Empowered diabetes management: life coaching and pharmacist counseling for employed adults with diabetes

A Rubric to Assess the Design and Intervention Quality of Randomized Controlled Trials in Health and Wellness Coaching

Objective

To collect health and wellness coaching (HWC) literature related to treatment of obesity and Type 2 Diabetes (T2D) for systematic assessment using a novel rubric.

Data Source

Pubmed, CINAHL, and PsychInfo.

Study Inclusion and Exclusion

Given 282 articles retrieved, only randomized and controlled trials meeting a HWC criteria-based definition were included; studies with intervention <4 months or <4 sessions were excluded.

Data Extraction

Rubric assessment required details of two theoretical frameworks (i.e., study design and HWC intervention design) be extracted from each included paper.

Data Synthesis

Data were derived from a 28-item rubric querying items such as sampling characteristics, statistical methods, coach characteristics, HWC strategy, and intervention fidelity.

Results

29 articles were reviewed. Inter-rater rubric scoring yielded high intraclass correlation (r = .85). Rubric assessment of HWC literature resulted in moderate scores (56.7%), with study design scoring higher than intervention design; within intervention design, T2D studies scored higher than obesity.

Conclusions

A novel research design rubric is presented and successfully applied to assess HWC research related to treatment of obesity and T2D. Most studies reported beneficial clinical findings; however, rubric results revealed moderate scores for study and intervention design. Implications for future HWC research are discussed.

The impact of health and wellness coaching on patient-important outcomes in chronic illness care: A systematic review and meta-analysis

BACKGROUND

Health and Wellness Coaching (HWC) may be beneficial in chronic condition care. We sought to appraise its effectiveness on quality of life (QoL), self-efficacy (SE), depression, and anxiety.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane CENTRAL for randomized trials published January 2005 - March 2023 that compared HWC to standard clinical care or another intervention without coaching. We examined QoL, SE, depression, or anxiety outcomes. Meta-analysis utilizing the random-effects model was used to estimate the pooled standardized mean difference (SMD).

RESULTS

Thirty included studies demonstrated that HWC improved QoL within 3 months (SMD 0.62 95 % CI 0.22-1.02, p = 0.002), SE within 1.5 months (SMD 0.38, 95 % CI 0.03-0.73, p = 0.03), and depression at 3, 6, and 12 months (SMD 0.67, 95 % CI 0.13-1.20, p = 0.01), (SMD 0.72, 95 % CI 0.19-1.24, p = 0.006), and (SMD 0.41, 95 % CI 0.09-0.73, p = 0.01) Certainty in the evidence for most outcomes was either very low or low primarily due to the high risk of bias, heterogeneity, and imprecision.

CONCLUSION

HWC improves QoL, SE, and depression across chronic illness populations. Future research needs to standardize intervention reporting and outcome collection.

PRACTICE IMPLICATIONS

Future HWC studies should standardize intervention components, reporting, and outcome measures, apply relevant chronic illness theories, and aim to follow participants for greater than one year.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

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.

Dosing of Health and Wellness Coaching for Obesity and Type 2 Diabetes: Research Synthesis to Derive Recommendations

Health and wellness coaching (HWC) is an effective intervention for lifestyle disease such as obesity and type 2 diabetes. The evolving HWC profession needs recommendations to guide clinical practice, particularly the appropriate dose of coaching. The purpose of this paper was to systematically review and synthesize HWC literature to derive HWC programming recommendations. Of 102 papers retrieved, 88 were retained with data extracted determining HWC session number, frequency, duration, program length, and total coaching load. Differential analysis yielded no statistical difference in programming variables for randomized control trials and other designs, nor for studies with significant findings v. those not finding statistical significance, allowing these data to be pooled. The HWC intervention for obesity was slightly more intense (15 sessions over 7-8 mo) than the diabetes programming (12 sessions over 9-10 mo). On average, HWC programming applied in the peer-reviewed literature was 12-15 sessions of 35-40 min duration over 7-9 months. These recommendations for HWC programming variables are put forth as initial practice guidelines and should be examined with comparative effectiveness study for optimization. HWC best practice guidelines for other patient groups (e.g., heart disease, cancer, and chronic pain) should also be studied once an adequate literature data base is available.

