A Culturally competent intervention of education and care for black women with type 2 diabetes

Development of a culturally tailored sleep intervention for midlife African American women: A scoping review

STUDY OBJECTIVES

Sleep disturbances are prevalent among midlife African American women (AAW). Given the cultural and psychosocial factors influencing AAW's sleep health, we aim to develop culturally tailored sleep interventions that address their unique needs.

METHODS

This scoping review examines (1) sleep in midlife AAW, (2) factors contributing to their sleep disturbances, (3) previous culturally tailored sleep interventions evaluated in this population, and (4) strategies for developing culturally tailored sleep interventions for midlife AAW. CINAHL, PubMed, and PsycINFO were searched for relevant sources.

RESULTS

Midlife AAW experience worse sleep quantity and quality, both objective and subjective, than White women. Factors contributing to midlife AAW's sleep disturbances include vasomotor symptoms, racism-related stress, various stressors and psychological factors, the superwoman/strong Black woman schema, and environmental factors. A very few studies have applied culturally tailored sleep interventions involving midlife AAW, including sleep health education delivered by peer educators. Recommendations for developing and evaluating a culturally tailored sleep intervention for midlife AAW include the following: (1) use linguistically and culturally tailored methods for recruitment and content, (2) incorporate cultural concepts and values such as religious beliefs and spirituality, (3) address population-specific sleep barriers such as racism-related stress, (4) involve family members, (5) involve community facilitators, and (6) implement interventions in culturally familiar settings, such as churches.

CONCLUSIONS

This study provides practical strategies for developing tailored sleep interventions for midlife AAW. Future research should continue to explore and refine these approaches to improve sleep health outcomes for AAW and promote their overall well-being.

Process Evaluations of Diabetes Self-Management Programs: A Systematic Review of the Literature

OBJECTIVE

To conduct a systematic review of process evaluations (PEs) of diabetes self-management programs (DSMPs).

DATA SOURCE

An electronic search using Medline (Ovid), Embase (Ovid), CINAHL (Ensco), Academic Search (Ebsco), and APA PsycInfo (Ebsco).

STUDY INCLUSION AND EXCLUSION CRITERIA

Peer-reviewed, empirical quantitative, qualitative, or mixed-method studies were included if they (1) were a traditional, group-based DSMP, (2) involved adults at least 18 years with T1DM or T2DM, (3) were a stand-alone or embedded PE, and (4) published in English.

DATA EXTRACTION

The following process evaluation outcomes were extracted: fidelity, dose delivered, dose received, reach, recruitment, retention, and context. Additional items were extracted, (eg, process evaluation type, data collection methods; theories; frameworks or conceptual models used to guide the process evaluation, and etc).

DATA SYNTHESIS

Due to heterogeneity across studies, studies were synthesized qualitatively (narratively).

RESULTS

Sixty-eight studies (k) in 78 articles (n) (k = 68; n = 78) were included. Most were mixed methods of low quality. Studies were typically integrated into outcome evaluations vs being stand-alone, lacked theoretical approaches to guide them, and incorporated limited outcomes such as dose received, reach, and retention.

CONCLUSION

Future research should 1) implement stand-alone theoretically grounded PE studies and 2) provide a shared understanding of standardized guidelines to conduct PEs. This will allow public health practitioners and researchers to assess and compare the quality of different programs to be implemented.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

PROSPERO CRD42021245772.

An Integrative Review of Sistah Circles in Empirical Research

Sistah circles are spaces shared by Black women who share similar goals, exchange resources (e.g., support), and invest in developing strong relational bonds over time. Considering the significance of sistah circles for Black women's wellness and survival, in this study we examined how this phenomenon has been researched in the social sciences literature and, in turn, offered a more refined conceptual definition and framework that will direct future research on this topic. Specifically, we completed an integrative review of empirical studies on sistah circles using social science databases and search engines to identify relevant literature. Articles included for review met the following criteria: (a) published between 2000 and 2020, (b) analyzed empirical data, (c) were composed of Black women participants, and (d) mentioned Black women groups or friendships. Qualifying sources ( N = 45) were organized into a taxonomy of three types of sistah circles: health-focused, social, and professional. We also analyzed sample characteristics, research methods, and publication trends across all of the articles included in the review. Based upon our taxonomy and results of our review, we highlight the strengths and limitations of the current scholarship focused on Black women's sistah circles and offer suggestions regarding future research and practice. Additional online materials for this article are available on PWQ's website at http://journals.sagepub.com/doi/suppl/10.1177/03616843231154564

Cultural adaptation and psychometric evaluation of the Kinyarwanda version of the problem areas in diabetes (PAID) questionnaire

Background

High prevalence rates in diabetes-related distress have been observed in several studies; however, in the region of Sub-Saharan Africa evidence is lacking as is, for example, the case for Rwanda, where diabetes prevalence is expected to increase over the next decade. The aim of this study is to report on the translation and cultural adaption of the problem areas in diabetes (PAID) questionnaire into Kinyarwanda and its psychometric properties.

Methods

The questionnaire was translated following a standard procedure. Interviews were conducted with 29 participants before producing a final version. For the psychometric evaluation, a sample of 266 patients with diabetes mellitus, aged 21–64 years old were examined. Participants either came from a separate cluster-randomised controlled trial or were recruited ad-hoc for this study. The evaluation included testing internal consistency, known groups validity, and construct validity. A series of confirmatory factor analysis were conducted investigating seven previously established factorial structures. An exploratory factor analysis (EFA) was also carried out to examine the structure further.

Results

The full scale showed good internal reliability (Cronbach’s α = 0.88). A four-factor solution previously tested in Spain with subdimensions of emotional, treatment, food-related and social-support problems demonstrated adequate approximate fit (RMSEA = 0.056; CFI = 0.951; TLI = 0.943). The EFA revealed a four-factor structure; however, two of these factors were not as homogeneous and easily interpretable as those of the Spanish model.

Conclusions

The psychometric properties of the Kinyarwanda version of PAID are acceptable. The questionnaire can be helpful in research and clinical practice in Rwanda, however certain cross-cultural differences should be taken into account.

