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The Impact of Diabetes on Low-income Diabetic Patients Between the Ages of 40 to 65

Student’s Name

Institutional of Affiliation

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Professor

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The Impact of Diabetes on Low-income Diabetic Patients Between the Ages of 40 to 65

Abstract

The project below will discuss the impact of diabetes on low-income diabetic patients between

the ages of 40 to 65 on how to properly manage their diabetes through various medical and

controlling lifestyle interventions (Arnold et al., 2016). According to the National Centre for

Biotechnology Information (2020), over 300 million people are victims of this infectious disease

on the globe. The patients are either characterized as type 1, 2 or have symptoms related to pre-

diabetes. The diagnosis of this disease is based on the glucose levels in blood. Among the basic

symptoms of diabetic individuals is fatigue, itchy skin and continuous urination (Gurka, Filipp,

& DeBoer, 2018). That probably justifies the definition of diabetes as, a condition that results

from continuous hyperglycemia that is caused by deficiency in insulin secretion or too much

resistance to the hormone or both. Therefore, that causes a rise in the blood glucose levels which

apart from causing other health effects could lead to eventual death of the victim.

However, studies have indicated that the disease is more prevalent among the rich for a variety

of reasons. First, the poor often have time to practice and their diets are not much comprehensive

as compared to the rich. According to psychiatric nursing the issue is well managed if it fully

follows the following procedures: orientation, identification, exploitation and resolution (Zong,

et al, 2018). The infection is multi-factorial and requires long-term interventions to avert future

issues because it alters both the physical and psychosocial features of a person. First of all, the

most significant intervention is providing education on its causes, signs, symptoms and its

management (Jung, et al., 2019). The research below applied bibliographic research as the main

method where reference was mainly based on PubMed in terms of management of the infection.
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The search applied key terms like, diabetes, education, management, medical interventions, and

low-income. The research conducted was covered from 2001-2020.

As per the results from the literature, provision of education on the management of the infection

among low-income earners in the society requires dynamic, holistic and proper transmission on

the patient centred framework since it not only promotes personal but also health care

management (Qin, Blanchette, & Yoon, 2020). However, there are other medical interventions

that are applied in the suppression of the impact of diabetes. The first one is the introduction of a

diet rich in L-Arginine which affects the production of insulin hormone. Besides, the

supplements also reduce depression and promote the various vascular function in a way that any

punitive signs and symptoms related to diabetes will completely diminish (Stokes, & Preston,

2017). Together with this intervention, the patients are advised to also apply oral hypoglycemic

and Metformin.

Therefore, the management of diabetes will also require a well-planned project management

framework. In this project, clinicians with professional knowledge in controlling the symptoms

of diabetes are the main participants. However, there are some particulars that will be required to

be filled to make the exercise confidential, legitimate and successful (Arguello, Mauldin, Goyal,

2020). The components include the following: a consent form, letter of intent and project

evaluation tools. After the project evaluation, all the findings will be collected, tabulated and

interpreted as required. In terms of the protection rights for the percipients who are diabetic

patients will undergo a confidentiality process to protect their privacy and personal information

from unauthorized access (Arnold, et al., 2016). The process will be effective by ensuring that

participation is voluntary and the participants sing a consent with well instituted guidelines that

would not affect the employment status of the doctors and nurses who will participate in the
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process. Consequently, the process of project evaluation cannot be ignored at all. All the

components, evaluations and documents used during the study are collected to determine the

effectiveness of the findings made from the study. The evaluation criteria will measure the

readability, reliability, accuracy and quality of the whole process (Witt, 2019). That will follow

the last process where a summary of the whole process is made to determine any missing

contents and then the information is forwarded to the content experts.

Introduction

Diabetes is a deadly disease that seriously affects millions of Americans. A 2017 study noted that

almost one-third of US adults over 65 have diabetes (Kalyani et al., 2017). The poor most often

have far less adequate diets than the wealthy and also engage in lifestyle practices at odds with

maintaining proper health; suffice it to say, those who number among America's poor are much

more likely to contract diabetes than those who are wealthy (Gaskin et al., 2014). The basic

nature of this issue is that we have millions of Americans dying from a disease that is almost

entirely preventable through proper health hygiene.

