How can structured self-management patient education improve outcomes in people with type 2 diabetes?

Patient-centered nutrition education improved the eating behavior of persons with uncontrolled type 2 diabetes mellitus in North Ethiopia: a quasi-experimental study

Background

Improving the clinical outcome of people with type 2 diabetes mellitus by modifying their eating behavior through nutrition education is an important element of diabetes self-management. Significant data from the literature supports this idea, however in the Ethiopian setting, there is a practice gap. Therefore, the purpose of this study was to assess how patient-centered nutrition education affected the eating behavior and clinical outcomes of people with uncontrolled type 2 diabetes mellitus.

Method

In this quasi-experimental trial, 178 people with uncontrolled type 2 diabetes were purposely assigned to the intervention (n = 89) or control (n = 89) arm. The intervention arm was given patient-centered nutrition education, whereas the control arm received the routine care. Eating behavior and clinical outcome indicators such as HbAc, lipid profile, anthropometric indices, and blood pressure were assessed in both groups at the start and completion of the intervention. All scale variables were tested for normality and log transformed when appropriate. The baseline characteristics of the intervention and control groups were compared using the t-test for continuous variables and the chi-square test for categorical variables. The effect of nutrition education was determined using a difference in differences (DID) approach. P < 0.05 was established as the criterion of significance.

Result

Food selection (DID = 15.84, P < 0.001), meal planning (DID = 31.11, P < 0.001), and calorie needs (DID = 37.65, P < 0.001) scores were statistically higher in the nutrition education arm. Furthermore, their overall eating behavior score (DID = 27.06, P < 0.001) was statistically greater than the controls. In terms of clinical outcomes, the overall picture reveals that the intervention did not outperform over the routine care. However, in comparison to the controls, the intervention arm showed clinically significant improvement in HbA1c (DID = -0.258, P = 0.485).

Conclusion

Patient-centered nutrition education has resulted in positive adjustments in the eating behavior of people with uncontrolled type 2 diabetes mellitus. Furthermore, it has shown a great potential for improving their glycemic control.

Underlying mechanisms of diabetes knowledge influencing diabetes self-management behaviors among patients with type II diabetes in rural China: Based on health belief model

OBJECTIVE

To investigate the association between diabetes knowledge and diabetes self-management (DSM) behaviors and to explore the influence mechanism between them among patients with type 2 diabetes mellitus (T2DM) based on health belief model in rural China.

METHODS

This cross-sectional study included 483 participants with T2DM from 8 villages of 3 townships in Jiangsu Province. All participants completed a structured questionnaire, including demographic information, diabetes knowledge, DSM behaviors, health beliefs, and cognitive function. Multiple linear regression and mediation analysis were performed to analyze the association between diabetes knowledge and DSM behaviors, furthermore the mechanism between them.

RESULTS

Diabetes knowledge and self-efficacy positively influenced DSM behaviors. Health beliefs multiply mediated the association between diabetes knowledge and DSM behaviors. Perceived behavioral barriers mediated the relationship between diabetes knowledge and DSM behaviors, where a suppression effect existed. A chain-mediated effect was found: diabetes knowledge affected perceived benefits, followed by self-efficacy, and finally DSM behaviors.

CONCLUSION

Diabetes knowledge acquisition played an important role in improving DSM behaviors, and health beliefs multiply mediated the relationship between them.

PRACTICE IMPLICATIONS

When designing interventions, health systems and health providers should refocus on diabetes knowledge, emphasize the benefits of self-management, and consider the barriers that patients may encounter.

Relationship between diabetic knowledge, attitudes and practices among patients with diabetes in China: a structural equation model

OBJECTIVES

Whether the routine delivery of diabetes-related knowledge can change patients' attitudes and hence influence their self-management activities remains unknown in primary healthcare settings in China. Thus, this study aims to explore the complex transformation process between knowledge, attitude and practice (KAP) among patients with diabetes in a city in China.

DESIGN

A cross-sectional study.

SETTING

Yuhuan City, Zhejiang Province, China.

PARTICIPANTS

A total of 803 patients with diabetes were invited to attend a questionnaire survey and 782 patients with type 2 diabetes completed the survey. The average age of participants was 58.47 years old, 48.21% of whom only attended primary school or below.

PRIMARY AND SECONDARY OUTCOME MEASURES

A questionnaire based on existing scales and expert consultation was applied to assess patients' socio-demographic information (SI), disease progression risk and diabetes-related KAP. A structural equation model was built to analyse the relationships between patients' characteristics and KAP.

RESULTS

No significant association was found between patients' knowledge and attitude (β=0.01, p=0.43). Better knowledge and attitude were both found to be associated with better diet and physical activities (β=0.58, p<0.001; β=0.46, p=0.01). However, patients with a more positive attitude toward diabetic care showed worse foot care practice (β=-0.13, p=0.02), while better knowledge was associated with better foot care practice (β=0.29, p<0.001). In addition, patients with higher SI (β=0.88, p<0.001) and/or disease progression risk (β=0.42, p<0.001) tended to present higher levels of disease knowledge.

CONCLUSIONS

While successful KAP transformation has been achieved in practice for diet and physical activities, there is a need to improve foot care practice. Health education should also prioritise the prevention, detection and care of diabetic foot. Also, appropriate methods should be adopted to deliver health education to vulnerable patients, such as the elderly, those living in rural areas, those with minimal education, the unemployed and low-income patients.

Assessment of the quality and reliability of the information on spasticity on youtube

BACKGROUND

Youtube has become an influential source of health. This study aimed to evaluate the reliability and quality of YouTube videos on spasticity.

METHODS

The keywords " spasticity, spasticity treatment, spasticity exercises" were used to search for videos. According to the search results, 180 videos were analyzed, videometric characteristics of the videos were recorded, and 2 groups were formed as health professionals and non-health professionals according to the video source. In addition, low, medium and high quality groups were formed using the global quality score (GQS). The reliability of the videos was evaluated using the modified DISCERN (mDISCERN) scale. Video popularity was assessed using the video power index (VPI).

RESULTS

After excluding videos that met the exclusion criteria, the remaining 68 videos were analyzed. The videos were uploaded by healthcare professionals (n = 47, 69.1%) and non-healthcare professionals (n = 21, 30.9%). The popularity (VPI), reliability (mDISCERN) and quality (GQS) of videos uploaded by healthcare professionals were significantly higher (p = 0.002, p = 0.001, p = 0.021, respectively). Most of the videos were of high quality according to GQS (n = 40, 58.8%). All of the high quality videos were of healthcare professionals. The number of sources from healthcare professionals was significantly higher in high quality videos than in both low (p = 0.001) and medium (p = 0.001) quality videos.

CONCLUSION

We can conclude that most of the YouTube videos on spasticity are reliable and of high quality. However, it should be kept in mind that patients may be exposed to low-quality and unreliable videos with misleading content.

The effects of a nurse-led integrative medicine-based structured education program on self-management behaviors among individuals with newly diagnosed type 2 diabetes: a randomized controlled trial

Background

International guidelines advocate providing prompt structured education to individuals with diabetes at diagnosis. However, among the few eligible structured education programs, heterogeneous intervention regimens and inconsistent findings were reported. Eligible programs for Chinese individuals with diabetes are lacking. This study aimed to investigate the effects of a nurse-led integrative medicine-based structured education program on self-management behaviors, glycemic control and self-efficacy among individuals with newly diagnosed type 2 diabetes.

