자연주의적 탐구조사(Naturalistic Inquiry)

XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Aim. The aim of this paper is to distinguish the integrative review method from other review methods and to propose methodological strategies specific to the integrative review method to enhance the rigour of the process.

Background.  Recent evidence-based practice initiatives have increased the need for and the production of all types of reviews of the literature (integrative reviews, systematic reviews, meta-analyses, and qualitative reviews). The integrative review method is the only approach that allows for the combination of diverse methodologies (for example, experimental and non-experimental research), and has the potential to play a greater role in evidence-based practice for nursing. With respect to the integrative review method, strategies to enhance data collection and extraction have been developed; however, methods of analysis, synthesis, and conclusion drawing remain poorly formulated.

Discussion.  A modified framework for research reviews is presented to address issues specific to the integrative review method. Issues related to specifying the review purpose, searching the literature, evaluating data from primary sources, analysing data, and presenting the results are discussed. Data analysis methods of qualitative research are proposed as strategies that enhance the rigour of combining diverse methodologies as well as empirical and theoretical sources in an integrative review.

Conclusion.  An updated integrative review method has the potential to allow for diverse primary research methods to become a greater part of evidence-based practice initiatives.

/pdf/the-integrative-review-updated-methodology-j4hzxjmz6b.pdf

The integrative review: updated methodology

Qualitative content analysis is commonly used for analyzing qualitative data. However, few articles have examined the trustworthiness of its use in nursing science studies. The trustworthiness of q...

https://journals.sagepub.com/doi/pdf/10.1177/2158244014522633

Qualitative Content Analysis: A Focus on Trustworthiness

The rejection of reliability and validity in qualitative inquiry in the 1980s has resulted in an interesting shift for "ensuring rigor" from the investigator’s actions during the course of the research, to the reader or consumer of qualitative inquiry. The emphasis on strategies that are implemented during the research process has been replaced by strategies for evaluating trustworthiness and utility that are implemented once a study is completed. In this article, we argue that reliability and validity remain appropriate concepts for attaining rigor in qualitative research. We argue that qualitative researchers should reclaim responsibility for reliability and validity by implementing verification strategies integral and self-correcting during the conduct of inquiry itself. This ensures the attainment of rigor using strategies inherent within each qualitative design, and moves the responsibility for incorporating and maintaining reliability and validity from external reviewers’ judgements to the investigators themselves. Finally, we make a plea for a return to terminology for ensuring rigor that is used by mainstream science.

/pdf/verification-strategies-for-establishing-reliability-and-2jxdw91v7c.pdf

Verification Strategies for Establishing Reliability and Validity in Qualitative Research

Research shows a link between increased social support and decreased complications after myocardial infarction (MI). In a current randomized controlled trial (RCT), a social support intervention administered by nurse and peer advisors is being examined to determine its influence on the health outcomes of unpartnered, post-MI elders. This qualitative study (as part of the larger RCT) sought a better understanding regarding the experience of the peer advisor. Data sources included peer advisor logs, a focus group, and telephone interviews with peer advisors. Findings revealed that helping, mutual sharing, committing, and benefiting are characteristics of peer experiences. Primarily because of their personal experience of recovery from MI, peer advisors had a remarkable ability to relate to assigned post-MI elders, offering a unique form of social support complementary to current health practices.

The Peer Advisor Experience Providing Social Support

One priority in nursing research is the development of middle-range theories that are applicable to nursing practice. The purpose of this article is to describe the development of a middle-range theory, adapting to diabetes mellitus, through theory and concept synthesis. The adaptation to chronic illness model explicates the conceptual relationships of the Roy adaptation model in a theory specific to chronic illness. Several concepts in the diabetes literature, self-management, integration, and health-within-illness were synthesized with the theory through examination of empirical evidence. This method of theory development increases the specificity of the existing theory and informs the application to nursing practice.

