Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: a systematic and narrative review of randomized controlled trials

Time to question diabetes self-management support for Arabic-speaking migrants: exploring a new model of care

AIM

The objective of this study was to explore a new model for diabetes self-management support in Arabic-speaking migrants.

METHODS

Two qualitative methods were used: face-to-face semi-structured individual interviews and focus groups. Interviews were audio-taped, transcribed verbatim and coded thematically. Arabic-speaking migrants with Type 2 diabetes were recruited from several primary, secondary and tertiary healthcare settings in metropolitan Melbourne, Australia. These settings were purposefully selected to obtain a diverse group of participants. Data collection continued until saturation was reached. This is the first study that involved members of Arabic-speaking communities in Australia in a formal process of consumer and public involvement to inform research design and recruitment in order to provide evidence for a new model of diabetes self-management for Arabic-speaking migrants.

RESULTS

No self-management support was offered to Arabic-speaking migrants beyond the initial diagnosis period. Significant knowledge gaps and skills deficits in all self-management domains were evident. The provision of tailored self-management support was considered crucial. When asked about preferred structure and delivery modalities, a strong preference was reported for face-to-face storytelling interactions over telephone- or internet-based interventions. Gender-specific group education and self-management support sessions delivered by Arabic-speaking diabetes health professionals, lay peers or social workers trained in diabetes self-management were highly regarded.

CONCLUSIONS

A patient and public involvement approach allows genuine engagement with Arabic-speaking migrants with diabetes. There is urgent need for a new model for self-management support among Arabic-speaking migrants. Findings yielded new recommendations for diabetes health professionals working with these migrant communities to support behaviour change.

Cultural adaptations to augment health and mental health services: a systematic review

BACKGROUND

Membership in diverse racial, ethnic, and cultural groups is often associated with inequitable health and mental health outcomes for diverse populations. Yet, little is known about how cultural adaptations of standard services affect health and mental health outcomes for service recipients. This systematic review identified extant themes in the research regarding cultural adaptations across a broad range of health and mental health services and synthesized the most rigorous experimental research available to isolate and evaluate potential efficacy gains of cultural adaptations to service delivery.

METHODS

MEDLINE, PsycINFO, CINAHL, EMBASE, and grey literature sources were searched for English-language studies published between January 1955 and January 2015. Cultural adaptations to any aspect of a service delivery were considered. Outcomes of interest included changes in service provider behavior or changes in the behavioral, medical, or self-reported experience of recipients.

RESULTS

Thirty-one studies met the inclusion criteria. The most frequently tested adaptation occurred in preventive services and consisted of modifying the content of materials or services delivered. None of the included studies focused on making changes in the provider's behavior. Many different populations were studied but most research was concerned with the experiences and outcomes of African Americans. Seventeen of the 31 retained studies observed at least one significant effect in favor of a culturally adapted service. However there were also findings that favored the control group or showed no difference. Researchers did not find consistent evidence supporting implementation of any specific type of adaptation nor increased efficacy with any particular cultural group.

CONCLUSIONS

Conceptual frameworks to classify cultural adaptations and their resultant health/mental health outcomes were developed and applied in a variety of ways. This review synthesizes the most rigorous research in the field and identifies implications for policy, practice, and research, including individualization, cost considerations, and patient or client satisfaction, among others.

Formative evaluation on cultural tailoring breathing awareness meditation smartphone apps to reduce stress and blood pressure

BACKGROUND

Chronic stress is an independent risk factor for essential hypertension (EH), cardiovascular disease (CVD), and is sometimes confronted by mal-adaptive coping behaviors (e.g., stress eating, excessive alcohol consumption, etc.). Pre-essential hypertension (preEH) is the leading predictor of future EH status. Breathing awareness meditation (BAM) can result in clinically beneficial blood pressure (BP) reductions, though face-to-face sessions presents barriers to reach those in need. The purpose of this study was to identify if a culturally tailored approach is needed in the design and preferences between groups of preEH African American and White adults toward using a smartphone BAM app, the Tension Tamer (TT) app.

METHODS

TT includes audio delivered BAM instructions, real-time heart rate, feedback graphs and motivational reinforcement text messaging. Questionnaires and two focus groups each of African American and White adults, [n=34, mean age =43.1 years, (SD 13.8 years), 44.1% African American] were conducted to understand stress, EH knowledge, app usage along with feedback from a hands-on demonstration of TT. Grounded theory using NVivo 10 was used to develop themes and combined with the questionnaires in the analysis.

RESULTS

No racial differences were found in the analysis including app use scenarios, preferences, knowledge, technology use or the attitudes and acceptance toward mobile health (mHealth) programs. Reported stress was high for African Americans [PSS-4: mean 6.87 (SD 3.3) versus mean 4.56 (SD 2.6); P=0.03]. Four main themes were found: (I) stress was pervasive; (II) coping strategies were both positive and negative; (III) BAM training was easy to incorporated; and (IV) tracking stress responses was useful. Responses suggest that additional personalization of app interfaces may drive ownership and adherence to protocols. Measures and reports of heart rate monitoring while in session were favorably viewed with low issues with confidentiality or trust issues on collected session data.

CONCLUSIONS

Results suggest that a culturally tailored approach may be unnecessary in the design of BAM apps. Further investigation is warranted for other racial groups, age ranges, and disease conditions.

Cultural Adaptation of Diabetes Self-Management Education for Marshallese Residing in the United States: Lessons Learned in Curriculum Development

BACKGROUND

Type 2 diabetes is a significant public health problem, with U.S. Pacific Islander communities bearing a disproportionate burden. The Marshallese are a Pacific Islander community that has significant inequities in diabetes, yet few evidence-based diabetes interventions have been developed to address this inequity.

OBJECTIVES

We used a community-based participatory research (CBPR) approach to adapt an evidence-based diabetes self-management education (DSME) intervention for the Marshallese.

METHODS

Our team used the Cultural Adaptation Process Model, in addition to an iterative process consisting of formative data and previous literature review, and engagement with community and academic experts.

LESSONS LEARNED

Specific cultural considerations were identified in adapting DSME components, including the dichotomous versus gradient conceptualization of ideas, the importance of engaging the entire family, the use of nature analogies, and the role of spirituality.

CONCLUSIONS

We identified key cultural considerations to incorporate into a diabetes self-management program for the Marshallese. The insights gained can inform others' work with Pacific Islanders.

Exploring culturally competent primary care diabetes services: a single-city survey

AIMS

To determine the cultural competence of diabetes services delivered to minority ethnic groups in a multicultural UK city with a diabetes prevalence of 4.3%.

METHODS

A semi-structured survey comprising 35 questions was carried out across all 66 general practices in Coventry between November 2011 and January 2012. Data were analysed using descriptive statistics. The cultural competence of diabetes services reported in the survey was assessed using a culturally competent assessment tool (CCAT).

