Gender and treatment differences in knowledge, health beliefs, and metabolic control in Mexican Americans with type 2 diabetes

Gender Differences in Self-Efficacy for Diabetes Self-Management Among Hispanics: The Mediating Role of Perceived Support and Depressive Symptoms

PURPOSE

The purpose of this study is to examine the extent to which perceived support and depressive symptoms might interfere with Hispanic patients' ability to manage their diabetes and whether these effects vary by gender.

METHODS

Data were collected from a cohort of 232 Hispanic men and women with type 2 diabetes mellitus (T2DM). Conditional process analysis was used to test a moderated mediation model of the time-lagged processes associating gender, diabetes support, and depressive symptoms with reported self-efficacy after 3 months.

RESULTS

Increased depressive symptoms were associated with lower self-efficacy, but the conditional effects varied among men and women. The index of moderated mediation was significant, indicating that among women, the indirect effect of depressive symptoms on self-efficacy was contingent on lower levels of perceived support. Among men, increased depressive symptoms were directly associated with declines in self-efficacy and were not conditional on perceived support.

CONCLUSIONS

Results of the study have important implications for gender health equity. Mental health screening and an assessment of support needs may be important for determining appropriate complementary therapies when treating Hispanic women with chronic conditions such as diabetes. Attention to possible differences in gender-specific mental health needs could lead to improved self-management, better glycemic control, and more equitable health outcomes.

Access to care, nativity and disease management among Latinos with diabetes in a safety-net healthcare setting

Introduction

Latinos in the U.S. are disproportionately affected by diabetes and its complications. The role of access to care and nativity in diabetes management are important areas of research, as these findings can help direct tailored interventions.

Methods

We examined associations between access to care, acculturation and glycemic control among Latino patients with diabetes seen in a safety net emergency department. We used regression models to estimate the individual predictors' associations with glycemic control and then estimated adjusted associations by controlling for all relevant predictors. We tested for a moderating role of nativity in the associations between access to care and glycemic control.

Results

In unadjusted analysis, we found the most significant predictors of glycemic control to be access to primary care (β = −0.89, p = 0.011), capacity for self-monitoring glucose (β = −0.68, p = 0.022), mental health comorbidities (β = 0.95, p = 0.013), male gender (β = −0.49, p = 0.091) and nativity (β = −0.81, p = 0.034). In adjusted analysis, nativity was no longer a significant predictor of glycemic control (β = −0.32, p = 0.541). Nativity did not significantly moderate the association of access to care and glycemic control.

Conclusions

Our findings show a direct association between access to care and glycemic control among low-income Latinos seeking care in the emergency department. This supports concerns that many researchers, clinicians and policy analysts have expressed regarding access to care for immigrants. The importance of primary care and access to supplies to perform self-management in achieving glycemic control and reducing risk of complications indicate that ensuring access to quality care is critical to the health of this vulnerable group.

Sex-related illness perception and self-management of a Thai type 2 diabetes population: a cross-sectional descriptive design

BACKGROUND

Increased knowledge concerning the differences in the illness perception and self-management among sexes is needed for planning proper support programs for patients with diabetes. The aim of this study was to investigate the illness perception and self-management among Thai women and Thai men with type 2 diabetes and to investigate the psychometric properties of the translated instruments used.

METHODS

In a suburban province of Thailand, 220 women and men with type 2 diabetes participated in a cross-sectional descriptive study. The participants were selected using a multistage sampling method. Data were collected through structured interviews and were analyzed using group comparisons, and psychometric properties were tested.

RESULTS

Women and men with type 2 diabetes demonstrated very similar experiences regarding their illness perception and no differences in self-management. Women perceived more negative consequences of the disease and more fluctuation in the symptoms than men, whereas men felt more confident about the treatment effectiveness than women. Furthermore, the translated instruments used in this study showed acceptable validity and reliability.

CONCLUSIONS

The Thai sociocultural context may influence people's perceptions and affect the self-care activities of Thai individuals, both women and men, with type 2 diabetes, causing differences from those found in the Western environment. Intervention programs that aim to improve the effectiveness of the self-management of Thai people with diabetes might consider a holistic and sex-related approach as well as incorporating Buddhist beliefs.

Knowledge attitude and practice regarding diabetes mellitus among Nondiabetic and diabetic study participants in Bangladesh

BACKGROUND

Increased awareness amongst large population groups is a major determinant for the prevention of diabetes and its complications as well as related metabolic disorders. Knowledge and attitude are the principal markers of awareness that need to be studied in various population groups in specific racial and cultural contexts. The present study was undertaken to explore knowledge, attitude and practice (KAP) regarding -diabetes mellitus (DM) among nondiabetic (nonDM) and type 2 diabetes mellitus (T2DM) patients in Bangladesh.

METHODS

A cross-sectional study was conducted among 18,697 adults (aged 18 years and above; 7796 male and 10,901 female; 6780 nonDM and 11,917 T2DM) selected purposively from the OPD of 19 healthcare centres in and around Dhaka and in northern parts of Bangladesh. KAP were assessed by a pre-structured, interviewer-administered questionnaire and categorised using predefined scores of poor (mean + 1 SD). Univariate and bivariate statistical analysis were done as appropriate. Multivariate linear regression was done to examine the association between diabetes related KAP and other covariates.

RESULTS

The mean (±SD) age (years) of all the study participants was 46 ± 14, mean BMI 24.4 ± 4.1 and mean waist-hip ratio (WHR) was 0.93 ± 0.07. The proportion of poor, average and good knowledge scores among T2DM subjects were 17%, 68% and 15% respectively. The corresponding values for attitude score were 23%, 67% and 10% respectively. The KAP regarding diabetes was found to be better among people who were living with diabetes compared to their counterparts. DM males showed better knowledge and practice regarding diabetes, compared to nonDM counterparts (M ± SD; 44.18 ± 16.13 vs 40.88 ± 15.62, p = <0.001; 66.00 ± 29.68 vs 64.21 ± 31.79, p < 0.001, respectively). Females showed better attitude score compared to males. Overall KAP were found to be significantly higher (p < 0.001) in middle aged (31-50 years) participants in each group. Participants from urban residents, higher educational background and upper socio-economic class demonstrated significantly greater score in terms of KAP in both nonDM and T2DM groups (p < 0.001). On linear regression analysis, knowledge scores correlated strongly with education, income, residence, diabetic state, BMI and attitude.

