Psychometric evaluation of the Informed Consent Process Scale in Chinese.

BACKGROUND: Informed consent is essential for the ethical conduct of clinical research and is a culturally sensitive issue. But, a measurable Chinese version of the scale to evaluate the informed consent process has not yet been explored in the existing literature. RESEARCH OBJECTIVES: This study aimed to develop and psychometrically test the Chinese version of the Informed Consent Process Scale. RESEARCH DESIGN: Back-translation was conducted to develop the Chinese version of the questionnaire. A cross-sectional survey was administered, after which an exploratory factor analysis was conducted. PARTICIPANTS: We recruited a total of 375 participants who had experience in signing an informed consent form within the previous 3 years in Taiwan. ETHICAL CONSIDERATIONS: This study was approved by two Institutional Review Boards and the autonomy of the participants was respected. FINDINGS: The Chinese version of the Informed Consent Process Scale is composed of three factors with 23 items showing evidence of acceptable reliability and validity. Three major factors were extracted and labeled: Factor 1 - 'Understanding of the research', Factor 2 - 'Trust and confidence' and Factor 3 - 'Doubt and uncertainty'. The three factors accounted for is 52.954 of the total variance with Cronbach's α of .917. DISCUSSION AND CONCLUSION: The finding corroborates previous studies showing that participants had too little understanding on the informed consent forms they signed and implied the need to clarify the critical points in clinical research. The psychometric results indicated good internal consistency and validity for this newly constructed instrument, and it was found worthy of conducting further testing and application.

Vegetation response to invasive Tamarix control in southwestern U.S. rivers: a collaborative study including 416 sites.

Most studies assessing vegetation response following control of invasive Tamarix trees along southwestern U.S. rivers have been small in scale (e.g., river reach), or at a regional scale but with poor spatial-temporal replication, and most have not included testing the effects of a now widely used biological control. We monitored plant composition following Tamarix control along hydrologic, soil, and climatic gradients in 244 treated and 172 reference sites across six U.S. states. This represents the largest comprehensive assessment to date on the vegetation response to the four most common Tamarix control treatments. Biocontrol by a defoliating beetle (treatment 1) reduced the abundance of Tamarix less than active removal by mechanically using hand and chain-saws (2), heavy machinery (3) or burning (4). Tamarix abundance also decreased with lower temperatures, higher precipitation, and follow-up treatments for Tamarix resprouting. Native cover generally increased over time in active Tamarix removal sites, however, the increases observed were small and was not consistently increased by active revegetation. Overall, native cover was correlated to permanent stream flow, lower grazing pressure, lower soil salinity and temperatures, and higher precipitation. Species diversity also increased where Tamarix was removed. However, Tamarix treatments, especially those generating the highest disturbance (burning and heavy machinery), also often promoted secondary invasions of exotic forbs. The abundance of hydrophytic species was much lower in treated than in reference sites, suggesting that management of southwestern U.S. rivers has focused too much on weed control, overlooking restoration of fluvial processes that provide habitat for hydrophytic and floodplain vegetation. These results can help inform future management of Tamarix-infested rivers to restore hydrogeomorphic processes, increase native biodiversity and reduce abundance of noxious species.

The chronic kidney disease self-efficacy (CKD-SE) instrument: development and psychometric evaluation.

BACKGROUND: Self-management has been associated with positive health outcomes among adults with chronic kidney disease (CKD). Perceived disease-related self-efficacy (DSE) is considered a critical component in the successful self-management of chronic disease. A valid and reliable instrument for measuring CKD patients' self-efficacy is needed. This study aims to develop and test a new instrument to measure the DSE of patients with early stage CKD. METHODS: A total of 594 Taiwanese patients with early stage CKD recruited from two medical centers and one regional hospital in southern Taiwan completed the questionnaire. The CKD self-efficacy (CKD-SE) was evaluated using exploratory factor analyses (EFA) and measures of reliability. RESULTS: EFA identified four distinct factors with loadings ranging from 0.557 to 0.970: autonomy, self-integration, problem solving and seeking social support, accounting for 64.348% of the total variance. Cronbach's alpha coefficients for the subscales ranged from 0.843 to 0.901. CONCLUSION: This promising 25-item CKD-SE instrument can be used for the early identification of patients with low DSE, thus allowing the development of interventions to help these patients attain an appropriate level of DSE.

