Goal setting in diabetes self-management: taking the baby steps to success

Self-management goals of cancer survivors with an ostomy

OBJECTIVES

Ostomies due to cancer surgery impose complex and enduring care challenges that necessitate cancer survivors" self-management. The objective of this analysis is to evaluate ostomates' self- management goals using a qualitative approach.

METHODS

A multi-site randomized controlled trial testing the Ostomy Self-Management Training program (OSMT) was delivered via telehealth to a group of cancer survivors with an ostomy randomized to either the OSMT program with goal setting or usual care (UC), without goal setting. Goals were classified by type and frequency according to a modified City of Hope Health-Related Quality of Life framework (physical, psychological, social, spiritual, ostomy-specific, and healthcare quality domains), using a directed and systematic content analysis approach.

RESULTS

The 524 self-management goals analyzed by domain frequencies physical (29.4%), ostomy specific (29.0%) and social well-being (25.0%) were predominant. Managing other health issues (7.6%), psychological issues (6.0%), and spiritual well-being issues (3.0%) were next. Common self-management themes were ostomy care independence (87.5%), handling cancer-related issues (62.5%), achieving acceptance (56.2%), resuming physical activity (43.0%), and maintaining fluid/diet balance (43.0%).

DISCUSSION/CONCLUSION

Goal-setting offers insights into self-management concerns of cancer survivors with ostomies. Results demonstrate the broad aspects of self-management ostomates face.

PRACTICE IMPLICATIONS

Self-management training with patient goal-setting may be used to help ostomates with cancer and their health care providers identify areas for needed education and support.

Non-pharmacological interventions for self-management of fatigue in adults: An umbrella review of potential interventions to support patients recovering from critical illness

PURPOSE

Fatigue is a common symptom after critical illness. However, evidence-based interventions for fatigue after critical illness are lacking. We aimed to identify interventions to support self-management of fatigue caused by physical conditions and assess their effectiveness and suitability for adaptation for those with fatigue after critical illness.

MATERIALS AND METHODS

We conducted an umbrella review of systematic reviews. Databases included CINAHL, PubMed, Medline, PsycINFO, British Nursing Index (BNI), Web of Science, Cochrane Database of Systematic Reviews (CDSR), JBI Evidence Synthesis Database, and PROSPERO register. Included reviews were appraised using the JBI Checklist for Systematic Reviews and Research Syntheses. Results were summarised narratively.

RESULTS

Of the 672 abstracts identified, 10 met the inclusion criteria. Reviews focused on cancer (n = 8), post-viral fatigue (n = 1), and Systemic Lupus Erythematosus (SLE) (n = 1). Primary studies often did not address core elements of self-management. Positive outcomes were reported across all reviews, and interventions involving facilitator support appeared to be most effective.

CONCLUSIONS

Self-management can be effective at reducing fatigue symptoms and improving quality of life for physical conditions and has clear potential for supporting people with fatigue after critical illness, but more conclusive data on effectiveness and clearer definitions of self-management are required.

Effect of multidisciplinary collaborative empowerment education on psychological distress and quality of life in patients with colorectal cancer undergoing chemotherapy

PURPOSE

To evaluate the effects of multidisciplinary collaborative empowerment education on psychological distress and quality of life (QoL) in patients with colorectal cancer undergoing chemotherapy.

METHODS

A quasi-experimental study was conducted using repeated measures at pre- and post-intervention in the fourth chemotherapy cycle. Sixty patients with colorectal cancer aged 36-84 years were allocated to the intervention and control groups. The intervention group received multidisciplinary empowerment education, while the control group received routine health education. Psychological distress involving depression and anxiety symptoms was assessed using The Kessler Psychological Distress Scale (K10) and QoL was measured using The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTCQLQ-C30). Repeated-measures analysis of variance was used to examine intervention effects. Statistical analyses were performed using the SPSS software (version 26.0).

RESULTS

Psychological distress was considerably lower and QoL was considerably better in patients following multidisciplinary empowerment education in the intervention group than those in the control group. In addition, psychological distress significantly decreased and QoL improved in the intervention group compared to baseline.

CONCLUSION

Multidisciplinary collaborative empowerment education was effective in improving the psychological distress and QoL among patients with colorectal cancer undergoing chemotherapy. These findings suggest that the establishment of multidisciplinary collaborative empowerment education might be considered as an innovative means of clinical patient education during combination chemotherapy to improve health outcomes in patients with colorectal cancer. However, our results should be interpreted with caution because of the small sample size. Further validation in a larger sample or randomized controlled design is necessary in the future.

Patient Goals for Living with Rheumatoid Arthritis: A Qualitative Study

Rheumatoid arthritis is highly individualized in terms of its flare ups and periods of remission. Each patient's unique experience requires a high level of personalization in terms of treatment making it necessary to understand what their goals for living are. This study explores patient perceptions on how the burden of RA shapes patients' goals for living and their preferences for symptom and side-effect management within the United States. Fifteen patients diagnosed with RA with varying lengths of diagnosis were interviewed. A thematic analysis was conducted to construct a conceptual framework. Emerging themes identified disease burdens as: (1) inability to perform essential needs, (2) negative feelings about disease, and (3) its influence on relationships. These burdens shaped desired goals for living which guided the symptom and side-effect priorities the patient wanted managed. Practitioners should consider patient goals and preferences in conjunction with disease progression when engaging in treatment decisions.

Applying a socioecological framework to chronic disease management: implications for social informatics interventions in safety-net healthcare settings

Objective

Vulnerable populations face numerous barriers in managing chronic disease(s). As healthcare systems work toward integrating social risk factors into electronic health records and healthcare delivery, we need better understanding of the interrelated nature of social needs within patients' everyday lives to inform effective informatics interventions to advance health equity.

Materials and Methods

We conducted in-depth interviews, participant-led neighborhood tours, and clinic visit observations involving 10 patients with diabetes in underserved San Francisco neighborhoods and 10 community leaders serving those neighborhoods. We coded health barriers and facilitators using a socioecological framework. We also linked these qualitative data with early persona development, focusing on patients' experiences in these communities and within the healthcare system, as a starting place for our future informatics design.

Results

We identified social risk and protective factors across almost every socioecological domain and level-from physical disability to household context to neighborhood environment. We then detailed the complex interplay across domains and levels within two critical aspects of patients' lives: housing and food. Finally, from these data we generated 3 personas that capture the intersectional nature of these determinants.

Conclusion

Drawing from different disciplines, our study provides a socioecological approach to understanding health promotion for patients with chronic disease in a safety-net healthcare system, using multiple methodologies. Future digital health research should center the lived experiences of marginalized patients to effectively design and implement informatics solutions for this audience.

Living with severe asthma: the role of perceived competence and goal achievement

OBJECTIVE

The overall aim of this study was to examine, among individuals living with severe asthma, the role of perceived competence in achieving their goals.

METHODS

Qualitative research methods were used to conduct in-depth semistructured interviews. Interviews were video and/or audio recorded, transcribed and analyzed inductively and deductively, informed by the self-determination theory construct of perceived competence. Thirty-six face-to-face interviews, lasting 1.5-4 h, were conducted across Australia.

RESULTS

Feeling competent to achieve asthma goals played a role in participants' ability to achieve broader goals. Their desire to achieve their broader goals was strongly driven by their perceived ability to master managing their condition, which at times required more than medical strategies. Two main themes were discerned from the analysis: (1) learning how to look after yourself: self-care is important and (2) reaching an agreement with severe asthma: being at one with the illness.

DISCUSSION

This study highlighted the influence of perceived competence on self-management and goal achievement in severe asthma. Healthcare providers could explore patients' perceived competence to set and achieve goals, as a self-management strategy. Future research should consider these findings when developing and implementing patient-driven, self-management interventions for those living with severe asthma.

Utilizing continuous glucose monitoring in primary care practice: What the numbers mean

Use of continuous glucose monitoring (CGM) has been shown to improve glycemia control, reduce hypoglycemia, lower glycemic variability and enhance quality of life for individuals with type 1 diabetes and type 2 diabetes. However, many primary care physicians may be unfamiliar with the how CGM data can interpreted and acted upon. As adoption of this technology continues to grow, primary care physicians will be challenged to integrate CGM into their clinical practices. This article is intended to provide clinicians with practical guidance in interpreting and utilizing CGM data with their patients.

