Martha M. Funnell

The Reliability and Validity of a Brief Diabetes Knowledge Test

OBJECTIVE To examine the reliability and validity of a brief diabetes knowledge test. The diabetes knowledge test has two components: a 14-item general test and a 9-item insulin-use subscale. RESEARCH DESIGN AND METHODS Two populations completed the test. In one population, patients received diabetes care in their community from avariety of providers, while the other population received care from local health departments. Cronbachs coefficient a was used to calculate scale reliability for each sample. To determine validity, patient group differences were examined. It was hypothesized that test scores would be higher for patients with type 1 diabetes, for patients with more education, and for patients who had received diabetes education. RESULTS The coefficient as for the general test and the insulin-use subscale indicate that both are reliable, α ≥ 0.70. In the community sample, patients with type 1 diabetes scored higher than patients with type 2 diabetes on the general test and the insulin-use subscale. In the health department sample, patients with type 1 scored higher than patients with type 2 on the insulin-use subscale. For both samples, scores increased as the years of formal education completed increased, and patients who received diabetes education scored higher than patients who did not. CONCLUSIONS Although the samples differed demographically, the reliability and validity of the test were supported in both the community andthe health department samples. This suggests that the test is appropriate for a variety of settings and patient populations.

Empowerment: An Idea Whose Time Has Come in Diabetes Education

We have learned much in the past 10 years about how to help patients to acquire diabetes-related knowledge and skills and how to use strategies to help patients change behaviors. However, the application ofknowledge and techniques should be guided by a relevant, coherent, educational philosophy. Empowerment offers a practical conceptual framework for diabetes patient education. Empowering patients provides them with the knowledge, skills, and responsibility to effect change and has the potential to promote overall health and maximize the use of available resources. It is an idea whose time has come for diabetes education.

Self-Management Aspects of the Improving Chronic Illness Care Breakthrough Series: Implementation With Diabetes and Heart Failure Teams

Self-management is an essential but frequently neglected component of chronic illness management that is challenging to implement. Available effectiveness data regarding self-management interventions tend to be from stand-alone programs rather than from efforts to integrate self-management into routine medical care. This article describes efforts to integrate self-management support into broader health care systems change to improve the quality of patient care in the Chronic Illness Care Breakthrough Series. We describe the general approach to system change (the Chronic Care Model) and the more specific self-management training model used. The process used in training organizations in self-management is discussed, and data are presented on teams from 21 health care systems participating in a 13-month-long Breakthrough Series to address diabetes and heart failure care. Available system-level data suggest that teams from a variety of health care organizations made improvements in support provided for self-management. Improvements were found for both diabetes and heart failure teams, suggesting that this improvement process may be broadly applicable. Lessons learned, keys to suc cess, and directions for future research and practice are discussed.

Development and Validation of the Diabetes Care Profile

To determine the reliability and the validity of the Diabetes Care Profile (DCP), an instrument that assesses the social and psychological factors related to diabetes and its treatment, two studies with separate populations and methodologies were conducted In the first study, the DCP was administered to, and physiologic measures collected from, individuals with diabetes being cared for in a community setting (n = 440). In the second study, the DCP and several previously validated scales were administered to individuals with diabetes receiving care at a university medical center (n = 352). Cronbachs alphas of individual DCP scales ranged from .60 to .95 (Study 1) and from .66 to .94 (Study 2). Glycohemoglobin levels correlated with three DCP scales (Study 1). Several DCP scales discriminated among patients with different levels of disease severity. The results of the studies indicate that the DCP is a reliable and valid instrument for measuring the psychosocial factors related to diabetes and its treatment.

Implementing Practical Interventions to Support Chronic Illness Self-Management

BACKGROUND Self-management support (SMS) is the area of disease management least often implemented and most challenging to integrate into usual care. This article outlines a model of SMS applicable across different chronic illnesses and health care systems, presents recommendations for assisting health care professionals and practice teams to make changes, and provides tips and lessons learned. Strategies can be applied across a wide range of conditions and settings by health educators, care managers, quality improvement specialists, researchers, program evaluators, and clinician leaders. Successful SMS programs involve changes at multiple levels: patient-clinician interactions; office environment changes; and health system, policy, and environmental supports. PATIENT-CLINICIAN INTERACTION LEVEL: Self-management by patients is not optional but inevitable because clinicians are present for only a fraction of the patients life, and nearly all outcomes are mediated through patient behavior. Clinicians who believe they are in control or responsible for a patients well-being are less able to adopt an approach that acknowledges the central role of the patient in his or her care. SUMMARY AND CONCLUSIONS Self-management should be an integral part of primary care, an ongoing iterative process, and patient centered; use collaborative goal setting and decision making; and include problem solving, outreach, and systematic follow-up.

