RESUMO
OBJECTIVES: To identify challenges and coping strategies of young people with Type 1 diabetes (T1D) and their families in Bolivia through qualitative analysis of interviews with beneficiaries of Centro Vivir con Diabetes (CVCD), a diabetes health center supported by the International Diabetes Federation Life for a Child (LFAC) program. METHODS: Eighteen young people aged 14-33 and at least one caregiver participated in semi-structured interviews in five cities in Bolivia from May to June 2016. Interviews were recorded, transcribed, and analyzed using inductive thematic analysis. RESULTS: Participants described needing guidance at diagnosis and facing stigma in communities. Young people expressed that life with T1D was 'la vida normal' (a normal life), although interpretations of normalcy varied. For some, 'la vida normal' meant resistance to T1D; for others it indicated acceptance. DISCUSSION: Access to interdependent spheres of support allowed young people to form a new normal around T1D. Receiving supplies through the CVCD/LFAC partnership maintained family connection to clinical care, CVCD education helped families share in T1D management, and peer support mitigated stigma for young people. Programs like CVCD that combine supply-based aid with clinical education for whole families, create effective support for young people with T1D in low- and middle-income countries.
Assuntos
Diabetes Mellitus Tipo 1 , Adaptação Psicológica , Adolescente , Bolívia , Cuidadores , Criança , Família , HumanosRESUMO
Type 2 diabetes is a significant and increasing burden in adolescents and young adults. Clear strategies for research, prevention, and treatment of the disease in these vulnerable patients are needed. Evidence suggests that type 2 diabetes in children is different not only from type 1 but also from type 2 diabetes in adults. Understanding the unique pathophysiology of type 2 diabetes in youth, as well as the risk of complications and the psychosocial impact, will enable industry, academia, funding agencies, advocacy groups, and regulators to collectively evaluate both current and future research, treatment, and prevention approaches. This Consensus Report characterizes type 2 diabetes in children, evaluates the fundamental differences between childhood and adult disease, describes the current therapeutic options, and discusses challenges to and approaches for developing new treatments.
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Atenção à Saúde , Complicações do Diabetes/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Adolescente , Idade de Início , Alostase , Criança , Consenso , Diabetes Mellitus Tipo 2/metabolismo , Diabetes Mellitus Tipo 2/psicologia , Diabetes Mellitus Tipo 2/terapia , Dietoterapia , Gerenciamento Clínico , Etnicidade/estatística & dados numéricos , Terapia por Exercício , Humanos , Hipoglicemiantes/uso terapêutico , Grupos Minoritários/estatística & dados numéricos , Risco , Comportamento de Redução do Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: To identify factors that predict medication adherence and to examine relationships among adherence, glycemic control, and indices of insulin action in TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth). RESEARCH DESIGN AND METHODS: A total of 699 youth 10-17 years old with recent-onset type 2 diabetes and ≥80% adherence to metformin therapy for ≥8 weeks during a run-in period were randomized to receive one of three treatments. Participants took two study pills twice daily. Adherence was calculated by pill count from blister packs returned at visits. High adherence was defined as taking ≥80% of medication; low adherence was defined as taking <80% of medication. Depressive symptoms, insulin sensitivity (1/fasting insulin), insulinogenic index, and oral disposition index (oDI) were measured. Survival analysis examined the relationship between medication adherence and loss of glycemic control. Generalized linear mixed models analyzed trends in adherence over time. RESULTS: In this low socioeconomic cohort, high and low adherence did not differ by sex, age, family income, parental education, or treatment group. Adherence declined over time (72% high adherence at 2 months, 56% adherence at 48 months, P < 0.0001). A greater percentage of participants with low adherence had clinically significant depressive symptoms at baseline (18% vs. 12%, P = 0.0415). No adherence threshold predicted the loss of glycemic control. Longitudinally, participants with high adherence had significantly greater insulin sensitivity and oDI than those with low adherence. CONCLUSIONS: In the cohort, the presence of baseline clinically significant depressive symptoms was associated with subsequent lower adherence. Medication adherence was positively associated with insulin sensitivity and oDI, but, because of disease progression, adherence did not predict long-term treatment success.
