A diagnosis of prediabetes when combined with lifestyle advice and support is considered helpful rather than a negative label by a demographically diverse group: A qualitative study.

AIMS: The aim of this study was to explore the experience and perceptions of a diagnosis of prediabetes among a demographically diverse sample of New Zealanders who had, and had not, regressed to normoglycaemia following participation in a primary care nurse-delivered intervention for 6 months. The sample included Indigenous Maori who have high rates of diabetes and associated co-morbidities. METHODS: A purposefully selected sample of 58 people with prediabetes and BMI >25 kg/m2, stratified by male/female, Maori/non-Maori, and those who had/had not regressed to normoglycaemia, after completing 6-months of a prediabetes intervention were interviewed. Interviews were audio-recorded and transcribed. Data were analysed by thematic analysis. RESULTS: Most participants recalled being shocked when told they had prediabetes, but they did not perceive the diagnosis to be a label in a negative sense, and some, described the diagnosis as helpful. Participants appreciated knowing that prediabetes could be reversed, and the opportunity to be able to take supported action and make lifestyle changes through the nurse-delivered prediabetes lifestyle intervention. Participants' clear preference was to take control and make dietary changes, not to take Metformin. CONCLUSIONS: Prediabetes was not considered a negative label, but an opportunity, when coupled with a primary care nurse-delivered dietary intervention.

Proximal and distal influences on dietary change among a diverse group with prediabetes participating in a pragmatic, primary care nurse-led intervention: a qualitative study.

OBJECTIVE: To understand motivators, facilitators and challenges to dietary change amongst a diverse sample of New Zealanders with prediabetes participating in a primary care nurse-led individualised dietary intervention. DESIGN: A qualitative study involving semi-structured, face-to-face interviews with a stratified sample of adults with prediabetes and BMI ≥ 25 kg/m2, purposefully selected from a larger 2-year primary care-based prediabetes dietary intervention study. Thematic analysis was undertaken. A socio-ecological model guided interpretation. SETTING: Hawke's Bay, Aotearoa/New Zealand, April 2018-March 2020. PARTICIPANTS: Fifty-eight people aged 28-69 years, with similar numbers of men and women, indigenous Maori and non-Maori, and those who had and had not regressed to normoglycaemia at 6 months. RESULTS: Motivators for wanting to make dietary changes were determination not to progress to diabetes; wanting to be healthy and contribute to others and encouragement by others. Facilitators for adopting and maintaining changes were a strong desire to be healthy; personal determination and feeling supported. Challenges were compromised control over life and environmental factors; feeling unsupported by others; social occasions; financial constraints and living with other health conditions. Developing their own strategies to overcome challenges was empowering, enabling a sense of control. These factors were similar across demographic and glycaemic outcome groups. CONCLUSIONS: Influences on dietary change involved personal, interpersonal, organisational, environmental and policy factors. Although findings appeared similar across groups, dietary interventions need to address the specific ways motivators, facilitators and challenges manifest for individuals and social groups and be tailored accordingly within the context of the wider obesogenic and socio-economic environment.

Motor Developmental Outcomes in Children Exposed to Maternal Diabetes during Pregnancy: A Systematic Review and Meta-Analysis.

Studies on the association of maternal diabetes with motor development in children provide inconsistent findings. We searched MEDLINE/PubMed, EMBASE, Emcare, PsycINFO, and Google Scholar databases for primary observational, case-control, or cohort studies that report on the motor development of children exposed to maternal diabetes during pregnancy. Quality appraisal and data extraction were performed independently and in duplicate. A meta-analysis of summary measures was performed using random-effect models. Eighteen studies were identified for inclusion, however, only 13 were included in the meta-analysis. Exposure to maternal diabetes during pregnancy was associated with a lower pooled motor development in children and a decrease in both gross and fine motor development. Among all other factors, pre-existing diabetes and other gestational comorbidities, such as hypertension and obesity, or low socioeconomic status, also affect child development. Therefore, among children of diabetic mothers, those with other gestational comorbidities or pre-existing diabetes were more likely to be at risk developmentally.

The effectiveness of a primary care nursing-led dietary intervention for prediabetes: a mixed methods pilot study.