CONCLUSIONS

The overall level of knowledge and practice concerning diabetes among Bangladeshi population is average, but the overall level of attitude is good both in nonDM and T2DM subjects. To prevent diabetes and its complications there is an urgent need for coordinated educational campaigns with a prioritized focus on poorer, rural and less educated groups.

Hispanic Acculturation and Gender Differences in Support and Self-Efficacy for Managing Diabetes

Purpose

The purpose of this study was to determine whether perceived support, social norms, and their association with self-efficacy varied by gender and language-based acculturation in Hispanic men and women with uncontrolled type 2 diabetes mellitus (T2DM).

Methods

A cross-sectional, secondary analysis of baseline survey data from a randomized control trial. Participants were 248 Hispanic patients from 4 community health centers who participated in a culturally targeted intervention for diabetes management. Quantitative statistical methods were used, including chi-square analyses, one-way ANOVA, and multiple regression.

Results

Gender and language both moderated the relationship between social factors and self-efficacy. Regardless of language, better perceived support was associated with improved self-efficacy in women but not men. Dietary norms were associated with self-efficacy in English-speaking men and women, while physical activity norms were associated with self-efficacy for Spanish-speaking women only.

Conclusions

This study builds on previous research by exploring the extent to which the social context of diabetes self-management may vary in its effects depending on gender and acculturation. The findings revealed potentially important differences based on both gender and language, suggesting that interventions must be designed with these differences in mind. Diabetes-specific support from family members, especially spouses, may be especially important for Hispanic women. For both men and women, it may be effective to find creative ways of involving the family in creating healthier social norms and expectations.

The relationship of social support with treatment adherence and weight loss in Latinos with type 2 diabetes

OBJECTIVE

Little is known about the effects of social support on weight loss in Latinos. This study determined whether sex moderated and treatment adherence mediated the association between social support and weight loss.

METHODS

Data from 278 Latino males and females with type 2 diabetes in the Intensive Lifestyle Intervention of the Look AHEAD trial were analyzed. Multivariable modeling tested for moderation and parallel multiple mediator modeling simultaneously tested the mediating effects of adherence to physical activity, diet, and session attendance on the relationship between baseline social support and percent weight loss at 1 year.

RESULTS

Social support for physical activity (having family and friends join in physical activity) was related to weight loss. Adherence to physical activity was related to both social support for physical activity and weight loss. Sex did not moderate these relationships. Adherence to physical activity completely mediated the relationship between social support for physical activity and weight loss.

CONCLUSIONS

Increasing companionship for physical activity may be an effective intervention strategy to promote behaviors important for weight loss among Latinos.

Gender differences in the perception of difficulty of self-management in patients with diabetes mellitus: a mixed-methods approach

Aim

The aim of this study was to examine the challenges of self-management of diabetes comparing gender.

Methods

Sixty-four women and 129 men (mean age 63 vs. 60 years) with diabetes mellitus (DM) were interviewed using 12 categories (classification codes b1300, d240, d570, d620, d845, d920, e410 + e414, e420, e425, e465, e560) related to self-care management selected from 99 categories of the International Classification of Functioning, Disability and Health (ICF) Core Set for DM. In a mixed-methods analysis, interviews were analyzed according to the Grounded Theory approach, and gender effects on ICF categories related to self-care management were investigated using logistic models.

Results

In quantitative data, compared with men, women tended to experience greater difficulty obtaining foods/ingredients for well-balanced meals to maintain appropriate glucose level (P = 0.004); handling stress and other psychological demands around diabetes treatment (P = 0.034); and social norms, practices, and ideologies that defined an experience of unpleasant treatment after disclosure of DM diagnosis to close family and friends (P = 0.023). Qualitative data shows that women perceived prejudice against people with DM from close family, friends, and neighbors. In contrast, men reported excessive media information on diabetes treatment, which induced prejudice by family members and at the workplace.

Conclusions

Women were more likely to be sensitive to attention from close family and friends, whereas men were more likely to be occupied by work and daily living concerns. Health professionals should pay attention to such gender differences in a patient-professional relationship.

Social factors and barriers to self-care adherence in Hispanic men and women with diabetes

OBJECTIVE

To explore quantitatively the extent to which social support, social norms and barriers are associated with self-efficacy and self-care adherence in Hispanic patients with diabetes and the extent to which these differ for men and women.

METHODS

Baseline survey data were collected from 248 low-SES, Hispanic men and women who were participants in a randomized controlled trial of a culturally targeted intervention for diabetes management. Student's t, Pearson correlations and multiple regression were used to analyze the data.

RESULTS

Compared to men, women were less likely to receive support, faced more barriers, reported less self-efficacy and had lower levels of self-care adherence. Perceived support was consistently correlated with better self-efficacy in women but not men, even though men reported higher levels of support.

CONCLUSION

The lack of adequate support seems to be a fundamental barrier for Hispanic women with diabetes.

PRACTICE IMPLICATIONS

Health care providers should be sensitive to sociocultural influences in Hispanic groups that may facilitate men's self-care adherence, but could potentially hamper women's efforts. Interventions designed for Hispanics should augment women's support needs and address culture and social factors that may differentially impact the ability of men and women to manage their diabetes.

Gender-Specific Factors Influencing Diabetes Self-Care Behaviors and Health-Related Quality of Life Among Older Adults With Type 2 Diabetes in South Korea

The purpose of the current study was to identify gender-specific factors influencing diabetes self-care behaviors and health-related quality of life among older adults with type 2 diabetes in South Korea. This is a secondary analysis using data from 278 older adults (77 women, 201 men) with type 2 diabetes. An independent t test and hierarchical multiple regression analyses were used to analyze the data. No significant mean differences in diabetes self-care behaviors and health-related quality of life were observed according to gender. Regarding predictors by gender, the number of diabetes-related complications was a unique predictor of diabetes self-care behaviors in older men, whereas duration of diabetes and barriers were unique predictors in older women. Depression was a significant common predictor of health-related quality of life in older men and women. Nurses should be aware of and consider gender specificity when developing intervention programs for promoting self-care behaviors and health-related quality of life.

Gender differences in lay knowledge of type 2 diabetes symptoms among community-dwelling Caucasian, Latino, Filipino, and Korean adults - DiLH survey

PURPOSE

The purpose of this study was to explore gender differences in lay knowledge of type 2 diabetes symptoms among community-dwelling Caucasian, Latino, Filipino, and Korean Americans.

