In this assignment, you will add the remaining Introductory sections to the proposal. You will incorporate any edits or recommendations provided by your Faculty Project Advisor into this revised worki

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Implementation of Type 2 Diabetes Self-Management Education in an Impoverished Community

Leonne M. Reid

NGR 7911

Dr. Valerie Martinez

University of Central Florida

September 26, 2022

Table of Contents (Draft)

Abstract 3

Background and Significance 4

Description of the Organization 6

Organizational Needs Assessment 6

Local Problem Statement 7

Literature Review and Synthesis and Possible Solutions 7

Search Strategy 7

Inclusion Criteria 8

Quality Appraisal 8

Synthesized Key Findings 9

Interventions Used to Improve the Problem and their Outcomes 9

Peer Support or Coaching or Peer Health Coaching 9

Patient Education 10

Lifestyle Modification Programs 11

Problem-solving or Problem-Solving Therapy 11

Facilitators and Barriers of Implementation of the Interventions Identified 12

References 14

(To be developed later)

Ethnic and racial minority groups in the US, particularly impoverished communities, bear a more significant load from the increasing incidence of type II diabetes , making the disease a primary focus for disparities in healthcare research . T2D is a complicated, dire disease in which the weight of self-care is on the patient. Unfortunately, T2D is among the greatest difficult chronic health conditions to manage and control. The increased demand for the disease management and the incorporation of complicated self-management routines in the day-to-day lives of diabetics has been proven to lead to increased stress, leaving individuals discouraged, frustrated, and overwhelmed. These demands could also cause depression, anxiety, and reduced well-being (Papelbaum et al., 2010). However, patient behaviors such as lifestyle modifications associated with exercise and diet, medication, record keeping, and daily blood glucose monitoring are crucial in effectively managing the disease. This is often referred to as self-management.

Self-management enthusiastically participates in self-care actions to enhance a person’s well-being and behaviors. This considerable burden affects patients from impoverished communities that usually find it challenging to deal with self-management. This is mainly because of cultural, economic, and social barriers, inadequate access to diabetes self-care and self-management resources, and high survival demands among disadvantaged populations . Recent immigrants and refugees might also experience difficulties adhering to diabetes self-management practices due to various factors, including the absence of preventive care, leading to late treatment and diagnosis . Cultural differences in how people perceive the origin and treatment of diabetes might also make it challenging to manage the disease among disadvantaged populations (Heerman & Willis, 2011).

Nonetheless, self-management is the most effective way of managing diabetes among populations that lack access to quality healthcare. Most of these practices require no to little financial resources. For instance, self-management practices require patients to control and monitor their diet, engage in more physical activity, and monitor their glucose levels . Social support systems might address the effects of environmental and economic drawback s by increasing access to social capital, thus promoting self-efficacy behaviors. Nam et al. (2011) state that social support is essential since it is related to the hindrance and facilitation of self-care among patients suffering from chronic diseases like diabetes. Families are the key foundation of social support since they help patients manage their condition successfully.

Ideally, social support is a multifaceted idea that correlates with several social networks (institutional, community-based, occupational, or familial) surrounding a patient. It has a high potential to exert either negative or positive influences on the person’s capability to control the condition independently. A patient’s capacity to use social capital to capitalize on established resources could play a significant responsibility in self-care. They could activate constructive social capital resources by seeking and getting help from substantial people in several social positions, such as family members that understand how to manage the disease, thus minimizing the challenges associated with their poverty status that limit them from addressing the condition effectively. In most cases, some attributes of the health care system affect effective disease self-care, especially among disadvantaged communities for whom the cost and access to healthcare might provide significant barriers to achieving effective self-management.

This paper aims to determine if self-management is effective in controlling and managing type II diabetes in impoverished societies. This organization seeks ways to enhance the health outcomes of persons in disadvantaged populations, and self-management is the cheaper and more effective intervention. Therefore, this strategy in poor communities would help people with diabetes from this region manage the disease because they often struggle with barriers such as lack of financial resources and access to quality health care. Before this organization implements this strategy in managing the disease, it has to conduct thorough research on the efficacy of the intervention to determine whether it will go ahead with the plan.

(To be developed later)

(To be developed later)

An all-inclusive search was performed through Ebscohost utilizing the following databases: PsycInfo, PsycArtiCLES, MEDLINE, Health Source: Nursing/Academic Edition, CINAHL, and Academic Search Complete . The top search terms used include randomized controlled trials, self-management, patient education, self-care, type 2 diabetes, and diabetes mellitus. Only peer-reviewed articles written in English between January 2015 to 2022 were selected. Additionally, the Cochrane Library was looked up for self-management review. The first search yielded 62 peer-reviewed articles abstracted for self-management intervention topics. Forty-six articles were excluded since they failed to meet the inclusion criteria . Besides, they were duplicates . Out of the remaining sixteen articles for review, the themes included patient education, lifestyle modification programs, peer support, and lifestyle adaptation. The reference lists of the selected articles were then analyzed .

