Process evaluation of a medical assistant health coaching intervention for type 2 diabetes in diverse primary care settings

The Feasibility of the Diabetes Self-Management Coaching Program in Primary Care: A Mixed-Methods Randomized Controlled Feasibility Trial

BACKGROUND

Diabetes mellitus, a chronic metabolic disorder associated with elevated blood sugar levels, is a significant cause of morbidity, mortality, and disability globally. The rampant rise in the prevalence of diabetes presents a public health burden and a challenge to the primary care setting. Diabetes self-management coaching is an emergent, client-centered, solution-focused approach to enhance self-efficacy and self-care behavior, control glycemia, and prevent acute and chronic complications. Currently, there is no diabetes self-management support strategy in the primary care setting in Ethiopia. Therefore, this study assessed the feasibility, acceptability, and fidelity of implementing the Diabetes Self-Management Coaching Program in primary care in Ethiopia.

METHOD

A single-center, single-blinded, parallel group mixed-methods feasibility randomized control design was applied to assess the feasibility, acceptability, and fidelity of the Diabetes Self-Management Coaching Program in primary care. Adult patients with type 2 diabetes with HbA1c ≥ 7%, taking diabetic medication, and living in Gondar town were included in the study. A block randomization technique with a block size of four was used to allocate participants into the treatment and control groups. The treatment group attended a 12-week Diabetes Self-Management Coaching Program in addition to undergoing usual care, while the control group received the usual care for the same period. Data were collected at baseline, at the end of the intervention, and after the follow-up period. Descriptive statistics such as the frequency, mean, median, and standard deviations were computed. Based on the normality assessment, the baseline group difference was examined using the independent sample Student's t-test, the Mann-Whitney U test, and the chi-square test.

RESULT

This study's eligibility, recruitment, retention, and adherence rates were 23%, 70%, 90%, and 85%, respectively. Both the qualitative and quantitative findings show that the program was feasible to implement in primary care and acceptable to the participants. The fidelity assessment of the Diabetes Self-Management Coaching Program indicates an appropriate intervention implementation.

CONCLUSIONS

This study demonstrated remarkable recruitment, retention, and adherence rates. The Diabetes Self-Management Coaching Program was feasible, acceptable, and implementable in primary care in Ethiopia. As a result, we recommend that a large-scale multi-center cluster randomized controlled trial with an adequate sample can be designed to evaluate the effect of the DSM Coaching Program on clinical and behavioral outcomes.

Effectiveness of a health literacy intervention to improve diabetes outcomes in rural family medicine clinics: a randomized pragmatic trial

Background

Adults with diabetes mellitus (DM) living in rural areas often face limited access to medical and specialist care, minimal exposure to diabetes education, and transportation challenges. Rural residents also tend to be older, poorer, less educated, under-insured and have lower health literacy compared to their urban counterparts.

Aims

We tested the effectiveness of the American College of Physicians (ACP) diabetes health literacy intervention in rural community clinics to improve a range of diabetes-related patient outcomes and determine whether the intervention reduces disparities by health literacy.

Methods

We recruited 756 English-speaking adults with uncontrolled Type 2 DM from rural clinics in Arkansas. Trained health coaches reviewed the ACP Diabetes Guide and conducted counseling and action-planning monthly to participants randomized to the intervention. The enhanced usual care (EUC) arm received an American Diabetes Association workbook and was followed as usual. Interviews were conducted at baseline, 3 and 6 months, and clinical outcomes, including hemoglobin A1C and blood pressure values, were extracted from charts through 12 months post-baseline. Health literacy was measured at baseline using the Newest Vital Sign (NVS). Our primary outcome was A1C at 6 months, with other clinical values and self-reported diabetes-related knowledge, self-efficacy, distress, and self-care behaviors examined as secondary outcomes.

Results

Participants had a mean age of 55.8 (SD=11.7), 68% were female, two-thirds had an annual household income <$15,000, and 52% had limited health literacy. Overall, the intervention had little effect on outcomes at 6 and 12 months, including our primary outcome of A1C at 6 months (Intervention Least Squared Means (LSM) 8.28, 95% CI 8.11, 8.46; EUC LSM 8.44, 95% CI 8.26, 8.61). Diabetes knowledge was greater in those with adequate (LSM 9.46, 95% CI 9.25, 9.67) compared to those with limited health literacy (LSM 8.11, 95% CI 7.91, 8.23, p<0.001) at baseline. This disparity remained in the EUC arm after 6 months but disparities were mitigated in the intervention arm (interaction p<0.001).

