Interrelation between adult persons with diabetes and their family: a systematic review of the literature

An exploratory study of factors in disordered eating behavior in diabetes self-management in Japan

AIMS/INTRODUCTION

Diet directly affects glucose metabolism, and eating behavior is influenced by various daily life stressors. This study was conducted to investigate the relationship between common psychosomatic stressors on endocrine hormones and eating behavior in patients with type 2 diabetes.

MATERIALS AND METHODS

This cross-sectional study was performed in 40 patients with type 2 diabetes. Resting hormone blood sampling and four self-reported questionnaires were employed.

RESULTS

Patients who scored higher on the 'anger/hostility' (AH) subcategory of the profile of mood state (POMS) questionnaire had significantly higher serum cortisol (β = 0.40, P = 0.01 by least squares adjusted for age and sex). In the eating behavior questionnaire, the subcategories of 'feeling of hunger/satiation' (β = 0.49, P < 0.01) and 'eating as diversion' (β = 0.39, P = 0.03) were associated with higher serum cortisol. Resting morning cortisol levels were higher in participants who rated high on the POMS-AH and in those who reported 'irritated when hungry' and 'tend to eat when irritated or anxious'. Sleep quality showed no association with eating behavior.

CONCLUSIONS

Mood state is associated with eating behavior. Anger increases cortisol levels and may lead to compulsive eating. Various forms of hostility are important factors in appetite control and increased cortisol secretion, and can be an impediment to successful dietary self-management in patients with type 2 diabetes. Thus, assessment of mood state and control of negative mood are important therapeutic targets in diabetes management.

Implications on self-care behaviors among older Korean immigrants diagnosed with diabetes residing in the United States: a path analytical approach

Background

Diabetes is a prevalent chronic disease. Although self-care is the crucial element in managing diabetes, older Korean immigrants with diabetes face challenges in performing effective self-care related to vulnerability as minority immigrants.

Purpose

This study measures sociodemographics, self-efficacy, social support, diabetes knowledge, and diabetes self-care activities among older Korean immigrants in the United States. This study also aims to demonstrate the direct and indirect effects of the related factors on diabetes self-care activities using a path analysis.

Methods

This study uses a cross-sectional design. Convenience sampling targeted Korean immigrants aged 55 or older using paper and online surveys. Four instruments were used to measure variables: self-efficacy was measured by the General Self-Efficacy scale, diabetes knowledge by the Simplified Diabetes Knowledge Test, social support by the Lubben Social Network Scale-6, and diabetes self-care by the Summary of Diabetes Self-Care Activities questionnaire. Using path analysis, the effects of related factors on self-care activities were analyzed.

Results

190 older Korean immigrants participated, 53.2% female, and 46.8% male. The mean age was 67.2 (SD = 9.9; range, 58-93). A path model shows that sociodemographics (sex, age, education, and years in the United States), diabetes knowledge, self-efficacy, and family support predict diabetes self-care.

Conclusions

The path model demonstrates the effects of sociodemographics, self-efficacy, diabetes knowledge, and social support on diabetes self-care among older Korean immigrants. The findings can help to understand diabetes self-care among the minority ethnic older group and can be used to develop culturally tailored education, counseling, and healthcare services.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01363-6.

The role of social support and self-management on glycemic control of type 2 diabetes mellitus with complications in Ghana: A cross-sectional study

Background and Aims

Diabetes mellitus (DM) can result in detrimental complications which are connected with long-term impairments and disabilities. Chronic complications are well-known consequences of type 2 diabetes mellitus (T2DM) progression, which reduce patient quality of life, place a burden on the healthcare system, and increase mortality. Measures to promote health outcomes for people with DM are scanty; the study therefore aimed at determining the effects of self-management and social support on glycemic control of T2DM with complications in Ghana.

Methods

A cross-sectional design using convenience sampling was conducted on 400 T2DM patients using Hensarling's Diabetes Family Support Scale and Summary of Diabetes Self‑Care Activities scale. Data analysis was conducted using descriptive, Pearson Moment Product Correlation and Binary Logistic Regression on self-management, social support, and glycemic control in T2DM patients.

Results

Social support among participants was high and there was a positive correlation or relationship between social support and T2DM self-management. There was a correlation between social support and self-management (r = 0.149, p < 0.05) and diet control (r = 0.221, p < 0.05). The results also showed a significant correlation between medication adherence and glycemic management (r = 0.116, p < 0.05) while female T2DM participants, individuals with at least primary education were less likely to have low self-management relative to T2DM.

Conclusion

Though the level of T2DM self-management was high it does not translate to good glycemic control. Focused health education programs should be incorporated into patients' care plans which will be particularly relevant for patients with T2DM and will contribute to positive physiological and psychological outcomes. Furthermore, a more robust monitoring and follow-up scheme should be scaled up or instituted for patients with T2DM.

I have never been invited-A cross-sectional explorative study of family members' experiences of encounters with healthcare professionals in diabetes care

AIM

To explore the experiences of family members of adult persons with type 1 diabetes concerning both the approach of healthcare professionals and feelings of alienation in encounters with professional diabetes care.

METHODS

A cross-sectional explorative quantitative and qualitative design. The Family Involvement and Alienation Questionnaire-Revised (FIAQ-R), including an open-ended question, was answered by 37 family members of adult persons with type 1 diabetes. Analyses included descriptive statistics and qualitative analysis. The study has received ethical approval.

RESULTS

Family members rated the approach of the healthcare professionals as being somewhat positive and considered that the approach towards them is important. They only felt partially alienated from the professional care. Qualitative data revealed that the family members often lacked direct access to the professional care and that their involvement was dependent on their relationship with the person with diabetes. Findings highlighted that the family members' wish to be involved in the care was sometimes unanswered.

CONCLUSION

Based on the findings, it is reasonable to stress the importance of considering family members' perspectives and involving them in diabetes care to improve overall patient support.

'We are in control of this thing, and we know what to do now': Pilot and process evaluation of 'Diabetes Together', a couples-focused intervention to support self-management of Type 2 Diabetes in South Africa

We piloted the delivery of a prototype couples-focused intervention, 'Diabetes Together' with 14 people living with diabetes (PLWD) and their partners, in Cape Town, South Africa in 2022. We aimed to: assess feasibility of recruiting couples in this setting; explore acceptability of intervention materials and changes needed; and investigate whether our prespecified logic model captured how the intervention may work. We used questionnaires, interviews and focus groups after each workshop and after couples completed counselling. We conducted a process evaluation to identify intervention modifications and used inductive thematic analysis to explore whether the data supported our logic model. Twelve of the 14 couples completed the second workshop and 2 couples completed two counselling sessions post-workshop. Feedback showed participants appreciated the intervention and limited improvements were made. Thematic analysis identified four main themes: (1) involving partners matters; (2) group work supports solidarity with other couples; (3) improving communication between partners is crucial; and (4) taking part helped couples to take control of diabetes. Data suggested the logic model should explicitly acknowledge the importance of group education and of equalising partners' knowledge. This pilot suggests that 'Diabetes Together' increased knowledge and skills within couples and could facilitate improved, collaborative self-management of diabetes.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

AIMS

Family/friend Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS' effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT.

METHODS

Persons with diabetes (PWDs) were randomized to FAMS or control with their support person (family/friend, optional). FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period.

RESULTS

PWDs (N = 329) were 52 % male, 39 % reported minoritized race or ethnicity, with mean HbA1c 8.6 ± 1.7 %. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64 %; 95 % CI [-1.22 %, -0.05 %]), but overall mean effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27 %; 95 % CI [-0.49 %, -0.09 %]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19 %; 95 % CI [-0.40 %, -0.01 %]).

CONCLUSIONS

Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

The role of family in supporting adherence to diabetes self-care management practices: An umbrella review

AIMS

Synthesize a review of reviews of the family's role in supporting adherence to diabetes self-care management practices (DSMP) for adults with type 2 diabetes (DM2).

DESIGN

An umbrella review.

DATA SOURCES

Scopus, Web of Science including MEDLINE, CINAHL via EBSCO, PubMed and Science Direct were searched for systematic reviews from their year of establishment until June 2021.