Over one-third of American adults over 65 fall prey to a malignant disease unnecessarily in their

declining years. Diabetes is commonly the product of sub-optimal dietary and lifestyle decisions

over many years (American Academy of Family Physicians, 2020). Decisions made in one's

younger years will often negatively impact one's life in his or her late 60s and beyond

(Tanokashira, et al., 2018). For those between the ages of 40 and 65 who are already diabetic,

certain health behaviors can enhance health outcomes later in life. The literature demonstrates

that there are research gaps within this particular cohort (Spurr, et al., 2019). Researchers have

not given much attention to whether or not there are specific anti-diabetic drugs, or particular

health and dietary practices, that might serve this age cohort better than other alternatives. On
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balance, it seems that early detection, a disciplined regimen, and strong nursing practice focusing

on developing honest interpersonal relationships can combine to allow people with diabetes in

this age cohort to manage their symptoms optimally.

Statement of Purpose

The purpose of this project is to provide an educational brochure for low-income diabetic

patients between the ages of 40 to 65 on how to properly manage their diabetes through

medication and lifestyle interventions. This template is implemented either in the homes of the

patients or in a long-term care setting.

Theoretical Framework and Nursing's Meta-Paradigms

Theoretical Framework: Peplau's Interpersonal Relations in Nursing

Hildegard Peplau's (2004) Interpersonal Relations in Nursing Theory is utilized as the theoretical

framework for the development of this project. A brief overview of the theory is presented and

discusses how the theory guides the project’s development. In addition, Peplau’s (2004)

theoretical definitions for nursing’s four metaparadigm concepts (nursing, health, person, and

environment) and the project author’s operational definition for nursing’s four metaparadigm

concepts are presented.

There are many components and propositions to be found within the theory noted above. The

theory encompasses the four meta-paradigm concepts of nurse, health, patient, and environment

(Peplau, 2004). The theory also encompasses four sequential phases as the patient proceeds from

ill health to good health: orientation, identification, exploitation, and resolution (Han, et al.,

2015). Orientation means the assessment period wherein the nurse gains an understanding of the

patient's health and circumstances; identification means the period wherein a nursing care plan is

developed for the patient; the exploitation phase is the period wherein the nurse takes action
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toward meeting the goals of the nursing care plan, and resolution is when the situation is

evaluated after some time. The nurse and patient ascertain if the problem has been resolved

(Peplau, 2004). The overarching aim of the theory is for nurses to engage in psychodynamic

practice whereby they identify their feelings and behavior, identify and empathize with patient

difficulties, and use progressive human relations to productively address challenges at every step

on the way to better health.

Interpersonal Relations in Nursing Theory: Its Consequential Place

Hildegard Peplau is regarded as an influential figure in the history of psychiatric nursing (Peplau,

2004). Her theory is perceived as essential in nursing because it expressly addresses the

correlation between patient experiences, chiefly with nursing staff, and their eventual health

outcomes (Hagerty et al., 2017). It is the pre-eminent theory for understanding the vital import of

interpersonal relations in optimal nursing care, as it explicitly reveals all of the key functions that

an effective nurse must fulfill, while also describing in detail the four critical stages that

encompass the process of intervention – orientation, identification, exploitation and resolution –

that lead to a final resolution of the issue at hand (Pieroth, et al., 2017). No other theory provides

a more detailed description of the various roles of the nurse or provides an equivalent

explanation of the stages required for healing.

Interpersonal Relations in Nursing Theory and Nursing’s Four Metaparadigm: Theoretical

and Conceptual Definitions

Specifically, in her Interpersonal Relations in Nursing Theory, Peplau (2004) defines nursing’s

four metaparadigm concepts (nurse, health, patient, and environment) in the following way. “The

nurse is described as initially a stranger to the patient, then a teacher, a resource person providing

information and insight, a counselor, a surrogate, and a leader” (Petiprin, 2020, para.9).
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Operationally, the nurse assumes all of these features and is also the person who steers the

patient onward to a better and more assertive and independent state of being (Petiprin, 2020,

para.9).

Peplau (2004) also conceptualizes health in a theoretical fashion as physical and mental

well-being, with the absence of illness; health in an operational sense is best described as “the

inertia of the personality and other human ‘processes’ toward constructive, personal, creative and

productive living” (Petiprin, 2020, para.2). According to Peplau’s theory, a person may be

perceived as “a sentient being with capacities and, both actively and passively, addresses or

mitigates wants or needs” (Peplau, 2004, 765). Operationally, we may also define a person as an

organism that constantly adapts to stimuli, seeking to reduce anxiety by addressing their basic

needs (Petiprin, 2020, para.2). The theoretic definition of environment can be described as “that

which envelops and surrounds the individual, providing stimulus and feedback in one form or

another” (Peplau, 2004). Another way to describe the environment in operational terms is “the

assemblage of forces outside the person which work upon the individual and, implicitly, upon his

or her well-being;” it may also be described as the culture that envelops the patient (Petripin,

2020, para.2; Peplau, 2004).

