suffering from urinary incontinence with the mean age of 66.54 ± 5.76 years. The acquired data were put in four main categories of “resilience” with three subcategories, “change in lifestyle” with six subcategories, “attempt for treatment of the condition” with three subcategories, and “receiving support” with two subcategories.

Conclusion

The study results indicated that the older women suffering from urinary incontinence were resilient against the condition, had changed their lifestyles to manage the condition, and sought treatment. In addition, receiving support from the family and the society played a significant role in the follow-up and management of the condition. The present study findings can help healthcare team members focus on urinary incontinence, design care programs for older women with this condition, and improve their quality of life. Furthermore, focusing on young and middle-aged women's health, providing them with the necessary training for taking care of the genitourinary system, and raising their awareness for preventing urinary incontinence during old ages can be helpful. Moreover, increasing the healthcare team's sensitivity and following the patients up can help diagnose, manage, and treat the condition before exerting adverse impacts on their quality of life.

"I Had to Rediscover Our Healthy Food": An Indigenous Perspective on Coping with Type 2 Diabetes Mellitus

Type 2 Diabetes Mellitus (T2DM) is disproportionally prevalent among the Bedouin minority in Israel, with especially poor treatment outcomes compared to other indigenous groups. This study uses the perspective of the Bedouins themselves to explore the distinct challenges they face, as well as their coping strategies. The study is based on an interpretive interactionist analysis of 49 semi-structured interviews with Bedouin men and women. The findings of the analysis include three themes. First, physical inequality: the Bedouin community's way of coping is mediated by the transition to a semi-urban lifestyle under stressful conditions that include the experience of land dispossession and the rupture of caring relationships. Second, social inequality: they experience an inaccessibility to healthcare due to economic problems and a lack of suitable informational resources. Third, unique resources for coping with T2DM: interviewees use elements of local culture, such as religious practices or small enclaves of traditional lifestyles, to actively cope with T2DM. This study suggests that there is a need to expand the concept of active coping to include indigenous culture-based ways of coping (successfully) with chronic illness.

Perceptions of psychosocial and interpersonal factors affecting self-management behaviors among African Americans with diabetes

Background

Objective

Methods

Results

Conclusion

Facilitators and barriers to self-management of patients chronic kidney disease

This study explored the facilitators and barriers self-management of patients' early stages chronic kidney disease (CKD). This study used a descriptive phenomenological qualitative design, eight participants were recruited using a purposive technique sampling. The data collection instruments employed included in-depth interviews using semi-structured interview guidelines, field notes, and tape recorders. The Colaizzi method was used for data analysis. The results were two themes (1) facilitator of self-management: health status, self-motivation, and independence in activities; (2) barriers of self-management: personal characteristics of the patients, has a miss-perception about the disease, dependency and not compliance. This study identified facilitators and barriers of self-management patients with early stages of CKD. Therefore, nurses have an important role in conducting a comprehensive health assessment.

Perceptions of African American Adults With Type 2 Diabetes on Family Support: Type, Quality, and Recommendations

PURPOSE

The overall purpose of the study was to explore perceptions of family support in diabetes self-management among African American adults with type 2 diabetes.

METHODS

A qualitative study using focus group methodology and individual interviews was conducted. Thirty-seven African American adults with type 2 diabetes were recruited in the Midwest, United States. Data were analyzed using qualitative content analysis.

RESULTS

Themes emerged from the perspectives of the social interdependence theory. Positive family support included emotional support, instrumental support, and specific information or advice on diabetes management strategies. Positivity, family communication, and healthy eating/meal planning were perceived as helpful family behaviors. Negative support was perceived as intentional or unintentional behaviors. Family members' help in decision-making included goal setting with family member(s) and help in making decisions on diet and exercise. Recommendations included exercise and nutritional programs, support groups, family involvement, and materials and resources. Motivations for attending diabetes programs included involving family members, sharing success stories, seeing positive results, encouraging and caring, and providing incentives.

CONCLUSIONS

Intervention programs for African Americans should specifically target challenges in family support, healthy eating, and physical activity at an interpersonal level. Health care providers should assess family roles and family support to facilitate diabetes self-management for African Americans.

Barriers and facilitators to type 2 diabetes management in the Caribbean region: a qualitative systematic review

OBJECTIVE

The objective of this systematic review was to summarize the barriers and facilitators to type 2 diabetes mellitus management in the Caribbean region.

INTRODUCTION

The prevalence of type 2 diabetes mellitus in the Caribbean is of significant concern. Poor management of type 2 diabetes mellitus increases the risks of complications and death. Several studies have been conducted to explore the barriers and facilitators to type 2 diabetes mellitus management in the Caribbean; however, a systematic review has yet to be conducted.

INCLUSION CRITERIA

Eligible participants were adults (aged 18 and above) with type 2 diabetes mellitus, their families/carers, and health care professionals whose work involves the management of type 2 diabetes mellitus in the Caribbean. The review included studies that focused on their views, experiences, attitudes, understandings, perceptions, and perspectives regarding the barriers and facilitators to type 2 diabetes mellitus management.

METHODS

Electronic searches of MEDLINE, Embase, CINAHL/BNI (EBSCOhost), PsycINFO, AMED, Web of Science, and Scopus were conducted from database inception to March 2020. Additionally, gray literature was searched via EThOS, OpenGrey, and ProQuest Dissertations and Theses. JBI methodology for conducting qualitative systematic reviews was followed. Screening of studies, assessment of methodological quality, and data extraction were conducted independently by two reviewers. Findings from studies were synthesized using a meta-aggregation approach, and confidence in the findings was ranked using the ConQual approach.