Financial, Occupational and Physical Challenges and Blood Glucose Monitoring in Type 2 Diabetes

Background

Blood glucose monitoring effects are changing for people living with type 2 diabetes. However, there is a lack of recent data surrounding financial, occupational, or physical stressors that affect the adherence of diabetes self-management practices. This article looks to examine specific financial, physical, and occupational challenges in adherence to blood glucose monitoring in type 2 diabetes.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) 2017-2020 Pre-Pandemic data of adults 18+ were analyzed. These data were used to examine the relationships between insurance coverage, health status, occupation, and self-monitoring of blood glucose levels in the United States.

Results

This study found that respondents had a statistically significant association with five variables: prescription drug coverage (in-part or full), occupation status, gender, age, and three race subcategories (non-Hispanic White, Black, and Other-Multiracial) with blood glucose monitoring.

Conclusion

This study may help certified health education specialists (CHES) and diabetes care and educator specialists (DCES) to better identify which groups of individuals are at highest risk for poor adherence to specific blood glucose monitoring in type 2 diabetes.

Making Specific Plan Improves Physical Activity and Healthy Eating for Community-Dwelling Patients With Chronic Conditions: A Systematic Review and Meta-Analysis

Background

Implementation intention formed by making a specific action plan has been proved effective in improving physical activity (PA) and dietary behavior (DB) for the general, healthy population, but there has been no meta-analysis of their effectiveness for patients with chronic conditions. This research aims to analyze several explanatory factors and overall effect of implementation intention on behavioral and health-related outcomes among community-dwelling patients.

Methods

We searched CIHNAL (EBSCO), PUBMED, Web of Science, Science Direct, SAGE Online, Springer Link, Taylor & Francis, Scopus, Wiley Online Library, CNKI, and five other databases for eligible studies. Random-effects meta-analysis was conducted to estimate effect sizes of implementation intention on outcomes, including PA, DB, weight, and body mass index. And the eligible studies were assessed by the Cochrane Collaboration's tool for risk of bias assessment. Sensitivity analysis adopted sequential algorithm and the p-curve analysis method.

Results

A total of 54 studies were identified. Significant small effect sizes of the intervention were found for PA [standard mean difference (SMD) 0.24, 95% confidence interval (CI) (0.10, 0.39)] and for the DB outcome [SMD -0.25, 95% CI (-0.34, -0.15)]. In moderation analysis, the intervention was more effective in improving PA for men (p < 0.001), older adults (p = 0.006), and obese/overweight patients with complications (p = 0.048) and when the intervention was delivered by a healthcare provider (p = 0.01).

Conclusion

Implementation intentions are effective in improving PA and DB for community dwelling patients with chronic conditions. The review provides evidence to support the future application of implementation intention intervention. Besides, the findings from this review offer different directions to enhance the effectiveness of this brief and potential intervention in improving patients' PA and DB.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=160491.

Inconsistent Counselor Fidelity in Delivering an Evidence-Based Adherence Intervention During a PrEP Trial

Evidence-based adherence counseling interventions must be delivered with fidelity to ensure that their effectiveness is retained, but little is known regarding how counselors in biomedical HIV trials deliver these interventions. Forty-two counselors from the MTN-025/HOPE Study, which was conducted in 14 sites in sub-Saharan Africa, participated. They completed a quantitative assessment and consented for their HOPE counseling session ratings to be analyzed. Twenty-two (52%) self-identified as research nurses and 20 (48%) as counselors. Of 928 session ratings, 609 (66%) were classified as Good, 188 (20%) as Fair, and 131 (14%) as Poor, based on pre-established criteria. Overall mean ratings for session tasks and global components (each rated from 1 to 5) were 4.12 (SD = 0.45; range 2.46-4.73) and 4.02 (SD = 0.64; range 1.75-4.79), respectively. Twenty-six (62%) counselors attained Good or Fair ratings on at least 85% of their sessions, but 33% of counselors had more than 25% of their sessions rated as Poor; three counselors (7%) never met criteria for a Good session. Even after extensive training, counselors' fidelity to the intervention varied. Our findings highlight the value of fidelity monitoring using session audio-recordings, the importance of ongoing coaching and support, and the need to plan for counselors with consistently poor fidelity.