RESULTS

Thirty-four general practices (52%) responded and six important findings emerged across those practices. (1) Ninety-four per cent of general practices reported the ethnicity of their populations. (2) One in three people with diabetes was from a minority ethnic group. (3) Nine (26.5%) practices reported a diabetes prevalence of between 55% and 96% in minority ethnic groups. (4) The cultural competences of diabetes services were assessed using CCAT; 56% of practices were found to be highly culturally competent and 26% were found to be moderately culturally competent. (5) Ten practices (29%) reported higher proportionate attendance at diabetes annual checks in the majority white British population compared with minority ethnic groups. (6) Cultural diversity in relation to language and strong cultural traditions around food were most commonly reported as barriers to culturally competent service delivery.

CONCLUSIONS

Seven of the eight cultural barriers identified in the global evidence were present in the city. Use of the CCAT to assess existing service provision and the good baseline recording of ethnicity provide a sound basis for commissioning culturally competent interventions in the future.

Improving management of type 2 diabetes in South Asian patients: a systematic review of intervention studies

OBJECTIVES

Optimal control of type 2 diabetes is challenging in many patient populations including in South Asian patients. We systematically reviewed studies on the effect of diabetes management interventions targeted at South Asian patients with type 2 diabetes on glycaemic control.

DESIGN

Systematic review of MEDLINE, EMBASE and CINAHL databases for randomised controlled trials (RCTs) and pre-post-test studies (January 1990 to February 2014). Studies were stratified by where interventions were conducted (South Asia vs Western countries).

PARTICIPANTS

Patients originating from Pakistan, Bangladesh or India with type 2 diabetes.

PRIMARY OUTCOME

Change in glycated haemoglobin (HbA1c). Secondary end points included change in blood pressure, lipid levels, anthropomorphics and knowledge.

RESULTS

23 studies (15 RCTs) met criteria for analysis with 7 from Western countries (n=2532) and 16 from South Asia (n=1081). Interventions in Western countries included translated diabetes education, additional clinical care, written materials, visual aids, and bilingual community-based peers and/or health professionals. Interventions conducted in South Asia included yoga, meditation or exercise, community-based peers, health professionals and dietary education (cooking exercises). Among RCTs in India (5 trials; n=390), 4 demonstrated significant reductions in HbA1c in the intervention group compared with usual care (yoga and exercise interventions). Among the 4 RCTs conducted in Europe (n=2161), only 1 study, an education intervention of 113 patients, reported a significant reduction in HbA1c with the intervention. Lipids, blood pressure and knowledge improved in both groups with studies from India more often reporting reductions in body mass index and waist circumference.

CONCLUSIONS

Overall, there was little improvement in HbA1c level in diabetes management interventions targeted at South Asians living in Europe compared with usual care, although other outcomes did improve. The smaller studies in India demonstrated significant improvements in glycaemic and other end points. Novel strategies are needed to improve glycaemic control in South Asians living outside of India.

Eliminating disparities among Latinos with type 2 diabetes: Effective eHealth strategies

Latinos are at increased risk for obesity and type 2 diabetes (T2D). Well-designed information technology (IT) interventions have been shown to be generally efficacious in improving diabetes self-management. However, there are very few published IT intervention studies focused on Latinos. With the documented close of the digital divide, Latinos stand to benefit from such advances. There are limited studies on how best to address the unique socio-cultural-linguistic characteristics that would optimize adoption, use and benefit among Latinos. Successful e-health programs involve frequent communication, bidirectionality including feedback, and multimodal delivery of the intervention. The use of community health workers (CHWs) has been shown consistently to improve T2D outcomes in Latinos. Incorporating CHWs into eHealth interventions is likely to address barriers with technology literacy and improve patient activation, satisfaction and adherence. Additionally, tailored interventions are more successful in improving patient activation. It is important to note that tailoring is more than linguistic translation; tailoring interventions to the Latino population will need to address educational, language, literacy and acculturation levels, along with unique illness beliefs and attitudes about T2D found among Latinos. Interventions will need to go beyond the lone participant and include shared decision making models that incorporate family members and friends.

Health Beliefs of Marshallese Regarding Type 2 Diabetes

OBJECTIVES

The Marshallese population suffers from disproportionate rates of type 2 diabetes. This study identifies the underlying beliefs and perceptions that affect diabetes self-management behavior in the US Marshallese population living in Arkansas.

METHODS

The study employs focus groups with a semi-structured interview guide developed using a community-based participatory research (CBPR) approach and the Health Belief Model. Data were collected from 41 participants; bilingual community co-investigators provided translation as needed.

RESULTS

The results show high-perceived threat, with most participants describing diabetes as inevitable and a death sentence. Participants are generally unaware of the benefits of diabetes self-management behaviors, and the Marshallese population faces significant policy, environmental, and systems barriers to diabetes self-management. The primary cue to action is a diagnosis of diabetes, and there are varying levels of self-efficacy.

CONCLUSIONS

The research grounded in the Health Belief Model provides important contributions that can help advance diabetes self-management efforts within Pacific Islander communities.

Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: an updated Cochrane Review of randomized controlled trials

AIMS

To give an updated perspective of interventions from additional data collected since our first review, conducted in 2008.

BACKGROUND

This updated Cochrane Review incorporates new information from recent randomized controlled trials on culturally appropriate diabetes health education interventions.

METHODS

An electronic literature search of six databases was repeated, with databases of ongoing trials checked and three journals hand-searched. Meta-analysis was carried out for sufficiently homogeneous outcomes, and common themes among trials were highlighted.

RESULTS

A total of 22 new trials were added to the original 11. Meta-analysis of 28 trials containing suitable data showed significant improvements in glycaemic control (HbA1c ) and diabetes knowledge over a period of 24 months, after the delivery of culturally appropriate education to participants, compared with those receiving 'conventional' care. There were no consistent benefits over the control group in other selected outcome measures, and lack of data continued to make analysis of several outcome measures difficult.

CONCLUSIONS

Research activity in this field has increased considerably over the past 6 years, with culturally appropriate diabetes education showing consistent benefits over conventional care in terms of glycaemic control and diabetes knowledge, sustained in the short- to mid-term. Further research is needed to determine the clinical significance of these improvements and their cost-effectiveness.

Medicine-taking experiences and associated factors: comparison between Arabic-speaking and Caucasian English-speaking patients with Type 2 diabetes

AIM

The aim of this study was to explore and compare medication-taking experiences and associated issues in Arabic-speaking and Caucasian English-speaking patients with Type 2 diabetes in Australia.

