Revision and Psychometric Evaluation of the Diabetes Knowledge Questionnaire for People With Type 2 Diabetes.

Objective: Diabetes knowledge is associated with health, including lower A1C levels. The Diabetes Knowledge Questionnaire (DKQ-24), developed 30 years ago for Mexican Americans with type 2 diabetes and since used with diverse samples in many countries, contains outdated items that no longer accurately assess current knowledge needed for diabetes self-management. We revised the DKQ-24 and tested psychometric properties of the DKQ-Revised (DKQ-R) with a diverse sample. Methods: We conducted a five-phase instrumentation study as follows: 1) DKQ-24 items were revised to reflect current diabetes care standards; 2) the Delphi method was used to evaluate the DKQ-R's content validity (n = 5 experts); 3) cognitive interviews were conducted with people with type 2 diabetes (n = 5) to assess their interpretations of DKQ-R items; 4) cross-sectional administration of the DKQ-R to adults with type 2 diabetes was carried out to assess internal consistency reliability and convergent validity; and 5) an item analysis was conducted using discrimination index and point biserial analysis. Results: After receiving the experts' feedback and conducting the cognitive interviews, 39 items were administered to 258 participants with type 2 diabetes (42.2% women; 29.1% Latino, 42.6% Asian, mean age 55.7 years). To select the final items, we considered the item discrimination index, as well as item-to-total correlations, content area, and participant feedback. The final 22-item DKQ-R uses the same yes/no/I don't know response format as the DKQ-24. The DKQ-R is strongly correlated with the DKQ-24 (r = 0.71, P <0.01) and is weakly correlated with diabetes numeracy (r = 0.23, P <0.01), indicating adequate convergent validity; a Kuder-Richardson-20 coefficient of 0.77 indicated good reliability. Conclusion: The DKQ-R is a reliable and valid updated measure of diabetes knowledge for diverse populations with type 2 diabetes.

Impact of Fatigue and Its Influencing Factors on Diabetes Self-Management in Adults With Type 2 Diabetes: A Structural Equation Modeling Analysis.

PURPOSE: The purposes of this study were to (1) examine the relationships between fatigue, its influencing factors, and diabetes self-management and (2) test the mediation effects of fatigue on the link between the influencing factors and diabetes self-management in adults with type 2 diabetes. METHODS: This cross-sectional, correlational study was guided by the theory of unpleasant symptoms. Data were collected using structured questionnaires. Fatigue was measured by the Fatigue Symptom Inventory and the Multidimensional Fatigue Inventory. Diabetes self-management was measured by the Summary of Diabetes Self-Care Activities. From March to July 2021, a convenience sample of 150 participants was recruited from 2 diabetes outpatient clinics of a regional hospital in Taiwan. Data were analyzed using structural equation modeling. RESULTS: A more recent diagnosis of diabetes, more depressive symptoms, and lower sleep quality were related to higher fatigue. Higher fatigue correlated with less performance in diabetes self-management. Fatigue mediated the relationship between depressive symptoms, sleep quality, and diabetes self-management. CONCLUSIONS: Fatigue had a mediating effect on the link between psychological influencing factors and diabetes self-management. Future development of fatigue interventions integrating depressive symptoms and sleep management will likely increase the performance of diabetes self-management and improve the health outcomes in adults with type 2 diabetes. The study tested the theory of unpleasant symptoms using empirical data and will assist in building theory-guided fatigue interventions to improve diabetes self-management in people with type 2 diabetes.

Predicting return of lung function after a pulmonary exacerbation using the cystic fibrosis respiratory symptom diary-chronic respiratory infection symptom scale.

Background: Pulmonary exacerbations (PExs) in people with cystic fibrosis (PwCF) are associated with increased healthcare costs, decreased quality of life and the risk for permanent decline in lung function. Symptom burden, the continuous physiological and emotional symptoms on an individual related to their disease, may be a useful tool for monitoring PwCF during a PEx, and identifying individuals at high risk for permanent decline in lung function. The purpose of this study was to investigate if the degree of symptom burden severity, measured by the Cystic Fibrosis Respiratory Symptom Diary (CFRSD)- Chronic Respiratory Infection Symptom Scale (CRISS), at the onset of a PEx can predict failure to return to baseline lung function by the end of treatment. Methods: A secondary analysis of a longitudinal, observational study (N = 56) was conducted. Data was collected at four time points: year-prior-to-enrollment annual appointment, termed "baseline", day 1 of PEx diagnosis, termed "Visit 1", day 10-21 of PEx diagnosis, termed "Visit 2" and two-weeks post-hospitalization, termed "Visit 3". A linear regression model was performed to analyze the research question. Results: A regression model predicted that recovery of lung function decreased by 0.2 points for every increase in CRISS points, indicating that participants with a CRISS score greater than 48.3 were at 14% greater risk of not recovering to baseline lung function by Visit 2, than people with lower scores. Conclusion: Monitoring CRISS scores in PwCF is an efficient, reliable, non-invasive way to determine a person's status at the beginning of a PEx. The results presented in this paper support the usefulness of studying symptoms in the context of PEx in PwCF.

