Edwin B. Fisher

In the Diabetes Initiative of The Robert Wood Johnson Foundation, an ecological perspective helped identify the following key resources and supports for self-management (RSSM): individualized assessment, collaborative goal setting, skills enhancement, follow-up and support, access to resources, and continuity of quality clinical care. These RSSM reflect the grounding of diabetes self-management in the context of social and environmental influences. Research supports the value of each of these key resources and supports. Differences among self-management interventions may be seen as complementary, rather than conflicting, ways of providing RSSM. This way of understanding differences among interventions may aid development of varied programs to reach diverse audiences. In contrast to the “5 A’s” model of key provider services (Assess, Advise, Agree, Assist, and Arrange), RSSM articulate self-management from the perspective of individuals’ needs. Both approaches emphasize identification of goals, teaching of skills, and facilitation and reinforcement of the use of those skills.

Recent studies show diabetes can be prevented. Growing knowledge of its biological bases opens further prevention opportunities. This article focuses on behavioral science research that may advance these opportunities. An ecological model guides attention to how prevention research may be pursued at the individual, group, or community levels. Three key areas are reviewed: risk communication, screening, and preventive interventions. Research on diabetes risk communication is limited but suggests that many are relatively unaware of risks and may have misconceptions about the disease. Amid policy debates and research regarding the potential benefits and costs of screening, identification of diabetes may itself be risky in terms of psychological and social consequences. The Diabetes Prevention Program and other studies make clear that diabetes can be prevented, both by the combination of weight loss and physical activity and by medications. Research needs to address promoting these methods to individuals as well as to groups and even whole communities. Fundamental as well as applied research should address how risks of diabetes are understood and may be communicated; how to enhance benefits and minimize psychological and other risks of screening; how to promote healthy eating and weight loss, physical activity, and appropriate use of medications to prevent diabetes; and how to reduce socioeconomic and cultural disparities in all these areas.

OBJECTIVES: This study evaluated a community organization approach that emphasized involvement of audiences in program planning and implementation in promoting nonsmoking among African American residents of low-income neighborhoods. METHODS: The quasi-experimental design involved a 24-month intervention in 3 low-income, predominantly African American neighborhoods in St. Louis. Intervention neighborhoods were compared with comparable, untreated neighborhoods in Kansas City. RESULTS: The program was successful in engaging audience members in its governance and in instigating numerous and diverse neighborhood activities to promote nonsmoking. The prevalence of smoking declined from 34% to 27% in program neighborhoods but only from 34% to 33% in comparison neighborhoods. This difference was apparent within all demographically defined subsamples, indicating that observed changes were consistent and not attributable to confounding by demographic characteristics. CONCLUSIONS: A community organization approach emphasizing local authority for program decisions and involvement of informal networks may have an appreciable impact on smoking among residents of low-income, African American neighborhoods.

Directive and Nondirective Support were distinguished (interrater agreement = 88.2%) through open-ended interviews completed by 60 adults with Insulin Dependent Diabetes Mellitus. Supporting validity, the sum of both Directive and Nondirective Support was correlated with scores on the Interpersonal Support Evaluation List (ISEL;r=.36). Supporting their distinction, Directive and Nondirective Support were inversely correlated (r=26), and Directive but not Nondirective Support decreased with age. Partial correlations controlled for general support, as measured by the ISEL, to examine the unique associations of Directive and Nondirective Support. For those less than 30 years old, Nondirective Support was associated with better metabolic control (p = .004). For those 30 or older, Directive Support appeared counterproductive, being associated with greater negative mood (p = .02). Different types of support may play different roles in different areas of disease management (e.g., metabolic control versus mood) and as a function of individual characteristics such as age.

Non-insulin-dependent diabetes mellitus is epidemic among African-American women in the United States; reports of its prevalence among African Americans range from 50% to 60% higher than among whites. African Americans also incur higher rates of diabetes-related complications such as blindness, end-stage renal disease, and amputations. Data indicate that non-insulin-dependent diabetes among African Americans is associated with lower socioeconomic status and with obesity. Because obesity has been hypothesized as contributing to the growing numbers of non-insulin-dependent diabetics among African-American women, new strategies are urgently needed to promote weight loss in this population. Community organization can broaden health education and facilitate behavior change toward development of life- and self-mastery skills. Specific strategies of this approach include (1) integrating community values into health messages, (2) facilitating neighborhood "ownership" and decision-making, (3) utilizing existing formal and informal networks, and (4) empowering individuals and community. Community organization may be a promising strategy among low-income minority communities to reduce the risk of non-insulin-dependent diabetes by promoting changes in dietary patterns, because it ensures that the health messages and programs that emerge will be consistent with existing sociocultural norms and beliefs.