Anne C. Larme

Attitudes of Primary Care Providers Toward Diabetes: Barriers to guideline implementation

OBJECTIVE Primary care providers have been slow to adopt standards of care for diabetes, and continuing medical education (CME) programs have been minimally effective in changing provider behavior. The objective of this study was to explore the previously reported finding that attitudes, rather than knowledge, may impede primary care provider adherence to standards of care. RESEARCH DESIGN AND METHODS Study participants included 31 primary care providers attending an eight-session CME program on diabetes. Providers rated on a 10-point scale how the treatment of diabetes compared with that of five other chronic conditions (hypertension, hyperlipidemia, angina, arthritis, and heart failure; 1 = easier to 10 = harder; midpoint 5.5). In a subsequent open-ended qualitative interview, providers explained their scale ratings. RESULTS Diabetes was rated as significantly harder to treat than hypertension (24 of 30 >5.5; P < 0.001) and angina (20 of 30 >5.5; P = 0.03). A majority also rated hyperlipidemia (18 of 30) and arthritis (18 of 30) as easier to treat than diabetes. Explanatory themes underlying provider frustrations with diabetes include characteristics of the disease itself and the complexity of its management, and a perceived lack of support from society and the health care system for their efforts to control diabetes. CONCLUSIONS CME that addresses provider attitudes toward diabetes in addition to updating knowledge may be more effective than traditional CME in promoting adherence to standards of care. Additional changes are needed in our health care system to shift from an acute to a chronic disease model to effectively support diabetes care efforts.

Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes

Background. The influence of continuity of care on outcomes of care for patients with type 2 diabetes is poorly understood. Objective. To examine the relationships between continuity, glucose control, and advancement through stages of change for selfmanagement behaviors. Design. Prospective cohort study. Setting. Five community health centers on the Texas‐Mexico border. Subjects. A random sample of 256 adults, 18 years of age and older with an established diagnosis of type 2 diabetes. Measures. Stage of change for diet and exercise were assessed during two patient interviews, averaging 18.9 months apart. Phlebotomy was performed at each interview to measure glycosolated hemoglobin (HbA1C). Medical records were abstracted for ambulatory care utilization. A continuity score was calculated based on the number of visits and number of providers seen. Results. Patients who advanced one or more stages of change for diet had higher levels of continuity. As continuity improved, the change in HbA1C was smaller. (r = –0.25; P <0.001) This relationship remained significant after controlling for number of visits, months since diagnosis, number of days in the study, duration of diabetes, and advancement in stage of change for diet. Advancement through stage of change for diet explained a significant amount of the variance in the relationship between continuity and HbA1C (t test = –11.33; P <0.01). Conclusions. Continuity of care with a primary care provider is associated with better glucose control among patients with type 2 diabetes. This relationship appears to be mediated by changes in patient behavior regarding diet.

Collaborative care needs and preferences of primary care patients with multimorbidity

Objective  To explore the collaborative care needs and preferences in primary care patients with multiple chronic illnesses.

Patient choice in diabetes education curriculum : Nutritional versus standard content for type 2 diabetes

OBJECTIVE To examine the effects of patient choice between two education curriculums that emphasized either the standard or nutritional management of type 2 diabetes on class attendance and other outcomes among a mostly Hispanic patient population. RESEARCH DESIGN AND METHODS A total of 596 patients with type 2 diabetes were randomly assigned to either a choice or no choice condition. Patients in the choice condition were allowed to choose their curriculum, while patients in the no choice condition were randomly assigned to one of the two curriculums. Outcomes were assessed at baseline and at a 6-month follow-up. RESULTS When given a choice, patients chose the nutrition curriculum almost four times more frequently than the standard curriculum. Contrary to our hypothesis, however, patients who had a choice did not significantly increase their attendance rates or demonstrate improvements in other diabetes outcomes compared with patients who were randomly assigned to the two curriculums. Patients in the nutrition curriculum had significantly lower serum cholesterol at a 6-month follow-up, whereas patients in the standard curriculum had significant improvements in glycemic control. Of the randomized patients, 30% never attended any classes; the most frequently cited reasons for nonattendance were socioeconomic. Hispanic patients, however, were just as likely as non-Hispanic patients to attend classes and participate at the follow-up. Patients who attended all five classes of either curriculum significantly increased their diabetes knowledge, gained less weight, and reported improved physical functioning compared with patients who did not attend any classes. CONCLUSIONS Although providing patients with a choice in curriculums at the introductory level did not improve outcomes, differential improvements were noted between patients who attended curriculums with different content emphasis. We suggest that diabetes education programs should provide the opportunity for long-term, repetitive contacts to expand on the modest gains achieved at the introductory level, as well as provide more options to match individual needs and interests and to address socioeconomic barriers to participation.