The sociocultural mechanism of obesity: The influence of gender role attitudes on obesity and the gender gap

Worldwide, women are more likely to be obese than men, but research on the mechanism of the gender gap in obesity is relatively lacking. This article uses five rounds of Chinese General Social Survey (CGSS) data from 2010 to 2017 to empirically test the impact of gender role attitudes on obesity and the gender gap and to explore the mechanism. The main results show that the traditional gender role attitude will improve the probability of obesity in women, but it will not positively impact obesity in men. Using the proportion of "March 8th red flag bearer" at the provincial level as an instrumental variable to alleviate the possible estimation errors caused by omitted variables, the results show that the lower the proportion of red flag bearers, the higher the probability of obesity of women, and still will not improve the probability of obesity of men. The robustness test based on the generalized propensity score method (GPSM) supports the above results. The mechanism analysis shows that economic status and market participation are two essential mechanisms of gender role attitudes and female obesity. Traditional gender role attitudes increase the risk of women's obesity by reducing their economic status and labour market participation.

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.

Assessment tools measuring health-related empowerment in psychosocially vulnerable populations: a systematic review

BACKGROUND

Many programs are undertaken to facilitate the empowerment of vulnerable populations across the world. However, an overview of appropriate empowerment measurements to evaluate such initiatives remains incomplete to date. This systematic review aims to describe and summarise psychometric properties, feasibility and clinical utility of the available tools for measuring empowerment in psychosocially vulnerable populations.

METHODS

A systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was completed. A descriptive approach was used for data analysis. Papers were eligible if they explored the development, validation, cross-cultural translation or the utility of an empowerment measurement tool in the context of psychosocially vulnerable populations.

RESULTS

Twenty-six included articles described twenty-six separate studies in which 16 empowerment measurement tools were developed, validated/translated, or used. There was heterogeneity in empowerment constructs, samples targeted, and psychometric properties measured. The measurement of reliability of the included instruments was satisfactory in most cases. However, the validity, responsiveness, interpretability, feasibility and clinical utility of the identified measurement tools were often not adequately described or measured.

CONCLUSION

This systematic review provides a useful snapshot of the strengths as well as limitations of existing health related empowerment measurement tools used with psychosocially vulnerable populations in terms of their measurement properties, and constructs captured. It highlights significant gaps in empowerment tool measurement, development and evaluation processes. In particular, the results suggest that in addition to systematic assessments of psychometric properties, the inclusion of feasibility and clinical utility as outcome measures are important to assess relevance to clinical practice.

Effectiveness of Health Coaching in Diabetes Control and Lifestyle Improvement: A Randomized-Controlled Trial

Background: The study aimed to look into the effectiveness of a 6-month health coaching intervention for HbA1c and healthy diet in the treatment of patients with type 2 diabetes. Methods: The study was carried out via a two-armed, randomized controlled trial that included 114 diabetic patients at a medical center in Taiwan. During the 6-month period, the intervention group had health coaching and usual care for 6 months, and the control group had usual care only. The outcome variables were HbA1c level and healthy diet for follow-up measurement in the third and sixth month. Results: The study discovered a significant decrease in HbA1c and health diet improvement after the 6-month health coaching. Patients in the intervention group decreased their daily intake of whole grains, fruits, meats and protein, and fats and oils while increasing their vegetables intake. Conclusions: Health coaching may be conducive to the blood sugar control and healthy diet of patients with type 2 diabetes. Further study on health coaching with higher-quality evidence is needed.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Implementation of a fidelity monitoring process to assess delivery of an evidence-based adherence counseling intervention in a multi-site biomedical HIV prevention study

