Applying the social ecological theory to type 2 diabetes prevention and management

Exploring type 2 diabetes self-management practices in rural Bangladesh: facilitators, barriers and expectations-a qualitative study protocol

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a global public health crisis impacting low-income and middle-income countries such as Bangladesh. While self-management is encouraged for individuals with T2DM, there is a significant lack of knowledge regarding the factors of facilitators, barriers and expectations associated with T2DM self-management in Bangladesh. This research aims to investigate the potential elements that support, impede and are anticipated in the effective practice of self-management for T2DM in rural areas of Bangladesh.

METHODS AND ANALYSIS

This study will use an exploratory qualitative approach. 16 focus group discussions, 13 in-depth interviews and 9 key informant interviews will be conducted among multilevel stakeholders, including people with T2DM, their caregivers, healthcare providers, health managers/administrators and policy planners. Interviews will be audio-recorded, transcribed, translated and analysed using thematic analysis.

ETHICS AND DISSEMINATION

This research project has been approved by the Monash University Human Research Ethics Committee (project reference number: 39483) and the Ethical Review Committee of the Centre for Injury Prevention and Research, Bangladesh (Memo: CIPRB/ERC/2023/14). Research findings will be disseminated in peer-reviewed journals and conference presentations. Published reports will include group data. Individual data privacy will be strictly maintained.

Development of a Web-Based Diabetes Prevention Program (DPP) for Chinese Americans: A Formative Evaluation Approach

Increasing evidence demonstrates that an online Diabetes Prevention Program (DPP) can delay the onset of type 2 diabetes. However, little has been done for Chinese Americans. This study, using Community-Based Participatory Research and Intervention Mapping approaches, describes a formative research process in the development of a culturally and linguistically tailored online DPP program among Chinese Americans with prediabetes living in New York City. Using a triangulation approach, data were collected to inform the development of an online DPP curriculum through (1) a literature review, (2) three focus groups (n = 24), and (3) a community advisory board meeting among 10 key informants knowledgeable in community needs, diabetes care, and lifestyle interventions. Participants indicated online DPPs would be very useful and easily accessible. However, key barriers including low computer skills/literacy and technology self-efficacy were identified. In addition, taking meal photos and tracking pedometer steps daily were found to be acceptable self-motoring tools for sustaining a healthy lifestyle. Furthermore, the integration of features such as text message reminders and the creation of social support groups into the online DPP curriculum was proposed to minimize attrition. This theory-based formative research to develop a culturally and linguistically appropriate web-based DPP curriculum was well-received by Chinese Americans and warrants testing in future intervention studies.

Improving type 2 diabetes care and self-management at the individual level by incorporating social determinants of health

OBJECTIVE

Suboptimal social determinants of health impede type 2 diabetes self-management. They are usually considered at population and community levels, not individually. The study objective was to draw on perspectives of people who have type 2 diabetes to identify and explore the impact of social determinants on self-management and ways to incorporate them into individual care.

METHODS

Purposively selected participants chose to partake in focus groups or interviews. Data were analysed and themes identified through deductive and inductive thematic analysis.

RESULTS

Social issues hinder type 2 diabetes self-management. Additionally, an individual's feelings and poor mental health, competing priorities and understanding about diabetes are important considerations. Support was provided via health professionals, community supports, financial support, personal support and informal self-management support.

CONCLUSIONS

Social determinants of health could be formally incorporated into individual care for people with type 2 diabetes if a socio-ecological view of health is taken as it considers the broader social and environmental circumstances in peoples lives.

IMPLICATIONS FOR PUBLIC HEALTH

Care for people with type 2 diabetes could be transformed if social determinants of health are formally assessed and responded to at an individual level. A socio-ecological view of health in individual care and clinical settings would enable social determinants of health to be formally incorporated into type 2 diabetes care.

A mixed-methods approach to understanding the perspectives, experiences, and attitudes of a culturally tailored cognitive behavioral therapy/motivational interviewing intervention for African American patients with type 2 diabetes: a randomized parallel design pilot study

Background

African American (AA) adults are 60% more likely to be diagnosed with diabetes mellitus (DM) and experience more complications than non-Hispanic White adults. Cognitive behavioral therapy (CBT) has shown to be an effective modality for helping patients improve health behaviors and regulate emotional states. Motivational interviewing (MI) addresses participant engagement and motivation. Therefore, MI was combined with CBT as an approach to the process of learning using CBT skills to promote healthy lifestyle choices. We aimed to assess the effects of a culturally tailored CBT/MI intervention on glycemic control in AA participants and understand their perspectives, attitudes, and experiences while participating in this intervention.