Knowledge and Attitude About Pre-exposure Prophylaxis Among Primary Care Clinicians at a Federally Qualified Health Center in Central Texas: A Cross-sectional Study.

ABSTRACT: Pre-exposure prophylaxis (PrEP) for HIV prevention is a highly effective tool in preventing HIV, yet PrEP is underprescribed. Primary care providers are ideally positioned to increase access to and awareness of PrEP, but health care providers' knowledge of PrEP greatly varies. To evaluate PrEP knowledge and attitudes of primary care providers, we conducted a descriptive cross-sectional study examining primary providers' knowledge and concerns about PrEP. Participants ( n = 122) included physicians, nurses, pharmacists, and residency trainees in family medicine, internal medicine, and obstetrics. Despite high awareness of PrEP among these primary care providers (91.7%), fewer reported feeling comfortable prescribing PrEP (62.5%), and the average number of PrEP prescriptions per provider written in the last 6 months was less than 1. PrEP remains key to preventing HIV, but prescriptions remain low. Health care providers would benefit from additional education and training on communicating with their patients about sexual health and HIV prevention.

Illness Perceptions Mediate the Impact of Depressive Symptoms on Quality of Life Among Latinos with Type 2 Diabetes.

Latinos' type 2 diabetes (T2DM) and concurrent depression significantly lower quality of life (QoL). Patients' beliefs about their diabetes, called illness perceptions (IP), may account for the impact of depression on QoL. Using secondary data, we explored predictive and mediation relationships among IP, depression, and QoL among Mexican American adults with T2DM using hierarchical multiple regression and mediation analyses. Participants (n = 75) were predominately middle-aged, female, most scoring low on depressive-symptoms, who believed that diabetes was a chronic disease with serious consequences, controllable by treatment and personal self-management. Participants with higher acculturation and weak perceptions about negative consequences of diabetes reported better QoL. Depressive symptoms' impact on QoL were mediated by overall IP and perceptions about diabetes consequences, in particular. By eliciting patients' perceptions about disease consequences and teaching realistic ways to avoid them, clinicians may alleviate the impact of depression on QoL.

Self-management of the Dual Diagnosis of HIV/AIDS and Diabetes During COVID-19: A Qualitative Study.

The purpose of this qualitative secondary analysis research was to describe the impact of the COVID-19 pandemic on self-management behaviors and practices for people living with the dual diagnoses of HIV/AIDS and type 2 diabetes mellitus and to identify early pandemic-specific disruptions or changes to their self-management practices. In-depth interviews conducted in May-June 2020 with 9 participants, and analyzed using content analysis, revealed 5 themes: adjusting to living with HIV/AIDS and diabetes impacts beliefs about COVID-19 risks; COVID-19 information seeking and accuracy; trade-offs in self-managing multiple chronic conditions; balance between safety, relationships, and the society at large; and discordant perceptions and actions. Some participants were resilient from previous experiences. Many received mixed messages about their risk for COVID-19, resulting in inaccurately or inconsistently applying guidelines for social isolation.

Term Newborn Care Recommendations Provided in a Kenyan Postnatal Ward: A Rapid, Focused Ethnographic Assessment.

