Statement of the Problem: Diabetes Mellitus is a chronic illness that affects approximately 18 million (6.3%) of the United States’ population. Type 2 diabetes accounts for 16 million (90-95%) of all cases. Approximately one in four (25%) persons over the age of 60 has type 2 diabetes(ADA, 2003). Since 1991 the number of U.S. adults with diabetes mellitus has increased by 61% and is projected to double by the year 2050(CDC, 2003a). The 8th annual report of the Diabetes Initiative of South Carolina ranks the state as 2nd in the U.S. in prevalence of known cases of diabetes in adults (8.5%= 240, 000) and at least 120,000 more undiagnosed cases(Colwell, 2003; DHEC, 2002). Nationally over 200,000 people die each year because of related complications (CDC, 2002a). Diabetes Mellitus is more prevalent in African Americans. Over 13% have the disease, making African Americans 2 to 3 times more likely to have diabetes (Anderson-Loftin & Moneyham, 2000). Fewer AA, when compared to whites have good metabolic control of diabetes (Jenkins, McNary, Carlson et al., in press 2004), and AA experience higher rates of serious complications (Anderson-Loftin, Barnett, Sullivan, Bunn, & Tavakoli, 2002; DPP, 2002). The cost of diabetes in the US is estimated to exceed $132 billion, and AA share a disproportionate burden of these costs (CDC, 2002a; HHS, 2003). Diabetes can cause blindness, heart disease, stroke, kidney failure, amputations, and pregnancy complications (Harris, 2001; Karter et al., 2002). Additional complications include hypertension, nervous system damage, and periodontal disease(Maillet, Melkus, & Spollett, 1996). Improved glycemic control decreases the risk for developing microvascular complications (Nasr, Hoogwerf, Faiman, & Reddy, 1999; The Writing Team for the Diabetes, Complications Trial/Epidemiology of Diabetes, & Complications Research, 2002). According to the American Diabetes Association (ADA) for every 1% reduction in A1c, the risk for developing microvascular complications decreases by 40 % (CDC, 2002a; Harris, 2001). The current recommended treatment goal for A1C is less than 7%. An A1c greater than 8% is the level identified for aggressive action (AADE, 2002). A review of Medicare claims data revealed less frequent testing and higher levels of glycated hemoglobins in African Americans (Arday et al., 2002) . Accordingly, levels greater than 7% correlate with increased medical charges. Harris (2001) relates improved diabetes care as a benefit to both payers and patients. According to the UKPDS (1998), blood pressure control produces even better outcomes than glycemic control alone. Diabetes is a chronic illness that most often relies on self-management. The Center for Disease Control and Prevention and National Diabetes Education Program (CDC, 2002b) collaborating with six national minority organizations develop and deliver prevention and control programs and messages to African Americans that are culturally appropriate. Federally funded programs, such as Healthy People 2010, are designed and implemented to promote improved health and self-management in African American men and women (HHS, 2000). Another major drive is to decrease the disparate prevalence and outcomes that exist within the African American population burdened with the morbidity and mortality of this disabling and deadly disease (IOM, 2003; Jenkins, 2003; Karter et al., 2002; Koroukian, 2002; Pearcy & Keppel, 2002; Weiss & Hutchinson, 2000; J. Weiss & Hutchinson, 2001). The literature is saturated with recommendations for culture specific interventions. However, few extant research studies exist that explore needs, perception, beliefs, and barriers to self management of older African Americans with type 2 DM (Banks-Wallace & Conn, 2002; Henderson & Ainsworth, 2003; Weiss & Hutchinson, 2000). Qualitative studies exploring the beliefs and attitudes related to diabetes control suggest further study in this area (Egede, 2002; Weiss & Hutchinson, 2000)

Methods: The following methods will be used to reach my aims. 1)Complete a systematic and analytic review of existing literature related to the key domains/dimensions of diabetes management including: (a) processes (communication, content, frequency, source, etc.) of care by diabetes primary and specialists encounters. (b) knowledge and perception of recommendations. (c) problem solving related to adoption of recommendations. (d) self-management approaches and success according to stages of change. 2)Review documented psychometric evidence related to tools to measure domains, including self-management behaviors (e.g. medication compliance, physical activity, healthy eating, glucose monitoring) with a focus on evidence of use of instruments with minority populations. 3)Assemble a draft instrument to address patient understanding of provider recommendations related to diabetes management, patient implementation of recommendations, and patient problem solving skills related to overcoming barriers to self management. 4)Implement an expert review process to critique the instrument draft. The panel will consist of four experts in diabetes self-management research. The panel members will receive an executive summary of the literature review, the tools and their psychometric properties, and the draft instrument prior to review. The panel will convene by conference call and will critique the instrument and make suggestions for change. Panel members to be invited include Dr. Russell Glasgow, Dr. David Marrero, Dr. Anne Skelly, Dr. Frank Vinicor. The panel will also review the instrument after pretesting. Each expert panel member will receive $300 for panel participation. 5)After implementing recommended changes from the expert review panel, cognitive pretesting of the instrument will be done with two focus groups: one group of 6-8 males and another group of 6-8 females. Each person will receive $30 for their active participation. 6)Following refinement, the instrument will be tested by 10-15 adult subjects with diabetes who will answer the questions. Each adult will record information related to time for completion, any comments, as well as their answers. Each adult will be interviewed to ascertain any concerns related to survey development, knowledge of intended meaning, as well as answers to questions. Each person will receive $25 for their active participation. 7)The survey will then be used for collection of data related to patient understanding of provider recommendations, problem solving, and self monitoring for a population of AA with diabetes who are enrolled in REACH 2010: Charleston and Georgetown Diabetes Coalition. The psychometric properties of the instrument will be established from the data.

Results: I anticipate that I will prepare and submit 2-3 papers for publication by the end of Year 1, in addition to the literature review (that will serve as my comprehensive exam), my dissertation proposal (the research plan) and my dissertation (the research plan, results, discussion, and conclusions). The literature review will describe the current state of science related to diabetes self management and methods for improving self-management with a focus on AA. The tools and their psychometric properties will be especially helpful to researchers who what to measure changes in diabetes self-management behaviors. Currently, I am unaware of an existing tool that measures patient understanding/perception of provider recommendations, patient implementation of recommendations, and methods used from solving problems related to diabetes management. Thus, the tool can be used for assessing needs and evaluating interventions related to patient/provider interactions and diabetes self management.