Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus

ACTonDiabetes: study protocol of a pragmatic randomised controlled trial for the evaluation of an acceptance and commitment-based internet-based and mobile-based intervention for adults living with type 1 or type 2 diabetes

INTRODUCTION

Living with diabetes can be burdensome and lead to serious emotional distress and impaired mental health. Acceptance and commitment therapy (ACT) can support people facing the challenges of living with diabetes. This trial aims to evaluate the effectiveness and cost-effectiveness of the internet-based and mobile-based intervention (IMI) 'ACTonDiabetes' in reducing diabetes distress against enhanced treatment as usual (TAU+) following specialised diabetes care.

METHODS AND ANALYSIS

A two-armed pragmatic randomised controlled trial will be conducted to evaluate the guided IMI ACTonDiabetes against TAU+. A total of 210 adults with type 1 or type 2 diabetes and elevated diabetes distress (Problem Areas in Diabetes ≥40) will be recruited at a specialised diabetes centre. The intervention begins 2-4 weeks after hospital discharge and takes about 7-10 weeks to complete. Assessments are performed at baseline and 5 and 10 weeks as well as 6 and 12 months after randomisation. The primary outcome is diabetes distress at a 10-week follow-up (T2). Secondary outcomes are depression (Patient Health Questionnaire-8), psychological well-being (WHO-5), quality of life (Assessment of Quality of Life-8 Dimension), Diabetes-related Self-Management Questionnaire, diabetes acceptance (Acceptance and Action Diabetes Questionnaire) and negative treatment effects (Inventory for the Assessment of Negative Effects of Psychotherapy). All statistical analyses will be performed based on the intention-to-treat principle with additional per-protocol analyses. Changes in outcomes will be evaluated using the general linear model. A health-economic evaluation will be conducted from a societal perspective. Reasons for drop-out will be systematically investigated.

ETHICS AND DISSEMINATION

This clinical trial has been approved by the State Medical Chamber of Baden-Württemberg (file no. B-F-2019-010). Trial results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00016738.

Relating Land Use/Cover and Landscape Pattern to the Water Quality under the Simulation of SWAT in a Reservoir Basin, Southeast China

Understanding the relationship between land use/cover pattern and water quality could provide guidelines for non-point source pollution and facilitate sustainable development. The previous studies mainly relate the land use/cover of the entire region to the water quality at the monitoring sites, but the water quality at monitoring sites did not totally reflect the water environment of the entire basin. In this study, the land use/cover was monitored on Google Earth Engine in Tang-Pu Reservoir basin, China. In order to reflect the water quality of the whole study area, the spatial distribution of the determinants for water quality there, i.e., the total nitrogen and total phosphorus (TN&TP), were simulated by the Soil and Water Assessment Tool (SWAT). The redundancy analysis explored the correlations between land use/cover pattern and simulated TN&TP. The results showed that: (1) From 2009 to 2019, forest was the dominant land cover, and there was little land use/cover change. The landscape fragmentation increased, and the connectivity decreased. (2) About 25% TP concentrations and nearly all the TN concentrations at the monitoring points did not reach drinking water standard, which means nitrogen and phosphorus pollution were the most serious problems. The highest output per unit TN&TP simulated by SWAT were 44.50 kg/hm2 and 9.51 kg/hm2 and occurred in areas with highly fragile landscape patterns. (3) TN&TP correlated positively with cultivated and construction land but negatively with forest. The correlation between forest and TN&TP summited at 500–700-m buffer and construction land at 100-m buffer. As the buffer size increased, the correlation between the cultivated land, and the TN weakened, while the correlation with the TP increased. TN&TP correlated positively with the Shannon’s Diversity Index and negatively with the Contagion Index. This study provides a new perspective for exporting the impact of land use/cover pattern on water quality.

Relaxation training significantly reduced blood glucose levels in patients with type 1 diabetes mellitus

PURPOSE/OBJECTIVE

The present study was designed to test whether adding a relaxation training technique to the medical treatment of patients with type 1 diabetes mellitus could, adjusting for the non-specific factors of therapy, lead to an improvement in the patients' condition.

METHOD

Forty-six participants were randomly allocated either to an experimental (intervention) group, receiving weekly sessions of relaxation training, or to a control group (placebo) receiving weekly blood circulation training exercises. Measures included the State and Trait Anxiety Inventory, blood glucose levels, high-density lipoprotein levels, cholesterol levels, body weight, HbA1c levels, the Mood Adjective Checklist (MACL), a diary checklist, and urine glucose levels. Assessment of psychological and physiological parameters was conducted before and upon completion of the intervention (8 weeks).

RESULTS

Trait anxiety and the main metabolic measurement of blood glucose levels and HbA1C revealed significant differences over time, predominantly among patients in the intervention group.

CONCLUSIONS

Relaxation techniques as an adjunct to medical treatment are a useful tool for patients with type 1 diabetes mellitus.

Nurse practitioner-physician comanagement of primary care patients: The promise of a new delivery care model to improve quality of care

BACKGROUND

The U.S. primary care system is under tremendous strain to deliver care to an increased volume of patients with a concurrent primary care physician shortage. Nurse practitioner (NP)-physician comanagement of primary care patients has been proposed by some policy makers to help alleviate this strain. To date, no collective evidence demonstrates the effects of NP-physician comanagement in primary care.

PURPOSE

This is the first review to synthesize all available studies that compare the effects of NP-physician comanagement to an individual physician managing primary care.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework guided the conduct of this systematic review. Five electronic databases were searched. Titles, abstracts, and full texts were reviewed, and inclusion/exclusion criteria were applied to narrow search results to eligible studies. Quality appraisal was performed using Downs and Black's quality checklist for randomized and nonrandomized studies.

RESULTS

Six studies were identified for synthesis. Three outcome categories emerged: (a) primary care provider adherence to recommended care guidelines, (b) empirical changes in clinical patient outcomes, and (c) patient/caregiver quality of life. Significantly more recommended care guidelines were completed with NP-physician comanagement. There was variability of clinical patient outcomes with some findings favoring the comanagement model. Limited differences in patient quality of life were found. Across all studies, the NP-physician comanagementcare delivery model was determined to produce no detrimental effect on measured outcomes and, in some cases, was more beneficial in reaching practice and clinical targets.

PRACTICE IMPLICATIONS

The use of NP-physician comanagement of primary care patients is a promising delivery care model to improve the quality of care delivery and alleviate organizational strain given the current demands of increased patient panel sizes and primary care physician shortages. Future research should focus on NP-physician interactions and processes to isolate the attributes of a successful NP-physician comanagement model.

