Methods to improve the translation of evidence-based interventions: A primer on dissemination and implementation science for occupational safety and health researchers and practitioners.

Objective: A limited focus on dissemination and implementation (D&I) science has hindered the uptake of evidence-based interventions (EBIs) that reduce workplace morbidity and mortality. D&I science methods can be used in the occupational safety and health (OSH) field to advance the adoption, implementation, and sustainment of EBIs for complex workplaces. These approaches should be responsive to contextual factors, including the needs of partners and beneficiaries (such as employers, employees, and intermediaries). Methods: By synthesizing seminal literature and texts and leveraging our collective knowledge as D&I science and/or OSH researchers, we developed a D&I science primer for OSH. First, we provide an overview of common D&I terminology and concepts. Second, we describe several key and evolving issues in D&I science: balancing adaptation with intervention fidelity and specifying implementation outcomes and strategies. Next, we review D&I theories, models, and frameworks and offer examples for applying these to OSH research. We also discuss widely used D&I research designs, methods, and measures. Finally, we discuss future directions for D&I science application to OSH and provide resources for further exploration. Results: We compiled a D&I science primer for OSH appropriate for practitioners and evaluators, especially those newer to the field. Conclusion: This article fills a gap in the OSH research by providing an overview of D&I science to enhance understanding of key concepts, issues, models, designs, methods and measures for the translation into practice of effective OSH interventions to advance the safety, health and well-being of workers.

Predicting diabetes distress in patients with Type 2 diabetes: a longitudinal study.

AIMS: Diabetes distress (DD) is a condition distinct from depression that is related to diabetes outcomes. In those without distress initially, little is known about what indicators place patients at risk for subsequent distress over time. METHODS: From a community-based, three-wave, 18-month study of Type 2 diabetic patients (n = 506), we identified patients with no DD at T1 who displayed DD at T2, T3 or both (n = 57). Using logistic regression with full and trimmed models, we compared them with patients with no DD at all three time points (n = 275) on three blocks of variables: patient characteristics (demographics, depression, extra-disease stress), biological (HbA(1c), body mass index, comorbidities, complications, blood pressure, non-high-density lipoprotein-cholesterol), and behavioural variables (diet, exercise). Selected interactions with stress and major depressive disorder (MDD) were explored. RESULTS: The odds of becoming distressed over time were higher for being female, previously having had MDD, experiencing more negative events or more chronic stress, having more complications, and having poor diet and low exercise. Negative life events increased the negative effects of both high HbA(1c) and high complications on the emergence of distress over time. CONCLUSIONS: We identified a list of significant, independent direct and interactive predictors of high DD that can be used for patient screening to identify this high-risk patient cohort. Given the impact of high DD on diabetes behavioural and biological indicators, the findings suggest the usefulness of regularly appraising both current life and disease-related stressors in clinical care.

Lessons learned from laparoscopic treatment of gastric and gastroesophageal junction stromal cell tumors.

BACKGROUND: Stromal cell tumors of the gastric and gastroesophageal junction are rare neoplasms that traditionally have been resected for negative margins using an open approach. This study aimed to evaluate the efficacy laparoscopic resection of gastric and gastroesophageal stromal cell tumors and the lessons learned from experience with this method. METHODS: This retrospective review evaluated all patients who underwent laparoscopic resection of gastric or esophageal stromal cell tumors at a tertiary referral center between December 2002 and March 2005. Medical records were reviewed with regard to patient demographics, preoperative evaluation, operative approach, tumor location and pathology, length of operation, complications, and length of hospital stay. RESULTS: A total of 12 consecutive patients with a mean age of 55 +/- 5.9 years were treated. Preoperative endoscopic ultrasound (EUS) was performed for 11 of 12 patients with a diagnostic accuracy of 100%, whereas EUS-guided fine-needle aspiration was performed for 10 of 12 patients with a diagnostic accuracy of 50%. Four patients with symptomatic gastroesophageal junction leiomyomas were treated with enucleation and Nissen fundoplication. Eight patients were treated with laparoscopic wedge resection of gastric lesions. Complete R0 resection was achieved for all the patients undergoing laparoscopic resection. Intraoperative endoscopy was performed for four patients and resulted in shorter operative times. The average operative time for this entire series was 169 +/- 17 min: 199 +/- 24 min for the first six cases and 138 +/- 19 min for the last six cases. The median hospital length of stay was 2 days. One patient with esophageal leiomyoma had persistent dysphagia at the 12-month follow-up assessment. There were no other complications and no deaths in this series of patients. CONCLUSIONS: Laparoscopic resection of gastric and gastroesophageal junction stromal cell tumors may be performed safely with low patient morbidity. This approach can achieve adequate surgical margins and lead to short hospital stays. Improvements in the technique have led to shorter operative times.

