Nelson, K. M., McFarland, L., & Reiber, G.
Research Article Critique
The ability to locate and critique relevant research evidence is an essential evidence-based practice (EBP) skill (Titler, 2008). This paper will critique a research article on a pertinent health issue that is diabetes care amongst veterans by Nelson, McFarland, & Reiber (2007). The article is entitled “Factors influencing disease self-management among veterans with diabetes and poor glycemic control”. The critique will focus on the various sections of the article with a bias towards the methodology section.
Overview of the Article
The problem noted by the authors is the relative lack of research on diabetes self-management amongst veterans. The author cites evidence suggesting that amongst nonveterans, interventions designed to enhance self-efficacy have been found to improve patient satisfaction, quality of life, and glycemic control. They further cite evidence from studies that suggest that readiness to change predicts physical activity, dietary behavior and improvements in glycemic control. The other problem cited by the authors is lack of information regarding diabetes self-management practices of veterans. The author supports the later problem by citing sources that suggest that the Department of Veterans Affairs has placed less emphasis on disease self-management. This is in spite of having implemented numerous organizational changes to enhance diabetes care.
Critique of the Article
The literature reviewed by the authors was mostly recent that is it had been published within the previous five years. The authors, however, cited some old sources (more than five years) for instance Anderson et al. (1995) and Prochaska & Velicer (1997). Justification was not provided for the use of the old sources. The literature reviewed to support the research problem identified by the author is appropriate though as it establishes the need for the study by delineating gaps in practice and available evidence. The authors do not state any research questions. Research questions pertinent to the study can, however, be easily deciphered. The authors used a theoretical framework for their study. The theoretical frameworks used were self efficacy theory and stages of change model. These models are not discussed as a distinct section but are represented diagrammatically. The diagram, however, manages to clearly illustrate how self-efficacy, stage of change, and advice from healthcare providers influence diabetes self-management behaviors and the clinical outcome of the study, HbA1c levels.
The research is not current since it was published about seven years ago. The issues discussed are, however, relevant to existing health issues. This is because the article sought to establish the factors that influence diabetes self-care practices with a focus on the veteran population. Non-adherence to diabetes medications, dietary, and physical activity regimens is a well recognized problem in the management of diabetes. This non-adherence adversely affects patients’ outcomes as it heightens the onset of diabetes-related complications like micro-vascular changes that lead to peripheral neuropathy.
The study used a non-experimental design as the authors did not attempt to control dependent variables, randomize subjects between groups, or to create a control group (Sim & Wright, 2000). This type of design was appropriate to the overall purpose of the research which was to describe and connect/relate. The authors to the study sought to determine current diabetes self-care practices amongst veterans and their link to provider advice, self-efficacy, and readiness to change. The timing of the design is cross-sectional as respondents responded to validated surveys sent to them and were not followed up prospectively (Macnee & McCabe, 2008).
The sample for the study consisted of 717 respondents which represented 56% of the participants eligible for the study. This sample was selected from a list of all patients with diabetes who received primary care at one of the veterans’ affairs primary care clinics in Washington DC. Other criteria for inclusion in the study included a HbA1c>8%, enrollment in the veterans affairs clinic for >1 year, geographic proximity to one of the clinics, and 2 or > visits to either clinic during the previous year. The persons found eligible for the study were invited to participate in the study through mail. The mail consisted of a 50-question survey and an introduction letter. Of 1286 eligible participants, 9% declined to participate in the study while 35% failed to respond. The authors state that the participants to the study were not significantly different from non-responders with regards to race/ethnicity, demographics, healthcare utilization, glycemic control, and service-connected disability. This information is essential as non-response bias would have been introduced if the characteristics of the non-respondents were significantly different from those of respondents. The manner in which the sample for the study was selected is appropriate to the purpose of the study. This is because the authors sought to describe diabetes self-care practices and their relation to readiness to change, self-efficacy, and provider advice in the natural settings of the participants. A major weakness of the study design is its reliance on self-report measures. This is because self-report measures are prone to recall bias and social desirability bias. Recall bias occurs due to the inability of respondents to accurately remember information. For instance, the study required participants to provide information on their undertaking physical activity during the preceding week. Social desirability bias occurs due to the desire of respondents to appear in a positive or favorable light (Polit & Back, 2008). Therefore, although the studies used validated instruments, it is possible that the responses provided by the participants were biased. The authors also cite their inability to control for these biases as a limitation of their study.
The study seems very practical as details of how the sample was selected, sample size, data collection processes, and data analysis are explicitly described and in most cases, justified. The results of the study are in addition described using descriptive statistics and presented using figures. The research process followed by the authors is appropriate for the nature of the study and is in keeping with current research practices. The authors propose that the findings of their study can be applied to improve diabetes care and glycemic control amongst veterans. They propose the planning of patient-centered interventions targeted at increasing the self-efficacy and readiness to change behaviors of veterans with diabetes. Notably, the authors are careful to caution that the findings of their study can only be generalized to a veteran population that consists of patients with demographics similar to those of the respondents of the study. In my opinion, the findings of the study can be applied in the manner prescribed by the authors. The findings may also be used as a basis for future prospective studies to determine causality between poor glycemic control and factors such as self-efficacy. The study could have been improved by selection of a more representative sample. The sample for the study consisted of mostly male elderly patients. This limits the extent to which the findings of the study can be generalized. The study could also have been improved by collection and inclusion of data on factors likely to confound the findings of the study such as duration of diabetes, type of diabetic medications used by a patient, and comorbid conditions. The writing of the article is clear and straightforward. Further research can be conducted on the subject. This research can include evaluation of the causality between poor glycemic control and factors like self-efficacy.
Conclusion
In summary, this paper has a critiqued a research article by Nelson, McFarland, & Reiber (2007) entitled “Factors influencing disease self-management among veterans with diabetes and poor glycemic control”. The literature review section of the article is appropriate and establishes the need for the study. The article focuses on a pertinent health issue. The study used a non-experimental cross-sectional design. The sample for the study is representative of the patients who attend veterans’ primary care clinics. It is, however, unrepresentative of the general population. This has implications on the generalization of the findings of the study. Reliance on self-report measures in the study may have introduced recall and other biases. The findings of the study can be used to improve the targeting of self-care interventions at diabetic clinics. They can also be used as a basis for future studies.
References
Macnee, C. L. & McCabe, S. (2008). Understanding nursing research: Using research evidence- based practice. Philadelphia, PA: Lippincott Williams and Wilkins.
Nelson, K. M., McFarland, L., & Reiber, G. (2007). Factors influencing disease self- management among veterans with diabetes and poor glycemic control. Journal of General Internal Medicine, 22(4), 442-447.
Polit, D. F. & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice. Philadelphia, PA: Lippincott Williams & Wilkins.
Sim, J. & Wright, C. (2000). Research in healthcare: Concepts, design, and methods. Cheltenham: Nelson Thornes Publishers Ltd.
Titler, M. G. (2008). The evidence for evidence-based practice implementation. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2659/.
