The diabetes educator: trying hard, but must concentrate more on behaviour

Development and evaluation of self-care intervention to improve self-care practices among people living with type 2 diabetes mellitus: a mixed-methods study protocol

INTRODUCTION

The management of diabetes mellitus (DM) depends on medication adherence, self-care and regular follow-up to prevent complications and premature mortality. This study aims to develop and implement the behavioural change theory and model based diabetes self-care intervention package to improve self-care practices among people living with type 2 DM.

METHODS AND ANALYSIS

An exploratory sequential mixed-method study design wherein, quantitative follows qualitative will be used to develop, implement and evaluate the effect of diabetes self-care intervention package among people living with type 2 diabetes. The qualitative research method will be used to identify barriers and facilitators for self-care practices among people living with type 2 DM and will also provide the basis for the development of the diabetes self-care intervention package. The quasi-experimental with control study design will be used to evaluate the developed intervention package among 220 randomly selected people living with type 2 diabetes in both intervention and control arms. Baseline, follow-ups and endline data will be collected using same prevalidated and structured questionnaire for each self-care activity. Difference-in-difference analysis will be used to measure for changes in the proportion of people living with type 2 DM doing different component of self-care practices, preintervention and postintervention in both arms.

ETHICS AND DISSEMINATION

Permission for conducting the study has been taken from Institutional Ethical Committee of PGIMER, Chandigarh (Ref no. NK/4538/PhD/226, Dated 18.08.18). The findings of the trial will be disseminated through publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

CTRI/2018/10/016108; Pre-results.

Development of a group-based diabetes education model for migrants with type 2 diabetes, living in Sweden

Aim:

To develop a diabetes education model based on individual beliefs, knowledge and risk awareness, aimed at migrants with type 2 diabetes, living in Sweden.

Background:

Type 2 diabetes is rapidly increasing globally, particularly affecting migrants living in developed countries. There is ongoing debate about what kind of teaching method gives the best result, but few studies have evaluated different methods for teaching migrants. Previous studies lack a theoretical base and do not proceed from the individuals’ own beliefs about health and illness, underpinned by their knowledge, guiding their health-related behaviour.

Methods:

A diabetes education model was developed to increase knowledge about diabetes and to influence self-care among migrants with type 2 diabetes. The model was based on literature review, on results from a previous study investigating knowledge about diabetes, on experience from studies of beliefs about health and illness, and on collaboration between researchers in diabetes care and migration and health and staff working in a multi-professional diabetes team.

Findings:

This is a culturally appropriate diabetes education model proceeding from individual beliefs about health and illness and knowledge, conducted in focus-group discussions in five sessions, led by a diabetes specialist nurse in collaboration with a multi-professional team, and completed within three months. The focus groups should include 4–5 persons and last for about 90 min, in the presence of an interpreter. A thematic interview guide should be used, with broad open-ended questions and descriptions of critical situations/health problems. Discussions of individual beliefs based on knowledge are encouraged. When needed, healthcare staff present at the session answer questions, add information and ensure that basic principles for diabetes care are covered. The diabetes education model is tailored to both individual and cultural aspects and can improve knowledge about type 2 diabetes, among migrants and thus increase self-care behaviour and improve health.

Behavior change in diabetes practitioners: An intervention using motivation, action planning and prompts

OBJECTIVES

It is important for health professionals to have behavior change skills to empower people to manage long-term-conditions. Theoretically derived, competency-based training can be particularly effective where it considers reflective and automatic routes to behavior change. The aim of this study was to develop, deliver and evaluate a motivational, action and prompting behavior change skills intervention for diabetes health practitioners in Scotland, UK.

METHODS

This was a longitudinal intervention study. A 2-day intervention was delivered to 99 health professionals. Participants set behavioral goals to change practice, completing action and coping plans post-training. Motivation and plan quality were evaluated in relation to goal achievement at 6-week follow-up.

RESULTS

Post-training, practitioners could develop high quality work-related action and coping plans, which they were motivated to enact. Although under half responded at follow-up, most reported successful goal achievement. There was no difference in plan quality for goal achievers, non-achievers and non-responders. Barriers and facilitators of behavior change included institutional, service-user and individual factors.

CONCLUSIONS

The intervention successfully used planning to implement participants' behaviour change goals.

PRACTICE IMPLICATIONS

Planning interventions are helpful to support clinicians to change their practice to help people self-manage diabetes care but may not fit demands of day-to-day clinical practice.

Motivation and Barriers to Maintaining Lifestyle Changes in Patients with Type 2 Diabetes after an Intensive Lifestyle Intervention (The U-TURN Trial): A Longitudinal Qualitative Study

The purpose of this study was to explore and identify factors that influence motivation for and barriers to adopting and maintaining lifestyle changes in patients with type 2 diabetes, following participation in an intensive multiple-lifestyle intervention. Participants were recruited from the U-TURN trial, a one-year, intensive lifestyle intervention for type 2 diabetes patients. This study was conducted over time; informants were interviewed twice after the trial ended with a six-month interval between interviews. The qualitative data from these individual interviews were analysed using systematic text condensation with an inductive approach. Five themes emerged: Social support and relatedness, Achievement of results, Support from healthcare professionals, Identification with and acceptance of the new lifestyle and Coping with ongoing challenges. These are all important for maintaining lifestyle changes and diabetes self-management. Changing one’s lifestyle can be a constant, difficult struggle. For sustainable progress after an intensive intervention, the changes must be adopted and endorsed by patients and co-opted into their social setting. Belonging to an exercise group, confidence in managing the lifestyle adjustments and handling of challenges through continual support and professional diabetes treatment are crucial in maintaining and adhering to the new lifestyle.

Barriers and facilitators of physical activity participation in adults living with type 1 diabetes: a systematic scoping review

To identify and map barriers and facilitators of physical activity (PA) in adults living with type 1 diabetes (T1D) in any care setting or environment. A scoping review was conducted in accordance with the PRISMA-ScR guidelines to address the aim of this review. Exclusion/inclusion criteria were determined a priori. Articles captured in the search were subject to title and abstract screening before full-text articles were assessed for eligibility against the exclusion/inclusion criteria. Included articles underwent critical appraisal before being charted, mapped, and discussed. Forty-six articles were included in the final synthesis. Most commonly, articles reported cross-sectional survey studies (46%), then qualitative designs (17%), and opinion or text (17%). Experimental studies accounted for 13% of included articles. Hypoglycaemia/fear of hypoglycaemia was the most commonly reported barrier and patient education the most commonly discussed facilitator. Quality appraisal revealed methodological issues among included articles. Higher quality research with theoretically sound behaviour-change interventions combined with targeted patient education is needed to address hypoglycaemia/fear of hypoglycaemia as a barrier to PA. Novelty: Hypoglycaemia and fear of hypoglycaemia were the most commonly reported barriers to PA in adults with T1D. Powered randomised controlled trials are required to establish efficacy of behaviour change interventions targeting these barriers to PA.

