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Exploring Healthy Coping Behaviors in Diabetes Self-managementA CommentaryFrom the Behavioral and Community Health Science Program, Louisiana Health Sciences Center School of Public Health, New Orleans. Correspondence to Leonard Jack Jr, PhD, MSc, c/o UNO Advanced Technology Center, Room 209, 2021 Lakeshore Drive, New Orleans, LA 70122 (ljack{at}lsuhsc.edu). The American Association of Diabetes Educators (AADE) is dedicated to advancing the role diabetes educators play in helping to improve the quality of diabetes education and care delivered to patients.1 One of AADE's standards of practice is that diabetes educators should provide information to patients using established principles of teaching, learning theory, and lifestyle counseling, for example, collaborative planning with patients regarding nutrition management and physical activity.1 AADE's mission and guiding principles support the rationale to periodically pause to assess the state of the science in diabetes self-management education. The AADE commissioned systematic review conducted by Fisher and associates, "Healthy Coping, Negative Emotions, and Diabetes Management: A Systematic Review and Appraisal," offers a comprehensive look into published studies of various research designs, sample sizes, and study quality.2 Specifically, researchers report on studies addressing psychological issues such as depression and anxiety and the many psychotherapeutic interventions (eg, general self-management, cognitive-behavioral, stress management, coping, problem solving, support groups, cognitive-analytic multisystemic therapy, psychoanalytic inpatient treatment, and medication therapy) used to address them.2 Researchers do an excellent job describing the multidimensional aspects of diabetes and how the relationship between psychosocial factors and disease management is complex. It is exciting to see the number of empirically tested research studies published between 1990 and 2007 that were captured in this systematic review. This is particularly encouraging as more published studies acknowledge how adjustment problems due to poor coping skills, poor problem-solving capacity, and the absence or inconsistent availability of family and social support negatively influence patients' self-care behaviors and glycemic control. This is in sharp contrast to a meta-analysis exploring studies of educational interventions and outcomes in diabetic adults published in 1990.3 This meta-analysis revealed that few studies included in the analysis examined causal links between psychological factors and diabetes self-management. More important, studies did not examine how psychological factors could impede patients' ability to fully participate and benefit from exposure to diabetes education. The researcher of this meta-analysis recommended 17 years ago that future studies in diabetes education rigorously examine various aspects of psychological functioning, particularly the less understood bidirectional relationship between diabetes and depression. Since this published 1990 meta-analysis, the field of diabetes self-management education has made tremendous progress in understanding the links/pathways between psychosocial factors and diabetes. Having made this important acknowledgment, we should move forward in applying these findings with both enthusiasm and caution. With regard to enthusiastically moving forward, it is abundantly clear based on Fisher and colleagues' findings2 that we should at the minimum ask patients several important open-ended questions about the "stress in their lives, the availability and quality of social support, and behaviors that could impair glycemic control and patients' beliefs regarding the cause of their diabetes."4 Direct questions about these issues will help diabetes educators to better understand the amount of stress and to what degree excessive stress impedes patients' ability to manage both life and their diabetes. Insights from direct questioning would also assist and reinforce diabetes educators' need to screen for other psychological disorders (eg, depression, anxiety, and eating disorders).4 In this instance, if possible, diabetes educators should provide this information to patients' physicians or make the appropriate referrals to mental health professionals. From a cautionary perspective, I agree with Fisher and associates2 that this systematic review and previously published reviews reveal serious methodological concerns (eg, controlling for bias and small sample sizes). In addition, while the number of randomized trials has increased, there are still unanswered questions regarding how interventions proven effective under tightly controlled test scenarios can realistically be translated into practice. Where there is evidence of patient outcome improvements, the key question becomes, what do we do with these findings? Furthermore, some experts in the field of utilization research may argue that we do not really know whether such evidence was derived with a clear understanding of the context of the real world in which diabetes educators execute their work.5 Hence, pausing to examine the summative evidence into effective psychosocial interventions that help improve patients' coping abilities is critical to advancing the field. It is important to mention that future systematic reviews and meta-analyses should be done both rigorously and consistently. In doing so, however, we must recognize and fully understand the circumstances and conditions under which studies reporting positive findings were derived. It may be that the circumstances and conditions (eg, fiscal and human resources) are quite different under research testing scenarios versus real-world conditions. Thus, we must be cautious not to stop at disseminating (eg, publishing) findings from this and other future systematic reviews without pointing out this and other limitations. We must be very clear that future studies examining psychosocial factors should take into consideration the real-world context of frontline diabetes educators. Can you imagine studies that take into consideration the intended users' needs, context, and readiness for adoption and use of recommendations generated from systematic reviews, meta-analyses, or clinical guidelines? To this end, it would be necessary to explore change processes at the individual, discipline, and system practice setting levels before studies are implemented and after new research findings are generated to improve adoption and utilization. It is known that intended and effective use of research findings must move beyond merely the publication of impressive findings.5 Thus, reinforcing the need for both reality-based research and the exploration of approaches to increase adoption and utilization is critical.6 There is simply a need for more research conducted by, with, and through diabetes educators. It is my perspective that this would help increase utilization of research findings by diabetes educators into practice.7 Diabetes educators would benefit tremendously if future psychosocial intervention research took into account the perceived relevance of such research based on the educators' own needs, their skill levels and experience, their reach to patients (time and frequency), and important system/organizational support needed to advance adoption. The latter area, the identification of system/organizational change approaches to either improve or sustain support of diabetes educators who adopt proven reality-based psychosocial interventions, is an area that continues to be underdeveloped and underexplored through research. Adoption and utilization of future research findings would increase if the users (diabetes educators, patients, and health care systems) are involved in conceptualizing future psychosocial interventions in diabetes self-management education to include identifying outcomes of interest. This would increase awareness of ongoing research and heighten the anticipation of future research findings among diabetes educators and the organizational systems in which educators offer their services. Hence, it would be more likely that study findings would be considered believable and viewed even more meaningful to diabetes educators. As a result, it is hoped that this would increase the number of reality-based psychosocial intervention studies published that could be captured in future systematic reviews or meta-analyses. Finally, we must find ways to have important conversations among diabetes educators about all systematic reviews and/or meta-analyses published in this issue of The Diabetes Educator. One way to do this would be to systematically engage AADE chapters throughout the country in ongoing dialogue and collaboration to make sure important findings from this publication really are translated into practice. Similar to publishing findings from systematic reviews and meta-analyses represented in this issue, there should also be future publications that highlight important lessons learned from the process of engaging AADE chapters and the extent to which practices in diabetes education change over time as a result of these rich discussions. I am hopeful that this would ultimately better position AADE to document achievement of its mission to provide and diffuse nationally evidence-based lifestyle counseling to patients living with diabetes.
The Diabetes Educator, Vol. 33, No. 6,
1104-1106 (2007)
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