Effectiveness of Interactive Self-Management Interventions in Individuals With Poorly Controlled Type 2 Diabetes: A Meta-Analysis of Randomized Controlled Trials

The effectiveness of diabetes self-management education intervention on glycaemic control and cardiometabolic risk in adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis

Diabetes mellitus (DM) poses a significant challenge to public health. Effective diabetes self-management education (DSME) interventions may play a pivotal role in the care of people with type 2 diabetes mellitus (T2DM) in low- and middle-income countries (LMICs). A specific up-to-date systematic review is needed to assess the effect of DSME interventions on glycaemic control, cardiometabolic risk, self-management behaviours, and psychosocial well-being among T2DM across LMICs. The MEDLINE, Embase, CINAHL, Global Health, and Cochrane databases were searched on 02 August 2022 and then updated on 10 November 2023 for published randomised controlled trials (RCTs) and quasi-experimental studies. The quality of the studies was assessed, and a random-effect model was used to estimate the pooled effect of diabetes DSME intervention. Heterogeneity (I2) was tested, and subgroup analyses were performed. Egger's regression test and funnel plots were used to examine publication bias. The risk of bias of the included studies was assessed using the Cochrane risk-of-bias tool for randomized trial (RoB 2). The overall assessment of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. A total of 5893 articles were retrieved, and 44 studies (n = 11838) from 21 LMICs met the inclusion criteria. Compared with standard care, pooled analysis showed that DSME effectively reduced the HbA1c level by 0.64% (95% CI: 0.45% to 0.83%) and 1.27% (95% CI: -0.63% to 3.17%) for RCTs and quasi-experimental design studies, respectively. Further, the findings showed an improvement in cardiometabolic risk reduction, diabetes self-management behaviours, and psychosocial well-being. This review suggests that ongoing support alongside individualised face-to-face intervention delivery is favourable for improving overall T2DM management in LMICs, with a special emphasis on countries in the lowest income group.

The impact of health literacy interventions on glycemic control and self-management outcomes among type 2 diabetes mellitus: A systematic review

Diabetes imposes an increasing health and economic burden on individuals living with it and their societies worldwide. Glycemic control is necessary to reduce morbidity and mortality of type 2 diabetes mellitus (T2DM). Self-management is the primary tool for managing diabetes. Health literacy (HL) is the primary driver of self-management activities. The aim of this review is to evaluate the impact of HL interventions on glycemic control and self-management outcomes among T2DM. MEDLINE, CINAHL, PubMed, Cochrane, Scopus, and Web of Science were searched for eligible papers. Fifteen randomized controlled trials published in English between 1997 and 2021, used HL-driven intervention, and measured the level of glycohemoglobin A1c (HbA1c) and self-management of T2DM patients were included in this review. The findings showed that HL-driven intervention had a positive impact on glycemic control and improved self-management behaviors. The level of glycemic control and self-management skills were improved through individual and telephone-based intervention respectively. Community worker-led interventions were effective in improvements in diabetes knowledge and self-care behaviors; however, nurse-led interventions were effective in glycemic control. Better glycemic control is achieved in hospital settings compared to outpatient settings. HL interventions yielded better improvement in self-management among people with longer diabetes duration (more than 7 years). It was possible to achieve a large reduction in HbA1c level after a 3-month intervention in hospital settings. HL-driven interventions are effective in glycemic and diabetes self-management outcomes.

Efficacy of a multidimensional self-management intervention on low-education women with metabolic syndrome: a cluster randomized controlled trial

Low-education women, a substantially older population, are subject to increased risks of metabolic syndrome and consequent cardiometabolic diseases; early detection and effective management were urgently needed. Ninety-nine women with metabolic syndrome, age 61 and education ≤ 6 years, from four community units were randomly assigned to either a self-management intervention (n = 51) or a control arm (n = 48). The intervention consisted of five dimensions, physical activity and diet modifications (daily exercise classes and two nutrition courses), goal setting, coaching and peer support, problem-solving, and self-monitoring. The control arm received an education leaflet. Assessments were performed at baseline, six months, and 18 months. Compared with the control, the intervention participants improved the overall rate of meeting the recommended servings for six health foods, including vegetables, dairy products, and nuts (except whole grains, fruits, and protein); the rate of meeting regular leisure-time physical activity; and criteria biomarkers-waist circumference, fasting blood glucose, high-density lipoprotein cholesterol (except blood pressure and triglycerides); as well as body weight and body mass index; consequently decreased the number of risk factors and rate of metabolic syndrome. In conclusion, the multidimensional self-management intervention improved physical activity, healthy eating, and metabolic syndrome risks among low-education women with metabolic syndrome.

The Victoria Assistive Devices and Coach (VADAC) study

INTERVENTION

A 90-day intervention employed peer coaching, with and without home-based electronic devices connected to an app, to assess effectiveness in enhancing self-reported health outcomes of older adults.

RESEARCH QUESTION

Does peer coaching aid older adults to better manage their chronic health conditions, and is the coaching further enhanced by home-based electronic devices?

METHODS

The study employed a pre-post intervention randomized controlled trial design with three groups: control (no coach, no devices), coach only, and coach + devices. Participants were 163 adults living in British Columbia, Canada, aged 65 to 98 years, with one or more chronic health conditions and access to a computer and Wi-Fi. Responses on five questionnaires assessed health outcomes pre- and post-intervention: Self-Efficacy Scale, PHQ-9, Medical Care, Patient Activation Measure and the RAND 36-Item Health Survey 1.0 Questionnaire.

RESULTS

Compared with the control group (no coach, no devices), participants with a coach reported decreased depression, higher activation levels and energy levels, and better handling of role limitations due to physical health, social functioning, and communication with their physician. Participants with coaches and devices showed similar improvements on these measures with further decreases in depression severity as well as improved self-efficacy, better handling of role limitations due to emotional problems, higher level of emotional well-being and general health ratings, and lower pain.

CONCLUSION

Peer coaches alone and in combination with assistive devices demonstrated several positive outcomes for older persons with chronic conditions that lasted at least 90 days. The program can enhance effectiveness of care provided by general practitioners.

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

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

Preferences Regarding Self-Management Intervention Outcomes of Dutch Chronically Ill Patients With Limited Health Literacy

Background:

For many chronically ill patients self-management of their disease is difficult. This may be especially true for people with limited health literacy as they are faced with additional challenges in the day-to-day management of their disease. Research has shown that self-management support is most effective when tailored to the needs and preferences of patients. Therefore, this study explores the preferences regarding self-management outcomes of chronically ill patients with limited health literacy.