Pre-Exposure Prophylaxis (PrEP) trials often implement counseling to support product adherence. Counseling fidelity can vary significantly across providers and time. Fidelity monitoring can ensure that counseling is delivered as designed. We describe the process, feasibility, and outcomes of monitoring Options counseling fidelity in an open-label study of the dapivirine vaginal ring MTN-025/HOPE. After initial training, 63 counselors from 14 sites in Sub-Sahara Africa audio-recorded counseling sessions with study participants. Sessions were rated by a New York-based team that included bilingual emigres from the study countries. Completed session rating forms were sent to counselors to provide feedback and counseling difficulties were discussed during monthly calls. Of 1456 study participants, 85.7% consented to at least one session, and 20% to all sessions, being audio-recorded. Among 9926 study visits in which Options was expected to occur, 5366 (54.1%) Options sessions were audio-recorded, of which 1238 (23.1%) were reviewed; 1039 (83.9%) were rated as "good" or "fair." Eleven counselors who failed to consistently deliver the intervention were reassigned to back-up status. This study demonstrates the feasibility and benefits of monitoring counseling fidelity using audio-recordings in a multi-site, multi-language, multi-country PrEP trial. Given the investment necessary to conduct such trials, providing counseling oversight is highly warranted.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

A training program incorporating a diabetes tool to facilitate delivery of quality diabetes care by community pharmacists in Malaysia and Australia

Objectives:

To assess a clinical training program on management of Type 2 Diabetes Mellitus (T2DM) incorporating a diabetes tool, the Simpler™ tool. Subsequently pharmacists’ experience utilising the tool to deliver structured, consistent, evidence-based T2DM care was explored.

Methods:

Full-time non-credentialed diabetes pharmacists providing diabetes medication management services in community settings were purposively recruited. Participants had either face-to-face or online training on diabetes management using the tool which took about two hours and 20 minutes to complete. Their diabetes management knowledge was assessed pre- and post-training using quantitative methodology. They were then required to apply the tool in daily practice for one month. Feedback on both the training sessions and tool utilisation were obtained through semi-structured interviews and analysed using a qualitative approach.

Results:

Twelve pharmacists participated: Six from Australia and six from Malaysia. Before attending the training session, their median test score was 6.5/27, IQR 1.4 (1st marker) and 5.3/27, IQR 2.0 (2nd marker). After training, the scores doubled to 14.3/27, IQR 4.5 (1st marker) and 11.3/27, IQR 3.1 (2nd marker), showing significant improvements (p=0.002). Interview data identified perceived effectiveness factor through use of the tool. Participants found the content relevant, structured, concise and easy to understand; enabled comprehensive medication reviews; focused on achieving glycaemic improvement; facilitated documentation processes and pharmacists’ role in T2DM management; and as a specific aid for diabetes management. Barriers included lack of accessibility to patients’ laboratory data in Australia.

Conclusions:

The targeted training improved pharmacists’ knowledge on diabetes management and supported the Simpler™ tool use in practice as a structured and beneficial method to deliver evidence-based T2DM care.

Community Pharmacist-Provided Wellness and Monitoring Services in an Employee Wellness Program: A Four-Year Summary

Objective: To assess the clinical outcomes of participants of an employee wellness program during four years of service implementation. Methods: A prospective cohort study was conducted at 15 independent community pharmacy chain locations in northwest and central Missouri. A total of 200 participants were enrolled in an employee wellness program, and the program included five monitoring groups-cholesterol, blood pressure, blood glucose, weight, and healthy participant groups. Participants selected a pharmacist wellness coordinator and wellness appointments were conducted, consisting of education, goal-setting, and monitoring through physical assessment and point of care testing. The primary outcome measures were total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG), body mass index (BMI), and waist circumference (WC). The secondary outcome measures were the proportion of patients who achieved the clinical value goals at baseline versus 48 months. The primary outcome measures among data collection time points were compared using one-way analysis of variance (ANOVA) tests, and the secondary outcomes were compared between baseline and 48 months by Chi-square or Fisher's exact tests. One-way ANOVA post hoc tests were also performed using least significant difference, to further identify which time points differed from each other. Results: At baseline, there were 134 patients in the cholesterol monitoring group, 129 in the weight monitoring group, 117 in the blood pressure monitoring group, 46 in the blood glucose monitoring group, and 26 in the healthy participant monitoring group. For patients in the blood pressure monitoring group, compared with baseline, there was a significant decrease in DBP at months 12, 24, 36, and 48, and a significant increase in the proportion of patients achieving blood pressure goals at 48 months. For patients in the blood glucose monitoring group, compared with baseline, there was a significant decrease in FBG at months 12, 24, 36, and 48, and a significant increase in the proportion of patients achieving blood glucose goals at 48 months. Conclusions: Pharmacist-led wellness visits provided to employee wellness patients in a community pharmacy may lead to improvements in BP and FBG values.

