Group based training for self-management strategies in people with type 2 diabetes mellitus

Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization

Current nutrition therapy recommendations for the prevention and treatment of diabetes are based on a systematic review of evidence and answer important nutrition care questions. First, is diabetes nutrition therapy effective? Clinical trials as well as systematic and Cochrane reviews report a ~1%-2% lowering of hemoglobin A1c values as well as other beneficial outcomes from nutrition therapy interventions, depending on the type and duration of diabetes and level of glycemic control. Clinical trials also provide evidence for the effectiveness of nutrition therapy in the prevention of diabetes. Second, are weight loss interventions important and when are they beneficial? Modest weight loss is important for the prevention of type 2 diabetes and early in the disease process. However, as diabetes progresses, weight loss may or may not result in beneficial glycemic and cardiovascular outcomes. Third, are there ideal percentages of macronutrients and eating patterns that apply to all persons with diabetes? There is no ideal percentage of macronutrients and a variety of eating patterns has been shown to be effective for persons with diabetes. Treatment goals, personal preferences (eg, tradition, culture, religion, health beliefs, economics), and the individual's ability and willingness to make lifestyle changes must all be considered by clinicians and/or educators when counseling and educating individuals with diabetes. A healthy eating pattern emphasizing nutrient-dense foods in appropriate portion sizes, regular physical activity, and support are priorities for all individuals with diabetes. Reduced energy intake for persons with prediabetes or type 2 diabetes as well as matching insulin to planned carbohydrate intake are intervention to be considered. Fourth, is the question of how to implement nutrition therapy interventions in clinical practice. This requires nutrition care strategies.

Development of an interprofessional program for cardiovascular prevention in primary care: A participatory research approach

BACKGROUND

The chronic care model provides a framework for improving the management of chronic diseases. Participatory research could be useful in developing a chronic care model-based program of interventions, but no one has as yet offered a description of precisely how to apply the approach.

OBJECTIVES

An innovative, structured, multi-step participatory process was applied to select and develop (1) chronic care model-based interventions program to improve cardiovascular disease prevention that can be adapted to a particular regional context and (2) a set of indicators to monitor its implementation.

METHODS

Primary care clinicians (n = 16), administrative staff (n = 2), patients and family members (n = 4), decision makers (n = 5), researchers, and a research coordinator (n = 7) took part in the process. Additional primary care actors (n = 26) validated the program.

RESULTS

The program targets multimorbid patients at high or moderate risk of cardiovascular disease with uncontrolled hypertension, dyslipidemia or diabetes. It comprises interprofessional follow-up coordinated by case-management nurses, in which motivated patients are referred in a timely fashion to appropriate clinical and community resources. The program is supported by clinical tools and includes training in motivational interviewing. A set of 89 process and clinical indicators were defined.

CONCLUSION

Through a participatory process, a contextualized interventions program to optimize cardiovascular disease prevention and a set of quality indicators to monitor its implementation were developed. Similar approach might be used to develop other health programs in primary care if program developers are open to building on community strengths and priorities.

Self-Care Practices among Diabetic Patients in Anand District of Gujarat

Background. Diabetes care requires a multipronged approach, wherein the patient has an important role to play. This study was undertaken to explore self-care practices of diabetic patients residing in Anand district of Gujarat. Methods. A cross-sectional study, involving 100 diabetic patients, was conducted in 2009-2010. Self-care practices in seven domains of physical activity, dietary practices, medication taking, monitoring of glucose, problem solving, foot care, and psychosocial adjustment were assessed using scores assigned to participants' responses. Results. The mean age was 60.9 (SD = 12.2) years and 57% were males. Majority (92%) were Hindus and were consulting private medical practitioners (71%). "Medication taking" was the domain with the best performance score (88.1%) and "problem solving" the worst (11.0%). The "psychosocial adjustment" of the participants was satisfactory (82.5%). Overall mean performance percentage score was 54.41%. Males had better performance scores as compared to females in areas of "physical activity," "dietary practices," and "problem solving." Housewives had poorer performance scores. Total mean performance score was similar for patients on treatment from specialists and general practitioners. Conclusion. A self-care education program designed for this region should address the lacunae identified in various domains with a special emphasis on females.

Evaluating the implementation of HeLP-Diabetes within NHS services: study protocol

Background

Self-management by people with type 2 diabetes is central to good health outcomes and the prevention of associated complications. Structured education to teach self-management is recommended by the National Institute for Heath and Clinical Excellence; however, only a small proportion of patients report being offered this education and even fewer attend. This study aims to evaluate the implementation of a new internet-based self-management intervention: HeLP-Diabetes (Healthy Living for People with type 2 Diabetes) within the National Health Service. Specific objectives are to a) determine the uptake and use of HeLP-Diabetes by services and patients; b) identify the factors which inhibit or facilitate use; c) identify the resources needed for effective implementation; d) explore possible effects of HeLP-Diabetes use on self-reported patient outcome measures.

Methods/Design

This study will use an iterative design to implement HeLP-Diabetes into existing health services within the National Health Service. A two stage implementation process will be taken, whereby batches of General Practice surgeries and diabetes clinics will be offered HeLP-Diabetes and will subsequently be asked to participate in evaluating the implementation. We will collect data to describe the number of services and patients who sign up to HeLP-Diabetes, the types of services and patients who sign up and the implementation costs. Semi-structured interviews will be conducted with patients and health professionals and cohorts of patient participants will be asked to complete self-report measures at baseline, 3 months, and 12 months.

Discussion

This study will evaluate the implementation of a new online self-management intervention and describe what happens when it is made available to existing National Health Services and patients with type 2 diabetes. We will collect data to describe the uptake and use of the intervention and the resources needed for widespread implementation. We will report on patient benefits from using HeLP-Diabetes and the resources needed to achieve these in routine practice. Interviews with key stake holders will identify, define and explain factors that promote or inhibit the normalization of new patterns of patient and professional activity arising from HeLP-Diabetes.

High saturated-fat and low-fibre intake: a comparative analysis of nutrient intake in individuals with and without type 2 diabetes

OBJECTIVE

The aim of dietary modification, as a cornerstone of type 2 diabetes (T2DM) management, is to optimise metabolic control and overall health. This study describes food and nutrient intake in a sample of adults with T2DM, and compares this to recommendations, and to intake in age, sex, body mass index (BMI) and social-class matched adults without T2DM.

DESIGN

A cross-sectional analysis of food and nutrient intake in 124 T2DM individuals (64% male; age 57.4±5.6 years, BMI 32.5±5.8 kg m(-2)) and 124 adults (age 57.4±7.0 years, BMI 31.2±5.0 kg m(-2)) with no diabetes (ND) was undertaken using a 4-day semiweighed food diary. Biochemical and anthropometric variables were also measured.

RESULTS

While reported energy intake was similar in T2DM vs ND (1954 vs 2004 kcal per day, P=0.99), T2DM subjects consumed more total-fat (38.8% vs 35%, P0.001), monounsaturated-fat (13.3% vs 12.2%; P=0.004), polyunsaturated-fat (6.7% vs 5.9%; P<0.001) and protein (18.6% vs 17.5%, P0.01). Both groups exceeded saturated-fat recommendations (14.0% vs 13.8%). T2DM intakes of carbohydrate (39.5% vs 42.9%), non-milk sugar (10.4% vs 15.0%) and fibre (14.4 vs 18.9 g) were significantly lower (P<0.001). Dietary glycaemic load (GL) was also lower in T2DM (120.8 vs 129.2; P=0.02), despite a similar glycaemic index (59.7 vs 60.1; P=0.48). T2DM individuals reported consuming significantly more wholemeal/brown/wholegrain breads, eggs, oils, vegetables, meat/meat products, savoury snacks and soups/sauces and less white breads, breakfast cereals, cakes/buns, full-fat dairy, chocolate, fruit juices, oily fish and alcohol than ND controls.

CONCLUSION

Adults with T2DM made different food choices to ND adults. This resulted in a high saturated-fat diet, with a higher total-fat, monounsaturated-fat, polyunsaturated-fat and protein content and a lower GL, carbohydrate, fibre and non-milk sugar content. Dietary education should emphasise and reinforce the importance of higher fibre, fruit, vegetable and wholegrain intake and the substitution of monounsaturated for saturated-fat sources, in energy balanced conditions.

Enhancing diabetes self-care among rural African Americans with diabetes: results of a two-year culturally tailored intervention

PURPOSE

The purpose of this study is to test the feasibility of conducting a community-based randomized controlled trial evaluating a culturally tailored community-based group diabetes self-management education (DSME) program among rural African Americans.

METHODS

Thirty-two African American rural adults with type 2 diabetes were recruited and 25 adults were retained and participated in an interventional study designed to test the effectiveness of the "Taking Care of Sugar" DSME program for the 2-year follow-up. Participants were selected from rural central Virginia. Primary outcomes variables included average blood sugar levels, cardiovascular risk factors, and general physical and mental health. These outcomes were assessed at baseline, 3 months, 6 months, and 12 months post baseline.