RESULTS

Eight studies were included in the review, all of which focused on patients' perspectives. There were five synthesized findings, including i) cultural demands and pressures impact self-management and general care of type 2 diabetes mellitus (low confidence evidence); ii) support systems' influence on the general management of type 2 diabetes mellitus (moderate confidence evidence); iii) personal and environmental background/circumstances can encourage and limit good self-management and general management of type 2 diabetes mellitus (high confidence evidence); iv) psychological factors that influence patients' actions towards the management of type 2 diabetes mellitus (moderate confidence evidence); and v) psychological factors and their influence on patients' adherence to type 2 diabetes mellitus management (low confidence evidence).

CONCLUSIONS

Patients in the Caribbean have multiple barriers and facilitators that limit and promote effective management of their type 2 diabetes mellitus. Identifying the barriers and facilitators to type 2 diabetes mellitus management in the Caribbean will assist with development of effective type 2 diabetes mellitus management programs. However, further qualitative studies on barriers and facilitators to type 2 diabetes mellitus management in the Caribbean that target health care professionals and families/carers should be conducted.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018097242.

A systematized review on diabetes gamification

Background: Gamification is an effective tool used to enhance the quality of education and training, to create motivation and enthusiasm, and to maintain competitiveness in the targeted population. Given that, the present study is an attempt to review gamification used in the field of diabetes systematically and its effects on the target group.

Methods: Articles were retrieved from eight databases via an electronic advanced search. The data were imported to Endnote; and to assess the quality of the articles, PRISMA and CASP were used. Finally, according to the inclusion criteria, the appropriate articles were selected.

Results: This study indicates that physical activity and nutrition were the most frequent diabetic subgroups in diabetes gamification. In addition, all diabetes gamification programs were designed to educate, teach skills and make behavior improvement in diabetics.

Conclusion: Diabetes gamification have the capacity to change health behaviors among all age groups and can create an innovative, attractive and interactive learning environment accompanied by fun and engagement. Professor, Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran; Librarianship and Medical Information Science, Iran University of Medical Sciences, Tehran, Iran.

Relative Contribution of Individual, Community, and Health System Factors on Glycemic Control Among Inner-City African Americans with Type 2 Diabetes

BACKGROUND

Health disparities disproportionately impact inner-city African Americans; however, limited information exists on the contribution of individual, community, and health system barriers on diabetes outcomes in this population.

METHODS

A cross-sectional study collected primary data from 241 inner-city African Americans with type 2 diabetes. A conceptual framework was used to specify measurements across the individual level, such as age and comorbidities; community level, such as neighborhood factors and support; and health system level such as access, trust, and provider communication. Based on current best practices, four regression approaches were used: sequential, stepwise with forward selection, stepwise with backward selection, and all possible subsets. Variables were entered in blocks based on the theoretical framework in the order of individual, community, and health system factors and regressed against HbA1c.

RESULTS

In the final adjusted model across all four approaches, individual-level factors like age (β = - 0.05; p < 0.001); having 1-3 comorbidities (β = - 2.03; p < 0.05), and having 4-9 comorbidities (β = - 2.49; p = 0.001) were associated with poorer glycemic control. Similarly, male sex (β = 0.58; p < 0.05), being married (β = 1.16; p = 0.001), and being overweight/obese (β = 1.25; p < 0.01) were associated with better glycemic control. Community and health system-level factors were not significantly associated with glycemic control.

CONCLUSION

Individual-level factors are key drivers of glycemic control among inner-city African Americans. These factors should be the key targets for interventions to improve glycemic control in this population. However, community and health system factors may have indirect pathways to glycemic control that should be examined in future studies.

Barriers and facilitating factors in the prevention of diabetes type 2 and gestational diabetes in vulnerable groups: A scoping review

Aims

Type 2 diabetes mellitus (T2DM) and gestational diabetes (GDM) are globally on the rise, accompanied by comorbidities and associated health costs. Increased physical activity, healthy nutrition, and weight loss have shown the potential to prevent T2DM/GDM. Despite this, reaching vulnerable groups remains a key challenge. The aim of this scoping review was to identify barriers and facilitating factors in the prevention of T2DM/GDM in vulnerable groups.

Methods

We conducted a systematic literature search in May 2018, updated in September 2019, in several databases (e.g. PubMed, Embase) to identify barriers and facilitating factors in the prevention of T2DM/GDM in vulnerable groups. Two reviewers independently screened the results. Extracted data was charted, categorized, and summarized.

Results

We included 125 articles. Ninety-eight studies were extracted, and eight categories of barriers and facilitating factors were formed. The most common categories of barriers were limited knowledge, family/friends, and economic factors, and the most common categories of facilitating factors were family/friends, social support, and knowledge.

Conclusion

This scoping review identified various barriers and facilitating factors in vulnerable groups. Preventive interventions should consider these barriers and facilitating factors in developing preventive interventions or in adapting existing ones.

Individual-, Community-, and Health System-Level Barriers to Optimal Type 2 Diabetes Care for Inner-City African Americans: An Integrative Review and Model Development

PURPOSE

The purpose of this integrative review is (1) to elucidate the unique barriers faced by inner-city African Americans for type 2 diabetes (T2DM) care; (2) to identify effective interventions/programs for optimal T2DM care at the individual, community, and health systems levels; and (3) to integrate 2 behavioral models and 1 social ecological model for framing interventions for inner-city African American to optimize T2DM care.