DESIGN AND METHODS

A cross-sectional survey was administered to a convenience sample of 904 adults (172 Caucasians, 248 Latinos, 234 Koreans, and 250 Filipinos) without diabetes at community events, community clinics, churches, and online in the San Francisco Bay Area and San Diego from August to December 2013. Participants were asked to describe in their own words signs and/or symptoms of diabetes. A multiple logistic regression analysis was performed to examine the association of lay symptom knowledge with gender after controlling for potential confounding factors.

RESULTS

Overall, the average age of the sample populations was 44 (SD ±16.1) years, 36% were male, and 58% were married. Increased thirst/dry mouth following increased urinary frequency/color/odor and increased fatigue/lethargy/low energy were the most frequently reported signs and symptoms (19.8%, 15.4%, and 13.6%, respectively). After controlling for known confounding factors, women were 1.6 (95% confidence interval, 1.2-2.3, P = .004) times more likely than men to report at least 1 diabetes symptom. However, this gender difference in knowledge of diabetes signs and symptoms did not significantly differ across Caucasians, Latinos, Filipinos, and Korean Americans (P = .87).

CONCLUSION

The findings underscore the importance of improving public knowledge and awareness of signs and symptoms of diabetes, particularly in men.

Effectiveness of diabetes self-management education on quality of life in diabetic elderly females

INTRODUCTION

Diabetes is a chronic illness that requires continuing medical care and patient self-management education to reduce the risk of long-term and acute complications. The aim of the present study was to determine the effectiveness of diabetes self-management education on quality of life in elderly females with diabetic mellitus (type 2) in Shiraz, Iran, 2013.

METHOD

The study was conducted from January to April 2014 at the Jahandidegan center, a day center affiliated to Shiraz welfare organization. The instrument used for the study was the Quality of life Questionnaire (WHO QOL-BREF) SF26. After an explanation of the aim of the study by the researcher, 90 participants with all the required criteria and G.H.Q score ? 23 were selected as the study sample for the intervention. Participants divided into experimental and control groups, and completed WHO QOL-BREF before the intervention, 2 and 3 months after the last session of education.

RESULT

It is shown that 2 and 3 months after the intervention, QOL scores had a significant difference between the two groups. In other words, the training sessions improved the score of QOL in the intervention group (P < 0.001) versus control group (P = 0.5).

CONCLUSION

The Behavioral Intervention Program significantly improved the quality of life outcomes of the diabetic elderly females. Thus, it is concluded that the diabetic individuals can be significantly improved following instruction by health care providers.

A systematic literature review of diabetes self-management education features to improve diabetes education in women of Black African/Caribbean and Hispanic/Latin American ethnicity

OBJECTIVE

This systematic literature review aims to identify diabetes self-management education (DSME) features to improve diabetes education for Black African/Caribbean and Hispanic/Latin American women with Type 2 diabetes mellitus.

METHODS

We conducted a literature search in six health databases for randomized controlled trials and comparative studies. Success rates of intervention features were calculated based on effectiveness in improving glycosolated hemoglobin (HbA1c), anthropometrics, physical activity, or diet outcomes. Calculations of rate differences assessed whether an intervention feature positively or negatively affected an outcome.

RESULTS

From 13 studies included in our analysis, we identified 38 intervention features in relation to their success with an outcome. Five intervention features had positive rate differences across at least three outcomes: hospital-based interventions, group interventions, the use of situational problem-solving, frequent sessions, and incorporating dietitians as interventionists. Six intervention features had high positive rate differences (i.e. ≥50%) on specific outcomes.

CONCLUSION

Different DSME intervention features may influence broad and specific self-management outcomes for women of African/Caribbean and Hispanic/Latin ethnicity.

PRACTICAL IMPLICATIONS

With the emphasis on patient-centered care, patients and care providers can consider options based on DSME intervention features for its broad and specific impact on outcomes to potentially make programming more effective.

Gender differences in diabetes self-management: a mixed-methods analysis of a mobile health intervention for inner-city Latino patients

BACKGROUND

The benefit of mobile health (mHealth) on diabetes management among low-income, inner-city patients is largely unknown, particularly for Latino patients. TExT-MED (Trial to Examine Text Message for Emergency Department Patients with Diabetes) is a text message-based program designed to improve disease knowledge, self-efficacy, and glycemic control among low-income, inner-city Latinos. In phase I, 23 patients participated in an acceptability and feasibility study. Contrary to our model, there was no increase in knowledge despite increases in self-efficacy and healthy behaviors. In phase II, we performed a mixed-methods analysis to understand how TExT-MED achieved these seemingly contradictory findings.

METHOD

We performed a qualitative analysis of focus groups with patients from phase I. We explored patients' receipt of health information from TExT-MED and other information sources. We used these qualitative findings to perform a mixed-methods analysis of the outcomes from phase I, reanalyzing the quantitative measures of self-efficacy, diabetes knowledge, and healthy behaviors.

RESULTS

We conducted two focus groups, one in English and one in Spanish. Through qualitative analysis, we found gender differences in information sources, dietary self-efficacy, and desired educational content. Applying this knowledge, we re-stratified phase I outcomes by gender and found differential changes in diabetes knowledge, self-efficacy, and behaviors. Men had increased self-efficacy while women showed increased knowledge.

CONCLUSIONS

The efficacy of mHealth on diabetes management was affected by gender. Specifically, men and women differ in their dietary self-efficacy, information sources, and desired topics in future mHealth interventions. To achieve maximal impact, future mHealth interventions should be mindful of this gender difference.

Self-management experiences among men and women with type 2 diabetes mellitus: a qualitative analysis

Background

The purpose of this study is to better understand differences in diabetes self-management, specifically needs, barriers and challenges among men and women living with type 2 diabetes mellitus (T2DM).

Methods

35 participants were recruited from a diabetes education center (DEC) in Toronto, Canada. Five focus groups and nine individual interviews were conducted to explore men and women's diabetes self-management experiences.