Methods

Employing a randomized controlled trial, 128 individuals with type 2 diabetes diagnosed in the preceding three to nine months were recruited from four university-affiliated tertiary hospitals in Xi’an City, Northwest China, and randomly allocated to the intervention or control groups after baseline assessments. Participants in the intervention group received a 4-week nurse-led integrative medicine-based structured education program, which is theoretically based on the Health Belief Model and Self-Efficacy Theory, in line with updated diabetes management guidelines, and informed by relevant systematic reviews. Participants in the control group received routine care. Self-management behaviors and self-efficacy were measured with the Summary of Diabetes Self-Care Activities and the Diabetes Management Self-Efficacy Scale at baseline, immediate post-intervention and 12 weeks following the intervention while Glycated Hemoglobin A was measured at baseline and the 12th-week follow-up. The intervention effects were estimated using the generalized estimating equation models.

Results

Participants in the intervention group exhibited significantly better self-management performance in specific diet regarding intake of fruits and vegetables at both follow-ups (β = 1.02, p = 0.011 and β = 0.98, p = 0.016, respectively), specific diet regarding intake of high-fat foods at the immediate post-intervention follow-up (β = 0.83, p = 0.023), blood glucose monitoring at the 12th-week follow-up (β = 0.64, p = 0.004), foot care at both follow-ups (β = 1.80, p <  0.001 and β = 2.02, p <  0.001, respectively), and medication management at both follow-ups (β = 0.83, p = 0.005 and β = 0.95, p = 0.003, respectively). The intervention also introduced significant improvements in Glycated Hemoglobin A (β = − 0.32%, p <  0.001), and self-efficacy at both follow-ups (β = 8.73, p <  0.001 and β = 9.71, p <  0.001, respectively).

Conclusions

The nurse-led integrative medicine-based structured education program could produce beneficial effects on multiple diabetes self-management behaviors, glycemic control and self-efficacy.

Trial registration

This study was retrospectively registered in the ClinicalTrials.gov. on 25/08/2017; registration number: NCT03261895.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00970-7.

Participation in structured diabetes self-management education programs and its associations with self-management behaviour - a nationwide population-based study

OBJECTIVE

To evaluate the relationship between participation in structured diabetes self-management education programs (DSME) and self-management behaviour (SMB) in routine care.

METHODS

The study included 864 ever- and 515 never-DSME participants from the population-based survey German Health Update (GEDA) 2014/2015. SMB and clinical care variables were: Following a diet plan, keeping a diabetes diary, holding a diabetes pass, self-monitoring of blood glucose (SMBG), foot self-examination (FSE), retinopathy screening, haemoglobin A1c (HbA1c) measurement and examination of the feet by clinicians (FEC). We conducted logistic regression analyses for association of DSME-participation with SMB, adjusting for various variables.

RESULTS

DSME-participation was significantly associated with SMB including following a diet plan (OR 1.88 [95% CI 1.21-2.92]), keeping a diabetes journal (OR 3.83 [2.74-5.36]), holding a diabetes health passport (OR 6.11 [4.40-8.48]), SMBG (OR 2.96 [2.20-3.98]) and FSE (OR 2.64 [2.01-3.47]) as well as retinopathy screening (OR 3.30 [2.31-4.70]), HbA1c measurement (OR 2.58 [1.88-3.52]), and FEC (OR 3.68 [2.76-4.89]) after adjusting for confounders.

CONCLUSION

DSME-participation is associated with higher frequencies of various SMB and clinical care variables in routine care. Never-DSME attenders are more likely not to receive retinopathy screening, FEC and HbA1c measurements as recommended.

PRACTICE IMPLICATIONS

Clinicians should refer diabetes patients to a DSME and ensure a regular follow up for never-DSME attenders.

Patient Centered Studies Focused on Type 2 Diabetes Management, Education, and Family Support: A Scoping Review

BACKGROUND

Although a large amount of research has been conducted in diabetes management, many of the articles do not focus on patient-centered questions and concerns. To address this shortcoming, patients and various other stakeholders from three northern Mississippi communities co-created research questions focused on Type 2 diabetes management.

OBJECTIVE

To identify the diabetes management literature pertaining to each of the six patient-developed research questions from March 2010 to July 2020.

METHODS

A scoping review was conducted via PubMed to identify research articles from March 2010 to July 2020 focused on patient-centered Type 2 diabetes studies relevant to the six research questions.

RESULTS

A total of 1,414 studies were identified via the search strategy and 34 were included for qualitative analysis following article exclusion. For one of the research questions, there were no articles included. For the remaining research questions, the number of articles identified ranged from two to eleven. After analysis of the included articles, it was found that these questions either lacked extensive data or had not been implemented in the practice of diabetes management.

CONCLUSION

Additional research is warranted for three of the five questions, as current evidence is either lacking or contradictory. In the remaining two questions, it seems that adequate current research exists to warrant transitioning to implementation focused studies wherein data may be generated to improve sustainability and scaling of current programming.

Insights about interventions to address food insecurity in adults with type 2 diabetes: Valuable lessons from the stories of African Americans living in the inner city

OBJECTIVES

This qualitative study aimed to gain insight from the perspectives of food insecure African Americans living in an inner city regarding important diabetes intervention strategies and components.

METHODS

Using a grounded theory approach, two focus groups (totaling 16 individuals) were conducted in Milwaukee, Wisconsin. Purposive, convenience sampling was used to identify food insecure adults with diabetes. Questions were asked using a moderator guide to explore challenges and barriers to managing diabetes within the context of food insecurity, and facilitators or resources that helped participants improve diabetes management. Questions were open ended and followed by probes asking for additional perspectives and personal experiences related to the overarching topic, and questions asking to clarify statements.

RESULTS

Overarching concepts and themes specific to possible interventions discussed during the focus groups included group education, peer support, access to community resources and programs, stress management, and faith-based programs as desired intervention outcomes.

CONCLUSIONS

Key findings from the current study show that inner-city African Americans with diabetes desire interventions that foster social and community support systems.

PRACTICE IMPLICATIONS

Given this insight, more robust and comprehensive interventions are needed to account for the multifaceted experience of food insecurity and diabetes within the inner-city environment.

Costs and its drivers for diabetes mellitus type 2 patients in France and Germany: a systematic review of economic studies

BACKGROUND

Type 2 diabetes represents an increasingly critical challenge for health policy worldwide. It absorbs massive resources from both patients and national economies to sustain direct costs of the treatment of type 2 diabetes and its complications and indirect costs related to work loss and wages. More recently, there are innovations based on remote control and personalised programs that promise a more cost-effective diabetes management while reducing diabetes-related complications. In such a context, this work attempts to update cost analysis reviews on type 2 diabetes, focusing on France and Germany, in order to explore most significant cost drivers and cost-saving opportunities through innovations in diabetes care. Although both countries approach care delivery differently, France and Germany represent the primary European markets for diabetes technologies.

METHODS

A systematic review of the literature listed in MEDLINE, Embase and EconLit has been carried out. It covered interventional, observational and modelling studies on expenditures for type 2 diabetes management in France or Germany published since 2012. Included articles were analysed for annual direct, associated and indirect costs of type 2 diabetes patients. An appraisal of study quality was performed. Results were summarised narratively.

RESULTS

From 1260 records, the final sample was composed of 24 papers selected according to predefined inclusion/exclusion criteria. Both France and Germany revealed a predominant focus on direct costs. Comparability was limited due to different study populations and cost categories used. Indirect costs were only available in Germany. According to prior literature, reported cost drivers are hospitalisation, prescriptions, higher HbA1c and BMI, treatment with insulin and complications, all indicators of disease severity. The diversity of available data and included costs limits the results and may explain the differences found.

CONCLUSIONS

Complication prevention and glycaemic control are widely recognized as the most effective ways to control diabetes treatment costs. The value propositions of self-based supports, such as hybrid closed-loop metabolic systems, already implemented in type 1 diabetes management, are the key points for further debates and policymaking, which should involve the perspectives of caregivers, patients and payers.