METHODS

Various healthcare settings in metropolitan Melbourne, Australia, were purposefully selected to obtain a diverse group of participants with Type 2 diabetes. Recruitment occurred at diabetes outpatient clinics in two tertiary referral hospitals, six primary care practices and ten community centres. Face-to-face semi-structured individual interviews and group interviews were employed. All interviews were audiotaped, transcribed and coded thematically. Data collection continued until saturation was reached.

RESULTS

In total, 100 participants were recruited into two groups: 60 were Arabic-speaking and 40 were Caucasian English-speaking. Both groups had similar demographic and clinical characteristics. Only 5% of the Arabic-speaking participants had well-controlled diabetes compared with 17.5% of the participants in the English-speaking group. Arabic-speaking participants actively changed medication regimens on their own without informing their healthcare professionals. Arabic-speaking patients had more knowledge gaps about their prescribed treatments, compared with the English-speaking group. Their use of diabetes medicines was heavily influenced by peers with diabetes and family members; conversely, they feared revealing their diagnosis within the wider Arabic community due to stigma and collective negative social labelling of diabetes. Confidence in non-Arabic-speaking healthcare providers was lacking.

CONCLUSIONS

Findings yielded new insights into medication-taking practices and associated factors in Arabic-speaking patients with diabetes. It is vital that healthcare professionals working with Arabic-speaking patients adapt their treatment approaches to accommodate different beliefs and views about medicines.

Family Model of Diabetes Education With a Pacific Islander Community

PURPOSE

The purpose of the study was to use a community-based participatory research approach to pilot-test a family model of diabetes education conducted in participants' homes with extended family members.

METHODS

The pilot test included 6 families (27 participants) who took part in a family model of diabetes self-management education (DSME) using an intervention-driven pre- and posttest design with the aim of improving glycemic control as measured by A1C. Questionnaires and additional biometric data were also collected. Researchers systematically documented elements of feasibility using participant observations and research field reports.

RESULTS

More than three-fourths (78%) of participants were retained in the study. Posttest results indicated a 5% reduction in A1C across all participants and a 7% reduction among those with type 2 diabetes. Feasibility of an in-home model with extended family members was documented, along with observations and recommendations for further DSME adaptations related to blood glucose monitoring, physical activity, nutrition, and medication adherence.

CONCLUSIONS

The information gained from this pilot helps to bridge the gap between knowledge of an evidence-based intervention and its actual implementation within a unique minority population with especially high rates of type 2 diabetes and significant health disparities. Building on the emerging literature of family models of DSME, this study shows that the family model delivered in the home had high acceptance and that the intervention was more accessible for this hard-to-reach population.

Immigrant community leaders identify four dimensions of trust for culturally appropriate diabetes education and care

This paper explores immigrant community leaders' perspectives on culturally appropriate diabetes education and care. We conducted exploratory workshops followed by focus groups with Punjabi, Nepali, Somali, and Latin American immigrant communities in Ottawa, Ontario. We used the constant comparative method of grounded theory to explore issues of trust and its impact on access and effectiveness of care. Detailed inquiry revealed the cross cutting theme of trust at the "entry" level and in relation to "accuracy" of diabetes information, as well as the influence of trust on personal "privacy" and on the "uptake" of recommendations. These four dimensions of trust stood out among immigrant community leaders: entry level, accuracy level, privacy level, and intervention level and were considered important attributes of culturally appropriate diabetes education and care. These dimensions of trust may promote trust at the patient-practitioner level and also may help build trust in the health care system.

A systematic review of research into black and ethnic minority patients' views on self-management of type 2 diabetes

CONTEXT

Eliciting patients' views of type 2 diabetes self-management provides insights on how policy and services might better support the needs of this population.

OBJECTIVE

To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self-management of type 2 diabetes.

SEARCH STRATEGY

A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free-text terms. Two relevant journals were also hand searched.

INCLUSION CRITERIA

Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self-management.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis.

MAIN RESULTS

Fifty-seven studies were included, of qualitative (n = 54), mixed-method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: 'Importance of identity'; 'Being understood by others' and 'Making sense of condition', all linked conceptually under the overarching theme 'Sense of self'. The quality of the studies varied.

DISCUSSION AND CONCLUSIONS

The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self-management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient-centred care and policies.

Popular Glucose Tracking Apps and Use of mHealth by Latinos With Diabetes: Review

BACKGROUND

Diabetes mellitus in the United States is an increasingly common chronic disease, costing hundreds of billions of dollars and contributing to hundreds of thousands of deaths each year. The prevalence of diabetes is over 50% higher in Latinos than in the general population, and this group also suffers from higher rates of complications and diabetes-related mortality than NHWs. mHealth is a promising new treatment modality for diabetes, though few smartphone apps have been designed specifically for Latinos.

OBJECTIVE

The objectives of our study were: (1) to identify the most common features of the most popular diabetes apps and consider how such features may be improved to meet the needs of Latinos; (2) to determine the use of diabetes apps among a sample of online Hispanics in the US.

METHODS

Our study consisted of two parts. First, 20 of the most popular diabetes apps were reviewed in order to ascertain the most prevalent features and functionalities. Second, an online survey was fielded through a popular health website for Latinos (HolaDoctor) inquiring about respondents' use of diabetes apps.

RESULTS

Approximately one-third of apps reviewed were available in Spanish. The most common features were blood glucose recording/annotation and activity logs. The majority of apps permitted exportation of data via e-mail but only a third enabled uploading to an online account. Twenty percent of apps reviewed could connect directly with a glucometer, and 30% had reminder functionalities prompting patients to take medications or check blood glucose levels. Over 1600 online surveys were completed during the second half of April 2014. More than 90% of respondents were from the United States, including Puerto Rico. The majority of respondents used a device running on an Android platform while only a quarter used an iPhone. Use of diabetes apps was approximately 3% among diabetic respondents and 3.6% among diabetic respondents who also had a smartphone. Among app users, blood glucose and medication diaries were the most frequently used functionalities while hemoglobin A1c and insulin diaries were the least used. A significant majority of app users did not share their progress on social media though many of these were willing to share it with their doctor.

CONCLUSIONS

Latino diabetics have unique needs and this should be reflected in diabetes apps designed for this population. Existing research as well as our survey results suggest that many Latinos do not possess the prerequisite diabetes knowledge or self-awareness to fully benefit from the most prevalent functionalities offered by the most popular diabetes apps. We recommend developers incorporate more basic features such as diabetes education, reminders to check blood glucose levels or take medications, Spanish language interfaces, and glucometer connectivities, which are relatively underrepresented in the most popular diabetes apps currently available in Spanish.

British-Pakistani women's perspectives of diabetes self-management: the role of identity

AIMS AND OBJECTIVES

To explore the effects of type 2 diabetes on British-Pakistani women's identity and its relationship with self-management.