The art and science of diabetes education: a culture out of balance.

In the past 20 years, behavioral science has helped create a growing body of theoretically derived, evidenced-based approaches to diabetes patient education. Health care professionals in all disciplines are being required to demonstrate that their practice is evidence based. For diabetes educators, behavioral science is the source of much of that evidence. However, effective diabetes education involves a combination of art and science. Establishing a therapeutic alliance with patients is an art. Diabetes educators must have the interpersonal skills, values, and personal traits needed to cultivate relationships with patients that are characterized by trust, respect, and acceptance. They must feel and be able to express compassion, empathy, and warmth. However, if someone outside the field were reviewing diabetes education evaluation research, they would probably conclude that diabetes educators are interchangeable cogs in a wheel. The positive impact of the therapeutic alliance is well documented in the counseling, psychotherapy, education, and nursing literature. However, evidence to support the important role of the diabetes educator's values, interpersonal skills, and ability to establish a therapeutic alliance with patients is absent from that literature. Valid and reliable measures used to document the impact of interpersonal skills counselors and teachers could be used in diabetes education with little or no adaptation. The evidence and tools exist; we now need to determine if the will exists.

Social support, quality of life, and self-care behaviors amongAfrican Americans with type 2 diabetes.

PURPOSE: The purpose of this study was to examine social support and its relationship to diabetes-specific quality of life and self-care behaviors in African Americans with type 2 diabetes. METHODS: The study followed a cross-sectional, observational design and recruited 89 African American adults, age 40 and older (mean = 60, SD = 10.5), diagnosed with type 2 diabetes. Participants completed measures assessing diabetes-specific quality of life, self-care behaviors (healthy eating, physical activity, self-monitoring of blood glucose, foot care, medication and/or insulin use), demographic background, and diabetes-related social support. Diabetes-related social support variables included amount of social support received, satisfaction with support, positive support behavior, negative support behavior, and primary source of support. RESULTS: Stepwise regressions, controlling for demographic variables, were conducted to identify predictors of diabetes-specific quality of life and self-care behaviors from the diabetes-related social support variables. Satisfaction with support was a predictor for improved diabetes-specific quality of life (r = -.579, P < .001) and blood glucose monitoring (r = .258, P < .05). Positive support behavior was a predictor for following a healthy eating plan (r = .280, P < .05), spacing out carbohydrates evenly throughout the day (r = .367, P < .01), and performing physical activity at least 30 minutes per day (r = .296, P < .05). Negative support behavior was a predictor for not taking medication as recommended (r = -.348, P < .01). CONCLUSIONS: Findings indicate that social support plays a role in diabetes-specific quality of life and self-management practices. Social support encompasses multiple dimensions that differentially influence specific diabetes health-related outcomes and behaviors.

A study of certified diabetes educators: influences and barriers.

PURPOSE: There were 2 related goals for this study. The first purpose was to describe the structure (type, staffing, and number of educational sessions provided), process (preferred learning approaches), and outcome measures commonly used to provide patient education. The second purpose was to identify the influences, resources, and constraints that affect and alter the attitudes and practices of diabetes educators. METHODS: A 30-item questionnaire that addressed 4 areas--demographics, practice characteristics, education program structure, and educational processes--was mailed to a sample of American Association of Diabetes Educators members. Three hundred sixty-one registered nurse and registered dietician certified diabetes educators completed the questionnaire and were included in the final analysis. RESULTS: This survey indicated that this group of certified diabetes educators has incorporated new research findings and innovative teaching methods into their practices. They experience few barriers and tend to make changes in their attitudes and practices based on scientific and experiential evidence. The 3 most highly rated influences on these changes were related to patient responses to their teaching, followed by continuing education conferences and new research findings. CONCLUSIONS: Based on these findings, providing continuing education that first and foremost incorporates experience-based examples of effective strategies supported by research published in professional journals appears to have the most influence on the practice of educators.

