Effect of peer support on diabetes distress: a cluster randomized controlled trial.

AIM: To investigate whether peer support would reduce diabetes distress and improve glycaemic control when added to usual diabetes education among adults with Type 2 diabetes in China. METHODS: We conducted a cluster randomized trial involving 400 adults with Type 2 diabetes from eight communities in Nanjing. All participants received usual education for an average of 2 h each month from physicians, certified diabetes educators, dieticians, psychologists and podiatric nurses. Peer support was led by trained peer leaders and included diabetes knowledge- and skills-sharing at least once a month, as well as peer-to-peer communication. The primary outcome was diabetes distress measured using the Diabetes Distress Scale at 12 months. Secondary outcomes included fasting plasma glucose, 2-h postprandial glucose and HbA1c concentration. Outcome data were collected from all participants at baseline, 6 months and 12 months. RESULTS: From 2012 to 2013, there were 200 participants in each study arm at baseline. Compared with the usual education arm, the peer support with usual education arm had greater reductions in regimen-related distress (1.4 ± 0.6 vs 1.2 ± 0.4; P=0.004) and total distress (1.3 ± 0.4 vs 1.2 ± 0.3; P=0.038) at 6 months. At 12 months, the scores for emotional burden (1.2 ± 0.3 vs 1.4 ± 0.6; P=0.002), physician-related distress (1.1 ± 0.3 vs 1.3 ± 0.4; P=0.001) and total scores (1.2 ± 0.3 vs 1.3 ± 0.4; P=0.002) were significantly lower in the peer support with usual education arm than in the usual education arm. Fasting plasma glucose levels were lower in the peer support with usual education arm than in the usual education arm at 6 months (7.5 ± 1.95 vs 8.0 ± 2.2; P=0.044) and 12 months (7.0 ± 2.3 vs 7.6 ± 1.5; P=0.008). CONCLUSIONS: Beyond the benefits of usual education, peer support was effective in reducing diabetes distress for Type 2 diabetes mellitus. (Clinical Trials Registry no: NCT02119572).

Complex relation among Health Belief Model components in TB prevention and care.

OBJECTIVES: This study aims to explore the relationships among components of the Health Belief Model, tuberculosis (TB) preventive behavior, and intention of seeking TB care. STUDY DESIGN: Cross section study. METHODS: Using convenience sampling, 1154 rural-to-urban migrant workers were selected between the ages of 18-50 years in six urban areas of three provinces in China. The survey was conducted by individual, face-to-face interviews with a standardized questionnaire. Lisrel 8.7 was used to conduct path analysis. RESULTS: The knowledge and benefits components of the Health Belief Model predicted preventive behaviors: cover nose/mouth when coughing or sneezing (ß = 0.24, 0.33 respectively), evade others' coughs (ß = 0.13, 0.25) and also predicted seeking TB care (ß = 0.27, 0.19). Susceptibility and severity also predicted seeking TB care (ß = 0.12, 0.16). There were also important relationships among model components. Knowledge of TB predicted both susceptibility (ß = 0.32-0.60) and severity (ß = 0.41-0.45). Further, each of susceptibility (ß = 0.30) and severity (ß = 0.41) predicted perceived benefits of preventive care. CONCLUSION: Thus, a path from knowledge, through severity and susceptibility, and then through benefits predicted prevention and TB care seeking behaviors.

Community Health Workers as Agents of Health Promotion: Analyzing Thailand's Village Health Volunteer Program.

The village health volunteers (VHVs) have been a regular part of Thailand's health system since the 1960s. Despite widespread recognition, little research has been conducted to describe VHV activities, the settings in which VHVs provide help, how the program is administered, and how changing politics and health problems in Thailand have influenced the program. In order to understand the roles and practices of the VHVs, we conducted in-depth semi-structured interviews and focus groups with VHVs, community leaders and members, and public health officials in three semi-urban communities in central Thailand. Using the Social Ecological Framework, we mapped factors that influenced how the VHVs provided support, including governmental oversight, collaboration with public health officials, and community trust. These influences are discussed as "points of consideration," which help to identify the strengths and tensions within the VHV program and best practices in supporting and assessing community health worker efforts.

Physician advice and support for physical activity: results from a national survey.

BACKGROUND: It is increasingly well documented that physical activity (PA) is a key preventive behavior and that visits to a physician provide an important opportunity for advice and counseling. This paper reports on physician counseling behaviors regarding PA and other chronic disease risk factors from a national survey. METHODS: A diverse sample of U.S. adults (N=1818), with oversampling of lower-income households, was surveyed about their PA level as well as a host of social, environmental, and physician counseling issues. RESULTS: Overall, 28% of respondents reported receiving physician advice to increase their PA level. Of those who received advice, only 38% received help formulating a specific activity plan and 42% received follow-up support. Patients who received advice and support were more likely to be older, nonwhite, and to have more chronic illnesses and more contact with their doctor. CONCLUSIONS: Physician advice, counseling, and follow-up are important components of the social-environmental supports needed to increase population PA levels. Health system changes, including teaching communication skills, prompts to use those skills, and system changes to support attention to PA, are needed to extend promotion of PA to more patients.