For this study, “the nurse is defined as an individual who takes on the roles of technical

expert, tutor, consultant, environment manager, administrator, observer, mediator, and researcher

for the patient’ (Petiprin, 2020, para.9); they will serve as a counselor and guide and will provide

much-needed information for the diabetic patient. Health, in the context of this project, will

mean spiritual and psychological well-being and optimism, as well as a movement toward

physical well-being (or, at a minimum, the maintenance of a current condition). The environment

is all of the stimuli that provide input and feedback to the patient to produce a response from the
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patient; a strong support system will inspire positive activities and practices, while a weak

support system will discourage such efforts.

Initial Review of the Literature

Besides, to produce an educational brochure, a review of the nursing and health-related literature

must first be carried out to explore optimal management of diabetes for those individuals aged 40

to 65 via medication and appropriate lifestyle changes. Certain keywords that were prominent,

and that will require further exploration include diabetics patients, low-income, lifestyle,

diabetes, middle-aged, diet, medicine, nursing, regimens. The chief databases to be reviewed are

CINAHL Plus with Full Text, EBSCO, AMED, and Atl Health Watch. The search has been

limited to 2015 to 2021 to ensure that only contemporary evidence-based practice is being

reviewed and synthesized for this project. A summary of the literature review is presented below.

Prevalence of Diabetes among Middle-Aged Individuals age 40-65 years old.

Among American adults, obesity and incipient diabetes are most common among Americans in

the West North Central, West South Central, and East South Central regions, with lower

prevalence found in the Pacific, New England, and Mid-Atlantic divisions (Gurka et al., 2018).

There are also significant differences in rates among white females, with non-Hispanic white

females having a high prevalence in the Midwest and South and lower prevalence in the West

and Northeast (Gurka et al., 2018). As noted previously, one-third of American adults will likely

acquire diabetes by 65 or shortly after (Kalyani et al., 2017). Middle-aged Americans are

increasingly at risk for diabetes as obesity rates are climbing steadily in America, and the odds of

having diabetes have climbed by a rate of 2.6% per year in the years between 1988 and 2014

(Stokes & Preston, 2017). In minority populations in Canada, most notably aboriginal populaces,

pre-diabetic obesity is a serious problem among young people under 18 and speaks to poor
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lifestyle and dietary choices (Spurr et al., 2017) that signify serious issues that will come to light

as these individuals grow older. Beyond that, diabetes and associated comorbidities have become

increasingly prevalent in the past two decades among Hispanic women and non-Hispanic white

males (Coxe et al., 2018).

Impact of Diabetes on Low/Middle Income Groups

Poor diagnosis contributes to the higher rates of cases related to diabetes among the low- or

middle-income groups. According to Fritz (2017), these groups face economic challenges to

acquire the requisite self-management and medical intervention care in the management of their

diabetic conditions essentially because of the developed private health care system. The burden

of diabetes has risen to levels that surpass the other infectious diseases. Apart from insufficient

finance, the low-income crowds face lack of education leading to unawares, problems in

accessing the health care facilities and eventually failing to control or prevent the acute

conditions related to diabetes (Akgoz, & Gozum, 2020). The low-quality care and level of

education offered to them is because they cannot afford to finance their health insurance.

The small number who bypass the economic conditions faced opt for low-income facilities. In

this case, they end up visiting several health care facilities and that hinders consistence and

comprehensiveness in the health care services offered to them. Therefore, this project offers an

insight into how efficient prevention of diabetes and proper management models can reduce the

ever-rising number of diabetic conditions (Gurka, Filipp, & DeBoer, 2018). That is only possible

if there is firsthand access to quality health care services, improvising training methods offered

to clinicians and involving the society when formulating policies that relate to the management

of dangerous diseases. Consequently, those policies should also reflect a global outlook in some

ways. For example, organizations, health professionals and other institutions are required to
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develop programmes and other models that are particularly for the low-income groups in the care

of diabetic conditions.

