The purpose of this study was to analyze the experiences of self-monitoring of blood glucose (SMBG) usage of adults with type 2 diabetes mellitus (T2DM) who are not using insulin. The sample consisted of 11 women and 8 men who were Caucasian Americans, 38 to 79 years of age. Data were analyzed using the grounded theory method including open and axial coding and the constant comparative method. The theory of "SMBG as a Cue in T2DM Self-Care" emerged from the data and is composed of four categories (a) Engaging, (b) Checking, (c) Responding, and (d) Establishing a Pattern. Engaging marks the beginning of SMBG. Participants began on the recommendation of their physician and monitored between 2-6 times a day. Participants monitored because of curiosity and over time reduced or kept their initial frequency. Checking occurs when the blood glucose is obtained. Two subcategories emerged: Evaluating and Validating. The main items participants evaluated or validated were the effects of foods in relation to blood glucose levels. Responding involves reacting to SMBG. Two subcategories emerged: Taking Action and Experiencing Emotion. Most actions involved changing foods consumed. Participants described feeling conflicted and "being bad" when not following through with an action. Emotions such as blame and fear were experienced when blood glucose levels were higher than normal, while happiness was experienced with normal levels. Establishing a Pattern occurs when participants decide on how often to monitor. Two subcategories emerged: Using Regularly and Using Sporadically. The pattern developed was based on obtaining "normal" blood glucose patterns or on the absence of ill symptoms of T2DM. Healthcare provider disinterest in SMBG and fingertip pain contributed to a decreased monitoring frequency. Participants described cyclical, iterative episodes of Checking, Responding, and varying their established patterns throughout their experiences with monitoring. Participants discussed the value and struggles of SMBG in a T2DM self-care regimen. The theory of SMBG as a Cue in T2DM Self-Care could be used to guide the development of effective intervention strategies to help individuals with T2DM achieve blood glucose control which, in turn, leads to avoidance of ill symptoms and complications of T2DM.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / A prioridade no tratamento do diabetes à garantir ao paciente seu equilÃbrio metabÃlico e mantÃlo assim, propiciando um estado o mais prÃximo possÃvel da fisiologia normal do organismo. Entretanto, um dos problemas que os profissionais de saÃde encontram à a dificuldade dos pacientes seguirem o tratamento de forma regular e sistemÃtica, pois estes frequentemente sÃo portadores de outras condiÃÃes mÃrbidas, fazendo uso de vÃrias medicaÃÃes alÃm das especÃficas para o diabetes. Este fato dificulta a adesÃo e o uso correto dos esquemas propostos. O objetivo deste estudo foi investigar as caracterÃsticas de adesÃo terapÃutica de portadores de Diabetes mellitus atendidos na rede pÃblica de saÃde no municÃpio de Fortaleza, Cearà e seus fatores relacionados. Foi realizado um estudo transversal, onde foram incluÃdos 140 pacientes atendidos do AmbulatÃrio de Diabetes do Hospital UniversitÃrio Walter CantÃdio (HUWC) e 116 pacientes do Centro de SaÃde AnastÃcio MagalhÃes (CSAM) no ano de 2010, selecionados de forma sequenciada. Para mensurar a prevalÃncia da nÃo adesÃo ao tratamento foi empregado o mÃtodo do autorrelato e considerado adesÃo quando o paciente fazia uso de pelo menos 90% do tratamento proposto. Na anÃlise dos dados foram utilizados o teste de Kalmogorov-Smirnov, teste t de Student, kendall tau b e o coeficiente de contingÃncia, com nÃvel de significÃncia estatÃstica de 5% (p<0,05), utilizando-se o software SPSS (Z14.0). Dos 256 pacientes, houve predomÃnio do sexo feminino (66,8%), casados (53,5%), aposentados (39,1%), com ensino fundamental incompleto (32,4%) e renda familiar mÃdia de 1 salÃrio mÃnimo (39,8%). Quanto à doenÃa, 93,7% possuÃam diabetes tipo 2, com uma mÃdia de 10 anos de diagnÃstico, 75,4% tambÃm eram hipertensos e a principal complicaÃÃo crÃnica encontrada foi a retinopatia (35,9%). As associaÃÃes medicamentosas foram prevalentes entre os pacientes (50,4%) e as drogas de escolha foram sulfonilureia (36,3%) e metformina (66%). A atividade fÃsica foi referida por 43,8% dos pacientes e a dieta por 57%. A adesÃo ao tratamento medicamentoso foi de 74% no CSAM e 77% no HUWC. Fatores relacionados à relaÃÃo profissional-paciente, como a qualidade e frequÃncia das orientaÃÃes, mostraram-se