A practical model of diabetes management and education.

This article discusses an evolving conceptual model of diabetes self-management and patient education. The model contains three primary levels or stages: 1) social environment and contextual factors, which have received little research attention; 2) patient-health care provider interactions, self-management behaviors, and short-term physiological outcomes, which constitute an ongoing cycle of care feedback system; and 3) longer term health and quality-of-life outcomes, which include the major societal costs of treating diabetes complications. The assessment and intervention implications of factors within each of these levels are discussed, with emphasis on both low-cost system-wide activities appropriate for all patients and higher cost activities and resources (e.g., intensive management à la the Diabetes Control and Complications Trial) for appropriately targeted or higher risk patients. I hope that such a systems approach to diabetes management can help reduce victim blaming (whether the victim is the noncompliant patient or the insensitive provider). Such conceptual models, if practically oriented, may help accelerate the development, evaluation, and dissemination of programs that facilitate both patient and health care team adherence to recommended guidelines for diabetes care.

Social environment and regimen adherence among type II diabetic patients.

We investigated the reliability and predictive validity of several measures of the social environment using a sample of 127 adults with type II (non-insulin-dependent) diabetes. Of particular interest was a revised scale of family support for performing diabetes self-care behaviors. Across four different aspects of the diabetes regimen, it was consistently found that regimen-specific measures of family support differentiated subjects who were low, medium, or high on adherence better than global family-support scores. Social-environment measures were generally successful in predicting a subject's level of regimen adherence after accounting for variance attributable to demographic factors. The family-support measures were the strongest and most consistent predictors of adherence, but measures of stress and medical-care satisfaction and the interaction between stress and the other social-environment measures also often improved the prediction of a subject's adherence status. These results support the usefulness of measures of the social environment specific to diabetes, and research to investigate other aspects of the social context of regimen adherence is recommended.

Evaluating diabetes education. Are we measuring the most important outcomes?

This article reviews the published literature on diabetes education evaluations and makes recommendations for outcome measures to be used in future research. We conclude that program evaluations to date have focused too narrowly on assessing knowledge and GHb outcomes to the exclusion of other important variables. To reflect the changing emphasis and conceptual basis of diabetes education, we recommend that future evaluations do the following: 1) report on the program's target population, recruitment methods, and representativeness of participants; 2) collect measures of self-efficacy and patient-provider interaction; 3) include quality of life and patient-functioning outcomes; and 4) use more standardized and objective measures of diabetes management behaviors. We close by providing practical examples of feasible collection measures for most settings and references to studies that have done so.

Personal-model beliefs and social-environmental barriers related to diabetes self-management.