Social Support, Quality of Life, and Self-Care Behaviors Among African Americans With Type 2 Diabetes:

Purpose The purpose of this study was to examine social support and its relationship to diabetes-specific quality of life and selfcare behaviors in African Americans with type 2 diabetes. Methods The study followed a cross-sectional, observational design and recruited 89 African American adults, age 40 and older (mean = 60, SD = 10.5), diagnosed with type 2 diabetes. Participants completed measures assessing dia- betes-specific quality of life, self-care behaviors (healthy eating, physical activity, self-monitoring of blood glucose, foot care, medication and/or insulin use), demographic background, and diabetes-related social support. Diabetes-related social support variables included amount of social support received, satisfaction with support, positive support behavior, negative support behavior, and primary source of support. Results Stepwise regressions, controlling for demographic variables, were conducted to identify predictors of diabetes-specific quality of life and selfcare behaviors from the diabetes-related social support variables. Satisfaction with support was a predictor for improved diabetes-specific quality of life (r = –.579, P < .001) and blood glucose monitoring (r = .258, P < .05). Positive support behavior was a predictor for following a healthy eating plan (r = .280, P < .05), spacing out carbohydrates evenly throughout the day (r = .367, P < .01), and performing physical activity at least 30 minutes per day (r = .296, P < .05). Negative support behavior was a predictor for not taking medication as recommended (r = –.348, P < .01). Conclusions Findings indicate that social support plays a role in diabetes-specific quality of life and self-management practices. Social support encompasses multiple dimensions that differentially influence specific diabetes health-related outcomes and behaviors.

Peer-based behavioural strategies to improve chronic disease self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research

The diagnosis of a chronic disease such as diabetes generally evokes strong emotions and often brings with it the need to make changes in lifestyle behaviours, such as diet, exercise, medication management and monitoring clinical and metabolic parameters. The diagnosis thus affects not only the person diagnosed but also the family members. Chronic illnesses are largely self-managed with approximately 99% of the care becoming the responsibility of patients and their families or others involved in the daily management of their illnesses. While the responsibility for outcomes, such as metabolic control and chronic complications, are shared with the health care team, the daily decisions and behaviours adopted by patients clearly have a strong influence on their future health and well-being. While diabetes self-management education is essential, it is generally not sufficient for patients to sustain behaviours and cope with a lifetime of diabetes. Peers have been proposed as one method for assisting patients to deal with the behavioural and affective components of diabetes and to provide ongoing self-management support. This paper first describes effective behavioural strategies in diabetes, based on multiple studies and/or meta-analyses, and then provides examples of their use by peers or in peer-based programmes in diabetes. A comprehensive search using the MEDLINE and Cinahl databases was conducted. Key search terms included peer mentors, peer leaders, peer educators, lay health workers and community health workers. Studies that clearly identified behavioural strategies used by peers were included.

Implementing an Empowerment-Based Diabetes Self-management Education Program

Diabetes educators are challenged to develop culturally appropriate, integrated, behaviorally based, effective education programs. This article describes the intervention used in a problem-based educational program for urban African Americans with diabetes. The intervention consisted of six 2-hour, weekly group educational and data collection sessions. No lectures were used, and the content was determined by participants’ questions and concerns. Culturally tailored written educational materials were also provided.

The Third Version of the Diabetes Attitude Scale

OBJECTIVE The objective of this study was to develop a third version of the Diabetes Attitude Scale (DAS-3) that is congruent with current scientific knowledge about diabetes, has improved subscale internal reliability scores, and is shorter than the earlier versions of this instrument. RESEARCH DESIGN AND METHODS The second DAS was revised and rewritten by a panel of diabetes experts, including patients, associated with the University of Michigan Diabetes Research and Training Center. The revised version of the instrument was sent to physicians, nurses, dietitians, and patients with diabetes. Completed and usable questionnaires were obtained from 384 patients with diabetes, 321 physicians, 540 nurses, and 569 dietitians. The total number of surveys used for these analyses was 1,814. RESULTS The study resulted in a revised DAS with 33 items and five discrete subscales. The subscales were attitudes toward the following: 1) need for special training to provide diabetes care, 2) seriousness of type 2 diabetes, 3) value of tight glucose control, 4) pyschosocial impact of diabetes, and 5) attitude toward patient autonomy. Overall, the subscale reliabilities of the DAS-3 were superior to the earlier versions of the scale. CONCLUSIONS The DAS-3 is a valid and reliable general measure of diabetes-related attitudes and is most suitable for comparisons across different groups of health care professionals and/or patients. The DAS-3 is also suitable for the evaluation of patient and/or professional education programs if those programs focus on the specific topic areas measured by the five DAS-3 subscales.

Using Focus Groups to Identify Psychosocial Issues of Urban Black Individuals With Diabetes

The purpose of this focus group research was to identify issues that could serve as topics for a series of educational videos portraying psychosocial issues of urban black individuals with diabetes. Four focus groups involving 34 black adults were conducted in the Detroit area. Psychosocial issues were identified and rated in order of priority by an expert panel. The major psychosocial issues identified were the importance of food and eating in the black culture, the necessity for learning more about diabetes and its complications, learning to interact effectively with healthcare providers and systems, and the need for help and support in managing psychosocial issues related to diabetes. Black individuals with diabetes face unique psychosocial challenges. Focus groups are an effective method for obtaining relevant, culturally specific, in-depth information about living with diabetes from patients who are members of minority groups.