National rates of emergency department visits associated with diabetes in Saudi Arabia, 2011-2015

BACKGROUND

Despite the fact that diabetes is an important component of the burden of disease on the individual and on the national healthcare systems in Saudi Arabia, knowledge of the volume of emergency department (ED) visits for diabetes is unclear.

OBJECTIVE

Examine changes in ED visit rates associated with diabetes.

DESIGN

Retrospective.

SETTINGS

Governmental hospitals.

METHODS

Publicly available records of health statistics published by the Saudi Ministry of Health from 2011 through 2015 were used to extract data on ED visits related to diabetes. ED visits associated with diabetes were compared over time and by gender. We calculated diabetes-specific rates per 10000 persons for each sex category by dividing the total number of diabetes-associated ED visits in that category by the sex-specific population. We calculated the rate difference (RD) with 95% CI between 2011 and 2015.

MAIN OUTCOME MEASURES

Diabetes-specific rates per 10000 persons for each sex category.

RESULTS

Total annual visits to the ED for management of diabetes increased from 617683 cases in 2011 to 748605 in 2015. The annual number of ED visits associated with diabetes increased by 21% over the study period (20% for males and 23% for females). Compared to males, females had a larger increase in visit rates from 240.5 to 249.8 visits per 10000 women over the study years (RD, 9.6 per 10000 persons, 95% CI -16.4 to 26.6 versus 5.7 per 10 000 persons, 95% CI-13.6 to 18.3 ; P=.01).

CONCLUSION

Although diabetes-associated ED visit rates dramatically increased in 2012, they remained relatively stable after 2012 to the end of the study period. More effective preventive diabetes programs that prevent the use of ED visits and other expensive healthcare resources among people with diabetes are needed.

LIMITATIONS

We had no information on the specific indications for the reported ED visits. These estimates may represent a lower bound on ED visits associated with diabetes since the private sector was not included.

CONFLICT OF INTEREST

None.

Impact of structured education on glucose control and hypoglycaemia in Type-2 diabetes: a systematic review of randomized controlled trials

Evidence for the use of structured education in diabetes management is accumulating and has shown positive influence in the management of Type-2 diabetes.

Objective

To assess the impact of structured education on glucose control and hypoglycaemia in the management of Type-2 diabetes.

Methods

A systematic review was done using Medline via Ovid and EMBASE databases of published English literature between 1980 and 2014. Included studies were randomized control trials that assessed the impact of structured education on glucose control and hypoglycaemia.

Results

Out of the 12,086 full text articles were identified, 36 full text articles were finally considered for this review after applying both inclusion and exclusion criteria, of which 34 were exclusively on the effect of structured diabetes education on glucose control whilst 2 were studies on the effects of structured diabetes education on glucose control and hypoglycaemia. Majority of the studies included a predominant Caucasian population. There was heterogeneity in the included studies such as intervention methods and intensity as well as follow up periods. Group based education was preferred over individual education by most studies. Overall, most of the studies showed a significant positive effect on glycaemic control compared with control groups. One study showed a significant impact of structured education on hypoglycaemia.

Conclusion

Structured education has positive impact on glucose control and hypoglycaemia in Type-2 diabetes and must be incorporated in routine care.

Funding

The study was funded by the authors.

Integration and Utilization of Peer Leaders for Diabetes Self-Management Support: Results From Project SEED (Support, Education, and Evaluation in Diabetes)

Purpose The purpose of the study was to evaluate the effectiveness of a peer leader-led (PL) diabetes self-management support (DSMS) group in achieving and maintaining improvements in A1C, self-monitoring of blood glucose (SMBG), and diabetes distress in individuals with diabetes. Diabetes self-management support is critical; however, effective, sustainable support models are scarce. Methods The study was a cluster randomized controlled trial of 221 people with diabetes from 6 primary care practices. Practices and eligible participants (mean age: 63.0 years, 63.8% female, 96.8% white, 28.5% at or below poverty level, 32.5% using insulin, A1C ≥7%: 54.2%) were randomized to diabetes self-management education (DSME) + PL DSMS (n = 119) or to enhanced usual care (EUC) (DSME + traditional DSMS with no PL; n = 102). Data were collected at baseline, after DSME (6 weeks), after DSMS (6 months), and after telephonic DSMS (12 months). Results Decreases in A1C occurred between baseline and post-DSME in both groups. Both groups sustained improvements during DSMS, but A1C levels increased during telephonic DSMS. Improvements in self-monitoring of blood glucose were observed in both groups following DSME and were sustained throughout. At study end, the intervention group was 4.3 times less likely to have diabetes regimen-related distress compared to EUC. Conclusions PL DSMS is as effective as traditional DSMS in helping participants to maintain glycemic control and self-monitoring of blood glucose (SMBG) and more effective at improving distress. With increasing diabetes prevalence and shortage of diabetes educators, it is important to integrate and use low-cost interventions in high-risk communities that build on available resources.

Diabetes education and medication adjustment in Ramadan (DEAR) program prepares for self-management during fasting with tele-health support from pre-Ramadan to post-Ramadan

BACKGROUND

We evaluated the outcome for fasting Muslims with diabetes prepared with pre-Ramadan optimization through education and medication adjustment, tele-support and intervention up to post-Ramadan.

METHODS

Muslims with diabetes planning to fast were recruited into a focused diabetes program for Ramadan fasting.It consisted of (a) a pre-Ramadan assessment and test fasting to optimize glycemic control, (b) education on diabetes management during fasting, (c) tele-monitoring from pre-Ramadan and (d) a post-Ramadan review. Their metabolic profiles and diaries for meals, activities and glucose monitoring were evaluated.

RESULTS

Twenty-nine participants were enrolled, with mean age 58.4 ± 9.2 years, 75.9% female, 79.3% Malays and 93.1% type 2 diabetes. A total of 92% needed medication adjustment and 93% fasted for at least 14 days. Glycated hemoglobin (HbA1c) and weight decreased from 8.8 ± 1.8% (72.7 mmol/mol) pre-Ramadan to 8.5 ± 1.7% (69.4 mmol/mol) post-Ramadan and 76.6 ± 20.3 kg pre-Ramadan to 75.9 ± 21.3 kg post-Ramadan, respectively. There were decreased complications of hypoglycemia from 13.8% to 10.3% and several-fold improvement in hyperglycemia from 31.0% to 3.5% during Ramadan fasting when compared with pre-Ramadan.

CONCLUSIONS

Muslims with diabetes were able to self-manage when fasting using tele-monitoring support and intervention, with decreased complications during Ramadan compared with pre-Ramadan.