Recruitment and enrollment of participants in an online diabetes self-management intervention in a virtual environment

Effective recruitment of research participants is essential for successful randomized controlled trials and remains one of the most challenging and labor-intensive aspects of conducting research. The purpose of this manuscript is to describe recruitment methods for this two-group, internet-based intervention trial and enrollment status in relation to recruitment methods, accounting for accrual rates and recruitment costs and to discuss our recruitment results and limitations informed by the Clinical Trials Transformation Initiative (CTTI) team's evidence and expert-based recommendations for recruitment. The primary study was a two-group randomized controlled trial designed to evaluate the efficacy of a virtual environment, Diabetes LIVE©, compared to a traditional website format to provide diabetes self-management education and support to adults with type 2 diabetes. Our recruitment experience was labor-intensive, multimodal, and required multiple iterations throughout the study to meet recruitment goals. To allow for more efficient and realistic budgets aligned with funding, researchers should engage stakeholders in recruitment planning and monitor and report personnel time and cost by recruitment methods. To allow for more efficient and effective recruitment into meaningful clinical trials and of interest to participants, researchers should use a participative approach during all study phases, including question development.

Providing culturally sensitive diabetes self-management education and support for black African and Caribbean communities: a qualitative exploration of the challenges experienced by healthcare practitioners in inner London

INTRODUCTION

Poor access to, and engagement with, diabetes healthcare is a significant issue for black British communities who are disproportionately burdened by type 2 diabetes (T2D). Tackling these inequalities is a healthcare priority. The purpose of this research was to explore the experiences of healthcare practitioners providing diabetes self-management education and support (DSMES) to African and Caribbean adults living with T2D to inform the development of a culturally tailored DSMES program.

RESEARCH DESIGN AND METHODS

Semi-structured interviews were carried out with a range of healthcare practitioners including diabetes specialist nurses, dietitians and general practitioners based in primary care in inner London. Thematic content analysis was used to identify barriers and facilitators relating to the provision of effective DSMES.

RESULTS

Ten interviews were conducted. There was a strong consensus among healthcare practitioners for the importance of DSMES in T2D healthcare. However, practitioners discussed this area of practice as overwhelmingly challenging and recognized a wide range of barriers that they face. Four themes were identified: (1) The tension between structural and responsive care needs, particularly with growing numbers of patients alongside incentivized targets driving a care agenda that does not meet the needs of diverse communities; (2) challenges posed by cultural beliefs and practices, particularly a distrust of conventional medicine, rejection of body mass index standards and a belief in 'God's will'; (3) building relationships through cultural understanding: insiders and outsiders, particularly the benefits of racial concordance and cultural knowledge/resources and (4) getting the messages across, particularly the need to address gaps in structured education.

CONCLUSION

Provision of culturally sensitive DSMES is a challenging area of practice for practitioners, who recognize the need for more training and resources to support them in developing cultural competence. Nonetheless, practitioners recognize the importance of DSMES and are striving to provide culturally sensitive care to their patients.

Culturally competent healthcare - A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision

BACKGROUND

Culturally and linguistically diverse patients access healthcare services less than the host populations and are confronted with different barriers such as language barriers, legal restrictions or differences in health beliefs. In order to reduce these disparities, the promotion of cultural competence in healthcare organizations has been a political goal. This scoping review aims to collect components and strategies from evaluated interventions that provide culturally competent healthcare for culturally and linguistically diverse patients within healthcare organizations and to examine their effects on selected outcome measures. Thereafter, we aim to organize identified components into a model of culturally competent healthcare provisions.

METHODS AND FINDINGS

A systematic literature search was carried out using three databases (Pubmed, PsycINFO and Web of Science) to identify studies which have implemented and evaluated cultural competence interventions in healthcare facilities. PICO criteria were adapted to formulate the research question and to systematically choose relevant search terms. Sixty-seven studies implementing culturally competent healthcare interventions were included in the final synthesis. Identified strategies and components of culturally competent healthcare extracted from these studies were clustered into twenty categories, which were organized in four groups: Components of culturally competent healthcare-Individual level; Components of culturally competent healthcare-Organizational level; Strategies to implement culturally competent healthcare and Strategies to provide access to culturally competent healthcare. A model integrating the results is proposed. The overall effects on patient outcomes and utilization rates of identified components or strategies were positive but often small or not significant. Qualitative data suggest that components and strategies of culturally competent healthcare were appreciated by patients and providers.

CONCLUSION

This scoping review used a bottom-up approach to identify components and strategies of culturally competent healthcare interventions and synthesized the results in a model of culturally competent healthcare provision. Reported effects of single components or strategies are limited because most studies implemented a combination of different components and strategies simultaneously.

HRQOL in Diverse Ethnic Groups with Diabetes: Findings from the 2014 BRFSS

OBJECTIVE

The study's objective is to examine differences in mental and physical health-related quality of life (HRQOL) in non-Hispanic White, non-Hispanic Black, and Hispanic adults with diabetes.

DESIGN

A secondary analysis of 2014 Behavioral Risk Factor Surveillance System (BRFSS) data was conducted. A total of 26 states participated in the 2014 BRFSS core and optional diabetes models (n = 17,923). HRQOL was measured by the number of mentally and physically unhealthy days during the past month, respectively. A series of regression models were developed to assess differences in HRQOL without and with inclusion of demographic (age, marital status, income, gender, and education) and diabetes-related (depression, sleep time, insulin use, complications, age of diabetes diagnosis, BMI, smoking, and exercise) factors.

RESULTS

In the fully adjusted models (inclusion of demographic and diabetes-related factors), non-Hispanic Whites had more mentally (β = 0.88, p = 0.03) and physically (β = 1.35, p = 0.01) unhealthy days per month compared to Hispanics. Non-Hispanic Blacks (β = 1.42, p < 0.01) also had more mentally unhealthy days per month in relation to Hispanics when adjusting for demographic and diabetes-related factors. Depression emerged as a potent predictor of mentally (β = 8.60; p < 0.0001) and physically (β = 4.43; p < 0.0001) unhealthy days in the multivariate models.

CONCLUSION

Non-Hispanic Black and White adults with diabetes may be more vulnerable to poor HRQOL compared to their Hispanic counterparts. Increased, widened application of diabetes interventions targeting depression appears warranted to improve HRQOL outcomes.

Effectiveness of an intervention to improve diabetes self-management on clinical outcomes in patients with low educational level

OBJECTIVE

To determine whether an intervention based on patient-practitioner communication is more effective than usual care in improving diabetes self-management in patients with type 2 diabetes with low educational level.

METHODS

12-month, pragmatic cluster randomised controlled trial. Nine physicians and 184 patients registered at two practices in a deprived area of Granada (Andalusia, Spain) participated in the study. Adult patients with type 2 diabetes, low educational level and glycated haemoglobin (HbA1c) > 7% (53.01 mmol/mol) were eligible. The physicians in the intervention group received training on communication skills and the use of a tool for monitoring glycaemic control and providing feedback to patients. The control group continued standard care. The primary outcome was difference in HbA1c after 12 months. Dyslipidaemia, blood pressure, body mass index and waist circumference were also assessed as secondary outcomes. Two-level (patient and provider) regression analyses controlling for sex, social support and comorbidity were conducted.

