sample research questions on diabetes

357 Diabetes Essay Topics & Examples

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🏆 Best Diabetes Essay Examples & Topics

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• Type 2 Diabetes The two major types of diabetes are type 1 diabetes and type 2 diabetes. Doctor: The first step in the treatment of type 2 diabetes is consumption of healthy diet.
• Adult-Onset Type 2 Diabetes: Patient’s Profile Any immediate care as well as post-discharge treatment should be explained in the best manner possible that is accessible and understandable to the patient.
• Living With a Chronic Disease: Diabetes and Asthma This paper will look at the main effects of chronic diseases in the lifestyle of the individuals and analyze the causes and the preventive measures of diabetes as a chronic disease.
• Leadership in Diabetes Management Nurses can collaborate and apply evidence-based strategies to empower their diabetic patients. The involvement of all key stakeholders is also necessary.
• Diabetes in Adults in Oxfordshire On a national level, Diabetes Research and Wellness Foundation aims to prevent the spread of the decease through research of the causes and effective treatment of diabetes 2 type.
• Case Study of Patient with DKA and Diabetes Mellitus It is manifested by a sharp increase in glucose levels and the concentration of ketone bodies in the blood, their appearance in the urine, regardless of the degree of violation of the patient’s consciousness.
• Intervention Methods for Type 2 Diabetes Mellitus An individual should maintain a regulated glycemic control using the tenets of self-management to reduce the possibility of complications related to diabetes.
• Relation Between Diabetes And Nutrition Any efforts to lessen and eliminate the risk of developing diabetes must involve the dietary habit of limiting the consumption of carbohydrates, sugar, and fats. According to Belfort-DeAguiar and Dongju, the three factors of obesity, […]
• Diabetes Mellitus: Symptoms, Types, Effects Insulin is the hormone that controls the levels of glucose in the blood, and when the pancreas releases it, immediately the high levels are controlled, like after a meal.
• Health Promotion: Diabetes Mellitus and Comorbidities This offers a unique challenge in the management of diabetes and other chronic diseases; the fragmented healthcare system that is geared towards management of short-term medical emergencies often is not well prepared for the patient […]
• Type 2 Diabetes as a Public Health Issue In recent years, a steady increase in the incidence and prevalence of diabetes is observed in almost all countries of the world.
• Diabetes Management: Case Study Type 1 and Type 2 diabetes contrast based on their definitions, the causes, and the management of the conditions. Since the CDC promotes the avoidance of saturated fat and the increase of fiber intake for […]
• Diabetes Mellitus Management in the Elderly Diabetes mellitus is a health complication involving an increase in the concentration in the concentration of blood sugar either due to a failure by cells to effectively respond to the production of insulin in the […]
• A Study of Juvenile Type 1 Diabetes in the Northwest of England The total number of children under seventeen years living with type 1 diabetes in North West England by 2009 was 2,630.
• Diabetes Prevention: The Sanofi-Aventis Leaflet Review Using the Flesh formula, it can be concluded that the leaflet has a good level of readability, but it can be improved in case it is shorter because a few sections of it are better […]
• Gestational Diabetes in a 38-Year-Old Woman The concept map, created to meet B.’s needs, considers her educational requirements and cultural and racial hurdles to recognize her risk factors and interventions to increase her adherence to the recommended course of treatment.B.said in […]
• Type 2 Diabetes Mellitus and Its Implications You call an ambulance and she is taken in to the ED. Background: Jean is still very active and works on the farm 3 days a week.
• Development of Comprehensive Inpatient and Outpatient Programs for Diabetes Overcoming the fiscal and resource utilization issues in the development of a comprehensive diabetes program is essential for the improvement of health and the reduction of treatment costs.
• Healthcare Cost Depending on Chronic Disease Management of Diabetes and Hypertension A sufficient level of process optimization and the presence of a professional treating staff in the necessary number will be able to help improve the indicators.
• Improving Glycemic Control in Black Patients with Type 2 Diabetes Information in them is critical for answering the question and supporting them with the data that might help to acquire an enhanced understanding of the issue under research. Finally, answering the PICOT question, it is […]
• Shared Decision-Making That Affects the Management of Diabetes The article by Peek et al.is a qualitative study investigating the phenomenon of shared decision-making that affects the management of diabetes. The researchers demonstrate the racial disparity that can arise in the choice of approaches […]
• Managing Obesity as a Strategy for Addressing Type 2 Diabetes When a patient, as in the case of Amanda, requires a quick solution to the existing problem, it is necessary to effectively evaluate all options in the shortest possible time.
• Tests and Screenings: Diabetes and Chronic Kidney Disease The test is offered to patients regardless of gender, while the age category is usually above 45 years. CDC1 recommends doing the test regardless of gender and is conducted once or twice to check the […]
• Obesity Management for the Treatment of Type 2 Diabetes American Diabetes Association states that for overweight and obese individuals with type 2 diabetes who are ready to lose weight, a 5% weight reduction diet, physical exercise, and behavioral counseling should be provided.
• COVID-19 and Diabetes Mellitus Lim et al, in their article, “COVID-19 and diabetes mellitus: from pathophysiology to clinical management”, explored how COVID-19 can worsen the symptoms of diabetes mellitus.
• The Importance of Physical Exercise in Diabetes II Patients The various activities help to improve blood sugar levels, reduce cardiovascular cases and promote the overall immunity of the patient. Subsequently, the aerobic part will help to promote muscle development and strengthen the bones.
• Diabetes Education Workflow Process Mapping DSN also introduces the patient to the roles of specialists involved in managing the condition, describes the patient’s actions, and offers the necessary educational materials.
• Diabetes: Treatment Complications and Adjustments One of the doctor’s main priorities is to check the compatibility of a patient’s medications. The prescriptions of other doctors need to be thoroughly checked and, if necessary, replaced with more appropriate medication.
• The Type 2 Diabetes Mellitus PICOT (Evidence-Based) Project Blood glucose levels, A1C, weight, and stress management are the parameters to indicate the adequacy of physical exercise in managing T2DM.
• Chronic Disease Cost Calculator (Diabetes) This paper aims at a thorough, detailed, and exhaustive explanation of such a chronic disease as diabetes in terms of the prevalence and cost of treatment in the United States and Maryland.
• Diabetes Mellitus Epidemiology Statistics This study entails a standard established observation order from the established starting time to an endpoint, in this case, the onset of disease, death, or the study’s end. It is crucial to state this value […]
• Epidemiology: Type II Diabetes in Hispanic Americans The prevalence of type II diabetes in Hispanic Americans is well-established, and the search for inexpensive prevention methods is in the limelight.
• Diabetes: Risk Factors and Effects Trends in improved medical care and the development of technology and medicine are certainly contributing to the reduction of the problem. All of the above indicates the seriousness of the problem of diabetes and insufficient […]
• Barriers to Engagement in Collaborative Care Treatment of Uncontrolled Diabetes The primary role of physicians, nurses, and other healthcare team members is to provide patients with medical treatment and coordinate that care while also working to keep costs down and expand access.
• Hereditary Diabetes Prevention With Lifestyle Modification Yeast infections between the fingers and toes, beneath the breast, and in or around the genital organs are the common symptoms of type 2 diabetes.
• Health Equity Regarding Type 2 Diabetes According to Tajkarimi, the number of research reports focusing on T2D’s prevalence and characteristics in underserved minorities in the U. Adapting the program’s toolkits to rural Americans’ eating and self-management habits could also be instrumental […]
• Diabetes Mellitus: Treatment Methods Moreover, according to the multiple findings conducted by Park et al, Billeter et al, and Tsilingiris et al, bariatric surgeries have a positive rate of sending diabetes into remission.
• Diagnosing Patient with Insulin-Dependent Diabetes The possible outcomes of the issues that can be achieved are discussing the violations with the patient’s family and convincing them to follow the medical regulations; convincing the girl’s family to leave her at the […]
• Human Service for Diabetes in Late Adulthood The mission of the Georgia Diabetic Foot Care Program is to make a positive difference in the health of persons living with diabetes.
• Diabetes: Symptoms and Risk Factors In terms of the problem, according to estimates, 415 million individuals worldwide had diabetes mellitus in 2015, and it is expected to rise to 642 million by the year 2040.
• Diabetes: Types and Management Diabetes is one of the most prevalent diseases in the United States caused when the body fails to optimally metabolize food into energy.
• Type 2 Diabetes’ Impact on Australian Society Consequently, the most significant impact of the disease is the increased number of deaths among the population which puts their lives in jeopardy. Further, other opportunistic diseases are on the rise lowering the quality of […]
• Epidemiology of Diabetes and Forecasted Trends The authors note that urbanization and the rapid development of economies of different countries are the main causes of diabetes. The authors warn that current diabetes strategies are not effective since the rate of the […]
• The Aboriginal Diabetes Initiative in Canada The ADI’s goal in the CDS was to raise type 2 diabetes awareness and lower the incidence of associated consequences among Aboriginal people.
• Communicating the Issue of Diabetes The example with a CGM sensor is meant to show that doctors should focus on educating people with diabetes on how to manage their condition and what to do in extreme situations.
• Obesity and Diabetes Mellitus Type 2 The goal is to define the features of patient information to provide data on the general course of the illness and its manifestations following the criteria of age, sex, BMI, and experimental data.
• The Prevention of Diabetes and Its Consequences on the Population At the same time, these findings can also be included in educational programs for people living with diabetes to warn them of the risks of fractures and prevent them.
• Uncontrolled Type 2 Diabetes and Depression Treatment The data synthesis demonstrates that carefully chosen depression and anxiety treatment is likely to result in better A1C outcomes for the patient on the condition that the treatment is regular and convenient for the patients.
• Type 2 Diabetes: Prevention and Education Schillinger et al.came to the same conclusion; thus, their findings on the study of the Bigger Picture campaign effectiveness among youth of color are necessary to explore diabetes prevention.
• A Diabetes Quantitative Article Analysis The article “Correlates of accelerometer-assessed physical activity and sedentary time among adults with type 2 diabetes” by Mathe et al.refers to the global issue of the prevention of diabetes and its complications.
• A Type 2 Diabetes Quantitative Article Critique Therefore, the main issue is the prevention of type 2 diabetes and its consequences, and this paper will examine one of the scientific studies that will be used for its exploration.
• The Diabetes Prevention Articles by Ford and Mathe The main goal of the researchers was to measure the baseline MVPA of participants and increase their activity to the recommended 150 minutes per week through their participation in the Diabetes Community Lifestyle Improvement Program.
• Type 2 Diabetes in Hispanic Americans The HP2020 objectives and the “who, where, and when” of the problem highlight the significance of developing new, focused, culturally sensitive T2D prevention programs for Hispanic Americans.
• Diabetes Mellitus as Problem in US Healthcare Simultaneously, insurance companies are interested in decreasing the incidence of diabetes to reduce the costs of testing, treatment, and provision of medicines.
• Diabetes Prevention as a Change Project All of these queries are relevant and demonstrate the importance of including people at high risk of acquiring diabetes in the intervention.
• Evidence Synthesis Assignment: Prevention of Diabetes and Its Complications The purpose of this research is to analyze and synthesize evidence of good quality from three quantitative research and three non-research sources to present the problem of diabetes and justify the intervention to address it.
• Diabetes Mellitus: Causes and Health Challenges Second, the nature of this problem is a clear indication of other medical concerns in this country, such as poor health objectives and strategies and absence of resources.
• Diabetes Mellitus (DM) Disorder Case Study Analysis Thus, informing the patient about the importance of regular medication intake, physical activity, and adherence to diet in maintaining diabetes can solve the problem.
• Diabetes Mellitus in Young Adults Thus, programs for young adults should predominantly focus on the features of the transition from adolescence to adulthood. As a consequence, educational programs on diabetes improve the physical and psychological health of young adults.
• A Healthcare Issue of Diabetes Mellitus Diabetes mellitus is seen as a primary healthcare issue that affects populations across the globe and necessitates the combination of a healthy lifestyle and medication to improve the quality of life of people who suffer […]
• Control of LDL Cholesterol Levels in Patients, Gestational Diabetes Mellitus In addition, some patients with hypercholesterolemia may have statin intolerance, which reduces adherence to therapy, limits treatment efficacy, and increases the risk of CVD.
• Exploring Glucose Tolerance and Gestational Diabetes Mellitus In the case of a glucose tolerance test for the purpose of diagnosing GDM type, the interpretation of the test results is carried out according to the norms for the overall population.
• Type 2 Diabetes Health Issue and Exercise This approach will motivate the patient to engage in exercise and achieve better results while reducing the risk of diabetes-related complications.
• Diabetes Interventions in Children The study aims to answer the PICOT Question: In children with obesity, how does the use of m-Health applications for controlling their dieting choices compare to the supervision of their parents affect children’s understanding of […]
• Diabetes Tracker Device and Its Advantages The proposed diabetes tracker is a device that combines the functionality of an electronic BGL tester and a personal assistant to help patients stick to their diet plan.
• Disease Management for Diabetes Mellitus The selection of the appropriate philosophical and theoretical basis for the lesson is essential as it allows for the use of an evidence-based method for learning about a particular disease.
• Latino People and Type 2 Diabetes The primary aim of the study is to determine the facilitators and barriers to investigating the decision-making process in the Latin population and their values associated with type 2 diabetes.
• Diabetes Self-Management Education and Support Program The choice of this topic and question is based on the fact that despite the high prevalence of diabetes among adolescents in the United States, the use of DSMES among DM patients is relatively low, […]
• Diabetes Mellitus Care Coordination The aim is to establish what medical technologies, care coordination and community resources, and standards of nursing practice contribute to the quality of care and safety of patients with diabetes.
• Healthy Lifestyle Interventions in Comorbid Asthma and Diabetes In most research, the weight loss in cases of comorbid asthma and obesity is reached through a combination of dietary interventions and physical exercise programs.
• PDSA in Diabetes Prevention The second step in the “Do” phase would be to isolate a few members of the community who are affected by diabetes voluntarily.
• Diabetes: Statistics, Disparities, Therapies The inability to produce adequate insulin or the body’s resistance to the hormone is the primary cause of diabetes. Diabetes is a serious health condition in the U.S.and the world.
• Type 2 Diabetes Prescriptions and Interventions The disadvantage is the difficulty of obtaining a universal model due to the complexity of many factors that can affect the implementation of recommendations: from the variety of demographic data to the patient’s medical history.
• Health Education for Female African Americans With Diabetes In order to address and inform the public about the challenges, nurses are required to intervene by educating the population on the issues to enhance their understanding of the risks associated with the conditions they […]
• Diabetes Risk Assessment and Prevention It is one of the factors predisposing patients suffering from diabetes to various cardiovascular diseases. With diabetes, it is important to learn how to determine the presence of carbohydrates in foods.
• Diabetes Mellitus: Preventive Measures In addition to addressing the medical specialists who will be of service in disease prevention, it will emphasize the intervention programs required to help control the spread of the illness.
• “The Diabetes Online Community” by Litchman et al. The researchers applied the method of telephone interviews to determine the results and effectiveness of the program. The study described the value of DOC in providing support and knowledge to older diabetes patients.
• Mobile App for Improved Self-Management of Type 2 Diabetes The central focus of the study was to assess the effectiveness of the BlueStar app in controlling glucose levels among the participants.
• Type 2 Diabetes in Minorities from Cultural Perspective The purpose of this paper is to examine the ethical and cultural perspectives on the issue of T2DM in minorities. Level 2: What are the ethical obstacles to treating T2DM in ethnic and cultural minorities?
• Ethics of Type 2 Diabetes Prevalence in Minorities The purpose of this article analysis is to dwell on scholarly evidence that raises the question of ethical and cultural aspects of T2DM prevalence in minorities.
• Type 2 Diabetes in Minorities: Research Questions The Level 2 research questions are: What are the pathophysiological implications of T2DM in minorities? What are the statistical implications of T2DM in minorities?
• Improving Adherence to Diabetes Treatment in Primary Care Settings Additionally, the patients from the intervention group will receive a detailed explanation of the negative consequences of low adherence to diabetes treatment.
• An Advocacy Tool for Diabetes Care in the US To ensure the implementation and consideration of my plea, I sent a copy of the letter to the government officials so it could reach the president.
• Diabetes and Allergies: A Statistical Check The current dataset allowed us to test the OR for the relationship between family history of diabetes and the presence of diabetes in a particular patient: all variables were dichotomous and discrete and could take […]
• Type 2 Diabetes in Adolescents According to a National Diabetes Statistics Report released by the Centers for Disease Control and Prevention, the estimated prevalence of the disease was 25 cases per 10,000 adolescents in 2017. A proper understanding of T2D […]
• Analysis of Diabetes and Its Huge Effects In the US, diabetes is costly to treat and has caused much physical, emotional and mental harm to the people and the families of those who have been affected by the disease.
• Nursing: Self-Management of Type II Diabetes Sandra Fernandes and Shobha Naidu’s journal illustrates the authors’ understanding of a significant topic in the nursing profession.”Promoting Participation in self-care management among patients with diabetes mellitus” article exposes readers to Peplau’s theory to understand […]
• The Impact of Vegan and Vegetarian Diets on Diabetes Vegetarian diets are popular for a variety of reasons; according to the National Health Interview Survey in the United States, about 2% of the population reported following a vegetarian dietary pattern for health reasons in […]
• “Diabetes Prevention in U.S. Hispanic Adults” by McCurley et al. This information allows for supposing that face-to-face interventions can be suitable to my practicum project that considers measures to improve access to care among African Americans with heart failure diseases. Finally, it is possible to […]
• Diabetes Disease of the First and Second Types It is a decrease in the biological response of cells to one or more effects of insulin at its average concentration in the blood. During the first type of diabetes, insulin Degludec is required together […]
• The Trend of the Higher Prevalence of Diabetes According to the CDC, while new cases of diabetes have steadily decreased over the decades, the prevalence of the disease among people aged below twenty has not.
• Person-Centered Strategy of Diabetes and Dementia Care The population of focus for this study will be Afro-American women aged between sixty and ninety who have diabetes of the second type and dementia or are likely to develop dementia in the future.
• Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services For example, during one of my interactions with the patient, I was asked whether the hospital had the policy to avoid face-to-face interaction during the pandemic with the help of video examinations.
• Diets to Prevent Heart Disease, Cancer, and Diabetes In order to prevent heart disease, cancer, and diabetes, people are required to adhere to strict routines, including in terms of diet. Additionally, people wanting to prevent heart disease, cancer, and diabetes also need to […]
• The Centers for Diabetes’ Risks Assessment In general, the business case for the Centers for Diabetes appears to be positive since the project is closely aligned with the needs of the community and the targets set by the Affordable Care Act.
• Diabetes Mellitus as Leading Cause of Disability The researchers used data from the Centers for Disease Control and Prevention, where more than 12% of older people in the US live with the condition.
• Depression in Diabetes Patients The presence of depression concomitant to diabetes mellitus prevents the adaptation of the patient and negatively affects the course of the underlying disease.
• The Relationship Between Diabetes and COVID-19 After completing the research and analyzing the articles, it is possible to suggest a best practice that may be helpful and effective in defining the relationship between diabetes and COVID-19 and providing a way to […]
• Pre-diabetes and Urinary Incontinence Most recent reports indicate that a physiotherapy procedure gives a positive result in up to 80% of patients with stage I or SUI and mixed form and 50% of patients with stage II SUI.
• Type 1 Diabetes: Recommendations for Alternative Drug Treatments Then, they have to assess the existing levels of literacy and numeracy a patient has. Tailoring educational initiatives to a person’s unique ethnic and cultural background is the basis of cultural competence in patient education.
• Type 2 Diabetes: A Pharmacologic Update Diabetes presents one of the most common diagnoses in causes of ED visits among adults and one of the leading causes of death in the United States.
• Type 2 Diabetes and Its Treatment The main difference in type 2 diabetes is the insensitivity of the body’s cells to the action of the hormone insulin and their insulin resistance.
• Diabetes: Vulnerability, Resilience, and Care In nursing care, resilience is a critical concept that shows the possibility of a person to continue functioning and meeting objectives despite the existing challenges.
• Diabetes Prevention in the United States The analysis of these policies and the other strategies provides the opportunity to understand what role they might play in the improvement of human health. NDPP policy, on the other hand, emphasizes the role of […]
• Teaching Experience: Diabetes Prevention The primary objective of the seminar is to reduce the annual number of diabetes cases and familiarize the audience with the very first signs of this disease.
• Summary of Type 2 Diabetes: A Pharmacologic Update The authors first emphasize that T2D is one of the most widespread diseases in the United States and the seventh leading cause of death.
• Insulin Effects in a Diabetes Person I will use this source to support my research because the perception of diabetes patients on insulin therapy is essential for understanding the impact they cause on the person.
• Diabetes and Medical Intervention In the research conducted by Moin et al, the authors attempted to define the scope of efficiency of such a tool as an online diabetes prevention program in the prevention of diabetes among obese/overweight population […]
• Diabetes Mellitus Type 2 and a Healthy Lifestyle Relationship The advantage of this study over the first is that the method uses a medical approach to determining the level of fasting glucose, while the dependences in the study of Ugandans were found using a […]
• Diabetes and Its Economic Effect on Healthcare For many years, there has been an active increase in the number of cases of diabetes of all types among the global population, which further aggravates the situation.
• Diabetes: Epidemiological Analysis I would like to pose the following question: how can epidemiology principles be applied to these statistics for further improvements of policies that aim to reduce the impact of diabetes on the U.S.population? The limited […]
• Pathogenesis and Prevention of Diabetes Mellitus and Hypertension The hormone is produced by the cells of the islets of Langerhans found in the pancreas. It is attributed to the variation in the lifestyle of these individuals in these two geographical zones.
• Parental Intervention on Self-Management of an Adolescent With Diabetes Diabetes development and exposure are strongly tied to lifestyle, and the increasing incidents rate emphasizes the severity of the population’s health problem.
• Addressing the Needs of Hispanic Patients With Diabetes Similarly, in the program at hand, the needs of Hispanic patients with diabetes will be considered through the prism of the key specifics of the community, as well as the cultural background of the patients.
• Diabetes Issues: Insulin Price and Unaffordability According to the forecast of researchers from Stanford University, the number of people with type 2 diabetes who need insulin-containing drugs in the world will increase by about 79 million people by 2030, which will […]
• Diabetes: Epidemiologic Study Design For instance, the range of their parents’ involvement in the self-management practices can be a crucial factor in treatment and control.
• What to Know About Diabetes? Type 1 diabetes is caused by autoimmune reaction that prevent realization of insulin in a body. Estimated 5-10% of people who have diabetes have type 1.
• Diabetes in Saudi Arabia It is expected that should this underlying factor be discovered, whether it is cultural, societal, or genetic in nature, this should help policymakers within Saudi Arabia create new governmental initiatives to address the problem of […]
• “Medical Nutrition Therapy: A Key to Diabetes Management and Prevention” Article Analysis In the process of MNT application, the dietitian keeps a record of the changes in the main components of food and other components of the blood such as blood sugars to determine the trend to […]
• Nutrition and Physical Activity for Children With a Diabetes When a child understands that the family supports him or her, this is a great way to bring enthusiasm in dealing with the disease.
• Global and Societal Implications of the Diabetes Epidemic The main aim of the authors of this article seems to be alerting the reader on the consequences of diabetes to the society and to the whole world.
• Diabetes and Hypertension Avoiding Recommendations Thus, the promotion of a healthy lifestyle should entail the encouragement of the population to cease smoking and monitor for cholesterol levels.
• Pregnant Women With Type I Diabetes: COVID-19 Disease Management The grounded theory was selected for the given topic, and there are benefits and drawbacks of utilizing it to study the experiences of pregnant women with type I diabetes and COVID-19.
• Current Recommendations for the Glycemic Control in Diabetes Management of blood glucose is one of the critical issues in the care of people with diabetes. Therefore, the interval of the A1C testing should also depend on the condition of the patient, the physician’s […]
• Diabetes Mellitus: Types, Causes, Presentation, Treatment, and Examination Diabetes mellitus is a chronic endocrinologic disease, which is characterized by increased blood glucose concentration.
• Diabetes Problem at Country Walk Community: Intervention and Evaluation This presentation develops a community health nursing intervention and evaluation tool for the diabetes problem affecting Country Walk community.
• The Minority Diabetes Initiative Act’s Analysis The bill provides the right to the Department of Health and Human Services to generate grants to public and nonprofit private health care institutions with the aim of providing treatment for diabetes in minority communities.
• Communication Challenges Between Nurses and Patients With Type 2 Diabetes According to Pung and Goh, one of the limitations of communication in a multicultural environment is the language barrier that manifests itself in the direct interaction of nurses with patients and in the engagement work […]
• Diabetes Type 2 from Management Viewpoint Demonstrate the effects of type 2 diabetes and provide background information on the disease; Discuss the management plans of diabetes centers and critically analyze the frameworks implemented in the hospitals; Examine the existing methodology models […]
• Nursing Plan for the Patient with Diabetes Type 2, HTN, and CAD The health of the population is the most valuable achievement of society, so the preservation and strengthening of it is an essential task in which everyone should participate without exception.
• Diagnosis and Classification of Diabetes Mellitus Diabetes is a serious public health concern that introduces a group of metabolic disorders caused by changes in the sugar blood level.
• Diabetes Mellitus Type II: A Case of a Female Adult Patient In this presentation, we are going to develop a care plan for a 47-year-old woman with a 3-year-old history of Diabetes Mellitus Type 2 (also known as Type II DM).
• Diabetes Insipidus: Disease Process With Implications for Healthcare Professionals This presentation will consider the topic of Diabetes Insipidus (DI) with a focus on its etiology and progress.
• The Nature of Type 1 Diabetes Mellitus Type 1 diabetes mellitus is a chronic autoimmune disease that has an active genetic component, which is identified by increased blood glucose levels, also known as hyperglycemia.
• Imperial Diabetes Center Field Study The purpose is to examine the leadership’s practices used to maintain and improve the quality and safety standards of the facility and, using the observations and scholarly research, offer recommendations for improvement.
• Diabetes Risk Assessment After completing the questionnaire, I learned that my risk for the development of diabetes is above average. Modern risk assessment tools allow identifying the current state of health and possibilities of developing the disease.
• The Role of Telenursing in the Management of Diabetes Type 1 Telemedicine is the solution that could potentially increase the coverage and improve the situation for many t1DM patients in the world.
• Health Issues of Heart Failure and Pediatric Diabetes As for the population, which is intended to participate in the research, I am convinced that there is the need to specify the patients who should be examined and monitored.
• Juvenile Diabetes: Demographics, Statistics and Risk Factors Juvenile diabetes, also referred to as Type 2 diabetes or insulin-dependent diabetes, describes a health condition associated with the pancreas’s limited insulin production. The condition is characterized by the destruction of the cells that make […]
• Diabetes Mellitus: Pathophysiologic Processes The main function of insulin produced by cells within the pancreas in response to food intake is to lower blood sugar levels by the facilitation of glucose uptake in the cells of the liver, fat, […]
• Type 2 Diabetes Management in Gulf Countries One such study is the systematic review on the quality of type 2 diabetes management in the countries of the cooperation council for the Arab states of the Gulf, prepared by Alhyas, McKay, Balasanthiran, and […]
• Patient with Ataxia and Diabetes Mellitus Therefore, the therapist prioritizes using the cushion to the client and persuades the patient to accept the product by discussing the merits of the infinity cushion with a low profile in enabling the customer to […]
• Diabetes Evidence-Based Project: Disseminating Results In this presentation, the involvement of mentors and collaboration with administration and other stakeholders are the preferred steps, and the idea to use social networking and web pages has to be removed.
• The Problem of Diabetes Among African Americans Taking into consideration the results of the research and the information found in the articles, the problem of diabetes among African Americans has to be identified and discussed at different levels.
• Childhood Obesity, Diabetes and Heart Problems Based on the data given in the introduction it can be seen that childhood obesity is a real problem within the country and as such it is believed that through proper education children will be […]
• Hypertension and Antihypertensive Therapy and Type 2 Diabetes Mellitus In particular, Acebutolol impairs the functions of epinephrine and norepinephrine, which are neurotransmitters that mediate the functioning of the heart and the sympathetic nervous system.
• Diabetes: Diagnosis and Treatment The disease is characterized by the pancreas almost not producing its own insulin, which leads to an increase in glucose levels in the blood.
• How to Manage Type 2 Diabetes The article is significant to the current research problem as the researchers concluded that the assessment of metabolic processes in diabetic patients was imperative for adjusting in the management of the condition.
• Type 2 Diabetes Analysis Thus, type 2 diabetes has medical costs, or the difficulties of coping up with the illness, economic ones, which are the financial costs of managing it, and the organizational ones for the healthcare systems.
• Clinical Trial of Diabetes Mellitus On the other hand, type II diabetes mellitus is caused by the failure of the liver and muscle cells to recognize the insulin produced by the pancreatic cells.
• Diabetes: Diagnosis and Related Prevention & Treatment Measures The information presented on the articles offers an insight in the diagnosis of diabetes among various groups of persons and the related preventive and treatment measures. The study identified 3666 cases of initial stages of […]
• Reinforcing Nutrition in Schools to Reduce Diabetes and Childhood Obesity For example, the 2010 report says that the rates of childhood obesity have peaked greatly compared to the previous decades: “Obesity has doubled in Maryland over the past 20 years, and nearly one-third of youth […]
• The Connection Between Diabetes and Consuming Red Meat In light of reporting the findings of this research, the Times Healthland gave a detailed report on the various aspects of this research.
• Synthesizing the Data From Relative Risk Factors of Type 2 Diabetes Speaking of such demographic factors as race, the white population suffers from it in the majority of cases, unlike the rest of the races, the remaining 0.
• Using Exenatide as Treatment of Type 2 Diabetes Mellitus in Adults Kendal et al.analyzed the effects of exenatide as an adjunct to a combination of metformin and sulfonylurea against the combination of the same drugs without the adjunct.
• Enhancing Health Literacy for People With Type 2 Diabetes Two professionals, Andrew Long, a professor in the school of heath care in the University of Leeds, and Tina Gambling, senior lecturer in the school of health care studies from the University of Cardiff, conducted […]
• The Scientific Method of Understanding if Coffee Can Impact Diabetes The hypothesis of the experiment ought to be straightforward and understandable. The control group and the experiment group for the test are then identified.
• Gestational Diabetes Mellitus: Review This is because of the current patterns that show an increase in the prevalence of diabetes in offspring born to mothers with GDM.
• Health Service Management of Diabetes During the task, Fay makes a countless number of short calls and often takes water irrespective of the time of the day or the prevailing weather conditions.
• Necrotizing Fasciitis: Pathophysiology, Role of Diabetes In the event of such an infection, the body becomes desperate to get rid of the intruders. For WBC, zero is given if the count is below 15cells/mm3, one is given if the count lies […]
• The Benefits of Sharing Knowledge About Diabetes With Physicians
• Gestational Diabetes Mellitus – NSW, Australia
• Health and Wellness: Stress, Diabetes and Tobacco Related Problems
• 52-Year-Old Female Patient With Type II Diabetes
• Healthy People Project: Personal Review About Diabetes
• Nursing Diagnosis: Type 1 Diabetes & Hypertension
• Nursing Care For the Patient With Diabetes
• Nursing Care Development Plan for Diabetes and Hypertension
• Coronary Heart Disease Aggravated by Type 2 Diabetes and Age
• Diabetes as the Scourge of the 21st Century: Locating the Solution
• Psychosocial Implications of Diabetes Management
• Gestational Diabetes in a Pregnant Woman
• Diabetes Mellitus: Prominent Metabolic Disorder
• Holistic Approach to Man’s Health: Diabetes Prevention
• Holistic Image in Prevention of Diabetes
• Educational Strategies for Diabetes to Patients
• Diabetes and Obesity in the United Arab Emirates
• Epidemiological Problem: Diabetes in Illinois
• Diabetes as a Chronic Condition
• Managing Diabetes Through Genetic Engineering
• Diabetes, Functions of Insulin, and Preventive Practices
• Treating of Diabetes in Adults
• Counseling and Education Session in Type II Diabetes
• Diabetes II: Reduction in the Incidence
• Community Health Advocacy Project: Diabetes Among Hispanics
• Community Health Advocacy Project: Hispanics With Diabetes
• Hispanics Are More Susceptible to Diabetes That Non-Hispanics
• Rates Diabetes Between Hispanics Males and Females
• Diabetes Mellitus and HFSON Conceptual Framework
• Prince Georges County Community Health Concern: Diabetes
• Fats and Proteins in Relation to Type 2 Diabetes
• Alcohol Interaction With Medication: Type 2 Diabetes
• Diabetes Management and Evidence-Based Practice
• Critical Analysis of Policy for Type 2 Diabetes Mellitus in Australia
• The Treatment and Management of Diabetes
• Obesity and Diabetes: The Enemies Within
• Impact of Diabetes on the United Arab Emirates’ Economy
• Childhood Obesity and Type 2 Diabetes
• Health Nursing and Managing Diabetes
• Diabetes Management: How Lifestyle, Daily Routine Affect Blood Sugar
• Diabetes Management: Diagnostics and Treatment
• Diabetes Mellitus Type 2: The Family Genetic History
• Diabetes Type II: Hormonal Mechanism and Intracellular Effects of Insulin
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• Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes: Medical Terminology Definition
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• v.21(2); 2018 Apr

