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).

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.

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.

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.

Implications for the practicing physician of the psychosocial dimensions of smoking.

The multifaceted nature of smoking includes its physiologic, social, and psychologic dimensions and its career features. It develops over time, through phases such as experimentation or conditioning. It also is given up over time, often after several unsuccessful attempts. Several repetitions of a sequence of considering cessation, attempting to quit, and relapsing are likely to precede permanent cessation. Those who are not ready to commit themselves to quitting may be reached by low-key information more than by too forceful exhortation. Those who are ready to quit may select from among a range of approaches, including group clinics, "self-help" manuals, and physician counseling. Maintenance requires as much attention as does cessation. Cooperation from those around the quitter, reminders to use skills for coping with stressors or temptations, and continued encouragement from the physician may all encourage long-term abstinence. Owing to the multifaceted nature of smoking and quitting and the multiple approaches to cessation and its maintenance, the physician may best be viewed as a catalyst for nonsmoking. If appropriate to his or her practice, this may include extended patient counseling, but those unable to provide this may still make great contributions through brief information on why it is important to quit, encouragement to do so, timely referral to other staff or to materials and programs available in the community, and continued expression of interest in the patient's efforts and/or success. All these may catalyze quitting without demanding excessive time or skills beyond those commonly employed by the physician. In catalyzing nonsmoking, the physician can also be an effective proponent of community or voluntary agency programs as well as institutional and governmental policies to limit smoking in health care facilities and public places. The American College of Chest Physicians' policy encouraging nonsmoking among its Fellows and in their offices is an excellent example of this catalyst role.

An eight-year experience with porcine bioprosthetic cardiac valves.

A total of 589 porcine bioprostheses were implanted in 509 patients from January, 1976, through December, 1983. Of the valves implanted, 390 were Hancock and 199 were Carpentier-Edwards. A total of 1,633 patient-years was accrued, with a mean follow-up of 38 months per patient. Two hundred eight patients had aortic valve replacement, 209 had mitral valve replacement, and 79 had multiple valve replacements, of which 46 were aortic and mitral replacements. The mortality for isolated aortic valve replacement was 5.8%; for isolated mitral replacement, 8.6%, and for all patients, 10.9%. Late mortality was 3.9% per patient-year. The actuarial survival rate at 5 years was 79% for aortic, 68% for mitral, and 76% for aortic-mitral valve replacement. There were 12 thromboembolic events (0.73% per patient-year). Two episodes occurred in patients with an aortic bioprosthesis, nine in patients with a porcine mitral valve, and one in a patient with mitral and tricuspid bioprosthetic valves. The probability of remaining free of thromboembolism at 5 years was 99% for the group having aortic valve replacement, 93% for those having mitral replacement, and 100% for the group having aortic-mitral valve replacements. Thirteen episodes of endocarditis occurred (0.8% per patient-year). Seven of the 13 patients died as a direct result of endocarditis. The probability of remaining free of prosthetic endocarditis at 5 years was 97% for the aortic valve replacement group, 95% for the mitral group, and 97% for the aortic-mitral group. There were 20 instances of xenograft failure (1.2% per patient-year). The probability of remaining free of valve failure at 5 years was 96% for the aortic valve replacement group, 93% for the mitral group, and 93% for the aortic-mitral replacement group. Primary tissue failure of a prosthesis occurred in seven patients, all with Hancock valves (0.43% per patient-year). As yet there has been no primary tissue failure of the Carpentier-Edwards prosthesis. There also appears to be a lower incidence of thromboembolism (Edwards, 0.3% per patient-year; Hancock, 0.8% per patient-year) and endocarditis (Edwards, 0.6% per patient-year; Hancock, 1.0% per patient-year). The low incidence of complications with the porcine bioprosthetic valve, especially the Carpentier-Edwards, encourages us to recommend its continued use, especially in situations in which anticoagulation is contraindicated.

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.