Interventions to Improve Management of Chronic Conditions Among Racial and Ethnic Minorities

Digital and mhealth interventions can be effective in improving health outcomes among minority patients with diabetes, congestive heart failure, and chronic respiratory diseases. A number of electronic and digital approaches to individual and population-level interventions involving telephones, internet and web-based resources, and mobile platforms have been deployed to improve chronic disease outcomes. This paper summarizes the evidence supporting the efficacy of various behavioral and digital interventions targeting intermediate outcomes and hospitalizations with particular emphasis on studies examining the effects of these interventions on racial and ethnic minority population.

Diabetes self-care and its associated factors among elderly diabetes in primary care

Objectives

Diabetes is a primarily self-manageable condition. Healthcare professionals usually offer education, treatment, and support, but patients themselves are responsible for the daily management of their condition. Increasing the effectiveness of self-management support may have a considerable impact on health care, especially for elderly people. The aim of this study was to describe diabetes self-care among elderly diabetics and to determine its associated factors.

Methods

This report describes a cross-sectional study involving 143 elderly diabetes patients in the outpatient department of the Hospital Universiti Sains Malaysia (HUSM). Self-care activities assessed in this study included dietary control, physical activity, self-monitoring of blood glucose, medication adherence, and situational related adherence behaviour, all of which were obtained using the validated Malay Elderly Diabetes Self-Care Questionnaire (MEDSCaQ).

Results

The mean (±SD) age of the subjects was 67.9 (±5.4) years old. A majority was Malay, with a mean HbA1c of 8.4 (±1.9). The mean diabetes self-care score was 26.5 (±8.0). Factors with a positive impact on diabetes self-care included being non-Malay (β = 5.275, p = 0.002), having family as care givers (β = 8.995, p = 0.004), having a higher level of family support (β = 0.159, p = 0.042), and possessing acceptable (β = 4.375, p = 0.001) or good knowledge of diabetes (β = 5.893, p = 0.004). The presence of neuropathy negatively impacted self-care, while diabetes nephropathy had a positive impact on self care (β = −4.053, p = 0.003).

Conclusions

Elderly individuals with type 2 diabetes in HUSM have a moderate score of diabetes self-care practice based on the MEDSCaQ. Determinants for good diabetes self-care include race, social support, having care-takers during periods of illness, diabetes knowledge, and diabetic microvascular complications.

Glucose and Cardiac Risk Factor Control in Individuals With Type 2 Diabetes

Purpose

The purpose of this descriptive study was to describe attainment of glucose and coronary heart disease (CHD) risk factor goals and to identify factors that were associated with successful goal achievement.

Methods

A cross-sectional survey enrolled 110 subjects with type 2 diabetes undergoing screening for asymptomatic myocardial ischemia.

Results

Many participants had HbA1c levels ≥7% (45%), and 46% to 79% were not meeting goals for CHD risk reduction. Individual factors of age, gender, and anxiety; the illness-related factor of lipid-lowering therapy; and the family-related factor of living alone were independently associated with 1 of the 7 outcomes under study. Illness-related factors of a longer duration of diabetes were strongly associated with glucose and blood pressure control, insulin use with glucose control and waist circumference, and antihypertensive use with blood pressure, triglycerides, and body mass index. Family-related factors of higher income were significantly associated with poorer glucose control and higher body mass index, while higher levels of perceived support by family and friends were associated with a lower risk of not meeting lipid goals. However, individual factors, represented by several aspects of personal model beliefs (exercising regularly, testing glucose, and checking one’s feet) and physical activity, were consistently related to lipid and weight control.

Conclusions

A variety of factors were associated with control of blood glucose and CHD risk factors, suggesting that a one-size-fits-all approach to multiple risk factor reduction efforts may not result in goal attainment.

Promotora Diabetes Intervention for Mexican Americans

PURPOSE

The purpose of this randomized controlled trial is to determine the effectiveness of an intervention led by promotoras (community lay workers) on the glycemic control, diabetes knowledge, and diabetes health beliefs of Mexican Americans with type 2 diabetes living in a major city on the Texas-Mexico border.

METHODS

One hundred fifty Mexican American participants were recruited at a Catholic faith-based clinic and randomized into 2 groups. Personal characteristics, acculturation, baseline A1C level, diabetes knowledge, and diabetes health beliefs were measured. The intervention was culturally specific and consisted of participative group education, telephone contact, and follow-up using inspirational faith-based health behavior change postcards. The A1C levels, diabetes knowledge, and diabetes health beliefs were measured 3 and 6 months postbaseline, and the mean change between the groups was analyzed.

RESULTS

The 80% female sample, with a mean age of 58 years, demonstrated low acculturation, income, education, health insurance coverage, and strong Catholicism. No significant changes were noted at the 3-month assessment, but the mean change of the A1C levels, F(1, 148) = 10.28, P < .001, and the diabetes knowledge scores, F(1, 148) = 9.0, P < .002, of the intervention group improved significantly at 6 months, adjusting for health insurance coverage. The health belief scores decreased in both groups.

CONCLUSIONS

The intervention resulted in decreased A1C levels and increased diabetes knowledge, suggesting that using promotoras as part of an interdisciplinary team can result in positive outcomes for Mexican Americans who have type 2 diabetes. Clinical implications and recommendations for future research are suggested.

Racial and Ethnic Disparities in Preventable Hospitalizations for Chronic Disease: Prevalence and Risk Factors

BACKGROUND

Hospitalizations due to ambulatory care sensitive conditions (ACSCs) result in high morbidity and economic burden on the American healthcare system. Admissions due to chronic ACSCs, in particular, cost the American healthcare system over 30 billion dollars annually.

OBJECTIVES AND METHODS

This paper presents the current research on racial and ethnic disparities in the burden of hospitalizations due to chronic ACSCs. For this narrative review, we evaluated over 800 abstracts from MEDLINE and Google Scholar and cited 62 articles.

RESULTS

Since 1998, racial and ethnic disparities in hospitalizations from chronic ACSCs have increased resulting in over 430,000 excess hospitalizations among non-Hispanic Blacks compared to non-Hispanic Whites.

CONCLUSIONS

Racial disparities in chronic ACSCs hospitalizations are pervasive in the USA. There is need for more research on the pathways through which an individual's race modifies the risk for hospitalizations due to chronic ACSCs.

Positive parenting for healthy living (Triple P) for parents of children with type 1 diabetes: protocol of a randomised controlled trial

Background

Type 1 diabetes is a serious, life-long condition which causes major health, social and economic burden for children, their families and the community. Diabetes management involves strict adherence to a complex regimen, and poor management and non-adherence are a persistent problem among children. Parent-child interactions and parenting have been identified as crucial points of intervention to support children’s health and emotional well-being, yet few parenting interventions have been developed or evaluated for parents of young children. This paper describes a randomised controlled trial of a brief, group-based parenting intervention for parents of young children (2-10 years) with type 1 diabetes compared against care as usual (CAU).

