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 a variety of providers, while the other population received care from local health departments. Cronbach's coefficient alpha 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 alpha s for the general test and the insulin-use subscale indicate that both are reliable, alpha > or = 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 and the health department samples. This suggests that the test is appropriate for a variety of settings and patient populations.

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). Cronbach's 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.

Community diabetes care. A 10-year perspective.

OBJECTIVE: To compare diabetes care and education at the community level in 1981 and 1991 in order to record progress achieved in the decade of the 1980s, determine if there is a gap that must be closed to reach diabetes-related objectives for 2000, and establish a baseline to which changes stimulated by the Diabetes Control and Complications Trial can be compared. RESEARCH DESIGN AND METHODS: In eight Michigan communities, representative primary-care physicians (61 in 1981; 68 in 1991) and their diabetic patients (428 and 440) were identified. Communities, physicians, and patients were randomly selected. Participating patients were interviewed and examined in their community or home to assess the kind and extent of diabetes care they had been receiving; their metabolic, nutritional, educational, and psychosocial status; their diabetic history and current status; and other related factors. The diabetic status, care, and education of the 1981 community patients were compared with those of patients studied in 1991. RESULTS: Positive changes in diabetes care and education at the community level from 1981 to 1991 were seen in the areas of patient glucose monitoring, insulin administration practices, hypertension control, exercise recommendations in diabetic management; and smoking rates. Negative changes occurred in the percentage of non-insulin-dependent diabetes mellitus (NIDDM) patients receiving diabetes education and frequency of office visits to the patient's primary-care physician. Changes of indeterminate value included a sharp decline in primary diabetes admissions to the hospital and a decrease in the proportion of NIDDM patients managed with insulin. Many other hoped-for changes from 1981 status, such as screening for retinopathy, foot-care practices, and overall metabolic control of diabetes, did not occur. CONCLUSIONS: The decade of the 1980s produced modest, but not impressive, improvements in diabetes care and education at the community level. Progress must be accelerated if the diabetes-related objectives included in the national targets for health promotion and disease prevention for 2000 are to be met.

Guidelines vs practice in the delivery of diabetes nutrition care.

The American Dietetic Association and the American Diabetes Association have published recommendations for the nutrition care of people with diabetes. However, the frequency of this care is rarely documented. As part of a study of diabetes care and education practices, the Michigan Diabetes Research and Training Center collected extensive data from 440 randomly selected adults who receive diabetes care from community physicians. These data provided a basis for comparison between diabetes nutrition care as recommended and as delivered in typical American communities. In this population (mean age = 61 years; 54% women), 89% (393) had non-insulin-dependent diabetes mellitus (NIDDM). Of these, 152 were managed with insulin (NIDDM/I) and 241 were not managed with insulin (NIDDM/NI). Most of the NIDDM/NI group was overweight (71%) and had elevated levels of glycated hemoglobin (62%) and serum cholesterol (53%). Yet they were significantly less likely than those with NIDDM/I to see a dietitian. The most frequently reported reason for not seeing a dietitian was that a physician had not referred them (53%). More than 90% of those with NIDDM/I or NIDDM/NI who were referred to a dietitian saw one. Because this population was from randomly selected communities, physicians, and patients, the results are probably generalizable to other regions of the United States. This study shows that in community practice, insulin use is the primary marker of the need for nutrition intervention, and the lack of physician referral to a dietitian is an important barrier to people receiving recommended diabetes nutrition care.

An assessment of computer use, knowledge, and attitudes of diabetes educators.

A questionnaire to survey attitudes, use, and knowledge of computers was sent to 816 randomly selected members of AADE to determine the degree to which currently available computer resources are used in diabetes education and to investigate the need for future computing resources designed to support diabetes education. Analysis of the data showed that even diabetes educators who use computers infrequently have a generally favorable attitude toward them. Highest use of computers is in noneducational applications, mostly for word processing and record keeping. Most respondents believe that computers have yet to make a major contribution to the teaching and learning process in diabetes education, and few felt adequately prepared for creative use or development of computer applications. Increasing the role of computers in support of patient education will require encouragement and demonstrations of computer efficacy from health care institutions and professional organizations.

The characteristics of early diagnostic hypotheses generated by physicians (experts) and students (novices) at one medical school.

