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

A Randomized Clinical Trial of a Culturally Tailored Diabetes Education Curriculum With and Without Real-Time Continuous Glucose Monitoring in a Latino Population With Type 2 Diabetes: The CUT-DM With Continuous Glucose Monitoring Study

BACKGROUND

Data on culturally tailored diabetes education with and without real-time continuous glucose monitoring (RT-CGM) in Latinos with type 2 diabetes, who are not on intensive insulin management, is lacking.

RESEARCH DESIGN AND METHODS

This is an open-label randomized control trial of Latinos with uncontrolled (HbA1c > 8.0%) type 2 diabetes conducted in a Federally Qualified Health Center (FQHC). All participants received 12 one-hour culturally tailored education sessions. Patients were randomized (1:1) to education sessions only (blinded CGM) or cyclic (50 days wear: 10 days on, 7 days off) RT-CGM. The primary outcome was a change in HbA1c from baseline to 12 weeks in those with or without CGM. Secondary outcomes included 24-week HbA1c, CGM, and metabolic parameters.

RESULTS

Participants (n = 120) were 46 years old on average, 44% female, 98% preferred Spanish language, 30% with income <$25,000, 68% uninsured and 26% using basal insulin only. Mean 1-hour session attendance and RT-CGM wear was 7.0 (±4.4) and 27.9 (±20.5) days, respectively. Mean baseline HbA1c was 10.5% (±1.8). HbA1c reduced by 1.9% (95% confidence interval [CI]: 1.5-2.3) overall (P < .001). Participants in the RT-CGM group reduced HbA1c at 12 weeks by 2.3% (95% CI: 1.5-3.2) compared to 1.5% (95% CI: 0.6-2.3) in the blinded CGM group (P =.04). At 24 weeks, overall HbA1c reduction was maintained but between-group differences attenuated.

CONCLUSIONS

In a Latino type 2 diabetes population that was primarily noninsulin-requiring, virtually delivered, culturally tailored education improved HbA1c, with RT-CGM conferring greater improvement. RT-CGM should be an adjunctive therapy to diabetes education, irrespective of insulin use but continued cyclic CGM use may be needed for sustained effect.

Predicting preventive self-care behaviours among type 2 diabetes based on the health belief model in Bandar Abbas city: a cross-sectional study

OBJECTIVES

It is essential to manage type 2 diabetes mellitus (T2DM) through self-care behaviours and to ascertain the predictors of correct health training for the control of diabetes. The aim of this study was to determine the predictive role of the constructs of the health belief model in encouraging T2DM to adopt self-care behaviours in Bandar Abbas city.

DESIGN

This cross-sectional study was conducted in 2022 in Bandar Abbas.

PARTICIPANTS

Participants were 246 patients with T2DM referring to six comprehensive healthcare centres in Bandar Abbas city. They were enrolled using the accessible sampling method and were requested to complete a questionnaire.

RESULTS

The results of the present study indicated that the health belief model could explain 50.73% of the variance in patients with T2DM's self-care behaviours. Among the constructs of the health belief model, the constructs of self-efficacy (52.4%), perceived barriers (38.8%) and perceived susceptibility (34.9%) best predicted the adherence of patients to self-care behaviours, suggesting that these constructs can be considered to improve self-care behaviours in patients with T2DM.

CONCLUSIONS

According to the results of this study, the health belief model can be a suitable and effective tool for predicting self-care behaviours in patients with T2DM. There was a statistically significant correlation was found between self-care behaviours and all the constructs except perceived barriers. Considering the positive effects of the health belief model in improving the self-care of patients with type 2 diabetes, it is suggested to use this model in planning interventions to improve self-care in other diseases affected by lifestyle-based behaviour.

Family model diabetes self-management education and support in faith-based organizations in the Republic of the Marshall Islands: A study protocol

INTRODUCTION

The Republic of the Marshall Islands (RMI) is an independent nation and a member of the United States (US) Affiliated Pacific Islands through a Compact of Free Association. Health disparities in the RMI are striking, with high rates of type 2 diabetes mellitus (T2DM). The International Diabetes Federation has documented age-adjusted prevalence of T2DM at 23.0 %, compared to the US (13.2 %) and globally (9.8 %). T2DM has a devastating impact on patients and their families.

METHODS

The purpose of this article is to present the study protocol for the fully powered two-arm cluster randomized controlled trial using a wait-list control to evaluate the effectiveness of a Family Diabetes Self-Management Education and Support (Family DSMES) program when delivered in a group setting by community health workers (CHWs) in faith-based organizations (FBOs) in the RMI. The study used a community engaged approach, and the study protocol includes adaptations based on the results of our one-arm pilot study.

SUMMARY

This study will provide new and innovative information on the effectiveness of Family DSMES delivered in a group setting by CHWs in FBOs in the RMI. The knowledge gained from this research will inform DSMES interventions conducted with Marshallese and other Pacific Islander communities, as well as DSMES interventions conducted in other low-resource countries.

Effectiveness of Multilevel and Multidomain Interventions to Improve Glycemic Control in U.S. Racial and Ethnic Minority Populations: A Systematic Review and Meta-analysis

BACKGROUND

Racial and ethnic disparities in type 2 diabetes outcomes are a major public health concern. Interventions targeting multiple barriers may help address disparities.

PURPOSE

To conduct a systematic review and meta-analysis of diabetes self-management education (DSME) interventions in minority populations. We hypothesized that interventions addressing multiple levels (individual, interpersonal, community, and societal) and/or domains (biological, behavioral, physical/built environment, sociocultural environment, and health care system) would have the greatest effect on hyperglycemia.

DATA SOURCES

We performed an electronic search of research databases PubMed, Scopus, CINAHL, and PsycINFO (1985-2019).

STUDY SELECTION

We included randomized controlled trials of DSME interventions among U.S. adults with type 2 diabetes from racial and ethnic minority populations.

DATA EXTRACTION

We extracted study parameters on DSME interventions and changes in percent hemoglobin A1c (HbA1c).

DATA SYNTHESIS

A total of 106 randomized controlled trials were included. Twenty-five percent (n = 27) of interventions were exclusively individual-behavioral, 51% (n = 54) were multilevel, 66% (n = 70) were multidomain, and 42% (n = 45) were both multilevel and multidomain. Individual-behavioral interventions reduced HbA1c by -0.34 percentage points (95% CI -0.46, -0.22; I2 = 33%) (-3.7 [-5.0, -2.4] mmol/mol). Multilevel interventions reduced HbA1c by -0.40 percentage points (95% CI -0.51, -0.29; I2 = 68%) (-4.4 [-5.6, -3.2] mmol/mol). Multidomain interventions reduced HbA1c by -0.39 percentage points (95% CI -0.49, -0.29; I2 = 68%) (-4.3 [-5.4, -3.2] mmol/mol). Interventions that were both multilevel and multidomain reduced HbA1c by -0.43 percentage points (95% CI -0.55, -0.31; I2 = 69%) (-4.7 [-6.0, -3.4] mmol/mol).

LIMITATIONS

The analyses were restricted to RCTs.

CONCLUSIONS

Multilevel and multidomain DSME interventions had a modest impact on HbA1c. Few DSME trials have targeted the community and society levels or physical environment domain. Future research is needed to evaluate the effects of these interventions on outcomes beyond HbA1c.