Results

The average age of participants was 57 years and just over half (51.4%) were female. Analyses revealed five themes: disclosure and identity as a person living with diabetes; self-monitoring of blood glucose (SMBG); diet struggles across varying contexts; utilization of diabetes resources; and social support. Women disclosed their diabetes more readily and integrated management into their daily lives, whereas men were more reluctant to tell friends and family about their diabetes and were less observant of self-management practices in social settings. Men focused on practical aspects of SMBG and experimented with various aspects of management to reduce reliance on medications whereas women focused on affective components of SMBG. Women restricted foods from their diets perceived as prohibited whereas many men moderated their intake of perceived unhealthy foods, except in social situations. Women used socially interactive resources, like education classes and support groups whereas men relied more on self-directed learning but also described wanting more guidance to help navigate the healthcare system. Finally, men and women reported wanting physician support for both affective and practical aspects of self-management.

Conclusions

Our findings highlight the differences in needs and challenges of diabetes self-management among men and women, which may inform gender-sensitive diabetes, care, counseling and support.

Health and psychosocial outcomes in U.S. adult patients with diabetes from diverse ethnicities

Within the United States, diabetes is a serious public health concern and patients with diabetes are more likely to experience clinical depression, psychological distress, and depressive symptoms than those without. Negative psychosocial factors are associated with poorer diabetes management and glycemic control. Overall, both the rates of diabetes and related psychological distress are greater for persons of diverse ethnicities than for non-Latino whites, and have reached epidemic proportions in certain groups. The following article will provide an overview across ethnicities of the rates of diabetes, health outcomes, psychosocial outcomes, and unique cultural and linguistic challenges that contribute to disparities within US diabetes patients of diverse ethnicities. Using this information, our hope is that health care practitioners and researchers alike can better respond to the psychosocial needs of ethnically diverse patients.

Improvement of primary health care of patients with poorly regulated diabetes mellitus type 2 using shared decision-making--the DEBATE trial

BACKGROUND

Since 2004, a national Disease Management Program (DMP) has been implemented in Germany, which includes educational measures aimed at patients with type-2 diabetes (T2D). However, about 15-20% of T2D patients remain in poor metabolic control. Qualitative research shows that one reason for this might be an increasing frustration of general practitioners (GPs) with the management of their poorly regulated T2D patients over time. We aim at approaching this problem by improving the GP-patient-communication and fostering shared decision-making.

METHODS/DESIGN

An educative intervention will be tested within a multi-centred cluster-randomized controlled trial (RCT) in Germany. We include 20 GPs in three regions. Each of the 60 GPs will recruit about 13 patients meeting the inclusion criteria (total of 780 patients). GPs allocated to the intervention group will receive a peer-visit from a specifically trained GP-colleague who will motivate them to apply patient-centred communication techniques including patient-centred decision aids. GPs allocated to the control group will not take part in any intervention program, but will provide care as usual to their patients. The primary inclusion criterion for patients at the time of the recruitment is an HbA1c-level of over 8.0. Primary outcome is the change of HbA1c at 6, 12, 18, and 24 months compared to HbA1c at baseline. Secondary outcomes include patient's participation in the process of shared decision-making and quality of life.

DISCUSSION

If this intervention proves to be effective it may be integrated into the existing Disease Management Program for T2D in Germany.

Developing a family-based diabetes program for Latino immigrants: do men and women face the same barriers?

This study examined barriers and facilitators to diabetes self-management among Latino immigrants with diabetes and whether similarities and differences were observed by gender. Eight focus groups were conducted with 24 women and 21 men Latinos; four focus groups involved women only and four involved men only. Themes were identified using a combined deductive/inductive approach and an iterative process of consensus coding. Gender similarities and differences emerged. Barriers to self-management were primarily social for the women, whereas for men, structural aspects related to work were prominent. Interventions aimed at improving diabetes self-management among US Latino immigrants should consider tailored approaches to help men and women overcome distinct barriers.

Gender differences in functional limitations in adults living with type 2 diabetes: biobehavioral and psychosocial mediators

BACKGROUND

Differences in functional limitations between adults with and without diabetes are more evident in women than they are in men.

PURPOSE

This study aims to investigate if there are gender differences in biological, behavioral, and psychosocial variables, and how these gender-related variables explain the gender-functional limitations relationship in adults with type 2 diabetes.

METHODS

We drew data on 1,619 adults with type 2 diabetes from the Health and Retirement Study and its diabetes-specific mail survey. The fit of a series of mediation models to the data was assessed by structural equation modeling.

RESULTS

Although women had better diet and blood glucose self-monitoring behaviors than did men, they reported less favorable body mass index, glycosylated hemoglobin (HbA1c) value, blood pressure, early complications, exercise behaviors, perceived control, self-efficacy, coping, depressive symptoms, and family support than did men. Psychosocial factors made an indirect contribution in the gender-functional limitations relationship by way of their strong association with biological and behavioral factors, two factors that directly and completely mediated the gender-functional limitations relationship.

CONCLUSIONS

Interventions promoting psychosocial well-being and empowering perceived diabetes control, coping, and self-efficacy in women with type 2 diabetes may help improve biological and behavioral determinants, and further, their long-term functional health.

Levels of acculturation and effect on glycemic control in Mexicans and Mexican Americans with type 2 diabetes

BACKGROUND

Acculturation of Mexican Americans toward the predominant American culture has been shown to influence health outcomes. Little is known about the role of acculturation in diabetes control.

OBJECTIVE

To measure the association between acculturation and diabetes control in Mexicans and Mexican Americans with type 2 diabetes mellitus (T2DM).

DESIGN

Cross-sectional survey and chart review.

SETTING

Ambulatory family medicine clinics.

PATIENTS

Sixty-six Mexican and Mexican American adults with T2DM for ≥ 1 year. INSTRUMENT AND OUTCOMES: A survey tool was developed that included the General Acculturation Index developed by Balcazar et al to measure acculturation. Basic demographics, psychosocial factors, patient satisfaction, and patients' most recent hemoglobin A(1c) (HbA(1c)) levels were also obtained.

RESULTS

There was no significant correlation between acculturation score and HbA(1c) levels. On binary logistic regression, HbA(1c) levels were associated with patient satisfaction in having their questions answered (odds ratio [OR], 0.44; P < 0.05), interference of diabetes with daily life (OR, 1.4; P < 0.05), male gender (OR, 3.93; P < 0.01), and number of diabetes complications (OR, 1.81; P < 0.05). In the multivariate linear regression model, age (beta, -0.348; P < 0.05) and frequency of physician visits (beta, -0.403; P < 0.05) were the only variables significantly associated with glycemic control. Variables included in the model that were not associated with glycemic control include family history of diabetes and confidence in diabetes treatment efficacy.