Diabetes‐related complications: Which research topics matter to diverse patients and caregivers?

Maman joyce dogba.

1 Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec City, QC, Canada

2 Office of Education and Professional Development, Faculty of Medicine, Laval University, Quebec City, QC, Canada

Mylène Tantchou Dipankui

Selma chipenda dansokho, france légaré, holly o. witteman.

3 Centre Hospitalier Universitaire de Québec (CHU de Québec) Research Centre [Health of populations and best health practices axis], Quebec City, QC, Canada

Associated Data

Diabetes is a chronic disease with increasing prevalence worldwide. Although research has improved its treatment and management, little is known about which research topics matter to people living with diabetes, particularly among under‐represented groups.

To explore the importance of research topics among a diverse range of people living with any type of diabetes or caring for someone living with any type of diabetes.

We used a convergent mixed‐method design with quantitative and qualitative aspects. We surveyed a national sample of people living with diabetes and caregivers of people with diabetes, asking them to rate the importance of 10 predetermined important research topics. We also held three focus groups in two major cities to explore research concerns of people who are under‐represented in research.

469 adults (57% men, 42% women) in Canada completed the online survey, indicating that all 10 areas of research mattered to them, with the highest ratings accorded to preventing and treating kidney, eye and nerve complications. Fourteen individuals participated in three focus groups and similarly noted the importance of research on those three complications. Additionally, focus group participants also noted the importance of research around daily management. No new topics were identified.

Conclusions

This study confirmed the importance of research topics among a population of people living with or caring for someone with diabetes. Findings from this study were used to inform the vision for Diabetes Action Canada—a pan‐Canadian Strategy for Patient‐Oriented Research ( SPOR ) Network on diabetes and its complications.

1. INTRODUCTION

Diabetes is a chronic disease with increasing prevalence worldwide. 1 In 2014, an estimated 422 million adults, representing 8.5% of the global population, were living with diabetes. 2 The economic burden of this disease and its complications account for a growing proportion of local and national budgets. 3 , 4 For individuals, diabetes has negative psychosocial consequences that diminish quality of life. 5 While research has improved the treatment and management of diabetes and increased longevity, 6 mismatches between the focus of research and what matters to patients may lead to research waste. 7 , 8 Involving patients in the early stages of research is the first step in reducing such waste, as it helps increase the relevance of topics studied regarding such chronic diseases as diabetes. 9 People living with chronic diseases may develop a high degree of expertise which can provide new insight into how to improve their conditions and self‐care. 10 , 11 The patient perspective may complement that of the clinician and researcher by providing a more holistic interpretation of health and the experience of a health condition. 11

When seeking to involve patients as partners in research, it is critical to avoid reproducing or even exacerbating health inequities. Major disparities persist in the diagnosis, treatment, disease management and health outcomes of groups such as ethnic minorities, immigrants, people living in poverty, people whose mental health require regular follow‐up with a psychiatrist and seniors, all of whom are more vulnerable to diabetes‐related complications. 12 , 13 , 14 , 15 , 16 In spite of these continuing disparities, minority groups continue to be under‐represented in research, and engagement in defining research questions is no exception. Additionally, there is little guidance on how to facilitate the full participation of members of these groups in setting research priorities. 17 , 18 For example, although previous research in the United Kingdom has identified research priorities among people living with type 1 diabetes, those involved were predominantly white and female. 19

This study aimed to involve a national sample of people living with diabetes and caregivers of people living with diabetes in rating the importance of research topics around diabetes‐related complications. We further sought to capture the perspectives of people who are under‐represented in research. Our primary research question was as follows: What topics are most important to people living with or caring for someone living with diabetes regarding disease‐related complications as a means to help better orient future research priorities?

2.1. Study design

We used a multipronged mixed‐methods (QUAN + QUAL) approach with a convergent design 20 to capture what was important to people living with diabetes and caregivers regarding research on diabetes‐related complications. 21 , 22 According to the convergent mixed‐methods design, quantitative and qualitative methods are complementary during data collection, data analysis or both. In our case, we combined 21 the quantitative and qualitative data after we completed both sets of data collection. The study consisted of two components accordingly: (i) quantitative: an anonymous online survey to poll a national sample of people living with diabetes or caregivers of people living with diabetes on the importance of 10 predetermined research topics; and (ii) qualitative: holding focus groups with people living with diabetes who are members of under‐represented groups, in order to explore the views and experiences of those predicted to be under‐represented in the online survey. 23

2.2. Research ethics

This study was approved by the Research Ethics Board of the Centre Hospitalier Universitaire de Québec (Quebec City, approval #: 2016‐2578). In agreeing to follow the link and take the online survey, participants provided implied consent. No survey questions were mandatory, meaning that respondents could skip questions if they wished. No attention filter was included. Prior to each focus group, we described the project and allowed participants to ask questions. Verbal consent of focus group participants was recorded.

2.3. Procedures

2.3.1. online survey.

The online survey included questions on socio‐demographics, the person's experience with diabetes‐related complications and analog scales to rate the importance of 10 pertinent disease‐related complication research topics. These topics were identified in the literature describing previous priority‐setting exercises conducted with people living with type 1 diabetes, 19 and via email consultation with researchers, clinicians, representatives of patient organizations, caregivers and patient partners as part of a 6‐month funding application planning process.

Demographic data gathered from participants included: age, gender, ethnicity, income and education levels, geographical location and country of birth (inside or outside of Canada). Prior to finalizing the survey, all survey questions were iteratively reviewed by a person living with type 1 diabetes, a person living with type 2 diabetes, and a parent of a child with type 1 diabetes. The survey also contained three validated scales 24 , 25 , 26 , 27 , 28 to measure fear or distress associated with living with diabetes and its complications (see Appendix S1 ). These scales were included because we believed that fear or distress might influence how individuals rate the importance of research topics relative to the levels of fear they experience regarding these complications. If we were to observe large variations in ratings of importance, these data would allow us to explore potential reasons for the variation. The survey also included comment boxes where participants could provide additional information, including an open‐ended question asking for their ideas on additional topics concerning diabetes and diabetes‐related complications that require more research.

2.3.2. Survey participants

Over a 3‐day period in September 2015, we recruited participants through Qualtrics online sampling services. 29 To be included in the study, participants had to be living in Canada, aged ≥18 years, living with type 1 or type 2 diabetes, or caring for a child or an adult with diabetes and able to complete the survey in English or French. To ensure demographic diversity and offset variations in response rates, we established desired quotas based on gender (50/50 men and women), type of diabetes and relationship with diabetes (people with diabetes themselves, parents of children with diabetes, caregivers for adults with diabetes). We could not put quotas in place regarding ethnicity due to sampling constraints. In keeping with standard amounts for surveys administered by panel services, participants who completed the survey received $1.00‐$1.50 in compensation for their time answering our questions. We aimed for approximately 500 respondents. This target was selected as an achievable sample size that would allow for a broad sample of respondents and aligned with previous, similar research that sought feedback from 583 people living with diabetes about research questions they would like to see addressed. 19

2.3.3. Focus groups

Members of some groups may be less likely to complete online surveys, and thus, be under‐represented in survey‐based research. Therefore, we held 3 focus groups with patients and caregivers who were members of such groups. 30 To ensure variation in perspectives, we partnered with community organizations working with seniors, economically disadvantaged people, immigrants and people whose mental health requires follow‐up with a psychiatrist. 31 , 32 , 33 Two experienced qualitative researchers (MJD and MDT) conducted the focus groups using an established protocol. During the focus groups, patients were invited to discuss their experience with diabetes and its related complications, their perspectives and their concerns about the long‐term complications of diabetes. Participants also explained why, in their view, the concerns raised should be investigated by researchers.

2.3.4. Focus group participants

We used a convenience sample of members of under‐represented populations in the province of Quebec. We recruited focus group participants through three community‐based organizations that provide services to seniors, immigrants and people whose mental health requires regular follow‐up with a psychiatrist. To be eligible to participate in the focus groups, participants needed to be: living in Canada, aged ≥18 years, living with type 1 diabetes, type 2 diabetes or caring for a person with diabetes, and able to understand and express themselves in French. Participants who were unable to comfortably express themselves in French were excluded from the study.

To recruit participants, the organizations circulated information about the study to its clients or members. Interested participants contacted the research associate either by email or by phone. The research associate contacted all potential participants to explain the study, assess their eligibility, answer questions and discuss logistics. A reminder call and/or email was sent to all participants 2 days prior to the scheduled focus group to confirm the time and location.

We held the three focus groups at times convenient for participants. Furthermore, to increase accessibility, the focus groups were held in the offices of the partnering community organizations; a common practice when working with members of vulnerable populations. 34 We conducted two focus groups in Quebec City: (i) seniors; and (ii) people whose mental health requires regular follow‐up with a psychiatrist. We conducted the third in Montreal with a group of immigrants. Each focus group was audio‐recorded and lasted between 70 and 90 minutes. Participants received $50 in appreciation for their time and 10$ for transportation. 19

2.4. Data analysis

Our interest in conducting both qualitative and quantitative portions was to ensure inclusion of diverse perspectives. In other words, while research often uses quantitative and qualitative methods to collect different types of data from the same population to inform a research question, we used different methods to collect data from groups both more and less likely to participate in different types of research, in an attempt to capture more representative results. Therefore, we carried out quantitative and qualitative analyses separately before bringing both parts together. Our first step was to conduct descriptive statistics using SPSS version 22 (Armonk, NY, USA: IBM Corp.) to measure central tendency and examine the range of variation in responses to our questions about the importance of 10 important diabetes research areas. We recorded focus group discussions and transcribed them verbatim. We performed a six‐stage thematic analysis 35 , 36 using NVivo qualitative analysis software (QSR International Pty Ltd. Version 10, 2012). We started by generating initial codes and themes, and inductively refining these themes based on the data. MTD analysed focus group data under the guidance of MJD. The codes were labelled with short phrases using the words of participants. Then, MTD sorted codes into potential themes and collated all relevant coded data extracts within the identified themes and subthemes. During this analysis, the codes, themes and subthemes were revised and refined. We used field notes 37 to validate and complete the information gathered during the focus groups. After separate analyses were completed, we combined the findings from each study to analyse how complementary or contradictory they were. We additionally examined how focus group findings could improve our interpretation of the statistical analysis.

3.1. Characteristics of participants

3.1.1. online survey.

Of the 500 participants surveyed, 31 were excluded from our analyses because they either completed the survey in a time deemed too fast to provide thoughtful answers (ie, 10 minutes or less) or because their responses were inconsistent with the questions. The remaining 469 participants were 57% men, had a mean age of 44 (SD = 15), came from across the 10 provinces and 3 territories of Canada, and represented a broad range of educational backgrounds and income levels. In line with our concerns and predictions about representation, participants predominantly identified as White or Caucasian (93%). Participants completed the survey in English (78%) or French (22%) and were either living with diabetes (96%) and/or caring for a child (<1%) or adult with diabetes (3%). Ten percent (10%) of participants were dealing with type 1 diabetes; 89% with type 2 diabetes; and 1% with another or unknown type. Median time living with diabetes was 19.5 years for type 1 diabetes (IQR 9.8‐30.0 years) and 8.0 years for type 2 diabetes (IQR 4.0‐15.0 years.) (See Table  1 A,B).

Online Survey Data

SD, sample standard deviation; IQR, interquartile range.

A vast majority of participants with type 1 or type 2 diabetes (45% and 60%, respectively) reported other health concerns, some of which may be diabetes‐related complications (see Table S1 ). These concerns were, for types 1 and 2 respectively, eye complications (34% and 15% of participants), heart complications (13% and 24% of participants), kidney complications (22% and 8% of participants), mental health complications (34% and 27% of participants) and nerve complications (40% and 30% of participants). Many participants reported not having been screened for these complications in the previous year. Of those with type 1 and type 2 diabetes, respectively, 63% and 78% reported not receiving screening for eye complications within the past year; 71% and 68% reported not receiving screening for heart complications; 53% and 70% reported not receiving screening for kidney complications; 68% and 86% reported not receiving screening for mental health complications; and 61% and 70% reported not receiving screening for nerve complications.

3.1.2. Focus groups

Of the 23 people who initially expressed an interest in participating in the study, 5 were ineligible because they neither had diabetes nor cared for a person with diabetes; 2 withdrew because they were unavailable on the day of the focus group and 2 withdrew without explanation. Of the 14 remaining individuals who participated in the 3 focus groups, 7 (50%) were female and 3 total (21%) were living with type 1 diabetes. The characteristics of participants are shown in Table  2 .

Focus Groups: Characteristics of the 14 participants

3.2. Data analysis

3.2.1. online survey.

We report here the medians rather than the means because the distribution of responses to the survey questions about the importance of research topics regarding preventing and treating the complications of diabetes was not symmetrical. The median scores for people with both type 1 and type 2 diabetes were between 84 and 100 (on a 0 to 100 rating scale, with 100 indicating extremely important) indicating that participants assigned high importance to all 10 predetermined research topics with relatively little variation between topics. Topics that had the highest median scores and the least variation in responses were preventing and treating kidney, eye, heart and nerve problems. Research topics for which participants had the widest interquartile range in scores were as follows: preventing and treating mental health problems, developing and testing smart insulin, patient and caregiver education, and artificial pancreas research (type 1) (see Table  3 ).

Online survey results regarding the importance of diabetes‐related research topics

Cronbach's alphas were .94, .93 and .94, respectively, for the Fear of Complications Scale, 28 Hypoglycemia Fear Scale 24 , 25 , 26 and Diabetes Distress Scale. 27 People with type 1 diabetes and type 2 diabetes had mean scores of 23 (SD 10) and 18 (SD 10), respectively, on the Fear of Complications Scale (range 0‐45). Participants with type 1 diabetes had a mean score of 34 (SD 17) on the Hypoglycemia Fear Scale (range 0‐108) indicating sometimes fearing hypoglycaemia, while participants with type 2 diabetes had a mean score of 21 (SD 16) indicating being concerned less often. Finally, participants with type 1 diabetes and type 2 diabetes had mean scores of 2.81 (SD 1.23) and 2.23 (SD 1.27) on the Diabetes Distress Scale. Using the cut‐off score recommended by Fisher et al 38 this indicates that on average, participants with type 1 diabetes had moderate but non‐clinical levels of distress (threshold = 3) (see Table S1 ).

Comments provided by participants in the open box sections of the survey aligned with the quantitative findings and illustrate the emotional distress linked to diabetes and diabetes management, the fear associated with episodes of hypoglycaemia and its consequences, and with the long‐term complications of the disease (see Table  3 ).

3.2.2. Focus groups

The thematic analysis allowed us to identify a set of general concerns about diabetes‐related complications as reported by members of under‐represented groups.

3.3. General concerns about diabetes‐related complications

Participants in the focus groups provided further insight into the nature of their concerns about the impact of diabetes on their quality of life, life‐expectancy (Table  4 , citation 1) and vulnerability to other diseases (Table  4 , citation 2). Most participants reported being most afraid of complications that potentially lead to functional impairment (blindness), additional morbidity (chronic renal failure) or death (hypoglycaemia) (Table  4 , citation 3). Furthermore, participants pointed to the challenge of continuously monitoring and managing the disease (Table  4 , citations 4, 5 and 6).