Methods

A total of 35 patients with limited health literacy were invited to a concept-mapping procedure consisting of two card sorting tasks. Patients ranked 60 outcomes, which are often found in literature in relation to self-management, to the level that was important for themselves. Means were calculated for each outcome and domain, and differences within the group were analyzed.

Results

For patients with limited health literacy, satisfaction with care is the most important outcome domain. This domain includes overall satisfaction, the communication with health care providers, the provision of information and trust. At an outcome level, outcomes related to symptom management and improving competences to self-management scored very high. No differences between patient groups for age and sex were found.

Conclusion

Chronically ill patients with limited health literacy prefer a wide variety of outcomes for their self-management. Next to health related outcomes, patients mostly prefer to work on their competences for self-management. For health care professionals, acting on these patient preferences and building a solid relationship will enhance successful self-management.

Effect of educational interventions on knowledge of the disease and glycaemic control in patients with type 2 diabetes mellitus: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Globally, type 2 diabetes has continued to increase, now accounting for over 90% of all diabetes cases. Though the magnitude of uncontrolled glycaemic levels in patients with type 2 diabetes is steadily rising, evidence showed that effectively controlled glycaemic levels can prevent complications and improve the quality of life of these patients. As little is known about the effect of educational interventions on this population, this systematic review and meta-analysis evaluated the effectiveness of educational interventions versus standard care on glycaemic control and disease knowledge among patients with type 2 diabetes.

METHODS

PubMed, Google Scholar, Cochrane Library, Scopus, African Journals Online and Wiley Online Library were searched. Two authors independently assessed within-trial risk of bias in each included study using revised Cochrane risk-of-bias tool for randomised trials. A random-effects model was employed to estimate combined effect sizes. Subgroup analyses were employed to investigate possible sources of heterogeneity between studies. The overall certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

A total of 19 trials with 2708 study participants were included in the review. Primary outcomes (glycaemic control) were reported in 18 trials. The pooled estimated impact of educational intervention on glycaemic levels using the random-effects model was -0.83 (95% CI: -1.17 to -0.49, p<0.001). Subgroup analyses revealed greater A1c reductions in those studies with intervention duration of up to 3 months and with empirical intervention designs. Educational interventions led to significant increases in participants' knowledge of type 2 diabetes (standardised mean difference: 1.16; 95% CI: 0.71 to 1.60; I2=93%).

CONCLUSION

In the current review overall, educational interventions can potentially lead to improved glycaemic control levels in patients with type 2 diabetes despite heterogeneity across the studies. Besides, the findings showed that educational interventions could increase disease knowledge among patients with type 2 diabetes.

PROSPERO REGISTRATION NUMBER

CRD42020205838.

Towards a better understanding of self-management interventions in type 2 diabetes: A meta-regression analysis

AIMS

Attributes that operationally conceptualize diabetes self-management education (DSME) interventions have never been studied previously to assess their impact on relevant outcomes of interest in people with type 2 diabetes (T2D). The aim of this study was to determine the impact of existing interventions classified by their delivery of skills or information related attributes on immediate (knowledge), intermediate (physical activity), post-intermediate (HbA1c), and long-term (quality of life) outcomes in people with T2D.

METHODS

PubMed, Embase, PsycINFO, and Cochrane Library/Cochrane CENTRAL as well as the grey literature were searched to identify interventional studies that examined the impact of DSME interventions on the four different outcomes. Eligible studies were selected and appraised independently by two reviewers. A meta-regression analysis was performed to determine the impact of delivery of the skills- and information-related attributes on the chosen outcomes.

RESULTS

142 studies (n = 25,511 participants) provided data, of which 39 studies (n = 5278) reported on knowledge, 39 studies (n = 8323) on physical activity, 99 studies (n = 17,178) on HbA1c and 24 studies (n = 5147) on quality of life outcomes. Meta-regression analyses demonstrated that skills-related attributes had an estimated effect suggesting improvement in knowledge (SMD [standardized mean difference] increase of 0.80; P = 0.025) and that information-related attributes had an estimated effect suggesting improvement in quality of life (SMD increase of 0.96; P = 0.405). Skill- and information-related attributes did not have an estimated effect suggesting improvement in physical activity or in HbA1c.

CONCLUSIONS

The study findings demonstrate that the skills and information related attributes contribute to different outcomes for people with T2D. This study provides, for the first time, preliminary evidence for differential association of the individual DSME attributes with different levels of outcome.

The effectiveness of self-management programmes for people with type 2 diabetes receiving insulin injection: A systematic review and meta-analysis

BACKGROUND

People with type 2 diabetes (T2D) receiving insulin injection are reported to encounter challenges to achieve optimal glycaemic control. The evidence on effectiveness of self-management programmes for T2D people receiving insulin injection is far from conclusive.

AIM

To examine the effectiveness of self-management programmes for people with T2D receiving insulin injection.

METHODS

Twelve databases were searched from dates of inception to June 2021. All randomised controlled trials (RCTs) and controlled clinical trials examining the effectiveness of self-management programmes were included. The methodological quality was appraised using the Joanna Briggs Institute critical appraisal tools by two independent researchers. Data were summarised narratively or pooled statistically where appropriate.

RESULTS

Nine RCTs involving 2613 participants were included. At post-intervention, meta-analysis results showed that self-management programmes significantly improved glycated haemoglobin A1c (HbA1c) (mean difference [MD]: -0.21, 95% confidence interval [CI] -0.29 to -0.12, P < .001), self-management behaviours (standardised MD [SMD]: 0.23, 95% CI: 0.12 to 0.33, P < .001) and self-efficacy (SMD: 0.20, 95% CI: 0.09 to 0.31, P = .0002). Only one intensive lifestyle intervention reported significant improvements in body weight and waist circumference. Three RCTs demonstrated significant improvements in body mass index compared with the control group. Only one study demonstrated significant improvements in total cholesterol and triglycerides in favour of the intervention group. At six months post-intervention, pooled results of two studies revealed decreased diabetes-related distress (MD: -2.98, 95% CI: -5.15 to -0.82, P = .007). No significant changes in blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, depression and anxiety were found.

CONCLUSIONS

Self-management programmes have the potential to improve glycaemic control, weight management, blood lipids, self-management behaviours, self-efficacy and diabetes-related distress of people with T2D receiving insulin injection. More rigorous experimental trials are warranted to examine the effectiveness of self-management programme and its maintenance.