Evaluating the effect of health education program on outcomes of type I diabetic patients: A randomized controlled study

Background; findings from the meta-analysis have shown that patients present improvements in glycaemic control, and in the prevention and control of the acute and chronic complications, when they receive effective treatment, self-management support and regular monitoring. The present study aimed to evaluate the effect of implementing a health education program on outcomes of type I diabetic patients. Quasi-experimental study design was used to fulfill the aim of the study. The study was conducted in the outpatient diabetic clinic at Asyut University Hospital; 60 adult male and female patients who attended the outpatient diabetic clinic were included. Two tools were used in this study; structured interviewing questionnaire with three parts; part one: demographic patient variables, part two: patient's medical data and part three: patient's knowledge regarding diabetes, the second tool is evaluation of type I diabetic patients' outcomes (pre/post). Results revealed that the highest percentage of the studied samples were in the age group 18 to less than 30 years, 90.0% of the study group and 83.4% of the control group were having a family history of diabetes, a statistically significant difference was found in the study group patients pre and post application of the program regarding insulin injection and glycemic control. Conclusion: this study demonstrated the effectiveness of health education program implementation on the outcomes of type I diabetic patients in terms of improved knowledge and practicing exercise, teeth care, feet care and on glycemic control.

What are the development priorities for management of type 2 diabetes by general practitioners in Ningbo, China: a qualitative study of patients' and practitioners' perspectives

OBJECTIVES

To explore patients' and general practitioners' (GPs') perspectives on primary care management of patients with type 2 diabetes mellitus (T2DM) in Ningbo, China. We aimed to understand the current benefits and challenges and to identify development priorities.

DESIGN

Exploratory qualitative descriptive study using face-to-face interviews and analysed by thematic, inductive analysis.

SETTING

11 primary care facilities spread across the city of Ningbo, China.

PARTICIPANTS

23 patients with T2DM and 20 GPs involved in caring for patients with T2DM.

RESULTS

GPs were considered the first point of contact and providers of information. However, the care varied, and many GPs lacked confidence and felt overworked. The medication was a particularly weak area. The diagnostic screening commenced late, leading to crisis presentations. Patients were variably informed about their condition, contributing to poor adherence.

CONCLUSIONS

Future developments of primary care for T2DM in Ningbo should centre around improving GP confidence and workload and patient education and adherence.

Effect of an educational intervention on public knowledge, attitudes, and intended practices towards diabetes mellitus: A quasi-experimental study

AIM

To assess the impact of educational workshops on the knowledge, attitudes, and intended practices (KAP) of the general public towards diabetes in Jordan in terms of symptoms, risk factors, complications, and prevention.

METHODS

A pharmacist led educational intervention and Propensity score matching was carried out for a convenience sample to assess Jordanians pre- and post-knowledge, attitudes, and practices towards diabetes mellitus (DM) using a validated questionnaire.

RESULTS

Among the 357 invited participants, 335 attended the educational workshops (response rate 93.8%). Prior to intervention, participants showed an overall knowledge score of 16.03 ± 4.88. About half of the participants knew that a sedentary lifestyle is a risk factor for getting DM (n = 172, 51.3%). Following educational intervention, knowledge scores significantly improved to be 21.36 ± 2.11 (P value < .001). A similar finding was obtained for attitude scores, where mean attitude scores significantly improved from 2.74 ± 1.94 before intervention to 4.40 ± 1.87 following the workshop (P value < .001). As for the intended practices, the educational intervention improved the participants' intent to exercise, eat healthy foods, and do annual screening.

CONCLUSIONS

Participants' knowledge, attitudes, and intended practices improved following a trained pharmacy led educational intervention. These encouraging results highlight the need for continuous national educational interventions about diabetes provided by trained health care professionals such as pharmacists. Future studies are needed to evaluate the impact of improved knowledge and perceptions on actual long-term practice.

Individual differences in impulsivity and need for cognition as potential risk or resilience factors of diabetes self-management and glycemic control

Objective

Impulsivity is marked by insufficient reflection and forethought, whereas Need for Cognition (NFC) also referred to as cognitive motivation or intellectual engagement is marked by elaborated thinking. The aim of this study was to investigate the potential role of these personality traits as resilience or risk factors, respectively, in diabetes self-management and glycaemic control. Further, it was examined whether diabetes-specific self-efficacy could serve as a mediator of these relationships.

Design/Measures

Data of 77 participants with type 2 diabetes was ascertained, using self-report instruments for NFC, impulsivity, diabetes-specific self-efficacy, and diabetes self-management. Glycemic control was assessed by the biomarker HbA_1c.

Results

While NFC was strongly positively associated with diabetes self-management and glycemic control, impulsivity showed a reverse pattern. Results of simple and serial mediation models showed that the effects on diabetes self-management and HbA1c of both, impulsivity and NFC, were mediated by self-efficacy.

Conclusion

The moderate to high standardized coefficients suggests that NFC might be an important protective factor and impulsivity a possible risk factor for effective diabetes self-management and glycemic control. These traits could be applied for an easy-to-use questionnaire-based patient screening, enabling trait-tailored treatments and programs which in turn may lower economic and health costs associated with poor diabetes-care.

Patient Centered Studies Focusing on Diabetes Self-Management: A Scoping Review

BACKGROUND

Type 2 diabetes continues to be a significant burden to patients and health systems globally. Addressing this condition from an alternative perspective, patients and various other stakeholders from three northern Mississippi communities co-created patient-centered research questions focused on type 2 diabetes management.

OBJECTIVE

The objective of this scoping review was to explore current literature focusing on nine patient- centered research questions to establish current knowledge and identify future research needs in the area of type 2 diabetes.

METHODS

A scoping review was conducted to obtain an overview of research related to the study purpose. The PubMed database was searched from March 2013 to March 2018 to identify patient-centered studies focused on type 2 diabetes and relevant to one of the nine research questions.

RESULTS

A total of 33 studies were identified and included. For five of the research questions, there was either no previous research literature or only "related" studies could be identified. These largely unexplored topics included how the understanding of guidelines by healthcare providers, specialty, and communication of medication side-effects impact patients' understanding and outcomes, the impact of improving patients' preparedness to communicate with providers, and whether younger patients require weight management programs that account for this populations' needs.

CONCLUSION

This lack of previous literature presents a unique opportunity to partner with patients to conduct this study and help improve the management of type 2 diabetes.

Influence of Supervised Disease Understanding and Diabetes Self-Management on Adherence to Oral Glucose-Lowering Treatment in Patients with Type 2 Diabetes

INTRODUCTION

Systematic patient education has been reported to improve adherence to treatment, leading to better clinical outcomes. This cluster randomized real-world study investigated the effect of a systematic education program and telephone support on self-reported adherence to oral glucose-lowering treatment in patients with type 2 diabetes mellitus (T2DM).

METHODS

Centers were randomized (1:1) to provide either standard-of-care (control group) or standard-of-care along with the education program and telephone support (empowerment group). Adherence to treatment and satisfaction with treatment were assessed using the four-item Morisky Medication Adherence Scale (MMAS-4) and the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The study population included 457 patients (258/199 male/female) with T2DM and non-optimal glycemic control, on oral antidiabetic treatment (age 62.7 [11.4]; disease duration 8.5 [6.5] years).

