The relationship between health beliefs, adherence, and metabolic control of diabetes

Adherence to medication and glucose control in diabetic patients in Duhok, Iraq

Background: Diabetes mellitus is a chronic, progressive disorder that causes a variety of health problems. Adherence to medication is a major factor in the treatment outcome. The goal of this study is to translate and test the psychometric features of the Kurdish version of the Morisky Medication Adherence Scale (MMAS-8) among type 2 diabetic patients.

Methods: The research used a cross-sectional approach. The researchers looked at a convenient sample of diabetic Kurdish individuals. MMAS-8 was translated into Kurdish using a normal “forward–backward” technique. It was then tested on 307 type 2 diabetic outpatients in a convenience sample. Internal consistency was checked for reliability. Convergent and known group validity were used to confirm validity. For the authentic statistical analysis, the Statistical Package for Social Sciences (SPSS) version 20 was used.

Results: According to MMAS-8, 20 patients (6.5%) had a high adherence rate, 66 (21.5%) had a medium adherence rate, and 221 (72%) had a low adherence rate. There was no significant link between adherence score and gender (P = 0.055), illness duration (P = 0.251), or educational level (P = 0.12). There was a significant connection between adherence and HBA1C (P 0.001).

Conclusion: The results of this validation study show that the Kurdish version of the MMAS-8 is a reliable and valid measure of medication adherence that may now be used. non-adherent. Developing patients’ treatment adherence will improve treatment managements and control.

"The Heidelberg Five" personality dimensions: Genome-wide associations, polygenic risk for neuroticism, and psychopathology 20 years after assessment

HeiDE is a longitudinal population-based study that started in the 1990s and, at baseline, assessed an array of health-related personality questionnaires in 5133 individuals. Five latent personality dimensions (The Heidelberg Five) were identified and interpreted as Emotional Lability (ELAB), Lack of Behavioral Control (LBCN), Type A Behavior (TYAB), Locus of Control over Disease (LOCC), and Psychoticism (PSYC). At follow-up, 3268 HeiDE participants (post-QC) were genotyped on single nucleotide polymorphism (SNP) arrays. To further characterize The Heidelberg Five, we analyzed genomic underpinnings, their relations to the genetic basis of the Big Five trait Neuroticism, and longitudinal associations with psychiatric symptoms at follow-up. SNP-based heritability was significant for ELAB (34%) and LBCN (29%). A genome-wide association study for each personality dimension was conducted; only the phenotype PSYC yielded a genome-wide significant finding (p < 5 × 10^-8 , top SNP rs138223660). Gene-based analyses identified significant findings for ELAB, TYAB, and PSYC. Polygenic risk scores for Neuroticism were only associated with ELAB. Each of The Heidelberg Five was related to depressive symptoms at follow-up. ELAB, LBCN, and PSYC were also associated with lifetime anxiety symptoms. These results highlight the clinical importance of health-related personality traits and identify LBCN as a heritable "executive function" personality trait.

Factors Associated with Poor Hemoglobin A1c Control in Patients with Type 2 Diabetes

BACKGROUND

The limited implementation of clinical pharmacy service programs and the lack of studies identifying barriers to achieve blood glucose control have all attributed to the increased proportion of type 2 diabetes patients who have poor glycemic control in Jordan.

OBJECTIVE

To explore factors associated with higher HbA1c in patients with type 2 diabetes in Jordan.

METHODS

Variables including socio-demographics, disease and treatment factors were collected from171 patients with type2 diabetes at an outpatient diabetes clinic in Amman. Validated questionnaires were used to assess medication adherence, self-care activities, diabetes knowledge and healthrelated quality of life in addition to data collected from medical records. After the single-predictor analysis, stepwise linear regression was performed to develop a model with variables that best predicted hemoglobin A1c.

RESULTS

Medication adherence was inversely associated with HbA1c values (β = -0.275; t = 2.666; P < 0.01), indicating better glycemic control. Receiving insulin therapy was also associated with less HbA1c values and better glycemic control (β = - 0.184; t = 2.080; P < 0.05). Patients who had one or more comorbid conditions (β = 0.215; t = 2.264; P < 0.05) and those with longer diabetes duration (β = 0.092; t = 1.339; P < 0.05) were found to have significantly higher HbA1c values.

CONCLUSION

Emphasizing medication adherence, particularly for patients with longer duration of diabetes and those with multiple comorbid diseases should be strongly considered in future diabetes management programs implemented to improve glycemic control in patients with type 2 diabetes.

Glycemic control among primary care patients with type 2 diabetes mellitus in the Gaza Strip, Palestine

AIM

In this study, we aimed to assess the level of good glycemic control, to determine association between adherence to antidiabetic medications and glycosylated hemoglobin (HbA1c) and to examine factors influencing good glycemic control.

MATERIALS AND METHODS

A cross-sectional design was employed among 369 patients with type 2 diabetes mellitus (T2DM) from four Ministry of Health health centers in 2016. A sample of 3 ml blood was taken to measure the HbA1c, and patients were asked to fill out a pretested questionnaire. Univariate and multivariate logistic regressions, to identify independent factors associated with good glycemic control, were conducted using SPSS software version 22 (IBM Corp, Armonk, NY, USA).

RESULTS

Mean [±standard deviation (SD)] of HbA1c was 8.97 (2.02) and one fifth of patients had good glycemic control (HbA1c ⩽ 7%). Factors associated with good glycemic control were: older age [odds ratio (OR) = 0.96, 95% confidence interval (CI): 0.933-0.988), high medication adherence (OR: 2.757, 95% CI: 1.308-4.693), and better health literacy (OR= 2.124, 95% CI: 1.917-4.921). Duration of diabetes mellitus (DM > 7 years) was inversely related to good glycemic control (OR = 2.255, 95% CI: 1.189-4.276).