Methods

Using a randomized, parallel design pilot study (web-based group vs in-person group), 20 participants aged ≥ 18 years, identifying as AA and having a glycosylated hemoglobin (HbA1c) > 8%, were recruited. A CBT/MI intervention was administered in six sessions over 3 months. Participants completed baseline and follow-up assessments on measures for diabetes control (HbA1c), self-efficacy, generalized anxiety, depression, perceived stress, health-related quality of life, and cognitive ability. Post-CBT/MI intervention focus groups were conducted to determine patient perspectives regarding the intervention.

Results

Fourteen participants completed the study, their mean HbA1c improved from 10.0 to 8.9% (t(26) = 0.5, p-value = 0.06). The Diabetes Distress Scale demonstrated decreased distress overall (t(26) = 2.6; p-value = 0.02). The Generalized Anxiety Disorder Scale demonstrated decreased generalized anxiety for all participants (t(26) = 2.2; p = 0.04). Themes identified in focus groups included (1) intervention group social support through information sharing, (2) mental health and personal identities in diabetes understanding and management, and (3) receptivity to CBT/MI intervention positively impacts self-efficacy through improved health literacy.

Conclusion

This group-based, culturally tailored CBT/MI intervention for type 2 DM care was positively received by AA participants and helped improve diabetes control, as demonstrated by the change in HbA1c. There were additional benefits of social support through group interactions and a stronger sense of self-efficacy due to health education. A comprehensive treatment plan using a CBT/MI intervention may be useful in promoting healthy diabetes self-management.

Trial registration

ClinicalTrials.gov, NCT03562767. Registered on 19 June 2018

Food Access, Diet Quality, and Nutritional Status of Older Adults During COVID-19: A Scoping Review

Background: COVID-19 has imposed challenges for older adults to access food, particularly in minority, lower income, and rural communities. However, the impact of COVID-19 on food access, diet quality, and nutrition of diverse older adult populations has not been systematically assessed. Objective: To examine changes in food access, diet quality, and nutritional status among older adults during the COVID-19 pandemic and the potential differential impacts of the COVID-19 pandemic on these nutrition-related outcomes using the framework of the socio-ecological model. Methods: An electronic search was conducted on 3 databases (PubMed, CINAHL, and Web of Science) on March 7, 2021. Original, peer-reviewed English-language studies published 10/1/2019-3/1/2021 were considered for which the mean age of participants was 50 years and older. In order to be considered, studies must have examined food access, food security, or nutrition constructs as an outcome. Results: The initial search yielded 13,628 results, of which 9,145 were duplicates. Of the remaining 4,483 articles, 13 articles were in scope and therefore selected in the final analysis, which can be characterized as descriptive (n = 5), analytical (n = 6), and correlational (n = 2). Studies were conducted among community-dwelling older adult populations (n = 7) as well as those temporarily residing in hospital settings (n = 6) in 10 countries. None of the in-scope studies examined the impact of food programs or specific public policies or disaggregated data by race/ethnicity. Conclusions: More research is needed to examine the impact of COVID-19 on food access/security and the differential barriers experienced by older adult populations.

Perceptions of drug users and community gate keepers on the causes and consequences of synthetic drug use in Kunming: A three-level social-ecological approach

Synthetic drug use (SDU) is on the rise in China. Utilizing a grounded three-level social-ecological theoretical model, we aim to better understand how users, medical professionals, and other community gatekeepers perceive the causes and consequences of synthetic drug use in Kunming, China. Past work typically relies on drug users confined to rehabilitation facilities. Utilizing qualitative methods, our work integrates how various community actors perceive problems around synthetic drug use. Thirty face-to-face interviews were conducted in Kunming that were audio-recorded and transcribed. We identify emergent personal, interpersonal and societal level themes shaping SDU which provided our grounded theoretical model. Regardless of their social position, informants identified curiosity, peer networks that facilitated exposure, and the communality of sharing the drug experience as reasons to try synthetic drugs. Drug users reported negative consequences of SDU including the inability to sleep, a fear that others might discover one was using, and the difficulty of quitting. Medical professionals and others in the community were more likely to identify potential harms of SDU. Still, these community members felt synthetic drugs were less problematic than traditional drugs and reported less prejudice and stigma about these new drugs. Overall, medical professionals felt ill-prepared to deal with this new epidemic.

The participatory development of a national core set of person-centred diabetes outcome constructs for use in routine diabetes care across healthcare sectors

BACKGROUND

This study sought to utilise participatory research methods to identify the perspectives of people with diabetes regarding which diabetes outcomes were most important to them. These findings were then used to support an expert working group representing multiple health sectors and healthcare disciplines and people with diabetes to establish a core set of patient-important outcome constructs for use in routine diabetes care.

