A randomized trial of an intervention to improve self-care behaviors of African-American women with type 2 diabetes: impact on physical activity

Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: an updated Cochrane Review of randomized controlled trials

AIMS

To give an updated perspective of interventions from additional data collected since our first review, conducted in 2008.

BACKGROUND

This updated Cochrane Review incorporates new information from recent randomized controlled trials on culturally appropriate diabetes health education interventions.

METHODS

An electronic literature search of six databases was repeated, with databases of ongoing trials checked and three journals hand-searched. Meta-analysis was carried out for sufficiently homogeneous outcomes, and common themes among trials were highlighted.

RESULTS

A total of 22 new trials were added to the original 11. Meta-analysis of 28 trials containing suitable data showed significant improvements in glycaemic control (HbA1c ) and diabetes knowledge over a period of 24 months, after the delivery of culturally appropriate education to participants, compared with those receiving 'conventional' care. There were no consistent benefits over the control group in other selected outcome measures, and lack of data continued to make analysis of several outcome measures difficult.

CONCLUSIONS

Research activity in this field has increased considerably over the past 6 years, with culturally appropriate diabetes education showing consistent benefits over conventional care in terms of glycaemic control and diabetes knowledge, sustained in the short- to mid-term. Further research is needed to determine the clinical significance of these improvements and their cost-effectiveness.

Having their say: patients' perspectives and the clinical management of diabetes

Using an illness narratives framework, we provide 1 method that health care providers can use to obtain insight into the perceptions and experiences of their patients living with diabetes. We propose that understanding patients' cultural perspectives help explains their health behavior and can lead to more productive partnering between provider, patient, and community health resources that support adherence and improved health outcomes. We conclude with resources available to assist health care providers in their efforts to deliver culturally appropriate diabetes care and examples of culturally tailored community-based public health initiatives that have been effective in improving diabetes outcomes among African-American patients.

Impact of Physical Activity on Glycemic Control and Insulin Resistance: A Study of Community-dwelling Diabetic Patients in Eastern China

Objective The aim of this study was to evaluate the relationship of various intensities of physical activity with glycemic control and insulin resistance in eastern China. Methods A population-based, cross-sectional study was conducted in eastern China. The subjects included 604 community-dwelling people. The participants were classified as insufficiently active (IA); sufficiently active (SA) and very active (VA) according to the International Physical Activity Questionnaire (IPAQ). Insulin sensitivity was assessed using the homeostasis model assessment of insulin resistance (HOMA-IR). Related social, biological, lifestyle factors and clinical characteristics were recorded and used as potential confounders. Results The cohort of 604 type 2 diabetes patients were classified according to the activity level: 107 subjects who were classified as IA, 329 met the criteria for SA, and the rest were VA. The proportion of obese patients, smokers, patients with hypertension, and the body weight, body mass index (BMI), waist circumference, hemoglobin A1c protein (HbA1c), and 2-h postprandial blood glucose (2hPG) were significantly lower in the SA and VA groups than in the IA group (p<0.05 or 0.01). The SA group had lower levels of fasting blood glucose (FPG) and HOMA-IR than the IA and VA groups (p<0.05 or 0.01). HOMA-IR was positively correlated with FPG, 2hPG, HbA1c, waist circumference and BMI. HOMA-IR was negatively correlated with the total walking activity (p<0.05). After adjusting for FPG, 2hPG, HbA1c, waist circumference and BMI among the groups, a partial correlation analysis showed a correlation between HOMA-IR and the total walking activity. Conclusion Physical activity is a significant factor regarding glycemic control and insulin sensitivity, although SA and walking may be superior to VA for ameliorating insulin sensitivity.

Effectiveness of a Peer Support Programme versus Usual Care in Disease Management of Diabetes Mellitus Type 2 regarding Improvement of Metabolic Control: A Cluster-Randomised Controlled Trial

AIM

Testing the effectiveness of peer support additionally to a disease management programme (DMP) for type 2 diabetes patients.

METHODS

Unblinded cluster-randomised controlled trial (RCT) involving 49 general practices, province of Salzburg, Austria. All patients enrolled in the DMP were eligible, n = 337 participated (intervention: 148 in 19 clusters; control: 189 in 20 clusters). The peer support intervention ran over 24 months and consisted of peer supporter recruitment and training, and group meetings weekly for physical exercise and monthly for discussion of diabetes related topics.

RESULTS

At two-year follow-up, adjusted analysis revealed a nonsignificant difference in HbA1c change of 0.14% (21.97 mmol/mol) in favour of the intervention (95% CI -0.08 to 0.36%, p = 0.22). Baseline values were 7.02 ± 1.25% in the intervention and 7.08 ± 1.25 in the control group. None of the secondary outcome measures showed significant differences except for improved quality of life (EQ-5D-VAS) in controls (4.3 points on a scale of 100; 95% CI 0.08 to 8.53, p = 0.046) compared to the intervention group.

CONCLUSION

Our peer support intervention as an additional DMP component showed no significant effect on HbA1c and secondary outcome measures. Further RTCs with a longer follow-up are needed to reveal whether peer support will have clinically relevant effects.

TRIAL REGISTRATION

This trial has been registered with Current Controlled Trials Ltd. (ISRCTN10291077).

Peer-Led, Empowerment-Based Approach to Self-Management Efforts in Diabetes (PLEASED): A Randomized Controlled Trial in an African American Community

PURPOSE

We compared a 3-month diabetes self-management education (DSME) program followed by a 12-month peer support intervention with a 3-month DSME program alone in terms of initial and sustained improvements in glycated hemoglobin (HbA1c). Secondary outcomes were risk factors for cardiovascular disease (CVD), diabetes distress, and social support.

METHODS

We randomized 106 community-dwelling African American adults with type 2 diabetes to a 3-month DSME program followed by 12 months of weekly group sessions and supplementary telephone support delivered by peer leaders or to a 3-month DSME program with no follow-up peer support. Assessments were conducted at baseline, 3, 9, and 15 months.

RESULTS

No changes in HbA1c were observed at 3 months or at 15 months for either group. The peer support group either sustained improvement in key CVD risk factors or stayed the same while the control group worsened at 15 months. At 15 months, the peer-support group had significantly lower low-density lipoprotein cholesterol levels (-15 mg/dL, P = .03), systolic blood pressure (-10 mm Hg, P = .01), diastolic blood pressure (-8.3 mm Hg, P = .001), and body mass index (-0.8 kg/m(2), P = .032) than the DSME-alone group.

CONCLUSIONS

In this population of African American adults, an initial DSME program, whether or not followed by 12 months of peer support, had no effect on glycemic control. Participants in the peer-support arm of the trial did, however, experience significant improvements in some CVD risk factors or stay approximately the same while the control group declined.

Rethinking peer support for diabetes in Vancouver's South-Asian community: a feasibility study

AIM

To examine the feasibility and potential health impact of a diabetes self-management education and support intervention involving peer support on glycaemic control and diabetes distress.

METHODS

A total of 41 South-Asian adults with Type 2 diabetes were recruited for a 24-week diabetes self-management education and support pilot intervention involving peer support. The intervention consisted of six weekly education sessions co-facilitated by a certified diabetes educator and two peer leaders, followed by 18 weekly support sessions facilitated by two peer leaders. Education sessions were guided entirely by participants' self-management questions and also emphasized goal setting and action planning. Support sessions were based on empowerment principles and participants discussed self-management challenges, shared emotions, asked self-management questions, problem-solved in a group, set goals, and developed and evaluated action plans. Feasibility outcomes included recruitment and retention. Primary health-related outcomes included HbA1c levels and diabetes distress (measured at baseline, 6 and 24 weeks). Programme satisfaction was also assessed.

RESULTS

Pre-established criteria for recruitment and retention were met. Paired t-tests showed no changes in HbA1c and diabetes distress at 6 weeks. At 24 weeks, HbA1c levels deteriorated [54 mmol/mol (7.1%) vs 61 mmol/mol (7.7%)] while diabetes distress scores improved (2.0 vs 1.7).

CONCLUSIONS

Although feasible, findings suggest this peer-support model may have a positive impact on diabetes distress, but not on HbA1c levels. Culturally responsive modifications (e.g. intervention location) to the pilot model are needed and could lead to more favourable health outcomes for this community. Such a re-designed peer-support model will require further investigation.