CONCLUSION

Our study showed that glycemic control was suboptimal, and factors associated with that were: older age, high medication adherence, and better health literacy. Knowledge of these factors could be an entry toward helping patients and targeting interventions to improve glycemic control and prevent diabetes-related complications.

Health Beliefs of Blue Collar Workers

The study compared the health beliefs of participants and non-participants in a blood pressure and cholesterol screening held at the worksite. A cross sectional, ex-post facto design was used. Questionnaires measuring health beliefs related to cardiac screening and prevention of cardiac problems were distributed to a convenience sample of 200 blue-collar workers in a large manufacturing plant in the Midwest. One hundred fifty-one (75.5%) completed questionnaires were returned, of which 45 had participated in cardiac worksite screening in the past month. A multivariate analysis of variance was used to analyze data. Participants perceived significantly fewer barriers to cardiac screening and scored significantly higher on self efficacy than non-participants. These findings concur with other studies identifying barriers and self efficacy as important predictors of health behavior. Occupational health nurses' efforts are warranted to reduce barriers and improve self efficacy by advertising screenings, scheduling them at convenient times and locations, assuring privacy, and keeping time inconvenience to a minimum.

Information seeking behavior of patients with diabetes mellitus: a cross-sectional study in an outpatient clinic of a university-affiliated hospital in Athens, Greece

BACKGROUND

The purpose of this study is to examine the information behavior of diabetic patients, a relatively unexplored field of diabetes care, including their needs for information, resources used, obstacles encountered and degree of satisfaction for diabetes-related information acquisition.

METHODS

203 patients (males: 110, type 2:172) followed-up in the outpatient Diabetes Clinics of a University-affiliated hospital in Greece were assessed, using a validated questionnaire.

RESULTS

Patients identified diet (61.4%) and diabetic complications (41.9%) as "the most important" for their information needs and the treating physician (94.6%) for information resources. Internet importance and frequency of use ranked low. Main obstacles to information seeking were "lack of time" and "cost". Most patients (71.4%) stated they were "quite" or "very satisfied" with the current possibilities of information seeking.

CONCLUSIONS

Diabetic patients' stated information needs and information sources, as well as main obstacles to obtaining information could potentially have important implications in designing a future information campaign.

A comparison of adherence to hypoglycemic medications between Type 2 diabetes patients with and without serious mental illness

Inadequate self-management of chronic medical conditions like Type 2 diabetes may play a role in the poor health status of individuals with serious mental illnesses. We compared adherence to hypoglycemic medications and blood glucose control between 44 diabetes patients with a serious mental illness and 30 patients without a psychiatric illness. The two groups did not differ in their ability to manage a complex medication regimen as assessed by a performance-based measure of medication management capacity. However, significantly fewer patients with a mental illness self-reported nonadherence to their hypoglycemic regimens compared to those without a mental illness. Although individuals with mental illnesses also had better control of blood glucose, this metabolic parameter was not correlated with adherence to hypoglycemic medications in either patient group. The experience of managing a chronic mental illness may confer advantages to individuals with serious mental illnesses in the self-care of co-occurring medical conditions like Type 2 diabetes.

Job stress and healthy behavior among male Japanese office workers

BACKGROUND

Lifestyle modification in healthy workers is challenging. We aim to investigate associations between job stress and healthy behavior change among workers.

METHODS

This cross-sectional study investigated 1,183 Japanese male white-collar workers in 2008 during health checkups for Metabolic Syndrome. Healthy behavior included either a calorie-focused diet or regular exercise. Job stress was measured by Job Content Questionnaire based on the job demands-control model and tension-anxiety and anger-hostility scales on the Profile of Mood States.

RESULTS

Healthy behaviors were confirmed in 54% of study subjects. Multivariate logistic model showed that healthy behaviors were positively associated with a higher degree of work control and negatively associated with greater work demand. Work control and support were negatively correlated with tension-anxiety and depression, whereas work demand and strain were positively correlated with these two emotion domains (all P's < 0.0001).

CONCLUSIONS

It is suggested that addressing job stress is of clinical importance to promote healthy behaviors.

Cancer genetic counselees' self-reported psychological distress, changes in life, and adherence to recommended surveillance programs 3-7 years post counseling

The aim of the present cross-sectional study was to investigate psychological distress, changes in life, adherence to surveillance programs and satisfaction with cancer genetic counseling based on Swedish participants' self-reported data. A total of 218 probands (72% response rate) affected by breast, breast/ovarian or colorectal cancer and/or a family history of cancer were surveyed 3-7 years after receiving cancer genetic counseling. Participants reported a relatively high level of anxiety and a low level of depression. Probands affected by colorectal cancer reported a higher level of depression than did non-affected individuals with a family history of colorectal cancer. Overall, the participants reported moderate changes in family relations, priorities and appreciation of daily life activities. The majority of at-risk probands reportedly adhered to recommended surveillance programs. The mean level of satisfaction with cancer genetic counseling was high. About half of the participants would have accepted additional counseling sessions, contact with a psychologist or further help concerning informing family members. The present results indicate no adverse effects of genetic counseling, but they do suggest that typical counseling procedures could be improved by provision of additional psychosocial support.

The importance of health belief models in determining self-care behaviour in diabetes

Patients' self-care behaviours have a major role in diabetes management. Diabetes education provides the required knowledge, but despite this, self-care is often suboptimal. The degree to which patients follow advice as regards the various self-care behaviours is determined by their health beliefs (Illness Representations or Personal Models) of diabetes. Psychometric studies have tried to categorize and measure the beliefs about illness that influence patients to adhere to treatment recommendations in diabetes. Various models have been proposed to explain the relationship between beliefs and behaviour. Leventhal's Self-Regulatory Model, which takes account of the emotional as well as the objective rational response to illness, currently seems to offer the best system for identifying the determinants of patient self-care behaviour. A review of interventions indicates those based on psychological theory offer professionals the best chance of maximizing their patients' contribution to diabetes self-management and achieving improved outcomes, both glycaemic and psychosocial. Studies designed specifically to modify illness representations are now being undertaken. This brief review aims to summarize developments in this area of psychological theory over the last 20 years and the implications for promoting better self-care behaviour in diabetes.