METHODS

26 people with diabetes and family members were recruited through purposive sampling to participate in interviews, focus groups, voting and plenary activities in order to be part of identifying outcome constructs. Content and qualitative analysis methods were used with literature reviews to inform a national multi-stakeholder consensus process for a core set of person-centred diabetes outcome constructs to be used in routine diabetes care across health care settings.

RESULTS

21 people with diabetes and 5 family members representing type 1 and 2 diabetes and a range of age groups, treatment regimens and disease burden identified the following patient-reported outcome constructs as an important supplement to clinical indicators for outcome assessment in routine diabetes care: self-rated health, psychological well-being, diabetes related emotional distress and quality of life, symptom distress, treatment burden, blood sugar regulation and hypoglycemia burden, confidence in self-management and confidence in access to person-centred care and support. Consensus was reached by a national multi-stakeholder expert group to adopt measures of these constructs as a national core diabetes outcome set for use in routine value-based diabetes care.

CONCLUSIONS

We found that patient-reported outcome (PRO) constructs and clinical indicators are needed in core diabetes outcome sets to evaluate outcomes of diabetes care which reflect key needs and priorities of people with diabetes. The incorporation of patient-reported outcome constructs should be considered complementary to clinical indicators in multi-stakeholder value-based health care strategies. We found participatory research methods were useful in facilitating the identification of a core prioritised set of diabetes outcome constructs for routine value-based diabetes care. The use of our method for involving patients may be useful for similar efforts in other disease areas aimed at defining suitable outcomes of person-centred value-based care. Future research should focus on developing acceptable and psychometrically valid measurement instruments to evaluate these outcome constructs as part of routine diabetes care.

Barriers to and facilitators of diabetes self-management practices in Rupandehi, Nepal- multiple stakeholders' perspective

BACKGROUND

Self-management of diabetes is associated with glycaemic control and adherence to medication and healthy lifestyle practices. There is lack of information on the barriers to and facilitators of diabetes self-management practices in low income country, Nepal. This study aimed to explore the barriers to and facilitators of Type 2 diabetes self-management practices taking multiple stakeholders' perspectives in Nepal.

METHODS

Four focus group discussions and 16 semi-structured interviews with people with Type 2 diabetes, caregivers, health care providers and health managers were conducted from April to May 2018 in Rupandehi district of Western Nepal. They were audio-recorded, transcribed, and analysed using a thematic approach.

RESULTS

Five main themes emerged that influenced diabetes self-management practices: individual factors, socio-cultural and economic factors, health system and policy factors, availability and accessibility of resources, and environmental factors. The important barriers were: lack of knowledge about diabetes self-management practices, cultural practices, insufficient counselling, lack of guidelines and protocols for counselling, and financial problems. The major facilitators were: motivation; support from family, peers, and doctors; and availability of resources in the community.

CONCLUSION

Based on our findings, a multilevel approach is needed to address these barriers and facilitators. These findings will help guide strategies to develop programs that impart knowledge and skills to improve the diabetes self-management practices of people with Type 2 diabetes.

How do reminder systems in follow-up screening for women with previous gestational diabetes work? - a realist review

BACKGROUND

Women with previous gestational diabetes have an increased risk of developing type 2 diabetes later in life. Recommendations therefore urge these women to participate in follow-up screening, 4-12 weeks postpartum and every 1-3 years thereafter. We sought to theorize how reminder interventions to support early detection of diabetes work, for whom, and in what circumstances.

METHODS

We used a method informed by realist review and synthesis. A systematic, iterative search in six electronic databases (PubMed, MEDLINE Ovid, The Cochrane Library, CINAHL, EMBASE) had a primary focus on experimental intervention studies and included additional information in relation to identified intervention studies. Analysis inductively identified context-mechanism-outcome configurations present in the evidence.

RESULTS

We located 16 articles eligible for inclusion. A cross-case comparison identified seven grouped context-mechanism-outcome configurations leading to intervention mechanisms relating to changes in women's reasoning and behavior. Configurations were thematically ordered in relation to Systems Resources, Women's Circumstances, and Continuity of Care. These were mapped onto a socio-ecological model and discussed according to identified middle-range theories.

CONCLUSION

Our findings adds to the body of evidence, that reminders have the potential to be effective in increasing participation in the recommended follow-up screening. Our study may assist researchers and policy and decision makers to analyze and judge if reminders are feasible and/or likely to succeed in their specific context. Further research into the perspective of socially disadvantaged and overweight women is needed to avoid unintended consequences such as social inequality in service use and stigmatization in future programs.

Applying Community-Engaged Intervention Mapping to Preparing Nurse Scientists

BACKGROUND

Preventing and managing chronic illness necessitates multilevel, theory-based interventions targeting behaviors, environmental factors, and personal determinants that increase risk for illness onset, greater burden, and poorer outcomes.