Effectiveness of smartphone application-based self-management interventions in patients with type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

AIMS

To synthesize evidences on smartphone application-based intervention and determine its effectiveness on glycaemic control, self-management behaviours, psychological well-being, quality of life and cardiometabolic risk factors.

DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

DATA SOURCES

Major English and Chinese electronic databases were searched from January 2008 to January 2021, including PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, China National Knowledge Infrastructure (CNKI), Wanfang and Sinomed.

REVIEW METHODS

RCTs were screened and selected if they used smartphone applications to support patients in the self-management of diabetes. Data extraction and methodological assessment were performed by two reviewers independently. Meta-analysis was performed to pool the intervention effect on outcomes of interest using RevMan 5.3.

RESULTS

Across 19 included trials involving 2585 participants, smartphone application-based interventions were associated with a clinically and statistically significant reduction of glycated haemoglobin (HbA1c). Beneficial effects were also observed in participants' behavioural performance, especially in medication adherence. Intervention effects on psychological status, quality of life and cardiometabolic risk factors were nonsignificant. Subgroup analysis showed interactive approach with medium frequency or flexible facilitator-patient interaction induced a larger effect on HbA1c reduction. Besides, patients with baseline HbA1c ≥9% benefited more than those with HbA1c <9% from the use of smartphone applications.

CONCLUSIONS

Smartphone application-based diabetes self-management intervention could optimize patients' glycaemic control and enhance participants' self-management performance. Further endeavour is required to examine the long-term effects and cost-effectiveness of smartphone application-based intervention before promoting the adoption and dissemination of such intervention.

IMPACT

This review supports the potential of smartphone application-based intervention as effective approach to optimize glycaemic control and promote self-management engagement among patients with type 2 diabetes. Suggestions for future research and practice are provided and discussed.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Correlation of Symptom Distress, Self-Efficacy, and Social Support With Problem-Solving and Glycemic Control Among Patients With Type 2 Diabetes

PURPOSE

The purpose of the study was to examine the associations of self-efficacy, social support, and symptom distress with perceived problem-solving and glycemic control among patients with type 2 diabetes.

METHOD

Using baseline data from a parent study, which examined the effect of a problem-solving-focused intervention on medication adherence among patients with type 2 diabetes, this secondary analysis examined the relationships among self-efficacy, social support, symptom distress, problem-solving, and A1C. Of 358 patients enrolled at baseline, 304 (mean age = 64.1 years, 57.2% female) were included in the current analysis. Multiple linear regression was used to identify potential correlates of problem-solving and A1C.

RESULTS

The results showed that self-efficacy, social support, and symptom distress were independent predictors of problem-solving; they significantly improved the prediction of perceived problem-solving in diabetes management after controlling covariates. Adding problem-solving to the model did not improve the prediction for A1C.

CONCLUSION

The current study suggests that self-efficacy, social support, and symptom distress are essential factors associated with patients' perceived problem-solving in diabetes management. Researchers and clinicians should consider both personal factors and psychosocial factors such as self-efficacy, social support, and symptom distress when examining patients perceived problem-solving and developing tailored interventions to improve diabetes management. In addition, health care providers should consider these important aspects when providing tailored care to this patient population.

The Effectiveness of a Self-Efficacy-Focused Structured Education Program (SSEP) in Improving Metabolic Control and Psychological Outcomes of Type 2 Diabetes Patients: A 12-Month Follow-Up of a Multicenter Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

The 12-month follow-up effect of the self-efficacy-focused structured education program (SSEP) requires in-depth confirmation. This study aims to verify whether the benefits of SSEP can be maintained in 12 months.

MATERIALS AND METHODS

A multicenter randomized controlled trial with 12-month follow-up conducted among 265 type 2 diabetes patients not on insulin from 4 hospitals in mainland China. The intervention group (n = 133) was administrated with SSEP, and the control group (n = 132) received the routine education. The indicators of metabolic and psychosocial aspects of the patients were assessed at baseline and 12 months.

RESULTS

As opposed to the control group, the primary outcomes of HbA1c in the intervention group were improved obviously in the 12th month during the 12-month follow-up (-1.13%, P < 0.001). The secondary outcomes (ie, waist circumference, total cholesterol, low-density lipoprotein cholesterol, diabetes self-efficacy, diabetes self-management behaviors, diabetes knowledge and diabetes distress) were improved significantly in the intervention group as compared with the control group in the 12th month during the 12-month follow-up (-3.14 cm, P = 0.001; -0.30 mmol/L, P = 0.032; -0.25 mmol/L, P = 0.008; 0.87, P < 0.001; 10.67, P < 0.001; 3.42, P < 0.001; -4.97, P < 0.001). The non-significant difference in the secondary outcomes (ie, systolic pressure, diastolic pressure, triglycerides and high-density lipoprotein cholesterol) was identified between the two groups in the 12th month during the 12-month follow-up (P > 0.05).

CONCLUSION

The SSEP provided sustainable benefits in outcomes of HbA1c, waist circumference, total cholesterol, low-density lipoprotein cholesterol, diabetes knowledge, diabetes distress, diabetes self-efficacy and diabetes self-management behaviors for type 2 diabetes patients not on insulin in the 12th month during the 12-month follow-up. Thus, it will be an effective education model capable of being generalized nationwide, and it can be referenced for the nations and regions under consistent conditions.

CLINICAL TRIAL REGISTRY

Chinese Clinical Trial Registry (ChiCTR-IOR-17011007).

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

CONCLUSION

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

Effectiveness of a Diabetes Education Program based on Tailored interventions and Theory of Planned Behaviour: Cluster randomized controlled trial protocol

AIM

To measure the Effectiveness of a Diabetes Education Program for people with T2DM, based on Tailored interventions and the Theory of Planned Behaviour.

DESIGN

Cluster randomized controlled clinical trial.

METHODS

This multicentre study will be carried out at 30 primary healthcare centres, where 436 persons with Type 2 Diabetes Mellitus (T2DM), aged between 18-75 years, will be recruited. The experimental educational program to be applied is modelled using components obtained from a systematic review and prior qualitative analysis. In addition, a taxonomy of nursing practice is used to standardize the program, based on the Theory of Planned Behaviour as a conceptual model. The intervention will be carried out by community nurses, using ADAPP-Ti^® , an application developed with FileMaker Pro v.18. The control group will receive usual care and data will be collected at 6, 12, and 18 months, for both groups. The primary outcome considered will be glycosylated haemoglobin and cardiovascular factors, while the secondary ones will be tobacco consumption, body mass index, barriers to self-care, health-related quality of life, and lifestyle modification. The protocol was approved by the Ethics Committee of the Province of Malaga (Spain) in November 2014.