Health care allocation and selective neglect in rural Peru

This study of health care allocation to children in northern Puno, Peru, utilizes quantitative and qualitative data to explore differential resource allocation to children in rural Andean households. As part of a broader ethnographic study of health in two communities, quantitative data on reported health status, symptoms, and treatments (both lay and specialist) were collected for 23 children under the age of 7 over a one year period. Additional data were collected from local health post records. Data were analyzed by gender, and by three age groups (birth to 1 year, 1-3 years, 4-6 years) to determine if differences existed in the allocation of health care. The data suggest a pattern of discrimination against females and younger children, especially infants under age one, despite the fact that these groups were reported to be sicker. Differences were especially significant in the allocation of biomedical treatments, the most costly in terms of parental time, effort, and money. Ethnographic data on child illness, gender, and developmental concepts help to explain why children of different genders and ages may be treated differently in the rural andes. They provide a context in which to interpret health care allocation data, and, in the absence of a population-based study, reinforce findings based on the limited study sample. Female children are valued less because of their future social and economic potential. Females are also regarded to be less vulnerable to illness than male children, meaning that less elaborate measures are necessary to protect their health. Young children are thought to have a loose body-soul connection, making them more vulnerable to illness, and are though to be less human than older individuals. The folk illnesses uraña (fright) and larpa explain child deaths in culturally acceptable ways, and the types of funerals given to children of different ages indicate that the death of young children is not considered unusual. Health care allocation and ethnographic data suggest that selective neglect (passive infanticide) may be occurring in rural Peru, possibly as a means of regulating family size and sex ratio. It is important to go beyond placing blame on individual parents or on culture, however, to address the underlying causes of differential health care allocation, such as poor socioeconomic conditions, lack of access to contraceptives, and female subordination.

Stage of change advancement for diabetes self-management behaviors and glucose control

PURPOSE This study was conducted to evaluate whether patients with type 2 diabetes who participated in diabetes education advanced through stages of change for self-management behaviors and to determine if movement was related to glucose control. METHODS A cohort of 428 patients with type 2 diabetes participated in a traditional diabetes education program in a large urban center in the Southwest. The sample was predominantly female with less than a high school education, a mean age of 52 years, and a mean duration of diabetes of 7 years. Two interviews were conducted approximately 9 months apart, at 1 to 4 weeks before the educational program and at 6 months after completing it. Blood specimens were collected at each interview to measure hemoglobin A1C (A1C) levels. RESULTS Most of the patients advanced 1 or more stages of change for at least 1 self-management behavior. Those with diabetes for less than 2 years were significantly more likely to advance at least 1 stage of change for diet and exercise than those with diabetes for more than 2 years. Such advancement was significantly associated with a decline in A1C. CONCLUSIONS Patients with type 2 diabetes who participated in diabetes education advanced through stages of change for self-care behaviors. The intervention was more effective for those with a shorter duration of diabetes.

Environment, vulnerability, and gender in Andean ethnomedicine

In Cuyo Cuyo, in the southern Peruvian highlands, ethnomedicine is rife with images of human vulnerability to a hostile and unpredictable environment. This is represented in the ethnomedical system by a focus on wayras, air- or wind-borne illnesses that enter through vulnerable body openings such as the head, orifices, lower back, and feet. Women are viewed to be more vulnerable, or débil, than men to illness because they have an extra orifice, the vagina, they lose copious amounts of blood, which is thought to be irreplaceable, during childbirth. and because they suffer more negative emotions, which are thought to attract wayras and other illnesses to the body. The relationship of ethnomedical beliefs to the Andean physical and political economic environment is explored within the context of social and economic change. Negative beliefs about womens bodies have negative effects on womens roles and position vis-à-vis men in present day Cuyo Cuyo. Ethnomedical beliefs reflect and reinforce gender inequalities in present day Peru and are part of a cultural ideology that in general devalues women. This case study demonstrates that power is a key dimension in the cultural construction of medical knowledge. whether in non-Western or Western societies.

