Recruitment and retention strategies for a community-based weight management study for multi-ethnic elementary school children and their parents.

This article describes successful recruitment and retention strategies for a community-based weight management study in two school districts in North Carolina. Recruitment and retention on both district and school levels and child and parent levels are discussed. A total of 358 children and 358 parents from eight schools in rural North Carolina participated in a randomized controlled trial to test the effectiveness of a nutrition and exercise education, coping skills training, and exercise intervention. Recruitment and retention at the district and school level included meeting with superintendents and receiving a proper introduction to school principals and consistently clear communication throughout the study. At the school level, relationships were developed with the principal and other key personnel to keep lines of communication open during the study. Recruitment and retention strategies at the child and parent level included allowing adequate time for questions during consent and assent and providing a free nutrition and exercise program, a light meal, homework assistance, child care for other children who came to the program, and transportation vouchers if needed. Successful recruitment and retention strategies at the district and school levels and child and parent levels are important for conducting longitudinal community-based studies.

Perceptions of coronary heart disease risk in African American women with type 2 diabetes: a qualitative study.

PURPOSE: The purpose of this study was to explore the perceptions of coronary heart disease (CHD) risk in a group of southern African American women with type 2 diabetes (T2DM). METHODS: Semistructured interviews were conducted in participants' homes or setting of choice. The interviews were conducted with 6 participants from a larger study of 48 women who were stratified into levels of low, medium, and high perception of CHD risk, with 2 participants in each group. The interviews were analyzed using NVivo software; both investigators recoded and analyzed the data. RESULTS: African American women with T2DM do not believe they are at risk for CHD unless they are told specifically by their primary health care provider that they have heart disease. The African American women in the study expressed that managing their diabetes to prevent heart disease can be overwhelming. Participants identified faith beliefs called not claiming the illness as a reason they did not perceive themselves at risk for CHD. CONCLUSIONS: Not claiming an illness may influence health and preventive behaviors. Many African American women with T2DM may not claim their illness. Diabetes educators should acknowledge and address women's beliefs to create an appropriate plan of care.

Controlled trial of nursing interventions to improve health outcomes of older African American women with type 2 diabetes.

BACKGROUND: Type 2 diabetes affects one in five African American women older than 60 years. These women face distinct challenges in managing diabetes self-care. Therefore, tailored self-care interventions for this population need to be developed and tested. OBJECTIVES: The effectiveness of a tailored, four-visit, in-home symptom-focused diabetes intervention with and without booster telephone calls was compared with an attentional control focused on skills training for weight management and diet. METHODS: African American women (n = 180; >55 years old, Type 2 diabetes mellitus >1 year, HbA1c >7%) were randomly assigned to the intervention or attentional control condition. Half the intervention participants were assigned to also receive a telephone-delivered booster intervention. Participants were evaluated at baseline and 3, 6, and 9 months. RESULTS: : Baseline HbA1 was 8.3 in the intervention group (n = 60), 8.29 in the intervention with booster group (n = 55), and 8.44 in the attentional control condition (n = 59). HbA1c declined significantly in the whole sample (0.57%) with no differences between study arms. Participants in the booster arm decreased HbA1c by 0.76%. Symptom distress, perceived quality of life, impact of diabetes, and self-care activities also improved significantly for the whole sample with no significant differences between study arms. DISCUSSION: Parsimonious interventions of four in-person visits yielded clinically significant decreases in HbA1c. Although the weight and diet program was intended as an attentional control, the positive effects suggest it met a need in this population. Because the contents of both the intervention and the attentional control were effective despite different approaches, a revised symptom-focused intervention that incorporates weight and diet skills training may offer even better results.

Effective recruitment and retention strategies for older members of rural minorities.

