Resiliency in Persons Experiencing Homelessness: A Concept Analysis Using the Evolutionary Framework.

INTRODUCTION: Homelessness is a critical societal issue, with those affected facing disproportionate chronic and acute health conditions. At the core of understanding their experiences is the concept of resiliency. Understanding resiliency in homelessness is crucial because it highlights the dynamic interplay between inherent qualities and external challenges, underscoring the need to reassess societal value judgements and inform nursing practices in research, education and advocacy. AIM: This paper aims to conduct a comprehensive concept analysis to propose a revised definition of resiliency in the context of homelessness. METHODS: Rogers's evolutionary method was the analytical tool of choice, perfect for examining the fluid and evolving nature of resiliency within the context of homelessness. The method entails analysing the concept's transformation over time and across disciplines, accepting variability in definitions based on the chronological and contextual constructs. DISCUSSION: The findings revealed that resiliency in homelessness is an inherent quality and a developed response shaped by the interplay of innate capacities and environmental challenges. It uncovered a need to reassess societal value judgements. Resiliency among people without housing suggests strengths that go unrecognised by conventional measures. CONCLUSION: The analysis concludes that resiliency is not a static trait but a dynamic process encompassing individual, social and environmental dimensions. In each case, nursing is poised to make a significant difference in nursing research, practice, education and advocacy, potentially inspiring new approaches and interventions. No public or private was used in the development of this article.

Connections matter: Exploring the relationship between belonging and psychosocial well-being in type 1 diabetes in Iran.

AIM: Identify the relationship between a sense of belonging and psychosocial well-being in individuals with type 1 diabetes (T1D) in Iran. BACKGROUND: Understanding this relationship is vital for tailored nursing interventions to enhance individual's sense of belonging and improve diabetes outcomes. METHODS: This cross-sectional study included 205 participants selected via multi-stage cluster and simple random sampling from health centers in Iranian. Electronic surveys designed on Google Forms, using valid and reliable scales and compliant with HIPAA, assessed sense of belonging, distress, and burnout. Data were analyzed using SPSS (version 25). RESULTS: Participants reported high sense of belonging with varying levels of diabetes distress and burnout. Multiple regression analysis of 205 participants showed that sense of belonging index (SOBI) scores significantly predicted diabetes distress (F(2,203) = 39.71, p < 0.001) and burnout (F(2, 203) = 42.319, p < 0.001). Sense of Belonging Instrument-Psychological (SOBI-P) scores were negatively correlated with both distress (r = -0.52, p < 0.001) and burnout (r = -0.53, p < 0.001), indicating higher belonging is linked to lower distress and burnout. Sense of Belonging Instrument-Antecedents (SOBI-A) scores had positive but non-significant correlations (distress: r = 0.07, p = 0.27; burnout: r = 0.10, p = 0.13). SOBI-P accounted for ∼30 % of the variance in distress (R2 = 0.275) and burnout (R2 = 0.288), with significant contributions to both models (t = -8.8, p < 0.001; t = -9.02, p < 0.001). Anticipated belonging showed no significant correlations with distress or burnout. CONCLUSION: The negative correlations between personal belonging, self-reported distress, and burnout suggest that enhancing the psychological sense of belonging may be an effective strategy to mitigate diabetes-related distress and burnout Stigmatization and financial strain in Iran may exacerbate emotional burden, regimen related distress, and burnout. The lack of association between anticipated belonging and psychosocial well-being underscores differences in present and future perceptions of support, emphasizing the need for culturally sensitive nursing interventions.

Psychosocial comorbidities of diabetes during the COVID-19 pandemic in Iran.