BACKGROUND: Primary care nurse-led prediabetes interventions are seldom reported. We examined the implementation and feasibility of a 6-month multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice in patients with prediabetes, with weight and glycated haemoglobin (HbA1c) as outcomes. METHODS: This study used a convergent mixed methods design involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation, and was conducted in two neighbouring provincial cities in New Zealand, with indigenous Maori populations comprising 18.2% and 23.0%, respectively. Participants were non-pregnant adults aged ≤ 70 years with newly diagnosed prediabetes (HbA1c 41-49 mmol/mol), body mass index (BMI) ≥ 25 kg/m2 and not prescribed Metformin. A structured dietary intervention tool delivered by primary care nurses with visits at baseline, 2-3 weeks, 3 months and 6 months was implemented in four intervention practices. Four control practices continued to provide usual care. Primary quantitative outcome measures were weight and HbA1c. Linear and quantile regression models were used to compare each outcome between the two groups at follow-up. Qualitative data included: observations of nurse training sessions and steering group meetings; document review; semi-structured interviews with a purposive sample of key informants (n = 17) and intervention patients (n = 20). Thematic analysis was used. RESULTS: One hundred fifty-seven patients with prediabetes enrolled (85 intervention, 72 control), 47.8% female and 31.2% Maori. Co-morbidities were common, particularly hypertension (49.7%), dyslipidaemia (40.1%) and gout (15.9%). Baseline and 6 month measures were available for 91% control and 79% intervention participants. After adjustment, the intervention group lost a mean 1.3 kg more than the control group (p < 0.001). Mean HbA1c, BMI and waist circumference decreased in the intervention group and increased in the control group, but differences were not statistically significant. Implementation fidelity was high, and it was feasible to implement the intervention in busy general practice settings. The intervention was highly acceptable to both patients and key stakeholders, especially primary care nurses. CONCLUSIONS: Study findings confirm the feasibility and acceptability of primary care nurses providing structured dietary advice to patients with prediabetes in busy general practice settings. The small but potentially beneficial mean weight loss among the intervention group supports further investigation. TRIAL REGISTRATION: ANZCTR ACTRN12615000806561 . Registered 3 August 2015 (Retrospectively registered).

A nurse-led education and cognitive behaviour therapy-based intervention among adults with uncontrolled type 2 diabetes: A randomised controlled trial.

RATIONALE, AIMS AND OBJECTIVES: Diabetes mellitus is associated with significant morbidity, mortality, and escalating health care costs. Research has consistently demonstrated the importance of glycaemic control in delaying the onset, and decreasing the incidence, of both the short-term and long-term complications of diabetes. Although glycaemic control is difficult to achieve and challenging to maintain, it is key to reducing negative disease outcomes. The aim of this study was to determine whether a nurse-led educational intervention alone or a nurse-led intervention using education and acceptance and commitment therapy (ACT) was effective in reducing hemoglobin A1c (HbA1c ) in people living with uncontrolled type 2 diabetes compared to usual care. METHODS: Adults over the age of 18 years, with a confirmed diagnosis of type 2 diabetes and HbA1c outside of the recommended range (4%-7%, 20-53 mmol/mol) for 12 months or more, were eligible to participate. Participants were randomised to either a nurse-led education intervention, a nurse-led education plus ACT intervention, or a usual care. One hundred and eighteen participants completed baseline data collection (N = 34 education group, N = 39 education plus ACT, N = 45 control group). An intention to treat analysis was used. RESULTS: A statistically significant reduction in HbA1c in the education intervention group was found (P = .011 [7.48, 8.14]). At 6 months, HbA1c was reduced in both intervention groups (education group -0.21 and education and ACT group -0.04) and increased in the control group (+0.32). A positive change in HbA1c (HbA1c reduced) was noted in 50 participants overall. Twice as many participants in the intervention groups demonstrated an improvement as compared to the control group (56% of the education group, 51% education plus ACT, and 24% control group. CONCLUSIONS: At 6 months post intervention, HbA1c was reduced in both intervention groups with a greater reduction noted in the nurse-led education intervention.

A nurse-led interdisciplinary approach to promote self-management of type 2 diabetes: a process evaluation of post-intervention experiences.