Finally, the topics were researched using topics and keywords such as the specific intervention name, self-management, patent education, self-care, type II diabetes, and diabetes mellitus. The assessment of reference lists for the selected articles stretched the date range of this study from 2010 to 2022. At the end of the reviews and search, the ultimate sum of articles included in this analysis was fourteen (14).

Experts in this topic independently screened the selected articles for quality appraisal and inclusion criteria. Once the pieces were screened, the experts met to discuss the quality appraisal and inclusion criteria . For the articles to be included in the official review, they were analyzed using the following inclusion criteria. The article must have:

1. Provided quantitative and qualitative empirical (descriptive, cohort study, quasi-experimental, RCT, systematic review, or meta-analysis) evaluative support.

2. Identified an intervention.

3. Included an outcome variable of self-care and self-management.

4. Included adult respondents with type II diabetes.

5. Operationalized as a psychosocial indicator (such as support, stage of change, depression, stress, or emotional adjustment), physiological indicator (such as cholesterol, HbA1c, weight, blood pressure, blood glucose level), self-management outcomes (such as SBGM pattern, medication, exercise, diet) and knowledge.

To evaluate the quality of the articles selected for this analysis, the studies were graded based on the evidence grading system for the American Diabetes Association (ADA). The reports required to qualify as Grade A (high quality), Grade B (good quality), and Grade C (low quality) to be analyzed. This study used this grading structure to analyze the quality of the articles and settled on the studies that provided high-quality evidence. This is because they provide reliable and valid evidence which could be used to support changes in the nursing practice. Grade C (low quality) articles were also included in the review because even though the evidence provided by these articles is poor, some of these articles offered extra helpful information and insight about some intervention practices. The quality of the articles selected for this review could be summarized as high-quality randomized clinical trials (1), good quality systematic reviews (2), good quality meta-analysis (1), low-quality integrative review (1), high-quality qualitative descriptive study (1), and good quality literature reviews (4) (See Appendix H).

Peer support, peer coaching, and health coaching utilize volunteers or health care providers, often referred to as peer supporters or coaches, to offer self-management care to individuals with the same healthcare condition as them or those they consider their peers (Thom et al. 2013 ). These peers and coaches could include health care professionals, family members, educators, community health workers, and patients. Ideally, peer health coaching is done to connect a patient to other patients that have the same health issues. Regardless of peer support or coaching, the objective is to motivate and engage type II diabetes patients in self-care and self-management. Peer support and coaching interventions have been adequately researched in the disease education. Tang et al. (2011) explains that in diabetes self-management, peers and coaches play multiple roles such as group facilitator, mentor, case manager, educator, cultural translator, and advocate. Peer support and coaching are often delivered by trained professionals and primarily emphasize self-management interventions based on documented curricula and time-limited. Based on efficiency, support and peer health coaching have effectively helped lower HbA1c levels and improve self-management (Powers et al., 2015). Due to such favorable results, peer support and health coaching have received significant interest as effective interventions for the disease self-care.

Diabetes self-management education (DSME) has been the most common and effective strategy for managing diabetes . This intervention program has evolved over the decades to include biopsychosocial treatment models and affective and behavioral tactics to deal with the psychosocial and medical requirements of individuals with type II diabetes . Patient education could be administered in different modalities, to groups or individuals, professionals or peers, in extended or short-term sessions. DSME entails a variety of crucial components which should be maintained to prevent complications related to diabetes- monitoring checks, physical activity, adherence to diet, and treatments. Powers et al. (2015) found that implementing self-management education effectively improves the quality of life for T2D.

Lifestyle modification programs are used to improve health outcomes through behavior and lifestyle changes. Lifestyle modification programs could comprise a variety of topics such as stress management, exercise, diet, and medications . This intervention program has had a long history in managing diabetes because it usually combines interventions targeting behavior modification, exercise, diet, and medication management. Delahanty et al. (2013), Kerrison et al. (2017), and Carpenter, DiChiacchio, & Barker (2019) Lifestyle modification programs such as self-efficacy, healthy diets, and greater exercise have helped patients with type II diabetes manage their weight and control their glycemic and HbA1c levels ( Delahanty et al., 2013; Kerrison et al., 2017; Carpenter, DiChiacchio, & Barker, 2019) .