Discussion

Our intensive intervention was well received, but insufficient to improve outcomes. Strategies may need to attend to other barriers faced by rural patients beyond health literacy to improve health behaviors and outcomes.

Medical Assistant Health Coaching for Type 2 Diabetes in Primary Care: Results From a Pragmatic Cluster Randomized Controlled Trial

OBJECTIVE

This cluster (clinic-level) randomized controlled trial (RCT) compared medical assistant (MA) health coaching (MAC) with usual care (UC) among at-risk adults with type 2 diabetes in two diverse real-world primary care environments: a federally qualified health center (FQHC; Neighborhood Healthcare) and a large nonprofit private insurance-based health system (Scripps Health).

RESEARCH DESIGN AND METHODS

A total of 600 adults with type 2 diabetes who met one or more of the following criteria in the last 90 days were enrolled: HbA1c ≥8% and/or LDL cholesterol ≥100 mg/dL and/or systolic blood pressure (SBP) ≥140 mmHg. Participants at MAC clinics received in-person and telephone self-management support from a specially trained MA health coach for 12 months. Electronic medical records were used to examine clinical outcomes in the overall sample. Behavioral and psychosocial outcomes were evaluated in a subsample (n = 300).

RESULTS

All clinical outcomes improved significantly over 1 year in the overall sample (P < 0.001). The reduction in HbA1c was significantly greater in the MAC versus UC group (unstandardized Binteraction = -0.06; P = 0.002). A significant time by group by site interaction also showed that MAC resulted in greater improvements in LDL cholesterol than UC at Neighborhood Healthcare relative to Scripps Health (Binteraction = -1.78 vs. 1.49; P < 0.05). No other statistically significant effects were observed.

CONCLUSIONS

This was the first large-scale pragmatic RCT supporting the real-world effectiveness of MAC for type 2 diabetes in U.S. primary care settings. Findings suggest that this team-based approach may be particularly effective in improving diabetes outcomes in FQHC settings.

Demystifying diabetes health coaching: A scoping review unveiling the 'who' and 'where' of health coaching for adults with type 2 diabetes

Type 2 diabetes (T2D) is a complex chronic condition that requires ongoing self-management. Diabetes health coaching interventions provide personalized healthcare programming to address physical and psychosocial aspects of diabetes self-management.

AIMS

This scoping review aims to explore the contexts and settings of diabetes health coaching interventions for adults with T2D, using the RE-AIM framework.

METHODS

A search was completed in MEDLINE, PsycINFO, Emcare, Embase and Cochrane. Included citations described adults with exclusively T2D who had received a health coaching intervention. Citations were excluded if they focused on any other types of diabetes or diabetes prevention.

RESULTS

A total of 3418 records were identified through database and manual searches, with 29 citations selected for data extraction. Most health coaching interventions were delivered by health professionals, many employed lay health workers and a few included peer coaches. While many health coaching interventions were delivered remotely, in-person intervention settings were distributed among primary care, community health settings and non-healthcare sites.

CONCLUSION

The findings of this review suggest that diabetes health coaching may be implemented by a variety of providers in different settings. Further research is required to standardize training and implementation of health coaching and evaluate its long-term effectiveness.

Self-management education for children with epilepsy and their caregivers. A scoping review

Self-management education programs have been highly successful in preparing people to manage medical conditions with recurring events. A detailed curriculum for epilepsy patients, and their caretakers, is lacking. Here we assess what is available for patients who have disorders with recurring events and offer an approach to developing a potential self-care curriculum for patients with seizures and their caregivers. Among the anticipated components are a baseline efficacy assessment and training tailored to increasing self-efficacy, medication compliance, and stress management. Those at risk of status epilepticus will also need guidance in preparing a personalized seizure action plan and training in how to decide when rescue medication is appropriate and how to administer the therapy. Peers, as well as professionals, could teach and provide support. To our knowledge, no such programs are currently available in English. We encourage their creation, dissemination, and widespread use.