Critique Nursing Journal Article

Complications from, and economic costs associated with diabetes are on the rise. The concern is that this global health epidemic is only expected to worsen in the coming decades. One quantitative research study aims to improve patient outcomes specifically related to proper control of blood glucose level, by linking patient outcomes with health literacy and patient trust. A quantitative study consisting of a convenience sample of 102 subjects from two urban health care centers was used.
Patient demographics, socioeconomic status, and diabetes related knowledge, and depression were measured. The results of this study are mixed in supporting the hypothesis that lower health literacy directly impacts glycemic control. The 2010 journal article titled, “Impact of health literacy and patient trust on glycemic control in urban USA population” from Nursing Health and Sciences, hypothesizes a direct relationship between a patient’s overall health literacy and the ability to maintain glycemic control.
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The study’s intent is to examine questions related to health literacy and a patient’s trust in their healthcare provider to make a connection to how well the subjects managed glycemic control. Questions related to potential depression are also relevant. Author, Josephine M. Mancuso, PhD, ANP-BC from Marquette University, has published articles in the following nursing journals: Journal Of Nursing Care Quality, Journal Of Professional Nursing: Official Journal Of The American Association Of Colleges Of Nursing, Western Journal Of Nursing Research, and Nursing & Health Sciences.
In this research study, the author seeks to examine correlation between dependent and independent variables. The suspected purpose is often to generate hypotheses that can be tested in experimental research. In her study, Mancuso used the following set of eligibility criterion: subjects were ? 18 years of age, fluent in English, confirmed diabetes type 1 or 2, HbA1c within 6 months of the study, and received treatment for diabetes at least twice in the previous year. Using the above criteria, 102 subjects total ere selected from two different urban healthcare clinics (Mancuso, 2010). This study aims to draw correlation between glycemic control (dependent variable) and overall health literacy and patient trust (independent variables). According to Polit & Beck, a dependent variable is what is measured in an experiment and what is affected during the experiment. The dependent variable responds to the independent variable. It is called “dependent” because it cannot exist without the independent variable. An independent variable can be controlled and manipulated (Polit & Beck, 2010).
Strength of this research is the highlighting positive effects of proper glycemic control on overall health. The author states, “Control of blood glucose is a central outcome of diabetes management” (2010). This suggests that with proper maintenance of blood glucose levels and by lowering the HbA1c by 1%, patients can extend their life expectancy 5-8 years with lowered risks of eye, kidney, and peripheral nerve complications (2010). Strength is also found in validation of statistical information from the American Diabetes Association.
While conducting the study, Mancuso noted that 35% of participants achieved the desired HbA1c of ?7% (2010). She cites the ADA reporting that, “37% of adults diagnosed with diabetes in the USA achieve glycemic control” (Mancuso, 2010). It is important for all individuals with diabetes to be mindful of blood glucose levels and HbA1c levels to reduce potential life-limiting complications of diabetes. Finally, strength in the research is found in the correlation of a person’s level of depression and trust in healthcare providers.
Mancuso states, “The current ?ndings are congruent with and add to the other studies that evaluated the in?uence of patient trust and depression on glycemic control” (2010). This is important to healthcare professionals in part because communication can be hindered if depression is present. Recognizing depression and opening lines of communication is crucial in establishing patient trust (2010). When a patient trusts the health care professional, they will likely be more open to discussing symptoms, adherence to medication management, and non-compliance with health care regimen.
With this information, the health care professional can create a plan of care that is individualized and meets the unique learning style needs of every patient. Improving patient trust will improve patient outcomes. Limiting characteristics that potentially threaten the validity of the results include a relatively small sample size of a homogenous population, potential cultural bias and lack of congruent variables. If a sample size is too small, it may be difficult to find any significance in the relationship between the variables.
