Article
Increasing diabetes self-management education in community settings: A systematic review

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Abstract

Overview: This report presents the results of a systematic review of the effectiveness and economic efficiency of self-management education interventions for people with diabetes and forms the basis for recommendations by the Task Force on Community Preventive Services. Data on glycemic control provide sufficient evidence that self-management education is effective in community gathering places for adults with type 2 diabetes and in the home for adolescents with type 1 diabetes. Evidence is insufficient to assess the effectiveness of self-management education interventions at the worksite or in summer camps for either type 1 or type 2 diabetes or in the home for type 2 diabetes. Evidence is also insufficient to assess the effectiveness of educating coworkers and school personnel about diabetes.

Introduction

Diabetes self-management education (DSME), the process of teaching people to manage their diabetes,1 has been considered an important part of the clinical management of diabetes since the 1930s and the work of Joslin.2 The American Diabetes Association (ADA) recommends assessing self-management skills and knowledge of diabetes at least annually and providing or encouraging continuing education.3 DSME is considered “the cornerstone of treatment for all people with diabetes” by the Task Force to Revise the National Standards for Diabetes Self-Management Education Programs,1 a group representing national public health and diabetes-related organizations. This need is also recognized in objective 5-1 of Healthy People 20104: to increase to 60% (from the 1998 baseline of 40%) the proportion of persons with diabetes who receive formal diabetes education.

The goals of DSME are to optimize metabolic control and quality of life and to prevent acute and chronic complications, while keeping costs acceptable.5 Unfortunately, 50% to 80% of people with diabetes have significant knowledge and skill deficits6 and mean glycated hemoglobin (GHb)a levels are unacceptably high both in people with type 17b and type 28 diabetes. Furthermore, less than half of people with type 2 diabetes achieve ideal glycemic control9 (hemoglobin A1c [HbA1c] <7.0%).3

The abundant literature on diabetes education and its effectiveness includes several important reviews demonstrating positive effects of DSME on a variety of outcomes, particularly at short-term follow-up.6, 10, 11, 12, 13, 14 These reviews, however, and most of the existing literature, focus primarily on the clinical setting.

The systematic review presented here includes published studies that evaluated the effectiveness of DSME delivered outside of traditional clinical settings, in community centers, faith institutions and other community gathering places, the home, the worksite, recreational camps, and schools. This review does not examine evidence of the effectiveness of clinical care interventions for the individual patient; recommendations on clinical care may be obtained from the ADA,15 and screening recommendations are available from the U.S. Preventive Services Task Force.16 The focus of this review is on people who have diabetes; primary prevention of diabetes is not addressed. For prevention of type 2 diabetes, the best strategies are weight control and adequate physical activity among people at high risk, including those with impaired glucose tolerance.17, 18 These topics will be addressed in other systematic reviews in the Guide to Community Preventive Services (the Community Guide).

Section snippets

The guide to community preventive services

The systematic review in this report represents the work of the independent, nonfederal Task Force on Community Preventive Services (the Task Force), as described elsewhere.19, 20 A supplement to the American Journal of Preventive Medicine, “Introducing the Guide to Community Preventive Services: Methods, First Recommendations and Expert Commentary,” published in January 2000,21 includes the background and methods used in developing the Community Guide.

Methods

A detailed description of the Community Guide’s methods for conducting systematic reviews and linking evidence to determinations of effectiveness has been published,22 and a brief description is available in this supplement.19 Our conceptual approach to DSME is shown in the analytic framework (Figure 1), which portrays the relationships between the intervention, intermediate outcomes (knowledge, psychosocial mediators, and behaviors), and short- and long-term health and quality of life

Reviews of evidence

Evidence of the effectiveness of DSME was reviewed in four settings: community gathering places, the home, recreational camps, and the worksite. The effectiveness of educating coworkers and school personnel about diabetes was also reviewed. The effectiveness of interventions for type 1 and type 2 diabetes was examined separately, as the education of children and adolescents (who usually have type 1 diabetes) is very different from the education of adults (who usually have type 2 diabetes).

Methodologic issues

Future studies on the effectiveness of DSME interventions in community settings need to address a number of methodologic issues. First, attention must be paid to the internal validity of studies and potential sources of bias. Second, randomized controlled trials should be performed to facilitate conclusions about efficacy and causal inference. Observational studies are useful to assess effectiveness, but the study design must control for potential confounders and secular trends. Additionally,

Conclusions

Self-management is critical to the health of the person with diabetes, and the objectives for ideal self-management interventions in diabetes are clear: behavioral interventions must be practical and feasible in a variety of settings; a large percentage of the relevant population must be willing to participate; the intervention must be effective for long-term, important physiologic outcomes as well as behavioral endpoints and quality of life; patients must be satisfied; and the intervention

Acknowledgements

The authors thank Stephanie Zaza, MD, MPH, for support, technical assistance, and editorial review; Kristi Riccio, BSc, for technical assistance; and Kate W. Harris, BA, for editorial and technical assistance. The authors acknowledge the following consultants for their contribution to this manuscript: Tanya Agurs-Collins, PhD, Howard University Cancer Center, Washington, DC; Ann Albright, PhD, RD, California Department of Health Services, Sacramento; Pam Allweiss, MD, Lexington, KY; Elizabeth

References (120)

  • V.G Carande-Kulis et al.

