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published_or_final_version / Community Medicine / Master / Master of Public Health

No description available.

Although considered a substanially preventable disease, Type 2 diabetes is reaching epidemic status within the Maori population. This study sought to investigate factors that positively and negatively influenced levels of physical activity for Maori within Otepoti/Dunedin, and to discuss ideas and potential initiatives that could increase levels of physical activity and aid in the prevention of Type 2 diabetes. Eighteen Maori (9 males; 9 females) from this rohe (area) participated in a four hour focus group interview (groups of three) and were also invited to attend an evaluation hui. A Maori-centered research orientation was used throughout the research process. Individual transcripts from focus groups, debriefing discussion and content from the evaluation hui were inductively analysed to identify the main themes. The 'active' participants were physically active because of the benefits they attained for health and longevity, and to undertake task-oriented activity such as gathering kai. Barriers to physical activity (i.e., family, work), a contemporary societal shift towards inactivity, and negative personal attitudes and perceptions towards physical activity detrimentally affected levels of physical activity. Initiatives to increase levels of physical activity included community, educational and work-based initiatives. A key element of each proposed initiative was a 'by Maori for Maori' approach, with a focus on strengthening whānau and iwi networks, a comfortable environment and social support. While education was believed to be a key component for Type 2 diabetes prevention, an avoidance barrier and fatalistic attitudes could negatively affect any attempt to prevent Type 2 diabetes and increase levels of physical activity. The results indicated that to strengthen Maori identity, increase levels of physical activity and prevent Type 2 diabetes, positive changes (taking responsibility for health), cultural changes (a shift towards a stronger identity and belief in the taonga [treasure] of being Maori), societal changes ( a more positive view of Maori, better role models and education), and social economic changes (better access to exercise facilities, healthy food and education for those in the lower deprivation indices) were needed.

Type I diabetes has the ability to promote change in the family. In truth, although the child with diabetes is the diagnosed patient, the whole family has diabetes. While the challenges that families have to face are many, families seem to have the ability to “bounce back” (i.e., they have resilience). Research on the construct of resilience, and more specifically, family resilience has surged in recent times. However, South African research on family resilience is limited. This study aimed to explore and describe the factors that facilitate adjustment and adaptation in families that include a child living with Type I diabetes. The Resiliency Model of Stress, Adjustment and Adaptation, developed by McCubbin and McCubbin (2001) served as a framework to conceptualise the families’ adjustment and adaptation process. Non-probability purposive and snowball sampling techniques were employed. Sixteen families participated in this study, providing a total of 31 participants. Participants consisted of the caregivers of a family living with a child between the ages of four and 12 with Type I diabetes. The study was triangular in nature, with an exploratory, descriptive approach. A biographical questionnaire with an open-ended question was used in conjunction with seven other questionnaires to gather data. These questionnaires were: The Family Hardiness Index (FHI), the Family Time and Routine Index (FTRI), the Social Support Index (SSI), the Family Problem-Solving Communication (FPSC) Index, the Family Crises-Oriented Personal Evaluation Scales (F-COPES), the Relative and Friend Support Index, and the Family Attachment and Changeability Index 8 (FACI8). Descriptive statistics were used to describe the biographical information. Quantitative data were analysed by means of correlation and regression analysis, and a content analysis was conducted to analyse the qualitative data. The results of the quantitative analysis indicated three significant positive correlations with the FACI8. These variables were family hardiness (measured by the FHI), family problem-solving communication (measured by the FPSC), and family time and routines (measured by the FTRI). The results of the qualitative analysis revealed that social support, the caregivers’ acceptance of the condition, and spirituality and religion were the most important strength factors that contributed to the families’ adjustment and adaptation. Although the study had a small sample and many limitations, the study could be used as a stepping-stone for future research on resilience in families living with chronic medical conditions and will contribute to family resilience research in the South African context.

