Mixed-Methods Study of Disability Self-Management in Mexican Americans With Osteoarthritis.

BACKGROUND: Health disparities in osteoarthritis (OA) outcomes exist both in the occurrence and treatment of functional limitation and disability for Mexican Americans. Although the effect of self-management of chronic illness is well established, studies demonstrate little attention to self-management of function or disability, despite the strong potential effect on both and, consequently, on patients' lives. OBJECTIVE: The purpose of this study pilot was to develop and test key variable relationships for a measure of disability self-management among Mexican Americans. METHODS: In this sequential, two-phased, mixed-methods, biobehavioral pilot study of Mexican American women and men with OA, a culturally tailored measure of disability self-management was created, and initial relationships among key variables were explored. RESULTS: First, a qualitative study of 19 adults of Mexican American descent born in Texas (United States) or Mexico was conducted. The Mexican American Disability Self-Management Scale was created using a descriptive content analysis of interview data. The scale was tested and refined, resulting in 18 items and a descriptive frequency of therapeutic management efforts. Second, correlations between study variables were estimated: Disability and function were negatively correlated. Disability correlated positively with social support and activity effort. Disability correlated negatively with disability self-management, pain, and C-reactive protein. Function was positively correlated with age, pain, and depression. Liver enzymes (alanine transaminase) correlated positively with pain and anxiety. DISCUSSION: This mixed-methods study indicates directions for further testing and interventions for disability outcomes among Mexican Americans.

Revision and Psychometric Evaluation of the Diabetes Knowledge Questionnaire for People With Type 2 Diabetes.

Objective: Diabetes knowledge is associated with health, including lower A1C levels. The Diabetes Knowledge Questionnaire (DKQ-24), developed 30 years ago for Mexican Americans with type 2 diabetes and since used with diverse samples in many countries, contains outdated items that no longer accurately assess current knowledge needed for diabetes self-management. We revised the DKQ-24 and tested psychometric properties of the DKQ-Revised (DKQ-R) with a diverse sample. Methods: We conducted a five-phase instrumentation study as follows: 1) DKQ-24 items were revised to reflect current diabetes care standards; 2) the Delphi method was used to evaluate the DKQ-R's content validity (n = 5 experts); 3) cognitive interviews were conducted with people with type 2 diabetes (n = 5) to assess their interpretations of DKQ-R items; 4) cross-sectional administration of the DKQ-R to adults with type 2 diabetes was carried out to assess internal consistency reliability and convergent validity; and 5) an item analysis was conducted using discrimination index and point biserial analysis. Results: After receiving the experts' feedback and conducting the cognitive interviews, 39 items were administered to 258 participants with type 2 diabetes (42.2% women; 29.1% Latino, 42.6% Asian, mean age 55.7 years). To select the final items, we considered the item discrimination index, as well as item-to-total correlations, content area, and participant feedback. The final 22-item DKQ-R uses the same yes/no/I don't know response format as the DKQ-24. The DKQ-R is strongly correlated with the DKQ-24 (r = 0.71, P <0.01) and is weakly correlated with diabetes numeracy (r = 0.23, P <0.01), indicating adequate convergent validity; a Kuder-Richardson-20 coefficient of 0.77 indicated good reliability. Conclusion: The DKQ-R is a reliable and valid updated measure of diabetes knowledge for diverse populations with type 2 diabetes.

Barriers and facilitators to healthcare for people without documentation status: A systematic integrative literature review.

