Diabetes has quickly become an epidemic in the United States and affects all genders and races. Some ethnic groups are at greater risk for being diagnosed and face devastating health consequences due to poor diabetes self-management. Diabetes self-management education (DSME) is considered to be a positive step toward patient self-efficacy and diabetes management. The benefits of diabetes self-management education can only be realized if patients diagnosed with diabetes not only enroll, but complete the program. The purpose of this research study was to investigate the association between race and gender and dropout rates among participants enrolled in a DSME program. Archival data from a DSME were collected for 352 participants enrolled in the program. A multiple logistic regression was used to analyze whether independent variables of race and gender were predictors of dropout rates. Chi-square was used to explore if there was an association between race and gender and drop-out rates. Results revealed that there was no statistically significant association between race and gender and dropout rates from participants in a DSME program. Positive implications for social change include exploring the reasons participants choose to drop-out of a DSME program and potentially identify those at risk for droppoing out due to challenges and barriers.

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Poorly controlled diabetes is common among the majority of youth with type 1 diabetes and can lead to adverse health outcomes at an early age. There is a need to change this to minimise the risk of negative long-term consequences. The onset of complications from diabetes can be prevented or delayed with good management as demonstrated by blood glucose being kept close to or within the normal range. Diabetes control is challenging for young people due to a combination of physiological and psychological factors. Diabetes control needs to be monitored both at an individual level and also at a population level, in order to optimise health outcomes and provide important information for health service provision. There are gaps in knowledge relating to the current level of diabetes control at a population level and of the epidemiological characteristics of youth with type 1 diabetes in the Canterbury region in New Zealand. There has been no research of this nature in the Canterbury region since 2003. There are also gaps in knowledge and a lack of national and international research that investigates psychosocial characteristics of youth with type 1 diabetes and the impact these may have on diabetes control. There is a potentially promising intervention, namely, Motivational Interviewing (MI), that although previous research investigating it with diabetes has shown some promise, methodological problems have limited the conclusions that can be drawn. This thesis, within the New Zealand context, addresses some of these gaps and adds to the body of knowledge of research concerning diabetes control and youth with type 1 diabetes, and investigates MI intervention for youth with poorly controlled diabetes. The thesis encompasses three studies. The first study is an audit that provides up-to-date information on epidemiological characteristics and clinical outcomes for the youth population with type 1 diabetes residing in the Canterbury region. The second study is a cross-sectional study that investigates the relationship between glycaemic control and key psychosocial characteristics: illness beliefs, self-efficacy, and quality of life in youth with type 1 diabetes in Canterbury. The third study is a longitudinal study that investigates the efficacy of MI as an intervention for youth with poorly controlled type 1 diabetes, and explores its impact on diabetes outcomes using statistical and clinical analyses. The first study showed that from 2003 to 2010 the prevalence of adolescents and young adults with type 1 diabetes in Canterbury has increased; there is therefore an increased demand on health resources. In addition, in 2010 glycaemic control at a population level was in the poorly controlled diabetes range and this had remained unchanged since 2003. This suggests the need for more intensive interventions. The second study found that poor diabetes control in youth with type 1 diabetes is influenced by a number of factors, including negative views on diabetes, lower perceived personal control, higher diabetes-related concerns, and lower levels of worry about complications. These findings provide a new understanding of the importance of balancing worries about diabetes complications and the perception of diabetes as a threatening condition. The third study showed that the MI intervention was generally successful in improving diabetes outcomes – clinical, psychosocial, and behavioural changes were observed. Statistically and clinically significant positive changes were found across multiple variables: glycated haemoglobin (HbA1c), glycaemic variability, adherence, and psychosocial functioning. Taken together, the findings of the three studies indicate that majority of youth with type 1 diabetes in the Canterbury region had poor glycaemic control, which suggests that additional interventions may be required to improve management of their condition, especially interventions targeting psychosocial functioning (e.g., illness perceptions) and diabetes self-management. Motivational Interviewing may be a viable option, and therefore further research into this approach is recommended.

abstract: Type 1 diabetes (T1D) is one of the most common chronic diseases in youth and it has been shown that adolescents have the worst glycemic control of any age group. The objective of this study was to develop, test and evaluate the feasibility of an online intervention (Can-Do-Tude) that uses the principles of motivational interviewing (MI) to deliver tailored diabetes self-management education to adolescents with T1D. Bandura’s efficacy belief system was used to guide the design of this study. The study used a multi-phase, multi-method approach. The first phase (alpha) of this study was a qualitative descriptive design to examine the intervention’s fidelity. Evaluation of performance was conducted by experts in the fields of MI, T1D, adolescence and/or online education. The second phase (beta) was a quantitative descriptive design conducted in order to evaluate feasibility by examining the acceptability (recruitment, retention and satisfaction) and implementation (diabetes self-management self-efficacy) to determine whether the intervention was appropriate for further testing. First phase findings showed that the intervention passed all measures with the content experts (n = 6): it was functional, accurate, usable and secure. Improvements to the intervention were made based on reviewer recommendations. For the second phase 5 adolescents between 14 and 17 were enrolled. Three adolescents completed all 4 weeks of the intervention while 2 completed only 3 weeks. Participants (n = 3) rated satisfaction on a 5-point Likert-type scale ranging from “not at all” satisfied (1) to “very much” satisfied (5). There was a positive response to the intervention (M = 4.28, SD = 0.55). Implementation was measured by a pre- and post-test for diabetes self-management self-efficacy. Participants (n = 3) demonstrated overall improvements in diabetes self-management self-efficacy (Z = -2.952, p = .007). Implications for further Can-Do-Tude research are planned at a metropolitan diabetes center using updated technology including an application platform. Although the sample was small, findings indicate that the intervention can be conducted using a web-based format and there is initial evidence of improvement in self-efficacy for diabetes self-management. / Dissertation/Thesis / Doctoral Dissertation Nursing and Healthcare Innovation 2017

