Self-Management Behaviors, Glycemic Control, and Metabolic Syndrome in Type 2 Diabetes.

BACKGROUND: Diabetes self-management and glycemic control are suboptimal among Chinese patients with Type 2 diabetes with a large proportion of patients identified with metabolic syndrome. OBJECTIVES: Based on social cognitive theory, this study examines the effect of selected personal, behavioral, and environmental factors on self-management behaviors, glycemic control, metabolic syndrome and Type 2 diabetes. METHODS: A cross-sectional study was conducted among 207 Chinese with Type 2 diabetes living in a suburban area of Beijing, China. Regression models were applied to examine the effect of selected personal, behavioral, and environmental factors on self-management behaviors, glycemic control, and metabolic syndrome. The relationship among individual self-management behaviors, glycemic control, and metabolic syndrome was also examined. RESULTS: Self-efficacy was significantly associated with all self-management behaviors. Social support was related to overall self-management, diabetes knowledge was related to diet, and depressive symptoms was related to self-monitoring. Problem-solving and self-management behaviors related to medication adherence and diet were significant correlates of glycemic control. Health literacy and self-management behaviors related to physical activity were correlates of metabolic syndrome. DISCUSSION: Findings suggest that a multifactorial approach may be beneficial when providing care for Chinese with Type 2 diabetes. In addition, these findings provide support for developing and testing tailored interventions that address problem-solving, health literacy, and self-efficacy, among other factors, to help patients achieve optimal glycemic control and thereby reduce their risk for metabolic syndrome and related complications.

Psychometric Properties of the Problem Solving Inventory in Caregivers of Individuals With Memory Loss.

Limited research exists assessing problem-solving capabilities among caregivers of individuals with memory loss using a validated instrument. To address this gap, the current study evaluated the psychometric properties of the Problem Solving Inventory (PSI) using data at baseline and 8 weeks from a randomized controlled trial among caregivers (N = 78) of community-dwelling individuals with memory loss. Participants were mainly White (85.9%), female (71.8%), and on average age 66.5. Cronbach's alphas ranged from 0.84 to 0.92 for the subscales and overall PSI. Test-retest reliability over 8 weeks ranged from 0.44 to 0.56. Five factors were retained through exploratory factor analysis. Spearman's correlations showed convergent validity and discriminant validity between scores on the PSI and Beck Depression Inventory®-II (r = 0.32, p < 0.01), the Self-Efficacy for Managing Chronic Disease Scale (r = -0.44, p < 0.001), and the Newest Vital Sign questionnaire (r = -0.07, p > 0.05). Findings show that the PSI is reliable and valid in assessing problem-solving capabilities among caregivers of individuals with memory loss. [Journal of Gerontological Nursing, 44(6), 25-32.].

Health literacy and its correlates in informal caregivers of adults with memory loss.

This secondary analysis examined health literacy among informal caregivers of community-dwelling older adults with memory loss and assessed correlates of caregiver health literacy using the Abilities, Skills and Knowledge Model. Caregiver health literacy (n = 91) was assessed by the Newest Vital Sign. Limited health literacy presented in 38.5% caregivers, with significantly low document literacy. Health literacy was associated bivariately with age, education, global cognitive function, executive function, and working memory (all ps < 0.001), as well as medication knowledge (p = 0.015). Hierarchical regression analyses revealed that older age (p = 0.017), and lower global cognitive function (p < 0.001), working memory (p = 0.001), and academic skills (years of education) (p = 0.004), independently predicted lower health literacy (R2 = 0.54). Medication knowledge, however, was not found to be an independent predictor in the model. Findings suggest limited health literacy is a potential issue among informal caregivers of adults with memory loss. Appropriate assessment and personalized support are needed for informal caregivers who are at high risk for poor health literacy.

Testing a model of health-related quality of life in women living with HIV infection.