BACKGROUND: The psychosocial impacts of the COVID-19 pandemic are mainly focused on the general population, while pandemics do not impact the mental health of the entire population uniformly, especially vulnerable populations with underlying health conditions. This study aimed to investigate diabetes psychosocial comorbidities among Iranians with type 1 diabetes (T1D) during the COVID-19 pandemic. This study aimed to investigate diabetes psychosocial comorbidities among Iranians with type 1 diabetes (T1D) during the COVID-19 pandemic. MATERIALS AND METHODS: This was a cross-sectional study of 212 adults with T1D in different cities in Iran. Study participants completed an online survey in April-June 2020. The survey collected self-reported data on diabetes psychosocial comorbidities (i.e. diabetes burnout, diabetes distress, and depressive symptoms). Demographic and COVID-19 data before and during the pandemic were also collected. Responses were analyzed using ordinary least squares and logistic regression methods. RESULTS: Around 17.5% reported being tested for COVID-19 virus, 8% were diagnosed positive, 10.8% were hospitalized, and 92.9% followed precaution recommendations during the pandemic. Participants had high levels of diabetes distress (57.1%), depressive symptoms (60.8%), and diabetes burnout (mean score = 3.1 out of 5). During the pandemic, trouble paying for the very basic needs was a consistent factor increasing the risk of diabetes distress, diabetes burnout, and depressive symptoms. Lack of access to diabetes care was only associated with diabetes burnout, while diabetes hospitalization/emergency department (ED) visit was associated with diabetes distress. Existing diabetes disparities before the pandemic were also associated with higher scores of diabetes psychosocial comorbidities [accessing diabetes supplies and medications (P < 0.0001) and places for physical exercise (P < 0.0333)]. CONCLUSION: The negative impact of the COVID-19-related changes on individuals with diabetes, as one of the most vulnerable populations, must be recognized alongside the physical, financial, and societal impact on all those affected. Psychological interventions should be implemented urgently in Iran, especially for those with such characteristics.

Regional Comparison of Diabetes Psychosocial Comorbidities Among Americans With Type 1 Diabetes During the COVID-19 Pandemic.

PURPOSE: The purpose of this study was to compare diabetes psychosocial comorbidities among adults with type 1 diabetes (T1D) across the United States during the onset of COVID-19 pandemic. METHODS: Adults with T1D from 4 main US geographic regions including South (n = 367), West (n = 234), Northeast (n = 250), and Midwest (n = 247) completed a cross-sectional online survey between April and June 2020. Data collection was done on psychosocial measures, glycemic variability, sociodemographic characteristics, and various challenges related to the COVID-19 pandemic. Chi-square, Fisher's exact, Kruskal-Wallis tests, ordinary least squares, proportional odds, and ordinal logistic regression methods were used for data analysis. RESULTS: In the South, 51.2% of participants had moderate to high levels of diabetes distress, and this was significantly (P = .03) higher than other regions. Northeast region had the lowest prevalence of moderate to severe diabetes burnout (19.8%), but this was not significantly different compared to the other regions. Participants in the South had also the highest mean score on the 8-item Patient Health Questionnaire, with 30.3% of them reporting moderate to severe depressive symptoms. However, there were no significant differences in depressive symptoms among the regions. Glycemic control, demographic characteristics, and COVID-19-related challenges were associated with different psychosocial comorbidities in different regions. CONCLUSIONS: When providing information and support to individuals with diabetes in time of crisis like the COVID pandemic, providers should consider psychosocial aspects of diabetes care. Diabetes disparities and contextual factors vary geographically in the United States; these factors may impact the psychosocial comorbidities of diabetes in each region.

Emotional burden and care of adults with type 1 diabetes during the COVID-19 pandemic in Brazilian regions.

AIMS: This study investigated the emotional burden in persons with type 1 diabetes (PWT1D) during the COVID-19 pandemic in Brazilian regions and evaluated which COVID-19, sociodemographic/clinical characteristics are related to it. METHODS: In a cross-sectional study, T1D adults completed a web-based survey from May to July 2020. We collected sociodemographic/clinical data, and participants answered COVID-19 related questions. Diabetes burnout was evaluated by Diabetes burnout scale. Type 1 Diabetes scale assessed Diabetes Distress and PHQ-8 measured depressive symptoms. RESULTS: DD and DS levels were similar in all Brazilian regions. DB was higher in Central-West/North/Northeast. Higher DB was associated with females, lower-income, higher HbA1c, and shorter time since T1D diagnosis. Predictors of experiencing higher levels of DD included: difficulty access to safe places to exercise, participants without a partner, male gender, young age, and higher HbA1c. Higher depressive symptoms were associated with difficulty to access diabetes supplies, and higher HbA1c (p < 0.05). CONCLUSIONS: The mean levels of DB, DD, and DS were high in all Brazilian regions. A great number of PWT1D had their diabetes care impaired and relied on family as their main support during the pandemic. The subgroups identified at risk should be prioritized in mental health support.

