published_or_final_version / Public Health / Master / Master of Public Health

Physical inactivity has been widely regarded as a leading cause of non-communicable chronic diseases such as type 2 diabetes mellitus (T2DM) and hypertension. Physical activity (PA) has been shown to be the most effective self-care behaviour in alleviating T2DM, an incurable chronic disease. Previous behavioural modification programs intended to encourage and maintain PA behaviour among middle-aged and older patients with T2DM have had inconsistent results. PA has remained as a recommended diabetes self-care behaviour with the lowest compliance rate in many regions of the world. This thesis proposes a program focusing on health literacy (HL) as a means to nurture T2DM patients’ ability to navigate, read, understand, process, comprehend and act on health information, and thereby modify PA behaviour. This approach is proposed for three reasons: (1) the flood of available health information of varying quality affects patients’ decision making with regard to self-care behaviour; (2) the high prevalence of low HL in the US, Europe, and Asia affects the comprehension of self-care behaviour programs; (3) because 50% of older T2DM patients are impaired cognitively due to the impact of aging and hence have difficulty in carrying out suitable self-care behaviour without proper guidance. All of these factors can influence the effectiveness of PA behavioural modification programs designed to help middle-aged and older T2DM patients make self-care decisions based on sound health information according to their level of HL. This thesis reviews existing HL-oriented programs and models and validates the instrument used to examine the effects of a culture-, language-, disease- and age-specific, theory-based, HL-oriented program on PA behaviour among middle-aged and older patients with T2DM. In the study, 324 middle-aged and older Chinese T2DM patients recruited from two hospital diabetes centres in Hong Kong were divided randomly into intervention and control groups. The intervention group participated in an HL-oriented program on PA behaviour. The program significantly improved the mean of PA behaviour of patients in the intervention group from a sedentary level (under 1,000 average Metabolic Equivalents/minutes/week; 4463 mean number of steps per week) to an internationally acceptable standard (over 2,000 average METs-minutes/week; 7459 mean number of steps per week), and this improvement was maintained at three- and six-month follow-ups. The PA behaviour of the control group actually subsided. This study showed that a program addressing and nurturing patients’ ability to explore, understand and manage health information on T2DM and PA was effective in improving the PA behaviour of middle-aged and older adults with T2DM. This thesis is the first study to use objective measurements to evaluate the effect of a culture-, language-, disease- and age-specific, theory-based, HL-oriented program on PA behaviour. It extends the generalizability of culture and language-sensitive HL oriented programming from the United States (where previous HL studies were conducted) to China. The study can serve as a model for future investigations of self-care behaviour among patients with different chronic illnesses in various regions of China. / published_or_final_version / Nursing Studies / Doctoral / Doctor of Philosophy