RESULTS

MMAS-4 high adherence rates for the control and empowerment groups were increased by 3.8% and 16.8% at 4 months (Breslow-Day test p = 0.04) and by 8.5% and 18.8% at 8 months of follow-up, respectively (Breslow-Day test p = 0.09), compared to baseline. Intense physical activity was increased in both control and empowerment groups by 2.3% and 13.9% at 4 months (Breslow-Day test p = 0.082) and by 4.0% and 22.5% at 8 months of follow-up (Breslow-Day test p < 0.001). Baseline mean (SD) HbA1c was significantly lower in the control group compared with the empowerment group [7.7% versus 8.0%, p = 0.001] and decreased in both groups at 4 months by 0.7% and 0.9%, respectively. The change from baseline in the mean DTSQ status score at 4 months was greater in the empowerment group, and the effect was sustained at 8 months (control group: 29.1, 30.5, and 30.9; empowerment group: 25.0, 28.7, and 29.4 at baseline, 4 and 8 months, respectively, p < 0.001).

CONCLUSION

Systematic education combined with telephone support delivered by physicians might be associated with improvement in treatment adherence and treatment satisfaction in patients with T2DM.

FUNDING

MSD, Greece.

Managing with Learning Disability and Diabetes: OK-Diabetes - a case-finding study and feasibility randomised controlled trial

BACKGROUND

Obesity and type 2 diabetes are common in adults with a learning disability. It is not known if the principles of self-management can be applied in this population.

OBJECTIVES

To develop and evaluate a case-finding method and undertake an observational study of adults with a learning disability and type 2 diabetes, to develop a standardised supported self-management (SSM) intervention and measure of adherence and to undertake a feasibility randomised controlled trial (RCT) of SSM versus treatment as usual (TAU).

DESIGN

Observational study and an individually randomised feasibility RCT.

SETTING

Three cities in West Yorkshire, UK.

PARTICIPANTS

In the observational study: adults aged > 18 years with a mild or moderate learning disability, who have type 2 diabetes that is not being treated with insulin and who are living in the community. Participants had mental capacity to consent to research and to the intervention. In the RCT participants had glycated haemoglobin (HbA_1c) levels of > 6.5% (48 mmol/mol), a body mass index (BMI) of > 25 kg/m² or self-reported physical activity below national guideline levels.

INTERVENTIONS

Standardised SSM. TAU supported by an easy-read booklet.

MAIN OUTCOME MEASURES

(1) The number of eligible participants identified and sources of referral; (2) current living and support arrangements; (3) current health state, including level of HbA_1c, BMI and waist circumference, blood pressure and lipids; (4) mood, preferences for change; (5) recruitment and retention in RCT; (6) implementation and adherence to the intervention; (7) completeness of data collection and values for candidate primary outcomes; and (8) qualitative data on participant experience of the research process and intervention.

RESULTS

In the observational study we identified 147 eligible consenting participants. The mean age was 54.4 years. In total, 130 out of 147 (88%) named a key supporter, with 113 supporters (77%) being involved in diabetes management. The mean HbA_1c level was 54.5 mmol/mol [standard deviation (SD) 14.8 mmol/mol; 7.1%, SD 1.4%]. The BMI of 65% of participants was > 30 kg/m² and of 21% was > 40 kg/m². Many participants reported low mood, dissatisfaction with lifestyle and diabetes management and an interest in change. Non-response rates were high (45/147, 31%) for medical data requested from the primary care team. In the RCT, 82 participants were randomised. The mean baseline HbA_1c level was 56 mmol/mol (SD 16.5 mmol/mol; 7.3%, SD 1.5%) and the mean BMI was 34 kg/m² (SD 7.6 kg/m²). All SSM sessions were completed by 35 out of 41 participants. The adherence measure was obtained in 37 out of 41 participants. The follow-up HbA_1c level and BMI was obtained for 75 out of 82 (91%) and 77 out of 82 (94%) participants, respectively. Most participants reported a positive experience of the intervention. A low response rate and difficulty understanding the EuroQol-5 Dimensions were challenges in obtaining data for an economic analysis.

LIMITATIONS

We recruited from only 60% of eligible general practices, and 90% of participants were on a general practice learning disability register, which meant that we did not recruit many participants from the wider population with milder learning disability.

CONCLUSIONS

A definitive RCT is feasible and would need to recruit 194 participants per arm. The main barrier is the resource-intensive nature of recruitment. Future research is needed into the effectiveness of obesity treatments in this population, particularly estimating the longer-term outcomes that are important for health benefit. Research is also needed into improving ways of assessing quality of life in adults with a learning disability.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41897033.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 26. See the NIHR Journals Library website for further project information.

A survey on patients' characteristics, perception of family support and diabetes self-management among type 2 diabetes patients in South-West Nigeria

AIM

To determine the association between patients' characteristics, perception of family support and diabetes self-management (DSM) behaviours among type 2 diabetes patients.

DESIGN

A descriptive cross-sectional design was used and data were collected between July-September 2016. The study is part of a larger quasi-experimental study.

METHODS

One hundred and ninety-seven diabetes mellitus (DM) patients from two teaching hospitals in south-west Nigeria participated. Questionnaire was used in collecting information on sociodemographic, clinical data, DSM and perception of family support.

RESULTS

Most (71.6%) of the participants were females and 35% were on insulin therapy. Mean age was 60.7 (SD: 11.3) years and 11.7% had had DM for over 20 years. Overall, DSM was positively influenced by previous diabetes education and duration of diabetes. Perception of family support was also positively associated with and influenced DSM.

Defining Quality in Hand Surgery From the Patient's Perspective: A Qualitative Analysis

PURPOSE

Quality measures are used to evaluate health care delivery. They are traditionally developed from the physician and health system viewpoint. This approach can lead to quality measures that promote care that may be misaligned with patient values and preferences. We completed an exploratory, qualitative study to identify how patients with hand problems define high-quality care. Our purpose was to develop a better understanding of the surgery and recovery experience of hand surgery patients, specifically focusing on knowledge gaps, experience, and the surgical process.

METHODS

A steering committee (n = 10) of patients who had previously undergone hand surgery reviewed and revised an open-ended survey. Ninety-nine patients who had undergone hand surgery at 2 tertiary care institutions completed the open-ended, structured questionnaire during their 6- to 8-week postoperative clinic visit. Two reviewers completed a thematic analysis to generate subcodes and codes to identify themes in high-quality care from the patient's perspective.

RESULTS

We identified 4 themes of high-quality care: (1) Being prepared and informed for the process of surgery, (2) Regaining hand function without pain or complication, (3) Patients and caregivers negotiating the physical and psychological challenges of recovery, and (4) Financial and logistical burdens of undergoing hand surgery.

CONCLUSIONS

Multiple areas that patients identify as representing high-quality care are not reflected in current quality measures for hand surgery. The patient-derived themes of high-quality care can inform future patient-centered quality measure development.

CLINICAL RELEVANCE

Efforts to improve health care delivery may have the greatest impact by addressing areas of care that are most valued by patients. Such areas include patient education, system navigation, the recovery process, and cost.

Patient empowerment and the Mediterranean diet as a possible tool to tackle prediabetes associated with overweight or obesity: a pilot study

AIM

The objective of this study was to investigate the effect of implementation of short-term patient empowerment as applied to Mediterranean diet (MD) adherence on metabolic and anthropometric parameters in prediabetic overweight or obese subjects.

METHODS

The sample included 42 subjects with prediabetes, aged 18-75 years and with body mass index (BMI) > 25 kg/m², who received dietary advice on MD by nutritionists during session groups every 2 weeks for 4 months. Data on energy caloric intake and macronutrient consumption were collected using a 7-day food diary record. Adherence to MD was investigated through the PREvención con DIeta MEDiterránea (PREDIMED) questionnaire. No advice was given regarding caloric restriction and physical activity. At baseline and at the end of the study, each subject underwent anthropometric, metabolic, and nutritional assessments.