DISCUSSION

The degree of metabolic control in T2DM is not always associated with healthy lifestyles and significant levels of medication are often prescribed to achieve clinical objectives. An intervention focused on needs, based on the best available evidence and a solid conceptual framework, might successfully consolidate appropriate self-care behaviour in this population.

IMPACT

The study will result in the publication of an educational program featuring well-defined interventions and activities that will enable clinicians to tailor health care to the individual's needs and to combat treatment inertia in attending this population.

Effectiveness of Social Cognitive Theory-Based Interventions for Glycemic Control in Adults With Type 2 Diabetes Mellitus: Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

For those living with type 2 diabetes mellitus (T2DM), failing to engage in self-management behaviors leads to poor glycemic control. Social cognitive theory (SCT) has been shown to improve health behaviors by altering cognitive processes and increasing an individual's belief in their ability to accomplish a task.

OBJECTIVE

We aim to present a protocol for a systematic review and meta-analysis to systematically identify, evaluate, and analyze the effect of SCT-based interventions to improve glycemic control in adults with T2DM.

METHODS

This protocol follows the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Data sources will include PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Cochrane Library, and Web of Science, and data will be reviewed with the use of customized text mining software. Studies examining SCT-based behavioral interventions for adults diagnosed with T2DM in randomized controlled trials located in the outpatient setting will be included. Intervention effectiveness will be compared with routine care. Screening and data collection will be performed in multiple stages with three reviewers as follows: (1) an independent review of titles/abstracts, (2) a full review, and (3) data collection with alternating teams of two reviewers for disputes to be resolved by a third reviewer. Study quality and risk of bias will be assessed by three reviewers using the Cochrane risk of bias tool. Standardized mean differences will be used to describe the intervention effect sizes with regard to self-efficacy and diabetes knowledge. The raw mean difference of HbA1c will be provided in a random effects model and presented in a forest plot. The expected limitations of this study are incomplete data, the need to contact authors, and analysis of various types of glycemic control measures accurately within the same data set.

RESULTS

This protocol was granted institutional review board exemption on October 7, 2019. PROSPERO registration (ID: CRD42020147105) was received on April 28, 2020. The review began on April 29, 2020. The results of the review will be disseminated through conference presentations, peer-reviewed journals, and meetings.

CONCLUSIONS

This systematic review will appraise the effectiveness of SCT-based interventions for adults diagnosed with T2DM and provide the most effective interventions for improving health behaviors in these patients.

TRIAL REGISTRATION

PROSPERO CRD42020147105; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=147105.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/17148.

Improving Self-Care Management in Low-Income Latinos With Type 2 Diabetes Using Peer-Led U.S. Conversation Maps: A Quality Improvement Project in a Free Clinic

A culturally sensitive Healthy Interactions Conversations Maps program was implemented for teaching diabetes self-management education (DSME) to Latinos with type 2 diabetes using peer-led educators in a community health center. Patients were invited to participate in a group care setting to improve access to providers and DSME. Goals were to improve diabetes distress, self-efficacy, and glycemic control as measured by A1C. Significant improvements were found for mean diabetes self-efficacy scores from before (2.53 ± 0.59) to after (2.91 ± 0.50) DSME (P <0.001). Mean A1C decreased significantly from before (9.51 ± 1.72%) to after (8.79 ± 1.68%) DSME (P = 0.043) at the end of the 6-month intervention. Thus, this program was found to be a useful tool for providing DSME in community health clinics serving low-income Latinos.

Self-regulation mechanisms in health behavior change: a systematic meta-review of meta-analyses, 2006-2017

Self-regulation is one primary mechanism in interventions for health behavior change and has been examined in numerous recent meta-analyses. This pre-registered meta-review (PROSPERO CRD42017074018) examined Mmeta-analyses of any intervention and health behavior/outcome were eligible if they quantitatively assessed self-regulation and appeared between January 2006 and August 2017. In total, 66 meta-analyses were ultimately eligible; 27% reported a protocol, 11% used GRADE; 58% focused on RCTs. Reviews satisfied only a moderate number of items on the AMSTAR 2 (M = 45.45%, SD = 29.57%). Only 6% of meta-analyses directly examined whether changes in self-regulation predicted the behavior change (i.e., self-efficacy and physical activity, l = 2; frequency of self-monitoring and goal attainment, l = 1; cognitive bias modification and addiction, l = 1). Meta-analyses more routinely assessed self-regulation by comparing the efficacy of intervention components (97%), such as those from behavior change taxonomies. Meta-analyses that focused on intervention components identified several as successful, including personalized feedback, goal setting, and self-monitoring; however, none were consistently successful in that each worked only for some health behaviors and with particular populations. Some components had inconclusive evidence, given that they were only examined in low- quality reviews. Future reviewers should utilize advanced methods to assess mechanisms, and study authors should report hypothesized mechanisms to facilitate synthesis.

Kaizen: Interactive Gaming for Diabetes Patient Education

Objective: An estimated 100 million Americans have diabetes, undiagnosed diabetes, a high risk of being diagnosed with diabetes, or prediabetes. Many complications can arise if diabetes is poorly managed. Hence, the need for adequate knowledge, skills, and ability to care for oneself, known as diabetes self-care management, is needed to reduce complication rates. We used an interactive platform that incorporates principles of gamification to enhance user engagement to enhance diabetes knowledge. The purpose of this descriptive pilot study was to discover what adult patients with diabetes thought about this novel educational approach to diabetes education. Materials and Methods: We collected focus group data from participants at a diabetes clinic after they played an interactive diabetes trivia game, on our software platform (Kaizen Education). Transcripts were coded and common themes were identified. Results: We conducted 9 focus groups that included 33 adult (age >18) participants who had diabetes. An overarching theme of play/gaming as a form of learning was apparent, and after analyzing the coding several themes emerged, including preferences and desired environments (clinic and home) for learning, desired players (including family, significant others), and a good balance of question difficulty. Conclusions: Participants were overwhelmingly positive about gamified education and felt empowered to lead discussions with their health care providers about diabetes self-care education, in a sense "flipping" the traditional clinic patient education paradigm. These results suggested that a flipped clinic approach could be beneficial, empowering, and engaging for patients.