Methods/design

Families will be randomised to either Positive Parenting for Healthy Living Triple P or CAU. Positive Parenting for Healthy Living Triple P involves 2 × 2 h group sessions. Outcomes will be assessed via parent and child questionnaire, home observations and blood glucose monitoring at baseline, 1-month and 6-months post-intervention. Primary outcomes will be parent- and child-reported parenting behaviour, parent-reported child behaviour and adjustment, and parent-reported child quality-of-life. Secondary outcomes will include parental self-efficacy with diabetes management, illness-specific and general parenting stress, parent-reported child illness behaviour, family quality-of-life, observed parenting and child behaviour, and child’s illness control.

Discussion

The theoretical background, study hypotheses, methods and planned analyses are discussed.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12613001281785. Registered 20 November, 2013.

A Nurse-Coaching Intervention for Women With Type 2 Diabetes

PURPOSE

The purpose of this pilot study was to determine the efficacy of a 6-month nurse-coaching intervention that was provided after diabetes education for women with type 2 diabetes.

METHODS

In this pilot study, 53 women were randomized to the nurse-coaching intervention or a standard care control condition. The nurse-coaching intervention consisted of 5 individualized sessions and 2 follow-up phone calls over 6 months. The nurse-coaching sessions included educational, behavioral, and affective strategies. Data were collected on physiologic adaptation (hemoglobin A1c [A1C] and body mass index [BMI]), self-management (dietary and exercise), psychosocial adaptation (diabetes-related distress and integration), and treatment satisfaction at baseline, 3 months, and 6 months.

RESULTS

Women in the treatment group demonstrated better diet self-management, less diabetes-related distress, better integration, and more satisfaction with care, and had trends of better exercise self-management and BMI. The A1C levels improved in both groups at 3 months, yet the difference between the groups was not significant. Attendance at nurse-coaching sessions was 96%.

CONCLUSIONS

This nurse-coaching intervention demonstrates promise as a means of improving self-management and psychosocial outcomes in women with type 2 diabetes.

Self-Management of Heart Disease by Older Adults

A randomized, controlled trial involving 636 older individuals was conducted to evaluate an intervention to enhance self-management of heart disease. Program participants experienced less impact of illness on their psychosocial functioning (p <.05), especially their emotional behavior (p < .05) and alertness (p < .01). Compared to controls, male program participants experienced improvements in their physical functioning, specifically their ability to ambulate (p < .05) and the frequency and severity of their symptoms. Female program participants did not experience gains in physical functioning. Most group differences emerged by 12 months and decayed by the 18-month final evaluation. To accurately assess the pattern of change associated with a program of this type, evaluation over at least 18 months following program completion may be needed. Separate interventions for older men and women with heart disease appear warranted, as do follow-up activities at strategic points in time to sustain program effects.

Learning to listen in primary care: some educational challenges

Effective clinician listening and communicating directly affects patients' health, satisfaction with healthcare, and complaints. This influences healthcare policy and clinician training/assessment. Listening skills and consultation frameworks underpin training but are often poorly used in everyday clinical work. Primary care doctors provide continuity of care using listening skills to develop long term relationships. Additionally, they listen to patients and colleagues in other ways such as surveys, participation groups, and significant event reviews. All these factors challenge educators to offer systematic training which ensures that future primary care clinicians/leaders develop conscious competence in listening at different levels and in differing contexts.

Evaluation of the UCL Diabetes Self-management Programme (UCL-DSMP): A Randomized Controlled Trial

Self-management has been described as the cornerstone of care for diabetes. Many self-management studies are limited by poor methodology and poor descriptions of the intervention. The current study developed a theoretically based self-management programme for patients with type 2 diabetes, which was evaluated via a randomized controlled trial. At immediate post-intervention and three-month follow-up the intervention group showed significant improvement relative to controls on self-management behaviours, quality of life and illness beliefs. A trend towards improved HbA1c was also observed. Documentation in a manual and development of a training programme for facilitators ensures the programme is replicable.

Diabetes Education in a Mexican-American Population: Pilot Testing of a Research-Based Videotape

A diabetes education videotape was designed and pilot tested in a sample of 30 Spanish-speaking Hispanic diabetic adults in a rural Texas-Mexico border community. The videotape provided an overview of diabetes, with emphasis on the concept of blood glucose; relationships between food, medications, exercise, and blood glucose levels; and blood glucose monitoring. Outcomes of videotape effectiveness were based on a 20-item knowledge test and interview data to assess acceptability of videotapes as a learning tool. Comparison of the knowledge test scores of the experimental group (those who viewed the tape before taking the knowledge test) with the control group (those who took the test before viewing the tape) produced a positive, moderate effect size of 0.61. Interviews with subjects indicated enthusiastic acceptance of the videotape as a means of transmitting diabetes information.

Predictors of Diabetes-Specific Knowledge and Treatment Satisfaction Among Costa Ricans

PURPOSE

The purpose of this study was to identify predictors of disease-specific knowledge and patient satisfaction among adult Costa Ricans with type 2 diabetes. Knowledge differences between Costa Ricans and Spanish-speaking US Latinos also were tested. The psychometric viability of a Spanish-language diabetes knowledge and client satisfaction measure with Costa Ricans was reviewed.

METHODS

The Diabetes Knowledge Questionnaire (DKQ) and the Client Satisfaction Questionnaire (CSQ) were administered to 162 Costa Rican adults with type 2 diabetes who were receiving services in the greater San Jose area. Sociodemographic, medical history, and anecdotal information also was collected.

RESULTS

More years of education, younger age, longer diabetes duration, and home glucose monitoring predicted diabetes knowledge. Home glucose monitoring and treatment with only oral hypoglycemics predicted significantly lower patient satisfaction. Costa Ricans exhibited greater diabetes knowledge than respondents in an earlier study with Spanish-speaking Latinos. CSQ psychometric limitations with Costa Ricans were identified.

CONCLUSIONS

The greater diabetes knowledge among Costa Ricans than US Latinos is likely due to more consistent, stable, and accessible care. Older, less educated, and newly diagnosed Costa Rican diabetes patients require more focused attention.

The Aging, Community and Health Research Unit-Community Partnership Program for older adults with type 2 diabetes and multiple chronic conditions: a feasibility study

BACKGROUND

Few studies have examined the effectiveness of community-based self-management interventions in older adults with type 2 diabetes mellitus (T2DM) and multiple chronic conditions (MCC). The objectives of this study were to examine the feasibility of implementation in practice (primary) and the feasibility of study methods and potential effectiveness (secondary) of the Aging, Community and Health-Community Partnership Program, a new 6-month interprofessional, nurse-led program to promote diabetes self-management in older adults (>65 years) with T2DM and MCC.