Evaluating the Impact of Goal Setting on Improving Diet Quality in Chronic Kidney Disease

Background: Improving diet quality in chronic kidney disease (CKD) is challenging due to a myriad of competing recommendations. Patient-centered goal setting can facilitate dietary behavior change; however, its role in improving diet quality in CKD has not been investigated.

Aim: The aim of the study is to evaluate the effects of goal setting on improving diet quality in stages 3–4 CKD.

Methods: Forty-one participants completed a 6-month dietitian-led telehealth (combined coaching calls and text messages) intervention as part of a larger RCT. Participants set one to two diet-related SMART goals and received weekly goal tracking text messages. Dietary intake was assessed using the Australian Eating Survey at baseline, 3, and 6 months, with diet quality determined using the Alternate Healthy Eating Index (AHEI).

Results: Significant improvements in AHEI (+6.9 points; 95% CI 1.2–12.7), vegetable (+1.1 serves; 95% CI 0.0–2.3) and fiber intake (+4.2 g; 95% CI 0.2–8.2) were observed at 3 months in participants setting a fruit and/or vegetable goal, compared with those who did not. However, no significant or meaningful changes were observed at 6 months. No other goal setting strategy appeared in effect on diet intake behavior or clinical outcomes in this group of CKD participants.

Conclusions: Patient-centered goal setting, particularly in relation to fruit and vegetable intake, as part of a telehealth coaching program, significantly improved diet quality (AHEI), vegetable and fiber intake over 3 months. More support may be required to achieve longer-term behavior change in stages 3–4 CKD patients.

A Web-Based Computer-Tailored Program to Improve Treatment Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial

Background

Adherence to core type 2 diabetes mellitus (T2DM) treatment behaviors is suboptimal, and nonadherence is generally not limited to one treatment behavior. The internet holds promise for programs that aim to improve adherence. We developed a computer-tailored eHealth program for patients with T2DM to improve their treatment adherence, that is, adherence to both a healthy lifestyle and medical behaviors.

Objective

The objective of this study is to examine the effectiveness of the eHealth program in a randomized controlled trial.

Methods

Patients with T2DM were recruited by their health professionals and randomized into either the intervention group, that is, access to the eHealth program for 6 months, or a waiting-list control group. In total, 478 participants completed the baseline questionnaire, of which 234 gained access to the eHealth program. Of the 478 participants, 323 were male and 155 were female, the mean age was 60 years, and the participants had unfavorable BMI and HbA_1c levels on average. Outcome data were collected through web-based assessments on physical activity (PA) levels, caloric intake from unhealthy snacks, and adherence to oral hypoglycemic agents (OHAs) and insulin therapy. Changes to separate behaviors were standardized and summed into a composite change score representing changes in the overall treatment adherence. Further standardization of this composite change score yielded the primary outcome, which can be interpreted as Cohen d (effect size). Standardized change scores observed in separate behaviors acted as secondary outcomes. Mixed linear regression analyses were conducted to examine the effectiveness of the intervention on overall and separate treatment behavior adherence, accommodating relevant covariates and patient nesting.

Results

After the 6-month follow-up assessment, 47.4% (111/234) of participants in the intervention group and 72.5% (177/244) of participants in the control group were retained. The overall treatment adherence improved significantly in the intervention group compared with the control group, reflected by a small effect size (d=0.27; 95% CI 0.032 to 0.509; P=.03). When considering changes in separate treatment behaviors, a significant decrease was observed only in caloric intake from unhealthy snacks in comparison with the control group (d=0.36; 95% CI 0.136 to 0.584; P=.002). For adherence to PA (d=−0.14; 95% CI −0.388 to 0.109; P=.27), OHAs (d=0.27; 95% CI −0.027 to 0.457; P=.08), and insulin therapy (d=0.35; 95% CI −0.066 to 0.773; P=.10), no significant changes were observed. These results from the unadjusted analyses were comparable with the results of the adjusted analyses, the per-protocol analyses, and the sensitivity analyses.

Conclusions

Our multibehavior program significantly improved the overall treatment adherence compared with the control group. To further enhance the impact of the intervention in the personal, societal, and economic areas, a wide-scale implementation of our eHealth intervention is suggested.

Trial Registration

Netherlands Trial Register NL664; https://www.trialregister.nl/trial/6664

Mindfulness Training for Primary Care for Portuguese-Speaking Immigrants: A Pilot Study

Background: Portuguese-speaking immigrants are a growing underserved population in the Unites States who experience high levels of psychological distress and increased vulnerability to mental health disorders such as depression and anxiety. Current evidence shows that mindfulness-based interventions (MBIs) are effective to promote physical and mental health among educated English speakers; nonetheless, the lack of diversity in the mindfulness literature is a considerable limitation. To our knowledge, the feasibility and acceptability of MBIs among Portuguese-speaking immigrants have not yet been investigated. Methods: This single-arm pilot study (N = 30) explored the feasibility, acceptability, and cultural aspects of Mindfulness Training for Primary Care (MTPC)-Portuguese among Portuguese-speaking immigrants in the Boston area. MTPC is an 8-week, primary care-adapted, referral-based, insurance-reimbursable, trauma-informed MBI that is fully integrated into a healthcare system. The study also examined intervention preliminary effectiveness on mental health outcomes (depression and anxiety symptoms) and self-regulation (emotional regulation, mindfulness, self-compassion, interoceptive awareness), and initiation of health behavior was explored. Results: Primary care providers referred 129 patients from 2018 to 2020. Main DSM-5 primary diagnoses were depression (76.3%) and anxiety disorders (6.7%). Participants (N = 30) attended a mean of 6.1 (SD 1.92) sessions and reported a mean of 213.7 (SD = 124.3) min of practice per week. All survey finishers would recommend the program to a friend, found the program helpful, and rated the overall program as "very good" or "excellent," and 93% would participate again, with satisfaction mean scores between 4.6 and 5 (Likert scale 0-5). Participants and group leaders provided feedback to refine MTPC-Portuguese culturally responsiveness regarding materials language, settings, time, food, and community building. Patients exhibited reductions in depression (d = 0.67; p < 0.001) and anxiety (d = 0.48; p = 0.011) symptoms, as well as enhanced emotional regulation (d = 0.45; p = 0.009), and among survey finishers, 50% initiated health behavior change through action plan initiation. Conclusion: This pilot study suggests that MTPC-Portuguese is feasible, acceptable, and culturally appropriate among Portuguese-speaking patients in the Boston area. Furthermore, the intervention might potentially decrease depression and anxiety symptoms, facilitate health behavior change, and improve emotional regulation. MTPC-Portuguese investigation with larger samples in controlled studies is warranted to support its dissemination and implementation in the healthcare system. Clinical Trial Registration: Identifier: NCT04268355.

'It is like learning how to live all over again' A systematic review of people's experiences of living with a chronic illness from a self-determination theory perspective

Objective: To conduct a systematic review and synthesis of qualitative evidence exploring the views and experiences of people living with a chronic illness that utilised self-determination theory. Methods: We searched MEDLINE via OvidSP, PsycINFO via OvidSP, PubMed, CINAHL, EMBASE, Google Scholar, the journals Qualitative Health Research and Qualitative Research. Studies were included if they used qualitative methods, explored the subjective experiences of people living with a chronic illness and underpinned the analysis with self-determination theory. Results: From 4605 articles, six met the inclusion criteria. The synthesis culminated in a line of argument that patients endeavoured to be 'free from disease'. People's desire to live a life free from disease required nurturing their: (1) need to feel empowered (autonomy), (2) perceived ability to self-care (competence) and, (3) their need to feel a sense of belonging (relatedness). Conclusion: This review has highlighted that the majority of studies included in this review focused on the clinical aspects of managing a chronic condition and changing patient health behaviours. This suggests that there is a need for deep reflection on the current practice of caring for patients with a chronic illness. Exploring the lived experience has the potential to unravel the psychological and emotional needs of those living with a chronic illness.

