Strong in body and spirit: lifestyle intervention for Native American adults with diabetes in New Mexico

The Medicine Wheel as a public health approach to lifestyle management interventions for indigenous populations in North America

This analytic essay intends to elevate Medicine Wheel, or generally "four directions" teachings, to encourage a more comprehensive alignment of lifestyle intervention components with traditional ecological knowledge systems of Indigenous cultures in North America. North American Medicine Wheels provided people with a way to orient themselves both within their traditional belief systems and to the seasonal changes in their areas, improving survivability. The wheel or circle is a sacred symbol, indicating the continuity and perpetuity of all of life. The four directions are iconized in many Indigenous cultures across North America with different directions representing different aspects of our world and of ourselves, different seasons of the year and of our lives, different beings of the earth and tribes of humans with a balance among those necessary for health and wellbeing. In the context of public health, teachings of the four directions warn that a lack of balance limits our ability to achieve optimal health. While there is much public health success in lifestyle interventions, existing practice is limited by a siloed and one size fits all approach. Medicine Wheel teachings lay out a path toward more holistic and Indigenous-based lifestyle intervention that is modifiable depending on tribal teachings and needs, may appeal to a variety of Indigenous communities and is in alignment with health behavior change theory. It is a public health imperative that lifestyle management interventions are fully optimized to rigorously determine what can be achieved when interventions are implemented in a holistic and Indigenous-based manner, and in alignment with an Indigenous model of health. This more complete alignment would allow for a stronger foundation to further explore and develop social determinants (i.e., housing, employment, etc.) and structural intervention enhancements to inform public health practice and promote health equity.

Salient beliefs about modifiable risk behaviours among patients living with diabetes, hypertension or both: A qualitative formative study

Background

Although there is evidence of the key role played by focusing on local knowledge in designing appropriate interventions regarding modifiable risk behaviours among patients living with diabetes and hypertension in Mangochi (and Malawi), little is known about local salient beliefs.

Aim

With a focus on the theory of planned behaviour as a theoretical lens, this study aimed to identify salient beliefs about modifiable risk behaviours among patients with diabetes, hypertension or both in Mangochi, south-eastern Malawi. Specifically, the objectives were to identify advantages and disadvantages (behavioural salient beliefs), people who approve or disapprove (normative salient beliefs) and enablers and barriers (control salient beliefs) for measures to change modifiable risk behaviours among patients with diabetes, hypertension or both in Mangochi, Malawi.

Setting

A hypertension diabetes clinic at Mangochi District Hospital, south-eastern Malawi.

Methods

A formative qualitative study of a quasi-experimental trial was conducted among 25 patients, purposefully sampled, who were living with diabetes, hypertension or both at Mangochi District Hospital in February 2019. Researchers conducted in-depth interviews with patients using an interview guide informed by the theory of planned behaviour’s elicitation interview guide. Thematic content analysis was used to identify emerging themes.

Results

A total of 25 participants were recruited, of which 12 (48%) were living with diabetes. Five thematic areas emerged from this analysis: physical and psychological fitness, social disconnection, perceived support systems, perceived enablers and perceived barriers to change.

Conclusion

Appropriate words for each salient belief were identified. Future researchers should use the identified salient beliefs when designing interventions based on the theory of planned behaviour in diabetes and hypertension.

Contribution

The paper adds to the body of knowledge informing the use of theory of planned behavior in addressing modifiable risk factors among practitioners, specialists and academics in primary care and Family Medicine in the field of noncommunicable diseases in Mangochi Malawi and beyond.

A Systematic Review of Interventions to Increase Physical Activity Among American Indian and Alaska Native Older Adults

BACKGROUND AND OBJECTIVES

Physical activity (PA) is a powerful protective factor known to reduce risk for chronic conditions across the life span. PA levels are lower among American Indians and Alaska Natives (AIANs) when compared with other racial/ethnic groups and decrease with age. This evidence justifies a synthesis of current intervention research to increase PA levels among AIANs. This systematic review examines completed interventions to increase PA among AIAN older adults and considers recommended practices for research with Indigenous communities.

RESEARCH DESIGN AND METHODS

The systematic review was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic review protocols and reporting guidelines. Three electronic databases, PubMed, Web of Science, and PsycINFO, were searched for academic literature. Trials investigating interventions to increase PA among AIAN adults older than 50 years were eligible. The Quality Assessment Tool for Quantitative Studies was used to evaluate the quality of evidence.

RESULTS

Three published trials were identified, including one group-level, clinic-based and two individual-level, home-based interventions. All were 6 weeks in duration, took place in urban areas, and used self-report PA measures. Findings indicated an overall increase in PA levels, improved PA-related outcomes, and improved psychosocial health among participants. None described community-engaged or culture-centered research strategies.

DISCUSSION AND IMPLICATIONS

The narrow yet promising evidence represents a need for expanded research and a call to action for using culture-centered strategies. An advanced understanding of cultural and contextual aspects of PA may produce more impactful interventions, supporting health and mobility across the life span.

Gamification for Family Engagement in Lifestyle Interventions: A Systematic Review

The majority of chronic conditions that plague the USA are modifiable by lifestyle change. Lifestyle interventions that incorporate family members for social support and that use game design elements to engage family members have the potential to improve upon traditional interventions, which have largely been unsustainable. Determining the populations where family member support in a lifestyle intervention are present and the extent of gamification of lifestyle intervention components that engage these family members is an important and underexplored area of work. A systematic review of lifestyle interventions involving family members were reviewed for game design elements using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Game design elements related to engaged learning and motivational affordances from previous literature were included. Sixty-one studies met inclusion criteria. These studies reported on 50 independent interventions that were reviewed. Thirty-one of these interventions addressed lifestyle in those with a chronic condition, and 19 addressed lifestyle in those at high risk for chronic conditions. The majority of the lifestyle interventions included at least one game design element, yet overall there were limited elements utilized together. Compared with successful gamified programs that have greatly impacted a population's health behaviors, there were relatively a limited number of elements reported, particularly those that support social relatedness, such as meaningful storylines. Meaningfulness of the game design elements chosen and their arrangement was not apparent. Technology was under-utilized as a potential modality for intervention component delivery. Developing products to train researchers to properly apply game design elements to intervention components, as well as test their effectiveness, are areas for future research.

Implementation outcomes of a culturally adapted diabetes self-management education intervention for Native Hawaiians and Pacific islanders

BACKGROUND

Native Hawaiians and Pacific Islanders (NHPIs) experience a disproportionate burden of type 2 diabetes and related complications. Although diabetes self-management education and support (DSMES) interventions have generally yielded positive results, few NHPIs have been included in these studies, and even fewer studies have been evaluated using a randomized controlled trial design and/or implementation research methods. The purpose of this pilot study was to evaluate implementation outcomes of a culturally adapted diabetes self-management education intervention delivered by peer educators to Native Hawaiians and Pacific Islanders residing in Honolulu, Hawai'i.

METHODS

In three study sites, the peer educators and 48 participants randomized to the intervention were invited to participate in the mixed methods implementation research. We used a convergent parallel design to collect implementation data including fidelity, feasibility, acceptability, appropriateness, adoption, and sustainability. Data were collected from class observations, participants' class feedback, and post-intervention focus groups with participants and peer educators.