Adapting to Diabetes Mellitus: A Theory Synthesis:

Overweight and obesity in youth with type 1 diabetes (T1D) is now prevalent and accounts for significant health consequences, including cardiovascular complications and dual diagnosis of type 2 diabetes. Physical activity and lifestyle are modifiable and play an important role in the prevention and management of excessive weight, but it is unclear how these factors relate to overweight and obese youth with T1D. Thus, a systematic review was conducted to examine how physical activity, sedentary behavior, sleep, and diet are related to overweight/obesity in youth with T1D. Seven observational and intervention studies published between 1990 and 2013 were included in the review. Prevalence of overweight ranged from 12.5% to 33.3%. Overweight in youth with T1D was associated with infrequent napping, increased screen time, and skipping breakfast and dinner but was not related to time engaged in physical activity. Weight-related interventions indicated modest weight loss along with improved glycemic control. In light of this review, there is a need for high quality research that examines all levels of activity in youth with T1D to identify lifestyle modification targets for weight prevention and management.

/pdf/overweight-and-obesity-in-youth-with-type-1-diabetes-5241mn5s73.pdf

Overweight and obesity in youth with type 1 diabetes.

Over one third of U.S. middle- and high-school-age youth are now overweight or obese (Ogden, Carroll, Kit, & Flegal, 2012), and this proportion has been projected to double by 2030 (Wild, Roglic, Green, Sicree, & King, 2004). Physical activity has been a predominant health behavior examined in the context of reducing youth overweight and obesity, even though moderate to vigorous activities only account for 3% of time spent awake (Katzmarzyk, 2010). However, there is now emerging evidence at the population level that sedentary time—engaging in prolonged sitting as distinct from not engaging in moderate to vigorous physical activity—may be related to adverse health consequences that are additional to those attributable to insufficient leisure-time physical activity levels (Owen, Healy, Matthews, & Dunstan, 2010; Pate, O’Neill, & Lobelo, 2008; Rey-Lopez, Vicente-Rodriguez, Biosca, & Moreno, 2008). Sedentary behaviors, which often encompass screen-based activities, involve reclined or sitting posture and do not increase energy expenditure substantially above the resting level of 1.0 to 1.5 metabolic equivalents (Pate et al., 2008). There is evidence linking sedentary behavior to overweight and obesity, type 2 diabetes, cardiovascular disease, cancer, and all-cause mortality (Dunstan et al., 2010; Healy, Dunstan, Salmon, Shaw, et al., 2008; Katzmarzyk, Church, Craig, & Bouchard, 2009; Owen, Bauman, & Brown, 2008).

Among youth, a recent systematic review reported that watching TV for more than 2 hr per day was associated with unfavorable body composition, metabolic and cardiovascular disease biomarkers, decreased fitness, lowered scores for self-esteem and prosocial behavior, as well as decreased academic achievement (Tremblay, LeBlanc, Kho, et al., 2011). Decreasing sedentary behavior is increasingly recognized as being an important target for youth obesity prevention efforts (Spanier, Marshall, & Faulkner, 2006).

Although sedentary behaviors encompass structured (e.g., sitting at desks in school), unstructured (e.g., leisure TV or computer games), and incidental (e.g., car or bus transportation) time, among research that focuses on youth, “screen time”—including TV viewing time—is the most often used measure of time spent engaged in a sedentary behavior (Tremblay, Le-Blanc, Kho, et al., 2011). Not surprisingly, rapid advancements in communication and entertainment technologies, and the ubiquitous presence of screen devices in youth’s lives, provide multiple opportunities for youth to engage in sedentary behaviors (Colley et al., 2011; Matthews et al., 2008). Recent evidence suggests that youth can spend up to 11 hr per day using screen-based technologies, such as smartphones, tablets, computers, and TV (Rideout, Foehr, & Roberts, 2010). Such excessive screen time can be associated with snacking and overeating (Bickham, Blood, Walls, Shrier, & Rich, 2013), and potentially displaces participation in physical activities (Bar-Or et al., 1998; Van den Bulck & Van Mierlo, 2004), with consequent implications for weight gain (Marshall, Biddle, Gorely, Cameron, & Murdey, 2004).