RESULTS

The HbA1c levels at 12 months decreased in both groups. Multilevel analysis showed a greater improvement in the intervention group (between-group HbA1c difference= 0.16; p=0.049). No statistically significant differences between groups were observed for dyslipidaemia, blood pressure, body mass index and waist circumference.

CONCLUSIONS

In this pragmatic study, a simple and inexpensive intervention delivered in primary care showed a modest benefit in glycaemic control compared with usual care, although no effect was observed in the secondary outcomes. Further research is needed to design and assess interventions to promote diabetes self-management in socially vulnerable patients.

Renal Disease Risk Factors Among Risk Groups Comprised of African American Women With Type 2 Diabetes: A Secondary Analysis

PURPOSE

The purpose of this study was to explore and describe the prevalence of renal disease risk factors and the categorization of renal disease risk groups among African American women with type 2 diabetes mellitus (T2DM) who participated in a self-management and coping skills training intervention. We also explored and described the change in renal disease risk factors within and between risk groups, determining if participation in a culturally relevant coping skills training intervention decreased renal disease risk.

METHODS

This study was a secondary analysis of data from a longitudinal intervention study and included all 109 African American women with T2DM from the primary intervention study. This study examined the prevalence of 4 renal disease risk factors among the women at baseline via descriptive statistics, used cluster analysis to divide the women into risk groups and categorize the risk groups, and also measured the change in risk factors over time among risk groups via mixed modeling.

RESULTS

A majority of the women had a hemoglobin A1C ≥7% (62.39%) and were obese (75.93%). The high-risk cluster displayed clinically significant declines in mean systolic blood pressure, triglycerides, and A1C in both the control and intervention groups, and the intervention was more effective in reducing triglycerides and A1C levels among high-risk participants than low-risk. Overall, the control, high-risk group exhibited the largest declines in systolic blood pressure, triglycerides, and A1C.

CONCLUSIONS

This study displays the importance of acknowledging African American women with type 2 diabetes mellitus (T2DM) at high risk for renal disease in health care settings, which is often overlooked, and realizing that renal disease risk reduction is obtainable.

Quality of care provided by mid-level health workers: systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of care provided by mid-level health workers.

METHODS

Experimental and observational studies comparing mid-level health workers and higher level health workers were identified by a systematic review of the scientific literature. The quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria and data were analysed using Review Manager.

FINDINGS

Fifty-three studies, mostly from high-income countries and conducted at tertiary care facilities, were identified. In general, there was no difference between the effectiveness of care provided by mid-level health workers in the areas of maternal and child health and communicable and noncommunicable diseases and that provided by higher level health workers. However, the rates of episiotomy and analgesia use were significantly lower in women giving birth who received care from midwives alone than in those who received care from doctors working in teams with midwives, and women were significantly more satisfied with care from midwives. Overall, the quality of the evidence was low or very low. The search also identified six observational studies, all from Africa, that compared care from clinical officers, surgical technicians or non-physician clinicians with care from doctors. Outcomes were generally similar.

CONCLUSION

No difference between the effectiveness of care provided by mid-level health workers and that provided by higher level health workers was found. However, the quality of the evidence was low. There is a need for studies with a high methodological quality, particularly in Africa - the region with the greatest shortage of health workers.

Community Interventions to Improve Glycemic Control in African Americans with Type 2 Diabetes: A Systemic Review

PURPOSE

The purpose of this study was to conduct a systematic review of published community interventions to evaluate different components of community interventions and their ability to positively impact glycemic control in African Americans with T2DM.

METHODS

Medline, PsychInfo, and CINAHL were searched for potentially eligible studies published from January 2000 through January 2012. The following inclusion criteria were established for publications: (1) describe a community intervention, not prevention; (2) specifically indicate, in data analysis and results, the impact of the community intervention on African American adults, 18 years and older; (3) measure glycemic control (HbA1C) as an outcome measure; and (4) involve patients in a community setting, which excludes hospitals and hospital clinics.

RESULTS

Thirteen studies out of 9,233 articles identified in the search met the predetermined inclusion criteria. There were 5 randomized control trials and 3 reported improved glycemic control in the intervention group compared to the control group at the completion of the study. Of the 8 studies that were not randomized control trials, 6 showed a statistically significant change in HbA1C.

CONCLUSION

In general, the community interventions assessed led to significant reductions in HbA1C in African Americans with type 2 diabetes. Community health workers did not have a greater impact on glycemic control in this sample. The findings of this study provides insight for designing community-based interventions in the future, such as including use of multiple delivery methods, consideration of mobile device software, nutritionist educator, and curriculum-based approaches.

Characteristics and effectiveness of diabetes self-management educational programs targeted to racial/ethnic minority groups: a systematic review, meta-analysis and meta-regression

BACKGROUND

It is not clear to what extent educational programs aimed at promoting diabetes self-management in ethnic minority groups are effective. The aim of this work was to systematically review the effectiveness of educational programs to promote the self-management of racial/ethnic minority groups with type 2 diabetes, and to identify programs' characteristics associated with greater success.

METHODS

We undertook a systematic literature review. Specific searches were designed and implemented for Medline, EMBASE, CINAHL, ISI Web of Knowledge, Scirus, Current Contents and nine additional sources (from inception to October 2012). We included experimental and quasi-experimental studies assessing the impact of educational programs targeted to racial/ethnic minority groups with type 2 diabetes. We only included interventions conducted in countries members of the OECD. Two reviewers independently screened citations. Structured forms were used to extract information on intervention characteristics, effectiveness, and cost-effectiveness. When possible, we conducted random-effects meta-analyses using standardized mean differences to obtain aggregate estimates of effect size with 95% confidence intervals. Two reviewers independently extracted all the information and critically appraised the studies.

RESULTS

We identified thirty-seven studies reporting on thirty-nine educational programs. Most of them were conducted in the US, with African American or Latino participants. Most programs obtained some benefits over standard care in improving diabetes knowledge, self-management behaviors and clinical outcomes. A meta-analysis of 20 randomized controlled trials (3,094 patients) indicated that the programs produced a reduction in glycated hemoglobin of -0.31% (95% CI -0.48% to -0.14%). Diabetes knowledge and self-management measures were too heterogeneous to pool. Meta-regressions showed larger reduction in glycated hemoglobin in individual and face to face delivered interventions, as well as in those involving peer educators, including cognitive reframing techniques, and a lower number of teaching methods. The long-term effects remain unknown and cost-effectiveness was rarely estimated.