RESULTS

In 314 end-of-class feedback surveys, 97% of respondents expressed that they were satisfied or highly satisfied with the class content and activities, 98% reported that the classes and materials were very useful, 94% reported very applicable, and 93% reported materials were culturally appropriate. Respondents identified several aspects of the program as especially enjoyable: interactions with peer educators, meeting in groups, learning about other participants' experiences with diabetes, and the information presented in each class. Major themes that emerged from the end-of-intervention focus groups were the relevance of the educational materials, strategies to manage blood glucose, hands-on activities, cultural aspects of the program, including the stories and analogies used to convey information, and appreciation of the group format and peer educators.

CONCLUSIONS

Results from this research support a culturally tailored, peer educator approach to DSMES among NHPIs. Delivery of the Partners in Care program is feasible in health care and community settings and is a reimbursable DSMES program.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01093924 prospectively registered 01.20.09.

Putting Self-Management in the Context of Community-Dwelling American Indians Living With Type 2 Diabetes

PURPOSE

The purpose of this qualitative descriptive study was to examine the National Standards for Diabetes Self-Management Education and Support (DSMES) defined diabetes self-care behaviors (healthy eating, being active, taking medication, monitoring, problem solving, reducing risk, and healthy coping) in the context of older community-dwelling American Indians (AIs).

METHODS

Secondary theme analysis of transcribed semistructured qualitative interview data from 28 participants in the Native Elder Care Study aged >60 years identified factors that influence the DSMES self-care behaviors in the context of community-dwelling AIs.

RESULTS

Four themes that characterized barriers, facilitators, and opportunities for DSMES to support self-care behaviors included community food security, care partners in self-care, community opportunities for diabetes support, and blending of both health worlds.

CONCLUSION

Tribal communities have contemporary strengths and cultural traditions that can be activated to enhance diabetes self-management education and support. Diabetes educators can work in tandem with community health representatives to strengthen the social and community support within which individual AIs with type 2 diabetes mellitus live. Community-based participatory research with AI caregivers, dyads, families, youth, and Indian Health Service clinicians may help to improve tribal food policy and school health initiatives, as well as develop intergenerational interventions for modeling effective diabetes self-management.

Integrating community health representatives with health care systems: clinical outcomes among individuals with diabetes in Navajo Nation

BACKGROUND

We studied the impact of Community Outreach and Patient Empowerment (COPE) intervention to support Community Health Representatives (CHR) on the clinical outcomes of patients living with diabetes in the Navajo Nation extending into the States of Arizona, Utah, and New Mexico. The COPE intervention integrated CHRs into healthcare teams by providing a structured approach to referrals and home visits.

METHODS

We abstracted routine clinical data from the Indian Health Service's information system on individuals with diabetes mellitus seen at participating clinical sites from 2010 to 2014. We matched 173 COPE participants to 2880 patients with similar demographic and clinical characteristics who had not participated in COPE. We compared the changes in clinical outcomes between the two groups using linear mixed models.

RESULTS

Over the four years of the study, COPE patients had greater improvements in glycosylated hemoglobin (- 0.56%) than non-COPE participants (+ 0.07%) for a difference in differences of 0.63% (95% confidence interval (CI): 0.50, 0.76). Low-density lipoprotein fell more steeply in the COPE group (- 10.58 mg/dl) compared to the non-COPE group (- 3.18 mg/dl) for a difference in differences of 7.40 mg/dl (95%CI: 2.00, 12.80). Systolic blood pressure increased slightly more among COPE (2.06 mmHg) than non-COPE patients (0.61 mmHg). We noted no significant change for body mass index in either group.

CONCLUSION

Structured outreach by Community Health Representatives as part of an integrated care team was associated with improved glycemic and lipid levels in the target Navajo population.

TRIAL REGISTRATION

Trial registration: NCT03326206. Registered 31 October 2017 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03326206.

Effect of family-oriented diabetes programs on glycemic control: A meta-analysis

BACKGROUND

Efficacy of programs for patients with diabetes mellitus (DM) that have promoted family members to help with patients' self-care activities has been largely inconsistent. This meta-analysis aims to assess the effect of family-oriented diabetes programs for glycemic control (GC).

METHODS

Electronic literature searches were conducted for clinical trials with a parallel design wherein there were two groups according to whether family members were included (intervention group) or not included (control group) and changes in glycohemoglobin A1C (A1C) were assessed as a study outcome. Each effect size (i.e. difference in A1C change between the intervention and control group) was pooled with a random-effects model.

RESULTS

There were 31 eligible trials consisting of 1466 and 1415 patients in the intervention and control groups, respectively. Pooled A1C change [95% confidence interval (CI)] was -0.45% (-0.64% to -0.26%). Limiting analyses to 21 trials targeted at patients with type 1 DM or 9 trials targeted at patients with type 2 DM, the pooled A1C changes (95% CI) were -0.35% (-0.55% to -0.14%) and -0.71% (-1.09% to -0.33%), respectively.

CONCLUSION

This meta-analysis suggests that focusing on the family as well as the individual patient in self-management diabetes programs to improve the performance of self-care activities of patients with DM is effective in terms of proper GC.

Developing a culturally tailored multigenerational intervention to prevent and manage type 2 diabetes in American Indian families living in rural settings: Findings from a focus group study

The study purpose was to understand the characteristics of interventions that would be most relevant and beneficial to address the diabetes-related needs and challenges of rural American Indians/Alaska Natives (AIAN) with type 2 diabetes (T2D) and their families. In an exploratory study design, we held a total of seven focus groups in Florida and rural Oklahoma. Groups included 3-13 individuals (62 total, 77% were female, mean age 55.3 [11.4] years and mean duration of diabetes 10.4 [SD 9.1] years) who were referred by staff from HealthStreet, Consent2Share mechanism, and by tribal educators. All groups were moderated by the same American Indian research team member using a discussion guide with open-ended questions, followed by probes. Findings revealed themes centered on optimal intervention components, barriers to type 2 diabetes-prevention and management (T2D-PM), personal experiences with T2D, and impact of family behaviors on T2D-PM. Findings indicate that the participants desire diabetes programs that include family members and a hands-on, culturally meaningful approach. Creating an intervention based on the AIAN community's insights that include the entire family may improve T2D-PM outcomes for this population.

Risk factors for pre-diabetes and diabetes in adolescence and their variability by race and ethnicity

Adolescent risk factors for pre-diabetes and diabetes in young adulthood were examined in three minority groups and compared to those in non-Hispanic Whites. Retrospective cohort study with data on 8337 adolescent respondents from Add Health (1994-2008). Participants included 5131 non-Hispanic Whites, 1651 non-Hispanic Blacks, 1223 Hispanics, and 332 American Indians/Alaska Natives. Diabetes was defined as: hemoglobin A1C ≥ 6.5%, glucose > 125 mg/dl, self-reported diabetes, or self-reported diabetes medication use, in Wave 4 data. Pre-diabetes was defined as hemoglobin A1C ≥ 5.7%. Relative risk regression models were used to evaluate the association between risk factors and risk of diabetes and pre-diabetes, controlling for body mass index, sedentary and physical activity habits, fast food consumption, and parental education, parental diabetes status, and financial stability. 484 participants developed diabetes; 2878 developed pre-diabetes between 1994 and 2008. Pre-diabetes and diabetes were more prevalent in non-Hispanic Blacks (55% and 12%, respectively) than in American Indians/Alaska Natives (43% and 11%), Hispanics (37% and 6%), and non-Hispanic Whites (27% and 3%). In all races, higher body mass index and parental diabetes were associated with higher risk of pre-diabetes and diabetes, while female sex was associated with lower risk of pre-diabetes. Efforts to reduce the risk of pre-diabetes and diabetes in adolescents should emphasize parental diabetes and BMI in all races, independent of physical activity, sedentary behaviors, or fast food consumption. Future interventions might be interested in targeting households, rather than individuals, to prevent pre-diabetes and diabetes in adolescents and young adults.

