Effect of problem-solving-based diabetes self-management training on diabetes control in a low income patient sample.
ABSTRACT: Lower socioeconomic status is associated with excess disease burden from diabetes. Diabetes self-management support interventions are needed that are effective in engaging lower income patients, addressing competing life priorities and barriers to self-care, and facilitating behavior change.To pilot test feasibility, acceptability, and effect on disease control of a problem-based diabetes self-management training adapted for low literacy and accessibility.Two-arm randomized controlled trial powered to detect a 0.50% change in A1C at follow-up with a 2-sided alpha of 0.05 in a pooled analysis.Fifty-six urban African-American patients with type 2 diabetes and suboptimal blood sugar, blood pressure, or cholesterol control recruited from a diabetes registry within a university-affiliated managed care organization.A group, problem-based diabetes self-management training designed for delivery in an intensive and a condensed program format. Three intensive and three condensed program groups were conducted during the trial.Clinical (A1C, systolic blood pressure [SBP], diastolic blood pressure [DBP], LDL and HDL cholesterol) and behavioral (knowledge, problem solving, self-management behavior) data were measured at baseline, post-intervention, and 3 months post-intervention (corresponding with 6-9 months following baseline).Adoption of both programs was high (>85% attendance rates, 95% retention). At 3 months post-intervention, the between-group difference in A1C change was -0.72% (p?=?0.02), in favor of the intensive program. A1C reduction was partially mediated by problem-solving skill at follow-up (ß = -0.13, p?=?0.04). Intensive program patients demonstrated within-group improvements in knowledge (p?
Project description:OBJECTIVE:To compare the effectiveness of three delivery modalities of Decision-making Education for Choices In Diabetes Everyday (DECIDE), a nine-module, literacy-adapted diabetes and cardiovascular disease (CVD) education and problem-solving training, compared with an enhanced usual care (UC), on clinical and behavioral outcomes among urban African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS:Eligible participants (n = 182) had a suboptimal CVD risk factor profile (A1C, blood pressure, and/or lipids). Participants were randomized to DECIDE Self-Study (n = 46), DECIDE Individual (n = 45), DECIDE Group (n = 46), or Enhanced UC (n = 45). Intervention duration was 18-20 weeks. Outcomes were A1C, blood pressure, lipids, problem-solving, disease knowledge, and self-care activities, all measured at baseline, 1 week, and 6 months after completion of the intervention. RESULTS:DECIDE modalities and Enhanced UC did not significantly differ in clinical outcomes at 6 months postintervention. In participants with A1C ?7.5% (58 mmol/mol) at baseline, A1C declined in each DECIDE modality at 1 week postintervention (P < 0.05) and only in Self-Study at 6 months postintervention (b = -0.24, P < 0.05). There was significant reduction in systolic blood pressure in Self-Study (b = -4.04) and Group (b = -3.59) at 6 months postintervention. Self-Study, Individual, and Enhanced UC had significant declines in LDL and Self-Study had an increase in HDL (b = 1.76, P < 0.05) at 6 months postintervention. Self-Study and Individual had a higher increase in knowledge than Enhanced UC (P < 0.05), and all arms improved in problem-solving (P < 0.01) at 6 months postintervention. CONCLUSIONS:DECIDE modalities showed benefits after intervention. Self-Study demonstrated robust improvements across clinical and behavioral outcomes, suggesting program suitability for broader dissemination to populations with similar educational and literacy levels.
Project description:OBJECTIVE To report results from YourWay, an Internet-based self-management intervention for adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS A total of 72 adolescents with type 1 diabetes, ages 13-17 years, were randomized to a usual-care-plus-Internet support or a usual-care group. The intervention was designed to enhance problem-solving barriers to self-management. A1C was obtained from medical records, and problem-solving and self-management were obtained via adolescent report. RESULTS Group differences were not statistically significant using intent-to-treat analyses. Using as-treated analyses, adolescents in the treatment condition showed statistically significant improvement in self-management (d = 0.64; P = 0.02) and important improvements in problem-solving (d = 0.30; P = 0.23) and A1C (d = -0.28; P = 0.27). Mean A1C for the intervention group remained constant (-0.01%), while the control group increased (0.33%). CONCLUSIONS This brief trial suggests that self-management support delivered through a secure website may improve self-management and offset typical decreases in adolescent glycemic control.