Smoking causes Type II diabetes (T2DM). However, there were limited research on the needs, concerns and intention of smokers with T2DM about quitting smoking. This study aimed to explore the behaviors and perceptions on smoking and quitting smoking in patients with T2DM. I conducted both qualitative and quantitative studies. The qualitative study involved T2DM patients who were current smokers or ex-smokers, and could communicate in Cantonese. Semi-structured focus group and individual in-depth interviews were conducted. The quantitative study was cross-sectional, using a standardized questionnaire to identify the intention to quit smoking, knowledge regarding the health risks of smoking and their determinants in T2DM smokers who (1) were aged 18 years or above; (2) can communicate in Cantonese; (3) had daily consumption of at least 2 cigarettes in the past 30 days; and (4) diagnosed with T2DM for at least 6 months with stable condition. Structured multiphase regression analyses were used to identify factors associated with intention to quit smoking and knowledge on the health impact of smoking. In the qualitative study, I recruited 22 current smokers and 20 ex-smokers with T2DM at data saturation. The current T2DM smokers did not quit smoking because of satisfaction with their current health status, misconceptions of no association between T2DM and smoking, and the perceived hazards of quitting. In contrast, ex-smokers had a positive evaluation of quitting smoking, accepted the quit advice from medical professionals and received more family support. Moreover, psychological addiction and weight gain after smoking cessation were the major barriers for T2DM patients to quit smoking. In the cross-sectional study, I recruited 526 smokers with T2DM from nine outpatient clinics specialized in diabetes. They scored on average 47.5 (95% CI=45.6-49.4) out of 0-100 in knowledge regarding health impact of smoking, and 389 (74%, 95% CI=70.3%-77.8%) of them were in pre-contemplation stage. The multiphase regression analysis showed that T2DM smokers with no intention to quit were those who smoked during alcohol drinking (OR=5.98, 95% CI=1.89-18.98, p=0.002). In contrast, those less likely associated with pre-contemplation stage were those who perceived a worse level of health (OR=0.41, 95%, CI=0.19-0.86, p=0.019), perceived greater importance of quitting (OR=0.67, 95% CI=0.58-0.78, p<0.0001), had higher confidence of quitting (OR=0.77, 95% CI=0.67-0.88, p<0.0001), or had more knowledge regarding health impact of smoking (OR=0.98, 95%, CI=0.97-0.999, p=0.035). In addition, a higher score on Decisional Balance Inventory-Cons of smoking (coefficient=1.61, 95% CI=0.56-2.66, p=0.003) or confidence in quitting was associated with a higher knowledge score (coefficient=1.30, 95% CI=0.59-2.01, p<0.001). Conclusively, this is the first study to assess the smoking behaviors and perceptions in patients with T2DM. Many T2DM smokers were reluctant to quit smoking due to inadequate knowledge of the health impact of smoking. Patient education, weight control and behavioral counseling are suggested as the critical components of an effective smoking cessation intervention for T2DM patients. / published_or_final_version / Nursing Studies / Master / Master of Philosophy

Background and Objectives: In a previous randomized study, we reported the benefits of providing integrated care by the Joint Asia Diabetes Evaluation (JADE) Program consisting of comprehensive assessment (CA) and 3-4 monthly follow up (FU) assessments with personalized feedback reports and decision support on control of cardio-metabolic risk factors through reduced clinical inertia and improved self-care. Further, provision of additional peer support improved psychological well-being and all-cause hospitalization especially in those with negative emotions who tended to have co-morbidities. However, given the multicomponent nature of the program, the differential effects of peer support in different patient subgroups and independent effect of personalized FU reports had not been systematically evaluated.. In this thesis, I used a randomized and case-control design to examine the effects of providing regular FU reports and peer support on metabolic control, psychological health, and all-cause hospitalization in patients with diabetes. / Methods: Between February and December 2013, 1488 Chinese patients with diabetes aged 18-75 years underwent CA using the JADE portal and returned in 4 weeks in groups to receive their personalized CA report with explanation by nurses about their complications, risk factors and treatment