METHODS

PRISMA guidelines were followed to systematically search PubMed, PsychInfo, and CINAHL. Integration of models was based on underlying principles of social ecological models.

RESULTS

The search returned 1183 articles. Forty-six articles were synthesized after applying inclusion criteria. Multiple barriers for the individual level, community level, and health system level were identified. Major barriers include lack of knowledge, lack of social support, and self-management support. Interventions identified in this review show that among inner-city African Americans with T2DM, the focus is placed at the health systems level, with very limited focus toward addressing individual- and community-level barriers. Final synthesis includes development of a new integrated model that explains barriers to care across multiple levels.

CONCLUSIONS

These findings highlight the fragmentation that may be occurring between policy, research, and practice for achieving health equity and addressing health disparities for T2DM care among inner-city African Americans. The new model is an important step in the pursuit of equity in T2DM by specifying the complex barriers that occur across multiple levels. The application of this model using the 2017 National Standards for Diabetes-Self Management Education and Support are discussed.

Enablers and barriers to effective diabetes self-management: A multi-national investigation

OBJECTIVE

The study aimed to identify the common gaps in skills and self-efficacy for diabetes self-management and explore other factors which serve as enablers of, and barriers to, achieving optimal diabetes self-management. The information gathered could provide health professionals with valuable insights to achieving better health outcomes with self-management education and support for diabetes patients.

METHODS

International online survey and telephone interviews were conducted on adults who have type 1 or type 2 diabetes. The survey inquired about their skills and self-efficacy in diabetes self-management, while the interviews assessed other enablers of, and barriers to, diabetes self-management. Surveys were analysed using descriptive and inferential statistics. Interviews were analysed using inductive thematic analysis.

RESULTS

Survey participants (N = 217) had type 1 diabetes (38.2%) or type 2 diabetes (61.8%), with a mean age of 44.56 SD 11.51 and were from 4 continents (Europe, Australia, Asia, America). Identified gaps in diabetes self-management skills included the ability to: recognize and manage the impact of stress on diabetes, exercise planning to avoid hypoglycemia and interpreting blood glucose pattern levels. Self-efficacy for healthy coping with stress and adjusting medications or food intake to reach ideal blood glucose levels were minimal. Sixteen participants were interviewed. Common enablers of diabetes self-management included: (i) the will to prevent the development of diabetes complications and (ii) the use of technological devices. Issues regarding: (i) frustration due to dynamic and chronic nature of diabetes (ii) financial constraints (iii) unrealistic expectations and (iv) work and environment-related factors limited patients' effective self-management of diabetes.

CONCLUSIONS

Educational reinforcement using technological devices such as mobile application has been highlighted as an enabler of diabetes self-management and it could be employed as an intervention to alleviate identified gaps in diabetes self-management. Furthermore, improved approaches that address financial burden, work and environment-related factors as well as diabetes distress are essential for enhancing diabetes self-management.

Managing with Learning Disability and Diabetes: OK-Diabetes - a case-finding study and feasibility randomised controlled trial

BACKGROUND

Obesity and type 2 diabetes are common in adults with a learning disability. It is not known if the principles of self-management can be applied in this population.

OBJECTIVES

To develop and evaluate a case-finding method and undertake an observational study of adults with a learning disability and type 2 diabetes, to develop a standardised supported self-management (SSM) intervention and measure of adherence and to undertake a feasibility randomised controlled trial (RCT) of SSM versus treatment as usual (TAU).

DESIGN

Observational study and an individually randomised feasibility RCT.

SETTING

Three cities in West Yorkshire, UK.

PARTICIPANTS

In the observational study: adults aged > 18 years with a mild or moderate learning disability, who have type 2 diabetes that is not being treated with insulin and who are living in the community. Participants had mental capacity to consent to research and to the intervention. In the RCT participants had glycated haemoglobin (HbA_1c) levels of > 6.5% (48 mmol/mol), a body mass index (BMI) of > 25 kg/m² or self-reported physical activity below national guideline levels.

INTERVENTIONS

Standardised SSM. TAU supported by an easy-read booklet.

MAIN OUTCOME MEASURES

(1) The number of eligible participants identified and sources of referral; (2) current living and support arrangements; (3) current health state, including level of HbA_1c, BMI and waist circumference, blood pressure and lipids; (4) mood, preferences for change; (5) recruitment and retention in RCT; (6) implementation and adherence to the intervention; (7) completeness of data collection and values for candidate primary outcomes; and (8) qualitative data on participant experience of the research process and intervention.

RESULTS

In the observational study we identified 147 eligible consenting participants. The mean age was 54.4 years. In total, 130 out of 147 (88%) named a key supporter, with 113 supporters (77%) being involved in diabetes management. The mean HbA_1c level was 54.5 mmol/mol [standard deviation (SD) 14.8 mmol/mol; 7.1%, SD 1.4%]. The BMI of 65% of participants was > 30 kg/m² and of 21% was > 40 kg/m². Many participants reported low mood, dissatisfaction with lifestyle and diabetes management and an interest in change. Non-response rates were high (45/147, 31%) for medical data requested from the primary care team. In the RCT, 82 participants were randomised. The mean baseline HbA_1c level was 56 mmol/mol (SD 16.5 mmol/mol; 7.3%, SD 1.5%) and the mean BMI was 34 kg/m² (SD 7.6 kg/m²). All SSM sessions were completed by 35 out of 41 participants. The adherence measure was obtained in 37 out of 41 participants. The follow-up HbA_1c level and BMI was obtained for 75 out of 82 (91%) and 77 out of 82 (94%) participants, respectively. Most participants reported a positive experience of the intervention. A low response rate and difficulty understanding the EuroQol-5 Dimensions were challenges in obtaining data for an economic analysis.