RESULTS

From baseline to 3-month follow-up assessment, participants exhibited significant improvement on several physiological and behavioral measures. Given the small sample size, hypothesis testing was limited. Results show change from baseline over time, illustrating that the primary outcome of A1C decreased, although not significant. Additionally, participants reported more knowledge about diabetes self-management and personal care skills (ie, exercise and foot care) that persisted over time. The feasibility of the culturally tailored DSME was established, and participation with the program was high.

CONCLUSIONS

A community-based group DSME program using storytelling is feasible. This research will help to inform clinicians and health policymakers as to the types of interventions that are feasible in a larger rural population. If such a program is carried out, we can improve knowledge, reduce complications, and improve quality of life among rural African Americans.

Self-management education programmes for osteoarthritis

BACKGROUND

Self-management education programmes are complex interventions specifically targeted at patient education and behaviour modification. They are designed to encourage people with chronic disease to take an active self-management role to supplement medical care and improve outcomes.

OBJECTIVES

To assess the effectiveness of self-management education programmes for people with osteoarthritis.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PyscINFO, SCOPUS and the World Health Organization (WHO) International Clinical Trial Registry Platform were searched, without language restriction, on 17 January 2013. We checked references of reviews and included trials to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials of self-management education programmes in people with osteoarthritis were included. Studies with participants receiving passive recipients of care and studies comparing one type of programme versus another were excluded.

DATA COLLECTION AND ANALYSIS

In addition to standard methods we extracted components of the self-management interventions using the eight domains of the Health Education Impact Questionnaire (heiQ), and contextual and participant characteristics using PROGRESS-Plus and the Health Literacy Questionnaire (HLQ). Outcomes included self-management of osteoarthritis, participant's positive and active engagement in life, pain, global symptom score, self-reported function, quality of life and withdrawals (including dropouts and those lost to follow-up). We assessed the quality of the body of evidence for these outcomes using the GRADE approach.

MAIN RESULTS

We included twenty-nine studies (6,753 participants) that compared self-management education programmes to attention control (five studies), usual care (17 studies), information alone (four studies) or another intervention (seven studies). Although heterogeneous, most interventions included elements of skill and technique acquisition (94%), health-directed activity (85%) and self-monitoring and insight (79%); social integration and support were addressed in only 12%. Most studies did not provide enough information to assess all PROGRESS-Plus items. Eight studies included predominantly Caucasian, educated female participants, and only four provided any information on participants' health literacy. All studies were at high risk of performance and detection bias for self-reported outcomes; 20 studies were at high risk of selection bias, 16 were at high risk of attrition bias, two were at high risk of reporting bias and 12 were at risk of other biases. We deemed attention control as the most appropriate and thus the main comparator.Compared with attention control, self-management programmes may not result in significant benefits at 12 months. Low-quality evidence from one study (344 people) indicates that self-management skills were similar in active and control groups: 5.8 points on a 10-point self-efficacy scale in the control group, and the mean difference (MD) between groups was 0.4 points (95% confidence interval (CI) -0.39 to 1.19). Low-quality evidence from four studies (575 people) indicates that self-management programmes may lead to a small but clinically unimportant reduction in pain: the standardised mean difference (SMD) between groups was -0.26 (95% CI -0.44 to -0.09); pain was 6 points on a 0 to 10 visual analogue scale (VAS) in the control group, treatment resulted in a mean reduction of 0.8 points (95% CI -0.14 to -0.3) on a 10-point scale, with number needed to treat for an additional beneficial outcome (NNTB) of 8 (95% CI 5 to 23). Low-quality evidence from one study (251 people) indicates that the mean global osteoarthritis score was 4.2 on a 0 to 10-point symptom scale (lower better) in the control group, and treatment reduced symptoms by a mean of 0.14 points (95% CI -0.54 to 0.26). This result does not exclude the possibility of a clinically important benefit in some people (0.5 point reduction included in 95% CI). Low-quality evidence from three studies (574 people) showed no signficant difference in function between groups (SMD -0.19, 95% CI -0.5 to 0.11); mean function was 1.29 points on a 0 to 3-point scale in the control group, and treatment resulted in a mean improvement of 0.04 points with self-management (95% CI -0.10 to 0.02). Low-quality evidence from one study (165 people) showed no between-group difference in quality of life (MD -0.01, 95% CI -0.03 to 0.01) from a control group mean of 0.57 units on 0 to 1 well-being scale. Moderate-quality evidence from five studies (937 people) shows similar withdrawal rates between self-management (13%) and control groups (12%): RR 1.11 (95% CI 0.78 to 1.57). Positive and active engagement in life was not measured.Compared with usual care, moderate-quality evidence from 11 studies (up to 1,706 participants) indicates that self-management programmes probably provide small benefits up to 21 months, in terms of self-management skills, pain, osteoarthritis symptoms and function, although these are of doubtful clinical importance, and no improvement in positive and active engagement in life or quality of life. Withdrawal rates were similar. Low to moderate quality evidence indicates no important differences in self-management , pain, symptoms, function, quality of life or withdrawal rates between self-management programmes and information alone or other interventions (exercise, physiotherapy, social support or acupuncture).

AUTHORS' CONCLUSIONS

Low to moderate quality evidence indicates that self-management education programmes result in no or small benefits in people with osteoarthritis but are unlikely to cause harm.Compared with attention control, these programmes probably do not improve self-management skills, pain, osteoarthritis symptoms, function or quality of life, and have unknown effects on positive and active engagement in life. Compared with usual care, they may slightly improve self-management skills, pain, function and symptoms, although these benefits are of unlikely clinical importance.Further studies investigating the effects of self-management education programmes, as delivered in the trials in this review, are unlikely to change our conclusions substantially, as confounding from biases across studies would have likely favoured self-management. However, trials assessing other models of self-management education programme delivery may be warranted. These should adequately describe the intervention they deliver and consider the expanded PROGRESS-Plus framework and health literacy, to explore issues of health equity for recipients.

Is adherence a relevant issue in the self-management education of diabetes? A mixed narrative review

While therapeutic patient education is now recognized as essential for optimizing the control of chronic diseases and patient well-being, adherence to treatment and medical recommendations is still a matter of debate. In type 2 diabetes, the nonadherence to therapy, estimated at more than 40%, is perceived as a barrier for improving the prognosis despite recent therapeutic advances. Interventional studies have barely begun to demonstrate the effectiveness of technical and behavioral actions. The aim of this review is to question the concept of adherence in terms of therapeutic education based on quantitative and qualitative data. The research on therapeutic education has shown the effectiveness of structured actions in type 2 diabetes, but adherence is rarely an end point in randomized trials. A positive but inconsistent or moderate effect of education actions on adherence has been shown in heterogeneous studies of varying quality. Program types, outlines, theoretical bases, and curricula to set up for action effectiveness are still being discussed. Qualitative studies, including sociological studies, provide a useful and constructive focus on this perspective. Adherence is a soft and flexible tool available to the patient in his/her singular chronic disease trajectory, and as such, integrates into individual therapeutic strategies, including socio-cultural interactions, beyond the medical explanation of the disease and the patient. Four key elements for the development of structured therapeutic education are discussed: 1) the access to health literacy, 2) the contextualization of education activities, 3) the long-term chronic dimension of self-management, and 4) the organizational aspects of health and care. Rather than focusing the objective on behavioral changes, structured therapeutic education actions should attempt to provide tools and resources aimed at helping individuals to manage their disease in their own context on a long-term basis, by developing health literacy and relational and organizational aspects of the health professionals and system.

Strategies for enhancing information, motivation, and skills for self-management behavior changes: a qualitative study of diabetes care for older adults in Korea

PURPOSE

To describe strategies for enhancing information, motivation, and skills related to changes in diabetes self-management behavior among community-dwelling older adults in Korea.

PATIENTS AND METHODS

A total of five focus group interviews (three separate focus groups) were conducted with 12 older adults with type 2 diabetes and five diabetes educators. Qualitative content analysis was used.

RESULTS

"One's own willingness and ability" emerged as a fundamental belief about the strategies for diabetes self-management. Six major themes under three categories were identified. Under the information category, the recurrent themes were: 1) repeatedly offering detailed knowledge regarding self-management, 2) providing information about current health status, and 3) identifying experiential knowledge of blood glucose control. The recurrent themes in the motivation category were: 1) ensuring a positive attitude regarding self-management, and 2) encouragement or feedback from significant others. Furthermore, in the skills category, we found that the following theme emerged: hands-on skills training with numerical standards.

CONCLUSION

This study identified six tailored strategies for enhancing information, motivation, and skills for diabetes self-management behavior changes. These strategies can be used in the development of a culturally sensitive diabetes self-management program for older adults.