Diabetic Risk Factors

There are obvious risk factors, such as obesity, that spark diabetes. Still, one under-appreciated

factor is the lack of a strong support team to steer individuals toward better health decisions

(Zong et al., 2018). Therefore, to elaborate upon this point, while also calling attention to the

significance of the nurse's role, there is some empirical evidence that nurse-based Tele-coaching

can ameliorate glycemic control and systolic blood pressure among adult individuals struggling

with Type 2 Diabetes Mellitus (Chen et al., 2019). Thus, insistent and reliable support is vital to

a successful outcome. As well, it is significant to understand that persistent organic pollutants

(POPS) are key in predisposing middle-aged individuals, especially women, to diabetes,

diabetogenic predisposition being very much linked to a history of poor eating habits and a

propensity for long-term prior weight gain

Related to the above problem is the absence of a realistic weight loss program among

many (most) American adults, which is worsened by the absence of outside or extrinsic support

(Fruh, 2017). Nurses can aid in helping patients through difficult circumstances by establishing

realistic weight-loss targets, providing motivation to struggling patients or subjects, and creating

a customizable weight-loss program appropriate for the specifics of the individual in question

Coxe, Lennertz, & Martine, 2018). Finally, as poor dietary habits and lifestyle choices begin

early in life, long before middle-age, researchers state that lipoprotein density in youth is closely

associated with later risk for diabetes and heart issues (Jung et al., 2019). Those at risk must

begin intensive exercises and weight management programs as early as possible, as waiting until

adulthood to change course may prove to be too late.

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Interventions to Improve Physical Activity

In this case, to combat diabetes, it is necessary to combat obesity, a high body mass index, and

sedentary tendencies. Nurses who wish to achieve success in guiding patients down a better path

must establish strong psychosocial support. There is abundant evidence that diabetes self-

management through robust physical activity is very much expedited or frustrated – by the

degree of social support individuals receive to mitigate (Lee et al., 2017). Although essentially

focused upon cardiovascular health, one recent study holds that nurse-led physical activity

sessions, including those as rudimentary as walking outdoors, can lead to significant health gains

for at-risk, middle-aged adults (Akgoz & Gozum, 2020). Another empirical study that focused on

Korean-Americans concludes that daily consumption of vegetables and daytime physical activity

is imperative in combating diabetes onset among Korean-Americans. They are middle-aged and

older (Han et al., 2015). While there are no surprises in the sources above, patients must be

exposed to nursing professionals who are enthusiastic about physical activity, capable of

engaging reluctant patients, modeling physical activity, and empowering the patient to have a say

in his or her regimen (Arnold et al., 2016). Effective and conscientious nurses, who are strong at

motivating others, can make a substantial difference in their patients’ lives

Interventions to Improve Diet

Concerning diet, there is empirical support for the conclusion that middle-aged men benefit

greatly from strong social support in terms of the quality of their dietary intake (Pieroth et al.,

2017). Intervening to aid in enhancing personal diet means modeling what a proper diet should

be and encouraging self-reliance within the patient since this is crucial to improve the self-

management of diabetes (Qin et al., 2020; Witt, 2019). At a minimum, it seems that patients will

benefit tremendously from a medically regulated diet program, as regular oversight and a
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disciplined diet can result in bringing HbA1c levels into the normal range (Arguello et al., 2020).

One strategy for individuals who have developed poor health habits is a combination of

systematic regulation and constant feedback. The research demonstrates that we can assist

diabetic individuals to better manage their risk of health complications by providing support,

especially regarding diet and lifestyle (Monti, et al, 2017). Therefore, we can reduce obesity and

chronic conditions associated with obesity to manage their disease and its complications better.

Nurse modeling, surrogacy, and counseling support can allow individuals to steer a better course

(Paul & Fitzpatrick, 2020). Additionally, nurses should be well-versed in dietary considerations

for those who might be described as eclectic diabetic sufferers – such as American women who

have gestational diabetes.

Well-Regarded Medication Interventions

There is evidence that supplementation of an individual's diet with L-Arginine can positively

impact insulin secretion, insulin sensitivity, oxidative stress, and vascular function to such an

extent as to significantly diminish diabetic symptoms or even render a subject diabetes-free

(Monti et al., 2017). Furthermore, it is emphasized that adherence to a regular oral hypoglycemic

medication regimen will effectively control diabetes symptoms (Fernandez et al., 2017). The

emphasis upon consistent ingestion of the aforementioned oral agents is also found in other

researches (Cho & Park, 2017). Some researchers suggest that Metformin treatment can

effectively combat the diabetes-associated decline in hippocampal neurogenesis, though this is

yet unproven and should be further explored (Tanokashira et al., 2018).