Citations from focus groups participants

In addition to these general and common concerns, four specific themes arose from the focus group discussions:

Theme 1: The bidirectional relation between individual history and socio‐economic context, and the management of diabetes

Two aspects of individual history and context were mentioned by participants: (i) the influence of previous life‐experiences on the management of diabetes; and (ii) the impact of socio‐economic conditions on the outcomes of the disease. Regarding the first point, participants said they suspected a strong relation between their previous life‐experiences and the management of diabetes‐related complications. They wished that this relation could be investigated. For example, one participant talked about adopting bad eating habits such as dieting during the day and binging at night because she saw a loved one in a diabetic coma. (Table  4 , citations 7 and 8).

With respect to the second point, discussions in both focus groups focused on the need for studies examining the cost of diabetes treatment (Table  4 , citation 9). For example, some participants argued that they sometimes had to choose between paying their rent and buying insulin and complained that this should be a concern to researchers.

Theme 2: The need to better understand the danger of polymedication toxicity in patients with multiple comorbidities

Focus group participants who were either elderly or had experienced mental health problems expressed their concerns about toxic drug interactions resulting from polymedication. They stressed the urgent need to understand, whether and/or to what extent, there may be interactions between their diabetes medication and other treatments (Table  4 , citation 10).

Theme 3: The need to better understand barriers to quality care for immigrants living with diabetes

Focus group participants who were immigrants had two core concerns regarding diabetes and its related complications for researchers to address, notably: (i) how to improve access to quality care for immigrants with diabetes; and (ii) how to make health‐care professionals more knowledgeable about the specific care needs of immigrants living with diabetes. Most immigrants in the study talked about cultural or linguistic barriers to navigating the health system. For example, one participant talked about how she had learned to be assertive in expressing her needs (Table  4 , citation 11). Another participant talked about his experience going back and forth between the doctor and the pharmacist without answers to his needs (Table  4 , citation 12). Finally, participants who were immigrants unanimously reported that health‐care professionals were inadequately trained to detect symptoms and diagnose diabetes among individuals who are newcomers to the country. One participant, for example, said that this led to a failure to recognise pre‐diabetes symptoms, forcing this person to consult multiple physicians before a glycaemia test was requested (Table  4 , citation 13).

Theme 4: The need for better dissemination of the research results on diabetes

Focus group participants also expressed concerns about not having access to updated information on diabetes. They reported being aware of on‐going research, but were never informed by community organizations about the research results (Table  4 , citations 14 and 15).

Participants also pointed to a need for better information for their loved ones and relatives, to help them understand and provide better support in the management of the disease (Table  4 , citations 16, 17, 18).

4. DISCUSSION

This study aimed to explore the importance of diabetes‐related complication research topics relevant to those living with or caring for someone living with diabetes. Additionally, we wished to explore the reasons why these topics are important from the perspective of under‐represented populations. Findings from both the quantitative and qualitative components of the study complement each other and can be summarized in three main points.

First, the alignment of what is important for patients in diabetes research. Both survey and focus group participants indicated the importance of preventing and treating well‐known complications of diabetes such as kidney, eye and nerve problems. This finding confirms that research on such complications matters to patients and caregivers. Second, the need for more research about the bidirectional influence of the “life context” on diabetes.   Our participants also pointed out that there are a number of individual and contextual factors, such as individual circumstances (eg, life conditions, previous experiences), socio‐economic status and the experience of managing the condition that need further exploration, especially for the most under‐represented people included in this study. Finally, the third point was the need to deepen diabetes‐related research in under‐represented populations. Our results further suggest that research topics should be tailored to address specific challenges such as access to culturally relevant care for immigrants. 39

Consistent with other studies, 40 , 41 our quantitative data show that participants had moderate levels of emotional distress around diabetes‐related complications. Our qualitative analysis provided some insight into the nature of these concerns. For example, the fear that diabetes‐related complications (eg, kidney failure or blindness) may result in functional impairment or death (eg, as a result of a hypoglycaemia). Additionally, fears were often amplified not only by personal experience as shown in other studies, 42 , 43 , 44 , 45 , 46 but also by witnessing others dealing with such complications (such as having seen a loved one with kidney failure or experiencing a hypoglycaemic episode). These experiences impact how research topics are rated by those whose lives are touched by the disease. Unfortunately, further investigation of these questions was not possible with this study for two reasons: (i) the focus group participants were not asked to rate the complications as did online survey participants; and (ii) the focus groups were conducted separately from the quantitative portion of the study.

Overall, our findings point to a need for more research on diabetes, its complications and the bidirectional influence of a number of individual and contextual factors such as individual circumstances (eg, life conditions, previous experiences, emotional distress); socio‐economic status; and the experience of managing the condition, especially for the most under‐represented groups included in this study. It was suggested that research topics should be tailored to address specific challenges, such as access to culturally competent care for immigrants. 39

Our study did, however, have a few limitations. Due to time and budget constraints, focus group activities were restricted to Montreal and Quebec City, where our team is based. This limited our ability to recruit in other cities across Canada and also limited a true representation of the country's population. Although our respondents and their experiences reflect a broad sample of the population of Canada, several other groups who may have particular needs (eg, pregnant women, Indigenous peoples, parents or guardians of children with diabetes, as well as caregivers) were under‐represented in the online survey and were absent in the focus groups. Therefore, our sample lacks representation of some other under‐represented populations in Canada. Additionally, language barriers may have limited our selection of participants and excluded individuals, particularly those from under‐represented groups such as immigrants. Furthermore, because this online survey and focus group based study relied on participant self‐reports, the data could be limited by the subjects’ ability for introspection, their individual interpretations and social desirability bias. 47 Finally, because this was a preliminary study aimed at exploring the importance of different research topics to those living with diabetes and caregivers in Canada, we did not undertake prioritization activities that require trading‐off one priority against another to produce a ranked list. Such activities are planned for future research.

One strength of this study is its use of qualitative and quantitative methods to help capture the experiences of under‐represented groups and diverse participants from across Canada. This approach proved feasible as a method for efficiently exploring patients’ and caregivers’ preliminary views on research topics within a short period of time.

5. CONCLUSIONS

This study confirmed the importance of research topics regarding diabetes‐related complications within a population of people living with diabetes or caring for someone with diabetes, and further explored reasons why these topics might be important for certain groups of under‐represented people. The results of this study about what matters most to people living with, and caring for those living with diabetes, including people from under‐represented populations, informed the research program of a 5‐year pan‐Canadian Strategy for Patient‐Oriented Research Network on Diabetes and its related complications (2016‐2021). 39 A broad range of people living with diabetes are now involved as patient partners in this network, collaborating on research projects, research planning and supporting network governance. We anticipate that our results and on‐going work will contribute to the development of targeted interventions better aligned with improving the health and well‐being of people whose lives are touched by diabetes.

AUTHOR CONTRIBUTIONS

M.J.D. provided the study concept and design, supervised the protocol development and research, enrolled patients for the qualitative stage, facilitated focus groups, analysed data and provided the first draft of the manuscript. S.C.D. conducted the descriptive statistics, wrote the quantitative part of the manuscript, reviewed and edited the manuscript. M.T.D. enrolled patients for the qualitative stage, facilitated focus groups, analysed data and wrote the manuscript. F.L. reviewed and edited the manuscript. H.O.W. supervised the survey data collection, reviewed and edited the manuscript. M.J.D. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

CONFLICT OF INTEREST

The authors report no conflict of interest.

Supporting information

Acknowledgements.

The authors thank people living with diabetes, their caregivers and community organizations across Canada for their invaluable contributions to this study. The authors thank Judith Kashul for linguistic editing of this manuscript. Additionally, we thank Mary Zettl, for her contribution editing, coordinating and finalizing this article for publication.

Dogba MJ, Dipankui MT, Chipenda Dansokho S, Légaré F, Witteman HO. Diabetes‐related complications: Which research topics matter to diverse patients and caregivers? Health Expect . 2018; 21 :549–559. https://doi.org/10.1111/hex.12649 [ PMC free article ] [ PubMed ] [ Google Scholar ]

This study was funded through a subgrant of the Canadian Institutes of Health Research (CIHR SCD 139932)

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Barriers to Diabetes Prevention

Limitations of current prediabetes assessment tools, limitations of treatment approaches, clinical experience, case 1: j.n., case 2: j.w., case 3: d.w., clinical applications, 1. screen for diabetes., 2. in patients with prediabetes, stratify the likelihood of near-term progression to diabetes., 3. initiate appropriate interventions., 4. monitor effectiveness of intervention., acknowledgments, using a quantitative measure of diabetes risk in clinical practice to target and maximize diabetes prevention interventions.

Paul A. Rich, MD, is a physician at Comprehensive Physician Associates, LLC, in Youngstown, Ohio. Charles F. Shaefer, MD, FACP, is a physician at University Physicians, Primary Care, in Augusta, Ga. Christopher G. Parkin, MS, is president of CGParkin Communications, Inc., in Boulder City, Nev. Steven V. Edelman, MD, is a professor of medicine at the University of Southern California, San Diego.

Note of disclosure:   The authors have received consulting fees from Tethys, Bioscience, Inc., which developed the PreDx test.

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Paul A. Rich , Charles F. Shaefer , Christopher G. Parkin , Steven V. Edelman; Using a Quantitative Measure of Diabetes Risk in Clinical Practice to Target and Maximize Diabetes Prevention Interventions. Clin Diabetes 1 April 2013; 31 (2): 82–89. https://doi.org/10.2337/diaclin.31.2.82

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A n estimated 79 million American adults are at risk for developing type 2 diabetes, based on a condition referred to as prediabetes. 1   Although there is currently no cure for type 2 diabetes, studies have definitively shown that the progression from prediabetes to diabetes can be delayed or prevented through lifestyle modifications and pharmacological treatment. 2 – 4   Unfortunately, the vast majority of people with prediabetes are undiagnosed. Indeed, a recent study by Geiss et al. 5   found that < 8% of U.S. adults with prediabetes are aware of their condition.

Given the growing diabetes epidemic and the alarming prevalence of unawareness among those at risk for developing this disease, the American Diabetes Association (ADA) recommends screening of all patients who are at risk for prediabetes or who may have undiagnosed diabetes ( Table 1 ). 6  

Individuals meeting the criteria in Table 1 should have their glycemic status assessed by fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), or A1C. As shown in Table 2 , the diagnosis of prediabetes is based on glucose or A1C values that are higher than normal but not at levels diagnostic of diabetes. 6  

According to ADA recommendations, individuals who are identified as having prediabetes should be referred to an ongoing support program that targets weight loss and increased physical activity, and these programs should be covered by third-party payers. 6   The ADA further recommends that treatment with metformin be considered for at-risk patients who have a BMI ≥ 35 kg/m 2 , are < 60 years of age, and/or are women with prior gestational diabetes. 6  

Criteria for Testing Adult Patients for Prediabetes or Diabetes 6  

Given the significant clinical and economic costs associated with type 2 diabetes, it is crucial that diabetes prevention be a priority for the health care system. However, it is also important to consider that a relatively small percentage of individuals who have prediabetes will progress to overt type 2 diabetes within 5 years. The 5-year conversion rate from prediabetes to type 2 diabetes ranges from 10% 7   to 23% 8   depending on the diagnostic criteria used.

Because considerable resources are required to provide diabetes prevention programs to the ever-increasing number of patients with prediabetes, accurate tools are needed to identify prediabetic individuals who are most likely to progress to type 2 diabetes. This should allow for more efficient and effective use of health care resources and optimize health care outcomes.

Criteria for Diagnosis of Prediabetes or Diabetes 6  

This article discusses the clinical application of a validated prognostic test (PreDx, Tethys Bioscience, Inc., Emeryville, Calif.) that provides clinicians with an estimate of the 5-year likelihood of progression to type 2 diabetes for patients who have been identified through screening as having prediabetes. 9 – 12   Patient cases are presented to demonstrate how the PreDx test can be used within various clinical scenarios to facilitate implementation of diabetes prevention therapies (lifestyle-based and pharmacological) and then monitor the effectiveness of those interventions.

Although efforts have been made to address the significant and growing epidemic of diabetes, strategies to activate clinicians to aggressively screen for and treat individuals with prediabetes have been minimally successful. We have identified two major obstacles to these diabetes prevention efforts: 1 ) limitations of current assessment tools and 2 ) constraints on clinicians' time and resources.

Screening for prediabetes is the essential first step in diabetes prevention, and although current tools and assessment protocols are relatively effective for the initial identification of at-risk individuals, they do not adequately address the need to identify individuals who are at the highest risk for progressing to diabetes in the near term. These tools and approaches are either difficult to implement in clinical practice or lack the specificity required for accurate detection of high-risk individuals.

The OGTT is a specific indicator of diabetes risk and is considered to be the gold standard for detection of prediabetes. 13   However, its complexity, poor reproducibility, associated costs, time requirements, and patient inconvenience often inhibit routine use in clinical practice. 6 , 14 , 15   The OGTT is rarely performed for purposes other than clinical research and to assess glycemia status in women during pregnancy.

A fasting plasma glucose test to assess for impaired fasting glucose (IFG) can be performed easily in most clinical settings. However, this method of screening for prediabetes casts a very wide net, identifying ~ 26% of the adult population as at risk (prediabetes), 16   with minimal stratification for level of risk of progressing to type 2 diabetes.

Furthermore, although A1C testing has recently been added to the armamentarium of prediabetes detection options, 6   use of A1C levels often fails to identify most adults with prediabetes. 17 – 19   A recent study by Fajans et al. 17   found that ~ 33% of individuals with early diabetes or impaired glucose tolerance (IGT) have A1C levels < 5.7%. Moreover, there is growing evidence questioning the reliability of the A1C test. Many factors can influence glycation and, thus, the test's accuracy. 17 , 20   These include weaknesses in analytical methods, ethnicity, and various medical conditions such as presence of hemoglobinopathies, iron deficiency, any type of anemia, chronic liver disease, and fast or slow glycation. 20  

Other methods, such as measuring components of the metabolic syndrome or calculating risk scores based on clinical measures (e.g., lipid levels, blood pressure, and waist circumference), have also been used to identify patients most likely to develop diabetes. 21   However, these approaches require multiple measures and also suffer from low specificity. 8 , 22  

Lifestyle interventions such as dietary modification, physical exercise, and modest weight loss have been shown to prevent or delay the progression from prediabetes to frank type 2 diabetes. 2 , 23 , 24   Because these interventions often involve significant changes in eating habits and physical activity, patients need initial counseling to help them understand the changes they are being asked to make, as well as ongoing support and encouragement from their health care providers to sustain those new behaviors.

Unfortunately, many patients do not receive the level of care they need to make and sustain these changes; barely half of patients receive the preventive, chronic disease, and acute care services recommended by national health care organizations and agencies. 25  

A key contributor to this suboptimal care is lack of physician time. 26 , 27   Yarnell et al. 27   determined that clinicians would require 21.7 hours/day to effectively meet the needs of a typical patient population of 2,500. Looking specifically at diabetes prevention interventions used in the Diabetes Prevention Program, 2   it is noteworthy that these interventions required ~ 75% of staff time to treat the 25% of patients randomized to the intensive lifestyle intervention group.

Pharmacological treatment with metformin has also been shown to delay or prevent progression to diabetes. However, treatment with metformin in elderly patients has shown limited effectiveness. 28   Furthermore, use of metformin is not approved by the U.S. Food and Drug Administration (FDA) in individuals with prediabetes, 29   and many clinicians are reluctant to prescribe this medication without strong evidence for its necessity.

Given the growing, worldwide diabetes epidemic, there is an everincreasing need for new testing methodologies that can accurately diagnose individuals who have the highest likelihood of developing diabetes and that can support both clinicians and patients in initiating and sustaining effective prevention strategies. The PreDx test is a relatively new prognostic blood test that may help clinicians address these issues.

The PreDx test is a multimarker blood test that can be used in primary care practices to help determine the 5-year likelihood of a patient progressing from prediabetes to type 2 diabetes. 9   Early detection of these highest-risk individuals may facilitate more effective patient management by enabling clinicians to focus health care resources earlier and to more effectively initiate and monitor diabetes prevention interventions.

The multimarker PreDx test is based on seven biomarkers (glucose, A1C, insulin, C-reactive protein, ferritin, interleukin-2 receptor α, and adiponectin) that are independently associated with diabetes risk. 22   The test measures these markers in a fasting blood sample, and its results, along with patients' sex and age, are placed into an algorithm that generates an objective and quantitative score to distinguish among people at high, moderate, and low 5-year probability of developing type 2 diabetes. 10 – 12   This information enables clinicians to focus interventions on the relatively few patients who are genuinely at a high 5-year risk of developing diabetes, thus avoiding unnecessary treatment and expenses for patients who are less likely to develop diabetes within the next 5 years.

A study by Kolberg et al. 10   demonstrated that the performance characteristics of the PreDx test were similar to those of the OGTT but superior to all other methodologies, including FPG, A1C, fasting insulin, and the HOMA-IR (homeostasis model of assessment—insulin resistance) for predicting the 5-year likelihood of type 2 diabetes. The PreDx test was also found to be superior to metabolic syndrome components and clinical risk scores for detection of near-term conversion to diabetes. 9 , 11   Furthermore, unlike the OGTT, the PreDx test requires only a single blood draw and does not involve monitoring patients over a 2-hour time period.

In a recent analysis of the European Diabetes Prevention Study, Tuomilehto et al. 30   demonstrated that the test not only identifies those who are most likely to develop diabetes, but also facilitates monitoring the efficacy of therapeutic interventions through follow-up testing, thus enabling clinicians to modify the intervention if the PreDx test indicates that it has not been successful.

The PreDx test report ( Figure 1 ) provides a single numerical score from < 1 to 9.9 (lowest to highest risk) that indicates each patient's likelihood of progressing to type 2 diabetes within the next 5 years. On the first page, the PreDx score, which is categorized as “low” (green), “moderate” (yellow), or “high” (red), is presented, as is the patient's absolute 5-year diabetes risk (%). The patient's risk relative to the general population is also provided. For example, a score of 5.8 corresponds to a 4.6% 5-year risk of developing type 2 diabetes, which represents a 1.4-fold increase in risk compared to the 5-year risk in the general population (3.4%). 9   The second page of the report provides results and reference ranges of the individual biomarkers used to determine the PreDx score.

Because the PreDx test requires a simple fasting blood draw using standard sample collection and handling procedures, it is relatively easy to incorporate into routine clinical practice. However, cost-effectiveness is also an important factor when considering adoption of new diagnostic technology. In a recent health economic analysis by Sullivan et al., 31   use of the PreDx test in combination with fasting glucose measurement showed an incremental cost-effectiveness ratio (ICER) of $17,000 per quality-adjusted life year (QALY) gained at 5 years and produced a cost savings at 10 years. Without using the PreDx test, detection of high-risk patients based only on FPG resulted in an ICER of $235,000 per QALY gained at 5 years and $94,600 per QALY gained at 10 years. Based on this analysis, the authors concluded that the cost-effectiveness of diabetes prevention may be improved by identification of high-risk individuals using the PreDx test.

Sample of the PreDx test report form. The test report provides the PreDx score, as well as the corresponding absolute and relative 5-year likelihood of progression to type 2 diabetes. The individual analytes that are used to calculate the PreDx score and their reference ranges are also provided.

The clinical utility of the PreDx test is twofold: 1 ) to stratify patients with prediabetes according to their 5-year likelihood of developing type 2 diabetes and 2 ) to monitor and quantify the impact of lifestyle and/or pharmacological interventions. A key advantage of the PreDx test is its potential to motivate patients to make necessary lifestyle modifications to reduce their risk.

Many clinicians have reported that use of the PreDx test has motivated their highest-risk patients to make significant lifestyle changes that could delay or prevent the progression to type 2 diabetes. 22   Albeit anecdotal, these clinician-reported changes in patient motivation are supported by a recent study by Markowitz et al. 32   that looked at how genetic testing for diabetes risk affects motivation. Most study participants reported that “higher” risk results would prompt them to modify their health behaviors.

Other studies have shown that presenting A1C results to patients in graphic formats is linked to improved glycemic control. 33 , 34   These studies suggest that providing patients with an objective measure of risk can be an effective motivator for making lifestyle changes.

There is also growing evidence that use of the PreDx test positively affects clinician behaviors, prompting more intensive management of high-risk patients. A retrospective study 35   using comprehensive electronic medical records from a health care system treating ~ 3.2 million patients found that those who received the PreDx test were more likely to have follow-up monitoring of biometric risk factors by a physician than patients who did not receive the test. In addition, patients with high PreDx scores were more intensively treated for risk factor control than those with lower PreDx scores or no test. Moreover, there was significant improvement in risk factors for patients who received the PreDx test.

Using the PreDx test in our own practices, we have observed similar findings with many of our patients. The following case studies are representative of our experiences.

J.N. is a 62-year-old white man who is, 6′1″ tall and has a family history of coronary artery disease (CAD) and hypertension but no history of type 2 diabetes. In 2001, he was surgically treated for CAD and is currently taking medication for dyslipidemia and hypertension. J.N. is a nonsmoker and drinks alcohol occasionally.

Previous efforts to encourage J.N. to make lifestyle changes to reduce his cardiovascular risk have been unsuccessful. He continues to eat an unhealthy diet (high in calories and saturated fat) and remains sedentary with no formal exercise program.

J.N. was seen in the clinic for an annual physical exam in November 2010 ( Table 3 ). Although his FPG was only slightly elevated, the PreDx score indicated that J.N. was at very high risk for developing type 2 diabetes within the next 5 years (PreDx score 8.5, 5-year diabetes risk of 16.5%).

We adjusted his lipid and blood pressure medication doses based on his elevated LDL cholesterol and blood pressure, counseled J.N. on the need for lifestyle changes, and referred him to a formal diabetes prevention program at a local hospital. Although J.N. elected not to participate in a formal program, he initiated a diet and exercise routine consisting of cycling ~ 10 miles daily and eating a reduced-calorie diet that was high in fiber and low in saturated fat.

At his next annual exam (March 2012), his blood pressure, fasting glucose, and lipid levels were improved, and his PreDx score was significantly lower (PreDx score 4.5). This reduced his 5-year diabetes risk from a baseline of 16.5% to 2.8%—less than half of the 5-year risk of the general population within his age-group (6.7%). 4  

Physical Assessment and Laboratory Values, Case 1

Physical Assessment and Laboratory Values, Case 2

J.W. is a 71-year-old white man who is 5′10″ tall and has a history of hypertension, hyperlipidemia, obesity, and IFG dating back to 2008. He is a nonsmoker and has a family history of heart disease and diabetes.

When seen in March 2011, J.W. weighed 263 lb (BMI 37 kg/m 2 ) and had elevated blood pressure, lipid, and fasting glucose levels ( Table 4 ). His PreDx score was 9.2, giving him an absolute 5-year risk for diabetes of 28.6%.

J.W. was counseled on the need to modify his diet, exercise regularly, and lose weight. When he returned for follow-up in September 2011, he had lost 70 lb, reduced his BMI to 27 kg/m 2 , and significantly improved his blood pressure and lipid status. Although his PreDx score had decreased to 7.0, he was still at relatively high risk for developing diabetes despite the significant weight loss.

At his next follow-up visit in March 2012, J.W. had gained 5 lb and his FPG had risen to 101 mg/dl. His PreDx score had increased to 8.0, giving him a 12.2% 5-year diabetes risk. At that visit, we started J.W. on metformin (500 mg/day). Four months later, he had lost 1 lb, his FPG was < 100 mg/dl, and his PreDx score had dropped to 4.3, reducing his 5-year diabetes risk to 2.6%—less than half of the risk of the general population within his age-group (6.7%). 4  

D.W. is a 58-year-old white man who is 6′1″ tall and has a history of hypertension, hyperlipidemia, obesity, arterial fibrillation, and IFG dating back to 2010. He is a nonsmoker and has a family history of CAD.

When seen in January 2012, D.W. weighed 281 lb (BMI 38 kg/m 2 ) and had normal blood pressure and elevated lipid and fasting glucose levels ( Table 5 ). Despite his elevated FPG of 110 mg/dl, which placed him in the prediabetes glucoregulatory category, his PreDx score was 6.3. This gave him a 5-year diabetes risk of 5.6%.