Problem-solving therapy (PST) is a strategy for behavioral modification used to determine what needs to be done to attain a goal that is not apparent (Schumann et al., 2011). The primary objective of problem-solving therapy is to minimize adverse emotional reactions, enable behavior change, and improve positive emotional responses. Problem-solving therapy entails teaching individuals suffering from a chronic disease how to deal with life issues by breaking them down into two different sections: utilizing problem-solving skills and employing problem-solving orientations to life. Additionally, problem-solving therapy mainly focuses on teaching a patient skills such as recognizing the health issue, defining the problems, comprehending them, setting health objectives associated with the health issue, identifying alternative strategies to solve the health issue, analyzing and selecting the best methods, implementing these alternatives, and analyzing their effort in solving the problem.

Problem-solving therapy (PST) has had an extended history in counselling and clinical mindset to deal with substance abuse, coping skills and stress management, relational and family distress, and several mental health disorders. Additionally, problem-solving therapy has been constantly used within diabetes care and education and is recognized as a crucial skill, intervention, and process in diabetes self- management.

Barriers to type II diabetes self-management include lack of support, shortage of resources, inadequate behavioral beliefs and knowledge, and suffering from health issues. When patients lack support from their families (such as lack of emotional support, taking medications, and eating healthy) and professionals, it interferes with the efficacy of self-management interventions. Some health issues, such as insomnia, physical discomfort, and hyperglycemia, could also interfere with self-care. This is because these issues reduce patient motivation to engage in self-management interventions. Moreover, the shortage of resources, such as limited access to patient education, lack of finances to buy healthy foods, little blood glucose monitoring, and unavailability of hypoglycemic medications.

Lastly, inadequate behavioral beliefs, knowledge, and confusion about taking diabetes medications interfere with the efficacy of diabetes self-management. Shi et al. (2020) found that many diabetic patients did not understand how to use hypoglycemic agents. Many were confused about the medications' side effects, usage, and names, which prevents them from efficiently managing diabetes. Recognizing these barriers is essential in creating effective strategies, including promoting successful self-management, implementing patient-centered care, reinforcing social and medical support, and creating favorable environments. Also, understanding these barriers will help patients understand how they are going to deal with these barriers and educate their families and peers on how they can help them manage the disease on their own.

Carpenter, R., DiChiacchio, T., & Barker, K. (2019). Interventions for self-management of type 2 diabetes: an integrative review. International Journal of Nursing Sciences, 6(1), 70-91.

Delahanty, L. M., Peyrot, M., Shrader, P. J., Williamson, D. A., Meigs, J. B., Nathan, D. M., & DPP Research Group. (2013). Pretreatment, psychological, and behavioral predictors of weight outcomes among lifestyle intervention participants in the Diabetes Prevention Program (DPP). Diabetes care , 36(1), 34-40.

Heerman, W. J., & Wills, M. J. (2011). Adapting models of chronic care to provide effective diabetes care for refugees. Clinical Diabetes, 29(3), 90-95.

Nam, S., Chesla, C., Stotts, N. A., Kroon, L., & Janson, S. L. (2011). Barriers to diabetes management: patient and provider factors. Diabetes research and clinical practice, 93(1), 1-9.

Kerrison, G., Gillis, R. B., Jiwani, S. I., Alzahrani, Q., Kok, S., Harding, S. E., ... & Adams, G. G. (2017). The effectiveness of lifestyle adaptation for the prevention of prediabetes in adults: a systematic review. Journal of diabetes research, 2017.

Papelbaum, M., Lemos, H. M., Duchesne, M., Kupfer, R., Moreira, R. O., & Coutinho, W. F. (2010). The association between quality of life, depressive symptoms and glycemic control in a group of type 2 diabetes patients. Diabetes research and clinical practice, 89(3), 227-230.

Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Hess Fischl, A., ... & Vivian, E. (2015). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes care, 38(7), 1372-1382.

Schumann, K. P., Sutherland, J. A., Majid, H. M., & Hill-Briggs, F. (2011). Evidence-based behavioral treatments for diabetes: problem-solving therapy. Diabetes Spectrum, 24(2), 64-69.

Shi, C., Zhu, H., Liu, J., Zhou, J., & Tang, W. (2020). Barriers to self-management of type 2 diabetes during COVID-19 medical isolation: a qualitative study. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 13, 3713.

Tang, T. S., Funnell, M. M., Gillard, M., Nwankwo, R., & Heisler, M. (2011). Training peers to provide ongoing diabetes self-management support (DSMS): results from a pilot study. Patient education and counseling, 85(2), 160-168.

Thom, D. H., Ghorob, A., Hessler, D., De Vore, D., Chen, E., & Bodenheimer, T. A. (2013). Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. The Annals of Family Medicine, 11(2), 137-144.