Community health workers in primary care practice: redesigning health care delivery systems to extend and improve diabetes care in underserved populations

New, comprehensive, approaches for chronic disease management are needed to ensure that patients, particularly those more likely to experience health disparities, have access to the clinical care, self-management resources, and support necessary for the prevention and control of diabetes. Community health workers (CHWs) have worked in community settings to reduce health care disparities and are currently being deployed in some clinical settings as a means of improving access to and quality of care. Guided by the chronic care model, Baylor Health Care System embedded CHWs within clinical teams in community clinics with the goal of reducing observed disparities in diabetes care and outcomes. This study examines findings from interviews with patients, CHWs, and primary care providers (PCPs) to understand how health care delivery systems can be redesigned to effectively incorporate CHWs and how embedding CHWs in primary care teams can produce informed, activated patients and prepared, proactive practice teams who can work together to achieve improved patient outcomes. Respondents indicated that the PCPs continued to provide clinical exams and manage patient care, but the roles of diabetes education, nutritional counseling, and patient activation were shifted to the CHWs. CHWs also provided patients with social support and connection to community resources. Integration of CHWs into clinical care teams improved patient knowledge and activation levels, the ability of PCPs to identify and proactively address specific patient needs, and patient outcomes.

WITHDRAWN: Group based diabetes self-management education compared to routine treatment, waiting list control or no intervention for people with type 2 diabetes mellitus

The review authors of this review update are unable to continue with their work. The Cochrane Metabolic and Endocrine Disorders Review Group is seeking very experienced new authors to perform an update on this complex intervention review.

At June 2015, this review has been withdrawn. This review is out of date although it is correct as the date of publication. The latest version is available in the 'Other versions' tab on the Cochrane Library, and may still be useful to readers.

The editorial group responsible for this previously published document have withdrawn it from publication.

Race/ethnicity moderates the relationship between chronic life stress and quality of life in type 2 diabetes

AIMS

To determine whether chronic life stress is differentially associated with quality of life (QoL) for Blacks vs. Hispanics with type 2 diabetes.

METHODS

We assessed self-reported chronic stress and QoL in 125 patients with type 2 diabetes who self-identified as either non-Hispanic Black or Hispanic. Separate cross-sectional two-way interaction models (stress × race/ethnicity) with physical and mental health as outcomes were examined.

RESULTS

The two-way interaction predicted mental (b=3.12, P=.04) but not physical health. Simple slopes analyses indicated that under conditions of high stress, Blacks (b=-4.4, P<.001), but not Hispanics, experienced significantly lower levels of mental health. In exploratory analyses, we examined a three-way interaction (stress × race/ethnicity × social support) with physical and mental health as outcomes. Results indicated the three-way interaction predicted mental (b=.62, P=.01) but not physical health. Simple slopes analyses indicated that under conditions of high stress, high levels of social support improved mental health for Hispanics (b=1.2, P<.001), but not for Blacks.

CONCLUSIONS

Black patients with type 2 diabetes may be particularly vulnerable to the deleterious effects of high chronic stress. Social support buffers effects of stress on mental health in Hispanics but not Blacks, which suggests differences in the use and/or quality of social support between Hispanics and Blacks. Longitudinal investigations that examine race/ethnicity, stress, social support, and QoL should help clarify the processes that underlie these observed relations.

When it comes to lifestyle recommendations, more is sometimes less: a meta-analysis of theoretical assumptions underlying the effectiveness of interventions promoting multiple behavior domain change

A meta-analysis of 150 research reports summarizing the results of multiple behavior domain interventions examined theoretical predictions about the effects of the included number of recommendations on behavioral and clinical change in the domains of smoking, diet, and physical activity. The meta-analysis yielded 3 main conclusions. First, there is a curvilinear relation between the number of behavioral recommendations and improvements in behavioral and clinical measures, with a moderate number of recommendations producing the highest level of change. A moderate number of recommendations is likely to be associated with stronger effects because the intervention ensures the necessary level of motivation to implement the recommended changes, thereby increasing compliance with the goals set by the intervention, without making the intervention excessively demanding. Second, this curve was more pronounced when samples were likely to have low motivation to change, such as when interventions were delivered to nonpatient (vs. patient) populations, were implemented in nonclinic (vs. clinic) settings, used lay community (vs. expert) facilitators, and involved group (vs. individual) delivery formats. Finally, change in behavioral outcomes mediated the effects of number of recommended behaviors on clinical change. These findings provide important insights that can help guide the design of effective multiple behavior domain interventions.

Impact of a community health workers-led structured program on blood glucose control among latinos with type 2 diabetes: the DIALBEST trial

OBJECTIVE

Latinos with type 2 diabetes (T2D) face major healthcare access and disease management disparities. We examined the impact of the Diabetes Among Latinos Best Practices Trial (DIALBEST), a community health worker (CHW)-led structured intervention for improving glycemic control among Latinos with T2D.

RESEARCH DESIGN AND METHODS

A total of 211 adult Latinos with poorly controlled T2D were randomly assigned to a standard of healthcare (n = 106) or CHW (n = 105) group. The CHW intervention comprised 17 individual sessions delivered at home by CHWs over a 12-month period. Sessions addressed T2D complications, healthy lifestyles, nutrition, healthy food choices and diet for diabetes, blood glucose self-monitoring, and medication adherence. Demographic, socioeconomic, lifestyle, anthropometric, and biomarker (HbA1c, fasting blood glucose, and lipid profile) data were collected at baseline and 3, 6, 12, and 18 months (6 months postintervention). Groups were equivalent at baseline.

RESULTS

Participants had high HbA1c at baseline (mean 9.58% [81.2 mmol/mol]). Relative to participants in the control group, CHWs had a positive impact on net HbA1c improvements at 3 months (-0.42% [-4.62 mmol/mol]), 6 months (-0.47% [-5.10 mmol/mol]), 12 months (-0.57% [-6.18 mmol/mol]), and 18 months (-0.55% [-6.01 mmol/mol]). The overall repeated-measures group effect was statistically significant (mean difference -0.51% [-5.57 mmol/mol], 95% CI -0.83, -0.19% [-9.11, -2.03 mmol/mol], P = 0.002). CHWs had an overall significant effect on fasting glucose concentration that was more pronounced at the 12- and 18-month visits. There was no significant effect on blood lipid levels, hypertension, and weight.

CONCLUSIONS

DIALBEST is an effective intervention for improving blood glucose control among Latinos with T2D.

A community-based, culturally relevant intervention to promote healthy eating and physical activity among middle-aged African American women in rural Alabama: findings from a group randomized controlled trial

OBJECTIVE

We examined the efficacy of a community-based, culturally relevant intervention to promote healthy eating and physical activity among African American (AA) women between the ages of 45-65 years, residing in rural Alabama.

METHODS

We conducted a group randomized controlled trial with counties as the unit of randomization that evaluated two interventions based on health priorities identified by the community: (1) promotion of healthy eating and physical activity; and (2) promotion of breast and cervical cancer screening. A total of 6 counties with 565 participants were enrolled in the study between November 2009 and October 2011.

RESULTS

The overall retention rate at 24-month follow-up was 54.7%. Higher retention rate was observed in the "healthy lifestyle" arm (63.1%) as compared to the "screening" arm (45.3%). Participants in the "healthy lifestyle" arm showed significant positive changes compared to the "screening" arm at 12-month follow-up with regard to decrease in fried food consumption and an increase in both fruit/vegetable intake and physical activity. At 24-month follow-up, these positive changes were maintained with healthy eating behaviors, but not engagement in physical activity.

CONCLUSIONS

A culturally relevant intervention, developed in collaboration with the target audience, can improve (and maintain) healthy eating among AA women living in rural areas.

Identification of patient-centered outcomes among African American women with type 2 diabetes

AIMS

African American women carry a disproportionate diabetes burden, yet there is limited information on strategies to identify outcomes women perceive as important intervention outcomes (patient-centered outcomes). This study presents a brief strategy to solicit these outcomes and to describe outcomes identified using the highlighted strategy.