Although D.W. was strongly counseled on the need to reduce his weight through diet modification and exercise to address his cardiovascular risk, we determined that prescribing a diabetes medication to help prevent diabetes was unwarranted at this time. We will continue to closely follow D.W. to help support his lifestyle modification efforts, and we will use fasting glucose and, if necessary, a follow-up PreDx test to monitor his glucoregulatory status and any changes in his diabetes risk.

Physical Assessment and Laboratory Values, Case 3

The three patient cases presented in this article illustrate how the PreDx test can both motivate patients to make necessary lifestyle changes and guide treatment decisions regarding referral to formal diabetes prevention programs and/or pharmacological interventions. In the first case, the PreDx test prompted the patient to initiate intensive dietary modification and a regular exercise program to reduce his diabetes risk. As demonstrated in the second case, the PreDx test not only helped motivate the patient to lose a significant amount of weight but, on follow-up, it provided an indication that lifestyle changes were not effective enough and that pharmacological treatment with metformin was needed. The third patient case provides an example of how the PreDx test can help us more efficiently use resources. Reliance on the FPG value alone may have prompted us to initially prescribe a diabetes medication that could have potentially affected the patient's employment status and health care coverage and could have important side effects. Instead, we focused our attention on lifestyle intervention efforts and his other cardiovascular risk factors.

It is important to note that, although the three cases presented above illustrate the use of the PreDx test in white men, a recent analysis using blood samples from the Insulin Resistance and Atherosclerosis Study (a study in a multiethnic U.S. cohort) demonstrated that PreDx test performance characteristics were similar in whites, Hispanics, and African Americans and did not differ based on sex. 36   Many insurers currently provide reimbursement for the test; the reimbursement rate varies by payer.

To help clinicians effectively use the PreDx test in their practices, we have constructed a straightforward, four-step process to identify and implement diabetes prevention efforts in patients with prediabetes.

Use the screening criteria presented in Table 1 to identify and screen all patients who may be at risk for diabetes or prediabetes. Patients meeting the criteria in Table 1 should have their glucoregulatory status assessed using FPG, A1C, or OGTT. Although each method has advantages and disadvantages, all are adequate for assessing the presence of diabetes or prediabetes as defined by the ADA. 6     Table 2 presents the glycemic thresholds for diabetes and prediabetes.

Use the PreDx test to assess the patient's 5-year likelihood of progressing from prediabetes to type 2 diabetes. As discussed above, the PreDx test classifies patients as low, moderate, or high risk and provides an estimate of the 5-year likelihood of progressing to type 2 diabetes. Because all patients with prediabetes are at risk for macrovascular and potentially microvascular disease regardless of the PreDx score, clinicians must appropriately manage blood pressure, lipids, and body weight through lifestyle and/or pharmacological interventions.

Patients with normal glucose regulation or prediabetes should be re-screened for diabetes with one of the above-mentioned tests (Step 1) annually, or sooner if they develop symptoms of diabetes.

In patients with prediabetes, based on the PreDx test in conjunction with other clinical information, appropriate lifestyle and/or pharmacological interventions should be instituted. We know that lifestyle interventions such as weight loss and regular physical activity can prevent or delay the development of type 2 diabetes. 2   However, changing health habits is a difficult task for most patients. All patients with prediabetes, irrespective of their PreDx score, should receive counseling related to increased diabetes risk and the importance of good nutrition and physical activity for diabetes prevention and general health.

As deemed appropriate and based on the clinical picture and PreDx score, we recommend that patients be referred to a formal diabetes prevention program in their community where they can receive counseling and support from qualified health care providers. If a community program is not available or if the patient is unwilling or unable to participate in such a program, clinicians can provide lifestyle counseling and support during clinic visits. The National Diabetes Education Program (NDEP), in partnership with the National Institutes of Health, offers clinicians a comprehensive guide (G.A.M.E. P.L.A.N.) for diabetes prevention strategies and patient counseling. The guide can be downloaded free of charge from the NDEP Web site ( http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=71 ). The National Diabetes Prevention Program also provides information and resources to clinicians and patients. These resources can be obtained from the Centers for Disease Control and Prevention at its Web site ( http://www.cdc.gov/diabetes/prevention ).

In addition to lifestyle changes, pharmacological interventions with metformin, thiazolidinediones, and α-glucosidase inhibitors have also been shown to be effective in slowing or preventing the progression to type 2 diabetes. 2 – 4   There are no medications approved by the FDA for treatment of prediabetes. However, if the risk:benefit profile for individual patients is deemed to be favorable, these medications may be considered for use in combination with lifestyle interventions or when behavioral interventions have failed. 6  

After initiating the above interventions, clinicians may then use the PreDx test quarterly or biannually to monitor treatment effectiveness, make any necessary adjustments to patients' treatment plan, and provide feedback to patients to sustain and enhance motivation and engagement in their diabetes prevention efforts.

The diabetic epidemic shows no signs of slowing. With an estimated 79 million American adults currently considered to be at risk for developing type 2 diabetes, 1   providing the necessary clinical and financial resources to deliver intensive preventive care to all of these individuals will be a difficult (if not impossible) task. Although it is clear that diabetes prevention should remain a high priority for patients, clinicians, and payers, it is also crucial that new technologies such as the PreDx test be used to accurately diagnose individuals who have the highest likelihood of developing diabetes in the near term to enhance the clinical efficacy of prevention efforts and ensure the viability of the national health care system.

Funding for the development of this article was provided by Tethys Bioscience, Inc., of Emeryville, Calif., which developed the PreDx test.

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223 helpful picot question examples and examples of picot questions and ideas, bob cardens.

• August 22, 2022
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In Nursing, A PICOT Question is a structured question frame that helps you define the nursing concept or phenomenon that make up a specific structured question.

As per Nursing Researchers, the PICO(T) framework is used to formulate precise clinical research questions by breaking it down as follows:

• P for Population refers to the specific group of patients or the nature of the disease being studied. For example, the effect of hypertension in adults aged 50 and above.
• I for Intervention denotes the treatment or action under consideration, such as administering a new drug to lower blood pressure.
• C for Comparison involves what the intervention is being compared against, like the standard medication for hypertension.
• O for Outcome implies the effects that are being measured to see if the intervention was successful, such as the reduction in blood pressure levels.
• T for the Timeframe for implementation

Yet to select a PICOT Question?

Our expert Nursing Writers can help you select a great PICOT in your field and help you write from the first submission (picot template) to the last full Capstone Paper Submission.

An example of a PICO question is: In adults aged 50 and above with hypertension (Population), does the new drug ABC (Intervention) reduce blood pressure more effectively (Outcome) than the standard drug XYZ (Comparison) within a 6-month period (Timeframe)?

The post below includes a comprehensive list of 223 PICOT Question Examples and Good Examples of PICOT Questions for nursing students and papers in different subject areas such as diabetes, mental health, falls, emergency nursing, pregnancy, hypertension, and nursing burnout.

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31 Useful Examples of PICOT Questions Nursing for BSN, MSN or DNP

• Anxiety Interventions PICOT Question Example: Among adults with diagnosed anxiety disorders (P), does cognitive-behavioral therapy (I) compared to pharmacological interventions (C) lead to improved symptom management and overall well-being (O) over a -week intervention period (T)?
• NICU (Neonatal Intensive Care Unit) – PICOT Question Example: In premature infants admitted to the NICU (P), does implementing skin-to-skin kangaroo care (I) compared to traditional incubator care (C) result in better neonatal outcomes, including reduced length of hospital stay and improved bonding between parents and infants (O) during the first month post-birth (T)?
• Elderly PICOT Question Example: In elderly individuals residing in long-term care facilities (P), does implementing a regular exercise program (I) compared to the usual care routine (C) result in reduced incidence of falls and improved mobility and quality of life (O) during a six-month intervention period (T)?
• Infections PICOT Question Example: Among adults with hospital-acquired infections (P), does the implementation of strict hand hygiene protocols (I) compared to standard infection control measures (C) lead to a reduction in the incidence of nosocomial infections and improved patient outcomes (O) within a three-month intervention period (T)?
• Breast Cancer PICOT Question Example: In women diagnosed with early-stage breast cancer (P), does adjuvant chemotherapy combined with targeted therapy (I) compared to adjuvant chemotherapy alone (C) result in improved survival rates and reduced risk of cancer recurrence (O) over a five-year follow-up period (T)?
• Nursing Competency PICOT Question Example: Among newly graduated nurses (P), does participation in a comprehensive mentorship program (I) compared to standard orientation and preceptorship (C) result in increased nursing competencies and improved job satisfaction (O) over a six-month period (T)?
• Community Nursing PICOT Question Example: In underserved communities (P), does implementing a community health worker program (I) compared to the absence of such a program (C) lead to improved access to healthcare services and better management of chronic diseases (O) over a one-year intervention period (T)?
• CHG Dressings PICOT Question Example: In patients with surgical site infections (P), does using chlorhexidine gluconate (CHG) dressings (I) compared to traditional dressings (C) result in faster wound healing and reduced incidence of wound infections (O) during the post-operative period (T)?
• HTN Modification PICOT Question Example: Among adults with uncontrolled hypertension (P), does implementing a combination of lifestyle modifications including diet, exercise, and stress management (I) compared to pharmacological interventions alone (C) lead to better blood pressure control and reduction in cardiovascular risks (O) over a six-month intervention period (T)?
• CAUTI (Catheter-Associated Urinary Tract Infection) PICOT Question Example: In hospitalized patients with indwelling urinary catheters (P), does implementing a nurse-driven catheter removal protocol (I) compared to standard care (C) result in a decrease in the incidence of catheter-associated urinary tract infections and improved patient outcomes (O) within a two-week intervention period (T)?
• Discharge Teaching PICOT Question Example: In adult patients being discharged from a hospital setting (P), does the implementation of a structured discharge teaching program (I) compared to standard discharge instructions (C) result in improved medication adherence and decreased readmission rates (O) within the first  days post-discharge (T)?
• Care of Mental Health Needs PICOT Question Example: In individuals with diagnosed mental health disorders (P), does the integration of collaborative care models (I) compared to traditional care models (C) result in improved access to mental health services and decreased psychiatric hospitalizations (O) within a six-month intervention period (T)?
• Nursing Bariatric Surgery – PICOT Question Example: In adult patients undergoing bariatric surgery (P), does the provision of specialized nursing care and comprehensive postoperative monitoring (I) compared to standard nursing care (C) result in reduced postoperative complications and improved patient outcomes (O) within the first  days after surgery (T)?
• Nursing Student PICOT Question Example: In nursing students undergoing clinical rotations (P), does the use of simulation-based teaching methods (I) compared to traditional didactic lectures (C) result in improved clinical skills competency and confidence (O) during the first semester of the nursing program (T)?
• Patient Rights PICOT Question Example: In hospitalized patients (P), does the implementation of a patient rights education program (I) compared to standard care practices (C) result in increased patient autonomy and satisfaction (O) during their hospital stay (T)?
• Quality Improvement PICOT Question Example: In healthcare organizations implementing quality improvement initiatives (P), does the use of Lean Six Sigma methodology (I) compared to traditional quality improvement methods (C) result in reduced medication errors and improved patient safety outcomes (O) within a one-year intervention period (T)?
• Patient Safety PICOT Question Example: In acute care settings (P), does the implementation of a standardized handoff communication process (I) compared to informal handoff practices (C) result in decreased adverse events and improved patient safety (O) during shift transitions (T)?
• Nursing Clinical Problem and PICOT Question Example: In adult patients with chronic pain (P), does the use of non-pharmacological pain management interventions (I) compared to pharmacological interventions alone (C) result in improved pain control, reduced opioid consumption, and enhanced functional ability (O) within a three-month treatment timeframe (T)?
• Water Birth PICOT Question Example: In pregnant women with uncomplicated pregnancies (P), does the utilization of water immersion during labor and birth (I), compared to traditional land-based births (C), result in decreased labor pain, shorter labor duration, and reduced use of medical interventions (O) without compromising maternal and neonatal outcomes within a hospital setting (T)?
• Psych PICOT Question Example: In individuals with acute psychiatric conditions (P), does a therapeutic milieu approach (I) compared to standard care approaches (C) result in reduced agitation, improved symptom management, and decreased use of seclusion and restraint (O) during an inpatient psychiatric treatment period (T)?
• PICOT question example for training intervention: – (P) Among adult employees in a corporate setting, (I) does participation in a workplace wellness program, (C) compared to no wellness program, (O) lead to a decrease in absenteeism and an improvement in overall employee well-being and job satisfaction, (T) within a one-year intervention period?
• (P) In patients with type  diabetes, (I) does a low-carbohydrate diet, (C) compared to a standard diabetic diet, (O) result in better glycemic control and weight loss, (T) over a six-month period?
• (P) In pregnant women, (I) does prenatal yoga, (C) compared to no exercise, (O) reduce the risk of gestational diabetes and improve birth outcomes, (T) throughout pregnancy?
• (P) In children aged – with autism spectrum disorder, (I) does early intervention behavioral therapy, (C) compared to no early intervention, (O) lead to improved social communication skills and decreased maladaptive behaviors, (T) over a two-year period?
• (P) Among hospitalized children, (I) does distraction therapy, (C) compared to standard care, (O) reduce pain and anxiety during medical procedures, (T) in the acute care setting?
• PICOT question examples for pain management in pediatrics: – (P) In children with postoperative pain, (I) does the use of music therapy, (C) compared to pharmacological interventions alone, (O) result in decreased pain scores and reduced opioid use, (T) during the immediate postoperative period?
• (P) Among nursing students, (I) does high-fidelity simulation, (C) compared to traditional clinical education, (O) improve critical thinking skills and clinical decision-making abilities, (T) during the final year of the nursing program?
• (P) In healthcare professionals, (I) does simulation-based team training, (C) compared to didactic training alone, (O) enhance teamwork and communication skills in emergency situations, (T) within a six-month training period?
• Example of a systematic review PICOT question: – (P) In patients with chronic low back pain, (I) does acupuncture, (C) compared to standard care or sham acupuncture, (O) result in improved pain relief and functional outcomes, (T) over a -week treatment period?
• PICOT question examples of fall prevention: – (P) Among elderly individuals living in residential care facilities, (I) does the implementation of a multifactorial fall prevention program, (C) compared to usual care, (O) reduce the rate of falls and fall-related injuries, (T) over a one-year period?
• PICOT question examples dementia: (P) Among older adults with mild cognitive impairment, (I) does regular engagement in cognitive training exercises, (C) compared to no cognitive intervention, (O) delay the progression to dementia and improve cognitive function, (T) over a three-year follow-up period?
• PICOT question examples labor and delivery:- (P) In pregnant women with gestational diabetes, (I) does exercise during pregnancy, (C) compared to no exercise, (O) improve glycemic control and reduce the risk of cesarean section deliveries, (T) throughout the antenatal period?
• PICOT question examples stroke: (P) In stroke survivors, (I) does participation in a post-stroke rehabilitation program, (C) compared to no structured rehabilitation, (O) lead to better functional outcomes and reduced risk of secondary stroke events, (T) within the first six months post-stroke
• (P) Among adolescents with major depressive disorder, (I) does cognitive-behavioral therapy, (C) compared to pharmacotherapy alone, (O) result in a decrease in depressive symptoms and improved overall well-being, (T) over a -week treatment period?
• (P) In adults with schizophrenia, (I) does family psychoeducation, (C) compared to standard individual therapy, (O) enhance medication adherence, reduce hospital readmissions, and improve social functioning, (T) over a one-year period?