METHODS

This study used a prospective one-group pre-test/post-test design. Participants were recruited from a specialized diabetes clinic. They received a median of three in-home/clinic visits by certified diabetes educators (CDEs) and attended a median of three group wellness sessions provided by the CDEs in partnership with a community-based seniors' association. The primary outcome was the feasibility of the program (acceptability, fidelity, implementation barriers/facilitators). Secondary outcomes included the feasibility of the study methods (recruitment/retention rates and procedures, eligibility criteria, data collection and analysis methods) and potential effectiveness of the program based on 6-month changes in self-reported outcomes including self-management behavior (diet, exercise, self-monitoring), health status (quality of life, mental health), and costs of service use. Analysis of feasibility outcomes was primarily based on descriptive statistics. The potential effectiveness of the program was explored using different tests, with the results expressed using descriptive statistics and effect estimates (95 % confidence intervals).

RESULTS

In total, 45 (88 %) of 51 eligible persons consented to participate. Of these, 37 (82 %) completed the 6-month follow-up. Participants and providers viewed the program as acceptable and feasible. Participants had a higher SF-12 physical component summary score at 6 months compared with baseline (mean score difference 3.0, 95 % CI 0.2-5.8). Median costs for diabetes care increased over 6 months (reflecting inclusion of program costs), while other service costs either decreased or remained unchanged.

CONCLUSIONS

This study offers preliminary evidence that the program was feasible to deliver and acceptable to participants and providers. Initial results suggest that the program may improve physical functioning. A randomized controlled trial is feasible, with some adaptations to the program and study methods that were identified from this feasibility study.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01880476.

Exploring interprofessional collaboration during the integration of diabetes teams into primary care

Background

Specialised diabetes teams, specifically certified nurse and dietitian diabetes educator teams, are being integrated part-time into primary care to provide better care and support for Canadians living with diabetes.

This practice model is being implemented throughout Canada in an effort to increase patient access to diabetes education, self-management training, and support. Interprofessional collaboration can have positive effects on both health processes and patient health outcomes, but few studies have explored how health professionals are introduced to and transition into this kind of interprofessional work.

Method

Data from 18 interviews with diabetes educators, 16 primary care physicians, 23 educators’ reflective journals, and 10 quarterly debriefing sessions were coded and analysed using a directed content analysis approach, facilitated by NVIVO software.

Results

Four major themes emerged related to challenges faced, strategies adopted, and benefits observed during this transition into interprofessional collaboration between diabetes educators and primary care physicians: (a) negotiating space, place, and role; (b) fostering working relationships; (c) performing collectively; and (d) enhancing knowledge exchange.

Conclusions

Our findings provide insight into how healthcare professionals who have not traditionally worked together in primary care are collaborating to integrate health services essential for diabetes management. Based on the experiences and personal reflections of participants, establishing new ways of working requires negotiating space and place to practice, role clarification, and frequent and effective modes of formal and informal communication to nurture the development of trust and mutual respect, which are vital to success.

Effectiveness of a self-management intervention with personalised genetic and lifestyle-related risk information on coronary heart disease and diabetes-related risk in type 2 diabetes (CoRDia): study protocol for a randomised controlled trial

Background

Many patients with type 2 diabetes fail to achieve good glycaemic control. Poor control is associated with complications including coronary heart disease (CHD). Effective self-management and engagement in health behaviours can reduce risks of complications. However, patients often struggle to adopt and maintain these behaviours. Self-management interventions have been found to be effective in improving glycaemic control. Recent developments in the field of genetics mean that patients can be given personalised information about genetic- and lifestyle-associated risk of developing CHD. Such information may increase patients’ motivation to engage in self-management. The Coronary Risk in Diabetes (CoRDia) trial will compare the effectiveness of a self-management intervention, with and without provision of personalised genetic- and lifestyle-associated risk information, with usual care, on clinical and behavioural outcomes, the cognitive predictors of behaviour, and psychological wellbeing.

Methods/Design

Participants will be adults aged 25–74 years registered with general practices in the East of England, diagnosed with type 2 diabetes, with no history of heart disease, and with a glycated haemoglobin level of ≥6.45 % (47 mmol/mol). Consenting participants will be randomised to one of three arms: usual care control, group self-management only, group self-management plus personalised genetic- and lifestyle-associated risk information. The self-management groups will receive four weekly 2-hour group sessions, focusing on knowledge and information sharing, problem solving, goal setting and action planning to promote medication adherence, healthy eating, and physical activity. Primary outcomes are glycaemic control and CHD risk. Clinical data will be collected from GP records, including HbA1c, weight, body mass index, blood pressure, and HDL and total cholesterol. Self-reported health behaviours, including medication adherence, healthy eating and physical activity, and cognitive outcomes will be assessed by questionnaire. Measures will be taken at baseline, 3 months (questionnaire only), 6 months and 12 months post-baseline.

Discussion

This study will determine whether the addition of personalised genetic- and lifestyle-associated CHD risk information to a group self-management intervention improves diabetes control and CHD risk compared with group self-management and usual care. Effectiveness of the combined intervention on health behaviours cognitions theorised to predict them, and psychological outcomes will also be investigated.

Trial registration

This study has been registered at ClinicalTrials.gov; registration identifier NCT01891786, registered 28 June 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1073-7) contains supplementary material, which is available to authorized users.

A systematic review of parenting interventions for parents of children with type 1 diabetes

OBJECTIVE

To summarize the parenting intervention literature for parents of children aged 2-10 years (mean age <10 years) with type 1 diabetes and to evaluate intervention efficacy in improving a range of parent, family and child outcomes. The present review de-emphasizes the traditional medical approach to illness management summarized in previous reviews and focuses on parenting factors identified in the literature as important to diabetes management. This review article is important as it outlines the present state of parenting intervention literature for this population.

METHODS

Electronic searches were conducted for seven databases (Cumulative index to nursing and allied health literature, MEDLINE, PsycINFO, PubMed, Scopus, The Cochrane library and Web of Science) from their start dates until April 2014. Reference lists of all included papers were also searched for potentially relevant articles.

RESULTS

Seven papers, representing six studies, met the inclusion criteria. Three studies primarily focused on improving parenting practices. The intervention programmes described in the remaining studies comprised multiple components; thus, it is difficult to establish the contribution of the parenting components to improving outcomes.

CONCLUSIONS

Parenting interventions may help to improve responsibility sharing and cooperation in diabetes management, child behaviour difficulties, parental behaviour, parents' psychological distress and child health outcomes. This review suggests the need for further well-designed trials of parenting interventions to determine their specific contribution to improving outcomes for this population.

