Impact of a social network-based intervention promoting diabetes self-management in socioeconomically deprived patients: a qualitative evaluation of the intervention strategies.

OBJECTIVE: There is a need for effective interventions that improve diabetes self-management (DSM) among socioeconomically deprived patients with type 2 diabetes. The group-based intervention Powerful Together with Diabetes (PTWD) aimed to increase social support for DSM and decrease social influences hindering DSM (eg, peer pressure, social norms) in patients living in deprived neighbourhoods. Through a qualitative process evaluation, this paper aims to study whether this intervention changed social support and social influences, and which elements of the intervention contributed to this. METHODS: The intervention group (IG) was compared with a standard group-based educational intervention (control group, CG). 27 qualitative in-depth interviews with participants (multiethnic sample) and 24 interviews with group leaders were conducted. Interviews were coded and analysed using MAXQDA according to framework analysis. RESULTS: Patients in the IG experienced more emotional support from group members and more instrumental and appraisal support from relatives than those in the CG. Also, they were better able to recognise and cope with influences that hinder their DSM, exhibited more positive norms towards DSM and increased their priority regarding DSM and their adherence. Finally, the engagement in DSM by relatives of participants increased. Creating trust between group members, skills training, practising together and actively involving relatives through action plans contributed to these changes. CONCLUSIONS: A group-based intervention aimed at creating trust, practising together and involving relatives has the potential to increase social support and diminish social influences hindering DSM in socioeconomically deprived patients with diabetes. Promising elements of the intervention were skills training and providing feedback using role-playing exercises in group sessions with patients, as well as the involvement of patients' significant others in self-management tasks, and actively involving them in making an action plan for self-management. These positive results justify the value of further evaluating the effectiveness of this intervention in a larger sample. TRIAL REGISTRATION NUMBER: NTR1886, Results.

No clear effect of diabetes education on glycaemic control for Turkish type 2 diabetes patients: a controlled experiment in general practice.

BACKGROUND: In Turkish immigrant diabetics, problems with communication and cultural differences may hinder delivery of diabetes care. METHODS: In a prospective controlled study, the effect of an ethnic-specific diabetes education programme on glycaemic control and cardiovascular risk factors in Turkish type 2 diabetes patients was assessed, by comparing Turkish diabetics who were offered the education programme with Turkish diabetics offered routine care only (control group). From 16 general practices (31 GPs) in Rotterdam, 104 Turkish type 2 diabetes patients were recruited, 85 of whom could be assessed at one-year follow-up. Glycaemic control, lipid concentrations, blood pressure and body mass index were measured. RESULTS: Compared with the control group, mean HbA(1C) in the intervention group decreased by 0.3% (95% CI -0.8 to 0.2). A significant decrease in HbA(1C) was observed in women with HbA(1C) >7% at baseline (-0.9%; 95% CI -1.73 to -0.09) but not in the other subgroups studied. serum lipid concentrations, blood pressure and body mass index remained unchanged in the intervention group. CONCLUSION: Ethnic-specific diabetes education by Turkish female educators has no obvious beneficial effect on glycaemic control or cardiovascular risk profile. More focus on specific patient selection and gender equality between educators/patients may prove worthwhile.

The effect of cross-gender hormonal treatment on bone metabolism in male-to-female transsexuals.

A deficiency of sex hormones leads in both sexes to increased bone loss, and hormonal substitution can prevent this. The effect of the change of hormonal environment on bone metabolism in transsexuals is unknown. Transilial bone biopsies were obtained from 23 male-to-female transsexuals (mean age +/- SD, 38.0 +/- 11.7 years) after estrogen (ethinylestradiol, 100 micrograms/day) and antiandrogen treatment (cyproterone acetate, 100 mg/day) for 8-41 months. Histomorphometric data were compared with those from 11 healthy men (39.6 +/- 9.4 years). There was no difference in bone volume, bone surface, or trabecular thickness between transsexuals and controls. Eroded surface and osteoclast number were not different between the groups. The osteoid volume, surface, and thickness were significantly lower in the transsexuals than in the controls. The mineral apposition rate and adjusted apposition rate were normal, but mineralizing surface and bone formation rate were suppressed in the transsexuals compared with data reported from the literature. The results indicate that antiandrogen and estrogen treatment in male-to-female transsexuals may suppress bone turnover and is not associated with bone loss.