RESULTS

Approximately 40.5% of subjects had achieved restoration of normal glucose tolerance by the end of the study. Fasting plasma glucose, glycated hemoglobin (HbA1C), BMI, waist circumference, blood pressure, visceral adiposity index, triglycerides, and total and LDL cholesterol levels were significantly decreased, while HDL cholesterol had significantly increased by the end of the study. The subjects significantly increased adherence to MD, as assessed by the PREDIMED questionnaire at follow-up. A reduction of prevalence of the metabolic syndrome was also reported. Interestingly, the PREDIMED score correlated with HbA1C values at follow-up, after adjusting for BMI and total caloric intake.

CONCLUSIONS

Implementation of short-term patient empowerment as applied to MD adherence was shown to improve anthropometric and metabolic parameters in prediabetic overweight or obese subjects. This is of considerable importance, given that diet must be the cornerstone of treatment in patients at high risk of developing type 2 diabetes.

Developing and Validating the Educational Materials for a Nurse-Led Self-Management Education in Adults with Type 2 Diabetes

<b><i>Background:</i></b> Diabetes education and self-care are the cornerstones of diabetes management. There are few nurse-led structured diabetes management programs available in Iran. <b><i>Objectives:</i></b> This paper aims to develop and validate a nurse-led diabetes self-management intervention for patients with type 2 diabetes. <b><i>Method:</i></b> The theoretical framework underpinning the intervention was the Bandura’s self-efficacy theory. The seven basic steps of the Taba model were used to develop and validate the study intervention. <b><i>Results:</i></b> The preliminary results from this study suggest that the study intervention was carefully contextualized and linked to the existing diabetes care. Overall, the intervention was very well received and appreciated by the respondents. <b><i>Conclusion:</i></b> This was the first known validated nurse-led diabetes self-management intervention available in the Persian Language.

Management of Chronic Disease and Hospitalization Due to Diabetes among Type 2 Diabetes Patients in Korea: Using the National Sample Cohort Data 2002⁻2013

To prevent negative outcomes for diabetes patients, developing self-management skills is imperative. This study aimed to examine the association between management of chronic disease (MCD), which mainly involves educating patients about their chronic diseases for obtaining self-management skills and hospitalization due to diabetes among type 2 diabetes patients in Korea. Korean National Health Insurance Service National Sample Cohort data from 2002 to 2013 were used. A total of 54,031 type 2 diabetes patients were included in the study. If patients received the MCD within 1 year from the onset of diabetes, we categorized them as “MCD received patients” We reclassified these groups into five groups: “non-receiving”, “1–3 times”, “4–6 times”, “7–9 times” and “10–12 times” The dependent variable of this study was hospitalization due to diabetes. Cox proportional hazard regression was used. Of the patients, 86.2% (n = 46,571) did not received the MCD within the 1 year from the onset of diabetes. The number of MCDs received increased and the hazard ratio (HR) for hospitalization due to diabetes decreased; particularly, patients who received MCD 10–12 times per annum showed the lowest HR for hospitalization due to diabetes compared to patients in the MCD non-received group (1–3 times per annum: HR: 0.81, p = 0.0001; 4–6 times per annum: HR: 0.82, p = 0.0248; 7–9 times per annum: HR: 0.75, p = 0.0054; 10–12 times per annum: HR: 0.61, p < 0.0001). Considering the importance of raising self-managing diabetes skills, the findings can aid in determining the outcomes of the MCD program.

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.

A web-based program to improve treatment adherence in patients with type 2 diabetes: Development and study protocol

BACKGROUND

Many patients with type 2 diabetes mellitus (T2DM) sub-optimally adhere to core treatment recommendations, such as healthy diets, sufficient physical activity and pharmacological support. This paper describes the development of the web-based computer-tailored program My Diabetes Profile (MDP), incorporating identified success factors of web-based interventions, and the protocol for testing the effectiveness of this program in a randomized multicentre trial.

METHODS

Formative research - including the input of a program committee, qualitative and quantitative studies with patients and health professionals and a literature search - yielded input for the development of the MDP program. MDP provides video and text tailored advice, based on determinants and salient beliefs derived from the I-Change Model, on decreasing unhealthy snack intake, increasing physical activity, and improving adherence to both oral blood glucose lowering drugs and self-administered insulin therapy. Patients with T2DM recruited by practice nurses and diabetes nurses across the Netherlands fill in online questionnaires at baseline and six-months follow-up. Participants are randomized on patient level to the intervention group (access to the MDP program) or control group (receiving care as usual).

DISCUSSION

The formative research using co-creation principles proved essential in the development of the MDP program and involved various disciplines in T2DM management including target group representatives. Co-creation revealed clearly that patients needed short and attractive messages. Consequently, a mix of video and short text messages were chosen for the ultimate program format. Pilot testing was useful to further shape the program to needs of patients and professionals.

TRIAL REGISTRATION

Dutch Trial Register NTR6840; Archived program website: http://www.webcitation.org/6xXz01S7X.

The diabetes self-management educational programs and their integration in the usual care: A systematic literature review

The increasing prevalence of type 2 diabetes has highlighted the importance of evidence-based guidelines for effective prevention, management and treatment. Diabetes self-management education (SME) produces positive effects on patient behaviours and health status. We analyzed the literature to identify (i) the level of integration between usual care and SME programs and (ii) any possible differences across them in terms of outcomes. Searches were made on three databases - PubMed, Scopus and Web of Science - to identify relevant publications on diabetes SME to 2015, which also describe the provider of usual care. In total, 49 studies met the inclusion criteria. We identified three levels of integration (high, medium and low) between usual care and SME programs based on the level of involvement of usual care professionals within the SME programs. In most cases, the primary care physician was responsible for the diabetes patients. Patient health behaviors and/or outcomes improve in most of the studies, independently from the level of integration. However, findings suggest that when patients/participants could perceive that usual care provider is highly involved in SME delivery, educational programs produced results that appear to be more positive.

Development of a supported self-management intervention for adults with type 2 diabetes and a learning disability

BACKGROUND

Although supported self-management is a well-recognised part of chronic disease management, it has not been routinely used as part of healthcare for adults with a learning disability. We developed an intervention for adults with a mild or moderate learning disability and type 2 diabetes, building on the principles of supported self-management with reasonable adjustments made for the target population.

METHODS

In five steps, we:Clarified the principles of supported self-management as reported in the published literatureIdentified the barriers to effective self-management of type 2 diabetes in adults with a learning disabilityReviewed existing materials that aim to support self-management of diabetes for people with a learning disabilitySynthesised the outputs from the first three phases and identified elements of supported self-management that were (a) most relevant to the needs of our target population and (b) most likely to be acceptable and useful to themImplemented and field tested the intervention.

RESULTS

The final intervention had four standardised components: (1) establishing the participant's daily routines and lifestyle, (2) identifying supporters and their roles, (3) using this information to inform setting realistic goals and providing materials to the patient and supporter to help them be achieved and (4) monitoring progress against goals.Of 41 people randomised in a feasibility RCT, thirty five (85%) completed the intervention sessions, with over three quarters of all participants (78%) attending at least three sessions.Twenty-three out of 40 (58%) participants were deemed to be very engaged with the sessions and 12/40 (30%) with the materials; 30 (73%) participants had another person present with them during at least one of their sessions; 15/41 (37%) were reported to have a very engaged main supporter, and 18/41 (44%) had a different person who was not their main supporter but who was engaged in the intervention implementation.

CONCLUSIONS

The intervention was feasible to deliver and, as judged by participation and engagement, acceptable to participants and those who supported them.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41897033 (registered 21/01/2013).