Is the use of insulin analogues cost-effective?

Many patients with diabetes fail to achieve their glycaemic targets despite clear evidence that glycaemic control can prevent or delay the development of costly complications in diabetes. This article describes how insulin analogues (insulins lispro, aspart, glulisine, glargine and detemir) may have a role to play in overcoming barriers to insulin acceptance and improving adherence with therapy, and examines their cost-effectiveness as determined in published studies. Cost-effectiveness studies attempt to assess all the costs and all the benefits of a particular therapy. Pharmacoeconomic models, which calculate the long-term effect of interventions, show that over periods such as 10 or 35 years the higher prescription costs of analogues are offset by a lower incidence of acute hypoglycaemic events and costly, chronic complications such as nephropathy. This results in costs per 'quality-adjusted life year' that fall well within accepted limits for good value for money. Retrospective analyses of managed care databases show that higher prescription costs for analogues are offset by lower hypoglycaemia-related costs and/or inpatient claims. Relative to human insulins, analogues provide a better balance between glycaemic control and tolerability. Patients' fear of hypoglycaemia is allayed; the pen devices used with analogues facilitate insulin injection; and the pharmacokinetic characteristics lead to increased flexibility and convenience. All these factors can help increase adherence with therapy, which may in itself be cost-saving. Taken overall, these results indicate that insulin analogues are a cost-effective therapy.

A health protection model for Hispanic adults with Type 2 diabetes

AIMS

The Hispanic Health Protection Model (HHPM) was designed to assist practitioners' systematic assessment of Hispanic people to establish baselines and evaluate the success of early diabetes treatment. This article provides the research basis of the HHPM and related assessment tools.

BACKGROUND

The treatment of diabetes incorporates lifestyle change, and this adjustment is particularly important to follow with vulnerable groups. One such group is the Hispanic population, since the impact of diabetes is greatest on economically disadvantaged segments of this population, who suffer disproportionately higher Type 2 diabetes prevalence and higher levels of morbidity and mortality as compared with other populations. Traditional Hispanic health beliefs are often in conflict with Western medicine, so the adjustments to the lifestyle demands of this disease need to be evaluated.

METHODS

To understand this discrepancy fully in patient outcomes, a culturally sensitive assessment framework was developed based on health protection theories and research with Hispanic people with diabetes and, based on this framework, assessment tools were translated for use during interviews with low literacy, Spanish-speaking patients.

CONCLUSIONS

The HHPM translated measures of premorbid lifestyle, health beliefs, support, self-efficacy, quality of life, knowledge of diabetes, and physiological parameters can be used during consecutive clinic visits during the first six months of therapy to map the success of patients' understanding of and psychological adjustment to diabetes.

RELEVANCE TO CLINICAL PRACTICE

The HHPM is a culturally-relevant, systematic, and holistic approach to assessing adjustment of Hispanic people to a new diagnosis of diabetes, including their psychological, cognitive, and physiological outcomes. Using this type of systematic approach will allow practitioners to target barriers to therapy, such as a lack of self-efficacy or incomplete knowledge of the disease and its treatment in a strategic manner to improve patient success in managing the complex lifestyle changes of diabetes mellitus.

Comparing three theories in predicting reproductive health behavioral intention in adolescent women with diabetes

BACKGROUND

Understanding factors that affect decision-making in using preconception planning is important to reduce the rate of unplanned pregnancies and pregnancy-related complications in all women with diabetes. Previously, there were no studies of reproductive health-related beliefs, attitudes, or behaviors of adolescent women with diabetes. Constructs from social cognitive models, such as, the health belief model (HBM), theory of reasoned action, and social cognitive theory, are factors that can influence these behavioral outcomes.

OBJECTIVE

To compare the predictive powers of these three theories in regard to decision-making with reproductive health behaviors in teens with diabetes and to identify a composite model of the strongest predictors across all three theories.

METHOD

Data were collected from a telephone interview by same-gender research assistants on a sample of 87 female adolescents with type 1 diabetes (T1D) from four medical centers using the reproductive health attitudes and behavior (RHAB) questionnaire. Measures represent demographic variables, constructs of the three theories, and behavioral outcomes. Standard multiple regression analyses were used to examine the prediction of the three theories in the outcome variable [intention for using birth control (BC)].

RESULTS

Among the three theories considered, the HBM explained the highest percent of variance (24.4%) in intention to using BC. The best composite model consisted of perceived barriers, cues to action, and self-efficacy (explaining 26.1% of the variance). These three variables were also the strongest predictors among all constructs considered.

CONCLUSION

In this sample of adolescent females with T1D, the strongest predictors from the three theories for intention to using BC appeared to be perceived barriers, cues to action, and self-efficacy. Intervention studies to decrease future unplanned pregnancies in this high-risk population could focus on strategies to target these factors that are amenable to change.

Understanding the complex associations between patient–provider relationships, self-care behaviours, and health-related quality of life in type 2 diabetes: A structural equation modeling approach

OBJECTIVES

To assess associations between perceptions of the patient-provider relationship (PPR), BMI, and adherence to diet and exercise in a rural population with type 2 diabetes and determine how these variables relate to HRQL.

METHODS

A model of the hypothesized relationships between the constructs was proposed and tested using structural equation modeling (SEM) and data collected as part of a controlled study to improve care for individuals with type 2 diabetes in rural health regions.