Participant Evaluation of a Prediabetes Intervention Program Designed for Rural Adults

The type 2 diabetes epidemic is a global crisis threatening the health and economies of many nations. This study aimed to evaluate a prediabetes intervention program designed for rural adults in southwestern Ontario based on the feedback of participants. Rural adults with prediabetes were referred by physicians to an intervention program developed to assist with unique barriers rural adults face related to the built environment and socioeconomic status when adopting a healthy lifestyle. After 6 monthly education sessions offered by a dietitian and a nurse, participants completed a questionnaire to share their program experience. In addition, 6 focus groups consisting of 5-9 participants were conducted to assess program acceptability, feasibility, and practicality. Of 49 enrolled, 35 participants aged 60.8 ± 7.1 (mean ± SD) evaluated the program. Participants reported finding the program to be acceptable, feasible, and practical due to the interactive nature of the sessions, the group setting and the availability of health professionals. This prediabetes lifestyle intervention program was perceived as successfully addressing rural adults' needs in terms of adopting a healthy lifestyle. Feedback received through program evaluation, which included a participant experience survey and focus groups has helped improve this program and may benefit other prediabetes education intervention programs.

Pilot randomized controlled trial of a complex intervention for diabetes self-management supported by volunteers, technology, and interprofessional primary health care teams

Background

Most health care for people with diabetes occurs in family practice, yet balancing the time and resources to help these patients can be difficult. An intervention empowering patients, leveraging community resources, and assisting self-management could benefit patients and providers. Thus, the feasibility and potential for effectiveness of “Health Teams Advancing Patient Experience, Strengthening Quality through Health Connectors for Diabetes Management” (Health TAPESTRY-HC-DM) as an approach supporting diabetes self-management was explored to inform development of a future large-scale trial.

Methods

Four-month pilot randomized controlled trial (RCT), sequential explanatory qualitative component. Participants—patients of an interprofessional primary care team—were over age 18 years, diagnosed with diabetes and hypertension, and had Internet access and one of the following: uncontrolled HbA1c, recent diabetes diagnosis, end-stage/secondary organ damage, or provider referral. The Health TAPESTRY-HC-DM intervention focused on patient health goals/needs, integrating community volunteers, eHealth technologies, interprofessional primary care teams, and system navigation. Pilot outcomes included process measures (recruitment, retention, program participation), perceived program feasibility, benefits and areas for improvement, and risks or safety issues. The primary trial outcome was self-efficacy for managing diabetes. There were a number of secondary trial outcomes.

Results

Of 425 eligible patients invited, 50 signed consent (11.8%) and 35 completed the program (15 intervention, 20 control). Volunteers (n = 20) met 28 clients in 234 client encounters (home visits, phone calls, electronic messages); 27 reports were sent to the interprofessional team. At 4 months, controlling for baseline, most outcomes were better in the intervention compared to control group; physical activity notably better. The most common goal domains set were physical activity, diet/nutrition, and social connection. Clients felt the biggest impact was motivation toward goal achievement. They struggled with some of the technologies. Several participants perceived that the program was not a good fit, mostly those that felt they were already well-managing their diabetes.

Conclusions

Health TAPESTRY-HC-DM was feasible; a large-scale randomized controlled trial seems possible. However, further attention needs to be paid to improving recruitment and retention. The intervention was well received, though was a better fit for some participants than others.

Trial registration

ClinicalTrials.gov, NCT02715791. Registered 22 March 2016—retrospectively registered.

[Diabetes education and counselling in adult patients with diabetes (Update 2019)]

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

The effects of an empowerment-based self-management intervention on empowerment level, psychological distress, and quality of life in patients with poorly controlled type 2 diabetes: A randomized controlled trial

BACKGROUND

There is considerable interest in advocating empowerment in diabetes care. Health professionals, however, often fail to realize empowerment in clinical practice, especially in patients with poorly controlled type 2 diabetes.

OBJECTIVES

To evaluate the effectiveness of an empowerment-based intervention on empowerment level, psychological distress, and quality of life among patients with poorly controlled type 2 diabetes.

DESIGN

An analysis of secondary outcomes of a prospective multi-center, randomized, parallel, investigator-blinded controlled trial.

METHODS

A total of 242 adult patients with poorly controlled type 2 diabetes [Hemoglobin A1c (HbA1c)≥ 58 mmol/mol in the recent six months] were randomly allocated to either intervention (n = 121) or attentional control (n = 121) groups. The design of the intervention was based on the Empowerment Process Model. The intervention group received a 6-week empowerment-based transitional care program, with significant emphasis on establishing personally meaningful goals, facilitating collaborative partnership and shared decision-making, resolving life-disease conflicts via situational reflection. Participants in the attentional control group received two general health education classes and post-discharge social calls on top of routine care. Outcomes of interest include empowerment level, diabetes distress, and quality of life. Participants were invited to complete a set of questionnaires before randomization, one-week, and three-month post-intervention. Statistical analyses were performed using the generalized estimating equations based on the intention-to-treat principle.

RESULTS

Comparing with the attention control group, participants in the intervention group showed significant improvements on empowerment level [(β= 0.163; 95% confidence interval (CI): 0.011 to 0.316, p = 0.036) at one-week post-intervention and (β= 0.176; 95% CI: 0.020 to 0.331, p = 0.027) at three-month post-intervention, respectively]. This group of patients also displayed significant reduction in terms of emotional-distress (β= -0.424, 95% CI: -0.798 to -0.049, p = 0.027) and regimen-distress (β= -0.397, 95% CI: -0.702 to -0.091, p = 0.011) at three-month post-intervention and physician-related distress (β= -0.236, 95% CI: -0.466 to -0.006, p = 0.044) at one-week post-intervention. Significant improvement in quality of life (β= 4.151, 95% CI: 1.291, 7.012, p = 0.004) at three-month post-intervention was also observed in the intervention group.

CONCLUSIONS

Findings provide empirical evidence for the values of an empowerment-based intervention program for patients with poorly controlled type 2 diabetes in increasing the empowerment level and perceived quality of life and reducing diabetes distress. Long-term effects of the intervention and its underlying mechanisms need further investigation.