AIMS: To identify the barriers and facilitators to healthcare for people without documentation status. DESIGN: We conducted a systematic integrative literature review following the Whittemore and Knafl methodology. METHODS: Literature search was conducted to identify studies addressing barriers or facilitators to healthcare for people without documentation status in the United States between 2012 and 2022. Studies were critiqued for quality, with results analysed thematically using the social-ecological model. DATA SOURCES: Searches were conducted in PubMed, PAIS, Web of Science, CINAHL and Psych Info in October 2022. RESULTS: The review incorporated 30 studies (19 qualitative and 11 quantitative). People without documentation status encountered numerous healthcare barriers such as intrapersonal (lack of financial resources and health insurance, fear), interpersonal (language and cultural discrepancies, discrimination), community (bureaucratic requirements, anti-immigrant rhetoric) and policy-related barriers. Conversely, linguistically and culturally competent care, empathetic and representative staff, health navigators, safety-net clinics and supportive federal policies emerged as key facilitators. CONCLUSION: These findings illuminate the complex healthcare disparities experienced by people without documentation status and underscore facilitators enhancing care accessibility. Future research is needed to explore interventions to increase access to care for this population. IMPACT: This paper provides a comprehensive examination of the complex barriers and facilitators to healthcare for people without documentation status in the United States. The findings support the value of universal healthcare access, a priority of the World Health Organization, and can inform healthcare policies and practices worldwide. REPORTING METHOD: The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution was needed. TRIAL AND PROTOCOL REGISTRATION: The study protocol was registered with the PROSPERO database (registration number: CRD42022366289).

The influences of depression and loneliness on A1C among middle-aged and older adults with diabetes.

Even before increased social isolation associated with the COVID-19 pandemic, 43% of adults aged 60 and older reported experiencing loneliness. Depression and loneliness often co-exist and are significant issues faced by middle-aged as well as older adults because each condition is likely to worsen health outcomes. This study of middle-aged and older adults examined how depression and loneliness affect diabetes (DM) control (A1C levels). This study is a secondary analysis of data from the Midlife in the United States Refresher (MIDUS-R) survey, a national survey of adults aged 25-74 years. Correlation analyses were conducted, and a hierarchical logistic regression was estimated to predict A1C levels ≤7% (recommended goal) or >7 using 1) demographics and physical health (ethnicity, gender, education, age, and comorbidities), 2) family and friend support, and 3) depression and loneliness. The sample of 92 participants with DM and A1C data from the MIDUS-R had mean age = 57.37, were 51% male, 68% non-Hispanic White; 39.1% had A1C >7. The average level of depression was low (CES-D mean 9.42) and loneliness was moderate (UCLA scale mean 12.43). Loneliness was correlated with A1C (r= .26, p< .05); depressive symptoms (r= .71, p< .001), family and friends support (r= -.36, r= -.38, respectively, both p< .001). Only loneliness significantly predicted higher A1C levels. People with higher levels of loneliness had increased odds of having A1C >7 (OR = 1.18, p < .05) after controlling for depression and all other variables. Loneliness had a greater impact than depression on A1C level among persons with DM. Healthcare providers should assess patients for loneliness as well as depression and reduce adverse health impacts by referring to psychosocial support as needed.

Health status and Healthcare Access of Southeast Asian refugees in the United States: An integrative review.

OBJECTIVE: Since 2010, more than 527,000 refugees have resettled in the United States (US), most from Asia, fleeing war, violence, and persecution. However, there is little research that integrates findings about health among Southeast Asian refugees (SEAR). DESIGN: We conducted an integrative review of studies that examined health status, risk factors, and barriers to healthcare access among SEAR in the US. We synthesized findings of studies published from 1980, when the Refugee Act was enacted, to 2022 using five databases. We reviewed 20 articles and data were extracted into a table for synthesis. RESULTS: Participants were from Cambodia, Vietnam, Laos, Burma and the Thailand-Myanmar border. Hypertension (12%-64%), hypercholesterolemia (37%-39%), diabetes (0.6%-27%), heart disease (7%), bone and muscle problems (23%-50%), and chronic pain (8%-51%) were most common physical health problems; and PTSD (45%-86%) and depression (20%-80%) were the most common mental health problems. Trauma, resettlement stress, lack of community or religious engagement were associated with mental health problems. Language differences, transportation, and lack of health insurance were the most significant obstacles to receiving healthcare. CONCLUSION: SEAR experienced worse physical and mental health than the general US population. Different patterns of disease were identified depending on gender, time settled in the US, and ethnic group. Qualitative and longitudinal studies will elucidate refugees' experience and should guide interventions.