RATIONALE, AIMS AND OBJECTIVES: Self-management of type 2 diabetes through diet, exercise and for many medications, are vital in achieving and maintaining glycaemic control in type 2 diabetes. A number of interventions have been designed to improve self-management, but the outcomes of these are rarely explored from a qualitative angle and even fewer through a process evaluation. METHOD: A process evaluation was conducted using a qualitative design with participants randomized to an intervention. Seventy-three people living with type 2 diabetes and hyperglycaemia for a minimum of 1 year, randomized to one of two interventions (n = 34 to an education intervention and n = 39 to an education and acceptance and commitment therapy intervention) completed stage one of the process evaluation, immediately following the intervention through written feedback guided by open-ended questions. A purposive sample of 27 participants completed semi-structured interviews at 3 and 6 months post intervention. Interview data were transcribed and data analysed using a thematic analysis. RESULTS: The majority of participants described an increase in knowledge around diabetes self-management and an increased sense of personal responsibility. Participants also described changes in self-management activities and reflected on the challenges in instigating and maintaining change to improve diabetes management. CONCLUSION: The complexities of implementing change in daily life to improve glycaemic control indicate the need for ongoing support post intervention, which may increase and maintain the effectiveness of the intervention.

The Experience of Fatigue Across Long-Term Conditions: A Qualitative Meta-Synthesis.

CONTEXT: Fatigue is a common and debilitating symptom associated with many long-term conditions and is reported to cause significant levels of distress for those individuals. There is a substantial body of literature related to the nature of fatigue; however, this has not been drawn together and compared across conditions. OBJECTIVES: The aim of this review was to synthesize data on the nature of fatigue across long-term conditions. METHODS: The review was designed as a qualitative meta-synthesis and followed the Joanna Briggs Institute guidelines for synthesizing qualitative research. The following databases were searched for the period January 1980 to January 2016, Ovid (Medline, Embase, CINAHL, and PsycINFO) and manual searching from the reference lists from articles identified by electronic search. Fifty-seven studies were included in the review, and findings related to the nature of fatigue were extracted and findings meta-synthesized. RESULTS: The perceived nature of fatigue across long-term conditions was encompassed in one synthesis; the fatigue experience is without precedent, with four categories: a different fatigue to any experienced before, the intensity of fatigue is overwhelming, the trajectory of fatigue, and impact on sleep and sleep disturbance. Just over half of the participants in the included studies were diagnosed with cancer. Patterns in the experience of fatigue by condition were found for cancer-related fatigue and post-stroke fatigue where data were able to be synthesized. CONCLUSION: Although similarities in the nature of the fatigue experienced were found across conditions, differences were also evident and could be mapped for cancer-related fatigue and post-stroke fatigue. Further qualitative research on the experience of fatigue across a wide range of chronic conditions would further contribute to understanding similarities and differences across conditions and inform both research and practice in relation to assessment and management.

Liminality and decision making for upper limb surgery in tetraplegia: a grounded theory.

PURPOSE: To explore, from the perspective of the person with tetraplegia, the issues that influenced decision making about upper limb surgery and develop a conceptual framework describing the decision making process. METHOD: Purposive and theoretical sampling of 22 people with tetraplegia, followed by interviews. Ten people had upper limb surgery and 12 had not. Verbatim transcripts were analyzed with constructivist grounded theory. RESULTS: Participants responded to the offer of surgery in one of three ways: yes, let me have it; no thanks; or possibly. Many influences on the decision about surgery had a temporal element, such as hope for the cure or recovery from SCI, inadequate physical or social supports while rehabilitating, life roles and goals, and the avoidance of re-hospitalization. The conceptual framework illustrated that many participants entered a liminal state within which they required a stimulus to review their decision about upper limb surgery. CONCLUSION: Decision making is a temporal process, and for some the process was a prolonged and liminal one. Therefore, multiple offers for surgery are required to allow for changing thoughts and circumstances throughout an individual's lifetime. Flexibility with regard to timing for surgery and type of rehabilitation may increase the uptake, especially for women. IMPLICATIONS FOR REHABILITATION: • Multiple offers for upper limb surgery are required throughout an individual's lifetime to account for changing thoughts and priorities. • Identification of the type of support required (informational, emotional) may assist in decreasing the time taken to make the decision about surgery. • Flexibility in surgical and rehabilitation options, especially for women, may increase the uptake of surgery.

Time since diagnosis as a predictor of symptoms, depression, cognition, social concerns, perceived benefits, and overall health in cancer survivors.