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Diabetes Mellitus Tipo 2/tratamento farmacológico , Adesão à Medicação , Adolescente , Glicemia/metabolismo , Índice de Massa Corporal , Criança , Estudos de Coortes , Depressão/sangue , Depressão/diagnóstico , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/sangue , Resistência à Insulina , Masculino , Metformina/uso terapêutico , Sensibilidade e Especificidade , Fatores SocioeconômicosRESUMO
Individuals with type 1 diabetes are at increased risk for depression, anxiety disorder, and eating disorder diagnoses. People with type 1 diabetes are also at risk for subclinical levels of diabetes distress and anxiety. These mental/behavioral health comorbidities of diabetes are associated with poor adherence to treatment and poor glycemic control, thus increasing the risk for serious short- and long-term physical complications, which can result in blindness, amputations, stroke, cognitive decline, decreased quality of life, as well as premature death. When mental health comorbidities of diabetes are not diagnosed and treated, the financial cost to society and health care systems is catastrophic, and the human suffering that results is profound. This review summarizes state-of-the-art presentations and working group scholarly reports from the Mental Health Issues of Diabetes Conference (7-8 October 2013, Philadelphia, PA), which included stakeholders from the National Institutes of Health, people living with type 1 diabetes and their families, diabetes consumer advocacy groups, the insurance industry, as well as psychologists, psychiatrists, endocrinologists, and nurse practitioners who are all nationally and internationally recognized experts in type 1 diabetes research and care. At this landmark conference current evidence for the incidence and the consequences of mental health problems in type 1 diabetes was presented, supporting the integration of mental health screening and mental health care into routine diabetes medical care. Future research directions were recommended to establish the efficacy and cost-effectiveness of paradigms of diabetes care in which physical and mental health care are both priorities.
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Diabetes Mellitus Tipo 1/psicologia , Transtornos Mentais/etiologia , Adolescente , Adulto , Idoso , Criança , Congressos como Assunto , Análise Custo-Benefício , Diabetes Mellitus Tipo 1/economia , Diabetes Mellitus Tipo 1/terapia , Feminino , Nível de Saúde , Humanos , Masculino , Transtornos Mentais/economia , Transtornos Mentais/terapia , Saúde Mental , Pessoa de Meia-Idade , Avaliação das Necessidades , Educação de Pacientes como Assunto , Philadelphia , Qualidade de Vida , Fatores Sexuais , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To examine the relationships between stressful life events and physiological measures, adherence to prescribed oral medication regimens, depressive symptoms, and impaired quality of life (QoL) in adolescents with recent-onset type 2 diabetes (T2D). STUDY DESIGN: Data were collected from 497 ethnically diverse participants (66% female) in the final year of the Treatment Options for Type 2 Diabetes in Adolescents and Youth multicenter clinical trial. Exposure to 32 possible events over the previous year and rating of subsequent distress were collected by self-report and summarized as a major stressors score. This score was analyzed for relationship to glycemic control (hemoglobin A1c and treatment failure), body mass index, diagnosis of hypertension or triglyceride dyslipidemia, adherence to a prescribed oral medication regimen, presence of depressive symptoms, and impaired QoL. RESULTS: The total number of major stressful life events in the adolescents with T2D was calculated, with 33% reporting none, 67% reporting ≥ 1, 47% reporting ≥ 2, 33% reporting ≥ 3, and 20% reporting ≥ 4. There were no associations between the major stressors score and physiological measures or diagnosis of comorbidities. The odds of medication nonadherence increased significantly from those reporting ≥ 1 major stressor (OR, 1.58; P = .0265) to those reporting ≥ 4 major stressors (OR, 2.70; P = .0009). Significant odds of elevated depressive symptoms and impaired QoL were also found with increased reporting of major stressors. CONCLUSION: Exposure to major stressful life events is associated with lower adherence to prescribed oral medication regimens and impaired psychosocial functioning in adolescents with T2D.