Integrating the Consolidated Framework for Implementation Research (CFIR) into a Culturally Responsive Evaluation (CRE) Approach to Conduct Mixed-Method Evaluations of Diabetes Prevention and Management Programs Reaching Underresourced Populations and Communities

Diabetes is a significant population health threat. Evidence-based interventions, such as the Centers for Disease Control and Prevention's National Diabetes Prevention Program and diabetes self-management education and support programs, can help prevent, delay, or manage the disease. However, participation is suboptimal, especially among populations who are at an increased risk of developing diabetes. Evaluations of programs reaching populations who are medically underserved or people with lower incomes can help elucidate how best to tailor evidence-based interventions, but it is also important for evaluations to account for cultural and contextual factors. Culturally responsive evaluation (CRE) is a framework for centering an evaluation in the culture of the programs being evaluated. We integrated CRE with implementation and outcome constructs from the Adapted Consolidated Framework for Implementation Research (CFIR) to ensure that the evaluation produced useful evidence for putting evidence-based diabetes interventions to use in real-world settings, reaching populations who are at an increased risk of developing diabetes. The paper provides an overview of how we integrated CRE and CFIR approaches to conduct mixed-methods evaluations of evidence-based diabetes interventions.

Effectiveness of a culturally tailored diabetes education curriculum with real-time continuous glucose monitoring in a Latinx population with type 2 diabetes: the CUT-DM with CGM for Latinx randomised controlled trial study protocol

INTRODUCTION

The prevalence of type 2 diabetes (T2D) is increasing in the Latinx community. Despite telehealth and technology becoming more available, these resources are not reaching the Latinx population. Diabetes education is a cornerstone of treatment; however, access to culturally tailored content is a barrier to the Latinx population. Real-time continuous glucose monitoring (RT-CGM) is a patient-empowering tool that can improve glycaemic control, but it is not readily available for Latinx patients with T2D. We aim to evaluate a culturally tailored diabetes self-management education and support (DSMES) curriculum, using a team-based approach to improve glycaemic control, promote healthy behaviours and enhance patient access with the use of telehealth in Latinx individuals. The primary aim of the study is to evaluate the additive effectiveness of RT-CGM on glycaemia and behavioural changes among Latinx patients undergoing a culturally tailored DSMES. A sub aim of the study is to evaluate family members' change in behaviours.

METHODS

We propose a randomised controlled trial of blinded versus RT-CGM with 100 Latinx participants with T2D who will receive DSMES via telemedicine over 12 weeks (n=50 per group). The study will be conducted at a single large federally qualified health centre system. The control group will receive culturally tailored DSMES and blinded CGM. The intervention group will receive DSMES and RT-CGM. The DSMES is conducted by community health educators weekly over 12 weeks in Spanish or English, based on participant's language preference. Patients in the RT-CGM group will have cyclical use with a goal of 50 days wear time. The primary outcomes are changes in haemoglobin A1c and CGM-derived metrics at 3 and 6 months. The secondary outcomes include participants' self-management knowledge and behaviour and household members' change in lifestyle.

ETHICS AND DISSEMINATION

The study proposal was approved by the University of Washington ethics/institutional review board (IRB) Committee as minimal risk (IRB ID: STUDY00014396) and the Sea Mar IRB committee.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT05394844.

Effectiveness of self-management interventions for long-term conditions in people experiencing socio-economic deprivation in high-income countries: a systematic review and meta-analysis

BACKGROUND

Long-term conditions (LTCs) are prevalent in socio-economically deprived populations. Self-management interventions can improve health outcomes, but socio-economically deprived groups have lower participation in them, with potentially lower effectiveness. This review explored whether self-management interventions delivered to people experiencing socio-economic deprivation improve outcomes.

METHODS

We searched databases up to November 2022 for randomized trials. We screened, extracted data and assessed the quality of these studies using Cochrane Risk of Bias 2 (RoB2). We narratively synthesized all studies and performed a meta-analysis on eligible articles. We assessed the certainty of evidence using GRADE for articles included in the meta-analysis.

RESULTS

The 51 studies included in this review had mixed findings. For the diabetes meta-analysis, there was a statistically significant pooled reduction in haemoglobin A1c (-0.29%). We had moderate certainty in the evidence. Thirty-eight of the study interventions had specific tailoring for socio-economically deprived populations, including adaptions for low literacy and financial incentives. Each intervention had an average of four self-management components.

CONCLUSIONS

Self-management interventions for socio-economically deprived populations show promise, though more evidence is needed. Our review suggests that the number of self-management components may not be important. With the increasing emphasis on self-management, to avoid exacerbating health inequalities, interventions should include tailoring for socio-economically deprived individuals.

A Multi-Method Study of Patient Reach and Attendance in a Pragmatic Trial of Diabetes Shared Medical Appointments

Shared medical appointments (SMAs) are an evidence-based approach to diabetes care in primary care settings, yet practices can struggle to ensure participation, especially among racial and ethnic minority and low-income patients. We conducted a multimethod evaluation of reach and attendance in the Invested in Diabetes study of the comparative effectiveness of two SMA delivery models (standardized and patient-driven) in two practice settings (federally qualified health centers [FQHCs] and clinics serving more commercially insured patients). Through this study, 22 practices reached 6.2% of patients with diabetes through SMAs over 3 years, with good attendance for both practice types and both SMA delivery models. FQHCs were especially successful at enrolling underserved populations and improved attendance with virtual SMAs.

Stories for change protocol: A randomized controlled trial of a digital storytelling intervention for Hispanic/Latino individuals with type 2 diabetes

BACKGROUND

Hispanic/Latino adults are disproportionately impacted by type 2 diabetes mellitus (T2D). The Stories for Change (S4C) Diabetes digital storytelling intervention promotes T2D self-management among Hispanic/Latino people. We describe the S4C protocol and participant baseline characteristics.

METHODS

Study eligibility criteria: Hispanic or Latino, age 18-70 years, ≥1 office visit within a year at a participating clinic, T2D diagnosis for ≥6 months, HbA1c ≥ 8%, and intention to continue care at the recruitment clinic. We used a two-group, parallel randomized controlled trial design and an intervention derived through a community-based participatory research approach. All participants received usual diabetes care and two cards describing how to engage healthcare teams and access diabetes-related resources. At baseline, the intervention group additionally viewed the 12-min, intervention video (four stories about diabetes self-management). To encourage subsequent video viewing, participants received five monthly text messages. The messages prompted them to self-rate their motivation and self-efficacy for T2D management. The control group received no additional intervention. Bilingual (English/Spanish) staff collected data at baseline, six weeks, three months, and six months including biometric measurements and a survey on diabetes self-management outcomes, theory-based measures, and the number of video views. We reviewed the number of diabetes-related appointments attended using electronic medical record data.

RESULTS

Participants (n = 451; 70% women, mean age = 53 years) had an average HbA1C ≥9%. Intervention participants reported identifying with the storytellers and engaging with the stories.

CONCLUSION

We present a digital storytelling intervention protocol that provides a template for future health promotion interventions prioritizing health disparity populations.

CLINICALTRIAL

gov#NCT03766438.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Predictors of self-care behaviors and glycemic control among patients with type 2 diabetes mellitus

Aims

This study used the Extended Theory of Reasoned Action (ETRA) to predict self-care behaviors and HbA1c among patients with type 2 diabetes in Iran.

Materials and methods

A cross-sectional study was performed using a multistage random sample. A total of 240 patients with type 2 diabetes, who were referred to the diabetes healthcare centers in Chaldoran, participated in the research. Instruments consisting of standardized questionnaires were used based on the Extended Theory of Reasoned Action (ETRA) constructs and the summary scale of diabetes self-care behaviors measure.

Findings

The results of this study demonstrated that demographic variables explained ~ 7% (p-value = 0.23) and ETRA constructs 18% of the variance (p-value = 0.02) in behavioral intention, respectively. According to the hierarchical multiple linear regressions on self-care behaviors, demographic factors (p-value 0.001) dictated 45.7% of the variation of the self-care behavior, while knowledge, attitude, self-efficacy, and behavioral intention (p-value 0.001) accounted for 63.4% of the variance. The ETRA constructs, self-care practices, and demographic factors together account for almost 57% of the variation in the HbA1c. Self-care practices were the best indicator of HbA1c (β = -0.593).

