National standards for diabetes self-management education and support

Stakeholder engagement in diabetes self-management: patient preference for peer support and other insights

BACKGROUND

Self-management support (SMS) for patients with diabetes can improve adherence to treatment, mitigate disease-related distress, and improve health outcomes. Translating this evidence into real-world practice is needed, as it is not clear which SMS models are acceptable to patients, and feasible and sustainable for primary care practices.

OBJECTIVE

To use the Boot Camp Translation (BCT) method to engage patient, practice, community resource and research stakeholders in translation of evidence about SMS and diabetes distress into mutually acceptable care models and to inform patient-centred outcomes research (PCOR).

PARTICIPANTS

Twenty-seven diabetes care stakeholders, including patients and providers from a local network of federally qualified health centres participated.

METHODS

Stakeholders met in-person and by conference call over the course of 8 months. Subject matter experts provided education on the diabetes SMS evidence. Facilitators engaged the group in discussions about barriers to self-management and opportunities for improving delivery of SMS.

KEY RESULTS

BCT participants identified lack of social support, personal resources, trust, knowledge and confidence as barriers to diabetes self-management. Intervention opportunities emphasized peer support, use of multidisciplinary care teams and centralized systems for sharing information about community and practice resources. BCT informed new services and a PCOR study proposal.

CONCLUSIONS

Patients and family engaged in diabetes care research value peer support, group visits, and multidisciplinary care teams as key features of SMS models. SMS should be tailored to an individual patient's health literacy. BCT can be used to engage multiple stakeholders in translation of evidence into practice and to inform PCOR.

Dropout From an eHealth Intervention for Adults With Type 2 Diabetes: A Qualitative Study

Background

Adequate self-management is the cornerstone of type 2 diabetes treatment, as people make the majority of daily treatment measures and health decisions. The increasing prevalence of type 2 diabetes mellitus (T2DM) and the complexity of diabetes self-management demonstrate the need for innovative and effective ways to deliver self-management support. eHealth interventions are promoted worldwide and hold a great potential in future health care for people with chronic diseases such as T2DM. However, many eHealth interventions face high dropout rates. This led to our interest in the experiences of participants who dropped out of an eHealth intervention for adults with T2DM, based on the Guided Self-Determination (GSD) counseling method.

Objective

In this study, we aimed to explore experiences with an eHealth intervention based on GSD in general practice from the perspective of those who dropped out and to understand their reasons for dropping out. To the best of our knowledge, no previous qualitative study has focused on participants who withdrew from an eHealth self-management support intervention for adults with T2DM.

Methods

A qualitative design based on telephone interviews was used to collect data. The sample comprised 12 adults with type 2 diabetes who dropped out of an eHealth intervention. Data were collected in 2016 and subjected to qualitative content analysis.

Results

We identified one overall theme: “Losing motivation for intervention participation.” This theme was illustrated by four categories related to the participants’ experiences of the eHealth intervention: (1) frustrating technology, (2) perceiving the content as irrelevant and incomprehensible, (3) choosing other activities and perspectives, and (4) lacking face-to-face encounters.

Conclusions

Our findings indicate that the eHealth intervention based on GSD without face-to-face encounters with nurses reduced participants’ motivation for engagement in the intervention. To maintain motivation, our study points to the importance of combining eHealth with regular face-to-face consultations. Our study also shows that the perceived benefit of the GSD eHealth intervention intertwined with choosing to focus on other matters in complex daily lives are critical aspects in motivation for such interventions. This indicates the importance of giving potential participants tailored information about the aim, the content, and the effort needed to remain engaged in complex interventions so that eligible participants are recruited. Finally, motivation for engagement in the eHealth intervention was influenced by the technology used in this study. It seems important to facilitate more user-friendly but high-security eHealth technology. Our findings have implications for improving the eHealth intervention and to inform researchers and health care providers who are organizing eHealth interventions focusing on self-management support in order to reduce dropout rates.

Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews

OBJECTIVES

Examine Peer Support (PS) for complex, sustained health behaviors in prevention or disease management with emphasis on diabetes prevention and management.

DATA SOURCES AND ELIGIBILITY

PS was defined as emotional, motivational and practical assistance provided by nonprofessionals for complex health behaviors. Initial review examined 65 studies drawn from 1442 abstracts identified through PubMed, published 1/1/2000-7/15/2011. From this search, 24 reviews were also identified. Extension of the search in diabetes identified 30 studies published 1/1/2000-12/31/2015.

RESULTS

In initial review, 54 of all 65 studies (83.1%) reported significant impacts of PS, 40 (61.5%) reporting between-group differences and another 14 (21.5%) reporting significant within-group changes. Across 19 of 24 reviews providing quantifiable findings, a median of 64.5% of studies reviewed reported significant effects of PS. In extended review of diabetes, 26 of all 30 studies (86.7%) reported significant impacts of PS, 17 (56.7%) reporting between-group differences and another nine (30.0%) reporting significant within-group changes. Among 19 of these 30 reporting HbA1c data, average reduction was 0.76 points. Studies that did not find effects of PS included other sources of support, implementation or methodological problems, lack of acceptance of interventions, poor fit to recipient needs, and possible harm of unmoderated PS.

CONCLUSIONS

Across diverse settings, including under-resourced countries and health care systems, PS is effective in improving complex health behaviors in disease prevention and management including in diabetes.

Diabetes Self-Management Education Programs in Nonmetropolitan Counties - United States, 2016

Problem/Condition

Diabetes self-management education (DSME) is a clinical practice intended to improve preventive practices and behaviors with a focus on decision-making, problem-solving, and self-care. The distribution and correlates of established DSME programs in nonmetropolitan counties across the United States have not been previously described, nor have the characteristics of the nonmetropolitan counties with DSME programs.

Reporting Period

July 2016.

Description of Systems

DSME programs recognized by the American Diabetes Association or accredited by the American Association of Diabetes Educators (i.e., active programs) as of July 2016 were shared with CDC by both organizations. The U.S. Census Bureau’s census geocoder was used to identify the county of each DSME program site using documented addresses. County characteristic data originated from the U.S. Census Bureau, compiled by the U.S. Department of Agriculture’s Economic Research Service into the 2013 Atlas of Rural and Small-Town America data set. County levels of diagnosed diabetes prevalence and incidence, as well as the number of persons with diagnosed diabetes, were previously estimated by CDC. This report defined nonmetropolitan counties using the rural-urban continuum code from the 2013 Atlas of Rural and Small-Town America data set. This code included six nonmetropolitan categories of 1,976 urban and rural counties (62% of counties) adjacent to and nonadjacent to metropolitan counties.

Results

In 2016, a total of 1,065 DSME programs were located in 38% of the 1,976 nonmetropolitan counties; 62% of nonmetropolitan counties did not have a DSME program. The total number of DSME programs for nonmetropolitan counties with at least one DSME program ranged from 1 to 8, with an average of 1.4 programs. After adjusting for county-level characteristics, the odds of a nonmetropolitan county having at least one DSME program increased as the percentage insured increased (adjusted odds ratio [AOR] = 1.10, 95% confidence interval [CI] = 1.08–1.13), the percentage with a high school education or less decreased (AOR = 1.06, 95% CI = 1.04–1.07), the unemployment rate decreased (AOR = 1.19, 95% CI = 1.11–1.23), and the natural logarithm of the number of persons with diabetes increased (AOR = 3.63, 95% CI = 3.15–4.19).

Interpretation

In 2016, there were few DMSE programs in nonmetropolitan, socially disadvantaged counties in the United States. The number of persons with diabetes, percentage insured, percentage with a high school education or less, and the percentage unemployed were significantly associated with whether a DSME program was located in a nonmetropolitan county.