targets. Amongst them, I selected 288 high risk patients defined as 1) HbA1c≥8%, 2) obesity (body mass index≥27.5 kg/m² and/or waist≥80cm (women) or ≥90cm (men), and/or 3) chronic kidney disease (CKD, eGFR<60ml/min/1.73m²) and offered them a telephone-based peer support program, to which 144 (50%) agreed (P+ group) and 144 (50%) refused (P- group). Within each group, they were also randomized to receive 2 JADE FU reports by mail after their clinic visits. These FU reports displayed their trends of ABC (HbA1c, BP, LDL-C) control and body weight with individualized reminders for self-care during a 12-month period. In the remaining patients (n=1200), half were randomized to receive 2 FU reports by mail (R+ group: n=600) while half received usual care (R- group: n=600). Amongst patients not offered peer support, 425 patients (50% received FU report) were matched to the P+ group (52% received FU report) on a 3:1 basis by age, gender, diabetes duration, and baseline HbA1c as a control group. The outcome measures were reduction in HbA1c and all-cause hospitalization at month 12. / Results: Amongst patients not offered peer support, after a median (IQR) follow-up period of 575 (519-646) days, the R+ group had greater reduction in HbA1c (mean [95% CI]: -0.24[-0.35,-0.14]% versus -0.15[-0.24,-0.06]%, p=0.030) with similar hospitalization rate and frequency compared with the R- group. Amongst patients offered peer support, the P+ group and P- group had similar baseline clinical and psychological-behavioral parameters. After 530 (463-575) days, the P+ group (n=138) tended to have greater reduction in HbA1c (-0.75[-0.97,-0.52]% versus -0.42[-0.68,-0.15]%, p=0.106) with significant improvements in mental health and quality of life than the P- group (n=131). In the case-control cohort for peer support,the P+ group tended to have greater reduction in HbA1c than the control group (n=425) (-0.75[-0.97,-0.52]% versus -0.49[-0.64, -0.35]%, p=0.119) with lower rate, frequency and length of hospitalization. On multivariable analysis of the entire cohort (n=1488), peer support (β coefficient [95% CI] -0.31[-0.56, -0.06], p=0.015) and receiving FU reports (-0.14[-0.25, -0.04], p=0.009) were independent predictors for reduction in HbA1c. Peer support (OR [95% CI] 0.36[0.16, 0.79], p=0.011) and CKD with FU reports (0.40[0.18, 0.88], p=0.022) were also associated with reduced hospitalization. / Conclusion: In this real-world quality improvement program, both peer support and regular personalized feedback report by mail were associated with reduced HbA1c in patients with diabetes. Peer support was associated with lower risk of hospitalization, while feedback report was associated with reduced hospitalization only in patients with diabetes and comorbid CKD. / 背景及目的：在一項隨機對照研究中，我們發現通過亞洲糖尿病評估計劃JADE提供整合了全面糖尿病併發症篩查（CA）、定期隨訪（FU）評估、個體化回饋報告及決策支持的綜合護理可通过降低臨床惰性，促進自我管理從而改善糖尿病風險因素的控制。在此基礎上，同伴支持可進一步改善患者的心理健康，降低住院率， 并且在有負面情緒的人群中作用尤其明顯。然而，由於綜合護理由多部分組成，個體的作用並未被系統評估。本文分別採用隨機對照和病例對照研究，評估個體化隨訪報告和同伴支持對糖尿病患者代謝控制、心理健康及住院率的作用。 / 研究方法：2013 年2 月至12 月，1488 位年齡18 至75 歲的糖尿病患者進行了CA，並于4 周後領取個體化CA 報告，由護士說明其併發症和危險因子的控制以及治療有無達標。其中，我邀請了288 位有以下高危因素的患者參加一項基於電話的同伴支持計劃：1）糖化血紅蛋白（HbA1c）≥8%；2）肥胖（體重指數≥27.5 kg/m² 和/或女性腰圍≥80cm/男性腰圍≥90cm；和/或3）慢性腎臟病（CKD，腎小球濾過率<60 ml/min/1.73m²）。其中，144 位（50%）同意（P+ 組）參與，144 位（50%）（P- 組）拒絕參與。每組再隨機抽取一半患者郵寄2 份JADEFU 報告。該報告顯示了患者HbA1c、血壓、低密度膽固醇和體重的控制情況，並附有針對自我管理的個體化建議。餘下的1200 位患者中，隨機抽取一半患者（R+ 組，n=600）郵寄2 份JADE FU 報告，另外一半患者常規護理（R- 組，n=600）。未被邀請參加同伴支持計劃的1200 位患者中，425 位（50%有FU 報告）按年齡、性別、病程和基礎HbA1c 與P+組（52%有FU 報告）匹配成為對照組。研究指標為12 個月後HbA1c 和住院率的改變。 / 研究結果：未提供同伴支援的患者中，經過575（519-646）日的隨訪，R+組HbA1c 降低更多（ 均值[95% 置信區間]: -0.24[-0.35,-0.14]% versus-0.15[-0.24,-0.06]%, p=0.030），但住院率與R-組相同。提供同伴支持的患者中，P+組和P-組研究開始時臨床、心理和行為指標皆相似。530（463-575）日後，與P-組比較，P+組有HbA1c 降低更多的趨勢（-0.75[-0.97,-0.52] % versus-0.42[-0.68,-0.15]%, p=0.106），住院率相似，但心理健康和生活品質均有明顯改善。在病例對照研究中，與對照組比較（n=425），P+組（n=142） HbA1c降低更多（-0.92[-1.25, -0.59]% versus -0.39[-0.58, -0.21], p=0.004），且住院率、住院次數和時間皆有明顯降低。採用多變量回歸分析，同伴支持（β 係數[95% 置信區間] -0.31[-0.56, -0.06], p=0.015）和FU 報告（-0.14[-0.25, -0.04], p=0.009）均是降低HbA1c 的獨立預測因子。同伴支持（0.36[0.16, 0.79], p=0.011） 和CKD伴FU 報告（0.40[0.18, 0.88], p=0.022）與住院风险降低明顯相關。 / 結論：在此項品質改進計畫中，同伴支持和定期郵寄個體化隨訪報告均与糖尿病患者的糖化血紅蛋白降低相關。同伴支持伴隨住院风险降低，但個體化隨訪報告僅在糖尿病伴慢性腎臟病患者中与住院风险降低相關。 / Yin, Junmei. / Thesis Ph.D. Chinese University of Hong Kong 2015. / Includes bibliographical references (leaves 209-235). / Abstracts also in Chinese; appendix 4 in Chinese. / Title from PDF title page (viewed on 06, October, 2016). / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only.