METHODS

Thirty-four African-American women with type 2 diabetes were enrolled in group-based, diabetes/weight management interventions. A diabetes educator asked participants to write down their intervention expectations followed by verbal sharing of responses. Expectation-related themes were identified using an iterative, qualitative, team analytic approach based on audio-recorded responses.

RESULTS

The majority of the expectation-related themes (6 of 10) were reflective of self-care education/management and weight loss-related patient-centered outcomes. The remaining themes were associated with desires to help others prevent or manage diabetes, reduce negative diabetes-related emotions, get rid of diabetes, and stop taking diabetes medications.

CONCLUSION

This study adds to a limited body of knowledge regarding patient-centered outcomes among a group that experiences a disproportionate diabetes burden. Future work could include integrating outcomes that are less commonly addressed in diabetes-related lifestyle interventions (e.g., diabetes-related negative emotions), along with more commonly addressed outcomes (e.g., weight loss), to increase the patient-centeredness of the interventions.

Systematic review of behavioural interventions with culturally adapted strategies to improve diet and weight outcomes in African American women

Behavioural interventions incorporating features that are culturally salient to African American women have emerged as one approach to address the high rates of obesity in this group. Yet, the systematic evaluation of this research is lacking. This review identified culturally adapted strategies reported in behavioural interventions using a prescribed framework and examined the effectiveness of these interventions for diet and weight outcomes among African American women. Publications from 1 January 1990 through 31 December 2012 were retrieved from four databases, yielding 28 interventions. Seventeen of 28 studies reported significant improvements in diet and/or weight change outcomes in treatment over comparison groups. The most commonly identified strategies reported were 'sociocultural' (reflecting a group's values and beliefs) and 'constituent involving' (drawing from a group's experiences). Studies with significant findings commonly reported constituent-involving strategies during the formative phases of the intervention. Involving constituents early on may uncover key attributes of a target group and contribute to a greater understanding of the heterogeneity that exists even within racial/ethnic groups. Available evidence does not, however, explain how culturally adapted strategies specifically influence outcomes. Greater attention to defining and measuring cultural variables and linking them to outcomes or related mediators are important next steps.

Relative contributions of naturalistic and constructed support: two studies of women with type 2 diabetes

Do distinct sources of social support have differential effects on health? Although previous research has contrasted family and friend support (naturalistic support), research on the relative effects of naturalistic support and constructed support (e.g., support groups) is extremely rare. Two studies of women with type 2 diabetes were conducted that assessed the independent effects of naturalistic and constructed support on physical activity and glycosylated hemoglobin (HbA1c). Participants were women diagnosed with type 2 diabetes from the intervention arms of two randomized controlled trials: primarily European American women (Study 1; N = 163) and exclusively Hispanic women (Study 2; N = 142). Measures assessed physical activity, HbA1c, and friend and family support at baseline and at 6 months, as well as group support after 6 months of intervention. In Study 1, only group support was related to increases in physical activity (ΔR(2) = .036). In Study 2, group support and family support showed independent effects on increases in physical activity (ΔR(2) = .047 and .060, respectively). Also, group support was related to decreases in HbA1c in Study 1 (ΔR(2) = .031) and Study 2 (ΔR(2) = .065). Overall, constructed (group) support was related to outcomes most consistently, but naturalistic (family) support showed some independent relation to physical activity improvement.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effectiveness and safety of patient activation interventions for adults with type 2 diabetes: systematic review, meta-analysis, and meta-regression

BACKGROUND

Patient activation interventions (PAIs) engage patients in care by promoting increased knowledge, confidence, and/or skills for disease self-management. However, little is known about the impact of these interventions on a wide range of outcomes for adults with type 2 diabetes (DM2), or which of these interventions, if any, have the greatest impact on glycemic control.

METHODS

Electronic databases were searched from inception through November 2011. Of 16,290 citations, two independent reviewers identified 138 randomized trials comparing PAIs to usual care/control groups in adults with DM2 that reported intermediate or long-term outcomes or harms. For meta-analyses of continuous outcomes, we used a random-effects model to derive pooled weighted mean differences (WMD). For all-cause mortality, we calculated the pooled odds ratio (OR) using Peto's method. We assessed statistical heterogeneity using the I (2) statistic and conducted meta-regression using a random-effects model when I (2) > 50 %. A priori meta-regression primary variables included: intervention strategies, intervention leader, baseline outcome value, quality, and study duration.

RESULTS

PAIs modestly reduced intermediate outcomes [A1c: WMD 0.37 %, CI 0.28-0.45 %, I (2) 83 %; SBP: WMD 2.2 mmHg, CI 1.0-3.5 mmHg, I (2) 72 %; body weight: WMD 2.3 lbs, CI 1.3-3.2 lbs, I (2) 64 %; and LDL-c: WMD 4.2 mg/dL, CI 1.5-6.9 mg/dL, I (2) 64 %]. The evidence was moderate for A1c, low/very low for other intermediate outcomes, low for long-term mortality and very low for complications. Interventions had no effect on hypoglycemia (evidence: low) or short-term mortality (evidence: moderate). Higher baseline A1c, pharmacist-led interventions, and longer follow-up were associated with larger A1c improvements. No intervention strategy outperformed any other in adjusted meta-regression.

CONCLUSIONS

PAIs modestly improve A1c in adults with DM2 without increasing short-term mortality. These results support integration of these interventions into primary care for adults with uncontrolled glycemia, and provide evidence to insurers who do not yet cover these programs.

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

BACKGROUND

It is not clear to what extent educational programs aimed at promoting diabetes self-management in ethnic minority groups are effective. The aim of this work was to systematically review the effectiveness of educational programs to promote the self-management of racial/ethnic minority groups with type 2 diabetes, and to identify programs' characteristics associated with greater success.

METHODS

We undertook a systematic literature review. Specific searches were designed and implemented for Medline, EMBASE, CINAHL, ISI Web of Knowledge, Scirus, Current Contents and nine additional sources (from inception to October 2012). We included experimental and quasi-experimental studies assessing the impact of educational programs targeted to racial/ethnic minority groups with type 2 diabetes. We only included interventions conducted in countries members of the OECD. Two reviewers independently screened citations. Structured forms were used to extract information on intervention characteristics, effectiveness, and cost-effectiveness. When possible, we conducted random-effects meta-analyses using standardized mean differences to obtain aggregate estimates of effect size with 95% confidence intervals. Two reviewers independently extracted all the information and critically appraised the studies.

RESULTS

We identified thirty-seven studies reporting on thirty-nine educational programs. Most of them were conducted in the US, with African American or Latino participants. Most programs obtained some benefits over standard care in improving diabetes knowledge, self-management behaviors and clinical outcomes. A meta-analysis of 20 randomized controlled trials (3,094 patients) indicated that the programs produced a reduction in glycated hemoglobin of -0.31% (95% CI -0.48% to -0.14%). Diabetes knowledge and self-management measures were too heterogeneous to pool. Meta-regressions showed larger reduction in glycated hemoglobin in individual and face to face delivered interventions, as well as in those involving peer educators, including cognitive reframing techniques, and a lower number of teaching methods. The long-term effects remain unknown and cost-effectiveness was rarely estimated.

CONCLUSIONS

Diabetes self-management educational programs targeted to racial/ethnic minority groups can produce a positive effect on diabetes knowledge and on self-management behavior, ultimately improving glycemic control. Future programs should take into account the key characteristics identified in this review.

Can physical activity interventions for adults with type 2 diabetes be translated into practice settings? A systematic review using the RE-AIM framework

Despite the strong evidence base for the efficacy of physical activity in the management of type 2 diabetes, a limited number of physical activity interventions have been translated and evaluated in everyday practice. This systematic review aimed to report the findings of studies in which an intervention, containing physical activity promotion as a component, has been delivered within routine diabetes care. A comprehensive search was conducted for articles reporting process data relating to components of the RE-AIM (Reach, Effectiveness, Adoption, Implementation and/or Maintenance) framework. Twelve studies met the selection criteria. Of the nine studies which measured physical activity as an outcome, eight reported an increase in physical activity levels, five of which were significant. Tailoring recruitment, resources and intervention delivery to the target population played a positive role, in addition to the use of external organisations and staff training. Many interventions were of short duration and lacked long-term follow-up data. Findings revealed limited and inconsistent reporting of useful process data.