RESULTS

In the final model, positive perceptions of the PPR had a direct impact on adherence to diet (beta = 0.23; p < 0.05), exercise (beta = 0.13; p < 0.05) and diabetes management attitudes (beta = 0.33; p < 0.05). The direct path from management attitudes to exercise was also significant (beta = 0.12; p < 0.05). Direct predictors of HRQL included management attitudes (beta = 0.16; p < 0.05), exercise adherence (beta = 0.14, p < 0.05) and BMI (beta = -0.23; p < 0.05). Exercise adherence predicted BMI, whereas adherence to diet did not. The final model had an acceptable fit with the measured data (chi2 = 30.6 (26, N = 372), p = 0.25; RMSEA = 0.02; TLI = 0.98; SRMR = 0.02).

CONCLUSION

Patient-provider relationship and exercise adherence appeared to be key constructs in the model. HRQL in people with type 2 diabetes was positively associated with exercise adherence, which was related to a positive PPR. Adherence to diet was also related to a positive PPR, but diet adherence had no association with HRQL.

Health beliefs and regimen adherence in minority adolescents with type 1 diabetes

OBJECTIVE

To examine the appraisal of short- and long-term diabetes health risk and adherence, determine whether health risk predicts adherence and glycemic control in an ethnic minority sample, and determine whether perceptions of personal risk differ from risk to others.

METHODS

Seventy-four youths with type 1 diabetes (ages 11-16) completed measures of risk perception and regimen adherence during their clinic visit; parents completed a measure of their children's adherence. Glycosylated hemoglobin A1c level was measured as part of the clinic visit.

RESULTS

Regression analyses predicting parental report and self-reported adherence from appraisal of risk yielded nonsignificant results; perceived short-term complications to self predicted glycemic control. Appraisal of risk was higher for short- and long-term complications occurring to someone else with diabetes than to self. Greater risk for short-term complications than for long-term complications to self and other was found.

CONCLUSIONS

The distinction between long-term and short-term complications and complications occurring to ones' self or someone else with diabetes was supported. Assessment of perceived risks for short-term complications is important for this age group and should be addressed in interventions to improve adherence.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship of health beliefs and complication prevention behaviors of Chinese individuals with Type 2 Diabetes Mellitus

This study aimed to identify the relationship of health beliefs and complication prevention behaviors among Chinese individuals with Type 2 Diabetes Mellitus in Malaysia. A correlation study using the Health Belief Model (HBM) framework was undertaken with 128 Chinese subjects with Type 2 Diabetes of both gender, mean age 60.5 +/- 8.42 years from one urban hospital and four rural health centers. Research tool was a 60-item questionnaire with responses recorded on 5-point Likert scale. Data was analyzed with descriptive statistics, Spearmen correlation and Mann-Whitney U-test. The majority of the subjects had less than 6 years of education. Seventy-two percent of them were aware of diabetes complications and its risk factors. However, few subjects practiced complication preventive measures because of lack of perceived seriousness of diabetes and lack of perceived susceptibility to diabetes complications. There were significant correlations between complication prevention behaviors and perceived severity (P < 0.05), perceived susceptibility (P < 0.05 ) and perceived barrier (P < 0.05 ); subjects' education level and perceived severity (P < 0.05), perceived susceptibility (P < 0.05) and complication prevention behavior (P < 0.05). There was no significant correlation between health beliefs and settings; genders; disease duration and treatment mode. In conclusion, poor complication preventive behavior among the subjects was associated with lack of perceived seriousness of diabetes and lack of perceived susceptibility to diabetes complications.

Psychosocial predictors of relapse among diabetes patients: a 2-year follow-up after inpatient diabetes education

In a 2-year follow-up study of diabetes patients (N=309) who received 2 weeks of inpatient diabetes education, the authors investigate the relationship of several demographic, clinical, and psychosocial factors with relapse, defined as the worsening of glycemic control. The patients with no improvement in glycemic control after diabetes education were more likely to have higher scores on the depression subscale of the Profile of Mood States, compared to the patients with improvement. Kaplan-Meier survival analyses showed that patients who had no prior diabetes education, whose meals were prepared by their spouses, and who had less social support were more likely to relapse and relapsed within a significantly shorter period of time than those who had prior diabetes education, cooked for themselves, and had more social support.

Factors associated with the attitudes and expectations of patients suffering from beta-thalassaemia: a cross-sectional study

Regular transfusions and iron chelation therapy have transformed the life expectancy of homozygous beta-thalassaemia patients, so that it can now be considered a chronic condition. A health questionnaire survey of all adults suffering from beta-thalassaemia major receiving treatment on the Island of Crete, Greece was carried out with the aim of ascertaining the factors that are associated with their attitudes and expectations. The responses of 67 of the 72 patients, aged 18-45 years, were analyzed using Principal Component Analysis to extract three component indicators (Adaptability, Optimism and Pessimism Indicators), which reflected their attitudes towards life and two component indicators (Healing and Therapy Indicators) that reflected their expectations from life. These were then tested against the respondents' socio-demographic characteristics, their health status and satisfaction with the services. It was found that the Optimism Indicator was associated with a positive comparative assessment of health status, while the Adaptability Indicator was associated with a positive subjective assessment of health status. The Adaptability Indicator was also higher in those satisfied with the services but it was lower in the best-educated group. The pessimism indicator was associated with a negative comparative assessment of health status and with the lowest level education. The expectation indicators showed an interaction with gender and other parameters such as admission to hospital. The relationship between the attitudes and the expectations of patients suffering from a chronically disability condition and specific experiences during their treatment regimens raises several issues related to the need for better health education and psychological support of the group of patients, as well as issues related to the communication skills of the staff caring for them.