Patterns of Glycemic Variability During a Diabetes Self-Management Educational Program

Background: Variations in blood glucose levels over a given time interval is termed as glycemic variability (GV). Higher GV is associated with higher diabetes-related complications. The current study was done with the aim of detecting the sensitivity of various GV indices among individuals with type 2 diabetes mellitus of different glycemic control status. Methods: We performed a longitudinal study among individuals with type 2 diabetes mellitus (T2DM) who were participating in a two-week diabetes self-management education (DSME) program. Participants were categorized by their HbA1c as poor (≥8%), acceptable (7%–8%), and optimal control (<7%). Continuous glucose monitoring (CGM) sensors recorded interstitial glucose every 15 min from day 1. The evaluated GV measures include standard deviation (SD), coefficient of variation (CV), mean amplitude of glycemic excursion (MAGE), continuous overlapping net glycemic action (CONGA), mean of daily difference for inter-day variation (MODD), high blood glucose index (HBGI), and low blood glucose index (LBGI). Results: A total of 41 study participants with 46347 CGM values were available for analysis. Of 41 participants, 20 (48.7%) were in the poor, 10 (24.3%) in the acceptable, and 11 (26.8%) in the optimal control group. The GV indices (SD; CV; MODD; MAGE; CONGA; HBGI) of poorly controlled (77.43; 38.02; 45.82; 216.63; 14.10; 16.62) were higher than acceptable (50.02; 39.32; 30.79; 138.01; 8.87; 5.56) and optimal (34.15; 29.46; 24.56; 126.15; 8.67; 3.13) control group. Glycemic variability was reduced in the poorly and acceptably controlled groups by the end of the 2-week period. There was a rise in LBGI in the optimally controlled group, indicating pitfalls of tight glycemic control. Conclusion: Indices of glycemic variability are useful complements, and changes in it can be demonstrated within short periods.

Self-efficacy-focused education in persons with diabetes: a systematic review and meta-analysis

AIMS

The aims of this study were to assess the effectiveness of self-efficacy-focused education on health outcomes in persons with diabetes and review the strategies employed in the interventions.

BACKGROUND

The traditional educational interventions for persons with diabetes were insufficient to achieve the desired outcomes. Self-efficacy-focused education has been used to regulate the blood sugar level, behaviors, and psychosocial indicators for persons with diabetes.

DESIGN

This study is a systematic review and meta-analysis.

METHODS

Studies on the effectiveness of self-efficacy-focused education in persons with diabetes were searched in six databases from inception until January 2018. The data were extracted and the quality of literature was assessed independently. Review Manager 5.3 was applied for the meta-analysis. Besides, the findings were summarized for narrative synthesis.

RESULTS

Sixteen trials with 1,745 participants were included in the systematic review and ten trails with 1,308 participants in the meta-analysis. The meta-analysis for A1C, self-efficacy, self-management behaviors, knowledge, and quality of life (QOL) were represented in four, six, six, three, and three studies, respectively. The findings indicated that self-efficacy-focused education would probably reduce A1C, enhance self-efficacy, regulate self-management behaviors, increase knowledge, and improve the QOL for patients with diabetes. Weak quality studies, limited participants, and heterogeneity hindered the results pooled of the other secondary outcomes of fasting blood glucose, 2-hour plasma glucose, weight, weight circumference, body mass index, plasma lipid profile, and other psychological indicators. Goal setting, self-management skills practicing and recording, peer models, demonstration, persuasion by health providers, and positive feedback were the most commonly used strategies in the interventions. However, physiological/emotion arousal strategies were relatively less applied and varied significantly.

CONCLUSION

Individuals with diabetes may benefit a lot from the self-efficacy-focused education. However, insufficient high-quality studies, short-term follow-up period, relatively deficient physiological/emotion strategies, and incomplete outcome assessments were the drawbacks in most studies. Establishing satisfactory self-efficacy-focused education and better evaluating the effects were required in further studies.

Interventions for self-management of type 2 diabetes: An integrative review

BACKGROUND

Type 2 diabetes mellitus has been identified as one of the most challenging chronic illnesses to manage. Since the management of diabetes is mainly accomplished by patients and families, self-management has become the mainstay of diabetes care. However, a significant proportion of patients fail to engage in adequate self-management. A priority research question is how do interventions affect the self-management behaviors of persons with Type 2 diabetes?

PURPOSE/OBJECTIVES

The purpose of this integrative review is to provide a summary and critique of interventions that support diabetes self-management in the patient with Type II diabetes mellitus.

DESIGN

An integrative review design, with a comprehensive methodological approach of reviews, allowing inclusion of experimental and non-experimental studies.

PROCEDURES

A comprehensive search was conducted via Ebscohost using databases of Academic Search Complete, CINAHL, Health Source: Nursing/Academic Edition, MEDLINE, PsycArtiCLES, and PsycInfo. The final number of papers used for this review were: motivational interviewing (6), peer support/coaching (10), problem solving therapy (3), technology-based interventions (30), lifestyle modification programs (7), patient education (11), mindfulness (3), and cognitive behavioral therapy (5).

RESULTS

Studies were examined from seventeen countries including a broad range of cultures and ethnicities. While interventions have shown mixed results in all interventional categories, many studies do support small to modest improvements in physiologic, behavioral, and psychological outcome measures. Considerable heterogeneity of interventions exists. The most commonly reported physiologic measure was HbA1c level. Outcome measures were collected mostly at 6 and 12 months. Duration of most research was limited to one year.

CONCLUSIONS

Research exploring the impact of interventions for self-management has made major contributions to the care of persons with type 2 diabetes, from offering suggestions for improving care, to stimulating new questions for research. However, implications for clinical practice remain inconclusive, and limitations in existing research suggest caution in interpreting results of studies.

A Practice-Based Research Database to Study Perinatal Nurse Home Visiting to Pregnant Women With Diabetes

BACKGROUND AND AIMS

Accumulation of real-world evidence from practice-based perinatal nurse home visits to pregnant women with diabetes prompted this translational perinatal health disparities research. Given the global diabetes epidemic, this academic-community partnered research team is studying the utilization, processes, and outcomes of this understudied model of perinatal nurse home visiting that provide home-based enhanced diabetes care to pregnant women. Because the nursing records provide the rich source of data for the study, our aim is to provide an in-depth description of the Philadelphia Pregnancy and Diabetes Home Visiting (PPD-HV) research database developed from data in the longitudinal nursing records.

METHODS

This descriptive study uses retrospective data abstracted from paper-based perinatal nurse home visiting clinical records to create the PPD-HV, a HIPAA compliant, secure REDCap electronic research database. The sample includes 248 urban, pregnant women with diabetes who received a total of 1,644 home visits during the year 2012. The setting was Philadelphia, a large metropolitan city in the northeastern part of the United States. The PPD-HV database followed the information fields of the paper-based clinical nursing forms, which were originally designed by following the Omaha System to guide documenting the nursing process used in caring for patients in their homes.