BACKGROUND: Neonatal mortality (death within 0-28 d of life) in Kenya is high despite strong evidence that newborn care recommendations save lives. In public healthcare facilities, nurses counsel caregivers on term newborn care, but knowledge about the content and quality of nurses' recommendations is limited. PURPOSE: To describe the term newborn care recommendations provided at a tertiary-level, public referral hospital in Western Kenya, how they were provided, and related content taught at a university nursing school. METHODS: A rapid, focused ethnographic assessment, guided by the culture care theory, using stratified purposive sampling yielded 240 hours of participant observation, 24 interviews, 34 relevant documents, and 268 pages of field notes. Data were organized using NVivo software and key findings identified using applied thematic analysis. RESULTS: Themes reflect recommendations for exclusive breastfeeding, warmth, cord care, follow-up examinations, and immunizations, which were provided orally in Kiswahili and some on a written English discharge summary. Select danger sign recommendations were also provided orally, if needed. Some recommendations conflicted with other providers' guidance. More recommendations for maternal care were provided than for newborn care. IMPLICATIONS FOR PRACTICE: There is need for improved consistency in content and provision of recommendations before discharge. Findings should be used to inform teaching, clinical, and administrative processes to address practice competency and improve nursing care quality. IMPLICATIONS FOR RESEARCH: Larger studies are needed to determine whether evidence-based recommendations are provided consistently across facilities and other populations, such as community-born and premature newborns, who also experience high rates of neonatal mortality in Kenya.

Counting, Coping, and Navigating the Flux: A Focused Ethnographic Study of HIV and Diabetes Self-Management.

Approximately 10-15% of people living with HIV are also diagnosed with diabetes. To manage their two chronic conditions, people must undertake certain activities and adopt behaviors. Due to overlapping symptoms, complex medication regimens, and heavy patient workloads, implementing these self-management practices can be difficult. In this focused ethnography, data were collected from semi-structured interviews and limited participant-observation with a selected subset of participants to gain insight into self-management challenges and facilitators. We conducted interviews and multiple observations with 22 participants with HIV+T2DM over the period of 9 months. Participants experienced numerous barriers to self-management in the areas of diet, medication adherence, and mental health. Social and familial support, as well as consistent access to care, were facilitators for optimal self-management. At the same time participants' lives were in a unique flux shaped by the dual diagnoses, and therefore, required constant mental and physical adjustments, thus illustrating challenges of managing chronicity.

Increasing utilisation of skilled attendants at birth in sub-Saharan Africa: A systematic review of interventions.

BACKGROUND: Maternal mortality is a critical global public health concern, especially in low- and middle-income countries in sub-Saharan Africa. Although maternal mortality rates have declined by approximately 39% in sub-Saharan Africa over the last decade, maternal deaths during pregnancy and in childbirth remain high. Interventions to improve mothers' use of skilled birth attendants may decrease maternal mortality in sub-Saharan African countries. OBJECTIVES: This systematic literature review examines components of and evaluates the effectiveness of interventions to increase use of skilled birth attendants in sub-Saharan Africa. METHODS: Guided by the PRISMA model for systematic reviews, the PubMed, Web of Science, and CIHNAL databases were searched for studies from years 2003 through June 2020. RESULTS: The 28 articles included in this review reported on interventions incorporating community health workers, phone or text messages, implementation of community-level initiatives, free health care, cash incentives, an international multi-disciplinary volunteer team, and a group home for pregnant women, which improved use of skilled birth attendants to varying degrees. Only one study reported improved outcomes with the use of community health workers. All of the interventions using text messages increased hospital utilization for births. CONCLUSIONS: Interventions implemented in sub-Saharan Africa hold promise for improving maternal health. Multi-level interventions that involve community members and local leaders can help address the multi-faceted issue of poor maternal health outcomes and mortality. Interventions should focus on capacity building and on training and mentoring of formally-trained health care providers and community health workers in order to expand access.

Predictors of Subjective Cognitive Decline Among People With Diabetes: Data From the Behavioral Risk Factor Surveillance System.

PURPOSE: The purpose of this study was to examine the prevalence of subjective cognitive decline (SCD) and SCD-related functional limitations among people with diabetes and to identify socioeconomic and comorbidity risk factors associated with SCD. METHODS: This study analyzed data from the 2017 Behavioral Risk Factor Surveillance System (BRFSS) with background variables (race, gender, education, and age), health-related factors (self-rated health, BMI, insurance, and comorbid conditions), and health behaviors (smoking, exercise, alcohol consumption) entered simultaneously to estimate logistic regression models of SCD. RESULTS: Within the sample (n = 5263 adults with diabetes), 48% were age ≥65 years; 50% were male; 55% were non-Hispanic White; and of the 15% who reported having SCD, 57% had functional limitations. Increased odds of reporting SCD were observed among individuals who were Hispanic (odds ratio [OR] = 2.21, P < .001), male (OR = 1.47, P < .01), depressed (OR = 3.85, P < .001), or had arthritis (OR = 1.43, P < .03). Participants with better self-rated health had a reduced likelihood of SCD (OR = 0.51, P < .001). CONCLUSIONS: Health care providers should assess high-risk patients for self-rated cognitive dysfunction and offer early interventions.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science.

