Enhancing support via interactive technologies

Feasibility of a culturally adapted technology-delivered, family-based childhood obesity intervention for Latino/Hispanic families in rural Nebraska: the Hispanic Family Connections study protocol

INTRODUCTION

Addressing childhood obesity risk factors like home environment, parental roles, excess weight, physical activity and healthy eating among Latino/Hispanic (L/H) families living in rural communities is an important priority. However, evidence supporting these interventions among L/H families living in rural communities is missing. Our trial will use cultural adaptation and implementation science frameworks to evaluate the feasibility of delivering a culturally appropriate family-based childhood obesity (FBCO) programme via an automated telephone system (interactive voice response) to L/H families in rural Nebraska.

METHODS AND ANALYSIS

A mixed-methods feasibility trial for L/H families with overweight or obese children. Aim 1 will focus on collaboratively adapting and evaluating all intervention materials to fit the rural L/H community profile better, including translation of materials to Spanish, culturally relevant content and images, and use of health communication strategies to address different levels of health literacy. In aim 2, a 6-month feasibility trial with contextual evaluation will randomise 48 dyads (parent and child) to either Family Connections (FC; n=29) or a waitlist standard-care group (n=29) to determine overall study reach, preliminary effectiveness in reducing child body mass index (BMI) z-scores, potential for programme adoption, implementation and sustainability through local health departments (RE-AIM outcomes). We will also evaluate health department perceptions of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) constructs (innovation, context, recipient characteristics) and FC participants' view of the intervention (ie, relative advantage, observability, trialability, complexity, compatibility). The study will answer three critical questions: (1) is a telephone-delivered FBCO programme in rural Nebraska culturally relevant, usable and acceptable by L/H families?; (2) is a telephone-delivered FBCO programme effective at reducing BMI z-scores in L/H children living in rural Nebraska? and (3) what real-world institutional and contextual factors influence the impact of the intervention and might affect its potential ability to sustainably engage a meaningful population of L/H families who stand to benefit?

ETHICS AND DISSEMINATION

This protocol was approved by the University of Nebraska Medical Center Institutional Review Board (IRB#:0745-20-EP). Dissemination of findings will occur through ClinicalTrials.gov, in scientific forums and to the local rural communities, pilot data to inform the design of a larger clinical trial.

TRIAL REGISTRATION NUMBER

NCT04731506.

From black box to toolbox: Outlining device functionality, engagement activities, and the pervasive information architecture of mHealth interventions

mHealth interventions that deliver content via mobile phones represent a burgeoning area of health behavior change. The current paper examines two themes that can inform the underlying design of mHealth interventions: (1) mobile device functionality, which represents the technological toolbox available to intervention developers; and (2) the pervasive information architecture of mHealth interventions, which determines how intervention content can be delivered concurrently using mobile phones, personal computers, and other devices. We posit that developers of mHealth interventions will be better able to achieve the promise of this burgeoning arena by leveraging the toolbox and functionality of mobile devices in order to engage participants and encourage meaningful behavior change within the context of a carefully designed pervasive information architecture.

Design and methods of "diaBEAT-it!": a hybrid preference/randomized control trial design using the RE-AIM framework

BACKGROUND

Diabetes prevention is a public health priority that is dependent upon the reach, effectiveness, and cost of intervention strategies. However, understanding each of these outcomes within the context of randomized controlled trials is problematic.

PURPOSE

To describe the methods and design of a hybrid preference/randomized control trial using the RE-AIM framework.

METHODS

The trial, which was developed using the RE-AIM framework, will contrast the effects of 3 interventions: (1) a standard care, small group, diabetes prevention education class (SG), (2) the small group intervention plus 12 months of interactive voice response telephone follow-up (SG-IVR), and (3) a DVD version of the small group intervention with the same IVR follow-up (DVD-IVR). Each intervention includes personal action planning with a focus on key elements of the lifestyle intervention from the Diabetes Prevention Program (DPP). Adult patients at risk for diabetes will be randomly assigned to either choice or RCT. Those assigned to choice (n=240) will have the opportunity to choose between SG-IVR and DVD-IVR. Those assigned to RCT group (n=360) will be randomly assigned to SG, SG-IVR, or DVD-IRV. Assessment of primary (weight loss, reach, & cost) and secondary (physical activity, & dietary intake) outcomes will occur at baseline, 6, 12, and 18 months.

CONCLUSION

This will be the first diabetes prevention trial that will allow the research team to determine the relationships between reach, effectiveness, and cost of different interventions.

Social organization of self-management support of persons with diabetes: a health systems comparison

OBJECTIVE

Identify important organizational elements for providing self-management support (SMS).

DESIGN

Semi-structured qualitative interviews conducted in two healthcare systems.