LIMITATIONS

We recruited from only 60% of eligible general practices, and 90% of participants were on a general practice learning disability register, which meant that we did not recruit many participants from the wider population with milder learning disability.

CONCLUSIONS

A definitive RCT is feasible and would need to recruit 194 participants per arm. The main barrier is the resource-intensive nature of recruitment. Future research is needed into the effectiveness of obesity treatments in this population, particularly estimating the longer-term outcomes that are important for health benefit. Research is also needed into improving ways of assessing quality of life in adults with a learning disability.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41897033.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 26. See the NIHR Journals Library website for further project information.

Effect of ecological momentary assessment, goal-setting and personalized phone-calls on adherence to interval walking training using the InterWalk application among patients with type 2 diabetes-A pilot randomized controlled trial

OBJECTIVES

The objective was to investigate the feasibility and usability of electronic momentary assessment, goal-setting and personalized phone-calls on adherence to a 12-week self-conducted interval walking training (IWT) program, delivered by the InterWalk smartphone among patients with type 2 diabetes (T2D).

METHODS

In a two-arm pilot randomized controlled trial (Denmark, March 2014 to February 2015), patients with T2D (18-80 years with a Body Mass Index of 18 and 40 kg/m2) were randomly allocated to 12 weeks of IWT with (experimental) or without additional support (control). The primary outcome was the difference between groups in accumulated time of interval walking training across 12 weeks. All patients were encouraged to use the InterWalk application to perform IWT for ≥90 minute/week. Patients in the experimental group made individual goals regarding lifestyle change. Once a week inquiries about exercise adherence was made using an ecological momentary assessment (EMA). In case of consistent self-reported non-adherence, the patients would receive a phone-call inquiring about the reason for non-adherence. The control group did not receive additional support. Information about training adherence was assessed objectively. Usability of the EMA was assessed based on response rates and self-reported satisfaction after 12-weeks.

RESULTS

Thirty-seven patients with T2D (66 years, 65% female, hemoglobin 1Ac 50.3 mmol/mol) where included (n = 18 and n = 19 in experimental and control group, respectively). The retention rate was 83%. The experimental group accumulated [95%CI] 345 [-7, 698] minutes of IWT more than the control group. The response rate for the text-messages was 83% (68% for males and 90% for females). Forty-one percent of the experimental and 25% of the control group were very satisfied with their participation.

CONCLUSION

The combination inquiry about adherence using EMA, goal-setting with the possibility of follow-up phone calls are considered feasible interventions to attain training adherence when using the InterWalk app during a 12-week period in patients with T2D. Some uncertainty about the effect size of adherence remains.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02089477.

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.

Factors associated with self-management among Vietnamese adults with type 2 diabetes

AIM

The study described diabetes self-management (DSM), diabetes knowledge, family and friends' support, healthcare providers' support, belief in treatment effectiveness and diabetes management self-efficacy, and explored DSM's associations among Vietnamese adults with type 2 diabetes mellitus (T2DM).

DESIGN

A cross-sectional design was applied.

METHODS

The study used self-report questionnaires to collect data from 198 participants. Descriptive statistics and structural equation modelling (SEM) was used for data analysis.

RESULTS

Vietnamese adults with T2DM performed DSM limitedly in certain aspects. They had strong belief in treatment effectiveness, good family and friends support, limited diabetes knowledge, healthcare professional support and self-efficacy. Their DSM was directly associated with diabetes knowledge, family and friends' support, healthcare providers' support, belief in treatment effectiveness and diabetes management self-efficacy. Their DSM was indirectly associated with diabetes knowledge and family and friends' support through their belief in treatment effectiveness and diabetes management self-efficacy.

Understanding 'context' in the self-management of type 2 diabetes with comorbidities: A systematic review and realist evaluation

OBJECTIVE

To identify contextual factors that affect self-management of diabetes with comorbidities, and to evaluate in what way these factors affect self-management effectiveness.

METHODS

A systematic review of literature considered English language articles published within Medline, PsycINFO, Pubmed, CINAHL Plus, and Scopus databases that focussed on individuals' experiences of type 2 diabetes from primary intervention or observational studies. A realist evaluation approach was used to analyse themes identified within the literature. Context-mechanism-outcome theories were constructed to identify underlying contextual factors and to construct a model illustrating diabetes self-management effectiveness.

RESULTS

Of 1519 articles identified, 30 met inclusion criteria. Adherence was found to be the common mechanism that (within given contexts) determined self-management effectiveness. Limited financial resources were identified as the key context. Our model makes explicit a structural weaknesses of diabetes self-management.

CONCLUSIONS

Coping with diabetes in the context of people's lives requires attention to issues that are often outside the remit of the person with diabetes, the health care team, and the health system within which self-management is located. Realist evaluations illuminate programme mechanisms and fine-tune context. They aid initial understandings of how an intervention or programme is thought to work, in order to influence and (re)design (new) programmes.

