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

BULLYING AMONG SCHOOL-AGED youth is increasingly being recognized as an important problem affecting well-being and social functioning. While a certain amount of conflict and harassment is typical of youth peer relations, bullying presents a potentially more serious threat to healthy youth development. The definition of bullying is widely agreed on in literature on bullying.1–4 Bullying is a specific type of aggression in which (1) the behavior is intended to harm or disturb, (2) the behavior occurs repeatedly over time, and (3) there is an imbalance of power, with a more powerful person or group attacking a less powerful one. This asymmetry of power may be physical or psychological, and the aggressive behavior may be verbal (eg, name-calling, threats), physical (eg, hitting), or psychological (eg, rumors, shunning/exclusion).

The majority of research on bullying has been conducted in Europe and Australia. Considerable variability among countries in the prevalence of bullying has been reported. In an international survey of adolescent health-related behaviors, the percentage of students who reported being bullied at least once during the current term ranged from a low of 15% to 20% in some countries to a high of 70% in others.5,6 Of particular concern is frequent bullying, typically defined as bullying that occurs once a week or more. The prevalence of frequent bullying reported internationally ranges from a low of 1.9% among 1 Irish sample to a high of 19% in a Malta study.1,7–12

Bullying takes many forms, and findings about the types of bullying that occur are fairly similar across countries. A British study involving 23 schools found that direct verbal aggression was the most common form of bullying, occurring with similar frequency in both sexes.13 Direct physical aggression was more common among boys, while indirect forms were more common among girls. Similarly, in a study of several middle schools in Rome, the most common types of bullying reported by boys were threats, physical harm, rejection, and name-calling.14 The most common forms for girls were name-calling, teasing, rumors, rejection, and taking of personal belongings.

Research examining characteristics of youth involved in bullying has consistently found that both bullies and those bullied demonstrate poorer psychosocial functioning than their noninvolved peers. Youth who bully others tend to demonstrate higher levels of conduct problems and dislike of school, whereas youth who are bullied generally show higher levels of insecurity, anxiety, depression, loneliness, unhappiness, physical and mental symptoms, and low self-esteem.1–4,8,15–25 Males who are bullied also tend to be physically weaker than males in general.2 The few studies that have examined the characteristics of youth who both bully and are bullied found that these individuals exhibit the poorest psychosocial functioning overall.15,17,19,26

The current research provides a foundation for an understanding of the bullying problem. However, it is insufficient to guide intervention and policy development. Moreover, little is known specifically about bullying among US youth.6 In one county-wide middle school survey, 24.1% of youth reported bullying others at least once in the past semester26; it is not known whether this is characteristic of the rest of the nation.

The purpose of this study was to report the prevalence of bullying in a nationally representative sample of US youth in grades 6 through 10, along with information on differences in the prevalence of bullying by sex, grade, and race. In addition, the relationships among bullying, being bullied, and psychosocial adjustment are explored for 3 distinct groups: bullies only, those bullied only, and those who both bully and are bullied.

https://jamanetwork.com/journals/jama/articlepdf/193774/JOC01746.pdf

Bullying Behaviors Among US Youth: Prevalence and Association With Psychosocial Adjustment

25. Multiple Imputation for Nonresponse in Surveys. By D. B. Rubin. ISBN 0 471 08705 X. Wiley, Chichester, 1987. 258 pp. £30.25.

Multiple Imputation for Nonresponse in Surveys

Statistical Analysis with Missing Data

Background
People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

Objectives
To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search methods
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria
Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis
Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results
For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions
For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Interventions for enhancing medication adherence.

School Bullying Among Adolescents in the United States: Physical, Verbal, Relational, and Cyber

Bullying and victimization are prevalent problems in the area of adolescent peer relationships. Middle school students (N = 4,263) in one Maryland school district completed surveys covering a range of problem behaviors and psychosocial variables. Overall,30.9% of the students reported being victimized three or more times in the past year and 7.4% reported bullying three or more times over the past year. More than one half of the bullies also reported being victimized. Those bully/victims were found to score less favorably than either bullies or victims on all the measured psychosocial and behavioral variables. Results of a discriminant function analysis demonstrated that a group of psychosocial and behavioral predictors—including problem behaviors, attitudes toward deviance, peer influences, depressive symptoms, school-related functioning, and parenting—formed a linear separation between the comparison group (never bullied or victimized), the victim group, the bully group, and the bully/victim group.

Bullies, Victims, and Bully/Victims: Distinct Groups of At-Risk Youth

Objective To determine whether the relationship between bullying and psychosocial adjustment is consistent across countries by standard measures and methods. Design Cross-sectional self-report surveys were obtained from nationally representative samples of students in 25 countries. Involvement in bullying, as bully, victim, or both bully and victim, was assessed. Setting Surveys were conducted at public and private schools throughout the participating countries. Participants Participants included all consenting students in sampled classrooms, for a total of 113 200 students at average ages of 11.5, 13.5, and 15.5 years. Main Outcome Measures Psychosocial adjustment dimensions assessed included health problems, emotional adjustment, school adjustment, relationships with classmates, alcohol use, and weapon carrying. Results Involvement in bullying varied dramatically across countries, ranging from 9% to 54% of youth. However, across all countries, involvement in bullying was associated with poorer psychosocial adjustment ( P Conclusions The association of bullying with poorer psychosocial adjustment is remarkably similar across countries. Bullying is a critical issue for the health of youth internationally.

https://jamanetwork.com/journals/jamapediatrics/articlepdf/485786/POA30469.pdf

Tonja R. Nansel

Papers

Bullying Behaviors Among US Youth: Prevalence and Association With Psychosocial Adjustment

School Bullying Among Adolescents in the United States: Physical, Verbal, Relational, and Cyber

Bullies, Victims, and Bully/Victims: Distinct Groups of At-Risk Youth

Cross-national consistency in the relationship between bullying behaviors and psychosocial adjustment.

Adolescent bullying involvement and perceived family, peer and school relations: commonalities and differences across race/ethnicity.