SETTING

Kaiser Permanente Northern California and the Danish Health Care System.

SUBJECTS

36 managers and healthcare professionals in the two healthcare systems.

MAIN OUTCOME MEASURES

Elements important to providing self-management support to persons with diabetes.

RESULTS

Healthcare professionals' provision of SMS was influenced by healthcare system organization and their perceptions of SMS, the capability and responsibility of healthcare systems, and their roles in the healthcare organization. Enabling factors for providing SMS included: strong leadership; aligned incentives; use of an integrated health information technology (HIT) system; multidisciplinary healthcare provider teams; ongoing training for healthcare professionals; outreach; and quality goals. Barriers to providing SMS included lack of collaboration between providers and skeptical attitudes towards prevention and outreach.

CONCLUSIONS AND IMPLICATIONS

Implementation of SMS can be improved by an understanding of the elements that enhance its provision: (1) initiatives seeking to improve collaboration and integration between providers; (2) implementation of an integrated HIT system; and (3) ongoing training of healthcare professionals.

Weight gain prevention among black women in the rural community health center setting: the Shape Program

BACKGROUND

Nearly 60% of black women are obese. Despite their increased risk of obesity and associated chronic diseases, black women have been underrepresented in clinical trials of weight loss interventions, particularly those conducted in the primary care setting. Further, existing obesity treatments are less effective for this population. The promotion of weight maintenance can be achieved at lower treatment intensity than can weight loss and holds promise in reducing obesity-associated chronic disease risk. Weight gain prevention may also be more consistent with the obesity-related sociocultural perspectives of black women than are traditional weight loss approaches.

METHODS/DESIGN

We conducted an 18-month randomized controlled trial (the Shape Program) of a weight gain prevention intervention for overweight black female patients in the primary care setting. Participants include 194 premenopausal black women aged 25 to 44 years with a BMI of 25-34.9 kg/m2. Participants were randomized either to usual care or to a 12-month intervention that consisted of: tailored obesogenic behavior change goals, self-monitoring via interactive voice response phone calls, tailored skills training materials, 12 counseling calls with a registered dietitian and a 12-month YMCA membership.Participants are followed over 18 months, with study visits at baseline, 6-, 12- and 18-months. Anthropometric data, blood pressure, fasting lipids, fasting glucose, and self-administered surveys are collected at each visit. Accelerometer data is collected at baseline and 12-months.At baseline, participants were an average of 35.4 years old with a mean body mass index of 30.2 kg/m2. Participants were mostly employed and low-income. Almost half of the sample reported a diagnosis of hypertension or prehypertension and 12% reported a diagnosis of diabetes or prediabetes. Almost one-third of participants smoked and over 20% scored above the clinical threshold for depression.

DISCUSSION

The Shape Program utilizes an innovative intervention approach to lower the risk of obesity and obesity-associated chronic disease among black women in the primary care setting. The intervention was informed by behavior change theory and aims to prevent weight gain using inexpensive mobile technologies and existing health center resources. Baseline characteristics reflect a socioeconomically disadvantaged, high-risk population sample in need of evidence-based treatment strategies.

TRIAL REGISTRATION

The trial is registered with clinicaltrials.gov NCT00938535.

Computer use, internet access, and online health searching among Harlem adults

PURPOSE

Computer use, Internet access, and online searching for health information were assessed toward enhancing Internet use for health promotion.

DESIGN

Cross-sectional random digit dial landline phone survey.

SETTING

Eight zip codes that comprised Central Harlem/Hamilton Heights and East Harlem in New York City.

SUBJECTS

Adults 18 years and older (N=646).

MEASURES

Demographic characteristics, computer use, Internet access, and online searching for health information.

ANALYSIS

Frequencies for categorical variables and means and standard deviations for continuous variables were calculated and compared with analogous findings reported in national surveys from similar time periods.

RESULTS

Among Harlem adults, ever computer use and current Internet use were 77% and 52%, respectively. High-speed home Internet connections were somewhat lower for Harlem adults than for U.S. adults overall (43% vs. 68%). Current Internet users in Harlem were more likely to be younger, white vs. black or Hispanic, better educated, and in better self-reported health than non-current users (p<.01). Of those who reported searching online for health information, 74% sought information on medical problems and thought that information found on the Internet affected the way they eat (47%) or exercise (44%).

CONCLUSIONS

Many Harlem adults currently use the Internet to search for health information. High-speed connections and culturally relevant materials may facilitate health information searching for underserved groups.

Outcomes of minimal and moderate support versions of an internet-based diabetes self-management support program

OBJECTIVE

Internet and other interactive technology-based programs offer great potential for practical, effective, and cost-efficient diabetes self-management (DSM) programs capable of reaching large numbers of patients. This study evaluated minimal and moderate support versions of an Internet-based diabetes self-management program, compared to an enhanced usual care condition.