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.

Diabetes-related quality of life is enhanced by glycaemic improvement in older people

AIMS

To investigate the validity and reliability of the Audit of Diabetes-Dependent Quality of Life instrument in older Italians with diabetes and to test the association of diabetes-related quality of life with glycaemic control over time.

METHODS

A total of 558 outpatients with Type 2 diabetes from the Diabetic Unit of the Italian National Research Centre on Aging Hospital in Ancona were enrolled to complete questionnaires (Audit of Diabetes-Dependent Quality of Life-19 and the Short-Form-12), and to undergo clinical and biochemical testing at baseline and at 12 months of follow-up. The overall impact of diabetes using the average weighted impact score from the Audit of Diabetes-Dependent Quality of Life questionnaire was calculated. Participants were categorized according to this score as having either less or more negative diabetes-related quality of life.

RESULTS

Participants had a mean ± SD age of 67.7 ± 9.2 years and 51.8% were male. Factor analysis and Cronbach's coefficient of internal consistency (Cronbach's α = 0.931) confirmed that the 19 domain-specific Audit of Diabetes-Dependent Quality of Life items could be combined into a single scale in this Italian population. The impact score correlated with the physical (r = 0.275; P < 0.001) and mental components (r = 0.291; P < 0.001) of the Short-Form-12 questionnaire. Significant differences were found according to diabetic complications in specific Audit of Diabetes-Dependent Quality of Life items and impact scores. Insulin use had a greater association with a more negative quality of life compared with other antidiabetic agents. A multivariate linear regression model with restricted linear spline application showed that the relationship between HbA1c and impact score was not linear and that the change in the impact score was associated with improved glycaemic control in those with a less negative diabetes-related quality of life at 12 months.

CONCLUSIONS

The Audit of Diabetes-Dependent Quality of Life-19 is a valid tool for measuring the impact of diabetes on quality of life in older Italians. Perception of diabetes-related quality of life is associated with glycaemic control over time.

Barriers to medication taking among Kuwaiti patients with type 2 diabetes: a qualitative study

BACKGROUND

Nonadherence to medications among Kuwaitis with type 2 diabetes mellitus (T2DM) is believed to be a major barrier to appropriate management of the disease. Published studies of barriers to medication adherence in T2DM suggest a Western bias, which may not adequately describe the Kuwaiti experience.

AIM

The purpose of this study was to explore barriers to medication adherence among Kuwaiti adults with T2DM.

METHODS

Semi-structured interviews were conducted with 20 Kuwaiti patients with type 2 diabetes. The interviews were digitally recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Barriers to medication adherence were identified. Emerging themes were: 1) lack of education/awareness about diabetes/medications, 2) beliefs about medicines/diabetes, 3) spirituality and God-centered locus of control, 4) attitudes toward diabetes 5) perceptions of self-expertise with the disease and body awareness, 6) social stigma, 7) perceptions of social support, 8) impact of illness on patient's life, 9) perceptions of health care providers' attitudes toward patients, and 10) health system-related factors, such as access difficulties and inequalities of medication supply and services.

CONCLUSION

Personal, sociocultural, religious, health care provider, and health care system-related factors may impede medication adherence among Kuwaitis with type 2 diabetes. Interventions to improve care and therapeutic outcomes in this particular population must recognize and attempt to resolve these factors.

Psychosocial interventions for the diabetic patient

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

Real-world evaluation of the effects of counseling and education in diabetes management

Background. Patient education has long been recognized as a component of effective diabetes management, but the impact of counseling and education (C/E) interventions on health care costs is not fully understood. Objectives. To identify the incidence and type of diabetes C/E received by type 2 diabetes patients and to evaluate associated economic and clinical outcomes. Methods. This retrospective cohort study used the Premier-Optum Continuum of Care database (2005-2009) to compare adult patients with type 2 diabetes receiving C/E to those not receiving C/E (control). The index date was the first C/E date or, in the control cohort, a randomly assigned date on which some care was delivered. Patients had at least 6 months' pre-index and 12 months' post-index continuous health plan coverage. Health care costs and glycemic levels were evaluated over 12 and 6 months, respectively, with adjustment for differences in baseline characteristics using propensity score matching (PSM). Results. Of 26,790 patients identified, 9.3% received at least one C/E intervention (mean age 53 years, 47% men) and 90.7% received no C/E (mean age 57 years, 54% men). Standard diabetes education was the most common form of C/E (73%). After PSM, C/E patients had some improvements in glycemic levels (among those with laboratory values available), without increased risk for hypoglycemia, and incurred $2,335 per-patient less in diabetes-related health care costs, although their total health care costs increased. Conclusions. Despite the low uptake of C/E services, C/E interventions may be associated with economic and clinical benefits at 12 months. Further analyses are needed to evaluate the long-term cost-effectiveness of such initiatives.

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.

Does a 2.5-year self-management education and support intervention change patterns of healthcare use in African-American adults with type 2 diabetes?

AIMS

To investigate the impact of a 2.5-year diabetes self-management education and support intervention on healthcare use and to examine factors associated with patterns of healthcare use.

METHODS

We recruited 60 African-American adults with type 2 diabetes who completed a 2.5-year empowerment-based diabetes self-management education and support intervention. Primary healthcare use outcomes included acute care visits, non-acute care visits and days lost to disability. Acute care was a composite score calculated from the frequency of urgent care visits, emergency department visits and hospitalizations. Non-acute care measured the frequency of scheduled outpatient visits. To examine change in patterns of healthcare use, we compared the frequency of healthcare visits over the 6-month period preceding the intervention with that in the last 6 months of the intervention.

RESULTS

No significant changes in patterns of healthcare use were found for acute care, non-acute care or days lost to disability. Multiple regression models found higher levels of depression (P = 0.001) to be associated with a greater number of non-acute healthcare visits, and found longer duration of diabetes (P = 0.019) and lower levels of diastolic blood pressure (P = 0.025) to be associated with fewer days lost to disability.

CONCLUSIONS

Participation in a long-term diabetes self-management education and support intervention had no impact on healthcare use in our sample of African-American subjects.

Evaluating a diabetes self-management support peer leader training programme for the English- and Punjabi-speaking South-Asian community in Vancouver

AIMS

The purpose of this single-cohort study was to implement and evaluate a programme that trains peers to deliver a diabetes self-management support programme for South-Asian adults with Type 2 diabetes and to assess the perceived efficacy of and satisfaction with this programme.

