1
|
Hassan S, Rac VE, Hodges B, Leake P, Cobbing S, Gray CM, Bartley N, Etherington A, Abdulwasi M, Cheung HCK, Anderson M, Woods NN. Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review. BMJ Open 2024; 14:e081006. [PMID: 38262651 PMCID: PMC10806612 DOI: 10.1136/bmjopen-2023-081006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/09/2024] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented. DESIGN We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance. DATA SOURCES We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022. ELIGIBILITY CRITERIA We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs' training was described. DATA EXTRACTION AND SYNTHESIS The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency. RESULTS Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes. CONCLUSION This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations. PROSPERO REGISTRATION NUMBER CRD42022369208.
Collapse
Affiliation(s)
- Samah Hassan
- University Health Network, Toronto, Ontario, Canada
- Program for Health System and Technology Evaluation, Ted Rogers Centre for Heart Research at Peter Munk Cardiac Centre, Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN), Toronto, Ontario, Canada
| | - Valeria E Rac
- University Health Network, Toronto, Ontario, Canada
- Program for Health System and Technology Evaluation, Ted Rogers Centre for Heart Research at Peter Munk Cardiac Centre, Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN), Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation (IHPME), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN), Toronto, Ontario, Canada
- Diabetes Action Canada, CIHR SPOR Network, Toronto, Ontario, Canada
| | - Brian Hodges
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Patti Leake
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
| | - Saul Cobbing
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Department of Physiotherapy, University of KwaZulu-Natal, Durban, South Africa
| | - Catharine Marie Gray
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Nicola Bartley
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Andrea Etherington
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
| | - Munira Abdulwasi
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Hei-Ching Kristy Cheung
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
| | - Melanie Anderson
- University Health Network, Toronto, Ontario, Canada
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Nicole N Woods
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Kopelowicz A, Wali S, Polzin R, Ruiz ME, Nandy K. Promotore-Led Versus Registered Nurse-Led Diabetes Self-Management Education in Mexican Americans: A Randomized Clinical Trial. Sci Diabetes Self Manag Care 2023; 49:374-383. [PMID: 37593833 DOI: 10.1177/26350106231192353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
PURPOSE The purpose of this study is to compare the benefits of a diabetes self-management program led by registered nurses (RNs) versus community health workers (promotores) for Spanish-speaking Mexican Americans with type 2 diabetes (T2DM). METHODS Three hundred thirty Spanish-speaking Mexican American adults with T2DM were randomly assigned to "Tomando Control de Su Diabetes" delivered for six 2.5-hour sessions either by promotores or RNs. The primary outcome measure was the Summary of Diabetes Self-Care Activities (SDSCA). Evaluations were made at baseline, 6 weeks, and at 3, 6, and 12 months. Mixed-effects regression models were fit to test if participants had differential changes in the SDSCA total score by group over time, controlling for demographic and clinical factors. RESULTS SDSCA scores were significantly higher at all time points compared to baseline and not statistically different between the 2 groups. Only years of education correlated with improvement in diabetes self-management behaviors. No moderating variables predicted improvement between groups. CONCLUSIONS Spanish-speaking Mexican American adults with T2DM who participated in a diabetes educational program with promotores or RNs demonstrated similar improvements. Promotores may increase the accessibility of effective diabetes self-management training for this difficult-to-reach population.
Collapse
Affiliation(s)
- Alex Kopelowicz
- Department of Psychiatry, Olive View-UCLA Medical Center, Sylmar, California
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Soma Wali
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rhonda Polzin
- Department of Nursing, Olive View-UCLA Medical Center, Sylmar, California
| | | | - Karabi Nandy
- Department of Population & Data Sciences, UT Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
3
|
Konnyu KJ, Yogasingam S, Lépine J, Sullivan K, Alabousi M, Edwards A, Hillmer M, Karunananthan S, Lavis JN, Linklater S, Manns BJ, Moher D, Mortazhejri S, Nazarali S, Paprica PA, Ramsay T, Ryan PM, Sargious P, Shojania KG, Straus SE, Tonelli M, Tricco A, Vachon B, Yu CH, Zahradnik M, Trikalinos TA, Grimshaw JM, Ivers N. Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes. Cochrane Database Syst Rev 2023; 5:CD014513. [PMID: 37254718 PMCID: PMC10233616 DOI: 10.1002/14651858.cd014513] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations. OBJECTIVES To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care. SEARCH METHODS We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section. SELECTION CRITERIA We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy. DATA COLLECTION AND ANALYSIS We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors. Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available. MAIN RESULTS We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted. Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three. Combinations of the three most effective QI strategies were estimated to lead to the below effects: - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%; - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg; - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other). AUTHORS' CONCLUSIONS There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.