Conclusion

ETRA constructs and self-care behavior can be the best determinants of HbA1c level in type 2 diabetes. This model is suggested to be applied in designing intervention programs to improve HbA1c in these groups of patients.

[Diabetes education and counseling in adult patients with diabetes (Update 2023)]

Diabetes education and self-management play a critical role in diabetes care. Patient empowerment aims to actively influence the course of the disease by self-monitoring and subsequent treatment modification as well as the ability of patients to integrate diabetes into their daily life and to appropriately adapt diabetes to their life style situation. Diabetes education has to be made accessible for all persons with the disease. In order to be able to provide a structured and validated education program, adequate personnel as well as space, organizational and financial prerequisites are required. Besides an increase in knowledge about the disease it has been shown that a structured diabetes education is able to improve diabetes outcome as measured by parameters, such as blood glucose, HbA1c, lipids, blood pressure and body weight in follow-up evaluations. Modern education programs emphasize the ability of patients to integrate diabetes into everyday life, stress physical activity besides healthy eating as important components of life style therapy and use interactive methods in order to increase the acceptance of personal responsibility. Specific situations (e.g. impaired hypoglycemia awareness, illness, travel), the occurrence of diabetic complications and the use of technical devices such as glucose sensor systems and insulin pumps require additional educational measures supported by adequate electronic tools (diabetes apps and diabetes web portals). New data demonstrate the effect of telemedicine and internet-based services for diabetes prevention and management.

How Outpatient Diabetes Education Programs Can Support Local Hospitals to Reduce Emergency Department Visits for Adults With Diabetes

OBJECTIVES

Our aim in this study was to assess the level of collaboration between a hospital-based outpatient diabetes education program (DEP) and emergency departments (EDs) for reducing number of ED revisits and hospital admissions by implementing intervention strategies to promote education services and streamlining referral and appointment intake processes.

METHODS

Patients (≥18 years of age) with an ED visit for hyper- or hypoglycemia were analyzed in 2 cohorts based on their intervention exposure. We conducted a single-cohort analysis of the exposed cohort (exposure to the intervention strategies) and compared 2-year outcomes with those of the unexposed cohort. Primary outcomes were hyper- or hypoglycemia-related ED revisit and hospitalization rates. Process outcomes included DEP referrals and DEP attendance.

RESULTS

There were no significant differences in ED revisits and hospital admissions between the exposed and unexposed cohorts. However, patients were more likely to be referred to a DEP by ED physicians (odds ratio [OR], 1.76; p=0.02) and to attend a DEP appointment (OR, 1.96; p<0.01) after intervention exposure. DEP attendees from both cohorts became less likely to revisit an ED (exposed: OR, 0.41; 95% confidence interval [CI], 0.23 to 0.71; unexposed: OR, 0.4; 95% CI, 0.15 to 1.15) at 12-month follow up; however, this reduction was sustained only among the exposed cohort (OR, 0.5; 95% CI, 0.31 to 0.81) and not the unexposed cohort (OR, 1.32; 95% CI, 0.60 to 2.91) at 24 months (p=0.04 when comparing the 2 cohorts).

CONCLUSIONS

Collaboration between outpatient DEPs with local EDs could effectively reduce diabetes-related ED revisits by increasing diabetes program utilization.

Effectiveness-implementation trial comparing a family model of diabetes self-management education and support with a standard model

BACKGROUND

Diabetes self-management education and support (DSMES) is an effective approach for improving diabetes self-care behaviors to achieve improved glycemic management and other health outcomes. Engaging family members may improve outcomes, both for the person with diabetes (PWD) and for the family members. However, family models of DSMES have been inconsistently defined and delivered. We operationalize Family-DSMES to be generalizable and replicable, detail our protocol for a comparative effectiveness trial comparing Standard-DSMES with Family-DSMES on outcomes for PWDs and family members, and detail our mixed-methods implementation evaluation plan.

METHODS

We will examine Family-DSMES relative to Standard-DSMES using a Hybrid Type 1 effectiveness-implementation design. Participants are ≥18 years old with type 2 diabetes mellitus and hemoglobin A1c ≥7.0%, recruited from rural and urban primary care clinics that are part of an academic medical center. Each participant invites a family member. Dyads are randomly assigned to Family- or Standard-DSMES, delivered in a small-group format via telehealth. Data are collected at baseline, immediately post-intervention, and 6-, 12-, and 18-months post-intervention. Outcomes include PWDs' hemoglobin A1c (primary), other biometric, behavioral, and psychosocial outcomes (secondary), and family members' diabetes-related distress, involvement in the PWD's diabetes management, self-efficacy for providing support, and biometric outcomes (exploratory). Our mixed-methods implementation evaluation will include process data collected during the trial and stakeholder interviews guided by the Consolidated Framework for Implementation Research.

CONCLUSION

Results will fill knowledge gaps about which type of DSMES may be most effective and guide Family-DSMES implementation efforts.

REGISTRATION

The trial is pre-registered at clinicaltrials.gov (#NCT04334109).

Study protocol for family model diabetes self-management education with Marshallese participants in faith-based organizations

Background

Culturally-appropriate family models of diabetes self-management education and support (DSMES) using community health workers (CHWs) have been shown to help address barriers to improving type 2 diabetes mellitus (T2DM) self-management for racial/ethnic minority communities; however, there is limited DSMES research among Marshallese and other Pacific Islanders. Using a community-based participatory research approach, we engaged community stakeholders to co-design a study to implement a culturally adapted family model DSMES (F-DSMES) intervention in faith-based organizations (FBOs) (i.e., churches).

Methods

Using a cluster-randomized controlled trial design, we will assess the effectiveness of the F-DSMES intervention for Marshallese patients with T2DM in Arkansas and Oklahoma. Twenty-four FBOs (with 12 primary participants per FBO) will be randomized to one of two study arms: the intervention arm or the wait-list control arm. Primary participants must have at least one family member willing to attend education sessions and data collection events. The F-DSMES intervention consists of ten h of diabetes education delivered by CHWs over eight to ten weeks. Data will be collected from the intervention arm at pre-intervention (baseline), immediate post-intervention (12 weeks), and three months post-intervention. The wait-list control arm will complete a second pre-intervention data collection before receiving the intervention. The primary study outcome will be glycemic control, as measured by HbA1c. Secondary measures include glucose, weight, body mass index, blood pressure, diabetes self-management behaviors, and diabetes management self-efficacy.

Conclusion

The knowledge gained from this research will inform future DSMES and other health promotion interventions conducted with Marshallese and other Pacific Islander communities.

The comparison of self-management group education and the standard care for patients with type 2 diabetes mellitus: An updated systematic review and meta-analysis

To investigate the efficacy of self-management group education versus the standard care for patients with type 2 diabetes mellitus (DM). An electronic search was performed in nine databases including PubMed for selecting eligible studies. Meta-analysis was used for pooling of the results. Of 3446 records screened, we included ten studies for this systematic review and meta-analysis. Regarding assessment of effectiveness, there was a significant superiority reported in the intervention group when compared to the usual/standard care (standardized mean difference [95% confidence interval] = 0.24 [0.15; 0.32]). The intervention group had a significant reduction in the levels of hemoglobin A1C (HbA1C), fasting blood glucose, low-density lipoprotein, total cholesterol, and body mass index compared to the usual/standard care (p < 0.05). Moreover, no significant difference was observed in the levels of high-density lipoprotein, systolic blood pressure (SBP), or diastolic blood pressure (DBP) between the two groups (p > 0.05). Self-management group education interventions are recommended in patients with type 2 DM for their effectiveness in different clinical aspects.