Effects of a Psychoeducational Program on Hemoglobin A1c Level and Health-Related Quality of Life in Patients with Type 2 Diabetes Mellitus, Jazan, Saudi Arabia

BACKGROUND

Diabetes mellitus (DM) is a growing health problem. Care programs should involve the patients to upgrade their diabetes condition and health-related quality of life (HRQoL).

OBJECTIVE

The present study aimed to assess the effects of a psychoeducational intervention program on an indicator of glycemic control and HRQoL among type 2 diabetic patients.

METHODS

In this quasi-experimental (pre- and postinterventional) study, 99 outpatients with type 2 diabetes were selected randomly from those attending primary health care centers in Jazan, Saudi Arabia, in 2016. Hemoglobin A1c levels (HbA1c) were measured by the colorimetric method, and HRQoL was assessed by the Arabic version of the RAND 36-Item Health Survey 1.0 (RAND-36). The psychoeducational program was conducted on the participants for 4 weeks, and preprogram findings were compared with the postprogram findings after a 5-month follow-up.

RESULTS

After the intervention, there was a statistically significant reduction in the mean value of HbA1c from 9.8 to 7.7 (P < 0.001), and there was significant improvement in the mean scores of the following HRQoL scales: role limitations due to emotional problems, energy/fatigue, emotional well-being, and general health (P < 0.01). In addition, the impact of the program on HRQoL was better among males and among patients who were older than forty years than among women and patients who were forty years old or younger.

CONCLUSION

The application of such psychoeducational intervention programs can be helpful in the improvement of HbA1c levels and HRQoL for patients with DM.

Impact of written information on control and adherence in type 2 diabetes

INTRODUCTION

Diabetes therapeutic education and information by leaflets is important. This study aimed to understand the effectiveness of written information to diabetic patients, after six months, in the control of diabetes and medication adherence.

METHOD

Non-pharmacological clinical trial. Randomized sample of diabetic patients of 65 volunteer doctors, distributed among the five health regions in Portugal. At the first appointment, patients were randomized in four groups (three intervention with validated leaflets and one control), leaflet reading being reinforced at the follow-up appointments in a 6-months period. Variables collected: HbA1c, home blood glucose, weight, waist circumference, blood pressure, cigarettes smoked, physical activity level, adherence to medication, medication, height, diabetes progression, age, sex and educational background. Descriptive and inferential statistics.

RESULTS

From the 709 patients recruited, 702 were studied in this 6-months period with no statistical differences in the baseline variables studied. After six months of intervention, the adherence to medication improved in the leaflet group (p=0.034). This was noticed in those under 65 years of age (p=0.027), with diabetes for ≤ 5 years (p=0.010), with educational background up to 4 years (p=0.030) and 9 years (p=0.006) and with HbA1c ≥ 7% at the beginning of the study.

CONCLUSION

Interventions with leaflets handed in primary healthcare to people with diabetes type 2 can bring benefits in what concerns adherence to therapeutics, namely in younger people with a less studies.

Targeting "hardly reached" people with chronic illness: a feasibility study of a person-centered self-management education approach

BACKGROUND

Self-management education is critical to the development of successful health behavior changes related to chronic illness. However, people in high-risk groups attend less frequently or benefit less from patient education programs than do people with more socioeconomic advantages.

AIM

The aim was to test the feasibility of a participatory person-centered education approach and tool-kit targeting self-management of chronic illness in hardly reached people.

METHODS

After participating in a training program, educators (n=77) tested the approach in practice. Data collection included online questionnaires for educators (n=65), observations of education sessions (n=7), and interviews with educators (n=11) and participants (n=22). Descriptive statistics were calculated. Transcripts of interviews and observations were analyzed using systematic text condensation. Feasibility was examined in terms of practicality, integration, suitability, and efficacy.

RESULTS

Educators had a positive response to the approach and found that the tools supported involving participants in education and support. Participant satisfaction varied, depending on the ability of educators to integrate the tools into programs in a meaningful way. The tools provided time for reflection in the education process that benefited participants and educators alike. Educators found it challenging to allow participants to help set the agenda and to exchange experiences without educator control. Barriers to use reported by educators included lack of time for both training and preparation.

LIMITATIONS

The testing included varied groups of participants, some groups included members of hardly reached populations and others did not. Also, some tools were only tried in practice by a few educators.

CONCLUSION

The approach was feasible in terms of practicality, integration, acceptability, and efficacy and perceived by educators as suitable for both hardly reached participants and those who are less disadvantaged. Implementation of the approach requires time for training and preparation.

Exploring beliefs on diabetes treatment adherence among Dutch type 2 diabetes patients and healthcare providers

OBJECTIVE

Despite well-known beneficial effects, adherence to core elements of diabetes treatment is suboptimal. This study, conducted in the Netherlands, aimed to explore if and how treatment adherence success factors are applied in diabetes consultations, and to explore salient personal beliefs about type 2 diabetes treatment including both healthy lifestyle adaptations and pharmacotherapy.

METHODS

A qualitative study using semi-structured interviews among nine Dutch healthcare providers predominantly involved in diabetes management and 19 Dutch type 2 diabetes patients. Data was systematically analysed through deductive coding analysis using Nvivo.

RESULTS

Most patients visited their consultations unprepared. Patients did not or vaguely experience goal-setting in consultations, whereas healthcare providers indicated to set treatment goals. Shared-decision making was applied, however patients were rather passive collaborators as mostly healthcare providers were in charge of making treatment decisions. Despite suboptimal treatment adherence, many advantages and few disadvantages of treatment strategies were reported. Adherence self-efficacy was lower in situations outside daily routine.

CONCLUSION

Treatment adherence success factors are not optimally applied, and in particular treatment adherence self-efficacy could be improved.

PRACTICE IMPLICATIONS

The application of treatment adherence success factors in consultations could be improved, and personal beliefs should be addressed to improve treatment adherence and optimize counselling.

New model for diabetes primary health care based on patient empowerment and the right to preventive health: the MIDE program

Objective.

To evaluate Mexico’s national Integrated Management of Diabetes in Stages (Manejo Integral de la Diabetes por Etapas, MIDE) program using three types of indicators: process, structure, and impact.

Methods.

A cross-sectional study was conducted using data for 97 452 people with diabetes (PWD) who participated in the MIDE patient empowerment program (PEP) at “MIDE modules” (standardized diabetes health care units) at Mexico’s Institute for Social Security and Services for State Workers (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, ISSSTE) hospital clinics and family medical clinics nationwide between 2007 and 2014. The program promotes diabetes patient empowerment and self-care through outpatient consultations with a multidisciplinary health care team supported by continuous training. Baseline data were compared with results post-program for the following indicators: process (metabolic control (MetC), based on glycated hemoglobin (HbA1c), triglyceride (TG), and total cholesterol (TC) levels); structure (number of MIDE modules installed at ISSSTE clinics and number of patients/health personnel accredited as diabetes experts/awarded diplomas); and impact (average number of patient illness days (IDs) and hospitalization episodes (HEs) per PWD over a 12-month period).

Results.

Over the seven-year study period, the proportion of patients with MetC (HbA1c < 7.0%, TG < 150 mg/dL, and TC < 200 mg/dL) increased significantly (from 35.4% to 60% (with a peak level of 62% in 2013); P < 0.001); average HbA1c, triglycerides, and total cholesterol per PWD dropped by 25%, 31%, and 11% respectively; average number of IDs and HEs per PWD over a 12-month period dropped by 38% and 41% respectively; a total of 140 MIDE modules were installed at ISSSTE clinics; and a total of 1 117 diplomas were awarded to 826 health professionals, and 2 613 PWD were accredited as “patient experts in diabetes.”