The effects of a supportive-educational intervention on women with type 2 diabetes and diabetic peripheral neuropathy: a randomized controlled trial

Purpose:

To determine the effect of a supportive educational intervention based on the Orem self-care model on women with type 2 diabetes and diabetic peripheral neuropathy.

Design:

A randomized controlled trial.

Setting:

Hospital outpatient diabetes clinic.

Subjects:

Adult women with type 2 diabetes and mild-to-moderate diabetic peripheral neuropathy. Out of 410 patients, 120 diabetic patients were recruited and randomly assigned to trial group ( N = 60) and control group ( N = 60).

Intervention:

The trial group received a designed intervention consist of one-month supportive educational program with three months of follow-up (totally four months), based on self-care requisites according to the Orem self-care regarding diabetic peripheral neuropathy. The control group only received a routine care program in the diabetes clinic.

Main measurements:

The main outcomes were symptoms and severity of diabetic neuropathy. Further outcomes were fasting blood sugar and glycosylated hemoglobin.

Results:

By the end of the intervention, the number of participants reduced from 60 to 58 in the trial group and to 57 in the control group (totally 115). The intervention significantly decreased mean score of diabetic neuropathy symptoms (trial group: 3.26 vs. control group: 9.57, P = 0.001), severity (trial group: 5.86 vs. control group: 9.02, P = 0.001), fasting blood sugar (trial group: 151 vs. control group: 204, P = 0.001), and glycosylated hemoglobin (trial group: 7.85 vs. control group: 8.62, P = 0.004).

Conclusion:

Delivering a supportive-educational intervention based on the Orem self-care model on outpatient diabetes clinic can decrease the symptoms and severity of diabetic peripheral neuropathy.

Trial registration:

It was registered in the Iranian Registry of Clinical Trials (IRCT2015021521095N1).

Status and influencing factors of diabetes information acquisition among rural elderly with pre-diabetes in Yiyang City, China: a cross-sectional study

OBJECTIVE

This study was designed to investigate the status of diabetes information acquisition and its influencing factors among patients, 60 years and older, with pre-diabetes in rural China.

DESIGN

This is a cross-sectional study.

SETTING

The survey was conducted in 42 rural communities in Yiyang City, Hunan Province, China.

PARTICIPANTS

A total of 461 elderly with pre-diabetes participated in this study, and 434 of them completed the survey (434/461, 94.1%).

OUTCOME MEASURES

Information on sociodemographic and diabetic information-seeking behaviours were assessed through the structured questionnaires and described by percentages, mean±SD. The influencing factors of diabetes information acquisition were analysed using multiple linear regression analysis.

RESULTS

The average score of diabetes information acquisition in the subjects was 8.39±11.28. The most popular and trusted source of diabetes information for the subjects was doctors. The level of information acquisition not only declined as the age progressed (95% CI -3.754 to -0.143) but also proved lowest among subjects with less than 1 year of education (95% CI 0.756 to 4.326). In addition, the level of information acquisition among elderly individuals with pre-diabetes, but with no history of hyperglycaemia, was lower than among those with a history of hyperglycaemia (95% CI 3.398 to 11.945).

CONCLUSIONS

These data indicated that the lack of ability to acquire diabetes information in elderly with pre-diabetes was common in rural China. Improving the ability of rural residents to access information should be incorporated into rural diabetes prevention efforts, especially for the elderly with pre-diabetes with low education and no history of hyperglycaemia.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-15007033; Pre-results.

Comparison of self-care in non-cardiac diabetic patients

BACKGROUND

In general, the majority of diabetic patients suffering from a lack of capability in controlling different aspects of self-care have likely been prone to cardiovascular disease. To reduce the economic burden in societies and the rate of death on one hand, and improve life expectancy, on the other hand, it seems necessary to emphasize self-care training in diabetic patients. The purpose of this study was to determine comparison of self-care in cardiac and non-cardiac diabetic patients.

METHODS

This descriptive-analytic study was carried out with 136 diabetic participants selected using random sampling and divided into two groups of 68 non-cardiac diabetic patients. Data were collected using a demographic and diabetic patient's self-management questionnaire (DSMQ). For the analysis of the data, SPSS16 was employed to check the significance test at the level of P<0.05.

RESULTS

In this study, twenty-eight (41.2%) and forty (58.8%) of the participants in each group were male and female, respectively. Their ages spanned from (61.35±13.34) in non-cardiac diabetic group to (65.94±8.74) in cardiac diabetic participants. There were significant differences between two groups, specifically in patients with cardiac diabetic disease in different aspects, for instance, including glucose monitoring (F=4.977, P=0.027, η²=0.036), diet control (F=9.125, P=0.003, η²=0.064), physical activity (F=22.954, P=0.0001, η²=0.146) and health care awareness (F=31.366, P=0.0001, η²=0.19).

CONCLUSION

According to DSMQ questionnaire in the present study, glucose monitoring, diet control, physical activity, and health care awareness in diabetic patients with heart disease were significantly reported to have been better than the other group with no cardiac problem. Due to insufficient self-care in diabetic patients and some consequences such as poor health, heart disease as one of the complications of diabetes, hospital re-admission and heavy costs, the therapeutic team should be alerted to self-care training.

Impact of an educational DVD on anxiety and glycaemic control in women diagnosed with gestational diabetes mellitus (GDM): A randomised controlled trial

AIMS

The diagnosis of gestational diabetes mellitus (GDM) during pregnancy can lead to anxiety. This study evaluated the impact of an innovative patient-centred educational DVD on anxiety and glycaemic control in women newly diagnosed with GDM.

METHODS

150 multi-ethnic women, aged 19-44years, from three UK hospitals were randomised to either usual care plus DVD (DVD group, n=77) or usual care alone (control group, n=73) at GDM diagnosis. Primary outcomes were anxiety (State-Trait Anxiety Inventory) and mean 1-h postprandial capillary self-monitored blood glucose for all meals, on day prior to follow-up.

RESULTS

No significant difference between the DVD and control group were reported, for anxiety (37.7±11.7 vs 36.2±10.9; mean difference after adjustment for covariates (95% CI) 2.5 (-0.8, 5.9) or for mean 1-h postprandial glucose for all meals (6.9±0.9 vs 7.0±1.2mmol/L; -0.2 (-0.5, 0.2). However, the DVD group had significantly lower postprandial breakfast glucose compared to the control group (6.8±1.2 vs 7.4±1.9mmol/L; -0.5 (-1.1, -<0.1; p=0.04).