RESEARCH DESIGN AND METHODS

A three-arm practical randomized trial was conducted to evaluate minimal contact and moderate contact versions of an Internet-based diabetes self-management program, offered in English and Spanish, compared to enhanced usual care. A heterogeneous sample of 463 type 2 patients was randomized and 82.5% completed a 4-month follow-up. Primary outcomes were behavior changes in healthy eating, physical activity, and medication taking. Secondary outcomes included hemoglobin A1c, body mass index, lipids, and blood pressure.

RESULTS

The Internet-based intervention produced significantly greater improvements than the enhanced usual care condition on three of four behavioral outcomes (effect sizes [d] for healthy eating = 0.32; fat intake = 0.28; physical activity= 0.19) in both intent-to-treat and complete-cases analyses. These changes did not translate into differential improvements in biological outcomes during the 4-month study period. Added contact did not further enhance outcomes beyond the minimal contact intervention.

CONCLUSIONS

The Internet intervention meets several of the RE-AIM criteria for potential public health impact, including reaching a large number of persons, and being practical, feasible, and engaging for participants, but with mixed effectiveness in improving outcomes, and consistent results across different subgroups. Additional research is needed to evaluate longer-term outcomes, enhance effectiveness and cost-effectiveness, and understand the linkages between intervention processes and outcomes.

The nested structure of cancer symptoms. Implications for analyzing co-occurrence and managing symptoms

OBJECTIVE

Although many cancer patients experience multiple concurrent symptoms, most studies have either focused on the analysis of single symptoms, or have used methods such as factor analysis that make a priori assumptions about how the data is structured. This article addresses both limitations by first visually exploring the data to identify patterns in the co-occurrence of multiple symptoms, and then using those insights to select and develop quantitative measures to analyze and validate the results.

METHODS

We used networks to visualize how 665 cancer patients reported 18 symptoms, and then quantitatively analyzed the observed patterns using degree of symptom overlap between patients, degree of symptom clustering using network modularity, clustering of symptoms based on agglomerative hierarchical clustering, and degree of nestedness of the symptoms based on the most frequently co-occurring symptoms for different sizes of symptom sets. These results were validated by assessing the statistical significance of the quantitative measures through comparison with random networks of the same size and distribution.

RESULTS

The cancer symptoms tended to co-occur in a nested structure, where there was a small set of symptoms that co-occurred in many patients, and progressively larger sets of symptoms that co-occurred among a few patients.

CONCLUSIONS

These results suggest that cancer symptoms co-occur in a nested pattern as opposed to distinct clusters, thereby demonstrating the value of exploratory network analyses to reveal complex relationships between patients and symptoms. The research also extends methods for exploring symptom co-occurrence, including methods for quantifying the degree of symptom overlap and for examining nested co-occurrence in co-occurrence data. Finally, the analysis also suggested implications for the design of systems that assist in symptom assessment and management. The main limitation of the study was that only one dataset was considered, and future studies should attempt to replicate the results in new data.

The influence of literacy on patient-reported experiences of diabetes self-management support

BACKGROUND

Variability in disease-related outcomes may relate to how patients experience self-management support in clinical settings.

OBJECTIVES

The purpose of this study was to identify factors associated with experiences of self-management support during primary care encounters.

METHODS

A cross-sectional survey was conducted of 208 patients seen in a multidisciplinary diabetes program in an academic medicine clinic. Multiple regression analysis was used to test associations between patient-rated experiences of self-management support (Patient Assessment of Chronic Illness Care) and race, gender, insurance status, literacy, duration of diabetes, and intensity of care management.

RESULTS

The Patient Assessment of Chronic Illness Care ratings decreased with age (r = -.235, p = .001), were higher for women than for men (3.95 vs. 3.65, t = 2.612, p= .010), and were greater for those with more education (F= 3.927, p = .009) and greater literacy skills (t = 3.839, p< .001). The ratings did not vary between racial (t = -1.108, p = .269) or insurance (F = 1.045, p = .374) groups and were unaffected by the duration of diabetes (r= .052, p = .466) and the intensity of care management (F = 1.028, p = .360). In multivariate models, literacy was the only variable contributing significantly to variation in self-management support ratings.

DISCUSSION

Even when considering the objective intensity of health services delivered, literacy was the sole variable contributing to differences in patient ratings of self-management support. Although conclusions are limited by the cross-sectional nature of this study, the results emphasize the need to consider literacy when developing and communicating treatment plans requiring self-management skills.