Validation of the Revised Brief Diabetes Knowledge Test (DKT2).

PURPOSE: The purpose of this study is to examine the reliability and validity of the revised Diabetes Knowledge Test (DKT2). The original test was updated to reflect current diabetes care and education guidelines. The test has 2 components: a 14-item general test and a 9-item insulin use subscale. METHODS: Two samples were used to evaluate the DKT2. The first came from an online survey company (Qualtrics, LCC) (n = 101) and the second from University of Michigan's (UofM) Diabetes Registry (n = 89). Cronbach's coefficient alpha was used to calculate reliability. To examine validity, comparisons by type of diabetes, insulin use and oral medication use, and educational level were completed. Correlations between diabetes duration and both the general test and insulin subscale were calculated for the UofM sample. RESULTS: The two samples differed demographically. While the reliabilities between the samples were disparate, when combined, the coefficient alphas demonstrated reliability for both the general test (.77) and the insulin use subscale (.84). The validation comparisons proved to be similar; different results occurred between samples but when combined demonstrated validity. CONCLUSIONS: The reliability and validity tests were inconsistent by sample. The different results can, in part, be attributed to the demographic differences between the 2 samples. With the exception of age, the samples differed in every other measured variable. However, when the samples were combined, the analyses supported the reliability and validity of the Diabetes Knowledge Test 2. The DKT2 is a quick and low-cost method of assessing general knowledge of diabetes and diabetes self-care.

Empowerment and self-management after weight loss surgery.

The bariatric surgery health-care professional team are often frustrated and discouraged when patients are unwilling or unable to follow their advice to achieve ideal outcomes after obesity surgery. The acute care model that suffices for other types of surgery is inadequate after a surgery that requires chronic life-long behavioral changes. Practical interventions that facilitate collaborative relationships and foster patient-centered practices are the key to giving up feeling responsible for the choices that patients make, by being responsible to them, and achieving better outcomes.

Choosing and using theories in diabetes education research.

Diabetes educators use theories all the time, even if they are not aware of it. To teach, one must have some assumptions about how people learn and what constitutes effective teaching. The purpose of this article is to help diabetes educators interested in research and evaluation choose appropriate theories. The article will review the 4 purposes of theories, that is, description, explanation, prediction, and control, as well as the degree to which a theory has been articulated and elaborated. The importance of a theory's personal resonance, its explanatory power, and its utility will also be examined. The article will also review how to use 1 or more theories at each stage of a research or evaluation project.

Implementing an empowerment-based diabetes self-management education program.

Diabetes educators are challenged to develop culturally appropriate, integrated, behaviorally based, effective education programs. This article describes the intervention used in a problem-based educational program for urban African Americans with diabetes. The intervention consisted of six 2-hour, weekly group educational and data collection sessions. No lectures were used, and the content was determined by participants' questions and concerns. Culturally tailored written educational materials were also provided.

Developing a new generation of ongoing: Diabetes self-management support interventions: a preliminary report.