Effect of Telephone-Delivered Collaborative Goal Setting and Behavioral Activation vs Enhanced Usual Care for Depression Among Adults With Uncontrolled Diabetes: A Randomized Clinical Trial

IMPORTANCE

Depression symptoms are present in one-third of patients with diabetes, contributing to significant adverse consequences. Population screening of high-risk patients coupled with telephone delivery of evidence-based therapies for comorbid diabetes may address barriers to care.

OBJECTIVE

To evaluate the effectiveness of proactive population screening plus telephone delivery of a collaborative goal-setting intervention among high-risk patients with uncontrolled diabetes and depression.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, 225 participants (intervention [n = 136] and control [n = 89]) were enrolled from a regional Veterans Healthcare System serving Southeast Texas from November 1, 2012, through June 24, 2016. Data were gathered at baseline and 6 and 12 months after intervention. Patients selected had uncontrolled diabetes (hemoglobin A1c [HbA1c] >7.5%]) and clinically significant depression (Patient Health Questionnaire-9 scores [PHQ-9] ≥10) and were living more than 20 miles from the Veterans Affairs medical center. Data collection was completed on December 6, 2016, and final analyses were completed by January 25, 2018. All analyses were intent to treat.

INTERVENTIONS

Healthy Outcomes Through Patient Empowerment (HOPE) included 9 telephone sessions with 24 trained health care professionals using collaborative goal-setting and behavioral activation methods. The control group received enhanced usual care (EUC) and notification of high-risk status.

MAIN OUTCOMES AND MEASURES

Change in depression symptoms using PHQ-9 and glycemic control using HbA1c from baseline to 6 months and to 12 months. Secondary analyses evaluated clinically significant responses for these measures.

RESULTS

Among 225 participants, 202 (89.8%) were men, the mean (SD) age was 61.9 (8.3) years, 145 (64.4%) were married, and 156 (69.3%) had some education beyond high school. For the overall study, 38 participants (16.9%) were lost to follow-up or withdrew at 6 months and another 21 (9.3%) were lost to follow-up or withdrew at 12 months. Repeated-measures analysis with multiple imputation for missing data assessing the interaction of treatment group (HOPE vs EUC) and time (baseline, 6 months, and 12 months) found no significant improvement in PHQ-9 (β, 1.56; 95% CI, -0.68 to 3.81; P = .17) or HbA1c (β, -0.005; 95% CI, -0.73 to 0.72; P = .82). Analyses using t test for change from baseline to 12 months showed a HOPE vs EUC between-group mean difference for PHQ-9 of 2.14 (95% CI, 0.18 to 4.10; P = .03) and for HbA1c of -0.06% (95% CI, -0.61% to 0.50%; P = .83). A secondary analysis of patients experiencing a clinical response found that 52.1% of HOPE participants had clinically significant responses in PHQ-9 at 12 months vs 32.9% in EUC (difference, 0.19; 95% CI, 0.04-0.33; P = .01).

CONCLUSIONS AND RELEVANCE

Telephone-delivered, collaborative goal setting produced clinically significant reductions in depression symptoms but not glycemic control among patients who remained engaged at 12 months compared with EUC among a population screened sample of high-risk patients with diabetes and depression. Although the intervention created some lasting effect for depression, additional strategies are needed to maintain engagement of this high-risk population within an interprofessional team approach to primary care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01572389.

Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range

Improvements in sensor accuracy, greater convenience and ease of use, and expanding reimbursement have led to growing adoption of continuous glucose monitoring (CGM). However, successful utilization of CGM technology in routine clinical practice remains relatively low. This may be due in part to the lack of clear and agreed-upon glycemic targets that both diabetes teams and people with diabetes can work toward. Although unified recommendations for use of key CGM metrics have been established in three separate peer-reviewed articles, formal adoption by diabetes professional organizations and guidance in the practical application of these metrics in clinical practice have been lacking. In February 2019, the Advanced Technologies & Treatments for Diabetes (ATTD) Congress convened an international panel of physicians, researchers, and individuals with diabetes who are expert in CGM technologies to address this issue. This article summarizes the ATTD consensus recommendations for relevant aspects of CGM data utilization and reporting among the various diabetes populations.

Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range

Improvements in sensor accuracy, greater convenience and ease of use, and expanding reimbursement have led to growing adoption of continuous glucose monitoring (CGM). However, successful utilization of CGM technology in routine clinical practice remains relatively low. This may be due in part to the lack of clear and agreed-upon glycemic targets that both diabetes teams and people with diabetes can work toward. Although unified recommendations for use of key CGM metrics have been established in three separate peer-reviewed articles, formal adoption by diabetes professional organizations and guidance in the practical application of these metrics in clinical practice have been lacking. In February 2019, the Advanced Technologies & Treatments for Diabetes (ATTD) Congress convened an international panel of physicians, researchers, and individuals with diabetes who are expert in CGM technologies to address this issue. This article summarizes the ATTD consensus recommendations for relevant aspects of CGM data utilization and reporting among the various diabetes populations.

Diabetes empowerment scores among type 2 diabetes mellitus patients and its correlated factors: A cross-sectional study in a primary care setting in Malaysia

BACKGROUND

There are limited studies on diabetes empowerment among type 2 diabetes patients, particularly in the primary care setting.

AIM

To assess the diabetes empowerment scores and its correlated factors among type 2 diabetes patients in a primary care clinic in Malaysia.

METHODS

This is a cross sectional study involving 322 patients with type 2 diabetes mellitus (DM) followed up in a primary care clinic. Systematic sampling method was used for patient recruitment. The Diabetes Empowerment Scale (DES) questionnaire was used to measure patient empowerment. It consists of three domains: (1) Managing the psychosocial aspect of diabetes (9 items); (2) Assessing dissatisfaction and readiness to change (9 items); and (3) Setting and achieving diabetes goal (10 items). A score was considered high if it ranged from 100 to 140. Data analysis was performed using SPSS version 25 and multiple linear regressions was used to identify the predictors of total diabetes empowerment scores.

RESULTS

The median age of the study population was 55 years old. 56% were male and the mean duration of diabetes was 4 years. The total median score of the DES was 110 [interquartile range (IQR) = 10]. The median scores of the three subscales were 40 with (IQR = 4) for “Managing the psychosocial aspect of diabetes”; 36 with (IQR = 3) for “Assessing dissatisfaction and readiness to change”; and 34 with (IQR = 5) for “Setting and achieving diabetes goal”. According to multiple linear regressions, factors that had significant correlation with higher empowerment scores among type 2 diabetes patients included an above secondary education level (P < 0.001), diabetes education exposure (P = 0.003), lack of ischemic heart disease (P = 0.017), and lower glycated hemoglobin (HbA1c) levels (P < 0.001).

CONCLUSION

Diabetes empowerment scores were high among type 2 diabetes patients in this study population. Predictors for high empowerment scores included above secondary education level, diabetes education exposure, lack of ischemic heart disease status and lower HbA1c.

Spirituality, Social Support, and Diabetes: A Cross-Sectional Study of People Enrolled in a Nurse-Led Diabetes Management Program in Peru

INTRODUCTION

In Peru, people living with diabetes mellitus (PLDM) represent 7% of the adult population, each with a $54,000 lifetime cost. For Latinos, spirituality provides meaning and purpose of life while social support affects behavioral choices and adherence decisions. The purpose of this study was to determine the relationship between spirituality and social support for PLDM participating in a nurse-led diabetes management program in a public hospital in Lima, Peru.

METHOD

This cross-sectional study included adult PLDM (N = 54). The instrument included demographic items and the Spanish versions of the social/vocational concern dimension of the Diabetes Quality of Life Questionnaire and the Reed's scale of spiritual perspective.

RESULTS

There was an inverse relation between social support and spiritually practices (p = .020) and spiritual beliefs (p = .005). PLDM with 5 years or more in the program had significantly higher scores in social support (p = .020) and spiritual practices (p = .010).