Also, a small sample size may not provide a representative distribution of the population being studied (Mancuso, 2010). In addition, the study’s objective and design were incongruent. Lack of a control group threatens internal validity because it was not clear if any benefits “observed” accurately reflected correlation between dependent and independent variables. Perhaps with this low income demographic, simply having access to a physician would have been sufficient to foster improved patient outcomes. In addition, it is not clear how or why these urban health care centers were selected.
Whether or not there is any affiliation bias remains uncertain. External validity is questioned because it was not clear to whom the results would benefit. Potential bias is evidenced in the following statement by Mancuso, “The use of such similar samples that capture the working poor is rather generalized in its interpretations. This could lead to potential bias as socioeconomic and demographic information was collected” (2010). Additionally, patient trust develops from an initial vulnerability that eventually results in a reliance on the provider to care for their interests and needs.
If a person is feeling intimidated or their current health literacy level prevents them from fully understanding information given, faulty findings may be demonstrated in this quantitative study. Further limitation is discovered in the lack of identified interventions that increased health literacy and patient trust. Whether an intervention is effective, on whom it is effective, how much benefit it produces and whether or not it is associated with negative outcomes should be addressed. Clearly, this study had many weaknesses that limit its value and the applicability of results.
It is not clear why the study was not labeled simply as an exploratory qualitative study. Possibly further research exists on the topic. Ultimately, the convenience sample of 102 patients with diabetes demonstrated that patient trust and patient depression was significant. In addition, there was a significant positive correlation between a test subject’s lack of knowledge of diabetes management and low health literacy (Mancuso, 2010). Discovery of the correlation between an increase in health literacy and an increase in diabetes knowledge was found (2010).
A positive correlation was found between a patient’s HbA1c level and that patient suffering from depression. A negative correlation was found between patient trust and HbA1c. As patient trust increased, HbA1c decreased (Mancuso, 2010). These results indicate that promotion of the patient–provider relationship, adequate depression screening in individuals with diabetes, as well as needed exploration of new strategies for diabetes education are much needed interventions in the goal of glycemic control.
According to the study, the majority of participants who demonstrated poor glycemic control conversely demonstrated health literacy. It is not known how or why some individuals with satisfactory health literacy revealed poor glycemic control. Because of this, the study fails to connect health literacy and glycemic control in the test subjects (Mancuso, 2010). The significant variables related to proper glycemic control were patient trust and depression (Mancuso, 2010).
Brega,et al state, “results indicated that diabetes-related knowledge is a key mediator of the relationship between health literacy and glycemic control and highlighted the important association of diabetes knowledge with health behavior” (2012). Similarly, a study by Coffman, Norton & Beene, acknowledged a knowledge deficiency related to diabetes. This lack of knowledge when coupled with low health literacy created obstacles to health care and prevented fitting interventions (2012). The importance of the direction of this study is most relevant.
The author attempts to address barriers to glycemic control that lead to complications from diabetes. Disease complications and rising costs associated with diabetes, is likened to a public health crisis that is projected to only get worse. The improvement of diabetes related outcomes could potentially positively impact all health care system. Future research in all areas of diabetic monitoring and teaching will be needed to advance the structure of diabetes education. The WHO estimates that 347 million people worldwide have diabetes.
The WHO projects that diabetes related deaths will double between 2005 and 2030 (2013). No longer is diabetes associated with the gluttonous rich. The WHO states, “More than 80% of people with diabetes live in low and middle-income countries” (WHO, 2013). Diabetes has become a disease of poverty in developed countries. Incidents of diabetes is increasing most rapidly in developing countries, in theory, because industrialization and urbanization have led to a decrease in time to prepare a nutritious meal and costs associated with fresh produce is prohibitive.
Preservation of functional status and improvement in quality of life can be achieved with proper management of diabetes through adequate glycemic control. Depression and any correlation with patient trust of healthcare providers will need further investigation in other patient demographics. As we struggle to combat diabetes, ongoing encouragement of individuals to change their lifestyle choices may be the best way to proceed.

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