Diagnosis of type 2 diabetes: a qualitative analysis of patients' emotional reactions and views about information provision

Research about diagnosis of chronic illness indicates this is an emotional time for patients. Information provision is especially salient for diabetes management. Yet current orthodoxy suggests that too much information at the time of diagnosis is unhelpful for patients. In this study, we used in-depth interviews with 40 newly diagnosed type 2 diabetic (T2DM) patients in Scotland, to explore their emotional reactions about diagnosis, and their views about information provision at the time of diagnosis. Data were analysed using a thematic approach. Our results showed three main 'routes' to diagnosis: 'suspected diabetes' route; 'illness' route; and 'routine' route. Those within the 'routine' route described the most varied emotional reactions to their diagnosis. We found that most patients, irrespective of their route to diagnosis, wanted more information about diabetes management at the time of diagnosis. We suggest that practitioners would benefit from being sensitive to the route patients follow to diagnosis, and prompt, simple but detailed advice about T2DM management would be helpful for newly diagnosed patients.

The effect of the health belief model in explaining exercise participation among Jordanian myocardial infarction patients

This study describes the effect of health belief model (HBM) in explaining exercise participation among Jordanian myocardial infarction (MI) patients. A convenient sample of 98 MI patients was recruited from four governmental hospitals in northern Jordan. A self-reported questionnaire and structured interview were designed to obtain the needed information. Study results indicated that Jordanian MI patients had a high score in perceived severity and a low score in perceived barriers. Results also showed a significant correlation between exercise participation and health belief variables and sociodemographics such as age, annual income, level of education, and physician recommendation. These findings have implications for designing intervention programs aimed at improving physical activity by all MI patients. These programs should consider culture, socioeconomic status, personal system, and demographics. Further research is needed to develop a culturally sensitive instrument that takes into consideration the cultural variation and the specific needs of MI patients.

Provider-patient interaction in diabetes care: effects on patient self-care and outcomes. A systematic review

A systematic review of the research literature using Medline, Embase, Psyclit/Psycinfo and the Cochrane Library files 1980 through 2001, identified only eight publications based on well-designed studies involving randomised controlled trials (RCTs)--testing the effects of modification of provider-patient interaction and provider consulting style on patient diabetes self-care and diabetes outcomes, in general practice or hospital outpatient settings. Review of these publications leads to the tentative conclusion that focusing on patient behaviour--directly enhancing patient participation i.e. by assistant-guided patient preparation for visits to doctors, empowering group education, group consultations, or automated telephone management--is more effective than focusing on provider behaviour to change their consulting style into a more patient-centred one. The latter proves hard to sustain, needs intensive support, and is not very effective in improving patient self-care and health outcomes when executed alone. Patient behaviour focused interventions show good efficacy and efficiency, and improve patient self-care and diabetes outcomes. More well-designed intervention studies focusing on enhancing patient participation in primary and hospital outpatient diabetes care are needed.

Poor lipid control in type-2 diabetics with and without ischemic heart disease

To determine the frequency of type-2 diabetics who have target lipoprotein blood levels, to study these levels in patients with ischemic heart disease and cardiovascular disease risk factors, and to study the possible causes of poor control, we reviewed hyperlipdemic type-2 diabetics who were on regular follow up to the medical outpatient clinic of King Abdulaziz University Hospital from January 2000 to January 2001. A total of 202 patients were studied with mean age of 60 yr and equal male to female ratio. The mean duration of diabetes was 10 yr and it was 7 yr for hyperlipidemia. The mean level of LDL was 3.15 mmol/L and it was 1.0 mmol/L and 2.47 mmol/L for HDL and TG, respectively. Only 31% of patients had LDL < 2.6 mmol/L, 28% had HDL > 1.1 mmol/L, and 37% had TG < 1.7 mmol/L. No significant difference was found in the frequency of target level of LDL in patients with IHD and those without; 26% vs 34% (0.4). Similarly, no difference was found in those with hypertension, obesity, and patients with family history of IHD compared to those without these risk factors; 30%, 26%, 16% vs 34%, 36%, 33% (p = 0.2, 0.1, 0.4, respectively). Males were found to have a higher frequency of target LDL level compared to females; 38% vs 25% (p = 0.04). Poor diet restriction was found in 90% of patients' with poor control, lack of patients' knowledge in 62%, 70% have financial reasons, 86% of patients on multiple medications, and in 16% the treating physician took no proper action. In conclusion, a low frequency of type-2 diabetics have target levels of lipoproteins. Diabetics with IHD and CVD risk factors also have poor lipid control. Poor control was associated with poor diet compliance and use of multiple medications. Proper management and control of this disease is needed among elderly patients.

Influence of oral antidiabetic drugs compliance on metabolic control in type 2 diabetes. A survey in general practice

BACKGROUND

To address compliance with oral antidiabetic agents and its impact on metabolic control in type 2 diabetic patients treated in general practice.

METHODS

Prospective assessment of self-reported compliance with a standardized questionnaire in an homogeneous cohort of 11,896 type 2 diabetic patients treated by their general practitioner with one or two oral antidiabetic agents, and analysis of determinants of compliance with treatment (age, diabetes duration, educational level, severity of complications, frequency of antidiabetic oral agents daily dosing).

RESULTS

Optimal compliance (no omission) was reported in only 46% of cases. In multivariate analysis, HbA(1c) levels were positively correlated with age, daily dosing frequency of oral antidiabetic agents and low educational level, but not with diabetes duration. Low daily dosing was associated with a better metabolic control. HbA(1c) levels were associated with compliance with treatment, with a 1.4% mean difference between group with optimal and group with worst compliance.

CONCLUSIONS

These results suggest the interest of reducing daily dosing frequency of oral antidiabetic agents, in order to improve compliance with treatment and metabolic control.