Self-Management Model fails to Predict Quality of Life for People Living with Dual Diagnosis of HIV and Diabetes.

The objective of this study was to test a self-management model for self-management in people living with HIV and type 2 diabetes (PLWH + T2DM). We conducted a predictive, longitudinal study of data from a national research cohort of PLWH using lag analysis to test short- and long-term health outcomes for PLWH + T2DM. We used a dataset from the Center for AIDS Research (CFAR) Network of Integrated Clinic Systems (CNICS), a nation-wide research network of 8 clinics that serves PLWH. Patient-reported outcomes, collected at clinic visit, included depression, adherence, CD4 cell count, and health-related quality of life (HRQoL). We computed summary statistics to describe the sample. Using lag analysis, we then modeled the three variables of adherence, CD4 count, and HRQoL as a function of their predecessors in our conceptual model. In the final model, an increase of in medication adherence corresponded to a small increase in HRQoL. An increase in CD4 count corresponded to a small increase in HRQoL. An increase in lagged depression was associated with a small decrease in HRQoL. The model was not sufficient to predict short- or long-term outcomes in PLWH + T2DM. Although depression had a moderate impact, the final model was not clinically significant. For people with a dual diagnosis of HIV and T2DM, variables other than those traditionally addressed in self-management interventions may be more important.

RESUMEN: El objetivo de este estudio era evaluar un modelo de autocontrol para el autocontrol en aquellas personas que viven con VIH y diabetes de tipo 2 (PLWH + T2DM). Llevamos a cabo un estudio predictivo y longitudinal de la información proveniente de un estudio nacional de una población base de PLWH usando un análisis de retraso para evaluar los resultados en la salud a corto y largo plazo para PLWH + T2DM. Utilizamos un conjunto de datos del Center for AIDS Research [Instituto para la Investigación del SIDA] (CFAR) Network of Integrated Clinic Systems [Red de Sistemas de Clínicas Integradas] (CNICS), una red de investigación nacional que cuenta con ocho clínicas al servicio de PLWH. Los resultados que los pacientes reportaron, recolectados en una visita médica, incluyen depresión, adherencia, conteo de células CD4 y la calidad de vida relacionado con la salud (HRQoL). Calculamos el resumen estadístico para describir la muestra. Utilizando análisis de retraso, modelamos luego las tres variables de adherencia, conteo de células CD4 y el HRQoL como función de su antecesor en nuestro modelo conceptual. En el modelo final, un aumento en la adherencia al medicamento correspondió a un aumento en el HRQoL. Un aumento en el conteo de células CD4 correspondió a un aumento en el HRQoL. Se asoció un aumento de depresión retardada con una disminución en el HRQoL. El modelo no fue suficiente como para predecir resultados a corto o largo plazo en PLWH + T2DM. A pesar de que la depresión tenía un impacto moderado, el modelo final no fue clínicamente significativo. Para aquellas personas con un diagnóstico doble de VIH y T2DM, otras variables, además de las que se abordan tradicionalmente en las intervenciones de autocontrol, podrían ser más importantes.

Term Newborn Care Recommendations Provided in a Kenyan Postnatal Ward: A Rapid, Focused Ethnographic Assessment.

