Anne H. Skelly

Self-Efficacy and Confidence in Outcomes as Determinants of Self-Care Practices in Inner-City, African-American Women with Non-Insulin-Dependent Diabetes

The puipose of this study was to examine the extent to which Perceived self-efficacy and confidence in outcomes, selected demographic variables, and disease characteristics (age, duration of diabetes, presence of documented complications) affect an individuals adherence over time to a diabetes regimen of home glucose testing, medication/insulin administration, diet, and exercise. A convenience sample of 118 inner-city, African-American women with type II, non-insulin-dependent diabetes mellitus receiving outpatient care at a large urban hospital were asked to complete measures of each of the psychosocial variables on two occasions, separated by an interval of 4 to 5 months, and coinciding with their next scheduled clinic visit. Bivariate and multivariate analyses at Times 1 and 2 demonstrated the ability of self-efficacy alone to explain diet, exercise, and home-testing behaviors while suggesting variability within individuals in sense of self-efficacy over time.

“They Care But Don’t Understand”: Family Support of African American Women With Type 2 Diabetes

PURPOSE This study evaluated the relationship between perceived social support among African American women with type 2 diabetes and diabetes self-management. METHODS The sample included 12 African American female patients at a diabetes clinic in the southeastern United States. Focus group participants responded to questions related to social support and its influence on diabetes management. RESULTS Support comes particularly from family, but also friends and/or healthcare providers. The dual challenges of diabetes management and multicaregiving were an expected theme from the sessions. A unique emerging theme, however, was the womens perception of a lack of understanding of their needs by members of their social networks. Participants believed that those who provide support claim they care and try to be helpful but provide minimal physical assistance or emotional understanding of their needs, which could vary daily. Those who provide informational support seem to care but misunderstand the type of information actually needed and how best to deliver it. CONCLUSIONS Healthcare providers can help improve communication with these women by actively seeking to meet their support needs and educating families so that provisional support is more meaningful and diabetes management more attainable.

A Diabetes Management Program for African American Women With Type 2 Diabetes

PURPOSE this paper describes a clinic and community-based diabetes intervention program designed to improve dietary, physical activity, and self-care behaviors of older African American women with type 2 diabetes. It also describes the study to evaluate this program and baseline characteristics of participants. METHODS The New Leaf... Choices for Healthy Living With Diabetes program consists of 4 clinic-based health counselor visits, a community intervention with 12 monthly phone calls from peer counselors, and 3 group sessions. A randomized, controlled trial to evaluate the effectiveness of this intervention is described. RESULTS Seventeen focus groups of African American women were used to assessed the cultural relevance/acceptability of the intervention and measurement instruments. For the randomized trial, 200 African American women with type 2 diabetes were recruited from 7 practices in central North Carolina. Mean age was 59, mean diabetes duration was 10 years, and participants were markedly overweight and physically inactive. CONCLUSIONS Participants found this program to be culturally relevant and acceptable. Its effects on diet, physical activity, and self-care behaviors will be assessed in a randomized trial.

Developing socio-spatial knowledge networks: a qualitative methodology for chronic disease prevention.

Chronic disease is a significant and costly social problem. The burden is even more pronounced in communities with high rates of a particular chronic disease. Assessment of health belief systems and the local geographies of health beliefs can assist community health planners to create cost-effective strategic intervention programs where populations are at high risk for chronic diseases. In this paper, we elaborate the concept of socio-spatial knowledge networks (SSKNs) and demonstrate that SSKNs can be useful in informing the design of health care prevention strategies. In our project, we demonstrate how to identify key socio-spatial information for intervention strategies which will prevent or delay the onset of a particular chronic disease, Type 2 diabetes. Our qualitative framework allows us to determine which sites might be best characterized as socio-spatial knowledge network nodes for sharing diabetes information and which sites might be less suited to such exchange. Our strategy explores cross-cultural similarities, differences, and overlap in a multi-ethnic rural North Carolina context through simple techniques such as mapping social networks and sites in which people share their knowledge and beliefs about diabetes. This geographical analysis allows us to examine exactly where health knowledge coincides with other social support, and where such resources may be improved in a particular community. Knowing precisely what people in a community understand about a chronic disease and its treatment or prevention and knowing where people go to share that information helps to (1) identify strategic locations within a community for future interventions and, (2) evaluate the effectiveness of existing interventions. The geographical approach presented here is one that can serve other communities and health practitioners who hope to improve chronic disease management in diverse local environments.

Controlled trial of nursing interventions to improve health outcomes of older African American women with type 2 diabetes.

Background:Type 2 diabetes affects one in five African American women older than 60 years. These women face distinct challenges in managing diabetes self-care. Therefore, tailored self-care interventions for this population need to be developed and tested. Objectives:The effectiveness of a tailored, four-visit, in-home symptom-focused diabetes intervention with and without booster telephone calls was compared with an attentional control focused on skills training for weight management and diet. Methods:African American women (n = 180; >55 years old, Type 2 diabetes mellitus >1 year, HbA1c >7%) were randomly assigned to the intervention or attentional control condition. Half the intervention participants were assigned to also receive a telephone-delivered booster intervention. Participants were evaluated at baseline and 3, 6, and 9 months. Results:Baseline HbA1 was 8.3 in the intervention group (n = 60), 8.29 in the intervention with booster group (n = 55), and 8.44 in the attentional control condition (n = 59). HbA1c declined significantly in the whole sample (0.57%) with no differences between study arms. Participants in the booster arm decreased HbA1c by 0.76%. Symptom distress, perceived quality of life, impact of diabetes, and self-care activities also improved significantly for the whole sample with no significant differences between study arms. Discussion:Parsimonious interventions of four in-person visits yielded clinically significant decreases in HbA1c. Although the weight and diet program was intended as an attentional control, the positive effects suggest it met a need in this population. Because the contents of both the intervention and the attentional control were effective despite different approaches, a revised symptom-focused intervention that incorporates weight and diet skills training may offer even better results.