RESULTS

Using REDCap, the PPD-HV research database is robust with 239 variables and captures longitudinal clinical nursing data. Among the pregnant women with diabetes receiving nurse home visits, the mean age was 30.7 years, most were single, and had given birth to other children.

LINKING EVIDENCE TO ACTION

Real-world clinical nursing practice data provide a rich source of research data to advance understandings about this model of enhanced diabetes care and the pregnant women with diabetes receiving the care. Considering the global epidemic of diabetes, this is a perinatal nurse home visiting model to replicate and evaluate.

Pharmacotherapeutic empowerment and its effectiveness in glycemic control in patients with Diabetes Mellitus

AIMS

To develop an intervention and evaluate its effectiveness in pharmacotherapeutic empowerment of patients with type 2 diabetes mellitus (T2DM).

METHOD

This is an intervention study with before and after evaluation. The intervention was conducted between 2015 and 2016 with users of the Unified Health System (SUS) in Brazil. The study was divided into six stages: initial evaluation, three individual patient-pharmacist meetings every 15 days over 6 weeks, clinical discussion between pharmacists, and final evaluation. At each meeting with the patient, specific themes for empowerment were addressed using educational booklets and pharmaceutical care. Clinical and laboratory evaluations and questionnaires on self-efficacy (IMDSES), self-care (QAD) and distress (PAID-5) were conducted before and three months after the intervention.

RESULTS

47 patients completed the intervention. Glycated hemoglobin of patients had a median reduced from 7.0% to 6.6% after the intervention (p = 0.02). There was a significant difference (p < 0.01) in the reduction in total cholesterol, fasting glycemia, creatinine and blood pressure. Participants showed significant improvements (p < 0.01) in scores related to self-efficacy and self-care and less distress related to T2DM.

CONCLUSION

The results of the study suggest that the strategy developed is effective in promoting the empowerment of T2DM patients, improved glycemic control and self-care.

Comparison of three meta-analytic methods using data from digital interventions on type 2 diabetes

AIMS

Pooling the effect sizes of randomized controlled trials (RCTs) from continuous outcomes, such as glycated hemoglobin level (HbA1c), is an important method in evidence syntheses. However, due to challenges related to baseline imbalances and pre/post correlations, simple analysis of change scores (SACS) and simple analysis of final values (SAFV) meta-analyses result in under- or overestimation of effect estimates. This study was aimed to compare pooled effect sizes estimated by Analysis of Covariance (ANCOVA), SACS, and SAFV meta-analyses, using the example of RCTs of digital interventions with HbA1c as the main outcome.

MATERIALS AND METHODS

Three databases were systematically searched for RCTs published from 1993 through June 2017. Two reviewers independently assessed titles and abstracts using predefined eligibility criteria, assessed study quality, and extracted data, with disagreements resolved by arbitration from a third reviewer.

RESULTS

ANCOVA, SACS, and SAFV resulted in pooled HbA1c mean differences of -0.39% (95% CI: [-0.51, -0.26]), -0.39% (95% CI: [-0.51, -0.26]), and -0.34% (95% CI: [-0.48-0.19]), respectively. Removing studies with both high baseline imbalance (≥±0.2%) and pre/post correlation of ≥±0.6 resulted in a mean difference of -0.39% (95% CI: [-0.53, -0.26]), -0.40% (95% CI: [-0.54, -0.26]), and -0.33% (95% CI: [-0.48, -0.18]) with ANCOVA, SACS, and SAFV meta-analyses, respectively. Substantial heterogeneity was noted. Egger's test for funnel plot symmetry did not indicate evidence of publication bias for all methods.

CONCLUSION

By all meta-analytic methods, digital interventions appear effective in reducing HbA1c in type 2 diabetes. The effort to adjust for baseline imbalance and pre/post correlation using ANCOVA relies on the level of detail reported from individual studies. Reporting detailed summary data and, ideally, access to individual patient data of intervention trials are essential.

Effectiveness of Digital Interventions for Improving Glycemic Control in Persons with Poorly Controlled Type 2 Diabetes: A Systematic Review, Meta-analysis, and Meta-regression Analysis

BACKGROUND

Digital interventions may assist patients with type 2 diabetes in improving glycemic control. We aimed to synthesize effect sizes of digital interventions on glycated hemoglobin (HbA1c) levels and to identify effective features of digital interventions targeting patients with poorly controlled type 2 diabetes.

MATERIALS AND METHODS

MEDLINE, ISI Web of Science, and PsycINFO were searched for randomized controlled trials (RCTs) comparing the effects of digital interventions with usual care. Two reviewers independently assessed studies for eligibility and determined study quality, using the Cochrane Risk of Bias Assessment Tool. The Behavioral Change Technique Taxonomy V1 (BCTTv1) was used to identify BCTs used in interventions. Mean HbA1c differences were pooled using analysis of covariance to adjust for baseline differences and pre-post correlations. To examine effective intervention features and to evaluate differences in effect sizes across groups, meta-regression and subgroup analyses were performed.

RESULTS

Twenty-three arms of 21 RCTs were included in the meta-analysis (n = 3787 patients, 52.6% in intervention arms). The mean HbA1c baseline differences ranged from -0.2% to 0.64%. The pooled mean HbA1c change was statistically significant (-0.39 {95% CI: [-0.51 to -0.26]} with substantial heterogeneity [I² statistic, 80.8%]) and a significant HbA1c reduction was noted for web-based interventions. A baseline HbA1c level above 7.5%, β = -0.44 (95% CI: [-0.81 to -0.06]), the BCTs "problem solving," β = -1.30 (95% CI: [-2.05 to -0.54]), and "self-monitoring outcomes of behavior," β = -1.21 (95% CI: [-1.95 to -0.46]) were significantly associated with reduced HbA1c levels.

CONCLUSIONS

Digital interventions appear effective for reducing HbA1c levels in patients with poorly controlled type 2 diabetes.

Factors associated with self-management among Vietnamese adults with type 2 diabetes

AIM

The study described diabetes self-management (DSM), diabetes knowledge, family and friends' support, healthcare providers' support, belief in treatment effectiveness and diabetes management self-efficacy, and explored DSM's associations among Vietnamese adults with type 2 diabetes mellitus (T2DM).

DESIGN

A cross-sectional design was applied.

METHODS

The study used self-report questionnaires to collect data from 198 participants. Descriptive statistics and structural equation modelling (SEM) was used for data analysis.