Community involvement in design, implementation and evaluation of nutrition interventions to reduce chronic diseases in indigenous populations in the U.S.: a systematic review

Background

Indigenous peoples of the United States disproportionately experience chronic diseases associated with poor nutrition, including obesity and diabetes. While chronic disease related health disparities among Indigenous people are well documented, it is unknown whether interventions adequately address these health disparities. In addition, it is unknown whether and to what extent interventions are culturally adapted or tailored to the unique culture, worldview and nutrition environments of Indigenous people. The aim of this review was to identify and characterize nutrition interventions conducted with Indigenous populations in the US, and to determine whether and to what degree communities are involved in intervention design, implementation and evaluation.

Methods

Peer-reviewed articles were identified using MEDLINE. Articles included were published in English in a refereed journal between 2000 and 2015, reported on a diet-related intervention in Indigenous populations in the US, and reported outcome data. Data extracted were program objectives and activities, target population, geographic region, formative research to inform design and evaluation, partnership, capacity building, involvement of the local food system, and outcomes. Narrative synthesis of intervention characteristics and the degree and type of community involvement was performed.

Results

Of 1060 records identified, 49 studies were included. Overall, interventions were successful in producing changes in knowledge, behavior or health (79%). Interventions mostly targeted adults in the Western region and used a pre-test, post-test design. Involvement of communities in intervention design, implementation, and evaluation varied from not at all to involvement at all stages. Of programs reporting significant changes in outcomes, more than half used at least three strategies to engage communities. However, formative research to inform the evaluation was not performed to a great degree, and fewer than half of the programs identified described involvement of the local food system.

Conclusions

The extent of use of strategies to promote community engagement in programs reporting significant outcomes is notable. In planning interventions in Indigenous groups, researchers should consider ways to involve the community in intervention design, execution and evaluation. There is a particular need for studies focused on Indigenous youth in diverse regions of the US to further address diet-related chronic conditions.

Culturally responsive approaches to health promotion for Native Hawaiians and Pacific Islanders

CONTEXT

Obesity, diabetes and cardiovascular disease (CVD) have reached epidemic proportions among Native Hawaiians/Pacific Islanders (NHPI). Culturally responsive interventions that account for their interpersonal, sociocultural and socioeconomic realities are a public health priority.

OBJECTIVE

To describe cultural adaptation and culturally grounded approaches to developing health interventions for NHPI and to review the culturally responsive approaches used by, and outcomes from, two long-standing community-based participatory research projects (CBPR) in Hawai'i: PILI 'Ohana and KāHOLO Projects.

METHODS

A literature review of 14 studies from these two projects was done to exemplify the methods applied to culturally adapting existing evidence-based interventions and to developing novel interventions from the 'ground up' to address health disparities in NHPI. Of the 14 studies reviewed, 11 were studies of the clinical and behavioural outcomes of both types of interventions.

RESULTS

Both culturally adapted and culturally grounded approaches using community-based assets and NHPI cultural values/practices led to establishing sustainable and scalable interventions that significantly improved clinical measures of obesity, diabetes and hypertension.

CONCLUSION

Several recommendations are provided based on the lessons learned from the PILI 'Ohana and KāHOLO Projects. Multidisciplinary and transdisciplinary research using CBPR approaches are needed to elucidate how human biology is impacted by societal, environmental and psychological factors that increase the risk for cardiometabolic diseases among NHPI to develop more effective health promotion interventions and public health policies.

Emotional and Behavioral Aspects of Diabetes in American Indians/Alaska Natives

American Indians and Alaska Natives (AI/ANs) bear a disproportionate burden of diabetes and associated long-term complications. Behavioral interventions play a vital role in promoting diabetes medical and psychological outcomes, yet the development of interventions for AI/AN communities has been limited. A systematic review was conducted of studies focused on the psychosocial and behavioral aspects of diagnosed diabetes among AI/ANs. Ovid and PubMed databases and published reference lists were searched for articles published between 1987 and 2014 that related to the psychosocial and behavioral aspects of type 1 or type 2 diabetes in the AI/AN population. Twenty studies were identified that met the inclusion criteria. Nineteen studies were observational and one study was intervention based. Two of the studies used community-based participatory research methodology. Of the 20 studies, 2 discussed cultural influences associated with diabetes self-management and 10 identified the specific tribes that participated in the study. Tribal affiliations among the studies were broad with the number of AI/AN participants in each study ranging from 30 to 23,529 participants. Emotional and behavioral topics found in the literature were adherence ( n = 2), depression ( n = 9), physical activity ( n = 3), psychosocial barriers ( n = 1), social support ( n = 3), and stress ( n = 2). Relatively few studies were identified using AI/AN populations over a 27-year period. This is in stark contrast to what is known about the prevalence and burden that type 1 and type 2 diabetes mellitus place on AI/AN communities. Future research should promote community engagement through the use of community-based participatory research methodologies, seek to further understand and describe the emotional and behavioral context for diabetes self-management in this population, and develop and test innovative interventions to promote the best possible diabetes outcomes.

Promotora Diabetes Intervention for Mexican Americans

PURPOSE

The purpose of this randomized controlled trial is to determine the effectiveness of an intervention led by promotoras (community lay workers) on the glycemic control, diabetes knowledge, and diabetes health beliefs of Mexican Americans with type 2 diabetes living in a major city on the Texas-Mexico border.

METHODS

One hundred fifty Mexican American participants were recruited at a Catholic faith-based clinic and randomized into 2 groups. Personal characteristics, acculturation, baseline A1C level, diabetes knowledge, and diabetes health beliefs were measured. The intervention was culturally specific and consisted of participative group education, telephone contact, and follow-up using inspirational faith-based health behavior change postcards. The A1C levels, diabetes knowledge, and diabetes health beliefs were measured 3 and 6 months postbaseline, and the mean change between the groups was analyzed.

RESULTS

The 80% female sample, with a mean age of 58 years, demonstrated low acculturation, income, education, health insurance coverage, and strong Catholicism. No significant changes were noted at the 3-month assessment, but the mean change of the A1C levels, F(1, 148) = 10.28, P < .001, and the diabetes knowledge scores, F(1, 148) = 9.0, P < .002, of the intervention group improved significantly at 6 months, adjusting for health insurance coverage. The health belief scores decreased in both groups.

CONCLUSIONS

The intervention resulted in decreased A1C levels and increased diabetes knowledge, suggesting that using promotoras as part of an interdisciplinary team can result in positive outcomes for Mexican Americans who have type 2 diabetes. Clinical implications and recommendations for future research are suggested.