CONCLUSIONS

The results in this trial did not highlight any differences between those who received the intervention and those who received usual care. It is possible that women already felt supported by their frequent attendance at specialist clinics for monitoring and advice. Healthcare professional and family support are key elements to empowering women with GDM and require further consideration in future interventions. Nonetheless, educational resources such as this will be beneficial to help support women given the current resource and time implications of the year on year rises in the incidence of gestational diabetes.

Effectiveness of a multidisciplinary risk assessment and management programme-diabetes mellitus (RAMP-DM) on patient-reported outcomes

Little is known about how the patient-reported outcomes is influenced by multidisciplinary-risk-assessment-and-management-programme for patients with diabetes mellitus (RAMP-DM). This paper aims to evaluate the effectiveness of RAMP-DM on patient-reported outcomes. This was a prospective longitudinal study on 1039 diabetes mellitus patients (714/325 RAMP-DM/non-RAMP-DM) managed in primary care setting. 536 and 402 RAMP-DM participants, and 237 and 187 non-RAMP-DM participants were followed up at 12 and 24 months with completed survey, respectively. Patient-reported outcomes included health-related quality of life, change in global health condition and patient enablement measured by Short Form-12 Health Survey version-2 (SF-12v2), Global Rating Scale, Patient Enablement Instrument respectively. The effects of RAMP-DM on patient-reported outcomes were evaluated by mixed effect models. Subgroup analysis was performed by stratifying haemoglobin A1c (HbA1c) (optimal HbA1c < 7 % and suboptimal HbA1c ≥ 7 %). RAMP-DM with suboptimal HbA1c was associated with greater improvement in SF-12v2 physical component summary score at 12-month (coefficient:3.80; P-value < 0.05) and 24-month (coefficient:3.82;P-value < 0.05), more likely to feel more enabled at 12-month (odds ratio: 2.57; P-value < 0.05), and have improved in GRS at 24-month (odds ratio:4.05; P-value < 0.05) compared to non-RAMP-DM participants. However, there was no significant difference in patient-reported outcomes between RAMP-DM and non-RAMP-DM participants with optimal HbA1c. Participation in RAMP-DM is effective in improving physical component of HRQOL, Global Rating Scale and patient enablement among diabetes mellitus patients with suboptimal HbA1c, but not in those with optimal HbA1c. Patients with sub-optimal diabetes mellitus control should be the priority target population for RAMP-DM. This observational study design may have potential bias in the characteristics between groups, and randomized clinical trial is needed to confirm the results.

Postprandial glucose and insulin levels in type 2 diabetes mellitus patients after consumption of ready-to-eat mixed meals

PURPOSE

To compare the effects of three ready-to-eat mixed meals, with a high fiber content and low glycemic index, on postprandial glycemic and insulinemic response in patients with Type 2 diabetes mellitus (T2DM).

METHODS

The current study followed a prospective, three-way, cross-over design. Twenty-four patients with T2DM consumed three ready-to-eat mixed meals, i.e., "wild greens pie" (meal 1), "chicken burgers with boiled vegetables" (meal 2) and "vegetable moussaka" (meal 3) and an oral glucose load, all providing 50 g of carbohydrates. Venous blood was collected at 0, 30, 60, 90 and 120 min postprandial. Statistical analyses included repeated measures analysis of variance and calculations of the area under the glucose and insulin curves (AUC) for each one of the test meals and the oral glucose load.

RESULTS

Patients consuming each one of the three mixed meals showed better postprandial glycemic responses compared to the oral glucose load (P < 0.001). Furthermore, patients consuming meal 3 showed a better insulinemic response compared to the oral glucose load and meal 1, after 60 and 120 min postprandial, respectively (P < 0.05). In addition, the increase observed in HOMA-IR values from T0 to T120 was significantly lower for meal 3, compared to the oral glucose load (P < 0.001).

CONCLUSIONS

The three ready-to-eat mixed meals examined in the present study were found to elicit significantly lower glycemic responses compared to the oral glucose load in diabetic patients. The mixed meals examined in the present study could be proposed as effective, palatable and practical solutions for diabetics for glucose control.

Behavioral Programs for Type 1 Diabetes Mellitus: A Systematic Review and Meta-analysis

BACKGROUND

Whether behavioral approaches for self-management programs benefit individuals with type 1 diabetes mellitus is unclear.

PURPOSE

To determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate effect.

DATA SOURCES

6 electronic databases (1993 to June 2015), trial registries and conference proceedings (2011 to 2014), and reference lists.

STUDY SELECTION

36 prospective, controlled studies involving participants of any age group that compared behavioral programs with usual care, active controls, or other programs.

DATA EXTRACTION

One reviewer extracted and another verified data. Two reviewers assessed quality and strength of evidence (SOE).

DATA SYNTHESIS

Moderate SOE showed reduction in glycated hemoglobin (HbA1c) at 6 months after the intervention compared with usual care (mean difference, -0.29 [95% CI, -0.45 to -0.13] percentage points) and compared with active controls (-0.44 [CI, -0.69 to -0.19] percentage points). At the end of the intervention and 12-month follow-up or longer, there were no statistically significant differences in HbA1c (low SOE) for comparisons with usual care or active control. Compared with usual care, generic quality of life at program completion did not differ (moderate SOE). Other outcomes had low or insufficient SOE. Adults appeared to benefit more for glycemic control at program completion (-0.28 [CI, -0.57 to 0.01] percentage points) than did youth (-0.12 [CI, -0.43 to 0.19] percentage points). Program intensity appeared not to influence effectiveness; some individual delivery appears beneficial.

LIMITATIONS

All studies had medium or high risk of bias. There was scarce evidence for many outcomes.

CONCLUSION

Behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up, but improvement for other outcomes has not been shown. (PROSPERO registration number: CRD42014010515).

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERD registration number: CRD42014010515).

Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis

BACKGROUND

Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs.

PURPOSE

To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes.

DATA SOURCES

6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists.

STUDY SELECTION

Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs.

DATA EXTRACTION

One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias.

DATA SYNTHESIS

Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥ 11 contact hours) led to clinically important improvements in glycemic control (≥ 0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support-especially those offering 10 or fewer contact hours-provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥ 75% nonwhite participants).

LIMITATIONS

All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions.

CONCLUSION

Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515).