PURPOSE: The purpose of this article was to describe effective recruitment and retention strategies used in a community-based intervention study for older, rural African American women with type 2 diabetes. METHODS: The study's design was a randomized control test using a 3-group experimental design in a sample of 180 older, rural African American women (55 years of age and older), with type 2 diabetes. The study employed a range of strategies to successfully recruit and retain older African American women. These strategies were initially developed based on a review of the literature and the investigators' prior experience. They were modified as the research progressed. RESULTS: More than a quarter of the participants were recruited from outpatient clinics. In-person outreach to health care providers was essential to engage and retain their help in recruiting patients. The research team made it easy and rewarding for women to participate in the study by providing a toll-free phone number, culturally appropriate intervention materials, intervention in the home, and incentives. Developing a relationship of trust with participants and the community was critical throughout the study period. Through the use of these strategies, the target enrollment of 180 women was met with 91% retention rate at the completion of the study. CONCLUSION: The use of multiple strategies can enhance recruitment and retention of rural, older African American women into a research study. Strategies are most effective when they build a relationship of trust with participants and the community and make it easy and rewarding for women to participate.

Conceptual model of symptom-focused diabetes care for African Americans.

PURPOSE: Development of a conceptual model and description of its use to guide the content and format of a community-based intervention. CONCEPTUAL MODEL: We developed a symptom-focused model for type 2 diabetes for older African American women based on the UCSF symptom management model. Key concepts in this model are symptom experience, symptom management, and health outcomes. METHODS: Review of literature, intervention protocol. CONCLUSIONS: The symptom-focused conceptual model is an innovative approach to tailoring care to a distinct population and to engaging participants in their own self-care. CLINICAL RELEVANCE: Diabetes is a major cause of morbidity and mortality in African Americans; and diabetes self-management is the cornerstone of care. To better meet the distinct needs of diverse populations and positively affect health outcomes, new tailored approaches should be developed that are culturally sensitive and acceptable.

Outcomes of an intervention to reduce uncertainty among African American women with diabetes.

Poor adjustment to diabetes in older African American women may result from uncertainty, stemming from a lack of information about self-care activities, a complexity of self-care activities, comorbid conditions, and a lack of resources. This study evaluated a telephone intervention to reduce uncertainty (through problem-solving strategies, information, cognitive reframing, and improved patient-provider communication)--namely, to measure its effects on diabetes self-care and psychosocial adjustment. Sixty-eight older African American women were randomly assigned to an experimental group and a control group. The experimental group received the intervention for 4 weeks, and the control group received usual care. Psychosocial adjustment and self-care were measured in all participants at baseline and 6 weeks postbaseline. The experimental group reported increased participation in exercise (self-care component; p < .001) and improvement in psychosocial adjustment (p < .001). Thus, reducing the uncertainty related to diabetes self-care improves self-care exercise, as well as psychosocial adjustment.

Tailoring a diabetes self-care intervention for use with older, rural African American women.

PURPOSE: The purpose of this study was to tailor a diabetes management intervention to the cultural and age-related needs and preferences of older, rural African American women. METHODS: Findings from exploratory research, clinical experience, and review of the literature were used to inform the development of a culture- and function-specific intervention. Findings informed the design of the intervention, format of intervention delivery, format of intervention materials, and training provided to interventionists. Intervention materials were reviewed by a community advisory board, and the intervention was pilot tested with 43 women. RESULTS: The intervention's delivery was tailored to the needs of older African American women through the use of 1-hour, in-home sessions that used a storytelling format to share information. The design of the intervention individualized its content to each woman's symptom experience, self-care practices, and coping strategies. Extensive training sensitized intervention nurses to coping strategies (spirituality, church, family) and barriers to self-care (functional limitations, stress, the multi-caregiver role) that are common among older African American women. Intervention materials were culturally sensitive and in large-print format. CONCLUSIONS: African American women's cultural background may have a strong influence on health behaviors and beliefs. Older women's health behaviors are further influenced by changes in their functional abilities. Therefore, the authors tailored a diabetes self-care management intervention to be specific to older African American women's cultural and functional differences. An initial pilot of the intervention found high levels of participant satisfaction with the intervention, improvements in diabetes self-care practices, and a trend toward greater metabolic control.

Managing uncertainty in diabetes: an intervention for older African American women.