The Value of Measuring Diabetes Burnout.

PURPOSE OF REVIEW: Diabetes represents a chronic illness with significant physical and psychological morbidities. This review aims to summarize current conceptualizations of diabetes burnout in individuals with diabetes and describe its associated adverse outcomes in this population while proposing possible mechanisms of action and targets of intervention. RECENT FINDINGS: "Diabetes burnout" may result in adverse long-term outcomes including poor treatment compliance, diabetes complications, and depression. Diabetes burnout may impact not only individuals, but also providers, and caregivers and family members of affected individuals. Diabetes burnout may results from sustained cognitive stresses of chronic treatment adherence, assessment of realistic treatment goals, and treatment challenges. Early screening and interdisciplinary approaches for patient-centered diabetes care are critical for sustained diabetes social support. Future work exploring these approaches may identify early support and targeted interventions for the long-term support of individuals with diabetes.

Cross-national comparison of psychosocial well-being and diabetes outcomes in adults with type 1 diabetes during the COVID-19 pandemic in US, Brazil, and Iran.

BACKGROUND: The COVID-19 pandemic is a global public health emergency, which presents wide-ranging negative impacts on individuals with diabetes. To examine psychosocial well-being and diabetes outcomes in individuals with type 1 diabetes during the COVID-19 pandemic, and investigate how these factors vary in different countries. METHODS: Between April and June 2020 we employed a cross national comparative research study in the United States (US), Brazil, and Iran to collect data from 1788 adults with type 1 diabetes using web-based survey. Study participants answered questions relevant to diabetes distress, diabetes burnout, depressive symptoms, COVID-19 related changes, and socio-demographic characteristics. They also reported their last Hemoglobin A1c (HbA1c) and daily Time-in-Range (TiR) blood glucose. We analyzed data using comparative tests (Chi-square, Kruskal-Wallis and McNemar test), logistic and linear regression adjusted for fixed effects. RESULTS: There were significant changes prior and during the pandemic regarding access to diabetes care, diabetes supplies and medications, healthy food and safe places to exercise in all countries (p < 0.05). Participants in Iran experienced higher levels of diabetes distress (57.1%), diabetes burnout (50%), and depressive symptoms (60.9%), followed by Brazil and US (p < 0.0001). US participants reported better glycemic control (HbA1c = 6.97%, T1R = 69.64%) compared to Brazil (HbA1c = 7.94%, T1R = 51.95%) and Iran (HbA1c = 7.47%, T1R = 51.53%) (p < 0.0001). There were also significant relationships between psychosocial well-being, diabetes outcomes, socio-demographic data, and COVID-19 related challenges in overall sample (p < 0.05). CONCLUSIONS: Regardless of differences among US, Brazil, and Iran, our findings revealed that different countries may experience similar challenges related to the COVID-19 pandemic which can impact negatively diabetes outcomes and psychosocial well-being in individuals with type 1 diabetes. Countries need to consider modifiable variables associated with poor diabetes outcomes and sub optimal psychosocial well-being and target vulnerable population using significant socio-demographic variables.

Development and validation of a scale to measure diabetes burnout.

INTRODUCTION: The aim of this study is to establish reliability and validity of the Diabetes Burnout Scale (DBS) among adults with type 1 diabetes (T1D). METHODS: We used a multi-stage, mixed methods approach to developing the DBS. First, the research team identified twenty-eight candidate items through a review of the literature and 117 qualitative narratives from adults living with T1D. Next, items were revised based on the expert (n = 20) and individual with T1D (n = 10) feedback. The resulting 18-item DBS measure along with validated measures of diabetes distress, depressive symptoms, and questions related to diabetes outcomes (i.e., last reported hemoglobin A1c [HbA1c] and Time-in-Range [TiR]) were completed by 1099 adults with T1D across the U.S. The sample was randomly divided into two subsets (n1 = 561, n2 = 538) for exploratory and confirmatory factor analyses (EFA/CFA) to determine the underlying structure of the DBS. Regression analyses examined the relationships of the DBS with self-reported glycemic control and socio-demographic characteristics. RESULTS: Based on the EFA three factors are identified and the DBS demonstrated strong internal consistency with Cronbach alphas (≥0.80). The validation and confirmatory analysis for the structure of the DBS provided consistent results with EFA. Higher burnout (overall DBS) was positively associated with diabetes distress (b = 0.74; p < 0.01) and depressive symptoms (b = 0.61; p < 0.01). Overall DBS, however was the strongest predictor for poorer HbA1c (r2 = 0.19; p < 0.01) and lower TiR (r2 = 0.17; p < 0.01) compared to diabetes distress and depressive symptoms. CONCLUSION: The 12-item DBS is a reliable and valid scale to measure diabetes burnout in adults with diabetes. The results provide a weak to strong degree of association between the validated DBS scale, T1-DDS and PHQ-8. The DBS can contribute to advancement of diabetes science by measuring diabetes burnout and informing clinical interventions to improve psychosocial care in individuals with diabetes.