BACKGROUND: Neonatal mortality (death within 0-28 d of life) in Kenya is high despite strong evidence that newborn care recommendations save lives. In public healthcare facilities, nurses counsel caregivers on term newborn care, but knowledge about the content and quality of nurses' recommendations is limited. PURPOSE: To describe the term newborn care recommendations provided at a tertiary-level, public referral hospital in Western Kenya, how they were provided, and related content taught at a university nursing school. METHODS: A rapid, focused ethnographic assessment, guided by the culture care theory, using stratified purposive sampling yielded 240 hours of participant observation, 24 interviews, 34 relevant documents, and 268 pages of field notes. Data were organized using NVivo software and key findings identified using applied thematic analysis. RESULTS: Themes reflect recommendations for exclusive breastfeeding, warmth, cord care, follow-up examinations, and immunizations, which were provided orally in Kiswahili and some on a written English discharge summary. Select danger sign recommendations were also provided orally, if needed. Some recommendations conflicted with other providers' guidance. More recommendations for maternal care were provided than for newborn care. IMPLICATIONS FOR PRACTICE: There is need for improved consistency in content and provision of recommendations before discharge. Findings should be used to inform teaching, clinical, and administrative processes to address practice competency and improve nursing care quality. IMPLICATIONS FOR RESEARCH: Larger studies are needed to determine whether evidence-based recommendations are provided consistently across facilities and other populations, such as community-born and premature newborns, who also experience high rates of neonatal mortality in Kenya.

An integrative review of fatigue in adults with type 2 diabetes mellitus: Implications for self-management and quality of life.

AIMS AND OBJECTIVES: To synthesise empirical studies on factors related to fatigue and its impact on diabetes self-management (DSM) and quality of life (QOL) in adults with type 2 diabetes mellitus (T2DM). BACKGROUND: Fatigue is commonly reported in people with T2DM, a chronic condition that is highly prevalent worldwide. However, a holistic understanding of the consequences and factors related to fatigue in adults with T2DM is not well synthesised. DESIGN: This integrative review used Whittemore and Knafl's methodology and was reported according to the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. METHODS: The theory of unpleasant symptoms (TOUS) was used as a conceptual model to guide the review. The PubMed, PsychINFO and CINAHL databases were searched to identify studies that recruited adults with T2DM, were peer-reviewed, written in English and investigated fatigue as a primary or secondary outcome. Two investigators independently appraised the quality of the studies and extracted the data. RESULTS: Twenty-nine articles met the inclusion criteria: 23 observational studies, two randomised controlled trials, one quasi-experimental study and three qualitative studies. All articles were of high quality. Physiological (e.g. T2DM duration, complications and inflammatory biomarkers), psychological (e.g. diabetes distress, depression and sleep quality) and situational factors (e.g. race/ethnicity, education and social support) were related to fatigue. Studies reported fatigue as a barrier to physical activity, healthy eating behaviours and the physical aspect of QOL. CONCLUSIONS: Multiple factors are related to fatigue in adults with T2DM. Gaps in the literature include the multiple dimensions of fatigue, the effectiveness of interventions to alleviate fatigue and fatigue experiences in under-represented populations. RELEVANCE TO CLINICAL PRACTICE: This integrative review supports the complex origin of fatigue and its impact on adults with T2DM. Nurses should evaluate modifiable factors related to fatigue and provide support to help improve DSM and QOL in this population.

Counting, Coping, and Navigating the Flux: A Focused Ethnographic Study of HIV and Diabetes Self-Management.

Approximately 10-15% of people living with HIV are also diagnosed with diabetes. To manage their two chronic conditions, people must undertake certain activities and adopt behaviors. Due to overlapping symptoms, complex medication regimens, and heavy patient workloads, implementing these self-management practices can be difficult. In this focused ethnography, data were collected from semi-structured interviews and limited participant-observation with a selected subset of participants to gain insight into self-management challenges and facilitators. We conducted interviews and multiple observations with 22 participants with HIV+T2DM over the period of 9 months. Participants experienced numerous barriers to self-management in the areas of diet, medication adherence, and mental health. Social and familial support, as well as consistent access to care, were facilitators for optimal self-management. At the same time participants' lives were in a unique flux shaped by the dual diagnoses, and therefore, required constant mental and physical adjustments, thus illustrating challenges of managing chronicity.

Community engagement as a foundation for improving neighborhood health.