Collapse
Affiliation(s)
- Kristin J Konnyu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sharlini Yogasingam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Johanie Lépine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katrina Sullivan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Alun Edwards
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Michael Hillmer
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Sathya Karunananthan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - John N Lavis
- McMaster Health Forum, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Stefanie Linklater
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Braden J Manns
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sameh Mortazhejri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Timothy Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Peter Sargious
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Kaveh G Shojania
- University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Marcello Tonelli
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Andrea Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
- Epidemiology Division and Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence, Queen's University, Kingston, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Occupational Therapy Program, University of Montreal, Montreal, Canada
| | - Catherine Hy Yu
- Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - Michael Zahradnik
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Thomas A Trikalinos
- Departments of Health Services, Policy, and Practice and Biostatistics, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
| |
Collapse
|
4
|
Leung T, Nandy K, Ruiz ME, Polzin R, Kurator K, Wali S. Improving Self-management of Type 2 Diabetes in Latinx Patients: Protocol for a Sequential Multiple Assignment Randomized Trial Involving Community Health Workers, Registered Nurses, and Family Members. JMIR Res Protoc 2023; 12:e44793. [PMID: 36645708 PMCID: PMC9887518 DOI: 10.2196/44793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 12/24/2022] [Accepted: 12/25/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The rate of Type 2 diabetes mellitus (T2DM) among Mexican American individuals is 16.3%, about twice that of non-Hispanic White individuals. While a number of education approaches have been developed and shown to improve diabetes self-management behaviors and glycemic control for Spanish-speaking Latinx patients with T2DM, there is little research to guide health practitioners regarding which interventions to apply and when so that resources are used efficiently, and treatment outcomes are maximized. OBJECTIVE This study aimed to describe an adaptive intervention that integrates community mental health workers, diabetes nurse educators, family members, and patients as partners in care while promoting diabetes self-management for Mexican American individuals with T2DM. The project incorporates four evidence-based, culturally tailored treatments to determine what sequence of intervention strategies work most efficiently and for whom. Given the increasing prevalence of T2DM, achieving better control of diabetes and lowering the associated medical complications experienced disproportionally by Mexican American individuals is a public health priority. METHODS Funded by the National Institute of Nursing Research (National Institutes of Health grant R01 NR015809), this project used a sequential multiple assignment randomized trial and included 330 Spanish-speaking Latinx patients with T2DM. In the first phase of the study, subjects were randomly assigned to an evidence-based diabetes self-management educational program called Tomando Control delivered in a group format for 6, biweekly 1.5-hour sessions, led either by a community health worker or a diabetes nurse educator. In the second phase of the study, those subjects who did not improve their diabetes self-management behaviors were rerandomized to receive either an augmented version of Tomando Control or a multifamily group treatment focused on problem-solving. The primary outcome measure was the "Summary of Diabetes Self-Care Activities." Evaluations were made at baseline and at 3, 6, and 12 months. RESULTS This study was funded in June 2016 for a period of 5 years. Institutional review board approval was obtained in November 2016. Between March 2017 and September 2020, a total of 330 patients were recruited from the outpatient primary care clinics of Olive View-UCLA Medical Center, with a brief hiatus between May 2020 and July 2020 due to COVID-19 restrictions. The study interventions were completed in December 2020. Data collection began in March 2017 and was completed in December 2021. Data analysis is expected to be completed in Spring 2023, and results will be published in Fall 2023. CONCLUSIONS The results of this trial should help practitioners in selecting the optimal approach for improving diabetes self-management in Spanish-speaking, Latinx patients with T2DM. TRIAL REGISTRATION ClinicalTrials.gov NCT03092063; https://clinicaltrials.gov/ct2/show/NCT03092063. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44793.