The growing pandemic of diabetes mellitus (DM) is continuing to spread around the world with developing countries being most vulnerable. Diabetes mellitus is the direct cause of 5 percent of deaths worldwide at present, with an expected increase of 50percent in the next 10 years. Diabetes mellitus was virtually unknown in Africa at the start of the 20th century but the incidence is expected to increase by 80 percent by 2025. South African estimates indicate that at present there are up to four million people living with DM in South Africa, with an expected rise of 25 percent by 2020. If DM is not adequately controlled, life-threatening complications ensue, resulting in financial, physical and emotional costs both for people living with the condition and for their families. There is also a great financial burden on the state, both directly due to the cost of providing health care and indirectly due to loss of productivity and a reduced tax base. Global initiatives against DM include the Diabetes Strategy for Africa compiled by the International Diabetes Federation and World Health Organization. There are several forms of DM with Type 2 being the most common with an estimated 95% of cases. Optimal glycaemic control is essential for the management of DM, potentially allowing the course of the disease to be slowed or halted. The previous medical model of management of chronic disease has changed to an empowerment approach where the person living with the condition is a partner in the management process. This is particularly true of DM where all aspects of life are affected by the condition. During Phase One of this study, a qualitative, exploratory, descriptive, contextual approach was utilized to explore and describe the experiences of persons living with DM and of diabetes nurse educators who assist them in Nelson Mandela Bay. During Phase Two, a conceptual framework was created and utilized to develop strategies which professional nurses may use in facilitating self-management by persons living with DM. Persons living with DM experience a definite initial experience on diagnosis of DM but gradually gain an acceptance and acknowledgment of their condition. They have definite views on the concept of self-management and experience both positive and negative factors influencing self-management. They also have definite ideas on how professional nurses may assist them in achieving self-management. These findings were confirmed ii by the experiences of the diabetes nurse educators who formed the second group of participants in this study. The ACE approach to self-management of DM consists of an Action Strategy, a Coordination Strategy and an Education Strategy. The ACE approach makes use of grand and functional strategies implemented on the macro (national), meso (provincial) and micro (local) levels to enable the professional nurse to assist persons living with DM to achieve self-management of their condition. Grand strategies need to be implemented on a macro or meso level to enable the professional nurse to function effectively on a micro level. Assisting the patient has to go beyond merely improving knowledge about the condition but has to include individual goal setting as well as problem solving skills and coping strategies as part of a therapeutic relationship between the professional nurse and the person living with DM. The level of personal responsibility achieved by persons living with DM is affected by the memes which they hold regarding their level of health and their ability to address any barriers to self-management which they may experience. Making use of the process of the therapeutic relationship, the professional nurse is able to positively influence the memes held by persons living with DM and assist them in achieving a greater level of personal responsibility. The therapeutic relationship is potentially influenced by all three of the strategies described above. This study provides insight into the experiences of persons living with DM and of the diabetes nurse educators who assist them in Nelson Mandela Bay. Recommendations regarding the implementation of a National Diabetes Policy on a macro level are made, as well as recommendations for nursing practice, education and research. The strategies which were evaluated by an Expert Panel provide a tool for the professional nurse to use while assisting persons living with DM by facilitating the growth of personal responsibility leading to self-management.

Diabetes is a serious health threat that disproportionately affects Hispanics of Puerto Rican heritage. Current evidence supports diabetes prevention programs to change health behaviors in people who are at risk and thus prevent the development of type 2 diabetes. However, few interventions exist for Hispanics, and even fewer have been designed for Puerto Rican adults. A literature review of community-based diabetes prevention programs involving at-risk Hispanics was conducted using a cultural sensitivity framework to determine the state of the science and identify gaps in knowledge regarding diabetes prevention for Puerto Ricans. An integrated theoretical framework was developed using constructs from the extended parallel process model (perceived severity and susceptibility) and social cognitive theory (self-efficacy) to design program components aimed to educate and motivate positive dietary behavior change in Puerto Rican adults. The two key components were a diabetes health threat message and dietary skill building exercises that incorporated spirituality and relevant faith practices, and were culturally-tailored for Puerto Ricans. A pretest-posttest, concurrent mixed methods design was used to test the impact and evaluate feasibility of a diabetes health threat message and skill-building exercises in a sample of Puerto Rican adults. A total of 24 participants enrolled in the study and attended six-weekly meetings that included baseline data collection, a health threat message, dietary skill building exercises, focus group interviews, posttest data collection, and an end-of-study potluck gathering. All of the study participants were Puerto Rican and a majority were female (70.8%), with a mean age of 55.5 years (SD 13.71). Most had a family history of diabetes (n = 21, 87.5%) and believed they were at-risk for the disease (n = 16, 66.7%). Using Wilcoxon matched-pairs signed rank test, significant increases or improvements were found in perceptions of diabetes severity (p < .01), dietary self-efficacy (p = .002), and dietary patterns (p = .02) at posttest in comparison to baseline. Spearman's rank correlations found moderate to strong relationships between the following variables: perceived severity and weight (rs = -.44, p = .03), dietary self-efficacy and dietary patterns (rs = .43, p = .04), dietary self-efficacy and fasting blood glucose levels (rs = - .45, p = .03), and American acculturation and weight (rs = .51, p = .02). The qualitative themes that emerged contributed to our understanding of participants' perspective relative to the health threat message, dietary skill building exercises, and the importance of cultural relevance and spirituality. The data support feasibility of this faith-based intervention that had an attendance rate of 58% and no loss of sample due to attrition. Diabetes prevention interventions for at-risk Puerto Ricans adults that incorporate a faith-based, culturally-tailored health threat message and dietary skill building exercises may help educate those who are at-risk and motivate lifestyle behavior change to prevent the development of diabetes. Further faith-based, culturally-tailored diabetes prevention research is indicated for Puerto Rican adults.