OBJECTIVES

The purpose of this article is to provide the basis for multilevel interventions, describe community-engaged intervention mapping as an approach to designing theory-based interventions, and discuss potential benefits of applying community-engaged intervention mapping in preparing nurse scientists to build programs of interdisciplinary research in preventing and managing chronic illness.

METHODS

Community-engaged intervention mapping integrates two methodological approaches: intervention mapping and community-engaged research.

RESULTS

The six-step intervention mapping approach provides a logical structure for preparing nurse scientists in designing, adapting, and implementing multilevel, theory-based interventions. Community-engaged research approaches offer principles and direction for engaging patients, clinicians, community members, and other stakeholders throughout the research process. Integrating these methods retains the theoretical integrity of interventions; improves the relevance and timely completion of the research and its products; and enhances intended beneficiaries and the community's understanding, trust, and use of the results.

DISCUSSION

Potential benefits of preparation in community-engaged intervention mapping to nurse scientists and nursing science include explicit consideration of multilevel factors influencing health. Additional benefits include guidance for linking relevant constructs from behavior- and environment-oriented theories with evidence-based methods for affecting desired changes in care and quality of life outcomes. Moreover, enhancement of the theoretical fidelity of the intervention, explication of the mechanisms influencing change in the primary outcome, and improved relevance and feasibility of interventions for intended beneficiaries and potential adopters are other benefits.

Social Relationships and Risk of Type 2 Diabetes Among Postmenopausal Women

OBJECTIVES

We examined whether social relationship variables (social support, social strain, social network size, and stressful life events) were associated with risk of developing type 2 diabetes among postmenopausal women.

METHOD

139,924 postmenopausal women aged 50-79 years without prevalent diabetes at baseline were followed for a mean of 14 years. 19,240 women developed diabetes. Multivariable Cox proportional hazard models tested associations between social relationship variables and diabetes incidence after consideration of demographics, depressive symptoms, and lifestyle behaviors. We also examined moderating effects of obesity and race/ethnicity, and we tested whether social variable associations were mediated by lifestyle or depressive symptoms.

RESULTS

Compared with the lowest quartile, women in the highest social support quartile had lower risk of diabetes after adjusting for demographic factors, health behaviors, and depressive symptoms (hazard ratio [HR] = 0.93, 95% confidence interval [CI] = 0.89-0.97). Social strain (HR = 1.09, 95% CI = 1.04-1.13) and stressful life events (HR = 1.10, 95% CI = 1.05-1.15) were associated with higher diabetes risks. The association between diabetes and social strain was stronger among African American women. Social relationship variables had direct relationships to diabetes, as well as indirect effects partially mediated by lifestyle and depressive symptoms.

DISCUSSION

Social support, social strain, and stressful life events were associated with diabetes risk among postmenopausal women independently of demographic factors and health behaviors. In addition to healthy behaviors such as diet and physical activity, healthy social relationships among older women may be important in the prevention of diabetes.

Identifying the Predictors of Self-Management Behaviors in Patients with Diabetes Based on Ecological Approach: A Systematic Review

BACKGROUND

Recognizing and promoting the factors that affect the self-management behaviors of diabetes lead to a reduction in the number of patients and an improvement in the quality of care. The ecological approach focuses on the nature of people's interactions with their physical and socio-cultural environments.

OBJECTIVE

The purpose of this study was to identify the predictors of self-management behaviors with a comprehensive approach in these patients.

METHODS

The keywords were investigated in the relevant national and international databases, including PubMed, Google Scholar, Science Direct, Scopus, and Scientific Information Database, Magiran, and Iran Medex, to obtain the articles published from 2009 to 2019. The search and article selection strategy was developed based on the Prisma checklist and was carried out in three steps.

RESULTS

Most studies have shown that personal factors had the highest prediction power for the self-management of diabetes. The interpersonal factors, society and policy-making factors, and group and organization factors were then the most frequently reported predictors of self-management behaviors in diabetic patients.

CONCLUSION

Self-management of diabetes is necessary for controlling it because 95% of care is done by the patient. When designing self-management interventions, factors are based on the individual level that is to increase self-management behaviors.