Motivation for health behaviours: a systematic review of the nursing literature

AIMS AND RATIONALE: This research review examines nursing and allied health studies exploring motivation for health behaviours to identify the state of understanding of this construct within nursing. This review contributes to nursing science by synthesizing nursing research regarding motivation for health behaviour.

METHODS

Integrative research review methodology.

FINDINGS

Problems of existing research include nonprobability sampling of heterogeneous populations, low statistical power, and colinearity. Studies identifying predictors of motivation explained large proportions of variance using regression. Motivation was not a significant predictor of health behaviours for over one-third of the studies. Overall, the studies suggest that either motivation is not being effectively measured because of a lack of conceptual clarity or that motivation is not an essential determinant of health behaviours. The latter cannot be verified until psychometric research advances current measurement of motivation to a higher level. LIMITATIONS; The literature for this review was accessed through the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database. Databases for other disciplines were not included in this search. This work represents a first step towards understanding motivation for health behaviour as it is currently defined in the literature. Future studies are necessary to broaden this understanding beyond nursing.

CONCLUSIONS

Motivation is a frequently cited rationale underlying the adoption and maintenance of health behaviours in research and practice. Motivation is complex and multidimensional, and clearer definitions for motivation are needed. Populations that have been underrepresented in motivation research need to be targeted in future research. Researchers and practitioners are challenged to examine carefully the role of motivation for health behaviours and explore other factors that may more strongly influence health behaviours.

The association between diabetes metabolic control and drug adherence in an indigent population

OBJECTIVE

Studies of the association between diabetes metabolic control and adherence to drug therapy have yielded conflicting results. Because low socioeconomic and minority populations have poorer diabetes outcomes and greater barriers to adherence, we examined the relationship between adherence and diabetes metabolic control in a large indigent population.

RESEARCH DESIGN AND METHODS

The study population consisted of patients receiving medical care from a university-based internal medicine clinic serving a low-income population in rural central Virginia. The sample comprised 810 patients with type 2 diabetes who received oral diabetes medications from the clinic pharmacy and had at least one HbA(1c) determination during the study period. Multiple linear regression was used to examine the association of HbA(1c) level as well as change in HbA(1c) level with medication adherence, demographic, and clinical characteristics.

RESULTS

Better metabolic control was independently associated with greater medication adherence, increasing age, white (versus African-American) race, and lower intensity of drug therapy. For each 10% increment in drug adherence, HbA(1c) decreased by 0.16% (P < 0.0001). Controlling for other demographic and clinical variables, the mean HbA(1c) of African-Americans was 0.29% higher than that of whites (P = 0.04). Additionally, the intensity of diabetes drug therapy for African-Americans was lower, as was their measured adherence to it. There was no association between metabolic control and gender, income, encounter frequency, frequency of HbA(1c) testing, or continuity of care.

CONCLUSIONS

Adherence to medication regimens for type 2 diabetes is strongly associated with metabolic control in an indigent population; African-Americans have lower adherence and worse metabolic control. Greater efforts are clearly needed to facilitate diabetes self-management behaviors of low-income populations and foster culturally sensitive and appropriate care for minority groups.

Relation of diabetic patients' health-related control appraisals and physician-patient interpersonal impacts to patients' metabolic control and satisfaction with treatment

Desire for healthcare control, health locus of control, perceived control over diabetes, satisfaction with diabetes treatment, and general personality traits were assessed in 54 Type 1 and Type 2 diabetic patients of the same male endocrinologist during a regularly scheduled office visit. At the end of the consultation, both patients and the physician completed a measure describing the interpersonal impacts produced in each by the other's control and affiliation behaviors. Patient success at diabetes control was assessed via glycosylated hemoglobin A1C (HA1C) level on the day of the visit and variability in HA1C levels across several visits. Patients' satisfaction with treatment was unrelated to diabetes control measures. Patients' desire for behavioral involvement in their own healthcare and NEO Agreeableness scores were positively associated with diabetes control. Better diabetes control also resulted when the physician perceived patients to be more controlling and less submissive, and when there was more reciprocity in patient and physician's perceptions of the other's controlling interpersonal behavior. Findings support the conclusion that both a patient's self-reported desire for involvement in his or her healthcare and the transactional fit of patient-physician interpersonal behaviors are potentially important contributors to better diabetes outcomes.

The ADKnowl: identifying knowledge deficits in diabetes care

AIMS

To present the ADKnowl measure of diabetes-related knowledge and evaluate its use in identifying the nature and extent of patient and health professional knowledge deficits.

METHOD

The ADKnowl was used in a large-scale study of 789 patients (451 treated with insulin and 338 treated with tablets and/or diet) attending for annual review at one of two hospital out-patient diabetes clinics

RESULTS

Knowledge deficits were apparent in the patients. For example, 57% did not recognize the inaccuracy of the statement 'fresh fruit can be eaten freely with little effect on blood glucose levels'. Seventy-five percent of patients did not know that it is advisable to trim toenails to the shape of the toe. Knowledge deficits were identified for many other areas of diabetes management, e.g. prevention of hypoglycaemia, avoidance of ketoacidosis. Sixteen health professionals at the clinics answered the same items. Contrary to recommendations, 25% of health professionals thought that fresh fruit could be eaten freely. Seventy-five percent of health professionals did not know the current recommendations for trimming toenails. As expected, HbA1c did correlate with scores from two specific items, while HbA1c did not correlate with summed ADKnowl score.

CONCLUSIONS

Patient knowledge deficits were identified. Some specific knowledge deficits among health professionals may be the cause of some patient knowledge deficits. The ADKnowl is a useful tool in assessing both patient and health professional knowledge deficits and is available for use in a context of continuing evaluation.