CONCLUSIONS

Acculturation was not associated with glycemic control in this population. Family physicians should not assume that acculturation difficulties explain poor glycemic control in their Mexican American patients with T2DM.

Having a diagnosis of diabetes is not associated with general diabetes knowledge in rural Hispanics

PURPOSE

The prevalence of diabetes among Hispanics in Washington State is 30% greater than it is for non-Hispanic whites. Hispanics also have higher rates of diabetes-related complications and mortality due to the disease. Although interventions have been developed for the Hispanic community, studies in rural settings are limited. To address this we conducted a study to identify factors associated with general diabetes knowledge in a rural Hispanic population.

METHODS

This study was conducted as part of a larger project in partnership with a local community hospital in Washington State's Lower Yakima Valley. Diabetes knowledge was assessed as part of a screening survey using 5 statements selected from the Diabetes Knowledge Questionnaire. Men and women (N = 1,297) between the ages of 18 and 92 attending community-oriented events took part in the survey. Gender, education, age, birthplace, diabetic status, and family history of diabetes were tested as predictors of diabetes knowledge.

FINDINGS

Overall, general knowledge was high with 71%-84% of participants responding correctly to 4 of 5 statements, while only 17% of participants responded correctly to a fifth statement. Although no variable was associated with all statements, family history, gender, and education were most frequently associated with knowledge. Diabetic status, age, and birthplace were less often or not associated with the knowledge statements.

CONCLUSION

Contrary to expectations, having a diagnosis of diabetes was not among the factors most frequently associated with diabetes knowledge. Future research should investigate the roles of family history, gender, and diabetic status as conduits of diabetes education among rural Hispanics.

Chronic illness self-care and the family lives of older adults: a synthetic review across four ethnic groups

The purpose of this paper is to integrate the literature on family and social ties among older ethnic minority men and women with the literature on chronic illness self-care among elders in these groups, in order to increase understanding of social influences on self-care behavior, raise questions for future research, and inform culturally appropriate interventions to maximize the health-promoting potential of social relationships. The paper presents demographic and chronic illness prevalence information, and then summarizes literature about patterns of chronic illness self-care behaviors for older African-Americans, Latinos, Asian-Americans, and American Indians in the U.S. For each group, the sociological literature about residential, cultural, and socioeconomic patterns, family lives, and other social ties is then reviewed, and the self-care literature that has accounted for these patterns is discussed. Finally, six themes are outlined and related questions are identified to further illuminate the social context of older adults' chronic illness self-care.

Review of type 2 diabetes management interventions for addressing emotional well-being in Latinos

PURPOSE

The purpose of this article is (1) to investigate if type 2 diabetes management programs with Latino participants address emotional well-being in addition to the standard diabetes self-care behaviors and (2) to describe the approaches taken to improve psychological and diabetes management outcomes.

METHODS

Online article and research databases, Internet searches, and review of article citations were used to identify relevant articles published 1995-2008. Type 2 diabetes management interventions with a psychological (emotion or cognitive) component or outcome measure and Latino sample were selected. Articles were limited to randomized clinical/controlled trials and pre-post comparative studies.

RESULTS

Thirteen interventions met the inclusion criteria for this review. Eight studies included emotion outcome measures, and 13 included at least one cognitive outcome measure. One study was specifically designed to improve emotional well-being. This study was not targeted for Latinos but did include Latino participants. A specialized depression case manager and collaborative care model showed significant improvements in depression and mental functioning. Psychological improvements were also found in those studies that assessed cognitive outcomes and were based on cognitive theories. The most frequent cognitive outcomes assessed were diabetes knowledge, problem solving, and self-efficacy.

CONCLUSIONS

Few type 2 diabetes interventions address emotional well-being in Latinos. More attention has been directed toward designing culturally sensitive community-based programs for improving behavior and physical outcomes. Because some Latino groups believe that negative emotions cause diabetes and because depression and anxiety are associated with poor self-management, programs should address emotional well-being as an important aspect of diabetes management.

Gender differences in views about cognitive health and healthy lifestyle behaviors among rural older adults

PURPOSE

Research suggests that men and women often differ in knowledge and beliefs about causes and treatments of a variety of diseases. This study examines gender differences in views about cognitive health and behaviors that have been associated with its maintenance, focusing on older adults living in rural areas.

DESIGN AND METHODS

We conducted 6 focus groups in rural West Virginia. Participants included 37 women and 30 men, aged 55 years and older.

RESULTS

Men and women held similar views of cognitive decline, as well as largely similar views about causes of Alzheimer's disease (AD). However, women were more concerned about developing AD than were men. Gender differences were also noted with respect to healthy lifestyle beliefs, including diet, leisure-time physical activity, and strategies to maintain cognitive health.

IMPLICATIONS

Findings illustrate the importance of considering gender with respect to health beliefs, health behaviors, and health promotion, and emphasize the need to develop interventions designed for specific populations. Results highlight a critical need to translate research findings to the community.

Illness Beliefs Regarding the Causes of Diabetes among Latino College Students

This study examined the validity of the Klonoff and Landrine (1994) illness-belief scale when applied to Latino college students (n=156; 34% male, 66% female) at high-risk for future diabetes onset. Principal factor analysis yielded four significant factors - emotional, folk-beliefs, punitive, gene/hereditary - which accounted for 64.5% of variance and provided a culturally-relevant Latino perspective of the causes of diabetes. Additional analyses by age, gender, immigrant status and psychological acculturation revealed significant differences by age on the emotional and folk illness factors and a negative correlation between assimilation and endorsement of the emotional factor. The implication of these four illness factors for predicting health-related behaviors and health-outcomes among young Latinos was discussed as were recommendations for future research.

Patient beliefs and sense of control among Spanish-speaking patients with diabetes in northeast Colorado

PURPOSE

Latinos have higher diabetes prevalence and complication rates with lower use of self-management compared to other populations. This study evaluated perceived barriers to diabetes control among Spanish-speaking only patients in rural Colorado.

METHODS

Thirty-five Spanish-speaking patients with diabetes were randomly sampled and interviewed about their attitudes and beliefs concerning diabetes, self-management activities, and the care they received.

RESULTS

Patients perceived a high level of control over their diabetes. A minority of patients were adherent to recommended dietary changes or levels of exercise. Use of herbal home remedies to maintain glycemic control was common. Almost half of respondents felt that susto played a role in the development of their diabetes. Three fourths of those testing their glucose felt their physician was not interested in reviewing their blood sugar log.

