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Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations |
Eakin E G, Bull S S, Glasgow R E, Mason M |
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Authors' objectives To review the effectiveness of diabetes self-management education (DSME) interventions for under-served and minority populations.
Searching MEDLINE was searched from 1987 to 2001 using the keyword 'diabetes', together with: 'self-management', 'programs',' initiatives', 'projects', 'African Americans', 'Asians', 'Latinos', 'Hispanics', 'older adults', 'elderly', 'under-served' and 'low-income'. The search was restricted to publications in English. Bibliographies of identified studies and previous reviews were searched for relevant articles. Formative evaluation studies were stated to be excluded, although these were later identified as part of the review.
Study selection Study designs of evaluations included in the reviewRandomised controlled trials or quasi-experimental studies employing a comparison group were eligible for inclusion in the review.
Specific interventions included in the reviewEducational interventions that aimed to teach diabetes self-management (e.g. blood glucose monitoring, glycaemic control, dietary habits and exercise) were eligible for inclusion in the review. These included hospital, clinic, community and research centre settings with interventions that were given either in group or individual sessions or were phone-based. These sometimes included: informational mailings, media campaigns to increase knowledge and early detection; classes in physical activity/exercise and diet/nutrition, community lifestyles, history and culture; videotapes and handouts; peer support; home visits/calls from a nurse regarding education compliance and to facilitate access to primary care. The control interventions included 'usual care' (e.g. a 1-hour lecture), assessment only, where observational groups or waiting-list were offered treatment at a later period.
Participants included in the reviewMembers of racial and ethnic minority groups of either gender, low-literacy groups, low-income groups, and older adults with a variety of chronic conditions were eligible for inclusion in the review. The study participants included overweight type 2 diabetes mellitus African Americans, type 2 low-literate African Americans, type 2 Mexican Americans, Canadian Aboriginal adults with or at risk of type 2, type 2 older adults, Zuni Indians, obese Pima Indians who were normoglycaemic, and type 2 veterans. The mean ages ranged from 34 to 68 years and the majority of the participants were female.
Outcomes assessed in the reviewThe key outcomes assessed in the review were:
physiological, including weight, body composition, body mass index, waist circumference, cholesterol or lipids, blood-pressure, glucose tolerance, glycosylated haemoglobin and fasting blood glucose;
behavioural, including diet or nutrient intake, smoking, alcohol intake and physical activity;
psychosocial, including depression, social support, self-efficacy, quality of life and peer support;
knowledge, including nutrition and general diabetes self-management; and
'other', including the costs to provide the intervention and changes in medication regime.
The outcomes were reported as short-term results at less than 12 months and long-term results at greater than 12 months.
How were decisions on the relevance of primary studies made?The authors do not state explicitly how the papers were selected for the review, or how many of the reviewers performed the selection, although they do mention that a single searcher performed the literature search.
Assessment of study quality A summary methodologic rating of 0 to 9 was calculated using a rating system based upon the RE-AIM model (Reach, Efficacy, Adoption, Implementation, Maintenance) (see Other Publications of Related Interest) and the following criteria: study design (0 to 3), analysis (0 to 1), dependent variables (0 to 1), reach (0 to 1), implementation (0 to 1) and attrition (0 to 2). The authors do not state who performed the validity assessment.
Data extraction The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction.
Data were extracted on: study, design and methodological rating; sample and reach; setting and type of intervention; key outcomes and length of follow-up; efficacy at or less than 12 months; adoption and implementation; and maintenance (both individual and system) at or greater than 12 months.
Methods of synthesis How were the studies combined?Owing to inadequate information provided in the majority of studies and the heterogeneous nature of the outcome measures, no statistical pooling of the data was undertaken. The studies were combined narratively, according to the following outcomes: methodology rating, reach, theory-based interventions/formative evaluation, efficacy, (physiological, behavioural, psychosocial, knowledge and 'other'), adoption, implementation, and maintenance.
How were differences between studies investigated?No formal test of heterogeneity was undertaken.
Results of the review Ten controlled studies (n=1,322) were included in the review. Six used a randomised controlled design and four a quasi-experimental design (most often a non-randomised comparison group).
Methodology rating.
The scores ranged from 2 to 8, with 4 studies receiving 7 or more on a scale of 0 to 9.
Reach.
Five of the 10 studies reported reach, with participation rates that ranged from less than a third to 90% (median 68%). Only one study reported the representativeness of study participants in comparison with the whole population.
Theory-based interventions/formative evaluation.
Four studies described theoretical basis, which ranged from theories of education and self-directed learning to community development theory. Seven studies described or referenced the formative work (e.g. focus groups) that guided the development or adaptation of the intervention to the target population.
Efficacy.
In terms of short-term physiological outcomes, 5 of the 9 studies reported a significantly greater reduction weight in intervention than in comparison conditions. Three of the 9 studies reported significant reductions in one or more measures of blood glucose control. For short-term behavioural outcomes, 3 of the 5 studies reported significantly greater short-term positive changes in dietary patterns, and/or physical activity for intervention than control conditions. Only 2 studies reported on short-term changes in diabetes knowledge, and neither found significant short-term increases. One of the 3 studies found short-term significant differences in psychosocial outcomes in favour of the intervention.