OBJECTIVE: Health inequities and disparities are associated with non-White race/ethnicity, immigrant status, income, and geographic location. Community engagement is essential to identify health and social needs and to plan health care and social services programs. To begin a larger community-based participatory study, the purpose of this study was to explore community residents' perceptions of barriers and facilitators to achieving and maintaining health. DESIGN, SAMPLE, AND MEASUREMENTS: This qualitative descriptive study used focus group interviews. We recruited a convenience sample (n = 50) from community meetings and gathering for five audio-recorded focus groups that used a semi-structured interview guide. Transcripts were coded to identify common topics in each group and major themes across groups. RESULTS: Participants were predominantly women (58%), Hispanic/Latinx, and Spanish-speaking (57%), who rented their homes (69%). Two main themes emerged: (a) social determinants as barriers to health and (b) need for trust to participate in health programs. CONCLUSIONS: Although health care providers are frequently concerned about providing access to care, community members identified a variety of social determinants that affected their health. Listening and responding to community members' priorities are the foundation to improving health in neighborhoods directly affected by inequities.

Retention in care in aging adults with a dual diagnosis of HIV infection and type 2 diabetes mellitus: a longitudinal retrospective cross-sectional study.

BACKGROUND: This study aimed to investigate the measures of retention in care (RIC) in persons living with HIV (PLWH) and type 2 diabetes mellitus (T2DM) by age group (younger vs. older adults). METHODS: This was a longitudinal retrospective cross-sectional study that used secondary data from the Center for AIDS Research Network of Integrated Clinical Systems (CNICS). We examined RIC in 798 adult PLWH + T2DM who visited a CNICS clinic at least once in 2015. Six measures of RIC were examined: missed visits [measured as a continuous variable (total number of missed visits) and dichotomous variable (0 = never missed, 1 = missed)], visit adherence, 6-month visit gap, 4-month visit constancy, and the Health and Resources Services Administration HIV/AIDS Bureau's RIC measure. We calculated Spearman correlation coefficients and conducted logistic regression and multi-group path analysis. RESULTS: Most RIC measures were significantly correlated (p < 0.05) with one another; only 4-month visit constancy was not correlated with other measures. Except for the number of missed visits in older adult PLWH + T2DM, we found no significant relationships between RIC measures and CD4 cell count using logistic regression. However, multi-group path analysis demonstrated significant positive relationships between most RIC measures and CD4 cell count in both age groups. In younger adults living with HIV (YALWH) + T2DM, HbA1c level, but not CD4 count, was significantly associated with most RIC measures. CONCLUSIONS: RIC is related to disease control (CD4 cell count and HbA1c level) in PLWH + T2DM and notably, HbA1c level was only significantly affected in YALWH + T2DM. A future study is needed to find more accurate reasons for the fact that only HbA1c level had significant relationships in YALWH + T2DM. The findings from this study provide guidance in measuring RIC in PLWH who have comorbidities.

Culturally-tailored interventions for chronic disease self-management among Chinese Americans: a systematic review.

Objectives: Literature review evaluating the effectiveness and cultural surface and deep structures of interventions designed to improve Chinese Americans' chronic disease self-management.Method: PubMed, PsycINFO, CINAHL, and Health Source databases were searched for research conducted from 1990 to 2016 on self-management interventions for Chinese Americans with chronic disease.Results: Ten articles comprised eight interventions, which each addressed a dimension of cultural surface structure, all providing linguistically appropriate messages delivered via bilingual staff. Five interventions also addressed cultural deep structure dimensions by providing culturally congruent counsellors or educators, or incorporating Chinese cultural values and social customs. Six interventions resulted in significant improvements in major outcome variables. Participants also reported high satisfaction and retention rates were high.Conclusion: Culturally-tailored interventions that incorporate surface and deep structural elements of culture are sensitive and generally effective for Chinese Americans to improve access to health care, disease awareness, social environment, and participants' ability to practice self-management skills.

Biomarkers panels can predict fatigue, depression and pain in persons living with HIV: A pilot study.