PURPOSE: The purpose of this secondary analysis was to test Ferrans et al.'s (J Nurs Scholarsh 37(4):336-342, 2005) revised model of health-related quality of life (HRQoL) (2005) modified from the Wilson and Cleary (J Am Med Assoc 273(1):59-65, 1995) model on women living with HIV. The primary aim was to test this model, examining the relations among the five central components (biological function, symptoms, functional status, general health perceptions, and HRQoL). The secondary aim was to explore the individual (age, children, race, marital status, education) and environmental (HIV-related stigma, social support) characteristics that may impact the main components of the model. METHODS: This study employed a cross-sectional correlational design using baseline data from 178 women living with HIV/AIDS who participated in one of the two independent randomized controlled trials designed to enhance HIV medication adherence. Path analysis using structural equation modeling was used to examine the hypothesized multivariate relations proposed in the revised Wilson and Cleary (J Am Med Assoc 273(1):59-65, 1995) model of HRQoL. RESULTS: While the revised model did not fit, exploratory post hoc modified models with a path from depressive symptoms to overall general health had an adequate model fit. Women with lower depressive symptoms (r = -.457, p < .01), lower HIV-related stigma (r = -.462, p < .01), higher social support (r = .413, p < .01), higher physical functioning (r = .350, p < .01), and higher general health perceptions (r = .537, p < .01) had higher overall HRQoL. CONCLUSIONS: The results of this study have the potential to assist healthcare professionals in improving HRQoL for women living with HIV/AIDS.

Characteristics and Correlates of Caregivers' Perceptions of Their Family Members' Memory Loss.

BACKGROUND: Understanding caregiver's perceptions of their family member's memory loss is a necessary step in planning nursing interventions to detect and address caregiver burden. OBJECTIVE: The purpose of this study was to characterize caregivers' perceptions of their family members' memory loss and identify potential correlates within Leventhal's common sense model (CSM). METHODS: This secondary analysis used baseline data from a larger randomized controlled trial. Patients with memory loss and their caregivers (N = 83 dyads) from the community were included. The adapted Brief Illness Perception Questionnaire (BIPQ) assessed caregivers' illness perceptions. Eight additional instruments measured correlates within the CSM. Responses were described; multiple linear regression was used to predict BIPQ dimension scores, and logistic regression was used to predict dichotomized BIPQ scores. RESULTS: Most caregivers were female, White, and spouses of the patients; they reported a range of perceptions on the nine BIPQ dimensions. Patients' cognitive function consistently emerged as a significant correlate of caregivers' illness perceptions, explaining the most variance in caregivers' perceived consequences, identity, and treatment control (p < .01). Caregivers' reactions to patients' behavioral symptoms and caregivers' trait anxiety were associated with perceived illness coherence (p < .01). Caregivers with higher severity of daily hassles and White caregivers perceived that their family members' memory loss would last longer (p < .001). DISCUSSION: Caregivers' perceptions of family members' memory loss varied; distinct dimensions of caregivers' illness perception were associated with a range of clinical and psychosocial factors. This exploratory study demonstrates the complexity of applying the CSM to caregivers of persons with memory loss.

An intervention to maximize medication management by caregivers of persons with memory loss: Intervention overview and two-month outcomes.

Overseeing medication-taking is a critical aspect of dementia caregiving. This trial examined a tailored, problem-solving intervention designed to maximize medication management practices among caregivers of persons with memory loss. Eighty-three community-dwelling dyads (patient + informal caregiver) with a baseline average of 3 medication deficiencies participated. Home- and telephone-based sessions were delivered by nurse or social worker interventionists and addressed basics of managing medications, plus tailored problem solving for specific challenges. The outcome of medication management practices was assessed using the Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) and an investigator-developed Medication Deficiency Checklist (MDC). Linear mixed modeling showed both the intervention and usual care groups had fewer medication management problems as measured by the MedMaIDE (F = 6.91, p < .01) and MDC (F = 9.72, p < .01) at 2 months post-intervention. Reduced medication deficiencies in both groups suggests that when nurses or social workers merely raise awareness of the importance of medication adherence, there may be benefit.

The role of social support on the relationship of depressive symptoms to medication adherence and self-care activities in adults with type 2 diabetes.

AIM: To examine the mediating role of social support on the relationship of depressive symptoms to medication adherence and self-care activities in Korean adults. BACKGROUND: Recent evidence suggests that higher levels of social support are associated with improved medication adherence and self-care activities; however, the role of social support on the relationship of depressive symptoms to medication adherence and self-care activities is less well understood. DESIGN: A cross-sectional survey. METHODS: The data were collected from 311 Korean adults with type 2 diabetes who were taking hypoglycaemic agents in the period 2012-2013. Depressive symptoms, social support, medication adherence and self-care activities were assessed using structured questionnaires. Multiple regression analysis with adjustment for covariates and the Sobel test were used to examine the mediating effect of social support on the relationship of depressive symptoms to medication adherence and self-care activities. RESULTS: There were statistically significant differences by subgroups with and without depressive symptoms in social support, medication adherence and self-care activities of diet, physical activity and stress management. The Sobel test confirmed that social support mediated the effect of depressive symptoms on medication adherence and self-care activities of diet, physical activity and stress management. CONCLUSION: The evidence from this study suggests that social support-enhancing interventions that also manage depressive symptoms may be more timely and effective than interventions that target depressive symptoms alone in promoting adherence to medication adherence and self-care activities in this population.