Project description:IntroductionOlder adults have complex medication self-management challenges that can contribute to poor disease control.MethodsIn 2016, an interprofessional medication self-management program was implemented in an internal medicine primary care residency clinic caring for a large proportion of indigent patients. This was a 1-year, quasi-experimental, pre–post study approved by the Institutional Review Board to evaluate the impact of this program on hypertension and diabetes control in older adults. Patients aged 60 years or older with both systolic blood pressure > 140 mm Hg and A1C > 7.5% were included in the study; patients who did not have these characteristics were excluded. Interprofessional team members (nurses, certified medical assistants, pharmacist, dietician, social worker, and nurse technician) obtained 6-month medication fill histories from pharmacies and provided findings to physicians prior to patient appointments. During patient appointments, medication self-management interventions were performed such as motivational interviewing and regimen simplification. Members contacted patients by phone after each appointment for ongoing medication self-management support.ResultsOf 50 patients, the mean age was 67 years, 78% were female, 88% were black, the mean baseline systolic blood pressure was 159.8 mm Hg, and A1C was 9.7%. The 1-year mean systolic blood pressure was significantly reduced [151.5 mm Hg vs 141.8 mm Hg, ?9.7 mm Hg difference, 95% confidence interval (CI) ?6.19 to ?13.19, P < 0.001], and the 1-year mean A1C was significantly reduced (9.6% vs 8.6%, ?1.0% difference, 95% CI ?0.49 to ?1.39, P < 0.001) after implementation. Compared to baseline, the mean systolic blood pressure and A1C were significantly lower at each follow-up visit.ConclusionThis interprofessional medication self-management initiative improved systolic blood pressure and A1C in underserved older adults in an internal medicine residency clinic.
Project description:Patients with diabetes and depression often have self-management needs that require between-visit support. This study evaluated the impact of telephone-delivered cognitive behavioral therapy (CBT) targeting patients' management of depressive symptoms, physical activity levels, and diabetes-related outcomes.Two hundred ninety-one patients with type 2 diabetes and significant depressive symptoms (Beck Depression Inventory scores ? 14) were recruited from a community-based, university-based, and Veterans Affairs health care systems. A manualized telephone CBT program was delivered weekly by nurses for 12 weeks, followed by 9 monthly booster sessions. Sessions initially focused exclusively on patients' depression management and then added a pedometer-based walking program. The primary outcome was hemoglobin A1c levels measured at 12 months. Blood pressure was a secondary outcome; levels of physical activity were determined by pedometer readings; depression, coping, and health-related quality of life were measured using standardized scales.Baseline A1c levels were relatively good and there was no difference in A1c at follow-up. Intervention patients experienced a 4.26 mm Hg decrease in systolic blood pressure relative to controls (P=0.05). Intervention patients had significantly greater increases in step counts (mean difference, 1131 steps/d; P=0.0002) and greater reductions in depressive symptoms (58% remitted at 12 mo vs. 39%; P=0.002). Intervention patients also experienced relative improvements in coping and health-related quality of life.This program of telephone-delivered CBT combined with a pedometer-based walking program did not improve A1c values, but significantly decreased patients' blood pressure, increased physical activity, and decreased depressive symptoms. The intervention also improved patients' functioning and quality of life.
Project description:Churches may provide a familiar and accessible setting for chronic disease self-management education and social support for Latinos with diabetes.We assessed the impact of a multi-faceted church-based diabetes self-management intervention on diabetes outcomes among Latino adults.This was a community-based, randomized controlled, pilot study.One-hundred adults with self-reported diabetes from a Midwestern, urban, low-income Mexican-American neighborhood were included in the study.Intervention participants were enrolled in a church-based diabetes self-management program that included eight weekly group classes led by trained lay leaders. Enhanced usual care participants attended one 90-minute lecture on diabetes self-management at a local church.The primary outcome was change in glycosylated hemoglobin (A1C). Secondary outcomes included changes in low-density lipoproteins (LDL), blood pressure, weight, and diabetes self-care practices.Participants' mean age was 54 ± 12 years, 81 % were female, 98 % were Latino, and 51 % were uninsured. At 3 months, study participants in both arms decreased their A1C from baseline (-0.32 %, 95 % confidence interval [CI]: -0.62, -0.02 %). The difference in change in A1C, LDL, blood pressure and weight from baseline to 3-month and 6-month follow-up was not statistically significant between the intervention and enhanced usual care groups. Intervention participants reported fewer days of consuming high fat foods in the previous week (-1.34, 95 % CI: -2.22, -0.46) and more days of participating in exercise (1.58, 95 % CI: 0.24, 2.92) compared to enhanced usual care from baseline to 6 months.A pilot church-based diabetes self-management intervention did not reduce A1C, but resulted in decreased high fat food consumption and increased participation in exercise among low-income Latino adults with diabetes. Future church-based interventions may need to strengthen linkages to the healthcare system and provide continued support to participants to impact clinical outcomes.