OBJECTIVE: The specific aims of the present study were to report on the level of personal beliefs and social and environmental barriers across different regimen areas and patient subgroups and on the relationship of personal models and perceived barriers to the level of self-management. RESEARCH DESIGN AND METHODS: This study focused on several issues related to personal models (representations of illness) and perceived barriers to diabetes self-management among a large heterogeneous survey sample of 2,056 adults throughout the U.S. RESULTS: Respondents felt that diabetes was a serious disease and that their self-management activities will control their diabetes and reduce the likelihood of long-term complications. Most frequently reported barriers were related to dietary adherence, followed by exercise and glucose testing barriers. Both personal models and barriers significantly predicted level of self-management in all three regimen areas studied (diet, exercise, and glucose testing) after controlling for the influence of demographic and medical history factors. Regimen-specific models and barriers proved to be stronger predictors than more global measures. Differences on personal models and barriers were observed among different patient groups (e.g., age, health insurance, and insulin-taking status). Possible reasons for these differences and implications for intervention and future research are discussed. CONCLUSIONS: Both the personal-model and barriers scales had good internal consistency and predicted variance in each of the self-management variables after controlling for demographic and medical history factors. These brief self-report personal-model scales demonstrated good internal reliability and were as predictive of self-management as the lengthier interview-based measures in previous studies. The assessment of the treatment effectiveness component of personal models may be sufficient for most clinical purposes.

Adherence to IDDM regimens: relationship to psychosocial variables and metabolic control.

Thirty-four adolescents (ages 12-14 yr) with IDDM completed a questionnaire assessing regimen adherence over the previous week and psychosocial measures potentially related to adherence. Four aspects of the IDDM regimen were studied: insulin injections, dietary patterns, glucose testing, and exercise. Psychosocial variables included (1) Social Learning Theory measures of diabetes-specific family behaviors and barriers to adherence and (2) more general measures of family interaction. Glycosylated hemoglobin levels were predicted accurately (R = 0.68) from a combination of three adherence measures. The psychosocial measures were not directly related to metabolic control, but they were associated with adherence. Degree of adherence to one aspect of the IDDM regimen was not related to adherence to other aspects of the regimen and different psychosocial variables predicted adherence to different regimen components. The diabetes-specific measures were generally more predictive of adherence than were the more global measures. Implications and limitations of this cross-sectional, correlational study were discussed.

Patient perspective on factors contributing to nonadherence to diabetes regimen.

This study assessed levels of regimen adherence and reasons for nonadherence to different aspects of diabetes regimen for persons with type I (insulin-dependent, N = 24) and type II (non-insulin-dependent, N = 184) diabetes. Standardized questions revealed few differences between type I and type II participants on either levels of reported adherence or reasons for nonadherence. Subjects reported adhering least well to dietary and physical activity components of the regimen. Open-ended questions revealed that the most common reasons for dietary nonadherence were the situational factors of eating out at restaurants and inappropriate food offers from others. In contrast, negative physical reactions were the most frequently reported reasons for exercise nonadherence. The implications of these findings for diabetes education are discussed.

Supportive and nonsupportive family behaviors: relationships to adherence and metabolic control in persons with type I diabetes.

The Diabetes Family Behavior Checklist (DFBC) was administered to 54 adults and 18 adolescents (less than 19 yr of age) with insulin-dependent diabetes mellitus (IDDM). Subjects and family members completed parallel forms of the DFBC at initial and 6-mo follow-up home interviews. During each of these periods, adherence was assessed via self-report, 1 wk of self-monitoring, and 24-h dietary recalls. The results showed reliable differences between adolescents and adults. More negative interactions with family members were reported by adolescents and their family members, and adolescents were in poorer metabolic control. For adults but not adolescents, negative DFBC scores were prospectively predictive of poorer regimen adherence over the 6-mo interval for measures of glucose testing, insulin injection, and dietary adherence. In addition, higher negative DFBC scores for adults were marginally associated with higher HbA1 levels (P less than 0.10). We conclude that the DFBC is a promising measure of family interaction related specifically to the IDDM regimen and that, for adults, higher levels of nonsupportive family behaviors may be related to reduced regimen adherence and poor control.

Smoking and diabetes.