fortemente associados à adesÃo ao tratamento (p<0,001), assim como, os fatores relacionados à doenÃa, onde pacientes com controle bom ou aceitÃvel do diabetes (p<0,007) e que nÃo possuÃam internaÃÃes obtiveram melhor adesÃo (p<0,018). Quanto à influÃncia do sistema de saÃde, pessoas mais satisfeitas e que melhor qualificaram o serviÃo apresentaram melhor adesÃo (p<0,045). Na anÃlise clÃnica houve predomÃnio do sobrepeso (39,5%) e obesidade (32%). As medidas alteradas de circunferÃncia abdominal (65,6%), cervical (68,8%) e relaÃÃo cintura-quadril (78,1%) estiveram presentes em grande parte dos pacientes do CSAM e HUWC. Os valores antropomÃtricos alterados nÃo apresentaram diferenÃa na anÃlise da adesÃo. Quanto aos exames laboratoriais, em ambos os locais, a maioria dos pacientes que apresentaram adesÃo estava com glicemia de jejum (65,1%), pÃs-prandial (61,7%) e hemoglobina glicada (68,1%) acima dos valores recomendados. Identificou-se um elevado nÃmero de fatores que podem influenciar na adesÃo ao tratamento, sendo um problema frequente na prÃtica clÃnica. As taxas nÃo satisfatÃrias de adesÃo à terapÃutica farmacolÃgica podem justificar possivelmente o mau controle metabÃlico entre os pacientes. Traduzem a necessidade de se ampliar o foco na atenÃÃo integral a estas pessoas.

京都大学 / 0048 / 新制・課程博士 / 博士(人間健康科学) / 甲第18467号 / 人健博第21号 / 新制||人健||2(附属図書館) / 31345 / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 任 和子, 教授 横出 正之, 教授 田村 恵子 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

Self-monitoring of blood glucose (SMBG) can be effective in preventing poor outcomes associated with diabetes mellitus but previous research has identified that SMBG is not being undertaken in line with current recommendations. Guidance informs health professionals to educate patients on how they should self-monitor but very little is know about how patients self-monitor in the real world. In this thesis, a quantitative scoping study is first presented. This study used routine data sources to examine the levels and patterns of self-montoring in different population groups and then proceeded to a larger qualitative study to explore and question what patients are doing in practice in relation to self-monitoring, and why. This involved a qualitative multi-case study of patients, their support people, health care practitioners (HCPs) and patient diaries. Ten individuals and their nominated support people and HCPs formed ten cases among whom 21 in-depth semi-structured interviews were carried out and six patient diaries analysed. The exploratory work was framed around Stones’ version of structuration theory and uncovered a complex linkage of individual motives for monitoring, associated responses and behaviours in relation to the motive, and the underpinning attitudes and beliefs behind the motive. The following key points emerged from the analysis. People have differing relationships with their diabetes and this links with the level of engagement they have with their condition. Resistance to support people and health services was commonly observed. Experiences of diabetes reviews were important, with an identified need for them to feel more like collaboration and less like surveillance. A significant factor was the gaps and limitations in knowledge and understanding around diabetes for patients, relatives, support people and HCPs; and, finally, there was a noted maintenance of blood glucose levels higher than recommended through SMBG in several participants, which stemmed from a fear of hypoglycemic episode. The analysis concluded that although self-monitoring of blood glucose, in theory, and when considered in isolation, is a simple process to undertake, its application in the wider context of self-management and the individual is much more complicated. The process is influenced by many complex factors and generates a variety of responses and behaviours, some not in keeping with good diabetes self-management. There was a significant lack of person-centered approaches to managing diabetes which was, in part, due to existing health systems and processes. Therefore, there is a need to raise awareness of the gaps that exist in terms of such approaches as well as the gaps in knowledge and understanding of individuals with diabetes and those caring for and supporting them. In more specific terms, it is essential to develop and evaluate individual approaches to patients in relation to their self-monitoring and associated self-management in the context of their own lives, which involves the assessment of engagement and understanding around self-monitoring.