Partnering with diabetes educators to improve patient outcomes

Diabetes is a chronic, progressive disease that affects millions worldwide. The paradigm of diabetes management has shifted to focus on empowering the person with diabetes to manage the disease successfully and to improve their quality of life. Diabetes self-management education is a collaborative process through which people with diabetes gain the knowledge and skills needed to modify their behavior and to self-manage successfully the disease and its related conditions. Diabetes educators are health care professionals who apply in-depth knowledge and skills in the biological and social sciences, communication, counseling, and pedagogy to enable patients to manage daily and future challenges. Diabetes educators are integral in providing individualized education and promoting behavior change, using a framework of seven self-care behaviors known as the AADE7 Self-Care Behaviors™, developed by the American Association of Diabetes Educators. The iterative process of promoting behavior change includes assessment, goal setting, planning, implementation, evaluation, and documentation. Diabetes educators work as part of the patient's health care team to engage with the patient in informed, shared decision making. The increasing prevalence of diabetes and the growing focus on its prevention require strategies for providing people with knowledge, skills, and strategies they need and can use. The diabetes educator is the logical facilitator of change. Access to diabetes education is critically important; incorporating diabetes educators into more and varied practice settings will serve to improve clinical and quality of life outcomes for persons with diabetes.

Reducing resistance to treatment, through group intervention, improves clinical measurements in patients with type 2 diabetes

BACKGROUND

Studies have shown that group Therapeutic Patient Education (TPE) may empower patients with type 2 diabetes to better manage their disease. The mechanism of these interventions is not fully understood. A reduction in resistance to treatment may explain the mechanism by which TPE empowers participants to improve self-management. The Objective of this study was to examine the effectiveness of diabetes groups in reducing resistance to treatment and the association between reduced resistance and better management of the disease.

METHODS

In a program evaluation study, we administered validated questionnaires to measure resistance to treatment (RTQ) in 3 time periods: before the intervention (T1), immediately after the intervention (T2) and six months later (T3). Clinical measures (HbA1C, blood pressure, HDL, LDL and total cholesterol, Triglycerides and BMI) were retrieved from Maccabi Healthcare Services computerized systems, for T1;T2 and a year post intervention (T3). Linear mixed models were used adjusting for age, gender, social support and family status.

RESULTS

157; 156 and 106 TPE participants completed the RTQ in T1; T2 and T3 respectively. HbA1C and systolic and diastolic blood pressure were significantly reduced in the group which achieved a reduction in three out of the five RTQ components. For the other clinical measurements no significant changes were observed.

CONCLUSION

Our findings suggest that reducing resistance to treatment, through an educational program for patients with diabetes, is associated with a better disease control. Identifying patients with higher resistance to treatment, and including components that reduce resistance in patient education programs, have the potential to increase the effectiveness of these programs.

Use of behavioral change techniques in web-based self-management programs for type 2 diabetes patients: systematic review

Background

Type 2 diabetes mellitus (T2DM) is a highly prevalent chronic metabolic disease characterized by hyperglycemia and cardiovascular risks. Without proper treatment, T2DM can lead to long-term complications. Diabetes self-management is recognized as the cornerstone of overall diabetes management. Web-based self-management programs for T2DM patients can help to successfully improve patient health behaviors and health-related outcomes. Theories can help to specify key determinants of the target behaviors and behavior change strategies required to arrive at the desired health outcomes, which can then be translated into specific behavioral techniques or strategies that patients can learn to apply in their daily life. From previous reviews of a wide range of online diabetes self-management tools and programs, it appears that it is still unclear which behavioral change techniques (BCTs) are primarily used and are most effective when it comes to improving diabetes self-management behaviors and related health outcomes.

Objective

We set out to identify which BCTs are being applied in online self-management programs for T2DM and whether there is indication of their effectiveness in relation to predefined health outcomes.

Methods

Articles were systematically searched and screened on the mentioned use of 40 BCTs, which were then linked to reported statistically significant improvements in study outcomes.

Results

We found 13 randomized controlled trials reporting on 8 online self-management interventions for T2DM. The BCTs used were feedback on performance, providing information on consequences of behavior, barrier identification/problem solving, and self-monitoring of behavior. These BCTs were also linked to positive outcomes for health behavior change, psychological well-being, or clinical parameters.

Conclusions

A relatively small number of theory-based online self-management support programs for T2DM have been reported using only a select number of BCTs. The development of future online self-management interventions should be based on the use of theories and BCTs and should be reported accurately.

Web-based self-management with and without coaching for type 2 diabetes patients in primary care: design of a randomized controlled trial

BACKGROUND

Self-management is recognized as the cornerstone of overall diabetes management. Web-based self-management programs have the potential of supporting type 2 diabetes patients with managing their diabetes and reducing the workload for the care provider, where the addition of online coaching could improve patient motivation and reduce program attrition. This study aims to test the hypothesis that a web-based self-management program with coaching will prove more effective on improving patient self-management behavior and clinical outcome measures than a web-based self-management program without coaching.

METHODS

The effects of a web-based self-management program with and without coaching will be tested with a nested randomized controlled trial within a healthcare group in the Netherlands. In one year 220 type 2 diabetes patients will be randomized into an intervention group (n = 110) or a control group (n = 110). The control group will receive only the online self-management program. The intervention group will receive the online self-management program and additional online coaching. Participants will be followed for one year, with follow-up measurements at 6 and 12 months.

DISCUSSION

The intervention being tested is set to support type 2 diabetes patients with their diabetes self-management and is expected to have beneficial effects on self-care activities, well being and clinical outcomes. When proven effective this self-management support program could be offered to other health care groups and their type 2 diabetes patients in the Netherlands.

TRIAL REGISTRATION

Nederlands Trial Register NTR4064.

Trial to examine text message-based mHealth in emergency department patients with diabetes (TExT-MED): a randomized controlled trial

STUDY OBJECTIVE

Increasingly, low-income inner-city patients with diabetes utilize emergency departments (EDs) for acute and chronic care. We seek to determine whether a scalable, low-cost, unidirectional, text message-based mobile health intervention (TExT-MED) improves clinical outcomes, increases healthy behaviors, and decreases ED utilization in a safety net population.

METHODS

We conducted an randomized controlled trial of 128 adult patients with poorly controlled diabetes (glycosylated hemoglobin [Hb A1C] level ≥8%) in an urban, public ED. The TExT-MED group received 2 daily text messages for 6 months in English or Spanish. The primary outcome was change in Hb A1C level. Secondary outcomes included changes in medication adherence, self-efficacy, performance of self-care tasks, quality of life, diabetes-specific knowledge, ED utilization, and patient satisfaction.

RESULTS

Hb A1C level decreased by 1.05% in the TExT-MED group compared with 0.60% in the controls (Δ0.45; 95% confidence interval [CI] -0.27 to 1.17) at 6 months. Secondary outcomes favored the TExT-MED group, with the most sizable change observed in self-reported medication adherence (as measured by the Morisky Medication Adherence Scale, an 8-point validated scale with higher scores representing better adherence), which improved from 4.5 to 5.4 in the TExT-MED group compared with a net decrease of -0.1 in the controls (Δ1.1 [95% CI 0.1 to 2.1]). Effects were larger among Spanish speakers for both medication adherence (1.1 versus -0.3; Δ1.4; 95% CI 0.2 to 2.7) and Hb A1C (-1.2% versus -0.4%) in the TExT-MED group. The proportion of patients who used emergency services trended lower in the TExT-MED group (35.9% versus 51.6%; Δ15.7%; 95% CI 9.4% to 22%). Overall, 93.6% of respondents enjoyed TExT-MED and 100% would recommend it to family/friends.

CONCLUSION

The TExT-MED program did not result in a statistically significant improvement in Hb A1C. However, trends toward improvement in the primary outcome of Hb A1C and other secondary outcomes, including quality of life, were observed, the most pronounced being improved medication adherence. TExT-MED also decreased ED utilization. These findings were magnified in the Spanish-speaking subgroup. Technologies such as TExT-MED represent highly scalable, low-cost, and widely accessible solutions for safety-net ED populations.

Nutrition therapy recommendations for the management of adults with diabetes

There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals; personal and cultural preferences; health literacy and numeracy; access to healthful choices; and readiness, willingness, and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrient dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.

A study to assess the feasibility of undertaking a randomized controlled trial of adherence with eye drops in glaucoma patients

BACKGROUND

Adherence with therapy could influence the progression of glaucoma and ultimately affect the onset of visual impairment in some individuals. This feasibility study evaluated the measures to be used for a future randomized controlled trial assessing the effects of group-based education on adherence with eye drops.