PURPOSE/OBJECTIVES: To assess whether health and other factors are different in short-term cancer survivors (less than five years since diagnosis), long-term survivors (5-10 years), and very long-term survivors (more than 10 years). DESIGN: A cross-sectional survey. SETTING: New Zealand. SAMPLE: 836 survivors of adult-onset cancers (6 months to 43 years since diagnosis). METHODS: Survivors were recruited using community-based methods and answered a mailed questionnaire. MAIN RESEARCH VARIABLES: Physical and emotional health, depression, symptoms, cognitive difficulty, social concerns, and perceived benefits of cancer. FINDINGS: Physical and emotional health, depression, physical symptoms, and perceived benefits of cancer were not associated with time since diagnosis, but longer time since diagnosis was associated with decreases in cognitive difficulties and social concerns. The survivors in this study reported a mean of 8.4 physical symptoms, regardless of time since diagnosis, with the most frequent being fatigue (76%), aches and pain (75%), and trouble sleeping (68%). CONCLUSIONS: Most survivors enjoyed a moderately good level of health. However, some adverse effects, such as symptoms, were similar in short-, long-, and very long-term survivors, suggesting that interventions may be needed to prevent persistent issues as time progresses. IMPLICATIONS FOR NURSING: The findings suggest a need to reconsider the common attitude that survivors who finish treatment should be able to return to normal life. Assessment of symptoms, particularly fatigue, pain, and sleep issues, is important even in very long-term survivors.

Differences between older and younger cancer survivors in seeking cancer information and using complementary/alternative medicine.

OBJECTIVE: The purpose of this study was to describe the differences between younger and older cancer survivors in seeking cancer information, using complementary and alternative medical (CAM) services, and using conventional support services. DESIGN AND METHODS: Participants were 836 survivors of adult cancers (6 months-43 years since completion of primary cancer treatment) in New Zealand who answered a mailed questionnaire between April 2007 and January 2008. RESULTS: Younger survivors (aged <60 years at diagnosis) were more likely to seek information from sources beyond their physicians and used different sources for that information, compared to older survivors. Older and younger survivors used similar conventional support services, but different CAM services. In logistic regression analyses, information-seekers were 5.9 times more likely to use CAM than those who did not seek cancer information (p = 0.02), but the association between information-seeking and CAM use depended on age (p = 0.02). Older cancer survivors who did not seek information from sources beyond that provided by physicians were less likely to use CAM. IMPLICATIONS: Physicians should consider talking to older cancer survivors about their use of information sources or CAM therapies. A conversation between physician and patient may uncover inaccurate information or CAM use that has potential for adverse effects, while allowing the physician to encourage CAM that is potentially useful. Even a brief conversation may be sufficient to encourage older cancer survivors to take action themselves to find services that support their recovery from cancer and cancer treatment.

Changes in employment and household income during the 24 months following a cancer diagnosis.

GOALS OF WORK: The purpose of the study was to describe the changes in employment and household income following a cancer diagnosis. MATERIALS AND METHODS: Participants were 68 recent cancer survivors (6-24 months since diagnosis) aged 18 years or older who were employed full- or part-time prior to receiving a cancer diagnosis. Data were both quantitative and qualitative. Participants completed a mailed questionnaire about various issues faced by cancer survivors, including 36 questions about work, finances, and income. In addition, space was provided for participants to write optional narrative details about work experiences. MAIN RESULTS: Before cancer, all 68 participants were employed, 45 full-time and 23 part-time. After completion of primary cancer treatment, 49 (72%) were employed (29 full-time and 20 part-time). A decrease in household income after cancer diagnosis was reported by 37% of participants. Of those who were the main income earners in their households prior to cancer, 26% were no longer the main earners after cancer. The qualitative data about work difficulties fell broadly into two areas: physical difficulties and attitudes of employers. CONCLUSIONS: Though limited by a comparatively small sample size, this study is the first to focus on employment in the very early survivorship period, using both questionnaire and qualitative data. The findings show that many individuals continue to work during and after treatment, though reduction of work hours or quitting work is not uncommon. The complex factors associated with work decisions are not easily assessed with questionnaires, and in-depth qualitative studies of recent cancer survivors are warranted.

Parent's perceptions of interactions with health professionals in the pathway to gaining a diagnosis of tuberous sclerosis (TS) and beyond.

This paper presents selected findings from a qualitative study on the lived experience of young people with tuberous sclerosis (TS) and their families. In-depth interviews with 109 participants from 40 families were undertaken. This paper presents the findings in relation to parents' interactions with health professionals before, during and after a diagnosis of TS was given. The majority of parents recalled examples of both positive and negative experiences with health professionals. Negative experiences included having to 'fight' for the recognition of symptoms and the reluctance of doctors to move on beyond a diagnosis of epilepsy. Attributes valued by parents pre-diagnosis included health professionals showing understanding at diagnosis, flexibility, support, accessibility, time and attention, honesty, reliability, sensitivity and post-diagnosis a willingness to find out and share information and to consult colleagues and other professionals. The interviews indicated that these were not always demonstrated by professionals.