Given the health implications and excessive use of screen-based media, the American Academy of Pediatrics (AAP) introduced guidelines in 2001 for total entertainment screen time to not exceed 2 hr per day (American Academy of Pediatrics, 2001). The guideline was recently updated to recommend that youth not have access to the Internet or TV in their bedrooms, and for parents to monitor media use (American Academy of Pediatrics, 2013). Similar guidelines have been adopted from government health agencies in the United States and Canada (National Heart, Lung, and Blood Institute, 2013; Tremblay, LeBlanc, Janssen, et al., 2011). These guidelines and the development of screen-time interventions have been largely derived from studies that employed a quantitative methodology to elucidate the factors that underpin screen time. Quantitatively derived factors that appear to correlate with sedentary time in youth include sociodemographic attributes (parental income and education, race/ethnicity), access to screen-based media, neighborhood factors, parental behavior, psychosocial (depression, few peers) and family factors (parental and sibling behavior and viewing habits), as well as other health behaviors (physical activity and dietary behavior; Gorely, Marshall, & Biddle, 2004; Salmon, Tremblay, Marshall, & Hume, 2011; Zabinski, Norman, Sallis, Calfas, & Patrick, 2007).

Further, several screen-time interventions have been conducted, some of which have focused on the aforementioned correlates of sedentary time to facilitate behavior change. As evaluated by two recent meta-analyses, these interventions have had significant, albeit limited, success in reducing overall screen time in youth (Biddle, O’Connell, & Braithwaite, 2011; Maniccia, Davison, Marshall, Manganello, & Dennison, 2011). However, there is some inconsistency between these findings: Another meta-analysis found no net effect on reductions in screen time or body mass index following screen-time interventions (Wahi, Parkin, Beyene, Uleryk, & Birken, 2011).

Qualitative research can complement and advance the knowledge base gained through quantitative studies, as it is discovery-oriented and ideal for hypothesis generation, and takes the lived experience of study participants into consideration (Pope, Mays, & Popay, 2007). Further, qualitative research is particularly useful for exploring perceptions, processes, barriers, and facilitators of complex phenomena (Johnson & Waterfield, 2004), including sedentary behaviors. As demonstrated in a qualitative review of physical activity in youth (Allender, Cowburn, & Foster, 2006), synthesizing qualitative studies provides one avenue for identifying and conceptually defining parental and youth perceptions of behavior. It can also provide a more in-depth understanding of how diverse factors interact, as well as suggest possible cause– effect relationships that can be explored using quantitative methodology. In addition, the examination of parent- and youth-endorsed barriers and facilitators to sedentary behaviors, such as screen time, may identify the strategies that can be used in behavior change interventions to reduce the time that youth are sedentary (Biddle et al., 2011). Investigating insights from both parent and youth perspectives is essential, as youth are often the targets for behavior change, and parents have a strong influence on the participation of their children in sedentary pursuits (Norton, Froelicher, Waters, & Carrieri-Kohlman, 2003).

To date, no synthesis of qualitative findings pertaining to sedentary behavior barriers and facilitators in youth has been conducted; however, a more comprehensive exploration of this complex and modifiable health risk behavior may lead to a greater understanding of the obstacles and reveal novel practical strategies to reduce sedentary time. Therefore, the aim of this study was to use qualitative metasynthesis techniques (Sandelowski & Barroso, 2007; Sandelowski, Docherty, & Emden, 1997) to identify and conceptually define the barriers and facilitators to reducing screen time in youth 11 to 18 years of age. The metasynthesis seeks to integrate results from a number of different but interrelated qualitative studies to generate new insights and deepen understanding of the contextual dimensions of a health-related phenomenon (Walsh & Downe, 2005). An inductive approach was taken to derive the barriers and facilitators to reduce screen time from the extensive and varied raw data that were presented in the primary articles (Thomas, 2006).

Robin Whittemore

Papers

The Peer Advisor Experience Providing Social Support

Adapting to Diabetes Mellitus: A Theory Synthesis:

Overweight and obesity in youth with type 1 diabetes.

Reducing Youth Screen Time: Qualitative Metasynthesis of Findings on Barriers and Facilitators

Anxiety in Youth With Type 1 Diabetes.