Kids helping kids: The lived experience of adolescents who support friends with mental health needs.

PROBLEM: Adolescent mental health is a significant health care issue. Friends play an important role in the lives of adolescents with mental health concerns and help to improve outcomes related to depression and suicide. However, little is known about the experiences of adolescents who help their friends with these concerns. METHODS: A phenomenological research design involving unstructured interviews was used to answer the question: what is the lived experience of adolescents who provide support to friends with anxiety, depression, or who express suicidal ideation?" Participants for this study were aged 16-17 and included both males (n = 2) and females (n = 3). FINDINGS: Participants described their experience as "Kids Helping Kids" which is defined by the following themes: Being Fearful, Maintaining Vigilance, Seeking Knowledge, Keeping Secrets, Involving Others, Setting Boundaries, and Feeling Honored. CONCLUSION: Helping a friend with mental health concerns can be challenging yet rewarding. Nurses should be aware of this role that some adolescents undertake and include the friends of adolescents with mental health concerns as part of plans of care.

New insights into diabetes burnout and its distinction from diabetes distress and depressive symptoms: A qualitative study.

AIMS: This study aimed to corroborate the main hypotetized dimensions of diabetes burnout, and its distinction from diabetes distress and depressive symptoms among adults with type 1 diabetes (T1D). METHODS: A qualitative descriptive study was employed to collect data from 31 eligible participants using semi-structured individual phone interviews. Participants were recruited through purposive sampling among a larger sample of adults with T1D in a previous study. Data was analyzed using qualitative content analysis including immersion, reduction, and interpretation. RESULTS: Exhaustion and detachment were frequent manifestations of diabetes burnout that often accompanied by instances during which participants experienced a loss of control over diabetes. Whereas individuals' support systems could either help or hinder diabetes burnout. Participants saw burnout as separate but closely related to distress and depressive symptoms, with some suggesting correlations among burnout, distress, and depressive symptoms, while others expressed that distress caused their burnout and depressive symptoms. CONCLUSIONS: Diabetes burnout reflects a significant yet unexplored concept which might explain the complexities of suboptimal self-management and poor diabetes outcomes. Emerging evidence suggesting diabetes burnout as a distinct concept calls for more studies to mitigate diabetes burnout as an obstacle to optimal diabetes care.

I don't have the choice to burnout; experiences of parents of children with type 1 diabetes.

AIM: The purpose of the study was to explore the description of diabetes burnout in parents of children with type 1 diabetes (T1D). BACKGROUND: Parents of children with T1D struggle to balance diabetes management and typical parenting challenges, which may lead to diabetes burnout. Although diabetes burnout is a familiar concept in public forum and diabetes literature, science on diabetes burnout in parents is lacking. METHODS: In this qualitative descriptive study, a systematic approach was used to search existing relevant YouTube videos about diabetes burnout produced by parents of children with T1D. Verbatim transcripts of 21 videos meeting inclusion criteria were analyzed using a qualitative content analysis approach. To summarize video characteristics, descriptive statistics were used. RESULTS: It identifies four primary themes related to diabetes burnout in this population: "exhaustion compounded by stress," "powerlessness to control diabetes," "grief for the loss of a normal life," and "coping strategies." CONCLUSION: The findings of this study may serve to clarify how parents of children with T1D may experience diabetes burnout. The findings may also inform diabetes care and illuminate the role of social media in improving family center support.

Burnout, distress, and depressive symptoms in adults with type 1 diabetes.