BACKGROUND: Persons living with HIV experience high symptom burden that can negatively impact medication adherence, work productivity, and quality of life. Symptoms are highly subjective, which can lead to under- or improper treatment. The purpose of this exploratory study was to examine relationships between circulating biomarkers representative of inflammatory, coagulation, and vascular function pathways and prevalent HIV symptoms. SETTING AND SAMPLE: Adults >18 years who were diagnosed with HIV and spoke English for this cross-sectional study were recruited from community clinics and organizations. METHODS: Symptom burden was measured with the HIV Symptom Index; depression with the Patient Health Questionnaire. Human multiplex kits were used to determine serum concentrations of select biomarkers representing inflammatory, coagulation, and vascular function pathways. The biomarkers were included as features in machine learning models to determine which biomarkers predicted the most prevalent HIV symptoms (fatigue and muscle/joint pain) and the symptom of depression. RESULTS: Participants (N = 32) were representative of the local population of people with HIV, being mostly Black (54.4%) and male (60.6%). Depression was predicted by age, gender, glucose, hemoglobin A1c, and inflammation. Muscle/joint pain was predicted by adiponectin, C-reactive protein, and serum amyloid A (SAA). Fatigue was predicted by adiponectin, SAA, and soluble interleukin-1 receptor type II (sIL-1RII). CONCLUSION: Biomarker clusters can be a tool to monitor symptoms. Adding an objective measure to subjective patient experiences could improve management and monitoring of symptoms. Defining a biomarker cluster for the objective assessment of HIV symptoms warrants further investigation; however, the presence of comorbid conditions needs to be controlled.

Integrated review of healthcare provider postnatal newborn care recommendations in Sub-Saharan Africa.

AIMS: To (1) identify formal and informal healthcare provider knowledge and counselling on newborn care recommendations; (2) identify care guidelines used; and (3) determine healthcare provider training regarding recommendations. BACKGROUND: In sub-Saharan Africa, many newborn deaths occur in the community between days two to 42 of life. INTRODUCTION: Formal and informal healthcare providers, including nurses and community health workers, counsel newborn caregivers but little is known about their recommendations. METHODS: Integrative review of studies conducted 2000-2018 after search of PubMed, CINAHL, Embase, and African healthcare journals. Study quality was assessed and findings synthesized. FINDINGS: Twelve qualitative, quantitative, or mixed-methods studies (quality good to poor) from seven countries were included. Eleven reported on one to three recommendations; one study reported on eight recommendations. Knowledge or counselling on feeding, cord care, recognizing illness, referrals, informal treatment, home visits, immunizations, follow-up examinations, thermal care, low birthweight, and bed net usage were reported. Formal healthcare providers gave recommendations in only two studies. Four studies documented use of guidelines. Six studies reported on training. DISCUSSION: Studies were primarily descriptive, limiting quality. Feeding and cord care recommendations were prioritized. Care guidelines were underutilized. Additional training on recommendations is needed. These findings regarding healthcare providers align with other regions with high neonatal mortality. CONCLUSION: Research is needed to improve and sustain knowledge, counselling, and guideline usage among providers to address neonatal mortality. IMPLICATIONS FOR NURSING: The unique role of nurses to promote newborn health appears under-researched. Nurse professionalization and specialization may contribute to sustained knowledge of and counselling on newborn recommendations. IMPLICATIONS FOR HEALTH POLICY: As countries adopt universal health care, policies that enable formal providers to encourage maternal-newborn engagement in newborn health promotion before transition to the community are needed. Collaboration between formal and informal providers may improve dissemination of recommendations and contribute to gains in newborn health.

The additive effect of type 2 diabetes on fibrinogen, von Willebrand factor, tryptophan and threonine in people living with HIV.