The objective of this review is to summarize the literature on diabetes and smoking related to epidemiological risks, efficacy and cost-effectiveness of different cessation approaches, and implications for clinical practice. Over 200 studies were reviewed, with special emphasis placed on publications within the past 10 years. Intervention studies that included patients with diabetes but did not report results separately by disease are included. Diabetes-specific studies are highlighted. There are consistent results from both cross-sectional and prospective studies showing enhanced risk for micro- and macrovascular disease, as well as premature mortality from the combination of smoking and diabetes. The general cessation literature is extensive, generally well-designed, and encouraging regarding the impact of cost-effective practical office-based interventions. In particular, system-based approaches that make smoking a routine part of office contacts and provide multiple prompts, advice, assistance, and follow-up support are effective. Although there is minimal information on the effectiveness of cessation interventions specifically for people with diabetes, there is no reason to assume that cessation intervention would be more or less effective in this population. There is a clear need to increase the frequency of smoking cessation advice and counseling for patients with diabetes given the strong and consistent data on smoking prevalence; combined risks of smoking and diabetes for morbidity, mortality, and several complications; and the proven efficacy and cost-effectiveness of cessation strategies.

Effects of a brief office-based intervention to facilitate diabetes dietary self-management.

OBJECTIVE: There is a pressing need for brief practical interventions that address diabetes management. Using a randomized design, we evaluated a medical office-based intervention focused on behavioral issues relevant to dietary self-management. RESEARCH DESIGN AND METHODS: There were 206 adult diabetes patients randomized to usual care or brief intervention, which consisted of touchscreen computer-assisted assessment to provide immediate feedback on key barriers to dietary self-management, and goal setting and problem-solving counseling for patients. Follow-up components to the single session intervention included phone calls and interactive video or videotape instruction as needed. RESULTS: Multivariate analyses of covariance revealed that the brief intervention produced greater improvements than usual care on a number of measures of dietary behavior (e.g., fewer calories from saturated fat, fewer high-fat eating habits and behaviors) at the 3-month follow-up. There were also significant differences favoring intervention on changes in serum cholesterol levels and patient satisfaction but not on glycosylated hemoglobin. The intervention effects were relatively robust across a variety of patient characteristics, the two participating physicians, and intervention staff members. CONCLUSIONS: If the long-term results are equally positive and generalize to other setting, this intervention could provide a prototype for a feasible cost-effective way to integrate patient views and behavioral management into office-based care for diabetes.

The summary of diabetes self-care activities measure: results from 7 studies and a revised scale.

OBJECTIVE: To review reliability, validity, and normative data from 7 different studies, involving a total of 1,988 people with diabetes, and provide a revised version of the Summary of Diabetes Self-Care Activities (SDSCA) measure. RESEARCH DESIGN AND METHODS: The SDSCA measure is a brief self-report questionnaire of diabetes self-management that includes items assessing the following aspects of the diabetes regimen: general diet, specific diet, exercise, blood-glucose testing, foot care, and smoking. Normative data (means and SD), inter-item and test-retest reliability, correlations between the SDSCA subscales and a range of criterion measures, and sensitivity to change scores are presented for the 7 different studies (5 randomized interventions and 2 observational studies). RESULTS: Participants were typically older patients, having type 2 diabetes for a number of years, with a slight preponderance of women. The average inter-item correlations within scales were high (mean = 0.47), with the exception of specific diet; test-retest correlations were moderate (mean = 0.40). Correlations with other measures of diet and exercise generally supported the validity of the SDSCA subscales (mean = 0.23). CONCLUSIONS: There are numerous benefits from standardization of measures across studies. The SDSCA questionnaire is a brief yet reliable and valid self-report measure of diabetes self-management that is useful both for research and practice. The revised version and its scoring are presented, and the inclusion of this measure in studies of diabetes self-management is recommended when appropriate.

Quality of life and associated characteristics in a large national sample of adults with diabetes.