METHODS

People diagnosed with glaucoma within the previous 12 months attending a regional ophthalmology clinic in the North West of England were recruited. A two-session education program delivered one week apart had been devised as part of a previous project. A combined adult learning and health needs approach to education was taken. Outcomes measured were knowledge of glaucoma, self-report of adherence, illness perception, beliefs about medicines, patient enablement, and general health (Short Form-12). Adherence was also measured objectively using a Medical Events Monitoring System device.

RESULTS

Twenty-six participants consented to undertake the educational program and 19 produced analyzable data. Knowledge of glaucoma, illness perception, beliefs about medicine, and patient enablement all showed statistically significant improvements after education. Mean adherence with eye drops was maintained above 85% before and for 3 months after attendance at the educational program. Self-report exaggerated adherence by at least 10% when compared with the objective Medical Events Monitoring System data, and in fact the kappa agreement was zero.

CONCLUSION

All questionnaires other than the Short Form-12 were considered to be valuable measures and use of a Medical Events Monitoring System device was considered to be an objective surrogate measure for adherence with eye drops. A multicenter, randomized, controlled equivalence trial of group versus individualized education using adherence as the primary outcome is the next step.

New terminology for the treatment of tobacco dependence: a proposal for debate

Tobacco dependence is characterised as a chronic, relapsing disorder that typically requires multiple quit attempts before successful, long-term abstinence is achieved (Steinberg, Foulds, Richardson, Burke, & Shah, 2006). Best practice, evidence-based treatment includes multiple-session counselling and pharmacotherapy, or the combination of both (Fiore et al., 2008). The field has moved past the notion that tobacco dependence is simply a bad habit, a vice, or a moral deficiency that can be overcome by willpower or education alone (Mars & Ling, 2008). However, the language used in discussing treatment has not always been consistent with this evidence. Some words and phrases used lend themselves to varied meanings, and could lead to significant misunderstanding not only among professionals in the field, but also among the general public (O'Brien, 2010; Davis, 1992; Perkins, 1999; Hughes, 2013). In this paper, we discuss some commonly used, problematic terminology, and suggest more appropriate terms (Table 1).

[Diabetes education in adult diabetic patients]

Diabetes education has gained a critical role in diabetes care. The empowerment of patients aims to actively influence the course of the disease by self-monitoring and treatment modification. Diabetes education has to be made accessible for all patients with the disease. To be able to provide a structured and validated education program adequate personal as well as space, organizational and financial background are required. Besides an increase in knowledge about the disease it has been shown that structured diabetes education is able to improve diabetes outcome measured by parameters like blood glucose, HbA1c, blood pressure and body weight in follow-up evaluations.

Using GIS and secondary data to target diabetes-related public health efforts

OBJECTIVES

To efficiently help communities prevent and manage diabetes, health departments need to be able to target populations with high risk but low resources. To aid in this process, we mapped county-level diabetes-related rates and resources/use using publicly available secondary data to identify Michigan counties with high diabetes prevalence and low or no medical and/or community resources.

METHODS

We collected county-level diabetes-related rates and resources from Web-based sources and mapped them using geographic information systems (GIS) software. Data included age-adjusted county diabetes rates, diabetes-related medical resource and resource use (i.e., the number of endocrinologists and percentage of Medicare patients with diabetes who received hemoglobin A1c testing in the past year), community resources (i.e., the number of certified diabetes self-management education and diabetes support groups), as well as population estimates and demographics (e.g., rural residence, education, poverty, and race/ethnicity). We created GIS maps highlighting areas that had higher-than-median rates of disease and lower-than-median resources. We also conducted linear, logistic, and Poisson regression analyses to confirm GIS findings.

RESULTS

There were clear regional trends in resource distribution across Michigan. The 15 counties in the Upper Peninsula were lacking in medical resources but higher in community resources compared with the 68 counties in the Lower Peninsula. There was little apparent association between need (diabetes prevalence) and diabetes-related resources/use. Specific counties with high diabetes prevalence and low resources were easily identified using GIS mapping.

CONCLUSION

Using public data and mapping tools identified diabetes health-service shortage areas for targeted public health programming.

Do older adults aged 60-75 years benefit from diabetes behavioral interventions?

OBJECTIVE

In this secondary analysis, we examined whether older adults with diabetes (aged 60-75 years) could benefit from self-management interventions compared with younger adults. Seventy-one community-dwelling older adults and 151 younger adults were randomized to attend a structured behavioral group, an attention control group, or one-to-one education.

RESEARCH DESIGN AND METHODS

We measured A1C, self-care (3-day pedometer readings, blood glucose checks, and frequency of self-care), and psychosocial factors (quality of life, diabetes distress, frustration with self-care, depression, self-efficacy, and coping styles) at baseline and 3, 6, and 12 months postintervention.

RESULTS

Both older (age 67 ± 5 years, A1C 8.7 ± 0.8%, duration 20 ± 12 years, 30% type 1 diabetes, 83% white, 41% female) and younger (age 47 ± 9 years, A1C 9.2 ± 1.2%, 18 ± 12 years with diabetes, 59% type 1 diabetes, 82% white, 55% female) adults had improved A1C equally over time. Importantly, older and younger adults in the group conditions improved more and maintained improvements at 12 months (older structured behavioral group change in A1C -0.72 ± 1.4%, older control group -0.65 ± 0.9%, younger behavioral group -0.55 ± 1.2%, younger control group -0.43 ± 1.7%). Furthermore, frequency of self-care, glucose checks, depressive symptoms, quality of life, distress, frustration with self-care, self-efficacy, and emotional coping improved in older and younger participants at follow-up.

CONCLUSIONS

The findings suggest that, compared with younger adults, older adults receive equal glycemic benefit from participating in self-management interventions. Moreover, older adults showed the greatest glycemic improvement in the two group conditions. Clinicians can safely recommend group diabetes interventions to community-dwelling older adults with poor glycemic control.

Effects of self-care, self-efficacy, social support on glycemic control in adults with type 2 diabetes

Background

A number of studies have examined the influence of self-efficacy, social support and patient-provider communication (PPC) on self-care and glycemic control. Relatively few studies have tested the pathways through which these constructs operate to improve glycemic control, however. We used structural equation modeling to examine a conceptual model that hypothesizes how self-efficacy, social support and patient-provider communication influence glycemic control through self-care behaviors in Chinese adults with type 2 diabetes.

Methods

We conducted a cross-sectional study of 222 Chinese adults with type 2 diabetes in one primary care center. We collected information on demographics, self-efficacy, social support, patient-provider communication (PPC) and diabetes self-care. Hemoglobin A1c (HbA1c) values were also obtained. Measured variable path analyses were used to determine the predicted pathways linking self-efficacy, social support and PPC to diabetes self-care and glycemic control.

Results

Diabetes self-care had a direct effect on glycemic control (β = −0.21, p = .007), No direct effect was observed for self-efficacy, social support or PPC on glycemic control. There were significant positive direct paths from self-efficacy (β = 0.32, p < .001), social support (β = 0.17, p = .009) and PPC (β = 0.14, p = .029) to diabetes self-care. All of them had an indirect effect on HbA1c (β =–0.06, β =–0.04, β =–0.03 respectively). Additionally, PPC was positively associated with social support (γ = 0.32, p < .001).

Conclusions

Having better provider-patient communication, having social support, and having higher self-efficacy was associated with performing diabetes self-care behaviors; and these behaviors were directly linked to glycemic control. So longitudinal studies are needed to explore the effect of self-efficacy, social support and PPC on changes in diabetes self-care behaviors and glycemic control.

Implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial

OBJECTIVE

To determine the effectiveness of an intervention to enhance self management support for patients with chronic conditions in UK primary care.

DESIGN

Pragmatic, two arm, cluster randomised controlled trial.

SETTING

General practices, serving a population in northwest England with high levels of deprivation.

PARTICIPANTS

5599 patients with a diagnosis of diabetes (n=2546), chronic obstructive pulmonary disease (n=1634), and irritable bowel syndrome (n=1419) from 43 practices (19 intervention and 22 control practices).

INTERVENTION

Practice level training in a whole systems approach to self management support. Practices were trained to use a range of resources: a tool to assess the support needs of patients, guidebooks on self management, and a web based directory of local self management resources. Training facilitators were employed by the health management organisation.

MAIN OUTCOME MEASURES

Primary outcomes were shared decision making, self efficacy, and generic health related quality of life measured at 12 months. Secondary outcomes were general health, social or role limitations, energy and vitality, psychological wellbeing, self care activity, and enablement.

RESULTS

We randomised 44 practices and recruited 5599 patients, representing 43% of the eligible population on the practice lists. 4533 patients (81.0%) completed the six month follow-up and 4076 (72.8%) the 12 month follow-up. No statistically significant differences were found between patients attending trained practices and those attending control practices on any of the primary or secondary outcomes. All effect size estimates were well below the prespecified threshold of clinically important difference.