Family interventions to improve diabetes outcomes for adults

Diabetes self-care is a critical aspect of disease management for adults with diabetes. Since family members can play a vital role in a patient's disease management, involving them in self-care interventions may positively influence patients' diabetes outcomes. We systematically reviewed family-based interventions for adults with diabetes published from 1994 to 2014 and assessed their impact on patients' diabetes outcomes and the extent of family involvement. We found 26 studies describing family-based diabetes interventions for adults. Interventions were conducted across a range of patient populations and settings. The degree of family involvement varied across studies. We found evidence for improvement in patients' self-efficacy, perceived social support, diabetes knowledge, and diabetes self-care across the studies. Owing to the heterogeneity of the study designs, types of interventions, reporting of outcomes, and family involvement, it is difficult to determine how family participation in diabetes interventions may affect patients' clinical outcomes. Future studies should clearly describe the role of family in the intervention, assess quality and extent of family participation, and compare patient outcomes with and without family involvement.

Nutrition-based interventions to address metabolic syndrome in the Navajo: a systematic review

AIMS AND OBJECTIVES

The objective of this systematic review is to identify nutrition-based interventions that may be effective for the prevention and treatment of metabolic syndrome in the Navajo.

BACKGROUND

Metabolic syndrome, a major risk factor for cardiovascular disease, affects almost half of the Navajo population. The diet of the Navajo, heavy in fat and refined carbohydrates, has been identified as an important contributing factor to the high rates of metabolic syndrome in this population.

DESIGN

A search was conducted on PubMed, EMBASE and CINAHL to identify studies published before October, 2013, involving nutrition-based interventions in adult populations similar to the Navajo targeting at least one measure of metabolic syndrome.

METHODS

Data on efficacy and participation were gathered and synthesised qualitatively.

RESULTS

Out of 19 studies included in this systematic review, 11 interventions were identified to be effective at improving at least one measure of metabolic syndrome. Level of exposure to the intervention, frequency of intervention activities, family and social support, cultural adaptation and case management were identified as factors that may improve the efficacy of an intervention.

CONCLUSIONS

Multiple nutrition-based interventions have been found to be effective in populations similar to the Navajo.

RELEVANCE TO CLINICAL PRACTICE

Development of a strategy to address metabolic syndrome in the Navajo may involve aspects from multiple interventions to increase efficacy and maximise participation.

Improving behavioral and clinical indicators in Asians and Pacific Islanders with diabetes: findings from a community clinic-based program

AIMS

This project tested the six-month impact of Stanford's Diabetes Self-Management Program (DSMP), adapted for Asians and Pacific Islanders (APIs), on behavioral and clinical indicators.

METHODS

Participants attended DSMP workshops at a community health center. Employing a one-group, pre-post-test design, data were collected at baseline and six-months. Ninety-six eligible API adults were enrolled. All attended four or more of the six weekly sessions, and 82 completed data collection. Measures included body mass index, blood pressure, blood lipids, blood glucose, HbA1c, as well as health behaviors. Data were analyzed by descriptive statistics and paired t-tests.

RESULTS

Adaptations to DSMP were minimal, but critical to the local acceptance of the program. At six-months, significant behavioral improvements included: (1) increased minutes in stretching and aerobic exercise per week (p<0.001); (2) reduced symptoms of hypoglycemia and hyperglycemia (p<0.001); (3) increased self-efficacy (p<0.001); and (4) increased number of days and times testing blood sugar levels (p<0.001). Significant clinical improvements included: (1) lower BMI (p<0.001); (2) lower HbA1c (p<0.001); (3) lower total cholesterol, triglycerides, and LDL (p<0.001); and (4) lower blood pressure (p<0.001).

CONCLUSIONS

Findings suggest that the DSMP can be successfully adapted to API populations and can improve clinical measures as well as health behaviors.

Outcomes from a diabetes self-management intervention for Native Hawaiians and Pacific People: Partners in Care

BACKGROUND

Culturally adapted interventions are needed to reduce diabetes-related morbidity and mortality among Native Hawaiian and Pacific People.

PURPOSE

The purpose of this study is to pilot test the effectiveness of a culturally adapted diabetes self-management intervention.

METHODS

Participants were randomly assigned in an unbalanced design to the Partners in Care intervention (n = 48) or wait list control group (n = 34). Assessments of hemoglobin A1c, understanding of diabetes self-management, performance of self-care activities, and diabetes-related distress were measured at baseline and 3 months (post intervention). Analysis of covariance was used to test between-group differences. The community steering committee and focus group data informed the cultural adaptation of the intervention.

RESULTS

There were significant baseline adjusted differences at 3 months between the Partners in Care and wait list control group in intent-to-treat (p < 0.001) and complete case analyses (p < 0.0001) for A1c, understanding (p < 0.0001), and performing diabetes self-management (p < 0.0001).

CONCLUSIONS

A culturally adapted diabetes self-management intervention of short duration was an effective approach to improving glycemic control among Native Hawaiian and Pacific Islanders.

Lost in translation--the role of family in interventions among adults with diabetes: a systematic review

AIMS

Family interventions are increasingly recognized as important in the care of people with diabetes. The aim of this study was to synthesize the existing literature on family interventions among adults with Type 1 and Type 2 diabetes and to determine the degree to which they were family centred.

METHODS

The literature search was carried out in four databases (Scopus, CINAHL, PsycINFO and ERIC). Two reviewers independently screened the search results. Only English-language articles about interventions on education, care and/or support of adult individuals with diabetes involving the participation of both the individual with diabetes and at least one family member were included.

RESULTS

From an initial 1480 citations, 10 reports were included. The intervention studies varied considerably in terms of design and population. The family dimension generally represented a modest part of the interventions: Two interventions applied a family-relevant theoretical framework. Disease knowledge and lifestyle changes were more prevalent intervention themes than family issues. Biological and behavioural outcomes were most prevalent, whereas psychosocial and family outcomes were used in six of the studies.

CONCLUSIONS

The number of trials and statistically significant results in family interventions targeting adults with diabetes is limited. Because of inhomogeneity, it is difficult to come to a conclusion on effective approaches in family interventions. The interventions are inconsistent with regard to theoretical framework, intervention themes and measured outcomes. However, psychosocial and familial dimensions seem sensitive to family-based interventions. From development to evaluation, the family dimension needs to be included to prove the specific effect of family interventions.

Social support and glycemic control in type 2 diabetes: a systematic review of observational studies

OBJECTIVE

We aim to systematically review observational studies examining the association between social support and glycemic control in adults with type 2 diabetes.

METHODS

We searched MEDLINE, PsycINFO, EMBASE, Scopus, Web of Science and Sociological Abstracts to July 2012 for observational studies investigating the association between structural or functional aspects of social support (social networks, community ties, marital status, family support, perceived, actual, emotional or instrumental social support) and glycemic control (HbA1c).

RESULTS

From electronic and reference searches, 29 studies were eligible. Twenty different assessments of social support were used. Family support and composite measures of support were most frequently associated with reduced HbA1c. There was no evidence for a beneficial effect of other support measures on HbA1c.

