Diego Osuna

Self-Efficacy, Problem Solving, and Social-Environmental Support Are Associated With Diabetes Self-Management Behaviors

OBJECTIVE To evaluate associations between psychosocial and social-environmental variables and diabetes self-management, and diabetes control. RESEARCH DESIGN AND METHODS Baseline data from a type 2 diabetes self-management randomized trial with 463 adults having elevated BMI (M = 34.8 kg/m2) were used to investigate relations among demographic, psychosocial, and social-environmental variables; dietary, exercise, and medication-taking behaviors; and biologic outcomes. RESULTS Self-efficacy, problem solving, and social-environmental support were independently associated with diet and exercise, increasing the variance accounted for by 23 and 19%, respectively. Only diet contributed to explained variance in BMI (β = −0.17, P = 0.0003) and self-rated health status (β = 0.25, P < 0.0001); and only medication-taking behaviors contributed to lipid ratio (total–to–HDL) (β = −0.20, P = 0.0001) and A1C (β = −0.21, P < 0.0001). CONCLUSIONS Interventions should focus on enhancing self-efficacy, problem solving, and social-environmental support to improve self-management of diabetes.

Twelve-month outcomes of an Internet-based diabetes self-management support program.

OBJECTIVE Internet-based programs offer potential for practical, cost-effective chronic illness self-management programs. METHODS We report 12-month results of an Internet-based diabetes self-management program, with and without additional support, compared to enhanced usual care in a 3-arm practical randomized trial. Patients (n=463) were randomized: 77.3% completed 12-month follow-up. Primary outcomes were changes in health behaviors of healthy eating, physical activity, and medication taking. Secondary outcomes were hemoglobin A1c, body mass index, lipids, blood pressure, and psychosocial factors. RESULTS Internet conditions improved health behaviors significantly vs. usual care over the 12-month period (d for effect size=.09-.16). All conditions improved moderately on biological and psychosocial outcomes. Latinos, lower literacy, and higher cardiovascular disease risk patients improved as much as other participants. CONCLUSIONS The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact. However, 12-month magnitude of effects was small, suggesting that different or more intensive approaches are necessary to support long-term outcomes. Research is needed to understand the linkages between intervention and maintenance processes and downstream outcomes. PRACTICE IMPLICATIONS Automated self-management interventions should be tailored and integrated into primary care; maintenance of patient self-management can be enhanced through links to community resources.

Outcomes of Minimal and Moderate Support Versions of an Internet-Based Diabetes Self-Management Support Program

OBJECTIVEInternet and other interactive technology-based programs offer great potential for practical, effective, and cost-efficient diabetes self-management (DSM) programs capable of reaching large numbers of patients. This study evaluated minimal and moderate support versions of an Internet-based diabetes self-management program, compared to an enhanced usual care condition.RESEARCH DESIGN AND METHODSA three-arm practical randomized trial was conducted to evaluate minimal contact and moderate contact versions of an Internet-based diabetes self-management program, offered in English and Spanish, compared to enhanced usual care. A heterogeneous sample of 463 type 2 patients was randomized and 82.5% completed a 4-month follow-up. Primary outcomes were behavior changes in healthy eating, physical activity, and medication taking. Secondary outcomes included hemoglobin A1c, body mass index, lipids, and blood pressure.RESULTSThe Internet-based intervention produced significantly greater improvements than the enhanced usual care condition on three of four behavioral outcomes (effect sizes [d] for healthy eating = 0.32; fat intake = 0.28; physical activity= 0.19) in both intent-to-treat and complete-cases analyses. These changes did not translate into differential improvements in biological outcomes during the 4-month study period. Added contact did not further enhance outcomes beyond the minimal contact intervention.CONCLUSIONSThe Internet intervention meets several of the RE-AIM criteria for potential public health impact, including reaching a large number of persons, and being practical, feasible, and engaging for participants, but with mixed effectiveness in improving outcomes, and consistent results across different subgroups. Additional research is needed to evaluate longer-term outcomes, enhance effectiveness and cost-effectiveness, and understand the linkages between intervention processes and outcomes.

Recruitment for an Internet-Based Diabetes Self-Management Program: Scientific and Ethical Implications

BackgroundLittle is known about the reach of Internet self-management interventions.PurposeThe aim of this study was to evaluate different definitions of participation rate and compare characteristics among subcategories of participants and nonparticipants on demographic and clinical factors using de-identified electronic medical record data.MethodsData are presented on recruitment results and characteristics of 2,603 health maintenance organization members having type 2 diabetes invited to participate in an Internet self-management program.ResultsThere was a 37% participation rate among all members attempted to contact and presumed eligible. There were several significant differences between participants and nonparticipants and among subgroups of participants (e.g., proactive volunteers vs. telephone respondents) on factors including age, income, ethnicity, smoking rate, education, blood pressure, and hemoglobin A1c.ConclusionThese results have important implications for the impact of different recruitment methods on health disparities and generalization of results. We provide recommendations for reporting of eligibility rate, participation rate, and representativeness analyses.

Methods for the cultural adaptation of a diabetes lifestyle intervention for Latinas: an illustrative project.

Because Latinas experience a high prevalence of type 2 diabetes and its complications, there is an urgent need to reach them with interventions that promote healthful lifestyles. This article illustrates a sequential approach that took an effective multiple-risk-factor behavior-change program and adapted it for Latinas with type 2 diabetes. Adaptation stages include (a) information gathering from literature and focus groups, (b) preliminary adaptation design, and (c) preliminary adaptation test. In this third stage, a pilot study finds that participants were highly satisfied with the intervention and showed improvement across diverse outcomes. Key implications for applications include the importance of a model for guiding cultural adaptations, and the value of procedures for obtaining continuous feedback from staff and participants during the preliminary adaptation test.