Educating Patients With Diabetes About Cardiovascular Disease Risk

In persons with diabetes mellitus, atherosclerosis is increased, develops prematurely, and is associated with an accelerated progression of atherosclerotic changes. More than 55% of deaths from diabetes are from cardiovascular disease. Central to the optimal management of diabetes and the prevention of chronic complications is effective patient education. The necessity of optimal glycemic control in the prevention of long-term diabetes-related complications, particularly microvascular disease, has been a primary focus of diabetes education during the past decade. It has become clear that to prevent cardiovascular disease in persons with diabetes, an increased emphasis on patient education aimed at reducing cardiovascular disease risk factors is essential. This review explores the scope, impact, and prevention of diabetes-related cardiovascular disease, focusing on integration of cardiovascular disease risk reduction during patient teaching and education programs.

Automated telephone counseling for parents of overweight children: a randomized controlled trial

BACKGROUND

Interactive technologies have the potential to increase the reach and frequency of practical clinical interventions that assist the parents of overweight and at-risk children to promote healthy lifestyle behaviors for their families.

DESIGN

A practical RCT evaluated the relative effectiveness of three interventions to support parents of overweight or at-risk children to change the home environment to foster more healthful child eating and activity behaviors, thereby reducing child BMI and BMI z-scores. A secondary purpose was to determine the patterns of use and potential dose effect for the highest-intensity intervention.

SETTING/PARTICIPANTS

Parent-and-child (aged 8-12 years) dyads (N=220) who received care from Kaiser Permanente Colorado were assigned randomly to one of the three Family Connections (FC) interventions: FC-workbook, FC-group, or FC-interactive voice response (IVR) counseling.

MAIN OUTCOME MEASURES

Child BMI z-scores, as well as symptoms of eating disorders and body image, were assessed at baseline, 6 months, and 12 months.

RESULTS

The BMI z-scores of children assigned to the FC-IVR intervention were the only ones that decreased from baseline to 6 months (0.07 SD) and from baseline to 12 months (0.08 SD, p<0.05). Children whose parents completed at least six of the ten FC-IVR counseling calls had decreased BMI z-scores to a greater extent than children in the FC-workbook or FC-group interventions at both 6 months (p<0.05) and 12 months (p<0.01). No intervention increased child symptoms of eating disorders or body dissatisfaction at any time point.

CONCLUSIONS

This trial demonstrated that automated telephone counseling can support the parents of overweight children to reduce the extent to which their children are overweight.

TRIAL REGISTRATION

NCT00433901.

Diabetes self-management education: a review of published studies

Diabetes self-management is seen as the cornerstone of care for all individuals with diabetes who want to achieve successful health-related outcomes and is considered most effective when delivered by a multidisciplinary team with a comprehensive plan of care. There is a growing body of literature on both educational and psychosocial interventions, aimed at helping individuals to better manage their diabetes. However, the progress of this research and its implications for clinical practice remain unclear and sometimes controversial. This paper therefore aims to further clarify this literature by considering published evidence for the effectiveness of self-management education, including community-based peer support groups and ongoing home telephone support.

Piloting a behavioral intervention delivered through interactive voice response telephone messages to promote weight loss in a pre-diabetic population

OBJECTIVE

To pilot test the feasibility and effectiveness of interactive voice response (IVR) calls targeting physical activity and healthful eating as strategies for weight loss for patients with pre-diabetes.

METHODS

Participants (N=77) who engaged in a 90-min diabetes prevention class were randomly assigned to receive IVR support targeting physical activity and nutrition weight loss strategies or to a no-contact control. Physical activity, dietary intake, and body weight were assessed prior to and following the 3-month intervention.

RESULTS

Eighty-five percent of the intervention participants completed at least half of the intervention. Participants assigned to receive the intervention lost an average of 2.6% of body weight during the 3 months while control participants lost an average of 1.6%. To determine the effect of the calls when used we found that those who used the system lost approximately 3% of body weight which approached significance when compared to controls (p<.06).

CONCLUSION

IVR holds promise for follow-up encounters with patients with pre-diabetes.

PRACTICE IMPLICATIONS

IVR can be used to provide physical activity and nutrition counseling that can enhance the potential reach and effectiveness of health professionals working with patients who have diabetes while placing a minimal burden on financial resources and staff time.

Using the American Association of Diabetes Educators Outcomes System to identify patient behavior change goals and diabetes educator responses

PURPOSE

The purpose of this article is to ascertain patients' self-identified and mutually identified or agreed on (working with diabetes educators) behavior change goals and examine the diabetes educators' response to these goals during the provision of diabetes self-management education.