METHODS

We recruited eight South-Asian adults who completed a 20-h peer-leader training programme conducted over five sessions (4 h per session). The programme used multiple instructional methods (quizzes, group brainstorming, skill building, group sharing, role-play and facilitation simulation) and provided communication, facilitation, and behaviour change skills training. To graduate, participants were required to achieve the pre-established competency criteria in four training domains: active listening, empowerment-based facilitation, five-step behavioural goal-setting, and self-efficacy. Participants were given three attempts to pass each competency domain.

RESULTS

On the first attempt six (75%), eight (100%), five (63%) and five (63%) participants passed active listening, empowerment-based facilitation, five-step behavioural goal-setting, and self-efficacy, respectively. Those participants who did not pass a competency domain on the first attempt were successful in passing on the second attempt. As a result, all eight participants graduated from the training programme and became peer leaders. Satisfaction ratings for programme length, balance between content and skills development, and preparation for leading support activities were uniformly high. Ratings for the instructional methods ranged between effective and very effective.

CONCLUSION

Findings suggest it is feasible to train and graduate peer leaders with the necessary skills to facilitate a diabetes self-management support intervention.

Do older adults aged 60-75 years benefit from diabetes behavioral interventions?

OBJECTIVE

In this secondary analysis, we examined whether older adults with diabetes (aged 60-75 years) could benefit from self-management interventions compared with younger adults. Seventy-one community-dwelling older adults and 151 younger adults were randomized to attend a structured behavioral group, an attention control group, or one-to-one education.

RESEARCH DESIGN AND METHODS

We measured A1C, self-care (3-day pedometer readings, blood glucose checks, and frequency of self-care), and psychosocial factors (quality of life, diabetes distress, frustration with self-care, depression, self-efficacy, and coping styles) at baseline and 3, 6, and 12 months postintervention.

RESULTS

Both older (age 67 ± 5 years, A1C 8.7 ± 0.8%, duration 20 ± 12 years, 30% type 1 diabetes, 83% white, 41% female) and younger (age 47 ± 9 years, A1C 9.2 ± 1.2%, 18 ± 12 years with diabetes, 59% type 1 diabetes, 82% white, 55% female) adults had improved A1C equally over time. Importantly, older and younger adults in the group conditions improved more and maintained improvements at 12 months (older structured behavioral group change in A1C -0.72 ± 1.4%, older control group -0.65 ± 0.9%, younger behavioral group -0.55 ± 1.2%, younger control group -0.43 ± 1.7%). Furthermore, frequency of self-care, glucose checks, depressive symptoms, quality of life, distress, frustration with self-care, self-efficacy, and emotional coping improved in older and younger participants at follow-up.

CONCLUSIONS

The findings suggest that, compared with younger adults, older adults receive equal glycemic benefit from participating in self-management interventions. Moreover, older adults showed the greatest glycemic improvement in the two group conditions. Clinicians can safely recommend group diabetes interventions to community-dwelling older adults with poor glycemic control.

Predictors of diabetes outcomes in Mexico: testing the Hispanic health protection model

Given the high morbidity and mortality rate of Hispanic immigrants to the United States, a study of the Hispanic Health Protection Model (HHPM) was replicated with 109 residents in Mexico who were newly diagnosed with diabetes. People with diabetes from rural clinics in Tlaxcala underwent a three-phase interview process with laboratory and weight follow-up over 4 to 6 months following a confirmed diagnosis of diabetes. This predictive, correlational study replicated the HHPM and the previous U.S. findings, including relationships between lifestyle profile, health beliefs, professional and social support, self-efficacy, diabetes knowledge, quality of life (self-satisfaction and impact of diabetes), and changes in HbA1c and body mass index. The study found that participants frequently followed good lifestyle practices while continuing to adhere to culturally based treatment and attribution beliefs. There were moderate perceptions of diabetes self-care efficacy, low ratings of support, very poor understanding of diabetes, continued obesity, acceptable quality of life ratings, and near-normal HbA1c levels.

Evidence-based decision-making: the case for diabetes care

Clinical decisions in diabetes care are complex, because they cover a wide range of unrelated issues which are affected by varied contexts of healthcare providers from multiple disciplines. The purpose of this paper is to reflect on the extent to which evidence is used to underpin clinical decisions within the area of diabetes care. In order to do this, it is necessary to capture information on the application of principles of evidence-based practice in diabetes care. Publications debating the nature of evidence-based practice and diabetes care were identified through searching the MEDLINE and CINAHL databases and located through the search engine Google. Additional publications were identified from references cited in relevant papers. These publications viewed evidence-based decisions as a balanced integration of different aspects of the clinical situation such as patient preference and clinician experience, in addition to the best available evidence. Simultaneously, each aspect of clinical care needs different forms of evidence. This is the argument for evidence-based diabetes care, where heterogeneous variables interact in different milieus. In conclusion, evidence-based diabetes care is a loose structure and set of ideas which needs to be adjusted according to each specific clinical situation.

Coping and distress as predictors of glycemic control in diabetes

This study attempts to identify the relative contribution of coping styles (task-, emotion-oriented and avoidance) and anxiety and diabetes-related distress to glycemic control in IDDM (Insulin Dependent Diabetes Mellitus) patients. Recent research suggests that coping and distress may as well be determinants as consequences of certain characteristics of the illness and subject. This points to the need to control some of these variables in diabetic research. Ninety seven IDDM patients from an outpatient unit were included. Measures were self-report questionnaires (CISS, STAI-Y, PAID) and biological data (HbA1C i.e. metabolic control). When potential confounds were controlled for (current age, age at onset, gender, presence of complication), three main predictors of metabolic control could be isolated through hierarchical regression analysis: (1) presence of complications; (2) task-oriented coping style; and (3) diabetes-related distress. Three steps were included in predictors: illness and subject variables (step 1); coping styles (step 2); and negative emotions (step 3). Each step contributed to a significant increase in variance. Emotion-oriented coping style appeared as redundant with distress measures. Results suggest that the relations between psychological predictors and metabolic control would be closer in women. These results partly replicate other findings, and advocate for a better consideration of emotional factors in the prediction of blood glucose control in this disease.

Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis

BACKGROUND

Diabetes self-management education (DSME) can be delivered in many forms. Group based DSME is widespread due to being a cheaper method and the added advantages of having patient meet and discuss with each other. assess effects of group-based DSME compared to routine treatment on clinical, lifestyle and psychosocial outcomes in type-2 diabetes patients.

METHODS

A systematic review with meta-analysis. Computerised bibliographic database were searched up to January 2008 for randomised controlled trials evaluating group-based DSME for adult type-2 diabetics versus routine treatment where the intervention had at least one session and =/>6 months follow-up. At least two reviewers independently extracted data and assessed study quality.