Project description:Patient problem solving and decision making are recognized as essential to effective self-management across multiple chronic diseases. However, a health-related problem-solving instrument that demonstrates sensitivity to disease control parameters in multiple diseases has not been established.To determine, in two disease samples, internal consistency and associations with disease control of the Health Problem-Solving Scale (HPSS), a 50-item measure with 7 subscales assessing effective and ineffective problem-solving approaches, learning from past experiences, and motivation/orientation.Cross-sectional study.Outpatients from university-affiliated medical center HIV (N = 111) and diabetes mellitus (DM, N = 78) clinics.HPSS, CD4, hemoglobin A1c (HbA1c), and number of hospitalizations in the previous year and Emergency Department (ED) visits in the previous 6 months.Administration time for the HPSS ranged from 5 to 10 minutes. Cronbach's alpha for the total HPSS was 0.86 and 0.89 for HIV and DM, respectively. Higher total scores (better problem solving) were associated with higher CD4 and fewer hospitalizations in HIV and lower HbA1c and fewer ED visits in DM. Health Problem-Solving Scale subscales representing negative problem-solving approaches were consistently associated with more hospitalizations (HIV, DM) and ED visits (DM).The HPSS may identify problem-solving difficulties with disease self-management and assess effectiveness of interventions targeting patient decision making in self-care.
Project description:BACKGROUND:Adolescents with type 1 diabetes commonly have poor glycaemic control. We aimed to test the efficacy of a newly developed adaptive behavioral intervention (Flexible Lifestyles Empowering Change; FLEX) on metabolic and psychosocial outcomes in adolescents with type 1 diabetes. METHODS:Young people (13-16 years, type 1 diabetes duration >1 year, HbA1c of 64-119 mmol/mol [8·0-13·0%], and without other serious medical conditions or pregnancy) from two clinical sites (Colorado and Ohio, USA) were eligible for enrolment. One caregiver was required to participate actively in the study. Adolescent participants were randomly assigned to the FLEX intervention, which used motivational interviewing and problem-solving skills training to enhance patients' self-management, or usual care control. Intervention fidelity was assessed by a behavioral psychologist with specific expertise in motivational interviewing and who was not otherwise involved in the study via audiotaped sessions. The primary outcome was measurement of glycated haemoglobin A1c (HbA1c) at 18 months. Secondary outcomes included motivation and intention, problem solving skills, self-management behaviors, symptoms of depression, health related quality of life, fear of hypoglycemia, diabetes family conflict, risk factors for T1D complications (BMI, blood pressure, and plasma lipids), and hypoglycemia derived from continuous glucose monitoring (percent time below 3·0 and 3·9 mmol/l [54 and 70 mg/dl]). Intention-to-treat analyses used mixed effects models, with fixed effects including site, timepoint, intervention group, intervention by timepoint, and baseline level of primary (HbA1c) or secondary outcomes (?=0·05). FLEX is registered on clinicaltrials.gov, number NCT01286350. FINDINGS:Young people recruited from May 1, 2014 to April 4, 2016 were randomly assigned to FLEX (n=130) or usual care control (n=128). Mean diabetes duration was 6·4 (SD 3·8) years, and 71% (181 out of 256) of patients used insulin pump therapy. Retention was 93%, with 241 out of 258 completing the 18-month assessment. The intervention fidelity score was 4·40 of 5·00 for motivational interviewing and 97% for session content. At 18 months, HbA1c was not significantly different between intervention (83  mmol/mol at baseline; 84  mmol/mol at follow-up); and control (80  mmol/mol at baseline; 82  mmol/mol at follow-up); change in intervention versus control was -0·7 mmol/mol (95% CI -4·7 to 3·4, p=0·75). The intervention was associated with improved scores for motivation (p=0·011), problem solving (p=0·024), diabetes self-management profile (p=0·013), youth report of overall quality of life (p=0·0089), selected domains related to fear of hypoglycaemia (p=0·036 for youth's helplessness or worry; p=0·0051 for parent's efforts to maintain high blood glucose), parent report of diabetes family conflict (p=0·0001), total cholesterol (p=0·038), and diastolic blood pressure (p=0·015). A total of 54 serious adverse events were identified; 34 of these were diabetes-related, including low blood glucose requiring assistance (n=3) and high blood glucose with diabetic ketoacidosis and emergency response (n=25). INTERPRETATION:The FLEX intervention did not significantly change HbA1c among these adolescents with elevated HbA1c, but did positively affect several psychosocial outcomes over 18 months. Further analyses will provide information regarding drivers of positive response to the intervention and will point to future directions for improvement in the approach. FUNDING:National Institutes of Health and National Institute of Diabetes Digestive Diseases and Kidney and the Helmsley Charitable Trust.