REVIEW METHODS

The review followed the Joanna Briggs Institute (JBI) guidelines for umbrella reviews. The JBI data extraction form for systematic reviews and research syntheses was used for data extraction. Methodological quality was assessed using the JBI Critical Appraisal Checklist for Systematic reviews and Research Syntheses.

RESULTS

Nineteen reviews met the inclusion criteria. The key findings were summarized using a narrative and thematic analysis methods. Four main themes were identified: family interactions and diabetes self-management, family support as informal social support, factors affecting families' roles, and tailoring culturally sensitive family-based interventions.

CONCLUSION

There appears to be a consensus regarding the impact of family on adults' self-management of DM2. Additional research is needed to comprehend the role of the family in underrepresented populations and examine what constitutes a family and the diverse family functions in different groups.

IMPACT

Enhancing adherence to self-care management practices is crucial for the well-being of adults with DM2. Family support is a key to successful self-care management at home. However, understanding the unique needs of adults with DM2 and their families can help healthcare professionals plan appropriate support strategies and sustainable family-based interventions.

NO PATIENT OR PUBLIC CONTRIBUTION

This review did not incorporate direct patients or public input as it summarizes evidence from previously published systematic reviews.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

Aims

Family/friends Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT.

Methods

Persons with diabetes (PWDs) and their support persons (family/friend, optional) were randomized to FAMS or control. FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period.

Results

PWDs (N=329) were 52% male, 39% from minoritized racial or ethnic groups, with mean HbA1c 8.6±1.7%. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64%; 95% CI [-1.22%, -0.05%]), but overall effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27%; 95% CI [-0.49%, -0.09%]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19%; 95% CI [-0.40%, -0.01%]).

Conclusions

Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

Development and Implementation of Diabetes Care by a Community Network Based on a Chronic Care Model

INTRODUCTION

This participatory action research was conducted by the collaborative health-related team in a district, in Thailand. The community network jointly developed a care model for diabetic patients in primary care using the Chronic Care Model (CCM) and evaluated the effectiveness of implemented model.

METHODS

Data was collected between October 2021 and March 2022 and involved 2 groups: 1) a community network of 25 people including representatives of the community hospital, primary care hospital, Sub-district administrative organization, community leaders, community representatives, representatives of diabetic patients, and representatives of caregivers of diabetic patients, and 2) 41 people with type 2 diabetes and 41 of their family caregivers. The research was conducted in 4 stages: planning, action, observation, and reflection.

RESULTS

Both quantitative and qualitative data were collected, and the overall average knowledge scores of diabetic patients, family caregivers, and community representatives significantly increased from before (6.07 ± 2.11, 7.07 ± 1.98, P = .024, 5.74 ± 1.88, 7.37 ± 2.25, P < .001, 7.47 ± 2.44, 8.99 ± 1.72, P = .010) respectively. For satisfaction, diabetic patients were most satisfied with family caregiver support, while the community network representatives were most satisfied with their participation in planning a model for diabetic patients in primary care. After model implementation, the blood sugar-controlled patients (HbA1c < 7 mg%) significantly increased (0 and 9.76%, P = .045), although the fasting blood sugar (FBS) of diabetic patients did not improve.

CONCLUSION

The development and implementation of diabetes care based on CCM, promoted community participation and involvement in diabetes care. This model mainly affected diabetic patients who could control their HbA1c level and the satisfaction of the community network.

Diabetes-related shame among people with type 2 diabetes: an internet-based cross-sectional study

INTRODUCTION

Emerging evidence suggests that diabetes stigma and negative emotions associated with it may impair the quality of life of people with diabetes. Among these psychological distresses, shame is considered the most distressing of all human emotional experiences and may be a condition to which diabetes clinicians should pay attention. This epidemiological study focused on diabetes-related shame and aimed to determine the prevalence of diabetes-related shame, its factors, and its association with psychological indicators.

RESEARCH DESIGN AND METHODS

A cross-sectional online survey was conducted among people with type 2 diabetes preregistered with a research firm. The questionnaire included experience of diabetes-related shame and demographic data such as age, clinical characteristic measures such as hemoglobin A1c (HbA1c), and psychological indicators, including the WHO Five Well-Being Index (WHO-5) and Problem Areas In Diabetes-5 (PAID-5). Differences in each indicator between people with diabetes who experienced shame and those who did not were analyzed with the unpaired t-test. As supplemental analysis, binomial logistic regression analysis was used to identify factors associated with the prevalence of diabetes-related shame.

RESULTS

Of the 510 participants, 32.9% experienced diabetes-related shame and 17.5% concealed their disease from colleagues or friends. Those who had experienced diabetes-related shame showed significantly lower WHO-5 and higher PAID-5 scores (p<0.001). However, no significant difference was found in HbA1c (p=0.36). Binomial logistic regression revealed that women, young adults, those without a college degree, those with low self-efficacy, and those with a strong sense of financial burden or external pressure were at higher risk of experiencing diabetes-related shame.

CONCLUSIONS

Among people with type 2 diabetes mellitus, diabetes-related shame was associated with diabetes-specific emotional distress and low psychological well-being. Further research and care development are needed to address diabetes-related shame and improve the quality of life of people with diabetes.

Effectiveness-implementation trial comparing a family model of diabetes self-management education and support with a standard model

BACKGROUND

Diabetes self-management education and support (DSMES) is an effective approach for improving diabetes self-care behaviors to achieve improved glycemic management and other health outcomes. Engaging family members may improve outcomes, both for the person with diabetes (PWD) and for the family members. However, family models of DSMES have been inconsistently defined and delivered. We operationalize Family-DSMES to be generalizable and replicable, detail our protocol for a comparative effectiveness trial comparing Standard-DSMES with Family-DSMES on outcomes for PWDs and family members, and detail our mixed-methods implementation evaluation plan.

METHODS

We will examine Family-DSMES relative to Standard-DSMES using a Hybrid Type 1 effectiveness-implementation design. Participants are ≥18 years old with type 2 diabetes mellitus and hemoglobin A1c ≥7.0%, recruited from rural and urban primary care clinics that are part of an academic medical center. Each participant invites a family member. Dyads are randomly assigned to Family- or Standard-DSMES, delivered in a small-group format via telehealth. Data are collected at baseline, immediately post-intervention, and 6-, 12-, and 18-months post-intervention. Outcomes include PWDs' hemoglobin A1c (primary), other biometric, behavioral, and psychosocial outcomes (secondary), and family members' diabetes-related distress, involvement in the PWD's diabetes management, self-efficacy for providing support, and biometric outcomes (exploratory). Our mixed-methods implementation evaluation will include process data collected during the trial and stakeholder interviews guided by the Consolidated Framework for Implementation Research.

CONCLUSION

Results will fill knowledge gaps about which type of DSMES may be most effective and guide Family-DSMES implementation efforts.

REGISTRATION

The trial is pre-registered at clinicaltrials.gov (#NCT04334109).

Deconstructing type 2 diabetes self-management of Australian Pacific Islander women: Using a community participatory research and talanoa approach

Community-based participatory research using culturally appropriate talanoa approaches provided the framework to explore diabetes self-management of Australian Pacific Islander (API) women living with type 2 diabetes in South-East Queensland. Data collection included interviews with key informants (21), in-depth interviews with API women with diabetes (10), talanoa group discussions (7) and monthly steering committee meetings. Using an interpretive-constructionist lens and the interpretations of community members, four cultural constructs in diabetes self-management emerged: self-identity, spirituality, stigma and denial, and structural factors. Self-identity connected the women to their Pacific heritage that framed their collective roles as primary caregivers in the community. This gave the women a strong sense of belonging and helped maintain cultural, family and relational connections which were important for their day-to-day management of diabetes. Although spirituality through religion supported the women to cope with their diabetes a total reliance on God resulted in disengagement with self-care. Shame associated with disclosure also prevented effective self-management. Finally, structural factors such as access to healthcare, poor health literacy and cultural barriers associated with obesogenic environments impeded women from seeking appropriate diabetes care. However, family and community were critical in ensuring women were supported with their diabetes self-management. The findings highlight the importance of engaging families in healthcare planning decisions in the development of culturally responsive models of diabetes support care for API women with type 2 diabetes.