Resourcefulness and health practices of diabetic women

More than one fourth of the millions of Americans with Type 2 diabetes experience depression, of which two thirds are women. Unless the individual is resourceful, coexisting diabetes and depression adversely affect one' health practices. The effects of diabetic and depressive symptoms on health practices and the mediating and moderating role of learned resourcefulness in this relationship were examined in 90 women with Type 2 diabetes. Regression analyses showed direct negative effects of diabetic and depressive symptoms on health practices. The effects of depressive, but not diabetic, symptoms were partially mediated by resourcefulness; no moderating effects were found. The results suggest the need to test interventions to minimize symptoms associated with diabetes, particularly depression. Teaching resourcefulness to Type 2 diabetic women may promote their positive health practices by minimizing their depression.

Expanded health belief model predicts diabetes self-management in college students

An instrument was designed to determine relationships between constructs of the Expanded Health Belief Model and to identify characteristics of college students who successfully manage their diabetes. The Diabetes College Scale was developed to measure attitudes and behaviors pertinent to diabetes management and college life. It was tested for content validity, test-retest reliability, and internal consistency. Data were collected from college students using a cross-sectional design. Campus health care providers were invited via electronic mail to administer the survey to students with Type I diabetes. Ninety-eight questionnaires were mailed to interested providers, of which 86 (88%) were returned. Mean scores for attitude constructs, seven behaviors, and two outcomes were measured. Twenty-six experts established content validity. Instrument reliability was evaluated using paired t-tests, Cronbach's alpha, and correlation coefficients. Correlation coefficients and stepwise multiple regression analysis evaluated relationships among variables measured. Intention and emotional response were strong predictors of exercise, whereas health importance and intention were predictive of testing blood sugar. Situational factors and emotional response were substantial barriers to optimal diabetes self-care. College health care providers should address these areas in providing services to this population. Additional testing of the instrument is also recommended.

Interpreting diabetes mellitus: differences between patient and provider models of disease and their implications for clinical practice

Current medical literature suggests that Type 2 diabetes mellitus can be controlled by diet and hypoglycemic agents or diet and insulin therapy. Nevertheless, adhering to a low glucose dietary regimen remains problematic for a majority of patients, and management of the disease is an ongoing source of frustration for physicians and other providers. While calling for more research on the physician's experience of treating chronic conditions like diabetes, the authors argue that much of the current frustration stems from the different frames or explanatory models that physicians and patients use to understand the disease. By comparing physician narratives collected in several clinical contexts (e.g., medical lectures, precepting sessions, patient care sessions and personal interviews) with patient stories obtained primarily through narrative interviews, the authors highlight crucial differences in the way physicians and patients experience and think about the disease. In particular, the authors highlight differences between physicians and patients across five dimensions: etiology, symptoms/signs, factors which affect blood sugar, ideal blood sugar, and future prospects. In concluding, the authors sketch out elements of a theory of clinical practice involving diabetes care. Data for the study was collected at two family practice training sites in Chicago.

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

PURPOSE

This study was conducted to better understand how older African Americans with diabetes view their illness, and to develop a conceptual framework for approaching their care.

METHODS

Researchers conducted interviews of 19 African American patients 65 years or older who attended clinics at an urban academic medical center. The mean age of the patients was 73 years, 58% were female, 63% had a complication from diabetes, and 58% were taking insulin. Patients were asked open-ended questions about how diabetes affected their lives and their attitudes toward treatment. Data were analyzed through a grounded-theory perspective.

RESULTS

Patients showed variation in the degree to which they believed that diabetes affected their lives and how aggressive they wished treatment to be. Themes included issues of quality of life, health beliefs, and the social context. Paradoxical, contradictory statements were common, expressing ambivalence and uncertainty regarding the effect of the illness and the treatment.

CONCLUSIONS

Wide variation exists in the attitudes of older African Americans toward their diabetes and treatment. Patients frequently expressed ambivalence toward the care of their illness. Providers should explore these issues and help patients resolve their ambivalence if patient preferences are to be respected in the overall treatment plan.

Impact of pharmacy counseling on compliance and effectiveness of combination lipid-lowering therapy in patients undergoing coronary artery revascularization: a randomized, controlled trial

This randomized, controlled trial evaluated the impact of personalized follow-up on compliance rates in high-risk patients receiving combination lipid-lowering therapy over 2 years. A random sample of 30 patients 7-30 days after cardiac surgery had baseline fasting low-density lipoprotein levels higher than 130 mg/dl. All patients received lovastatin 20 mg/day and colestipol 5 g twice/day. Weekly telephone contact was made with each patient for 12 weeks. Short- and long-term compliance was assessed by pill and packet counts and refill records. Compliance and lipid profile results were significantly better in the intervention group (p<0.05) up to 2 years after the start of therapy than in the control group for all parameters except high-density lipoprotein. However, this effect was not apparent during the first 12 weeks of therapy. Short-term telephone follow-up favorably affected compliance and lipid profile results up to 2 years after start of therapy.

Development and evaluation of an intervention program: "Control on Campus"

PURPOSE

This study was designed to develop and test an intervention for college students with type 1 diabetes.

METHODS

A diabetes program, "Control on Campus," and guide were developed based on the Expanded Health Belief Model and Social Learning Theory. Diabetes knowledge, attitudes, and behaviors were assessed preprogram, postprogram, and at follow-up for 3 intervention cohorts and a control group.

RESULTS

Reporting of HbA1c values and diabetes knowledge improved significantly as a result of the intervention compared with no increase in the control group. Furthermore, participants reported feeling more support on campus after the intervention, appeared to have overcome their fears associated with testing their blood glucose, reported an increased frequency of blood glucose testing, and were more likely to test when they felt their blood glucose level was low.