    Methods for systematic review of economic evaluations for the Guide to Community Preventive Services

    Am J Prev Med

    (2000)
  • S.K Kumanyika et al.

    Lose weight and wina church-based weight loss program for blood pressure control among black women

    Patient Educ Couns

    (1992)
  • P.A Newcomb et al.

    Education to increase ophthalmologic care in older onset diabetes patientsindications from the Wisconsin Epidemiologic Study of Diabetic Retinopathy

    J Diabetes Complications

    (1992)
  • G Mimura

    Summer camp

    Diabetes Res Clin Pract

    (1994)
  • J Pichert et al.

    Problem solving anchored instruction about sick days for adolescents with diabetes

    Patient Educ Couns

    (1994)
  • A Misuraca et al.

    Summer camps for diabetic childrenan experience in Campania, Italy

    Diabetes Res Clin Pract

    (1996)
  • National standards for diabetes self-management education programs

    Diabetes Educ

    (1995)
  • Standards of medical care for patients with diabetes mellitus

    Diabetes Care

    (2001)
  • Healthy people 2010

    (2000)
  • S Clement

    Diabetes self-management education

    Diabetes Care

    (1995)
  • M Rosilio et al.

    Factors associated with glycemic control. A cross-sectional nationwide study in 2,579 French children with type 1 diabetes

    Diabetes Care

    (1998)
  • M.I Harris

    Health care and health status and outcomes for patients with Type 2 diabetes

    Diabetes Care

    (2000)
  • M.I Harris et al.

    Racial and ethnic differences in glycemic control of adults with type 2 diabetes

    Diabetes Care

    (1999)
  • S.A Brown

    Effects of educational interventions in diabetes carea meta-analysis of findings

    Nurs Res

    (1988)
  • S.L Norris et al.

    Effectiveness of self-management training in type 2 diabetessystematic review of randomized controlled trials

    Diabetes Care

    (2001)
  • S.E Hampson et al.

    Behavioral interventions for adolescents with type 1 diabeteshow effective are they?

    Diabetes Care

    (2000)
  • American Diabetes Associationclinical practice recommendations 2001

    Diabetes Care

    (2001)
  • Screening for diabetes mellitus. Guide to clinical preventive services

    (1996)
  • J.P Helmrich et al.

    Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus

    N Engl J Med

    (1991)
  • J Tuomilehto et al.

    Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. For the Finnish Diabetes Prevention Study Group

    N Engl J Med

    (2001)
  • Recommendations for healthcare system and self-management education interventions to reduce morbidity and mortality from diabetes

    Am J Prev Med

    (2002)
  • Introducing the Guide to Community Preventive Servicesmethods, first recommendations and expert commentary

    Am J Prev Med

    (2000)
  • Z.T Bloomgarden et al.

    Randomized, controlled trial of diabetic patient educationimproved knowledge without improved metabolic status

    Diabetes Care

    (1987)
  • T Korhonen et al.

    A controlled trial on the effects of patient education in the treatment of insulin-dependent diabetes

    Diabetes Care

    (1983)
  • T.J Lockington et al.

    Knowledge profile and control in diabetic patients

    Diabet Med

    (1988)
  • M Peyrot

    Behavior change in diabetes education

    Diabetes Educ

    (1999)
  • W Wilson et al.

    Psychosocial predictors of self-care behaviors (compliance) and glycemic control in non-insulin-dependent diabetes mellitus

    Diabetes Care

    (1986)
  • D Grembowski et al.

    Self-efficacy and health behavior among older adults

    J Health Soc Behav

    (1993)
  • Tests of glycemia in diabetes

    Diabetes Care

    (2001)
  • J.M Evans et al.

    Frequency of blood glucose monitoring in relation to glycaemic controlobservational study with diabetes database

    Br Med J

    (1999)
  • The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus

    N Engl J Med

    (1993)
  • G.M Reaven

    Beneficial effect of moderate weight loss in older patients with non-insulin-dependent diabetes mellitus poorly controlled with insulin

    J Am Geriatr Soc

    (1985)
  • R.R Wing et al.

    Long-term effects of modest weight loss in type II diabetic patients

    Arch Intern Med

    (1987)
  • N.B Watts et al.

    Prediction of glucose response to weight loss in patients with non-insulin-dependent diabetes mellitus

    Arch Intern Med

    (1990)
  • Nutrition recommendations and principles for people with diabetes mellitus

    Diabetes Care

    (2001)
  • Diabetes mellitus and exercise

    Diabetes Care

    (2001)
  • Aspirin therapy in diabetes

    Diabetes Care

    (2001)
  • Smoking and diabetes

    Diabetes Care

    (2001)
  • Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)

    Lancet

    (1998)
  • Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetesUKPDS 38

    Br Med J

    (1998)
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