Inadequate, expensive health care services for the chronically ill, confront the lay person as one of the major forces in the social movement toward self-care. The purpose of this predictive correlational study was to investigate within a theoretical framework derived from Orem's conceptual model of nursing relationships among family as a social support system, exercise of self-care agency, and health status for the person with a chronic illness. The sample group was 51 chronically ill adults diagnosed with diabetes mellitus who attended diabetic instructions from one of the Central Indiana Hospitals. Findings indicated a weak positive correlation between self-care and cohesion and weak negative correlation between health status and cohesion. Findings also revealed significant differences between male and female for the variables self-care and conflict.Conclusions were that this study supported certain relationships proposed by Orem's conceptual model in nursing. Results can guide diabetics in providing optimal daily self-care. Professionals in the health care arena can utilize the results for educational development and encouragement of self-care agency in the adult diabetic. The family members can also clarify roles in supporting the diabetic adult. / School of Nursing

In severely ill hospitalised patients with diabetes mellitus (type 1 and type 2) there is an increase in metabolic rate. Insulin requirements are increased and glycaemic control becomes more difficult to achieve. The insulin sliding-scale is a form of „top up‟ therapy used to supplement the patients existing hypoglycaemic medication. In 2002, research at Livingstone Hospital found that 14 different sliding scales were used in 38 patients (Du Plessis, 2002: 79). In 2006 the nurses and doctors working in the general medical wards at Livingstone Hospital indicated that they were willing to use a standardised insulin sliding scale protocol (Smith, 2006: 56). Thus the aim of this study was to assess whether a standardised insulin protocol can be effectively implemented. The objectives of the study were to: 1) assess insulin usage via insulin sliding scales prior to the implementation of the standardised insulin protocol; 2) implement the standardised insulin protocol; and 3) reassess insulin usage after the implementation of the standardised insulin protocol. As the study involved evaluating the use of insulin via the insulin sliding scale and the implemented insulin protocol, it occurred in four phases. The preliminary phase entailed obtaining ethical approval. The pre-intervention phase included data collection in the form of a nursing questionnaire and the auditing of patient medical records using a data collection tool. The intervention phase involved education sessions on the new insulin protocol for the nursing staff, and the implementation of a standardised insulin protocol, while the post-intervention phase comprised of post-intervention data collection, which included a nursing questionnaire, a prescribers questionnaire and the auditing of patient medical records using a data collection tool. The overall impression obtained from the comparison between the pre- and post-intervention nursing questionnaire was conflicting; in some aspects the educational intervention was successful in others not. Regardless the indication obtained was that the nursing staff require more in-service training on a more regular basis as a lack of knowledge regarding diabetes mellitus as