136 Practical PICOT Questions Examples from Different Nursing Practice Areas

• PICOT questions are a critical tool used in evidence-based nursing practice to frame and answer specific clinical questions. The PICOT format stands for: Population/Patient Problem (P), Intervention (I), Comparison (C), Outcome (O), and Time (T). Here are examples of PICOT questions in the specified areas:
• Bariatric Surgery – In adults with morbid obesity (P), how does bariatric surgery (I) compared to lifestyle modifications (C) affect diabetes remission rates (O) within the first two years post-operation (T)?
• Obesity – Among adolescents with obesity (P), does implementation of a school-based exercise program (I) compared to no structured program (C) reduce the incidence of obesity-related comorbidities (O) over one academic year (T)?
• Nurse Practitioner – In patients with hypertension treated by nurse practitioners (P), how does the use of telehealth follow-up consultations (I) compare with in-person consultations (C) in controlling blood pressure (O) over six months (T)?
• Community Health Nursing – For elderly patients living in community housing (P), does a community nursing educational intervention on nutrition and exercise (I) compared to standard care (C) affect the rates of falls(O) over one year(T)?
• Sepsis – In adult ICU patients with sepsis (P), does the early initiation of broad-spectrum antibiotics (I) compared to delayed initiation following culture results(C) impact mortality rates(O) within thirty days of treatment(T)?
• Flu Vaccine – Does administering flu vaccine in the workplace(I) compared to non-workplace settings(C) increase vaccination rates(P) during the flu season(O over a period of one year(T)?
• Psychosocial Effect of Hemodialysis – In patients undergoing hemodialysis for end-stage renal disease(P), how does cognitive-behavioral therapy(I) versus usual care(C) affect their psychosocial well-being(O) after six months(T)?
• Falls – How does implementing a fall prevention program(I) compared to standard nursing care(C) affect the incidence of patient falls(P) in an acute care setting over 12 months(T)?
• Emergency Nursing – For patients presenting with acute myocardial infarction in emergency nursing care(P), does immediate percutaneous coronary intervention(I), as opposed to thrombolytic therapy(C), improve survival rates(O) within one month post-intervention(T)?
• Pain Management: In adults with chronic lower back pain, how does cognitive-behavioral therapy, compared with traditional pain management education, affect pain levels within a 12-week period?
• Obstetrics: Among pregnant women with gestational diabetes, does daily self-monitoring of blood glucose levels, compared to weekly in-clinic monitoring, lead to better control of blood glucose levels up to delivery?
• CLABSI (Central Line-Associated Bloodstream Infection): In adult ICU patients requiring central lines, is the use of chlorhexidine wash cloths for daily skin cleaning more effective than soap and water in reducing CLABSI rates within the first 30 days of line insertion?
• CAUTI (Catheter-Associated Urinary Tract Infections): Does the implementation of a nurse-driven protocol for early catheter removal compared to standard care decrease the incidence of CAUTI in post-operative patients within one month after surgery?
• Quality Improvement: In hospital wards, how does the introduction of an electronic health record system compared with paper-based systems affect the quality of patient care over the first year following implementation?
• Chronic Granulomatous Disease: For children diagnosed with chronic granulomatous disease, does prophylactic antibiotic therapy compared to no prophylaxis decrease the incidence of bacterial infections over a two-year period?
• Nursing Pseudomonas Infections: In patients hospitalized with cystic fibrosis, is inhalation therapy using tobramycin more effective than IV administration in reducing Pseudomonas aeruginosa load after four weeks of treatment?
• Educational PICOT questions for nurse educators: In nursing students, how does the use of simulation compared to traditional teaching methods (I), contribute to improved knowledge retention and skill acquisition (O), during clinical practice (T)?
• In nursing education programs, how does the integration of technology and interactive learning materials (I), affect student engagement and knowledge transfer (O), in the classroom (T)?
• In adult diabetes patients, how does regular physical exercise (I), compared to sedentary lifestyle (C), affect blood glucose control (O), over a 6-month period (T)?
• – P: In elderly diabetes patients, how does self-monitoring of blood glucose levels (I), compared to regular doctor visits (C), influence medication adherence (O), and overall glycemic control (O)?
• P: In hospitalized patients, how does the implementation of an educational program on DVT prevention (I), compared to standard care (C), reduce the incidence of venous thromboembolism (O), during the hospital stay (T)?
• P: In surgical patients, how does the use of compression stockings (I), in addition to early ambulation (C), contribute to the prevention of deep vein thrombosis (O), after the procedure (T)?
• – P: In elderly patients with congestive heart failure, how does daily monitoring of weight and fluid intake (I), compared to standard care (C), impact hospital readmissions (O), within 30 days of discharge (T)?
• – P: In patients with congestive heart failure, how does the administration of beta-blockers (I), in conjunction with lifestyle modifications (C), influence cardiac function (O), and quality of life (O)?
• – P: In adolescent athletes, how does pre-participation screening by a sports medicine specialist (I), compared to general physical examination (C), improve the detection of cardiac abnormalities (O), associated with sudden cardiac arrest (T)?
• – P: In recreational runners, how does dynamic stretching exercises (I), compared to static stretching (C), affect the risk of muscle strains (O), during long-distance running (T)?
• – P: In hypertensive African American adults, how does adherence to the DASH diet (I), compared to usual dietary intake (C), influence blood pressure control (O), over a 12-week period (T)?
• – P: In pregnant women with hypertension, how does antenatal care by a multidisciplinary team (I), compared to standard prenatal care (C), affect maternal and fetal health outcomes (O), throughout the pregnancy (T)?
• – P: In adult cancer patients receiving chemotherapy, how does the use of acupuncture (I), compared to pharmacologic interventions (C), alleviate chemotherapy-induced nausea and vomiting (O), during treatment cycles (T)?
• – P: In palliative care for cancer patients, how does the implementation of early supportive care interventions (I), compared to standard care (C), improve quality of life (O), in the terminal stage of the disease (T)?
• – P: In nursing staff working in intensive care units, how does the implementation of mindfulness-based stress reduction programs (I), compared to no intervention (C), reduce burnout (O), and improve job satisfaction (O)?
• – P: In nurse managers, how does a supportive leadership style (I), compared to an autocratic leadership style (C), impact nurse burnout rates (O), and turnover intentions (O)?
• – P: In elderly patients with multiple chronic conditions, how does the use of care coordination and case management programs (I), compared to standard primary care (C), influence hospitalization rates (O), and healthcare utilization (O)?
• – P: In pediatric primary care settings, how does the implementation of routine developmental screening (I), compared to no screening (C), impact early detection of developmental delays (O), and subsequent intervention (O)?
• Mental Health: How does individualized patient education on coping strategies compared with standard group therapy affect anxiety levels in adults diagnosed with generalized anxiety disorder over three months?
• Post-surgery: In patients undergoing total knee replacement, does using continuous passive motion machines, compared to no machine use, result in better range of motion six weeks post-operation?
• Example of PICOT question for young people with depression: (P) Among adolescents diagnosed with depression, (I) does the implementation of a peer support program, (C) compared to standard counseling services, (O) lead to improved depressive symptoms, and (T) within a six-month period following treatment initiation?
• Clinical question with PICOT format example: (P) In patients with acute myocardial infarction, (I) does early mobilization, (C) compared to bed rest for the initial 24 hours, (O) improve patient outcomes in terms of morbidity and mobility, and (T) during the hospital stay?
• PICOT question examples postpartum Pitocin administration: (P) For postpartum women who have delivered vaginally, (I) does the administration of prophylactic Pitocin, (C) compared to placebo or no treatment, (O) reduce the incidence of postpartum hemorrhage, and (T) within the first two hours after delivery?
• PICOT question examples in nursing MRSA: (P) In hospitalized patients with MRSA-positive wounds, (I) is the use of chlorhexidine bathing, (C) compared to standard soap and water bathing, (O) more effective in reducing hospital-acquired MRSA infections, and (T) over a one month period?
• PICOT question examples CABG: (P) Among patients undergoing coronary artery bypass graft surgery (CABG), (I) does perioperative beta-blocker therapy, (C) when compared to not using beta-blockers, (O) decrease the incidence of postoperative atrial fibrillation, and (T) within 30 days following surgery?
• Example of PICOT question regarding the effect of breast cancer screening: (P) In women aged 40-49 years old at average risk for breast cancer, (I) does annual mammography screening, (C) compared to biennial screening or no screening at all, (O) significantly reduce mortality rates from breast cancer, and (T ) over ten years?
• Long term care facility and pressure ulcers PICOT question examples: (P ) In patients residing in long-term care facilities,  I ) is the use of advanced static mattresses ), C ) compared to standard foam mattresses ), O ) more effective in preventing pressure ulcers , ) T ) during a three-month period?
• Nursing PICOT question examples surgery : P ) For patients post-operative abdominal surgery , I ) does the implementation of an enhanced recovery after surgery ERAS protocol , C ) compared to traditional postoperative care , O ) lead to shorter hospital stays and lower readmission rates , T ) within 30 days post discharge?
• Examples of PICOT questions breastfeeding : P ) Among primiparous mothers intending to breastfeed , I ) do breastfeeding workshops given prenatally , C ) as opposed to only routine prenatal care , O ) increase rates successful initiation continuation breastfeeding T six weeks after birth ?
• PICOT question example for nurse practitioner student : P  In primary care settings treating adult patients diabetes , I comprehensive diabetic education provided nurse practitioners , C standard diabetic information pamphlets O improve glycemic control T one year follow ?
• Example of PICOT question for suicide: (P) In adults with a history of previous suicide attempts, (I) does ongoing cognitive-behavioral therapy, (C) compared to no therapy, (O) reduce the incidence of future suicide attempts, and (T) over what time period?
• PICOT question examples homelessness: (P) Among homeless individuals, (I) does the implementation of a comprehensive housing and support program, (C) compared to standard homeless services, (O) improve overall health outcomes, and (T) within the first year of program implementation?
• Example of PICOT question for CAUTI: (P) In hospitalized patients with indwelling urinary catheters, (I) does the introduction of a nurse-led catheter care bundle, (C) compared to usual care without a dedicated protocol, (O) reduce the incidence of catheter-associated urinary tract infections, and (T) during the duration of hospitalization?
• Qualitative PICOT question examples: (P) For parents of children with type 1 diabetes, (I) how do they describe their experiences with home-based care management, (C) compared to those who do not have structured home care support, and how do these experiences affect their daily living and management routines over a period of six months?
• PICOT question examples for mental health: (P) In adolescents diagnosed with depression, (I) does participation in school-based mindfulness programs, (C) compared to no participation in such programs, (O), enhance their mental well-being and coping strategies for stress, and (T), across one academic year?
• PICOT question example ventilator-associated pneumonia in infants: (P) In neonates requiring mechanical ventilation in the NICU, (I), does the utilization of advanced ventilator circuit hygiene protocols, (C), compared to standard hygiene practices, (O), result in a lower incidence rate of ventilator-associated pneumonia, and over what time period?
• Examples of PICOT questions in nursing simulation:  (P) For nursing students participating in high-fidelity simulation scenarios focused on acute patient deterioration events,(I), does it increase their ability to identify patient compromise early on,(C), when compared to traditional clinical placement learning,(O), enhance critical thinking skills within one semester?
• Physician-assisted suicide PICOT question examples:  (P), In terminally ill patients considering physician-assisted suicide,(I), how do these patients describe their decision-making process,(C), compared to those who choose life-extending measures,(O), and what factors influence their choices within the last six months of life? 
• Examples of intervention questions for PICOT:  (P) In overweight adults diagnosed with Type 2 diabetes,(I( does involvement in an intensive lifestyle modification program(C( compared with standard diabetes education only(O( significantly improve HbA1c levels(T( over a course of 12 months? 
• PICOT question examples about elders:   For elderly residents in long-term care facilities, I (does regular physical activity programming (as opposed to sporadic or no formal exercise interventions(O) improve mobility scores( assessed biannually over two years? 
• PICOT question restraint examples:  (P) In acutely ill psychiatric patients hospitalized for violent behavior, (O) does routine use of therapeutic communication strategies by nursing staff, (C) compared with restraints as a first-line intervention, (I) result in reduced incidents of violence against staff and other patients, (T) measured during a six-month follow-up period?
• Here are examples of PICOT questions in nursing research across various specializations, including the specific elements of the Population (P), Intervention (I), Comparison (C), Outcome (O), and Time (T):
• Examples of PICOT questions for psychiatric nursing: (P) Among adolescents with major depressive disorder, (I) does the use of dialectical behavior therapy, (C) compared to the use of pharmacotherapy alone, (O) lead to a greater reduction in self-harm behaviors, and (T) within the first six months of treatment?
• Examples of PICOT questions for orthopedic nursing: (P) In elderly patients suffering from osteoarthritis of the knee, (I) is physical therapy with supervised exercise, (C) compared to at-home exercise programs without supervision, (O) more effective in improving joint mobility and reducing pain levels, and (T) over a 12-week treatment period?
• PICOT intervention question examples for weight loss: (P) Among adults classified as obese, (I) does participation in a medically supervised weight loss program, including dietary counseling and physical activity planning, (C) compared to standard care provided by a primary care physician, (O) result in greater weight loss and BMI reduction, and (T) at one year follow-up?
• PICOT question examples for PACU: [Post Anesthesia Care Unit] Nursing: (P) In postoperative patients recovering from general anesthesia, (I) does guided imagery during early recovery phase, (C) compared to standard postoperative care without guided imagery techniques, (O) lead to decreased levels of reported pain and anxiety scores, and (T) within the first 24 hours post-surgery?
• PICOT question examples cardiac arrest: (P) For cardiac arrest survivors who have returned to spontaneous circulation after resuscitation efforts, (I) does induced hypothermia therapy at 33 degrees Celsius for 24 hours, C compared to normothermia at 37 degrees Celsius standard management care after cardiac arrest , O improve neurological status and survival outcome , T in one month follow up.
• PICOT question examples about caring: P For nurses working long shifts P is implementing a mindfulness-based stress reduction program I compared to no structured stress management intervention C effective in lowering self-reported burnout levels O over six A period . 
• Example of PICOT questions for breast cancer screening: P Among women aged 40-60 with no prior history of breast cancer I do yearly mammograms I compared with biennial check-ups C detect cancers at earlier stages O A T 5-year period 
• Screening PICOT questions example:( P )In adults aged 50-74 years considered at average risk for colorectal cancer, (I)does undergoing annual fecal immunochemical testing, (C) compared to biennial colonoscopy screenings, (O) result in increased screening adherence rates and similar detection rates for advanced colorectal neoplasia , (T) over a ten-year period ?
• Examples intervention picot question : P hospital nurses working night shifts , I provision nap time during break using dark rest rooms sound-proofing C exposure standard lit rest areas minimal noise control around seating arrangements O better sleep quality alertness post-break response times emergency situation T three-month trial period.
• Example PICOT question on reducing anxiety: (P) Among adults suffering from chronic anxiety, (I) does the implementation of mindfulness-based stress reduction (MBSR) techniques, (C) compared to the use of traditional pharmacotherapy alone, (O) more effectively reduce symptoms of anxiety, (T) within a twelve-week treatment period?
• PICOT questions example for congestive heart failure pdf: (P) In patients with congestive heart failure, (I) does daily remote patient monitoring, (C) compared to usual care without daily monitoring, (O) decrease the rate of hospital readmissions, (T) within six months following discharge?
• PICOT question examples health screening: (P) For middle-aged adults at increased risk of cardiovascular disease, (I) does the introduction of a yearly comprehensive health screening program, (C) compared to biennial screenings, (O) lead to earlier identification and management of cardiovascular risk factors, (T) over a five-year period?
• PICOT question examples COPD: (P) In patients diagnosed with chronic obstructive pulmonary disease (COPD), (I) does using an inhaled corticosteroid and long-acting bronchodilator combination, (C) as opposed to long-acting bronchodilator monotherapy, (O) improve quality of life and exacerbation frequency, (T) over one year?
• PICOT question examples understaff: (P) Within a hospital setting experiencing nursing understaffing, (I) does the implementation of a strategic float pool system, (C) compared to traditional staffing methods, (O) improve patient outcomes and staff satisfaction rates, (T) during the course of one year?
• PICOT question example obesity: (P) Among obese adolescents ages 12-16, (I) is participation in a structured after-school sports program, ((C)) when compared with no structured physical activity intervention, ((O)) more effective in reducing BMI percentages and improving self-esteem levels, ((T)), within a six-month intervention period?
• Example of gynecologic PICOT question measurable in 6 weeks: (P) Among women with gynecologic conditions, (I) does the implementation of an exercise program, (C) compared to standard care, (O) lead to a reduction in pain levels and improvement in quality of life, (T) within a 6-week intervention period?
• Example evidence-based practice PICOT questions: (P) In patients with chronic pain, (I) does the use of mindfulness meditation, (C) compared to standard pain management techniques, (O) result in a decrease in pain severity and an improvement in overall well-being, (T) over a 12-week intervention period?
• PICOT question examples training: (P) Among healthcare professionals, (I) does the implementation of a communication skills training program, (C) compared to no training, (O) lead to enhanced patient satisfaction and improved rapport-building abilities, (T) within a three-month training period?
• Examples of PICOT questions in the ED: (P) In adult patients presenting to the emergency department with suspected myocardial infarction, (I) does the immediate administration of aspirin, (C) compared to delayed administration, (O) result in a decrease in mortality rates and improvement in cardiac outcomes, (T) within the first 24 hours of presentation?
•  PICOT question examples for home health: (P) Among elderly patients receiving home health care services, (I) does the implementation of a falls prevention program, (C) compared to standard care, (O) lead to a decrease in fall-related injuries and an improvement in functional independence, (T) over a six-month intervention period?
• PICOT question example PVA: (P) Among patients undergoing peripheral vascular access procedures, (I) does the use of ultrasound-guided cannulation, (C) compared to blind cannulation, (O) result in a decrease in procedure-related complications and an improvement in first-attempt success rates, (T) within the first hour of the procedure?
• PICOT question examples FNP: (P) In individuals with type 2 diabetes, (I) does the implementation of a nurse-led family nurse practitioner (FNP) intervention, (C) compared to standard primary care, (O) lead to improved glycemic control and enhanced self-management knowledge, (T) over a six-month intervention period?
• Geriatric pregnancy PICOT question example: (P) Among pregnant women over the age of 40, (I) does the implementation of a specialized geriatric pregnancy care program, (C) compared to standard prenatal care, (O) result in a decrease in pregnancy complications and an improvement in maternal and fetal outcomes, (T) from conception to delivery?
• Examples of PICOT questions to research: (P) In neonates admitted to the neonatal intensive care unit, (I) does skin-to-skin contact, (C) compared to incubator care, (O) lead to improved breastfeeding rates and enhanced physiological stability, (T) during the hospital stay?
• Example of a PICOT question related to ER nursing: (P) Among adult patients with suspected sepsis in the emergency room, (I) does the implementation of an early goal-directed therapy protocol, (C) compared to standard care, (O) result in a decrease in mortality rates and improved sepsis management, (T) within the first six hours of presentation?
• PICOT question example on nursing simulation: (P) Among nursing students participating in simulation-based education, (I) is high-fidelity simulation, (C) compared to low-fidelity simulation, (O) more effective in improving clinical decision-making skills and enhancing self-confidence, (T) within a semester-long nursing program?
• PICOT question example on safety: (P) Among healthcare workers in a hospital setting, (I) does the implementation of a safety checklist, (C) compared to standard procedures, (O) result in reduced medication errors and improved patient safety, (T) within a six-month intervention period?
• PICOT question example regarding breast cancer: (P) Among women aged 40-60 with a family history of breast cancer, (I) does the regular consumption of a plant-based diet, (C) compared to a standard diet, (O) reduce the risk of developing breast cancer and improve overall health outcomes, (T) over a five-year period?
• PICOT question example in nutrition and geriatrics: (P) Among elderly individuals residing in long-term care facilities, (I) does the implementation of a personalized nutrition plan, (C) compared to a standard diet, (O) improve nutritional status and reduce the risk of malnutrition-related complications, (T) over a six-month intervention period?
• PICOT question example on ventilator-associated pneumonia: (P) Among mechanically ventilated patients in intensive care units, (I) does regular oral care with chlorhexidine rinse, (C) compared to standard oral care practices, (O) reduce the incidence of ventilator-associated pneumonia and improve patient outcomes, (T) within a four-week period?
• PICOT question example in emergency room settings: (P) Among adult patients presenting to the emergency room with acute chest pain, (I) does the implementation of a chest pain triage protocol, (C) compared to usual care, (O) improve time to diagnosis and reduce the rate of missed myocardial infarctions, (T) within a two-month period?
• PICOT question example for polypharmacy: (P) Among elderly individuals taking multiple medications, (I) does the implementation of a pharmacist-led medication review, (C) compared to routine care, (O) reduce the number of medication-related adverse events and improve medication adherence, (T) over a three-month intervention period?
• PICOT question example on infection: (P) Among surgical patients in a hospital setting, (I) does the implementation of a pre-operative antibiotic prophylaxis protocol, (C) compared to standard pre-operative care, (O) reduce the incidence of surgical site infections and improve patient outcomes, (T) within a post-operative two-week period?
• PICOT question example on the theory of attainment: (P) Among nursing students in a baccalaureate program, (I) does the utilization of a transformative learning framework, (C) compared to traditional instructional methods, (O) enhance critical thinking skills and promote professional self-efficacy, (T) over the course of the program?
• PICOT question example on nursing simulation: (P) Among nursing students in a simulation-based learning environment, (I) does the use of high-fidelity mannequins and realistic scenarios, (C) compared to traditional lecture-based instruction, (O) result in improved clinical competence and confidence, (T) during the course of their education?
• PICOT question example on safety: (P) Among healthcare workers in a hospital setting, (I) does the implementation of a safety checklist, (C) compared to standard safety protocols, (O) lead to a reduction in the number of medical errors and adverse events, (T) over a six-month period?
• PICOT question example regarding breast cancer: (P) Among women aged 40-65 with a family history of breast cancer, (I) does the regular use of breast self-examination, (C) compared to no routine breast self-examination, (O) result in early detection and improved survival rates, (T) within a five-year follow-up period?
• PICOT question example in nutrition and geriatrics: (P) Among elderly residents in long-term care facilities, (I) does the implementation of a nutrition-focused quality improvement program, (C) compared to standard dietary practices, (O) lead to improved nutritional status and decreased incidences of malnutrition-related complications, (T) over a one-year intervention period?
• PICOT question example on ventilator-associated pneumonia: (P) Among critically ill patients on mechanical ventilation, (I) does the implementation of a ventilator bundle care protocol, (C) compared to standard respiratory care practices, (O) result in a lower incidence of ventilator-associated pneumonia and improved patient outcomes, (T) within a two-month period?
• PICOT question example for emergency room: (P) Among adult patients presenting to the emergency room with acute chest pain, (I) does the use of point-of-care cardiac biomarker testing, (C) compared to standard laboratory-based testing, (O) lead to shorter turnaround times for diagnosis and initiation of appropriate treatments, (T) during the patient’s emergency department visit?
• PICOT question example for polypharmacy: (P) Among older adults (65+) with multiple chronic conditions, (I) does the implementation of a comprehensive medication review, (C) compared to standard medication management practices, (O) result in a reduction in the number of medication-related adverse events and improved patient adherence, (T) over a six-month period?
• PICOT question example on infection: (P) Among hospitalized patients with surgical wounds, (I) does the use of antibacterial dressings, (C) compared to standard non-antibacterial dressings, (O) lead to a lower incidence of surgical site infections and faster wound healing, (T) within a two-week post-operative period?
• PICOT question example for theory of attainment: (P) Among undergraduate nursing students, (I) does the integration of a self-regulated learning approach, (C) compared to traditional lecture-based instruction, (O) result in improved academic performance and self-efficacy, (T) throughout their nursing education program?
• PICOT question example: “Anxiety Interventions in Adolescents: A PICOT Question Example” – PICOT Question: In adolescents ages 13-18 who have been diagnosed with anxiety (P), does cognitive-behavioral therapy (I) compared to pharmacological interventions (C) result in a greater reduction of anxiety symptoms (O) within a 12-week intervention period (T)?
• NICU Nursing Interventions: A PICOT Question Example – PICOT Question: In preterm infants in the Neonatal Intensive Care Unit (NICU), does skin-to-skin care (kangaroo care) (P) compared to incubator care (C) promote better weight gain and breastfeeding rates (O) during the hospital stay (T) as assessed within the first month of life?
• PICOT Questions for Elderly Care: An Example – PICOT Question: In elderly individuals aged 65 and above receiving home healthcare services (P), does implementing fall prevention strategies and exercise programs (I) compared to standard care (C) result in a decreased rate of fall-related injuries (O) within a 6-month period (T)?
• Infection Prevention PICOT Question Examples – PICOT Question: Among patients admitted to the hospital (P), does implementing strict hand hygiene protocols (I) compared to standard infection control practices (C) reduce the incidence of nosocomial infections (O) during the hospital stay (T)?
• PICOT Questions Related to Breast Cancer: An Example PICOT Question: Among women aged 40-60 with a family history of breast cancer (P), does regular mammography screening (I) compared to no routine screening (C) lead to earlier detection and improved survival rates (O) within a 5-year period (T)?
• PICOT Question for Nursing Competency: An Example of PICOT Question: In nursing students during their clinical placements (P), does simulation-based training (I) compared to traditional classroom-based learning (C) enhance clinical competence and confidence (O) at the end of the nursing program (T)?
• PICOT Questions for Community Nursing: An Example PICOT Question: In underserved rural communities (P), does implementing community health worker programs (I) compared to no community health worker involvement (C) improve access to healthcare services (O) within a one-year intervention period (T)?
• PICOT Question Example: Effectiveness of CHG Dressings – PICOT Question: In patients with surgical wounds (P), does the use of Chlorhexidine Gluconate (CHG) dressings (I) compared to standard wound dressings (C) decrease the rate of surgical site infections (O) during the hospital stay (T)?
• PICOT Question Examples for Hypertension Modification – PICOT Question: In hypertensive patients with comorbid diabetes (P), does lifestyle modification (exercise, diet, and weight loss) (I) compared to antihypertensive medication alone (C) result in better blood pressure control and glycemic management (O) within a 3-month intervention period (T)?
• PICOT Question Examples for CAUTI Prevention – PICOT Question: In hospitalized patients requiring indwelling urinary catheters (P), does implementing a nurse-led daily catheter care bundle (I) compared to standard catheter care practices (C) reduce the incidence of catheter-associated urinary tract infections (CAUTIs) (O) during the hospital stay (T)?

6 PICOT question examples Diabetes

• The PICOT question components include: (P) Adults with type 2 diabetes in the primary care setting, (I) does diabetes self-management with education (DSME) program intervention help control patients A1c? (C) when compared to the absence of self-management or DSME education (O), there will be a reduction in A1c (T) within three months.
• PICOT Question: In patients with diabetes type 2, how do inpatient diabetes management and education compared to outpatient care and education improve glycemic control over a period of 6 months?
• Among diabetic children patients (P), how does adopting various lifestyles (I), compared to non-adoption of new lifestyles (C), reduce the risk of diabetes-related complications (O) for a period of one year (T)?
• Among Adult patient with type 2 diabetes, does diabetes self-management education and diabetes awareness brings better result on maintaining a healthy lifestyle without diabetes complication and help to better control A1c?
• In African-American patients suffering from diabetes type 2 (P), how effective is the use of insulin (I) as compared to dietary modification and lifestyle changes (C ) in lowering the blood sugar levels in the body (O)within one month (T) after the initial diagnosis?
• In African Americans with type II diabetes, how does exercise compared to a sedentary lifestyle affect their quality of life?

4 PICOT question examples for falls

• For community-dwelling adults over the age of 65, is a multifactorial weekly, group fall prevention program more beneficial than weekly conventional PT for improving scores on the Berg Balance Scale?
• Among adult patients in the acute care setting would the implementation of patient-centered interventions be more effective compared to the usual fall prevention interventions in reducing incidence of falls one month after implementation?
• In 65+ and older adults with a one-year history of falling (P), does family involvement through education (I) compared to care without family participation (C) decrease the number of falls and fall-related complications (O) over six months (T)?
• For patients 80 years or older at risk of falls- as determined by performance on the TUG, 30-second chair stand, or 4-stage balance tests- is the Otago exercise program more effective than a strengthening program alone in preventing falls over follow-up periods of at least 6 and up to 12 months.

5 PICOT question examples of emergency nursing

• In emergency nursing, does changing patient triage and caregiver workflow as compared with the current model reduce patient overcrowding and decrease patient length of stay?
• In Emergency Departments, does the Application of over-crowding indices compared to Raw ED volumes, lead to Prognostic accuracy for over-crowding related outcomes (increased error rates, ED length of stay, staff burnout), reliability, physician/patient acceptability, external validity.
• In Emergency Departments, does Operational Improvement Interventions to Reduce ED Overcrowding and/or Overcrowding Related Sequelae, compared to Routine ED operations lead to over-crowding related outcomes (error rates, ED length of stay, staff burnout), physician/patient acceptability, external validity.
•  In the emergency department (ED), how does a nurse-initiated protocol (NIP) for chest pain (CP) patients compared to no protocol use influence length of stay (LOS) in the ED over 8 weeks?
•  In emergency nursing (P) how does violence prevention training (I) compared to no training ( C) affect nurses perspective of violence in the emergency room (O) within the first month of implementation (T)?

6 PICOT question examples Pregnancy

Are mothers given cesarian sections in their first pregnancy more likely to experience uterine rupture during subsequent pregnancies when compared with first-time mothers giving vaginal birth?

• Is transvaginal ultrasound performed on expectant mothers more effective than laparoscopy in diagnosing ectopic pregnancies?
• In women experiencing their first pregnancy, do pregnancy-tracking mobile apps result in fewer unnecessary hospital visits when compared with self-tracking over the course of the pregnancy?
• For a pregnant person seeking surgical abortion at < 14 weeks of gestation, is pain control with any particular method (I) safer, more effective and/or more satisfactory/acceptable compared with pain control with a different method or no pain control (C)?
• For a pregnant person seeking surgical abortion at ≥ 12 weeks of gestation, is cervical priming with medical methods (mifepristone, misoprostol, or both) a safe, effective and satisfactory/acceptable alternative to mechanical methods (laminaria, foley bulb, dilapan)?
• How do pregnant women (P) newly diagnosed with diabetes (I) perceive reporting their blood sugar levels (O) to their healthcare providers during their pregnancy and six weeks postpartum (T)?

5 PICOT question examples hypertension

• In overweight adults with hypertension (P), does changing diet and exercise (I) result in weight loss and reduced blood pressure (O) within a three month time period (T)?
• Does telemonitoring blood pressure (I) in patients with hypertension (P) improve blood pressure control (O) within one year of initiation of the medication (T)?
• Are patient education programs effective (compared to no intervention) in increasing patient exercise in the population of patients age 65 and older with high blood pressure?
• Are 30- to 50- year old women (P) who have high blood pressure (I) compared with those without high blood pressure (C)at increased risk for an acute myocardial infarction (O) during the first year after hysterectomy (T)?
•  In adult patients diagnosed with hypertension (P), how does home blood pressure monitoring (I) compared to no blood pressure monitoring (C) affect blood pressure (O) twelve weeks after diagnosis (T)?

5 PICOT question examples for nursing burnout

• Do nurses who practice stress management have lower levels of burnout compared to nurses who do not practice stress management?
• For ED nurses, how does a nurse education program addressing coping skills for work related stress impact job satisfaction, patient satisfaction scores, and reduce nurse desensitization?
• Among nursing practitioners (P), will encouraged retired professionals to return to the workforce (I), compared to not doing this (C), provide additional nurse aids to minimize the current shortage of nurses (O) within a year (T)?
• Among nurses having chronic burnout, what would be the effect or impact of increasing the nurse enrolment compared to the issue of exploring retention strategies to resolve the nursing shortage that is currently affecting the United States healthcare over the next eight years? 
• Among nursing staff in the emergency department, intensive care unit, neonatal intensive care unit, and labor and delivery, how does the proactive implementation of nursing staff education on burnout and depressive symptoms, assessment of burnout and depressive symptoms, and referral, compared to not educating or screening staff, affect burnout, stress recognition, and nurse turnover rates within three months of education and implementation of the interactive screening program for suicide prevention

4 PICOT question examples for medication errors

• For nurses administering medication in a long-term acute care hospital, does implementing the Medication Reconciliation Timeout Process (MRTP) decrease the medication errors, compared to the usual medication practice, in one month?
• In consideration of patients in acute units with dynamic medication needs, what methods are imperative in reinforcing the five rights and communication practices contrasted with increasing computer knowledge, lead to a decrease in mediation error events over the subsequent fiscal year.
• In critically ill patients, does the integration of health information technology compared to conventional methods in the medication management process reduce medication errors during hospital stays?
• In community dwelling adults, how effective is hands-only CPR versus hands plus breathing CPR at preventing mortality?