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.

Type 1 diabetes mellitus: can coaching improve health outcomes?

OBJECTIVE

To evaluate the introduction of coaching in the interdisciplinary care of individuals with type 1 diabetes mellitus in the public health care system.

SUBJECTS AND METHODS

Ten patients routinely attending a public health care service and with a glycated hemoglobin (HbA1c) level above 75% participated in eight coaching sessions. This study evaluated the patients' self-management of the disease and personal behavior. The participants were assessed at the beginning of the program and on two occasions after the intervention, with evaluation of biochemical and anthropometric data, and frequency of self-monitoring of blood glucose (SMBG). Questionnaires were applied during these evaluations to analyze emotional burden (B-PAID), medication adherence (Morisky Adherence Scale), and self-efficacy (IMDSES).

RESULTS

HbA1c had a median level of 8.0% (range 76-10.3%) at the beginning of the study and reduced significantly 3 months after initiation of the intervention (7.78% [6.5-10%], p = 0.028), with no significant increase at 6 months (8.3% [713-9.27%], p = 0.386). SMBG improved significantly from the beginning to the end of the study, with the median number of glucose tests per week varying from 16.5 (range 0-42) at baseline to 29.0 (7-42) at 3 months and 27.5 (10-48) at 6 months (p = 0.047). No significant differences were observed in anthropometric parameters or in the scores of the instruments between the three measurements.

CONCLUSION

A coaching intervention focused on patients' values and sense of purpose may provide added benefit to traditional diabetes education programs and could be an auxiliary method to help individuals with type 1 diabetes achieve their treatment goals.

Developing an obesity intervention in Micronesia: From needs assessment to planning

Evidence-based obesity reduction programs in the Pacific are scarce to nonexistent. Using a community-based participatory research model (CBPR) we developed a collaboration between our university and a small Pacific Island nation. We established an advisory council of local stakeholders and then conducted an extensive needs assessment with youth, parents, professionals, and lay public. Only 9% of participants had tried a weight loss program. There was a strong tendency to engage in binge-eating cycles; difficulty eating healthy during frequent community celebrations with few healthy food options available in general; and limited traditions that involved physical activity. Participants wanted to learn how to increase their physical activity, make healthier food choices, and learn to reward themselves for healthy behaviors. Diets were most frequently high in energy or protein foods, followed by starch, sugary and fried foods; they ate vegetables and fruits least often. Together, our team then created the culturally relevant Fit Kit Palau^©. We highlight lessons learned including how to determine partnerships; manage multiple cultural and geographic barriers; build capacity; and balance program fidelity with responsivity. As the program moves forward, we hope to increase access, engagement, and adherence and provide a model for other PI countries.

Collective empowerment strategies for patients with Diabetes Mellitus: A systematic review and meta-analysis

AIMS

To perform a systematic review and meta-analysis to identify and analyze collective empowerment strategies for patients with Diabetes Mellitus (DM).

METHODS

The systematic review was performed using PubMed/MEDLINE, Science Direct and BVS. The term "Diabetes Mellitus" was used with each of the following describers, along with the connector "AND": "self-care", "health education", "motivation" and "empowerment". Inclusion criteria were: intervention study with control group published between 2004 and 2014. For meta-analysis, RevMan V 5.3 software was used.

RESULTS

Among the nine analyzed articles, 66.7% (n=6) were developed in patients diagnosed with DM2. Concerning the indicators for intervention effectiveness evaluation, all articles (n=9) used glycated hemoglobin (HbA1c) and the most used instrument was Summary of Diabetes Self Care Activities Measure, representing 44.4% (n=4) of the studies. The types of strategies used were similar in the articles. There was evidence of a decrease in HbA1c levels in 66.7% (n=6). The meta-analysis found significant evidence indicating beneficial effects of empowerment.

CONCLUSIONS

Programs based on collective empowerment in DM have shown the interventions lead to improvement in clinical parameters, behavior, increased knowledge about DM, and self-care.