Public Health Action

Monitoring the distribution of DSME programs at the county level provides insight needed to strategically address rural disparities in diabetes care and outcomes. These findings provide information needed to assess lack of availability of DSME programs and to explore evidence-based strategies and innovative technologies to deliver DSME programs in underserved rural communities.

Associations Between Economic Pressure and Diabetes Efficacy in Couples With Type 2 Diabetes

Objective

The purpose of this study was to explore dyadic associations between economic pressure and diabetes self-efficacy via emotional distress in patients with type 2 diabetes and their partners.

Background

Understanding how economic pressure is associated with successful diabetes management is an important area for research, as couples with type 2 diabetes can incur heavy economic pressures that could likely influence diabetes outcomes.

Method

Data from 117 married couples were used to test actor-partner associations using moderated mediation analyses in a structural equation modeling framework. Problem-solving communication was tested as a possible moderator of the economic pressure-emotional distress pathway.

Results

Results revealed that greater patient economic pressure was associated with lower patient and spouse confidence in the patient's diabetes management ability through higher levels of patient emotional distress. The deleterious association between economic pressure and emotional distress was less pronounced when spouses reported more effective problem-solving communication.

Conclusion

These results provide evidence that the economic pressure couples with type 2 diabetes face may reduce the patient and spouse's confidence in the patient's diabetes management ability.

Implications

This study demonstrates the importance of couple's relationship processes in buffering the impact of economic pressure on diabetes management, providing a clear target for intervention and education efforts.

Time to question diabetes self-management support for Arabic-speaking migrants: exploring a new model of care

AIM

The objective of this study was to explore a new model for diabetes self-management support in Arabic-speaking migrants.

METHODS

Two qualitative methods were used: face-to-face semi-structured individual interviews and focus groups. Interviews were audio-taped, transcribed verbatim and coded thematically. Arabic-speaking migrants with Type 2 diabetes were recruited from several primary, secondary and tertiary healthcare settings in metropolitan Melbourne, Australia. These settings were purposefully selected to obtain a diverse group of participants. Data collection continued until saturation was reached. This is the first study that involved members of Arabic-speaking communities in Australia in a formal process of consumer and public involvement to inform research design and recruitment in order to provide evidence for a new model of diabetes self-management for Arabic-speaking migrants.

RESULTS

No self-management support was offered to Arabic-speaking migrants beyond the initial diagnosis period. Significant knowledge gaps and skills deficits in all self-management domains were evident. The provision of tailored self-management support was considered crucial. When asked about preferred structure and delivery modalities, a strong preference was reported for face-to-face storytelling interactions over telephone- or internet-based interventions. Gender-specific group education and self-management support sessions delivered by Arabic-speaking diabetes health professionals, lay peers or social workers trained in diabetes self-management were highly regarded.

CONCLUSIONS

A patient and public involvement approach allows genuine engagement with Arabic-speaking migrants with diabetes. There is urgent need for a new model for self-management support among Arabic-speaking migrants. Findings yielded new recommendations for diabetes health professionals working with these migrant communities to support behaviour change.

Provider- and patient-related determinants of diabetes self-management among recent immigrants: Implications for systemic change

OBJECTIVE

To examine provider- and patient-related factors associated with diabetes self-management among recent immigrants.

DESIGN

Demographic and experiential data were collected using an international survey instrument and adapted to the Canadian context. The final questionnaire was pretested and translated into 4 languages: Mandarin, Tamil, Bengali, and Urdu.

SETTING

Toronto, Ont.

PARTICIPANTS

A total of 130 recent immigrants with a self-reported diagnosis of type 2 diabetes mellitus who had resided in Canada for 10 years or less.

MAIN OUTCOME MEASURES

Diabetes self-management practices (based on a composite of 5 diabetes self-management practices, and participants achieved a score for each adopted practice); and the quality of the provider-patient interaction (measured with a 5-point Likert-type scale that consisted of questions addressing participants' perceptions of discrimination and equitable care).

RESULTS

A total of 130 participants in this study were recent immigrants to Canada from 4 countries of origin-Sri Lanka, Bangladesh, Pakistan, and China. Two factors were significant in predicting diabetes self-management among recent immigrants: financial barriers, specifically, not having enough money to manage diabetes expenses (P = .0233), and the quality of the provider-patient relationship (P = .0016). Participants who did not have enough money to manage diabetes were 9% less likely to engage in self-management practices; and participants who rated the quality of their interactions with providers as poor were 16% less likely to engage in self-management practices.

CONCLUSION

Financial barriers can undermine effective diabetes self-management among recent immigrants. Ensuring that patients feel comfortable and respected and that they are treated in culturally sensitive ways is also critical to good diabetes self-management.

A Qualitative Inquiry of Lower Extremity Disease Knowledge Among African Americans Living With Type 2 Diabetes

The purpose of this study was to investigate how personal illness representations of type 2 diabetes affected the level of foot care knowledge and self-care strategies among African Americans adults. Thirteen African Americans (ages 32-72 years) participated in individual semistructured qualitative interviews regarding self-care practices and lower extremity disease knowledge related to type 2 diabetes. Using phenomenological methodology, all interviews were transcribed and analyzed by the research team for themes. Three major themes emerged from the interviews: basic foot care knowledge, lower extremity disease knowledge, and patient–provider communication. The study yielded that the majority of the participants lacked understanding of basic diabetic foot care as well as how lower extremity complications can evolve from uncontrolled type 2 diabetes. Diabetes self-management education is an essential component that could aid in the improvement of poor health outcomes of African Americans. Diabetes self-management education programs should consider implementing more detailed foot care educational tools, especially those individuals who are affected with complications due to the disease and that can lead to lower extremity amputations. This study provided insight on the importance of this knowledge as it relates to making common sense assumptions about the disease and self-management strategies.

Assessment of a web-based Guided Self-Determination intervention for adults with type 2 diabetes in general practice: a study protocol

INTRODUCTION

Self-management is deemed the cornerstone in overall diabetes management. Web-based self-management interventions have potential to support adults with type 2 diabetes (T2DM) in managing their disease. Owing to somewhat ambiguous results of such interventions, interventions should be theory-based and incorporate well-defined counselling methods and techniques for behavioural change. This study is designed to assess the effectiveness of a theory-driven web-based Guided Self-Determination (GSD) intervention among adults with T2DM in general practice to improve diabetes self-management behaviours and glycosylated haemoglobin (HbA1c).

METHODS AND ANALYSIS

A complex intervention design based on the framework of the UK Medical Research Council is employed as a guide for developing the intervention, assessing its feasibility and evaluating its effectiveness. The study consists of three phases: (1) the modelling phase adapting the original GSD programme for adults with T2DM, using a qualitative design, (2) feasibility assessment of the adapted intervention on the web, employing qualitative and quantitative methods and (3) evaluating the effectiveness of the intervention on diabetes self-management behaviours and HbA1c, using a quasi-experimental design. The first phase, which is completed, and the second phase, which is underway, will provide important information about the development of the intervention and its acceptability, whereas the third phase will assess the effectiveness of this systematically developed intervention.

ETHICS AND DISSEMINATION

The Norwegian Regional Committee for Medical and Health Research Ethics (REK west number 2015/60) has approved the study design. Patients recruited in the different phases will fill out an informed consent form prior to inclusion and will be guaranteed anonymity and the right to withdraw from the study at any time. The results of the study will be published in peer-reviewed journals, electronically and in print, and presented at research conferences.

TRIAL REGISTRATION NUMBER

NCT02575599.