OBJECTIVE: This study investigated the quality of life and the demographic, medical-history, and self-management characteristics associated with it. RESEARCH DESIGN AND METHODS: A diabetes self-management survey was sent to 2,800 adults with diabetes throughout the U.S. who were part of a marketing company national sample. The response rate was 73%. The final sample of 2,056 persons was heterogeneous: the average age was 59 years (range, 18-92 years); 53% had high school education or less; 86% had type II diabetes; 62% were female; and 31% reported being on an intensive management plan, such as the one used in the Diabetes Control and Complications Trial. Quality-of-life items included the social, physical, and mental health dimensions of the Short Form (SF-20) of the General Health Survey. RESULTS: Overall, respondents reported a moderate to low quality of life, relative to previous studies. Factors related to lower quality of life included: less education, lower income, older age, being female, type of health insurance (no medical insurance or Medicare/Medicaid recipients reported lower quality of life than those with either a health maintenance organization or private insurance), number of diabetes complications, number of comorbid illnesses, and lower levels of physical activity. Multiple regression analyses revealed that the level of self-reported exercise was the only significant self-management behavior to predict the quality of life, after controlling for demographic and medical variables. CONCLUSIONS: If the findings regarding physical activity are replicated, it may be that moderate-intensity physical activity programs could be initiated with diabetic individuals at risk of low quality of life. Quality of life is an important and understudied topic in diabetes that appears to be related to demographic, medical-history, and self-management factors.

Psychosocial predictors of self-care behaviors (compliance) and glycemic control in non-insulin-dependent diabetes mellitus.

This study assessed potential psychosocial correlates of self-care behaviors (compliance) and of glycemic control in a community sample of 184 people diagnosed as having non-insulin-dependent (type II) diabetes mellitus. Four different diabetes self-care behaviors were studied (medication taking, glucose testing, diet, and exercise), and glycemic control was assessed by glycosylated hemoglobin analyses. Multiple measures were collected within each of several categories of psychosocial variables including knowledge, stress, depression, anxiety, diabetes-specific health beliefs, and social support. Findings indicate that approximately 25% of the variance in self-care behaviors can be explained by psychosocial and demographic variables. In contrast, psychosocial variables were not significant predictors of level of glycemic control. The diabetes-specific psychosocial measures of health beliefs and social support were the most consistent and strongest predictors of self-care behavior across the different regimen areas studied. Possible reasons for these findings, limitations of the study, and directions for future research are discussed.

Nutrition education and social learning interventions for type II diabetes.

Two diabetes education programs were compared to a control condition. Seventy-eighty type II (non-insulin-dependent) diabetic outpatients were randomly assigned to nutrition education, nutrition education plus social learning intervention, or wait-list control conditions. Both interventions involved five weekly meetings that focused on reducing calorie intake, increasing dietary fiber, and decreasing fat consumption. The social learning condition also included individualized goal setting and feedback and training in problem-solving and relapse prevention. Within-group analyses and between-group comparisons generally revealed greater improvement in targeted goals (e.g., calorie intake, fat reduction) among intervention conditions than the control condition. There were few differences in more distal measures of outcome such as weight or glycosylated hemoglobin. The social learning component did not improve outcome more than the nutrition education program. Possible reasons for the observed findings and the advantages and limitations of focused time-limited diabetes education efforts are discussed.

The diabetes network internet-based physical activity intervention: a randomized pilot study.

OBJECTIVE: Because of other competing priorities, physical activity (PA) is seldom addressed in a consistent way in either primary care or diabetes education. This 8-week pilot study evaluated the short-term benefits of an Internet-based supplement to usual care that focused on providing support for sedentary patients with type 2 diabetes to increase their PA levels. RESEARCH DESIGN AND METHODS: A total of 78 type 2 diabetic patients (53% female, average age 52.3 years) were randomized to the Diabetes Network (D-Net) Active Lives PA Intervention or an Internet information-only condition. The intervention condition received goal-setting and personalized feedback, identified and developed strategies to overcome barriers, received and could post messages to an on-line "personal coach," and were invited to participate in peer group support areas. Key outcomes included minutes of PA per week and depressive symptomatology. RESULTS: There was an overall moderate improvement in PA levels within both intervention and control conditions, but there was no significant improvement in regard to condition effects. There was substantial variability in both site use and outcomes within the intervention and control conditions. Internal analyses revealed that among intervention participants, those who used the site more regularly derived significantly greater benefits, whereas those in the control condition derived no similar benefits with increased program use. CONCLUSIONS: Internet-based self-management interventions for PA and other regimen areas have great potential to enhance the care of diabetes and other chronic conditions. We conclude that greater attention should be focused on methods to sustain involvement with Internet-based intervention health promotion programs over time.