The use of traditional plant medicines for non-insulin dependent diabetes mellitus in South Texas

The use of traditional plant medicines, as well as the factors associated with their use, were documented in 662 outpatients with non‐insulin dependent diabetes mellitus enrolled at six primary care clinics in South Texas. Forty‐nine percent of the patients reported using alternative treatments for their diabetes, which included 61 different traditional plant medicines. The four most commonly reported were nopal (Opuntia streptacantha) or the prickly pear cactus, chaya (Cnidoscolus chayamansa), míspero (Eriobotrya japonica) or loquat, and sávila (Aloe vera). Logistic regression was used to develop a multivariate model which indicated that alternative medicine use is positively associated with age and diabetes‐related ‘hassles’, and was more likely among border residents and individuals who were born in Mexico. Disease severity was not associated with the use of alternative treatments when controlling for other variables. Users of alternative treatments also appeared just as likely to adhere to orthodox biomedical treatment recommendations as non‐users. While preliminary reports in the literature suggest that some of the identified plants have hypoglycaemic properties, information is limited or nonexistent for many of the other plants. Given their preponderance in this region, some of these plants should be targeted for further investigation to document their efficacy or to screen for toxicity.

PSYCHOMETRIC ASSESSMENT OF MEASURES OF PSYCHOLOGICAL SYMPTOMS, FUNCTIONAL STATUS, LIFE EVENTS, AND CONTEXT FOR LOW INCOME HISPANIC PATIENTS IN A PRIMARY CARE SETTING

This study assessed the psychometric properties of a set of nine commonly used lists in an English-speaking Hispanic sample taken from a primary care setting. These were the General Health Questionnaire-12, the Anxiety, Depression, and Somatization scales from the SCL-90, the Medical Outcomes Study Short Form-36, the Holmes and Rahe Family Life Changes, abbreviated versions of the Daily Hassles and Uplifts, the Herth Hope Index, Duke Social Support and Stress scales, Alcohol Use Disorders Identification Test, and Marlowe-Crowne Brief Social Desirability Scale. 68 adult patients completed the measures via structured interview. Internal consistency was measured using Cronbach alpha and the Kuder-Richardson-20. Construct validity was assessed using Pearson correlations among sets of scores. Internal consistencies were good-to-excellent for all measures except for the Duke Social Support and Stress scales (Stress scale), and the Brief Social Desirability Scale. Construct validity was suggested for all except the Mental Health and Energy/Fatigue scales of the Short Form-36. Further study is needed to verify these results in other Hispanic populations and to address other forms of reliability and validity.

Use of Qualitative Methods to Evaluate Diabetes Education Programs

From the Department of Orthodontics (Dr Larme), the Department of Nursing (Ms Meyer), and the Department of Medicine and Mexican American Medical Treatment Effectiveness Center (Dr Pugh), University of Texas Health Science Center at San Antonio, Texas, and Audie Murphy Memorial Veteran’s Hospital (Dr Pugh), San Antonio, Texas. At the time of this study, all three authors were affiliated with the Texas Diabetes Institute, San Antonio, Texas. Funding for this project was provided by a grant from the Texas Diabetes Council to the Texas Diabetes Institute and by the Agency for Health Care Policy and Research, Grant No. 1-U01-HS07397. Correspondence to Anne C. Larme, PhD, Department of Orthodontics, UTHSCSA, 7703 Floyd Curl Drive, San Antonio TX 78284. E-mail: larme@uthscsa.edu Reprint requests to The Diabetes Educator; 367 West Chicago Avenue, Chicago IL 60610-3025. Evaluation is an essential component of diabetes education programs. It helps build effective programs tailored to the needs of target populations and ultimately helps to improve program outcomes. Evaluation is also required for program recognition by the American Diabetes Association (ADA).’ Diabetes educators tend to view