CONCLUSION

We found marked variation in population, setting, measurement of social support and definition of outcome, limiting the methodological validity of research. Social support may be important in the management of type 2 diabetes, the need for consensus and standardization of measures is highlighted.

PRACTICE IMPLICATIONS

The presence of informal support should be explored in routine diabetes care.

Importance of family/social support and impact on adherence to diabetic therapy

Diabetes mellitus affects 24 million individuals in the US. In order to manage their diabetes successfully, patients must adhere to treatment regimens that include dietary restrictions, physical activity goals, and self-monitoring of glucose levels. Numerous factors affect patients' ability to adhere properly, eg, self-efficacy, treatment expectations, health beliefs, and lack of social support. Consequently, diabetes management can be quite complex, requiring lifelong commitment and drastic changes to the patient's lifestyle. Empirical studies have shown positive and significant relationships between social support and treatment adherence among patients with diabetes. Social support from family provides patients with practical help and can buffer the stresses of living with illness. However, the exact mechanism by which social support affects patient adherence is not yet completely understood. Further research is needed to address how the differences in types of support, such as functional or emotional support, are linked to outcomes for patients. The purpose of this review is to summarize what is known of the impact of social and family support on treatment adherence in patients with diabetes and to explore the current methods and interventions used to facilitate family support for diabetic patients.

A cardiovascular risk reduction program for American Indians with metabolic syndrome: the Balance Study

The Balance Study is a randomized controlled trial designed to reduce cardiovascular disease (CVD) risk in 200 American Indian (AI) participants with metabolic syndrome who reside in southwestern Oklahoma. Major risk factors targeted include weight, diet, and physical activity. Participants are assigned randomly to one of two groups, a guided or a self-managed group. The guided group attends intervention meetings that comprise education and experience with the following components: diet, exercise, AI culture, and attention to emotional wellbeing. The self-managed group receives printed CVD prevention materials that are generally available. The duration of the intervention is 24 months. Several outcome variables will be compared between the two groups to assess the effectiveness of the intervention program.

Addressing food insecurity in a Native American reservation using community-based participatory research

The food insecurity faced by many Native American communities has numerous implications for the health and welfare of families. To identify and address upstream causes of food insecurity in a rural California reservation, we conducted a community assessment using the Tool for Health and Resilience in Vulnerable Environments (THRIVE). Guided by a community-based participatory research orientation, the THRIVE tool was adapted using digital storytelling and implemented in a series of focus groups. As a result of the THRIVE assessment, community members identified racial injustice and physical and financial barriers to accessing healthy and culturally appropriate foods as areas of greatest importance. Subsequently, the project partnership developed policies to reduce identified barriers which included an integrated community supported agriculture and commodity food program, the introduction of Electronic Benefits Transfer and culturally appropriate foods at the local farmers' market and reallocation of shelf space at the grocery store to include vegetables and fruits as well as special foods for diabetics. Results suggest that a participatory research orientation coupled with the use of a culturally adapted THRIVE tool may be an effective means for identifying structural determinants of food insecurity and initiating novel policy interventions to reduce health disparities experienced by Native American communities.

Family support, medication adherence, and glycemic control among adults with type 2 diabetes

OBJECTIVE

We used a mixed-methods approach to explore the relationships between participants' perceptions of family members' diabetes self-care knowledge, family members' diabetes-specific supportive and nonsupportive behaviors, and participants' medication adherence and glycemic control (A1C).

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes participated in focus group sessions that discussed barriers and facilitators to diabetes management (n = 45) and/or completed surveys (n = 61) to collect demographic information, measures of diabetes medication adherence, perceptions of family members' diabetes self-care knowledge, and perceptions of family members' diabetes-specific supportive and nonsupportive behaviors. Most recent A1C was extracted from the medical record.

RESULTS

Perceiving family members were more knowledgeable about diabetes was associated with perceiving family members performed more diabetes-specific supportive behaviors, but was not associated with perceiving family members performed fewer nonsupportive behaviors. Perceiving family members performed more nonsupportive behaviors was associated with being less adherent to one's diabetes medication regimen, and being less adherent was associated with worse glycemic control. In focus groups, participants discussed family member support and gave examples of family members who were informed about diabetes but performed sabotaging or nonsupportive behaviors.

CONCLUSIONS

Participant reports of family members' nonsupportive behaviors were associated with being less adherent to one's diabetes medication regimen. Participants emphasized the importance of instrumental help for diabetes self-care behaviors and reported that nonsupportive family behaviors sabotaged their efforts to perform these behaviors. Interventions should inform family members about diabetes and enhance their motivation and behavioral skills around not interfering with one's diabetes self-care efforts.

Cardiovascular Disease Prevention Preferences of a Sample of Urban American Indians

This study identified program delivery preferences and barriers to physical activity and healthy eating. Ninety-nine urban dwelling American Indians completed a questionnaire at powwows, community events, and a community health center. Most frequently selected program delivery preferences were coaching or other human contact, with fewer willing to use computer or telephone coaching. Fifty-six selected attending 8, 12, or 16 sessions. Most frequently selected barriers to physical activity were lack of time ( n = 48) and pain from existing problems ( n = 33). Frequently identified barriers to eating healthy foods included expense ( n = 42), uncertainty regarding what foods are healthy ( n = 25), extra time needed for preparation ( n = 22), and lack of knowledge of how to prepare healthy food ( n = 22). Findings showed the need for programs to focus on decreasing the barriers of time for physical activity and healthy eating and encourage doing organized physical activity (not necessarily exercise) with others to increase physical activity.

The Family Education Diabetes Series (FEDS): community-based participatory research with a midwestern American Indian community

Indigenous people around the globe tend to struggle with poorer health and well-being than their non-indigenous counterparts. One area that this is especially evident is in the epidemic of diabetes in North America's American Indians (AIs) - who evidence higher prevalence rates and concomitant disease-related complications than any other racial/ethnic group. As researchers and AI communities work together to transcend conventional top-down, service-delivery approaches to care, community-based participatory research is beginning to show promise as a way to partner contemporary biomedical knowledge with the lived-experience, wisdom, and customs of Indigenous people. This study describes the Family Education Diabetes Series (FEDS) as an example of such effort, and highlights pilot findings assessing its value and impact across key diabetes-relevant variables. Following 36 intervention participants across baseline, 3-month, and 6-month time periods, data show significant improvements in weight, blood pressure, and metabolic control (A1c). Strengths and limitations of this investigation are presented, along with suggestions about how to further advance and empirically test the work across other Indigenous communities.

Family intervention to control type 2 diabetes: a controlled clinical trial

PURPOSE

Chilean patients with type 2 diabetes mellitus (T2DM) have a low rate of blood sugar control. We studied the effectiveness of a culturally sensitive family oriented intervention designed to improve metabolic control in primary care patients with uncontrolled T2DM.

METHODS

Patients with T2DM from three primary care clinics in Santiago, Chile were randomly selected for inclusion if they had a recent HbA1c ≥7%, were between 18 and 70 years old and lived with a family member. Patients from one clinic received the family oriented intervention; patients from the other two (control) clinics received standard care. The intervention involved family members in care and included family counselling during clinic visits, family meetings and home visits. The primary outcome was HbA1c, measured at 6 and 12 months.