Diabetes mellitus is one of the metabolic disorders prevailing all the over world. About 381.8 million people are affected by diabetes mellitus (DM) during 2013 and it is estimated to increase to 80% by 2035. Nephropathy, retinopathy, neuropathy and cardiovascular diseases are common complications arise in the patients suffering from diabetes Type I and Type II. Continuous monitoring of glucose will give greater clinical acumen on glucose metabolism of patients than conventional intensified glucose monitoring. It benefits patients to plan their meals and insulin dosages to prevent hypo-and hyperglycemia. Diabetes is a major cause of chronic kidney disease (CKD). Chronic kidney disease increases the risk of cardiovascular diseases (CVD). CVD and CKD are strongly intertwined. Urea and potassium are the major markers used in the diagnosis of chronic kidney disease and cardiovascular disease, respectively. Continuous monitoring of urea and potassium will help to initiate appropriate medical intervention to decelerate the progression of chronic kidney disease and cardiovascular disease. Conventional invasive blood withdrawal procedure has potential risks like infection, pain and discomfort to the patients. Moreover, invasive techniques deter periodic blood sampling as it requires for frequent vascular puncturing. At present, no medical device is available for continuous monitoring of blood analytes non-invasively. Present investigations aim at developing a non-invasive technique for monitoring blood analytes (glucose, urea and potassium) which have great potential to use as a point of care diagnostics. Interstitial fluid bathes the cells of the body and it is ultrafiltrate of plasma. It contains ions like potassium, sodium, etc., and neutral molecules like glucose, urea, etc. Analytes (glucose, urea and potassium) level in interstitial fluid equilibrates with blood with lag time of 0 – 15 minutes. Reverse iontophoresis is a process in which a small current is applied through the skin to enable the transdermal extraction of interstitial fluid. Reverse iontophoresis is a non-invasive method and it is suitable for developing an integrated system to extract and analyze the extracted analyte. It enables frequent analyte sampling in high risk patients like elderly and paediatric with more comfort than conventional methods. In the present work, investigations are conducted on non-invasive monitoring of blood glucose, urea and potassium using reverse iontophoresis (RI). As part of experimental investigations, in vitro models are developed. In vitro investigations are conducted to optimize the reverse iontophoresis parameters current density and time of extraction. With these optimized parameters, the in vivo investigations are conducted on human subjects. A dedicated instrumentation suitable for extraction of analytes is developed. Screen printed electrochemical glucose sensors suitable for revere iontophoresis applications are developed using mediated carbon ink. Glucose oxidase is immobilized on screen printed sensor using cross linking method. Electrochemical and material characterization studies are conducted on the developed sensors. The obtained results confirm that the suitability of developed sensor can be used for serum glucose measurement as well as for reverse iontophoresis. Screen printed potentiometric urea biosensors are also developed to monitor the blood urea level non-invasively using reverse iontophoresis. The extraction and sensing system consists of a reverse iontophoresis electrodes, a working electrode, and a reference electrode. Unease enzyme is immobilized in the polypyrrole matrix on the working electrode using cyclic voltammetry. The electrochemical and material characterizations are conducted on screen printed sensors. The sensitivity, selectivity and sensing range of sensors show that they have a potential application in reverse iontophoresis applications. The in vitro models are used to evaluate the developed (urea and glucose) sensors. They are further validated by this conducting the clinical investigations on 15 human subjects. A correlation between blood analyte (glucose and urea) level and transdermally extracted analytes (glucose and urea) is established. It is attempted to integrate both the sensors (glucose and urea) and evaluated their performance on human subjects. The effect of potassium present in the stratum corneum of skin during reverse iontophoresis is investigated by conducting in vivo studies on human subjects. Tape stripping technique is used to detect the presence of potassium in stratum corneum. Reverse iontophoresis investigations with and without passive diffusion are also conducted to analyze the effect of potassium in stratum corneum. Skin impedance is measured during reverse iontophoresis in order to study the effect of reverse iontophoreteic current on skin properties. The clinical investigations are conducted on human subjects to validate the performance of the developed sensors (glucose and urea) with the approval of Institute Human Ethical Committee (IHEC), IISc, Bangalore. Non-invasive monitoring of blood analytes (glucose and urea) on human subjects is successfully demonstrated with the indigenously developed sensors through reverse iontophoresis.