CONCLUSIONS

Diabetes management programs should recognize the barriers patients may have to self-management and help patients incorporate traditional beliefs into a workable treatment regimen.

Self-care practices of Malaysian adults with diabetes and sub-optimal glycaemic control

OBJECTIVE

To investigate the self-care practices of Malaysian adults with diabetes and sub-optimal glycaemic control.

METHODS

Using a one-to-one interviewing approach, data were collected from 126 diabetic adults from four settings. A 75-item questionnaire was used to assess diabetes-related knowledge and self-care practices regarding, diet, medication, physical activity and self-monitoring of blood glucose (SMBG).

RESULTS

Most subjects had received advice on the importance of self-care in the management of their diabetes and recognised its importance. Sixty-seven subjects (53%) scored below 50% in their diabetes-related knowledge. Subjects who consumed more meals per day (80%), or who did not include their regular sweetened food intakes in their daily meal plan (80%), or who were inactive in daily life (54%), had higher mean fasting blood glucose levels (p=0.04). Subjects with medication non-adherence (46%) also tended to have higher fasting blood glucose levels. Only 15% of the subjects practiced SMBG. Predictors of knowledge deficit and poor self-care were low level of education (p = <0.01), older subjects (p=0.04) and Type 2 diabetes subjects on oral anti-hyperglycaemic medication (p = <0.01).

CONCLUSION

There were diabetes-related knowledge deficits and inadequate self-care practices among the majority of diabetic patients with sub-optimal glycaemic control.

PRACTICE IMPLICATIONS

This study should contribute to the development of effective education strategies to promote health for adults with sub-optimal diabetes control.

A feasibility study of a culturally tailored diabetes intervention for Mexican Americans

Latinos, the fastest growing minority group in the United States, are among the hardest hit by diabetes. Among Latinos, Mexican Americans have the highest rate (23.9%) of diabetes. Good self-management can improve glycemic control and decrease diabetes complications but can be challenging to achieve. The purpose of this study was to test the feasibility and examine the effects of a culturally tailored intervention for Mexican Americans with type 2 diabetes on outcomes of self-management. The study used a pretest/posttest control group design with 10 participants in each group (N = 17). Feasibility and acceptability of the tailored diabetes self-management program was assessed by examining ease of recruitment and retention rates. The behavioral outcomes of self-efficacy, diabetes knowledge and self-care measures, and the biologic outcomes of weight, body mass index, HbA1C, and blood glucose were used to examine intervention effectiveness. Successful recruitment of participants came from personal referrals from providers or the promotora. Retention rates were 100% for the intervention group and 80% for the control group. Findings suggest that the intervention had a positive clinical and statistical effect on diabetes knowledge, weight, and body mass index. Improvements were also noted in self-efficacy scores, blood glucose, and HbA1C, but these changes did not reach statistical significance. A culturally tailored diabetes self-management program may result in improved outcomes for Mexican Americans with type 2 diabetes.

Analysis of behavioral risk factor surveillance system data to assess the health of Hispanic Americans with diabetes in El Paso County, Texas

PURPOSE

The purpose of this study is to determine and describe the health of Hispanic Americans who live in El Paso County, Texas, along the US-Mexico border, particularly the multidimensional self-management practices of those with diabetes. This study also assesses Hispanic Americans with diabetes consistent with Healthy People 2010 diabetes goals and objectives.

METHODS

Data from the 2002 Paso del Norte Behavioral Risk Factor Surveillance System are used for analysis of behavioral health risk factors associated with diabetes among Hispanic Americans in El Paso County, Texas. One- and two-way frequency tables with logistic regression and tests for comparison of means are used for data analysis.

RESULTS

The greatest numbers of Hispanic American residents are younger, with those diagnosed with diabetes aged 45 years and older and with lower level of education, lowest income level, and unable to work. The odds of having diabetes are 4 times greater with increasing age and 6 times greater with lower income level. The type of medical treatment is consistent with the frequency of various diabetes self-management behaviors to optimize health. Hispanic Americans are within the goal for several Healthy People 2010 targets for diabetes.

CONCLUSIONS

Hispanic Americans along the US-Mexico border remain at risk for development of diabetes, although several self-management behavioral activities are recognized as important for prevention of diabetes to optimize quality of life.

Health-illness transition experiences among Mexican immigrant women with diabetes

Multiple and complex health-illness transitions are required for successful diabetes self-management. Diabetes health-illness transitions influence the daily lives and interactions of Mexican immigrant women with diabetes. This article reports the findings from an intervention study designed to facilitate the health-illness transition in Mexican immigrant women with type 2 diabetes who reside in the Arizona-Sonora region of the US-Mexico border. There was a significant (P<0.001) increase from preintervention to postintervention in diabetes knowledge and diabetes self-efficacy and a significant decrease (P <or= 0.001) in psychosocial and health-related behavior problems.

Vulnerable Populations with Diabetes Mellitus

This review of the literature on vulnerable populations with diabetes identifies trends, summarizes major findings, and recommends strategies to fill gaps in the state of the science. For the purposes of this article "vulnerable populations" refers to members of diverse racial and ethnic groups, people of low-income, and those who live in rural and medically underserved areas.

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.

Factors contributing to intervention fidelity in a multi-site chronic disease self-management program

BACKGROUND AND OBJECTIVES

Disease self-management programs have been a popular approach to reducing morbidity and mortality from chronic disease. Replicating an evidence-based disease management program successfully requires practitioners to ensure fidelity to the original program design.

METHODS

The Florida Health Literacy Study (FHLS) was conducted to investigate the implementation impact of the Pfizer, Inc. Diabetes Mellitus and Hypertension Disease Self-Management Program based on health literacy principles in 14 community health centers in Florida. The intervention components discussed include health educator recruitment and training, patient recruitment, class sessions, utilization of program materials, translation of program manuals, patient retention and follow-up, and technical assistance.

RESULTS

This report describes challenges associated with achieving a balance between adaptation for cultural relevance and fidelity when implementing the health education program across clinic sites. This balance was necessary to achieve effectiveness of the disease self-management program. The FHLS program was implemented with a high degree of fidelity to the original design and used original program materials. Adaptations identified as advantageous to program participation are discussed, such as implementing alternate methods for recruiting patients and developing staff incentives for participation.