Sexual dysfunction in women with type 1 diabetes in Norway: A qualitative study of women's experiences

AIM

The aim of this study was to explore the experiences of sexual health and sexual challenges in women with type 1 diabetes (T1D).

METHODS

We used a qualitative study design and conducted semistructured interviews with 15 women (26-57 years) with T1D. The participants were recruited based on their Female Sexual Function Index score that indicated sexual dysfunction. We used thematic analysis to analyse the data.

RESULTS

We generated three themes, each with subthemes: (1) Diabetes is present at all times (subthemes: having diabetes is onerous, and diabetes affects the relationship with my partner); (2) various challenges related to sexual health (subthemes: experiencing reduced sexual desire and physical challenges, and challenges related to sexual health affect the relationship with my partner); and (3) diabetes may affect sexual function (subthemes: glucose levels and technical devices may have an impact on sexual function, and sexual health should be addressed in diabetes follow-up).

CONCLUSIONS

The women with T1D experienced different challenges related to their sexual health. The most common were reduced sexual desire, vaginal dryness and pain during intercourse. The study emphasizes the importance of addressing sexual health in diabetes follow-up to provide comprehensive health services to people with diabetes.

Association between social supports and depression among patients with diabetes mellitus in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

The adverse effects of poor social support on quality of life and adherence to treatment are established. However, the relationship between social support and depression is not well understood. In this systematic review and meta-analysis, we aim to examine the association between social support and depressive symptoms among type 2 patients with diabetes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, African Journals Online, Web of Science, and the Cochrane Library electronic databases. Some studies were also identified through manual Google search and Google scholar.

ELIGIBILITY CRITERIA

We systematically searched electronic databases for studies published up to October 2020. Only English-language articles were included.

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction and quality appraisal were conducted by two independent reviewers. A random-effect model was applied to estimate ORs with 95% CIs. The Higgins I² test was used to assess the heterogeneity between the studies. The risk of publication bias was estimated using the Egger test. Leave-one-out analysis was done. Data were analysed using Stata V.11.

RESULTS

Seven studies were included in the meta-analysis. The findings from included studies revealed that poor social support increases the odds of depression among patients with diabetes (adjusted OR=2.14, 95% CI 1.34 to 3.43, p=0.003). There was no risk of publication bias (p=0.064), and heterogeneity was substantial (I²=70.7%). The leave-one-out analysis confirmed the consistency of the findings.

CONCLUSIONS

Our meta-analysis revealed that patients who had poor social support were significantly associated with an increased level of depression. Additional studies exploring factors that might moderate or mediate this association are needed. Targeted interventions for comorbid depression should be implemented in clinical practice.

SYSTEMATIC REVIEW REGISTRATION

We have submitted the protocol for registration at the PROSPERO on 9 October 2020. But we have not yet received a registration number.

Development and validation of the self-management Barriers and Supports Evaluation for working-aged adults with type 1 diabetes mellitus

INTRODUCTION

To optimize type 1 diabetes mellitus self-management, experts recommend a person-centered approach, in which care is tailored to meet people's needs and preferences. Existing tools for tailoring type 1 diabetes mellitus education and support are limited by narrow focus, lack of strong association with meaningful outcomes like A1c, or having been developed before widespread use of modern diabetes technology. To facilitate comprehensive, effective tailoring for today's working-aged adults with type 1 diabetes mellitus, we developed and validated the Barriers and Supports Evaluation (BASES).

RESEARCH DESIGN AND METHODS

Participants 25-64 years of age with type 1 diabetes mellitus were recruited from clinics and a population-based registry. Content analysis of semistructured interviews (n=33) yielded a pool of 136 items, further refined to 70 candidate items on a 5-point Likert scale through cognitive interviewing and piloting. To develop and validate the tool, factor analyses were applied to responses to candidate items (n=392). Additional survey data included demographics and the Diabetes-Specific Quality of Life (QOL) Scale-Revised. To evaluate concurrent validity, hemoglobin A1c (HbA1c) values and QOL scores were regressed on domain scores.

RESULTS

Factor analyses yielded 5 domains encompassing 30 items: Learning Opportunities, Costs and Insurance, Family and Friends, Coping and Behavioral Skills, and Diabetes Provider Interactions. Models exhibited good to adequate fit (Comparative Fit Index >0.88 and Root Mean Squared Error of Approximation <0.06). All domains demonstrated significant associations with HbA1c and QOL in the expected direction, except Family and Friends. Coping and Behavioral Skills had the strongest associations with both HbA1c and QOL.

CONCLUSIONS

The BASES is a valid, comprehensive, person-centered tool that can tailor diabetes support and education to individuals' needs in a modern practice environment, improving effectiveness and uptake of services. Clinicians could use the tool to uncover patient-specific barriers that limit success in achieving HbA1c goals and optimal QOL.

Provider perspectives on emotional health care for adults with type 2 diabetes mellitus in the Dominican Republic

The emotional burden of type 2 diabetes mellitus (T2D) can complicate self-management. Exploring the feasibility of mental and physical health co-management in limited-resourced settings is needed. Thus, we assessed providers' awareness of the emotional burden their patients experience and their roles in supporting their patients with T2D. We conducted a formative qualitative study using in-depth interviews with 14 providers, including physicians, nurses, and community health workers recruited at two rural health clinics in the Dominican Republic. We coded transcripts using inductive and deductive codes and developed themes through iterative comparative analysis. All providers recognized that patients experience an emotional burden managing life with T2D. Some providers viewed the provision of emotional support as integral to their role and believed that they could do so. Others viewed it as the responsibility of the family or expressed the need for additional guidance on how to provide emotional support. Providers also identified several barriers to integrating emotional support into routine clinical care including personality characteristics, lack of training, and insufficient staffing. While providers recognize the need for emotional support, they identified individual, clinical, and systems-level barriers. Strategies to address these barriers include training specific providers on emotional support provision, balancing workload, and building or strengthening referral systems.

Family interventions for adults living with type 2 diabetes mellitus: A qualitative meta-synthesis

OBJECTIVE

Review and synthesize qualitative research on family interventions for adults living with type 2 diabetes.

METHODS

A qualitative metasynthesis was conducted. Analysis used imported concepts from realist evaluation - context, mechanisms, and outcomes.

RESULTS

Six studies met inclusion criteria in this qualitative systematic review. Powerful mechanisms were identified that occur outside the family intervention in the context of ethnic, racialized, and geographically defined groups. Many similarities were noted across contexts, such as low income. Mechanisms of interventions focused primarily on family member education. Outcomes were focused more on improving self-care behaviors, rather than family-oriented outcomes.

CONCLUSION

Systemic issues affecting social determinants of health set the context for family interventions for type 2 diabetes. When designing these interventions, intersectionality, scarcity, and family functioning may need to be considered.

PRACTICE IMPLICATIONS

Emphasis on education of family members may not be effective in improving diabetes outcomes, as many powerful mechanisms exist outside of these interventions.

Feasibility and efficacy of a pilot family model of diabetes self-management intervention in the Republic of the Marshall Islands

BACKGROUND

The Republic of the Marshall Islands (RMI) faces numerous health disparities, including one of the highest prevalence of type 2 diabetes mellitus (T2DM) in the world. Diabetes self-management education and support (DSMES) has shown efficacy in improving glycemic control and through increases in knowledge and self-management activities; however, there is limited research on DSMES in the RMI. This study evaluated the feasibility and efficacy of a culturally adapted family model of DSMES (F-DSMES) in the RMI. The F-DSME included 8 h of group educational classes delivered in churches by a community health worker.

METHODS

This pilot study assessed retention and dosage rates (e.g., class attendance) among the participants with T2DM (n = 41). Efficacy was evaluated by examining pre- and post-intervention differences in HbA1c, knowledge, family support, and self-management activities among those who completed the post-intervention data collection (n = 23).

RESULTS

The results indicate completion of post-intervention data collection and attendance were associated; 70% of participants who completed the post-intervention data collection received at least 6 h of intervention compared to 3 h for those who did not. Although the reduction in HbA1c was not statistically significant, participants demonstrated statically significant increases in knowledge, family support, and an increase in self-management including in checking of blood glucose and feet.