Introdução: O processo educativo e de suporte deve ser permanente e compartilhado, tendo o indivíduo com diabetes como o centro de toda a ação. A automonitorização glicêmica é, em geral, a primeira prática de autocuidado ensinada à criança com diabetes mellitus tipo 1 (DM1) em seu processo de autonomia no manejo da doença. Objetivos: Geral: Avaliar a efetividade da oficina educativa no desempenho da técnica de monitorização glicêmica capilar em crianças escolares com diagnóstico de DM1; Específicos: Verificar os Índices de Conformidade do procedimento da técnica de monitorização glicêmica das crianças escolares com DM1 antes e após serem submetidas à oficina educativa e comparar os Índices de Conformidade, pré- e pós-oficina, da técnica de automonitorização glicêmica das crianças com DM1 que serão submetidas à oficina educativa. Método: Trata-se de um estudo quantitativo, quase-experimental, pré-teste e pós-teste. Participaram do estudo 33 crianças escolares, de 6 a 11 anos, com DM1 há mais de um ano, usuárias de dois ambulatórios infantis de endocrinologia de um complexo hospitalar do município de São Paulo. Após a concordância dos pais e o assentimento da criança, foram assinados, respectivamente, o Termo de Consentimento Livre e Esclarecido e o Termo de Assentimento. A coleta de dados foi realizada por meio do emprego dos seguintes instrumentos: 1) Dados sociodemográficos; 2) Perfil de monitorização glicêmica e 3) Passos da técnica de monitorização glicêmica, antes da oficina educativa. Os instrumentos 2 e 3 foram reaplicados um mês e meio após o término da oficina. Resultados: Verificou-se que houve resultados estatísticos significativos para três passos da técnica de automonitorização glicêmica: trocar a lanceta do lancetador (p=0,021), pressionar o local de punção (p=0,057) e desprezar o material utilizado em recipiente adequado para perfurocortantes (p=0,004). A oficina educativa também foi eficaz para provocar mudança de comportamento nas crianças, uma vez que elas conseguiram sair de uma média de conformidade de 5,3 passos corretos da técnica de monitorização, para 6,58 passos, ou seja, passaram a executar um passo a mais em conformidade em relação ao que vinham realizando. Conclusão: A oficina educativa, por meio de atividades lúdicas, foi uma ferramenta eficaz para melhorar o desempenho da execução da técnica de automonitorização glicêmica capilar realizada por crianças escolares com DM1. / Introduction: In the case of diabetes, care must be patient-centered and the educational process and support must be permanent and shared. Blood glucose monitoring is generally the first practice of self-care taught to children with diabetes mellitus type 1 (DM1) to grant them autonomy to manage their disease. Objectives: General: To evaluate the effectiveness of the educational workshop on the performance of the capillary blood glucose monitoring technique in school children diagnosed with DM1; Specific: To check Compliance Indices of the blood glucose monitoring technique of school children with DM1 before and after being subjected to the educational workshop and to compare Compliance Indices, pre- and post-workshop, of the glucose monitoring technique of children with DM1 to be submitted to the educational workshop. Method: This is a quantitative quasi-experimental pretest and posttest study. The study included 33 school children, 6-11 years of age, with DM1 for more than a year, attended at two endocrinology pediatric clinics of a hospital complex in São Paulo. The Informed Consent Form and the Child Assent Form were signed by parents and children, respectively, upon agreeing with the protocol. Data collection was conducted through the use of the following instruments: 1) sociodemographic data; 2) glycemic profile monitoring and 3) steps for the glucose monitoring technique before the educational workshop. Steps 2 and 3 were reapplied six weeks after the end of the workshop. Results: We found that there were statistical significant results for three steps of the self-monitoring blood glucose technique: replacing the lancet of the lancing device (p = 0.021), press the puncture site (p = 0.057) and dispose of the material used in a suitable container for needles and other sharps (p = 0.004). The educational workshop was also effective to promote behavior changes in children, as they were able to move from an average of 5.3 correct steps in the compliance monitoring technique, to 6.58 steps. Therefore, they started to perform one more step correctly than they had previously done. Conclusion: The educational workshop using play activities was an effective tool to improve the performance of the capillary blood glucose monitoring technique performed by school children with DM1.