Behavioral science in diabetes. Contributions and opportunities.

OBJECTIVE: To summarize the current status of behavioral research and practice in diabetes and to identify promising future directions. RESEARCH DESIGN AND METHODS: We review behavioral science contributions to diabetes in self-management and patient empowerment, interventions with children and adolescents, and special problems including blood glucose awareness training and complications such as depression. We also identify emerging areas in which behavioral science stands to make significant contributions, including quality of life, worksite and community programs, interventions using new information technologies, and translation research evaluating practical programs in representative settings. We then discuss the gap between the generally encouraging research on behavioral contributions to diabetes and the infrequent incorporation of such contributions in practice. Suggestions are made for how to close this gap, including ways to increase understanding of behavioral issues, opportunities for funding of key research and implementation questions, and how behavioral science principles can become more integrated into diabetes organizations and care. CONCLUSIONS: Changes are required on the part of behavioral scientists in how they organize and present their research and on the part of potential users of this knowledge, including other health professions, organizations, and funding agencies. Integrating behavioral science advances with other promising genetic, medical, nutritional, technology, health care, and policy opportunities promises not only to broaden our understanding of diabetes but also to improve patient care, quality of life, and public health for persons with diabetes.

Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care.

As one of four work groups for the November 1999 conference on Behavioral Science Research in Diabetes, sponsored by the National Institute on Diabetes and Digestive and Kidney Diseases, the health care delivery work group evaluated the status of research on quality of care, patient-provider interactions, and health care systems' innovations related to improved diabetes outcomes. In addition, we made recommendations for future research. In this article, which was developed and modified at the November conference by experts in health care delivery, diabetes and behavioral science, we summarize the literature on patient-provider interactions, diabetes care and self-management support among underserved and minority populations, and implementation of chronic care management systems for diabetes. We conclude that, although the quality of care provided to the vast majority of diabetic patients is problematic, this is principally not the fault of either individual patients or health care professionals. Rather, it is a systems issue emanating from the acute illness model of care, which still predominates. Examples of proactive population-based chronic care management programs incorporating behavioral principles are discussed. The article concludes by identifying barriers to the establishment of a chronic care model (e.g., lack of supportive policies, understanding of population-based management, and information systems) and priorities for future research in this area needed to overcome these barriers.

Does the participation of a surgical trainee adversely impact patient outcomes? A study of major pancreatic resections in California.

BACKGROUND: Some patients have concerns regarding the impact of surgical trainees on the quality of care that they receive in teaching hospitals. No population-based data exist that describe outcomes of surgical procedures in teaching and nonteaching hospitals; however, institutional data suggest that teaching hospitals provide high-quality care. We hypothesized that the presence of a general surgery residency program (GSRP) is associated with superior outcomes for pancreatic resection, a complex surgical procedure. METHODS: A retrospective, population-based, risk-adjusted analysis of 5696 patients who underwent major pancreatic resection compares the outcomes of patients treated at hospitals with a GSRP (GSRP+) and those hospitals without a GSRP (GSRP-). RESULTS: GSRP+ hospitals had a lower operative mortality rate (8.3% vs 11.0%; P <. 001), a lower percentage of patients discharged to another acute care hospital or skilled nursing facility (6.5% vs 13.0%; P <.001), and a longer length of stay compared with GSRP- hospitals (22.1 +/- 0.4 days vs 19.6 +/- 0.3 days; P <.001). The observed difference in hospital mortality rates was not significant after an adjustment was made for patient mix and hospital volume (9.7% vs 10.0%). However, superior outcomes were found in the university teaching hospitals, as compared with the affiliated teaching and the nonteaching hospitals (5.3% [P <.001] vs 11.4% vs 11.0%; risk adjusted, 8.0% [P <.05] vs 10.9% vs 10.0%). CONCLUSIONS: The presence of surgical trainees does not have an adverse impact on the quality of care for One complex procedure, pancreatectomy, and is associated with superior operative mortality rate in university teaching hospitals.