CONCLUSIONS

This study provides important information to help address T2DM disparities in the RMI, including the feasibility and efficacy of F-DSMES. Additional research will help in understanding how to translate improvements in knowledge, family support, and self-management activities into improvements in HbA1c. This may include addressing social ecological factors that affect glycemic control.

Patient Markers of Successful Diabetes Management

PURPOSE

For individuals with diabetes, diabetes health status may not align with A1C targets. Patients may use nonclinical targets when assessing their diabetes management success. Identifying these targets is important in developing patient-centered management plans. The purpose of this study was to identify patient markers of successful diabetes management among patients in an urban academic health system.

METHODS

A secondary analysis of semistructured interviews was completed with 89 adults with type 1 or type 2 diabetes. Participants had a recent diabetes-related emergency department (ED) visits or hospitalization or were primary care patients with an A1C >7.5%. Interviews were conducted to saturation. Demographic data were collected via self-report and electronic medical records. Interviews were analyzed using conventional content analysis. This analysis focused on patient perceptions of successful management coded to "measuring management success."

RESULTS

Although most participants cited A1C or blood glucose as a marker of successful diabetes management, they had varied understanding of these metrics. Most used a combination of targets from the following categories: 1) A1C, blood glucose, and numbers; 2) engagement in medical care; 3) taking medication and medication types; 4) symptoms; 5) diet, exercise, and weight; and 6) stress management and social support.

CONCLUSION

Individuals not meeting glycemic goals and/or with recent diabetes-related ED visits or hospitalizations had varied understanding of A1C and blood glucose targets. They use multiple additional markers of successful management and had a desire for management discussions that incorporate these markers. These measures should be incorporated into their care plans along with clinical targets.

Spouse's Diabetes Status and Incidence of Depression and Anxiety: An 18-Year Prospective Study

OBJECTIVE

We investigated the risk of depression and anxiety in people whose spouse did or did not have diabetes. We also examined associations between depression and anxiety and severity of spouse's diabetes.

RESEARCH DESIGN AND METHODS

We analyzed prospective self-reported data about diagnosed depression/anxiety and diabetes in cohabiting couples in the national Panel Study of Income Dynamics (PSID) during 1999-2017 (n = 13,500, 128,833 person-years of follow-up, median follow-up 8.1 years). We used Poisson models to estimate incidence and incidence rate ratios (IRRs) of depression/anxiety, according to spouse's diabetes status overall and by severity of diabetes.

RESULTS

Age-, sex-, and race-adjusted incidence of depression/anxiety was 8.0/1,000 person-years (95% CI 6.5, 9.6) among those whose spouse had diabetes and 6.5/1,000 person-years (95% CI 6.0, 6.9) among those whose spouse did not have diabetes. Those whose spouse had diabetes had higher risk of depression/anxiety (IRR 1.24 [95% CI 1.01, 1.53]). Those whose spouse had diabetes-related limitations in daily activities (IRR 1.89 [95% CI 1.35, 2.67]) and diabetes combined with other chronic conditions (IRR 2.34 [95% CI 1.78, 3.09]) were more likely to develop depression/anxiety, while those whose spouse had diabetes with no limitations or additional chronic conditions had incidence of depression/anxiety similar to that of subjects whose spouses did not have diabetes.

CONCLUSIONS

People living with a spouse with diabetes are at higher risk of developing depression/anxiety than people whose spouse does not have diabetes; this risk is driven by the severity of the spouse's diabetes. Strategies to address the impacts of diabetes on families need to be devised and tested.

Prescription drug coverage satisfaction, cost-reducing behavior, and medication nonadherence among Medicare beneficiaries with type 2 diabetes

BACKGROUND: Medication nonadherence in individuals with type 2 diabetes can lead to poor glycemic control, resulting in increased risk for diabetes-related complications. OBJECTIVE: To examine associations between factors (ie, drug coverage satisfaction and cost-reducing behavior) and medication nonadherence among Medicare beneficiaries with type 2 diabetes. METHODS: We analyzed the 2016 Medicare Current Beneficiary Survey Public Use File for beneficiaries aged 65 years and older with reported type 2 diabetes (n=1,430; weighted n=5,846,943). Medicare beneficiaries were considered to have medication nonadherence if they reported skipping doses or taking smaller doses than prescribed. A survey-weighted logistic model, adjusted for sociodemographics and comorbidities, was conducted to examine associations of drug coverage satisfaction and cost-reducing behavior with medication nonadherence. RESULTS: Among Medicare beneficiaries aged 65 years and older with type 2 diabetes, 10.3% reported medication nonadherence. In the adjusted analysis, the risk for medication nonadherence was higher among those who were dissatisfied with the amount paid for medications (OR = 2.43; P = 0.002) compared with those who were satisfied, and those who spent less on basic needs to save for medications were more likely to report medication nonadherence (OR = 2.23; P = 0.011) than those who did not. CONCLUSIONS: Our findings suggest that medication nonadherence among Medicare beneficiaries with type 2 diabetes is associated with dissatisfaction with the amount paid for medications and cost-reducing behavior. Interventions that lower medication costs for Medicare beneficiaries may help to improve medication adherence among this at-risk population. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to disclose.

One Hundred Years of Insulin: Value Beyond Price in Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a chronic, progressive disease that frequently necessitates treatment with basal insulin to maintain adequate glycaemic control. In considering the value of different basal insulin therapies, although acquisition costs are of increasing importance to budget-constrained healthcare systems, value beyond simple price considerations should be taken into account. Whilst human basal insulins are of lower acquisition cost compared to long-acting insulin analogues, this difference in price has the potential to be offset in terms of total healthcare system value through the ultra-long duration of action and low variability in glucose-lowering activity which have been translated into real clinical benefits, in particular a reduced risk of hypoglycaemic events. The maintenance of glycaemic targets and avoidance of hypoglycaemia that have been associated with insulin analogues represent a significant value consideration, beyond price, for the use of basal insulin analogues to manage type 2 diabetes mellitus from the perspective of all stakeholders within the healthcare system, including payers, healthcare professionals, patients and society.

Family Functioning Assessment Instruments in Adults with a Non-Psychiatric Chronic Disease: A Systematic Review

There is little information on the evaluation of family functioning in adult patients with chronic non-psychiatric illness. The objective of this systematic review was to identify family functioning assessment instruments of known validity and reliability that have been used in health research on patients with a chronic non-psychiatric illness. We conducted a search in three biomedical databases (PubMed, Science Direct, and Web of Science), for original articles available in English or Spanish published between 2000 and 2019. The review was conducted in accordance with PRISMA guidelines. Fourteen articles were included in the review. The instruments Family Assessment Device, Family Adaptability and Cohesion Evaluation Scales, Family Functioning Health and Social Support, Family APGAR, Assessment of Strategies in Families-Effectiveness, Iceland Expressive Family Functioning, Brief Family Assessment Measure-III, and Family Relationship Index were identified. All of them are reliable instruments to evaluate family functioning in chronic patients and could be very valuable to help nurses identify families in need of a psychosocial intervention. The availability and clinical application of these instruments will allow nurses to generate knowledge on family health and care for non-psychiatric chronic conditions, and will eventually contribute to the health and wellbeing of adults with a non-psychiatric chronic disease and their families.

Factors influencing diabetes self-management in adults: an umbrella review of systematic reviews

OBJECTIVE

The objective of this review was to identify and describe the factors influencing diabetes self-management in adults by summarizing the available evidence concerning their types, categories, and relative importance.

INTRODUCTION

A wide range of factors, acting simultaneously, influence diabetes self-management and interfere with its actual application by patients. There is a variety of systematic reviews of these factors; however, a more thorough examination of their influences was lacking.

INCLUSION CRITERIA

Systematic reviews of qualitative or quantitative literature focusing on factors influencing adult diabetes self-management in general or on individual behaviors (ie, management of oral antidiabetic medication and insulin injections, self-monitoring of blood glucose, foot care, healthy eating, regular exercise, and smoking cessation) will be included.