Perceived barriers and facilitators to diet and physical activity among adults diagnosed with type 2 diabetes in Malawi

Diet and physical activity are crucial to Type 2 diabetes mellitus (T2DM) self-management. However, socio-environmental, and cultural factors can impede lifestyle behaviours, and hence T2DM management. This study aimed to identify barriers, facilitators and support for diet and physical activity among adults with T2DM in Malawi selected from a larger clinical assessment study, conducted in urban and semi-urban public hospitals. Four focus group discussions were conducted, and audio-recorded, transcribed verbatim, coded, then organised and analysed using thematic analysis. Emergent themes included: family, friends, and health worker ties that facilitated both diet and physical activity as socio-support systems. Diabetes peer groups occurred more often in urban than semi-urban areas. Dietary barriers to self-management of T2DM included: cost and access to food; lack of knowledge on what and how much to eat; challenges of separate preparation and purchase of food; dilemmas of what to eat during functions and travel; and conflicting dietary information from different sources. Comorbidities and fear of public ridicule were key perceived barriers to participants being physically active. Therefore, socio-environmental factors should be considered by nutritionists, dietitians, and health workers when developing and providing nutrition and physical activity education to adults with T2DM in Malawi.

Influence of urban green open space on residents' physical activity in China

Background

Urban green open space is a valuable resource for physical activities of urban inhabitants and has the potential to reduce chronic illness and improve health. Research on the relationships between green open space and physical activity is incomplete and limited in China. Thus, the study examines how the urban green open space contributes to physical activity.

Methods

A questionnaire was designed based on the social ecology theory to investigate the physical activity of 513 residents in urban green open space. We use the time and frequency of residents exercising in urban green space to measure physical activity, and use the factor analysis to synthesize a large number of original factors (i.e., infrastructure, safety, accessibility, landscape quality, and space environment) into relatively few composite indicators. Based on the collected data of the cross-sectional population, the Order Probit regression model was constructed to analyze how urban green open space affects the residents’ physical activity from the perspective of social ecology.

Results

① in community factors: accessibility is significantly positive correlation with residents’ physical activity, and there is no significant correlation between safety and physical activity; ②in natural factors: space environment and landscape quality are not significantly correlated with residents’ physical activity; ③ in built environmental factors: infrastructures, the area of green space, the size of open space, and entertainment facilities are significantly correlated to residents’ activity. Basketball courts, volleyball courts, swimming pools, and sports equipment will promote physical activity; ④ apart from the attributes of green open space, other factors are significantly correlated to physical activity in the green open space, e.g. having a companion.

Conclusions

Urban green open space plays an important role in promoting physical activity especially among the women and the old, and improving the attributes (such as accessibility, infrastructures, the area of green space, the size of open space and entertainment facilities) of the urban green open space and trying to set up group sports proper to play with companion (like “square dancing” and “Tai Chi”) can promote Chinese residents’ physical activity so as to improve public health. The results are significant to facilitate environment health.

Strengthening the Family - the 'Five-I' Approach

This article describes the importance of the family in diabetes care. It lists the multiple ways in which the family is related to diabetes: as a cause or culprit of diabetes, as a tool or technique for delivering diabetes care and as a target of diabetes or diabetes-care-related complications. The authors suggest an alliterative 'Five-I' approach to guide diabetes care professionals in addressing needs, and utilising strengths, of the family of a person with diabetes. The five 'I's stand for: involved independence, iterative information, interactive interviews, inspired introspection and integrated incorporation. This strategy, based upon evidence and experience, is supported by pragmatism and practicality.

Factors Impacting Adherence to Diabetes Medication Among Urban, Low Income Mexican-Americans with Diabetes

Mexican-Americans carry a high burden of type 2 diabetes and are disproportionately affected by diabetes related mortality and morbidity. Poor adherence to medication is an important barrier to achieving metabolic control and contributes to adverse health outcomes and health disparities. Little is known about barriers and facilitators to medication adherence among Mexican-Americans with diabetes. This is a qualitative study of semi-structured interviews with a sample of 27 adults (25 Mexican-Americans and 2 Latinos of other origin) with self-reported type 2 diabetes who were recruited as part of a church-based, randomized controlled trial for diabetes self-management education in a low-income, immigrant neighborhood of Chicago. Face-to-face, in-depth interviews were conducted (one in English and 26 in Spanish), audio-recorded, transcribed verbatim, and professionally translated. Systematic qualitative methods were used to analyze interviews. All 27 participants were Latino, and 25 were of Mexican descent. Participants' mean age was 57 years, 81% were female, 69% had an annual income less than $20,000 and 48% had no health insurance. Mean A1C level was 8.6% and mean systolic blood pressure was 125 mmHg. The majority of participants (85%) reported using oral diabetes medication and 35% reported taking insulin. 76% reported being affiliated with one of the two partnering catholic churches based in the South Lawndale neighborhood of Chicago, also known as Little Village. Concerns regarding effectiveness and negative impact of diabetes medication were prevalent and expressed by 13 (48%) of 27 participants. Dissatisfaction with ineffective provider communication and not being able to pay for medication were other important barriers to adherence and were expressed by 7% and 11% of participants, respectively. Family support, for example, family members assisting in organizing medications in boxes and reminding participants to take them, was reported by 15% of participants and emerged as an important facilitator to medication adherence. There is a gap in research on factors influencing adherence to diabetes medication among Mexican-Americans. Our study suggests that concerns regarding negative impact of diabetes medication and concerns regarding effectiveness are prevalent barriers to adherence. These barriers can be addressed through educational efforts targeting patients and clinicians by specifically including content on beliefs that lead to poor adherence in diabetes self-management interventions for patients and continuing medical education for providers and by developing interventions that engage family members as a support system for medication adherence.