Self-monitoring of blood glucose in a multiethnic population of rural older adults with diabetes.

Purpose The purpose of the study was to describe self-monitoring of blood glucose (SMBG) practices of 698 older adults with type 2 diabetes in the rural Southeast, to identify characteristics differentiating testers from nontesters, and to identify personal and support-related predictors of monitoring frequency. Methods The ELDER (Evaluating Long-term Diabetes Selfmanagement Among Elderly Rural Adults) study was a population-based, cross-sectional survey of African American, Native American, and white Medicare recipients = 65 years with diagnosed diabetes. Data were obtained through in-home interviews. Multiple logistic regression models were used to identify factors associated with SMBG and frequency of monitoring. Results Seventy-seven percent of respondents practiced SMBG in the previous week; 40% tested every day in that week. No ethnic differences were seen. Significant independent predictors of any SMBG were medication regimen (taking oral agents or insulin with or without oral agents) and health care provider (HCP) recommendation to test. Among those monitoring, significant independent predictors of SMBG frequency were medication regimen, HCP recommendation to test, duration of diabetes, and receiving help with testing, which was negatively associated with monitoring frequency. Conclusions Among rural older persons with diabetes, HCP recommendation significantly affected practicing SMBG and SMBG frequency. These findings suggest points of intervention by diabetes educators with this vulnerable population. Further research is needed to determine how older adults use SMBG data in their self-care regimen.

Outcomes of an intervention to reduce uncertainty among African American women with diabetes.

Poor adjustment to diabetes in older African American women may result from uncertainty, stemming from a lack of information about self-care activities, a complexity of self-care activities, comorbid conditions, and a lack of resources. This study evaluated a telephone intervention to reduce uncertainty (through problem-solving strategies, information, cognitive reframing, and improved patient—provider communication)—namely, to measure its effects on diabetes self-care and psychosocial adjustment. Sixty-eight older African American women were randomly assigned to an experimental group and a control group. The experimental group received the intervention for 4 weeks, and the control group received usual care. Psychosocial adjustment and self-care were measured in all participants at baseline and 6 weeks postbaseline. The experimental group reported increased participation in exercise (self-care component; p < .001) and improvement in psychosocial adjustment (p < .001). Thus, reducing the uncertainty related to diabetes self-care improves self-care exercise, as well as psychosocial adjustment.

Tailoring a Diabetes Self-Care Intervention for Use With Older, Rural African American Women

Purpose The purpose of this study was to tailor a diabetes management intervention to the cultural and age-related needs and preferences of older, rural African American women. Methods Findings from exploratory research, clinical experience, and review of the literature were used to inform the development of a culture- and function-specific intervention. Findings informed the design of the intervention, format of intervention delivery, format of intervention materials, and training provided to interventionists. Intervention materials were reviewed by a community advisory board, and the intervention was pilot tested with 43 women. Results The interventions delivery was tailored to the needs of older African American women through the use of 1-hour, in-home sessions that used a storytelling format to share information. The design of the intervention individualized its content to each womans symptom experience, self-care practices, and coping strategies. Extensive training sensitized intervention nurses to coping strategies (spirituality, church, family) and barriers to self-care (functional limitations, stress, the multi-caregiver role) that are common among older African American women. Intervention materials were culturally sensitive and in large-print format. Conclusions African American womens cultural background may have a strong influence on health behaviors and beliefs. Older womens health behaviors are further influenced by changes in their functional abilities. Therefore, the authors tailored a diabetes self-care management inter- vention to be specific to older African American womens cultural and functional differences. An initial pilot of the intervention found high levels of participant satisfaction with the intervention, improvements in dia- betes self-care practices, and a trend toward greater metabolic control.

African American Beliefs About Diabetes

In this presentation, a diabetes explanatory model of rural, African American adults at high risk for diabetes is described. Kleinman’s explanatory model of illness was used as the organizing framework. African American men and women (N = 42), between the ages of 18 and 51, participated. Participants described their knowledge and beliefs about diabetes, preventing diabetes, and whether diabetes could be cured or controlled. A common explanatory model of diabetes was not shared among the participants, and gender and age differences were apparent. Common themes included diabetes “running in families,” “eating too much sugar,” and “not taking care of yourself” as causes of diabetes. Weight and physical activity or exercise were not seen as contributing to the development of diabetes. Participants were not sure if diabetes could be prevented. These results provide information to address primary prevention of diabetes in this at-risk group.

Conceptual Model of Symptom-Focused Diabetes Care for African Americans

PURPOSE Development of a conceptual model and description of its use to guide the content and format of a community-based intervention. CONCEPTUAL MODEL: We developed a symptom-focused model for type 2 diabetes for older African American women based on the UCSF symptom management model. Key concepts in this model are symptom experience, symptom management, and health outcomes. METHODS Review of literature, intervention protocol. CONCLUSIONS The symptom-focused conceptual model is an innovative approach to tailoring care to a distinct population and to engaging participants in their own self-care. CLINICAL RELEVANCE Diabetes is a major cause of morbidity and mortality in African Americans; and diabetes self-management is the cornerstone of care. To better meet the distinct needs of diverse populations and positively affect health outcomes, new tailored approaches should be developed that are culturally sensitive and acceptable.