METHODS

We performed an extensive search of 11 bibliographic databases, including gray literature, up to June 2019. Quantitative and qualitative findings were summarized separately and labeled according to their types (eg, facilitator/barrier, strength and direction of association), categories (eg, demographic, social), and frequency of occurrence.

RESULTS

We identified 51 types of factors within 114 systematic reviews, which mostly addressed medication-taking behavior. Thirty-two (62.7%) factors were reported in both qualitative and quantitative literature. The predominant influences were psychological factors and behavioral attributes/skills factors. The most frequently reported facilitators of diabetes self-management were motivation to diabetes self-management, a favorable attitude to diabetes self-management, knowledge about the disease, medication and behaviors associated with diabetes self-management, skills, and self-efficacy/perceived behavioral control. The predominant barriers were the presence of depression, and polypharmacy or drug regimen complexity. The demographic factor of female sex was frequently reported for its negative influence on diabetes self-management, whereas older age was a positive factor. The social/cultural and physical environment were the least-studied categories. Other factors such as social support from family, friends, or networks; interventions led by health professionals; and a strong community environment with good social services favoring diabetes self-management were reported as major facilitators of diabetes self-management.

CONCLUSIONS

Essential components of interventions to promote effective diabetes self-management should aim to help adults manage the effects of specific factors related to their psychological and practical self-management experience. Screening for depression, in particular, should become an integral part of the support for adult diabetes self-management, as depression is a particular obstacle to the effectiveness of diabetes self-management. Future studies should more deeply examine the influence of factors identified in the sociocultural and physical environment categories. Research should properly consider and invest efforts in strengthening social support and innovative community care approaches, including pharmacist- and nurse-led care models for encouraging and improving adult diabetes self-management. Finally, researchers should examine non-modifiable factors - age, sex, or socioeconomic status - in the light of factors from other categories in order to deepen understanding of their real-world patterns of action on adult diabetes self-management.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018084665.

Family model diabetes self-management education and support in faith-based organizations in the republic of the Marshall Islands study protocol

BACKGROUND

Marshallese living in the Republic of the Marshall Islands (RMI) experience significant health disparities, with high rates of type 2 diabetes mellitus. In addition to health disparities, the RMI experienced nuclear testing that exposed inhabitants to nuclear fallout, unethical research practices, and contaminated natural food sources.

OBJECTIVES

This research uses a community-based participatory research (CBPR) approach to effectively engage community partners and honor their contributions in all stages of the research. A CBPR approach will leverage culturally situated knowledge and practices of the Marshallese community in the RMI to ensure the success of the research.

METHODS

This manuscript describes the methods used to test the feasibility of delivering a culturally adapted family model of diabetes self-management education and support in faith-based organizations in the RMI.

CONCLUSIONS

This manuscript describes the protocol for creating working with community partners and implementing a feasibility study in the RMI.

Evaluating the most popular diabetes websites in the USA: a content analysis

Over 1.5 million Americans are diagnosed with diabetes every year, and the majority of them go online to learn about their condition. Unfortunately, the online diabetes landscape is crowded, and the quality of website content is unknown-guidance for patients and healthcare providers regarding online diabetes information is needed. To address this, nine of the top diabetes websites in the USA were identified through a comprehensive, multiple-query search and a content analysis was conducted. Two coders, with high inter-coder reliability, evaluated these websites on six factors: (i) Design; (ii) Credibility; (iii) Accessibility; (iv) Literacy; (v) Engagement; and (vi) Diabetes Content. The analysis revealed that the websites presented most of the assessed design features. Few of the sites scored well on the credibility assessment, while the majority of sites did not note an author, editor or reviewer. With regard to accessibility, less than half of the items we assessed were met. Furthermore, the websites possessed wide variability in literacy, with an average readability grade level of 8.8. Most of the websites fared well in engagement, demonstrating multiple avenues to interact with the organization. All of the websites provided basic information regarding diabetes, but many did not include information for caregivers, providers or insurance information. In conclusion, patients and their family members will continue to seek online information about diabetes, its effects and treatment options. Therefore, this multiple-metric evaluation provides essential information for these individuals, and healthcare providers, who can now give better informed website recommendations to their patients and families.

Associations Between Social Support and Diabetes-Related Distress in People With Type 2 Diabetes Mellitus

Context

Diabetes is a complex, chronic condition and managing it can have psychosocial implications for patients, including an impact on relationships with their loved ones and physical wellness. The necessary modifications to daily behaviors can be very overwhelming, thus leading to diabetes-related distress.

Objective

To investigate the association between diabetes-related distress and perceived social support among people with type 2 diabetes.

Methods

This cross-sectional study surveyed a population with a lower socioeconomic status (Medi-Cal recipients, which are only given to low-income individuals) in Solano County, California. Patients who had type 2 diabetes mellitus, who were between 40 and 80 years old, and who had a medical appointment in the clinic(s) at least once between December 2015 and December 2016 were included. Patients who could not understand or speak English and patients whose primary care clinicians declined their participation in the study were excluded from the study. Each study participant was recruited at the end of their medical appointment, and the survey instrument in paper form was administered. The Problem Areas in Diabetes (PAID) scale, which indicates diabetes-related distress, and Multidimensional Scale of Perceived Social Support (MSPSS) with 3 subscales (family, friends, and significant others) were used in this study. Multiple linear regression models were used to analyze the associations between PAID and MSPSS surveys.

Results

For the 101 participants included in our study, multiple linear regression models showed statistically significant association between total MSPSS scores and total PAID scores (β = -.318; 95% CI, .577, -.0581; P=.017) as well as between MSPSS family subscale scores and total PAID scores (β= -.761; 95% CI, -1.35, -.168; P=.012). Among the 3 MSPSS subscales, higher perceived support from family members was found to be significantly associated with lower total PAID scores (β= -.761; 95% CI, -1.35, -.168; P=.012).

Conclusion

Our findings suggest that a higher level of perceived social support experienced was associated with lower diabetes-related distress among patients with type 2 diabetes. Osteopathic physicians have a central role in providing comprehensive, patient-centered, holistic care, and the attention to social support in chronic disease management can help remove barriers in providing optimal care.

"Together We Can Return to Balance"-Eastern Woodlands Native Perspectives and Type 2 Diabetes: A Qualitative Study

PURPOSE

To explore the perspectives of Eastern Woodlands Native people with type 2 diabetes (T2DM) in the context of health beliefs, T2DM disease self-management, and family and community connections.

METHODS

A qualitative descriptive method using face-to-face or telephonic semistructured interviews was employed with Native people ages 18 years or older who have a diagnosis of T2DM (N = 12) from an unidentified Eastern Woodlands tribe. The PEN-3 Cultural Model guided the study initially.

RESULTS

The overarching theme "together we can return to balance" corresponded to 5 subthemes: coming to know life paths with T2DM, acknowledging the imbalance, negotiating my way forward, making important connections, and sticking closer to Mother Earth. Dimensions within the subthemes suggest why Native people may not be reaching T2DM treatment goals. Reasons include incomplete diabetes knowledge, difficulty accessing resources, and contextual variations in adoption of conventional diabetes treatments.

CONCLUSION

This study identified themes from Native perspectives about T2DM self-management and about prospects that may mitigate incomplete knowledge and support. Integrating indigenous health and wellness knowledge with conventional principles of diabetes care presents several opportunities for nurses to advance diabetes self-management (DSM) education and support. Including Native health concepts when educating patients about DSM should be viewed as desirable for holistic family and community involvement that is central toward preventing disease progression.

Psychosocial adjustment of young offspring in the context of parental type 1 and type 2 diabetes: a systematic review

AIMS

To identify all available research on psychosocial outcomes in young people who have a parent with type 1 or type 2 diabetes.

METHODS

Embase, PsychInfo, Scopus, Web of Science, PubMed and ProQuest Social Sciences databases were searched according to a registered study protocol (PROSPERO CRD42019125301). Quality assessment, data extraction and data synthesis were carried out.