PURPOSE: The study examined the feasibility, acceptability, and potential impact of an innovative, community-based, ongoing self-management intervention aimed at enhancing and sustaining self-care behaviors over the long term among urban African Americans with type 2 diabetes. METHODS: Sixty-two African American men and women completed the study. Participants were invited to attend 24 weekly, consecutive, diabetes self-management support/ education groups. The flow of the weekly group sessions was guided by questions and concerns of the patients. Baseline and 6-month follow-up metabolic functioning, lipid profiles, cardiovascular functioning, and self-care behaviors were assessed. RESULTS: Ninety percent (n = 56) of the sample attended at least 1 session; 40% attended at least 12 or more sessions. Paired t tests found significant improvements in body mass index (P < .001), total cholesterol (P < .01), high-density lipoprotein (P < .05), and low-density lipoprotein (P < .001). Significant increases were also found for self-care behaviors (P < .05). CONCLUSIONS: Preliminary evidence suggests that participation in this weekly problem-based, self-management support intervention can yield diabetes-related health benefits.

Patient empowerment: reflections on the challenge of fostering the adoption of a new paradigm.

Diabetes is a self-managed illness in which the decisions most affecting the health and well being of patients are made by the patients themselves. Many of these decisions involve routine activities of daily living (e.g., nutrition, physical activity). Effective diabetes care requires patients and health care professionals to collaborate in the development of self-management plans that integrate the clinical expertise of health care professionals with the concerns, priorities and resources of the patient. Collaborative diabetes care requires a new "empowerment" paradigm that involves a fundamental redefinition of roles and relationships of health care professionals and patients. The challenges of fostering the adoption of a new paradigm differ substantially from those associated with the introduction of new technology. Those challenges are discussed in this paper.

Evaluating a problem-based empowerment program for African Americans with diabetes: results of a randomized controlled trial.

OBJECTIVE: The objective of this study was to evaluate the impact of a problem-based empowerment patient education program specifically tailored for urban African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS: The study used a randomized controlled trial (RCT) pretest/post-test design with repeated measures. Patients were randomly assigned to either a six-week intervention group or a six-week wait-listed control group. After completing the six sessions, patients were invited to participate in one of two follow-up conditions; attend a monthly support group or receive a monthly phone call from a nurse. Assessment measures included HbA1C, lipids, blood pressure, weight, self-management behavior and psychosocial adaptation. RESULTS: Both control and intervention patients showed a broad array of small-to-modest positive changes during the six-week RCT. These gains were maintained or improved upon during the one-year follow-up period. For patients in the two follow-up conditions, a positive correlation was seen between the number of follow-up contacts and their one-year HbA1C values. CONCLUSIONS: We believe that results of this study can be attributed to volunteer bias, study effects (ie, providing study data on several occasions to patients and their physicians during the one-year study period), and impact of the interventions. However, the study design does not allow us to examine the relative impact of these three factors on the patient improvements seen over the one-year study period.

Using focus groups of older African Americans and Latinos with diabetes to modify a self-care empowerment intervention.

OBJECTIVE: To make cultural and age-specific modifications to a self-care empowerment intervention. DESIGN: Focus groups with self-administered surveys. SETTING: Two public health diabetes and geriatrics clinic and two senior centers in and around South Los Angeles. PARTICIPANTS: African Americans and Latinos aged > or = 55 years with diabetes (N=79), and two groups of health educators (N=16). MAIN OUTCOME MEASURES: After describing the proposed intervention, the focus group facilitators asked participants: 1) whether the community of interest would be interested in the proposed empowerment intervention; 2) why or why not; and 3) how the intervention could be modified to better address the concerns of the study community of interest. All groups were audiotaped, transcribed, and (when appropriate) translated into English. Three independent investigators read all transcripts and completed standardized coding forms for each transcript. In addition, at the end of each focus group, all participants completed a self-administered written survey asking them to rate aspects of the proposed intervention. RESULTS: Older African Americans and Latinos endorsed the intervention but desired an expanded dietary educational component and identified disability as an important missing content area. Participants rejected the use of an audio learning tool and did not believe that matching group-facilitator sociodemographic characteristics was important as long as facilitators demonstrated cultural competency. CONCLUSIONS: These findings illustrate a model of participatory research in which researchers and community members work together to develop an empowerment intervention that will meet community needs and will have greater cultural appropriateness. Modifying the intervention in accordance with these findings should enhance the relevance and impact of the self-care intervention.