CONCLUSIONS

Diabetes self-management educational programs targeted to racial/ethnic minority groups can produce a positive effect on diabetes knowledge and on self-management behavior, ultimately improving glycemic control. Future programs should take into account the key characteristics identified in this review.

A randomized-controlled, pilot intervention on diabetes prevention and healthy lifestyles in the New York City Korean community

Asian Americans experience diabetes at a higher rate than non-Hispanic whites. Diabetes prevention programs using lifestyle interventions have been shown to produce beneficial results, yet there have been no culturally-tailored programs for diabetes prevention in the Korean community. We explore the impact and feasibility of a pilot Community Health Worker (CHW) intervention to improve health behaviors and promote diabetes prevention among Korean Americans using a randomized controlled trial. Between 2011 and 2012, a total of 48 Korean Americans at risk for diabetes living in New York City (NYC) participated in the intervention. Participants were allocated to treatment or control groups. A community-based participatory research approach guided development of the intervention, which consisted of 6 workshops held by CHWs on diabetes prevention, nutrition, physical activity, diabetes complications, stress and family support, and access to health care. Changes over 6 months were examined for clinical measurements (weight, BMI, waist circumference, blood pressure, glucose, and cholesterol); health behaviors (physical activity, nutrition, food behaviors, diabetes knowledge, self-efficacy, and mental health); and health access (insurance and self-reported health). In this small pilot study, changes were seen in weight, waist circumference, diastolic blood pressure, physical activity nutrition, diabetes knowledge, and mental health. Qualitative findings provide additional contextual information that inform ways in which CHWs may influence health outcomes. These findings demonstrate that a diabetes prevention program can be successful among a Korean American population in NYC, and important insight is provided for ways that programs can be tailored to meet the needs of vulnerable populations.

Assessing knowledge and attitudes of diabetes in Zuni Indians using a culture-centered approach

INTRODUCTION

The Zuni Pueblo, in collaboration with the University of New Mexico, have formed the Zuni Health Initiative (ZHI) engaged in community-based participatory research to plan and implement educational interventions to reduce health disparities. We conducted the first phase of ZHI study and identified barriers to healthcare. We concluded that the burden presented by these barriers ultimately translates into a lack of patient activation and engagement in their health care including for diabetes, effectively hindering adoption of healthy behaviors.

METHODS

Community health representatives (CHRs) led 10 one-hour focus group sessions to elicit information on diabetes knowledge and self-management strategies at which a total of 84 people participated. Audiotapes were translated and transcribed by bilingual ZHI staff. We reduced the text to thematic categories, constructed a coding dictionary and inserted the text into NVivo 9 program.

RESULTS

The focus groups revealed that despite extensive personal or family experiences with diabetes or complications, participants identified knowledge gaps in the disease progression and disease management. However, we gained insight into how many Zunis conceptualize the etiology of diabetes, risk factors associated with diabetes, sources of knowledge and self-management practices.

CONCLUSION

We concluded that many of the Zuni diabetics experience significant impacts on their life when they were diagnosed with diabetes and suffered the plight of stigmatization. We further concluded that developing Zuni culture specific diabetes care should focus on family involvement with continued education.

Behavior change interventions to improve the health of racial and ethnic minority populations: a tool kit of adaptation approaches

CONTEXT

Adapting behavior change interventions to meet the needs of racial and ethnic minority populations has the potential to enhance their effectiveness in the target populations. But because there is little guidance on how best to undertake these adaptations, work in this field has proceeded without any firm foundations. In this article, we present our Tool Kit of Adaptation Approaches as a framework for policymakers, practitioners, and researchers interested in delivering behavior change interventions to ethnically diverse, underserved populations in the United Kingdom.

METHODS

We undertook a mixed-method program of research on interventions for smoking cessation, increasing physical activity, and promoting healthy eating that had been adapted to improve salience and acceptability for African-, Chinese-, and South Asian-origin minority populations. This program included a systematic review (reported using PRISMA criteria), qualitative interviews, and a realist synthesis of data.

FINDINGS

We compiled a richly informative data set of 161 publications and twenty-six interviews detailing the adaptation of behavior change interventions and the contexts in which they were undertaken. On the basis of these data, we developed our Tool Kit of Adaptation Approaches, which contains (1) a forty-six-item Typology of Adaptation Approaches; (2) a Pathway to Adaptation, which shows how to use the Typology to create a generic behavior change intervention; and (3) RESET, a decision tool that provides practical guidance on which adaptations to use in different contexts.

CONCLUSIONS

Our Tool Kit of Adaptation Approaches provides the first evidence-derived suite of materials to support the development, design, implementation, and reporting of health behavior change interventions for minority groups. The Tool Kit now needs prospective, empirical evaluation in a range of intervention and population settings.

The effects of a culturally sensitive, empowerment-focused, community-based health promotion program on health outcomes of adults with type 2 diabetes

The purpose of the present study was to test the effects of a culturally sensitive, health empowerment-focused, community-based health promotion program tailored to adult patients with type 2 diabetes on these patients' body mass index (BMI), blood pressure, and self-reported blood glucose levels, treatment adherence, and stress levels. Study participants (N = 130) consisted mostly of African Americans (70%) and Hispanic/Latinos (22.3%) who were divided almost evenly between an intervention group and wait-list control group. The tested health promotion program is informed by Health Self-Empowerment Theory. At post-test, program participants in the intervention group as compared to those in the control group demonstrated significantly lower levels of BMI, diastolic blood pressure, and physical stress. Implications of these study findings for future similar programs and research are discussed.

Psychometric evaluation of a cultural competency assessment instrument for health professionals

BACKGROUND

Few valid and reliable measures exist for health care professionals interested in determining their levels of cultural and linguistic competence.

OBJECTIVE

To evaluate the measurement properties of the Cultural Competence Health Practitioner Assessment (CCHPA-129).

METHODS

The CCHPA-129 is a 129-item web-based instrument, developed by the National Center for Cultural Competence. Responses on the CCHPA -129 were examined using factor analysis; Rasch modeling; and differential item functioning across race, ethnicity, sex, and profession.

SUBJECTS

A total of 2504 practitioners, including 1864 nurses (RN/LPN/BSN); 341 clinicians (PA/NP); and 299 physicians (MD/DO), who completed the CCHPA-129 online between 2005 and 2008.