CONCLUSION

Spirituality and social support are important factors for managing PLDM. Nurse-led diabetes management programs with Latino participants should consider targeted spiritual and social support strategies to expand the holistic management. Future studies should explore the impact and effectiveness of spiritual and social support interventions on clinical outcomes.

The effect of goal setting in asthma self-management education: A systematic review

Background

Asthma self-management education combining with behavior therapy is considered to be more effective. Goal setting is a common behavior change technique used to help patients self-manage their symptoms. However, empirical evidence around its effectiveness on asthma management lacks clarity.

Aims

To systematically integrate and appraise the evidence for effectiveness of goal setting interventions on asthma outcomes.

Methods

Databases included CENTRAL, PubMed, EMBASE, CINAHL and Proquest Psychology Database were systematically searched for relevant intervention studies employing goal setting technique as a method in asthma education program for self-management. Characteristic of studies and outcomes in clinical, psychosocial and healthcare utilization outcome were extracted.

Results

From a total of 2641 citations, 45 full-text articles were assessed for eligibility and 9 studies met the inclusion criteria. Eight studies were randomized controlled trial and one was before-after study. None studies have a high methodological quality. Goal-setting based intervention appeared to improve symptom control, quality of life and self-efficacy in adult patients with asthma.

Conclusion

This systematic review highlighted the potential of a goal setting technique in the asthma self-management education. However, due to the limitations of the quality and quantity of the included literature, more rigorous studies are needed. In the future, better effective study protocol combining with goal setting approach and other behavior technique is needed to further investigate.

Mindfulness Training Enhances Self-Regulation and Facilitates Health Behavior Change for Primary Care Patients: a Randomized Controlled Trial

BACKGROUND

Self-management of health is important for improving health outcomes among primary care patients with chronic disease. Anxiety and depressive disorders are common and interfere with self-regulation, which is required for disease self-management. An insurance-reimbursable mindfulness intervention integrated within primary care may be effective for enhancing chronic disease self-management behaviors among primary care patients with anxiety, depression, trauma, and stress-related and adjustment disorders compared with the increasingly standard practice of referring patients to outside mindfulness resources.

OBJECTIVE

Mindfulness Training for Primary Care (MTPC) is an 8-week, referral-based, insurance-reimbursable program integrated into safety-net health system patient-centered medical homes. We hypothesized that MTPC would be more effective for catalyzing chronic disease self-management action plan initiation within 2 weeks, versus a low-dose comparator (LDC) consisting of a 60-min mindfulness introduction, referral to community and digital resources, and addition to a 6-month waitlist for MTPC.

PARTICIPANTS

Primary care providers (PCPs) and mental health clinicians referred 465 patients over 12 months. All participants had a DSM-V diagnosis.

DESIGN AND INTERVENTIONS

Participants (N = 136) were randomized in a 2:1 allocation to MTPC (n = 92) or LDC (n = 44) in a randomized controlled comparative effectiveness trial. MTPC incorporates mindfulness, self-compassion, and mindfulness-oriented behavior change skills and is delivered as insurance-reimbursable visits within primary care. Participants took part in a chronic disease self-management action planning protocol at week 7.

MAIN MEASURES

Level of self-reported action plan initiation on the action plan initiation survey by week 9.

KEY RESULTS

Participants randomized to MTPC, relative to LDC, had significantly higher adjusted odds of self-management action plan initiation in an intention-to-treat analysis (OR = 2.28; 95% CI = 1.02 to 5.06, p = 0.025).

CONCLUSIONS

An 8-week dose of mindfulness training is more effective than a low-dose mindfulness comparator in facilitating chronic disease self-management behavior change among primary care patients.

More than A1C: Types of success among adults with type-2 diabetes participating in a technology-enabled nurse coaching intervention

OBJECTIVE

Success in diabetes research and self-management is often defined as a significant decrease in glycated hemoglobin (A1C). The aim of this article is to explore different types of successes experienced by adults with type-2 diabetes participating in a health technology and nurse coaching clinical trial.

METHODS

A qualitative analysis was conducted using surveys and documentation from motivational interview-based coaching sessions between study nurses and intervention participants.

RESULTS

Of the 132 cases reviewed, types of success predominantly fell into five categories: 1) change in health behaviors; 2) change in mindset or awareness; 3) change in engagement with healthcare resources; 4) change in physical or emotional health; and 5) change in health indicators.

CONCLUSION

Experiences of success in diabetes are more varied than traditional A1C-based outcome models. Our findings suggest coaching and technology can assist patients to achieve a range of successes in diabetes management through goal setting, health tracking, resolving barriers, and aligning goals with factors that impact change.

PRACTICE IMPLICATIONS

While A1C reduction is a critical factor in decreasing risk of diabetes-related complications, when healthcare professionals focus on A1C as the main indicator of diabetes management success, important changes in individuals' health and well-being may be overlooked or undervalued.

Assessing the effectiveness of a goal-setting session as part of a structured group self-management education programme for people with type 2 diabetes

OBJECTIVES

To measure the number of people who have identified a behaviour change goal and completed an action-plan to meet their goal on completion of a diabetes self-management education programme (DSME) and level of success in sustaining their action-plan. The DSME people attended was Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND).

METHODS

Copies of action-plans were collected from participants. Postal questionnaires were sent to participants one week and three months following DESMOND to assess factors associated with setting and sustaining action-plans.

RESULTS

92% (253/275) of participants completed an action-plan. Reducing weight was the area most targeted. Physical activity was the most common goal. 68% (187/275) returned a three month questionnaire. 96% indicated they were still working on their action plan, with 87% reporting they were always/usually meeting their action-plan. 22% said they had discussed their goal with a health care professional (HCP) following DESMOND.

CONCLUSIONS

Goal-setting as part of a DSME can lead to behaviour change.

PRACTICE IMPLICATIONS

Goal-setting as part of a DSME enables participants to set and attain behaviour change goals. Informing HCPs of a person's action-plan following a DSME may further support a person undertaking behaviour change.

Hispanic Families’ Action Plans for a Healthier Lifestyle for Diabetes Management

Purpose

The purpose of this study was to conduct focus groups with Hispanic patients with type 2 diabetes and their family members who participated in a culturally tailored, family-based diabetes intervention about their action plans for a healthier lifestyle.

Methods

Five separate focus groups were led in Spanish by an experienced bicultural/bilingual moderator. The audiotaped sessions occurred at the end of the 8-week diabetes educational program. Data were transcribed in Spanish and translated into English. Qualitative content analysis was used to analyze the findings.

Results

Eighty-four Hispanic adults participated with an equal representation of patients with diabetes and family members. Most persons were female (63.1%) and the majority of persons were born in Mexico. The mean (SD) age of participants was 44.2 (14.3) years. Six themes emerged from the data: healthier eating habits, increasing physical activity, taking care of my sugar, coping with emotions, for the family, and empowerment and increased self-efficacy.

Conclusions

Hispanics created action plans that promoted healthier lifestyle behaviors individually and as a family. This type of behavior change may result in better diabetes management and fewer complications. Research studies are needed to assess the sustainability of action plans and their impact on glycemic control and diabetes risk factors. Additional studies are needed to address emotional eating and mental health factors.

A web-based program to improve treatment adherence in patients with type 2 diabetes: Development and study protocol

BACKGROUND

Many patients with type 2 diabetes mellitus (T2DM) sub-optimally adhere to core treatment recommendations, such as healthy diets, sufficient physical activity and pharmacological support. This paper describes the development of the web-based computer-tailored program My Diabetes Profile (MDP), incorporating identified success factors of web-based interventions, and the protocol for testing the effectiveness of this program in a randomized multicentre trial.

METHODS

Formative research - including the input of a program committee, qualitative and quantitative studies with patients and health professionals and a literature search - yielded input for the development of the MDP program. MDP provides video and text tailored advice, based on determinants and salient beliefs derived from the I-Change Model, on decreasing unhealthy snack intake, increasing physical activity, and improving adherence to both oral blood glucose lowering drugs and self-administered insulin therapy. Patients with T2DM recruited by practice nurses and diabetes nurses across the Netherlands fill in online questionnaires at baseline and six-months follow-up. Participants are randomized on patient level to the intervention group (access to the MDP program) or control group (receiving care as usual).