OBJECTIVES: One out of four older African American women (OAAW) may develop diabetes. The disproportionate number of complications suffered by OAAW with diabetes may be due in part to uncertainty about how to manage diabetes and prevent or manage complications. The purpose of this study was to test the efficacy of an individualized psychoeducational diabetes uncertainty management intervention (DM-UMI) directed at managing diabetes-related uncertainties and delivered by a nurse via telephone to OAAW. METHODS: Sixty-eight participants with diabetes were randomly assigned to an experimental or a control group. Participants in the experimental group received the DM-UMI, which was delivered for four weeks. The DM-UMI was composed of four strategies (intervention variables): improving diabetes knowledge, patient-provider communication, problem-solving and cognitive reframing, which were expected to reduce diabetes-related uncertainty (outcome variable). The control group received their usual care. Measurement occurred at two time points for all participants: at Time 1: baseline and at Time 2: 6 weeks post baseline. RESULTS: Despite improvement in all intervention variables only problem-solving (P < .001) was significantly related to decrease in uncertainty (P = .01). CONCLUSION: The study suggests that teaching problem-solving skills and assisting OAAW to apply these skills, via an individualized telephone intervention, may reduce ambiguities about diabetes care.

Type 2 diabetes mellitus.

Type 2 diabetes mellitus (T2DM) is a heterogeneous group of metabolic diseases resulting from defects in insulin secretion, insulin action, or both. It comprises most diagnosed cases of diabetes and disproportionately affects minorities. This article describes the classification of diabetes mellitus; defines the metabolic syndrome; and discusses the diagnosis, risk factors, and screening criteria for T2DM. The pathophysiology of T2DM, its acute and chronic complications, and signs and symptoms are presented, along with a brief overview of treatment.

African American beliefs about diabetes.

In this presentation, a diabetes explanatory model of rural, African American adults at high risk for diabetes is described. Kleinman's explanatory model of illness was used as the organizing framework. African American men and women (N=42), between the ages of 18 and 51, participated. Participants described their knowledge and beliefs about diabetes, preventing diabetes, and whether diabetes could be cured or controlled. A common explanatory model of diabetes was not shared among the participants, and gender and age differences were apparent. Common themes included diabetes "running in families", "eating too much sugar", and "not taking care of yourself" as causes of diabetes. Weight and physical activity or exercise were not seen as contributing to the development of diabetes. Participants were not sure if diabetes could be prevented. These results provide information to address primary prevention of diabetes in this at-risk group.

Complementary and alternative medicine use as health self-management: rural older adults with diabetes.

OBJECTIVE: . This study describes complementary and alternative medicine (CAM) use among rural older adults with diabetes, delineates the relationship of health self-management predictors to CAM therapy use, and furthers conceptual development of CAM use within a health self-management framework. Methods. Survey interview data were collected from a random sample of 701 community dwelling African American, Native American, and White elders residing in two rural North Carolina counties. We summarize CAM use for general use and for diabetes care and use multiple logistic modeling to estimate the effects of health self-management predictors on use of CAM therapies. RESULT: . The majority of respondents used some form of CAM for general purpose, whereas far fewer used CAM for diabetes care. The most widely used CAM categories were food home remedies, other home remedies, and vitamins. The following health self-management predictors were related to the use of different categories of CAM therapies: personal characteristics (ethnicity), health status (number of health conditions), personal resources (education), and financial resources (economic status). Discussion. CAM is a widely used component of health self-management among rural among older adults with diabetes. Research on CAM use will benefit from theory that considers the specific behavior and cognitive characteristics of CAM therapies.

Identifying diabetes knowledge network nodes as sites for a diabetes prevention program.

This paper reports on the methods used and results of a study that identified specific places within a community that have the potential to be sites for a diabetes prevention program. These sites, termed diabetes knowledge network nodes (DKNNs), are based on the concept of socio-spatial knowledge networks (SSKNs), the web of social relationships within which people obtain knowledge about type 2 diabetes. The target population for the study was working poor African Americans, Latinos, and European Americans of both sexes in a small rural southern town who had not been diagnosed with diabetes. Information was collected from a sample of 121 respondents on the places they visited in carrying out their daily activities. Data on number of visits to specific sites, degree of familiarity with these sites, and ratings of sites as places to receive diabetes information were used to develop three categories of DKNNs for six subgroups based on ethnicity and sex. Primary potential sites of importance to one or more subgroups included churches, grocery stores, drugstores, the local library, a beauty salon, laundromats, a community service agency, and a branch of the County Health Department. Secondary potential sites included gas stations, restaurants, banks, and post offices. Latent potential sites included three medical facilities. Most of the DKNNs were located either in the downtown area or in one of two shopping areas along the most used highway that passed through the town. The procedures used in this study can be generalized to other communities and prevention programs for other chronic diseases.