CONCLUSION

Effective program implementation depends on the talent, skill and willing participation of clinic staff. Program adaptations that conserve staff time and resources and recognize their contribution can increase program effectiveness without jeopardizing its fidelity.

Evaluation of awareness of diabetes mellitus and associated factors in four health center areas

OBJECTIVE

As in all chronic diseases, providing patients with necessary information about Diabetes Mellitus (DM) and educating them are the best method of control of DM and preventing further complication. The aim of this study was to investigate the awareness of DM and related factors in diabetics.

METHODS

This cross-sectional study was conducted in four health centre areas of Ankara (n = 96,348) between 1997 and 2000. In these areas, the researches were visited every home and detected the total of 2136 diagnosed patients with DM. 62.5% of diabetics (1334) participated in the study in which a face-to-face interview was conducted to fill in a questionnaire followed by eye examination and fasting blood glucose level testing. Chi-square test and logistic regression analyses were performed to investigate the relationships between factors.

RESULTS

Statistical analysis has shown that mean age of respondents was 57.4 +/- 10.9 years and majority were female (67.9%) and older onset DM (96.6%). Mean duration of DM was 7.8 +/- 6.5 years. Only 28.6% of patients (n = 382) have had informed about DM. The main information resource was found to be hospitals (76.4%), then media 19.1% and primary health care centers (PHCC) 3.9%. Patients who graduated from university were 13.5 times; who were under 50 years of age were 1.92 times; who have had prior eye examination were 1.84 times and who had co-morbidities were 1.52 times more likely to have informed about DM than the other groups.

CONCLUSION

Awareness of DM amongst diabetics is very low and mainly determined by their education levels. The PHCC play a very small role in dissemination of information towards diabetics.

PRACTICE IMPLICATIONS

Results from this study have implications for patient education efforts. Accurately, clinicians need to strive to improve overall levels of patients' awareness and knowledge of their specific conditions, regardless of their literacy. Many opportunities exist for raising diabetic's awareness of their disease and linking diabetic's growing health awareness with those health promoting behaviors known to reduce morbidity and mortality.

Diabetes self-management among low-income spanish-speaking patients: A pilot study

BACKGROUND

The prevalence of type 2 diabetes and diabetes-related morbidity and mortality is higher among low-income Hispanics when compared to that of Whites. However, little is known about how to effectively promote self-management in this population.

PURPOSE

The objectives were first to determine the feasibility of conducting a randomized clinical trial of an innovative self-management intervention to improve metabolic control in low-income Spanish-speaking individuals with type 2 diabetes and second to obtain preliminary data of possible intervention effects.

METHODS

Participants for this pilot study were recruited from a community health center, an elder program, and a community-wide database developed by the community health center, in collaboration with other agencies serving the community, by surveying households in the entire community. Participants were randomly assigned to an intervention (n = 15) or a control (n = 10) condition. Assessments were conducted at baseline and at 3 months and 6 months postrandomization. The intervention consisted of 10 group sessions that targeted diabetes knowledge, attitudes, and self-management skills through culturally specific and literacy-sensitive strategies. The intervention used a cognitive-behavioral theoretical framework.

RESULTS

Recruitment rates at the community health center, elder program, and community registry were 48%, 69%, and 8%, respectively. Completion rates for baseline, 3-month, and 6-month assessments were 100%, 92%, and 92%, respectively. Each intervention participant attended an average of 7.8 out of 10 sessions, and as a group the participants showed high adherence to intervention activities (93% turned in daily logs, and 80% self-monitored glucose levels at least daily). There was an overall Group x Time interaction (p = .02) indicating group differences in glycosylated hemoglobin over time. The estimated glycosylated hemoglobin decrease at 3 months for the intervention group was -0.8% (95% confidence intervals = -1.1%, -0.5%) compared with the change in the control group (p = .02). At 6 months, the decrease in the intervention group remained significant, -0.85% (95% confidence intervals = -1.2, -0.5), and the decrease was still significantly different from that of the controls (p = .005). There was a trend toward increased physical activity in the intervention group as compared to that of the control group (p = .11) and some evidence (nonsignificant) of an increase in blood glucose self-monitoring in the intervention participants but not the control participants. Adjusting for baseline depressive scores, we observed a significant difference in depressive symptoms between intervention participants and control participants at the 3-month assessment (p = .02).

CONCLUSIONS

Low-income Spanish-speaking Hispanics are receptive to participate in diabetes-related research. This study shows that the pilot-tested diabetes self-management program is promising and warrants the conduct of a randomized clinical trial.

Making sense of diabetes: cultural models, gender and individual adjustment to Type 2 diabetes in a Mexican community

This study was conducted among Type 2 diabetes patients attending Social Security clinics in Guadalajara, Mexico. The goals were to describe cultural models of diabetes causation, assess gender-related differences, and analyze the relationship between cultural knowledge and the status of diabetes control. In the first stage, open-ended interviews were conducted with 28 participants. On the basis of the themes elicited, a series of scenarios describing the causes of diabetes were constructed. In the second stage of the study, 46 individuals were asked to rate each of the scenarios on a 3-point scale. A cultural consensus model was used to analyze the scenario interviews to evaluate the level of cultural sharing, estimate each individual's level of cultural knowledge, and validate cultural themes about the causes of diabetes. Multiple regression analysis was used to estimate the relationship between cultural knowledge and the status of diabetes control. The results demonstrated that participants shared a single cultural model of diabetes causality that emphasized emotional and environmental explanations of diabetes. Women shared more knowledge than men. Better diabetes control was related to a higher level of cultural knowledge. The results suggest that diabetes prevention and care efforts should include community participation. It is important to increase male participation in health care. Psychological assistance and stress management education should become a part of health care services for individuals with Type 2 diabetes.

Meeting the health care needs of a rural Hispanic migrant population with diabetes

CONTEXT

There is a need for models of health care that provide accessible, culturally appropriate, quality services to the population of Hispanic migrant farmworkers at risk for or diagnosed with diabetes.

PURPOSES

The purposes of this study were to describe the Migrant Health Service, Inc (MHSI), Diabetes Program, the conceptual model on which it is based, and 4 types of outcomes achieved over a 3-year period.

METHODS

Types and amounts of medical services and education were studied. Qualitative data obtained from program records and documents were analyzed to determine the nature of the program. Quantitative data were used to measure outcomes of the program.