METHODS

The American Association of Diabetes Educators Outcome System was integrated into Web-based, touch-screen, and telephonic systems within 8 sites within the Pittsburgh Regional Initiative for Diabetes Education network. Data from patients and their diabetes educators were obtained from the Diabetes Self-management Assessment Report Tool (D-SMART) and Diabetes Educator Tool (D-ET).

RESULTS

Nine hundred fifty-four individuals with diabetes (type 1 and type 2) using the D-SMART self-identified healthy eating (74%) and being active (54%) as the most common behavior change goals. From that sample, 527 patients identified goals that were mutually identified or agreed on with their diabetes educator: healthy eating (94%), being active (59%), monitoring (49%), taking medication (26%), reducing risks (19%), problem solving (18%), and healthy coping (18%).

CONCLUSION

The most common behavior change goals identified by patients (self-identified or mutually identified with their diabetes educator) were healthy eating and being active. The behavior change goal least addressed by patients and educators alike was healthy coping. Mutually identified goals among educators and patients may improve targeted appropriate educational strategies to support patients in meeting their goals.

The Diabetes Self-management Assessment Report Tool (D-SMART): process evaluation and patient satisfaction

PURPOSE

The purpose of this article is to present the results of the process evaluation and patient experience in completing the Diabetes Self-management Assessment Report Tool (D-SMART), an instrument within the AADE Outcome System to assist diabetes educators to assess, facilitate, and track behavior change in the provision of diabetes self-management education (DSME).

METHODS

The D-SMART was integrated into computer and telephonic systems at 5 sites within the Pittsburgh Regional Initiative for Diabetes Education (PRIDE) network. Data were obtained from 290 patients with diabetes using the system at these programs via paper-and-pencil questionnaires following baseline D-SMART assessments and electronic system measurement of system performance. Process evaluation included time of completion, understanding content, usability of technology, and satisfaction with the system. Patients were 58% female and 85% Caucasian and had a mean age of 58 years. Fifty-six percent of patients had no more than a high school education, and 78% had Internet access at home.

RESULTS

Most patients reported completing the D-SMART at home (78%), in 1 attempt (86%) via the Internet (55%), and in less than 30 minutes. Seventy-six percent believed the questions were easy to understand, and 80% did not need assistance. Age was negatively associated with ease of use. Moreover, 76% of patients believed the D-SMART helped them think about their diabetes, with 67% indicating that it gave the diabetes educator good information about themselves and their diabetes. Most (94%) were satisfied with the D-SMART. Level of satisfaction was independent of the system being used.

CONCLUSIONS

The D-SMART was easily completed at home in 1 attempt, content was understandable, and patients were generally satisfied with the wording of questions and selection of answers. The D-SMART is easy to use and enhanced communication between the patient and clinician; however, elderly patients may need more assistance. Computer-based and telephonic D-SMARTs appear to be feasible and useful assessment methods for diabetes educators.

Patients' perceptions of Internet usage and their opportunity to obtain health information

The World Wide Web is increasingly an essential resource to obtain information for health promotion. Coherent information is still missing as to whether patients' opportunities to use the Internet and to access health information have changed at the same time. This study examines and compares, between two different time periods, patients' perceptions of Internet use, to obtain health information and associated factors. A two-stage survey design with a non-equivalent group was used. The data were collected with questionnaires from hospital patients during their discharge process and analysed using descriptive statistics. The vast majority of the patients had Internet access either at home or work. The proportion of Internet usage increased during the study period. Patients agree on the importance of using technology for health-information delivery, but they still prefer to receive information from health-care staff by face-to-face contacts. Well-educated and young respondents reported more frequent access to the Internet.

Supervisors' Attitudes and Skills for Active Listening with Regard to Working Conditions and Psychological Stress Reactions among Subordinate Workers

We investigated whether supervisors' listening attitudes and skills were related to working conditions and psychological stress reactions among their subordinates. The subjects included 41 male supervisors and their immediate subordinates (n=203). The supervisors completed a short version of the Active Listening Attitude Scale (ALAS) consisting of two subscales: Listening Attitude and Listening Skill for Active Listening. The subordinates rated working conditions and their psychological stress reactions using selected scales of the Job Content Questionnaire and the Brief Job Stress Questionnaire. Those subordinates who worked under supervisors with a higher score of Listening Attitude and Listening Skill reported a more favorable psychological stress reaction than those who worked under supervisors with a lower score of Listening Attitude and Listening Skill. Those subordinates who worked under supervisors with a higher score of Listening Skill reported higher worksite support than those who worked under supervisors with a lower score of Listening Skill. Those subordinates who worked under supervisors with a higher score of Listening Attitude reported higher job control than those who worked under supervisors with a lower score of Listening Attitude. A supervisor's listening attitude and skill appeared to affect psychological stress reactions predominantly among male subordinates than among female subordinates. Psychological stress reactions were lower among younger subordinates who worked under supervisors with high listening skill, while no statistically difference was observed among older subordinates. These findings suggest that a supervisor's listening attitude and skill have an effect on working conditions and psychological stress reactions among subordinates and that the effects vary according to the subordinates' sex and age.