Relationship of activity and social support to the functional health of older adults.

OBJECTIVES: According to J. W. Rowe and R. L. Kahn (1997), successful aging is the combination of low probability of disease, high functioning, and active engagement with life. The purpose of this study was to assess the relationship between active engagement with life and functioning in a convenience sample of community-dwelling adults aged 65 and older. METHODS: In this cross-sectional study, 244 members of an organization for older adults were mailed a survey containing the Activity Checklist and the Social Support Inventory as measures of engagement with life and the SF-12 Health Survey as a measure of functioning. RESULTS: Hierarchical linear regression showed that maintenance of instrumental, social, and high-demand leisure activities was associated with higher physical health scores and maintenance of low-demand leisure activities was associated with lower physical health scores. Maintenance of low-demand leisure activities was associated with higher mental health scores. DISCUSSION: If changes in potentially modifiable risk factors such as activity are associated with the beginning of functional decline, early intervention may be possible before disability ensues, thus reducing the risk of disability and ultimately health care costs.

A tool to organize instructions at discharge after treatment of asthmatic children in an emergency department.

Asthma exacerbations continue to be a major cause of visits to emergency departments (ED). Comprehensive care in the outpatient setting, with planning for early intervention for exacerbations, can reduce emergency visits. Thus, a major goal of ED intervention is to establish a link between the patient and the provider of ongoing asthma care, where complete education can be achieved and reinforced over time. When designing the Asthma 1-2-3 Plan discharge teaching tool for the ED, consideration was given to educational format, readability, patient population, and setting in which education was to be delivered. To evaluate use of the plan, ED records of patients enrolled in a separate asthma study, the Neighborhood Asthma Coalition (NAC), were audited for two 8-month intervals, May-December 1993 (before initiation of the plan) and May December 1994 (starting 1 month after completion of pilot testing on the plan in the ED). To evaluate effectiveness of the plan, records of physicians who cared for children in the NAC were evaluated. The database was reviewed for the date of the first visit for planned review of asthma that occurred after the acute asthma ED visit. After introduction of the plan, the proportion of children told to return to the physician for follow-up increased from 54% to 81%. The proportion of children given advice to return to their physician within the recommended 3 days or less increased from 11% to 54%. Chi2 Analyses showed that these changes were both statistically significant (p<0.0001). The plan was not effective in achieving increased follow-up visits for regular asthma care, in that 7% returned for follow-up within 7 days after an ED visit before the plan and only 6% returned for such a visit after the Plan. Successful initiation of a focused discharge teaching tool into the routine of the ED increased appropriate advice given at time of discharge from the ED. Although unsuccessful in increasing appropriate follow-up, the present intervention uses the ED not as a base for asthma education, but as a point for contacting patients in need of regular care and education, and for promoting access to that regular care.

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.

Neighbors for a smoke free north side: evaluation of a community organization approach to promoting smoking cessation among African Americans.

OBJECTIVES: This study evaluated a community organization approach that emphasized involvement of audiences in program planning and implementation in promoting nonsmoking among African American residents of low-income neighborhoods. METHODS: The quasi-experimental design involved a 24-month intervention in 3 low-income, predominantly African American neighborhoods in St. Louis. Intervention neighborhoods were compared with comparable, untreated neighborhoods in Kansas City. RESULTS: The program was successful in engaging audience members in its governance and in instigating numerous and diverse neighborhood activities to promote nonsmoking. The prevalence of smoking declined from 34% to 27% in program neighborhoods but only from 34% to 33% in comparison neighborhoods. This difference was apparent within all demographically defined subsamples, indicating that observed changes were consistent and not attributable to confounding by demographic characteristics. CONCLUSIONS: A community organization approach emphasizing local authority for program decisions and involvement of informal networks may have an appreciable impact on smoking among residents of low-income, African American neighborhoods.

Learn, share, and live: breast cancer education for older, urban minority women.

Among older urban minority women, for whom breast cancer risk is high and the propensity to be screened is low, both social support and breast cancer knowledge have been linked to mammography use. The authors describe a theory-based breast cancer education program implemented via an existing informal network for low-income urban elderly coordinated by a social service agency. The program is both structured and flexible. Core education sessions include delineated content and methods and are led by health professionals. Participants choose from a variety of follow-up activities to promote screening within their community. Pre- and posttests administered among 80 program attendees in two sites indicate significant improvement in knowledge (p < .001). Program attendees in each site also planned and participated in follow-up activities to promote screening among their peers. Learn, Share, and Live seems to be an effective program for promoting breast cancer screening among older, urban, primarily minority women.

Directive and nondirective social support in diabetes management.

Directive and Nondirective Support were distinguished (interrater agreement = 88.2%) through open-ended interviews completed by 60 adults with Insulin Dependent Diabetes Mellitus. Supporting validity, the sum of both Directive and Nondirective Support was correlated with scores on the Interpersonal Support Evaluation List (ISEL; r = .36). Supporting their distinction, Directive and Nondirective Support were inversely correlated (r = -.26), and Directive but not Nondirective Support decreased with age. Partial/correlations controlled for general support as measured by the ISEL, to examine the unique associations of Directive and Nondirective Support. For those less than 30 years old, Nondirective Support was associated with better metabolic control (p = .004). For those 30 or older, Directive Support appeared counterproductive, being associated with greater negative mood (p = .02). Different types of support may play different roles in different areas of disease management (e.g., metabolic control versus mood) and as a function of individual characteristics such as age.