A Narrative Review of Diabetes Intervention Studies to Explore Diabetes Care Opportunities for Pharmacists

Background. We conducted a review of current diabetes intervention studies in type 2 diabetes and identified opportunities for pharmacists to deliver quality diabetes care. Methods. A search on randomised controlled trials (RCT) on diabetes management by healthcare professionals including pharmacists published between 2010 and 2015 was conducted. Results and Discussion. Diabetes management includes multifactorial intervention which includes seven factors as outlined in diabetes guidelines, namely, glycaemic, cholesterol and blood pressure control, medication, lifestyle, education, and cardiovascular risk factors. Most studies do not provide evidence that the intervention methods used included all seven factors with exception of three RCT which indicated HbA1c (glycated hemoglobin) reduction range of 0.5% to 1.8%. The varied HbA1C reduction suggests a lack of standardised and consistent approach to diabetes care. Furthermore, the duration of most studies was from one month to two years; therefore long term outcomes could not be established. Conclusion. Although pharmacists' contribution towards improving clinical outcomes of diabetes patients was well documented, the methods used to deliver structured, consistent evidence-based care were not clearly stipulated. Therefore, approaches to achieving long term continuity of care are uncertain. An intervention strategy that encompass all seven evidence-based factors will be useful.

Empowerment in the Treatment of Diabetes and Obesity

As the available therapies for diabetes and obesity are not effective enough, diabetologists and educators search for new methods to collaborate with patients in order to support their health behaviors. The aim of this review is to discuss perspectives for the development of new empowerment-type therapies in the treatment of diabetes/obesity. Empowerment is a process whereby patients gain the necessary knowledge to influence their own behavior to improve the quality of their lives. It is carried out in five stages: (1) identify the problem, (2) explain the feelings and meanings, (3) build a plan, (4) act, and (5) experience and assess the execution. Although many years have passed since the advent and popularization of the concept of empowerment, the area remains controversial, mainly with regard to the methodology of therapy. Some previous studies have confirmed the positive effect of empowerment on body weight, metabolic control, and quality of life of patients with type 2 diabetes; however, few studies have been conducted in patients with type 1 diabetes. There is still a need to confirm the effectiveness of empowerment in accordance with Evidence Based Medicine by performing long-term observational studies in a large group of patients. In future, empowerment may become part of the standard of care for patients with diabetes and/or obesity.

Connected health: a review of the literature

The presence of social support, and more recently, connection, has been linked to multiple health benefits and longevity measures and the lack of connection is associated with premature morbidity and mortality. Connected health is a growing industry, and we were interested in determining whether or not scholars in the field have established the ways in which technology could facilitate or promote connection between patients and healthcare providers. This integrative literature review sought to collect and analyze research studies addressing social support or connection in a sample of patients with diabetes to evaluate the social support or connection metrics in use, the type of technology deployed by researchers to achieve connection, and to assess the state of the science in this area. We hypothesized that being connected to someone who cares is good for your health. We believe this holds true even when connection is accomplished with mobile technologies. Thirty five studies were included in this review, 21 utilized technology to enhance patient-provider connection. The articles included in this review were from a total of more than nine countries and took place in hospital, physician office, and community settings. They represented people from childhood through to old age. Technologies evaluated include: telephone interventions, email, text messaging, interactive voice response (IVR), video blogs, apps, websites, and social media. There were multiple operational definitions of social support and self-management used as variables within the studies. Findings from this review suggest that being connected does matter to patients with diabetes, and being connected to family matters the most, even though the associations are complex and not always predictable. Furthermore, patients with diabetes will utilize a variety of technologies to connect with healthcare providers, team members, and even other people with the same disease. The use of technology with diabetes patients positively impacts a variety of health outcomes, such as HbA1c, weight, physical activity, healthy eating, cholesterol and frequency of glycemic monitoring.

Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis

BACKGROUND

Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs.

PURPOSE

To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes.

DATA SOURCES

6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists.

STUDY SELECTION

Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs.

DATA EXTRACTION

One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias.

DATA SYNTHESIS

Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥ 11 contact hours) led to clinically important improvements in glycemic control (≥ 0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support-especially those offering 10 or fewer contact hours-provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥ 75% nonwhite participants).

LIMITATIONS

All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions.

CONCLUSION

Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515).