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Diabetes Mellitus Tipo 2 , Acontecimentos que Mudam a Vida , Adesão à Medicação/psicologia , Adesão à Medicação/estatística & dados numéricos , Adolescente , Criança , Depressão/etiologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/fisiopatologia , Diabetes Mellitus Tipo 2/psicologia , Feminino , Humanos , Masculino , Qualidade de Vida , Adulto JovemRESUMO
The shortage of nurses and midwives across the world and the migratory trends of these scarce professionals--primarily from low-income countries to fill staffing needs in high-income countries--are critical international health care issues. This article reviews some of the demographic, educational, and socioeconomic factors driving this global trend, the impact on health care delivery in low-income countries, and the effect on the implementation of global public health initiatives. Nurses and midwives migrate from low-income nations while concurrently qualified applicants are rejected from educational programs in high-income countries. The impact of migration on the viability of the health care delivery system in Guyana, South America, is presented as an exemplar nation within the broader global context of ethical dilemmas, pressures on educational systems, and the anti- and pro-migration arguments.
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Emigração e Imigração/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , Descrição de Cargo , Tocologia , Seleção de Pessoal/estatística & dados numéricos , Guiana , Humanos , Satisfação no Emprego , Pensões , Qualidade de Vida , Salários e Benefícios , Fatores Socioeconômicos , Desenvolvimento de PessoalRESUMO
OBJECTIVE: To evaluate temporal trends in pediatric type 1 diabetes (T1DM) management and resultant effects on outcomes. STUDY DESIGN: Two pediatric T1DM cohorts were followed prospectively for 2 years and compared; Cohort 1 (N = 299) was enrolled in 1997 and Cohort 2 (N = 152) was enrolled in 2002. In both cohorts, eligible participants were identified and sequentially approached at regularly scheduled clinic visits until the target number of participants was reached. Main outcome measures were hemoglobin A1c (A1c), body mass index Z score (Z-BMI), and incidence rate (IR; per 100 patient-years) of hypoglycemia, hospitalizations, and emergency room (ER) visits. RESULTS: At baseline, Cohort 2 monitored blood glucose more frequently than Cohort 1 (> or = 4 times/day: 72% vs 39%, P < .001) and was prescribed more intensive therapy than Cohort 1 (> or = 3 injections/day or pump: 85% vs 65%, P < .001). A1c was lower in Cohort 2 than Cohort 1 at baseline (8.4% vs 8.7%, P = .03) and study's end (8.7% vs 9.0%, P = .04). The cohorts did not differ in Z-BMI (0.83 vs 0.79, P = .57) or IR of hospitalizations (11.2 vs 12.9, P = .38). Cohort 2 had lower IR of total severe hypoglycemic events (29.4 vs 55.4, P < .001) and ER visits (22.0 vs 29.3, P = .02). CONCLUSIONS: T1DM management intensified during the 5 years between cohorts and was accompanied by improved A1c and stable Z-BMI. Along with improved control, IR of severe hypoglycemia and ER visits decreased by almost 50% and 25%, respectively.
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Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/tratamento farmacológico , Hipoglicemia/prevenção & controle , Insulina/administração & dosagem , Adolescente , Glicemia/análise , Automonitorização da Glicemia , Criança , Estudos de Coortes , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Seguimentos , Previsões , Teste de Tolerância a Glucose , Hospitalização/estatística & dados numéricos , Humanos , Hipoglicemia/epidemiologia , Injeções Subcutâneas , Insulina/efeitos adversos , Masculino , Probabilidade , Medição de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: To test the hypothesis that poor glycemic control in type 1 diabetes mellitus (T1DM) is associated with depression and poor quality of life (QOL), with a higher prevalence in persons of lower socioeconomic status (SES). STUDY DESIGN: Subjects with T1DM age 8 to 17 years (n = 222) were evaluated using the Childrens Depression Inventory, the Hollingshead Four-Factor Index to determine SES, and PedsQL questionnaires to ascertain QOL. HbAlC > 8% was considered indicative of poor glycemic control. RESULTS: A total of 110 well-controlled subjects and 112 poorly controlled subjects (HbA1C 7.1% +/- 0.7% vs 9.9% +/- 1.6%) were recruited. It was found that 9.5% of poorly controlled subjects were depressed, compared with 3% of well-controlled subjects. Logistic regression revealed a 27% increase in probability of depression per unit rise in HbA1C (P < .03). Higher SES was associated with better glycemic control (P < .0005) and QOL (P < .0005); longer duration of illness was not associated with poorer glycemic control. Diabetes QOL deteriorated with poorer glycemic control (P < .002). CONCLUSIONS: Poor glycemic control in peridatric T1DM is associated with lower SES and depression. The probability of depression increases as glycemic control worsens. Screening for depression should be routinely carried out in patients with T1DM, targeting patients with deteriorating glycemic control.