Collapse
Affiliation(s)
| | - Karabi Nandy
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Maria Elena Ruiz
- University of California, Los Angeles School of Nursing, Los Angeles, CA, United States
| | - Rhonda Polzin
- Department of Nursing, Olive View-UCLA Medical Center, Sylmar, CA, United States
| | - Kevin Kurator
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, United States
| | - Soma Wali
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, United States
| |
Collapse
|
5
|
Hamm LM, Yashadhana A, Burn H, Black J, Grey C, Harwood M, Peiris-John R, Burton MJ, Evans JR, Ramke J. Interventions to promote access to eyecare for non-dominant ethnic groups in high-income countries: a scoping review. BMJ Glob Health 2021; 6:e006188. [PMID: 34493531 PMCID: PMC8424858 DOI: 10.1136/bmjgh-2021-006188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022] Open
Abstract
PURPOSE People who are distinct from the dominant ethnic group within a country can experience a variety of barriers to accessing eyecare services. We conducted a scoping review to map published interventions aimed at improving access to eyecare for non-Indigenous, non-dominant ethnic groups residing in high-income countries. METHODS We searched MEDLINE, Embase and Global Health for studies that described an intervention to promote access to eyecare for the target population. Two authors independently screened titles and abstracts followed by review of the full text of potentially relevant sources. For included studies, data extraction was carried out independently by two authors. Findings were summarised using a combination of descriptive statistics and thematic analysis. RESULTS We screened 5220 titles/abstracts, of which 82 reports describing 67 studies met the inclusion criteria. Most studies were conducted in the USA (90%), attempted to improve access for Black (48%) or Latinx (28%) communities at-risk for diabetic retinopathy (42%) and glaucoma (18%). Only 30% included the target population in the design of the intervention; those that did tended to be larger, collaborative initiatives, which addressed both patient and provider components of access. Forty-eight studies (72%) evaluated whether an intervention changed an outcome measure. Among these, attendance at a follow-up eye examination after screening was the most common (n=20/48, 42%), and directly supporting patients to overcome barriers to attendance was reported as the most effective approach. Building relationships between patients and providers, running coordinated, longitudinal initiatives and supporting reduction of root causes for inequity (education and economic) were key themes highlighted for success. CONCLUSION Although research evaluating interventions for non-dominant, non-Indigenous ethnic groups exist, key gaps remain. In particular, the paucity of relevant studies outside the USA needs to be addressed, and target communities need to be involved in the design and implementation of interventions more frequently.
Collapse
Affiliation(s)
- Lisa M Hamm
- School of Optometry & Vision Science, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Aryati Yashadhana
- Centre for Health Equity Training Research & Evaluation, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- School of Social Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Helen Burn
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Joanna Black
- School of Optometry & Vision Science, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Corina Grey
- School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Performance Improvement, Auckland District Health Board, Auckland, New Zealand
| | - Matire Harwood
- School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Roshini Peiris-John
- School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
- Moorfields Eye Hospital, London, UK
| | - Jennifer R Evans
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Jacqueline Ramke
- School of Optometry & Vision Science, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
6
|
Yun Q, Ji Y, Liu S, Shen Y, Jiang X, Fan X, Liu J, Chang C. Can autonomy support have an effect on type 2 diabetes glycemic control? Results of a cluster randomized controlled trial. BMJ Open Diabetes Res Care 2020; 8:8/1/e001018. [PMID: 32299898 PMCID: PMC7199146 DOI: 10.1136/bmjdrc-2019-001018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/05/2020] [Accepted: 03/24/2020] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To assess whether social support or autonomy support intervention for patients with type 2 diabetes can achieve glycemic control at the end of intervention, and to test whether the glycemic control effect can be maintained for a long time. RESEARCH DESIGN AND METHODS In this cluster randomized controlled trial, 18 community healthcare stations (CHSs) were randomized to the following: (1) usual care group (UCG) offering regular public health management services, (2) social support group (SSG) providing 3-month social support intervention based on problem solving principles, and (3) autonomy support group (ASG) offering 3-month autonomy support intervention based on self-determination theory. A total of 364 patients registered in the CHSs were enrolled into either of the three groups. The primary outcome was hemoglobin A1c (HbA1c), and secondary outcomes were diabetes self-management (DSM) behaviors. Assessment was conducted at baseline and at 3 and 6 months. RESULTS Patients in ASG achieved better HbA1c reduction at the end of intervention (0.53% or 7.23 mmol/mol, p<0.001) than those in the UCG and successfully maintained it up to 6 months (0.42% or 5.41 mmol/mol, p<0.001). However, patients in SSG did not experience significant change in HbA1c at 3 or 6 months when compared with patients in UCG. Besides, patients in both the SSG (0.12, p<0.05) and ASG (0.22, p<0.001) experienced improvement in exercise at 3 months. Patients in ASG sustained improvement in exercise up to 6 months (0.21, p<0.001), but those in the SSG did not. CONCLUSIONS Autonomy support for patients with type 2 diabetes could help achieve glycemic control at the end of intervention and successfully maintain it up to 6 months. These findings indicate that autonomy support has positive long-term effects on DSM behaviors and glycemic control and can be recommended in future diabetes intervention programs. TRIAL REGISTRATION NUMBER ChiCTR1900024354.