BACKGROUND

Type 2 diabetes is more prevalent and has worse outcomes among some ethnic minority groups. This may be due to poorer self-management and an inadequate match of health services to patient needs. The influence that type 2 diabetes has on British-Pakistani women's identity and subsequent self-management has received limited attention.

DESIGN

An explorative qualitative study.

METHODS

Face-to-face semi-structured English and Urdu language interviews were conducted with a purposively selected heterogeneous sample of 15 British-Pakistani women with type 2 diabetes. Transcripts were analysed thematically.

RESULTS

Four themes emerged: Perceived change in self emphasised how British-Pakistani women underwent a conscious adaptation of identity following diagnosis; Familiarity with ill health reflected women's adjustment to their changed identity over time; Diagnosis improves social support enabled women to accept changes within themselves and Supporting family is a barrier to self-management demonstrated how family roles were an aspect of women's identities that was resilient to change. The over-arching theme Role re-alignment enables successful self-management encapsulated how self-management was a continuous process where achievements needed to be sustained. Inter-generational differences were also noted: first generation women talked about challenges associated with ageing and co-morbidities; second generation women talked about familial and work roles competing with self-management.

CONCLUSIONS

The complex nature of British-Pakistani women's self-identification requires consideration when planning and delivering healthcare.

RELEVANCE TO CLINICAL PRACTICE

Culturally competent practice should recognise how generational status influences self-identity and diabetes self-management in ethnically diverse women. Health professionals should remain mindful of effective self-management occurring alongside, and being influenced by, other aspects of life.

Socio-cultural influences on the behaviour of South Asian women with diabetes in pregnancy: qualitative study using a multi-level theoretical approach

BACKGROUND

Diabetes in pregnancy is common in South Asians, especially those from low-income backgrounds, and leads to short-term morbidity and longer-term metabolic programming in mother and offspring. We sought to understand the multiple influences on behaviour (hence risks to metabolic health) of South Asian mothers and their unborn child, theorise how these influences interact and build over time, and inform the design of culturally congruent, multi-level interventions.

METHODS

Our sample for this qualitative study was 45 women of Bangladeshi, Indian, Sri Lankan, or Pakistani origin aged 21-45 years with a history of diabetes in pregnancy, recruited from diabetes and antenatal services in two deprived London boroughs. Overall, 17 women shared their experiences of diabetes, pregnancy, and health services in group discussions and 28 women gave individual narrative interviews, facilitated by multilingual researchers, audiotaped, translated, and transcribed. Data were analysed using the constant comparative method, drawing on sociological and narrative theories.

RESULTS

Key storylines (over-arching narratives) recurred across all ethnic groups studied. Short-term storylines depicted the experience of diabetic pregnancy as stressful, difficult to control, and associated with negative symptoms, especially tiredness. Taking exercise and restricting diet often worsened these symptoms and conflicted with advice from relatives and peers. Many women believed that exercise in pregnancy would damage the fetus and drain the mother's strength, and that eating would be strength-giving for mother and fetus. These short-term storylines were nested within medium-term storylines about family life, especially the cultural, practical, and material constraints of the traditional South Asian wife and mother role and past experiences of illness and healthcare, and within longer-term storylines about genetic, cultural, and material heritage - including migration, acculturation, and family memories of food insecurity. While peer advice was familiar, meaningful, and morally resonant, health education advice from clinicians was usually unfamiliar and devoid of cultural meaning.

CONCLUSIONS

'Behaviour change' interventions aimed at preventing and managing diabetes in South Asian women before and during pregnancy are likely to be ineffective if delivered in a socio-cultural vacuum. Individual education should be supplemented with community-level interventions to address the socio-material constraints and cultural frames within which behavioural 'choices' are made.

Patient Experience in a Coordinated Care Model Featuring Diabetes Self-management Education Integrated Into the Patient-Centered Medical Home

Purpose

The purpose of this study is to gain insight about patient experience of diabetes self-management education in a patient-centered medical home.

Methods

Six focus groups consisting of 37 people with diabetes, diverse in race and ethnicity, were conducted at 3 sites. Participants described their experience in the program and their challenges in diabetes self-management; they also suggested services to meet their diabetes care needs.

Results

The most common theme was ongoing concerns about care and support. There was much discussion about the value of the support provided by health navigators integrated in the diabetes health care team. Frequent concerns expressed by participants centered on personal challenges in engaging in healthy lifestyle behaviors. Ongoing programmatic support of self-management goals was widely valued.

Conclusions

Individuals who received health care in a patient-centered medical home and could participate in diabetes self-management education with integrated support valued both activities. The qualitative results from this study suggest need for more formalized exploration of effective means to meet the ongoing support needs of people with diabetes.

Development of culturally sensitive dialog tools in diabetes education

Person-centeredness is a goal in diabetes education, and cultural influences are important to consider in this regard. This report describes the use of a design-based research approach to develop culturally sensitive dialog tools to support person-centered dietary education targeting Pakistani immigrants in Denmark with type 2 diabetes. The approach appears to be a promising method to develop dialog tools for patient education that are culturally sensitive, thereby increasing their acceptability among ethnic minority groups. The process also emphasizes the importance of adequate training and competencies in the application of dialog tools and of alignment between researchers and health care professionals with regards to the educational philosophy underlying their use.

Cross-sectional study of glycemic control among adults with type 2 diabetes

Type 2 diabetes mellitus is a chronic condition, a global concern, and a serious issue in Sri Lanka, where there is little data regarding the influence of dietary control, exercise, and adherence to medication behaviors among adults diabetes. In this cross-sectional, descriptive study, we identified current factors influencing glycemic control and glycemic control behavior among adults with diabetes. A total of 230 people attending diabetes clinics in a tertiary hospital and a primary care institute were administered the self-report Diabetes Information Form, assessing their socioeconomic and medical information and glycemic control behaviors. Data were analyzed by frequency distribution, percentages, mean scores, and standard deviation. The results indicated that most participants had not achieved the recommended fasting blood glucose level (< 126 mg/dL). Although dietary control was practised by 72%, regular exercise was not practised by 85%, and while 77% reported adhering to regular medication, they still had poor glycemic control. The findings highlight the need for health professionals to adopt new strategies for diabetes education to overcome issues related to misconceptions and barriers in providing diabetes care in Sri Lanka.

Health education via mobile text messaging for glycemic control in adults with type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Diabetes type 2 is an increasing problem worldwide that may be managed through education. Text-messaging using a cell phone can assist with self-care. The aim of this study was to systematically review the impact of education through mobile text-messaging on glycemic control.

METHODS

The design was a systematic review with meta-analysis. Five electronic databases were searched to access English studies involving a randomized controlled trial design that used text-messaging educational interventions in patients with type 2 diabetes during an 11-year period (2003-2013). Studies were evaluated using a quality assessment scale adapted from Jadad scale and Cochrane handbook. Extraction of data was carried out by two reviewers. A random-effect model with a standardized mean difference and Hedges's g indices was used for conducting the meta-analysis. Subgroup analyses were conducted and a Funnel plot was used to examine publication bias.