RESULTS

The initial search yielded 11 599 articles, 10 of which met the criteria for this review: six for type 1 diabetes and four for type 2 diabetes. Through thematic analysis, five categories emerged related to offspring psychosocial adjustment: offspring mental health, offspring physical health, offspring personal resources, parental illness characteristics and offspring caregiving. Overall, there were few studies focusing solely on the effects of parental type 1 and type 2 diabetes on young people. From the limited available research, there is weak evidence suggesting both parental types of diabetes can adversely impact young offspring. Illness-related variables were only explored in parental type 1 diabetes studies, while offspring caregiving was only examined in parental type 2 diabetes studies.

CONCLUSIONS

Research on the effects of parental diabetes on young people is scarce; however, there was weak evidence to suggest some young people are at risk of adverse psychosocial impacts. Given the rise in the incidence of diabetes globally, there is a pressing public health need to conduct more rigorously designed studies to ascertain the extent to which young people are at risk of mental and physical health problems and to identify risk and protective factors associated with youth adjustment in the context of parental diabetes.

Does social support effect knowledge and diabetes self-management practices in older persons with Type 2 diabetes attending primary care clinics in Cape Town, South Africa?

BACKGROUND

In South Africa with one of the most rapidly ageing populations in Africa despite the demographic impact of the HIV/AIDS epidemic, diabetes is a major cause of morbidity and mortality. Self-management is challenging for all those with the condition but is likely to create a higher demand for those who may have existing co-morbidities associated with age, and long-standing chronic diseases.

OBJECTIVE

To determine the relationship of social support, especially that of family and friends with their self-management.

METHODS

This cross-sectional study was undertaken in the Cape Town metropole primary care clinics. The sample comprised 406 people drawn from four community health centres (CHC) that are served by Groote Schuur Hospital at the tertiary level.

RESULTS

Of the 406 participants, 68.5% were females, 60.5% were living with a family member, and almost half were married. The mean duration of diabetes from diagnosis was eight years. More than half (57.4%) had no or only primary education. Half the participants (50.2%) had poor knowledge level in relation to symptoms and complications of diabetes. Multivariable linear regression showed older age was associated with poor knowledge (®: -1.893, 95% CI-3.754; -0.031) and higher income was associated with self-management practice (®: 3.434, 95% CI 0.797; 6.070). Most participants received family support to follow aspects of diabetes self-management. The ordinal logistic regression indicated that family support was positively associated with the self-management practice score for following a diabetic meal plan, taking care of feet, physical activity, testing blood sugar and handling participants' feelings about being diabetic, but not for taking medication.

CONCLUSIONS

Consideration needs to be given to developing and testing education programmes that focus on needs of older people with diabetes and emphases the role of family and friends.

State of the art: understanding and integration of the social context in diabetes care

We review the past 25 years of research addressing challenges people living with diabetes experience in their daily lives related to social contexts, i.e. in their family, at work and in society at large, and identify research gaps. We found that young people with diabetes, as they develop through to adulthood, are exposed to considerable risks to their physical and mental health. Family-system interventions have had mixed outcomes. Research in this area would benefit from attention to ethnic/cultural diversity, and involving fathers and other family members. In adults with diabetes, social support relates to better diabetes outcomes. While family member involvement in care is likely to affect health and psychosocial outcomes of the person with diabetes, key elements and mediators of effective family interventions need to be identified. The challenges of diabetes management at work are under-researched; distress and intentional hyperglycaemia are common. When depression is comorbid with diabetes, there are increased work-related risks, e.g. unemployment, sickness absence and reduced income. Research to support people with diabetes at work should involve colleagues and employers to raise awareness and create supportive environments. Stigma and discrimination have been found to be more common than previously acknowledged, affecting self-care, well-being and access to health services. Guidance on stigma-reducing choice of language has been published recently. Resilience, defined as successful adaptation to adversity such as stigma and discrimination, requires studies relevant to the specific challenges of diabetes, whether at diagnosis or subsequently. The importance of the social context for living well with diabetes is now fully recognized, but understanding of many of the challenges, whether at home or work, is still limited, with much work needed to develop successful interventions.

A novel exploration of the support needs of people initiating insulin pump therapy using a social network approach: a longitudinal mixed-methods study

AIMS

To establish what practical and emotional means of support are required on initiation of insulin pump therapy and how needs change over time, using GENIE, a social network intervention.

METHODS

The study's longitudinal design used semi-structured interviews, surveys (PAID, CLARKE) and HbA_1c values at time of pump initiation, and at 3 and 6 months. Interviews used GENIE to capture participants' expectations and experiences of pump therapy and associated support and resources. Thematic analysis was used with sequential, time-ordered matrices.

RESULTS

A total of 16 adults undertook 47 interviews. A total of 94 services, resources and activities were acquired, while tally, frequency and value of network members increased over time. The novelty of pump therapy impacted on participants' self-management needs. Key themes included: 1) the independent nature of managing diabetes; 2) overcoming the challenges and illness burden associated with pump use; 3) the need for responsive and tailored emotional and practical support; and 4) useful resources when incorporating pump therapy. GENIE was thought to be novel and beneficial.

CONCLUSIONS

A social network approach determined what resources and support people with diabetes require when incorporating a new health technology. Visualisation of support networks using concentric circles enabled people to consider and mobilise support and engage in new activities as their needs changed. The novelty of pump therapy creates new illness-related work, but mobilisation of personally valued flexible, tailored support can improve the process of adaptation.

Factors associated with subsequent diabetes-related self-care activities: The role of social support and optimism

Aim

This study aimed to explore how social support (external factor), optimism (internal factor) and their interaction associated with diabetes-related self-care activities (DRSCA) over 3 months among people with type 2 diabetes mellitus (T2DM).

Design

Both questionnaire-based and telephone-based survey were used. The data were collected face to face, the first time by questionnaire and the second time by telephone.

Methods

One hundred and fifty-five patients completed valid survey questionnaires (response rate was about 70% in the first and 62% in the second round). The association of social support and optimism with subsequent DRSCA was examined after adjusting for demographics and disease information.

Results

Based on results, optimism was significantly associated with subsequent DRSCA. In the dimensions of social support, objective social support and support use were significantly associated with subsequent DRSCA. The results showed that the mediation of optimism between the dimensions of social support and DRSCA was not significant after controlling for covariates. The results also indicated that social support and optimism played directly an important role in improving diabetes-related self-care activities.

The Internal Realities of Individuals With Type 2 Diabetes: Mediators Influencing Self-Management Beliefs via Grounded Theory Approach

Background: There has been an unabated rise in the prevalence of type 2 diabetes (T2D) worldwide. Although T2D is highly preventable, these trends suggest that a paradigm change is much needed in the way both clinicians and policy makers view what effective T2D strategies conventionally entail. Hence, it is becoming increasingly clear that T2D patients require more than just a pharmacological approach to their disease. Evidence indicate that culturally specific mediators can help foster better self-management practices. We intend to discover psychosocial mediators that influence and support self-management beliefs in T2D patients. Methods: We adopted the grounded theory approach to guide in-depth interviews with T2D patients and health care professionals (HCP) at a regional primary care clinic in Malaysia. Twenty-four T2D patients and 10 HCPs were recruited through purposive sampling method to examine the inner psychological narratives about how they perceive and what they believe beliefs about the disease. Two focus group discussions were also were conducted for data triangulation. Results: A functional framework for the psychosocial mediators influencing self-management beliefs in T2D patients was designed and characterized by 4 major processes: (1) health promotion, (2) personal expectations, (3) person-centered care, and (4) psychosocial support. The fulfillment of patients' personal expectations is central to better self-management beliefs. Conclusions: Positive emotional states are important in providing a positive environment to nurture self-management practices. A person-centered consultation that focuses on empathy and cultural sensitivities has the potential to foster behavioral change required to sustain self-care practices.

Social Support and Common Dyadic Coping in Couples' Dyadic Management of Type II Diabetes: Protocol for an Ambulatory Assessment Application

Background

Type II diabetes mellitus (T2DM) is a common chronic disease. To manage blood glucose levels, patients need to follow medical recommendations for healthy eating, physical activity, and medication adherence in their everyday life. Illness management is mainly shared with partners and involves social support and common dyadic coping (CDC). Social support and CDC have been identified as having implications for people’s health behavior and well-being. Visible support, however, may also be negatively related to people’s well-being. Thus, the concept of invisible support was introduced. It is unknown which of these concepts (ie, visible support, invisible support, and CDC) displays the most beneficial associations with health behavior and well-being when considered together in the context of illness management in couple’s everyday life. Therefore, a novel ambulatory assessment application for the open-source behavioral intervention platform MobileCoach (AAMC) was developed. It uses objective sensor data in combination with self-reports in couple’s everyday life.