Collapse
Affiliation(s)
- Qingping Yun
- School of Public Health, Peking University, Beijing, China
| | - Ying Ji
- School of Public Health, Peking University, Beijing, China
| | - Shenglan Liu
- School of Public Health, Peking University, Beijing, China
| | - Yang Shen
- School of Public Health, Peking University, Beijing, China
| | - Xuewen Jiang
- School of Public Health, Peking University, Beijing, China
| | - Xinyi Fan
- School of Public Health, Peking University, Beijing, China
| | - Jingnan Liu
- School of Public Health, Peking University, Beijing, China
| | - Chun Chang
- School of Public Health, Peking University, Beijing, China
| |
Collapse
|
7
|
Lawrenson JG, Graham-Rowe E, Lorencatto F, Rice S, Bunce C, Francis JJ, Burr JM, Aluko P, Vale L, Peto T, Presseau J, Ivers NM, Grimshaw JM. What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis. Health Technol Assess 2019; 22:1-160. [PMID: 29855423 DOI: 10.3310/hta22290] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetic retinopathy screening (DRS) is effective but uptake is suboptimal. OBJECTIVES To determine the effectiveness of quality improvement (QI) interventions for DRS attendance; describe the interventions in terms of QI components and behaviour change techniques (BCTs); identify theoretical determinants of attendance; investigate coherence between BCTs identified in interventions and determinants of attendance; and determine the cost-effectiveness of QI components and BCTs for improving DRS. DATA SOURCES AND REVIEW METHODS Phase 1 - systematic review of randomised controlled trials (RCTs) evaluating interventions to increase DRS attendance (The Cochrane Library, MEDLINE, EMBASE and trials registers to February 2017) and coding intervention content to classify QI components and BCTs. Phase 2 - review of studies reporting factors influencing attendance, coded to theoretical domains (MEDLINE, EMBASE, PsycINFO and sources of grey literature to March 2016). Phase 3 - mapping BCTs (phase 1) to theoretical domains (phase 2) and an economic evaluation to determine the cost-effectiveness of BCTs or QI components. RESULTS Phase 1 - 7277 studies were screened, of which 66 RCTs were included in the review. Interventions were multifaceted and targeted patients, health-care professionals (HCPs) or health-care systems. Overall, interventions increased DRS attendance by 12% [risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14] compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted and general QI interventions were effective, particularly when baseline attendance levels were low. All commonly used QI components and BCTs were associated with significant improvements, particularly in those with poor attendance. Higher effect estimates were observed in subgroup analyses for the BCTs of 'goal setting (outcome, i.e. consequences)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes (consequences) of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients and of 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting HCPs. Phase 2 - 3457 studies were screened, of which 65 non-randomised studies were included in the review. The following theoretical domains were likely to influence attendance: 'environmental context and resources', 'social influences', 'knowledge', 'memory, attention and decision processes', 'beliefs about consequences' and 'emotions'. Phase 3 - mapping identified that interventions included BCTs targeting important barriers to/enablers of DRS attendance. However, BCTs targeting emotional factors around DRS were under-represented. QI components were unlikely to be cost-effective whereas BCTs with a high probability (≥ 0.975) of being cost-effective at a societal willingness-to-pay threshold of £20,000 per QALY included 'goal-setting (outcome)', 'feedback on outcomes of behaviour', 'social support' and 'information about health consequences'. Cost-effectiveness increased when DRS attendance was lower and with longer screening intervals. LIMITATIONS Quality improvement/BCT coding was dependent on descriptions of intervention content in primary sources; methods for the identification of coherence of BCTs require improvement. CONCLUSIONS Randomised controlled trial evidence indicates that QI interventions incorporating specific BCT components are associated with meaningful improvements in DRS attendance compared with usual care. Interventions generally used appropriate BCTs that target important barriers to screening attendance, with a high probability of being cost-effective. Research is needed to optimise BCTs or BCT combinations that seek to improve DRS attendance at an acceptable cost. BCTs targeting emotional factors represent a missed opportunity to improve attendance and should be tested in future studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42016044157 and PROSPERO CRD42016032990. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- John G Lawrenson