The Mediating Role of Self-Efficacy in the Association Between Diabetes Education and Support and Self-Care Management

RESULTS

A total of 1,318 participants were included in the study (mean age = 52.9 years, SD = 9.6; 72.5% female, 56.4% Black, 3.1% Hispanic). Diabetes education was associated with increases in self-care activity scores related to general diet, physical activity, glucose self-monitoring, and foot care; care coordination was associated with glucose self-monitoring. In addition, mediation analysis models confirmed that improvements in self-efficacy led to improved self-care activities scores, mediating the association of diabetes education and self-care activities.

CONCLUSIONS

Diabetes education and self-efficacy were associated with better self-care. Receiving diabetes education led to a higher likelihood of engaging in self-care activities, driven in part by increases in self-efficacy. Future interventions that aim to improve diabetes self-management behaviors can benefit from targeting self-efficacy constructs and from the integration of diabetes education in the care coordination structure.

Bridge to Health/Puente a la Salud: a pilot randomized trial to address diabetes self-management and social needs among high-risk patients

Social needs contribute to persistent diabetes disparities; thus, it is imperative to address social needs to optimize diabetes management. The purpose of this study was to determine determine the feasibility and acceptability of health system-based social care versus social care + behavioral intervention to address social needs and improve diabetes self-management among patients with type 2 diabetes. Black/African American, Hispanic/Latino, and low-income White patients with recent hemoglobin A1C (A1C) ≥ 8%, and ≥1 social need were recruited from an integrated health system. Patients were randomized to one-of-two 6-month interventions: (a) navigation to resources (NAV) facilitated by a Patient Navigator; or (b) NAV + evidence-based nine-session diabetes self-management support (DSMS) program facilitated by a community health worker (CHW). A1C was extracted from the electronic health record. We successfully recruited 110 eligible patients (54 NAV; 56 NAV + DSMS). During the trial, 78% NAV and 80% NAV + DSMS participants successfully connected to a navigator; 84% NAV + DSMS connected to a CHW. At 6-month follow-up, 33% of NAV and 34% of NAV + DSMS participants had an A1C < 8%. Mean reduction in A1C was clinically significant in NAV (-0.65%) and NAV + DSMS (-0.72%). By follow-up, 89% of NAV and 87% of NAV + DSMS were successfully connected to resources to address at least one need. Findings suggest that it is feasible to implement a health system-based social care intervention, separately or in combination, with a behavioral intervention to improve diabetes management among a high-risk, socially complex patient population. A larger, pragmatic trial is needed to test the comparative effectiveness of each approach on diabetes-related outcomes.

BMC Endocrine Disorders' collection of articles on "Reducing inequalities in the Management of Endocrine Disorders"

Endocrine disorders represent a large component of the so-called "chronic non-communicable diseases", which are responsible for the lion share of morbidity and mortality in contemporary societies. As discussed in this retrospective collection of articles, solid evidence from diabetes mellitus, the exemplar of common chronic endocrine disorders, highlights profound inequity in all aspects of endocrine disorders' management and outcomes that should be considered and addressed at large.

The Individual Nutrition Education Needs among Patients with Type 2 Diabetes at the Public Health Centers in Padang, Indonesia: A Cross-Sectional Study

Background: The Indonesian Public Health Care (PHC) of Management Nutrition Therapy (MNT) guidelines describe that individual nutrition education is aimed to improve quality of MNT services. The guidelines were originally developed for non-communicable diseases (NCDs), not specially for type 2 diabetes mellitus (T2DM) purposes. The reluctance of patients with T2DM to attend individual nutrition education is a common public health care issue in Padang (Indonesia). Methods: The presented cross-sectional study aimed to determine the individual nutrition education needs among people with T2DM. A set questionnaire was distributed to 11 PHC selected from 11 districts in Padang and 179 patients with T2DM were recruited and interviewed. Results: Among the 179 patients with T2DM, 76.5% were females and housewives (49.2%), a slight majority (57.8%) were ≤58 years old and 45.9% had graduated from primary school. The highest numbers of patients with T2DM were in PHC Andalas (20.7%). Some 74.9% (134) of the people with T2DM routinely attended individual nutrition education classes for less than 30 min (60.3%). Patients with T2DM followed individual nutrition education at a PHC every 1–2 months (59.8%), and a majority of the individual nutrition education was given by a medical doctor (57.5%). In contrast, 42.3% of patients with T2DM did not attend individual nutrition education due to a lack of recommendation from a medical doctor and their reluctance (33.3%). Although a majority of patients with T2DM (62.6%) were satisfied with their individual nutrition education, (20.4% of patients with T2DM recommended the availability of booklets during individual nutrition education that can be read at home. Patients with T2DM needed individual nutrition education (88.8%) and the majority (25.1%) requested individual nutrition education topics about diabetes food recommendation. Even though patients with T2DM followed health professionals’ advice (78.2%), however, their HbA1c (76.5%) wasnot reduced. Patients with T2DM agreed that individual nutrition education can increase their knowledge (51.9%), unfortunately, they still have difficulty to control their blood glucose (5.6%). Conclusions: According to the patients with the T2DM perspective stated above, it is crucial to develop the tool kits and educate patients with T2DM following the Diabetes Nutrition Education (DNE) curriculum to improve glycemic control.

Disparities in HbA1c testing between aging US Latino and non-Latino white primary care patients

US Latinos disproportionately face diabetes-related disparities compared to non-Latino Whites. A number of barriers, including linguistic and cultural discordance, have been consistently linked to these disparities. Glycated hemoglobin (HbA1c) testing is used to assess glycemic control among individuals living with diabetes. This study aimed to compare HbA1c levels and corresponding testing rates among non-Latino Whites and Latinos with both English and Spanish preference from a national cohort of primary care patients within community health centers. We analyzed electronic health records from patients who turned 50 years of age (n = 66,921) and were diagnosed with diabetes during or prior to the study period. They also must have been under observation for at least one year from January 1, 2013 to December 31, 2017. We calculated the rates of HbA1c tests each person received over the number of years observed and used covariate-adjusted negative binomial regression to estimate incidence rate ratios for Spanish preferring Latinos and English preferring Latinos compared to non-Latino Whites. Spanish preferring Latinos (rate ratio = 1.23, 95% CI = 1.16-1.30), regardless of HbA1c level, had higher testing rates than non-Latino Whites and English preferring Latinos. English preferring Latinos with controlled HbA1c levels had higher rates of HbA1c testing compared to non-Latino whites. Overall, the Latinos with Spanish preference maintained higher HbA1c testing rates and had disproportionately higher rates of uncontrolled HbA1c levels compared to non-Latino whites. Future efforts should focus on understanding effective approaches to increasing engagement among Spanish preferring Latinos and addressing organizational-level barriers, given HbA1c disparities.

The effectiveness of e-health interventions for the treatment of overweight or obesity in children and adolescents: A systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to examine the effectiveness of e-health interventions for the treatment of children and adolescents with overweight or obesity. Databases were searched up to November 2020. Studies were randomized controlled trials where interventions were delivered via e-health (e.g., computers, tablets, and smartphones, but not phone calls). Studies should target the treatment of overweight or obesity in children or their agent of changes and report body mass index (BMI) or BMI z-score. A meta-analysis using a random-effects model was conducted. Nineteen studies met the inclusion criteria, and 60% were of high quality. The narrative review revealed variation in behavior change strategies and modes of delivery. The pooled mean reduction in BMI or BMI z-score showed evidence for a nonzero effect (standardized mean difference = -0.31, 95% confidence interval -0.49 to -0.13), with moderately high heterogeneity between studies (I²  = 74%, p < 0.001). Subgroup analysis revealed high heterogeneity in studies with a high or unclear risk of bias. E-health interventions can be effective in treating children and adolescents with overweight and obesity and should be considered by practitioners and policymakers. However, an understanding of the most effective and acceptable intervention components, long-term benefits, and sustainability should be further studied.