DISCUSSION

The formative research using co-creation principles proved essential in the development of the MDP program and involved various disciplines in T2DM management including target group representatives. Co-creation revealed clearly that patients needed short and attractive messages. Consequently, a mix of video and short text messages were chosen for the ultimate program format. Pilot testing was useful to further shape the program to needs of patients and professionals.

TRIAL REGISTRATION

Dutch Trial Register NTR6840; Archived program website: http://www.webcitation.org/6xXz01S7X.

Rationale and development of a randomized pragmatic trial to improve diabetes outcomes in patient-centered medical homes serving rural patients

Proper diabetes self-care requires patients to have considerable knowledge, a range of skills, and to sustain multiple health behaviors. Self-management interventions are needed that can be readily implemented and sustained in rural clinics with limited resources that disproportionately care for patients with limited literacy. Researchers on our team developed an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care that includes: 1) the American College of Physicians (ACP) Diabetes Guide that uses plain language and descriptive photographs to teach core diabetes concepts and empower patients to initiate behavior change; 2) a brief counseling strategy to assist patients in developing short-term, explicit and attainable goals for behavior change ('action plans'); and 3) a training module for health coaches that prepares them to assume educator/counselor roles with the Diabetes Guide as a teaching tool. While the intervention has previously been field tested and found to significantly improve patient knowledge, self-efficacy, and engagement in related health behaviors, its optimal implementation is not known. This project took advantage of a unique opportunity to modify and disseminate the ACP health literacy intervention among patients with type 2 diabetes cared for at rural clinics in Arkansas that are Patient-Centered Medical Homes (PCMH). These practices all had health coaches that could be leveraged to provide chronic disease self-management mostly via phone, but also at the point-of-care. Hence we conducted a patient-randomized, pragmatic clinical trial in 6 rural PCMHs in Arkansas, targeting individuals with uncontrolled type 2 diabetes.

Effects of a Nurse-Led Phone Follow-up Education Program Based on the Self-efficacy Among Patients With Cardiovascular Disease

BACKGROUND

The integration of self-efficacy (SE) theory within a nurse-led telephone follow-up education program (NP-FEP) has not been extensively evaluated for patients with cardiovascular disease.

OBJECTIVES

The aim of this study is to determine the effectiveness of an NP-FEP in improving SE (primary outcome) and achieving goals related to cardiovascular risk (secondary outcome) for patients with cardiovascular disease.

METHODS

In June and July 2013, a total of 403 patients with cardiovascular disease in Shanghai were randomized into the intervention and control groups. Personalized end goals were established for improving cardiovascular risk for each patient. The control group received conventional follow-up education, whereas the intervention group was contacted by telephone 11 times over a 6-month period with staged goals developed based on SE theory. Self-efficacy scores and goals for reducing cardiovascular risk were assessed at baseline, at the end of the 6-month intervention, and 12 months after enrollment.

RESULTS

The SE scores in both groups increased at 6 months and decreased slightly at 12 months. The baseline SE scores were similar between the groups (P > .05), but the average SE scores were increased more for the intervention group than for the control group at 6 (P < .05) and 12 (P < .05) months. In addition, the final goal achievement rates for the intervention group were significantly higher than for the control group (P < .05). The difference between the 2 groups was reflected by differences in cardiac disease risk factors defined by the World Health Organization.

CONCLUSION

The NP-FEP improved SE and facilitated achievement of goals related to risk factors in patients with cardiovascular disease for at least 1 year.

Effectiveness of self-management support interventions for people with comorbid diabetes and chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Self-management support interventions may potentially delay kidney function decline and associated complications in patients with comorbid diabetes and chronic kidney disease. However, the effectiveness of these interventions remains unclear. We investigated the effectiveness of current self-management support interventions and their specific components and elements in improving patient outcomes.

METHODS

Electronic databases were systematically searched from January 1, 1994, to December 19, 2017. Eligible studies were randomized controlled trials on self-management support interventions for adults with comorbid diabetes and chronic kidney disease. Primary outcomes were systolic blood pressure, diastolic blood pressure, estimated glomerular filtration rate, and glycated hemoglobin. Secondary outcomes included self-management activity, health service utilization, health-related quality of life, medication adherence, and death.

RESULTS

Of the 48 trials identified, eight studies (835 patients) were eligible. There was moderate-quality evidence that self-management support interventions improved self-management activity (standard mean difference 0.56, 95% CI 0.15 to 0.97, p < 0.007) compared to usual care. There was low-quality evidence that self-management support interventions reduced systolic blood pressure (mean difference - 4.26 mmHg, 95% CI - 7.81 to - 0.70, p = 0.02) and glycated hemoglobin (mean difference - 0.5%, 95% CI - 0.8 to - 0.1, p = 0.01) compared to usual care.

CONCLUSIONS

Self-management support interventions may improve self-care activities, systolic blood pressure, and glycated hemoglobin in patients with comorbid diabetes and chronic kidney disease. It was not possible to determine which self-management components and elements were more effective, but interventions that utilized provider reminders, patient education, and goal setting were associated with improved outcomes. More evidence from high-quality studies is required to support future self-management programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015017316 .

Exploring beliefs on diabetes treatment adherence among Dutch type 2 diabetes patients and healthcare providers

OBJECTIVE

Despite well-known beneficial effects, adherence to core elements of diabetes treatment is suboptimal. This study, conducted in the Netherlands, aimed to explore if and how treatment adherence success factors are applied in diabetes consultations, and to explore salient personal beliefs about type 2 diabetes treatment including both healthy lifestyle adaptations and pharmacotherapy.

METHODS

A qualitative study using semi-structured interviews among nine Dutch healthcare providers predominantly involved in diabetes management and 19 Dutch type 2 diabetes patients. Data was systematically analysed through deductive coding analysis using Nvivo.

RESULTS

Most patients visited their consultations unprepared. Patients did not or vaguely experience goal-setting in consultations, whereas healthcare providers indicated to set treatment goals. Shared-decision making was applied, however patients were rather passive collaborators as mostly healthcare providers were in charge of making treatment decisions. Despite suboptimal treatment adherence, many advantages and few disadvantages of treatment strategies were reported. Adherence self-efficacy was lower in situations outside daily routine.

CONCLUSION

Treatment adherence success factors are not optimally applied, and in particular treatment adherence self-efficacy could be improved.

PRACTICE IMPLICATIONS

The application of treatment adherence success factors in consultations could be improved, and personal beliefs should be addressed to improve treatment adherence and optimize counselling.

Improving Diabetes Self-Management Support: Goal-Setting Across the Continuum of Care

IN BRIEF Goal-setting has consistently been promoted as a strategy to support behavior change and diabetes self-care. Although goal-setting conversations occur most often in outpatient settings, clinicians across care settings need to better understand and communicate about the priorities, goals, and concerns of those with diabetes to develop collaborative, person-centered partnerships and to improve clinical outcomes. The electronic health record is a mechanism for improved communication and collaboration across the continuum of care. This article describes a quality improvement project that was intended to improve the person-centeredness of care for adults with diabetes by offering goal-setting and self-management support during and after hospitalization.

Disentangling self-management goal setting and action planning: A scoping review

INTRODUCTION

The ongoing rise in the numbers of chronically ill people necessitates efforts for effective self-management. Goal setting and action planning are frequently used, as they are thought to support patients in changing their behavior. However, it remains unclear how goal setting and action planning in the context of self-management are defined in the scientific literature. This study aimed to achieve a better understanding of the various definitions used.

METHODS

A scoping review was conducted, searching PubMed, Cinahl, PsychINFO and Cochrane. Inclusion and exclusion criteria were formulated to ensure the focus on goal setting/action planning and self-management. The literature was updated to December 2015; data selection and charting was done by two reviewers. A qualitative content analysis approach was used.

