Recent Trends in Diabetes Knowledge, Perceptions, and Behaviors: Implications for National Diabetes Education.

OBJECTIVES: Examine trends in diabetes-related knowledge, perceptions, and behavior among U.S. adults with and without a diagnosis of diabetes and among subpopulations at risk. Discuss implications for national diabetes education and for the National Diabetes Education Program (NDEP) in particular. METHODS: Three population-based NDEP National Diabetes Surveys (2006, 2008, and 2011) collected information on diabetes knowledge, education, and self-management; perceived and actual risk of diabetes; and lifestyle changes. RESULTS: Since 2006, U.S. adults significantly advanced their knowledge and awareness of diabetes and prediabetes. Perceived personal risk did not increase among people with prediabetes (PWP) or people at risk. Family history as a risk factor dropped in reported importance, especially among PWP and Hispanics. Diabetes self-management rose modestly, although checking blood sugar significantly declined. Trends in understanding the diabetes and cardiovascular disease link, A1C testing, and adjusted logistic regression results for perceived risk are discussed. DISCUSSION AND IMPLICATIONS: Although diabetes-related knowledge has reached high levels, stagnant perceived risk suggests people at risk are not applying this knowledge to themselves. Future surveys are planned to include additional, specific questions to capture people's movement toward behavior change and to identify where strategic efforts and educational interventions can help promote improved behaviors.

Applying national survey results for strategic planning and program improvement: the National Diabetes Education Program.

Since the 1970s, the federal government has spearheaded major national education programs to reduce the burden of chronic diseases in the United States. These prevention and disease management programs communicate critical information to the public, those affected by the disease, and health care providers. The National Diabetes Education Program (NDEP), the leading federal program on diabetes sponsored by the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), uses primary and secondary quantitative data and qualitative audience research to guide program planning and evaluation. Since 2006, the NDEP has filled the gaps in existing quantitative data sources by conducting its own population-based survey, the NDEP National Diabetes Survey (NNDS). The NNDS is conducted every 2­3 years and tracks changes in knowledge, attitudes and practice indicators in key target audiences. This article describes how the NDEP has used the NNDS as a key component of its evaluation framework and how it applies the survey results for strategic planning and program improvement. The NDEP's use of the NNDS illustrates how a program evaluation framework that includes periodic population-based surveys can serve as an evaluation model for similar national health education programs.

Understanding why some women with a history of gestational diabetes do not get tested for diabetes.

BACKGROUND: The proportion of women with previous gestational diabetes mellitus (GDM) receiving postpartum diabetes testing is far less than desired. Even in health care systems with high testing rates, some women remain untested. We explored what helps and what hinders women to obtain recommended testing. METHODS: In this mixed methods study, we recruited 139 patients with a history of GDM in their most recent pregnancy (6 months to 4.5 years before study enrollment) from a delivery system that had instituted a quality improvement program to increase postpartum diabetes testing rates. We determined whether they had received a postpartum diabetes test according to American Diabetes Association guidelines. Using survey data, we ran logistic regression models to assess correlates of testing status, and we conducted in-depth interviews with 22 women to provide greater context to their survey responses. RESULTS: Of the 139 women, 21 women (15%) did not complete recommended diabetes testing. From the survey data, women who visited a primary care provider had 72% (95% CI, 0.09-0.83) lesser odds of not having been tested. From the qualitative interviews, difficulty fitting testing around work and caregiver demands were the most common reasons for not testing. Untested women interpreted providers' reassurances that diabetes would resolve after delivery and lack of reminders to reschedule missed appointments and to complete diabetes testing as indicators that their physicians were not concerned about their diabetes risk. CONCLUSIONS: Among hard-to-reach women, multiple demands on their time were common explanations for not receiving a postpartum diabetes test. Consistent messages regarding long-term diabetes risk during pregnancy, access to postpartum primary care and convenient lab appointments, and systematic reminders to providers and patients are approaches that, in combination, may influence more resistant women to test.

Validation of self-reported weights and heights in the avoiding diabetes after pregnancy trial (ADAPT).

BACKGROUND: Randomized controlled trials that test the effectiveness of mobile health-based weight loss programs are attractive to participants, funders, and researchers because of the low implementation cost, minimal participant burden, and the ability to recruit participants from longer distances. Collecting weight data from geographically dispersed participants is a challenge. Relying on participant self-report is one approach to data collection, but epidemiologic studies indicate that self-reported anthropometric data may be inaccurate. METHODS: We provided women enrolled in a randomized controlled trial (RCT) of postpartum weight loss after gestational diabetes with a digital scale and training to collect and report weight via a web-based survey. To validate self-reported weights and heights, we visited 30 randomly selected women in their homes, with a reference scale and stadiometer, a mean of 34 days after the self-report. We ran linear regression models to identify characteristics that were associated with underreporting or overreporting of anthropometric measures. RESULTS: Of the 30 women we visited, 11 women (37%) were assigned to the weight loss intervention group and 19 women (63%) were in the control group. Mean age was 38.5 years (SD 4.5). The overall mean difference between participants' self-reported weights and the weights obtained at their home visit was 0.70 kg (+1.92). Women assigned to the intervention group underreported their weight in comparison with the control group by 1.29 kg (95% CI -2.52, -0.06). The overall difference in collected to self-reported height was -0.56 cm (±1.91). No characteristics were associated with underreporting or overreporting of height. CONCLUSIONS: Our research suggests that by providing a digital scale and developing a weight collection protocol, researchers can train women to collect and record their own study weights with reasonable validity. To achieve the level of validity required for clinical trials, researchers should consider additional strategies to assure the validity of the data. TRIAL REGISTRATION: NCT01923350.

Improving adherence to family planning guidelines in Kenya: an experiment.

QUALITY PROBLEM: Research in Kenya in the mid-1990s suggested poor quality family planning services and limited access to services. Clinical guidelines for family planning and reproductive health were published in 1991 and updated in 1997, but never widely distributed. CHOICE OF SOLUTION: Managers and trainers chose intensive, district-level training workshops to disseminate guidelines and update health workers on guideline content and best practices. INTERVENTION: Training workshops were held in 41 districts in 1999. Trainees were instructed to update their untrained co-workers afterwards. As a reinforcement, providers in randomly selected areas received a 'cascade training package' of instructional materials and training tips. Providers in 15 randomly selected clinics also received 'supportive supervision' visits as a second reinforcement. EVALUATION METHODOLOGY: A cluster-randomized experiment in 72 clinics assessed the overall impact of the training and the marginal benefits of the two reinforcing activities. Researchers and trainers created several dozen indicators of provider knowledge, attitudes, beliefs and practices. Binomial and multivariate analyses were used to compare changes over time in indicators and in aggregated summary scores. Data from patient interviews were analysed to corroborate provider practice self-reports. Cost data were collected for an economic evaluation. RESULTS: Post-test data collected in 2000 showed that quality of care and access increased after the intervention. The cascade training package showed less impact than supportive supervision, but the former was more cost-effective. LESSONS LEARNED: Service delivery guidelines, when properly disseminated, can improve family planning practices in sub-Saharan Africa.