Conclusions.

The MIDE PEP is feasible, usable, and acceptable to PWD. The program improves MetC; reduces the frequency of IDs and HEs; and facilitates patient participation, the involvement of health personnel, and shared decision-making.

Construction and validation of the Self-care Assessment Instrument for patients with type 2 diabetes mellitus

Objective:

to construct and validate the contents of the Self-care Assessment instrument for patients with type 2 diabetes mellitus.

Method:

methodological study, based on Orem's General Theory of Nursing. The empirical categories and the items of the instrument were elucidated through a focus group. The content validation process was performed by seven specialists and the semantic analysis by 14 patients. The Content Validity Indices of the items, ≥0.78, and of the scale, ≥0.90, were considered excellent.

Results:

the instrument contains 131 items in six dimensions corresponding to the health deviation self-care requisites. Regarding the maintenance, a Content Validity Index of 0.98 was obtained for the full set of items, and, regarding the relevance, Content Validity Indices ≥0.80 were obtained for the majority of the assessed psychometric criteria.

Conclusion:

the instrument showed evidence of content validity.

A pilot service-evaluation examining change in HbA1c related to the prescription of internet-based education films for type 2 diabetes

We undertook a pilot service-evaluation of prescribed internet-based patient education films for patients with type 2 diabetes. The uptake was 28% and film watching was associated with a relative mean difference in HbA1c of -9.0mmol/mol in the film watchers compared to non-watchers over a three-month period (P=0.0008).

A Clinical Practice Guideline to Guide a System Approach to Diabetes Care in Hong Kong

The Hospital Authority of Hong Kong is a statutory body that manages all the public medical care institutions in Hong Kong. There are currently around 400,000 diabetic patients under its care at 17 hospitals (providing secondary care for 40%) and 73 General Outpatient Clinics (providing primary care for 60%). The patient population has been growing at 6% to 8% per year over the past 5 years, estimated to include over 95% of all diagnosed patients in Hong Kong. In order to provide equitable and a minimal level of care within resources and local system factors constraints, a Clinical Practice Guideline on the management of type 2 diabetes mellitus was drawn in 2013 to guide a system approach to providing diabetes care. There is an algorithm for the use of various hypoglycemic agents. An organizational drug formulary governs that less expansive options have to be used first. A number of clinical care and patient empowerment programs have been set up to support structured and systematic diabetes care. With such a system approach, there have been overall improvements in diabetes care with the percentage of patients with glycosylated hemoglobin <7% rising from 40% in 2010 to 52% in 2015.

Prevention and Care Programs Addressing the Growing Prevalence of Diabetes in China

According to a 2010 national survey, 11 % of adults in China have diabetes, affecting 109.6 million individuals. The high prevalence of diabetes has been attributed to the aging of the population, the rapid adoption of energy-dense foods, and a reduction in physical activity. Collectively, these secular changes have created an obesogenic environment that can unmask diabetes in subjects with a genetic predisposition. The growing prevalence of maternal obesity, gestational diabetes, childhood obesity, and early-onset disease can lead to premature morbidity and mortality. Rising to meet these public health challenges, researchers in China have conducted randomized studies to demonstrate the benefits of lifestyle modification in preventing diabetes (the Da Qing Study), as well as that of team-based integrated care, using multiple strategies including peer support and information technology, in order to reduce hospitalizations, cardiovascular-renal complications, and premature deaths. With growing evidence supporting the benefits of these diabetes prevention and management programs, the next challenge is to use policies and systems to scale up the implementation of these programs through raising awareness, building capacity, and providing resources to reduce the human and socioeconomic burden of diabetes.

A scoping review of the literature on benefits and challenges of participating in patient education programs aimed at promoting self-management for people living with chronic illness

OBJECTIVE

To give a comprehensive overview of benefits and challenges from participating in group based patient education programs that are carried out by health care professionals and lay participants, aimed at promoting self-management for people living with chronic illness.

METHODS

We searched 8 literature databases. Full text articles meeting the inclusion criteria were retrieved and reviewed. Arksey and O'Malley's framework for scoping studies guided the review process and thematic analysis was undertaken to synthesize extracted data.

RESULTS

Of the 5935 titles identified, 47 articles were included in this review. The participants experienced the programs as beneficial according to less symptom distress and greater awareness of their own health, improved self-management strategies, peer support, learning and hope.

CONCLUSION

A substantial evidence base supports the conclusion that group based self-management patient education programs in different ways have been experienced as beneficial, but more research is needed.

PRACTICE IMPLICATIONS

The insights gained from this review can enable researchers, health care professionals, and participants to understand the complexity in evaluating self-management patient education programs, and constitute a basis for a more standardized and systematic evaluation. The results may also encourage health care professionals in planning and carrying out programs in cooperation with lay participants.

Effect of a structured diabetes education programme in primary care on hospitalizations and emergency department visits among people with Type 2 diabetes mellitus: results from the Patient Empowerment Programme

AIM

To assess whether a structured diabetes education programme, the Patient Empowerment Programme, was associated with a lower rate of all-cause hospitalization and emergency department visits in a population-based cohort of patients with Type 2 diabetes mellitus in primary care.

METHODS

A cohort of 24 250 patients was evaluated using a linked administrative database during 2009-2013. We selected 12 125 patients with Type 2 diabetes who had at least one Patient Empowerment Programme session attendance. Patients who did not participate in the Patient Empowerment Programme were matched one-to-one with patients who did, using the propensity score method. Hospitalization events and emergency department visits were the events of interest. Cox proportional hazard and negative binomial regressions were performed to estimate the hazard ratios for the initial event, and incidence rate ratios for the number of events.

RESULTS

During a median 30.5 months of follow-up, participants in the Patient Empowerment Programme had a lower incidence of an initial hospitalization event (22.1 vs 25.2%; hazard ratio 0.879; P < 0.001) and emergency department visit (40.5 vs 44%; hazard ratio 0.901; P < 0.001) than those who did not participate in the Patient Empowerment Programme. Participation in the Patient Empowerment Programme was associated with a significantly lower number of emergency department visits (incidence rate ratio 0.903; P < 0.001): 40.4 visits per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 36.2 per 100 patients annually in those who did. There were significantly fewer hospitalization episodes (incidence rate ratio 0.854; P < 0.001): 20.0 hospitalizations per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 16.9 hospitalizations per 100 patients annually in those who did.

CONCLUSIONS

Among patients with Type 2 diabetes, the Patient Empowerment Programme was shown to be effective in delaying the initial hospitalization event and in reducing their frequency.

Is "disease management" the answer to our problems? No! Population health management and (disease) prevention require "management of overall well-being"

BACKGROUND

Disease management programs based on the chronic care model have achieved successful and long-term improvement in the quality of chronic care delivery and patients' health behaviors and physical quality of life. However, such programs have not been able to maintain or improve broader self-management abilities or social well-being, which decline over time in chronically ill patients. Disease management efforts, population health management initiatives and innovative primary care solutions are still mainly focused on clinical and functional outcomes and health behaviors (e.g., smoking cessation, exercise, and diet) failing to address individuals' overall quality of life and well-being. Individuals' ability to achieve well-being can be assessed with great specificity through the application of social production function (SPF) theory. This theory asserts that people produce their own well-being by trying to optimize the achievement of instrumental goals (stimulation, comfort, status, behavioral confirmation, affection) that provide the means to achieve the larger, universal goals of physical and social well-being.