Barriers and facilitators to physical activity among urban residents with diabetes in Nepal

INTRODUCTION

Physical activity is an important component of type 2 diabetes management. Physical activity level among general population in Nepal is reported to vary considerably. However, knowledge on physical activity in Nepali diabetics is very limited. Engagement in physical activity could be influenced by perception of barriers against adopting the behavior and benefits of adopting it. This study explores the prevalence of physical activity and factors that promote and hinder the behavior among urban residing diabetic patients from Nepal.

METHODS

A descriptive cross-sectional design was adopted using a simple random sampling of type 2 diabetic patients from two diabetes clinics at Lalitpur and Kaski districts of Nepal. Two hundred and seventy participants were surveyed to obtain information on physical activity using Global Physical Activity Questionnaire. Metabolic equivalent values were calculated and categorized into high, moderate and low levels of physical activity. The information on perceived facilitators and barriers was collected by Exercise Barriers and Benefits Survey scale. Odds ratios and 95% confidence intervals of the measures were estimated using multinomial logistic regression.

RESULTS

The study showed relatively high prevalence of physical activity among the urban Nepali diabetic patients; 52% were moderately active and 28% highly active. Travel and work-related activities were the major contributors. Male participants, educated and those living in extended families were more motivated for physical activity than their counterparts. Physical fitness, strength and flexibility, better sleep at night, social interaction and longevity, were identified as the major facilitators. Family responsibilities, busy schedule and family discouragement were identified as barriers against being physically active.

CONCLUSION

The diabetic patients were mostly moderately physically active. Future research could explore different context-specific ways of remaining physically active, apart from walking and doing household chores. More focus should also be placed on leisure time physical activity as it was found to be low. Interventions could be designed by promoting the facilitators and addressing the barriers of physical activity, which is likely to reduce the healthcare costs of management of diabetic complications.

Development of a supported self-management intervention for adults with type 2 diabetes and a learning disability

BACKGROUND

Although supported self-management is a well-recognised part of chronic disease management, it has not been routinely used as part of healthcare for adults with a learning disability. We developed an intervention for adults with a mild or moderate learning disability and type 2 diabetes, building on the principles of supported self-management with reasonable adjustments made for the target population.

METHODS

In five steps, we:Clarified the principles of supported self-management as reported in the published literatureIdentified the barriers to effective self-management of type 2 diabetes in adults with a learning disabilityReviewed existing materials that aim to support self-management of diabetes for people with a learning disabilitySynthesised the outputs from the first three phases and identified elements of supported self-management that were (a) most relevant to the needs of our target population and (b) most likely to be acceptable and useful to themImplemented and field tested the intervention.

RESULTS

The final intervention had four standardised components: (1) establishing the participant's daily routines and lifestyle, (2) identifying supporters and their roles, (3) using this information to inform setting realistic goals and providing materials to the patient and supporter to help them be achieved and (4) monitoring progress against goals.Of 41 people randomised in a feasibility RCT, thirty five (85%) completed the intervention sessions, with over three quarters of all participants (78%) attending at least three sessions.Twenty-three out of 40 (58%) participants were deemed to be very engaged with the sessions and 12/40 (30%) with the materials; 30 (73%) participants had another person present with them during at least one of their sessions; 15/41 (37%) were reported to have a very engaged main supporter, and 18/41 (44%) had a different person who was not their main supporter but who was engaged in the intervention implementation.

CONCLUSIONS

The intervention was feasible to deliver and, as judged by participation and engagement, acceptable to participants and those who supported them.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41897033 (registered 21/01/2013).

Perspectives of Fear as a Barrier to Self-Management in Non-Hispanic Black Men With Type 2 Diabetes

BACKGROUND

Self-managing type 2 diabetes (T2D) is critical but often challenging for non-Hispanic Black (NHB) men. Fears may contribute to poor self-management; however, the evidence is sparse. The purpose of this study is to examine the relationship between fear and diabetes self-management in NHB men from the southern United States.

METHODS

Nineteen NHB men with T2D were recruited from barbershops and churches. Interviews were conducted using a semistructured interview guide. Transcripts were analyzed using a phenomenological approach and focused on identifying common themes describing the perceptions of fear as a barrier to self-managing T2D in the study participants.

RESULTS

More than 68% of the sample was >55 years of age, where 42% reported an annual income of ≥$100,000, 74% were married, and 26% had a college degree. Fifty-three percent expressed fear with diabetes management, while 47% reported no fears with diabetes management. Direct fears associated with self-management included the use of needles and syringes for self-monitoring and medication adherence, respectively. Indirect fears were associated with the development of adverse complications resulting in poor mental and physical quality of life. No fears were reported secondary to diabetes knowledge, perceived control, and social support.

CONCLUSIONS

In this sample of NHB men, fear was perceived by many as a direct barrier to self-management and an indirect barrier to optimal quality of life. These findings suggest the need to address the fears of NHB men when guiding treatment and developing research interventions to improve self-management skills.