Peer Support for Achieving Independence in Diabetes (Peer-AID): design, methods and baseline characteristics of a randomized controlled trial of community health worker assisted diabetes self-management support

BACKGROUND & OBJECTIVES

Community health workers (CHWs) may be an important mechanism to provide diabetes self-management to disadvantaged populations. We describe the design and baseline results of a trial evaluating a home-based CHW intervention.

METHODS & RESEARCH DESIGN

Peer Support for Achieving Independence in Diabetes (Peer-AID) is a randomized, controlled trial evaluating a home-based CHW-delivered diabetes self-management intervention versus usual care. The study recruited participants from 3 health systems. Change in A1c measured at 12 months is the primary outcome. Changes in blood pressure, lipids, health care utilization, health-related quality of life, self-efficacy and diabetes self-management behaviors at 12 months are secondary outcomes.

RESULTS

A total of 1438 patients were identified by a medical record review as potentially eligible, 445 patients were screened by telephone for eligibility and 287 were randomized. Groups were comparable at baseline on socio-demographic and clinical characteristics. All participants were low-income and were from diverse racial and ethnic backgrounds. The mean A1c was 8.9%, mean BMI was above the obese range, and non-adherence to diabetes medications was high. The cohort had high rates of co-morbid disease and low self-reported health status. Although one-third reported no health insurance, the mean number of visits to a physician in the past year was 5.7. Trial results are pending.

CONCLUSIONS

Peer-AID recruited and enrolled a diverse group of low income participants with poorly controlled type 2 diabetes and delivered a home-based diabetes self-management program. If effective, replication of the Peer-AID intervention in community based settings could contribute to improved control of diabetes in vulnerable populations.

State of the science: diabetes self-management interventions led by nurse principal investigators

Over the past decade, diabetes self-management (DSM) interventions have become increasingly heterogeneous to address the needs of diverse populations. The purpose of this integrative review is to summarize the state of the science regarding DSM interventions led by nurse principal investigators. The Preferred Reporting Items of Systematic Reviews and Meta-Analyses framework informed identification, selection, and appraisal of the literature. A total of 44 national and international studies (RCTs [randomized controlled trial] and quasi-experimental studies) were identified for inclusion. Across national studies, diverse ethnic groups (Latinos, African Americans, Asians, and Native Americans) were most frequently sampled (67%). Review findings identified (a) DSM intervention typologies (primary DSM intervention, DSM reinforcement intervention, and primary DSM intervention plus reinforcement intervention) and selection of blended or bundled intervention components; (b) DSM intervention translation to community-based, electronic, and home settings; and (c) DSM intervention delivery (interventionists, dosages, and fidelity).

Improving behavioral and clinical indicators in Asians and Pacific Islanders with diabetes: findings from a community clinic-based program

AIMS

This project tested the six-month impact of Stanford's Diabetes Self-Management Program (DSMP), adapted for Asians and Pacific Islanders (APIs), on behavioral and clinical indicators.

METHODS

Participants attended DSMP workshops at a community health center. Employing a one-group, pre-post-test design, data were collected at baseline and six-months. Ninety-six eligible API adults were enrolled. All attended four or more of the six weekly sessions, and 82 completed data collection. Measures included body mass index, blood pressure, blood lipids, blood glucose, HbA1c, as well as health behaviors. Data were analyzed by descriptive statistics and paired t-tests.

RESULTS

Adaptations to DSMP were minimal, but critical to the local acceptance of the program. At six-months, significant behavioral improvements included: (1) increased minutes in stretching and aerobic exercise per week (p<0.001); (2) reduced symptoms of hypoglycemia and hyperglycemia (p<0.001); (3) increased self-efficacy (p<0.001); and (4) increased number of days and times testing blood sugar levels (p<0.001). Significant clinical improvements included: (1) lower BMI (p<0.001); (2) lower HbA1c (p<0.001); (3) lower total cholesterol, triglycerides, and LDL (p<0.001); and (4) lower blood pressure (p<0.001).

CONCLUSIONS

Findings suggest that the DSMP can be successfully adapted to API populations and can improve clinical measures as well as health behaviors.

Training peer educators to promote self-management skills in people with serious mental illness (SMI) and diabetes (DM) in a primary health care setting

AIM

To describe the training and participant experience of patients with both severe mental illness (SMI) and diabetes (DM) who were enrolled in a Peer Educator Training Program adapted to a primary health care setting.

BACKGROUND

The mortality of patients with both SMI and DM is high. Illness self-management includes medications, psychosocial treatments, and healthy behaviors, yet treatment engagement is often sub-optimal with adherence rates of 52% for diabetic medications and 62% for antipsychotic medications among the SMI. To address this problem, a new behavioral intervention study targeting SMI and DM self-management used trained peer educators (PEs) with the same chronic conditions to enhance program effectiveness. A manual facilitated training on intervention topics such as SMI and DM therapies, stress management, and stigma reduction as well as training in group intervention techniques, telephone skills, and crisis management.

METHODS

We assessed PE attitudes and input using in-depth face-to-face interviews. Interviews were audio-taped, transcribed, coded, and analyzed using the classic method of content analysis emphasizing dominant themes. A member check-in was conducted where participants commented on analysis results.

FINDINGS

Six relevant descriptive themes emerged: (1) positive group experience; (2) success with learning manual content; (3) increased knowledge about SMI and DM; (4) improved self-management skills; (5) increased self-confidence and self-efficacy in becoming a PE; and being (6) united in purpose to help others self-manage their SMI and DM. Qualitative evidence supports structured training for SMI-DM PEs. Key components include written educational materials and the power of the group process to increase knowledge, self-management skills, confidence, and self-efficacy. Recommendations are offered to support further endeavors to mobilize peers with SMI to help other patients with complex comorbidities better manage their own health.

Examining Dose of Diabetes Group Medical Visits and Characteristics of the Uninsured

Type 2 diabetes is a significant problem for the uninsured. Diabetes Group Medical Visits (DGMVs) have been reported to improve outcomes. However, it is not known if the increased workload of the health care team to treat and educate patients at multiple visits has an impact on patient functioning and well-being. The aim of this study was to explore the impact of dose of DGMVs on biophysical outcomes of care in uninsured persons with diabetes. No significant correlations were found between number of DGMVs attended and biophysical outcomes of care. However, the majority of patients attended two or less DGMVs in 1 year. Dose of DGMVs did not impact outcomes and may not be enough to assure attendance. Involving patients to construct patient-centered interventions may decrease the treatment burden faced by both patients and providers. In addition, such interventions should be aimed at understanding reasons for low attendance, particularly in rural impoverished adults.

The Alberta Diabetes and Physical Activity Trial (ADAPT): a randomized trial evaluating theory-based interventions to increase physical activity in adults with type 2 diabetes

BACKGROUND

Physical activity (PA) is associated with reduced morbidity and mortality in individuals with type 2 diabetes mellitus (T2DM); however, most T2DM adults are insufficiently active.

PURPOSE

To explore the effectiveness of two innovative/theoretically based behavioral-change strategies to increase PA and reduce hemoglobin A1c (A1c) in T2DM adults.

METHODS

Participants (n = 287) were randomly assigned to a control group or an intervention group (i.e., print-based materials/pedometer group or print-based materials/pedometer plus telephone-counseling group). Changes in PA and A1c and other clinical measures were examined by Linear Mixed Model analyses over 18 months, along with moderating effects for gender and age.

RESULTS

PA and A1c levels did not significantly change in intervention groups. Step counts significantly increased in the print-based materials and pedometer plus telephone counseling group, for women.

CONCLUSIONS

No significant effects were found for PA or A1c levels for T2DM adults. The multi-component strategy including telephone counseling may have potential for women. The trial was registered on ClinicalTrials.gov identifier: NCT00221234.

Evaluation of the effectiveness of a problem-solving intervention addressing barriers to cardiovascular disease prevention behaviors in 3 underserved populations: Colorado, North Carolina, West Virginia, 2009

INTRODUCTION

In low-income and underserved populations, financial hardship and multiple competing roles and responsibilities lead to difficulties in lifestyle change for cardiovascular disease (CVD) prevention. To improve CVD prevention behaviors, we adapted, pilot-tested, and evaluated a problem-solving intervention designed to address barriers to lifestyle change.