2 PICOT questions examples for ICU nurses

• In mechanically ventilated ICU patients, does positioning the patient in semi-fowlers result in a lower incidence of nosocomial pneumonia when compared to the supine position?
• In the critically-ill patient (P), how does promoting early mobility within 72 hours of admission (I), compared with prolonged bed rest affect patient hospital length of stay (O) over a three month period (T)?

6 Childhood obesity PICOT Question Examples

• For Obese children does the use of community recreation activities compare to educational programs on lifestyle changes reduce the risk of diabetes mellitus?
• Does parental obesity play a role in their children’s body mass index (BMI) in the ages between five and twelve years of age?
• Will obese children in the community benefit from dietary and physical activity guidance, compared to having no nutritional or physical activity education, in a way that will reduce weight and health related concerns over the next five years?
• Among parents of children aged 3 to 12 years old with a BMI of 85% or greater, does understanding parental perception of their child’s weight increase a parent’s readiness to change toward a healthy lifestyle management?
• Will a change in policy directed at utilizing a tracking form for identifying overweight/obese children at a primary care center by its PCPs increase the identification of overweight/obese children?
• Among parents with young children, early education about healthy eating and exercise, as opposed to education provided to parents prior to when that child is born could lead to the prevention of child obesity within 5 years.

2 PICOT question examples Depression

• Does aerobic exercise improve the mental health status of adults with clinical depression? Whereas, the patient population identified would be adults (male and/or female); the intervention of interest is the use of aerobic activity/exercise as a therapeutic component; the comparison interventions include adults who don’t apply physical activity/exercise as a therapeutic intervention; the primary desired outcome is treatment of clinical depression; and the time frame would ideally be long-term benefits
• For patients on CABG waiting lists, does an intervention program consisting of presurgical home visits and follow-up calls from a specialist cardiac nurse lead to decreased patient anxiety and depression when compared with no intervention]?

Good PICOT question ideas for nurse practitioners

• PICO Question: For young athletes (aged 13-30 years) trying to return to sport after arthroscopic hip labral surgery, is short-term PT as beneficial as long-term PT in returning an athlete to sport at full strength?
•  In women over 70 years old with knee osteoarthritis (P), is aquatic therapy (I) more effective than land-based therapy (C) in decreasing pain with ambulation (O)?
• Is body support treadmill training (I) more effective than overground training (C) for improvement in gait motor outcomes (O) in a 48-year-old man with left hemiparesis due to stroke (P) ?
• In (P) adult patients with chronic low back pain presenting to outpatient physical therapy services, does the (I) integration of strategies based in psychologically informed practices (O) better promote patient self-management (increase self- efficacy) compared with (C) traditional PT practice alone.
• In patients who are 60 years of age and older who have had a reverse total shoulder arthroplasty, are there differences in clinical and/or patient reported outcomes between those having surgery for rotator cuff tear arthropathy as compared to those having the procedure for primary osteoarthritis?
• Is the Otago Exercise Program (OEP) or Tai Chi more effective at achieving clinically significant reductions in patients’ risk for falling with knee osteoarthritis (OA), ages 65 and up, and at risk for falls, as measured by the Timed Up and Go (TUG) assessment, 12 months following the initiation of treatment?
• In a 25-year-old athlete with a history of ACL injury, do deep squats or shallow squats impose less tensile and shear stress on the tibiofemoral joint and ACL?
• In a child with cerebral palsy, is an anterior walker more effective than a posterior walker in improving upright posture (measured by decreased hip and trunk flexion), gait parameters (such as cadence, walking velocity, stride and step length, single and double support/stance time) and energy efficiency (measured by oxygen consumption)?
• In a 60-year-old patient with hemiplegia due to stroke, does distraction through a cognitive task, compared to focusing exclusively on gait during a treadmill gait training intervention increase affected step length?
• What are the health benefits of a community-based exercise and health education program for underserved Latinas?

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• Open access
• Published: 24 July 2017

A qualitative study to explore the perception and behavior of patients towards diabetes management with physical disability

• Syed Wasif Gillani 1 , 2 ,
• Syed Azhar Syed Sulaiman 3 ,
• Mohi Iqbal Mohammad Abdul 1 , 4 &
• Sherif Y. Saad 5  

Diabetology & Metabolic Syndrome volume  9 , Article number:  58 ( 2017 ) Cite this article

17k Accesses

12 Citations

Metrics details

This study aimed to determine self-monitoring practices, awareness to dietary modifications and barriers to medication adherence among physically disabled type 2 diabetes mellitus patients.

Interview sessions were conducted at diabetes clinic—Penang general hospital. The invited participants represented three major ethnic groups of Malaysia (Malay, Chinese and Indians). An open-ended approach was used to elicit answers from participants. Interview questions were related to participant’s perception towards self-monitoring blood glucose practices, Awareness towards diet management, behaviour to diabetes medication and cues of action.

A total of twenty-one diabetes patients between the ages 35–67 years with physical disability (P1–P21) were interviewed. The cohort of participants was dominated by males (n = 12) and also distribution pattern showed majority of participants were Malay (n = 10), followed by Chinese (n = 7) and rest Indians (n = 4). When the participants were asked in their opinion what was the preferred method of recording blood glucose tests, several participants from low socioeconomic status and either divorced or widowed denied to adapt telemonitoring instead preferred to record manually. There were mixed responses about the barriers to control diet/calories. Even patients with high economic status, middle age 35–50 and diabetes history of 5–10 years were influenced towards alternative treatments.

Conclusions

Study concluded that patients with physical disability required extensive care and effective strategies to control glucose metabolism.

Practice implication

This study explores the patients’ perspectives regarding treatment management with physical disability.

The most recent report by International Diabetes Federation Diabetes Atlas estimates that there are currently 387 million people living with diabetes globally in 2014, a 105% increase from its last report in 2011 with most people living in the western pacific [ 1 ]. Recent systematic analysis study on global burden disease analysed data from health examination surveys and epidemiological studies included data from 2.7 million participants and 370 country-years reports that a total of 347 million adults are living with diabetes worldwide [ 2 ]. It is estimated that by 2030 a total of 439 million people will suffer from diabetes mellitus, which represents approximately 7.7% of the global adult population aged 20–79 years [ 3 ].

Patients with medication non adherence may failed to achieve optimal therapeutic outcomes [ 4 , 5 , 6 ]. Physiologically hemoglobin A1c inversely related to diabetes medication adherence [ 6 ]. Several studies have determined the link between medication non adherence with higher diabetes related complications, inpatient and emergency department utilizations [ 3 , 7 ]. There are several factors effecting the glycemic control and patient adherence to the treatment plan [ 8 , 9 ]. To achieve target glycemic control, patients needed to follow multiple care models including self-monitoring blood glucose (SMBG), Dietary modifications, exercise, improve diabetes medication knowledge and medication adherence [ 5 , 7 ].

Disability is a key indicator implicating both overall morbidity and success of public health efforts to compress the period of morbidity among geriatrics for the overall population. Disabilities are more prevalent among diabetics than among those without diabetes. Physical inactivity, obesity, peripheral arterial disease, neuropathy, coronary heart disease and depression contribute strongly to higher disability risk among diabetic persons. Better management of glycaemia and reduction of risk factors for cardiovascular disease provide long-term prevention of disability. Preventing disability will likely depend on a combination of secondary and tertiary prevention along with diabetes prevention [ 8 ]. Common disabling conditions among people with diabetes in the United States include arthritis that limits physical activity, depression, hearing loss, peripheral neuropathy and visual impairment that limits ability to read regular print [ 9 ]. Improving behaviors of patient and clinician regarding close monitoring of disease control parameters and timely treatment adjustments might improve quality of life among patients with multiple comorbidities and complex health care needs [ 10 ]. Diabetes-induced disability rate is increasing due to the fact that the vast majority of diabetics are living longer. Due to poor medication adherence among diabetic subjects contribute to exaggerated health cost. Diabetes associated disabilities contribute to great extend poor adherence to prescribed medications, since a huge number among diabetics at the time of diagnosis, have experienced disabilities [ 11 ]. Mortality among diabetics has now been postponed to older age in most cases; however disability and health loss due to diabetes is increasing, particularly in the older population [ 12 ]. The complexity of self-care often increases as diabetic subject is growing older. Since eyesight, hearing, fine motor skills and memory processes are altering with time resulting in a great impact on the individual’s ability to comply with self-care practices [ 13 ].

Physical disability and cognitive impairments are the major barriers to achieve optimal glycemic control and medication adherence. Somehow the research community ignored to explore the patients behavior to self-care practices and medication adherence with physical disability. Thus this study aimed to determine self-monitoring practices, awareness to dietary modifications and barriers to medication adherence among physically disabled type 2 diabetes mellitus patients.

Research design

Qualitative method explores the understanding of participants’ behavior “how and why people respond to disease management practices”. In addition, such methods also provide comprehensive answers to diverse questions from patient oriented barriers to drug related problems. The qualitative interview has the flexible nature of exploration that is advantageous to the researcher investigating knowledge, perception and barriers to respond.

Setting and participants

Interview sessions were conducted at diabetes clinic—Penang general hospital (2016–2017). The invited participants represented three major ethnic groups of Malaysia (Malay, Chinese and Indians).

Eligibility criteria: patient with physical disability (amputee arm and/or leg), diabetes type II mellitus and aged 18 years or above. Recruitment was performed in suggestion with physicians attending patients at diabetic clinic (6-months, systemic random sampling). Patients with cancer, pregnancy, inflammatory disorder or cognitive impairment (dementia etc.) were excluded.

Participants did not face any challenges when answering interview questions during the interview session as the questions used were simple and straightforward without the use of medical jargons.

Assessment tool

A semi-structured interview guide was used to conduct the study (Table  1 ). An open-ended approach was used to elicit answers from participants. Interview questions were related to participant’s perception towards self-monitoring blood glucose practices, Awareness towards diet management, behaviour to diabetes medication and cues of action. General probing was used during the interview sessions to facilitate questions (Can you explain further? What about your opinion on this? Can you further clarify etc.).

Tool development and validation

The interview probe guide was first developed after extensive literature search [ 10 , 11 , 12 , 13 ] and then discussed with the experts from both academic and practice oriented personnel. The purpose to conduct this process was to merge healthcare providers’ prospective coherently with interview specific probes. This will interest public health experts and endocrinologist to follow-up with research findings and improve future practices. A pilot study was conducted to pre-test the interview guide but the data is neither presented in this manuscript nor added to final analysis (sample size of pilot study—n = 8).

Interview process

Due to the large amount of participants who are from the Malay ethnic group interviews were conducted in local Malaysian language (n = 18). Interviews were conducted in English where language barrier was not a concern (n = 3). The back translate method is used to report the quotes of the local Malaysian language interviews to make sure the concepts translated properly. Three research assistants, one from each ethnic (Malay, Chinese, Indian) were trained to conduct the interviews. On average interview sessions were approximately forty minutes in length (30–60 min). The principle investigator facilitated all the interview sessions with research assistants and also documented field notes. Prior to interview patients’ demographic and disease data was collected by a structured questionnaire attached with patient information sheet and consent form.

Ethical considerations

Research ethics approval was acquired prior to the commencement of the study, from Clinical Research Committee (CRC), Ministry of Health Malaysia (NMRR-10-776-6941). Informed consent was obtained from all the participants in either English or Malay languages. Verbal consent was considered from those unable to read or write.

Data analysis/evaluation

All the interviews were audiotaped for verbatim transcriptions. All the interviews were transcribed by principle investigator to avoid bias. The transcripts were then verified for accuracy by relevant participants and proceed for analysis after approval. The principle investigator recorded the raw data thematically and then the themes were discussed with other expert independent researchers to ensure the reliability and trustworthiness [ 14 ]. Each transcript was repeatedly read by three independent experts to identify the common theme. Emergent theme was then discussed among all the authors to refine the analysis. The investigators continued (and not concluded) interviews until theoretical saturation was achieved, when subsequent interview not produce any new information (saturation + 3 formula applied) [ 15 ].

Results and findings

A total of twenty-one diabetes patients between the ages 35–67 years with physical disability (P1–P21) were interviewed. The cohort of participants was dominated by males (n = 12) and also distribution pattern showed majority of participants were Malay (n = 10), followed by Chinese (n = 7) and rest Indians (n = 4). Majority of them were married (n = 9) and also moderate socioeconomic status (n = 10). A total of eight participants had diabetes history of 11–15 years and about half of the participants (n = 10) reported oral treatment for diabetes. The demographic and clinical characteristics of participants are summarized in Table  2 . All the patients were asked about regular monitoring/follow-up to physician before the interview and majority of the participants (n = 18) reported either missed appointments or forget follow-up monitoring.

Perception towards self-monitoring blood glucose practices

When the participants were asked in their opinion what was the preferred method of recording blood glucose tests, several participants from low socioeconomic status and either divorced or widowed denied to adapt telemonitoring instead preferred to record manually.

“I (prefer to) manually record. I do not understand how to use a telephone especially opening (applications and other function on the telephone). To me manual (recording) is easier”… … (P10)

However, participants from moderate or high economic status and either single or married showed positive perception/willingness to adapt technology based monitoring.

“I am an old person I like it to be (hand) written. Anyway as long as someone shows me how to do it I can do it (electronic monitoring). Of course it’s easier because you bring your hand phone everywhere you go”…. (P18)

At the same time, participants also claimed that use of technology would be portable to carry along and helped them to record easily, also provide detailed log of all the tests to attending physicians and reduces dependency to others.

“(I prefer the) digitals way (telemedicine). Everyday you can see it in your digital way in the software (digital diary) so (there is) no need to record like manually. Sometime(s) even (if) you record manually the paper (is placed) wherever (and will go) missing. (With telemedicine) you have a backup. Due to (limited mobility) I am dependent on family members for (regular check - up), so this electronic log (will help my physician) to track down my performance”….. (P21) “I think, It’s useful to me as an indication (of my sugar control). I prefer that I can use it to check my blood sugar (levels and so I can study how this medication effect(s) my glucose (levels). Also this (reduces my dependency) to family members” … (P6)

Barrier to self-care practices; majority of participants with age >40 years and diabetes history >11 years showed concern about financial conflicts, however patients age >60 years either dependent to other caregiver for blood glucose monitoring or usually reluctant to self-monitoring and limited with the experience of diabetes related symptoms.

“Self - monitoring is okay but sometimes - financial conflict (unable to buy sticks for glucometer) let me forget about checking my sugar for months… then suddenly I few symptoms (hyperglycaemic or hypoglycaemic) pops - up and I remember to continue my sugar monitoring”… (P1) “Well what (I can say), I am (afraid) of blood, so I cant monitor (my self) sugar… sometimes my son (when free) check the sugar… Usually (twice or three) times per month.. but sometimes I feel (dizzy) so I asked him to check (blood sugar)” … (P7)

Awareness towards diet management

When the participants were asked before you diagnosed (diabetes), have you heard of calorie counting, majority of the participants regardless of age, marital status and years of diabetes history were denied.

“We do not know (about calories) we just eat whatever we fancy regardless how how much calorie is in the food”…. (P15)

There were mixed responses about the barriers to control diet/calories.

“It is not hard to control (our diet but) sometimes we (do not want to) waste (food) so we will finish (up any left overs). Sometimes your wife might be stressed at work and (when you) come back and say ‘What is this (kind of food)!” then it will become a big issue. (Do you) understand?”… (P8) “If we cook separately) it can affect our relationship (with or families). When I do it like that (insisting on eating healthy food) your (there will be) a rift in your family(ies) relationship so sometimes we do not follow (our diet) that strictly because dinner time is the only time (for a) family gathering so sometimes we will eat out” … (P3)

Participants have mentioned several strategies to control diet but it seems ineffective. Reduction in food intake especially carbohydrates as well as reducing food intake was reported. Even so, some participants remain hesitant to completely changing their diets in order to maintain a healthy relationship among their family members. Hence compromises are made. Eventually participant’s diets are not controlled.

“I have my wife (who does the cooking). I’m living in a standard family (of) more than six adult people and more than three children (we) have to cook a lot and then I will have to cook separately”…. (P2) “I change everything (diet) because rice is very bad. (I will eat) rice maybe two (to) three time(s) a day (week) only so (instead) I (will take) mee hoon (vermicelli)”…. (P14)

Behavior to diabetes medication

More than 80% participants (n = 18) were non-adherent to diabetes medications. Lack of disease knowledge was identified from participants’ behavior.

“(I will) change (my insulin medication) myself. (Although) the doctor has said not to and (if I am) afraid of hypo (glycaemia) I should check (my blood sugar) first, record (my blood sugar levels) and if I continue to be hypo (glycaemic) I should call (the clinic) to reduce (my insulin medication)”… … (P19) “It is not good (anti - diabetic medication) because it does not cure but instead worsens (diabetes). The medication keeps increase from half (a dose) to one (dose) to two (doses). Meaning it does not cure but worsens (my condition)”…. (P12)

At the same time, several lay beliefs found to influence the diabetes management. Participants’ lack of awareness towards diabetes treatment showed the possible (Tables  3 , 4 ) cause of non-adherence in the cohort.

“In the beginning I was worried (when I) took (insulin). He (my friend) told me that (insulin) is made out of swine. When I knew of it I did not want (to take insulin that is made from swine). What happens when (a by product of) swine enters (my) body? How am I going to bathe?”… (P1)

Even patients with high economic status, middle age 35–50 and diabetes history of 5–10 years were influenced towards alternative treatments.

“Pomegranate juice. (When I) ate that I checked that my blood (pressure) reduced a lot”. . (P17) “This (balsam apple) if you take it daily (your blood) sugar (levels) will go down ”… (P9) “Usually you soak ladies finger in the water (overnight) and you drink the water tomorrow morning it will also make the (blood) sugar (levels) go down”… (P5) “That “bile of earth” (Andgrographis paniculata) if you take that I can assure (you that) hundred percent your BP (blood pressure) will go down you sugar (will) also go down. In fact I have discussed with my doctor and he agrees. He is a very elderly man (but) he agree(s). But you can only take once week not more than three times (or else) you can not urinate and experience erectile dysfunction” …. (P16)

Cues of action

Mobile reminder.

Although it is advised that self-monitoring is important for diabetics to control their blood glucose levels but participants have reported limited practice to glucometer and family support remains an important factor to ensure compliance:

“Long - term basis we can do ourselves but (it is) better that someone (to) assist or remind us (to control out blood sugar levels) because I take everything easy so my wife will be my reminder she will remind me to do all this la (controlling diabetes). Even for technology (mobile - based) or whatever my wife will be the caretaker and remind (me) what to do and what to eat or not to eat”… (P11)

Diabetes education

Many participants acknowledge that diabetes education is important. Participants were interested to gain new knowledge while some showed initiative to attend diabetes education seminars organized by the local clinics. Some participants provided suggestions on how to better encourage other diabetics to attend diabetes education seminars. Participants suggest that as every diabetic should take the initiative to ensure adequate knowledge is obtained in order to better manage their disease:

“Because this one (diabetic education) is not compulsory. Hospitals should make (it) compulsory for all patient(s) to attend the classes. Patients should be forced to come (and) attend classes also support groups would be better (and) should be free that will help others to understand about diabetes”… . (P20)

Self-care practices including self-monitoring of blood glucose has an important role in diabetes management. Several studies have documented the relationship between knowledge and self-care practices including; physical activity and adherence to diet. All of them focused on either general population or type 2 diabetes patients but none of them have ever discussed the practices among physically disabled patient [ 16 – 19 ]. This study explores the patients’ practices and barriers to self-care practices.

Self-management is considered as an important part of diabetes care. Also, knowledge, awareness is the greatest weapon in the fight against diabetes mellitus that might help diabetics to understand disease risks, motivate them to seek proper treatment and care, and set up them to keep the disease under control [ 20 – 24 ].

Several variables influence the glucose metabolism among diabetic population, including weight status, gender, age and type of diabetes (insulin dependent versus non-insulin dependent). Majority of studies target the population between age 45–78 years [ 4 , 7 , 10 , 11 , 12 , 13 , 14 , 15 ] when weight concerns are at least level. However about 66% of this study participants were age <50 years. Also awareness of calorie counting as diet control strategy have never discussed before, thus this study have explore the patients’ awareness to understand the concept of calorie counting in diet modification plan. Usually this behavior overestimated with patients’ response only. Studies have suggested that pharmacist-led intervention model significantly improved patients’ knowledge and practices to dietary modification and physical activities [ 10 , 11 , 12 , 13 , 14 , 15 ].

Self-monitoring of blood glucose (SMBG) has been recommended by the American Diabetes Association as a test for monitoring the glycemic status [ 25 ].

Educational interventions involving patient participation and collaboration seemed to be more effective than didactic interventions in improving glycemic control. The process of self-management includes the tendency to structure situations and activate resources (self-perception), to accept options for action (self-reflection) and to believe in self-efficacy (self-regulation). Structured programs which mostly combine information, strategies for behavioral changes, and self-management strategies are still needed [ 26 ].

Aspects of the process of self-management (structuring the situation and activating resources [self-perception], accepting options for action [self-reflection] and believing in self-efficacy [self-regulation]) which lead to a change in the metabolic profile of patients using blood glucose self-monitoring. SMBG coupled with structured brief counseling provided patients with a tool for taking on more self-control and resulted in an improved outlook on life [ 27 ].

The study has found several lay beliefs that influence the treatment outcomes. Patients have also claimed the self-prescribing behavior and also lack of diabetes-disease based knowledge. Scientific literature debated on the use of herbal and natural remedies from last several decades, but patient’s behavior is reflective to functional-knowledge about the disease. Therefore, care-plan must include the elements of disease-knowledge, potential determents that influence the treatment course and patients-participation in treatment planning [ 10 , 13 , 15 ].

Limitations

The study is limited to patients with help-seeking behavior, clearly there are patients not willing to visit healthcare facilities and live in a hostile environment. The limitation of funding restricted the study to conduct a nationwide survey therefore results of this exploratory study are not truly representative of the entire population. This study has not performed any anthropometric (waist circumference, body mass index etc.) correlation with the patients’ responses thus future directions should focus on behavioral relationship with clinical variables.

This study had identified lack of diabetes related knowledge among physical disabled patients. Self-care blood glucose monitoring is somehow limited but the use of pharmacist or mobile devices might improve the practices. Also study concluded that patients with physical disability required extensive care and effective strategies to control glucose metabolism. Patients with physical disability should be considered as special population and healthcare professionals focus more on improving patients’ knowledge and behavior than treatment plan.

This study is the first to explore the patients’ behavior and practices to disease management among physically disabled type 2 diabetes mellitus patients.

Physical disability and cognitive impairments are the major barriers to achieve optimal glycemic control and medication adherence.

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Authors’ contributions

SWG: Principle investigator and drafted the manuscript. SASS: Participated in data collection and design the study. MIMA: Involved in qualitative analysis. SYS: Participated in study content analysis and helped to draft the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We would like to acknowledge the support of nursing staff and physicians for providing effective feedback on validation of probes and thematic analysis.

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Gillani, S.W., Sulaiman, S.A.S., Abdul, M.M. et al. A qualitative study to explore the perception and behavior of patients towards diabetes management with physical disability. Diabetol Metab Syndr 9 , 58 (2017). https://doi.org/10.1186/s13098-017-0257-6

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The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control

• Andreas Schmitt 1 ,
• Annika Gahr 1 ,
• Norbert Hermanns 1 ,
• Bernhard Kulzer 1 ,
• Jörg Huber 2 &
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Though several questionnaires on self-care and regimen adherence have been introduced, the evaluations do not always report consistent and substantial correlations with measures of glycaemic control. Small ability to explain variance in HbA 1c constitutes a significant limitation of an instrument’s use for scientific purposes as well as clinical practice. In order to assess self-care activities which can predict glycaemic control, the Diabetes Self-Management Questionnaire (DSMQ) was designed.

A 16 item questionnaire to assess self-care activities associated with glycaemic control was developed, based on theoretical considerations and a process of empirical improvements. Four subscales, ‘Glucose Management’ (GM), ‘Dietary Control’ (DC), ‘Physical Activity’ (PA), and ‘Health-Care Use’ (HU), as well as a ‘Sum Scale’ (SS) as a global measure of self-care were derived. To evaluate its psychometric quality, 261 patients with type 1 or 2 diabetes were assessed with the DSMQ and an established analogous scale, the Summary of Diabetes Self-Care Activities Measure (SDSCA). The DSMQ’s item and scale characteristics as well as factorial and convergent validity were analysed, and its convergence with HbA 1c was compared to the SDSCA.