Increased number of structured diabetes education attendance was not associated with the improvement in patient-reported health-related quality of life: results from Patient Empowerment Programme (PEP)

AIMS

To assess the effect of a structured education intervention, Patient Empowerment Programme (PEP) patient-reported health-related quality of life (HRQOL) among type 2 diabetes mellitus (T2DM) patients, and if positive effect is confirmed, to further explore any association between frequency of sessions attendance and HRQOL.

METHODS

A total of 298 T2DM patients were recruited when they attended the first session of PEP, between March and September 2010, and were followed over a one-year period from baseline. HRQOL data were assessed using Short Form-12 Health Survey version 2 (SF-12) and Short Form-6 Dimension (SF-6D) at baseline and one-year follow-up. Individuals' anthropometric and biomedical data were extracted from an administrative database in Hong Kong. Unadjusted and adjusted analyses of linear regression models were performed to examine the impact of PEP session attendance on the change in the HRQOL scores, accounting for the socio-demographic and clinical characteristics at baseline.

RESULTS

Of the 298 eligible patients, 257 (86.2%) participated in the baseline assessment and 179 (60.1%) patients completed the follow-up assessment, respectively. Overall, PEP resulted in a significant improvement in SF-12 bodily pain and role emotional subscales and SF-6D utility scores. These positive changes were not associated with the level of participation as shown in both unadjusted and adjusted analyses.

CONCLUSIONS

The PEP made significant improvement in bodily pain, role emotional and overall aspects of HRQOL. Higher number of session attendance was not associated with improvement in HRQOL in primary care real-world setting. Key Messages ● Participants with type 2 diabetes mellitus who participated in structured diabetes education programme made significant improvement in bodily pain and role emotional subscales and SF-6D scores. ● There was no association between the number of sessions attended and any aspect of HRQOL.

Psychometric Properties of the Diabetes Management Self-Efficacy Scale in Korean Patients with Type 2 Diabetes

Objectives. The aims of this study were to perform a cultural translation of the DMSES and evaluate the psychometric properties of the translated scale in a Korean population with type 2 diabetics. Methods. This study was conducted in patients with diabetes recruited from university hospitals. The first stage of this study involved translating the DMSES into Korean using a forward- and backward-translation technique. The content validity was assessed by an expert group. In the second stage, the psychometric properties of the Korean version of the DMSES (K-DMSES) were evaluated. Results. The content validity of the K-DMSES was satisfactory. Sixteen-items clustered into four-subscales were extracted by exploratory factor analysis, and supported by confirmatory factor analysis. The construct validity of the K-DMSES with the Summary of Diabetes Self-Care Activities scale was satisfactory (r = 0.50, P<0.001). The Cronbach's alpha and intraclass correlation coefficient were 0.92 and 0.85 (P<0.001; 95% CI = 0.75-0.91), respectively, which indicate excellent internal consistency reliability and test-retest reliability. Conclusions. The K-DMSES is a brief instrument that has demonstrated good psychometric properties. It is therefore feasible to use in practice, and is ready for use in clinical research involving Korean patients with type 2 diabetes.

Psychosocial interventions for the diabetic patient

Diabetes usually requires substantial life-long self-management by the patient. Psychological factors and the patient's health beliefs are important determinants of self-care behavior. Education has a modest influence on generating better self-care, but psychologically based interventions are clearly more effective. This review gives an overview of these interventions with some discussion of their basis in psychological theory. Some labels such as cognitive behavioral therapy and family therapy include a wide range of approaches. Randomized trials have generally produced improvement in measures of psychological well-being, but improved glycemic control has been more elusive. The influence on behavior can be very dependent on the individual therapist. Only a few trials have managed to sustain improvement in glycosylated hemoglobin beyond a year. Not all patients are prepared to engage and accept these forms of therapeutic intervention. We are still some way from moving psychological management from the trial situation into the diabetic clinic.

Diabetes self-management arrangements in Europe: a realist review to facilitate a project implemented in six countries

Background

Self-management of long term conditions can promote quality of life whilst delivering benefits to the financing of health care systems. However, rarely are the meso-level influences, likely to be of direct relevance to these desired outcomes, systematically explored. No specific international guidelines exist suggesting the features of the most appropriate structure and organisation of health care systems within which to situate self-management approaches and practices. This review aimed to identify the quantitative literature with regard to diabetes self-management arrangements currently in place within the health care systems of six countries (The United Kingdom, The Netherlands, Norway, Spain, Bulgaria, and Greece) and explore how these are integrated into the broader health care and welfare systems in each country.

Methods

The methodology for a realist review was followed. Publications of interest dating from 2000 to 2013 were identified through appropriate MeSH terms by a systematic search in six bibliographic databases. A search diary was maintained and the studies were assessed for their quality and risk of bias.

Results

Following the multi-step search strategy, 56 studies were included in the final review (the majority from the UK) reporting design methods and findings on 21 interventions and programmes for diabetes and chronic disease self-management. Most (11/21, 52%) of the interventions were designed to fit within the context of primary care. The majority (11/21, 52%) highlighted behavioural change as an important goal. Finally, some (5/21, 24%) referred explicitly to Internet-based tools.

Conclusions

This review is based on results which are derived from a total of at least 5,500 individuals residing in the six participating countries. It indicates a policy shift towards patient-centred self-management of diabetes in a primary care context. The professional role of diabetes specialist nurses, the need for multidisciplinary approaches and a focus on patient education emerge as fundamental principles in the design of relevant programmes. Socio-economic circumstances are relevant to the capacity to self-manage and suggest that any gains and progress will be hard to maintain during economic austerity. This realist review should be interpreted within the wider context of a whole systems approach regarding self-care support and chronic illness management.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-453) contains supplementary material, which is available to authorized users.

Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus

BACKGROUND

Ethnic minority groups in upper-middle-income and high-income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus.

SEARCH METHODS

A systematic literature search was performed of the following databases: The Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper-middle-income or high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta-analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education.Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) -0.4% (95% confidence interval (CI) -0.5 to -0.2); 14 trials; 1442 participants; high-quality evidence) and at six months (MD -0.5% (95% CI -0.7 to -0.4); 14 trials; 1972 participants; high-quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD -0.2% (95% CI -0.3 to -0.04); 9 trials; 1936 participants) and at 24 months (MD -0.3% (95% CI -0.6 to -0.1); 4 trials; 2268 participants; moderate-quality evidence) post intervention. Neutral effects on health-related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies - the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI -40 to -8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low-density lipoprotein (LDL) cholesterol or high-density lipoprotein (HDL) cholesterol were reported at any follow-up point. Other outcome measures (blood pressure, body mass index, self-efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient.Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self-reported via questionnaires, leading to high bias in subjective outcome assessment.