CONCLUSIONS

An intervention to enhance self management support in routine primary care did not add noticeable value to existing care for long term conditions. The active components required for effective self management support need to be better understood, both within primary care and in patients' everyday lives.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN90940049.

Improving quality of care for persons with diabetes: an overview of systematic reviews - what does the evidence tell us?

BACKGROUND

Ensuring high quality care for persons with diabetes remains a challenge for healthcare systems globally with consistent evidence of suboptimal care and outcomes. There is increasing interest in quality improvement strategies to improve diabetes management as reflected by a growing number of systematic reviews. These reviews are of varying quality and dispersed across many sources. In this paper, we present an overview of systematic reviews evaluating the impact of interventions to improve the quality of diabetes care.

METHODS

We searched for systematic reviews evaluating the effectiveness of any intervention intended to improve intermediate patient outcomes and process of care measures for patients with any type of diabetes. Two reviewers independently screened search results, appraised each systematic review using AMSTAR and extracted data from high quality reviews (AMSTAR score ≥ 5). Within reviews, we used vote counting by direction of effect to report the number of studies favouring an intervention for each outcome. We produced summaries of results for each intervention category.

RESULTS

We identified 125 reviews of varying methodological quality and summarised key findings from 50 high quality reviews. We categorised reviews by quality improvement intervention. Eight reviews were broad based (involving a variety of strategies). Other reviews considered: patient education and support (n = 21), telemedicine (n = 10), provider role changes (n = 7), and organisational changes (n = 4). Reviews reported intermediate patient outcomes (e.g. glycaemic control) (n = 49) and process of care outcomes (n = 9). There was evidence of considerable overlap of included studies between reviews.

CONCLUSIONS

There is consistent evidence from high quality systematic reviews that patient education and support, provider role changes, and telemedicine are associated with improvements in glycaemic and vascular risk factor control in patients. There is less evidence about the impact of quality improvement interventions on other key process measures such as screening patients for diabetic complications. This paper provides decision makers with a comprehensive overview of evidence from high quality systematic reviews about the effects of quality improvement interventions on improving diabetes care.

Impact of reinforcement of diabetes self-care on poorly controlled diabetes: a randomized controlled trial

PURPOSE

The purpose of the study was to assess the value of reinforcing diabetes self-management for improving glycemia and self-care among adults with type 2 diabetes who had at least 3 hours of prior diabetes education.

METHODS

In this randomized controlled trial, 134 participants (75% white, 51% female, 59 ± 9 years old, 13 ± 8 years with diabetes, A1C = 8.4% ± 1.2%) were randomized to either a group map-based program (intervention) or group education on cholesterol and blood pressure (control). Participants were assessed for A1C levels, diabetes self-care behaviors (3-day pedometer readings, 6-minute walk test, blood glucose checks, frequency of self-care), and psychosocial factors (distress, frustration, quality of life) at baseline, 3, 6, and 12 months post intervention and health literacy at baseline.

RESULTS

Groups did not differ on baseline characteristics including A1C levels, health literacy, or self-care; however, the intervention group had more years of education than controls. Intervention arm participants modestly improved A1C levels at 3 months post intervention but did not maintain that improvement at 6 and 12 months while control patients did not improve A1C levels at any time during follow-up. Importantly, frequency of self-reported self-care, diabetes quality of life, diabetes-related distress, and frustration with diabetes self-care improved in both groups over time.

CONCLUSIONS

Reinforcing self-care with diabetes education for patients who have not met glycemic targets helps improve A1C and could be considered a necessary component of ongoing diabetes care. The best method to accomplish reinforcement needs to be established.

Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society

OBJECTIVE

To review the evidence about the impact of hypoglycemia on patients with diabetes that has become available since the past reviews of this subject by the American Diabetes Association and The Endocrine Society and to provide guidance about how this new information should be incorporated into clinical practice.

PARTICIPANTS

Five members of the American Diabetes Association and five members of The Endocrine Society with expertise in different aspects of hypoglycemia were invited by the Chair, who is a member of both, to participate in a planning conference call and a 2-day meeting that was also attended by staff from both organizations. Subsequent communications took place via e-mail and phone calls. The writing group consisted of those invitees who participated in the writing of the manuscript. The workgroup meeting was supported by educational grants to the American Diabetes Association from Lilly USA, LLC and Novo Nordisk and sponsorship to the American Diabetes Association from Sanofi. The sponsors had no input into the development of or content of the report.

EVIDENCE

The writing group considered data from recent clinical trials and other studies to update the prior workgroup report. Unpublished data were not used. Expert opinion was used to develop some conclusions.

CONSENSUS PROCESS

Consensus was achieved by group discussion during conference calls and face-to-face meetings, as well as by iterative revisions of the written document. The document was reviewed and approved by the American Diabetes Association's Professional Practice Committee in October 2012 and approved by the Executive Committee of the Board of Directors in November 2012 and was reviewed and approved by The Endocrine Society's Clinical Affairs Core Committee in October 2012 and by Council in November 2012.

CONCLUSIONS

The workgroup reconfirmed the previous definitions of hypoglycemia in diabetes, reviewed the implications of hypoglycemia on both short- and long-term outcomes, considered the implications of hypoglycemia on treatment outcomes, presented strategies to prevent hypoglycemia, and identified knowledge gaps that should be addressed by future research. In addition, tools for patients to report hypoglycemia at each visit and for clinicians to document counseling are provided.

The ability of health promoters to deliver group diabetes education in South African primary care

Background

Diabetes makes a significant contribution to the burden of disease in South Africa. This study assesses a group diabetes education programme using motivational interviewing in public sector health centres serving low socio-economic communities in Cape Town. The programme was delivered by mid-level health promotion officers (HPOs).

Objectives

The aim of the study was to explore the experience of the HPOs and to observe their fidelity to the educational programme.

Methods

Three focus group interviews were held with the 14 HPOs who delivered the educational programme in 17 health centres. Thirty-three sessions were observed directly and the audio tapes were analysed using the motivational interviewing (MI) integrity code.

Results

The HPOs felt confident in their ability to deliver group education after receiving the training. They reported a significant shift in their communication style and skills. They felt the new approach was feasible and better than before. The resource material was found to be relevant, understandable and useful. The HPOs struggled with poor patient attendance and a lack of suitable space at the facilities. They delivered the majority of the content and achieved beginning-level proficiency in the MI guiding style of communication and the use of open questions. The HPOs did not demonstrate proficiency in active listening and continued to offer some unsolicited advice.

Conclusion

The HPOs demonstrated their potential to deliver group diabetes education despite issues that should be addressed in future training and the district health services. The findings will help with the interpretation of results from a randomised controlled trial evaluating the effectiveness of the education.

Diabetes group visits: integrated medical care and behavioral support to improve diabetes care and outcomes from a primary care perspective

Of the many innovations in health care delivery proposed in the context of health reform for those with chronic diseases such as diabetes, the group visit model is relatively easy to implement and is effective for improving health outcomes and patient and provider satisfaction, with a neutral to positive effect on health care costs. This article describes the evolution of group visits for those with diabetes, the theory underlying group visits for patients with chronic medical conditions, and the existing evidence for the effectiveness of this model. It also addresses implementation of groups in practice, with an emphasis on the practical aspects of program implementation, integration of behavioral expertise into medical groups, individualization in various practice settings, and reimbursement issues.

Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus

BACKGROUND

Diabetes is one of the commonest chronic medical conditions, affecting around 347 million adults worldwide. Structured patient education programmes reduce the risk of diabetes-related complications four-fold. Internet-based self-management programmes have been shown to be effective for a number of long-term conditions, but it is unclear what are the essential or effective components of such programmes. If computer-based self-management interventions improve outcomes in type 2 diabetes, they could potentially provide a cost-effective option for reducing the burdens placed on patients and healthcare systems by this long-term condition.

OBJECTIVES

To assess the effects on health status and health-related quality of life of computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus.

SEARCH METHODS

We searched six electronic bibliographic databases for published articles and conference proceedings and three online databases for theses (all up to November 2011). Reference lists of relevant reports and reviews were also screened.

SELECTION CRITERIA

Randomised controlled trials of computer-based self-management interventions for adults with type 2 diabetes, i.e. computer-based software applications that respond to user input and aim to generate tailored content to improve one or more self-management domains through feedback, tailored advice, reinforcement and rewards, patient decision support, goal setting or reminders.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the abstracts and extracted data. A taxonomy for behaviour change techniques was used to describe the active ingredients of the intervention.