ABSTRACT: People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

A systematic review and meta-analysis of patient activation in people living with chronic conditions.

OBJECTIVE: The objectives of this review are to (1) describe the state of the science of patient activation interventions for the self-management of chronic conditions; (2) identify effective intervention elements for improving patient activation; and (3) compare intervention effectiveness across chronic conditions. METHODS: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). PubMed, CINAHL, and Web of Science databases were searched. RESULTS: Thirty-two articles published between 2005 and 2019 were identified with intervention elements of self-management, disease management, and education. Meta-analysis of a subset of seven randomized controlled trials (n = 7) that used the 13-item version of the Patient Activation Measure with data collection points at 6 months demonstrated that patient activation did not change significantly in comparison with controls (MD = 0.25, 95 % CI = 0.02-0.47). CONCLUSION: Most interventions reported significant improvement in patient activation and were linked to tasks such as regular exercise and monitoring glucose. However, the meta-analysis of RCTs did not confirm these findings. PRACTICE IMPLICATIONS: Patient activation can be assessed and addressed uniformly across all chronic conditions to improve patient engagement in care.

Lessons learned from eight teams: The value of pilot and feasibility studies in self-management science.

Designing and conducting effective intervention research is an important domain of nursing science. Nurse scientists have long recognized people with chronic conditions need effective self-management strategies across the lifespan, so they have led the way in establishing theoretical and practical grounds for the science of self-management. Guidance from pilot and feasibility research for self-management interventions is scarce. Documented exemplars of successes and failures in pilot and feasibility study designs are scant in the literature. The purpose of this paper is to illustrate methodological approaches using pilot and feasibility examples. To maximize collective lessons learned in self-management science study design, features of our pilot and feasibility research strategies that yielded both desirable and undesirable outcomes are described, analyzed, and paired with alternative solutions. A National Institute of Nursing Research P30 grant center, awarded grants to 8 pilot investigators to pilot self-management interventions. A wide variety of chronic conditions were addressed, including heart failure, chronic kidney disease, multiple sclerosis, diabetes, and HIV. The investigators provided their experiences of study implementation. Common themes across the studies were identified. There were four lessons learned from these studies: 1) maximize resources and develop enough evidence for subsequent studies; 2) embed patient-centered feasibility within implementation testing with new patient populations; 3) develop a flexible participant recruitment plan to allow for adjustments when unexpected barriers arise; and 4) define study-specific data collection procedures to demonstrate feasibility. Researchers conducting preliminary small-scale self-management intervention research must balance resources to develop and implement interventions to meet pilot and feasibility objectives.

Resiliency and Self-Care Behaviors in Health Professional Schools.

Background: Resilience is crucial for students in health schools as care becomes more complex and as the adjustment to meet patient, environmental, and professional demands with success can seem a daunting challenge. Self-care activities can support the development of resilience in the student population. The purpose of this study is to explore and describe self-care practices, health-promoting behaviors, and resilience among students, faculty, and staff of the health professional schools at a large metropolitan university. Method: This was a cross-sectional study of data from 148 participants. Analysis included descriptive statistics, t tests, analysis of variance, crosstabs, and Pearson correlations. Results: Resilience was lower among students than among faculty and staff. The most frequent self-care activities were humor and music. Resilience was significantly correlated with the self-care behaviors of praying (p = .006), healthy sleeping habits (p = .024), reading (p = .007), and mindful acceptance (p = .025); yoga and meditation were not significantly correlated with resilience.

An interdisciplinary approach using case management and clinical pharmacy improves results for people with diabetes.

BACKGROUND: People with diabetes face many challenges to following healthcare provider recommendations for self-management and few are able to achieve and maintain reductions in average blood glucose level. Interdisciplinary teams are a promising strategy to help patients with diabetes improve outcomes. METHODS: An observational analysis of electronic health record data to evaluate the impact of a clinical pharmacist, case manager, or a combination of both on clinical outcomes for patients with diabetes. FINDINGS: All patients (N = 970), regardless of visit type, had a statistically significant improvement in A1C, LDL, and total cholesterol over 1 year. Patients who saw both a case manager and clinical pharmacist had the greatest improvements with the steepest changes across all measures. CONCLUSION: Clinics should create interdisciplinary teams that include a clinical pharmacist and a case manager to have the best outcomes for their patients with diabetes.