No study reported data on adoption, e.g., the percentage of settings or providers willing to deliver the intervention or participate in the study, or the representativeness of these.
Only one of the 10 studies reported information on whether the intervention was delivered as intended (over the phone via a nurse educator). Five studies reported participant adherence through session attendance, which ranged from 10 to 90% (median 60%).
Maintenance.
Four of the 10 studies reported on individual maintenance, and of these, 3 found no significant difference in long-term weight reductions for the interventions, compared with the control conditions. Two of the 4 studies found significant long-term improvements on various measures of blood glucose control. Two of the 3 studies found significant improvements in the intervention group in long-term dietary and/or physical activity outcomes. One study reported on long-term changes in diabetes knowledge which resulted in a non significant change. Two studies reported on long-term psychosocial outcomes, and found no significant differences between conditions. Two studies reported on systems level maintenance or continuation/institutionalisation of the intervention following the evaluation, and reported that the programme was ongoing.
Authors' conclusions Alternative modalities for the delivery of DSME interventions, especially those targeting under-served and difficult to reach populations, need to be evaluated. All but one of the studies reviewed used group-based sessions to deliver the intervention and session attendance was extremely variable, often not much better than 60%. In contrast, there were very high levels of implementation in the study that used proactive calls from a nurse educator to deliver the intervention.
People from under-served, low-income, and ethnic minority populations have many barriers to attending group-based meetings, i.e., lack of transportation, limited financial resources, limited access to childcare, increased likelihood of dealing with substance abuse, and mental health disorders. Interventions need to take these issues into account and look for ways to deliver more proactive interventions. For example, the use of proactive phone calls, touch-screen computer-assisted information delivery, and practice redesign interventions that incorporate self- management and peer support into primary care by scheduling diabetes patients for primary care visits at the same time. DSME interventions for under-served populations should explicitly address socio-contextual issues in the patients' lives. DSME interventions in community settings appear to be efficacious; other approaches worthy of investigation include the use of lay health workers and strategies that link patients with relevant community resources. Strategies targeting the individual patient need to be incorporated into policy- and environmental-level interventions.
CRD commentary The review question and the study selection criteria were stated clearly. The literature search was limited to MEDLINE only and publications in English; the authors note that this may have placed limitations on the scope of the review. Some efforts were made to find additional relevant material through manual searches of bibliographic references, but even so, the search may still have missed relevant articles on account of the limitations already highlighted. The authors provided almost no information on the literature selection, validation and data extraction processes. The decision to combine the data narratively, and not to undertake a statistical pooling, seems appropriate given the heterogeneity of the included studies and the inadequate information provided in the majority of studies.
The authors' conclusions are rather lengthy and include information which may have been covered better in the preceding discussion section, or in a section dedicated to research and policy implications, in order to give their conclusions more clarity. However, the conclusions do seem appropriate in the light of the data presented and discussed.
Implications of the review for practice and research Practice: The authors state that DSME interventions need to take the barriers that people from under-served, low-income, and ethnic minority populations have, to attending group-based meetings, into account and look for ways to deliver the interventions that are more proactive. These include the use of proactive phone calls, touch-screen computer-assisted information delivery, and practice redesign interventions which incorporate self-management and peer support into primary care by scheduling diabetes patients for primary care visits at the same time. DSME interventions should take the social-ecological factors impacting upon health in disadvantaged communities into account. Given the barriers to diabetes self-management faced by those of lower socioeconomic status, strategies for targeting the individual patient need to be incorporated into policy- and environmental-level interventions.
Research: The authors state that it is necessary to evaluate alternative modalities for the delivery of DSME interventions, especially those for targeting under-served and difficult to reach populations. As part of the work to address growing health disparities, the systematic evaluation of social-ecological factors impacting upon health in disadvantaged communities should be expanded. In particular, both qualitative and quantitative research is needed on factors related to why different providers and settings serving disadvantaged populations do or do not adopt DSME interventions. Multi-level interventions that combine DSME with health systems changes need to be investigated, as do policy interventions that provide prompts, opportunities, support, and incentives for participation and for maintenance of self-management.
Funding Robert Wood Johnson Foundation, grant number #041862.
Bibliographic details Eakin E G, Bull S S, Glasgow R E, Mason M. Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations. Diabetes/Metabolism Research and Reviews 2002; 18(1): 26-35 Other publications of related interest Eakin EG, Glasgow RE, Riley KM. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. J Fam Pract 2000; 49:158-68.
Indexing Status Subject indexing assigned by NLM MeSH Cost of Illness; Diabetes Mellitus /therapy; Health Priorities; Humans; MEDLINE; Medically Underserved Area; Minority Groups; Patient Education as Topic; Poverty; Self Care AccessionNumber 12002000853 Date bibliographic record published 31/03/2003 Date abstract record published 31/03/2003 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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