METHODS

The sample consisted of 81 participants from 3 underserved populations, including 28 Hispanic or non-Hispanic white women in a western community (site 1), 31 African-American women in a semirural southern community (site 2), and 22 adults in an Appalachian community (site 3). Incorporating focus group findings, we assessed a standardized intervention involving 6-to-8 week group sessions devoted to problem-solving in the fall of 2009.

RESULTS

Most sessions were attended by 76.5% of participants, demonstrating participant adoption and engagement. The intervention resulted in significant improvement in problem-solving skills (P < .001) and perceived stress (P < .05). Diet, physical activity, and weight remained stable, although 72% of individuals reported maintenance or increase in daily fruit and vegetable intake, and 67% reported maintenance or increase in daily physical activity.

CONCLUSION

Study results suggest the intervention was acceptable to rural, underserved populations and effective in training them in problem-solving skills and stress management for CVD risk reduction.

Impact of phone call intervention on glycemic control in diabetes patients: a systematic review and meta-analysis of randomized, controlled trials

Background

Telephone-delivered intervention can provide many supports in diabetes self-management to improve glycemic control. Several trials showed that telephone intervention was positively associated with glycemic outcomes in diabetes. The objective of this meta-analysis was to assess the impact of telephone contact intervention (intervention group) on glycemic control compared with standard clinical care (control group).

Methods

Randomized control studies of telephone intervention in diabetes were searched on Medline (Pubmed), the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science (ISI), and Scopus. Electronic search was done from inception to April 2013. The following MeSH terms were used: diabetes mellitus, randomized control trials and telemedicine, together with keywords including phone intervention, diabetes, and glycemic control. Historical search was also conducted on the references of relevant articles. The quality of the trials was assessed using Maastricht-Amsterdam scale. Treatment effect was estimated with mean difference in the change of hemoglobin A1c (HbA1c) from baseline between the intervention and control groups.

Results

A total of 203 articles were examined. Five trials involving 953 patients met the inclusion criteria and contributed to the meta-analysis. Telephone contact intervention was no more effective than standard clinical care in improving glycemic control (pooled mean difference in HbA1c −0.38%, 95%CI −0.91 to 0.16%).

Conclusions

This meta-analysis showed that the phone contact intervention was no more effective than standard clinical care in improving glycemic control in diabetes. However, telephone intervention may still have potential benefits especially for low-and middle-income countries; thus further large sample size and well-controlled studies are needed to evaluate the impact of the intervention.

The effects of a culturally sensitive, empowerment-focused, community-based health promotion program on health outcomes of adults with type 2 diabetes

The purpose of the present study was to test the effects of a culturally sensitive, health empowerment-focused, community-based health promotion program tailored to adult patients with type 2 diabetes on these patients' body mass index (BMI), blood pressure, and self-reported blood glucose levels, treatment adherence, and stress levels. Study participants (N = 130) consisted mostly of African Americans (70%) and Hispanic/Latinos (22.3%) who were divided almost evenly between an intervention group and wait-list control group. The tested health promotion program is informed by Health Self-Empowerment Theory. At post-test, program participants in the intervention group as compared to those in the control group demonstrated significantly lower levels of BMI, diastolic blood pressure, and physical stress. Implications of these study findings for future similar programs and research are discussed.

Telephone based self-management support by 'lay health workers' and 'peer support workers' to prevent and manage vascular diseases: a systematic review and meta-analysis

Background

Improved prevention and management of vascular disease is a global priority. Non-health care professionals (such as, ‘lay health workers’ and ‘peer support workers’) are increasingly being used to offer telephone support alongside that offered by conventional services, to reach disadvantaged populations and to provide more efficient delivery of care. However, questions remain over the impact of such interventions, particularly on a wider range of vascular related conditions (such as, chronic kidney disease), and it is unclear how different types of telephone support impact on outcome. This study assessed the evidence on the effectiveness and cost-effectiveness of telephone self-management interventions led by ‘lay health workers’ and ‘peer support workers’ for patients with vascular disease and long-term conditions associated with vascular disease.

Methods

Systematic review of randomised controlled trials. Three electronic databases were searched. Two authors independently extracted data according to the Cochrane risk of bias tool. Random effects meta-analysis was used to pool outcome measures.

Results

Ten studies were included, primarily based in community settings in the United States; with participants who had diabetes; and used ‘peer support workers’ that shared characteristics with patients. The included studies were generally rated at risk of bias, as many methodological criteria were rated as ‘unclear’ because of a lack of information.

Overall, peer telephone support was associated with small but significant improvements in self-management behaviour (SMD = 0.19, 95% CI 0.05 to 0.33, I² = 20.4%) and significant reductions in HbA1c level (SMD = -0.26, 95% CI −0.41 to −0.11, I² = 47.6%). There was no significant effect on mental health quality of life (SMD = 0.03, 95% CI −0.12 to 0.18, I² = 0%). Data on health care utilisation were very limited and no studies reported cost effectiveness analyses.

Conclusions

Positive effects were found for telephone self-management interventions via ‘lay workers’ and ‘peer support workers’ for patients on diabetes control and self-management outcomes, but the overall evidence base was limited in scope and quality. Well designed trials assessing non-healthcare professional delivered telephone support for the prevention and management of vascular disease are needed to identify the content of effective components on health outcomes, and to assess cost effectiveness, to determine if such interventions are potentially useful alternatives to professionally delivered care.

Interventions to promote physical activity in older people with type 2 diabetes mellitus: a systematic review

INTRODUCTION

Type 2 diabetes mellitus (T2DM) among people aged 60 years and above is a growing public health problem. Regular physical activity is one of the key elements in the management of T2DM. Recommendations suggest that older people with T2DM will benefit from regular physical activity for better disease control and delaying complications. Despite the known benefits, many remain sedentary. Hence, this review assessed interventions for promoting physical activity in persons aged 65 years and older with T2DM.

METHODS

A literature search was conducted using Ovid MEDLINE, PubMed, EMBASE, SPORTDiscus, and CINAHL databases to retrieve articles published between January 2000 and December 2012. Randomized controlled trials and quasi-experimental designs comparing different strategies to increase physical activity level in persons aged 65 years and older with T2DM were included. The methodological quality of studies was assessed.

RESULTS

Twenty-one eligible studies were reviewed, only six studies were rated as good quality and only one study specifically targeted persons aged 65 years and older. Personalized coaching, goal setting, peer support groups, use of technology, and physical activity monitors were proven to increase the level of physical activity. Incorporation of health behavior theories and follow-up supports also were successful strategies. However, the methodological quality and type of interventions promoting physical activity of the included studies in this review varied widely across the eligible studies.

CONCLUSION

Strategies that increased level of physical activity in persons with T2DM are evident but most studies focused on middle-aged persons and there was a lack of well-designed trials. Hence, more studies of satisfactory methodological quality with interventions promoting physical activity in older people are required.

Cost-effectiveness of health-related lifestyle advice delivered by peer or lay advisors: synthesis of evidence from a systematic review

BACKGROUND

Development of new peer or lay health-related lifestyle advisor (HRLA) roles is one response to the need to enhance public engagement in, and improve cost-effectiveness of, health improvement interventions. This article synthesises evidence on the cost-effectiveness of HRLA interventions aimed at adults in developed countries, derived from the first systematic review of the effectiveness, cost-effectiveness, equity and acceptability of different types of HRLA role.

METHODS

The best available evidence on the cost-effectiveness of HRLA interventions was obtained using systematic searches of 20 electronic databases and key journals, as well as searches of the grey literature and the internet. Interventions were classified according to the primary health behaviour targeted and intervention costs were estimated where necessary. Lifetime health gains were estimated (in quality-adjusted life years, where possible), based on evidence of effectiveness of HRLAs in combination with published estimates of the lifetime health gains resulting from lifestyle changes, and assumptions over relapse. Incremental cost-effectiveness ratios are reported.