Viva Bien!: overcoming recruitment challenges in a multiple-risk-factor diabetes trial.

OBJECTIVES To describe recruitment of Latinas in a randomized clinical trial conducted within 2 health care organizations. METHODS The study relied on project-initiated telephone calls as part of a multifaceted recruitment approach. Chi-square and t tests were conducted to compare participants and nonparticipants on a number of variables. RESULTS From 4045 telephone contacts, 280 Latinas agreed to participate. Most were ineligible due to non-Latino ethnicity (89%). Of eligible candidates, 61% took part. Few significant differences were found on participant vs nonparticipant characteristics. CONCLUSIONS Using appropriate recruitment procedures, a representative sample of Latinas can be obtained.

Effects of acculturation on a culturally adapted diabetes intervention for Latinas.

OBJECTIVE To inform the refinement of a culturally adapted diabetes intervention, we evaluated acculturations association with variables at several sequential steps: baseline measures of diet and physical activity, intervention engagement, putative mediators (problem solving and social resources), and outcomes (fat consumption and physical activity). METHOD Latina women (N = 280) recruited from health organizations were randomly assigned to a culturally adapted lifestyle intervention (¡Viva Bien!) or usual care. A brief version of the Acculturation Rating Scale for Mexican Americans-II (ARSMA-II) acculturation scales (Anglo and Latina orientations) was administered at baseline. Assessments at baseline, 6 months, and 12 months included social supportive resources for diet and exercise, problem solving, saturated fat consumption, and physical activity. RESULTS Latina orientation was negatively related to saturated fat intake and physical activity at baseline. Latina orientation also was positively related to session attendance during Months 6-12 of the intervention. Independent of 6-month intervention effects, Anglo orientation was significantly positively related to improvements in problem solving and dietary supportive resources. Anglo orientation related negatively to improved physical activity at 6 and 12 months. There were no Acculturation × Intervention interactions on putative mediators or outcomes. CONCLUSION The cultural adaptation process was successful in creating an engaging and effective intervention for Latinas at all levels of acculturation. However, independent of intervention effects, acculturation was related to putative mediating variables (problem solving and social resources) and an outcome variable (physical activity), an indication of acculturations general influence on lifestyle and coping factors.

Multiple-Behavior–Change Interventions for Women With Type 2 Diabetes

Type 2 diabetes is a costly chronic illness that is increasing in prevalence and associated with significant health problems, including heart disease.1 Furthermore, type 2 diabetes and heart disease share multiple lifestyle risk factors that tend to co-occur for many adults.2 Research has established the health benefits of adopting Mediterranean-style eating practices,3 engaging in physical activity,4,5 managing stress,6,7 and using social-environmental support to initiate and sustain health-related behaviors.8–10 Nevertheless, multiple–risk-factor intervention studies are rare11-13 and sorely needed, particularly to understand their potential to reach and benefit underserved populations. Multiple-behavior–change interventions appear necessary in light of the co-occurrence of risk factors,2 yet they are complex and demanding for both service providers and patients. Providers must have multiple competencies or the resources to assemble an interdisciplinary team with expertise in nutrition, exercise, smoking cessation, stress management, and motivational strategies. They must weigh the costs and benefits of sequential and simultaneous approaches to changing multiple behaviors, although thus far, those approaches seem to produce comparable effects.14 Patients must comprehend many intervention methods and devote sufficient effort to each. The purpose of this article is to describe the structure and content of the Mediterranean Lifestyle Program (MLP) and its results during 7 years of assessments, as well as a cultural adaptation of the MLP for Latinas (iViva Bien!) that was offered to members of a large health maintenance organization (HMO) and a community health center in the Denver, Colo., metropolitan area and its results during 2 years of evaluation. The adaptation of the MLP into iViva Bien! was intended to expand the generalizability of the intervention and to test its application in collaboration with health organizations, two important steps in developing an intervention that can be disseminated …

Linking internet-based diabetes self-management to primary care: lessons learned and implications for research translation and practice implementation

ABSTRACTThere has been little discussion of or research on the key translational issue of how to integrate patient self-management programs across multiple primary care clinics within an HMO. The purpose of this study was to summarize our experiences and lessons learned in trying to integrate information from a web-based diabetes self-management program into primary care and the electronic health record (EHR). We describe plans, implementation, adaptations made, and data on patient and physician reactions to the My Path diabetes self-management program provided to 331 adult primary care patients. Mixed methods results revealed that, despite the availability of a state-of-the-art EHR, the intervention was not well integrated into primary care. Information from health-promotion and disease management programs, even within the same organization and with advanced EHR systems, is challenging to integrate into busy primary care.

Variation in Hispanic Self-Identification, Spanish Surname, and Geocoding: Implications for Ethnicity Data Collection

This study examines the variation in surname analysis and geocoding, and their association with self-identified Hispanics in an HMO. We collected ethnicity data from three studies, and employed Spanish surname software and cen- sus tract level geocoding to create proxies for Hispanic ethnicity. We computed sensitivity, specificity, and estimated mul- tivariate logistic regression models to examine the variation in the likelihood of a match between self-identified Hispanics and surname. Sensitivity and specificity with respect to surname varied across the three studies, ranging from 57%-91% and 89%-96%, respectively. Relative to self-report, the sensitivity of the census tract measure of density of Hispanics, var- ied from 5%-15%. Multivariate models suggest that the likelihood of a match between self-identified Hispanics and sur- name was not associated with age or gender. Self-identified Hispanics living in neighborhoods with the highest density of Hispanics were less likely than those in more mixed neighborhoods to have a Spanish surname. Employing the Spanish surname software on only densely populated Hispanic census tracts may not always improve the likelihood of correctly identifying Hispanic subjects.