Significance of Educational Literature and Diabetes Log Sheet on Hemoglobin A1c

Diabetes mellitus (DM) is a major cause of morbidity worldwide. The prevalence of DM has doubled over the last 35 years and is escalating. Various complications and manifestations of diabetes have caused numerous deaths worldwide, with numbers increasing every year. There have been many advances and breakthroughs over the past decade in the management of DM. The major focus of many research studies has been to evaluate effective medication combinations, preventative measures, and the way to control such morbid conditions. Our focus in this review is to discuss specific secondary prevention techniques with the diabetes log sheet and educational literature on its effectiveness in controlling diabetes. Hemoglobin A1c (HbA1c) has been accepted as a diabetes control measure in many resources worldwide. Here, we have assessed articles on the effectiveness of the diabetes log sheet and educational literature on HbA1c levels. We will begin with a few key points to acknowledge diabetes initially, followed by discussing the effectiveness of the diabetes log sheet and literature on HbA1c.

Characteristics and Outcomes of Community Health Worker Training to Improve the Prevention and Control of Cardiometabolic Diseases in Low and Middle-Income Countries: A Systematic Review

Community health workers (CHWs) play an important role in controlling non-communicable diseases in low- and middle-income countries. The aim of this review was to describe the characteristics and outcomes of CHW training programs that focused on the prevention and control of cardiometabolic diseases in low- and middle-income countries (LMICs). Medline, CINAHL Complete, Academic Search Complete, Directory of Open Access Journal, ScienceDirect, ERIC, Gale Academic, and OneFile). Studies that described the training programs used to train CHWs for prevention and control of cardiovascular diseases and type2 diabetes mellitus in LMICs. Only studies that evaluated the outcomes of training programs in at least one of the 4 levels of Kirkpatrick's training evaluation model were included in the review. CHWs who underwent training focused on the prevention and control of cardiovascular disease and type 2 diabetes mellitus. We summarized the resulting evidence using qualitative synthesis through a narrative review. Training outcomes were assessed in relation to (1) CHW reactions to training, their degree of learning, and their behaviors following training, and (2) changes in biochemical and anthropometric indicators in target populations following the CHW program implementation. PROSPERO (CRD42020162116). Thirty-two studies were included. Methods used to train CHWs included: face-to-face lectures, interactive group activities, and blended teaching with online support. Training focused on identifying people with elevated risk of cardiometabolic diseases and their risk factors as well as supporting people to adopt healthy lifestyles. Many studies that utilized trained CHWs did not publish CHW training methods and evaluations, and therefore could not be included in this study. Training programs resulted in an increase in knowledge and skills among CHWs demonstrating that there are certain activities that can be shifted to CHWs following training.

Equity in the Provision of Diabetes Self-Management Education and Support

Diabetes self-management education and support (DSMES) interventions must be accessible to all people with diabetes. To address equity in the delivery of DSMES, interventions should consider the unique needs of various populations. This article outlines the needs of a wide range of populations, including people with diabetes who are racially or ethnically diverse; have limited English proficiency or literacy; are deaf or hard of hearing; are blind or have low vision; are neurodiverse; live with learning disabilities or intellectual or developmental disabilities; have dementia or cognitive impairment; or are of sexual and/or gender minority. The authors discuss how best to tailor DSMES to meet the needs of these diverse groups.

The Cost-Effectiveness Analysis of Self-Efficacy-Focused Structured Education Program for Patients With Type 2 Diabetes Mellitus in Mainland China Setting

Objective: To assess the long-term (50 years) cost-effectiveness of the self-efficacy-focused structured education program (SSEP) as opposed to routine education among patients with type 2 diabetes mellitus (T2DM) in mainland China from a healthcare service perspective. Methods: A cost-effectiveness analysis method was used. The IQVIA CORE Diabetes Model (version 9.0) was adopted to estimate the outcomes. The baseline cohort characteristics, variations of physiological parameters, costs of intervention and other treatments, and management-related diabetes were derived from a randomized controlled trial. Moreover, the complications costs and utilities were extracted from published sources. Furthermore, the univariate sensitivity analysis and the probabilistic sensitivity analysis were conducted. Results: As compared with the control group, the life expectancy and quality-adjusted life-year in the intervention group were increased. Besides, the intervention group achieved lower cumulative incidences of complications and saved more direct medical costs compared with the control group. The sensitivity analysis revealed that the SSEP had 100% probability to be cost-effective. Conclusion: The SSEP is recognized as a highly cost-effective option for managing patients with T2DM, which are projected to both improve clinical outcomes and reduce costs.

Ethnic Disparities in Diabetes

Diabetes disproportionably affects minorities in the United States. Substantial disparities exist in diabetes incidence, glycemic control, complications, mortality, and management. The most important biologic contributors to diabetes disparities are obesity, insulin resistance, and inadequate glycemic control. Providers and health systems must also recognize the behavioral, social, and environmental factors that promote and sustain racial/ethnic differences in diabetes and its complications. Metformin and sodium-glucose cotransporter 2 inhibitors are the most convenient drugs for treatment of diabetes in minority patients. Multilevel interventions at the patient, provider, health system, community, and policy levels are needed to reduce diabetes disparities in high-risk groups.

Feasibility and efficacy of a pilot family model of diabetes self-management intervention in the Republic of the Marshall Islands

BACKGROUND

The Republic of the Marshall Islands (RMI) faces numerous health disparities, including one of the highest prevalence of type 2 diabetes mellitus (T2DM) in the world. Diabetes self-management education and support (DSMES) has shown efficacy in improving glycemic control and through increases in knowledge and self-management activities; however, there is limited research on DSMES in the RMI. This study evaluated the feasibility and efficacy of a culturally adapted family model of DSMES (F-DSMES) in the RMI. The F-DSME included 8 h of group educational classes delivered in churches by a community health worker.

METHODS

This pilot study assessed retention and dosage rates (e.g., class attendance) among the participants with T2DM (n = 41). Efficacy was evaluated by examining pre- and post-intervention differences in HbA1c, knowledge, family support, and self-management activities among those who completed the post-intervention data collection (n = 23).

RESULTS

The results indicate completion of post-intervention data collection and attendance were associated; 70% of participants who completed the post-intervention data collection received at least 6 h of intervention compared to 3 h for those who did not. Although the reduction in HbA1c was not statistically significant, participants demonstrated statically significant increases in knowledge, family support, and an increase in self-management including in checking of blood glucose and feet.

CONCLUSIONS

This study provides important information to help address T2DM disparities in the RMI, including the feasibility and efficacy of F-DSMES. Additional research will help in understanding how to translate improvements in knowledge, family support, and self-management activities into improvements in HbA1c. This may include addressing social ecological factors that affect glycemic control.

Feeling better on hemodialysis: user-centered design requirements for promoting patient involvement in the prevention of treatment complications

OBJECTIVE

Hemodialysis patients frequently experience dialysis therapy sessions complicated by intradialytic hypotension (IDH), a major patient safety concern. We investigate user-centered design requirements for a theory-informed, peer mentoring-based, informatics intervention to activate patients toward IDH prevention.

METHODS

We conducted observations (156 hours) and interviews (n = 28) with patients in 3 hemodialysis clinics, followed by 9 focus groups (including participatory design activities) with patients (n = 17). Inductive and deductive analyses resulted in themes and design principles linked to constructs from social, cognitive, and self-determination theories.

RESULTS

Hemodialysis patients want an informatics intervention for IDH prevention that collapses distance between patients, peers, and family; harnesses patients' strength of character and resolve in all parts of their life; respects and supports patients' individual needs, preferences, and choices; and links "feeling better on dialysis" to becoming more involved in IDH prevention. Related design principles included designing for: depth of interpersonal connections; positivity; individual choice and initiative; and comprehension of connections and possible actions.

DISCUSSION

Findings advance the design of informatics interventions by presenting design requirements for outpatient safety and addressing key design opportunities for informatics to support patient involvement; these include incorporation of behavior change theories. Results also demonstrate the meaning of design choices for hemodialysis patients in the context of their experiences; this may have applicability to other populations with serious illnesses.