Evaluation of an internet diabetes self-management training program for adolescents and young adults

BACKGROUND

There are inadequate information and support resources available for adolescents and young adults with diabetes. This article describes the pilot phase of an Internet program to assist these individuals who are transitioning to adult-centered medical care.

METHODS

We developed an online program consisting of background information on diabetes, goal-setting exercises with individualized feedback, role-playing, group discussions, empowerment activities, and communication skills training designed to improve interactions with health professionals. We provided low-income participants enrolled in the study with recycled desktop computers and dial-up Internet service. They also received encouragement and computer use reminders from a diabetes educator. During a 6-month intervention period, we monitored participant utilization of the Internet program.

RESULTS

We recruited a convenience sample of 19 young adults with diabetes from the Chicago Childhood Diabetes Registry, as well as from two inner-city clinics. Participants accessed the program 4,445 times, with the discussion board receiving the greatest activity (2,256 total posted and read messages). Participants used the program most frequently at night, with an overall gradual decline in computer use over the 6-month period. To help maintain utilization, the diabetes educator placed a total of 439 telephone calls over 6 months (15-38 calls per participant).

CONCLUSIONS

The study demonstrated feasibility of using an Internet program to meet the informational and social needs of adolescents and young adults with diabetes. Participant involvement relied heavily upon reminders and encouragement from a diabetes educator and immediate family members.

A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes

AIMS

To assess Sweet Talk, a text-messaging support system designed to enhance self-efficacy, facilitate uptake of intensive insulin therapy and improve glycaemic control in paediatric patients with Type 1 diabetes.

METHODS

One hundred and twenty-six patients fulfilled the eligibility criteria; Type 1 diabetes for > 1 year, on conventional insulin therapy, aged 8-18 years. Ninety-two patients were randomized to conventional insulin therapy (n = 28), conventional therapy and Sweet Talk (n = 33) or intensive insulin therapy and Sweet Talk (n = 31). Goal-setting at clinic visits was reinforced by daily text-messages from the Sweet Talk software system, containing personalized goal-specific prompts and messages tailored to patients' age, sex and insulin regimen.

RESULTS

HbA(1c) did not change in patients on conventional therapy without or with Sweet Talk (10.3 +/- 1.7 vs. 10.1 +/- 1.7%), but improved in patients randomized to intensive therapy and Sweet Talk (9.2 +/- 2.2%, 95% CI -1.9, -0.5, P < 0.001). Sweet Talk was associated with improvement in diabetes self-efficacy (conventional therapy 56.0 +/- 13.7, conventional therapy plus Sweet Talk 62.1 +/- 6.6, 95% CI +2.6, +7.5, P = 0.003) and self-reported adherence (conventional therapy 70.4 +/- 20.0, conventional therapy plus Sweet Talk 77.2 +/- 16.1, 95% CI +0.4, +17.4, P = 0.042). When surveyed, 82% of patients felt that Sweet Talk had improved their diabetes self-management and 90% wanted to continue receiving messages.

CONCLUSIONS

Sweet Talk was associated with improved self-efficacy and adherence; engaging a classically difficult to reach group of young people. While Sweet Talk alone did not improve glycaemic control, it may have had a role in supporting the introduction of intensive insulin therapy. Scheduled, tailored text messaging offers an innovative means of supporting adolescents with diabetes and could be adapted for other health-care settings and chronic diseases.

Differential Resource Utilization Benefits with Internetbased Care Coordination in Elderly Veterans with Chronic Diseases Associated with High Resource Utilization

Our objective was to evaluate in a demonstration project whether our T-Care Program, telecare management via an Internet-based home-messaging device, reduces resource utilization by patients with congestive heart failure (CHF), diabetes mellitus (DM), and chronic obstructive pulmonary disease (COPD). Study participants were drawn from a group of high resource-utilizing veterans over age 60 and included 19 patients with CHF, 23 with DM, and 17 with COPD. Data were gathered on hospital admissions, bed days of care (BDOC), outpatient admissions, and emergency department visits 6 months before and 6 months after enrollment in the telecare program. Nonparametric tests examined pre- and postintervention effects. For patients with CHF, significant decreases were found with T-Care in total emergency department visits (30 to 10, p = 0.03) and hospital admissions (20 to 8, p = 0.03). The decrease in BDOC (179 to 53) was not significant (p = 0.07). Outpatient visits were unchanged (71 to 83, p = 0.38). There were no significant changes for patients with COPD: the apparent BDOC decrease (115 to 46) was not significant (p = 0.24). The outpatient visits by patients with DM decreased significantly (199 to 143, p = 0.03), but no significance was found for changes in their emergency department visits, hospital admissions, and BDOC. The apparent BDOC increase (38 to 198, p = 0.23) was related to two patients with extended stays for an amputation and mitral valve surgery. We found that telecare models may reduce resource utilization in elderly patients with chronic diseases, especially in patients with CHF. Because of the small sample size and lack of controls, larger and more carefully designed follow-up trials are needed to determine cost efficiency for different chronic diseases, and the relative value of the interpersonal contact versus the technological components of this care coordination model.