- Centre for Applied Vision Research, School of Health Sciences, City, University of London,London,UK
| | - Ella Graham-Rowe
- Centre for Health Services Research, School of Health Sciences, City, University of London,London,UK
| | - Fabiana Lorencatto
- Centre for Health Services Research, School of Health Sciences, City, University of London,London,UK
| | - Stephen Rice
- Health Economics Group, Institute of Health and Society, Newcastle University,Newcastle upon Tyne,UK
| | - Catey Bunce
- Department of Primary Care & Public Health Sciences, King's College London,London,UK
| | - Jill J Francis
- Centre for Health Services Research, School of Health Sciences, City, University of London,London,UK
| | | | - Patricia Aluko
- Health Economics Group, Institute of Health and Society, Newcastle University,Newcastle upon Tyne,UK
| | - Luke Vale
- Health Economics Group, Institute of Health and Society, Newcastle University,Newcastle upon Tyne,UK
| | - Tunde Peto
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast,Belfast,UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute,Ottawa, ON,Canada.,School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa,Ottawa, ON,Canada
| | - Noah M Ivers
- Department of Family and Community Medicine, Women's College Hospital - University of Toronto,Toronto, ON,Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute,Ottawa, ON,Canada.,Department of Medicine, University of Ottawa,Ottawa, ON,Canada
| |
Collapse
|
8
|
Lawrenson JG, Graham‐Rowe E, Lorencatto F, Burr J, Bunce C, Francis JJ, Aluko P, Rice S, Vale L, Peto T, Presseau J, Ivers N, Grimshaw JM. Interventions to increase attendance for diabetic retinopathy screening. Cochrane Database Syst Rev 2018; 1:CD012054. [PMID: 29333660 PMCID: PMC6491139 DOI: 10.1002/14651858.cd012054.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite evidence supporting the effectiveness of diabetic retinopathy screening (DRS) in reducing the risk of sight loss, attendance for screening is consistently below recommended levels. OBJECTIVES The primary objective of the review was to assess the effectiveness of quality improvement (QI) interventions that seek to increase attendance for DRS in people with type 1 and type 2 diabetes.Secondary objectives were:To use validated taxonomies of QI intervention strategies and behaviour change techniques (BCTs) to code the description of interventions in the included studies and determine whether interventions that include particular QI strategies or component BCTs are more effective in increasing screening attendance;To explore heterogeneity in effect size within and between studies to identify potential explanatory factors for variability in effect size;To explore differential effects in subgroups to provide information on how equity of screening attendance could be improved;To critically appraise and summarise current evidence on the resource use, costs and cost effectiveness. SEARCH METHODS We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, Web of Science, ProQuest Family Health, OpenGrey, the ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to identify randomised controlled trials (RCTs) that were designed to improve attendance for DRS or were evaluating general quality improvement (QI) strategies for diabetes care and reported the effect of the intervention on DRS attendance. We searched the resources on 13 February 2017. We did not use any date or language restrictions in the searches. SELECTION CRITERIA We included RCTs that compared any QI intervention to usual care or a more intensive (stepped) intervention versus a less intensive intervention. DATA COLLECTION AND ANALYSIS We coded the QI strategy using a modification of the taxonomy developed by Cochrane Effective Practice and Organisation of Care (EPOC) and BCTs using the BCT Taxonomy version 1 (BCTTv1). We used Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital (PROGRESS) elements to describe the characteristics of participants in the included studies that could have an impact on equity of access to health services.Two review authors independently extracted data. One review author entered the data into Review Manager 5 and a second review author checked them. Two