The items showed appropriate characteristics (mean item-total-correlation: 0.46 ± 0.12; mean correlation with HbA 1c : -0.23 ± 0.09). Overall internal consistency (Cronbach’s alpha) was good (0.84), consistencies of the subscales were acceptable (GM: 0.77; DC: 0.77; PA: 0.76; HU: 0.60). Principal component analysis indicated a four factor structure and confirmed the designed scale structure. Confirmatory factor analysis indicated appropriate fit of the four factor model. The DSMQ scales showed significant convergent correlations with their parallel SDSCA scales (GM: 0.57; DC: 0.52; PA: 0.58; HU: n/a; SS: 0.57) and HbA 1c (GM: -0.39; DC: -0.30; PA: -0.15; HU: -0.22; SS: -0.40). All correlations with HbA 1c were significantly stronger than those obtained with the SDSCA.

Conclusions

This study provides preliminary evidence that the DSMQ is a reliable and valid instrument and enables an efficient assessment of self-care behaviours associated with glycaemic control. The questionnaire should be valuable for scientific analyses as well as clinical use in both type 1 and type 2 diabetes patients.

Hyperglycaemia is a major predictor of the development of diabetes late complications, and improving glycaemic control has been shown to prevent microvascular as well as macrovascular events (the latter at least in type 1 diabetes) [ 1 – 3 ]. Although a number of internal and external factors contribute to the level of blood glucose [ 4 ], it is widely accepted that good self-care protects against complications in both type 1 and type 2 diabetes and that the patient must actively manage the disease’s requirements in order to achieve optimal blood glucose outcomes [ 1 , 5 , 6 ].

It has often been suggested that important psychosocial factors such as depression and emotional distress can interfere with self-care behaviours and therefore negatively impact glycaemic control [ 7 , 8 ]. Consequently, numerous studies have concentrated on negative emotional conditions and actually found associations with both reduced self-care activities [ 9 , 10 ] and elevated HbA 1c values [ 11 – 15 ]. However, research has yielded only limited insight into the suggested behavioural mechanisms between negative affect and hyperglycaemia, and this is to be explained at least partially by methodological problems of construct assessment.

A promising way to study such mechanisms is to utilise multiple regression or structural equation modeling and analyse the putative mediation of the relationship between an affective condition and HbA 1c by self-care. However, the applicability of this method and the conclusiveness of its results strongly depend on the self-care assessment’s ability to explain variance in the criterion variable [ 16 ]. If the measuring instrument is not sufficiently associated with HbA 1c , the putative mediation may actually not be observed. For example, this may have been the case with the analysis by Lustman et al. [ 17 ], who found an association between depression and hyperglycaemia but no mediation of the association by self-care behaviour.

Taken as a whole, weak associations with glycaemic outcomes [ 18 – 20 ] or the omission of reporting the critical data [ 21 , 22 ] can be frequently found among evaluations of eligible questionnaires, but there are also further obstacles. A recent review of psychometric tools identified a total of five questionnaires which assess self-management, but only one fully met the reviewers’ appraisal criteria [ 23 ].

That one questionnaire, which satisfied the reviewers’ expectations, was the Summary of Diabetes Self-Care Activities Measure (SDSCA), which is probably the most popular and most frequently used instrument in its regard. It has been evaluated in numerous studies, shown appropriate psychometric qualities and been translated into many languages. However, the authors stated that the questionnaire was not conceptualized to be closely linked to glycated haemoglobin, and consequently, its initial evaluation did not find any significant associations between its scales and HbA 1c [ 19 ]. Later studies have confirmed this lack of correlation, and to our knowledge no studies presenting moderate or strong correlations between the SDSCA and glycated haemoglobin have been reported [ 22 , 24 – 28 ].

While a valid assessment of diabetes self-care does not necessarily need to correlate with glycaemic outcome, a weak association between an instrument and HbA 1c nevertheless constitutes a major limitation for its use in research and also for practitioners interested in helping patients to improve or maintain good glycaemic control.

In order to facilitate the collection of appropriate data, the Diabetes Self-Management Questionnaire (DSMQ) was developed. The questionnaire was designed to assess self-care behaviours which can be related to the measure of HbA 1c , so that the data are suitable for mediational analyses. A second objective was to construct a brief instrument suitable for studies involving a multitude of data collection instruments including clinical trials. This article describes the DSMQ’s development and presents its first psychometric evaluation.

Two studies were conducted at the German Diabetes Center Mergentheim (GDCM), a tertiary referral centre for diabetes (Patients may be referred to the centre for different reasons. Providing intensive diabetes education, treating substantial problems of diabetes control, or performing major changes regarding a patient’s therapy may be typical reasons for referral. The average time of the stay is about 10 days.). Study 1 evaluated an initial set of 37 items on 110 in-patients, resulting in a final questionnaire containing 16 items. Study 2 assessed the psychometric properties of this 16-item scale on 261 in-patients.

Study participation was limited to patients with type 1 or 2 diabetes, adult age, sufficient German language skills, and providing informed consent. In-patients who met inclusion criteria were informed about the possibility to participate in a cross-sectional study of questionnaire evaluation. Patients who consented were assessed with the DSMQ and the SDSCA. Additionally, demographic and diabetes-specific characteristics were gained from the electronic patient records (sex, age, BMI, diabetes type, diabetes duration, type of diabetes treatment, late complication status, and current HbA 1c ). Both study samples reflected the typical clinic population composition, which mainly comprises of type 1 and type 2 diabetes in approximately equal percentages as well.

Data collection was carried out during a supplementary cross-sectional survey of the DIAMOS study (‘Strengthening Diabetes Motivation’) (Identifier: NCT01009138), approved by the Ethics Committee of the State Medical Chamber of Baden-Wuerttemberg (file number 2009-034-f). Written informed consent was obtained before participation.

Instruments and measures

Development of the diabetes self-management questionnaire (dsmq).

The DSMQ was developed at the Research Institute of the Diabetes Academy Mergentheim. It is the first German instrument targeting diabetes self-care, and was designed to assess behaviours associated with metabolic control within common treatment regimens for type 1 and type 2 diabetes in adult patients.

Initially, 37 items were generated with contents which, in view of the literature, were regarded as confirmed or promising predictors of glycaemic control. In this regard, the accuracy of medication intake and diet adjustment were regarded as important predictors in both type 1 and 2 diabetes. Poor adherence to insulin as well as oral medical regimens has been consistently associated with hyperglycaemia [ 29 – 33 ], and the change to a diet with a lower glycaemic index has shown the potential of improving glycaemic control regardless of diabetes type [ 34 , 35 ].

Another content of interest is self-monitoring of blood glucose (SMBG) as its impact on glycaemic control is well-established in type 1 as well as type 2 diabetes with insulin treatment [ 36 , 37 ]. Although there is uncertainty and debate about its benefit in insulin-naive patients [ 38 ], several studies suggest SMBG can be also advantageous in those [ 39 – 41 ], particularly when the feedback leads to relevant action [ 42 ]. Furthermore, two recent publications comparably concluded that SMBG can very well be an effective means of glycaemic control in insulin-naive patients if used in a structured and knowledgeable way [ 43 , 44 ].

Physical exercise as a means of metabolic control is commonly used in type 2 diabetes, and its effectiveness is well established [ 45 , 46 ]. Nevertheless, a recent meta-analysis found that exercise is also effective in improving HbA 1c levels in type 1 diabetes [ 47 ]. Therefore, physical activity (particularly with regard to diabetes treatment) was regarded as appropriate item content.

Finally, some items were designed to assess the patient’s adherence to (vs. avoidance of) appointments with health-care professionals, which, compared to previous questionnaires, is a somewhat new aspect. However, a higher frequency of primary care contacts is associated with a better glycaemic outcome [ 48 ], and the commonly motivating effect of feedback on HbA 1c is one putative explanation of this finding [ 49 ]. Furthermore, appointment adherence was found to predict glycaemic control independently of visit frequency [ 50 , 51 ]. Finally, appointment adherence seems to be reduced in depressed diabetes patients [ 9 ]. Therefore, this aspect should not be missed out when studying psychosocial predictors of diabetes control.

The final set of items tested in study 1 comprised of the following contents: Regularity of medication intake (4 items), diabetes-related aspects of diet (e. g. frequent consumption of foods complicating glycaemic control, adherence to dietary recommendations, alcohol consumption; 8 items), regularity of self-monitoring of blood glucose (4 items), regularity of physical activity (5 items), appointment adherence (4 items), several specific self-care activities, e. g. carriage of needed therapy devices, adequate treatment of hypoglycaemic/ hyperglycaemic episodes, record of blood glucose levels (5 items), and overall judgements of the adequacy of self-care (7 items). The items then were reviewed by a team of five psychologists, three diabetologists, and a sample of 15 diabetes patients, leading to the final item formulation.

All items were formulated as behavioural descriptions taking the first person view. Respondents are asked to rate the extent to which each statement applies to the personal self-management with regard to the previous eight weeks. The time frame was chosen in view of the specific time-dependence of HbA 1c values [ 52 , 53 ], as recommended by Johnson [ 4 ]. The rating scale was designed as a four-point Likert scale (in order to avoid a neutral response option and force a specific response) with the response options ‘applies to me very much’ (three points), ‘applies to me to a considerable degree’ (two points), ‘applies to me to some degree’ (one point), and ‘does not apply to me’ (zero points). The responses were converted such that higher scores are indicative of more effective self-care. To enable individual adjustment in items which assess aspects of SMBG or medical treatment, boxes offering to tick ‘is not required as a part of my treatment’ were added.

Analysis of responses as part of study 1 led to the identification of 16 items which formed the final scale for full psychometric assessment. Seven of these items are formulated positively and nine inversely with regard to what is considered effective self-care. The questionnaire allows the summation to a ‘Sum Scale’ score as well as estimation of four subscale scores. In view of their contents, the subscales were labelled ‘Glucose Management’ (items 1, 4, 6, 10, 12), ‘Dietary Control’ (items 2, 5, 9, 13), ‘Physical Activity’ (items 8, 11, 15), and ‘Health-Care Use’ (items 3, 7, 14). One item (16) requests an overall rating of self-care and is to be included in the ‘Sum Scale’ only. The full questionnaire is displayed in Table  1 .

Scoring of the questionnaire involved reversing negatively worded items such that higher values are indicative of more effective self-care. Scale scores were calculated as sums of item scores and then transformed to a scale ranging from 0 to 10 (raw score / theoretical maximum score * 10; for example, for the subscale ‘Glucose Management’ a raw score of 12 leads to a transformed score of 12 / 15 * 10 = 8). A transformed score of ten thus represented the highest self-rating of the assessed behaviour. If ‘not required as a part of my treatment’ had been marked in an item, it was not used, and the scale score computation was adapted accordingly (by reducing the theoretical maximum score by three points). However, in case of more than half of the items of a scale missing, a scale score should not be computed.

The questionnaire was translated into English using a standardised forward and backward translation procedure, as recommended by Bradley [ 54 ]. Two independent bilingual speakers and experts in diabetes treatment performed the forward translation. The results were reviewed and matched by the developmental team. An independent bilingual speaker familiar with the field completed the backward translation. Ultimately, the back-translated and original questionnaires were matched, and the English version was finalised.

Summary of Diabetes Self-Care Activities Measure (SDSCA)

The SDSCA is an 11 item scale, which assesses several self-care activities by the patient’s report on the previous week. The respondent marks the number of days of the week on which the indicated behaviours were performed. The questionnaire’s first ten items are summed to a total score and pairwise averaged to five scale scores. The five scales are called ‘General Diet’ , ‘Specific Diet’ , ‘Exercise’ , ‘Blood-Glucose Testing’ , and ‘Foot-Care’ , and represent the corresponding behaviours (‘General Diet’ regards to a prescribed or generally helpful diet, whereas the items of ‘Specific Diet’ assess the consumption of ‘fruits and vegetables’ and ‘high fat foods’). The eleventh item regards smoking and assesses the average number of cigarettes smoked per day.

A review of seven studies [ 22 ] reported good consistencies (with the exception of the scale ‘Specific diet’) as well as adequate retest-reliability and criterion validity of the scales: The mean inter-item-correlation of the scale items was r = 0.47, the mean retest-correlation of scales was r = 0.40, and the mean of criterion-related correlations (estimated for ‘General Diet’ , ‘Specific Diet’ , and ‘Exercise’) was r = 0.23.

In this study, reliability of the SDSCA’s sum scale as determined by Cronbach’s α coefficient was 0.63. For the scales ‘General Diet’ , ‘Exercise’ , ‘Blood-Glucose Testing’ , and ‘Foot-Care’ coefficients between 0.69 and 0.88 were observed. However, the scale ‘Specific Diet’ demonstrated a strikingly low consistency according to its α coefficient of 0.15, which corresponds to the results by Toobert et al. [ 22 ].

Glycaemic control

Glycated haemoglobin values were used as indicator of glycaemic control. All blood samples were analysed in the German Diabetes Center’s laboratory using high performance liquid chromatography (HPLC) performed with the Bio-Rad Variant II Turbo analyser. The period between blood sampling and questionnaire assessment was usually less than one week.

Statistical analyses

The analyses were performed using SYSTAT 10.2 (Systat Software, Point Richmond, CA, USA) and SPSS 21.0.0 (SPSS Inc., Chicago, IL, USA). Group comparisons involved One-way Analysis of Variance, Student’s t-test and Pearson’s chi-squared test. In all analyses a P -value of < 0.05 (two-tailed test) was considered as criterion of statistical significance.

To evaluate item characteristics, item difficulty indices (defined as percentage of agreements among all responses), inter-item-correlations and corrected item-total-correlations were computed, and the items were analysed for an increase of the scale’s reliability coefficient (Cronbach’s α) in case of item deletion. Additionally, the items’ correlations with the HbA 1c value were analysed. To estimate the scales’ internal consistencies, Cronbach’s α coefficients were computed. All item analyses were based on inverted item scores.

Exploratory principal component factor analysis (EFA) was used to evaluate the scale’s content structure. In this process, the varimax rotation was employed, as it usually produces explicit results which can facilitate the interpretation. Furthermore, it was assumed that the assessed self-care activities do not necessarily have to be correlated, which also suggests the orthogonal varimax rotation.

Confirmatory factor analysis (CFA) was performed using AMOS 21.0.0 to test the model defined by the EFA as well as a single factor model using the maximal likelihood estimation method. To evaluate the model fit, the Chi 2 /df ratio, comparative fit index (CFI), root mean square error of approximation (RMSEA), and the P -value of close fit (PCLOSE) were analysed. Adequate model fit is considered to be indicated by a Chi 2 /df ratio < 2 [ 55 ], a CFI value ≥ 0.90 [ 56 ], a RMSEA value < 0.08, and a PCLOSE > 0.05 [ 57 ].

To estimate the instrument’s validity, criterion-related correlations were analysed. The criteria were the SDSCA scales of self-care and the clinical outcomes BMI and HbA 1c . Since DSMQ scores as well as SDSCA scores were not normally distributed, Spearman’s correlations ( ρ ) were used. Patient characteristics such as sex, age, diabetes type, diabetes duration, type of medical therapy, and number of late complications were included in the analyses to examine possible associations (in case of the dichotomous variables sex, diabetes type, and use of insulin point-biserial correlations were estimated).

Additionally, known groups validity was assessed by assorting the patients into three groups according to the HbA 1c value, which were then examined regarding self-care activities as assessed by the DSMQ. Patients with HbA 1c values up to 7.5% were classified as ‘good glycaemic control’ , patients with values between 7.6 and 8.9% were classified as ‘medium glycaemic control’, and patients with values from 9.0% as ‘poor glycaemic control’. Between-groups differences were analysed using One-way Analyses of Variance.

To evaluate the instrument’s utility for the prediction of glycaemic control, the correlations of its scales with HbA 1c were compared to those of the equivalent scales of the SDSCA. Differences were tested for statistical significance using Steiger’s Z test of the difference between correlated correlations, as recommended by Meng, Rosenthal & Rubin [ 58 ].

If feasible (according to the sample sizes), the explained analyses were additionally performed on the basis of the diabetes type 1 and 2 subsamples in order to test the applicability of the questionnaire in both diabetes types.

Study 1: Development of the 16 item scale

In order to perform the item selection, 110 patients were assessed with the preliminary set of 37 items. The patients’ mean age was 51 ± 16 years, 44% were female and the mean BMI was 30 ± 7 kg/m 2 . 46% were diagnosed with type 1 diabetes and the average duration of the illness was 16 ± 10 years. The majority used an exclusive (64%) or medication-combined insulin therapy (22%), while only 13% used non-insulin medical treatments. The mean HbA 1c was 8.5 ± 1.8% and 53% of the patients were diagnosed with one or more late complications.

In a first step, 10 items without significant correlation with HbA 1c (two-sided P ≥ 0.05) were removed. The relevant items assessed dealing with hypoglycaemic episodes, calculation of carbohydrates, alcohol consumption, carriage of needed therapy devices, and weight control. The remaining 27 items showed correlations with the HbA 1c value between −0.19 and −0.43.

In a second step, two items which were found to decrease the internal consistency of this item selection were removed. For the remaining 25 items an α coefficient of 0.93 was observed.

In a third step, a principal component factor analysis was performed. The analysis identified five factors with eigenvalues higher than 1, which explained 64% of the variance. Varimax-rotated factor loadings were evaluated, and six items which did not show a loading of 0.50 or higher on any factor were removed. A renewed analysis of the remaining 19 items revealed a four factor structure, which still explained 61% of the variance.

In a fourth step, the factors were interpreted and the matching of items was rated. The factors could be easily interpreted as ‘dietary habits’ , ‘blood glucose measurement/ medication intake’ , ‘contact with health-care professionals’ , and ‘physical activity’. Regarding the associated items, there were three significant deviations: Firstly, one item which asks for overall self-care loaded primarily on ‘dietary habits’ (0.67). It was removed consequently. Secondly, one item which asks for the recording of blood glucose levels showed indeed a loading of 0.44 on the ‘blood glucose measurement/ medication intake’ factor, but it was primarily related to ‘contact with health-care professionals’ (0.61). Despite its bidimensionality and with a view to its correlation with HbA 1c of 0.38, it was decided to keep the item. Thirdly, one item showed substantial loadings (> 0.30) on all four factors. As this item regards overall self-care (‘my diabetes self-care is poor’), the pattern of factor loadings was rated to indicate an appropriate matching.

In the final step, the remaining 18 items were analysed for contentual redundancy. Among the items of ‘medication intake’ and ‘dietary habits’ , there were each two items of equivalent content and equal connotation. In each case, the item with the lower correlation with HbA 1c was removed.

According to the structure and its contents, four subscales were identified and labelled ‘Glucose Management’ (five items), ‘Dietary Control’ (four items), ‘Physical Activity’ (three items), and ‘Health-Care Use’ (three items). One additional item which addresses overall self-care (‘my diabetes self-care is poor’) is included in the ‘Sum Scale’ only (16 items).

Study 2: Evaluation of the 16 item scale

The psychometric properties of the final 16 item version of the DSMQ were assessed in 261 patients. The SDSCA served as comparison to assess the quality of our scale. The sample characteristics are presented in Table  2 . The sample was generally well matched to the first study’s sample, except that 58% of the patients were diagnosed with type 1 diabetes, which is 12% more than in the first study. However, with an average age of 52 ± 15 years, 44% female sex, a mean BMI of 30 ± 7 kg/m 2 , and a mean HbA 1c value of 8.6 ± 1.5% in this study, the two samples were highly comparable. Despite the slightly different proportions of diabetes types, rates of specific treatments, mean diabetes durations, and late complication statuses were highly similar (as can be seen in Table  2 ).

Item characteristics and reliability

Item analyses revealed a mean item difficulty of 46.7 (SD = 25.5). However, the indices of items 3, 4, and 7 were located in the peripheral zones of the distribution. The mean inter-item-correlation (or homogeneity) was 0.25 (SD = 0.15). The mean item-subscale-correlations were 0.56 (SD = 0.09) for ‘Glucose Management’, 0.57 (SD = 0.05) for ‘Dietary Control’, 0.59 (SD = 0.10) for ‘Physical Activity’, and 0.43 (SD = 0.01) for ‘Health-Care Use’. For the ‘Sum Scale’ a mean item-total-correlation of 0.46 (SD = 0.12) was observed, and in no case an item deletion led to an increase of the scale’s α coefficient (see Table  3 ). Two items (14, 15), however, showed item-total-correlations lower than 0.30. Still, those were highly correlated with their corresponding subscales. All items were negatively related to HbA 1c with a mean correlation of −0.23 (SD = 0.09). With the exception of the items 8 and 15, both on physical activity, all correlations with HbA 1c were significant. A detailed overview of the above item characteristics is displayed in Table  3 .

Reliability analyses revealed good internal consistency of the ‘Sum Scale’ and acceptable consistencies of the subscales (except the subscale ‘Health-Care Use’ which showed a marginal consistency value). Cronbach’s α coefficients were 0.77 for ‘Glucose Management’, 0.77 for ‘Dietary Control’, 0.76 for ‘Physical Activity’, and 0.60 for ‘Health-Care Use’. For the ‘Sum Scale’ an α coefficient of 0.84 was observed.

If item and scale properties were assessed in the diabetes type subsamples separately, the analyses collectively revealed comparable results. In type 1 diabetes patients, the mean inter-item-correlation was 0.30 (SD = 0.14), the mean item-subscale-correlation was 0.58 (SD = 0.07), and the mean item-total-correlation was 0.51 (SD = 0.11). All items showed negative associations with HbA 1c with a mean correlation of −0.25 (SD = 0.11), and with the exception of items 8, 11, and 15 all coefficients were significant. The DSMQ subscales showed α coefficients of averagely 0.76 (SD = 0.05) and the ‘Sum Scale’s α was 0.87.

In type 2 patients, the mean inter-item-correlation was 0.20 (SD = 0.17), the mean item-subscale-correlation was 0.50 (SD = 0.12), and the mean item-total-correlation was 0.40 (SD = 0.16). All items were negatively related to the HbA 1c value with a mean correlation of −0.22 (SD = 0.09) . However, in five cases (items 8, 9, 11, 14, and 15) the correlations were insignificant. The DSMQ scales’ α coefficients were averagely 0.68 (SD = 0.12) for the four subscales and 0.80 for the ‘Sum Scale’.

Factorial validity

EFA suggested a four factor structure according to the Kaiser-Guttman criterion explaining 60% of variance. This result was supported by the scree test. The varimax rotation converged in 6 iterations. In view of the items’ factor loadings the factors represented the contents of ‘effective blood glucose measurement and medication intake’ (items 1, 4, 6, 10, 12), ‘dietary habits facilitating diabetes control’ (items 2, 5, 9, 13), ‘avoidance of physical exercise’ (items 8, 11, 15), and ‘avoidance of medical appointments’ (items 3, 7, 14). Item 6, which asks for the recording of blood glucose levels, again (as in the first study) revealed a bidimensional structure with its additional loading on the diet factor. The global item 16 loaded substantially (≥ 0.30) on all factors except ‘avoidance of medical appointments’. The factor loadings are presented in Table  4 .

To test the observed factor structure, all items except item 16 were aggregated to four correlated factors (as suggested by the EFA) using CFA. The analysis revealed the following model fit indices: The Chi 2 /df ratio was 1.64, the CFI value was 0.96, the RMSEA value was 0.05, and the PCLOSE was 0.50. These results indicate a very appropriate fit of the four factor model. To evaluate the feasibility of integrating all items to a total scale, an additional single factor model (all 16 items aggregated on one factor) was tested. The analysis revealed a Chi 2 /df ratio of 1.74, a CFI value of 0.95, a RMSEA value was 0.053, and a PCLOSE of 0.34, which indicated an adequate fit of this model, too.

Known-groups validity

The comparison of patient groups with ‘good glycaemic control’ (HbA 1c ≤ 7.5%), ‘medium glycaemic control’ (HbA 1c 7.6 – 8.9%), and ’poor glycaemic control’ (HbA 1c ≥ 9.0%) revealed significant differences regarding both the DSMQ sum scores as well as the subscale scores. All results are shown in Table  5 .

