Digital health and diabetes management in the community
Digital health and self-management among patients with chronic disease have been gaining in popularity over recent years. The number of people living with diabetes in particular is steadily on the rise and self-management in this group can avoid costly and potentially life-threatening complications.
In this American randomised controlled trial (RCT), Whitehouse et al (2022) evaluated the effectiveness of a digital health intervention along with support from a community health worker on patient self-monitoring of blood glucose and glycosylated haemoglobin (hBA1c) among adults living with diabetes who are receiving Medicaid public health insurance.
In total, 150 people attending an urban outpatient clinic were enrolled into the trial. The authors highlighted that two intervention strategies showed promise for the promotion of changing behaviour and improving health outcomes across various populations: digital health interventions and community health workers.
Digital interventions would include the use of computers or mobile devices to promote self-monitoring of various health metrics, such as blood glucose levels. This strategy is used to raise awareness among individuals of both their metrics and their risk factors in order to shift attitudes towards healthier behaviours. Such digital interventions can also be enhanced with the use of financial incentives to support self-monitoring and reinforce habit change. Community health workers also work with patients to build and maintain health-promotion behaviours and connect them with resources, where needed.
Based on this, participants were randomly assigned to one of three groups: usual care, with a wireless glucometer if needed; digital health, with a lottery incentive for daily glucose monitoring; or hybrid support, the members of which received both the lottery and support from a community health worker if they had either low adherence or high blood glucose levels.
Of the original 150 participants, 102 (68%) of these completed the study, with loss to follow-up being greater than the researchers anticipated at both measured time intervals. The primary outcome measured was the difference between the hybrid and usual care arms at 3 months and the secondary outcome was the difference between hybrid and usual care arms at 6 months. Additionally, an exploratory analysis was also conducted between hybrid and digital health arms.
At the 3-month follow-up point, the glucose self-monitoring rate in the hybrid group was 0.72 vs. 0.65 in the usual care group (p=0.23). At 6 months, the change in HbA1c in the hybrid group was -0.74 vs -0.49 in the usual care arm (p=0.69). These were noted as the key results by the authors; however, neither of these was a statistically significant difference.
End-of-life experiences and preferences among Taiwanese adults
Caring for patients at the end of life can present both clinical and ethical challenges for nurses working in the community, particularly where decision-making capacity is affected. This Taiwanese study aimed to gather insight into the perspectives of Taiwanese adults on palliative care and end-of-life experiences, as well as their preferences related to communication, healthcare planning and life-sustaining treatment.
In this qualitative study, Huang et al (2023) carried out semi-structured interviews with 16 adults aged 20 years and older. The authors employed a convenience strategy approach to recruit their sample from a community centre in a metropolitan area in southern Taiwan. The main themes, which were personal experiences of end-of-life care and personal preferences for end-of-life care were then further broken down into categories and subcategories.
Participants' personal experiences were divided into observing the distress of those who are dying (further categorised into living with physical distress and living with emotional distress), and experiencing the distress of families, which was subcategorised to include encountering emotional distress. Participants' preferences were categorised into preferred end-of-life communication (subcategorised into the importance of timing, being optimistic, providing specific information and involving support persons); preparation for the end of life (including addressing financial and funeral matters, and clarifying healthcare choices); and the maintenance of quality of life (further divided into maintaining physical comfort, maintaining emotional comfort, and living a meaningful life).
This study did not set any criteria to recruit participants with experiences of loved ones who were dying. The authors pointed out that participants with such experiences were more likely to participate in the study. The authors noted that individuals often construct the meaning of end-of-life decisions based on their personal experiences related to end-of-life care, and that where people have experiences with loved ones at the end of life, this may shape their experiences of their own end-of-life care – particularly with regards to the maintenance of quality of life. This study suggested that Taiwanese families are more likely to follow the principle of beneficence, in contrast with the principle of autonomy, which is usually the preference for individuals, particularly with regards to end-of-life communication. The authors highlight that the strong value placed on obligation for one's family in Taiwan can shape individual preferences for preparing for the end of life.
The culture in the UK is more individualistic than that found in countries with a stronger emphasis on the collective community and family. However, it is interesting to compare and contrast similarities and differences between the perspectives and experiences of adults in Taiwan and those in the UK. The authors suggest a further exploration to garner insight into how personal end-of-life experiences shape health practices in advance care planning for the end of life.
Frailty in the community
In the UK, frailty is a growing concern with between a quarter and half of older adults aged over 85 years, and 10% of those aged over 65 years, experiencing this condition. Frailty, associated with older age and marked by body systems gradually losing their intrinsic reserves, is expected to continue to rise, with 12% of adults starting at only age 50 years and older having frailty worldwide.
Several tools exist to identify frailty in the community. Continuing with the international theme of this month's roundup, this Slovenian study evaluated the Tilburg Frailty Indicator (TFI) and psychometrically adapted it to assess multidimensional frailty in older adults living in community and nursing home settings in Slovenia. In total, 831 people aged over 65 years were recruited, with the help of community nurses and head nurses in nursing homes. The majority of participants (60%; n=501) lived in the community and the remaining (40%; n=330) were residing in nursing homes at the time of the study.
The TFI, which was originally developed for older adults in the Netherlands was translated into Slovene with the original author's permission, slightly adjusted to account for cultural differences and clarity of meaning and validated. It is a self-report questionnaire with 15 items across physical, psychological and social components, and the authors note that the translated version was easy to understand and could be completed in less than 15 minutes.
Data collection took place between March and August 2021. Making use of the Strengthening the Reporting of Observational Studies in Epidemiology Checklist for reporting cross-sectional studies, Kmetec et al (2024) evaluated the index, noting its average scale validity rating to be good, with satisfactory content validity. The authors concluded that the TFI can be effectively cross-culturally adapted without compromising its strong reliability and validity, as long as this is carefully done, and with the translation process being crucial. They note that its use to assess frailty in community-dwelling older adults across cultural contexts can additionally foster international collaboration.