Background-The Diabetes Prevention Program (DPP) found that an intensive lifestyle intervention can reduce the development of diabetes by more than half in adults with prediabetes, but there is little information about the feasibility of offering such an intervention in community settings. This study evaluated the delivery of a group-based DPP lifestyle intervention in partnership with the YMCA.

739 Patients with diabetes must make a series of daily decisions involving nutrition, physical activity, medication, blood glucose monitoring, and stress management. Patients must also interact effectively with the health care system, their family members, friends, and employers to obtain the support necessary to manage their diabetes (1). Thus, enhancing the perceived self-efficacy of patients to self-manage their diabetes is an important goal of diabetes care and education.Perceived self-efficacy has become an important and useful construct in psychology (2-4) because it is related to the willingness and the ability of people to engage in various behavioral challenges including preventive and disease management behaviors (5-15). Studies in diabetes have demonstrated the effect of perceived self-efficacy on the adherence behavior of adolescents (16,17), African-American women with diabetes (18), adults with complex insulin regimens (18,19), and adults with type 1 or type 2 diabetes (20-22). However, in these studies, self-efficacy has been defined primarily as the perceived ability to engage in various situation-specific self-management tasks such as blood glucose monitoring and ordering meals in a restaurant, or the studies have focused on the needs of particular group of patients (e.g., adolescents).In 1991, we conducted a randomized controlled trial to evaluate the effectiveness of a patient empowerment program for adults that focused entirely on psychosocial issues such as managing stress, obtaining family support, negotiating with health care professionals and employers, and dealing with uncomfortable emotions (23). Because we were unable to identify a measure of diabetes-related self-efficacy for adults that focused on these important psychosocial areas, we developed the Diabetes Empowerment Scale (DES), which is a 37-item Likert-type questionnaire (24), and we used it in that study. The study showed that the program resulted in both psychosocial and blood glucose level improvements. RESEARCH DESIGN AND METHODS Instrument developmentThe pilot version of the DES had 8 subscales that were keyed to the major content areas of the patient empowerment and education program (23,24). The structure of the DES and the patient empowerment program were based on our earlier work in patient empowerment (25)(26)(27). In an earlier study (25), we defined the purpose of the empowerment approach to diabetes education as helping patients make informed choices about their diabetes selfmanagement. In that study, we offered a 4-step behavior change model: 1) patient identification of problem areas, 2) exploration of the emotions associated with those problems, 3) development of a set of goals and strategies to overcome the barriers to achieving those goals, and 4) determining patients' motivation to make a commitment to the behavior change plan. That approach to facilitating behavior change in diabetic patients was adapted from earlier work in counseling psychology (28-31). Most of the patient empowerment program and DES subsc...

OBJECTIVEReasons for failing to initiate prescribed insulin (primary nonadherence) are poorly understood. We investigated barriers to insulin initiation following a new prescription.RESEARCH DESIGN AND METHODSWe surveyed insulin-naïve patients with poorly controlled type 2 diabetes, already treated with two or more oral agents who were recently prescribed insulin. We compared responses for respondents prescribed, but never initiating, insulin (n = 69) with those dispensed insulin (n = 100).RESULTSSubjects failing to initiate prescribed insulin commonly reported misconceptions regarding insulin risk (35% believed that insulin causes blindness, renal failure, amputations, heart attacks, strokes, or early death), plans to instead work harder on behavioral goals, sense of personal failure, low self-efficacy, injection phobia, hypoglycemia concerns, negative impact on social life and job, inadequate health literacy, health care provider inadequately explaining risks/benefits, and limited insulin self-management training.CONCLUSIONSPrimary adherence for insulin may be improved through better provider communication regarding risks, shared decision making, and insulin self-management training.

In the Diabetes Control and Complication Trial (DCCT), a Diabetes Quality of Life (DQOL) measure was developed to assess the psychosocial impact of intensified regimens. Its applicability for use with children and adolescents was limited by the exclusion criteria of the DCCT. In this study, the DQOL was modified for specific use in young diabetes populations. The result is an instrument composed of three intercorrelated scales--a Diabetes Life Satisfaction scale, a Disease Impact scale, and a Disease-Related Worries scale--with satisfactory levels of reliability. While the scale variances were independent of glycosylated hemoglobin values, they were related to adolescents' perception of their general health status. Self-perceived quality of life related to diabetes management is an important alternative outcome for diabetes education programs.

Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care. However, both VA and commercial managed care had room for improvement, especially for blood pressure control.