Project description:It is unknown whether computer-generated, patient-tailored feedback leads to improvements in glycemic control in people with type 2 diabetes.We recruited people with type 2 diabetes aged ? 40 years with a glycated hemoglobin (A1C) ? 7%, living in Hamilton, Canada, who were enrolled in a community-based program (Diabetes Hamilton) that provided regular evidence-based information and listings of community resources designed to facilitate diabetes self-management. After completing a questionnaire, participants were randomly allocated to either receive or not receive periodic computer-generated, evidence-based feedback on the basis of their questionnaire responses and designed to facilitate improved glycemic control and diabetes self-management. The primary outcome was a change in A1C after 1 year.A total of 465 participants (50% women, mean age 62 years, and mean A1C 7.83%) were randomly assigned, and 12-month A1C values were available in 96% of all participants, at which time the A1C level had decreased by an absolute amount of 0.24 and 0.15% in the intervention and control groups, respectively. The difference in A1C reduction for the intervention versus control group was 0.09% (95% CI -0.08 to 0.26; P = 0.3). No between-group differences in measures of quality of life, diabetes self-management behaviors, or clinical outcomes were observed.Providing computer-generated tailored feedback to registrants of a generic, community-based program that supports diabetes self-management does not lead to lower A1C levels or a better quality of life than participation in the community-based program (augmented by periodic A1C testing) alone.
Project description:We hypothesized that people with type 2 diabetes in an online diabetes self-management program, compared with usual-care control subjects, would 1) demonstrate reduced A1C at 6 and 18 months, 2) have fewer symptoms, 3) demonstrate increased exercise, and 4) have improved self-efficacy and patient activation. In addition, participants randomized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement.A total of 761 participants were randomized to 1) the program, 2) the program with e-mail reinforcement, or 3) were usual-care control subjects (no treatment). This sample included 110 American Indians/Alaska Natives (AI/ANs). Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups.At 6 months, A1C, patient activation, and self-efficacy were improved for program participants compared with usual care control subjects (P < 0.05). There were no changes in other health or behavioral indicators. The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects. The subgroup with initial A1C >7% demonstrated stronger improvement in A1C (P = 0.01). At 18 months, self-efficacy and patient activation were improved for program participants. A1C was not measured. Reinforcement showed no improvement.An online diabetes self-management program is acceptable for people with type 2 diabetes. Although the results were mixed they suggest 1) that the program may have beneficial effects in reducing A1C, 2) AI/AN populations can be engaged in and benefit from online interventions, and 3) our follow-up reinforcement appeared to have no value.
Project description:Diabetic patients with lower literacy or numeracy skills are at greater risk for poor diabetes outcomes. This study evaluated the impact of providing literacy- and numeracy-sensitive diabetes care within an enhanced diabetes care program on A1C and other diabetes outcomes.In two randomized controlled trials, we enrolled 198 adult diabetic patients with most recent A1C >or=7.0%, referred for participation in an enhanced diabetes care program. For 3 months, control patients received care from existing enhanced diabetes care programs, whereas intervention patients received enhanced programs that also addressed literacy and numeracy at each institution. Intervention providers received health communication training and used the interactive Diabetes Literacy and Numeracy Education Toolkit with patients. A1C was measured at 3 and 6 months follow-up. Secondary outcomes included self-efficacy, self-management behaviors, and treatment satisfaction.At 3 months, both intervention and control patients had significant improvements in A1C from baseline (intervention -1.50 [95% CI -1.80 to -1.02]; control -0.80 [-1.10 to -0.30]). In adjusted analysis, there was greater improvement in A1C in the intervention group than in the control group (P = 0.03). At 6 months, there were no differences in A1C between intervention and control groups. Self-efficacy improved from baseline for both groups. No significant differences were found for self-management behaviors or satisfaction.A literacy- and numeracy-focused diabetes care program modestly improved self-efficacy and glycemic control compared with standard enhanced diabetes care, but the difference attenuated after conclusion of the intervention.