Relapse as a model of nonadherence to dietary treatment of diabetes.

The generality of Marlatt and Gordon's (1980, 1985) model of relapse to dietary treatment of diabetes was tested. Forty-six adults with insulin-dependent diabetes mellitus (IDDM) and 43 obese adults with non-insulin-dependent diabetes mellitus were interviewed regarding their most recent dietary violations, and the results were coded using the schema developed by Marlatt and Gordon. As the model would predict, most nonadherence episodes occurred in a limited range of high-risk situations. Although the two diagnostic groups lapsed in remarkably similar situations, there was a tendency for the IDDM adults to report a larger proportion of lapses in situations characterized by negative emotions. Approximately 27% of the dietary lapses occurred when the person was busy with a competing activity or had no choice, and these lapses did not fit into Marlatt and Gordon's coding schema. These violations consistently differed from those studied by Marlatt and Gordon in that they were errors of omission rather than errors of commission. Evidence for the abstinence violation effect was not found in this sample. Overall, the results suggest that most nonadherence to dietary treatment of diabetes may be best understood as intermittent lapses that typically do not develop into full-blown relapses.

Smoking cessation: a practical guide for the physician.

Physicians play critical roles in efforts to encourage nonsmoking, both in their individual interventions with smokers and in their contributions to broader political, educational, and public health efforts to encourage nonsmoking. These broader efforts, much aided by the authority and concern of individual physicians and organized medicine will continue, also, to provide a supportive background for individual clinical efforts. Together, the broad based and the clinical activity potentiate each other in decreasing the prevalence of smoking. The difficulties individuals experience in quitting smoking are best understood when placed within the context of the billion dollar marketing of an addictive product; the reality that quitting smoking occurs gradually over time, many smokers attempting to quit several times before succeeding; and the influence of physicians' continuing clinical and community activity in maintaining a culture actively cognizant of the risks of smoking. Through brief clinical counseling as outlined in this article, physicians can help almost all of their smoking patients move toward becoming a nonsmoker by trying to quit or, at least, giving greater thought to doing so. Additionally, the physician can help patients eager to quit by referral to well developed programs and materials such as have been described. In all, then, numerous effective resources are available for the clinician who wishes to deal responsibly with the most important preventable cause of morbidity and mortality in the approximately 30 per cent of patients who smoke.

Determinants of cigarette smoking.

Smoking is a complex process influenced by social, environmental, psychologic, and biologic factors. This article explores the multiple determinants of smoking and how these variables interact to promote the persistence of smoking. Further examination of how smoking persistence varies in relation to several specific diseases is discussed.

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.

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.

Social support in worksite smoking cessation: qualitative analysis of the EASE project.

PURPOSE: Mobilize and study social support in EASE, a worksite smoking cessation program. DESIGN: Qualitative study of social support in two pilot and two test worksites. SETTING: Collaboration with American Lung Association of eastern Missouri to implement program in 12 companies between 1982 and 1985. SUBJECTS: Ninety-eight participants in cessation clinics at pilot and test sites and 350 randomly sampled respondents from among all 877 employees at test sites. INTERVENTION: Steering committees included representatives of management and line employees and tailored the program from plans and materials for program promotion, self-help manuals, and a standard curriculum for a Group Comprehensive Clinic. MEASURES: Implementation and participation from project records. Outcomes and perceptions of social support from surveys of employees. RESULTS: Twelve to 24 months after program initiation, smoking cessation among active participants ranged from 21% to 41%. Consistent with emphasis on promoting support for quitting throughout the worksite, 10% to 25% of nonparticipants were abstinent at follow-ups, exceeding national base rates. Surveys indicated greater importance of social support than of program's procedures or materials and greater benefits of social ties to nonsmokers than to others attempting to quit. Differences among companies in both reported social support for nonsmoking and cessation rates paralleled differences in Steering Committees' activities and organizational support for the program. CONCLUSION: Though limited by lack of experimental controls, this qualitative study of active program participants as well as random samples of all employees indicates social support can be a strength of worksite smoking cessation programs.