review authors independently assessed risks of bias in the included studies and extracted data. We rated certainty of evidence using GRADE. MAIN RESULTS We included 66 RCTs conducted predominantly (62%) in the USA. Overall we judged the trials to be at low or unclear risk of bias. QI strategies were multifaceted and targeted patients, healthcare professionals or healthcare systems. Fifty-six studies (329,164 participants) compared intervention versus usual care (median duration of follow-up 12 months). Overall, DRS attendance increased by 12% (risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14; low-certainty evidence) compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted (RD 0.17, 95% CI 0.11 to 0.22) and general QI interventions (RD 0.12, 95% CI 0.09 to 0.15) were effective, particularly where baseline DRS attendance was low. All BCT combinations were associated with significant improvements, particularly in those with poor attendance. We found higher effect estimates in subgroup analyses for the BCTs 'goal setting (outcome)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients, and 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting healthcare professionals.Ten studies (23,715 participants) compared a more intensive (stepped) intervention versus a less intensive intervention. In these studies DRS attendance increased by 5% (RD 0.05, 95% CI 0.02 to 0.09; moderate-certainty evidence).Fourteen studies reporting any QI intervention compared to usual care included economic outcomes. However, only five of these were full economic evaluations. Overall, we found that there is insufficient evidence to draw robust conclusions about the relative cost effectiveness of the interventions compared to each other or against usual care.With the exception of gender and ethnicity, the characteristics of participants were poorly described in terms of PROGRESS elements. Seventeen studies (25.8%) were conducted in disadvantaged populations. No studies were carried out in low- or middle-income countries. AUTHORS' CONCLUSIONS The results of this review provide evidence that QI interventions targeting patients, healthcare professionals or the healthcare system are associated with meaningful improvements in DRS attendance compared to usual care. There was no statistically significant difference between interventions specifically aimed at DRS and those which were part of a general QI strategy for improving diabetes care. This is a significant finding, due to the additional benefits of general QI interventions in terms of improving glycaemic control, vascular risk management and screening for other microvascular complications. It is likely that further (but smaller) improvements in DRS attendance can also be achieved by increasing the intensity of a particular QI component or adding further components.
Collapse
Affiliation(s)
- John G Lawrenson
- City University of LondonCentre for Applied Vision Research, School of Health SciencesNorthampton SquareLondonUKEC1V 0HB
| | - Ella Graham‐Rowe
- City University LondonSchool of Health Sciences, Centre for Health Services ResearchNorthampton SquareLondonUKEC1V 0HB
| | - Fabiana Lorencatto
- City University LondonSchool of Health Sciences, Centre for Health Services ResearchNorthampton SquareLondonUKEC1V 0HB
| | - Jennifer Burr
- University of St AndrewsSchool of Medicine, Medical and Biological Sciences BuildingFifeUKKY16 9TF
| | - Catey Bunce
- Kings College LondonDepartment of Primary Care & Public Health Sciences4th Floor, Addison HouseGuy's CampusLondonUKSE1 1UL
| | - Jillian J Francis
- City University LondonSchool of Health Sciences, Centre for Health Services ResearchNorthampton SquareLondonUKEC1V 0HB
| | - Patricia Aluko
- Newcastle UniversityNational Institute for Health Research (NIHR) Innovation ObservatoryTimes Central offices, 4th Floor, GallowgateNewcastle upon TyneUKNE1 4BF
| | - Stephen Rice
- Newcastle UniversityInstitute of Health & SocietyNewcastle upon TyneUKNE2 4AX
| | - Luke Vale
- Newcastle UniversityInstitute of Health & SocietyNewcastle upon TyneUKNE2 4AX
| | - Tunde Peto
- Queen's University BelfastCentre for Public HealthBelfastUKBT12 6BA
| | - Justin Presseau
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaOntarioCanadaK1H 8L6
| | - Noah Ivers
- Women's College HospitalDepartment of Family and Community Medicine76 Grenville StreetTorontoONCanadaM5S 1B2
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaOntarioCanadaK1H 8L6
- University of OttawaDepartment of MedicineOttawaONCanada
| | | |
Collapse
|
9
|