CONCLUSIONS

Overall, this research yielded substantial insight into the characteristics of college students with diabetes and was successful in designing and evaluating an intervention trial for this population.

Stories of meaning: lay perspectives on the origin and management of noninsulin dependent diabetes mellitus among older women in the United States

Researchers have sought to explain nonadherence to standard medical regimens by investigating a variety of sociodemographic variables, and, less often, by exploring variations between the health perspectives and life circumstances of the individual. While divergence between lay and professional perspectives on the etiology and treatment of chronic diseases, such as noninsulin dependent diabetes mellitus, may possibly account for the documented low rates of adherence to biomedical recommendations, health beliefs and activities are best understood as connected to an individual's personal history and circumstances. In order to evaluate the relationship between causal explanation of NIDDM and adherence, ethnographic interviews were conducted among 51 older (65+) women with diabetes and their physicians. We chose to investigate adherence to dietary recommendations because it represents one of the most challenging lifestyle modifications and is particularly important to maintaining glycemic control. The interviews involved ethnomedical and food frequency intake questionnaires and semi-structured interviews. Results reveal a stronger association between dietary adherence and etiological perspectives on diabetes than any sociodemographic factors, including ethnicity, education and income or other health belief factors. Informants suggested five categories that they believed were responsible for the onset of their NIDDM; poor past dietary practices (n = 22); familial tendency to have diabetes (n = 10); improper bodily functioning (n = 10); personal risk factors (n = 6); and currently being overweight (n = 3). Analyses indicated that those who implicate former dietary practices, currently being overweight, or having improper bodily functions were more likely to follow a standard recommended diet for individuals with diabetes. These findings also highlight the attempt by individuals with NIDDM to create 'stories' of meaning of their diabetes by linking their current management strategies for NIDDM with past practices and history. In addition, our results question the utility of the 'biomedical/alternative' labels.

Development of a community-based diabetes and hypertension preventive program

The purpose of this project was to develop rapport with a Chinese Community Association and then establish preventive diabetic and hypertension programs with the Chinese in Chinatown, Hawaii. Subjects were recruited from this Chinese Community Association. Two hundred Chinese responded to the invitation. Among these, 75 individuals had either Type 2 diabetes, hypertension or both. Thirty-six males and 39 females ranging in age from 51 years old to 96 years old (Mean = 71.76, SD = 9.58) participated. Surveys and educational programs were carried out in Chinese. Results were described in terms of quantitative measures (family support and health outcomes) and qualitative experiences (case studies). Eighty percent of participants had decreased their diastolic blood pressure from above 95 mmHg to below 90 mmHg and systolic blood pressure from above 155 mmHg to below 140 mmHg. Ninety-five (n = 71) percent of participants had maintained their glucose level within the 90 mg/dL to 150 mg/dL range with a mean reduction of 57.86 mg/dL in one year. The hardest thing for families was the glucose self-monitoring. Case studies suggested that open-minded active listening and persistence formed the basis for developing a culturally sensitive community-based self management program for chronic diseases. Collaboration among the community, public health nurses, and diabetes nurse educators facilitated the process of community education and health promotion.

Risky behavior and risk in adolescents with IDDM

PURPOSE

To determine: (1) the frequency of risky behaviors (alcohol and other drug use, smoking cigarettes, smokeless tobacco use, and unprotected intercourse); (2) the perception of general risks and diabetes-related risks from risky behaviors; (3) if perception of risk is related to engaging in risky behaviors; and (4) if perception of general risks and diabetes-related risks are influenced by age, gender, or race in adolescents with insulin dependent diabetes mellitus (IDDM). Decreasing risky behaviors in youth with IDDM is important because of their increased vulnerability to specific disease related physiologic and pathologic changes.

METHODS

A descriptive, cross-sectional design was used. Data on risky behavior and perception of risk were obtained by self-report during a regularly scheduled clinic visit. One hundred and fifty-five adolescents between ages of 10-20 years participated. Correlational and student's t-test analyses were used to test relationships and group differences (age, race, gender).

RESULTS

Thirty-nine percent of the sample reported alcohol use, 34% reported smoking cigarettes, 8% reported smokeless tobacco use, 10% reported drug use, and 29% reported unprotected intercourse. Perception of risk to peers from these behaviors was significantly higher (t = 8.1, df 153; p < .001) than risk to self. Females reported significantly lower (t = 3.08, df 52; p < .002) risk to self than males. There was no difference in perception of risk between youth who reported participating in risky behaviors (N = 38%) and those who did not (62%). Not surprisingly, the frequency of risky behavior increased with age (F = 15.46; p < .001).

CONCLUSIONS

Compared to community samples of middle school children, our sample had lower rates for most risky behaviors. As with community samples, the physical risks were known and perceived to be higher for peers than self. Perception of risk was not related to self-reports of risky behaviors. The lower rate of risky behaviors might reflect the success of educational efforts directed toward diabetes management or may be due to later initiation of behaviors, especially if personal social development is delayed. Additional research is indicated in order to understand the timing and trajectory of risky behavior and whether or not perception of risk deters youth with IDDM from engaging in risky behavior.

Self-care of adults with non-insulin-dependent diabetes mellitus: influence of family and friends

This study examined the relationships among the source of support, universal self-care, and health-deviation self-care behaviors in adults who control their blood glucose with oral agents. A descriptive correlational design was used. Respondents completed a total of 51 items on questionnaires. Significant differences were found between the group with family-plus-friend support and the group without support in relation to universal self-care and health-deviation self-care. A significant difference was also found between the group with family-plus-diabetes-group support and the group without support in relation to health-deviation self-care. Subjects who received support from friends in addition to family support reported higher universal and health-deviation self-care behaviors than those without support. Support systems explained 23% of variance in universal self-care and 17% of variance in health-deviation self-care.