If pharmaceutical coverage is available, lower-income middle-aged individuals may find the

following helpful in the management of their diabetes: 1) Peroxisome Proliferator-Activated

Receptor (PPAR) agonist; Protein Tyrosine Phosphatase 1B inhibitors; Aldose Reductase

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Inhibitors; a-glucosidase inhibitors; Dipeptidyl Peptidase IV (DPP-4) inhibitors; G Protein-

Coupled Receptor Agonists; and Sodium-Glucose Co-Transporter Inhibitors (Dowarah & Singh,

2017). These appear to have a strong record of successfully combating the disease (Kalyani,

Golden, & Cefalu, 2001). For middle-aged men, there is also the possibility that anti-diabetic

drugs, such as Metformin, might reduce the prospects of contracting prostate cancer: researchers

have found that there is an inverse relationship between Type II Diabetes Mellitus severity and

the risk of prostate cancer; common-place anti-diabetic drugs, including Metformin,

Sulfonylurea, and Insulin, can reduce or mitigate the severity of diabetes (Haggstrom et al.,

2016).

Significance and Justification

Findings from the literature review revealed a lack of knowledge in nursing and patient care

practice regarding the proper maintenance of diabetes for those sufferers who are middle-aged.

The key reason why this project is being developed is that many millions of Americans are being

diagnosed with diabetes, with many of these people in their early, intermediate or late middle-

age years. It would be beneficial for these patients to have guidance to mitigate the harmful

effect of their diabetes among this growing population (Haggstrom et al., 2016).

Through a careful study of the pharmacological agents which must be used, the proper diet

which is supposed to apply, and the proper exercise regimen which requires institution, a great

many advances can be made that will keep such men and women alive for much longer, as well

as permitting them to enjoy a higher standard of life.

Project Objectives

The objectives of this project are to:

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1. Conduct an extensive review of the literature exploring the management of diabetes

through medication and lifestyle changes using the following keywords both singularly

and in multiple combinations: “diabetes”; “middle-aged”; “diet”; “exercise,”; “regimen.”

The databases searched, limited to the years 2015 to 2021, will include AMED, Alt

Health Watch, CINAHL Plus with Full Text, and EBSCO Host;

2. A booklet will be developed, potentially with an accompanying brochure and PowerPoint

presentation.

Definition of Terms

The following concepts are defined theoretically and operationally for this project: diabetes,

health promotion behaviors, nutrition, and physical activities.

Diabetes is defined as one of the metabolic diseases comprised of persistent hyperglycemia

caused by the inability of the pancreas to produce adequate insulin, increased resistance to

insulin, or a combination of both conditions (Arguello et al., 2020). Operationally, we can define

diabetes as a disease affecting individuals aged 40 to 65 who cannot maintain a normal range of

blood glucose levels without medication or lifestyle changes.

Health promotion is “the process of enabling people to increase control over, and to improve,

their health.” (Karlsson et al., 2020, p. 53) Health promotion behavior is operationally defined as

behavior that increases an individual’s health markers, especially those related to diabetes, such

as blood glucose indicators like HgA1c.

Nutrition is theoretically defined as the numerous chemical and physiological activities that

convert food components into the body’s elements (Pieroth et al., 2017). Nutrition for this

project is defined as the healthful food intake that an individual diagnosed with diabetes

selectively consumes to maintain blood sugar within normal limits.

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Theoretically, physical activities are defined as bodily exertion to develop and maintain physical

fitness (Fruh, 2017). Operationally, physical activities are defined as any activities that patients

participate in to reduce insulin resistance and increase glucose metabolism.

Limitations

The Project Author recognizes the following project limitations:

1. One of the main issues with the project is that it is written in the native language which is

hard for the foreigners to understand. In case, it is used in teaching, then necessary

translation is required from the native language to their specific linguistic groups.

2. The project is relevant to the North American population and requires an expanded (outside

of North America) literature search to benefit a broader audience.