Diabetes beliefs among low-income, white residents of a rural North Carolina community.

CONTEXT: Every social group shares beliefs about health and illness. Knowledge and understanding of these health beliefs are essential for education programs to address health promotion and illness prevention. PURPOSE: This analysis describes the diabetes Explanatory Models of Illness (EMs) of low-income, rural, white Southerners who have not been diagnosed with diabetes. METHOD: In-depth interviews were conducted with low-income white women (n = 19) and men (n = 20) aged 18 to 54 years who resided in a rural Southern town. The tape-recorded interviews were completed by trained interviewers and were transcribed verbatim. Computer-assisted text analysis was used, and all transcripts were coded by 2 investigators. FINDINGS: Although all the participants had heard of diabetes, their EMs were vague and undeveloped. Women were more knowledgeable than men were. Family and heredity were widely believed to be causes, with heredity including genetic and learned behavior components. Participants disagreed about the role of diet and weight in causing diabetes; exercise was not perceived as related to causation. Participants had knowledge of those symptoms, complications, and treatments that could be observed. CONCLUSIONS: These rural, white Southerners did not share well-developed EMs for diabetes, with most having a vague and incomplete understanding of this disease. The diabetes beliefs of these rural Southerners differ significantly from current medical knowledge. To be effective, culturally appropriate primary prevention programs must recognize these lay beliefs.

Symptom-focused management for African American women with Type 2 diabetes: a pilot study.

The purpose of this pilot study was to test the effectiveness of an in-home, nurse-delivered, symptom-focused teaching/counseling intervention with older rural African American women who have type 2 diabetes. Forty-one participants were randomly assigned to either the intervention or the comparison group. Participants in the intervention showed statistically significant improvement in their medication, diet, home glucose monitoring self-care practices, perceptions of quality of life, and distress from symptoms. Both groups evidenced improvement of HbA(1c) levels. The intervention group achieved greater improvement, but the difference was not statistically significant. Participant satisfaction was high. Further studies should look into the cost of the intervention, as compared with that of usual care, and its long-term effects.

Familial roles of older African-American women with type 2 diabetes: testing of a new multiple caregiving measure.

OBJECTIVE: This study describes the development and validation of a new multiple caregiving (MC) measure and examines how familial caregiving relates to family composition and psychosocial factors among older African-American women with type 2 diabetes. RESEARCH DESIGN AND METHODS: The study sample included 345 African-American women with type 2 diabetes who participated in two lifestyle behavior interventions. A new 12-item survey of caregiving perceptions was tested for internal reliability and construct validity of two empirically defined scales (MC-role and MC-barriers). Multiple caregiving (MC) constructs were validated by using baseline measures of diabetes quality of life, social support, stress, diabetes competence, and self-care barriers. Correlational, analysis of variance, and multivariate analyses were used to examine the associations among familial MC variables and psychosocial and household factors. RESULTS: Surveys were completed by 299 (87%) participants who were an average of 60 years of age, with 10 years of diagnosed diabetes and 11 years of education. Both MC-role and MC-barriers scores were positively associated with putting the family's needs first, difficulty saying "no" to family, and the number of adults living in the household. MC-barriers were associated negatively with quality of life, and positively with stress, barriers to diabetes self-care, and negative perceptions of diabetes competence. In a multivariate model, age and difficulty saying "no" to family seeking help were significant independent predictors of MC-barriers. CONCLUSIONS: Findings suggest that a better understanding of African-American women with diabetes in the context of family and caregiving roles may be important to identifying culturally meaningful strategies to improve self-care behaviors.