An analysis of bone structure in patients with hip fracture.

The prevalence of osteoporosis in patients with hip fracture is not well defined. We performed a histomorphometric analysis of bone structural parameters in transilial biopsies of 39 patients with hip fracture (21 cervical, 18 trochanteric), 23 patients with one or more vertebral crush fractures and 20 control subjects. Trabecular bone volume (TBV) and trabecular surface density (Sv) were significantly lower in trochanteric than in cervical fractures. Mean trabecular plate thickness (MTPT), mean wall thickness (MWT) and TBV were significantly lower in trochanteric fractures than in the control group. Vertebral crush fractures are mainly characterized by a decreased TBV and Sv. There was a strong positive correlation between MWT and MTPT in trochanteric fractures suggesting that the decreased trabecular thickness in this group is due to decreased osteoblastic apposition. Trochanteric fractures are associated with serious osteoporosis, whereas cervical fractures constitute a more heterogeneous group. The osteoporosis of trochanteric fractures is characterized by significant trabecular thinning, whereas that of vertebral fractures is mainly associated with loss of trabecular plates.

Prevalence of type 2 diabetes mellitus, other cardiovascular risk factors, and cardiovascular disease in Turkish and Moroccan immigrants in North West Europe: a systematic review.

BACKGROUND: The prevalence of diabetes, other cardiovascular risk factors, and cardiovascular morbidity and mortality varies between immigrant groups in Western societies, but epidemiological data on these topics are scarce for Turks and Moroccan immigrant living in North West Europe. METHODS: Medline and Embase were systematically searched for studies containing data on the prevalence of diabetes, cardiovascular risk factors, and cardiovascular morbidity and mortality in Turkish or Moroccan immigrants living in Northwestern European countries. RESULTS: Eighteen studies were identified. Corresponding findings were a high prevalence of type 2 diabetes in Turkish and Moroccan immigrants, a high prevalence of smoking among Turkish men, and a very low prevalence of smoking in Moroccan women compared to the indigenous population. Because of lack of valid studies, no definite conclusions could be drawn for in particular blood pressure and lipids. One German study showed exceptionally lower cardiovascular mortality rates in Turkish immigrants. CONCLUSION: The reviewed studies yielded insufficient evidence for a good quality comparison of the cardiovascular risk profile between Turkish and Moroccan immigrants and indigenous populations. Diabetes mellitus was more prevalent in Turkish and Moroccan immigrants, smoking more prevalent in Turkish males, and very rare in Moroccan females.

Diabetes care in Dutch general practice: differences between Turkish immigrants and Dutch patients.

AIM: To compare the adherence to clinical guidelines by GPs as registered and glycaemic control in Turkish and Dutch type 2 diabetes patients. DESIGN: A retrospective cohort study. Search of general practice medical records for diabetes-related variables of Turkish and Dutch diabetes patients, stratified for age and gender. SETTING: Seventeen general practices (37 GPs) in the inner city of Rotterdam. SUBJECTS: 196 type 2 diabetes patients (106 Turkish and 90 Dutch), known with diabetes for at least 18 months, were followed for two years during the 1992-1997 period. MAIN OUTCOME MEASURES: 1) Level of care as registered in the medical records based on eight quantifiable criteria derived from the national guidelines for GPs; and 2) glycaemic control (fasting and non-fasting blood glucose levels). RESULTS: Turkish patients visited the GP for periodic control more often than Dutch patients. The other seven criteria were followed in an equal number of Turkish and Dutch patients. Turkish patients had a higher mean non-fasting plasma glucose level (12.9 mmol/l) than Dutch patients (10.8) (p=0.001) during the two-year follow-up. CONCLUSIONS: Although adherence to clinical guidelines as registered in Turkish and Dutch type 2 diabetes patients is comparable, Turkish patients have higher mean non-fasting plasma glucose level than their Dutch counterparts.