Stressors and Caregivers' Depression: Multiple Mediators of Self-Efficacy, Social Support, and Problem-Solving Skill.

Caring for an older adult with memory loss is stressful. Caregiver stress could produce negative outcomes such as depression. Previous research is limited in examining multiple intermediate pathways from caregiver stress to depressive symptoms. This study addresses this limitation by examining the role of self-efficacy, social support, and problem solving in mediating the relationships between caregiver stressors and depressive symptoms. Using a sample of 91 family caregivers, we tested simultaneously multiple mediators between caregiver stressors and depression. Results indicate that self-efficacy mediated the pathway from daily hassles to depression. Findings point to the importance of improving self-efficacy in psychosocial interventions for caregivers of older adults with memory loss.

The validity of self-reported medication adherence as an outcome in clinical trials of adherence-promotion interventions: Findings from the MACH14 study.

In medication adherence-promotion trials, participants in the intervention arm are often cognizant of the researcher's aim to improve adherence; this may lead to their inflating reports of their own adherence compared to control arm participants. Using data from 1,247 HIV-positive participants across eight U.S. Studies in the Multi-site Adherence Collaboration on HIV (MACH14) collaboration, we evaluated the validity of self-reported adherence by examining whether its association with two more objective outcomes [1], electronically monitored adherence and [2] viral load, varied by study arm. After adjusting for potential confounders, there was no evidence of greater overestimation of self-reported adherence among intervention arm participants, supporting its potential as a trial outcome indicator.

Surviving with lung cancer: medication-taking and oral targeted therapy.

Oral epidermal growth factor receptor inhibitors (EGFRIs) improve survival for non-small cell lung cancer (NSCLC) patients; however, medication-taking implications are unknown. We used grounded theory to explore the process of medication-taking for NSCLC patients receiving oral EGFRIs. Thirty-two interviews were conducted for 13 participants purposively selected for gender, race/ethnicity, age, time in therapy, dose reductions, and therapy discontinuation and theoretically sampled for age and health insurance carrier. The study produced a grounded theory, Surviving with Lung Cancer, in which participants framed EGFRI therapy within recognition of NSCLC as a life-limiting illness without cure. Medication-taking was a "window" into participants' process of surviving with metastatic cancer that included deciding and preparing to take EGFRIs and treating lung cancer as a chronic condition. Our results contribute to understanding how NSCLC patients view themselves in the context of a life-limiting illness and support development of a theoretically-based intervention to improve medication-taking with EGFRIs.

MACH14: a multi-site collaboration on ART adherence among 14 institutions.

The integration of original data from multiple antiretroviral (ARV) adherence studies offers a promising, but little used method to generate evidence to advance the field. This paper provides an overview of the design and implementation of MACH14, a collaborative, multi-site study in which a large data system has been created for integrated analyses by pooling original data from 16 longitudinal ARV adherence studies. Studies selected met specific criteria including similar research design and data domains such as adherence measured with medication event monitoring system, psychosocial factors related to adherence behavior, and virologic and clinical outcomes. The data system created contains individual data (collected between 1997 and 2009) from 2,860 HIV patients. Collaboration helped resolve the challenges inherent in pooling data across multiple studies, yet produced a data system with strong statistical power and potentially greater capacity to address key scientific questions than possible with single-sample studies or even meta-analytic designs.

Functional health literacy, medication-taking self-efficacy and adherence to antiretroviral therapy.

AIMS: To report a study of the relationship between functional health literacy and medication adherence, as mediated by medication-taking self-efficacy, while controlling for the effect of key demographic variables (such as race, income and level of education). BACKGROUND: Medication adherence is critical to successful HIV/AIDS self-management. Despite simplified regimens and the availability of tools to assist with medication-taking, adherence remains a challenge for many people living with HIV/AIDS. DESIGN: Cross-sectional, secondary analysis. METHODS: Data for this study of 302 adults living with HIV/AIDS who were taking antiretroviral medications were collected from January 2004-December 2007. Medication adherence was measured using electronic event monitors. Bivariate analyses and stepwise regression were conducted to examine the associations among functional health literacy, medication-taking self-efficacy and HIV medication adherence. RESULTS: Overall, functional health literacy was much higher than expected; however, adherence in this sample was sub-optimal. Higher medication-taking self-efficacy was associated with higher medication adherence; however, functional health literacy was not significantly related to either medication adherence or self-efficacy beliefs. Hence, medication-taking self-efficacy did not mediate the relationship between functional health literacy and medication adherence. CONCLUSIONS: Medication adherence continues to be an issue for people living with HIV/AIDS. Additional research is needed to understand the disparate findings related to functional health literacy and medication adherence in this and other studies examining this association.