A quasi-experimental study to mobilize rural low-income communities to assess and improve the ecological environment to prevent childhood obesity

Background

The Ecological Model of Childhood Overweight focuses on characteristics that could affect a child’s weight status in relation to the multiple environments surrounding that child. A community coaching approach allows community groups to identify their own strengths, priorities and identity. Little to no research currently exists related to community-based efforts inclusive of community coaching in creating environmental change to prevent childhood obesity particularly in rural communities.

Methods

A quasi-experimental study will be conducted with low-income, rural communities (n = 14) in the North Central region of the United States to mobilize capacity in communities to create and sustain an environment of healthy eating and physical activity to prevent childhood obesity. Two rural communities within seven Midwestern states (IN, KS, MI, OH, ND, SD, WI) will be randomly assigned to serve as an intervention or comparison community. Coalitions will complete assessments of their communities, choose from evidence-based approaches, and implement nutrition and physical activity interventions each year to prevent childhood obesity with emphasis on policy, system or environmental changes over four years. Only intervention coalitions will receive community coaching from a trained coach. Outcomes will be assessed at baseline, annually and project end using previously validated instruments and include coalition self-assessments, parental perceptions regarding the built environment, community, neighborhood, and early childhood environments, self-reflections from coaches and project staff, ripple effect mapping with coalitions and, final interviews of key stakeholders and coaches. A mixed-methods analysis approach will be used to evaluate if Community Coaching enhances community capacity to create and sustain an environment to support healthy eating and physical activity for young children. ANOVA or corresponding non-parametric tests will be used to analyze quantitative data relating to environmental change with significance set at P < .05. Dominant emergent themes from the qualitative data will be weaved together with quantitative data to develop a theoretical model representing how communities were impacted by the project.

Discussion

This project will yield data and best practices that could become a model for community development based approaches to preventing childhood obesity in rural communities.

Dimensions of medication adherence in African Americans with type 2 diabetes in rural North Carolina

PURPOSE

Personal perceptions and beliefs are one of the least studied patient factors influencing medication adherence. This study explored adherence experiences of rural African Americans with type 2 diabetes in rural southeastern North Carolina.

METHODS

Social-ecological theory guided a mixed methods approach. The Morisky Medication Adherence Scale (MMAS) assessed adherence. Clinical variables (HgA1c, fasting glucose levels, current medications) were obtained from medical records. Pearson correlation coefficients examined associations between demographics, clinical variables, and MMAS scores. Narrative data obtained from open-ended questions were analyzed through content analysis.

RESULTS

The study enrolled 45 rural residents with longstanding type 2 diabetes (11 years, 31% on insulin). The majority of MMAS scores (63%) reflected low adherence (<6); 30% averaged moderate adherence (6 to <8). Males had poor metabolic control (HgA1c 9.0); female glycemic control was moderately good (7.2). Adherence was associated with having health insurance (r = .594, p = .001) and working for pay (r = .440, p = .05). Participants frequently underused medications without consulting a provider; financial limitations served as a major barrier. Perceptions that diabetes only occurs when "sugar is high" are inconsistent with the course of this chronic disease.

CONCLUSIONS

High levels of nonadherence remain a major challenge for nursing care providers in economically distressed rural counties.

Evaluating diabetes health policies using natural experiments: the natural experiments for translation in diabetes study

The high prevalence and costs of type 2 diabetes makes it a rapidly evolving focus of policy action. Health systems, employers, community organizations, and public agencies have increasingly looked to translate the benefits of promising research interventions into innovative policies intended to prevent or control diabetes. Though guided by research, these health policies provide no guarantee of effectiveness and may have opportunity costs or unintended consequences. Natural experiments use pragmatic and available data sources to compare specific policies to other policy alternatives or predictions of what would likely have happened in the absence of any intervention. The Natural Experiments for Translation in Diabetes (NEXT-D) Study is a network of academic, community, industry, and policy partners, collaborating to advance the methods and practice of natural experimental research, with a shared aim of identifying and prioritizing the best policies to prevent and control diabetes. This manuscript describes the NEXT-D Study group's multi-sector natural experiments in areas of diabetes prevention or control as case examples to illustrate the selection, design, analysis, and challenges inherent to natural experimental study approaches to inform development or evaluation of health policies.