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.

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.

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.

Community organization to reduce the risk of non-insulin-dependent diabetes among low-income African-American women.

Non-insulin-dependent diabetes mellitus is epidemic among African-American women in the United States; reports of its prevalence among African Americans range from 50% to 60% higher than among whites. African Americans also incur higher rates of diabetes-related complications such as blindness, end-stage renal disease, and amputations. Data indicate that non-insulin-dependent diabetes among African Americans is associated with lower socioeconomic status and with obesity. Because obesity has been hypothesized as contributing to the growing numbers of non-insulin-dependent diabetics among African-American women, new strategies are urgently needed to promote weight loss in this population. Community organization can broaden health education and facilitate behavior change toward development of life- and self-mastery skills. Specific strategies of this approach include (1) integrating community values into health messages, (2) facilitating neighborhood "ownership" and decision-making, (3) utilizing existing formal and informal networks, and (4) empowering individuals and community. Community organization may be a promising strategy among low-income minority communities to reduce the risk of non-insulin-dependent diabetes by promoting changes in dietary patterns, because it ensures that the health messages and programs that emerge will be consistent with existing sociocultural norms and beliefs.

Implications of prosthetic valve implantation: an 8-year follow-up of patients with porcine bioprostheses.

Nurses in cardiovascular critical care settings routinely care for patients with implanted valvular prostheses. The presence of an artificial valve substitutes a new disease state for the preexisting valvular disease. Five hundred nine patients who underwent cardiac valve replacement with porcine bioprostheses and who were followed for a total of 1633 patient-years provide the data base for discussion of long-term survival, functional capacity, and morbidity associated with valvular prostheses. Seventy-two percent of patients survived 5 years after operation. New York Heart Association functional class was improved in 84%. Three major types of morbidity were documented: thromboembolism, endocarditis, and valve failure. Cardiovascular nurses should be familiar with the implications of valvular prostheses to provide appropriate patient education and to facilitate the prompt detection and treatment of valve-related complications.

The Type A belief system: relationships to hostility, social support, and life stress.

Certain core beliefs may underlie the Type A behavior pattern, predisposing individuals to health problems and impaired interpersonal relationships. Previous studies have revealed that the Type A Cognitive Questionnaire (TACQ), a self-report measure reflecting these beliefs, is indeed related to emotional distress. The current study assessed the TACQ's relationship to aspects of the interpersonal environment, including perceived social support and stressful events. It also investigated the TACQ's relationship to subtypes of hostility (ie, cynicism and paranoid alienation). Subjects were 111 college undergraduate volunteers. As hypothesized, the TACQ was significantly related to poor quality of social support and to greater perceived life stress. The TACQ appeared more strongly related to cynicism than to paranoid alienation. Findings were generally more pronounced for males. The discussion suggests that Type A beliefs may predispose individuals to health problems through impaired interactions with their interpersonal environment.

Psychosocial and physiological correlates of male gender role stress among employed adults.

Previous research has identified male gender role stress (MGRS) as a construct that leads men, as a function of traditional socialization processes, to appraise certain situations in ways that produce psychosocial and physiological distress. Because the initial research was based on college undergraduates, the current study explored the relationship of MGRS to psychosocial and physiological risk factors for cardiovascular disease among employed adults. As predicted, men obtained significantly higher scores than women on a measure, the MGRS Scale, developed to assess this construct. Women with elevated MGRS Scale scores, however, experienced undesirable outcomes much the same as their male counterparts. Specifically, MGRS Scale scores were significantly associated with Type A behavior, hostility, personal loss, life dissatisfaction, and elevated systolic and diastolic blood pressure. The authors discuss possible environmental contributors to the development and maintenance of MGRS, including organizational factors associated with male-dominated work environments.