Characterizing caregiver-mediated medication management in patients with memory loss.

Increasingly, family members are assisting with the complex task of medication management when patients are experiencing cognitive decline. To date, limited published research addresses caregiver-mediated medication management of patients with impaired cognition. Thus, the purpose of this study was to describe the characteristics and correlates of caregiver-mediated medication management in community-dwelling patients with memory loss. We used baseline data from the 91 patient-caregiver dyads participating in a randomized controlled trial designed to assist caregivers of patients with memory loss with medication management. The patient's level of cognitive impairment was not related to medication errors; however, the number of medications that patients were prescribed and taking was related to medication errors. Important factors to consider when discussing medication management with caregivers of patients with memory loss include the caregiver's age, cognitive ability, and depressive symptoms, as well as the caregiver's perception of the impact of the patient's behavioral problems.

Symptoms and Comorbidities Differ Based on Race and Weight Status in Persons with HIV in the Northern United States: a Cross-Sectional Study.

BACKGROUND: Persons with HIV (PWHIV) on highly active antiretroviral treatments (HAART) may require specialized care based on health and demographic indicators. This study investigated the association of comorbidities, race, weight status, and gastrointestinal (GI) and cardiovascular (CV) symptoms among PWHIV. METHODS: The Symptom Checklist, Co-Morbidity Questionnaire, and Sociodemographic Questionnaire were used to assess weight status and GI and CV symptoms among 283 PWHIV. Data were analyzed using latent class analysis on John's Macintosh Project 13 Platform. RESULTS: Participants were majority Black (50%), 69% male, and 35% AIDS diagnosed. Ages were 25 to 66. Clusters included least symptomatic status, weight gain, and weight loss by Black and non-Black participants. The non-Black weight gain cluster reported a higher incidence of AIDS (70.6% vs 38.2%), nausea (70.6% vs 17.6%), diarrhea (70.6% vs 26.5%), and shortness of breath (58.8% vs 20.6%) compared to the Black weight gain cluster. The Black weight loss cluster reported a higher incidence of CV symptoms such as chest palpitations (42.2% vs 2.7%), chest pain (44.4% vs 8.1%), and shortness of breath (73.3% vs 35.1%). Moreover, the Black weight loss cluster reported a higher incidence of all GI symptoms with the most prominent being diarrhea (71.1% vs 48.6%) compared to the non-Black weight loss cluster. CONCLUSIONS: The existing racial disparities in health-related quality of life for PWHIV may be improved through precision health and nutrition modifications. Continued research is needed investigating differential health outcomes among PWHIV on HAART. CLINICAL TRIAL REGISTRATION NUMBER: NCT00222716. Registered 22 September 2005. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT00222716?term=NCT00222716&draw=2&rank=1.

Assessing fidelity to an intervention in a randomized controlled trial to improve medication adherence.

BACKGROUND: Behavioral intervention effectiveness in randomized controlled trials requires fidelity to the protocol. Fidelity assessment tools tailored to the intervention may strengthen intervention research. OBJECTIVE: The aim of this study was to describe the assessment of fidelity to the structured intervention protocol in an examination of a nurse-delivered telephone intervention designed to improve medication adherence. METHODS: Fidelity assessment included random selection and review of approximately 10% of the audiorecorded intervention sessions, stratified by interventionist and intervention session. Audiotapes were reviewed along with field notes for percentage of agreement, addressing whether key components were covered during the sessions. Visual analog scales were used to provide summary scores (0 = low to 5 = high) of interaction characteristics of the interventionists and participants with respect to engagement, demeanor, listening skills, attentiveness, and openness. RESULTS: Four nurse interventionists delivered 871 structured intervention sessions to 113 participants. Three trained graduate student researchers assessed 131 intervention sessions. The mean percentage of agreement was 92.0% (±10.5%), meeting the criteria of 90% congruence with the intervention protocol. The mean interventionist interaction summary score was 4.5 ± 0.4, and the mean participant interaction summary score was 4.5 ± 0.4. DISCUSSION: Overall, the interventionists successfully delivered the structured intervention content, with some variability in both the percentage of agreement and quality of interaction scores. Ongoing assessment aids in ensuring fidelity to study protocol and having reliable study results.