RESULTS

Ten studies overall were identified that fulfilled inclusion criteria, involving a total of 960 participants. The mean age of the sample was 52.8 years and majority were females. Data were heterogeneous (I(2)=67.6). Analyses suggested a publication bias based on Egger's regression (P<0.05). HbA1c was reduced significantly in experimental groups compared to control groups (P<0.001). The effect size for glycemic control in studies that used text-messaging only was 44%. For studies that used both text-messaging and Internet, the effect size was 86%.

CONCLUSION

Mobile text-messaging for educating Type 2 diabetics appears to be effective on glycemic control. Further investigations on mobile applications to achieve educational goals involving other diseases are recommended.

Cultural barriers encountered by Norwegian community pharmacists in providing service to non-Western immigrant patients

BACKGROUND

Western societies' need for knowledge about how to meet the challenges in health care following increased immigration has emerged as studies have showed that non-Western immigrants tend to experience more obstacles to drug use and poorer communication with health professionals.

OBJECTIVES

To identify the cultural barriers encountered by Norwegian community pharmacists in providing service to non-Western immigrant patients and to outline how they are being addressed.

SETTING

Community pharmacies in Oslo, Norway.

METHODS

A qualitative study consisting of four focus groups was conducted. In total 19 ethnic Norwegian pharmacists (17 female and 2 male; mean age: 40.6 years) participated. They were recruited from 13 pharmacies situated in areas of Oslo densely populated by non-Western immigrants. The audio-records of the focus group discussions were transcribed verbatim. A thematic content analysis was conducted. Main outcome measure Cultural barriers identified by Norwegian community pharmacists in the encounter with non-Western immigrants.

RESULTS

All the pharmacists were in contact with non-Western immigrant patients on a daily basis. They said that they found it challenging to provide adequate service to these patients, and that the presence of language as well as other cultural barriers not only affected what the patients got out of the available information, but also to a great extent what kind of and how much information was provided. Although the pharmacists felt that immigrant patients were in great need of drug counselling, there were large disparities in how much effort was exerted in order to provide this service. They were all uncomfortable with situations where family or friends acted as interpreters, especially children. Otherwise, cultural barriers were related to differences in body language and clothing which they thought distracted the communication. All the pharmacists stated that they had patients asking about the content of pork gelatin in medicines, but few said that they habitually notified the patients of this unless they were asked directly. Ramadan fasting was not identified as a subject during drug counselling.

CONCLUSION

This focus group study shows that language and other cultural barriers, including differences in body language, non-Western gender roles, and all-covering garments, are of great concern for ethnic Norwegian community pharmacists in the encounter with non-Western immigrant patients. Although the pharmacists recognise their role as drug information providers for immigrant patients, large disparities were detected with respect to kind of and amount of information provided to these patients.

Contextual Factors in the Health of People With Serious Mental Illness

People living with serious mental illness (SMI) have shorter life expectancies than the general population. We examined how contextual factors influence the physical health of this population. We conducted interviews, focus groups, and participant observations with stakeholders from six behavioral health organizations. We found that consumers' avoidance of overt disagreement during medical visits, their mistrust of medical institutions, and cultural variations in body image influenced the clinical encounter. Mental health providers' ambivalence about intervening in consumers' physical health, primary care providers' misattribution of physical symptoms to mental disorders, and providers' stigmatization of consumers shaped clinical encounters. Consumers' diets were shaped by food environments and social norms associated with traditional diets. Internal and external factors impacted consumers' physical activity. In this article, we illustrate the importance of considering contextual factors in the development and implementation of interventions aimed at improving the physical health of people with SMI.

Characteristics and effectiveness of diabetes self-management educational programs targeted to racial/ethnic minority groups: a systematic review, meta-analysis and meta-regression

BACKGROUND

It is not clear to what extent educational programs aimed at promoting diabetes self-management in ethnic minority groups are effective. The aim of this work was to systematically review the effectiveness of educational programs to promote the self-management of racial/ethnic minority groups with type 2 diabetes, and to identify programs' characteristics associated with greater success.

METHODS

We undertook a systematic literature review. Specific searches were designed and implemented for Medline, EMBASE, CINAHL, ISI Web of Knowledge, Scirus, Current Contents and nine additional sources (from inception to October 2012). We included experimental and quasi-experimental studies assessing the impact of educational programs targeted to racial/ethnic minority groups with type 2 diabetes. We only included interventions conducted in countries members of the OECD. Two reviewers independently screened citations. Structured forms were used to extract information on intervention characteristics, effectiveness, and cost-effectiveness. When possible, we conducted random-effects meta-analyses using standardized mean differences to obtain aggregate estimates of effect size with 95% confidence intervals. Two reviewers independently extracted all the information and critically appraised the studies.

RESULTS

We identified thirty-seven studies reporting on thirty-nine educational programs. Most of them were conducted in the US, with African American or Latino participants. Most programs obtained some benefits over standard care in improving diabetes knowledge, self-management behaviors and clinical outcomes. A meta-analysis of 20 randomized controlled trials (3,094 patients) indicated that the programs produced a reduction in glycated hemoglobin of -0.31% (95% CI -0.48% to -0.14%). Diabetes knowledge and self-management measures were too heterogeneous to pool. Meta-regressions showed larger reduction in glycated hemoglobin in individual and face to face delivered interventions, as well as in those involving peer educators, including cognitive reframing techniques, and a lower number of teaching methods. The long-term effects remain unknown and cost-effectiveness was rarely estimated.

CONCLUSIONS

Diabetes self-management educational programs targeted to racial/ethnic minority groups can produce a positive effect on diabetes knowledge and on self-management behavior, ultimately improving glycemic control. Future programs should take into account the key characteristics identified in this review.

Impact of a diabetes control and management intervention on health care utilization in American Samoa

OBJECTIVES

To examine the impact of a successful 12-month behavioral intervention to improve diabetes control on health care utilization in American Samoa.

METHODS

A cluster-randomized design was used to assign 268 diabetes patients to a nurse-community health worker intervention or usual care. Hospitalizations, emergency department, and primary care physician visits were collected retrospectively for 1 year prior to, and during, the intervention to assess changes in health care utilization. The association of utilization changes with change in HbA1c during the intervention was assessed.

RESULTS

Adjusted incidence rate ratios (RR) for primary care physician visits were significantly higher in the community health worker relative to the usual care group (RR = 1.71; 95% CI, 1.25-2.33). There was no main intervention effect on emergency department utilization, but visits in the prior year modified the intervention effect on emergency department visits. Increased primary care physician utilization was associated with greater decreases in HbA1c (b = -0.10, SE = 0.04, p = 0.01).