AUTHORS' CONCLUSIONS

Culturally appropriate health education has short- to medium-term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long-term trials, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long-term, standardised, multi-centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium-term effects could lead to clinically important health outcomes, if sustained.

Podiatric physicians' perspectives on their role in promoting self-care in high-risk patients with diabetes

BACKGROUND

Foot self-care is key in preventing morbidity in high-risk diabetic patients. Motivational interviewing (MI) is an approach to encourage behavior change by patients that can be used in medical settings. The goal was to explore how podiatric physicians promote self-care in such patients and whether they use MI techniques.

METHODS

We conducted a 19-question online survey of US-based practicing podiatric physicians. Most answers were on a 5-point scale. The MI index was the sum of answers to five relevant questions.

RESULTS

Of 843 podiatric physicians, 86% considered foot self-care to be very important for high-risk diabetic patients, and 90% felt that it was their role to discuss foot self-care with them; 49% felt that they had training and were successful in promoting behavior change, but most were definitely (38%) or possibly (46%) interested in learning more. Only 24% of respondents scored at least 15 of 20 on the MI index. Higher MI scores were associated with more face time and more time discussing foot self-care but were not related to podiatric physicians' age, sex, geographic location, percentage of time in surgery, or years in practice. Reported barriers to counseling were lack of reimbursed time and poor patient engagement.

CONCLUSIONS

Most podiatric physicians view self-care behavior among high-risk diabetic patients and their role in promoting it as very important; most feel already proficient, but only a few demonstrate MI skills; most are willing to learn more. Success in behavioral counseling, such as MI, is likely to require more time and may be encouraged by a move from fee-for-service to outcome-based reimbursement.

The context of empowerment and self-care within the field of diabetes

There is a growing emphasis within the diabetes literature on the importance of empowerment as a way of encouraging people to take control of and responsibility for the successful management of their disease. Patients are actively encouraged to become active participants in their care, and there is an expectation that health-care professionals will facilitate this process. This article uses Bourdieu’s concept of field, as a bounded social space in which actors conduct their lives day-to-day, to explore the context within which issues of empowerment are addressed and negotiated. The practice of empowerment within the biologically defined and biomedically ‘policed’ field of diabetes is explored using empirical data from a study of diabetes health-care professionals’ understanding and practices around empowerment. It is concluded that rather than promoting active self-management and empowerment, the nature of the field of diabetes, and in particular its privileging of the biomedical, can mitigate against people with diabetes negotiating the field effectively and taking control of the disease and its management.

Development and validation of PRISM: a survey tool to identify diabetes self-management barriers

AIMS

Although most children with type 1 diabetes do not achieve optimal glycemic control, no systematic method exists to identify and address self-management barriers. This study develops and validates PRISM (Problem Recognition in Illness Self-Management), a survey-based tool for efficiently identifying self-management barriers experienced by children/adolescents with diabetes and their parents.

METHODS

Adolescents 13 years and older and parents of children 8 years and older visiting for routine diabetes management (n=425) were surveyed about self-management barriers. HbA1c was abstracted from the electronic health record. To develop PRISM, exploratory and confirmatory factor analyses were used. To assess validity, the association of PRISM scores with HbA1c was examined using linear regression.

RESULTS

Factor analyses of adolescent and parent data yielded well-fitting models of self-management barriers, reflecting the following domains: (1) Understanding and Organizing Care, (2) Regimen Pain and Bother, (3) Denial of Disease and Consequences, and (4) Healthcare Team, (5) Family, or (6) Peer Interactions. All models exhibited good fit, with χ(2) ratios<2.21, root mean square errors of approximation<0.09, Confirmatory Fit Indices and Tucker-Lewis Indices both >0.92, and weighted root mean square residuals<1.71. Greater PRISM barrier scores were significantly associated with higher HbA1cs.

CONCLUSIONS

Our findings suggest at least six different domains exist within self-management barriers, nearly all of which are significantly related to HbA1c. PRISM could be used in clinical practice to identify each child and family's unique self-management barriers, allowing existing self-management resources to be tailored to the family's barriers, ultimately improving effectiveness of such services.

Supporting self-management after attending a structured education programme: a qualitative longitudinal investigation of type 1 diabetes patients' experiences and views

BACKGROUND

Structured education programmes for patients with diabetes and other chronic conditions are being widely adopted. However, follow-up studies suggest that course graduates may struggle to sustain the self-care practices taught on their courses over time. This study explored the support needs of patients with type 1 diabetes after attending a structured education programme promoting an empowerment approach and training in use of flexible intensive insulin therapy, a regimen now widely advocated and used to manage this condition. The objective was to inform future support offered to course graduates.

METHODS

Repeat, in-depth interviews with 30 type 1 diabetes patients after attending Dose Adjustment for Normal Eating (DAFNE) courses in the UK, and six and 12 months later. Data were analysed using an inductive, thematic approach.

RESULTS

While the flexible intensive insulin treatment approach taught on DAFNE courses was seen as a logical and effective way of managing one's diabetes, it was also considered more technically complex than other insulin regimens. To sustain effective disease self-management using flexible intensive insulin treatment over time, patients often expected, and needed, on-going input and support from health care professionals trained in the approach. This included: help determining insulin dose adjustments; reassurance; and, opportunities to trouble-shoot issues of concern. While some benefits were identified to receiving follow-up support in a group setting, most patients stated a preference or need for tailored and individualised support from appropriately-trained clinicians, accessible on an 'as and when needed' basis.

CONCLUSIONS

Our findings highlight potential limitations to group-based forms of follow-up support for sustaining diabetes self-management. To maintain the clinical benefits of structured education for patients with type 1 diabetes over time, course graduates may benefit from and prefer ongoing, one-to-one support from health care professionals trained in the programme's practices and principles. This support should be tailored and personalised to reflect patients' specific and unique experiences of applying their education and training in the context of their everyday lives, and could be the subject of future research.

Effectiveness of nurse practitioner coordinated team group visits for type 2 diabetes in medically underserved Appalachia

PURPOSE

To study the effectiveness of multidisciplinary nurse practitioner coordinated team (NPCT) group visits in medically underserved Appalachia on the health, knowledge, and self-efficacy of patients with type 2 diabetes (DM). The study also identified perceived barriers to participating in the diabetes programs.

DATA SOURCES

A researcher-developed tool was used to assess demographic data, clinical data, and barriers to care. The participants completed the Diabetes Knowledge Tests and the Diabetes Empowerment Scales. Two groups were assessed. One group participated in the diabetes intervention, and the other received usual care. Both groups completed the instruments prior to the intervention and after the intervention was completed.