DISCUSSION

A shift in focus from the management of physical function, disease limitations, and lifestyle behaviors alone to an approach that fosters self-management abilities such as self-efficacy and resource investment as well as overall quality of life, is urgently needed. Disease management interventions should be aimed at adequately addressing all difficulties chronically ill patients face in life, such as the effects of pain and fatigue on the ability to maintain a job and social life and to participate in activities promoting physical and social well-being. Patients' ability to maintain engagement in stimulating work and social activities with the people who are important to them may be even more important than aspects of disease self-management such as blood pressure or glycemic control. Interventions should aim to make chronically ill patients capable of managing their own well-being and adequately addressing their needs in a broader sense. So, is disease management the answer to our problems in the time of aging populations and increased prevalence of unhealthy lifestyles, chronic illnesses, and comorbidity? No! Effective (disease) prevention, disease management, patient-centered care, and high-quality chronic care and/or population health management calls for management of overall well-being.

Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP)

Patient Empowerment Programme (PEP) in primary care was effective in preventing diabetes-related complications in patients with diabetes. Nevertheless, the effect of PEP on glycaemic control, weight control, and complications was unclear in obese type 2 diabetic patients. We aimed to assess whether PEP reduced all-cause mortality, first macrovascular and microvascular disease events. A cohort of 6372 obese type 2 diabetic patients without prior occurrence of macrovascular or microvascular disease events on or before baseline study recruitment date was linked to the administrative database from 2008 to 2013. Non-PEP participants were matched one-to-one with the PEP participants using propensity score method with respect to their baseline covariates. Cox proportional hazard regressions were performed to estimate the associations of the PEP intervention with the occurrence of first macrovascular or microvascular disease events and death from any cause, controlling for demographic and clinical characteristics. During a median 31.5 months of follow-up, 350 (PEP/non-PEP: 151/199) patients suffered from a first macrovascular or microvascular disease event while 95 patients (PEP/non-PEP: 34/61) died from any cause. After adjusting for confounding variables, PEP participants had lower incidence rates of all-cause mortality [hazard ratio (HR): 0.589, 95 % confidence interval (CI) 0.380-0.915, P = 0.018] and first macrovascular or microvascular disease events (HR: 0.782, 95 % CI 0.632-0.968, P = 0.024) than those with PEP. Enrolment to PEP was an effective approach in reducing all-cause mortality and first macrovascular or microvascular disease events in obese patients with type 2 diabetes.

The role of patient education in the prevention and management of type 2 diabetes: an overview

The management of type 2 diabetes mellitus includes ability and empowerment of the patient to change lifestyle, maintain an adequate diet and physical activity, manage the disease, and follow a specific program of periodic medical checks and education sessions. In addition, the patient should be able to correctly identify and adequately solve problems related to the disease and actively collaborate with the healthcare system. To obtain these goals, therapeutic patient education (TPE) is now considered a crucial element not only in the treatment but also in the prevention of type 2 diabetes. Several trials showed that TPE is able to improve clinical, lifestyle, and psycho-social outcomes. Nevertheless, studies have not clarified the ideal characteristics of a comprehensive patient education program in clinical practice. Other work is needed to answer open questions regarding the type of PTE (individual or group education), themes, frequency and number of education sessions, contact time between educator and patient, background of educators, use of new technologies, and barriers to self-management. The present review discusses these points on the basis of the most recent data of the literature.

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.

Patient explanations for non-attendance at type 2 diabetes self-management education: a qualitative study

AIM

To explore reasons for non-attendance at type 2 diabetes self-management education.

METHODS

To elicit the main themes explaining non-attendance, 15 semi-structured interviews were conducted with persons referred to, but not attending, self-management education. Systematic text condensation was applied to code and generate themes subsequently organised under individual and organisational factors.

RESULTS

Individual (illness, lack of perceived benefit) and organisational factors relating to schedule (four whole days, time of day, notification) and content (supermarket visit) were cited as reasons for non-attendance.

CONCLUSIONS

In this study, patients cited both individual and organisational factors as explaining non-attendance at type 2 diabetes self-management education. Further studies should take into account the importance of timing and of tailoring schedules and content to individuals' life situations and resources. As organisational factors are likely to vary across programmes and settings, more case studies are needed to further elucidate the dynamic relationship between individual and organisational factors to explain non-attendance at type 2 diabetes self-management education.

Addressing challenges and needs in patient education targeting hardly reached patients with chronic diseases

Some patients do not benefit from participation in patient education due to reasons related to disease burden, literacy, and socioeconomic challenges. In this communication, we address more specifically both the challenges that these hardly reached patients face in relation to patient education programs and the challenges educators face when conducting patient education with hardly reached patients. We define principles for the format and content of dialogue tools to better support this patient group within the population of individuals with diabetes.

Patient Empowerment Programme in primary care reduced all-cause mortality and cardiovascular diseases in patients with type 2 diabetes mellitus: a population-based propensity-matched cohort study

AIMS

To assess whether a structured diabetes education programme, the Patient Empowerment Programme (PEP), was associated with a lower risk of first cardiovascular disease (CVD) event and all-cause mortality in a population-based cohort of patients with type 2 diabetes mellitus (T2DM) in primary care.

METHODS

A Chinese cohort of 27 278 patients with T2DM and without previous CVD events on or before the baseline study recruitment date was linked to the Hong Kong administrative database from 2008 to 2013. The PEP was provided to patients with T2DM treated at primary care outpatient clinics through community trained professional educators. PEP non-participants were matched one-to-one with the PEP participants using a propensity score method with respect to their baseline covariates. Cox proportional hazard regression was performed to estimate the associations of the PEP with the occurrence of first CVD event, coronary heart disease, stroke, heart failure and death from any cause, controlling for baseline characteristics.

RESULTS

During a median of 21.5 months follow-up, 795 (352 PEP participants and 443 PEP non-participants) patients experienced a first CVD event. After adjusting for confounding variables, PEP participants had a lower rate of all-cause mortality [hazard ratio (HR) 0.564, 95% confidence interval (CI) 0.445-0.715; p < 0.001], first CVD (HR 0.807, 95% CI 0.696-0.935; p = 0.004) and stroke (HR 0.702; 95% CI 0.569-0.867; p = 0.001) than those without PEP.

CONCLUSIONS

Enrolment in the PEP was associated with lower all-cause mortality and a lower number of first CVD events among patients with T2DM. The CVD benefit of PEP might be attributable to improving metabolic control through empowerment of self-care and the enhancement of quality of diabetes care in primary care.

Disease Management: The Need for a Focus on Broader Self-Management Abilities and Quality of Life

The study objective was to investigate long-term effects of disease management programs (DMPs) on (1) health behaviors (smoking, physical exercise); (2) self-management abilities (self-efficacy, investment behavior, initiative taking); and (3) physical and mental quality of life among chronically ill patients. The study also examined whether (changes in) health behaviors and self-management abilities predicted quality of life. Questionnaires were sent to all 5076 patients participating in 18 Dutch DMPs in 2010 (T0; 2676 [53%] respondents). Two years later (T1), questionnaires were sent to 4350 patients still participating in DMPs (1722 [40%] respondents). Structured interviews were held with the 18 DMP project leaders. DMP implementation improved patients' health behavior and physical quality of life, but mental quality of life and self-management abilities declined over time. Changes in patients' investment behavior predicted physical quality of life at T1 (P<.001); physical activity, investment behavior (both P<.05), and self-efficacy (P<.01) at T0, and changes in self-efficacy and investment behavior (both P<.001) predicted patients' mental quality of life at T1. The long-term benefits of these DMPs include successful improvement of chronically ill patients' health behaviors and physical quality of life. However, these programs were not able to improve or maintain broader self-management abilities or mental quality of life, highlighting the need to focus on these abilities and overall quality of life. As coproducers of care, patients should be stimulated and enabled to manage their health and quality of life.