Understanding Diabetes-Related Distress Characteristics and Psychosocial Support Preferences of Urban African American Adults Living With Type 2 Diabetes: A Mixed-Methods Study

Purpose The purpose of this study is to understand diabetes-related distress (DRD) characteristics and identify psychosocial support preferences of urban African American adults living with type 2 diabetes (T2DM). Methods A 2-phase, mixed-methods sequential explanatory study design was used to gather data. In phase 1, a purposive sample of participants (N = 155) was recruited and asked to complete a written survey. The Diabetes Distress Scale (DDS17) was used to assess DRD, including subscales-emotional burden (EB), regimen distress (RD), interpersonal distress (ID), and physician distress (PD). In phase 2, a subset of phase 1 participants (N = 23) volunteered to attend 1 of 4 gender-stratified follow-up focus groups to contextualize the quantitative survey results. Results Survey findings indicate that on average, participants had moderate levels of DRD (aggregate), RD, and EB but had low ID and PD. During follow-up focus groups, participants described RD and EB as their primary distress types and emphasized that clinicians should prioritize the mental health aspects of T2DM similarly to its physical aspects. Participants expressed a desire for culturally appropriate peer support groups as a psychosocial support resource for distress coping and specifically requested the development of gender-stratified groups and groups for young adults. Conclusions Results support the need to screen for and address diabetes-related distress among African American patients with T2DM. Findings also inform the development of culturally appropriate psychosocial support resources to facilitate diabetes-related distress coping.

"I did not want to take that medicine": African-Americans' reasons for diabetes medication nonadherence and perceived solutions for enhancing adherence

BACKGROUND

Diabetes is disproportionally burdensome among African-Americans (AAs) and medication adherence is important for optimal outcomes. Limited studies have qualitatively examined reasons for nonadherence among AAs with type 2 diabetes, though AAs are less adherent to prescribed medications compared to whites. This study explored the reasons for medication nonadherence and adherence among AAs with type 2 diabetes and examined AAs' perceived solutions for enhancing adherence.

METHODS

Forty AAs, age 45-60 years with type 2 diabetes for at least 1 year prior, taking at least one prescribed diabetes medication, participated in six semistructured 90-minute focus groups. Using a phenomenology qualitative approach, reasons for nonadherence and adherence, as well as participants' perceived solutions for increasing adherence were explored. Qualitative content analysis was conducted.

RESULTS

AAs' reasons for intentional nonadherence were associated with 1) their perception of medicines including concerns about medication side effects, as well as fear and frustration associated with taking medicines; 2) their perception of illness (disbelief of diabetes diagnosis); and 3) access to medicines and information resources. Participants reported taking their medicines because they valued being alive to perform their social and family roles, and their belief in the doctor's recommendation and medication helpfulness. Participants provided solutions for enhancing adherence by focusing on the roles of health care providers, patients, and the church. AAs wanted provider counseling on the necessity of taking medicines and the consequences of not taking them, indicating the need for the AA community to support and teach self-advocacy in diabetes self-management, and the church to act as an advocate in ensuring medication use.

CONCLUSION

Intentional reasons of AAs with type 2 diabetes for not taking their medicines were related to their perception of medicines and illness. Solutions for enhancing diabetes medication adherence among AAs should focus on the roles of providers, patients, and the church.

Barriers to Self-Management in Depressed Women With Type 2 Diabetes

Purpose To describe the impact of family functioning on the self-management of type 2 diabetes (T2DM) and depression in a subsample of women who completed a randomized clinical trial using vitamin D3 (5000 or 50,000 IUs weekly) for depression treatment. Background Women are at higher risk for increased severity of T2DM when experiencing depression. Methods Narrative inquiry was used. A semi-structured interview was conducted to understand helpful strategies and barriers in managing T2DM and depression. In addition, women were asked their meaning of family quality of life (FQOL). Results Twenty-one women participated after completion of the six-month final visit in the randomized clinical trial. The mean age was 55.2 years. Participants were 24% Hispanic, 48% African-American, and 52% Caucasian. The major themes generated related to family issues that impacted their self-management, yet participants did not want to "bring fault" to their families. Three themes emerged: (a) experience of family hardships-"it's been hard for me," (b) lack of disclosure to family about being depressed-"no point in talking to them," and (c) the need for connectedness with family and others-"the way it used to be… close as a family." Conclusion Family-centered approaches could address barriers to self-management. A "family lens" for practice and research may improve health outcomes.

[Family, socioeconomic status and health services: Clues to health care in diabetic patients with lower limb amputations in Andalusia. A qualitative study]

Objetivo

Explorar la vivencia de los cuidados diabéticos en pacientes sometidos a amputación de miembros inferiores por pie diabético.

Diseño

Estudio cualitativo con perspectiva fenomenológica.

Emplazamiento

Área hospitalaria de Cádiz.

Participantes

Dieciséis participantes (11 hombres y 5 mujeres) con diabetes tipo 2 y amputación no traumática de miembros inferiores.

Métodos

Entrevistas semiestructuradas individuales y análisis de contenido de la información usando el método propuesto por Graneheim y Lundman.

Resultados

Se identificaron 4 categorías: 1. La familia es la piedra angular de los cuidados; 2. Los aspectos socioeconómicos y laborales determinan la calidad de los autocuidados; 3. La interacción paciente-personal de salud dinamiza los cuidados; y 4. Las limitaciones en la provisión de servicios sanitarios.

Conclusión

La familia, la situación económica y laboral y los factores del sistema sanitario constituyen los elementos más relevantes en los cuidados de pacientes con diabetes y amputación de miembros inferiores. Los determinantes sociales, económicos y laborales deben ser tomados en especial consideración y de manera más personalizada desde los servicios sanitarios para aumentar el impacto de los cuidados proporcionados en la prevención de las complicaciones de la diabetes mellitus.