CONCLUSIONS

The group that participated in the intervention had better clinical outcomes (blood glucose and A1Cs), greater knowledge, and better self-efficacy following the intervention than the usual care groups. This suggests that the intervention was important in improving outcomes of patients with type 2 DM. Barriers to care included fuel, time, family, work, and transportation. Barriers need to be addressed in order to have more patients participate in such programs.

IMPLICATIONS FOR PRACTICE

NPCT group visits may represent an effective means of integrating diabetes self-management education and medical management in a family practice clinic in medically underserved areas.

Bean and rice meals reduce postprandial glycemic response in adults with type 2 diabetes: a cross-over study

Background

Around the world, beans and rice are commonly consumed together as a meal. With type 2 diabetes increasing, the effect of this traditional diet pattern on glycemic response has not been studied fully.

Methods

We evaluated the glycemic response of bean and rice traditional meals compared to rice alone in adults with type 2 diabetes. Seventeen men and women with type 2 diabetes controlled by metformin (n = 14) or diet/exercise (n = 3) aged 35–70 years participated in the randomized 4 × 4 crossover trial. The white long grain rice control, pinto beans/rice, black beans/rice, red kidney beans/rice test meals, matched for 50 grams of available carbohydrate, were consumed at breakfast after a 12 hour fast. Capillary blood glucose concentrations at baseline and at 30 minute intervals up to 180 minutes postprandial were collected. MANOVA for repeated measures established glucose differences between treatments. Paired t tests identified differences between bean types and the rice control following a significant MANOVA.

Results

Postprandial net glucose values were significantly lower for the three bean/rice treatments in contrast to the rice control at 90, 120 and 150 minutes. Incremental area under the curve values were significantly lower for the pinto and black bean/rice meals compared to rice alone, but not for kidney beans.

Conclusions

Pinto, dark red kidney and black beans with rice attenuate the glycemic response compared to rice alone. Promotion of traditional foods may provide non-pharmaceutical management of type 2 diabetes and improve dietary adherence with cultural groups.

Trial registration

Clinical Trials number NCT01241253

A scoping review on the experiences and preferences in accessing diabetes-related healthcare information and services by British Bangladeshis

Diabetes is a chronic condition requiring lifelong self-management. Patients are encouraged to access appropriate services to facilitate optimum management of diabetes. Although equitable access to healthcare in the United Kingdom is a legal right, not all groups and individuals in the community experience equity. Despite various equality laws and numerous efforts to minimise health inequalities related to access, particular community groups are more likely to experience inequitable access than others. The Bangladeshi community are one such community who experience some of the worst diabetes-related health outcomes in the United Kingdom. Little is known about their experiences and preferences in accessing diabetes healthcare information and services. Consequently, we undertook a scoping review of the literature by following the York Scoping Reviews Framework to identify the experiences and preferences of Bangladeshi patients and carers when gaining access to diabetes-related healthcare information and services. We identified eight articles and reported our results in relation to four domains of access: health service availability, health service utilisation, health service outcomes and the notion of equity. The review identified that language and literacy issues were the most common barriers hindering access to information and services. Patient knowledge regarding diabetes and its management was generally low, and friends and family were frequently being used as information sources and as informal interpreters. Additionally, there were feelings of isolation from mainstream information and services possibly resulting in the high prevalence of depression in the Bangladeshi community with women more affected than men. Social networks combined with religious and cultural beliefs as well as wider societal duties played a crucial role in accessing information and services for this population, and the identification of these issues merit further research and are possible avenues towards improved access to healthcare information and services for the Bangladeshi population.

Marrying contradictions: healthcare professionals perceptions of empowerment in the care of people with Type 2 Diabetes

OBJECTIVE

The aim of the study was to establish how healthcare professionals (HCPs) involved in Type 2 Diabetes (T2D) perceive patient-empowerment. We aimed to identify their understanding of empowerment, and how these inform their day-to-day practice.

METHODS

Employing a qualitative approach, ten interviews with diabetes HCPs in two local Health Trusts were conducted. Data were transcribed verbatim and analysed using framework analysis.

RESULTS

HCPs viewed empowerment as a rejection of the paternalistic approach. Emphasis was given to ways of balancing clinical aims against patients' concerns. Some saw the approach as improving service quality, whereas others saw empowerment as a process of social justice. These were related variably to the expedient use of resources.

CONCLUSION

Models of empowerment, which promote that HCPs bring clinical expertise and patients 'lay' expertise of illness to the medical encounter, are inadequately descriptive of how empowerment approaches are actually engaged with, by HCPs.

PRACTICE IMPLICATIONS

The empowerment approach is construed and utilised in different ways. Clarification of what empowerment entails in practice for HCPs, as well as what HCPs perceive are its multiple aims, is required.

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

To determine if culturally appropriate health education is more effective than 'usual' health education for people with diabetes from ethnic minority groups living in high- and upper-middle-income countries. A systematic review with meta-analysis, following the methodology of the Cochrane Collaboration. Electronic literature searches of nine databases were made, with hand searching of three journals and 16 author contacts. The criteria for inclusion into the analysis were randomized controlled trials of a specified diabetes health education intervention, and a named ethnic minority group with Type 2 diabetes. Data were collected on HbA(1c), blood pressure, and quality-of-life measures. A narrative review was also performed. Few studies fitted the selection criteria, and were heterogeneous in methodologies and outcome measures, making meta-analysis difficult. HbA(1c) showed an improvement at 3 months [weighted mean difference (WMD) -0.32%, 95% confidence interval (CI) -0.63, -0.01] and 6 months post intervention (WMD -0.60%, 95% CI -0.85, -0.35). Knowledge scores also improved in the intervention groups at 6 months (standardized mean difference 0.46, 95% CI 0.27, 0.65). There was only one longer-term follow-up study, and one formal cost-effectiveness analysis. Culturally appropriate health education was more effective than 'usual' health education in improving HbA(1c) and knowledge in the short to medium term. Due to poor standardization between studies, the data did not allow determination of the key elements of interventions across countries, ethnic groups and health systems, or a broad view of their cost-effectiveness. The narrative review identifies learning points to direct future research.

Nursing care of clients treated with atypical antipsychotics who have a risk of developing metabolic instability and/or type 2 diabetes

OBJECTIVE

The aim of this article is to present a current discussion related to the nursing care of clients treated with atypical antipsychotic medicines and who have a risk of developing metabolic instability and/or Type 2 diabetes. The importance of such a discussion is to provide both the novice and the experienced nurse with additional knowledge of this current health issue with which to inform their nursing practice.