MAIN RESULTS

We identified 16 randomised controlled trials with 3578 participants that fitted our inclusion criteria. These studies included a wide spectrum of interventions covering clinic-based brief interventions, Internet-based interventions that could be used from home and mobile phone-based interventions. The mean age of participants was between 46 to 67 years old and mean time since diagnosis was 6 to 13 years. The duration of the interventions varied between 1 to 12 months. There were three reported deaths out of 3578 participants.Computer-based diabetes self-management interventions currently have limited effectiveness. They appear to have small benefits on glycaemic control (pooled effect on glycosylated haemoglobin A1c (HbA1c): -2.3 mmol/mol or -0.2% (95% confidence interval (CI) -0.4 to -0.1; P = 0.009; 2637 participants; 11 trials). The effect size on HbA1c was larger in the mobile phone subgroup (subgroup analysis: mean difference in HbA1c -5.5 mmol/mol or -0.5% (95% CI -0.7 to -0.3); P < 0.00001; 280 participants; three trials). Current interventions do not show adequate evidence for improving depression, health-related quality of life or weight. Four (out of 10) interventions showed beneficial effects on lipid profile.One participant withdrew because of anxiety but there were no other documented adverse effects. Two studies provided limited cost-effectiveness data - with one study suggesting costs per patient of less than $140 (in 1997) or 105 EURO and another study showed no change in health behaviour and resource utilisation.

AUTHORS' CONCLUSIONS

Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control and the effect was larger in the mobile phone subgroup. There is no evidence to show benefits in other biological outcomes or any cognitive, behavioural or emotional outcomes.

Non-pharmacological interventions for preventing secondary vascular events after stroke or transient ischemic attack

BACKGROUND

Stroke is the second leading cause of death among adults worldwide. Individuals who have suffered a stroke are at high risk of having another stroke likely leading to greater disability and institutionalization. Non-pharmacological interventions may have a role to play in averting a second stroke.

OBJECTIVES

To determine the effectiveness of multi-modal programs of non-pharmacological interventions compared with usual care in preventing secondary vascular events and reducing vascular risk factors after stroke or transient ischemic attack (TIA).

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (September 2012); The Cochrane Library databases CENTRAL, CDSR, DARE, HTA and NHS EED (2012 Issue 2); MEDLINE (1950 to February 2012); EMBASE (1974 to February 2012); CINAHL (1982 to February 2012); SPORTDiscus (1800 to February 2012); PsycINFO (1887 to February 2012) and Web of Science (1900 to February 2012). We also searched PEDro, OT Seeker, OpenSIGLE, REHABDATA and Dissertation Abstracts (February 2012). In an effort to identify further published, unpublished and ongoing trials we searched trials registers, scanned reference lists, and contacted authors and researchers.

SELECTION CRITERIA

We included randomized controlled trials evaluating the use of non-pharmacological interventions that included components traditionally used in cardiac rehabilitation (CR) programs in adults with stroke or TIA. Primary outcomes were a cluster of second stroke or myocardial infarction or vascular death. Secondary outcomes were (1) secondary vascular events: second stroke, myocardial infarction, and vascular death, as well as (2) vascular risk factors: blood pressure, body weight, lipid profile, insulin resistance and tobacco use. We also recorded adverse events such as exercise-related musculoskeletal injuries or cardiovascular events.

DATA COLLECTION AND ANALYSIS

Two review authors independently scanned titles and abstracts and independently screened full reports of studies that were potentially relevant. At each stage, we compared results. The two review authors resolved disagreements through discussion or by involving a third review author.

MAIN RESULTS

We identified one study, involving 48 participants, of a 10-week CR program for patients post-stroke that met the inclusion criteria. The results of this completed pilot trial show that patients post-stroke had significantly greater improvement in cardiac risk score in the CR group (13.4 ± 10.1 to 12.4 ± 10.5, P value < 0.05) when compared with usual care (9.4 ± 6.7 to 15.0 ± 6.1, P value < 0.05). In addition, five trials, which are ongoing, will likely meet the inclusion criteria for this review once completed.

AUTHORS' CONCLUSIONS

There is limited applicable evidence. Therefore, no implications for practice can be drawn. Further research is required and several trials are underway, the findings of which are anticipated to contribute to the body of evidence.

Internet-enabled pulmonary rehabilitation and diabetes education in group settings at home: a preliminary study of patient acceptability

Background

The prevalence of major chronic illnesses, such as chronic obstructive pulmonary disease (COPD) and diabetes, is increasing. Pulmonary rehabilitation and diabetes self-management education are important in the management of COPD and diabetes respectively. However, not everyone can participate in the programmes offered at a hospital or other central locations, for reasons such as travel and transport. Internet-enabled home-based programmes have the potential to overcome these barriers.

This study aims to assess patient acceptability of the delivery form and components of Internet-enabled programmes based on home groups for comprehensive pulmonary rehabilitation and for diabetes self-management education.

Methods

We have developed Internet-enabled home programmes for comprehensive pulmonary rehabilitation and for diabetes self-management education that include group education, group exercising (COPD only), individual consultations, educational videos and a digital health diary. Our prototype technology platform makes use of each user’s own TV at home, connected to a computer, and a remote control. We conducted a six-week home trial with 10 participants: one group with COPD and one with diabetes. The participants were interviewed using semi-structured interviews.

Results

Both home-based programmes were well accepted by the participants. The group setting at home made it possible to share experiences and to learn from questions raised by others, as in conventional group education. In the sessions, interaction and discussion worked well, despite the structure needed for turn taking. The thematic educational videos were well accepted although they were up to 40 minutes long and their quality was below TV broadcasting standards. Taking part in group exercising at home under the guidance of a physiotherapist was also well accepted by the participants. Participants in the COPD group appreciated the social aspect of group education sessions and of exercising together, each in their own home. The digital health diary was used as background information in the individual consultations and by some participants as a self-management tool. Participant retention was high, with no dropouts. None of the participants reported that the six-week duration of the home programmes was too long.

Conclusions

The Internet-enabled programmes for home-based groups in pulmonary rehabilitation and diabetes education were generally well accepted by the participants. Our findings indicate that conventional programmes have the potential to be delivered in socially supportive group settings at home.

Role of self-care in management of diabetes mellitus

Diabetes mellitus (DM) is a chronic progressive metabolic disorder characterized by hyperglycemia mainly due to absolute (Type 1 DM) or relative (Type 2 DM) deficiency of insulin hormone. World Health Organization estimates that more than 346 million people worldwide have DM. This number is likely to more than double by 2030 without any intervention. The needs of diabetic patients are not only limited to adequate glycemic control but also correspond with preventing complications; disability limitation and rehabilitation. There are seven essential self-care behaviors in people with diabetes which predict good outcomes namely healthy eating, being physically active, monitoring of blood sugar, compliant with medications, good problem-solving skills, healthy coping skills and risk-reduction behaviors. All these seven behaviors have been found to be positively correlated with good glycemic control, reduction of complications and improvement in quality of life. Individuals with diabetes have been shown to make a dramatic impact on the progression and development of their disease by participating in their own care. Despite this fact, compliance or adherence to these activities has been found to be low, especially when looking at long-term changes. Though multiple demographic, socio-economic and social support factors can be considered as positive contributors in facilitating self-care activities in diabetic patients, role of clinicians in promoting self-care is vital and has to be emphasized. Realizing the multi-faceted nature of the problem, a systematic, multi-pronged and an integrated approach is required for promoting self-care practices among diabetic patients to avert any long-term complications.

Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial

PURPOSE

Peer health coaches offer a potential model for extending the capacity of primary care practices to provide self-management support for patients with diabetes. We conducted a randomized controlled trial to test whether clinic-based peer health coaching, compared with usual care, improves glycemic control for low-income patients who have poorly controlled diabetes.

METHOD

We undertook a randomized controlled trial enrolling patients from 6 public health clinics in San Francisco. Twenty-three patients with a glycated hemoglobin (HbA1C) level of less than 8.5%, who completed a 36-hour health coach training class, acted as peer coaches. Patients from the same clinics with HbA1C levels of 8.0% or more were recruited and randomized to receive health coaching (n = 148) or usual care (n = 151). The primary outcome was the difference in change in HbA1C levels at 6 months. Secondary outcomes were proportion of patients with a decrease in HbA1C level of 1.0% or more and proportion of patients with an HbA1C level of less than 7.5% at 6 months. Data were analyzed using a linear mixed model with and without adjustment for differences in baseline variables.

RESULTS

At 6 months, HbA1C levels had decreased by 1.07% in the coached group and 0.3% in the usual care group, a difference of 0.77% in favor of coaching (P = .01, adjusted). HbA1C levels decreased 1.0% or more in 49.6% of coached patients vs 31.5% of usual care patients (P = .001, adjusted), and levels at 6 months were less than 7.5% for 22.0% of coached vs 14.9% of usual care patients (P = .04, adjusted).

CONCLUSIONS

Peer health coaching significantly improved diabetes control in this group of low-income primary care patients.