Primary and specialty medical care among ethnically diverse, older rural adults with type 2 diabetes: the ELDER Diabetes Study.

PURPOSE: Residents in rural communities in the United States, especially ethnic minority group members, have limited access to primary and specialty health care that is critical for diabetes management. This study examines primary and specialty medical care utilization among a rural, ethnically diverse, older adult population with diabetes. METHODS: Data were drawn from a cross-sectional face-to-face survey of randomly selected African American (n=220), Native American (n=181), and white (n=297) Medicare beneficiaries > or =65 years old with diabetes in 2 rural counties in central North Carolina. Participants were asked about utilization of a primary care doctor and of specialists (nutritionist, diabetes specialist, eye doctor, bladder specialist, kidney specialist, heart specialist, foot specialist) in the past year. FINDINGS: Virtually all respondents (99.0%) reported having a primary care doctor and seeing that doctor in the past year. About 42% reported seeing a doctor for diabetes-related care. On average, participants reported seeing 2 specialists in the past year, and 54% reported i seeing >1 specialist. Few reported seeing a diabetes specialist (5.7%), nutritionist (10.9%), or kidney specialist (17.5%). African Americans were more likely than others to report seeing a foot specialist (P < .01), while men were more likely than women to have seen bladder specialist (P = .02), kidney specialist (P = .001), and heart specialist (P = .004), after adjusting for potential confounders. Predictors of the number of specialists seen include gender, education, poverty status, diabetes medication use, and self-rated health. CONCLUSIONS: These data indicate low utilization of specialty diabetes care providers across ethnic groups and reflect the importance of primary care providers in diabetes care in rural areas.

Self-monitoring of blood glucose in a multiethnic population of rural older adults with diabetes.

PURPOSE: The purpose of the study was to describe self-monitoring of blood glucose (SMBG) practices of 698 older adults with type 2 diabetes in the rural Southeast, to identify characteristics differentiating testers from nontesters, and to identify personal and support-related predictors of monitoring frequency. METHODS: The ELDER (Evaluating Long-term Diabetes Self-management Among Elderly Rural Adults) study was a population-based, cross-sectional survey of African American, Native American, and white Medicare recipients > or =65 years with diagnosed diabetes. Data were obtained through in-home interviews. Multiple logistic regression models were used to identify factors associated with SMBG and frequency of monitoring. RESULTS: Seventy-seven percent of respondents practiced SMBG in the previous week; 40% tested every day in that week. No ethnic differences were seen. Significant independent predictors of any SMBG were medication regimen (taking oral agents or insulin with or without oral agents) and health care provider (HCP) recommendation to test. Among those monitoring, significant independent predictors of SMBG frequency were medication regimen, HCP recommendation to test, duration of diabetes, and receiving help with testing, which was negatively associated with monitoring frequency. CONCLUSIONS: Among rural older persons with diabetes, HCP recommendation significantly affected practicing SMBG and SMBG frequency. These findings suggest points of intervention by diabetes educators with this vulnerable population. Further research is needed to determine how older adults use SMBG data in their self-care regimen.

Diabetes meanings among those without diabetes: explanatory models of immigrant Latinos in rural North Carolina.

The prevalence of type 2 diabetes is increasing in the United States, particularly among minority individuals. Primary prevention programs for diabetes must be designed to address the beliefs of the populations they target. Little research has investigated the beliefs of those who do not have diabetes. This analysis uses in-depth interviews collected from Latino immigrants, not diagnosed with diabetes, living in a rural US community. Structured by the explanatory models [EM] of Illness framework, this analysis delineates the EMs of diabetes in this community. A significant number of the participants had little knowledge and few beliefs about diabetes. The EMs of those with knowledge of diabetes were varied, but several beliefs were widely held: (a) diabetes is a serious disease that is based on heredity or is inherent in all persons, (b) diabetes can result from several factors, including strong emotions and lifestyle characteristics (an unhealthy diet, not taking care of oneself), (c) beliefs about strong emotion and the importance of blood are related to diabetes causes, symptoms and treatment, and (d) a major and undesirable outcome of diabetes is weight loss. These results provide information for the design of health programs for the prevention of type 2 diabetes.