RESULTS

Evidence of the cost-effectiveness of HRLAs was identified from 24 trials included in the systematic review. The interventions were grouped into eight areas. We found little evidence of effectiveness of HRLAs for promotion of exercise/improved diets. Where HRLAs were effective cost-effectiveness varied considerably: Incremental Cost effectiveness Ratios were estimated at £6,000 for smoking cessation; £14,000 for a telephone based type 2 diabetes management; and £250,000 or greater for promotion of mammography attendance and for HIV prevention amongst drug users. We lacked sufficient evidence to estimate ICERs for breastfeeding promotion and mental health promotion, or to assess the impact of HRLAs on health inequalities.

CONCLUSIONS

Overall, there is limited evidence suggesting that HRLAs are cost-effective in terms of changing health-related knowledge, behaviours or health outcomes. The evidence that does exist indicates that HRLAs are only cost-effective when they target behaviours likely to have a large impact on overall health-related quality of life. Further development of HRLA interventions needs to target specific population health needs where potential exists for significant improvement, and include rigorous evaluation to ensure that HRLAs provide sufficient value for money.

Social support and glycemic control in type 2 diabetes: a systematic review of observational studies

OBJECTIVE

We aim to systematically review observational studies examining the association between social support and glycemic control in adults with type 2 diabetes.

METHODS

We searched MEDLINE, PsycINFO, EMBASE, Scopus, Web of Science and Sociological Abstracts to July 2012 for observational studies investigating the association between structural or functional aspects of social support (social networks, community ties, marital status, family support, perceived, actual, emotional or instrumental social support) and glycemic control (HbA1c).

RESULTS

From electronic and reference searches, 29 studies were eligible. Twenty different assessments of social support were used. Family support and composite measures of support were most frequently associated with reduced HbA1c. There was no evidence for a beneficial effect of other support measures on HbA1c.

CONCLUSION

We found marked variation in population, setting, measurement of social support and definition of outcome, limiting the methodological validity of research. Social support may be important in the management of type 2 diabetes, the need for consensus and standardization of measures is highlighted.

PRACTICE IMPLICATIONS

The presence of informal support should be explored in routine diabetes care.

Designing and implementing a comparative effectiveness study of two strategies for delivering high quality CHD prevention: methods and participant characteristics for the Heart to Health study

BACKGROUND

Although lifestyle and medications are effective for coronary heart disease (CHD) risk reduction, few studies have examined the comparative effectiveness of various strategies for delivering high quality CHD risk reduction. In this paper, we report on the design and baseline characteristics of participants for just such a trial.

METHODS

We conducted a randomized trial of the same lifestyle and medication intervention delivered in two alternate formats: counselor-delivered or web-based. The trial was conducted at 5 diverse practices in a family medicine research network and included men and women age 35-79 who were at high risk of CHD events based on 10-year predicted Framingham risk of ≥10% or a known history of cardiovascular disease. After individual-level randomization, participants in both arms received a decision aid plus four intensive intervention visits and 3 maintenance visits over 12 months. The primary outcome was change in 10-year predicted CHD risk among patients without prior cardiovascular disease. Secondary outcomes, measured among all participants, included changes in CHD risk factors, cost-effectiveness, and acceptability at 4 and 12-month follow-up.

RESULTS

We randomized 489 eligible patients: 389 without and 100 with a known history of cardiovascular disease. Mean age was 62.3. 75% were white, 25% African-American. 45% had a college education. 88% had health insurance. Mean 10-year predicted CHD risk was 16.9%.

CONCLUSION

We have successfully recruited a diverse sample of practices and patients that will provide a rich sample in which to test the comparative effectiveness of two strategies to implement high quality CHD prevention.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Assessment of a short diabetes knowledge instrument for older and minority adults

PURPOSE

The purpose of the study was to assess the performance of a Short Diabetes Knowledge Instrument (SDKI) in a large multi-ethnic sample of older adults with diabetes and to identify possible modifications to improve its ability to document diabetes knowledge.

RESEARCH DESIGN AND METHODS

A sample of 593 African American, American Indian, and white female and male adults 60 years and older, with diabetes diagnosed at least 2 years prior, was recruited from 8 North Carolina counties. All completed an interview that included a 16-item questionnaire to assess diabetes knowledge. A subsample of 46 completed the questionnaire a second time at a subsequent interview. Item-response analysis was used to refine the instrument to well-performing items. The instrument consisting of the remaining items was subjected to analyses to assess validity and test-retest reliability.

RESULTS

Three items were removed after item-response analysis. Scores for the resulting instrument were lower among minority and older participants, as well as those with lower educational attainment and income. Scores for test-retest were highly correlated.

CONCLUSIONS

The SDKI (13-item questionnaire) appears to be a valid and reliable instrument to evaluate knowledge about diabetes. Assessment in a multi-ethnic sample of older adults suggests that this instrument can be used to measure diabetes knowledge in diverse populations. Further evaluation is needed to determine whether or not this instrument can detect changes in knowledge resulting from diabetes education or other interventions.

Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care

BACKGROUND

In the last decades the presence of social inequalities in diabetes care has been observed in multiple countries, including Spain. These inequalities have been at least partially attributed to differences in diabetes self-management behaviours. Communication problems during medical consultations occur more frequently to patients with a lower educational level. The purpose of this cluster randomized trial is to determine whether an intervention implemented in a General Surgery, based in improving patient-provider communication, results in a better diabetes self-management in patients with lower educational level. A secondary objective is to assess whether telephone reinforcement enhances the effect of such intervention. We report the design and implementation of this on-going study.

METHODS/DESIGN

The study is being conducted in a General Practice located in a deprived neighbourhood of Granada, Spain. Diabetic patients 18 years old or older with a low educational level and inadequate glycaemic control (HbA1c > 7%) were recruited. General Practitioners (GPs) were randomised to three groups: intervention A, intervention B and control group. GPs allocated to intervention groups A and B received training in communication skills and are providing graphic feedback about glycosylated haemoglobin levels. Patients whose GPs were allocated to group B are additionally receiving telephone reinforcement whereas patients from the control group are receiving usual care. The described interventions are being conducted during 7 consecutive medical visits which are scheduled every three months. The main outcome measure will be HbA1c; blood pressure, lipidemia, body mass index and waist circumference will be considered as secondary outcome measures. Statistical analysis to evaluate the effectiveness of the interventions will include multilevel regression analysis with three hierarchical levels: medical visit level, patient level and GP level.

DISCUSSION

The results of this study will provide new knowledge about possible strategies to promote a better diabetes self-management in a particularly vulnerable group. If effective, this low cost intervention will have the potential to be easily incorporated into routine clinical practice, contributing to decrease health inequalities in diabetic patients.

TRIAL REGISTRATION

Clinical Trials U.S. National Institutes of Health, NCT01849731.

Effectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical activity in ethnic minorities. a systematic review

BACKGROUND

The importance of cultural adaptations in behavioral interventions targeting ethnic minorities in high-income societies is widely recognized. Little is known, however, about the effectiveness of specific cultural adaptations in such interventions.

AIM

To systematically review the effectiveness of specific cultural adaptations in interventions that target smoking cessation, diet, and/or physical activity and to explore features of such adaptations that may account for their effectiveness.

METHODS

Systematic review using MEDLINE, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials registers (1997-2009).

INCLUSION CRITERIA

a) effectiveness study of a lifestyle intervention targeted to ethnic minority populations living in a high income society; b) interventions included cultural adaptations and a control group that was exposed to the intervention without the cultural adaptation under study; c) primary outcome measures included smoking cessation, diet, or physical activity.

RESULTS

Out of 44904 hits, we identified 17 studies, all conducted in the United States. In five studies, specific cultural adaptations had a statistically significant effect on primary outcomes. The remaining studies showed no significant effects on primary outcomes, but some presented trends favorable for cultural adaptations. We observed that interventions incorporating a package of cultural adaptations, cultural adaptations that implied higher intensity and those incorporating family values were more likely to report statistically significant effects. Adaptations in smoking cessation interventions seem to be more effective than adaptations in interventions aimed at diet and physical activity.

CONCLUSION

This review indicates that culturally targeted behavioral interventions may be more effective if cultural adaptations are implemented as a package of adaptations, the adaptation includes family level, and where the adaptation results in a higher intensity of the intervention. More systematic experiments are needed in which the aim is to gain insight in the best mix of cultural adaptations among diverse populations in various settings, particularly outside the US.