Use of the Patient Assessment of Chronic Illness Care (PACIC) with diabetic patients: relationship to patient characteristics, receipt of care, and self-management

OBJECTIVE

There is a dearth of information on the extent to which diabetic patients receive care congruent with the chronic care model (CCM) and evidence-based behavioral counseling. This study evaluates a new instrument to fill this gap.

RESEARCH DESIGN AND METHODS

A heterogeneous sample of 363 type 2 diabetic patients completed the original Patient Assessment of Chronic Illness Care (PACIC), along with additional items that allowed it to be scored according to the "5As" (ask, advise, agree, assist, and arrange) model of behavioral counseling. We evaluated relationships between survey scores and patient characteristics, quality of diabetes care, and self-management.

RESULTS

Findings replicated those of the initial PACIC validation study but with a much larger sample of diabetic patients and more Latinos. Areas of CCM activities reported least often were goal setting/intervention tailoring and follow-up/coordination. The 5As scoring revealed that patients were least likely to receive assistance with problem solving and arrangement of follow-up support. Few demographic or medical characteristics were related to PACIC or 5As scores, but survey scores were significantly related to quality of diabetes care received and level of physical activity.

CONCLUSIONS

The PACIC and the new 5As scoring method appear useful for diabetic patients. Its use is encouraged in future research and quality improvement studies.

Patient-reported assessments in diabetes care: clinical and research applications

Patient-reported assessments play an increasing role in diabetes care and research today. These assessments are used to evaluate new treatment regimens, explore attitudes, beliefs, and needs of diabetes populations, support inclusion of psychosocial aspects in daily care, and establish new patient-centered standards for quality-of-care improvement initiatives. Much work remains to be done to ensure that these activities will result in improved access to patient-centered diabetes care.

Perceptions About Computers and the Internet in a Pediatric Clinic Population

BACKGROUND

A digital divide with respect to computer and Internet access has been noted in numerous studies and reports. Equally important to ownership is comfort with computers and Internet technology, and concerns about privacy of personal data.

OBJECTIVE

To measure how households in a pediatric clinic vary in their attitudes toward computers, concerns about Internet confidentiality, and comfort using the Internet and whether these views are associated with household income or education.

DESIGN/METHODS

A phone survey was administered to a population-based sample of parents with children aged 0 to 11 years. All children received medical care from a community-based clinic network serving patients in King County, Wash.

RESULTS

Eighty-eight percent of respondents used a computer once a week or more, and 83% of respondents reported favorable feelings toward computers. Although 97% of respondents were willing to share personal information over the Internet, many respondents considered data security important. While household income and parental education were associated with comfort and familiarity with computers, the effect is small. Respondents who already owned a computer and had Internet access did not differ in their perceptions according to socioeconomic or educational attainment.

CONCLUSIONS

Most families like using computers and feel comfortable using the Internet regardless of socioeconomic status. Fears about the digital divide's impact on the attitudes of parents toward computers or their comfort using the Internet should not be seen as a barrier to developing Internet-based health interventions for a pediatric clinic population.

The DAILY (Daily Automated Intensive Log for Youth) trial: a wireless, portable system to improve adherence and glycemic control in youth with diabetes

Blood glucose (BG) monitoring (BGM) is an important component of diabetes management. New wireless technologies may facilitate BGM and help to optimize glycemic control. We evaluated an integrated wireless approach with and without a motivational game in youth with diabetes. Forty youth, 8-18 years old, each received a handheld device fitted with a wireless modem and diabetes data management software, plus a wireless-enabled BG monitor. Half were randomized to receive the new technologies along with an integrated motivational game in which the participants would guess a BG level following collection of three earlier readings (Game Group). BG data, insulin doses, and carbohydrate intake were displayed graphically prior to the glucose estimation. The other group received the new technologies alone (Control Group). Both groups were instructed to perform BGM four times daily and transmit their data to a central server via the wireless modem. Feasibility of implementation and outcomes were ascertained after 4 weeks. Ninety-three percent of participants successfully transmitted their data wirelessly to the server. The Game Group transmitted significantly more glucose values than the Control Group (P < 0.001). The Game Group also had significantly less hyperglycemia (glucose >/=13.9 mmol/L or >/=250 mg/dL) than the Control Group (P < 0.001). Youth in the Game Group displayed a significant increase in diabetes knowledge over the 4-week trial (P < 0.005). Finally, there was a trend for more youth in the Game Group to maintain hemoglobin A1C values </=8% (P = 0.06). Thus a pediatric population with diabetes can successfully implement new technologies to facilitate BGM. Use of a motivational game appears to increase the frequency of monitoring, reduce the frequency of hyperglycemia, and improve diabetes knowledge, and may help to optimize glycemic control.