RESULTS

A total of 243 patients were enrolled and 209 (86%) completed the study. The intervention was fully administered to only 34% of patients in the intervention clinic. The reduction in the HbA1c from baseline to 12 months was not significantly different between clinics. During the second 6-month period, when the intervention was more intensive, the patients in the intervention clinic significantly improved their HbA1c (P < 0.001) compared to the control patients.

CONCLUSIONS

A family intervention for the control of T2DM was associated with a significant reduction in HbA1c when the intervention was provided. Incomplete implementation, low statistical power and potential confounding variables between groups could be some of the main factors that explain the lack of difference between clinics in the 12-month period.

Type 2 diabetes in Indigenous populations: quality of intervention research over 20 years

BACKGROUND

A robust evidence base is needed to reduce the disproportionately high rates of diabetes-related mortality and complications among Indigenous peoples.

OBJECTIVE

This study aimed to evaluate the quantity and methodological quality of published intervention research on Type 2 and gestational diabetes in the Indigenous populations of Australia, Canada, New Zealand, and the United States from 1989 to 2008. A robust evidence base is needed to reduce the disproportionately high rates of diabetes-related mortality and complications among Indigenous peoples.

METHODS

Systematic searches of Medline, Embase, and EBM Reviews identified publications focused on Type 2 or gestational diabetes in Indigenous peoples published between 1 January 1989 and 31 December 2008. Total publication number and proportion of research involving interventions over time were examined. The quality of intervention studies was evaluated using Cochrane's Effective Practice and Organisation of Care (EPOC) criteria.

RESULTS

Total publication number increased significantly over the 20 years (p<0.004). Research was predominantly descriptive (87%), with the proportion of research involving interventions increasing from 3% in 1989-1993 to 12% in 2003-2008 (χ(2)=12.42, df=3, p=0.006). However, only 25% (95%CI: 9-41%) of intervention studies met the EPOC methodological quality criteria; other studies lacked sufficient controls or measurements over time.

CONCLUSIONS

Increases in the amount of high-quality intervention research for prevention and treatment of Type 2 and gestational diabetes among Indigenous populations of these countries are needed.

Cultural translation of interventions: diabetes care in American Samoa

Translation of research advances into clinical practice for at-risk communities is important to eliminate disease disparities. Adult type 2 diabetes prevalence in the US territory of American Samoa is 21.5%, but little intervention research has been carried out there. We discuss our experience with cultural translation, drawing on an emerging implementation science, which aims to build a knowledge base on adapting interventions to real-world settings. We offer examples from our behavioral intervention study, Diabetes Care in American Samoa, which was adapted from Project Sugar 2, a nurse and community health worker intervention to support diabetes self-management among urban African Americans. The challenges we experienced and solutions we used may inform adaptations of interventions in other settings.

The internet diabetes self-management workshop for American Indians and Alaska Natives

Type 2 diabetes disproportionately affects American Indians and Alaska Natives (AI/ANs). In the larger population, patient self-management has become an increasing focus of the health care system to help reduce the impact of diabetes. However, little is known about patient self-management programs designed for AI/ANs. This study reports on the feasibility of implementing the Stanford Internet Diabetes Self-Management Workshop within the AI/AN population using a participatory research approach. This is a continuation of self-management studies to assist in meeting the needs of both patients and the health care system for health services that are effective (evidence based), efficient, and culturally appropriate. To our knowledge, this is the first study examining the effectiveness of an Internet-based diabetes patient self-management program among AI/ANs. This article reports on a pilot for a larger randomized study that is ongoing.

Race/ethnicity, social support, and associations with diabetes self-care and clinical outcomes in NHANES

PURPOSE

The purpose of this study was to evaluate how social support and race/ethnicity were associated with diabetes self-care behaviors and clinical outcomes.

METHODS

Using the cross-sectional 2005-2006 National Health and Nutrition Examination Survey (NHANES), the authors examined white, black, and Latino respondents who self-reported a diabetes diagnosis (n = 450), estimating the associations of social support on diabetes outcomes. The primary exposure was a social support index (0-5), which assessed the number of sources of support in one's life. Outcomes were self-care behaviors (controlling weight, exercising, controlling fat/caloric intake, checking feet, and self-monitoring blood glucose) and intermediate clinical outcomes (hemoglobin A1C, diastolic blood pressure, and low-density lipoprotein [LDL]).

RESULTS

There were no differences in social support by race/ethnicity. The authors observed several significant race/ethnicity by social support interactions in adjusted models, controlling for age, gender, education, self-reported health, depression, functional disability, insurance status, and insulin use. Among blacks, social support was associated with controlling weight (odds ratio [OR] = 1.55, P = .03), exercising (OR = 1.38, P = .03), controlling fat/calories (OR = 1.84, P = .03), and lower diastolic blood pressure (beta = -3.07, P = .02). Among whites, social support was associated with lower LDL (beta = -9.45, P = .01). No significant effects were noted for Latinos.

CONCLUSIONS

The relationship of social support with diabetes management differed by race/ethnicity, with the strongest findings among blacks. Social support may be influential for maintaining self-care behaviors among blacks and controlling lipid levels among whites.

Participants' assessments of the effects of a community health worker intervention on their diabetes self-management and interactions with healthcare providers

BACKGROUND

The specific ways in which community health worker (CHW) programs affect participants' healthcare behaviors and interactions with their healthcare providers, as well as mechanisms by which CHW programs influence these outcomes, are poorly understood. A qualitative descriptive study of participants in a successful CHW diabetes self-management program was designed to examine: (1) what gaps in diabetes care, with a focus on patient-doctor interactions, participants identify; (2) how the program influences participants' diabetes care and interactions with healthcare providers, and what gaps, if any, it addresses.

METHODS

From November 2005 to December 2006, semi-structured interviews with 40 African- American and Latino adults were conducted and analyzed. Participants had diabetes and had completed or were active in a CHW-led diabetes self-management program developed and implemented using community-based participatory research principles in Detroit. Interviews were audiotaped, transcribed, and coded through a consensual and iterative process.

RESULTS

Participants reported that prior to the intervention they had received inadequate information from healthcare providers for effective diabetes self-management, had had low expectations for help from their providers, and had not felt comfortable asking questions or making requests of their healthcare providers. Key ways participants reported that the program improved their ability to manage their diabetes were by providing (1) clear and detailed information on diabetes and diabetes care; (2) education and training on specific strategies to meet diabetes care goals; (3) sustained and nonjudgmental assistance to increase their motivation and confidence; and (4) social and peer support that enabled them to better manage their diabetes. The knowledge and confidence gained through the CHW intervention increased participants' assertiveness in asking questions to and requesting necessary tests and results from their providers.

CONCLUSIONS

Study findings suggest ways that CHW programs that provide both one-on-one support and group self-management training sessions may be effective in promoting more effective diabetes care and patient-doctor relationships among Latino and African-American adults with diabetes. Through these mechanisms, such interventions may help to mitigate racial and ethnic disparities in diabetes care and outcomes.