CONCLUSIONS

A culturally adapted community health worker diabetes intervention in American Samoa significantly increased primary care physician visits, and decreased emergency department visits among those with high emergency department usage in the prior year. These changes suggest important and beneficial impacts on health system utilization from the diabetes intervention in a low resource and high-risk population.

State of the science: diabetes self-management interventions led by nurse principal investigators

Over the past decade, diabetes self-management (DSM) interventions have become increasingly heterogeneous to address the needs of diverse populations. The purpose of this integrative review is to summarize the state of the science regarding DSM interventions led by nurse principal investigators. The Preferred Reporting Items of Systematic Reviews and Meta-Analyses framework informed identification, selection, and appraisal of the literature. A total of 44 national and international studies (RCTs [randomized controlled trial] and quasi-experimental studies) were identified for inclusion. Across national studies, diverse ethnic groups (Latinos, African Americans, Asians, and Native Americans) were most frequently sampled (67%). Review findings identified (a) DSM intervention typologies (primary DSM intervention, DSM reinforcement intervention, and primary DSM intervention plus reinforcement intervention) and selection of blended or bundled intervention components; (b) DSM intervention translation to community-based, electronic, and home settings; and (c) DSM intervention delivery (interventionists, dosages, and fidelity).

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

METHODS

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Developing Culturally Targeted Diabetes Educational Materials for Older Russian-Speaking Immigrants

PURPOSE

Older adults who immigrate late in life face many challenges adapting to a new country. Immigrants bring their cultural beliefs and behaviors with them, which can influence their ability to make dietary changes required when they have type 2 diabetes. Culturally targeted patient education materials are needed to improve immigrants' health literacy and abilities to self-manage diabetes. Currently, there is a scarcity of diabetes patient education materials to meet the educational needs of the Russian-speaking immigrant group. The purpose of this article is to describe a project in which culturally targeted diabetes education materials for older Russian-speaking immigrants were designed and developed.

CONCLUSIONS

Culturally targeted patient education materials are essential if they are to be accepted and used by clients from different ethnic minority populations. The creation of culturally relevant materials requires a team effort and community stakeholder input. The availability of materials on the internet facilitates access and use by health care providers. Culturally targeted education materials are an important component in addressing health literacy in ethnic minority populations. Next steps require that these materials be evaluated to test their impact on diabetes self-management behaviors and clinical outcomes such as adherence, amount of physical activity, and blood glucose levels.

Diabetes prevention in Hispanics: report from a randomized controlled trial

Introduction

Hispanics are at increased risk of developing type 2 diabetes. Lifestyle interventions are effective in preventing diabetes and restoring glucose regulation.

Methods

We recruited Hispanic men and women (N = 320) who were residents of the Lower Yakima Valley, Washington, aged 18 years or older with hemoglobin A1c (HbA1c) levels higher than 6% to a parallel 2-arm randomized-controlled trial conducted from 2008 through 2012. The trial compared participants in the intervention arm, who received an immediate educational curriculum (n = 166), to participants in the control arm, who received a delayed educational curriculum (n = 154). The home-based curriculum consisted of 5 sessions led by community health workers and was designed to inform participants about diabetes, diabetes treatment, and healthy dietary and physical activity behaviors. Participants were randomly assigned to the intervention and control arms, and analysts were blinded as to participant arm. We evaluated intervention effects on HbA1c levels; frequency (times per week) of fruit and vegetable consumption; and frequency (times per week) of mild, moderate, and strenuous leisure-time physical activity. At baseline, 3 months, and 6 months after randomization, participants completed a questionnaire and provided a blood sample. Analysts were blinded to intervention arm.

Results

The immediate intervention group (−0.64% [standard error (SE) 0.10]) showed a significant improvement in HbA1c scores (–37.5%, P = .04) compared with the delayed intervention group (–0.44%, P = .14). No significant changes were seen for dietary end points or changes in physical activity. We did observe a trend of greater increases in frequency of moderate and vigorous physical activity and a smaller increase in mild physical activity in the immediate intervention group than in the delayed intervention group.

Conclusion

This home-based intervention delivered by CHWs was associated with a clinically and statistically significant reduction in HbA1c levels in Hispanic adults with HbA1c levels higher than 6%.

Positionings in healthcare: diabetes training for Arabic-speaking immigrants

Purpose

– The purpose of this study is to explore how healthcare professionals in Denmark perceived and enacted their role as diabetes trainers for Arabic-speaking immigrants in three new local authority settings. The paper used positioning theory, which is a dynamic alternative to the more static concept of role in that it seeks to capture the variable, situationally specific, multiple and shifting character of social interaction, as the analytical tool to examine how people situationally produce and explain behaviour of themselves and others.

Design/methodology/approach

– The paper generated data through observation of diabetes training and of introductory interviews with training participants in three local authority healthcare centres over a total of five months. The authors conducted 12 individual interviews and two group interviews with healthcare professionals.

Findings

– Healthcare professionals shifted between three positionings – caregiver, educator and expert. The caregiver was dominant in professionals’ ideals but less in their practice. Healthcare professionals other-positioned participants correspondingly as: vulnerable, difficult students and chronically ill. The two first other-positionings drew on dominant images of an ethnic other as different and problematic.

Practical implications

– Becoming more reflexive and explicit about one's positionings offer the potential for a more conscious, confident, flexible and open-ended teaching practice. Such reflexivity may also reduce the perception that teaching challenges are rooted in participants’ ethnic background.

Originality/value

– The paper provides a new understanding of healthcare practice by showing professionals’ multiple and reciprocal positionings and the potential and risks in this regard. The paper demonstrates the need for healthcare workers to reflect on their positionings not only in relation to immigrants, but to all patients.

Community health education at student-run clinics leads to sustained improvement in patients' hepatitis B knowledge

While student-run clinics are often important healthcare safety nets for underserved populations, their efficacy for improving patient health knowledge has not been thoroughly explored. From September 2011 to April 2012, we assessed patients' retention of hepatitis B virus (HBV) knowledge after receiving student-led education at two student-run HBV screening and vaccination clinics. Patient education was provided by trained first and second-year medical, nursing, and pharmacy students, aided by a script and interpreters. Patient knowledge of HBV was evaluated at three points: before education, after the initial visit, and at one-month follow-up. Student-led education produced improved knowledge of HBV transmission, prevention, and management, which was retained 1 month after education for 52 patients tracked through time. Mean scores on an HBV knowledge survey improved from 56.4 % (SD = 15.2 %) at baseline to 66.6 % (SD = 15.1 %) after education, and 68.3 % (SD = 15.2 %) after one month. There was a statistically significant difference between the first and second (paired T test, p < 0.001) and the first and third tests (paired T test, p < 0.001), but no difference between the second and third tests (paired T test, p = 0.45). Multivariate analysis demonstrated that retention was correlated with patient educational background but independent of patient age, gender, income, primary language and number of years lived in the United States. Our study suggests that trained health professional students can effectively impart health knowledge that is retained by patients for at least 1 month. These results warrant consideration of student-led educational sessions at SRCs as a promising community health education model.