Development and Validation of an Inflammatory Bowel Diseases Monitoring Index for Use With Mobile Health Technologies

BACKGROUND & AIMS

Mobile health technologies are advancing rapidly as smartphone use increases. Patients with inflammatory bowel disease (IBD) might be managed remotely through smartphone applications, but no tools are yet available. We tested the ability of an IBD monitoring tool, which can be used with mobile technologies, to assess disease activity in patients with Crohn's disease (CD) or ulcerative colitis (UC).

METHODS

We performed a prospective observational study to develop and validate a mobile health index for CD and UC, which monitors IBD disease activity using patient-reported outcomes. We collected data from disease-specific questionnaires completed by 110 patients with CD and 109 with UC who visited the University of California, Los Angeles, Center for IBD from May 2013 through January 2014. Patient-reported outcomes were compared with clinical disease activity index scores to identify factors associated with disease activity. Index scores were validated in 301 patients with CD and 265 with UC who visited 3 tertiary IBD referral centers (in California or Europe) from April 2014 through March 2015.

RESULTS

We assessed activity of CD based on liquid stool frequency, abdominal pain, patient well-being, and patient-assessed disease control, and activity of UC based on stool frequency, abdominal pain, rectal bleeding, and patient-assessed disease control. The indices identified clinical disease activity with area under the receiver operating characteristic curve values of 0.90 in patients with CD and 0.91 in patients with UC. They identified endoscopic activity with area under the receiver operating characteristic values of 0.63 in patients with CD and 0.82 in patients with UC. Both scoring systems responded to changes in disease activity (P < .003). The intraclass correlation coefficient for test-retest reliability was 0.94 for CD and for UC.

CONCLUSIONS

We developed and validated a scoring system to monitor disease activity in patients with CD and UC that can be used with mobile technologies. The indices identified clinical disease activity with area under the receiver operating characteristic curve values of 0.9 or higher in patients with CD or UC, and endoscopic activity in patients with UC but not CD.

Effects of lifestyle intervention using patient-centered cognitive behavioral therapy among patients with cardio-metabolic syndrome: a randomized, controlled trial

BACKGROUND

Cardio-metabolic syndrome (CMS) is a highly prevalent condition. There is an urgent need to identify effective and integrated multi-disciplinary approaches that can reduce risk factors for CMS.

METHODS

Sixty-two patients with a history of CMS were randomized 1:1 into two groups: a standard information -only group (control), or a self-regulated lifestyle waist circumference (patient-centered cognitive behavioral therapy) intervention group. A pretest and posttest, controlled, experimental design was used. Outcomes were measured at the baseline (week 0) and at the end of intervention (week 12). Comparisons were drawn between groups and over time.

RESULTS

The mean (standard deviation) age of the subjects was 48.6 (5.8) years ranging from 32 to 63, and 56.9% of the participants were female. Both groups showed no significant differences in Demographic variables and the metabolic syndrome indicators at baseline. While the control group only showed modest improvement after 12 weeks, compared to baseline, the intervention group demonstrated significant improvement from baseline. This study controlled for patients' demographics and baseline characteristics when assessing the effects of intervention. After adjusting for age, education and baseline level, the experimental group and the control group were statistically significant different in the following post-treatment outcomes: WC (F = 35.96, P < 0.001), TG (F = 18.93, P < 0.001), RSBP (F = 33.89, P < 0.001) and SF-36(F = 157.93, P < 0.001). The results showed patients' age and education were not strong predictors of patients' outcome (including WC, TG, RSBP and SF-36).

CONCLUSIONS

Lifestyle intervention on patient-centered cognitive behavioral therapy can improve the physical and mental health conditions among individuals reporting a history of cardio-metabolic syndrome, and possibly provided preliminary benefits for the treatment of CMS.

TRIAL REGISTRATION

Chinese Clinical Trial Register #, ChiCTR15006148 .

Nurse-led patient-centered self-management support improves HbA1c in patients with type 2 diabetes-A randomized study

OBJECTIVES

The aim of this study was to evaluate the effect of a patient-centered self-management support, in type 2 diabetes (T2D) with regard to metabolic changes.

METHODS

182 patients were randomized into group intervention (GI), individual intervention (II) or internal controls (IC). An external control (EC) group was recruited from another county council. The intervention consisted of six sessions that featured themes, which regarded different views of their illness experiences. Data were collected in 2010 and 2011.

RESULTS

HbA1c was significantly decreased at 12-month follow-up with 5mmol/mol in the GI and 4mmol/mol in the II. In the IC group, the HbA1c was close to baseline. The EC group had increased HbA1c, though not significantly. When the HbA1c difference at baseline was adjusted, there was a significant difference between intervention groups and the EC-group.

CONCLUSION

Patient-centered self-management support, led by nurses, can lower HbA1c among patients with type 2 diabetes.

PRACTICE IMPLICATIONS

It is possible to train diabetes specialist nurses in clinical patient-centered care, and simultaneously influence patients' metabolic balance positively.

Perceptions of diabetes control among people with type 2 diabetes treated with basal insulin in Sweden, Switzerland, and the United Kingdom

OBJECTIVE

To investigate perceptions of control among people with uncontrolled and well controlled type 2 diabetes (T2D) treated with basal insulin, as well as differences in perceptions and diabetes management practices between the two groups.

RESEARCH DESIGN AND METHODS

Web surveys of 1012 people with uncontrolled T2D (HbA_1c >8.0% or 64 mmol/mol) on basal insulin in Sweden, Switzerland, and the UK and 295 people with well controlled T2D (HbA_1c <7.5% or 58 mmol/mol) on basal insulin in the UK were conducted.

RESULTS

People with uncontrolled T2D perceived a wide range of factors as very/extremely important for deciding whether they are well controlled, including diet (80.7%), HbA_1c value (78.9%), times per day insulin taken (78.8%), insulin units taken per day (77.6%), and energy levels (74.5%). Fifty-one percent of uncontrolled respondents considered the past week or more recently when thinking about control. Perceived major obstacles to control included stress (75.4%), other health issues (70.8%), medicine side effects (69.9%), food cravings (69.8%), doctor not understanding individual situation (67.6%), and life crises (66.9%). Many uncontrolled respondents reported that diabetes was very/extremely interfering with their lives, including energy level (71.0%), performance at work (70.0%), general health (69.9%), and doing what one wants (69.3%). Analyses showed significant differences between well controlled and uncontrolled UK respondents. Compared to the uncontrolled, people with well controlled T2D were significantly more likely to consider the last 24 hours/current time when thinking about control (50% vs. 21%, p < 0.001) and reported greater healthcare contact related to diabetes and more frequent glucose measurement. Study limits include potential selection bias of web surveys and possible recall bias in patient-reported data.

CONCLUSIONS

The results illuminate how people with T2D treated with basal insulin perceive control and show important differences between the well controlled and uncontrolled. Findings may have implications for improving patient and physician education and diabetes management.

Population Health Management for Older Adults: Review of Interventions for Promoting Successful Aging Across the Health Continuum

Background: The older adult population is expanding, living longer, with multiple chronic conditions. Understanding and managing their needs over time is an integral part of defining successful aging. Population health is used to describe the measurement and health outcomes of a population. Objectives: To define population health as applied to older adults, summarize lessons learned from current research, and identify potential interventions designed to promote successful aging and improved health for this population. Method: Online search engines were utilized to identify research on population health and health interventions for older adults. Results: Population health management (PHM) is one strategy to promote the health and well-being of target populations. Interventions promoting health across a continuum tend to be disease, risk, or health behavior specific rather than encompassing a global concept of health. Conclusion: Many existing interventions for older adults are simply research based with limited generalizability; as such, further work in this area is warranted.

Living with sub-optimal glycaemic control: the experiences of Type 2 diabetes diagnosis and education

AIM

The aim of this study was to explore the experiences of diagnosis and education for people living with Type 2 diabetes who have sub-optimal glycaemic control.