Culture and Food Practices of African American Women With Type 2 Diabetes

Purpose The goals of this descriptive ethnographic study were to (1) describe the day-to-day selection, preparation, and consumption of food among African American women (AAW) with type 2 diabetes mellitus (T2DM); (2) identify their typical food selections and consumption practices when dining out at restaurants and at social gatherings (ie, church functions, holidays); (3) highlight the valued behaviors and beliefs that influence these women's food practices; and (4) determine how social interactions influence those food practices. Methods Symbolic interactionism, a sensitizing framework, guided this study. Purposeful sampling was used to recruit 20 AAW from 35 to 70 years of age diagnosed with T2DM who shopped and prepared meals for their families and attended church functions where food was served. Data collection consisted of one-on-one interviews and observations of participants during church fellowship dinners, grocery shopping, and food preparation. A social anthropological approach to content analysis was used to describe behavioral regularities in food practices. Results Informants exhibited a constant struggle in food practices, particularly within the home setting. Difficulties in making dietary modifications resulted from conflicts between the need to change dietary practices to control diabetes and personal food preferences, food preferences of family members, and AAW's emotional dedication to the symbolism of food derived from traditional cultural food practices passed down from generation to generation. Conclusions African American women are the gatekeepers for family food practices, holding the keys to healthy dietary practices. This study helps to fill the research gap regarding cultural dietary food practices within this population.

Diet modification challenges faced by marginalized and nonmarginalized adults with type 2 diabetes: A systematic review and qualitative meta-synthesis

Objectives Diet modification is an important part of the prevention and treatment of type 2 diabetes, but sustained dietary change remains elusive for many individuals. This paper describes and interprets the barriers to diet modification from the perspective of people with type 2 diabetes, paying particular attention to the experiences of people who experience social marginalization. Methods A systematic review of primary, empirical qualitative research was performed, capturing 120 relevant studies published between 2002 and 2015. Qualitative meta-synthesis was used to provide an integrative analysis of this knowledge. Results Due to the central role of food in social life, dietary change affects all aspects of a person's life, and barriers related to self-discipline, emotions, family and social support, social significance of food, and knowledge were identified. These barriers are inter-linked and overlapping. Social marginalization magnifies barriers; people who face social marginalization are trying to make the same changes as other people with diabetes with fewer socio-material resources in the face of greater challenges. Discussion A social-ecological model of behavior supports our findings of challenges at all levels, and highlights the need for interventions and counseling strategies that address the social and environmental factors that shape and sustain dietary change.

Teenagers with visual impairment and new media: A world without barriers

Mobile communication technology is an essential part of life of adolescents nowadays, and those with visual impairments are no exception. In focus group interviews with students from a school for the blind and the visually impaired in Rio de Janeiro, Brazil, we found that, despite the visual nature of social media, they use and enjoy these resources as much as their sighted peers. These students are aware of the possibilities and constraints that social media might bring to them but, with the help of assistive technology, make the most of it. After listening to their voices, we noticed that it is high time we incorporate social media in our pedagogical practice, in order to develop their learning process and life skills.

Factors Influencing Diabetes Self-Management Among Medically Underserved Patients With Type II Diabetes

In this study, researchers compare and contrast issues regarding diabetes self-management between persons in good versus poor glycemic control. The sample comprises low-income racially diverse adults with diabetes from four mid-western community health centers; 44 patients participated in eight focus groups divided by control status (HbA1c of > 9 [uncontrolled] or < 7 [controlled]). Themes common to both groups included the impact of dietary restrictions on social interactions, food cravings, the impact of mental health on self-management, and the importance of formal and informal (friends and family) support. Those in the uncontrolled groups described fear about being able to control their diabetes, confusion about self-management, and difficulty managing their diabetes while caring for family members. Although those in the controlled groups acknowledged difficulties, they discussed resisting cravings, making improvements with small changes, positive feelings about their ability to control their diabetes, and enjoying new foods and exercise. Interventions should include mental health support, incorporate formal and informal patient support structures, and address literacy issues. Health care providers and intervention personnel should be very concrete about how to do self-management tasks and guide patients on how to alter their diabetes regimens for social and other important life events.

Self-Care Behaviors of Nepalese Adults With Type 2 Diabetes: A Mixed Methods Analysis

BACKGROUND

Most previously reported literature on diabetes self-care is either solely quantitative or qualitative research conducted in developed countries; findings may not be generalizable to developing countries with different sociodemographic and cultural factors.

PURPOSE

The study aims to develop an explanatory mediation model for self-care and enhance model interpretation through qualitative input.

METHODS

A quantitatively driven, sequential, mixed method design was used. Structured questionnaires were used to collect data for the quantitative component from 230 participants. Participants for the qualitative interview were selected using maximum variation sampling (n = 13), and interviewing was guided by semistructured questions.

RESULTS

Diabetes management self-efficacy had the strongest influence on diabetes self-care (standardized path coefficient = .42, p < .001), followed by perceived social support (standardized path coefficient = .26, p < .001), and educational status (standardized path coefficient = -.22, p < .001). Diabetes management self-efficacy significantly and partially mediated the relationship between diabetes duration and diabetes self-care (Sobel's z = 2.65, p < .001) and between expectation regarding aging and diabetes self-care (Sobel's z = 3.03, p < .001). Perceived social support significantly and partially mediated the relation between educational status and diabetes self-care (Sobel's z = -2.81, p < .001). The qualitative component elucidated nine themes interwoven in Nepalese culture, social structure, and religious belief. Responsibilities toward family and belief in God acted as boosters for self-care in the case of Nepalese adults, which differed by age, gender, and literacy status.

