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