BACKGROUND

The increasing prevalence of Type 2 diabetes is a global concern. Many people have difficulty maintaining optimal glycaemic control with up to 50% having HbA1c levels higher than recommended. A range of factors that have been suggested as possibly contributing to this, however, little is known about how their experience of diagnosis, education and support to attempt to understand the context of their self-management practices.

DESIGN

A qualitative thematic analysis of interviews conducted with people with sub-optimal glycaemic control prior to their participation in an intervention study.

METHOD

Thirty participants taking part in a psychosocial/educational intervention for people with sub-optimal glycaemic control were interviewed in 2012 before the intervention commenced. These interviews explored each participant's experience of the diagnosis and associated education. The interviews were transcribed and a thematic analysis was conducted.

FINDINGS

Almost all the participants had been shocked at receiving the diagnosis and felt it had been a moral indictment on their lifestyle. Many had been given the impression that they had a mild form of diabetes and most had been given very little information on self-management that they had found useful.

CONCLUSION

The findings suggest that for the participants there was a considerable gap between the rhetoric of person-centred services and the reality of the experiences of diagnosis and education for the self-management of Type 2 diabetes.

The diabetes nutrition education study randomized controlled trial: A comparative effectiveness study of approaches to nutrition in diabetes self-management education

OBJECTIVE

To compare the effectiveness of different approaches to nutrition education in diabetes self-management education and support (DSME/S).

METHODS

We randomized 150 adults with type 2 diabetes to either certified diabetes educator (CDE)-delivered DSME/S with carbohydrate gram counting or the modified plate method versus general health education. The primary outcome was change in HbA1C over 6 months.

RESULTS

At 6 months, HbA1C improved within the plate method [-0.83% (-1.29, -0.33), P<0.001] and carbohydrate counting [-0.63% (-1.03, -0.18), P=0.04] groups but not the control group [P=0.34]. Change in HbA1C from baseline between the control and intervention groups was not significant at 6 months (carbohydrate counting, P=0.36; modified plate method, P=0.08). In a pre-specified subgroup analysis of patients with a baseline HbA1C 7-10%, change in HbA1C from baseline improved in the carbohydrate counting [-0.86% (-1.47, -0.26), P=0.006] and plate method groups [-0.76% (-1.33, -0.19), P=0.01] compared to controls.

CONCLUSION

CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%.

PRACTICE IMPLICATIONS

Both carbohydrate counting and the modified plate method improve glycemic control as part of DSME/S.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Motivational interviewing and outcomes in adults with type 2 diabetes: A systematic review

OBJECTIVES

The management of type 2 diabetes (T2D) requires complex behavior changes and treatment regimens to achieve optimal outcomes. Interventions including motivational interviewing (MI) have been explored to help patients achieve behavior change and outcomes; this study aimed to explore evidence and gaps in the literature for MI interventions and outcomes in adults with T2D.

METHODS

A modified Cochrane method structured the search strategy among databases including MEDLINE, CINAHL, PsycINFO, and others. Inclusion criteria included randomized controlled trials that assessed the effects of MI on behavior changeoutcomes and resultant clinical outcomes in adults with T2D.

RESULTS

Of the initial 159 studies identified, 14 were eligible for retention. Behavior targets in the retained studies included dietary changes, physical activity, smoking cessation, and alcohol reduction. MI had significant impact on some dietary behaviors and on weight loss. MI intervention structures were heterogeneous across studies; fidelity assessment was infrequent.

CONCLUSION

The effects of MI interventions on outcomes in T2D showed promising results for dietary behaviors. Clinical change outcomes from MI-based interventions were most favorable for weight management in T2D.

PRACTICE IMPLICATIONS

Behavior-specific MI interventions may positively influence study outcomes. Assessment of MI intervention fidelity will enhance treatment integrity and claims for validity.

Perceptions of diabetes control among physicians and people with type 2 diabetes uncontrolled on basal insulin in Sweden, Switzerland, and the United Kingdom

Objective A large proportion of people with type 2 diabetes (T2D) remain uncontrolled on basal insulin. Yet, there is limited understanding of how people with uncontrolled type 2 diabetes (PWUD) perceive control and insulin intensification and whether their perceptions differ from those of physicians. The purpose of the study was to investigate perceptions of control and views on insulin intensification among physicians and PWUD. Research design and methods Web surveys of 1012 PWUD on basal insulin and 300 physicians were conducted in Sweden, Switzerland, and the United Kingdom. Results Analyses revealed significant differences between physicians and PWUD. Physicians were significantly more likely than PWUD to indicate that HbA1c (85.0% vs. 78.9%, p < 0.05), complications from diabetes (89.3% vs. 75.3%, p < 0.001), and frequency/severity of hypoglycemia (93.3% vs. 68.6%, p < 0.001) were very/extremely important for deciding whether or not diabetes is well controlled. In contrast PWUD were significantly more likely to place importance on a variety of factors, including energy levels (74.5% vs. 33.0%, p < 0.001), insulin units/day (77.6% vs. 29.0%, p < 0.001) and how predictable life is (72.1% vs. 29.3%, p < 0.001). PWUD also perceived significantly greater obstacles to control and viewed uncontrolled T2D as more interfering in their lives compared to physicians. Physicians were most reluctant to intensify insulin when there is a lack of patient agreement. Worries about weight gain and feelings of 'getting sicker' were the most frequently reported reasons why PWUD on basal insulin were reluctant to intensify insulin. Conclusions Results revealed a significant disconnect between physicians and PWUD in their perceptions of diabetes control. While physicians generally expressed a more focused and clinical view of diabetes control, patients had a broader view. Results also provide insights into PWUD and physicians' reluctance to intensify insulin. The findings suggest that physician and patient education on differing perceptions could benefit communication and improve diabetes management.

Hope matters to the glycemic control of adolescents and young adults with type 1 diabetes

This study investigated the association of hope and its factors with depression and glycemic control in adolescents and young adults with type 1 diabetes. A total of 113 patients were invited to participate. Significant negative correlations were found between hope and HbA1c and also between hope and depression. Hope showed a significant association with HbA1c and depression in the stepwise regression model. Among the hope factors, "inner positive expectancy" was significantly associated with HbA1c and depression. This study supports that hope matters to glycemic control and depression. Intervention strategies focusing on hope should be further explored.

Barriers to Diabetes Self-Management Among Rural Individuals in the Workplace

Higher rates of type 2 diabetes mellitus (T2DM) are found in rural populations and barriers lessen the ability of these individuals to effectively manage diabetes. By lessening potential barriers to self-care management, health professionals, especially occupational health nurses, can assist individuals confidently manage T2DM. In this article, the authors provide an overview of diabetes self-management barriers for rural populations and implications for health professionals who assist individuals with T2DM in the workplace.

Type 2 diabetes-related foot care knowledge and foot self-care practice interventions in the United States: a systematic review of the literature

Introduction

The purpose of this systematic literature review is to review published studies on foot care knowledge and foot care practice interventions as part of diabetic foot care self-management interventions.

Methods

Medline, CINAHL, CENTRAL, and Cochrane Central Register of Controlled Trials databases were searched. References from the included studies were reviewed to identify any missing studies that could be included. Only foot care knowledge and foot care practice intervention studies that focused on the person living with type 2 diabetes were included in this review. Author, study design, sample, intervention, and results were extracted.

Results

Thirty studies met the inclusion criteria and were classified according to randomized controlled trial (n=9), survey design (n=13), cohort studies (n=4), cross-sectional studies (n=2), qualitative studies (n=2), and case series (n=1). Improving lower extremity complications associated with type 2 diabetes can be done through effective foot care interventions that include foot care knowledge and foot care practices.