DISCUSSION

The results from this study suggest that tailored psychosocial interventions to promote diabetes management self-efficacy may be beneficial in promoting self-care among Nepalese adults with diabetes mellitus.

Understanding Challenges, Strategies, and the Role of Support Networks in Medication Self-management Among Patients With Type 2 Diabetes

Purpose

The purpose of this qualitative study was to investigate the challenges and strategies of patients with type 2 diabetes mellitus (T2DM) regarding daily management of their medication regimen focusing on the role of their support networks.

Methods

A purposeful sample of 25 patients with T2DM was recruited from local self-help groups, general practitioner practices, and a university hospital in southwestern Germany. Four semi-structured focus groups were conducted to identify the challenges patients experienced, the strategies they used, and their collaboration with support networks to assist them in self-managing their medication regimen. Sessions were audio- and video-recorded, fully transcribed, and subjected to computer-aided qualitative content analysis, guided by the Self- and Family Management Framework (SFMF).

Results

Patients with T2DM experienced numerous challenges affecting medication self-management arising from their personal situation, health status and resources, characteristics of their regimen, and how health care is currently organized. Patients’ self-initiated strategies included activating health care, community, social, and online resources; taking ownership of medication-related needs; and integrating medication-taking into daily life. Patients drew on self-help groups, family, and friends to discuss concerns regarding medication safety and receive experience-based information and advice for navigating within the health care system as well as practical hands-on support with daily medication self-management.

Conclusions

Understanding the challenges and building on strategies patients with T2DM devised help diabetes educators to better address patients’ needs and priorities and guide patient-centered interventions to support patients’ self-management activities. Community and social support networks operating in patients’ lives need to be engaged in the self-management support.

Perceived Barriers and Potential Strategies to Improve Self-Management Among Adults with Type 2 Diabetes: A Community-Engaged Research Approach

OBJECTIVE

Type 2 diabetes (T2D) is a leading cause of morbidity and mortality that disproportionately affects adults living in urban areas in the USA. Our goal was to actively engage community members in research to identify strategies to improve T2D self-management in an urban community in Baltimore, MD.

METHODS

We partnered with the Johns Hopkins Community Research Advisory Council to establish our stakeholder advisory board-the Diabetes Action Board (DAB). In response to input from DAB members regarding the best approaches for conducting community-centered T2D research, we conducted three 90-min focus groups of local adults living with T2D to identify ways to improve self-management. DAB members were involved in each stage of the research, including development of the protocol and materials, participant recruitment, and interpretation and dissemination of findings.

RESULTS

In total, 24 adults with self-reported T2D (75 % participation rate; 79 % female) residing in the local area participated in focus groups. Participants reported that barriers within their daily home and work environments, inadequate neighborhood resources, and suboptimal healthcare quality hindered their self-management. Reported strategies that may help to improve self-management included social support from family members, providers, and community members; improved access to healthy food; and wide availability of free or low-cost T2D educational materials and classes within the local area.

CONCLUSION

Our study demonstrates a successful mechanism for engaging community members in the design, implementation, and dissemination of T2D research. This research approach was beneficial for building a sustainable partnership to support future work in the local community.

An Analysis of the Recruitment and Participation of African American Men in Type 2 Diabetes Self-Management Research: A Review of the Published Literature

Research studies have shown that African American men have experienced higher rates of serious complications of type 2 diabetes, due in part to poor disease management. Although type 2 diabetes research among minority populations is consistently advancing, there still remains a scarcity of African American male representation within these studies. It is unclear if this scarcity stems from lack of interest among men, location of recruitment, or ways in which these men are motivated to participate in research studies. As a result, an analysis of recruitment methods and locations of literature that includes African American men with type 2 diabetes is needed. The purpose of this review of the literature is threefold: (a) determine the number of published empirical studies specific to type 2 diabetes self-management that included African Americans in the sample, (b) to evaluate the percentage of men that were represented in the study sample as compared to how many women, and

Psychometric Properties of the Modified Personal Diabetes Questionnaire Among Chinese Patients With Type 2 Diabetes

This study examined the psychometric properties of the Chinese version of the Personal Diabetes Questionnaire (C-PDQ). The PDQ was translated into Chinese using a forward and backward translation approach. After being reviewed by an expert panel, the C-PDQ was administered to a convenience sample of 346 adults with Type 2 diabetes. The Chinese version of the Summary of Diabetes Self-Care Activities (C-SDSCA) was also administered. The results of the exploratory factor analysis revealed a one-factor structure for the Diet Knowledge, Decision-Making, and Eating Problems subscales and a two-factor structure for the barriers-related subscales. The criterion and convergent validity were supported by significant correlations of the subscales of the C-PDQ with the glycated hemoglobin values and the parallel subscales in the C-SDSCA, respectively. The C-PDQ subscales also showed acceptable internal consistency (α = .61-.89) and excellent test-retest reliability (intraclass correlation coefficients: .73-.96). The results provide preliminary support for the reliability and validity of the C-PDQ. This comprehensive, patient-centered instrument could be useful to identify the needs, concerns, and priorities of Chinese patients with type 2 diabetes.