Factors that influence the decision to receive treatment for proliferative diabetic retinopathy.

Educational messages aimed at health professionals have stressed the importance of regular eye examinations for people with diabetes and the value of early treatment. To investigate whether the messages need to be expanded or tailored in a specific way, we asked people with diabetes (N = 37) to describe their reactions to the diagnosis of proliferative diabetic retinopathy and the factors that influenced their decision to seek treatment. The findings reaffirm the importance of the physician's recommendation in pursuing treatment. Furthermore, a constructive response (eg, "knew it had to be taken care of") to the diagnosis was associated with prior knowledge of the consequences of proliferative diabetic retinopathy. Minimal racial and gender differences were observed. White women reported being influenced by the experiences of others, and African Americans reported being influenced by the diabetes educator. These findings emphasize the importance of providing patient education not only following a diagnosis but also in anticipation of probable complications.

Two approaches to social support in smoking cessation: commodity model and nondirective support.

The commodity model of social support and features of Nondirective Support may clarify varied results of support interventions for smoking cessation. A commodity model views social support as attractive in and of itself and as an alternative to high-risk choices such as smoking. If such support is easily accessible, a would-be quitter is less likely to choose to smoke. Consistent with the commodity model, social support interventions tend to be effective as long as support remains available, but they lose their effects when support is terminated. From a second approach, Nondirective Support entails accepting recipients' goals, co-operating without taking control, and validating recipients' feelings. In contrast, Directive Support entails taking control and telling recipients what to do and feel. Review of support interventions indicates the value of the continued availability of support suggested by the commodity model and of Nondirective Support's flexibility and responsiveness to the person.

Acceptability and feasibility of a community approach to asthma management: the Neighborhood Asthma Coalition (NAC).

Understanding of asthma and co-management between patient and physician improves outcome. Feasibility of programs to achieve these goals in underserved settings is not documented. We used the Precede-Proceed model to document (a) community acceptance of a program to engage peer support of asthma management and care; (b) program revision to emphasize greater attention to availability of care and promotional events as channels for education; (c) engagement of intended audiences in planning and implementation; (d) participation of parents in program activities; and (e) peer-based education/support to reach parents, including socially isolated parents whose children experience heightened morbidity.

Articulation of asthma and its care among low-income emergency care recipients.

Low-income minority patients from East St. Louis, Illinois, a depressed midwestern urban city, who had visited acute care settings with asthma symptoms, participated in a focus group. Questions were constructed around the Health Belief Model to characterize participants' experiences in receiving asthma care, their confidence in long-term asthma self-management, barriers they perceived to managing their asthma, and recommendations they would make for improving asthma care in their community. Analysis of comments suggests an appreciable understanding of asthma triggers, limited coping behaviors for asthma symptoms, very limited practice of active asthma management, perception of the health care system as frequently insensitive to their needs or their knowledge of their own care, exchange of well-articulated information regarding how to deal with the system, and an apparent lack of awareness of any potential contribution of patient education or support system.

I get by with a little help from my family and friends: adolescents' support for diabetes care.

Evaluated and compared the support provided by family members and friends for adolescents' diabetes care. Family and friend support also were examined in relation to other measures of social support, to demographic variables (age, gender, duration of diabetes) and to adherence. Using a structured interview, 74 adolescents with diabetes described the ways that family members and friends provided support for diabetes management (insulin shots, blood glucose monitoring, eating proper meals, exercise), and for helping them to "feel good about their diabetes." Families provided more support than friends for three management tasks (insulin injections, blood glucose monitoring, meals); this support was largely instrumental. In contrast, friends provided more emotional support for diabetes than families. Greater family support was related to younger age, shorter disease duration, and better treatment adherence. Implications of the findings include encouraging parents to remain involved in adolescents' treatment management, and involving peers as supportive companions for meals and exercise.

Beliefs about smoking and diabetes care.

The purpose of this study was to address the following questions: 1) Do smokers with diabetes believe that cigarettes have favorable outcomes associated with diabetes management? 2) Do smokers with diabetes believe that quitting smoking negatively impacts diabetes management? 3) Do smokers with diabetes perceive significant others as being supportive of attempts to quit smoking? and 4) What is the relationship between these factors and attitude toward quitting smoking? Patients with insulin-dependent diabetes mellitus (IDDM) completed a measure of Attitude Toward Quitting Smoking, which assessed desire and confidence in ability to achieve cessation, and the Diabetes and Smoking Beliefs Questionnaire, which assessed beliefs regarding cigarettes and diabetes management. Smokers whose attitudes reflected less desire to quit and less confidence in doing so reported that cigarettes had utility in diabetes management, that quitting has negative effects on diabetes, and perceived significant others as only moderately supportive of attempts to quit smoking. Implications of these findings for diabetes education are discussed.