Chronic immune activation and ensuing inflammation that accompany HIV infection lead to adverse metabolic consequences and an increased risk of type 2 diabetes (T2D). We examined the additive effects of T2D on circulating biomarkers involved in inflammation, coagulation, and vascular function along with plasma amino acids in people living with HIV (PLWH). This cross-sectional study included PLWH with and without T2D (n = 32 total). Analyses involved a multiplex platform for circulating biomarkers and gas chromatography-vacuum ultraviolet spectroscopy for plasma amino acids. In PLWH and T2D, both fibrinogen (2.0 ± 0.6 vs 1.6 ± 0.4 µg/mL, p = 0.02) and von Willebrand factor (vWF) (40.8 ± 17.2 vs 26.7 ± 13.8 µg/mL, p = 0.02) were increased and tryptophan (47 ± 6 vs 53 ± 8 nmol/mL, p = 0.03) and threonine (102 ± 25 vs 125 ± 33 nmol/mL, p = 0.03) were decreased. Fibrinogen, as a biomarker of inflammation, and vWF, as a biomarker of endothelial dysfunction, are augmented by the combined effects of HIV and T2D and may contribute to the pathogenesis of T2D in PLWH. Chronic immune activation and inflammation compromise the integrity of the intestinal mucosa, which increases mucus production. Tryptophan metabolism is altered by a loss of intestinal membrane integrity and threonine is consumed in the production of mucus. Metabolic competition arising from increased protein synthesis in the setting of chronic inflammation along with the associated loss in intestinal membrane integrity may be a primary mechanism in the pathogenesis of T2D in PLWH and requires further investigation.

Pursuing Well-Being Among Rural-Dwelling Adults With Disabilities.

Through this constructivist grounded theory study, it was our purpose to create a substantive theory to explain how rural-dwelling, working-age adults with disabilities define and pursue well-being. Twelve rural-dwelling participants were interviewed up to 3 times to understand the processes involved in defining and pursuing well-being. From this exploration, we suggest that well-being is not a set state to be achieved and then enjoyed, rather well-being results from establishing and maintaining membership in the rural community. Membership facilitated access to the array of material and psychological supports needed for a sense of well-being. Findings support the assumption that urban models of care are insufficient for rural areas. This study also provides an understanding of how individuals in this population mobilize resources to overcome functional limitations and environmental barriers to establish group membership and create a sense of well-being. Implications for health care practice and policy are discussed.

Association between sleep and serious psychological distress in patients with diabetes.

Diabetes is the 7th leading cause of death in the U.S. and impacts patients' physical health and also increases the risk for psychological distress. Sleep disturbance is a common complaint in patients with diabetes and likely impacts psychological well-being. This study examined the relationship between sleep characteristics and serious psychological distress (SPD) in people with diabetes by conducting a secondary analysis of cross-sectional data from the 2015 National Health Interview Survey (N= 3474). Approximately 7% of the participants reported SPD and 27% reported sleep durations that were shorter or longer than the recommended 6-8 hours daily. Hierarchical logistic regression analysis showed that people who reported daily sleep of 1-5 hours or 9 or more hours were more likely to report SPD than individuals who slept 6-8 hours a day. Respondents who reported a higher frequency of taking medication for sleep and having trouble staying asleep were also substantially more likely to have SPD. However, an increase in the number of days feeling rested when waking up was a protective factor that decreased the risk of SPD. The findings suggest that both sleep disturbances and SPD, because of their high prevalence, should be included in the routine evaluation for diabetes care.

Mexican Americans' diabetes symptom prevalence, burden, and clusters.