RESULTS

Three factors representing domains of Knowledge, Adapting Practice, and Promoting Health for culturally and linguistically diverse populations accounted for 46% of the variance. Among Knowledge factor items, 53% (23/43) fit the Rasch model, item difficulties ranged from -1.01 logits (least difficult) to +1.11 logits (most difficult), separation index (SI) 13.82, and Cronbach's α 0.92. Forty-seven percent (21/44) Adapting Practice factor items fit the model, item difficulties -0.07 to +1.11 logits, SI 11.59, Cronbach's α 0.88; and 58% (23/39). Promoting Health factor items fit the model, item difficulties -1.01 to +1.38 logits, SI 22.64, Cronbach's α 0.92. Early evidence of validity was established by known groups having statistically different scores.

CONCLUSIONS

The 67-item CCHPA-67 is psychometrically sound. This shorted instrument can be used to establish associations between practitioners' cultural and linguistic competence and health outcomes as well as to evaluate interventions to increase practitioners' cultural and linguistic competence.

Enhancing diabetes self-care among rural African Americans with diabetes: results of a two-year culturally tailored intervention

PURPOSE

The purpose of this study is to test the feasibility of conducting a community-based randomized controlled trial evaluating a culturally tailored community-based group diabetes self-management education (DSME) program among rural African Americans.

METHODS

Thirty-two African American rural adults with type 2 diabetes were recruited and 25 adults were retained and participated in an interventional study designed to test the effectiveness of the "Taking Care of Sugar" DSME program for the 2-year follow-up. Participants were selected from rural central Virginia. Primary outcomes variables included average blood sugar levels, cardiovascular risk factors, and general physical and mental health. These outcomes were assessed at baseline, 3 months, 6 months, and 12 months post baseline.

RESULTS

From baseline to 3-month follow-up assessment, participants exhibited significant improvement on several physiological and behavioral measures. Given the small sample size, hypothesis testing was limited. Results show change from baseline over time, illustrating that the primary outcome of A1C decreased, although not significant. Additionally, participants reported more knowledge about diabetes self-management and personal care skills (ie, exercise and foot care) that persisted over time. The feasibility of the culturally tailored DSME was established, and participation with the program was high.

CONCLUSIONS

A community-based group DSME program using storytelling is feasible. This research will help to inform clinicians and health policymakers as to the types of interventions that are feasible in a larger rural population. If such a program is carried out, we can improve knowledge, reduce complications, and improve quality of life among rural African Americans.

A theoretical framework for a virtual diabetes self-management community intervention

Due to its high prevalence, chronic nature, potential complications, and self-management challenges for patients, diabetes presents significant health education and support issues. We developed and pilot-tested a virtual community for adults with type 2 diabetes to promote self-management education and provide social support. Although digital-based programs such as virtual environments can address significant barriers to reaching patients (i.e., child care, transportation, location), they must be strongly grounded in a theoretical basis to be well-developed and effective. In this article, we discuss how we synthesized behavioral and virtual environment theoretical frameworks to guide the development of SLIDES (Second Life Impacts Diabetes Education and Support).

Evaluation of a community health worker pilot intervention to improve diabetes management in Bangladeshi immigrants with type 2 diabetes in New York City

PURPOSE

The purpose of this study is to explore the impact and feasibility of a pilot Community Health Worker (CHW) intervention to improve diabetes management among Bangladeshi-American individuals with type 2 diabetes living in New York City.

METHODS

Participants were recruited at clinic- and community-based venues. The intervention consisted of 6 monthly, CHW-facilitated group sessions on topics related to management of diabetes. Surveys were collected at baseline and follow-up time points. Study outcomes included clinical, behavioral, and satisfaction measures for participants, as well as qualitative measures from CHWs.

RESULTS

Improvements were seen in diabetes knowledge, exercise and diet to control diabetes, frequency of checking feet, medication compliance, and self-efficacy of health and physical activity from baseline to 12 months. Additionally, there were decreases in A1C, weight, and body mass index. Program evaluation revealed a high acceptability of the intervention, and qualitative findings indicated that CHWs helped overcome barriers and facilitated program outcomes through communal concordance, trust, and leadership.

CONCLUSIONS

The intervention demonstrated high acceptability and suggested efficacy in improving diabetes management outcomes among Bangladeshi immigrants in an urban setting. The US Bangladeshi population will continue to increase, and given the high rates of diabetes, as well as linguistic and economic barriers faced by this community, effective and culturally tailored health interventions are needed to overcome barriers and provide support for diabetes management.

Influence of a Community Health Worker Intervention on Mental Health Outcomes among Low-Income Latino and African American Adults with Type 2 Diabetes

This study investigated the influence of a community health worker (CHW) diabetes lifestyle intervention on mental health outcomes. Our study was guided by the principles of community-based participatory research. Data were collected from 164 African American (N = 94) and Hispanic adults (N = 70) participating in a randomized, 6-month delayed intervention group design for improving glycemic control. The intervention time periods were baseline to 6 months for the treatment group and 6-12 months for the delayed group. Linear mixed models were used to conduct longitudinal analyses of the Problem Areas in Diabetes (PAID) and Patient Health Questionnaire (PHQ) scales. In the model adjusted for demographics, the PAID dropped significantly from pre-intervention to post-intervention within both the treatment and delayed groups (p < 0.05) with an average intervention effect of -6.4 (p < 0.01). The PAID dropped even further within the immediate group from 6 to 12 months. Although the PHQ did not change significantly, the PHQ-2 had an average intervention effect of -0.3 (p < 0.05) in the model adjusted for demographics. This study contributes to an understanding of how a CHW-led diabetes intervention can result in positive mental health outcomes for Latinos and African Americans with Type 2 diabetes. It also highlights the importance of further exploring what factors may contribute to racial/ethnic variation in mental health outcomes for African Americans and Latinos with diabetes and the role CHWs can play.

A methodological review of faith-based health promotion literature: advancing the science to expand delivery of diabetes education to Black Americans

Non-traditional avenues, such as faith-based organizations (FBOs), must be explored to expand delivery of diabetes self-management education (DSME) to benefit Black Americans with type 2 diabetes (T2D). The purpose of this study was to methodologically review the faith-based health promotion literature relevant to Blacks with T2D. A total of 14 intervention studies were identified for inclusion in the review. These studies detailed features of methods employed to affect health outcomes that DSME similarly targets. Analysis of the faith-based studies' methodological features indicated most studies used (1) collaborative research approaches, (2) pre-experimental designs, (3) similar recruitment and retention strategies, and (4) culturally sensitive, behaviorally oriented interventions with incorporation of social support to achieve positive health outcomes in Black Americans. Findings indicate FBOs may be a promising avenue for delivering DSME to Black Americans. Informed by the findings, a focused discussion on advancing the science of faith-based interventions to expand delivery of DSME to Black Americans with diabetes is provided.