How hypotheses generated at the outset of a physician-patient encounter influence the physician's diagnostic reasoning has received relatively little attention in the literature. Yet, this activity modulates the efficiency and accuracy of the diagnostic process. The authors proposed the theory that physicians (experts) would generate less specific initial diagnostic hypotheses than would students (novices). In 1988 and 1989, the hypotheses generated by 32 practicing physicians and 39 third-year medical students at one medical school were analyzed for number, specificity, and breadth (i.e., range) of diagnoses, and for differences between those generated by the physicians and by the students. The hypotheses were formulated on the basis of the initially available data--chief complaint and its duration, and basic demographic descriptions--from patients in three clinical scenarios. Compared with the physicians, the students generated significantly more hypotheses and significantly more specific hypotheses. There was no significant difference between the groups in the breadths of the hypotheses they selected, that is, the numbers of broad categories of diagnosis covered by individuals' hypotheses.

Community diabetes care in the 1980s.

This is a study of diabetes care and care outcomes for patients under the active care of private physicians. Randomly selected communities, physicians, and patients in Michigan were the subjects of this study. Data on the care practices of physicians and patients and care outcomes were collected from 1980 to 1981 and again in 1985 from eight communities, 61 physicians, and 261 patients. We found that the use of multiple injections of insulin and self-monitoring of blood glucose increased significantly, whereas hospitalizations for diabetes control decreased. The mean glycosylated hemoglobin values for this cohort of patients remained unchanged. The study results suggest that, for patients under the active care of community physicians, modern methods of diabetes care are being implemented, but the results of improved care do not show an impact on blood glucose control as measured by glycosylated hemoglobin values. The study was not designed to establish causation for the decrease in hospitalizations for these patients, but the data suggest that decreases may be more a function of changes in health-care policies rather than changes in patient health.

Psychosocial correlates of survival in diabetes.

The goal of this research was to quantify the relationships between patient survival and a set of explanatory variables in a randomly selected sample of community-based patients with non-insulin-dependent diabetes mellitus (NIDDM). The sample included 343 patients with NIDDM initially entered into the study in 1981-1982 and reexamined in 1985-1986. Mortality data were collected on reexamination in 1985 and updated from death-certificate data through 1 January 1986. The data collected from the patients included demographic and clinical variables, psychosocial variables related to diabetes, measures of physiologic control, hospitalization, and mortality. The Cox proportional-hazards model was used to compute a hazard rate for each individual and to determine risk covariates. The results indicated that the variables most associated with the risk of mortality were patient age, social impact of diabetes, renal function, complexity of diet regimen, and history of smoking. Two of these variables (social impact and complexity of diet regimen) were obtained from the Diabetes Educational Profile completed by all patients on entry to the study. The five predictor variables were more closely related to mortality than diabetes control as measured by HbA1, previous hospital admissions, previous heart attacks, and other physiologic measures frequently used as outcome measures. The only physiologic predictor was renal function.

Psychosocial adjustment to and control of diabetes mellitus: differences by disease type and treatment.

The relationship of diabetic patients' psychosocial adjustment to disease type, treatment mode, and indexes of control was examined in a representative community population. The psychometric properties of the Diabetes Educational Profile (DEP) and its application to psychosocial research in diabetes were also investigated. Findings support the reliability and validity of the DEP. Various measures of psychosocial adjustment were related to diabetes control but the specific relationships depended on the particular aspect of adjustment, the specific measure of diabetes control, and the type of disease and treatment. The findings suggest that analyses that aggregate dissimilar patient groups are subject to misinterpretation due to ecological masking and supressor effects. The results indicate that clinicians and researchers must recognize that patients with different disease types and treatment modes have different norms for psychological adjustment and diabetes control. Further, the particular aspects of psychosocial adjustment associated with diabetes control differ across patient groups.

The validation of a diabetes patient knowledge test.

Diabetes knowledge tests, used in conjunction with measures of patient attitudes and behaviors, can provide a useful basis for assessing educational needs and designing appropriate instructional experiences. Accurate decisions require instruments that measure patient knowledge of diabetes and its management with high reliability and validity. Data obtained from more than 950 administrations of two parallel forms of a Diabetes Patient Knowledge Test have provided documentation of patient knowledge levels, insight into the effectiveness of educational programs, and support for ongoing program revisions. These data have also allowed study of the psychometric properties of the test instruments, including factor structure, reliability, and validity. Each test form has an overall reliability of 0.89 and the forms are of equal difficulty. Five subcomponents (factors) labeled "Carbohydrates," "Blood Sugar," "Basics," "Food Exchanges," and "Insulin Administration" are measured in the tests. Evidence of content, construct, concurrent, and discriminant validity has been demonstrated.

Impact of an education program on perinatal care practices.

Education of health professionals has an important role in improving health care. A media-based, self-instructional, perinatal education program was developed and field tested in rural and urban regions of Michigan. Cognitive tests, chart audits, and consultation/referral times were used to measure the impact on education and patient care. The program effectively increased knowledge and improved patient care practices by physicians and nurses. This study presents evidence that a targeted educational program in a media-based format can significantly improve perinatal care.