Fisher EB, Boothroyd RI, Elstad EA, Hays L, Henes A, Maslow GR, Velicer C. Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews. Clin Diabetes Endocrinol 2017; 3:4. [PMID: 28702258 PMCID: PMC5471959 DOI: 10.1186/s40842-017-0042-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 05/09/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Examine Peer Support (PS) for complex, sustained health behaviors in prevention or disease management with emphasis on diabetes prevention and management. DATA SOURCES AND ELIGIBILITY PS was defined as emotional, motivational and practical assistance provided by nonprofessionals for complex health behaviors. Initial review examined 65 studies drawn from 1442 abstracts identified through PubMed, published 1/1/2000-7/15/2011. From this search, 24 reviews were also identified. Extension of the search in diabetes identified 30 studies published 1/1/2000-12/31/2015. RESULTS In initial review, 54 of all 65 studies (83.1%) reported significant impacts of PS, 40 (61.5%) reporting between-group differences and another 14 (21.5%) reporting significant within-group changes. Across 19 of 24 reviews providing quantifiable findings, a median of 64.5% of studies reviewed reported significant effects of PS. In extended review of diabetes, 26 of all 30 studies (86.7%) reported significant impacts of PS, 17 (56.7%) reporting between-group differences and another nine (30.0%) reporting significant within-group changes. Among 19 of these 30 reporting HbA1c data, average reduction was 0.76 points. Studies that did not find effects of PS included other sources of support, implementation or methodological problems, lack of acceptance of interventions, poor fit to recipient needs, and possible harm of unmoderated PS. CONCLUSIONS Across diverse settings, including under-resourced countries and health care systems, PS is effective in improving complex health behaviors in disease prevention and management including in diabetes.
Collapse
Affiliation(s)
- Edwin B. Fisher
- Peers for Progress, Gillings School of Global Public Health, University of North Carolina, Box 7440, Chapel Hill, NC 27599-7440 USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Box 7440, Chapel Hill, NC 27599-7440 USA
| | - Renée I. Boothroyd
- Frank Porter Graham Child Development Institute, University of North Carolina, Chapel Hill, NC USA
| | | | - Laura Hays
- Indiana University School of Nursing, Indianapolis, IN USA
| | - Amy Henes
- RTI International, Research Triangle Park, NC USA
| | - Gary R. Maslow
- Department of Pediatrics, Duke University, Durham, NC USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC USA
| | - Clayton Velicer
- National Public Relations and Communications, Kaiser Permanente, Oakland, CA USA
| |
Collapse
|
10
|
Siemon M, Shuster G, Boursaw B. The impact of state certification of community health workers on team climate among registered nurses in the United States. J Community Health 2015; 40:215-21. [PMID: 25060232 DOI: 10.1007/s10900-014-9919-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A number of states have adopted certification programs for community health workers (CHWs) to improve recognition of CHWs as members of health care teams, increase oversight, and to provide sustainable funding. There has been little research into the impact of state CHW certification on the diffusion and adoption of CHWs into existing health care systems. This study examined the impact of state CHW certification on the perceptions of team climate among registered nurses (RNs) who work with CHWs in states with and without CHW certification programs. The study recruited RNs using a purposeful sampling method and used an online survey, which included the Team Climate Inventory (TCI), and compared the perceptions of team climate between the two groups. The study found no significant differences in the overall mean TCI score or TCI subscale scores between RNs who work in states with CHW certification programs (n = 81) and those who work in states without CHW certification programs (n = 115). There was a statistically significant difference on one survey question regarding whether RNs believe state certification of CHWs improved the ability of their health care team to deliver quality care. More research is needed to assess impact of state certification of CHWs and other factors that influence the diffusion and adoption of CHWs into the current health care system.
Collapse
Affiliation(s)
- Mark Siemon
- Boise State University School of Nursing, 1910 University Dr., Boise, ID, 83725-1840, USA,
| | | | | |
Collapse
|