CONCLUSION

The resulting patient-facing informatics intervention will be evaluated in a pragmatic cluster-randomized controlled trial in 28 hemodialysis facilities in 4 US regions.

Factors influencing diabetes self-management in adults: an umbrella review of systematic reviews

OBJECTIVE

The objective of this review was to identify and describe the factors influencing diabetes self-management in adults by summarizing the available evidence concerning their types, categories, and relative importance.

INTRODUCTION

A wide range of factors, acting simultaneously, influence diabetes self-management and interfere with its actual application by patients. There is a variety of systematic reviews of these factors; however, a more thorough examination of their influences was lacking.

INCLUSION CRITERIA

Systematic reviews of qualitative or quantitative literature focusing on factors influencing adult diabetes self-management in general or on individual behaviors (ie, management of oral antidiabetic medication and insulin injections, self-monitoring of blood glucose, foot care, healthy eating, regular exercise, and smoking cessation) will be included.

METHODS

We performed an extensive search of 11 bibliographic databases, including gray literature, up to June 2019. Quantitative and qualitative findings were summarized separately and labeled according to their types (eg, facilitator/barrier, strength and direction of association), categories (eg, demographic, social), and frequency of occurrence.

RESULTS

We identified 51 types of factors within 114 systematic reviews, which mostly addressed medication-taking behavior. Thirty-two (62.7%) factors were reported in both qualitative and quantitative literature. The predominant influences were psychological factors and behavioral attributes/skills factors. The most frequently reported facilitators of diabetes self-management were motivation to diabetes self-management, a favorable attitude to diabetes self-management, knowledge about the disease, medication and behaviors associated with diabetes self-management, skills, and self-efficacy/perceived behavioral control. The predominant barriers were the presence of depression, and polypharmacy or drug regimen complexity. The demographic factor of female sex was frequently reported for its negative influence on diabetes self-management, whereas older age was a positive factor. The social/cultural and physical environment were the least-studied categories. Other factors such as social support from family, friends, or networks; interventions led by health professionals; and a strong community environment with good social services favoring diabetes self-management were reported as major facilitators of diabetes self-management.

CONCLUSIONS

Essential components of interventions to promote effective diabetes self-management should aim to help adults manage the effects of specific factors related to their psychological and practical self-management experience. Screening for depression, in particular, should become an integral part of the support for adult diabetes self-management, as depression is a particular obstacle to the effectiveness of diabetes self-management. Future studies should more deeply examine the influence of factors identified in the sociocultural and physical environment categories. Research should properly consider and invest efforts in strengthening social support and innovative community care approaches, including pharmacist- and nurse-led care models for encouraging and improving adult diabetes self-management. Finally, researchers should examine non-modifiable factors - age, sex, or socioeconomic status - in the light of factors from other categories in order to deepen understanding of their real-world patterns of action on adult diabetes self-management.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018084665.

Bridge to Health/ Puente a la Salud: Rationale and design of a pilot feasibility randomized trial to address diabetes self-management and unmet basic needs among racial/ethnic minority and low-income patients

Introduction

Racial/ethnic and socioeconomic disparities in diabetes prevalence and management persist. Unmet basic needs such as food insecurity and unstable housing interfere with optimal diabetes self-management. Bridge to Health/Puente a la Salud is a randomized pilot trial designed to examine the feasibility of testing the effectiveness of addressing unmet basic needs via navigation services versus navigation plus diabetes self-management support (DSMS) on improving diabetes-related outcomes among racial/ethnic minority and low-income patients with uncontrolled diabetes.

Material and methods

We recruited and randomized 110 African American, Hispanic, and Medicaid patients (any race/ethnicity) with diabetes and recent hemoglobin A1C ≥ 8% to one of two 6-month interventions: 1) Navigation only; or 2) Navigation + DSMS. In both arms, practice-embedded patient navigators help participants navigate social services and community-based resources to address unmet basic needs. In Navigation + DSMS, participants are also assigned to a community health worker (CHW) embedded in a local community-based organization who provides additional navigation support and delivers DSMS. A1C and unmet basic needs data are collected via routine lab and survey, respectively, at baseline and 6-month follow-up. Qualitative interviews with participants, health system leaders, CHWs, and patient navigators are conducted to explore intervention acceptability and determinants of implementation in a health care setting.

Discussion

Findings from this pilot feasibility study will enhance understanding about acceptability, preliminary clinical effectiveness, and facilitators and barriers to implementation of the Navigation only and Navigation + DSMS interventions and inform refinements of the overall study design for the larger, randomized clinical trial.

Cultural Identity Conflict Informs Engagement with Self-Management Behaviours for South Asian Patients Living with Type-2 Diabetes: A Critical Interpretative Synthesis of Qualitative Research Studies

The prevalence of type-2 diabetes (T2D) is increasing, particularly among South Asian (SA) communities. Previous research has highlighted the heterogeneous nature of SA ethnicity and the need to consider culture in SA patients' self-management of T2D. We conducted a critical interpretative synthesis (CIS) which aimed to a) develop a new and comprehensive insight into the psychology which underpins SA patients' T2D self-management behaviours and b) present a conceptual model to inform future T2D interventions. A systematic search of the literature retrieved 19 articles, including 536 participants. These were reviewed using established CIS procedures. Analysis identified seven constructs, from which an overarching synthesizing argument 'Cultural Conflict' was derived. Our findings suggest that patients reconstruct knowledge to manage their psychological, behavioural, and cultural conflicts, impacting decisional conflicts associated with T2D self-management and health professional advice (un)consciously. Those unable to resolve this conflict were more likely to default towards cultural identity, continue to align with cultural preferences rather than health professional guidance, and reduce engagement with self-management. Our synthesis and supporting model promote novel ideas for self-management of T2D care for SA patients. Specifically, health professionals should be trained and supported to explore and mitigate negative health beliefs to enable patients to manage social-cultural influences that impact their self-management behaviours.

Systematic review on the contents and parameters of self-management education programs in older adults with knee osteoarthritis

OBJECTIVE

The aim of this review was to determine the contents and parameters of self-management education programs (SMEPs) for older adults with knee osteoarthritis (KOA).

METHODS

A systematic electronic literature search (Scopus, MEDLINE, ProQuest, CINAHL, Cochrane and a grey literature specific site through Google Scholar) was undertaken between March and May 2018 (search updated in June 2019). Studies were selected based on predetermined criteria. Data relating to the contents and parameters of the SMEP were extracted and collated.

RESULTS

A total of 11 experimental studies met the inclusion criteria. Overall quality of the selected studies was good. The contents used for SMEP in older adults with KOA were information and management of KOA, healthy lifestyle and additional management strategies for KOA. The parameters used were face-to-face sessions led by health professionals and were chiefly group-based.

CONCLUSION

This review comprehensively summarises the structure of multifaceted SMEP for people with KOA, which could be used to inform clinical practice and future research.

Family model diabetes self-management education and support in faith-based organizations in the republic of the Marshall Islands study protocol

BACKGROUND

Marshallese living in the Republic of the Marshall Islands (RMI) experience significant health disparities, with high rates of type 2 diabetes mellitus. In addition to health disparities, the RMI experienced nuclear testing that exposed inhabitants to nuclear fallout, unethical research practices, and contaminated natural food sources.

OBJECTIVES

This research uses a community-based participatory research (CBPR) approach to effectively engage community partners and honor their contributions in all stages of the research. A CBPR approach will leverage culturally situated knowledge and practices of the Marshallese community in the RMI to ensure the success of the research.

METHODS

This manuscript describes the methods used to test the feasibility of delivering a culturally adapted family model of diabetes self-management education and support in faith-based organizations in the RMI.