INTRODUCTION: We identified established scales and subscales related to the hypostatized dimensions of diabetes burnout (exhaustion, detachment, powerlessness) emerging from our preliminary qualitative studies, and examined the relationship of diabetes burnout with diabetes distress, depressive symptoms, and diabetes outcomes. METHODS: In this cross-sectional study, adults with type 1 diabetes (n = 111) completed an online survey including measures of diabetes distress, depressive symptoms, and proposed measures of diabetes burnout. Participants also answered questions related to diabetes outcomes (i.e., last reported HbA1c, missed appointments) as well as other clinical and sociodemographic characteristics. Items related to diabetes burnout were identified and analyzed in an exploratory factor analysis (EFA). The items retained through the EFA were then used in a series of regression analyses to estimate the relationships of the diabetes burnout measure with participants' background characteristics, diabetes distress, depressive symptoms, and diabetes outcomes. RESULTS: The EFA provided mixed results. The proposed measures of powerlessness were consistent with the original hypothesis. However, the identified measures of exhaustion and detachment did not load onto the anticipated factors. After revising the subscales based on the results of the factor analysis, the measures of diabetes burnout demonstrated strong internal consistency with Cronbach alphas (all subscales and total scale ≥0.85). Diabetes burnout was significantly associated with both depression (es = 0.70; p < .01) and diabetes distress (es = 0.80; p < .01). While measures of diabetes burnout, distress, and depressive symptoms were significant predictors of multiple diabetes outcomes, overall diabetes burnout was no longer significantly related to these outcomes after controlling for diabetes distress and depressive symptoms. CONCLUSION: The results of the study provide a first step toward identifying a reliable, valid measure of diabetes burnout. Further research is needed to identify additional items to supplement/replace existing measures and to further differentiate diabetes burnout from diabetes distress and depressive symptoms.

CE: Original Research: Experiences of Diabetes Burnout: A Qualitative Study Among People with Type 1 Diabetes.

BACKGROUND: People with type 1 diabetes are at increased risk for diabetes burnout, resulting in suboptimal diabetes care and quality of life. While the existence of diabetes burnout is widely acknowledged, there is no evidence-based definition, means of measurement, or interventions to address it. OBJECTIVE: This study was aimed at increasing our understanding of the lived experiences of diabetes burnout among adults with type 1 diabetes. METHODS: A qualitative descriptive study was conducted with a sample of 18 adults with type 1 diabetes who reported a current or previous experience of diabetes burnout. Data were collected using in-depth interviews and analyzed using qualitative content analysis. RESULTS: Four main themes were identified: mental, emotional, and physical exhaustion from having diabetes; detachment from illness identity, diabetes self-care, and support systems; contributing factors to diabetes burnout; and strategies for preventing or overcoming diabetes burnout. CONCLUSION: Although exhaustion is an entry point for diabetes burnout, the findings suggest that detachment from illness identity, diabetes self-care, and support systems form a core component. Detachment may explain poor outcomes in individuals experiencing diabetes burnout.

Diabetes detachment: How cultural, contextual, and personal barriers influence low-income young women with diabetes in Appalachia.

AIM: This study explored the experiences of young low-income women with type 2 diabetes (T2D) in Appalachia, Tennessee. BACKGROUND: Diabetes care remains suboptimal across the United States particularly in underserved communities. METHODS: The study employed a descriptive qualitative case study collecting data using in-depth interview of a group of low-income women in their 20s with T2D. Data was analyzed using qualitative content analysis. RESULTS: The findings identified three themes: "frustration and stigma lead to detachment care," "frozen by fear and unable to overcome resource limitations" and "social support and an empowered perspective lead to a positive outlook." Cultural barriers combined with contextual and personal barriers resulted in detachment from diabetes care among study participants. CONCLUSION: Within Appalachia, leveraging the existing familism values along with culturally congruent education and support can help alleviating the burden of diabetes care.

A discussion paper on stigmatizing features of diabetes.

Aim: This manuscript aims to describe stigmatizing features of diabetes. Design: This article presents a narrative review of literature pertaining to stigma surrounding diabetes in different contexts. Methods: A literature search was conducted in CINAHL, PubMed and Web of Science for qualitative studies published between 2007-2017. The search was completed using various combinations of diabetes, T1DM, T2DM, stigma, social/public stigma, internalized/self-stigma, stigmatization and diabetes-related stigma in English. The reviewers then independently reviewed the eligible studies (N = 18) to extract data. Results: From the 18 studies included in this narrative review, seven features related to stigma in diabetes were identified. People with diabetes were most notably considered and stigmatized as being "sick," "death reminder," "rejected marriage candidate," "self-inflicting," "contagiousness," "requiring a dietary modification" and "drunk or drug abuser."