Sustaining Self-Management in Diabetes Mellitus

Successful management of diabetes depends on the individual’s ability to manage and control symptoms. Self-management of diabetes is believed to play a significant role in achieving positive outcomes for patients. Adherence to self-management behaviors supports high-quality care, which reduces and delays disease complications, resulting in improved quality of life. Because self-management is so important to diabetes management and involves a lifelong commitment for all patients, health care providers should actively promote ways to maintain and sustain behavior change that support adherence to self-management. A social ecological model of behavior change (McLeroy, Bibeau, Steckler, & Glanz, 1988) helps practitioners provide evidence-based care and optimizes patients’ clinical outcomes. This model supports self-management behaviors through multiple interacting interventions that can help sustain behavior change. Diabetes is a complex chronic disease; successful management must use multiple-level interventions.

Environmental factors that impact the eating behaviors of low-income African American adolescents in Baltimore City

OBJECTIVE

To understand environmental factors influencing the food-related habits of low-income urban African American adolescents.

DESIGN

Qualitative research was conducted between February and April, 2010, using in-depth interviews, focus groups, and direct observation.

SETTING

The study was conducted in low-income, predominantly African American neighborhoods of Baltimore City.

PARTICIPANTS

A total of 20 adolescents were interviewed in 18 in-depth interviews (n = 13) and 2 focus groups (n = 7). Participants were recruited from Baltimore City recreation centers and were eligible if they were African American and aged 10-16 years.

PHENOMENON OF INTEREST

The food-related habits of low-income, African American, urban adolescents and reported perceptions of their food environments.

ANALYSIS

Interviews were audio recorded, transcribed, coded, and analyzed for emerging themes.

RESULTS

Six thematic categories emerged and were organized into 4 environmental contexts: the neighborhood context (accessibility of food and safety of neighborhood), the school context (school food environment), the family context (family health history, role modeling, and monitoring) and the peer context (peer behaviors).

CONCLUSIONS AND IMPLICATIONS

Future efforts to reduce the obesity epidemic among low-income African American adolescents should address the social environment of the family; however, positive behavior change may not be sustainable without neighborhood or school food environment modifications.

Investigating social ecological contributors to diabetes within Hispanics in an underserved U.S.-Mexico border community

Hispanics bear a disproportionate burden of diabetes in the United States, yet relations of structural, socio-cultural and behavioral factors linked to diabetes are not fully understood across all of their communities. The current study examines disparities and factors associated with diabetes in adult Hispanics of Mexican-descent (N = 648) participating in a population survey of an underserved rural U.S.-Mexico border community. The overall rate of diabetes prevalence rate in the sample, based on self-report and a glucose testing, was 21%; much higher than rates reported for U.S. adults overall, for all Hispanic adults, or for Mexican American adults specifically. Acculturation markers and social determinants of health indicators were only significantly related to diabetes in models not accounting for age. Older age, greater BMI (>30), greater waist-to-hip ratio as well as lower fruit and vegetable consumption were significantly related to increased likelihood of diabetes when all structural, cultural, behavioral, and biological factors were considered. Models with sets of behavioral factors and biological factors each significantly improved explanation of diabetes relative to prior social ecological theory-guided models. The findings show a critical need for diabetes prevention efforts in this community and suggest that health promotion efforts should particularly focus on increasing fruit and vegetable consumption.

Barriers and facilitators to effective type 2 diabetes management in a rural context: a qualitative study with diabetic patients and health professionals

Although effective type 2 diabetes management is essential for the prevention of complications, it is rarely carried out. Type 2 diabetes deaths in rural areas are higher than in metropolitan areas. A focus group (n = 8) and telephone interviews with patients (n = 10), and telephone interviews with health professionals (n = 18) in rural areas were conducted to examine this issue in a rural context. Inductive thematic analysis was used to generate 13 themes of barriers and facilitators to type 2 diabetes management at intrapersonal (denial of the illness, motivation, knowledge and skills and lack of time), interpersonal (stress and relationships), organisational (access to recommended foods, transport, health professionals, and exercise options) and societal (engagement and societal attitudes) levels of influence. Across all themes, participants highlighted the difficulty of maintaining management behaviours.

Successful holistic management of type 2 diabetes with depression: a very personal story

We used illness narrative methods to evaluate the retrospective illness story of a bereaved woman who has recovered from type 2 diabetes and depression with comorbid hypertension, hyperlipidemia, vertigo, and obesity. Her spoken illness story was obtained with a single interview question: What happened? Our findings show that the patient searched for and found personal meaning in her illness. The finding of meaning in her illness appears to have supported her efforts to adopt more positive health beliefs and health behaviors. Although she received excellent health care throughout her illness, she attributes her return to good health to spiritual growth. We discuss the practice implications of this patient's illness story for clinicians who seek new insights into patients who have complex illness stories.