Biomarkers panels can predict fatigue, depression and pain in persons living with HIV: A pilot study.

BACKGROUND: Persons living with HIV experience high symptom burden that can negatively impact medication adherence, work productivity, and quality of life. Symptoms are highly subjective, which can lead to under- or improper treatment. The purpose of this exploratory study was to examine relationships between circulating biomarkers representative of inflammatory, coagulation, and vascular function pathways and prevalent HIV symptoms. SETTING AND SAMPLE: Adults >18 years who were diagnosed with HIV and spoke English for this cross-sectional study were recruited from community clinics and organizations. METHODS: Symptom burden was measured with the HIV Symptom Index; depression with the Patient Health Questionnaire. Human multiplex kits were used to determine serum concentrations of select biomarkers representing inflammatory, coagulation, and vascular function pathways. The biomarkers were included as features in machine learning models to determine which biomarkers predicted the most prevalent HIV symptoms (fatigue and muscle/joint pain) and the symptom of depression. RESULTS: Participants (N = 32) were representative of the local population of people with HIV, being mostly Black (54.4%) and male (60.6%). Depression was predicted by age, gender, glucose, hemoglobin A1c, and inflammation. Muscle/joint pain was predicted by adiponectin, C-reactive protein, and serum amyloid A (SAA). Fatigue was predicted by adiponectin, SAA, and soluble interleukin-1 receptor type II (sIL-1RII). CONCLUSION: Biomarker clusters can be a tool to monitor symptoms. Adding an objective measure to subjective patient experiences could improve management and monitoring of symptoms. Defining a biomarker cluster for the objective assessment of HIV symptoms warrants further investigation; however, the presence of comorbid conditions needs to be controlled.

Association between sleep and serious psychological distress in patients with diabetes.

Diabetes is the 7th leading cause of death in the U.S. and impacts patients' physical health and also increases the risk for psychological distress. Sleep disturbance is a common complaint in patients with diabetes and likely impacts psychological well-being. This study examined the relationship between sleep characteristics and serious psychological distress (SPD) in people with diabetes by conducting a secondary analysis of cross-sectional data from the 2015 National Health Interview Survey (N= 3474). Approximately 7% of the participants reported SPD and 27% reported sleep durations that were shorter or longer than the recommended 6-8 hours daily. Hierarchical logistic regression analysis showed that people who reported daily sleep of 1-5 hours or 9 or more hours were more likely to report SPD than individuals who slept 6-8 hours a day. Respondents who reported a higher frequency of taking medication for sleep and having trouble staying asleep were also substantially more likely to have SPD. However, an increase in the number of days feeling rested when waking up was a protective factor that decreased the risk of SPD. The findings suggest that both sleep disturbances and SPD, because of their high prevalence, should be included in the routine evaluation for diabetes care.

Mexican Americans' diabetes symptom prevalence, burden, and clusters.

AIMS: Type 2 diabetes mellitus (T2DM), serious and increasingly prevalent among Mexican Americans, produces symptoms related to high and low glucose levels, medication side effects, and long-term complications. This secondary analysis explored symptom prevalence, differences among symptom burden levels, and how symptoms clustered. METHODS: Clinical measurements and survey data (demographic, quality of life, and the symptom subscale of the Diabetes Symptom Self-Management Inventory) collected from Mexican American adults with T2DM (n = 71) were analyzed for symptom prevalence, differences across levels of symptom burden, and symptom clusters. Agglomerative hierarchical and k-means clustering analyses were performed on a Gower matrix. Internal validation methods and rank aggregation were used to identify the best clustering method of the two techniques and to identify symptoms that clustered together. RESULTS: Participants reported mean = 14 symptoms; tiredness and trouble sleeping were most prevalent. People with high symptom burden had significantly lower quality of life and perceptions of worse diabetes severity. Hierarchical clustering produced three symptom clusters: cluster 1 = 9 symptoms (e.g. intense thirstiness, dry mouth); cluster 2 = 9 symptoms (e.g., itching skin, weight gain, noise or light sensitivity); cluster 3 = 13 symptoms (e.g., nervous, headache, trouble concentrating, and memory loss). CONCLUSION: Mexican Americans with T2DM report several co-occurring symptoms. Quality of life is significantly worse for people with high symptom burden. Three distinct symptom clusters were identified. Studies with larger samples are needed to further diabetes symptom science. Clinicians should assess and address patients' co-occurring symptoms as a potential means of decreasing symptom burden and improving quality of life.