Conclusion

Preventing these complications, understanding the risk factors, and having the ability to manage complications outside of the clinical encounter is an important part of a diabetes foot self-care management program. Interventions and research studies that aim to reduce lower extremity complications are still lacking. Further research is needed to test foot care interventions across multiple populations and geographic locations.

Characteristics of the Spanish- and English-Language Self-Efficacy to Manage Diabetes Scales

Purpose

The purpose of this study was to examine the characteristics of the Spanish-language diabetes self-efficacy scale (DSES-S) and the English-language version (DSES).

Methods

This study consists of secondary data from 3 randomized studies that administered the DSES-S and DSES at 2 time points. The scales consist of 8 Likert-type 10-point items. Principal component analysis was applied to determine if the scales were unitary or consisted of subscales. Univariate statistics were used to describe the scales. Sensitivity to change was measured by comparing randomized treatment with control groups, where the treatment included methods designed to enhance self-efficacy. General linear models were used to examine the association between the scales and the 8 medical outcomes after controlling for demographic variables.

Results

Principal component analysis indicated that there were 2 subscales for both versions: self-efficacy for behaviors and self-efficacy to manage blood levels and medical condition. The measures had similar means across the 3 studies, high internal consistent reliability, values distributed across the entire range, and they showed no evidence of floor effects and little evidence of ceiling effects. The measures were sensitive to change. They were associated with several health indicators and behaviors at baseline, and changes were associated with changes in health measures.

Conclusions

The self-efficacy measures behaved consistently across the 3 studies and were highly reliable. Associations with medical indicators and behaviors suggested validity, although further study would be desirable to compare other measures of self-efficacy for people with type 2 diabetes. These brief scales are appropriate for measuring self-efficacy to manage diabetes.

Mindfulness meditation and the immune system: a systematic review of randomized controlled trials

Mindfulness meditation represents a mental training framework for cultivating the state of mindful awareness in daily life. Recently, there has been a surge of interest in how mindfulness meditation improves human health and well-being. Although studies have shown that mindfulness meditation can improve self-reported measures of disease symptomatology, the effect that mindfulness meditation has on biological mechanisms underlying human aging and disease is less clear. To address this issue, we conducted the first comprehensive review of randomized controlled trials examining the effects of mindfulness meditation on immune system parameters, with a specific focus on five outcomes: (1) circulating and stimulated inflammatory proteins, (2) cellular transcription factors and gene expression, (3) immune cell count, (4) immune cell aging, and (5) antibody response. This analysis revealed substantial heterogeneity across studies with respect to patient population, study design, and assay procedures. The findings suggest possible effects of mindfulness meditation on specific markers of inflammation, cell-mediated immunity, and biological aging, but these results are tentative and require further replication. On the basis of this analysis, we describe the limitations of existing work and suggest possible avenues for future research. Mindfulness meditation may be salutogenic for immune system dynamics, but additional work is needed to examine these effects.

Gender, diabetes education, and psychosocial factors are associated with persistent poor glycemic control in patients with type 2 diabetes in the Joint Asia Diabetes Evaluation (JADE) program

BACKGROUND

Factors associated with persistent poor glycemic control were explored in patients with type 2 diabetes under the Joint Asia Diabetes Evaluation (JADE) program.

METHODS

Chinese adults enrolled in JADE with HbA1c ≥8% at initial comprehensive assessment (CA1) and repeat assessment were analyzed. The improved group was defined as those with a ≥1% absolute reduction in HbA1c, and the unimproved group was those with <1% reduction at the repeat CA (CA2).

RESULTS

Of 4458 enrolled patients with HbA1c ≥8% at baseline, 1450 underwent repeat CA. After a median interval of 1.7 years (interquartile range[IQR] 1.1-2.2) between CA1 and CA2, the unimproved group (n = 677) had a mean 0.4% (95% confidence interval [CI] 0.3%, 0.5%) increase in HbA1c compared with a mean 2.8% reduction (95% CI -2.9, -2.6%) in the improved group (n = 773). The unimproved group had a female preponderance with lower education level, and was more likely to be insulin treated. Patients in the improved group received more diabetes education between CAs with improved self-care behaviors, whereas the unimproved group had worsening of health-related quality of life at CA2. Apart from female gender, long disease duration, low educational level, obesity, retinopathy, history of hypoglycemia, and insulin use, lack of education from diabetes nurses between CAs had the strongest association for persistent poor glycemic control.

CONCLUSIONS

These results highlight the multidimensional nature of glycemic control, and the importance of diabetes education and optimizing diabetes care by considering psychosocial factors.

Validation of the Greek Version of the Diabetes Management Self-Efficacy Scale (GR-DMSES)

Introduction

Self-efficacy has been found to have a direct relation with self-care in diabetes. Several tools have been developed and used for evaluating self-efficacy of diabetic patients, the most widely used being the Diabetes Management Self-Efficacy Scale (DMSES). The aim of the present study was to translate, culturally adapt, and validate the Greek DMSES (GR-DMSES) in order for it to be used in the ATTICA pilot study of the SmartCare EU-funded project.

Methods

Using standard procedures, the original version of DMSES was translated and culturally adapted into Greek. Content validity was assessed by an expert panel with the calculation of a content validity index of the overall scale. Α convenient sample was recruited to complete the questionnaire. Psychometric testing of the produced instrument included internal consistency test (Cronbach’s alpha), construct validity (factor analysis), and stability (intraclass correlation coefficient).

Results

One hundred and sixteen patients, aged 36–86 years, with type 2 diabetes (T2D) participated in the study. There were no items excluded from the original scale after the content validity procedure. The coefficient Cronbach's alpha for the internal consistency was 0.93 and the intraclass correlation coefficient for the stability with a 5-week time interval was 0.87 (P < 0.001). Factor analysis yielded four factors related to diet, medical therapy, medication and feet check, and physical activity.

Conclusion

The findings supported that the GR-DMSES was reliable and valid in measuring self-efficacy related to diabetes self-management, thus providing a quick and easy-to-use tool for health professionals dealing with Greek adults with T2D.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-015-0278-1) contains supplementary material, which is available to authorized users.

Impact of "Conversation Maps" on diabetes distress and self-efficacy of Chinese adult patients with type 2 diabetes: a pilot study

The objective was to compare Diabetes Conversation Maps-based education and traditional education in Chinese patients with type 2 diabetes. A total of 53 outpatients were randomized to the intervention group (Diabetes Conversation Maps-based education) and control group (traditional education). In the intervention group, six 1-hour sessions covering diabetes overview, living with diabetes, risk factors and complications of diabetes, starting insulin treatment, foot care, and healthy eating and exercise were provided during 4 weeks. The participants had to attend at least four sessions, followed by a monthly follow-up telephone call in the subsequent 3 months. In the control group, six 1-hour diabetes classes covering similar topics as those in the intervention group were provided over 4 weeks. Each participant needed to attend at least four sessions. A1C was assessed at baseline, 3 months and 6 months after the last educational session/class. Psychosocial metrics and self-care activities were evaluated at baseline and 6 months after the last educational session/class. Forty-six participants finished the study. After 6 months, the total score of diabetes distress scale was significantly lower and total score of diabetes empowerment scale-short form was significantly higher in the intervention group than the control group. The 3 months A1C was significantly lower in the intervention group than the control group. However, the 6 months A1C did not reach a statistically significant difference between groups. Compared to traditional education, Diabetes Conversation Maps were more effective in improving psychosocial metrics and 3-month A1C.