FINDINGS

The multiplecomponent MHSI Diabetes Program is addressing economic, cultural, and language barriers experienced by the target population. The program provides a continuum of health services and education that meet American Diabetes Association (ADA) Clinical Practice Recommendations on diabetes. The program exposes regional health care professionals and university students from numerous academic disciplines to Hispanic farmworker culture.

CONCLUSIONS

Evidence-based program management, patient care, and program evaluation are traits of this program, which offers accessible, culturally appropriate, quality health services and education to Hispanic farmworkers. The multicomponent program model has high potential for positively impacting the health of the target population.

Diabetes in Canadian Women

Health Issue

Diabetes mellitus (DM) is a chronic health condition affecting 4.8% of Canadian adults ≥ 20 years of age. The prevalence increases with age. According to the National Diabetes Surveillance System (NDSS) (1998–1999), approximately 12% of Canadians aged 60–74 years are affected. One-third of cases may remain undiagnosed. The projected increase in DM prevalence largely results from rising rates of obesity and inactivity.

Key Findings

DM in Canada appears to be more common among men than women. However, among Aboriginal Canadians, two-thirds of affected individuals are women. Although obesity is more prevalent among men than women (35% vs. 27%), the DM risk associated with obesity is greater for women. Socio-economic status is inversely related to DM prevalence but the income-related disparities are greater among women. Polycystic ovarian syndrome affects 5–7% of reproductive-aged women and doubles their risk for DM. Women with gestational diabetes frequently develop DM over the next 10 years.

Data Gaps and Recommendations

Studies of at risk ethnic/racial groups and women with gestational diabetes are needed. Age and culturally sensitive programs need to be developed and evaluated. Studies of low-income diabetic women are required before determining potential interventions. Lifestyle programs in schools and workplaces are needed to promote well-being and combat obesity/inactivity, together with lobbying of the food industry for needed changes. High depression rates among diabetic women influence self-care ability and health care expenditures. Health professionals need further training in the use of effective counseling skills that will assist people with DM to make and maintain difficult behavioural changes.

Hispanic Chronic Disease Self-Management

BACKGROUND

In light of health disparities and the growing prevalence of chronic disease, there is a need for community-based interventions that improve health behaviors and health status. These interventions should be based on existing theory.

OBJECTIVE

This study aimed to evaluate the health and utilization outcomes of a 6-week community-based program for Spanish speakers with heart disease, lung disease, or type 2 diabetes.

METHOD

The treatment participants in this study (n = 327) took a 6-week peer-led program. At 4 months, they were compared with randomized wait-list control subjects (n = 224) using analyses of covariance. The outcomes for all the treatment participants were assessed at 1 year, as compared with baseline scores (n = 271) using t-tests.

RESULTS

At 4 months, the participants, as compared with usual-care control subjects, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits (p <.05). At 1 year, the improvements were maintained and remained significantly different from baseline condition.

CONCLUSIONS

This community-based program has the potential to improve the lives of Hispanics with chronic illness while reducing emergency room use.

The role of active family nutritional support in Navajos' type 2 diabetes metabolic control

OBJECTIVE

We examined if active family nutritional support is associated with improved metabolic outcomes for Diné (Navajo) individuals living with type 2 diabetes.

RESEARCH DESIGN AND METHODS

The presence of family support, using variables identified in earlier ethnographic research, was assessed via surveys in a convenience sample of 163 diabetic individuals. Diabetes outcome measures (HbA(1c), serum glucose, triglycerides, total cholesterol, creatinine, and systolic and diastolic blood pressure measures) were extracted from participants' medical records. Bivariate analyses and multiple logistic regressions were conducted.

RESULTS

All measures of family support showed a relation with one or more indicators of metabolic control in bivariate analyses. In multivariate analyses, respondents were more likely to be in the best tertile for triglyceride (P < 0.05), cholesterol (P < 0.05), and HbA(1c) (P < 0.05) if another person cooked most of the meals. Respondents in families who bought/cooked "light" foods were more likely to be in the best tertile for triglyceride (P < 0.005) and cholesterol levels (P < 0.005), and those in families whose members ate "light" foods with them were more likely to be in the best tertile for triglycerides (P < 0.005). When all three support variables were entered into a multivariate model, only the variable "other family members cook the majority of the meals" was significantly associated with being in the lowest triglyceride (P = 0.05), HbA(1c) (P < 0.05), or cholesterol tertiles (P < 0.05). These relationships were most evident for women with diabetes.

CONCLUSIONS

Active family nutritional support, as measured by culturally relevant categories, is significantly associated with control of triglyceride, cholesterol, and HbA(1c) levels. The findings suggest that the family is a more useful unit of intervention for Diné individuals than for the individual alone when designing diabetes care strategies.

Reaching underserved populations and cultural competence in diabetes education

Diabetes self-management education has gained in importance over the past decade as research has documented the benefits of such interventions in improving glucose control and reducing diabetes-related complications. Although minority populations bear a disproportionate burden of diabetes, past strategies have not addressed cultural characteristics of groups typically underrepresented in diabetes research. Recent research literature on the development of culturally competent diabetes self-management is summarized and an example of a culturally competent intervention designed for Spanish-speaking Mexican Americans is presented. Recent research is laying the foundation for future intervention development to meet the cultural needs of racial/ethnic groups.

Applying practical preventive skills in a preclinical preceptorship

Learning primary care medicine includes learning to apply practical, preventive medicine skills during everyday encounters with patients. The authors relate their experiences with implementing a voluntary, preventive diabetic foot-care program within the Texas Statewide Family Practice Preceptorship Program (TSFPPP). They explain the background of the TSFPPP and their rationale for introducing prevention and selecting diabetic foot care as a first preventive training module. The program's structure, educational materials, and evaluations are described. Of the 158 students and 88 preceptors who were exposed to the program, the authors received evaluations from 86 preceptors and 110 students. Students documented that they had screened and provided foot-care education to 321 diabetic patients. On average, students saved their preceptors 5-10 minutes each time they examined a diabetic patient's feet or provided foot-care education. The students said that the wide variety of preceptors' practices, the time constraints placed upon the preceptors, and the preceptors' own guidelines for the voluntary preceptorship all posed challenges to completing the preventive activities. The preceptors reported that preclinical students could play an important preventive role in their practices; however, to get optimum results from a preventive module, it may be important for students and preceptors to determine which topics are introduced. Using the preceptor's suggestions, the authors are developing a smoking-cessation module.