3. The implementation of this education is not within the context of this project. 

Project Development Plan

A detailed topical outline of the brochure content regarding diabetic management created based

on the extensive review of evidence-based literature and the theoretical framework used in the

development of the brochure. After permission is granted from the D’Youville College Patricia

H. Garman School of Nursing, graduate faculty designee (Appendix A), five professionals with

knowledge and expertise in the management of diabetic patients will be asked if they are

interested in voluntarily participating as an expert content reviewer of the brochure. The content

expert panel will consist of one nurse educator, one family nurse practitioner, one registered

nurse, one dietitian, and one physician (Paul, & Fitzpatrick, 2020). If interested, the Project

Author will mail a packet containing a Letter of Intent (Appendix B), a copy of the Content

Expert Project Evaluation Tool created by the Project Author specifically for the project

(Appendix C), a copy of the brochure (Appendix D), and a self-addressed stamped envelope. The
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Letter of Intent will explain the project purpose and instructions for completing and returning the

Content Expert Project Evaluation Tool to the Project Author. The Content Expert Project

Evaluation Tool contains six evaluative items with space for narrative comments and suggestions

(Hagerty, et al., 2017). Approximately 20 minutes will be required to review the brochure and

was complete the Content Expert Project Evaluation Tool. Content experts will receive a self-

addressed envelope to return the Content Expert Project Evaluation Tool to the Project Author

(Fernandez, et al, 2017). Once all evaluation tools are returned to the Project Author, data will be

analyzed and reported narratively and in bar graph format. A summary of the evaluation results,

including the findings of the six evaluative items in the expert project evaluation tool, will be

provided to the content expert reviewers by postal mail.

Plan for the Protection of Human Subjects

Following approval from the D’Youville College Patricia H. Garman School of Nursing,

graduate faculty designee (Appendix A), five professionals with knowledge and expertise in the

field of diabetic management will be personally approached and asked to voluntarily participate

as a content expert in the review and evaluation of the brochure (Appendix D). The professionals

will advise the Content experts that participation or non-participation as expert reviewers will not

affect their employment status (Gurka, Filipp, & DeBoer, 2018).The Project Author has a

collegial, professional, and non-supervisory relationship with the content expert reviewers,

thereby protecting the participants from any risk of coercion. Content experts will be guaranteed

confidentiality since identifying characteristics will not be collected on the Content Expert

Project Evaluation Tool and because their names will not be revealed anywhere in the project

manuscript or required project presentations (Fruh, 2017). Only the Project Author will know the

names of the content expert reviewers. Return of the completed content expert Project Evaluation
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Tool (Appendix C) will indicate implied voluntary consent to participate as a content expert

reviewer. Content experts will receive advice that they will not withdraw from project

participation once the project evaluation tool is returned to the Project Author because the

evaluation tool should return without identifying information. Returned Content Expert Project

Evaluation Tools will be stored according to the D’Youville College Patricia H. Garman School

of Nursing protocol in a locked drawer located in the Project Author’s home office for six years

and then destroyed.

Plan for Project Evaluation

After obtaining full approval from the D’Youville College Patricia H. Garman School of Nursing

(Appendix A), the Project Author will mail a packet to each content expert reviewer containing

one Letter of Intent (Appendix B), one copy of the Content Expert Project Evaluation Tool

(Appendix C), one copy one the brochure (Appendix D), and one self-addressed stamped

envelope. The Content Expert Project Evaluation Tool will consist of six evaluative items scored

on a four-point Likert Scale that ranged from (1) Strongly Disagree. (2) Disagree, (3) Agree, and

(4) Strongly Agree. Space is then provided for narrative comments and suggestions following

each evaluative item. Evaluative items will ask reviewers to rate the brochure on clarity,

readability, applicability, quality, organization, and evidenced-based clinical relevance.

Approximately 20 minutes are required to review the brochure and complete the Content Expert

Project Evaluation Tool: Content experts will be given 14 days to complete and return the

Content Expert Project Evaluation Tool to the Project Author via postal mail using the self-

addressed stamped envelope in the original packet. Likert scale responses will be presented

narratively and displayed in both tabular and bar graph format. Content expert suggestions and

comments will be analyzed for common themes and presented narratively. A summary of the
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evaluation results, including the findings of the six evaluative items in the content project

evaluation tool, will be provided to the content expert reviewers by postal mail.

Summary

Chapter I presented the project introduction, statement of purpose, an overview of the theoretical

framework guiding project development, an initial review of the literature that focuses on

improving health outcomes for low-income diabetic patients age 40 to 65 by educating them on

both pharmacological and lifestyle interventions, the project significance and justification,

project objectives, definition of terms, project limitations, the project development plan, the

protection of human subjects, the plan for project evaluation, and a chapter summary. Chapter II

will provide a more extensive review of the literature focusing on the management of diabetes in

low-income patients, as well as a chapter summary. Chapter III will discuss the intended project

setting and population, the content expert participants, data collection methods, project tools, the

protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of

the project, implications for future advanced nursing practice, recommendations for future

projects and research, and a chapter summary.