The medicine wheel nutrition intervention: a diabetes education study with the Cheyenne River Sioux Tribe

OBJECTIVE

The Northern Plains Indians of the Cheyenne River Sioux Tribe have experienced significant lifestyle and dietary changes over the past seven generations that have resulted in increased rates of diabetes and obesity. The objective of this study was to determine if Northern Plains Indians with type 2 diabetes mellitus who are randomized to receive culturally adapted educational lessons based on the Medicine Wheel Model for Nutrition in addition to their usual dietary education will have better control of their type 2 diabetes than a nonintervention, usual care group who received only the usual dietary education from their personal providers.

DESIGN

A 6-month, randomized, controlled trial was conducted January 2005 through December 2005, with participants randomized to the education intervention or usual care control group. The education group received six nutrition lessons based on the Medicine Wheel Model for Nutrition. The usual care group received the usual dietary education from their personal providers.

PARTICIPANTS

One hundred fourteen Northern Plains Indians from Cheyenne River Sioux Tribe aged 18 to 65 years, with type 2 diabetes.

METHODS

Weight, body mass index (BMI), hemoglobin A1c, fasting serum glucose and lipid parameters, circulating insulin, and blood pressure were measured at the beginning and completion. Diet histories, physical activity, and dietary satiety surveys were measured at baseline and monthly through completion. Differences were determined using Student t tests, chi(2) tests, and analysis of variance.

RESULTS

The education group had a significant weight loss (1.4+/-0.4 kg, P<or=0.05) and decrease in BMI (1.0+/-0.1, P<or=0.05) from baseline to completion. The usual care group had no change in weight (0.5+/-0.5 kg) or BMI (0.5+/-0.2). There were no between group differences due to intervention in energy, carbohydrate, protein, and fat intake and physical activity.

CONCLUSIONS

The culturally based nutrition intervention promoted small but positive changes in weight. Greater frequency and longer duration of educational support may be needed to influence blood glucose and lipid parameters.

Systematic review of physical activity interventions implemented with American Indian and Alaska Native populations in the United States and Canada

OBJECTIVE

To describe physical activity (PA) interventions implemented in American Indian/Alaska Native (AI/AN) populations in the United States and Canada.

DATA SOURCES

MEDLINE, PubMed, ERIC, and Sociological Abstracts were used to identify peer-reviewed journal articles. Dissertation abstracts, Web sites, and conference proceedings were searched to identify descriptions within the gray literature from 1986 to 2006.

STUDY INCLUSION AND EXCLUSION CRITERIA

The target population had to be described as AI/ AN, aboriginal, native Hawaiian, and/or native U.S. Samoan. PA interventions among indigenous populations of Latin America were not included.

DATA EXTRACTION

Descriptions of 64 different AI/AN PA interventions (28 peer-reviewed journal articles and 36 in the gray literature) were identified.

DATA SYNTHESIS

Data were synthesized by geographic region, intervention strategy, target audience, activities, and sustainability.

RESULTS

Most interventions were conducted in the southwest United States (35.4%), in reservation communities (72%), and among participants 18 years and younger (57.8%). Forty-one percent of the 27 interventions with evaluation components reported significant changes in health, behavior, or knowledge.

CONCLUSIONS

Effective AI/AN PA interventions demonstrated impact on individual health and community resources. Program sustainability was linked to locally trained personnel, local leadership, and stable funding. Culturally acceptable and scientifically sound evaluation methods that can be implemented by local personnel are needed to assess the health and social impact of many long-running AI/AN PA interventions.

Individual patient education for people with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes is a common and costly chronic disease which is associated with significant premature mortality and morbidity. Although patient education is an integral component of diabetes care, there remain uncertainties regarding the effectiveness of different methods and modes of education.

OBJECTIVES

To evaluate the effectiveness of individual patient education on metabolic control, diabetes knowledge and psychosocial outcomes.

SEARCH STRATEGY

Multiple electronic bibliographic databases were searched, including The Cochrane Library, MEDLINE, Premedline, ERIC, Biosis, AMED, Psychinfo, EMBASE, CINAHL, APAIS-health, Australian Medical Index, Web of Science, dissertation abstracts and Biomed Central.

SELECTION CRITERIA

Randomized controlled and controlled clinical trials which evaluated individual education for adults with type 2 diabetes. The intervention was individual face-to-face patient education while control individuals received usual care, routine treatment or group education. Only studies that assessed outcome measures at least six months from baseline were included.

DATA COLLECTION AND ANALYSIS

Information was extracted by two reviewers who summarized both study characteristics and outcome statistics. A meta-analysis using a fixed-effect model was performed if there were adequate studies with a specified outcome of sufficient homogeneity. For outcomes where there were too few studies or the assessment measurements were not standardized or variable, the results were summarised qualitatively.

MAIN RESULTS

Nine studies involving 1359 participants met the inclusion criteria. Six studies compared individual education to usual care and three compared individual education to group education (361 participants). There were no long-term studies and overall the quality of the studies was not high. In the six studies comparing individual face-to-face education to usual care, individual education did not significantly improve glycaemic control (weighted mean difference (WMD) in HbA1c -0.1% (95% confidence interval (CI) -0.3 to 0.1, P = 0.33) over a 12 to 18 month period. However, there did appear to be a significant benefit of individual education on glycaemic control in a subgroup analysis of three studies involving participants with a higher mean baseline HbA1c greater than 8% (WMD -0.3% (95% CI -0.5 to -0.1, P = 0.007). In the two studies comparing individual to group education, there was no significant difference in glycaemic control between individual or group education at 12 to 18 months with a WMD in HbA1c of 0.03% (95% CI -0.02 to 0.1, P = 0.22). There was no significant difference in the impact of individual versus usual care or group education on body mass index systolic or diastolic blood pressure. There were too few studies to perform a meta-analysis on the effect of individual education on dietary self management, diabetes knowledge, psychosocial outcomes and smoking habits. No data were available on the other main outcome measures of diabetes complications or health service utilization and cost analysis in these studies.

AUTHORS' CONCLUSIONS

This systematic review suggests a benefit of individual education on glycaemic control when compared with usual care in a subgroup of those with a baseline HbA1c greater than 8%. However, overall there did not appear to be a significant difference between individual education and usual care. In the small number of studies comparing group and individual education, there was an equal impact on HbA1c at 12 to 18 months. Additional studies are needed to delineate these findings further.

Making diabetes self-management education culturally relevant for Filipino Americans in Hawaii

PURPOSE

The purpose of this study was to identify the cultural values, traditions, and perceptions of diabetes risk and self-care among Filipino Americans in Hawaii with type 2 diabetes that facilitate or impede engagement in diabetes self-management behaviors and education classes.

METHODS

This qualitative study used 2 rounds of semistructured focus groups and interviews. Participants included 15 patients with type 2 diabetes recruited from a large health-maintenance organization in Hawaii and 7 health care and cultural experts recruited from the community. The taped and transcribed focus groups and interviews were coded thematically. Participants evaluated example materials for diabetes self-management education (DSME) with Filipino Americans.

RESULTS

Several aspects of Filipino American culture were identified as central to understanding the challenges of engaging in self-management behaviors and DSME: (1) undertaking self-management while prioritizing the family and maintaining social relationships, (2) modifying diet while upholding valued symbolic and social meanings of food, (3) participating in storytelling in the face of stigma associated with diabetes, and (4) reconciling spiritual and biomedical interpretations of disease causality and its management. Respondents also emphasized the role of several qualitative aspects of perceived risk (eg, dread, control) in moderating their behaviors. Participants suggested ways to make DSME culturally relevant.