The purpose of this thesis is to study the level of understanding of e-health applications among users with diabetes in Bulgaria, to find out how they use those applications, and to provide knowledge on what m-health applications provide to people with diabetes, and what they actually need. This research used TAM variables combined with Innovation Diffusion Theory to produce knowledge on technology acceptance. Therefore, the factors of relative advantage, compatibility, complexity, trialability and observability will be used to determine perceived usefulness, perceived ease of use and behavior intention to use a technology. This research was intended to gather information on the use of diabetes self-management mobile apps in a standardized manner. The instrument used for the survey, a questionnaire, aimed to provide information on the use and experience of mobile health apps for managing diabetes. The final online survey was completed by 71 participants, 38 of which were female, 28 were male and 7 were of non-specified gender. The introductory stage of the survey showed that most of the respondents were between the ages of 31 to 40 years old (28.2 %), and that the largest part of the population sample has been diabetic for five years (32.4%). By taking into consideration the results, it can be said that 74.6% of relative advantage correspond to very high perceived usefulness on behalf of the respondents. And a score of 53.5% shows that the people who took part in the survey exhibit high perceived ease of use of the mobile applications.  This concludes that initially upon using diabetes self-management applications, the respondent’s exhibit high behavioral intention to do so and due to that the applications are not defined as complex, they are suitable for constant use.

Philosophiae Doctor - PhD / The increased pervasiveness of information communication and technology and increasing internet access creates anticipation for how contemporary technologies can address critical developmental problems. Non-communicable diseases are the leading cause of death globally, even though more than 40% of the deaths are premature and avoidable. Diabetes is such a disease that causes 80% of non-communicable disease deaths in low and middle-income countries. Diabetes is also the leading cause of death in the Western Cape province of South Africa. Diabetes thus constitutes a challenge to achieve Sustainable Development Goal 3 that focuses on health and well-being for all people, at all ages. The potential of technology, such as the use of m-health applications, is recognised as a means to advance the Sustainable Development Goals through supporting health systems in all countries.

Magister Commercii - MCom / Introduction: Diabetes mellitus is a global health problem with a high mortality rate. Self-management is an essential part of diabetes management and it includes self-care behaviour tasks such as healthy eating, being active and taking prescribed medication. In the current digital age, the use of technology for self- management of the disease is an important consideration. As a first step towards this, individuals have to first accept and use the technology. However, the literature indicates low levels of technology use amongst diabetic patients in environments with low socio- economic indicators and amongst minority groups. Previous studies suggest that there are many factors that influence technology acceptance such as economic, social and cultural factors. Mobile health (m-health) received recognition in healthcare literature in recent years and are known for delivering effective and efficient interventions to patients with chronic conditions such as diabetes. An investigation into m-health acceptance for diabetes management is vital as it impacts the achievement of development goals, including the United Nations’ SDG 3. This research posits that the culture of patients is a possible reason for the low acceptance and use of technology. Research based on the proliferation of culture as a determinant for diabetes self-management at an individual level is limited, especially in the South African context. The main research question pursued in the study reported in this thesis is How does culture influence m-health acceptance of diabetic patients in disadvantaged communities? Research design and methodology: Using an interpretivist paradigm, a case study research design provided the basis to collect data from 20 diabetes patients in Mitchells Plain and Strandfontein. The theoretical model that was used as a lens for investigation comprised a juxtaposition of Hofstede’s cultural dimensions and Unified- Theory of Acceptance and Use of Technology 2 (UTAUT2). The analysis of the qualitative data was undertaken with Atlas Ti, using a thematic content analysis process. Results: Eight themes emerged from the data and key results of the study indicate that opinions towards medical practitioners, which reflects power distance has a positive impact on users and non-users. Diabetic patients comply with the opinions of their doctors as they fear disagreeing with them. As such, this may result in having a positive influence on a participant’s ability to adopt and use mobile applications. Caregiver influence, which reflects femininity, has a negative influence on users as a result of diabetic patients being responsible for taking care of their family and others are both home carers and providers for their families. This indicates that patients are more concerned with the quality of their life and family than with the adoption mobile applications. Future work: It is recommended that research should be conducted in other areas in the Western Cape, specifically in the Cape flats to see whether the same sorts of results will be achieved in different communities. This could help policymakers and application developers tailor mobile applications for this target population.

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