Realist review to understand the efficacy of culturally appropriate diabetes education programmes

AIMS

Minority populations often face linguistic, cultural and financial barriers to diabetes education and care. The aim was to understand why culturally appropriate diabetes education interventions work, when they work best and for whom they are most effective.

METHODS

This review used a critical realist approach to examine culturally appropriate diabetes interventions. Beginning with the behavioural model and access to medical care, it reanalysed 11 randomized controlled trials from a Cochrane systematic review and related programme and training documents on culturally appropriate diabetes interventions. The analysis examined context and mechanism to understand their relationship to participant retention and statistically improved outcomes.

RESULTS

Minority patients with language barriers and limited access to diabetes programmes responded to interventions using health workers from the same ethnic group and interventions promoting culturally acceptable and financially affordable food choices using local ingredients. Programme incentives improved retention in the programmes and this was associated with improved HbA(1c) levels at least in the short term. Adopting a positive learning environment, a flexible and less intensive approach, one-to-one teaching in informal settings compared with a group approach in clinics led to improved retention rates.

CONCLUSIONS

Minority and uninsured migrants with unmet health needs showed the highest participation and HbA(1c) responses from culturally appropriate programmes.

Effect of 'activity monitor-based' counseling on physical activity and health-related outcomes in patients with chronic diseases: A systematic review and meta-analysis

AIM

This review evaluated the effects of activity monitor-based counseling on physical activity (PA) and generic and disease-specific health-related outcomes in adults with diabetes mellitus type II (DMII), chronic obstructive pulmonary disease (COPD), or chronic heart failure (CHF).

METHODS

Four electronic databases were searched for randomized controlled trials using activity monitor-based counseling versus control intervention or usual care in adults with DMII, COPD, or CHF. Pooled effect sizes were calculated using a random effects model.

RESULTS

Twenty-four articles were included: 21 DMII studies and 3 COPD studies. No CHF studies were identified. Pooled analysis showed that activity monitor-based counseling resulted in a significantly greater improvement in PA compared to control intervention or usual care in DMII. Furthermore, these interventions had a beneficial effect on hemoglobin A1c (HbA1c), systolic blood pressure, and body mass index (BMI) (P < 0.05), whereas no differences were found on diastolic blood pressure, and health-related quality of life. Meta-analysis of COPD studies was not possible due to lack of available data.

CONCLUSION

Activity monitor-based counseling had a beneficial effect on PA, HbA1c, systolic blood pressure, and BMI in patients with DMII. Data in patients with COPD and CHF are limited or non-existing, respectively.

Assessment of social support and its association to depression, self-perceived health and chronic diseases in elderly individuals residing in an area of poverty and social vulnerability in rio de janeiro city, Brazil

Objectives

Social support (SS) influences the elderly ability to cope with the losses of ageing process. This study was aimed at assessing SS among elderly users of a primary healthcare unit in a poor and violent area of Rio de Janeiro City, and at verifying its association with depression, self-perceived health (SPH), marital status and chronic illnesses.

Methods

A cross-sectional study was performed based on a convenience sample of 180 individuals aged 60 years or older. SS was measured with part of the Brazilian version of Medical Outcomes Study's SS scale, and SPH and depression were assessed, respectively, through one question and the Brazilian version of the Structured Clinical Interview for DSM-IV Axis I Disorders. SS medians were calculated for the categories of SPH, depression, marital status and chronic illnesses variables, and differences were evaluated with the Kruskal-Wallis and Mann-Whitney tests. Additionally, Pearson's chi-square test and logistic regression were employed to identify unadjusted and adjusted associations between SS and those variables.

Results

The participant’s mean age was 73 years old, and level of education was 3 years of school education on average. They were predominantly females (73.3%), and non-married (55.0%). Among them, 74.4% perceived their SS as satisfactory, 55.0% perceived their health as good, 27.8% were diagnosed with major depression and 83.3% had hypertension. Especially for those depressed and with bad SPH, the medians of SS measure were much lower than for others, reaching an unsatisfactory level. Moreover, controlling for other factors, non-depressed individuals were more likely (OR = 2.32) to have satisfactory SS.

Conclusion

in the violent and poor area explored in this research low SS is highly prevalent in the elderly. Depressed individuals are more likely to have low SS and this condition should be investigated in depressed elderly. The reduced scale is useful for low education individuals.

A systematic literature review of diabetes self-management education features to improve diabetes education in women of Black African/Caribbean and Hispanic/Latin American ethnicity

OBJECTIVE

This systematic literature review aims to identify diabetes self-management education (DSME) features to improve diabetes education for Black African/Caribbean and Hispanic/Latin American women with Type 2 diabetes mellitus.

METHODS

We conducted a literature search in six health databases for randomized controlled trials and comparative studies. Success rates of intervention features were calculated based on effectiveness in improving glycosolated hemoglobin (HbA1c), anthropometrics, physical activity, or diet outcomes. Calculations of rate differences assessed whether an intervention feature positively or negatively affected an outcome.

RESULTS

From 13 studies included in our analysis, we identified 38 intervention features in relation to their success with an outcome. Five intervention features had positive rate differences across at least three outcomes: hospital-based interventions, group interventions, the use of situational problem-solving, frequent sessions, and incorporating dietitians as interventionists. Six intervention features had high positive rate differences (i.e. ≥50%) on specific outcomes.

CONCLUSION

Different DSME intervention features may influence broad and specific self-management outcomes for women of African/Caribbean and Hispanic/Latin ethnicity.

PRACTICAL IMPLICATIONS

With the emphasis on patient-centered care, patients and care providers can consider options based on DSME intervention features for its broad and specific impact on outcomes to potentially make programming more effective.

The role of peer support in diabetes care and self-management

In light of the growing prevalence and healthcare costs of diabetes mellitus, it is critically important for healthcare providers to improve the efficiency and effectiveness of their diabetes care. A key element of effective disease management for diabetes is support for patient self-management. Barriers to care exist for both patients and healthcare systems. As a result, many people with diabetes do not get the care and support needed to successfully manage their diabetes.Disease management approaches that incorporate peer support may be a promising way to help provide self-management support to patients with diabetes. Trained peers provide emotional support, instrumental (tangible or material) support, education, and skills training to those they serve, and outreach and care coordination for provider systems. They play a unique role that complements and supports clinical care.To describe how peers are currently supporting diabetes care, a number of databases were searched for studies describing the roles of peers using relevant key words. This paper reviews current literature that describes the roles and duties of peers in interventions to improve diabetes care, with a focus on their contributions to six essential elements of self-management support: (i) access to regular, high-quality clinical care; (ii) an individualized approach to assessment and treatment; (iii) patient-centered collaborative goal setting; (iv) education and skills training; (v) ongoing follow-up and support; and (vi) linkages to community resources.Peers worked under a variety of titles, which did not define their duties. The scope of their work ranged from assisting health professionals to playing a central role in care. Providing education and follow-up support were the two most common roles. In all but one study, these roles were carried out during face-to-face contact, most frequently in community sites.A growing body of literature supports the value of peer models for diabetes management. Additional research can answer remaining questions related to such issues as cost effectiveness, sustainability, integration of peers into health and social service delivery systems, and recruitment, training, and support of peers. Continuing to develop and evaluate innovative models for more effectively mobilizing and integrating peers into diabetes care has great potential for improving diabetes outcomes worldwide.

Peer coaching to improve diabetes self-management: which patients benefit most?

BACKGROUND

Peer health coaching is an effective method of enhancing self-management support in patients with diabetes. It is unclear whether peer health coaching is equally beneficial to all patients with poor glycemic control, or is most effective for subgroups of patients.

OBJECTIVE

To examine whether the effect of peer health coaching on hemoglobin A1c (A1c) is modified by characteristics that are known to be associated with diabetes control.

DESIGN

Sub-group analyses of randomized control trial.

PARTICIPANTS

Two hundred and ninety nine patients with diabetes receiving care in public health clinics who participated in a randomized controlled trial of peer health coaches.

MAIN MEASURES

We examined whether the association between study group and change in A1c was modified by differences in patients' demographic, behavioral or psychosocial characteristics. Analyses were adjusted for co-variables associated with change in A1c.