Partnering With Community-Dwelling Individuals With Diabetes for Health Behavior Change Using Action Plans: An Innovation in Health Professionals Education and Practice

Health care practitioners support or hinder an individual's attempts to self-manage health behavior. Practitioners must understand an individual's health needs and goals to effectively partner for behavior change. Self-management support (SMS) promote efforts toward positive health behavior change. Practitioners need training to provide effective SMS, beginning with their formal education. The purpose of this educational practice project was to integrate an evidence-based intervention (SMS using action plans) into a nursing curriculum. Three sequential steps included (1) providing foundational SMS education, (2) SMS application with students' personal action plans, and (3) implementing SMS with community-dwelling individuals with diabetes. Students (n = 130) partnered with participants (n = 85), developing short- (n = 240) and long-term (n = 99) action plans during home visits. The average baseline Diabetes Empowerment Scale score measuring participant's perceived psychosocial diabetes management self-efficacy was 4.3 (1-5 scale, SD = 0.51, n = 83). Most common short-term actions related to physical activity (n = 100, 42%) and healthy eating (n = 61, 25%). Average participant confidence level was 7.7 (SD = 1.9, 0-10 scale). Short-term goal evaluation (n = 209) revealed 66% (n = 137) were met more than 50% of the time. Both participants (99%) and students (99%) expressed satisfaction with home visit and action plan experiences. This teaching-learning experience is replicable and applicable to any professional health care student.

Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review

Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.

Assessment of pharmacist-led patient counseling in randomized controlled trials: a systematic review

Background Pharmacists' counseling has improved health-related outcomes in many acute and chronic conditions. Several studies have shown how pharmacists have been contributing to reduce morbidity and mortality related to drug-therapy (MMRDT). However, there still is a lack of reviews that assemble evidence-based clinical pharmacists' counseling. Equally, there is also a need to understand structure characteristics, processes and technical contents of these clinical services. Aim of the review To review the structure, processes and technical contents of pharmacist counseling or education reported in randomized controlled trials (RCT) that had positive health-related outcomes. Methods We performed a systematic search in specialized databases to identify RCT published between 1990 and 2013 that have evaluated pharmacists' counseling or educational interventions to patients. Methodological quality of the trials was assessed using the Jadad scale. Pharmacists' interventions with positive clinical outcomes (p < 0.05) were evaluated according to patients' characteristics, setting and timing of intervention, reported written and verbal counseling. Results 753 studies were found and 101 RCT matched inclusion criteria. Most of the included RCTs showed a Jadad score between two (37 studies) and three (32 studies). Pharmacists were more likely to provide counseling at ambulatories (60 %) and hospital discharge (25 %); on the other hand pharmacists intervention were less likely to happen when dispensing a medication. Teaching back and explanations about the drug therapy purposes and precautions related to its use were often reported in RCT, whereas few studies used reminder charts, diaries, group or electronic counseling. Most of studies reported the provision of a printed material (letter, leaflet or medication record card), regarding accessible contents and cultural-concerned informations about drug therapy and disease. Conclusion Pharmacist counseling is an intervention directed to patients' health-related needs that improve inter-professional and inter-institutional communication, by collaborating to integrate health services. In spite of reducing MMRDT, we found that pharmacists' counseling reported in RCT should be better explored and described in details, hence collaborating to improve medication-counseling practice among other countries and settings.

Positive psychological characteristics in diabetes: a review

Positive psychological characteristics, such as optimism, self-efficacy, and resilience, have been increasingly associated with improved outcomes in medically ill individuals. However, there has been minimal systematic review of these characteristics and their associations with outcomes in people with diabetes. We aim to review these associations, their potential mediating mechanisms, and the evidence supporting interventions targeting these qualities. In people with diabetes, positive psychological characteristics are significantly associated with improved glycemic control, fewer complications, and reduced rates of mortality. Potential mechanisms mediating these associations include behavioral factors (e.g., improved treatment adherence), reduced inflammation, and improved neuroendocrine and autonomic functioning. Most psychosocial treatments in this population have focused on improving self-efficacy and resilience; such interventions may improve quality of life, well-being, and diabetes self-care. While untested in diabetes, interventions to boost other positive characteristics have been effective in other medically ill patients and may warrant further study in this cohort.