Introdução: O processo educativo e de suporte deve ser permanente e compartilhado, tendo o indivíduo com diabetes como o centro de toda a ação. A automonitorização glicêmica é, em geral, a primeira prática de autocuidado ensinada à criança com diabetes mellitus tipo 1 (DM1) em seu processo de autonomia no manejo da doença. Objetivos: Geral: Avaliar a efetividade da oficina educativa no desempenho da técnica de monitorização glicêmica capilar em crianças escolares com diagnóstico de DM1; Específicos: Verificar os Índices de Conformidade do procedimento da técnica de monitorização glicêmica das crianças escolares com DM1 antes e após serem submetidas à oficina educativa e comparar os Índices de Conformidade, pré- e pós-oficina, da técnica de automonitorização glicêmica das crianças com DM1 que serão submetidas à oficina educativa. Método: Trata-se de um estudo quantitativo, quase-experimental, pré-teste e pós-teste. Participaram do estudo 33 crianças escolares, de 6 a 11 anos, com DM1 há mais de um ano, usuárias de dois ambulatórios infantis de endocrinologia de um complexo hospitalar do município de São Paulo. Após a concordância dos pais e o assentimento da criança, foram assinados, respectivamente, o Termo de Consentimento Livre e Esclarecido e o Termo de Assentimento. A coleta de dados foi realizada por meio do emprego dos seguintes instrumentos: 1) Dados sociodemográficos; 2) Perfil de monitorização glicêmica e 3) Passos da técnica de monitorização glicêmica, antes da oficina educativa. Os instrumentos 2 e 3 foram reaplicados um mês e meio após o término da oficina. Resultados: Verificou-se que houve resultados estatísticos significativos para três passos da técnica de automonitorização glicêmica: trocar a lanceta do lancetador (p=0,021), pressionar o local de punção (p=0,057) e desprezar o material utilizado em recipiente adequado para perfurocortantes (p=0,004). A oficina educativa também foi eficaz para provocar mudança de comportamento nas crianças, uma vez que elas conseguiram sair de uma média de conformidade de 5,3 passos corretos da técnica de monitorização, para 6,58 passos, ou seja, passaram a executar um passo a mais em conformidade em relação ao que vinham realizando. Conclusão: A oficina educativa, por meio de atividades lúdicas, foi uma ferramenta eficaz para melhorar o desempenho da execução da técnica de automonitorização glicêmica capilar realizada por crianças escolares com DM1. / Introduction: In the case of diabetes, care must be patient-centered and the educational process and support must be permanent and shared. Blood glucose monitoring is generally the first practice of self-care taught to children with diabetes mellitus type 1 (DM1) to grant them autonomy to manage their disease. Objectives: General: To evaluate the effectiveness of the educational workshop on the performance of the capillary blood glucose monitoring technique in school children diagnosed with DM1; Specific: To check Compliance Indices of the blood glucose monitoring technique of school children with DM1 before and after being subjected to the educational workshop and to compare Compliance Indices, pre- and post-workshop, of the glucose monitoring technique of children with DM1 to be submitted to the educational workshop. Method: This is a quantitative quasi-experimental pretest and posttest study. The study included 33 school children, 6-11 years of age, with DM1 for more than a year, attended at two endocrinology pediatric clinics of a hospital complex in São Paulo. The Informed Consent Form and the Child Assent Form were signed by parents and children, respectively, upon agreeing with the protocol. Data collection was conducted through the use of the following instruments: 1) sociodemographic data; 2) glycemic profile monitoring and 3) steps for the glucose monitoring technique before the educational workshop. Steps 2 and 3 were reapplied six weeks after the end of the workshop. Results: We found that there were statistical significant results for three steps of the self-monitoring blood glucose technique: replacing the lancet of the lancing device (p = 0.021), press the puncture site (p = 0.057) and dispose of the material used in a suitable container for needles and other sharps (p = 0.004). The educational workshop was also effective to promote behavior changes in children, as they were able to move from an average of 5.3 correct steps in the compliance monitoring technique, to 6.58 steps. Therefore, they started to perform one more step correctly than they had previously done. Conclusion: The educational workshop using play activities was an effective tool to improve the performance of the capillary blood glucose monitoring technique performed by school children with DM1.