Improving diabetes care in rural areas: a systematic review and meta-analysis of quality improvement interventions in OECD countries

BACKGROUND AND AIMS

Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.

METHODS

We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.

RESULTS

Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).

CONCLUSIONS

This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.

Social epidemiology of diabetes and associated conditions

Research focusing on the social determinants of diabetes has focused on individual-level factors such as health behaviors, socioeconomic status, and depression. Fewer studies that incorporate a broader consideration of the multiple contexts or organizational levels (eg, family, health care setting, neighborhood) within which individuals are embedded exist in the mainstream diabetes literature. Such an approach would enhance our understanding of this complex disease, and thus, future avenues of research should consider the following: (1) a life-course approach, which examines the influence of early life exposures on the development of diabetes; (2) aiming to understand the biological mechanisms of social determinants of diabetes; and (3) implementing interventions on multiple levels. Integrating this multilevel and life-course approach will require transdisciplinary science that brings together highly specialized expertise from multiple disciplines. Broadening the study of social determinants is a necessary step toward improving the prevention and treatment of type 2 diabetes.

Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care

BACKGROUND

In the last decades the presence of social inequalities in diabetes care has been observed in multiple countries, including Spain. These inequalities have been at least partially attributed to differences in diabetes self-management behaviours. Communication problems during medical consultations occur more frequently to patients with a lower educational level. The purpose of this cluster randomized trial is to determine whether an intervention implemented in a General Surgery, based in improving patient-provider communication, results in a better diabetes self-management in patients with lower educational level. A secondary objective is to assess whether telephone reinforcement enhances the effect of such intervention. We report the design and implementation of this on-going study.

METHODS/DESIGN

The study is being conducted in a General Practice located in a deprived neighbourhood of Granada, Spain. Diabetic patients 18 years old or older with a low educational level and inadequate glycaemic control (HbA1c > 7%) were recruited. General Practitioners (GPs) were randomised to three groups: intervention A, intervention B and control group. GPs allocated to intervention groups A and B received training in communication skills and are providing graphic feedback about glycosylated haemoglobin levels. Patients whose GPs were allocated to group B are additionally receiving telephone reinforcement whereas patients from the control group are receiving usual care. The described interventions are being conducted during 7 consecutive medical visits which are scheduled every three months. The main outcome measure will be HbA1c; blood pressure, lipidemia, body mass index and waist circumference will be considered as secondary outcome measures. Statistical analysis to evaluate the effectiveness of the interventions will include multilevel regression analysis with three hierarchical levels: medical visit level, patient level and GP level.

DISCUSSION

The results of this study will provide new knowledge about possible strategies to promote a better diabetes self-management in a particularly vulnerable group. If effective, this low cost intervention will have the potential to be easily incorporated into routine clinical practice, contributing to decrease health inequalities in diabetic patients.

TRIAL REGISTRATION

Clinical Trials U.S. National Institutes of Health, NCT01849731.

Realist review to understand the efficacy of culturally appropriate diabetes education programmes

AIMS

Minority populations often face linguistic, cultural and financial barriers to diabetes education and care. The aim was to understand why culturally appropriate diabetes education interventions work, when they work best and for whom they are most effective.

METHODS

This review used a critical realist approach to examine culturally appropriate diabetes interventions. Beginning with the behavioural model and access to medical care, it reanalysed 11 randomized controlled trials from a Cochrane systematic review and related programme and training documents on culturally appropriate diabetes interventions. The analysis examined context and mechanism to understand their relationship to participant retention and statistically improved outcomes.

RESULTS

Minority patients with language barriers and limited access to diabetes programmes responded to interventions using health workers from the same ethnic group and interventions promoting culturally acceptable and financially affordable food choices using local ingredients. Programme incentives improved retention in the programmes and this was associated with improved HbA(1c) levels at least in the short term. Adopting a positive learning environment, a flexible and less intensive approach, one-to-one teaching in informal settings compared with a group approach in clinics led to improved retention rates.

CONCLUSIONS

Minority and uninsured migrants with unmet health needs showed the highest participation and HbA(1c) responses from culturally appropriate programmes.

The Cholesterol, Hypertension, And Glucose Education (CHANGE) study: results from a randomized controlled trial in African Americans with diabetes

BACKGROUND

Cardiovascular disease (CVD) and diabetes account for one-third of the mortality difference between African American and white patients. We evaluated the effect of a CVD risk reduction intervention in African Americans with diabetes.

METHODS

We randomized 359 African Americans with type 2 diabetes to receive usual care or a nurse telephone intervention. The 12-month intervention provided monthly self-management support and quarterly medication management facilitation. Coprimary outcomes were changes in systolic blood pressure (SBP), hemoglobin A1c (HbA1c), and low-density lipoprotein cholesterol (LDL-C) over 12 months. We estimated between-intervention group differences over time using linear mixed-effects models. The secondary outcome was self-reported medication adherence.

RESULTS

The sample was 72% female; 49% had low health literacy, and 37% had annual income <$10,000. Model-based estimates for mean baseline SBP, HbA1c, and LDL-C were 136.8 mm Hg (95% CI 135.0-138.6), 8.0% (95% CI 7.8-8.2), and 99.1 mg/dL (95% CI 94.7-103.5), respectively. Intervention patients received 9.9 (SD 3.0) intervention calls on average. Primary providers replied to 76% of nurse medication management facilitation contacts, 18% of these resulted in medication changes. There were no between-group differences over time for SBP (P = .11), HbA1c (P = .66), or LDL-C (P = .79). Intervention patients were more likely than those receiving usual care to report improved medication adherence (odds ratio 4.4, 95% CI 1.8-10.6, P = .0008), but adherent patients did not exhibit relative improvement in primary outcomes.

CONCLUSIONS

This intervention improved self-reported medication adherence but not CVD risk factor control among African Americans with diabetes. Further research is needed to determine how to maximally impact CVD risk factors in African American patients.

A structured, group-based diabetes self-management education (DSME) programme for people, families and whanau with type 2 diabetes (T2DM) in New Zealand: an observational study

BACKGROUND

Group-based diabetes self-management education (DSME) programmes have been shown to be effective. A programme tailored for the unique social and ethnic environment of New Zealand (NZ) was developed using concepts from internationally developed programmes.

AIM

To assess the effectiveness of a 6 week New Zealand specific DSME programme.