Effects of food-related interventions for African American women with type 2 diabetes

PURPOSE

The purpose of this systematic review is to synthesize research that tested culturally competent food-related interventions designed for African American women with type 2 diabetes, to review the current state of the literature and suggest recommendations for future research. Many African American women with type 2 diabetes are challenged to change their culturally rooted food habits to achieve diabetes control. Diabetes educators and clinicians who work with African American women need knowledge of effective interventions to assist their clients.

METHODS

Online databases and research articles' reference lists were searched for relevant studies published from 1989 to 2010 that tested culturally competent type 2 diabetes management interventions for African American women, that included at least 1 educational session on diet or nutrition, and that addressed a physiologic outcome, such as glycosylated hemoglobin or fasting blood glucose.

RESULTS

Fifteen studies met the inclusion criteria for this review. Among them, 64% to 100% of the participants were African Americans, and 65% to 100% were women. Six studies showed significant improvements in food practices, and 8 showed significant improvements in glycemic control as a result of the interventions.

CONCLUSIONS

Few studies focused solely on helping African American women make culturally relevant dietary changes to control type 2 diabetes. Most interventions addressed food habits as one of many components for diabetes control, perhaps overwhelming research participants with large amounts of varied information. Targeted interventions are recommended that focus on dietary changes as the foundation for diabetes self-management education for African American women.

The future of the cancer prevention workforce: why health literacy, advocacy, and stakeholder collaborations matter

In considering the role of the cancer prevention workforce in meeting the nation's future health care needs, it is vital to address the considerable gaps in information, communication, training, professional development, roles, and levels of collaboration among diverse disciplines, stakeholders, and constituencies. As part of an October 2009 symposium at The University of Texas MD Anderson Cancer Center entitled "Future Directions in Cancer Prevention and Control: Workforce Implications for Training, Practice, and Policy," the Health Policy and Advocacy Working Group was convened to discuss barriers to closing these gaps. Three major themes emerged from the group's deliberations and are discussed here: (1) the role of critical health literacy and evidence-based collaborations in cancer prevention education, research, and practice; (2) the implications of health advocacy for policy development and clinical and public health practice; and (3) culturally and linguistically appropriate cancer prevention programs and information within advocacy/workforce collaborations. Mechanisms for addressing these gaps are presented.

Diabetes and psychological profile of younger rural African American women with type 2 diabetes

PURPOSE

To describe diabetes self-care behaviors, diabetes-related distress, depressive symptoms, and diabetes-related needs among rural African American women with type 2 diabetes ages 21-50.

METHODS

A cross-sectional survey, including questionnaires and a single, open-ended question, was used to assess constructs of interest.

FINDINGS

Taking medication was the most frequently reported (5.5 days/week) self-care activity and exercise the least (3.0 days/week). Nearly half (44%) reported worrying about diabetes complications. Approximately one-third (31%) felt guilty about inconsistent self-care or fearful about living with diabetes. Seventy percent had a depression score suggestive of significant depressive symptomatology. Most diabetes-related concerns were about diet (34%) (i.e., what to eat), exercise (30%), taking medications (10%), and finances (8%).

CONCLUSIONS

Future research should explore specific diabetes self-care barriers/enablers and interventions should provide women with diabetes education, barrier management, and psychological support. Innovative delivery strategies are needed to provide this support in resource-limited rural communities.

Physical activity-related experiences, counseling expectations, personal responsibility, and altruism among urban African American women with type 2 diabetes

PURPOSE

The purpose of this study was to explore physical activity-related experiences, perceptions, and counseling expectations among urban, underactive, African American women with type 2 diabetes.

METHODS

Participants were recruited via flyers and endocrinologist referral. A professional, African American female moderator led 2 focus groups among 11 participants. Focus groups were conducted in a video- and audio-equipped focus group room in the evening hours. Using a content-based, stepped analytic approach, 2 raters independently analyzed data and collaborated to compare results and finalize themes.

RESULTS

Competing priorities and lack of motivation were perceived as significant barriers to physical activity. Physical activity-related counseling expectations (ie, physician encouragement) and experiences (physician advising) were inconsistent. Participants expressed a high degree of physical activity-related health responsibility. Altruistic intentions were high relative to helping others incorporate healthful lifestyle changes.

CONCLUSIONS

When counseling women about physical activity, diabetes educators should acknowledge and provide support and resources to help women incorporate more physical activity into their regular routines and enhance motivation for physical activity. Educators should also couple physical activity-related advice with encouragement and support. Because of high levels of altruism, educators should consider implementing group- and/or peer-based physical activity interventions in this patient group.

The Effect of a Diabetes Education, Coping Skills Training, and Care Intervention on Physiological and Psychosocial Outcomes in Black Women With Type 2 Diabetes

An 11-week culturally relevant group diabetes self-management training (DSMT), coping skills training (CST), and diabetes care intervention was compared to a 10-week usual diabetes education and diabetes care intervention on physiological and psychosocial outcomes in 109 Black women (aged 48 ± 10 years) with type 2 diabetes in primary care (PC). Strong time effects for hemoglobin A1c improvement were seen in both groups from baseline to 3 months and remained similar at 12 and 24 months (p < .0001). Systolic blood pressure (p =.01) and low-density lipoprotein cholesterol levels (p = .05) improved in both groups from baseline to 24 months. Baseline quality of life ([QOL]; Medical Outcome Study Short Form-36) was low. Social function, role-emotional, and mental health domains increased initially in both groups then declined slightly, with less decline for the experimental group at 12 months. At 24 months, experimental group scores increased. General health (p = .002), vitality (p = .01), role-physical, and bodily pain (p = .02) domains increased in both groups over time. Perceived provider support for diet (p = .0001) and exercise (p = .0001) increased in both groups over time. Diabetes-related emotional distress decreased in the experimental compared to the control group (group x time, p = .01). Findings suggest that both methods of diabetes education combined with care can improve metabolic control, QOL, and perceptions of provider care. CST may further assist in long-term improvements in health outcomes. Behavioral interventions are needed in addition to routine diabetes care, particularly in PC.