A systematic review of the identification of seniors at risk (ISAR) tool for the prediction of adverse outcome in elderly patients seen in the emergency department.

The purpose of this systematic review was to evaluate the predictive validity of the Identification of Seniors at Risk (ISAR) Tool in identifying elderly patients at risk of adverse outcomes after a visit to the emergency department (ED). Since older adults are frequently sent to the ED, screening for risk of adverse outcomes in elderly patients is increasingly important in the ED. Also it is a way to ensure that interventions based on a comprehensive geriatric assessment (CGA) are provided to patients identified at risk to reduce the risk of adverse outcomes. The ISAR is a six-item risk-screening tool for elderly patients seen in the ED. However the predictive validity of ISAR is controversial. Relevant studies from January 1999 through December 2014 were searched systematically in PubMed, Cochrane Library, Web of Knowledge, Scopus, CINAHL, Elsevier ScienceDirect databases. The language was restricted to English. This review was based on the recommendations of the Cochrane Handbook of Diagnostic Test Accuracy Reviews. Ten studies (8680 patients) were included in this review. With a cutoff score at least 2, the ISAR was proved to have poor validity related to revisiting the ED (AUC: 0.59-0.60) and hospital readmission (AUC: 0.59-0.60). The predictive validity of the ISAR related to mortality and composite outcomes was graded as poor to fair. It is not suitable to use the ISAR alone for identifying seniors at risk for adverse outcomes in the ED.

Faculty development for educational leadership and scholarship.

The Medical Education Scholars Program (MESP) at the University of Michigan Medical School is designed to develop leaders in medical education. The program's goals are to enable faculty to provide curriculum direction, improved teaching, educational research, and development, and institutional leadership at all levels of medical education. This one-year program uses a variety of educational methods and provides a broad curriculum in educational theory, assessment and evaluation, research design and methods, teaching-skills development, and educational leadership. Faculty are admitted on a competitive basis and one half-day per week of release time is funded as part of the program. Salient outcomes of the program (promotions, educational research and development, curriculum leadership, and educational scholarship) were measured in a pre- and post-program design in which each scholar acted as his or her own control. There were major increases in promotions and educational awards, new educational responsibilities, and new educational programs. A particularly important outcome was the emergence of educational scholarship in the professional portfolios of the program scholars in the form of peer-reviewed presentations and publications and educational grant funding. A cost-outcome analysis indicates that these multi-year outcomes were obtained from a one-time investment of approximately $21,000 per graduating scholar. This evaluation indicates that intensive faculty development programs can have measurable impacts on the careers of the participants and the institutional environment.

Are residents more comfortable than faculty members when addressing sociocultural diversity in medicine?

PURPOSE: Sociocultural medicine is a growing curricular area in medical education. Because faculty members and residents will teach these curricula and model these skills in patient care, it is important to assess their attitudes toward diversity. This study examined faculty members' and residents' attitudes toward sociocultural issues in medicine. METHOD: In November 2000, 198 physicians from the Department of Pediatrics at the University of Michigan Medical School completed a questionnaire on demographics and sociocultural attitudes in medicine while they attended a department-wide retreat on cultural competency. A factor analysis of the sociocultural attitudes measure yielded five dimensions accounting for 70% of the variance. These factors included sexual orientation, diversity in professional functions, discussing race/ethnicity in teaching forums, clinical skills, and alternative medicine. RESULTS: Significant differences were found between faculty members and residents for sexual orientation issues (t = 2.76, p <.01) and alternative medicine (t = 2.84, p <.01), with residents endorsing greater comfort in these areas of patient care. When controlling for demographic/background variables, group differences disappeared. Past exposure to multiculturalism emerged as a significant predictor for both sociocultural attitude dimensions. CONCLUSIONS: Findings suggested while residents felt more comfortable than faculty members did with sexual orientation and alternative medicine issues in medicine, attitudes may have been related more to previous diversity education than to seniority of the physician. Integrating diversity education within departments and across the medical education continuum likely benefits all physicians. In the area of sociocultural medicine, both faculty members and residents can offer perspectives valuable to medical students, colleagues, and the larger medical community.