Translating what we have learned into practice. Principles and hypotheses for interventions addressing multiple behaviors in primary care

BACKGROUND

The evidence base regarding what works in practice for helping patients change multiple risk behaviors is less developed than is the more basic literature on behavior change. Still, there is enough consistency of findings to present testable hypotheses for clinicians and administrators to evaluate and guide practice until more definitive evidence is available.

METHODS

The behavior change principles known as the 5A's outline a sequence of support activities (assess, advise, agree, assist, arrange) that are effective for helping patients to change various health behaviors. These same principles also apply at the clinic level for designing activities to support behavior change.

RESULTS

Successful practices promoting sustainable changes in multiple behaviors are patient centered, tailored, proactive, population based, culturally proficient, multilevel, and ongoing. Often a stepped-care model can be used to provide increasingly intensive (and costly) interventions for patients who are not successful at earlier intervention levels.

CONCLUSIONS

Contextual factors are influential in determining success at both the patient and the office practice level. Therefore, greater attention should be paid to creating supportive family, healthcare system, and community resources and policies. We enumerate 15 hypotheses to be tested for improving patient-clinician interactions and for medical office change.

Implementing practical interventions to support chronic illness self-management

BACKGROUND

Self-management support (SMS) is the area of disease management least often implemented and most challenging to integrate into usual care. This article outlines a model of SMS applicable across different chronic illnesses and health care systems, presents recommendations for assisting health care professionals and practice teams to make changes, and provides tips and lessons learned. Strategies can be applied across a wide range of conditions and settings by health educators, care managers, quality improvement specialists, researchers, program evaluators, and clinician leaders. Successful SMS programs involve changes at multiple levels: patient-clinician interactions; office environment changes; and health system, policy, and environmental supports. PATIENT-CLINICIAN INTERACTION LEVEL: Self-management by patients is not optional but inevitable because clinicians are present for only a fraction of the patient's life, and nearly all outcomes are mediated through patient behavior. Clinicians who believe they are in control or responsible for a patient's well-being are less able to adopt an approach that acknowledges the central role of the patient in his or her care.

SUMMARY AND CONCLUSIONS

Self-management should be an integral part of primary care, an ongoing iterative process, and patient centered; use collaborative goal setting and decision making; and include problem solving, outreach, and systematic follow-up.

Diabetes self-care: lessons from research on the family and broader contexts

The foundation of diabetes management is the self-care behavior of the patient. All of the systems within which the person with diabetes interacts, as well as the media and broader social and cultural values, affect this self-care behavior. In this article I focus on recent research that has examined the link between relationships in the patient's intimate network (i.e., family and close friends) and in the patient's exchange network (i.e., patient-provider relationship, Internet support). The goal of this review is to identify relational targets associated with self-care behaviors that are potentially modifiable within the diabetes medical care setting. Evidence-based suggestions are made for points of intervention entry, and areas for future research are explored.

The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results

BACKGROUND

A prerequisite to translating research findings into practice is information on consistency of implementation, maintenance of results, and generalization of effects. This follow-up report is one of the few experimental studies to provide such information on Internet-based health education.

METHODS

We present follow-up data 10 months following randomization on the "Diabetes Network (D-Net)" Internet-based self-management project, a randomized trial evaluating the incremental effects of adding (1) tailored self-management training or (2) peer support components to a basic Internet-based, information-focused comparison intervention. Participants were 320 adult type 2 diabetes patients from participating primary care offices, mean age 59 (SD = 9.2), who were relatively novice Internet users.

RESULTS

All intervention components were consistently implemented by staff, but participant website usage decreased over time. All conditions were significantly improved from baseline on behavioral, psychosocial, and some biological outcomes; and there were few differences between conditions. Results were robust across on-line coaches, patient characteristics, and participating clinics.

CONCLUSIONS

The basic D-Net intervention was implemented well and improvements were observed across a variety of patients, interventionists, and clinics. There were, however, difficulties in maintaining usage over time and additions of tailored self-management and peer support components generally did not significantly improve results.