Changing Beliefs and Behaviors Related to Sexually Transmitted Diseases in Vulnerable Women: A Qualitative Study.

BACKGROUND: The first step in health education is awareness of the people and their acceptance to change their behavior. Therefore, the aim of this study was to investigate the effects of empowerment program towards the concept of self-care and prevention of sexually transmitted diseases (STDs) in women at risk of STDs. MATERIALS AND METHODS: The present study was conducted as a qualitative approach (step of action and observation of an action) by using conventional content analysis method. An empowerment program regarding STDs (Action) was performed among 32 (with convenient sample) drug user women with addicted husbands referring to the counseling center for vulnerable women (drop in enter) in Isfahan in 2015. The knowledge of quiddity, transmission, and prevention of STDs, as well as some items of life skills such as self-awareness, interpersonal communication, and assertive behavior were taught in an educational program. Teaching methods were lectures, group, and individual training and role play. The impact of the program on modified belief and behavior change regarding STDs was evaluated with structured interviews. RESULTS: Analysis of the obtained results yielded three categories. The categories were awareness of STD, believing in being at risk, and decision and change. CONCLUSIONS: Promoting self-care and prevention through education programs based on action research can make a significant reduction in the incidence of problems and cause a behavior change in women with the disease or those at risk for STDs.

Diabetes Self-Management Education; Experience of People with Diabetes.

Introduction: Diabetes self-management education (DSME) is a major factor which can affects quality of life of people with diabetes (PWD). Understanding the experience of PWD participating in DSME programs is an undeniable necessity in providing effective DSME to this population. The Aim of the study was to explore the experiences of PWD from a local DSME program in Iran. Methods: This study applied a descriptive phenomenological approach. The participants were PWD attending a well-established local DSME program in an endocrinology and diabetes center in Isfahan, Iran. Fifteen participants willing to share their experience about DSME were selected through purposive sampling from September 2011 to June 2012. Data were collected via unstructured interviews and analyzed using Colaizzi's approach. Results: The experience of participants were categorized under three main themes including content of diabetes education (useful versus repetitive, intensive and volatile), teaching methods (traditional, technology ignorant) and learning environment (friendly atmosphere, cramped and dark). Conclusion: It seems the current approach for DSME cannot meet the needs and expectations of PWD attending the program. Needs assessment, interactive teaching methods, multidisciplinary approach, technology as well as appropriate physical space need to be considered to improve DSME.

Overcoming diabetes-related stigma in Iran: A participatory action research.

OBJECTIVE: The study aimed to overcome diabetes-related stigma in individuals living with type 1 Diabetes Mellitus (T1DM) in Iran. The study proposed that if individuals with T1DM and the community work together to develop and implement an anti-stigma program, diabetes-related stigma in individuals with T1DM can be reduced. RESEARCH DESIGN AND METHOD: This study was conducted as a participatory action research study based on Kemmis and McTaggert's (2000) Model to design and implement an anti-stigma program for T1DM. Participants were selected among individuals with T1DM, their family members, health care providers, and residents without diabetes in Isfahan, Iran. Data collection was conducted using interviews, focus groups, emails, and text messages. Content analysis was used to analyze the data to develop anti-stigma interventions. Interventions were prioritized based on the Suitability, Feasibility and Flexibility (SFF) Matrix. Anti-stigma interventions were implemented in different levels in Isfahan, Iran, from 2011 to 2014. The effect of the program was evaluated based on interviews, feedback, and focus groups at the individual level. However, interventions were implemented in different levels including community, organization, family, and individual. RESULTS: Participants with T1DM experienced significant empowerment during the project to overcome diabetes-related stigma. The three main themes indicating this feeling of empowerment are "from doubt to trust", "from shadow to light", and "from me to us". CONCLUSION: Participatory action research can be an effective way to reduce diabetes-related stigma in individuals living with T1DM. It integrates the voices of the marginalized group reducing stigma and discrimination against diabetes.