RESULTS

Out of 9115 retrieved articles, 58 met the inclusion criteria. We created an overview of goal setting phases that were applied (preparation, formulation of goals, formulation of action plan, coping planning and follow-up). Although the phases we found are in accordance with commonly known frameworks for goal setting, it was striking that the majority of studies (n = 39, 67%) did not include all phases. We also prepared an overview of components and strategies for each goal setting phase. Interestingly, few strategies were found for the communication between patients and professionals about goals/action plans. Most studies (n = 35, 60%) focused goal setting on one single disease and on a predefined lifestyle behavior; nearly half of the articles (n = 27, 47%) reported a theoretical framework.

DISCUSSION

The results might provide practical support for developers of interventions. Moreover, our results might encourage professionals to become more aware of the phases of the goal setting process and of strategies emphasizing on patient reflection. However, more research might be useful to examine strategies to facilitate communication about goals/action plans. It might also be worthwhile to develop and evaluate goal setting/action planning strategies for people with different and multiple chronic conditions.

Implementation of collaborative goal setting for diabetes in community primary care

Collaborative goal setting (CGS) is a cornerstone of diabetes self-management support, but little is known about its feasibility and effectiveness during routine care. The aim of this study was to evaluate the implementation of an existing CGS intervention when integrated by primary care staff. Using a mixed-methods approach guided by the RE-AIM framework, intervention adoption, implementation, reach, and effectiveness were evaluated over 12 months. Three of four sites adopted the CGS intervention, in which 521 patients with type 2 diabetes (9-29 % of those targeted) received CGS. For those with suboptimal glycemic control (A1C ≥ 7.5 %), %A1C decreased by 1.1 for those receiving CGS (n = 204, p < 0.001) compared to 0.4 for a group who did not (n = 41, p = 0.23). Practice characteristics influenced adoption and implementation, while isolation of CGS from the remainder of clinical care likely influenced reach and effectiveness. CGS may benefit patients with diabetes, but a lack of integration by practice staff is a key barrier to overcome during implementation.

Applying the Chronic Care Model to Support Ostomy Self-Management: Implications for Oncology Nursing Practice

BACKGROUND

Living with an ostomy requires daily site and equipment care, lifestyle changes, emotional management, and social role adjustments. The Chronic Care Ostomy Self-Management Training Program (CCOSMTP) offers an ostomy self-management curriculum, emphasizing problem solving, self-efficacy, cognitive reframing, and goal setting.

OBJECTIVES

The qualitative method of content analysis was employed to categorize self-reported goals of ostomates identified during a nurse-led feasibility trial testing the CCOSMTP.

METHODS

Thirty-eight ostomates identified goals at three CCOSMTP sessions. The goals were classified according to the City of Hope Health-Related Qualify of Life Model, a validated multidimensional framework, describing physical, psychological, social, and spiritual ostomy-related effects. Nurse experts coded the goals independently and then collaborated to reach 100% consensus on the goals' classification.

FINDINGS

A total of 118 goals were identified by 38 participants. Eighty-seven goals were physical, related to the care of the skin, placement of the pouch or bag, and management of leaks; 26 were social goals, which addressed engagement in social or recreational roles and daily activities; and 5 were psychological goals, which were related to confidence and controlling negative thinking. Although the goals of survivors of cancer with an ostomy are variable, physical goals are most common in self-management training.

Diabetes affects everything: Type 2 diabetes self-management among Spanish-speaking hispanic immigrants

This article is a report of qualitative findings of a mixed-methods study of the relationships among knowledge, self-efficacy, health promoting behaviors, and type 2 diabetes mellitus (T2DM) self-management among limited-english-proficient recent Hispanic immigrants, a population with increased incidence of T2DM and barriers to successful T2DM management. Semi-structured interviews were conducted with 30 participants, and physiological and demographic data also were collected. The participants generally attributed developing the disease to strong emotions and viewed T2DM as a serious disease. Although a majority understood the importance of exercise and diet in T2DM self-management, other aspects such as medication adherence were not well-understood. Obstacles to effective T2DM self-management were negative interactions and communications with health care providers and other personnel, cultural stigma related to the disease, financial constraints, immigration status, and the complexity of the disease. Suggested interventions to improve the care and self-management of this at-risk population are discussed.

Smart Devices for Older Adults Managing Chronic Disease: A Scoping Review

BACKGROUND

The emergence of smartphones and tablets featuring vastly advancing functionalities (eg, sensors, computing power, interactivity) has transformed the way mHealth interventions support chronic disease management for older adults. Baby boomers have begun to widely adopt smart devices and have expressed their desire to incorporate technologies into their chronic care. Although smart devices are actively used in research, little is known about the extent, characteristics, and range of smart device-based interventions.

OBJECTIVE

We conducted a scoping review to (1) understand the nature, extent, and range of smart device-based research activities, (2) identify the limitations of the current research and knowledge gap, and (3) recommend future research directions.

METHODS

We used the Arksey and O'Malley framework to conduct a scoping review. We identified relevant studies from MEDLINE, Embase, CINAHL, and Web of Science databases using search terms related to mobile health, chronic disease, and older adults. Selected studies used smart devices, sampled older adults, and were published in 2010 or after. The exclusion criteria were sole reliance on text messaging (short message service, SMS) or interactive voice response, validation of an electronic version of a questionnaire, postoperative monitoring, and evaluation of usability. We reviewed references. We charted quantitative data and analyzed qualitative studies using thematic synthesis. To collate and summarize the data, we used the chronic care model.

RESULTS

A total of 51 articles met the eligibility criteria. Research activity increased steeply in 2014 (17/51, 33%) and preexperimental design predominated (16/50, 32%). Diabetes (16/46, 35%) and heart failure management (9/46, 20%) were most frequently studied. We identified diversity and heterogeneity in the collection of biometrics and patient-reported outcome measures within and between chronic diseases. Across studies, we found 8 self-management supporting strategies and 4 distinct communication channels for supporting the decision-making process. In particular, self-monitoring (38/40, 95%), automated feedback (15/40, 38%), and patient education (13/40, 38%) were commonly used as self-management support strategies. Of the 23 studies that implemented decision support strategies, clinical decision making was delegated to patients in 10 studies (43%). The impact on patient outcomes was consistent with studies that used cellular phones. Patients with heart failure and asthma reported improved quality of life. Qualitative analysis yielded 2 themes of facilitating technology adoption for older adults and 3 themes of barriers.

CONCLUSIONS

Limitations of current research included a lack of gerontological focus, dominance of preexperimental design, narrow research scope, inadequate support for participants, and insufficient evidence for clinical outcome. Recommendations for future research include generating evidence for smart device-based programs, using patient-generated data for advanced data mining techniques, validating patient decision support systems, and expanding mHealth practice through innovative technologies.

A pilot randomized trial of technology-assisted goal setting to improve physical activity among primary care patients with prediabetes

Lifestyle behavior changes can prevent progression of prediabetes to diabetes but providers often are not able to effectively counsel about preventive lifestyle changes. We developed and pilot tested the Avoiding Diabetes Thru Action Plan Targeting (ADAPT) program to enhance primary care providers' counseling about behavior change for patients with prediabetes. Primary care providers in two urban academic practices and their patients with prediabetes were recruited to participate in the ADAPT study, an unblinded randomized pragmatic trial to test the effectiveness of the ADAPT program, including a streamlined electronic medical record-based goal setting tool. Providers were randomized to intervention or control arms; eligible patients whose providers were in the intervention arm received the ADAPT program. Physical activity (the primary outcome) was measured using pedometers, and data were gathered about patients' diet, weight and glycemic control. A total of 54 patients were randomized and analyzed as part of the 6-month ADAPT study (2010-2012, New York, NY). Those in the intervention group showed an increase total daily steps compared to those in the control group (+ 1418 vs - 598, p = 0.007) at 6 months. There was also a trend towards weight loss in the intervention compared to the control group (- 1.0 lbs. vs. 3.0 lbs., p = 0.11), although no change in glycemic control. The ADAPT study is among the first to use standard electronic medical record tools to embed goal setting into realistic primary care workflows and to demonstrate a significant improvement in prediabetes patients' physical activity.