Do words matter? Incongruent responses to inconsistently worded AUDIT-C alcohol screening instruments.

The first 3 questions of the Alcohol Use Disorders Identification Test (AUDIT-C) are often used as a brief alcohol screening instrument. However, the implications of common modifications made to the original AUDIT questions and response options have not been considered. The authors examined existing data from a randomized controlled trial of 310 persons with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) that was testing the efficacy of 2 antiretroviral medication adherence interventions. Logistic regression was used to model the probability of participants having inconsistent AUDIT-C item responses. Three patterns of conflicting responses to the AUDIT-C items were identified. Common item modifications resulted in 14% (n = 48) of the parent study sample reporting conflicting responses across related AUDIT-C items. The odds of having conflicting data were 3 times greater in opioid users (odds ratio [OR] = 3.139, 95% confidence interval [CI] = 1.267-7.777, P = .01) and greater in persons with higher levels of conscientiousness (OR = 1.053, 95% CI = 1.006-1.103, P = .03). Inconsistent question format and response options may impede proper scoring and interpretation of the AUDIT-C. Further discussion and consensus building are needed on the psychometrically ideal version of the AUDIT-C.

Predictive Utility of Brief Alcohol Use Disorders Identification Test (AUDIT) for human immunodeficiency virus antiretroviral medication nonadherence.

Alcohol use negatively affects adherence to antiretroviral therapy (ART), thus human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) care providers need accurate, efficient assessments of alcohol use. Using existing data from an efficacy trial of 2 cognitive-behavioral ART adherence interventions, the authors sought to determine if results on 2 common alcohol screening tests (Alcohol Use Disorders Identification Test--Consumption [AUDIT-C] and its binge-related question [AUDIT-3]) predict ART nonadherence. Twenty-seven percent of the sample (n = 308) were positive on the AUDIT-C and 34% were positive on the AUDIT-3. In multivariate analyses, AUDIT-C-positive status predicted ART nonadherence after controlling for race, age, conscientiousness, and self-efficacy (P = .036). Although AUDIT-3-positive status was associated with ART nonadherence in unadjusted analyses, this relationship was not maintained in the final multivariate model. The AUDIT-C shows potential as an indirect screening tool for both at-risk drinking and ART nonadherence, underscoring the relationship between alcohol and chronic disease management.

Personality traits and chronic illness: a comparison of individuals with psychiatric, coronary heart disease, and HIV/AIDS diagnoses.

This secondary analysis used the five-factor model of personality to examine personality traits in four samples of patients with chronic disorders. Profiles of personality traits differed across disorders. Although participants with psychiatric disorders and participants with HIV/AIDS had similar patterns of personality traits, patients with psychiatric disorders were more extreme on all traits except agreeableness. Patients with hyperlipidemia and those who had cardiothoracic transplants had similar patterns. Nurses and researchers need to consider personality traits that drive patterns of behavior in designing more effective ways to promote better health and manage disease.

Correlation of Symptom Distress, Self-Efficacy, and Social Support With Problem-Solving and Glycemic Control Among Patients With Type 2 Diabetes.

PURPOSE: The purpose of the study was to examine the associations of self-efficacy, social support, and symptom distress with perceived problem-solving and glycemic control among patients with type 2 diabetes. METHOD: Using baseline data from a parent study, which examined the effect of a problem-solving-focused intervention on medication adherence among patients with type 2 diabetes, this secondary analysis examined the relationships among self-efficacy, social support, symptom distress, problem-solving, and A1C. Of 358 patients enrolled at baseline, 304 (mean age = 64.1 years, 57.2% female) were included in the current analysis. Multiple linear regression was used to identify potential correlates of problem-solving and A1C. RESULTS: The results showed that self-efficacy, social support, and symptom distress were independent predictors of problem-solving; they significantly improved the prediction of perceived problem-solving in diabetes management after controlling covariates. Adding problem-solving to the model did not improve the prediction for A1C. CONCLUSION: The current study suggests that self-efficacy, social support, and symptom distress are essential factors associated with patients' perceived problem-solving in diabetes management. Researchers and clinicians should consider both personal factors and psychosocial factors such as self-efficacy, social support, and symptom distress when examining patients perceived problem-solving and developing tailored interventions to improve diabetes management. In addition, health care providers should consider these important aspects when providing tailored care to this patient population.