The effects of gender on the coping outcomes of young children following an unanticipated critical care hospitalization

PURPOSE

A prior evaluation of the predictors of child coping outcomes following an unanticipated critical hospitalization revealed gender differences, which were explored in this study to examine patterns of behavioral change over time.

DESIGN AND METHODS

Data from 163 mother-child (2-7 years) dyads were extracted for this study. Measures of child coping obtained 3 and 6 months following hospitalization included the Behavioral Assessment System for Children and the Post-Hospitalization Behavior Questionnaire.

RESULTS

Maladaptive behaviors in girls increased throughout the 6-month post-hospitalization period. Boys demonstrated a peak and then decline of those same behaviors.

PRACTICE IMPLICATIONS

Given this information, gender-specific child coping information can be developed for parents, which may lead to improved child outcomes.

Stigma in the context of hepatitis C: concept analysis

AIM

This paper is a report of a concept analysis of stigma in the context of hepatitis C.

BACKGROUND

Stigma is a complex and powerful social phenomenon that influences the course of illness and marginalizes populations. Knowledge of hepatitis C stigma is central to assisting people with hepatitis C self-manage their illness and reduce the disease burden.

DATA SOURCES

Thirty studies from 1995 to 2007 located in health and social sciences databases constituted the data for an evolutionary concept analysis and ecological theory guide the review.

FINDINGS

Stigma is a subjective and variable, perceived and/or experienced phenomenon, most frequently but not exclusively viewed as negative, that has interrelated intrapersonal, interpersonal and structural or institutional dimensions. The antecedents of hepatitis C stigma are help-seeking situations most frequently occurring in healthcare settings. Attributes include the association of hepatitis C with illicit drug use, fear of transmission of a contagious and life-threatening infection, acceptable level of risk, and the power to impose restrictions on the part of healthcare practitioners, family and friendship networks and society. Stigma consequences are mainly, but not exclusively, negative.

CONCLUSION

A central and distinctive feature of hepatitis C stigma in the Western world is its association with illicit drug use. Further research is required to understand the complexities associated with the sociocultural, situational and structural features that influence the stigma experience as well as the trajectory of the disease to understand the concept better and inform nursing practice.

An integrative literature review of lifestyle interventions for the prevention of type II diabetes mellitus

AIMS AND OBJECTIVES

An integrative literature review was undertaken to determine what type II diabetes prevention programmes have been evaluated, what type of programme is the most effective and how adherent to lifestyle changes adults are after participating in a prevention programme.

BACKGROUND

Type II diabetes is important because the disease is affecting millions of people worldwide. Obesity and sedentary lifestyles are preventable risk factors for type II diabetes, leading many researchers from around the world to examine different programmes that are focussed on prevention of the disease.

DESIGN

Integrative literature review.

METHOD

Search of electronic databases.

RESULTS

Diet, exercise, counselling and diet plus exercise were the types of prevention programmes, with the diet plus exercise being the most efficacious. Although many studies demonstrated excellent results initially, maintaining the effects of the lifestyle behaviour change proved to be difficult for participants, with only one study demonstrating the persistence of results after six years.

CONCLUSION

Future research should focus on long-term maintenance programmes, rather than just short-term prevention programmes to determine the need for booster interventions or other means to ultimately decrease the incidence of type II diabetes.

RELEVANCE TO CLINICAL PRACTICE

As front-line healthcare providers working across a broad array of settings, nurses are particularly well-suited to play an integral part in future applications of diabetes prevention programmes. Lifestyle interventions are being delivered in a variety of settings and venues such as the workplace, the Internet and places of worship. In addition, at-risk populations also can be targeted, particularly overweight and obese persons, with at least one parent having type II diabetes or persons with gestational diabetes.

Social Support and Physical Activity in Type 2 Diabetes A Social-Ecologic Approach

Purpose This study utilized social-ecology to describe sources of social-environmental support for physical activity perceived by people with type 2 diabetes, and examined the relationship between support and physical activity.

Methods Multidimensional support and physical activity were measured in 58 people with diabetes. Descriptive and correlational statistics were used.

Results Support from the media scored highest, followed by the health care team, personal support, workplace, family and friends, and lowest for the community. Physical activity was related to personal, media, and community support.

Conclusions Using a social-ecological approach, health care professionals must focus on enhancing support from media sources, strengthening community context, and bolstering personal self-management. Professionals must also critically examine patient-provider interactions to motivate lifestyle change.