Type 2 diabetes is a metabolic disease marked by an abnormally high level of glucose (sugar) in the blood. Type 2 diabetes is now reaching an epidemic level with more than 30 million adults in the United States afflicted and 1.5 million new cases documented every year. Type 2 diabetes is linked with obesity, heart disease, hypertension, and liver disease, and individuals with type 2 diabetes are at an increased risk for heart failure, stroke, blindness, kidney failure, and amputation. According to the Centers for Disease Control and Prevention, more than $245 billion was spent in the United States in 2012 on medical expenses related to diabetes and despite that, nearly a quarter of a million Americans are losing their lives due to this disease each year. Indeed, type 2 diabetes is one of the leading causes of death in the United States and worldwide; its prevalence has almost doubled in the last 35 years, from 4.7% of the total population in 1980 to 8.5% in 2014. Consequently, more than 400 million people are at high risk for severe health problems and complications, poor quality of life, and early death. Research such as the Diabetes Prevention Program (DPP), the Finnish Diabetes Prevention Study (DPS), the Vesterbotten Intervention Program (VIP), and the Diabetes Prevention Program Outcome Study (DPPOS) suggests that type 2 diabetes can be delayed, and even prevented, with a lifestyle behavioral modification program that includes healthy eating and/or exercise. Therefore, focus has been shifted from management to prevention. An early manifestation of dysfunction in the progression of type 2 diabetes is insulin resistance, a metabolic impairment associated with obesity. Indeed, it is estimated that ~90% of people with type 2 diabetes also are obese. The link between insulin resistance and obesity is well-established; however, the mechanistic basis(es) underpinning this link is/are still debated with multiple candidate molecules, systems, and pathways potentially involved. One theory that has gained traction in recent years suggests that type 2 diabetes, and the insulin-resistant state that predates it, are rooted in dysfunctional lipid metabolism (i.e., a reduced capacity to use lipid for energy production in circumstances where lipid would be preferred, such as in the basal fasting condition, after a high-fat meal, and during light- and moderate-intensity exercise). However, there are conflicting findings regarding the degree to which the ability to oxidize lipid during these circumstances is compromised for individuals with the overweight/obesity that is associated with the disease progression. The reason(s) for this ambiguity is/are unclear but might have to do with a number of factors that were poorly controlled when substrate selectivity (i.e., lipid vs. carbohydrate oxidation rates) were compared between normal-weight individuals and those with the overweight/obese condition. These include: (a) acute energy balance and macronutrient composition of the diet; (b) the intensity and duration of the exercise bout; and (c) subject characteristics including the amount of muscle tissue they possess, their cardiorespiratory fitness level, and, perhaps most importantly, their insulin-sensitivity state. The purpose of this dissertational work is to: (a) help to resolve this ambiguity by identifying the degree to which conflicting results that have been reported might be explained by factors that were left unaccounted for and/or inadequately controlled in previous research; and (b) compare substrate selectivity in normal-weight individuals and those with the overweight/obesity condition during a physiologically-equivalent exercise challenge with the aforementioned factors rigidly controlled.