Measuring perceptions of diabetes-related concepts: a preliminary study.

PURPOSE: This pilot study explored health professionals' and patients' perceptions of diabetes through the development of the Diabetes Semantic Differential Scales (DSDS). These scales evaluate the meaning of diabetes-related concepts. METHODS: Health professionals (n = 39) attending a CME course completed the health professional version of the DSDS. Patients (n = 70) completed the patient version of the DSDS. RESULTS: The reliability of the DSDS was supported. The scale scores of health professionals, African American patients, and Caucasian patients, examined initially by one-way analyses of variance, showed significant differences among the groups for 4 of the 18 diabetes concepts. Effect sizes were also examined among these groups. For 7 concepts, there was a significant practical difference between the perceptions of the health professionals and the African American patients. For the Caucasian patients, differences were noted for 6 concepts. CONCLUSIONS: There are 3 primary inferences from this pilot study. First, health professionals and patients are likely to hold different perceptions of key diabetes concepts. Second, the concepts on which professionals and patients differ are not always what one would expect. Third, health professionals should clarify patients' understanding of diabetes to minimize the potential for miscommunication.

Personalized follow-up increases return rate at urban eye disease screening clinics for African Americans with diabetes: results of a randomized trial.

OBJECTIVE: To evaluate the effectiveness of using personalized follow-up, as compared to reminder letters, in increasing return rates at urban eye disease screening clinics for African Americans with diabetes, and to identify factors predictive of the patient's likelihood of returning for annual follow-up exams. RESEARCH DESIGN AND METHODS: All patients attending free community-based retinopathy screening clinics who were advised to return in one year for another diabetes eye evaluation (DEE) were randomized to standard or personalized follow-up interventions. Patients in the standard follow-up group received reminder letters a month before it was time to return for their next annual DEE. Patients in the intensive personalized intervention also received the letters, but those patients who did not call for an appointment within 10 days received a phone call from project staff, encouraging them to return for a DEE. RESULTS: One hundred thirty-two African Americans with diabetes were randomized to one of the 2 treatments. The return rate for the intensive, personalized follow-up group was 66%, significantly (P=.001) higher than the 35% return rate for the standard follow-up group. CONCLUSION: This study demonstrated the efficacy of personal contact by telephone in improving return rates for annual DEEs in this population of patients. This finding is consistent with one of the key design principles of the project, which was to establish credible personal relationships with community leaders and patients as a means to maximize the utilization of the eye screening clinics.

Conducting community-based, culturally specific, eye disease screening clinics for urban African Americans with diabetes.

The purpose of this study was to evaluate the need for, and efficacy of, community-based culturally specific eye disease screening clinics for urban African Americans with diabetes. The study employed a variety of culturally specific methods in the design and performance of 43 community-based eye disease screening clinics in southeastern Michigan. One thousand, thirty-seven subjects were recruited for the study. Of that number, 817 identified themselves as African Americans and are the focus of this report. Of the 817 African-American patients screened, 84 (10%) needed to be examined by an ophthalmologist immediately (< 30 days), and 180 (22%) needed to be examined soon (within 1 to 3 months), while 544 (67%) were advised to return for another exam a year later. The project demonstrated that it was possible to use culturally specific techniques to identify a significant number of urban African Americans with diabetes in need of eye screening and treatment. However, lack of health insurance proved to be the primary barrier to receiving needed treatment. Although the project was successful, it is not a solution to what is essentially a health systems problem, ie, inadequate access to appropriate diabetes care for a significant number of our population.