Sociodemographic and Clinical Predictors of Self-Management among People with Poorly Controlled Type 1 and Type 2 Diabetes: The Role of Illness Perceptions and Self-Efficacy

Self-management is critical if people with diabetes are to minimise their risk of macrovascular and microvascular complications, yet adherence to self-management recommendations is suboptimal. Understanding the predictors of optimal diabetes self-management in specific populations is needed to inform effective interventions. This study investigated the role of demographic and clinical characteristics, illness perceptions, and self-efficacy in explaining adherence to self-management recommendations among people with poorly controlled diabetes in North West of England. Illness perceptions and self-efficacy data were collected using validated questionnaires and clinical data were obtained from hospital records. Correlations were used to investigate bivariate relationships between independent variables and self-management, and multiple regression techniques were used to determine demographic and psychosocial predictors of self-management. Various demographic and clinical characteristics were associated with adherence to self-management recommendations. In particular, employment status explained 11% of the variation in adherence to foot care whilst diabetes treatment category explained 9% of exercise and 21% of the variations in SMBG recommendations. Also, 22% and 8% of the variations in overall self-management were explained by illness perceptions and self-efficacy beliefs, respectively. Illness perceptions and self-efficacy beliefs of people with poorly controlled diabetes are important predictors of their self-management behaviours and could potentially guide effective interventions.

eHealth technologies to support nutrition and physical activity behaviors in diabetes self-management

Diabetes is a chronic, complex condition requiring sound knowledge and self-management skills to optimize glycemic control and health outcomes. Dietary intake and physical activity are key diabetes self-management (DSM) behaviors that require tailored education and support. Electronic health (eHealth) technologies have a demonstrated potential for assisting individuals with DSM behaviors. This review provides examples of technologies used to support nutrition and physical activity behaviors in the context of DSM. Technologies covered include those widely used for DSM, such as web-based programs and mobile phone and smartphone applications. In addition, examples of novel tools such as virtual and augmented reality, video games, computer vision for dietary carbohydrate monitoring, and wearable devices are provided. The challenges to, and facilitators for, the use of eHealth technologies in DSM are discussed. Strategies to support the implementation of eHealth technologies within practice and suggestions for future research to enhance nutrition and physical activity behaviors as a part of broader DSM are provided.

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).

Involving people with diabetes and the wider community in diabetes research: a realist review protocol

BACKGROUND

Patient and public involvement in diabetes research is now actively encouraged in different countries because it is believed that involving people with experience of the condition will improve the quality and relevance of the research. However, reviews of patient involvement have noted that inadequate resources, patients' and communities' lack of research knowledge, and researchers' lack of skills to involve patients and communities in research may present significant contextual barriers. Little is known about the extent of patient/community involvement in designing or delivering interventions for people with diabetes. A realist review of involvement will contribute to assessing when, how and why involvement works, or does not work, to produce better diabetes interventions.

METHODS/DESIGN

This protocol outlines the process for conducting a realist review to map how patients and the public have been involved in diabetes research to date. The review questions ask the following: How have people with diabetes and the wider community been involved in diabetes research? What are the characteristics of the process that appear to explain the relative success or failure of involvement? How has involvement (or lack of involvement) in diabetes research influenced the development and conduct of diabetes research? The degree of support in the surrounding context will be assessed alongside the ways in which people interact in different settings to identify patterns of interaction between context, mechanisms and outcomes in different research projects. The level and extent of the involvement will be described for each stage of the research project. The descriptions will be critically reviewed by the people with diabetes on our review team. In addition, researchers and patients in diabetes research will be asked to comment. Information from researcher-patient experiences and documents will be compared to theories of involvement across a range of disciplines to create a mid-range theory describing how involvement (or lack of involvement) in diabetes research influences the development and conduct of diabetes research.

Correlates of diabetes-related distress in type 2 diabetes: Findings from the benchmarking network for clinical and humanistic outcomes in diabetes (BENCH-D) study

OBJECTIVE

To evaluate correlates of high diabetes-related distress (HD) among individuals with type 2 diabetes mellitus (T2DM).

METHODS

The study involved a sample of patients with T2DM who filled in the Problem Areas in Diabetes questionnaire (PAID-5); a score ≥ 40 indicates HD. Additional instruments included: SF12 health survey (SF12), Well-Being Index (WHO-5), Diabetes Empowerment Scale-Short Form (DES-SF), Patient Assessment of Chronic Illness Care-Short Form (PACIC-SF), Health Care Climate-Short Form (HCC-SF), Global Satisfaction with Diabetes Treatment (GSDT), Summary of Diabetes Self-Care Activities (SDSCA-6); Barriers to Medications (BM), Perceived Social Support (PSS). Clinical data were extracted from computerized medical records. Multivariable logistic regression analyses were performed to identify correlates of HD.

RESULTS

Of 2374 patients (mean age 65.0±10.2 years, diabetes duration 14.0±15.3 years, 59.9% males), 1429 (60.2%) had HD. Compared to patients with a PAID-5 score<40 those with HD were more often female, living alone, had a lower level of education, higher HbA1c levels, a greater perceived impact of hyperglycemic and hypoglycemic symptoms, a greater number of diabetes-related complications, lower scores of WHO-5, DES-SF, PSS, GSDT, SF-12 PCS, SDSCA-healthy diet and physical activity subscales, higher scores of BM and SDSCA-SMBG component. Multivariable analyses confirmed the relationship between HD and symptoms of hyperglycemia, levels of empowerment, global satisfaction with treatment, perception of barriers to medication, and psychological well-being. Conclusion HD is extremely common among people with T2DM, affecting almost two-thirds of patients. High levels of distress are associated with worse clinical and psychosocial outcomes and should be considered as a key patient-centered indicator.

Factors Influencing Self-Management in Chinese Adults with Type 2 Diabetes: A Systematic Review and Meta-Analysis

Diabetes is a major public health problem in China. Diabetes self-management is critical for patients to achieved better health outcomes, however, previous studies have shown suboptimal diabetes self-management performance. We conducted a systematic review and meta-analysis to identify factors associated with diabetes self-management in Chinese adults. The results showed that confrontation, resignation, overall health beliefs, perceived susceptibility, perceived barriers, and self-efficacy were factors associated with overall diabetes self-management performance and six aspects of diabetes self-management behaviors. There is some limited evidence to suggest that provider-patient communication, married individuals, higher educational level, and higher household income level may also be linked to better diabetes self-management practice. Having healthcare insurance and utilizing chronic illness resources generally appeared to have a favorable effect on diabetes self-management performance. In addition, there were a number of factors for which the evidence is too limited to be able to ascertain its strength of association with diabetes self-management practice. The findings of this review suggest that diabetes self-management behaviors are affected by a wide range of personal and environmental factors, which allow health care providers to develop theory-based strategies to improve diabetes-self-management behaviors in this population.

Interplay among patient empowerment and clinical and person-centered outcomes in type 2 diabetes. The BENCH-D study

OBJECTIVE

We evaluated empowerment in T2DM and identified its correlates.

METHODS

A sample of individuals self-administered the Diabetes Empowerment Scale-Short Form (DES-SF) and other 9 validated instruments (person-centered outcomes). Correlates of DES-SF were identified through univariate and multivariate analyses. For person-centered outcomes, ORs express the likelihood of being in upper quartile of DES-SF (Q4) by 5 units of the scale.