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References

Akgoz, A.D., & Gozum, S. (2020). 'Effectiveness of a nurse-led physical activity intervention to

decrease cardiovascular disease risk in middle-aged adults: a pilot randomized controlled

study.’ Journal of Vascular Nursing, vol.38, no.3, pp.140-148.

American Academy of Family Physicians. (2020). 'Diabetes'. Retrieved September 20, 2020,

from

https://familydoctor.org/condition/diabetes/#:~:text=A%20diet%20high%20in

%20fat,diabetes)%20and%20other%20health%20problems.

Arguello, L.E., Mauldin, K., Goyal, D. (2020). 'Patients with pre-diabetes or Type 2 diabetes

mellitus in a medically supervised diet program.' The Journal for Nurse Practitioners,

vol.16, no.8, pp.612-616.

Arnold, P., Scheurer, D., Dake, A.W., Hedgpeth, A., Hutto, A., & Colquitt, C. (2016). 'Hospital

guidelines for diabetes management and the Joint Commission-American Diabetes

Association inpatient diabetes certification.' The American Journal of the Medical

Sciences, vol.351, no.4, pp.333-341.

Chen, D.Y.M., Wu, X.V., Chan, E.E., & Goh, Y.S. (2019). 'Nurse-led Tour-pointed-coaching on

modifiable cardiovascular risk factors in people with Type 2 Diabetes Mellitus: a

systematic review and meta-analysis.' Worldviews on Evidence-Based Nursing, vol.16,

no.6, pp.424-432.

Cho S, Jang H, Park K (2017) Trends in the management levels of metabolic risk factors in

middle-aged and elderly patients with type 2 diabetes mellitus: The Korean National

Health and Nutrition Examination Survey 1998–2014. PLoS ONE 12(12): e0189361.

https://doi.org/10.1371/journal.pone.0189361
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Coxe, L.M., Lennertz, K., & Martine, R.R. (2018). 'Challenges of increased diabetes prevalence:

implications of cardio and renal comorbidities for Hispanic and white middle-aged

nursing home residents'. Journal of Health & Human Services Administration, vol.40,

no.4, pp.433-461.

Dowarah, J., & Singh, V.P. (2017). 'Anti-diabetic drugs recent approaches and advancements.’

Bio-organic & Medicinal Chemistry, vol.28, no.5. Retrieved September 12, 2020, from

https://www.sciencedirect.com/science/article/abs/pii/S0968089619315081

Fernandez, A., Quan, J., Moffet,H., Parker, M.M., Schillinger, D., et al. (2017).'Adherence to

newly prescribed diabetes medications among insured Latino and white patient with diabetes'.

JAMA Internal Medicine, vol.177, no.3, pp.371-379.

Fritz, H. A. (2017). Challenges to developing diabetes self‐management skills in a low‐income

sample in North Carolina, USA. Health & social care in the community, 25(1), 26-34.

Fruh, S.M. (2017). 'Obesity: risk factors, complications, and strategies for sustainable long-term

weight management.' Journal of the American Association of Nurse Practitioners, vol.29,

no.S1, pp.S3-S14.

Gaskin, D.J., Thorpe, Jr., R.J., McGinty, E.E., Bower, K., Rohde, C., Young, J.H., LaViest, T.A.,

& Dubay, L. (2014). 'Disparities in Diabetes: the nexus of race, poverty and place.’

American Journal of Public Health, vol.104, no.11, pp.2147-2155.

Gurka, M.J., Filipp, S.L., & DeBoer, M.D.(2018). 'Geographical variation in the prevalence of

obesity, metabolic syndrome, and diabetes among US adults.’ Nutr & Diabetes 8, 14

(2018).

https://doi.org/10.1038/s41387-018-0024-2

Hagerty, T.A., Samuels, W., Norcini-Pala, A., & Gigliotti, E. (2017). 'Peplau's theory of
 21

Interpersonal Relations: an alternate factor structure for patient experience data?' Nursing

Science Quarterly, vol.30, no.2, pp.160-167.