RESULTS

Vietnamese adults with T2DM performed DSM limitedly in certain aspects. They had strong belief in treatment effectiveness, good family and friends support, limited diabetes knowledge, healthcare professional support and self-efficacy. Their DSM was directly associated with diabetes knowledge, family and friends' support, healthcare providers' support, belief in treatment effectiveness and diabetes management self-efficacy. Their DSM was indirectly associated with diabetes knowledge and family and friends' support through their belief in treatment effectiveness and diabetes management self-efficacy.

Exploring effects of self-management on glycemic control using a modified information-motivation-behavioral skills model in type 2 diabetes mellitus patients in Shanghai, China: A cross-sectional study

BACKGROUND

The original information-motivation-behavioral skills (IMB) model has been verified in type 2 diabetes mellitus (T2DM) patients, but the effects of the model on glycemic control remain unclear. The aim of this study was to modify the IMB model to explore the effects of self-management on glycemic control in T2DM patients in Shanghai, China.

METHODS

A cross-sectional study was conducted on participants recruited using a convenience sampling method between June and August 2015 in three tertiary hospitals and four community health service centers; 796 participants meeting the inclusion criteria (age ≥18 years and a diagnosis of T2DM) completed a questionnaire and blood test for glycemic control. Structural equation models were used to test the IMB framework.

RESULTS

The modified model demonstrated an acceptable fit of the data. Paths from information to self-management behaviors (β = 0.119, P = 0.001) and HbA1c (β = -0.140, P < 0.001), from motivation to behavioral skills (β = 0.670, P < 0.001), from behavioral skills to self-management behaviors (β = 0.562, P < 0.001), and from self-management behaviors to HbA1c (β = -0.343, P < 0.001) were all significant and in the predicted direction. Information and motivation varied with each other (r = 0.350, P < 0.001).

CONCLUSIONS

Glycemic control can be incorporated into the IMB model. The utility of the modified model in the study population is validated. Type 2 diabetes mellitus patients with poor control of glucose levels may be a better target population for application of the modified IMB model.

Self-tracking of Physical Activity in People With Type 2 Diabetes: A Randomized Controlled Trial

The purpose of this study was to determine the efficacy of an online self-tracking program on physical activity, glycated hemoglobin, and other health measures in patients with type 2 diabetes. Seventy-two patients with type 2 diabetes were randomly assigned to an intervention or control group. All participants received usual care. The intervention group received an activity tracker (Fitbit Zip) connected to an online lifestyle program. Physical activity was analyzed in average steps per day from week 0 until 12. Health outcome measurements occurred in both groups at baseline and after 13 weeks. Results indicated that the intervention group significantly increased physical activity with 1.5 ± 3 days per week of engagement in 30 minutes of moderate-vigorous physical activity versus no increase in the control group (P = .047). Intervention participants increased activity with 1255 ± 1500 steps per day compared to their baseline (P < .010). No significant differences were found in glycated hemoglobin A1c, with the intervention group decreasing -0.28% ± 1.03% and the control group showing -0.0% ± 0.69% (P = .206). Responders (56%, increasing minimally 1000 steps/d) had significantly decreased glycated hemoglobin compared with nonresponders (-0.69% ± 1.18% vs 0.22% ± 0.47%, respectively; P = .007). To improve effectiveness of eHealth programs, additional strategies are needed.

Medicare utilization, screening, and costs among participants in the Southeastern Diabetes Initiative: A population-based evaluation

AIMS

Type 2 diabetes mellitus imposes significant burdens on patients and health care systems. Population-level interventions are being implemented to reach large numbers of patients at risk of or diagnosed with diabetes. We describe a population-based evaluation of the Southeastern Diabetes Initiative (SEDI) from the perspective of a payer, the Centers for Medicare & Medicaid Services (CMS). The purpose of this paper is to describe the population-based evaluation approach of the SEDI intervention from a Medicare utilization and cost perspective.

METHODS

We measured associations between the SEDI intervention and receipt of diabetes screening (i.e., HbA1c test, eye exam, lipid profile), health care resource use, and costs among intervention enrollees, compared with a control cohort of Medicare beneficiaries in geographically adjacent counties.

RESULTS

The intervention cohort had slightly lower 1-year screening in 2 of 3 domains (4% for HbA1c; 9% for lipid profiles) in the post-intervention period, compared with the control cohort. The SEDI intervention cohort did not have different Medicare utilization or total Medicare costs in the post-intervention period from surrounding control counties.

CONCLUSIONS

Our analytic approach may be useful to others evaluating CMS demonstration projects in which population-level health is targeted for improvement in a well-defined clinical population.

The role of telenursing in the management of Diabetes Type 1: A randomized controlled trial

BACKGROUND

Diabetes Mellitus type 1 (T1DM) is a chronic disease that requires patients' self-monitoring and self-management to achieve glucose targets and prevent complications. Telenursing implicates technology in the interaction of a specialized nurse with patients with chronic diseases in order to provide personalized care and support.

OBJECTIVE

To evaluate the effect of telenursing on T1DM patients' compliance with glucose self-monitoring and glycemic control.

DESIGN

Randomized controlled study.

SETTINGS

Outpatient Department of Diabetes, Endocrinology and Metabolism of a University Hospital in Northern Greece.

METHODS

Ninety-four T1DM patients were recruited and randomized in two groups by a random number generator. The intervention group (N = 48) was provided with telenursing services. A specialized nurse made a weekly contact via telephone motivating patients to frequently measure blood glucose and adopt a healthy lifestyle. The control group (N = 46) received standard diabetes advice and care in the clinic. The primary outcome was the effect of the intervention in glucose control and glucose variability. The secondary outcome was the effect on frequency of self-monitoring. SPSS 20.0 was used for data analysis.

RESULTS

The two groups did not differ in age, sex, physical activity or initial HbA1c. In the intervention group, blood glucose significantly decreased at the end of the study in all predefined measurements, compared to control group: morning (93.18 ± 13.30 mg/dl vs. 105.17 ± 13.74 mg/dl, p < 0.005), pre-prandial (114.76 ± 9.54 mg/dl vs. 120.84 ± 4.05 mg/dl, p < 0.005), post-prandial (193.35 ± 25.36 mg/dl vs. 207.84 ± 18.80 mg/dl, p < 0.005), and HbA1c decreased significantly over time in the intervention group (8.3 ± 0.6% at the beginning of the study vs. 7.8 ± 1% at the end of the study, p = 0.03). In the intervention group there were also fewer omitted glucose measurements than in the control group.

CONCLUSIONS

Patients in the intervention group achieved better glucose control and more frequent self-monitoring than patients in routine care in the clinic. The findings of our study indicate that telenursing can motivate T1DM patients to better control their disease.