RESULTS

Overall, 2390 individuals were involved. Individuals in Q4 were younger, more often males, had higher levels of school education, lower HbA1c levels and prevalence of complications as compared to individuals in the other quartiles. The likelihood of being in Q4 was directly associated with higher selfreported self-monitoring of blood glucose (SDSCA6-SMBG) (OR=1.09; 95% CI: 1.03-1.15), higher satisfaction with diabetes treatment (GSDT) (OR=1.15; 95% CI: 1.07-1.25), perceived quality of chronic illness care and patient support (PACIC-SF) (OR=1.23; 95% CI: 1.16-1.31), and better person-centered communication (HCC-SF) (OR=1.10; 95% CI: 1.01-1.19) and inversely associated with diabetes-related distress (PAID-5) (OR=0.95; 95% CI: 0.92-0.98). Adjusted DES-SF mean scores ranged between centers from 69.8 to 93.6 (intra-class correlation=0.10; p<0.0001).

CONCLUSIONS

Empowerment was associated with better glycemic control, psychosocial functioning and perceived access to person-centered chronic illness care. Practice of diabetes center plays a specific role.

PRACTICE IMPLICATIONS

DES-SF represents a process and outcome indicator in the practice of diabetes centers.

Study protocol: mobile improvement of self-management ability through rural technology (mI SMART)

Background

There are 62 million Americans currently residing in rural areas who are more likely to have multiple chronic conditions and be economically disadvantaged, and in poor health, receive less recommended preventive services and attend fewer visits to health care providers. Recent advances in mobile healthcare (mHealth) offer a promising new approach to solving health disparities and improving chronic illness care. It is now possible and affordable to transmit health information, including values from glucometers, automated blood pressure monitors, and scales, through Bluetooth-enabled devices. Additionally, audio and video communications technologies can allow healthcare providers to conduct many parts of a physical exam remotely from varied settings. These technologies could remove geographical distance as a barrier to care and diminish the access to care issues faced by patients who live rurally. However, currently there is lack of studies that provide evidence of feasibility, acceptability, and effectiveness of mHealth initiatives on improved outcomes of care, a needed step to make the translation to implementation studies in healthcare systems. The purpose of this paper is to present the protocol for the first study of mI SMART (mobile Improvement of Self-Management Ability through Rural Technology), a new integrated mHealth intervention.

Methods

Our objective is to provide evidence of feasibility and acceptability for the use of mI SMART in an underserved population and establish evidence for the refinement of mI SMART. The proposed study will take place at Milan Puskar Health Right, a free primary care clinic in the state of West Virginia. The clinic provides health care at no cost to uninsured, low income; adults aged 18–64 living in West Virginia. We will enroll 30 participants into this feasibility study with plans of implementing a longitudinal randomized, comparative effectiveness design in the future. Data collection will include tracking of barriers and facilitators to using mI SMART on patient and provider feedback surveys, tracking of patient-provider communications, self-reports from patients on quality of life, adherence, and self-management ability, and capture of health record data on chronic illness measures.

Discussion

We expect that the mI SMART intervention, refined from participant and provider feedback, will be acceptable and feasible. We anticipate high patient-provider satisfaction, enhanced patient-provider communication, and improved health related quality of life, adherence to treatment, and self-management ability. In addition, we hypothesize that patients who use mI SMART will demonstrate improved physical outcomes such as blood glucose, blood pressure, and weight.

Experience of knowledge and skills that are essential in self-managing a chronic condition - a focus group study among people with type 2 diabetes

AIMS

The purpose of the study was to gain new knowledge about how people experience participating in diabetes self-management courses with other people with type 2 diabetes and how they perceive this influences their health and ability to self-manage the disease.

METHODS

We conducted five focus groups with 22 people with type 2 diabetes who had participated in a group-based diabetes self-management course. We systematically coded the data and analysed them using Knodel's method.

FINDINGS

Participants gained more nuanced and specific knowledge by participating in a group setting. They increased their theoretical and practical understanding of how to handle diabetes in everyday life. The diabetes self-management course made the participants more aware of having a disease they had to take more seriously. Learning by being in the situation while guided by professionals was useful. In addition, the participation learned from each other by carrying out real tasks in a context with others struggling with similar treatment demands. They wished more room to perform practical tasks and more independent activity. Further, they suggested to make parts of the course accessible online. Still, it was noted that web-based solutions cannot replace the practical parts or the dialogue between the participants. They expressed both a need and a wish for a refresher course.

CONCLUSION

This study underscored that the participants learned through concrete experience, and by trying out practical tasks by becoming part of the diabetes community. They felt safer regarding their own treatment by experiencing a variety of situations in real-life scenarios.

Participatory approach to the development of a knowledge base for problem-solving in diabetes self-management

OBJECTIVE

To develop an expandable knowledge base of reusable knowledge related to self-management of diabetes that can be used as a foundation for patient-centric decision support tools.

MATERIALS AND METHODS

The structure and components of the knowledge base were created in participatory design with academic diabetes educators using knowledge acquisition methods. The knowledge base was validated using scenario-based approach with practicing diabetes educators and individuals with diabetes recruited from Community Health Centers (CHCs) serving economically disadvantaged communities and ethnic minorities in New York.

RESULTS

The knowledge base includes eight glycemic control problems, over 150 behaviors known to contribute to these problems coupled with contextual explanations, and over 200 specific action-oriented self-management goals for correcting problematic behaviors, with corresponding motivational messages. The validation of the knowledge base suggested high level of completeness and accuracy, and identified improvements in cultural appropriateness. These were addressed in new iterations of the knowledge base.

DISCUSSION

The resulting knowledge base is theoretically grounded, incorporates practical and evidence-based knowledge used by diabetes educators in practice settings, and allows for personally meaningful choices by individuals with diabetes. Participatory design approach helped researchers to capture implicit knowledge of practicing diabetes educators and make it explicit and reusable.

CONCLUSION

The knowledge base proposed here is an important step towards development of new generation patient-centric decision support tools for facilitating chronic disease self-management. While this knowledge base specifically targets diabetes, its overall structure and composition can be generalized to other chronic conditions.

Adaptação psicológica e aceitação do diabetesmellitus tipo 2

Resumo Objetivo Avaliar a adaptação psicológica, por meio da aceitação da doença, e sua relação com o estresse percebido e valores de hemoglobina glicada A1c de pessoas com diabetes mellitus tipo 2, antes e após participarem de intervenções educativas em grupo. Métodos Estudo quase-experimental desenvolvido em unidade ambulatorial, tendo sido realizadas entrevistas com os sujeitos antes e após eles participarem de intervenções educativas em grupo, utilizando Mapas de Conversação em Diabetes. Resultados Os pacientes entrevistados apresentaram melhora da aceitação da doença após as intervenções. Verificou-se relação inversa entre a aceitação da doença, o estresse percebido e a média de hemoglobina glicada A1c, antes e após as intervenções. Conclusão A aceitação da doença pode melhorar após intervenções educativas em grupo. Maiores escores de aceitação da doença foram relacionados a menores escores de estresse percebido e a menores médias de hemoglobina glicada A1c.

Care Utilization Patterns and Diabetes Self-Management Education Duration

Objective. Previous studies have shown that receiving diabetes self-management education (DSME) is associated with increased care utilization. However, the relationship between DSME duration and care utilization patterns remains largely unexamined. Our purpose is to characterize DSME duration and examine the relationship between DSME duration and clinical- and self-care utilization patterns. Methods. The study sample included 1,446 adults who were ≥18 years of age, had diabetes, and had participated in the 2008 Florida Behavioral Risk Factor Surveillance System survey. Clinical- and self-care outcomes were derived using responses to the survey's diabetes module and were based on minimum standards of care established by the American Diabetes Association. The outcomes examined included self-monitoring of blood glucose at least once per day; receiving at least one eye exam, one foot exam, A1C tests, and an influenza vaccination in the past year; and ever receiving a pneumococcal vaccination. DSME duration was categorized as no DSME, >0 to <4 hours, 4-10 hours, and >10 hours. Results. After adjusting for sociodemographic variables, compared to those who did not receive DSME, those who had 4-10 or 10+ hours of DSME were more likely to receive two A1C tests (odds ratio [95% CI] 2.69 [1.30-5.58] and 2.63 [1.10-6.31], respectively) and have a pneumococcal vaccination (1.98 [1.03-3.80] and 1.92 [1.01-3.64], respectively). Those receiving 10+ hours of DSME were 2.2 times (95% CI 1.18-4.09) as likely to have an influenza vaccination. Conclusion. These data reveal a positive relationship between DSME duration and utilization of some diabetes clinical care services.