A tailored, interactive health communication application for patients with type 2 diabetes: study protocol of a randomised controlled trial

BACKGROUND

Type 2 diabetes is an increasingly common chronic condition whose prognosis can be improved by patient involvement and self-management. Patient involvement can be fostered by web-based Interactive Health Communication Applications (IHCAs) combining health information with decision support, social support and/or behaviour change support. They reach great numbers of patients at low cost and provide high-quality information and support at the time, place and learning speed patients prefer. Still, online tools often suffer from high attrition. Tailoring content and tone of IHCAs to the individual patient´s needs might improve their effectiveness. This study aims to test the effectiveness and usage of a tailored IHCA combining health information with decision support and behaviour change support for patients with type 2 diabetes.

METHODS/DESIGN

The effectiveness and usage of the tailored IHCA will be tested against a standard website with identical content in a single-blinded randomized trial with a parallel design. The content covers information on type 2 diabetes, its complications and sequelae, and its treatment options including health behaviour. In the intervention group the content is delivered in dialogue form, tailored to relevant patient characteristics (health literacy, attitudes towards self-care, and barriers to insulin treatment). In the control group the different sections are presented in a content tree, without any tailoring. Participants are blinded to group assignment. Eligibility criteria are age ≥ 18 years, self-reported type 2 diabetes, and Internet access. The study aims to include 414 participants in order to detect the expected small effect (Cohen's d=0.2), with measurements at baseline, directly after the first visit, and at 3-month follow-up. The primary hypothesis is that the tailored IHCA has larger effects on diabetes knowledge and patient empowerment (primary outcomes) than the standard website. Secondary outcomes are website usage as well as decisional conflict and preparation for decision making. All measurements are online self-report questionnaires.

DISCUSSION

IHCAs are a promising way to foster diabetes knowledge and self-management competencies. The present trial tries to increase the knowledge on how to develop more effective IHCAs for patients with type 2 diabetes.

TRIAL REGISTRATION

International Clinical Trials Registry DRKS00003322.

Effectiveness of a quality improvement intervention targeting cardiovascular risk factors: are patients responsive to information and encouragement by mail or post?

Introduction

There is important evidence on the beneficial effects of treatment of cardiovascular risk factors in terms of morbidity and mortality, but important challenges remain in motivating patients to adhere to their treatment regimen. This study aimed to describe the effectiveness of a quality improvement intervention that included information and regular encouragement by email or letter on cardiovascular risk factors for patients at high risk for cardiovascular disease.

Methods

This randomized single-blind study included patients of both sexes aged between 45 and 80 years old who had increased cardiovascular risk. Patients were randomly allocated to either a usual care group (UCG) or advanced care group (ACG). Patients in the UCG received regular care while patients in the ACG received usual care plus regular information and encouragement on cardiovascular risk factors by email or letter. Visits for both groups were planned at 0, 3, and 6 months. The outcome measures were blood pressure, weight, body mass index (BMI), waist circumference (WC), and smoking status.

Results

Out of 178 eligible patients from one single primary care practice, 55 participated in the study, three of whom dropped out. After 6 months, there was a significant decrease in mean systolic and diastolic blood pressure in the UCG and ACG (P < 0.05). The decreases were already significant after 3 months, except for systolic blood pressure in the UCG. There was also a significant increase in the proportion of patients who met the target values for blood pressure in the UCG and ACG. There was a nonsignificant decrease of the average weight in the ACG, but significantly more patients lost weight in the UCG (P = 0.02). BMI, WC, and smoking status did not change in either group.

Conclusion

This study found that there was a significant decrease of systolic and diastolic blood pressure in both study groups. Weight, BMI, WC, and smoking did not improve in either group. Information on cardiovascular risk factors and encouragement by means of letters or email did not provide additional benefits. Thus, effective patient empowerment probably requires more behaviorally sophisticated support to increase self-management, self-efficacy, and self-esteem in patients.

Validation of an information-motivation-behavioral skills model of self-care among Chinese adults with type 2 diabetes

BACKGROUND

Self-care is a crucial component of diabetes management. But comprehensive behavior change frameworks are needed to provide guidance for the design, implementation, and evaluation of diabetes self-care programs in diverse populations. We tested the Information-Motivation-Behavioral Skills (IMB) model in a sample of Chinese adults with Type 2 diabetes.

METHODS

A cross-sectional study of 222 Chinese adults with type 2 diabetes was conducted in a primary care center. We collected information on demographics, provider-patient communication (knowledge), social support (motivation), self-efficacy (behavioral skills), and diabetes self-care (behavior). The values of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were also obtained. Measured variable path analyses were used to the IMB framework.

RESULTS

Provider-patient communication (β = 0.12, p = .037), and social support (β = 0.19, p = .007) and self-efficacy (β = 0.41, p < .001) were independent, direct predictors of diabetes self-care behavior. Diabetes self-care behaviors had a direct effect on TC/HDL-C (β = -0.31, p < .001) and LDL-C/HDL-C (β = -0.30, p < .001).

CONCLUSIONS

Consistent with the IMB model, having better provider-patient communication, having social support, and having higher self-efficacy was associated with performing diabetes self-care behaviors; and these behaviors were directly linked to lipid control. The findings indicate that diabetes education programs should including strategies enhancing patients' knowledge, motivation and behavioral skills to effect behavior change.

Disparities in attendance at diabetes self-management education programs after diagnosis in Ontario, Canada: a cohort study

BACKGROUND

Patients newly-diagnosed with diabetes require self-management education to help them understand and manage the disease. The goals of the study were to determine the frequency of diabetes self-management education program utilization by newly-diagnosed patients, and to evaluate whether there were any demographic or clinical disparities in utilization.

METHODS

Using population-level health care data, all 46,553 adults who were diagnosed with any type of non-gestational diabetes in Ontario, Canada between January and June 2006 were identified. They were linked with a diabetes self-management education program registry to identify those who attended within 6 months of diagnosis. The demographic and clinical characteristics of attendees and non-attendees were compared.

RESULTS

A total of 9,568 (20.6%) patients attended a diabetes self-management education program within 6 months of diagnosis. Younger age, increasing socioeconomic status, and the absence of mental health conditions or other medical comorbidity were associated with attendance. Patients living in rural areas, where access to physicians may be limited, were markedly more likely to attend. Recent immigrants were 40% less likely to attend self-management education programs than longer-term immigrants or nonimmigrants.

CONCLUSION

Only one in five newly-diagnosed diabetes patients attended a diabetes self-management education program. Demographic and clinical disparities in utilization persisted despite a publicly-funded health care system where patients could access these services without direct charges. Primary care providers and education programs must ensure that more newly-diagnosed diabetes patients receive self-management education, particularly those who are older, poorer, sicker, or recent immigrants.

Community-based physical activity interventions for treatment of type 2 diabetes: a systematic review with meta-analysis

Evidence suggests engaging in regular physical activity (PA) can have beneficial outcomes for adults with type 2 diabetes (TD2), including weight loss, reduction of medication usage and improvements in hemoglobin A1c (HbA1c)/fasting glucose. While a number of clinical-based PA interventions exist, community-based approaches are limited. The objective of this study is to conduct a systematic review with meta-analysis to assess the effectiveness of community-based PA interventions for the treatment of TD2 in adult populations. A search of peer-reviewed publications from 2002 to June 2012 was conducted across several electronic databases to identify interventions evaluated in community settings. Twenty-two studies were identified, and 11 studies reporting HbA1c as an outcome measure were pooled in the meta-analysis. Risk of bias assessment was also conducted. The findings demonstrate community-based PA interventions can be effective in producing increases in PA. Meta-analysis revealed a lowering of HbA1c levels by -0.32% [95% CI -0.65, 0.01], which approached statistical significance (p < 0.06). Our findings can guide future PA community-based interventions in adult populations diagnosed with TD2.

Health information, behavior change, and decision support for patients with type 2 diabetes: development of a tailored, preference-sensitive health communication application

PURPOSE

Patient involvement in diabetes treatment such as shared decision-making and patient self-management has significant effects on clinical parameters. As a prerequisite for active involvement, patients need to be informed in an adequate and preference-sensitive way. Interactive Health Communication Applications (IHCAs) that combine web-based health information for patients with additional support offer the opportunity to reach great numbers of patients at low cost and provide them with high-quality information and support at the time, place, and learning speed they prefer. Still, web-based interventions often suffer from high attrition. Tailoring the intervention to patients' needs and preferences might reduce attrition and should thereby increase effectiveness. The purpose of this study was to develop a tailored IHCA offering evidence-based, preference-sensitive content and treatment decision support to patients with type 2 diabetes. The content was developed based on a needs assessment and two evidence-based treatment guidelines. The delivery format is a dialogue-based, tunneled design tailoring the content and tone of the dialogue to relevant patient characteristics (health literacy, attitudes toward self-care, and psychological barriers to insulin treatment). Both content and tailoring were revised by an interdisciplinary advisory committee.

CONCLUSION

The World Wide Web holds great potential for patient information and self-management interventions. With the development and evaluation of a tailored IHCA, we complement face-to-face consultations of patients with their health care practitioners and make them more efficient and satisfying for both sides. Effects of the application are currently being tested within a randomized controlled trial.