Effect of an intensive metabolic control lifestyle intervention in type-2 diabetes patients

OBJECTIVE

To evaluate the effectiveness of an intensive lifestyle intervention on metabolic control in patients with type 2 diabetes.

METHODS

199 patients recently diagnosed with type 2 diabetes, with lack of metabolic control and overweight/obesity, were randomly assigned to intensive lifestyle intervention or collaborative educational program alone, with 6 months of follow-up. Intervention included 150min of physical activity a week to reduce body weight by 7%. Both groups received 16 sessions on behavior modification over the course of the 6 months. Measurements were taken at baseline, 3 and 6 months. Results were analyzed and compared.

RESULTS

Significant weight loss was achieved by both groups, with greater loss in the intervention group. Those with lower baseline A1c appeared to benefit more from the educational program than intensive intervention over time.

CONCLUSIONS

Both interventions produced positive if modest changes in metabolic control. These results suggest that, for weight loss and control of A1c, an intensive intervention may be more effective.

PRACTICE IMPLICATIONS

The current study demonstrates the value of a systematic application of behavior modification and self-care techniques in the treatment of type 2 diabetes. It demonstrates the importance of intensive, all-inclusive treatment, and of attention to individual concerns.

Diabetes education for Chinese adults with type 2 diabetes: A systematic review and meta-analysis of the effect on glycemic control

AIMS

The purpose of this study is to systematically review evidence in English and Chinese publications to determine the size of glycemic effect of different diabetes education approaches for Chinese patients.

METHODS

CINAHL Plus, Embase, Ovid Medline, Scopus and the China National Knowledge Infrastructure database were searched. Studies were included if they were randomised controlled trials with a detailed description of education approach, with more than 50 Chinese-adult participants, reporting actual glycemic outcome and with at least 3-month follow-up. Data was systematically extracted and cross-checked by the authors. Methodological quality was assessed.

RESULTS

Fifty-three studies, including five English and 48 Chinese publications, were included. The overall weighted mean difference (WMD) in glycated haemoglobin (HbA1c) was -1.19% (-13mmol/mol). Ongoing regular education was most-commonly employed, with a reported WMD of -2.02% (-22mmol/mol). Glycemic control was further enhanced in studies using information reinforcement strategies.

CONCLUSIONS

Diabetes education in any format generates glycemic improvement for Chinese patients, but is particularly effective when an ongoing regular education is employed. Innovative strategies aligned with cultural concepts, such as employing patient examination to reinforce diabetes management knowledge and/or involving family in patient care deserve further trial to determine whether they enhance glycemic control in this group.

Setting Single or Multiple Goals for Diet and Physical Activity Behaviors Improves Cardiovascular Disease Risk Factors in Adults With Type 2 Diabetes

Purpose

The purpose of this study was to evaluate a 4-month telephone-based goal-setting and decision support intervention among adults with type 2 diabetes mellitus (T2DM) and multiple risk factors for cardiovascular disease (CVD).

Methods

A randomized pretest-posttest control group design was employed. Overweight or obese adults aged 40 to 75 years with T2DM and ≥1 additional CVD risk factor were provided with individualized CVD risk information. At baseline and each biweekly telephone call, the multiple-goal group self-selected both diet- and physical activity–related goals, the single goal group set a single goal, and the control group received information about community health resources. Dietary intake was assessed via a food frequency questionnaire, physical activity via questionnaire, and A1C and blood lipids via fasting fingerstick sample. Between-group differences for clinical (ie, A1C, blood pressure, and blood lipids), physical activity, and dietary variables were evaluated using Kruskal-Wallis, Mann-Whitney U, analysis of variance, and t tests.

Results

From pre- to postintervention, the single-goal group demonstrated significant improvement in systolic blood pressure and intake of servings of fruits, vegetables, and refined grains (all P < .05). The multiple-goal group reported significant reduction in percent energy from total, saturated, monounsaturated, and trans fat intake and significant increase in leisure time walking (all P < .05).

Conclusion

A multiple-goal approach over 4 months can improve dietary and physical activity outcomes, while a single-goal approach may facilitate improvement in one behavioral domain. Additional research is needed to evaluate maintenance of the achieved changes.

The PRIDE (Partnership to Improve Diabetes Education) Toolkit: Development and Evaluation of Novel Literacy and Culturally Sensitive Diabetes Education Materials

PURPOSE

Patients with low literacy, low numeracy, and/or linguistic needs can experience challenges understanding diabetes information and applying concepts to their self-management. The authors designed a toolkit of education materials that are sensitive to patients' literacy and numeracy levels, language preferences, and cultural norms and that encourage shared goal setting to improve diabetes self-management and health outcomes. The Partnership to Improve Diabetes Education (PRIDE) toolkit was developed to facilitate diabetes self-management education and support.

METHODS

The PRIDE toolkit includes a comprehensive set of 30 interactive education modules in English and Spanish to support diabetes self-management activities. The toolkit builds upon the authors' previously validated Diabetes Literacy and Numeracy Education Toolkit (DLNET) by adding a focus on shared goal setting, addressing the needs of Spanish-speaking patients, and including a broader range of diabetes management topics. Each PRIDE module was evaluated using the Suitability Assessment of Materials (SAM) instrument to determine the material's cultural appropriateness and its sensitivity to the needs of patients with low literacy and low numeracy. Reading grade level was also assessed using the Automated Readability Index (ARI), Coleman-Liau, Flesch-Kincaid, Fry, and SMOG formulas.

CONCLUSIONS

The average reading grade level of the materials was 5.3 (SD 1.0), with a mean SAM of 91.2 (SD 5.4). All of the 30 modules received a "superior" score (SAM >70%) when evaluated by 2 independent raters. The PRIDE toolkit modules can be used by all members of a multidisciplinary team to assist patients with low literacy and low numeracy in managing their diabetes.

Goal setting and lifestyle changes in a nurse-led counselling programme for leg ulcer patients: an explorative analysis of nursing records

AIMS AND OBJECTIVES

To describe goals set in individual nurse-led lifestyle counselling sessions in leg ulcer patients, and to explore patient and goal characteristics in relation to health behaviour change.

BACKGROUND

Goal setting is increasingly used in nurse-led counselling programmes, but the delivery is often unknown, especially in patient groups for which only recently programmes have been developed, such as patients with venous leg ulcers.

DESIGN

A secondary analysis of data collected in the intervention arm of a randomised clinical trial of counselling sessions in venous leg ulcer patients.

METHODS

Nursing records (n = 71) were explored for the number of goals set, topic, quality and course of goals during the trajectory. Furthermore, goals and patient characteristics were compared in relation to health behaviour change.

RESULTS

Forty-one patients (58%) succeeded in changing their behaviour after setting a goal. Setting goals for conducting leg exercises was chosen by most patients in this study, goals for adherence with compression therapy were chosen the least. Sixty-eight per cent of the goals met criteria for being Specific, Measurable and Time-bound. Patients who achieved behaviour change were significantly younger compared to the patients who did not. Except for age, there were no differences in characteristics between the group that did and did not achieve behaviour change.

CONCLUSIONS

Goal setting could be improved by setting goals more Specific, Measurable and Time-bound, and by setting goals on an essential topic for behaviour change. This explorative study did not show that goal characteristics, including the quality of goals, were related to patients' behaviour change.

RELEVANCE TO CLINICAL PRACTICE

The delivery of goal setting in this programme, and most likely in similar programmes, could be improved. Regular quality checks in daily goal setting practice should be considered. More research is needed into how to best provide health promotion to frail and elderly people.

Do low step count goals inhibit walking behavior: a randomized controlled study

OBJECTIVE

Confirmation and quantification of observed differences in goal-directed walking behavior.

DESIGN

Single-blind, split-half randomized trial.

SETTING

Small rural university, Pennsylvania, United States.

SUBJECTS

A total of 94 able-bodied subjects (self-selected volunteer students, faculty and staff of a small university) were randomly assigned walking goals, and 53 completed the study.

INTERVENTIONS

Incentivized pedometer-monitored program requiring recording the step-count for 56-days into a custom-made website providing daily feedback.

MAIN OUTCOME MEASURES

Steps logged per day.