CONCLUSIONS

This manuscript describes the protocol for creating working with community partners and implementing a feasibility study in the RMI.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Effect of diabetes self-management education (DSME) on glycated hemoglobin (HbA1c) level among patients with T2DM: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Type 2 Diabetes mellitus (T2DM) has been a global public health issue causing in physical, financial and psychosocial crises. The aim of this systematic review and meta-analysis (SRMA) was to evaluate the Diabetes Self-Management Education or Support (DSME/S) on glycosylated hemoglobin (HbA1c) among T2DM patients.

METHODS

This SRMA was made according to preferred reporting Items for systematic review and Meta-analysis (PRISMA) guidelines. The relevant articles were searched from four databases: Cochrane Library, MEDLINE (EBSCOhost), MEDLINE/PubMed and SCOPUS. Quality assessment was carried out. Pooled standard mean difference in HbA1c were calculated to obtain the effect size with random effect assumption. Subgroup analysis was conducted for assessing heterogeneity among the studies.

RESULTS

A total of 1312 studies were identified from databases. Among these 25 studies met inclusion criteria. From these 20 were included in the meta-analysis. In meta-analysis a pooled standard mean difference in HbA1c was -0.604 (95% confidence interval = -0.854 -0.353, I² = 90.3, p < 0.001). In subgroup analysis a significant reduction was seen among studies with less than four months, upper middle followed by lower middle income countries (LMICs), Western Pacific (WP) followed by Middle Eastern and Northern African (MENA) regions with moderate to substantial heterogeneity.

CONCLUSION

However, there is paucity of studies in underdeveloped countries. Therefore, further studies validated to these contexts are needed to evaluate the DSME effectiveness.

TRIAL REGISTRATION

PROSPERO database CRD42020124236.

The effectiveness of diabetes self-management education (DSME) on glycemic control among T2DM patients randomized control trial: systematic review and meta-analysis protocol

BACKGROUND

Type 2 Diabetes mellitus (T2DM) has been a global pandemic resulting in physical, financial and psychosocial crises. Thus, it is important to investigate pooled effectiveness of Diabetes Self-Management Education (DSME) on glycemic control among T2DM patients.

OBJECTIVE

The aim of this systematic review and meta-analysis is to investigate the association between DSME or Support (DSME/S) and glycemic control among T2DM patients.

METHODS

The systematic review and meta-analysis will include studies conducted throughout the world from 2010 to 2019. T2DM patients and their clinical, anthropometric, biomarkers from baseline to end line will be recorded. We will search all relevant articles from five databases namely; Cochrane Library, BioMed Central, MEDLINE (EBSCOhost), MEDLINE/PubMed and SCOPUS. Key terms will be used for questing relevant articles. Further efforts will be made to check quality of studies base on quality assessment instruments. Finally, the report will be made according Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Pooled standard mean difference in HbA1c will be used to calculate the effect size between the variables with random effects analysis assumption. Further subgroup analysis will be carried out for assessing the risk difference among groups.

CONCLUSION

Based on the existing and eligible researches this systematic review and meta-analysis will bring the best evidence on the effectiveness of DSME/S on glycemic control among the T2DM patients. Moreover, the subgroup analysis will inform the effectiveness heterogeneity based on continent, International Diabetes Federation (IDF) region, intervention period, World bank economic classification and glycemic markers used to follow the patients. The proposed review has been registered in the International PROSPERO website with registration number CRD42020124236.

Impact of a Culturally Tailored Diabetes Education and Empowerment Program in a Mexican American Population Along the US/Mexico Border: A Pragmatic Study

Background

The study purpose was to deliver a diabetes education program under real world conditions and evaluate its effect on diabetes-related clinical, self-management and psychosocial outcomes among Mexican Americans residing along the US/Mexico border.

Methods

A pragmatic study was conducted among adult patients with diabetes in three primary care clinics located along the US/Mexico border. A bilingual culturally tailored diabetes education program incorporating hands-on participatory techniques was delivered in 4 - 8 weekly group sessions. Clinical, self-management and psychosocial outcomes were evaluated pre- and post-intervention with surveys and medical record review.

Results

A total of 209 participants were enrolled; mean age was 58.9 years (range 23 - 94, standard deviation: 11.2); 68.4% were female; 91.1% were Hispanic. Significant improvements were observed in glycated hemoglobin (-1.1%, P < 0.001, n = 79), total cholesterol (-17.2 mg/dL, P = 0.041, n = 63), glucose self-monitoring (+1.3 times a week, P = 0.021, n = 115), exercise less than once a week (-18.2%, P < 0.001, n = 129), nutritional behavior (+2.23, P < 0.001, n = 115), knowledge (+1. 83, P < 0.001, n = 141) and diabetes-related emotional distress (-7.32, P = 0.002, n = 111). Benefits were observed with attendance rates as low as 50%.

Conclusion

A clinic-based culturally competent diabetes education/self-management program resulted in significant improvements in outcomes among Hispanic participants. Experimentally tested culturally appropriate interventions adapted for real world situations can benefit Mexican American diabetic patients even when attendance is imperfect.

Readability Following Cultural and Linguistic Adaptations of an Internet-Based Intervention for Tinnitus for Use in the United States

Purpose An Internet-based tinnitus intervention for use in the United States could improve the provision of tinnitus-related services. Although clinical trials of such interventions were completed in Europe, the United Kingdom, and Australia, their suitability for adults with tinnitus in the United States is yet to be established. The aim of this study was to improve the cultural and linguistic suitability, and lower the readability level, of an existing program for tinnitus to ensure its suitability for U.S. English- and Spanish-speaking populations. Method Guidelines for adaptation were followed and involved four phases: (a) cultural adaptations, as interventions targeted at specific cultures have been shown to improve outcomes; (b) creating Spanish materials to improve access of the materials to the large Spanish-speaking population in the United States; (c) professional review of the materials for acceptability as an intervention tool for a U.S. population; and (d) literacy-level adjustments to make the content accessible to those with lower levels of health literacy skills. Results Cultural adaptations were made by using word substitutions, changing examples, and modifying the spelling of certain words. The materials were then translated into Spanish and cross-checked. Professional review ensured suitability of the chapters. Literacy-level adjustments ensured all chapters were within the guidelines for readability grade levels below the sixth-grade level. Conclusions The previously developed tinnitus materials were revised to adhere to best practice guidelines and ensure cultural suitability for adults with tinnitus in the United States. As it is also available in Spanish, members of the large Hispanic community also have access to the intervention in their first language. Further studies should determine whether these changes improve patients' self-efficacy, engagement, and motivation to complete the intervention.

Long-term effectiveness of the Diabetes Conversation Map™ Program on health outcomes: A case-control retrospective cohort study

AIM

To evaluate the clinical and health behavioural outcomes of a large sample of participants from the Diabetes Conversation Map™ Program.

DESIGN

A matched-case-control study that was performed on a retrospective cohort study.

METHODS

Participants were 11,053 Clalit Health Services members with type 2 diabetes who enrolled in the Diabetes Conversation Map™ Program between January 2010 - April 2016. The matched-control group was formulated using sequential matching, by matching cases to controls at a ratio of 1:3, based on age, sex, and HbA1c level. The associations between the programme group and annual clinical and health behaviours were assessed between cases and controls at five time points using linear and Poisson regression analyses.

RESULTS

The intervention group had significantly lower HbA1c, glucose, and low-density lipoprotein levels and more frequent glucose blood testing each year up to 36 month post-enrolment compared with the matched controls. Other outcomes were significantly different for shorter time periods, including higher high-density lipoprotein and lower triglyceride levels at 6- and 12-month follow-up and lower diastolic blood pressure and greater medication adherence at 6-month follow-up.

CONCLUSIONS

Enrolment in the programme was associated with improved clinical and health behaviour outcomes for at least 6 months and most outcomes persisted for up to 36 months.