Coping as a mediator in the relationships of spiritual well-being to mental health in black women with type 2 diabetes

OBJECTIVE

Examine coping as a mediator in the relationships of spiritual well-being to mental health in Black women with type 2 diabetes (T2DM).

METHODS

Using a cross-sectional design, data were collected from a convenience sample of 45 Black women with T2DM. Measures of coping strategies, spiritual well-being (religious and existential well-being), and mental health, as measured by diabetes-specific distress (DSED), were collected. Bivariate findings informed mediational, trivariate model development.

RESULTS

Religious well-being was significantly related to cognitive reframing (CR) coping strategies (p = 0.026) but not DSED (p = 0.751). Existential well-being was significantly related to CR (beta = 0.575,p < 0.001), direct assistance (DA) coping (beta = 0.368, p = 0.006) and DSED (beta = -0.338, p = 0.023). Although CR (beta = -0.305, p = 0.021) and DA (beta = -0.262, p = 0.041) had significant bivariate associations with DSED, the relationships were not significant when existential well-being was controlled. However, the relationship of existential well-being to DSED was mediated by specific CR and DA strategies that were associated with DSED to varying degrees -"I came up with a couple different solutions to the problem" (beta = -0.301, p = 0.049); "I came out of the experience better than I went in" (beta = -0.308, p = 0.061); and "I talked to someone who could do something concrete about the problem" (beta = -0.272, p = 0.078).

CONCLUSION

Findings indicate that diabetes care address spiritual well-being, both its religious and existential components, in Black women with T2DM.

Content and frequency of writing on diabetes bulletin boards: does race make a difference?

BACKGROUND

Diabetes-related disparities are well documented among racial minority groups in the United States. Online programs hold great potential for reducing these disparities. However, little is known about how people of different races utilize and communicate in such groups. This type of research is necessary to ensure that online programs respond to the needs of diverse populations.

OBJECTIVE

This exploratory study investigated message frequency and content on bulletin boards by race in the Internet Diabetes Self-Management Program (IDSMP). Two questions were asked: (1) Do participants of different races utilize bulletin boards with different frequency? (2) Do message, content, and communication style differ by race? If so, how?

METHODS

Subjects were drawn by purposeful sampling from participants in an ongoing study of the effectiveness of the IDSMP. All subjects had completed a 6-week intervention that included the opportunity to use four diabetes-specific bulletin boards. The sample (N = 45) consisted of three groups of 15 participants, each who self-identified as American Indian or Alaskan Native (AI/AN), African American (AA), or Caucasian, and was stratified by gender, age, and education. Utilization was assessed by counting the number of messages per participant and the range of days of participation. Messages were coded blindly for message type, content, and communication style. Data were analyzed using descriptive and nonparametric statistics.

RESULTS

In assessing board utilization, AAs wrote fewer overall messages (P = .02) and AIs/ANs wrote fewer action planning posts (P = .05) compared with Caucasians. AIs/ANs logged in to the program for a shorter time period than Caucasians (P = .04). For message content, there were no statistical (P

CONCLUSIONS

Although Caucasians utilized the boards more than the other two groups, there were few differences in message type, content, or style. Since participation in bulletin boards is largely blind to race, age, gender, and other characteristics, it is not clear if finding few differences was due to this optional anonymity or because non-Caucasian participants assumed that they were communicating with Caucasians. If the low variability between racial groups indicates that the IDSMP is flexible enough to meet the needs of multiple racial groups, then online programs may be an accessible and effective tool to reduce health disparities. These questions need to be investigated in future studies.

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Key Words

• self-management
• race
• internet
• patient education
• diabetes

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MESH Headings

• Black People/statistics & numerical data
• Diabetes Mellitus/epidemiology
• Diabetes Mellitus/rehabilitation
• Diabetes Mellitus, Type 2/epidemiology
• Diabetes Mellitus, Type 2/rehabilitation
• Educational Status
• Female
• Health Behavior
• Humans
• Indians, North American/statistics & numerical data
• Internet
• Male
• Minority Groups
• Patient Education as Topic
• Quality of Life
• Self Care
• Surveys and Questionnaires
• United States
• White People/statistics & numerical data
• Writing
• Black or African American

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Grants

• F31 DK070558 NIDDK NIH HHS

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Affiliation(s)

Siobhan Case Stanford Patient Education Research Center, Stanford University, Palo Alto, CA 94304, USA
Valarie Jernigan
Audra Gardner
Philip Ritter
Catherine A Heaney
Kate R Lorig

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Collaborators Collapse

Type 2 diabetes in urban black and rural white women

PURPOSE

The purpose of this secondary analysis was to describe and compare physiological, psychosocial, and self-management characteristics of urban black and rural white women with type 2 diabetes (T2D) in the northeast United States.

METHODS

A descriptive, cross-sectional secondary analysis was conducted with baseline data from 2 independent study samples: rural white women and urban black women.

RESULTS

Results revealed the sample were on average educated, working, low-income, mid-life women with poor glycemic and blood pressure control, despite having a usual source of primary care. When compared, black women were younger, had lower income levels, worked more, and were often single and/or divorced. They had worse glycemic control, significantly higher levels of diabetes-related emotional distress, and less support than white women.

CONCLUSION

Despite differences in geography and study findings, both groups had suboptimal physiological and psychosocial levels that impede self-management. These findings serve to aid in the understanding of health disparities, emphasizing the importance of developing and evaluating effective interventions of diabetes care for women with T2D.

Culturally tailored intervention for rural African Americans with type 2 diabetes

PURPOSE

The purpose of this pilot study was to evaluate a culturally tailored intervention for rural African Americans. Social Cognitive Theory provided the framework for the study.

METHODS

Twenty-two participants were recruited and randomly assigned to either Group or Individual diabetes self-management (DSME). Group DSME included story-telling, hands-on activities, and problem-solving exercises. Individual DSME sessions focused on goal-setting and problem-solving strategies. Sessions were offered in an accessible community center over a 10-week period.

RESULTS

Outcomes included glycosylated hemoglobin (A1C), self-care actions, self-efficacy level, goal attainment, and satisfaction with DSME. Participants in both Group and Individual DSME improved slightly over the 3-month period in self-care activities, A1C level, and goal attainment. Although differences were not statistically significant, trends indicate improved scores on dietary actions, foot care, goal attainment, and empowerment for those experiencing Group DSME.

CONCLUSIONS

The culturally tailored approach was well received by all participants. Improvements among those receiving Individual DSME may indicate that brief sessions usinga culturally tailored approach could enhance self-care and glycemic control. Additional testing among more participants over a longer time period is recommended.

Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups

BACKGROUND

Ethnic minority groups in upper-middle and high income countries tend to be socio-economically disadvantaged and to have higher prevalence of type 2 diabetes than the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes.

SEARCH STRATEGY

We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals.

SELECTION CRITERIA

RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significant at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups.

AUTHORS' CONCLUSIONS

Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups.

Psychometric evaluation of the Problem Areas in Diabetes (PAID) survey in Southern, rural African American women with Type 2 diabetes

Background

The Problem Areas in Diabetes (PAID) survey is a measure of diabetes-related stress for which reported use has been in largely Caucasian populations. Our purpose was to assess the psychometric properties of the PAID in Southern rural African American women with Type 2 diabetes.

Methods

A convenience sample of African American women (N = 131) ranging from 21–50 years of age and diagnosed with Type 2 diabetes were recruited for a survey study from two rural Southern community health centers. Participants completed the PAID, Center for Epidemiological Studies-Depression Scale (CES-D), and the Summary of Diabetes Self-Care Activities Scale (SDSCA). Factor analysis, Cronbach's coefficient alpha, and construct validation facilitated psychometric evaluation.

Results

A principle component factor analysis of the PAID yielded two factors, 1) a lack of confidence subscale, and 2) a negative emotional consequences subscale. The Lack of Confidence and Negative Emotional Consequences subscales, but not the overall PAID scale, were associated with glycemic control and body mass index, respectively. Relationships with measures of depression and diabetes self-care supported construct validity of both subscales. Both subscales had acceptable (alpha = 0.85 and 0.94) internal consistency measures.

Conclusion

A psychometrically sound two-factor solution to the PAID survey is identified in Southern, rural African American women with Type 2 diabetes. Lack of confidence in and negative emotional consequences of diabetes self-care implementation provide a better understanding of determinants of glycemic control and weight than an aggregate of the two scales.

Cultural leverage: interventions using culture to narrow racial disparities in health care

The authors reviewed interventions using cultural leverage to narrow racial disparities in health care. Thirty-eight interventions of three types were identified: interventions that modified the health behaviors of individual patients of color, that increased the access of communities of color to the existing health care system, and that modified the health care system to better serve patients of color and their communities. Individual-level interventions typically tapped community members' expertise to shape programs. Access interventions largely involved screening programs, incorporating patient navigators and lay educators. Health care interventions focused on the roles of nurses, counselors, and community health workers to deliver culturally tailored health information. These interventions increased patients' knowledge for self-care, decreased barriers to access, and improved providers' cultural competence. The delivery of processes of care or intermediate health outcomes was significantly improved in 23 interventions. Interventions using cultural leverage show tremendous promise in reducing health disparities, but more research is needed to understand their health effects in combination with other interventions.

Coping and psychosocial adaptation to Type 2 diabetes in older Blacks born in the Southern US and the Caribbean

Older Black men and women (n = 212) with Type 2 diabetes completed questionnaires. Spearman's rho correlation indicated that confrontive coping strategies supported effective psychosocial adaptation for persons originally from Haiti and Jamaica, while emotive coping strategies were related to ineffective psychosocial adaptation for persons originally from Barbados and to increased psychological distress for all participants. Women used more palliative coping; no gender differences were observed for psychosocial adaptation. Health care orientation, extended family relationships, and psychological distress domains distinguished Blacks born in Haiti from Blacks born in Barbados and Jamaica, the Southern US and Jamaica, and the Southern US, Barbados, and Jamaica. Findings from this study may aid in the development of interventions focused on improving diabetes self-management for older Blacks.

Tomando Control: a culturally appropriate diabetes education program for Spanish-speaking individuals with type 2 diabetes mellitus--evaluation of a pilot project

PURPOSE

The purpose of this study was to pilot test the feasibility, acceptability, and efficacy of a culturally appropriate and culturally relevant Spanish-language cognitive-behavioral diabetes self-care educational intervention for Hispanic Americans with type 2 diabetes mellitus.

METHODS

The study site was an urban community health center in the Northeast, at which 16 Latino patients with type 2 diabetes mellitus were recruited. This was a 1-group pretest-posttest pilot study, during which qualitative and quantitative data were collected on demographic, physiologic (HbA1c, body mass index, lipids), psychosocial (diabetes-related distress and health beliefs), knowledge, and language-based acculturation variables at baseline, 3 months, and 6 months. Data were collected using questionnaires, laboratory data, and chart review. The intervention was culturally appropriate in terms of language, social emphasis, nutritional guidance, and acknowledgment of cultural health beliefs. Descriptive and inferential statistical analysis was used to evaluate response variables of glycemic control, lipid levels, and psychosocial and knowledge outcomes. The intervention acceptability process was evaluated by attendance and attrition.

RESULTS

This pilot study demonstrated excellent acceptance for and feasibility of this intervention. Most study participants (9 women, 7 men) were middle-aged married individuals who had had diabetes mellitus for an average of 8 years; English was a second language for all of them. Most were overweight and had suboptimal glycemic control and lipid profiles and moderate levels of knowledge at the outset of the study. Most had received a one-on-one diabetes educational session prior to the intervention. Over the 6 months of the study, most of both men and women showed an increase in knowledge scores, improvement in lipid profiles, and reduction in HbA1c levels. Men demonstrated a temporary increase in emotional distress much greater than that reported by women during the first 3 months of the study.

CONCLUSIONS

The findings suggest that a culturally relevant type 2 diabetes mellitus educational program, particularly one that addresses different learning needs and styles of men and women, can have a positive impact on Hispanic Americans with diabetes. Implications for practice include awareness of gender-based differences in response to self-management education, the importance of providing realistic samples of meals prepared in a manner consistent with American Diabetes Association principles, and the rationale for offering a brief and focused refresher course 6 to 9 months following this type of intervention.

Developing and refining interventions in persons with health disparities: the use of qualitative description

Eliminating health disparities by the year 2010 has become a clear priority for nursing and health sciences research. To date, much of the research has relied on traditional analytic methods to identify the disparities and develop clinical interventions. However, health disparities are typically embedded in complex, cultural and contextual issues. Interventions to improve access, quality and care among vulnerable populations need to be developed with these factors in mind. This article illustrates the benefits of using Qualitative Description as one method for assessing, developing and refining interventions with vulnerable populations. Qualitative Description study results have tremendous potential to translate directly to pressing health care situations and provide clear information about ways to improve care.