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Glicemia/análise , Depressão/epidemiologia , Complicações do Diabetes/epidemiologia , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/terapia , Qualidade de Vida , Classe Social , Adolescente , Criança , Complicações do Diabetes/sangue , Diabetes Mellitus Tipo 1/sangue , HumanosRESUMO
In rural, developing world communities, women are often isolated from biomedical services. Frequently, traditional birth attendants (TBAs) are the only caregivers during childbirth, both normal and complicated. Women trust their TBAs to manage their births. Globally, government and non-governmental organizations (NGOs) have sought to upgrade TBAs' skills and to encourage them to refer complications. However, most training programs have failed to change TBAs' practice substantially. Logistical barriers in reaching biomedical services in a timely manner are a key issue. Another is the difference between biomedical and traditional practitioners in the cognitive frameworks that shape decision making and management behaviors. The purpose of this study, conducted in Quintana Roo State, Mexico, was to listen to the voices of practicing Yucatec Maya TBAs (parteras) as they described decision making and management of complicated births. In-depth interviews with six practicing parteras in rural, isolated communities revealed that the parteras used traditional Maya ethnomedicine while valuing biomedical approaches. We isolated themes in decision making and mapped management of birth complications. Integrating TBAs' traditional knowledge into biomedical training programs is one way to honor their knowledge and make training relevant.
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Competência Clínica , Parto Domiciliar , Indígenas Norte-Americanos , Tocologia , Papel do Profissional de Enfermagem , Avaliação em Enfermagem , Adulto , Idoso , Competência Clínica/normas , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Indígenas Norte-Americanos/psicologia , Indígenas Norte-Americanos/estatística & dados numéricos , Serviços de Saúde Materna/normas , México , Pessoa de Meia-Idade , Avaliação em Enfermagem/métodos , Pesquisa em Educação em Enfermagem , Inquéritos e Questionários , Fatores de Tempo , Serviços de Saúde da Mulher/normasRESUMO
OBJECTIVE: To evaluate an ambulatory, family-focused intervention aimed at optimizing STUDY DESIGN: Study design We randomly assigned 105 children and adolescents, 8 to 17 years of age, with T1DM for < or =6 years, to a family-focused teamwork (TW) intervention or to standard multidisciplinary diabetes care (SC). Patients in both study groups were seen at 3- to 4-month intervals and were followed prospectively for 1 year. Measures of family involvement in diabetes tasks, DFC, and quality of life were performed at baseline and after 1 year. Hemoglobin A1c was measured at each visit. RESULTS: Patients (n = 100) completed follow-up, (50 in TW and 50 in SC). At entry, A1c was 8.4% +/- 1.3% in TW and 8.3% +/- 1.0% in SC. After 1 year, A1c was 8.2% +/- 1.1% in TW compared with 8.7% +/- 1.5% in SC (P <.05). Both groups had similar frequencies of blood glucose monitoring (BGM) and insulin dosing. Families exposed to the TW intervention maintained or increased family involvement significantly more than families exposed to SC (P =.05). In multivariate analysis, the TW intervention and the daily frequency of BGM significantly predicted A1c (R (2) = 0.17, P =.05). Despite increased family involvement, the TW group reported no increase in DFC or decrease in quality of life. CONCLUSIONS: The ambulatory TW intervention prevented the expected deterioration in glycemic control seen with SC in youths with T1DM of < or =6 years' duration. Successful family involvement may assist in the preservation of health and the prevention of long-term diabetes complications for youth with diabetes.