THE SYNERGY TO ENABLE GLYCEMIC CONTROL FOLLOWING EMERGENCY DEPARTMENT DISCHARGE PROGRAM FOR ADULTS WITH TYPE 2 DIABETES: STEP-DIABETES

OBJECTIVE

To evaluate a diabetes (DM) care delivery model among hyperglycemic adults with type 2 DM being discharged from the emergency department (ED) to home. The primary hypothesis was that a focused education and medication management intervention would lead to a greater short-term improvement in glycemic control compared to controls.

METHODS

A 4-week, randomized controlled trial provided antihyperglycemic medications management using an evidence-based algorithm plus survival skills diabetes self-management education (DSME) for ED patients with blood glucose (BG) levels ≥200 mg/dL. The intervention was delivered by endocrinologist-supervised certified diabetes educators. Controls received usual ED care.

RESULTS

Among 101 participants (96% Black, 54% female, 62.3% Medicaid and/or Medicare insurance), 77% completed the week 4 visit. Glycated hemoglobin A1C (A1C) went from 11.8 ± 2.4 to 10.5 ± 1.9% (P<.001) and 11.5 ± 2.0 to 11.1 ± 2.1% in the intervention and control groups, respectively (P = .012). At 4 weeks, the difference in A1C reduction between groups was 0.9% (P = .01). Mean BG decreased for both groups (P<.001), with a higher percentage of intervention patients (65%) reaching a BG <180 mg/dL compared to 29% of controls (P = .002). Hypoglycemia rates did not differ by group, and no severe hypoglycemia was reported. Medication adherence (Modified Morisky Score(©)) improved from low to medium (P<.001) among intervention patients and did not improve among controls.

CONCLUSIONS

This study provides evidence that a focused diabetes care delivery intervention can be initiated in the ED among adults with type 2 diabetes and hyperglycemia and safely and effectively completed in the ambulatory setting. Improvement in short-term glycemic outcomes and medication adherence were observed.

Technology Use for Diabetes Problem Solving in Adolescents with Type 1 Diabetes: Relationship to Glycemic Control

BACKGROUND

This study examines technology use for problem solving in diabetes and its relationship to hemoglobin A1C (A1C).

SUBJECTS AND METHODS

A sample of 112 adolescents with type 1 diabetes completed measures assessing use of technologies for diabetes problem solving, including mobile applications, social technologies, and glucose software. Hierarchical regression was performed to identify the contribution of a new nine-item Technology Use for Problem Solving in Type 1 Diabetes (TUPS) scale to A1C, considering known clinical contributors to A1C.

RESULTS

Mean age for the sample was 14.5 (SD 1.7) years, mean A1C was 8.9% (SD 1.8%), 50% were female, and diabetes duration was 5.5 (SD 3.5) years. Cronbach's α reliability for TUPS was 0.78. In regression analyses, variables significantly associated with A1C were the socioeconomic status (β = -0.26, P < 0.01), Diabetes Adolescent Problem Solving Questionnaire (β = -0.26, P = 0.01), and TUPS (β = 0.26, P = 0.01). Aside from the Diabetes Self-Care Inventory--Revised, each block added significantly to the model R(2). The final model R(2) was 0.22 for modeling A1C (P < 0.001).

CONCLUSIONS

Results indicate a counterintuitive relationship between higher use of technologies for problem solving and higher A1C. Adolescents with poorer glycemic control may use technology in a reactive, as opposed to preventive, manner. Better understanding of the nature of technology use for self-management over time is needed to guide the development of technology-mediated problem solving tools for youth with type 1 diabetes.

Patient perspectives on self-monitoring of blood glucose: perceived recommendations, behaviors and barriers in a clinic sample of adults with type 2 diabetes

BACKGROUND

Patient-centered perspectives on self-monitoring of blood glucose (SBMG) were assessed in adults with type 2 diabetes using a self-regulation conceptual framework.

METHODS

Participants (N = 589; 53 % female) were adults with type 2 diabetes who were recruited during routine appointments at a diabetes outpatient clinic in the Southeastern/lower Midwestern region of the United States.

RESULTS

Participant's had varying perceptions regarding provider recommendations for SMBG (responder n = 380). Personal blood glucose testing patterns were also varied and reports frequently omitted (responder n = 296). Respondent's most frequent personal pattern was to test "occasionally, as needed," which did not differ by insulin use status, gender or age. In those not prescribed insulin, HbA1c reflected better control in those testing at least once per week (p = .040) or with a blood glucose goal (p = .018). 30.9 % endorsed at least monthly perceived encounters with SMBG barriers, with higher reports by women (p = .005) and younger (p = .006) participants. Poorer glycemic control was observed for participants with more frequently reported scheduling (p = .025, .041) and discouragement (p = .003) barriers.

CONCLUSIONS

Findings suggest that many may experience difficulty integrating SMBG into their lives and are unsure of recommendations and appropriate function. Research is needed to promote best practice recommendations for SMBG.

Patient Experience in a Coordinated Care Model Featuring Diabetes Self-management Education Integrated Into the Patient-Centered Medical Home

Purpose

The purpose of this study is to gain insight about patient experience of diabetes self-management education in a patient-centered medical home.

Methods

Six focus groups consisting of 37 people with diabetes, diverse in race and ethnicity, were conducted at 3 sites. Participants described their experience in the program and their challenges in diabetes self-management; they also suggested services to meet their diabetes care needs.

Results

The most common theme was ongoing concerns about care and support. There was much discussion about the value of the support provided by health navigators integrated in the diabetes health care team. Frequent concerns expressed by participants centered on personal challenges in engaging in healthy lifestyle behaviors. Ongoing programmatic support of self-management goals was widely valued.

Conclusions

Individuals who received health care in a patient-centered medical home and could participate in diabetes self-management education with integrated support valued both activities. The qualitative results from this study suggest need for more formalized exploration of effective means to meet the ongoing support needs of people with diabetes.

Medical home implementation and trends in diabetes quality measures for AN/AI primary care patients

AIMS

Patient-centered medical home (PCMH) principles including provider continuity, coordination of care, and advanced access align with healthcare needs of patients with Type II diabetes mellitus (DM-II). We investigate changes in trend for DM-II quality indicators after PCMH implementation at Southcentral Foundation, a tribal health organization in Alaska.

METHODS

Monthly rates of DM-II incidence, hemoglobin A1c (HbA1c) measurements, and service utilization were calculated from electronic health records from 1996 to 2009. We performed interrupted time series analysis to estimate changes in trend.

RESULTS

Rates of new DM-II diagnoses were stable prior to (p=0.349) and increased after implementation (p<0.001). DM-II rates of HbA1c screening increased, though not significantly, before (p=0.058) and remained stable after implementation (p=0.969). There was non-significant increasing trend in both periods for percent with average HbA1c less than 7% (53 mmol/mol; p=0.154 and p=0.687, respectively). Number of emergency visits increased before (p<0.001) and decreased after implementation (p<0.001). Number of inpatient days decreased in both periods, but not significantly (p=0.058 and p=0.101, respectively).

CONCLUSIONS

We found positive changes in DM-II quality trends following PCMH implementation of varying strength and onset of change, as well as duration of sustained trend.