RESULTS

In total 21 studies (26 publications, 2833 participants) were included. Of all the participants 4 out of 10 were male, baseline age was 60 years, BMI 31.6, HbA1c 8.23%, diabetes duration 8 years and 82% used medication. For the main clinical outcomes, HbA1c was significantly reduced at 6 months (0.44% points; P=0.0006, 13 studies, 1883 participants), 12 months (0.46% points; P=0.001, 11 studies, 1503 participants) and 2 years (0.87% points; P<0.00001, 3 studies, 397 participants) and fasting blood glucose levels were also significantly reduced at 12 months (1.26 mmol/l; P<0.00001, 5 studies, 690 participants) but not at 6 months. For the main lifestyle outcomes, diabetes knowledge was improved significantly at 6 months (SMD 0.83; P=0.00001, 6 studies, 768 participants), 12 months (SMD 0.85; P<0.00001, 5 studies, 955 participants) and 2 years (SMD 1.59; P=0.03, 2 studies, 355 participants) and self-management skills also improved significantly at 6 months (SMD 0.55; P=0.01, 4 studies, 534 participants). For the main psychosocial outcomes, there were significant improvement for empowerment/self-efficacy (SMD 0.28, P=0.01, 2 studies, 326 participants) after 6 months. For quality of life no conclusion could be drawn due to high heterogeneity. For the secondary outcomes there were significant improvements in patient satisfaction and body weight at 12 months for the intervention group. There were no differences between the groups in mortality rate, body mass index, blood pressure and lipid profile.

CONCLUSIONS

Group-based DSME in people with type 2 diabetes results in improvements in clinical, lifestyle and psychosocial outcomes.

Improvement of HbA(1c) and stable weight loss 2 years after an outpatient treatment and teaching program for patients with type 2 diabetes without insulin therapy based on urine glucose self-monitoring

Objective

Long-term outcomes after participation in a structured diabetes treatment and teaching program (DTTP) for patients with diabetes without insulin use, primarily based upon postprandial urine glucose self-monitoring (UGSM).

Methods

A total of 126 patients took part in the DTTP in a university outpatient department in 2004–2005. We re-evaluated 119 (94.4%) at baseline and at 6 months, 12 months, and 24 months. Hemoglobin A_1c (HbA_1c) was DCCT adjusted.

Results

HbA_1c decreased significantly 6 months after education from 7.33% (±1.59%) to 6.89% (±0.98%; P = 0.001 versus baseline) and was maintained for up to 12 months (7.02% ± 1.07%; P = 0.017 versus baseline) as well as up to 24 months (6.96% ± 1.06%; P = 0.005 versus baseline). Weight decreased from 92.5 kg at baseline to 90.3 kg at 24 months (P = 0.014). A total of 36.5% of patients not on insulin therapy preferred UGSM, whereas 23.5% preferred blood glucose monitoring, at 24 months. Glucose control was similar in both groups at 24 months (HbA_1c UGSM 7.03 versus blood glucose monitoring 6.97%; P = 0.807).

Conclusion

Participation in the DTTP resulted in long-term behavior modification. HbA_1c of patients without insulin met the target 24 months after the DTTP, irrespective of the type of glucose self-monitoring.

Sustaining short-term improvements over the long-term: results from a 2-year diabetes self-management support (DSMS) intervention

AIM

This study examined the long-term impact of a 24-month, empowerment-based diabetes self-management support (DSMS) intervention on sustaining health-gains achieved from previous diabetes self-management education (DSME).

METHODS

Prior to the intervention, all participants received 6 months of mailed DSME consisting of weekly educational newsletters coupled with clinical feedback. The intervention consisted of 88 weekly group-based sessions that participants were encouraged to attend as frequently as they needed. Sessions were guided by participants' self-management questions and also emphasized experiential learning, coping, goal-setting, and problem-solving. Baseline, 6-month, and 30-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL.

RESULTS

This report is based on 60 African-American adults with type 2 diabetes (n=89 recruited at baseline) who completed the study. Post 6-month DSME, participants demonstrated significant improvements for diastolic BP (p<0.05), serum cholesterol (p<0.001), healthy diet (p<0.01), blood glucose monitoring (p<0.05) and foot exams (p<0.01). Post 24-month intervention, participants sustained the improvements achieved from the 6-month DSME and reported additional improvements for healthy diet (p<0.05), carbohydrate spacing (p<0.01), insulin use (p<0.05), and quality of life (p<0.05).

CONCLUSIONS

Findings suggest that an empowerment-based DSMS model can sustain or improve diabetes-related health gains achieved from previous short-term DSME.

Self-management problem solving for adolescents with type 1 diabetes: intervention processes associated with an Internet program

OBJECTIVE

Describe intervention processes associated with an Internet self-management problem solving program for adolescents with type 1 diabetes, and relate participant characteristics to program use.

METHODS

Forty-one adolescents with type 1 diabetes, aged 13-17, participated in an Internet intervention.

RESULTS

Participants reported psychosocial self-management barriers related to social issues (45%), time pressures (22%), and emotions (25%). Most adolescents (76%) completed the two guided problem solving cycles, and most (97%) problems were appropriate and specific to diabetes. Of the 61 diabetes problems reported, 92% were mostly or completely solved. Baseline hemoglobin A1c, diabetes duration, and age were not related to online activities, however females posted more often to the forum (U=130.0, Z=2.13, p=.033). The majority of parents (87%) interacted with their child about the website.

CONCLUSION

Adolescents experience psychosocial barriers to self-management that can be addressed by teaching problem solving via the Internet.

PRACTICE IMPLICATIONS

An Internet self-management problem solving program with minimal external support provides a viable option for diabetes clinics to improve pediatric diabetes outcomes.

Training peers to provide ongoing diabetes self-management support (DSMS): results from a pilot study

OBJECTIVE

This study determined the feasibility of training adults with diabetes to lead diabetes self-management support (DSMS) interventions, examined whether participants can achieve the criteria required for successful graduation, and assessed perceived efficacy of and satisfaction with the peer leader training (PLT) program.

METHODS

We recruited nine African-American adults with diabetes for a 46-h PLT pilot program conducted over 12 weeks. The program utilized multiple instructional methods, reviewed key diabetes education content areas, and provided communication, facilitation, and behavior change skills training. Participants were given three attempts to achieve the pre-established competency criteria for diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy.

RESULTS

On the first attempt 75%, 75%, 63%, and 75% passed diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy, respectively. Those participants who did not pass on first attempt passed on the second attempt. Participants were highly satisfied with the program length, balance between content and skills development, and preparation for leading support activities.

CONCLUSION

Findings suggest that it is feasible to train and graduate peer leaders with the necessary knowledge and skills to facilitate DSMS interventions.

PRACTICAL IMPLICATIONS

With proper training, peer support may be a viable model for translating and sustaining DSMS interventions into community-based settings.