RESULTS

During the first half of the study, the 5000 and 10,000 step group logged significantly different steps 7500 and 9000, respectively (P > 0.05). During the second half of the study, the 5000 and 10,000 step groups logged 7000 and 8600 steps, respectively (significance P > 0.05). The group switched from 5000 to →10,000 steps logged, 7900 steps for the first half and 9500 steps for the second half (significance P > 0.05). The group switched from 10,000 to 5000 steps logged 9700 steps for the first half and 9000 steps for the second half, which was significant (p > 0.05).

CONCLUSIONS

Levels of walking behavior are influenced by the goals assigned. Subjects with high goals walk more than those with low goals, even if they do not meet the assigned goal. Reducing goals from a high to low level can reduce walking behavior.

An Ecological Perspective on Diabetes Self-care Support, Self-management Behaviors, and Hemoglobin A1C Among Latinos

Purpose

The purpose of this study was to examine the role of self, interpersonal (ie, family/friend), and organizational (ie, health care) support in performing diabetes-related self-management behaviors and hemoglobin A1C (A1C) levels among rural Latinos with type 2 diabetes.

Methods

Cross-sectional data from baseline interviews and medical records were used from a randomized controlled trial conducted in rural Southern California involving a clinic sample of Latinos with type 2 diabetes (N = 317). Self-management behaviors included fruit and vegetable intake, fat intake, physical activity, glucose monitoring, daily examination of feet, and medication adherence. Multivariate linear and logistic regression models were used to assess the relationships of sources of support with self-management behaviors and A1C.

Results

Higher levels of self-support were significantly associated with eating fruits and vegetables most days/week, eating high-fat foods few days/week, engaging in physical activity most days/week, daily feet examinations, and self-reported medication adherence. Self-support was also related to A1C. Family/friend support was significantly associated with eating fruits and vegetables and engaging in physical activity most days/week. Health care support was significantly associated with consuming fats most days/week.

Conclusions

Health care practitioners and future interventions should focus on improving individuals’ diabetes management behaviors, with the ultimate goal of promoting glycemic control. Eliciting family/friend support should be encouraged to promote fruit and vegetable consumption and physical activity.

What barriers thwart postpartum women's physical activity goals during a 12-month intervention? A process evaluation of the Nā Mikimiki Project

Approximately 70% of new mothers do not meet national guidelines for moderate-to-vigorous physical activity (MVPA). The Nā Mikimiki ("the active ones") Project (2008-2011) was designed to increase MVPA among women with infants 2-12 months old. Participants' barriers to exercising and achievement of specific MVPA goals were discussed during telephone counseling calls over 12 months. Healthy, inactive women (n = 115, mean age = 31 ± 5 years, infants' mean age = 5.5 ± 3 months; 80% racial/ethnic minorities) received a total of 17 calls over 12 months in three phases. During Phase 1 weekly calls were made for a month, in Phase 2 biweekly calls were made for 2 months, and in Phase 3 monthly calls were made for 9 months. Across all phases, the most frequent barriers to achieving MVPA goals were: time/too busy (25%), sick child (11%), and illness (10%). Goals for MVPA minutes per week were achieved or surpassed 40.6% of the time during weekly calls, 39.9% during biweekly calls, and 42.0% during monthly calls. The least likely MVPA goals to be achieved (p < 0.04) were those which the woman encountered and for which she failed to overcome the barriers she had previously anticipated would impair her improvement of MVPA. This process evaluation demonstrated that telephone counseling somewhat facilitated the resolution of barriers and achievement of MVPA goals; thus, if clinical settings adopted such methods, chronic disease risks could be reduced in this vulnerable population of new mothers.

The design of a low literacy decision aid about rheumatoid arthritis medications developed in three languages for use during the clinical encounter

BACKGROUND

Shared decision-making in rheumatoid arthritis (RA) care is a priority among policy makers, clinicians and patients both nationally and internationally. Demands on patients to have basic knowledge of RA, treatment options, and details of risk and benefit when making medication decisions with clinicians can be overwhelming, especially for those with limited literacy or limited English language proficiency. The objective of this study is to describe the development of a medication choice decision aid for patients with rheumatoid arthritis (RA) in three languages using low literacy principles.

METHODS

Based on the development of a diabetes decision aid, the RA decision aid (RA Choice) was developed through a collaborative process involving patients, clinicians, designers, decision-aid and health literacy experts. A combination of evidence synthesis and direct observation of clinician-patient interactions generated content and guided an iterative process of prototype development.

RESULTS

Three iterations of RA Choice were developed and field-tested before completion. The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations. The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians.

CONCLUSIONS

The process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool. The use of RA Choice in the clinical encounter has the potential to enhance communication for RA patients, including those with limited health literacy and limited English language proficiency.

Goal setting: an integral component of effective diabetes care

Goal setting is a widely used behavior change tool in diabetes education and training. Prior research found specific relatively difficult but attainable goals set within a specific timeframe improved performance in sports and at the workplace. However, the impact of goal setting in diabetes self-care has not received extensive attention. This review examined the mechanisms underlying behavioral change according to goal setting theory and evaluated the impact of goal setting in diabetes intervention studies. Eight studies were identified, which incorporated goal setting as the primary strategy to promote behavioral change in individual, group-based, and primary care settings among patients with type 2 diabetes. Improvements in diabetes-related self-efficacy, dietary intake, physical activity, and A1c were observed in some but not all studies. More systematic research is needed to determine the conditions and behaviors for which goal setting is most effective. Initial recommendations for using goal setting in diabetes patient encounters are offered.

Update on health literacy and diabetes

PURPOSE

Inadequate literacy is common among patients with diabetes and may lead to adverse outcomes. The authors reviewed the relationship between literacy and health outcomes in patients with diabetes and potential interventions to improve outcomes.

METHODS

We reviewed 79 articles covering 3 key domains: (1) evaluation of screening tools to identify inadequate literacy and numeracy, (2) the relationships of a range of diabetes-related health outcomes with literacy and numeracy, and (3) interventions to reduce literacy-related differences in health outcomes.

RESULTS

Several screening tools are available to assess patients' print literacy and numeracy skills, some specifically addressing diabetes. Literacy and numeracy are consistently associated with diabetes-related knowledge. Some studies suggest literacy and numeracy are associated with intermediate outcomes, including self-efficacy, communication, and self-care (including adherence), but the relationship between literacy and glycemic control is mixed. Few studies have assessed more distal health outcomes, including diabetes-related complications, health care utilization, safety, or quality of life, but available studies suggest low literacy may be associated with increased risk of complications, including hypoglycemia. Several interventions appear to be effective in improving diabetes-related outcomes regardless of literacy status, but it is unclear if these interventions can reduce literacy-related differences in outcomes.

CONCLUSIONS

Low literacy is associated with less diabetes-related knowledge and may be related to other important health outcomes. Further studies are needed to better elucidate pathways by which literacy skills affect health outcomes. Promising interventions are available to improve diabetes outcomes for patients with low literacy; more research is needed to determine their effectiveness outside of research settings.

Abilities, skills and knowledge in measures of health literacy

OBJECTIVE

Health literacy has been recognized as an important factor in patients' health status and outcomes, but the relative contribution of demographic variables, cognitive abilities, academic skills, and health knowledge to performance on tests of health literacy has not been as extensively explored. The purpose of this paper is to propose a model of health literacy as a composite of cognitive abilities, academic skills, and health knowledge (ASK model) and test its relation to measures of health literacy in a model that first takes demographic variables into account.

METHODS

A battery of cognitive, academic achievement, health knowledge and health literacy measures was administered to 359 Spanish- and English-speaking community-dwelling volunteers. The relations of health literacy tests to the model were evaluated using regression models.

RESULTS

Each health literacy test was related to elements of the model but variability existed across measures.

CONCLUSION

Analyses partially support the ASK model defining health literacy as a composite of abilities, skills, and knowledge, although the relations of commonly used health literacy measures to each element of the model varied widely.

PRACTICE IMPLICATIONS

Results suggest that clinicians and researchers should be aware of the abilities and skills assessed by health literacy measures when choosing a measure.