a disease state may negatively affect patient outcomes. The overall response from the nursing staff towards the insulin protocol was positive. The prescribers‟ response to the insulin protocol was conflicted. The number of correct insulin sliding scale doses administered in the pre-intervention and post intervention phase improved by 5.25 percent. The number of incorrect insulin sliding scale doses administered during the pre- and post -intervention phase decreased by 5.25 percent. These results are positive and may be due to fewer sliding scales being prescribed in the post-intervention phase and the implemented insulin protocol. Only three (5.55%; n=54) inpatients with Type 1 diabetes mellitus were placed on the implemented protocol that is, the basal bolus regime, and rarely were dose adjustments to their insulin made rendering the effectives of the protocol undesirable. Only four (7.40%; n=54) inpatients with Type 2 diabetes mellitus were placed on the implemented protocol that is, an intermediate- to long-acting insulin (Protophane®). However all four patients experienced immediate improvements in their fasting blood glucose levels. These results indicated that by adding an intermediate- to long-acting insulin (Protophane®) to the therapy of a patient with Type 2 diabetes mellitus fasting blood glucose levels decrease. This would improve patient outcomes and decrease the risk of related diabetic complications. These limited results may indicate a clinical inertia on the part of the prescribers. Unfortunately overall the educational intervention was not successful and the implementation of the protocol was not successful and did not yield the desired results.

Thesis (M. A. (Nursing Science)) -- University of Limpopo, 2019 / Background: Non-attendance of diabetic patients at primary health care facilities for scheduled appointments has been identified as one of the most pressing issues in chronic illness, including diabetes mellitus, management and results into uncontrolled illnesses. Diabetes mellitus has an increased mortality and morbidity rate, thus has been identified as the second most frequent killer disease in South Africa. Aim of the study: The purpose of the study is to determine self-management strategies to maintain a healthy life for diabetic patients under treatment in primary health care facilities in the Sekhukhune District. Methods: A qualitative, phenomenological, explorative and descriptive study design was conducted in 5 clinics of the Sekhukhune District in the Elias Motswaledi Municipality in Limpopo Province. Data were collected through one-to-one interviews using semi-structured guide. An non-probability purposive sampling method was used to select participants until data saturation was reached. Data were analysed using Tech’s coding qualitative data analysis approach. Results: The findings of this research reveal that diabetic patients know the importance of adherence to diet. However, they also elaborated on the challenges they face, like inability to afford proper diet and their stress levels. They are aware of predisposing factors and recommend support structures like food parcels as well as adhering to the prescribed treatment. Conclusion and recommendations: Diabetic patients lack self-management strategies to maintain their quality of life when diagnosed with diabetes. Furthermore, the study concludes that diabetics lack encouragement and empowerment from health care workers and their families. The study recommends that diabetic patients adhere to a prescribed diet and treatment and that they could be offered food parcels and taught how to avoid factors that could trigger stress. Additionally, it is recommended that support structures be developed to assist diabetic patients about self-management strategies that they could use in order to maintain a good quality of v life. It is also recommended that the Department of Health employ Home-Based Carers in the facilities to assist diabetic patients with their day-to-day care.