Objective

The aim of this paper is to describe the design of the Dyadic Management of Diabetes (DyMand) study, funded by the Swiss National Science Foundation (CR12I1_166348/1). The study was approved by the cantonal ethics committee of the Canton of Zurich, Switzerland (Req-2017_00430).

Methods

This study follows an intensive longitudinal design with 2 phases of data collection. The first phase is a naturalistic observation phase of couples’ conversations in combination with experience sampling in their daily lives, with plans to follow 180 T2DM patients and their partners using sensor data from smartwatches, mobile phones, and accelerometers for 7 consecutive days. The second phase is an observational study in the laboratory, where couples discuss topics related to their diabetes management. The second phase complements the first phase by focusing on the assessment of a full discussion about diabetes-related concerns. Participants are heterosexual couples with 1 partner having a diagnosis of T2DM.

Results

The AAMC was designed and built until the end of 2018 and internally tested in March 2019. In May 2019, the enrollment of the pilot phase began. The data collection of the DyMand study will begin in September 2019, and analysis and presentation of results will be available in 2021.

Conclusions

For further research and practice, it is crucial to identify the impact of social support and CDC on couples’ dyadic management of T2DM and their well-being in daily life. Using AAMC will make a key contribution with regard to objective operationalizations of visible and invisible support, CDC, physical activity, and well-being. Findings will provide a sound basis for theory- and evidence-based development of dyadic interventions to change health behavior in the context of couple’s dyadic illness management. Challenges to this multimodal sensor approach and its feasibility aspects are discussed.

International Registered Report Identifier (IRRID)

PRR1-10.2196/13685

Enablers and barriers to treatment adherence in heterozygous familial hypercholesterolaemia: a qualitative evidence synthesis

OBJECTIVES

Individuals with heterozygous familial hypercholesterolaemia (FH) are at high risk of developing cardiovascular disease (CVD). This risk can be substantially reduced with lifelong pharmacological and lifestyle treatment; however, research suggests adherence is poor. We synthesised the qualitative research to identify enablers and barriers to treatment adherence.

DESIGN

This study conducted a thematic synthesis of qualitative studies.

DATA SOURCES

MEDLINE, Embase, PsycINFO via OVID, Cochrane library and CINAHL databases and grey literature sources were searched through September 2018.

ELIGIBILITY CRITERIA

We included studies conducted in individuals with FH, and their family members, which reported primary qualitative data regarding their experiences of and beliefs about their condition and its treatment.

DATA EXTRACTION AND SYNTHESIS

Quality assessment was undertaken using the Critical Appraisal Skills Programme for qualitative studies. A thematic synthesis was conducted to uncover descriptive and generate analytical themes. These findings were then used to identify enablers and barriers to treatment adherence for application in clinical practice.

RESULTS

24 papers reporting the findings of 15 population samples (264 individuals with FH and 13 of their family members) across 8 countries were included. Data captured within 20 descriptive themes were considered in relation to treatment adherence and 6 analytical themes were generated: risk assessment; perceived personal control of health; disease identity; family influence; informed decision-making; and incorporating treatment into daily life. These findings were used to identify seven enablers (eg, 'commencement of treatment from a young age') and six barriers (eg, 'incorrect and/or inadequate knowledge of treatment advice') to treatment adherence. There were insufficient data to explore if the findings differed between adults and children.

CONCLUSIONS

The findings reveal several enablers and barriers to treatment adherence in individuals with FH. These could be used in clinical practice to facilitate optimal adherence to lifelong treatment thereby minimising the risk of CVD in this vulnerable population.

PROSPERO REGISTRATION NUMBER

CRD42018085946.

Sex, race, and the role of relationships in diabetes health: intersectionality matters

Previous research has seldom used an intersectionality framework to consider how sex and race affect diabetes health, nor has it examined the role of sex and race in the well-established link between romantic relationship quality and health. This study targeted 200 adults with type 2 diabetes (46% Black; 45% female) and examined whether sex, race, and the interaction between sex and race predicted behavioral and psychological health, or moderated the link between relationship quality and health outcomes. Black women reported poorer diabetes self-care and lower self-efficacy compared to other groups. Relationship quality was associated with better self-care, increased self-efficacy, and lower depressive symptoms. The association between relationship quality and medication adherence was stronger for Black women, and the association between relationship quality and self-efficacy was stronger for both Black women and White men. Results suggest that Black women with diabetes experience more health disadvantages than other groups, but some of these disadvantages might be attenuated by supportive romantic relationships.

The Quality of Family Relationships, Diabetes Self-Care, and Health Outcomes in Older Adults

The purpose of the study was to investigate the relationship between family support, diabetes self-care, and health outcomes in older, community-dwelling adults. Using the theoretical framework of the Self-Care of Chronic Illness Theory and a cross-sectional design, 60 participants completed questionnaires related to diabetes self-care activities of the individual, supportive and nonsupportive diabetes behaviors of the family, and the quality of family relations. Participants indicated that diabetes self-care behaviors were performed frequently, with exercise reported as the least-performed behavior. Multiple regression analyses revealed that the quality of family relations as measured by the Family Relationship Index contributed significantly (26.0%) to the variability in A1C levels (R ² = 0.260, F(1, 40) = 14.037, P = 0.001). Neither family supportive behavior nor the quality of family relations contributed to diabetes self-care. It is recommended that health care providers include family members to assess diabetes family support and family relationships in the care of older adults with diabetes.

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.

Correlates of health care use among White and minority men and women with diabetes: An NHANES study

AIMS

The current study sought to identify patient-level factors related to health care use among White and minority men and women with diabetes.

METHODS

A sample of 447 of non-pregnant individuals with diabetes, ages 18-64, was drawn from the 2015-2016 National Health and Nutrition Examination Surveys dataset. Poisson regression models tested associations between health care use and self-rated health, depression, medical comorbidities, body mass index, marital status, number of children, income, insurance coverage, and age, stratified by gender and racial/ethnic minority status.

RESULTS

Poorer self-rated health was the only significant correlate of increased health care use among White men with diabetes whereas income and insurance were significant correlates of increased use among minority men. Among White and minority women, higher levels of depression and being single were correlated with greater health care use. Comorbid medical conditions and insurance coverage were also related to use among minority women.

CONCLUSIONS

Among individuals with diabetes, health care use among White men appeared to be driven by subjective health whereas financial factors were critical among minority men. Family structure and mental health were instrumentally associated with health care use among all women. These factors can be targeted to promote equitable access to care.

A survey on patients' characteristics, perception of family support and diabetes self-management among type 2 diabetes patients in South-West Nigeria

AIM

To determine the association between patients' characteristics, perception of family support and diabetes self-management (DSM) behaviours among type 2 diabetes patients.

DESIGN

A descriptive cross-sectional design was used and data were collected between July-September 2016. The study is part of a larger quasi-experimental study.

METHODS

One hundred and ninety-seven diabetes mellitus (DM) patients from two teaching hospitals in south-west Nigeria participated. Questionnaire was used in collecting information on sociodemographic, clinical data, DSM and perception of family support.

RESULTS

Most (71.6%) of the participants were females and 35% were on insulin therapy. Mean age was 60.7 (SD: 11.3) years and 11.7% had had DM for over 20 years. Overall, DSM was positively influenced by previous diabetes education and duration of diabetes. Perception of family support was also positively associated with and influenced DSM.

Two for one? Effects of a couples intervention on partners of persons with Type 2 diabetes: a randomized controlled trial

AIMS

To compare the outcomes of partners who participated in a telephone couples behavioural intervention to improve glycaemic control in persons with Type 2 diabetes with those of untreated partners of participants in an individual intervention or education; to explore 'ripple effects', i.e. positive behaviour changes seen in untreated partners.