Adherence to ocular hypotensive therapy: patient health education needs and views on group education

BACKGROUND

In this study the authors sought both to understand the health education needs of patients with glaucoma, with particular regard to adherence to glaucoma treatment, and to examine these patients' views of group education.

METHODS

Using a health promotion approach to health education, 27 qualitative interviews with new and established patients receiving glaucoma treatment were conducted. Health promotion is defined as a way of strengthening people's capacities to control and optimize their own health. The interviews were transcribed and were then analyzed thematically

RESULTS

NINE CATEGORIES OF HEALTH EDUCATION NEEDS WERE IDENTIFIED FROM THE TRANSCRIPTS: (1) to understand glaucoma; (2) to understand their diagnosis or understand the difficulties in giving a diagnosis; (3) to understand the implications of eye drops, their side effects, and how to renew the eye drops; (4) to feel confident to put in eye drops; (5) to put the condition into perspective - to know how to manage their risk; (6) to be able to ask questions of clinicians; (7) to be able to navigate the health care system; (8) to understand and be able to manage own adherence behavior; and (9) to know where to access other sources of information. The majority of patients had something positive to say about group education, and about half of the patients said they would attend group education if they were offered the opportunity.

CONCLUSION

A health promotion approach identified a wide range of patient-centered health education needs regarding adherence to glaucoma treatment. Group education will be attractive to some patients. Clinicians could use the health education needs identified in this study to guide the development of either individual or group-based educational intervention to improve adherence to glaucoma treatment. However, clinicians need to be aware that when developing a group intervention, attention will need to be given to making the education relevant to the circumstances of each patient.

Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial

BACKGROUND

Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33% have been recorded in Cape Town. Previous studies show that quality of care and health outcomes are poor. The development of an effective education programme should impact on self-care, lifestyle change and adherence to medication; and lead to better control of diabetes, fewer complications and better quality of life.

METHODS

TRIAL DESIGN

Pragmatic cluster randomized controlled trialParticipants: Type 2 diabetic patients attending 45 public sector community health centres in Cape TownInterventions: The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style. The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room.

OBJECTIVE

To evaluate the effectiveness of the group diabetes education programmeOutcomes:

PRIMARY OUTCOMES

diabetes self-care activities, 5% weight loss, 1% reduction in HbA1c.

SECONDARY OUTCOMES

self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol, quality of lifeRandomisation: Computer generated random numbersBlinding: Patients, health promoters and research assistants could not be blinded to the health centre's allocationNumbers randomized: Seventeen health centres (34 in total) will be randomly assigned to either control or intervention groups. A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80% to detect the primary outcomes with 5% precision. Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570.

DISCUSSION

The study will inform policy makers and managers of the district health system, particularly in low to middle income countries, if this programme can be implemented more widely.

TRIAL REGISTER

Pan African Clinical Trial Registry PACTR201205000380384.

Doctors' and nurses' views on patient care for type 2 diabetes: an interview study in primary health care in Oman

Aim

This study aimed at exploring the experiences of primary health-care providers of their encounters with patients with type 2 diabetes, and their preferences and suggestions for future improvement of diabetes care.

Background

Barriers to good diabetes care could be related to problems from health-care providers’ side, patients’ side or the health-care system of the country. Treatment of patients with type 2 diabetes has become a huge challenge in Oman, where the prevalence has increased to high levels.

Method

Semi-structured interviews were conducted with 26 health-care professionals, 19 doctors and seven nurses, who worked in primary health care in Oman. Qualitative content analysis was applied.

Findings

Organizational barriers and barriers related to patients and health-care providers were identified. These included workload and lack of teamwork approach. Poor patients’ management adherence and influence of culture on their attitudes towards illness were identified. From the providers’ side, language barriers, providers’ frustration and aggressive attitudes towards the patients were reflected. Decreasing the workload, availability of competent teams with diabetes specialist nurses and continuity of care were suggested. Furthermore, changing professional behaviours towards a more patient-centred approach and need for health education to the patients, especially on self-management, were addressed. Appropriate training for health-care providers in communication skills with emphasis on self-care education and individualization of care according to each patient's needs are important for improvement of diabetes care in Oman.

Mechanistic studies of lifestyle interventions in type 2 diabetes

AIM: To investigate the effect of lifestyle interventions in the non-pharmacological management of type 2 diabetes via a mechanistic approach.

METHODS: A randomized controlled trial was carried out on 60 type 2 diabetic male and female volunteers that fulfilled the inclusion criteria, with their proper consent and permission of the International Electrotechnical Commission for 1 year. 30 patients were included in the test group and 30 patients in the control group. Demographic details, anthropometrical status, physical activity, food habits and blood glucose lipid profile of the volunteers were recorded at baseline, the test group was directed for lifestyle intervention and final blood glucose lipid data were collected at the end of one year of patient follow-up.

RESULTS: After 1 year, the test group who had a lifestyle intervention was found to show a significant improvement in blood glucose lipid profile. The fasting plasma glucose level (FPG), postprandial plasma glucose level (PPG), glycosylated hemoglobin (HbA1c) and body mass index (BMI) values of the test group were reduced significantly, up to 145 ± 2.52, 174 ± 2.59, 6.3 ± 0.32 and 25 ± 0.41 respectively at the end of the study period, in comparison to the control group where FPG, PPG, HbA1c and BMI values were 193 ± 3.36, 249 ± 4.24, 7.2 ± 0.42 and 26 ± 0.65 respectively. Improvement in the total cholesterol (TC), triglyceride (TG), high-density lipoproteins (HDL) and low-density lipoproteins (LDL) values of the test group was also remarkable in comparison to the control group. The TC, TG, HDL and LDL values of the test group were reduced significantly, up to 149 ± 3.32, 124 ± 2.16, 58 ± 0.62 and 118 ± 2.31, respectively.

CONCLUSION: The significant improvement in the blood glucose lipid profile of the test group after 1 year signifies the value of non-pharmacological management of type 2 diabetes via lifestyle intervention strategies.

Effectiveness of using group visit model to support diabetes patient self-management in rural communities of Shanghai: a randomized controlled trial

Background

Diabetes has become a major public health problem in China. Support of patient self-management is a key component of effective diabetes care and improved patient outcomes. A series of peer-led community-based disease-specific self-management programs including diabetes have been widely disseminated in urban communities of Shanghai since 1999. However, the strategy of using trained lay leaders to support patient self-management faces challenges in rural communities in Shanghai. This study developed a Chinese diabetes group visit program as an alternative approach to support patient self-management and examined its effectiveness on self-management behaviors, self-efficacy and health status for patients with type 2 diabetes in rural communities of Shanghai.

Methods

208 patients with type 2 diabetes aged 35–80 years were randomly assigned to the intervention group (n=119) of 12 monthly group visit sessions or to a control group (n=89) of usual care. The trial was undertaken in two rural communities in Shanghai, China. Randomization and allocation to study group were carried out by using a random number table. Analysis of covariance was used to compare changes in the 17 self-management behavior, self-efficacy and health status related variables in two groups at 12 months’ follow-up based on 176 patients (n=98; n=78).

Results

Compared with controls, the intervention patients, on average, increased their duration of aerobic exercise by more than 40 minutes per week (p=0.001); had significant increase of 0.71 in mean score on self-efficacy to manage diabetes (p=0.02); and had significant improvements in measures of illness intrusiveness and systolic blood pressure. The intervention patients attended an average of 10.1 of the 12 program sessions with 75.6% of them attended 10 and more sessions.

Conclusion

The Chinese diabetes group visit model is a feasible, acceptable and effective alternative for supporting diabetes patient self-management in Chinese rural communities. The model requires larger studies to determine its effect on blood glucose control and health care utilization.

Trial registration

ISRCTN87909028

Translating patient self-management research into primary care: challenges and successes with group medical visits

Essential to the implementation of a patient-centered medical home is use of evidence-based interventions by a well-coordinated team of providers in a cost-effective manner. Group Medical Visits (GMVs), designed to increase self-management behaviors in patients with chronic illness, have shown inconsistently to be efficacious. Despite the modest results reported thus far in the literature, GMVs have been promoted by the American Academy of Family Physicians as an important component in the patient-centered medical home. This paper describes the challenges of translating GMVs into clinical practice when research support is not available. A review of 5+ years experience in conducting GMVs in clinical practice, including the numerous barriers, is presented through a "three-world view" model utilized by collaborative care leaders. This review is followed by a comparison of variables extracted from patients' electronic health records of those who participated in GMVs to similar patients who did not participate in GMVs. Results suggest that outcomes often reported in efficacy trials are not easily obtained in real clinical practice. Overcoming the operational and financial obstacles to offering GMVs is necessary before they can be promoted as essential elements in a patient-centered medical home.