DISCUSSION

The potential for psychosis to be a chronic condition is very high, and often people require antipsychotic medicine for lengthy periods throughout their lives. Sometimes, treatment is for life. The second generation of antipsychotic medicines was greeted with much enthusiasm since it was better tolerated than the first generation. However, each medication has desired and adverse effects and, when taken for lengthy periods, these effects may produce physical illness. Studies show that the prevalence of Type 2 diabetes and the metabolic syndrome was significantly higher in clients with a chronic psychiatric disorder, particularly schizophrenia.

CONCLUSIONS

Metabolic instability, especially weight gain, is associated with some psychotropic medicines. Nursing interventions need to include care assessment, planning, intervention, and evaluation for clients treated with antipsychotic medicines in terms of risk minimization strategies in routine nursing care.

A cognitive behavior therapy-based intervention among poorly controlled adult type 1 diabetes patients--a randomized controlled trial

OBJECTIVE

To examine the impact of a Cognitive Behavior Therapy (CBT)-based intervention on HbA(1c), self-care behaviors and psychosocial factors among poorly controlled adult type 1 diabetes patients.

METHODS

Ninety-four type 1 diabetes patients were randomly assigned to either an intervention group or a control group. The intervention was based on CBT and was mainly delivered in group format, but individual sessions were also included. All subjects were provided with a continuous glucose monitoring system (CGMS) during two 3-day periods. HbA(1c), self-care behaviors and psychosocial factors were measured up to 48 weeks.

RESULTS

Significant differences were observed with respect to HbA(1c) (P<0.05), well-being (P<0.05), diabetes-related distress (P<0.01), frequency of blood glucose testing (P<0.05), avoidance of hypoglycemia (P<0.01), perceived stress (P<0.05), anxiety (P<0.05) and depression (P<0.05), all of which showed greater improvement in the intervention group compared with the control group. A significant difference (P<0.05) was registered with respect to non-severe hypoglycemia, which yielded a higher score in the intervention group.

CONCLUSION

This CBT-based intervention appears to be a promising approach to diabetes self-management.

PRACTICE IMPLICATIONS

Diabetes care may benefit from applying tools commonly used in CBT. For further scientific evaluation in clinical practice, there is a need for specially educated diabetes care teams, trained in the current approach, as well as cooperation between diabetes care teams and psychologists trained in CBT.

The feasibility of a self-management education program for patients with type 2 diabetes mellitus: Do the perceptions of patients and educators match?

AIMS

To compare the feasibility experienced by patients with type 2 diabetes mellitus in a self-management educational program to the hindrance assessed by the educator of the program.

METHODS

Twenty-five type 2 diabetes patients on maximally tolerated oral hypoglycaemic agents followed a 6-month educational program consisting of five components: background, medication, physical exercise, nutrition and blood glucose self-monitoring. Medication was unchanged during the study. Outcome measures were feasibility encountered by the patient, hindrance observed by the educator and HbA(1c)-level.

RESULTS

The feasibility encountered by patients was significantly related to the hindrance assessed by the educators (rho 0.756, p<0.001). Feasibility increased significantly for three components but not for physical exercise and nutritional advice. Mean HbA(1c)-level decreased from 8.2+/-1.1% before onset of the program to 7.2+/-1.3% 6 weeks after termination of the program.

CONCLUSIONS

Feasibility experienced by the patients matched the hindrance noticed by the educators. This might have led to an increase in patients' self-efficacy, which in turn gives an improvement in self-management and glycaemic control.

An updated meta-analysis to assess the effectiveness of psychological interventions delivered by psychological specialists and generalist clinicians on glycaemic control and on psychological status

OBJECTIVE

To update a meta-analysis and determine the effectiveness of psychological interventions on glycaemic control measured by HbA(1c) and psychological status in type 2 diabetes and to compare effects when interventions are delivered by generalist clinicians compared to psychological specialists.

METHODS

We used the original review protocol and searched the Cochrane central register of controlled trials, Medline, Embase, PsychLIT, and Google Scholar from February 2003 (end of previous review) to March 2007. We extracted data on the participants, interventions, delivery methods, comparison groups and outcome measures.

RESULTS

35 trials were reviewed and meta-analysis of 19 trials (n=1431), reporting HbA(1c) found a reduction in HbA(1c) by 0.54% (-0.32; 95% CI: -0.47 to -0.16). In nine trials (n=832) interventions were delivered by diabetes or general clinicians reducing HbA(1c) by 0.51% (-0.27; 95% CI: -0.50 to 0.04). In nine trials, interventions (n=561) were delivered by psychological specialists reducing HbA(1c) by 0.57% (-0.36; 95% CI: -0.61 to 0.12). Meta-analysis of 13 trials reporting psychological status found psychological status to be lower in the intervention groups -0.56 (95% CI: 1.00 to -0.13). Trial quality for the majority of studies remained poor.

CONCLUSION

Our findings suggest that psychological and general clinicians are similarly effective in delivering psychological interventions, however, effect sizes for all clinicians have reduced since the earlier review.

PRACTICE IMPLICATIONS

Psychological training opportunities for generalist clinicians could lead to wider availability of effective psychological care.

Experience from a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients

AIM

To describe experience from a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients, in terms of feasibility, predictors and associations of improved glycaemic control.

METHODS

Data were collected on 94 poorly controlled adult type 1 diabetes patients who were randomised to a study evaluating the effects of a behavioural medicine intervention. Statistics covered descriptive and comparison analysis. Backward stepwise regression models were used for predictive and agreement analyses involving socio-demographic and medical factors, as well as measures of diabetes self-efficacy (DES), diabetes locus of control (DLOC), self-care activities (SDSCA), diabetes-related distress (Swe-PAID-20), fear of hypoglycaemia (HFS), well-being (WBQ), depression (HAD) and perceived stress (PSS).

RESULTS

The participation rate in the study was 41% and attrition was 24%. Of those patients actually participating in the behavioural medicine intervention, 13% withdrew. From the regression models no predictors or associations of improvement in HbA(1c) were found.

CONCLUSIONS

The programme proved to be feasible in terms of design and methods. However, no clear pattern was found regarding predictors or associations of improved metabolic control as the response to the intervention. Further research in this area is called for.