METHODS

The Diabetes Support Project was a three-arm randomized telephone intervention trial comparing outcomes of couples calls (CC), individual calls (IC) and diabetes education calls (DE). Couples included one partner with Type 2 diabetes and HbA_1c ≥ 58 mmol/mol (7.5%). All arms received self-management education (two calls). CC and IC arms participated in 10 additional behaviour change calls. CC included partners, emphasizing partner communication, collaboration and support. Blinded assessments were performed at 4, 8 and 12 months. Partner outcomes were psychosocial (diabetes distress, relationship satisfaction, depressive symptoms), medical (BMI, blood pressure) and behavioural (fat intake, activity).

RESULTS

Partners' (N = 268) mean age was 55.8 years, 64.6% were female and 29.9% were from minority ethnic groups. CC (vs. IC and DE) partners had greater reductions in diabetes distress, greater increases in marital satisfaction (4 and 8 months), and some improvements in diastolic BP. There were no consistent differences among arms in other outcomes. There was no evidence of a dietary or activity behaviour ripple effect on untreated partners, i.e. comparing partners in the IC and DE arms.

CONCLUSIONS

A collaborative couples intervention resulted in significant improvements in partner diabetes distress and relationship satisfaction. There were no consistent effects on behavioural or medical partner outcomes, and no evidence of diet or activity behaviour ripple effects, suggesting that partners should be targeted directly to achieve these changes. (Clinical Trial Registry No: NCT01017523).

Diabetes Disparities and Promising Interventions to Address Diabetes in Native Hawaiian and Pacific Islander Populations

PURPOSE OF REVIEW

The Native Hawaiian and Pacific Islander (NHPI) population is rapidly growing in the USA. NHPIs face significant health disparities and have a high prevalence of diabetes compared to the general US population.

RECENT FINDINGS

Recent culturally-adapted diabetes interventions have shown promise in addressing these disparities among NHPI communities. The interventions showed success by utilizing a community-based approach that honored NHPIs' collectivist culture, addressed social determinants of health that influence disease control and prevention, and utilized NHPI community health workers (CHWs) and peer educators for key roles in implementation of the intervention. To address health disparities in the NHPI community, much can be learned from existing, successful interventions. Promising interventions share several attributes. The interventions were: culturally adapted using a community-based participatory research approach; addressed specific social determinants of health (i.e., cost of healthy food, transportation, access to health care) that influence disease control and prevention; honored the collectivist culture of NHPI communities by integrating social networks and extended family members; and utilized NHPI community members, including peer educators and CHWs, for intervention implementation. Further investment to scale these interventions for regional and national implementation is needed to address the significant diabetes disparities that NHPIs face.

The role of spousal support for dietary adherence among type 2 diabetes patients: a narrative review

Healthy eating is key to successful management of type 2 diabetes (T2D). As discussed in this narrative review, there are strong indications that spousal support is an important element affecting dietary adherence in T2D. To provide a synthesized review of this evidence, Google Scholar and PubMed were searched, 28 relevant studies were selected, and the results were narratively summarized. A framework for information synthesis was developed which categorized results into three major themes: how gender roles and spousal dynamics function in spousal support for dietary adherence, the role of race and ethnicity in the influence of spousal support on dietary adherence, and the extant interventional work specifically targeting spousal support for T2D. The reviewed studies indicate that gender role performance is the principal factor in the relationship between spousal support and dietary adherence in T2D, though race and ethnicity also contribute. Despite this evidence, interventions that specifically target spousal support to improve dietary adherence in T2D have had limited efficacy. A better understanding of the relationship between spousal support and dietary adherence, as well as a subsequent utilization of this information to create targeted and effective interventions, would be of great benefit to the field of diabetes management.

Couples living with type 1 diabetes: An integrative review of the impacts on health and wellbeing

Impacts of type 1 diabetes and relationship factors on health and wellbeing of both persons with diabetes and partners (T1D partners) have not been investigated. Integrative review methods evaluated the evidence. From 323 titles, we included 24 studies involving 16,083 persons with diabetes and 1020 T1D partners. Studies were quantitative (n = 13), qualitative (n = 9) and mixed methods (n = 2). Maintaining resilient, good quality, intimate relationships optimises physical and psychological outcomes for persons with diabetes. Partners experience disturbed sleep and while general psychological health is maintained, distress surrounding hypoglycaemia is overwhelming for over a third of partners. Nurturing quality relationships could reap significant health benefits.

US Ethnic Group Differences in Family Member Support for People With Diabetes in the 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) Study

Purpose

The purpose of the study was to describe the perceptions of family members (FM) and people with diabetes (PWD) regarding the frequency and helpfulness of FM support for PWD, including differences among US ethnic groups.

Methods

The US 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) substudy was a survey of independent samples of 238 adult FM and 540 adult PWD. Outcome measures included ratings by FM and PWD of the frequency and perceived helpfulness of 7 FM support behaviors and composite scores for frequency and helpfulness.

Results

Ratings of individual FM support behaviors were strongly correlated between FM and PWD but significantly different among behaviors. FM and PWD reported most frequent support for listening, assisting, and doing activities with PWD and reporting PWD was doing poorly least frequently. Both groups reported listening, assisting, and reporting PWD was doing well as most helpful; reporting PWD was doing poorly was least helpful. PWD rated support and helpfulness of most behaviors lower than FM. Composite measures of support frequency and helpfulness were strongly correlated for both FM and PWD. Ethnic minority PWD and FM reported most support behaviors as more frequent and more helpful than non-Hispanic white Americans.

Conclusions

FM more frequently engage in the support behaviors they view as most helpful, but PWD perceive support to be less frequent and less helpful than FM. FM support differs across ethnic groups, with ethnic minorities reporting higher support frequency and helpfulness. Diabetes care providers should consider ethnic group differences in FM support for PWD.

Identifying and Understanding Barriers and Facilitators to Medication Adherence Among Marshallese Adults in Arkansas

Background: Significant health disparities are present in Marshallese adults residing in the United States, most notably a high incidence of type 2 diabetes and other chronic conditions. There is limited research on medication adherence in the Marshallese population. Objective: This study explored perceptions of and experiences with medication adherence among Marshallese adults residing in Arkansas, with the aim of identifying and better understanding barriers and facilitators to medication adherence. Methods: Eligible participants were Marshallese adults taking at least one medication for a chronic health condition. Each participant completed a brief survey and semistructured interview conducted in Marshallese by a bilingual Marshallese staff member. Interviews were recorded, transcribed, and translated from Marshallese to English. Qualitative data were coded for a priori and emergent themes. Results: A total of 40 participants were included in the study. The most common contributing factor for nonadherence was forgetting to take medication (82%). A majority of participants (70%) reported difficulty paying for medicine, 45% reported at least one form of cost-related nonadherence, and 40% engaged in more than one cost-related nonadherence practice. Family support and medication pill boxes were identified as facilitators for medication adherence. The majority of the participants (76.9%) stated that they understood the role of a pharmacist. Participants consistently desired more education on their medications from pharmacy providers. Conclusion: This is the first study to explore barriers and facilitators to medication adherence among Marshallese patients. The findings can be used to develop methods to improve medication adherence among Marshallese.

Criança diabética do tipo 1 e o convívio familiar: repercussões no manejo da doença

RESUMO A pesquisa objetivou escrever a repercussão do convívio familiar da criança diabética no manejo da doença. Trata-se de um estudo qualitativo descritivo, tipo estudo de caso, com criança diabética em seguimento ambulatorial de um hospital universitário, por meio de grupo focal. Análise de dados por análise de conteúdo do tipo temática. Observou-se que Adriana (nome fictício), 11 anos, não adere às orientações e tratamentos propostos pela equipe de saúde, resultando em inadequado manejo do diabetes e altos índices glicêmicos, decorrente da relação desarmoniosa com a família e da carência de gestão dos serviços de saúde. Condições crônicas de saúde interferem no cotidiano familiar e dificultam o tratamento, especialmente de crianças. A Atenção Primária à Saúde deve utilizar ferramentas como a gestão de caso e o projeto terapêutico singular para que, em conjunto com a família e com a criança, possa obter melhor adesão ao tratamento.