IMPACT

This is the first study to evaluate the Diabetes Conversation Map™ Program with a large sample over long period of time. This nurse-led group intervention evaluation adds to the literature on health outcomes on the lives of patients with type 2 diabetes.

STUDY REGISTRATION

This study was registered retrospectively to the Open Science Framework, the registration form can be found at: https://osf.io/63cse.

Positive health beliefs are associated with improvement of glycated hemoglobin and lipid profiles in Mexican patients with type 2 diabetes mellitus: a cross-sectional study

BACKGROUND

Health beliefs are relevant to consider in patients with type 2 diabetes since disease control depends mainly on the patient's behaviour. The aim of this study was to assess the association between health beliefs and glycated hemoglobin levels in Mexican patients with type 2 diabetes.

METHODS

An analytical cross-sectional study was conducted, and 336 patients were included. Fasting blood levels of glycated hemoglobin, glucose, cholesterol; triglycerides, high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c) were measured. Body fat percentage, weight, height; waist circumference, and systolic and diastolic blood pressures were also obtained. A previously validated self-administered questionnaire was used to assess the health beliefs with regards to non-pharmacological treatment. Health beliefs were classified as positive, neutral, and negative.

RESULTS

The average age of patients was 54.7 ± 8.5 years, with a higher proportion of females (69%). The questionnaire had a good internal consistency with a Cronbach's alpha score of 0.83. More than 90% of patients attributed a health benefit to diet and exercise, 30 to 40% experienced barriers, and more than 80% had a perception of complications associated to uncontrolled diabetes. Patients with positive health beliefs had lower HbA1c levels (8.2 ± 1.7%) compared to those with neutral (9.0 ± 2.3%), or negative (8.8 ± 1.8%; p = 0.042). The LDL-c levels were lower (p = 0.03), and HDL-c levels were higher (0.002) in patients with positive heath beliefs.

CONCLUSIONS

Positive health beliefs are associated with better metabolic control indicators in patients with type 2 diabetes.

A Framework for Addressing Diabetes-Related Disparities in US Latino Populations

Despite national efforts to redress racial/ethnic disparities, Latino Americans continue to share a disproportionate burden of diabetes-related morbidity and mortality. A better understanding of underlying causes and influencing factors is needed to guide future efforts to eliminate racial/ethnic disparities in diabetes control. The objectives of this review are: (1) to summarize our understanding of determinants and modifiable predictors of glycemic control; (2) to provide an overview of existing strategies to reduce diabetes-related disparities; and (3) to identify gaps in the literature regarding whether these interventions effectively address disparities in US Latino populations. Key findings include evidence that diabetes care services can be designed to accommodate heterogeneity within the Latino American community by addressing key modifiable predictors of poor glycemic control, including insurance status, diabetes care utilization, patient self-management, language access, culturally appropriate care, and social support services. Future research efforts should evaluate the effect of structurally tailored interventions that address these key modifiable predictors by targeting patients, providers, and health care delivery systems.

Impact of Motivational Interviewing on Self-Management in Patients With Type 2 Diabetes: Protocol for a Pilot Randomized Controlled Trial

Background

The nonpharmacological approach to diabetic control in patients with diabetes focuses on a healthy diet, physical activity, and self-management. Therefore, to help patients change their habits, it is essential to identify the most effective approach. Many efforts have been devoted to explain changes in or adherence to specific health behaviors. Such efforts have resulted in the development of theories that have been applied in prevention campaigns and include brief advice and counseling services. Within this context, motivational interviewing (MI) has proven to be effective in changing health behaviors for specific cases. However, stronger evidence is needed on the effectiveness of MI in treating chronic pathologies such as diabetes.

Objective

This study will obtain preliminary data on the impact of a nurse-led MI intervention in improving glycemic control, as well as clinical, psychosocial, and self-care outcomes for individuals with type 2 diabetes mellitus when compared with usual care, with the aim of improving diabetic control in patients with diabetes.

Methods

An open, two-arm, parallel, randomized controlled, pilot exploratory trial will be performed. Two government outpatient clinics in the New Territories West Cluster in Hong Kong will be involved. In total, 20 to 25 participants will be invited in each arm. Intervention participants will receive face-to-face MI interventions in addition to their usual care from the clinic. Control participants will only receive usual care. Outcomes are assessed at baseline, 6 months, and 12 months. The primary outcome measure is glycated hemoglobin levels. Secondary outcomes include blood pressure, BMI, hip and waist circumference, fasting blood, and psychosocial and self-care measures.

Results

This study is currently underway with funding support from the Hong Kong College of Family Physician Research Seed Fund 2017.

Conclusions

MI skills constitute the main strategies primary care nurses use on their patients. Having economical, simple, effective, and applicable techniques is essential for primary care professionals to help their patients change their lifestyle and improve their health. This study will provide scientific evidence on the effectiveness of MI. It will be performed with strict control over the data collection, ensuring the maintenance of therapeutic integrity.

Trial Registration

Centre for Clinical Research and Biostatistics CUHK_CCRB00614; https://tinyurl.com/v9awzk6

International Registered Report Identifier (IRRID)

DERR1-10.2196/15709

Diabetes self-management education exposure and glycated haemoglobin levels among Marshallese participants in a randomized controlled study

AIMS

A randomized control trial (RCT) of diabetes self-management education (DSME), undertaken by a community-based participatory research (CBPR) partnership between the University of Arkansas for Medical Sciences (UAMS) and the Marshallese community in Arkansas. The RCT examined the effect of hours of intervention exposure, with the hypothesis that increased exposure is one reason the Adapted-Family DSME was found to be more effective than the Standard DSME.

METHODS

Some 221 Marshallese with type 2 diabetes were randomized to an Adapted-Family DSME group (in-home setting) (n = 110) or a Standard DMSE group (community setting) (n = 111). The Adapted-Family DSME included 10 h of education that covered the core self-care elements recommended by the American Diabetes Association (ADA) and American Association of Diabetes Educators' (AADE) recommendations. The Standard DSME included 10 h of intervention with all ADA and AADE core elements.

RESULTS

The number of hours of intervention exposure in the Adapted-Family DSME arm (mean = 8.0; median = 10.0) was significantly higher than the number of hours of intervention received in the Standard DSME arm (mean = 1.5; median = 0.0). As hypothesized, higher exposure was associated with a significant reduction in HbA1c in a model including only study arm and exposure (P = 0.01), and in a model including study arm, exposure, and all demographic variables (P = 0.046).

CONCLUSIONS

This finding is consistent with previous reviews that showed increased exposure to DSME produced improved glycaemic control and ≥ 10 h of DSME produces clinically meaningful reductions in HbA1c .

Patient activation and Type 2 diabetes mellitus self-management: a systematic review and meta-analysis

Patient activation has been recognised as a reliable driver of self-management decision-making. This systematic review and meta-analysis examines existing evidence on whether embedding patient activation within Type 2 diabetes mellitus (T2DM) self-management programs can improve patient outcomes. This review has included 10 randomised controlled trials (RCTs) conducted between 2004 and 2019 retrieved from well-known databases such as MEDLINE, PubMed, CINAHL Plus, Scopus, ProQuest and ScienceDirect. The eligible RCTs were excluded if they scored low according to Cochrane Collaboration’s ‘risk of bias’ criteria. Random-effects meta-analyses showed that there were no significance changes in haemoglobin A1C (HbA1c), body mass index (BMI) and patient activation measure (PAM) between intervention and control groups after the intervention; however, the systematic review findings indicated that an improved patient activation level led to significant improvements in T2DM self-management and clinical outcomes including HbA1c level. Studies with a longer follow-up period conducted in community settings and delivered by peer coaches were more likely to lead to significant improvement in both patient activation levels and T2DM self-management and clinical outcomes. This review concludes that patient activation can be used as a reliable tool for improving T2DM self-management and clinical outcomes.