METHODS

In this observational study people with type 2 diabetes (aged 18-80 years) from diverse cultural backgrounds were recruited from primary care. Seventeen groups of six education sessions were run. Clinical data were collected from primary care at baseline, 3, 6 and 9 months. Participants also completed a self-administered questionnaire on diabetes knowledge, and self-management behaviours.

RESULTS

107 participants, mean age 56.7±11.3 years and mean duration of diabetes 7.5±7 years (NZ European (44%), Maori (24%), Pacific (16%) and Indian (16%)), were enrolled. Confidence in self-managing diabetes, regular examination of feet, physical activity levels and smoking rates all improved. Glycaemic control improved between baseline and 6 months (HbA1C 64.9±20.0 mmol/mol to 59.9±13.9 mmol/mol (p<0.05) (baseline 8.07%±1.80, 6 months 7.62%±1.25)), but was no different to baseline at 9 months. Systolic BP reduced from 131.9±16.4 to 127.4±18.2 mmHg (p<0.05) at 6 months, but increased to baseline levels by 9 months. Diastolic BP, triglycerides and urine microalbumin:creatinine ratio were significantly reduced at 3, 6 and 9 months.

CONCLUSION

A group-based DSME programme designed specifically for the NZ population was effective at improving aspects of diabetes care at 6 months. The attenuation of these improvements after 6 months suggests a refresher course at that time may be beneficial.

Targeted interventions for improved equity in maternal and child health in low- and middle-income settings: a systematic review and meta-analysis

BACKGROUND

Targeted interventions to improve maternal and child health is suggested as a feasible and sometimes even necessary strategy to reduce inequity. The objective of this systematic review was to gather the evidence of the effectiveness of targeted interventions to improve equity in MDG 4 and 5 outcomes.

METHODS AND FINDINGS

We identified primary studies in all languages by searching nine health and social databases, including grey literature and dissertations. Studies evaluating the effect of an intervention tailored to address a structural determinant of inequity in maternal and child health were included. Thus general interventions targeting disadvantaged populations were excluded. Outcome measures were limited to indicators proposed for Millennium Development Goals 4 and 5. We identified 18 articles, whereof 15 evaluated various incentive programs, two evaluated a targeted policy intervention, and only one study evaluated an intervention addressing a cultural custom. Meta-analyses of the effectiveness of incentives programs showed a pooled effect size of RR 1.66 (95% CI 1.43-1.93) for antenatal care attendance (four studies with 2,476 participants) and RR 2.37 (95% CI 1.38-4.07) for health facility delivery (five studies with 25,625 participants). Meta-analyses were not performed for any of the other outcomes due to scarcity of studies.

CONCLUSIONS

The targeted interventions aiming to improve maternal and child health are mainly limited to addressing economic disparities through various incentive schemes like conditional cash transfers and voucher schemes. This is a feasible strategy to reduce inequity based on income. More innovative action-oriented research is needed to speed up progress in maternal and child survival among the most disadvantaged populations through interventions targeting the underlying structural determinants of inequity.

Culturally adapting the prevention of diabetes and obesity in South Asians (PODOSA) trial

Type 2 diabetes is extremely common in South Asians, e.g. in men from Pakistani and Indian populations it is about three times as likely as in the general population in England, despite similarities in body mass index. Lifestyle interventions reduce the incidence of diabetes. Trials in Europe and North America have not, however, reported on the impact on South Asian populations separately or provided the details of their cross-cultural adaptation processes. Prevention of diabetes and obesity in South Asians (PODOSA) is a randomized, controlled trial in Scotland of an adapted, lifestyle intervention aimed at reducing weight and increasing physical activity to reduce type 2 diabetes in Indians and Pakistanis. The trial was adapted from the Finnish Diabetes Prevention Study. We describe, reflect on and discuss the following key issues: The core adaptations to the trial design, particularly the delivery of the intervention in homes by dietitians rather than in clinics. The use of both a multilingual panel and professional translators to help translate and/or develop materials. The processes and challenges of phonetic translation. How intervention resources were adapted, modified, newly developed and translated into Urdu and Gurmukhi (written Punjabi). The insights gained in PODOSA (including time pressures on investigators, imperfections in the adaptation process, the power of verbal rather than written information, the utilization of English and the mother-tongue languages simultaneously by participants and the costs) might help the research community, given the challenge of health promotion in multi-ethnic, urban societies.

Development of a diabetes prevention program for Surinamese South Asians in the Netherlands

Type 2 diabetes is highly prevalent among South Asian origin groups around the world. Not only is prevalence higher than in other ethnic groups, age at presentation is lower and these groups are more likely to experience complications. Evidence suggests that lifestyle interventions may prevent or delay the onset of diabetes. However, little is known about diabetes prevention in South Asians (SA). DH!AAN is a diabetes prevention program designed for Surinamese SA in The Netherlands. In this paper, we describe the theoretical frameworks and formative research that guided the development and cultural adaptation of DH!AAN. Cultural adaptation was based on analysis of the determinants of diet and physical activity, including socio-cultural factors, within our study population. This led to the incorporation of surface and deep structure elements in the intervention. One-to-one counseling by dieticians using motivational interviewing (MI) was the basis for the intervention. Additionally, we aimed to generate social support by including family members in parts of the intervention and group sessions to address issues relating to traditional food habits. We discuss our reflections on the development process and the choices made in developing this intervention. The results of DH!AAN will provide insight into the use of MI for this population group. Moreover, DH!AAN will provide evidence regarding the feasibility of diabetes prevention among South Asian populations.

Cultural adaptations of behavioral health interventions: a progress report

OBJECTIVE

To reduce health disparities, behavioral health interventions must reach subcultural groups and demonstrate effectiveness in improving their health behaviors and outcomes. One approach to developing such health interventions is to culturally adapt original evidence-based interventions. The goals of the article are to (a) describe consensus on the stages involved in developing cultural adaptations, (b) identify common elements in cultural adaptations, (c) examine evidence on the effectiveness of culturally enhanced interventions for various health conditions, and (d) pose questions for future research.

METHOD

Influential literature from the past decade was examined to identify points of consensus.

RESULTS

There is agreement that cultural adaptation can be organized into 5 stages: information gathering, preliminary design, preliminary testing, refinement, and final trial. With few exceptions, reviews of several health conditions (e.g., AIDS, asthma, diabetes) concluded that culturally enhanced interventions are more effective in improving health outcomes than usual care or other control conditions.

CONCLUSIONS

Progress has been made in establishing methods for conducting cultural adaptations and providing evidence of their effectiveness. Future research should include evaluations of cultural adaptations developed in stages, tests to determine the effectiveness of cultural adaptations relative to the original versions, and studies that advance our understanding of cultural constructs' contributions to intervention engagement and efficacy.