Clínica ampliada em saúde mental: cuidar e suposição de saber no acompanhamento terapêutico

Este trabalho investiga o acompanhamento terapêutico, entendido como intervenção em saúde mental baseada em cuidados domiciliares. Destacamos a importância de intervenções comunitárias privilegiando formas de lidar com o sofrimento, seja através de uma concepção médica dos sintomas, fundada na visibilidade, seja valorizando uma leitura psicanalítica que recorre à escuta. Carecendo de teorização independente que fundamente sua prática, o AT (acompanhamento terapêutico) apropria-se de teorias provenientes de outros campos do saber que guardam afinidades. Neste sentido, abordamos a influência da psicanálise e sua participação na clínica ampliada em saúde mental através da prática clínica do AT, utilizando dois conceitos operatórios de amplo alcance, que são: sujeito suposto saber, proveniente da obra de Lacan, e cuidado, derivado de Winnicott. Ambos respondem a questões do campo teórico e orientam a atuação clínica. Concluímos que o AT realiza exigências do manejo transferencial sob a forma do cuidar exercido no cotidiano do sujeito, no qual desejo e subjetividade são necessariamente reconhecidos, sem que se configure como tecnologia psicoterápica, situando-se mais propriamente como sentinela clínica no campo da psiquiatria comunitária e saúde coletiva.

Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups

BACKGROUND

Ethnic minority groups in upper-middle and high income countries tend to be socio-economically disadvantaged and to have higher prevalence of type 2 diabetes than the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes.

SEARCH STRATEGY

We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals.

SELECTION CRITERIA

RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significant at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups.

AUTHORS' CONCLUSIONS

Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups.

Knowledge after five-day teaching program in intensive insulin therapy performed at the onset of type 1 diabetes influence the development of late diabetic complications

We evaluated the influence of baseline diabetic knowledge on clinical course of type 1 diabetes treated with intensive functional insulin therapy (IFIT) from the onset of the disease. 86 subjects with newly diagnosed type 1 diabetes, aged 23.4+/-5.1 attended a five-day structured training program in IFIT at baseline, followed by a test consisting of 20 questions. Patients were divided into subgroups according to test results: group A>16, group B 12-16 and group C<12 scores. At follow-up (7.1+/-1.5 years) metabolic control and development of microangiopathy were assessed. Patients with low knowledge at baseline had higher HbA1c levels than subjects with higher knowledge (group C: 9.2+/-1.9 vs. group A: 7.7+/-1.5%, p<0.05 and vs. group B: 7.8+/-1.6%, p<0.05), higher BMI (group C: 23.9+/-3.2 vs. group A: 21.8+/-3.1 kg/m(2), p<0.05) and lower HDL-cholesterol level (group C: 1.8+/-0.5 vs. group A: 2.0+/-0.3 mmol/l, p<0.05). Patients with retinopathy and albuminuria at follow-up had lower level of diabetic knowledge at baseline (respectively: 12.5+/-3.6 vs. 14.2+/-3.3 scores, p<0.05; and 12.6+/-2.9 vs. 14.1+/-3.5 scores, p<0.05). The development of microangiopathy was associated with lower diabetic knowledge (RR=3.71; 95%CI: 1.15-12.01, p=0.02 for retinopathy and RR=4.33; 95%CI: 0.98-19.10, p=0.04 for microalbuminuria). The higher diabetic knowledge at baseline the better metabolic control and lower risk of microangiopathy in the future.

Contextualising accounts of illness: notions of responsibility and blame in white and South Asian respondents' accounts of diabetes causation

We undertook a secondary analysis of in-depth interviews with white (n = 32) and Pakistani and Indian (n = 32) respondents who had type 2 diabetes, which explored their perceptions and understandings of disease causation. We observed subtle, but important, differences in the ways in which these respondent groups attributed responsibility and blame for developing the disease. Whereas Pakistani and Indian respondents tended to externalise responsibility, highlighting their life circumstances in general and/or their experiences of migrating to Britain in accounting for their diabetes (or the behaviours they saw as giving rise to it), white respondents, by contrast, tended to emphasise the role of their own lifestyle 'choices' and 'personal failings'. In seeking to understand these differences, we argue for a conceptual and analytical approach which embraces both micro- (i.e. everyday) and macro- (i.e. cultural) contextual factors and experiences. In so doing, we provide a critique of social scientific studies of lay accounts/understandings of health and illness. We suggest that greater attention needs to be paid to the research encounter (that is, to who is looking at whom and in what circumstances) to understand the different kinds of contexts researchers have highlighted in presenting and interpreting their data.

Outcomes of educational interventions in type 2 diabetes: WEKA data-mining analysis

OBJECTIVE

To analyze which factors contribute to improvement in glycemic control in educational interventions in type 2 diabetes reported in randomized controlled trials (RCT) published in 2001-2005.

METHODS

Papers were extracted from Medline and Scopus using educational intervention and adults with type 2 diabetes as keywords. Inclusion criteria were RCT design. Data were analyzed with a data-mining program.

RESULTS

Of 464 titles extracted, 21 articles reporting 18 studies met the inclusion criteria. Data mining showed that for initial glycosylated hemoglobin (HbA1c) level < or = 7.9% the diabetes education intervention achieved a small change in HbA1c level, or from +0.1 to -0.7%. For initial HbA1c > or = 8.0%, a significant drop in HbA1c level of 0.8-2.5% was found. Data mining indicated that duration, educational content and intensity of education did not predict changes in HbA1c levels.

CONCLUSION

Initial HbA1c level is the single most important factor affecting improvements in glycemic control in response to patient education. Data mining is an appropriate and sufficiently sensitive method to analyze outcomes of educational interventions. Diversity in conceptualization of interventions and diversity of instruments used for outcome measurements could have hampered actual discovery of effective educational practices.

PRACTICE IMPLICATIONS

Participation in educational interventions generally seems to benefit people with type 2 diabetes. Use of standardized instruments is encouraged as it gives better opportunities to identify conclusive results with consequent development of clinical guidelines.

The use of telehealth for diabetes management: a qualitative study of telehealth provider perceptions

Background

Monitoring and Messaging Devices (MMDs) are telehealth systems used by patients in their homes, and are designed to promote patient self-management, patient education, and clinical monitoring and follow-up activities. Although these systems have been widely promoted by health care systems, including the Veterans Health Administration, very little information is available on factors that facilitate use of the MMD system, or on barriers to use.

Methods

We conducted in-depth qualitative interviews with clinicians using MMD-based telehealth programs at two Veterans Affairs Medical Centers in the Midwestern United States.

Results

Findings suggest that MMD program enrollment is limited by both clinical and non-clinical factors, and that patients have varying levels of program participation and system use. Telehealth providers see MMDs as a useful tool for monitoring patients who are interested in working on management of their disease, but are concerned with technical challenges and the time commitment required to use MMDs.

Conclusion

Telehealth includes a rapidly evolving and potentially promising range of technologies for meeting the growing number of patients and clinicians who face the challenges of diabetes care, and future research should explore the most effective means of ensuring successful program implementation.