Haggstrom, C., Van Hemlerijck, M., Zethelius, B., Robinson, D., Grundmark, B., Holmberg, L.,

et al. (2016). 'Prospective study of Type 2 Diabetes Mellitus, anti-diabetic drugs and risk

of prostate cancer'. International Journal of Cancer, vol.140, no.3, pp.611-617.

Han, B.H., Sadarangami, T., Wyatt, L.C., Zanowiak, J.M., Kwon, S.C., Trinh-Chevron, C., et al.

(2015). 'Correlates of physical activity among middle-aged and older Korean Americans

at risk for Diabetes.’ Journal of Nursing Scholarship, vol.48, no.1, pp.48-57.

Jung, L., Courts, E., Webber, P., & Zhou, Q.P. (2019). 'Effectiveness of early identification and

electronic interventions for teens with risk factors for developing heart disease

and diabetes.’ Journal of the American Association of Nurse Practitioners, vol.31,

no.1, pp.17-23.

Kalyani, R.R., Golden, S.H., & Cefalu, W.T. (2001). 'Diabetes and aging: unique

considerations and goals of care.’ Diabetes Care, vol.40, no.4, pp.440-443.

Karlsson, S., Ridbäck, A., Brobeck, E., & Norell Pejner, M. (2020). Health Promotion Practices

in Nursing for Elderly Persons in Municipal Home Care: An Integrative Literature

Review. Home Health Care Management & Practice, 32(1), 53-61.

Lee, L.T., Bowen, P.G., Mosley. M.K., & Turner, C.C. (2017). 'Theory of planned behavior:

social support and diabetes self-management. The Journal for Nurse Practitioners,

vol.13, no.4, pp.365-270.

Monti, L.D., Galluccio, E., Fontana, B., Spadoni, S., & Piatti, P.M. (2017). 'Decreased diabetes

risk over nine years after 18-month oral l-arginine treatment in middle-aged subjects with

impaired glucose tolerance and metabolic syndrome (extension evaluation of l-arginine

 22

study).' European Journal of Nutrition, vol.57, pp.2805-2817.

Paul, J.C., & Fitzpatrick. J.J. (2020). 'Postpartum glucose screening among women with

gestational diabetes.’ Applied Nursing Research, vol.56. Retrieved September 22, 2020,

from https://www.sciencedirect.com/science/article/pii/S0897189720306698

Peplau, H. E. (2004). Interpersonal Relations in Nursing. AJN, American Journal of Nursing,

52(6), 765. https://doi.org/10.1097/00000446-195206000-00062

Pieroth, R., Rigassio Radler, D., Guenther, P.M., Brewster, P.J., & Marcus, A. (2017). 'The

relationship between social support and diet quality in Middle-Aged and older adults in

the United States. Journal of the Academy of Nutrition and Dietetics, vol.117, no.8,

pp.1272-1278.

Qin, W., Blanchette, J.E., & Yoon, M. (2020). 'Self-efficacy and diabetes self-management in

middle-aged and older adults in the United States: a systematic review.’ Diabetes

Spectrum. https://doi.org/10.2337/ds19-0051

Spurr, S., Bally, J., Bullin, C., & Trinder, K. (2019). 'Type 2 diabetes in Canadian aboriginal

adolescents: risk factors and prevalence. Journal of Pediatric Nursing, vol.36, pp.111

-117.

Stokes, A., & Preston. S.H. (2017). 'The contribution of rising adiposity to the increasing

prevalence of diabetes in the United States.’ Preventive Medicine, vol.101, pp.91-95.

Tanokashira, D., Kurata, E., Fukuokaya, W., Kawabe, K., Kashiwada, M., Takeuchi, H., et al.

(2018). 'Metformin treatment ameliorates diabetes-associated decline in hippocamal

neurogenesis and memory via phosphorylation of insulin receptor substrate 1'. Retrieved

September 20, 2020, from

https://febs.onlinelibrary.wiley.com/doi/epdf/10.1002/2211-5463.12436
 23

Witt, L. (2019). 'The relationships among school nurse to student ratios, self-efficacy, and

glycemic control in adolescents with Type 1 diabetes. The Journal of School Nursing.

Retrieved September 21, 2020, from

https://journals.sagepub.com/doi/abs/10.1177/1059840519870314

Zong, G., Valvi, D., Coull, B., Goen, T., Hu, F.B., Nielsen, F., & Grandjean, P., et al. (2018).

'Persistent organic pollutants and risk of Type 2 Diabetes: a prospective investigation

among middle-aged women in Nurses' Health Study II'. Environment International,

vol.114, pp.334-342.