AIMS: Type 2 diabetes mellitus (T2DM), serious and increasingly prevalent among Mexican Americans, produces symptoms related to high and low glucose levels, medication side effects, and long-term complications. This secondary analysis explored symptom prevalence, differences among symptom burden levels, and how symptoms clustered. METHODS: Clinical measurements and survey data (demographic, quality of life, and the symptom subscale of the Diabetes Symptom Self-Management Inventory) collected from Mexican American adults with T2DM (n = 71) were analyzed for symptom prevalence, differences across levels of symptom burden, and symptom clusters. Agglomerative hierarchical and k-means clustering analyses were performed on a Gower matrix. Internal validation methods and rank aggregation were used to identify the best clustering method of the two techniques and to identify symptoms that clustered together. RESULTS: Participants reported mean = 14 symptoms; tiredness and trouble sleeping were most prevalent. People with high symptom burden had significantly lower quality of life and perceptions of worse diabetes severity. Hierarchical clustering produced three symptom clusters: cluster 1 = 9 symptoms (e.g. intense thirstiness, dry mouth); cluster 2 = 9 symptoms (e.g., itching skin, weight gain, noise or light sensitivity); cluster 3 = 13 symptoms (e.g., nervous, headache, trouble concentrating, and memory loss). CONCLUSION: Mexican Americans with T2DM report several co-occurring symptoms. Quality of life is significantly worse for people with high symptom burden. Three distinct symptom clusters were identified. Studies with larger samples are needed to further diabetes symptom science. Clinicians should assess and address patients' co-occurring symptoms as a potential means of decreasing symptom burden and improving quality of life.

Health Literacy in Adolescents With Sickle Cell Disease.

PURPOSE: To evaluate health literacy in a cohort of 75 adolescents with sickle cell disease (SCD). DESIGN AND METHODS: This cross-sectional, descriptive correlational study included assessment of demographic measures and appraisal of data resulting from completion of the REALM-Teen and Newest Vital Sign (NVS) instruments by 75 Black, non-Hispanic adolescents with SCD. Convenience sampling was utilized. Inclusion criteria were a diagnosis of one of the four primary genotypes of SCD and age 10-19years. RESULTS: Thirty-seven males and 38 females were recruited for the study. Their mean age was 14.7years (SD=2.2; range 8.1). Their grade level ranged from 4 to 12 (mean 8.7; SD=2.2). Scores on the REALM-Teen ranged from 12 to 66 (mean 53.7; SD=12.8). Scores on the NVS ranged from 0 to 6 (mean 2.37; SD=1.33). These health literacy scores were lower using both the REALM-Teen and the NVS instruments when compared to scores in all healthy adolescents and adults. Current grade level and health literacy scores showed a moderately high positive correlation (r=0.52, p<0.01). Health literacy scores were also significantly positively correlated with age (r=0.49, p<0.01) and income (r=0.37, p<0.01). CONCLUSIONS: Health literacy in adolescents with SCD is suboptimal. Future research should include identifying facilitators and barriers to health literacy levels in a larger cohort of adolescents with SCD. PRACTICE IMPLICATIONS: Health literacy is a potential facilitator of successful health outcomes for all adolescents. This study lays a solid foundation for future adolescent health literacy initiatives.

Home-based diabetes symptom self-management education for Mexican Americans with type 2 diabetes.

This pilot study evaluated an innovative diabetes symptom awareness and self-management educational program for Mexican Americans, a fast growing minority population experiencing a diabetes epidemic. Patients with diabetes need assistance interpreting and managing symptoms, which are often annoying and potentially life-threatening. A repeated measures randomized controlled trial was conducted with 72 Mexican Americans aged 25-75 years with type 2 diabetes. Experimental condition participants received eight weekly, in-home, one-on-one educational and behavior modification sessions with a registered nurse focusing on symptom awareness, glucose self-testing and appropriate treatments, followed by eight biweekly support telephone sessions. Wait-listed control condition participants served as comparisons at three time points. Hierarchical linear modeling was used to evaluate the effects of the intervention between- and within groups on psychosocial, behavioral and clinical outcomes. Participants were predominantly female, middle-aged, moderately acculturated and in poor glycemic control. Experimental group participants (n = 39) significantly improved glycemic control, blood pressure, symptoms, knowledge, self-efficacy, empowerment and quality of life. Post intervention focus groups reported satisfaction with the symptom focus. Addressing symptoms led to clinical and psychosocial improvements. Symptoms seem to be an important motivator and a useful prompt to engage patients in diabetes self-management behaviors to relieve symptoms and prevent complications.