CONCLUSIONS

Awareness of cultural values and qualitative aspects of perceived risk that influence Filipino Americans' engagement in diabetes self-care behaviors and classes may help to improve teaching methods, materials, and recruitment strategies.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Social support, self-efficacy and psychological stress responses among outpatients with diabetes in Yogyakarta, Indonesia

We attempted to study whether social support promotes self-efficacy and reduces stress responses of patients with diabetes in Yogyakarta, Indonesia. Diabetic outpatients at Dr. Sardjito Hospital voluntarily participated in a questionnaire survey. Data from 125 patients were subjected to analysis. The questionnaires included the scales and subscales of social support, self-efficacy, psychological stress response, and demographic measure. Data were analyzed by Spearman's rank correlation test to examine the relationships between parameters, Mann-Whitney U-test and Kruskal-Wallis test to compare the scales by characteristics, and structural equation modeling to explore the best-fit model. This study was performed in September 2003. It was found that augmentation of emotional support to patients significantly increased the 'active coping for the disease' and 'controllability of health', and that 'helplessness' was reduced significantly. Behavioral support affected only 'controllably of health'. Self-efficacy reduced stress response of the patients. It was also found that subjects who received support from their children significantly scored higher in perceived availability of social support than those without support from their children. To know their behavioral support better as well as emotional support may be one area to focus on in improving the health status of people with diabetes in Yogyakarta.

Development of a Planning and Evaluation Methodology for Assessing the Contribution of Theory to a Diabetes Prevention Lifestyle Intervention

The benefits of utilizing and measuring application of theory for behavior change programs are numerous, including the emergence of new theories and theoretically bound strategies. Despite recent attempts to make theory use more salient, there remains a dearth of practical frameworks for the development and evaluation of theory-based programs. Without literature documenting how theories have been specifically applied to interventions and their evaluation, health educators may not be well prepared to utilize theory for the design, implementation, or as a focus of the evaluation. Using a case study example of a diabetes prevention program, this article describes how theory was used for the program design and the evaluation and provides a framework for using theory in other programs. Issues discussed include: the challenges in successfully utilizing theory for intervention development and the processes of developing theoretically based instruments.

Reducing diabetes risk in American Indian women

BACKGROUND

American Indians experience high rates of type 2 diabetes. The impact of low-intensity interventions on diabetes risk among young American Indian women is unknown.

DESIGN

Randomized controlled trial.

SETTING/PARTICIPANTS

Community-based; participants were 200 young urban American Indian women who were block-randomized on fasting blood glucose (FBG) into intervention and control groups. Inclusion criteria included self-reported identity, aged 18-40 years, not pregnant, willingness to stay in urban area for 2 years, and not having type 2 diabetes. Measures were taken at baseline, 6, 12, and 18 months. Data were gathered in 2002-2006 and analyzed in 2006-2007.

INTERVENTION

Five discussion group sessions (one meeting per month for 5 months) were held focusing on healthful eating, physical activity, goal-setting, and social support.

MAIN OUTCOME MEASURES

Primary outcomes included dietary fat and vegetable consumption and self-reported physical activity. Secondary outcomes included cardiorespiratory fitness, insulin sensitivity, blood pressure, lipid profiles, percent body fat, BMI, intake of fruit, total sugar and sweetened beverages, FBG, and television viewing.

RESULTS

Mean vegetable and fruit intake increased significantly more in the intervention group than in the control group over time (group by visit interaction, p=0.02 and p=0.002, respectively). Both groups had significant increases in percent body fat and decreases in waist circumference, insulin sensitivity, blood cholesterol, LDL, television viewing, and total intakes of energy, saturated fat, sugar, and sweetened beverages.

CONCLUSIONS

A culturally influenced, low-intensity lifestyle intervention can improve self-reported intakes of vegetables and fruit over 18 months in young, urban American Indian women.

Diabetes treatments

With the aging of the population, physical inactivity, and growing rates of obesity, there has been a dramatic rise in the incidence of diabetes. Diabetes and its treatment is a holistic and dynamic experience, shaping many aspects of a person's life and well-being. Despite the biopsychosocial nature of this chronic disease, medications tend to be the principal intervention among medical professionals. Over the past fifteen years, however, diabetes researchers and clinicians have begun to develop interventions addressing the psychosocial aspects of diabetes. The majority of these interventions fall within the knowledge base and clinical abilities of social work practitioners. This paper systematically reviews psychosocial intervention studies with older adults, identifying and summarizing treatment protocols.

The development, implementation, and process evaluation of the REACH Detroit Partnership's Diabetes Lifestyle Intervention

PURPOSE

The purpose of this article was to describe the development, implementation, and process evaluation findings of a culturally tailored diabetes lifestyle intervention for African Americans and Latinos.

METHODS

African American and Latino adults with type 2 diabetes from 3 health care systems in Detroit, Michigan, participated in diabetes lifestyle intervention of the Racial and Ethnic Approaches to Community Health Detroit Partnership. The intervention curricula were culturally and linguistically tailored for each population. Trained community residents delivered the curricula in 5 group meetings aimed at improving dietary, physical activity, and diabetes self-care behaviors of study participants. The aims of the process evaluation were to assess participant satisfaction with the intervention, utility, and applicability of information and cultural relevance of intervention materials. Content analysis was used to analyze qualitative data. Matrices were developed along thematic lines, and common themes were determined by grouping responses by question.

RESULTS

Ninety-eight percent of participants attended 1 or more intervention classes; 41% attended all 5 meetings. Attendance rates ranged from 59% to 88% for individual meetings. Participants reported that program information and activities were useful, culturally relevant, and applicable to diabetes self-management. Participants also appreciated the convenient community location for meetings and the social support received from other participants.

CONCLUSIONS

A community-based, culturally tailored diabetes lifestyle intervention delivered by trained community residents was associated with high participant satisfaction and retention.

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.

Hemostasis and glycemic control in the cardiac surgical patient

The Centers for Disease Control and Prevention estimate that 6% of the US population meets diagnostic criteria for diabetes mellitus, with at least one third of this group being undiagnosed. A majority of adult blindness, renal insufficiency, and limb amputation may be directly attributed to diabetes. Although the incidence of type 1, autoimmune-mediated diabetes remains relatively stable, increasing age, physical inactivity, and obesity have produced explosive growth in insulin resistance and type 2 diabetes. A direct association between diabetes and atherothrombotic disease remains indisputable. However, recent data further suggest that even minor elevations of fasting plasma glucose, in "nondiabetic" subjects, increase cardiovascular risk. Alterations in hemostasis may play an important contributory role. Both hyperglycemia and hyperinsulinemia induce prothrombotic characteristics, including overexpression of vascular endothelial plasminogen activator inhibitor-1 (PAI-1), down-regulation of fibrinolysis, elevation of plasma coagulation proteins (ie, fibrinogen, factor VII, factor X), and enhanced platelet activation. Furthermore, endothelial dysfunction-characterized by an inflammatory phenotype-commonly accompanies diabetes. Given data supporting prothrombotic potential of both acute and chronic hyperglycemia, aggressive perioperative glucose control appears imperative.