KEY RESULTS

The effect of coaching on patient A1c was modified by patients' level of self-management and degree of medication adherence as baseline (p=.02, and p=.03 respectively in adjusted models). For participants with "low" self-management (one standard deviation below the mean score), the usual care group experienced a slight increase in A1c (0.3 %), while the health coaching group experienced a decrease (-0.9 %). For participants with "high" self-management (one standard deviation above the mean score), both groups experienced a similar decrease in A1c (usual care group: -1.0 %; health coaching group: -1.1 %). Participants with "low" medication adherence in the usual care group experienced an increase in A1c (0.5 %), while the health coaching group experienced a decrease (-0.8 %). Participants with "high" medication adherence experienced similar decreases (usual care group: -1.1 %; health coaching group: -1.3 %).

CONCLUSION

Peer health coaching had a larger effect on lowering A1c in patients with low levels of medication adherence and self-management support than in patients with higher levels. Peer health coaching interventions may be most effective if targeted to high-risk patients with diabetes with poor glycemic control and with poor self-management and medication adherence.

What might work? Exploring the perceived feasibility of strategies to promote physical activity among women living in socioeconomically disadvantaged neighbourhoods

This study aimed to investigate preferences for, perceived feasibility of and barriers to uptake of hypothetical physical activity promotion strategies among women from socioeconomically disadvantaged neighbourhoods. Semi-structured interviews were conducted with 20 purposively recruited women (18-45 years) living in socioeconomically disadvantaged urban and rural areas of Victoria, Australia. Participants indicated the most and least appealing of nine hypothetical strategies, strategies most likely to use and strategies most likely to increase physical activity. Interviews were digitally recorded and transcribed verbatim. Thematic and interpretive content analyses were used to identify emergent common and contrasting themes. A community centre-based program with free childcare, the provision of a cleaner while physical activity is undertaken and a neighbourhood-based program were the three most popular strategies. Mobile-telephone-delivered text messages, an online interactive diary and subsidized gym memberships were considered least useful. Irrespective of the strategy, components of importance commonly identified were social support; being accountable to someone; having the option of a structured or flexible attendance design; integration of multiple strategies and financial considerations. Issues around trust and privacy and weight loss also emerged as important. The findings provide important insights for the development of physical activity programs targeting socioeconomically disadvantaged women.

Peer-to-peer mentoring for individuals with early inflammatory arthritis: feasibility pilot

OBJECTIVES

To examine the feasibility and potential benefits of early peer support to improve the health and quality of life of individuals with early inflammatory arthritis (EIA).

DESIGN

Feasibility study using the 2008 Medical Research Council framework as a theoretical basis. A literature review, environmental scan, and interviews with patients, families and healthcare providers guided the development of peer mentor training sessions and a peer-to-peer mentoring programme. Peer mentors were trained and paired with a mentee to receive (face-to-face or telephone) support over 12 weeks.

SETTING

Two academic teaching hospitals in Toronto, Ontario, Canada.

PARTICIPANTS

Nine pairs consisting of one peer mentor and one mentee were matched based on factors such as age and work status.

PRIMARY OUTCOME MEASURE

Mentee outcomes of disease modifying antirheumatic drugs (DMARDs)/biological treatment use, self-efficacy, self-management, health-related quality of life, anxiety, coping efficacy, social support and disease activity were measured using validated tools. Descriptive statistics and effect sizes were calculated to determine clinically important (>0.3) changes. Peer mentor self-efficacy was assessed using a self-efficacy scale. Interviews conducted with participants examined acceptability and feasibility of procedures and outcome measures, as well as perspectives on the value of peer support for individuals with EIA. Themes were identified through constant comparison.

RESULTS

Mentees experienced improvements in the overall arthritis impact on life, coping efficacy and social support (effect size >0.3). Mentees also perceived emotional, informational, appraisal and instrumental support. Mentors also reported benefits and learnt from mentees' fortitude and self-management skills. The training was well received by mentors. Their self-efficacy increased significantly after training completion. Participants' experience of peer support was informed by the unique relationship with their peer. All participants were unequivocal about the need for peer support for individuals with EIA.

CONCLUSIONS

The intervention was well received. Training, peer support programme and outcome measures were demonstrated to be feasible with modifications. Early peer support may augment current rheumatological care.

TRIAL REGISTRATION NUMBER

NCT01054963, NCT01054131.

Testing a peer support intervention for people with type 2 diabetes: a pilot for a randomised controlled trial

BACKGROUND

People with Type 2 diabetes face various psycho-social, self-management and clinical care issues and evidence is mixed whether support from others with diabetes, 'peer support', can help. We now describe a 2 month pilot study of different peer support interventions.

METHODS

The intervention was informed by formative evaluation using semi-structured interviews with health professionals, community support groups and observation of diabetes education and support groups. Invitations to participate were mailed from 4 general practices and included a survey of barriers to care. Participants were randomized by practice to receive individual, group, combined (both individual and group) or no peer support. Evaluation included ethnographic observation, semi-structured interviews and questionnaires at baseline and post-intervention.

RESULTS

Of 1,101 invited, 15% expressed an interest in participating in the pilot. Sufficient numbers volunteered to become peer supporters, although 50% of these (8/16) withdrew. Those in the pilot were similar to other patients, but were less likely to feel they knew enough about diabetes (60.8% vs 44.6% p = 0.035) and less likely to be happy with the diabetes education/care to date (75.4% vs 55.4% p = 0.013). Key issues identified were the need to recruit peer supporters directly rather than through clinicians, to address participant diabetes educational needs early and the potential for group sessions to have lower participation rates than 1:1 sessions.

CONCLUSIONS

Recruitment to a full trial of peer support within the existing study design is feasible with some amendments. Attendance emerged as a key issue needing close monitoring and additional intervention during the trial.

Community-based physical activity interventions for treatment of type 2 diabetes: a systematic review with meta-analysis

Evidence suggests engaging in regular physical activity (PA) can have beneficial outcomes for adults with type 2 diabetes (TD2), including weight loss, reduction of medication usage and improvements in hemoglobin A1c (HbA1c)/fasting glucose. While a number of clinical-based PA interventions exist, community-based approaches are limited. The objective of this study is to conduct a systematic review with meta-analysis to assess the effectiveness of community-based PA interventions for the treatment of TD2 in adult populations. A search of peer-reviewed publications from 2002 to June 2012 was conducted across several electronic databases to identify interventions evaluated in community settings. Twenty-two studies were identified, and 11 studies reporting HbA1c as an outcome measure were pooled in the meta-analysis. Risk of bias assessment was also conducted. The findings demonstrate community-based PA interventions can be effective in producing increases in PA. Meta-analysis revealed a lowering of HbA1c levels by -0.32% [95% CI -0.65, 0.01], which approached statistical significance (p < 0.06). Our findings can guide future PA community-based interventions in adult populations diagnosed with TD2.

Physical activity among South Asian women: a systematic, mixed-methods review

INTRODUCTION

The objective of this systematic mixed-methods review is to assess what is currently known about the levels of physical activity (PA) and sedentary time (ST) and to contextualize these behaviors among South Asian women with an immigrant background.

METHODS

A systematic search of the literature was conducted using combinations of the key words PA, ST, South Asian, and immigrant. A mixed-methods approach was used to analyze and synthesize all evidence, both quantitative and qualitative. Twenty-six quantitative and twelve qualitative studies were identified as meeting the inclusion criteria.

RESULTS

Studies quantifying PA and ST among South Asian women showed low levels of PA compared with South Asian men and with white European comparison populations. However making valid comparisons between studies was challenging due to a lack of standardized PA measurement. The majority of studies indicated that South Asian women did not meet recommended amounts of PA for health benefits. Few studies assessed ST. Themes emerging from qualitative studies included cultural and structural barriers to PA, faith and education as facilitators, and a lack of understanding of the recommended amounts of PA and its benefits among South Asian women.

CONCLUSIONS

Quantitative and qualitative evidence indicate that South Asian women do not perform the recommended level of PA for health benefits. Both types of studies suffer from limitations due to methods of data collection. More research should be dedicated to standardizing objective PA measurement and to understanding how to utilize the resources of the individuals and communities to increase PA levels and overall health of South Asian women.