The aim of this study was to explore and describe the experiences of diabetes mellitus patients at the Piggs Peak Hospital in Swaziland, from the time of diabetes diagnosis to living with diabetes, adherence to treatment and implementing diabetes self-care. A descriptive, exploratory, contextual qualitative research was conducted. Data was gathered through semi-structured interviews with 26 participants purposively selected on diabetes days at the hospital. Data was analysed qualitatively. Results revealed that patients present late for diagnosis. Being diagnosed causes psychological distress of varying intensity and duration. Hospital visits are burdensome due to financial and transport challenges, as well as service shortcomings. Self-care activities are difficult due to financial challenges and nonconducive social circumstances at home. Social support is lacking. Diabetes patients fear insulin use and prefer oral tablets. It is concluded that diabetes self-care is burdensome for most patients of the PPH in Swaziland. The service providers, stakeholders, and government need to explore strategies for mitigating effects of various barriers to self-care as revealed in this study. / Health Studies / M.A. (Public Health)

The aim of this study was to explore and describe the experiences of diabetes mellitus patients at the Piggs Peak Hospital in Swaziland, from the time of diabetes diagnosis to living with diabetes, adherence to treatment and implementing diabetes self-care. A descriptive, exploratory, contextual qualitative research was conducted. Data was gathered through semi-structured interviews with 26 participants purposively selected on diabetes days at the hospital. Data was analysed qualitatively. Results revealed that patients present late for diagnosis. Being diagnosed causes psychological distress of varying intensity and duration. Hospital visits are burdensome due to financial and transport challenges, as well as service shortcomings. Self-care activities are difficult due to financial challenges and nonconducive social circumstances at home. Social support is lacking. Diabetes patients fear insulin use and prefer oral tablets. It is concluded that diabetes self-care is burdensome for most patients of the PPH in Swaziland. The service providers, stakeholders, and government need to explore strategies for mitigating effects of various barriers to self-care as revealed in this study. / Health Studies / M.A. (Public Health)

Introduction: Evidences indicate that human immuno-deficiency virus (HIV) and diabetes (DM) impact pregnancy outcomes but no experience on the integrated service delivery of HIV, DM and pregnancy care. This study explored the domains and levels of integration among DM, HIV and pregnancy care to prepare a service delivery model in Ethiopia. Methods: A sequential exploratory mixed method and the integration theoretical framework guided the study. An exploratory qualitative phase used focused group discussion, in-depth interview and observation to explore the level of integration and to refine a questionnaire for the quantitative phase. The data were transcribed and coded for theme-based analysis. The descriptive quantitative phase described HIV, DM and pregnancy care services, and determined the burden of DM among HIV patients and the prevalence of pregnancy and pregnancy outcomes. Data was analysed using Epi-info. The findings were triangulated, discussed and interpreted. Results: Seven themes were generated: joint plan, shared budget, monitoring system, structural location, the need of policy guide, the practice of integrated service delivery and suggested integration approaches. A coordinated HIV and pregnancy care services were noted. There was a linkage between diabetes and HIV, and diabetes and pregnancy care. The 1.5% of diabetes among HIV, the low number of pregnancies per a mother in diabetes (1.8) and HIV (1.3); the high adverse pregnancy outcomes among HIV (13.4% abortion, 12.4% low birth weight (LBW), 3.5% pre-term birth, 2.1% congenital malformation) and diabetes (3.2% big baby, 3.2% LBW, 3.1% Cesarean-section); the respective absent and low (16.2%) diabetes screening service at anti-natal and HIV clinics, the absent pregnancy care service for diabetic females justified the development of the tripartite integrated service delivery model of diabetes, HIV and pregnancy care. Conclusions: The model suggests active diabetes screening, evaluation and treatment at HIV and antenatal clinics. It considers the coordination between non-communicable diseases (NCD), HIV and maternal health units. Pregnancy care could be coordinated at HIV and NCD units. Full integration can be practiced between HIV and pregnancy care units. Preparing policy guide, building the capacity of health providers, advocating and piloting the model may be prioritized before the implementation of the model. / Health Studies / D. Litt. et Phil. (Health Studies)