According to these results, patients with ‘good glycaemic control’ reported significantly more ‘Glucose Management’, ‘Dietary Control’, ‘Physical Activity’, and ‘Health-Care Use’ than those with ‘poor control’. Correspondingly, in this group the mean ‘Sum Scale’ score was significantly higher.

Compared to the ‘medium glycaemic control’ group, patients with ‘good control’ reported significantly more ‘Glucose Management’ and ‘Physical Activity’. Furthermore, they had a higher ‘Sum Scale’ score than those with ‘medium control’. However, significant differences regarding ‘Dietary Control’ and ‘Health-Care Use’ were not observed.

Patients with ‘medium glycaemic control’ , on the other hand, reported significantly more ‘Glucose Management’ and ‘Dietary Control’ than those with ‘poor control’ , and they also had a higher ‘Sum Scale’ score. However, no significant differences were observed regarding ‘Physical Activity’ and ‘Health-Care Use’.

Convergent validity

The DSMQ’s associations with external criteria (patient characteristics, BMI, SDSCA scales, and HbA 1c value) as observed in the total sample as well as the diabetes type specific subsamples are presented in Table  6 .

The examination of the DSMQ’s correlations in the total sample of 261 patients revealed the following results: The subscale ‘Glucose Management’ was highly correlated with the equivalent SDSCA scale ‘Blood-Glucose Testing’ ( ρ = 0.57) and the HbA 1c value ( ρ = −0.39). The subscale ‘Dietary Control’ was highly correlated with the equivalent SDSCA scale ‘General Diet’ ( ρ = 0.52) and substantially with ‘Specific Diet’ ( ρ = 0.28). Furthermore, it showed a substantial negative correlation with HbA 1c ( ρ = −0.30). The subscale ‘Physical Activity’ was highly correlated with the equivalent SDSCA scale ‘Exercise’ ( ρ = 0.58). Its correlation with the HbA 1c value was −0.15 and there was also a high negative correlation with the BMI ( ρ = −0.41). Regarding the subscale ‘Health-Care Use’ there is no equivalent scale of the SDSCA. Nevertheless, it was significantly correlated with the SDSCA scales ‘General Diet’ ( ρ = 0.13), ‘Blood-Glucose Testing’ ( ρ = 0.26), ‘Foot Care’ ( ρ = 0.10), and ‘Smoking’ ( ρ = −0.19), and showed a substantial negative correlation with the HbA 1c value of −0.22. Finally, the DSMQ ‘Sum Scale’ showed substantial to high correlations between 0.20 and 0.51 with all SDSCA scales and was highly correlated with the SDSCA’s total score with 0.57. Its negative correlation with the HbA 1c value was high ( ρ = −0.40).

If convergent correlations were assessed separately by diabetes type, the analyses of both subsamples revealed results which were highly comparable to those presented above. All DSMQ subscales as well as the ‘Sum Scale’ still showed significant correlations of equivalent sizes with their relevant convergent criteria (see Table  6 ). However, one exception was observed regarding the subscale ‘Physical Activity’: Although it showed slight correlations with HbA 1c in both types of diabetes patients, none of those reached statistical significance.

DSMQ vs. SDSCA: Associations with HbA 1c

The comparison between the DSMQ scales and their equivalent SDSCA scales regarding the correlations with HbA 1c (and for the physical activity scales with BMI) revealed the following results:

As in the case with the DSMQ subscale ‘Glucose Management’ , the SDSCA’s equivalent scale ‘Blood-Glucose Testing’ was significantly correlated with the HbA 1c value ( ρ = −0.22, P < 0.001). However, the correlation between ‘Glucose Management’ and HbA 1c ( ρ = −0.39, P < 0.001) was significantly higher ( Z = −3.07, P < 0.01).

While the SDSCA scale ‘Specific Diet’ was not correlated with HbA 1c ( ρ = −0.02, P = 0.746), the scale ‘General Diet’ was ( ρ = −0.13, P = 0.042). However, the DSMQ subscale ‘Dietary Control’ showed a higher correlation ( ρ = −0.30, P < 0.001), and again the difference was significant ( Z = −2.84, P < 0.01).

In contrast to the DSMQ subscale ‘Physical Activity’ ( ρ = −0.15, P = 0.013), the equivalent SDSCA scale ‘Exercise’ was not correlated with HbA 1c ( ρ = 0.07, P = 0.239), and the difference between correlations was significant ( Z = −3.96, P < 0.001). Additionally, ‘Physical Activity’ showed a higher correlation with the BMI ( ρ = −0.41, P < 0.001) than the SDSCA scale ‘Exercise’ ( ρ = −0.18, P = 0.004), and this difference again was significant ( Z = −4.33, P < 0.001).

In contrast to the DSMQ ‘Sum Scale’ , which showed a notable correlation with the HbA 1c value of −0.40 ( P < 0.001), the SDSCA’s total score was not significantly correlated with HbA 1c ( ρ = −0.10, P = 0.123). This difference was highly significant ( Z = −5.39, P < 0.001).

When these correlational analyses were performed separately by diabetes type, the results were in total clearly consistent with the ones described above. In both diabetes types the DSMQ scales ‘Glucose Management’, ‘Dietary Control’ and ‘Sum Scale’ showed significantly higher correlations with HbA 1c than their equivalent SDSCA scales (all P < 0.05). However, neither the DSMQ subscale ‘Physical Activity’ nor its equivalent ‘Exercise’ were significantly correlated with HbA 1c in the subsamples (all P > 0.10). Therefore, the finding of a higher association between the DSMQ subscale and HbA 1c – as observed in the total sample – could not be replicated. Nevertheless, comparably to the total sample evaluation, ‘Physical Activity’ showed higher correlations with the BMI than the SDSCA scale ‘Exercise’ in both subsamples. However, only in the type 2 patients sample reached this difference statistical significance ( Z = −2.20, P < 0.05).

Discussion and conclusions

The purpose of this investigation was to describe the development of the DSMQ (study 1) and evaluate its psychometric properties (study 2). The questionnaire was developed on a broad theoretical and empirical basis, and its evaluation indicates very good psychometric properties with adequate item characteristics, satisfactory reliability, and good validity.

According to the generally satisfactory item properties and good item validity coefficients regarding HbA 1c the overall item selection appears very satisfying. Since the items assess a number of different aspects of self-care, the total scale is rather heterogeneous, which is reflected by the mean inter-item-correlation of 0.25. Against this background and with a view to the rather low number of items on each content, the internal consistency can be appraised as good (based on the standard by Nunnally and Bernstein [ 59 ]). For a polydimensional construct a higher alpha coefficient might even be unfavourable, for it suggests high item redundancy in the scale, as pointed out by Streiner [ 60 ]. The slightly lower item-total-correlations in two cases should be interpreted with a view to this aspect as well. The additional analyses of the subsamples revealed slightly better item properties and consistency in type 1 patients which can be partly attributed to the difference in sample size. In sum, all coefficients were in the acceptable range and suggest general applicability.

The EFA revealed a simple structure of four factors with high loadings of all items thereon. The factors were well interpretable and their contents clearly confirmed the designed scales. One discrepancy could be seen in item 6, which belongs to the subscale ‘Glucose Management’ but showed an additional loading on the dietary factor. But apart from that, the overall content structure is remarkably clear and indicates a good factorial validity. The EFA revealed a very good fit of the suggested four factor model, which also confirms the designed scales. Additionally, a single factor model was found to fit the data as well, which suggests the feasibility of the integration of all item scores to the ‘Sum Scale’.

The criterion-related correlations between the DSMQ scales and the SDSCA scales indicate a good convergence between parallel measures suggesting validity. The finding that all parallel scales show a strong convergence (> 0.5) has to be stressed particularly because the questionnaires employ markedly different time frames (one week in the SDSCA in contrast to eight weeks in the DSMQ) which might actually discount those correlations. Additionally, the throughout significant correlations with the objective outcome measure HbA 1c confirm the assumption of validity and, moreover, prove the questionnaire’s high utility for the intended scientific but also clinical purposes. The additional analyses of convergent correlations by diabetes type revealed comparably strong associations with external criteria in both type 1 and type 2 diabetes and provide good evidence of the DSMQ’s general applicability.

The known groups analysis showed significant differences between patient groups with ‘good’ , ‘medium’ , and ‘poor’ glycaemic control, which provides evidence of the questionnaire’s ability to discriminate between patients’ behaviours. According to these results, higher sum scores as well as subscale scores of the DSMQ allow to infer better self-care activities in view of glycaemic control.

Notably, the DSMQ and SDSCA are equivalent in the way that both questionnaires assess self-care activities, which in most cases are clearly related, as reflected by the correlations between the parallel scales. However, in spite of this commonality, self-care as assessed by the DSMQ is more strongly associated with glycated haemoglobin, which can be explained by the differently conceptualized functions [19; p. 367 et seq.]. Furthermore, the DSMQ’s timeframe focusses the relevant behaviours of the previous two months which apparently allows a more reliable assessment of self-care and a better prediction of the glycaemic outcome.

In the course of the item selection only self-care activities which showed relevant associations with glycaemic control were kept. For this reason, several specific self-care activities which may be of interest in regards of diabetes care are not covered by the DSMQ. However, the precise choice of contents is essential to ensure the questionnaire’s focus on self-care predictive of glycaemic control. It sum, it can be stated that the DSMQ’s development, particularly with a view to its specific objectives, appears clearly successful.

The main limitation of the studies is based on the composition of the samples. Both samples were drawn from in-patients at a tertiary referral centre for diabetes, where patients are usually hospitalized because of relevant problems of diabetes treatment and glycaemic control (reflected by the average HbA 1c values of 8.5 and 8.6% in the samples), and showed a relatively long average diabetes duration and a high prevalence of late complications. Therefore, the study participants cannot be rated as representative of the general diabetic population, which limits the generalizability of results [ 61 ]. Furthermore, the majority of patients was treated with insulin, whereas only a small percentage used non-insulin medical treatments. Thus, the pattern of correlations between the DSMQ scales and HbA 1c might differ when assessed in patients not treated with insulin or antidiabetic medication (for example, dietary aspects and physical activity then might have a larger impact on glycaemic control). For this reason, the properties demonstrated here should primarily be attributed to the questionnaire’s use in insulin-treated patients, for the present. However, with the exception of ‘medication intake’ (which is obviously related to medical regimens) all contents assessed by the DSMQ can be literarily related to glycaemic control regardless of the type of treatment [ 34 , 40 , 45 – 47 , 51 ]. Finally, although a wide spectrum of adult ages was covered in study 2 (from 18 to 86 years), data on the questionnaire’s use in youths or children are not available yet, suggesting further research in this regard.

Due to the generally short length of stay at the GDCM, the investigation was carried out cross-sectionally. Since no retest was performed, there is no information on the instrument’s stability or sensitivity to change. Furthermore, information on the questionnaire’s relations to common behavioural and psychological variables associated with diabetes care is currently still limited. In these regards additional analyses are needed. Nevertheless, the present results may be judged as promising.

The strengths of this investigation, on the other hand, lie in the theoretical and empirical basis of the questionnaire contents on recent results from self-care research, which facilitates the integration of our findings and supports face validity. The questionnaire development was performed through a highly formal process of item and test analysis (study 1), and its initial validation (study 2) was based on a very appropriate sample size. Furthermore a high accuracy of HbA 1c analysis was achieved (due to standardised analysis in a central laboratory), and the coincidence of blood sampling and psychometric assessment as well as the standardized data assessment ensure the internal validity of results.

Regarding its associations with HbA 1c, the DSMQ showed significant superiority to the German version of the SDSCA. It could be argued that the SDSCA’s lower correlations were the consequence of translation problems. However, already the original English version’s initial evaluation could not relate any of its scales with glycated haemoglobin [ 19 ], and this result is supported by studies from several countries, which did not find significant associations of the SDSCA scales with HbA 1c either [ 62 – 65 ]. Against this background, the present findings appear conclusive, suggesting that the DSMQ’s superiority may be attributed to the differences of construct assessment between the instruments.

In sum, in this initial study the DSMQ demonstrated very good psychometric properties. The questionnaire presents itself as an efficient instrument which provides reliable and valid information on diabetes self-care, and assesses four well-defined specific self-care activities associated with glycaemic control. It was designed especially to enable scientific studies of psychosocial barriers to self-care and glycaemic control. However, since good metabolic control can be regarded as the most important goal of diabetes treatment, the questionnaire appears also valuable for the clinical use as a screener or as diagnostic instrument to assess barriers of glycaemic control in individuals. Thus, the DSMQ should benefit future research and also be of value in clinical settings.

Abbreviations

Analysis of variance

Body mass index

Confirmatory factor analysis

Comparative fit index

Diabetes Self-management questionnaire

Exploratory factor analysis

German diabetes center mergentheim

Glycated haemoglobin

P-value of close fit

Root mean square error of approximation

Standard deviation

Summary of diabetes self-care activities measure

Self-monitoring of blood glucose.

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Acknowledgements

This work was supported by grants of the “Kompetenznetz Diabetes mellitus (Competence Network for Diabetes mellitus)” funded by the Federal Ministry of Education and Research (grant numbers 01GI0809, 01GI1107).

Parts of this work were presented in abstract form at the 18 th PSAD Spring Scientific Meeting, Zadar, Croatia, April 12–14, 2013, and the 48 th Annual Meeting of the German Diabetes Association, Leipzig, Germany, May 08–11, 2013.

We acknowledge the valuable contributions of Marion Fellmann-Hellinger, André Reimer, Bernhard Zweigle, Arne Schäfer, and Elisabeth Holler, German Diabetes Center Mergentheim.

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Andreas Schmitt, Annika Gahr, Norbert Hermanns, Bernhard Kulzer & Thomas Haak

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The authors declare that they have no competing interests.

Authors’ contributions

AS developed the questionnaire, designed/ carried out the study, analysed the data and drafted the manuscript. AG contributed to study design and article revision. NH contributed to study design, questionnaire translation and article revision. BK contributed to the article revision. JH contributed to the questionnaire translation and article revision. TH contributed to study design and article revision. All authors read and approved the final manuscript.

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Schmitt, A., Gahr, A., Hermanns, N. et al. The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health Qual Life Outcomes 11 , 138 (2013). https://doi.org/10.1186/1477-7525-11-138

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Received : 28 February 2013

Accepted : 12 August 2013

Published : 13 August 2013

DOI : https://doi.org/10.1186/1477-7525-11-138

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Get answers to your patients’ questions about managing their diabetes.

• Scott Kahan, MD, MPH, director of the National Center for Weight and Wellness, offers recommendations and resources  that health care professionals can use to address obesity, weight management, and metabolic changes for patients with diabetes.
• Some patients may need to make lifestyle changes to reach and maintain their weight goal. Kevin D. Hall, PhD, Integrative Physiology Section Chief, Laboratory of Biological Modeling, shares how health care professionals can use the NIH Body Weight Planner  with their patients to help them reach their goals.
• An expert in diabetes and exercise research, Sheri Colberg, PhD, FACSM, shares ways to help your patients with diabetes be more active .
• Krystal M. Lewis, PhD, a licensed clinical psychologist at the National Institute of Mental Health, offers advice to help patients with diabetes manage stress  to avoid complications. 
• Depression is more common for people with diabetes, and it is often associated with poorer health outcomes. Jeffrey Gonzalez, PhD, co-author of the “Psychiatric and Psychosocial Issues among Individuals Living with Diabetes” chapter in Diabetes in America, 3rd Edition , discusses how health care professionals can help patients with diabetes distress and depression .
• Diabetes self-management education and support can improve A1C levels and have a positive effect on other clinical, psychosocial, and behavioral aspects of diabetes. Margaret (Maggie) Powers, PhD, RD, CDE, a clinician and research scientist at the International Diabetes Center in Park Nicollet in Minneapolis, explains how you can help your patients .
• Arshiya Baig, MD, MPH, associate director of the Chicago Center for Diabetes Research and Translation, discusses how text messaging can enhance diabetes self-management and care .
• Marie T. Brown, MD, director of Practice Redesign at the American Medical Association, offers advice to streamline medication management to help improve patients’ medication adherence.
• Retinopathy. Diabetic retinopathy is an eye condition that can cause vision loss and blindness in people with diabetes. Research from the Diabetes Control and Complications Trial (DCCT) and the Epidemiology of Diabetes Interventions and Complications (EDIC) study  suggests that adjusting the frequency of eye screenings for people with type 1 diabetes based on their risk of severe eye problems, rather than automatically scheduling them annually, can help reduce costs for patients and could even result in quicker diagnosis and treatment of severe retinopathy. 
• Cardiovascular disease. For patients with diabetes, reducing their risk for cardiovascular disease should be a top priority. Nathan D. Wong, PhD, director of the Heart Disease Prevention Program at the University of California, Irvine, talks about the importance of broadening the clinical focus of diabetes care from hemoglobin A1C to also address other risk factors for cardiovascular disease  that are common in patients with diabetes.
• High blood pressure. People with high blood pressure, especially those with diabetes, are at higher risk for kidney disease. Lawrence J. Appel, MD, MPH, director of the Welch Center for Prevention, Epidemiology, and Clinical Research at Johns Hopkins University, discusses the link between high blood pressure and kidney disease  and the importance of early detection and management.
• Kidney disease. People with diabetes are at high risk for kidney disease. Meda E. Pavkov, MD, PhD, medical epidemiologist in the Chronic Kidney Disease Initiative within the Division for Diabetes Translation at the U.S. Centers for Disease Control and Prevention (CDC), discusses steps that people with diabetes can take to protect their kidneys .

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45 of the Best Diabetes Dissertation Topics

Published by Owen Ingram at January 2nd, 2023 , Revised On August 16, 2023

The prevalence of diabetes among the world’s population has been increasing steadily over the last few decades, thanks to the growing consumption of fast food and an increasingly comfortable lifestyle. With the field of diabetes evolving rapidly, it is essential to base your dissertation on a trending diabetes dissertation topic that fills a gap in research. 

Finding a perfect research topic is one of the most challenging aspects of dissertation writing in any discipline . Several resources are available to students on the internet to help them conduct research and brainstorm to develop their topic selection, but this can take a significant amount of time. So, we decided to provide a list of well-researched, unique and intriguing diabetes research topics and ideas to help you get started. 

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List of Diabetes Dissertation Topics

• Why do people recently diagnosed with diabetes have such difficulty accepting reality and controlling their health?
• What are the reactions of children who have recently been diagnosed with diabetes? What can be done to improve their grasp of how to treat the disease?
• In long-term research, people getting intensive therapy for the condition had a worse quality of life. What role should health professionals have in mitigating this effect?
• Why do so many individuals experience severe depression the months after their diagnosis despite displaying no other signs of deteriorating health?
• Discuss some of the advantages of a low-carbohydrate, high-fat diet for people with diabetes
• Discuss the notion of diabetes in paediatrics and why it is necessary to do this research regularly.
• Explain the current threat and difficulty of childhood obesity and diabetes, stressing some areas where parents are failing in their position as guardians to avoid the situation
• Explain some of the difficulties that persons with diabetes have, particularly when obtaining the necessary information and medical treatment
• Explain some of the most frequent problems that people with diabetes face, as well as how they affect the prevalence of the disease. Put out steps that can be implemented to help the problem.
• Discuss the diabetes problem among Asian American teens
• Even though it is a worldwide disease, particular ethnic groups are more likely to be diagnosed as a function of nutrition and culture. What can be done to improve their health literacy?
• Explain how self-management may be beneficial in coping with diabetes, particularly for people unable to get prompt treatment for their illness
• Discuss the possibility of better management for those with diabetes who are hospitalized
• What current therapies have had the most influence on reducing the number of short-term problems in patients’ bodies?
• How have various types of steroids altered the way the body responds in people with hypoglycemia more frequently than usual?
• What effects do type 1, and type 2 diabetes have on the kidneys? How do the most widely used monitoring approaches influence this?
• Is it true that people from specific ethnic groups are more likely to acquire heart disease or eye illness due to their diabetes diagnosis?
• How has the new a1c test helped to reduce the detrimental consequences of diabetes on the body by detecting the condition early?
• Explain the difficulty of uncontrolled diabetes and how it can eventually harm the kidneys and the heart
• Discuss how the diabetic genetic strain may be handed down from generation to generation
• What difficulties do diabetic people have while attempting to check their glucose levels and keep a balanced food plan?
• How have some individuals with type 1 or type 2 diabetes managed to live better lives than others with the disease?
• Is it true that eating too much sugar causes diabetes, cavities, acne, hyperactivity, and weight gain?
• What effect does insulin treatment have on type 2 diabetes?
• How does diabetes contribute to depression?
• What impact does snap participation have on diabetes rates?
• Why has the number of persons who perform blood glucose self-tests decreased? Could other variables, such as social or environmental, have contributed to this decrease?
• Why do patients in the United States struggle to obtain the treatment they require to monitor and maintain appropriate glucose levels? Is this due to increased healthcare costs?
• Nutrition is critical to a healthy lifestyle, yet many diabetic patients are unaware of what they should consume. Discuss
• Why have injuries and diabetes been designated as national health priorities?
• What factors contribute to the growing prevalence of type ii diabetes in adolescents?
• Does socioeconomic status influence the prevalence of diabetes?
• Alzheimer’s disease and type 2 diabetes: a critical assessment of the shared pathological traits
• What are the effects and consequences of diabetes on peripheral blood vessels?
• What is the link between genetic predisposition, obesity, and type 2 diabetes development?
• Diabetes modifies the activation and repression of pro- and anti-inflammatory signalling pathways in the vascular system.
• Understanding autoimmune diabetes through the tri-molecular complex prism
• Does economic status influence the regional variation of diabetes caused by malnutrition?
• What evidence is there for using traditional Chinese medicine and natural products to treat depression in people who also have diabetes?
• Why was the qualitative method used to evaluate diabetes programs?
• Investigate the most common symptoms of undiagnosed diabetes
• How can artificial intelligence help diabetes patients?
• What effect does the palaeolithic diet have on type 2 diabetes?
• What are the most common diabetes causes and treatments?
• What causes diabetes mellitus, and how does it affect the United Kingdom?

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How to find diabetes dissertation topics.

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5 Questions to Ask Your Health Care Team

What to know.

Ask these important questions to understand your diabetes treatment plan and stay on track with diabetes management.

1. How do I manage my ABCs?

A: Get a regular A 1C test to measure your average blood sugar over 2 to 3 months. Ask your health care team what your goal should be.

B: Try to keep your b lood pressure below 140/90 mm Hg (or the target your doctor sets).

C: Control your c holesterol levels.

s : Stop s moking or don't start.

Keeping your ABC numbers close to target levels can lower your risk of long-term health problems. Ask your health care team to help you set personal targets.

2. How will I know if my medicines are working?

Are your ABC numbers close to or at your target levels?

If the answer is yes , then your medicines and efforts are working. Keep up the good work!

If the answer is no , then meet with your health care team to see if your treatment plan needs to be changed. Be sure to bring all of your medicines and blood sugar records when you meet with your care team. Bring both prescription and over-the-counter medicines.

3. When and where can I learn more about managing diabetes?

The best times for diabetes education and support to manage diabetes are:

• When you're first diagnosed.
• Once a year when you review your educational, nutritional, and emotional needs with your health care team.
• When new complications come up (for example, changes in your physical or emotional health or financial needs).
• During changes in your care (for example, changes to your health care team, treatment plan, or living situation).
• Local diabetes education programs .
• Diabetes information sites, such the National Institute of Health's diabetes site .
• Local diabetes support groups. Ask your health care team for recommendations.

4. Which vaccines should I get?

Getting vaccinated is an important part of staying healthy, especially when you have diabetes. That's because people with diabetes have a higher risk of serious health problems that vaccines can prevent. Ask your health care team what vaccines you need and when.

5. When should I schedule health care appointments?

• See your regular health care team twice a year or more.
• See an eye doctor, foot doctor, and dentist once a year or more.

Regular health care helps you stay healthy, especially when you have diabetes. Ask to set up your next visit before you leave your health care provider's office.

Call on your health care team‎

Diabetes is a chronic disease that affects how your body turns food into energy. About 1 in 10 Americans has diabetes.

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