Mediating the effect of self-care management intervention in type 2 diabetes: A meta-analysis of 47 randomised controlled trials

Objective

To perform a meta-analysis assessing the effects of self-care management interventions in improving glycaemic control in type 2 diabetes by analysing the impact of different study characteristics on the effect size.

Methods

A literature search in eight scientific databases up to November 2007 included original studies of randomised controlled trials involving adult patients diagnosed with type 2 diabetes and evaluating a self-care management intervention.

Results

The 47 included studies yielded 7677 participants. The analysis showed a 0.36% (95% CI 0.21–0.51) improvement in glycaemic control in people who received self-care management treatment. In the univariate meta-regression sample size (effect size 0.42%, p = 0.007) and follow-up period (effect size 0.49%, p = 0.017) were identified to have significant effect on the effect size in favour of small studies and short follow-up. For type of intervention and duration of intervention there was a non-significant effect on effect size in favour of educational techniques and short interventions.

Conclusion

In type 2 diabetes, there are improvements in glycaemic control in people who receive self-care management treatment with a small advantage to intervention with an educational approach.

Practice implications

Further research on frequency and duration of intervention may provide useful information to identify the most effective regime.     

Acceptability,feasibility and effectiveness of a computer-tailored physical activity intervention in adolescents

Objective

To evaluate acceptability, feasibility and effectiveness of computer-tailored physical activity education among adolescents.

Methods

Two classes of 7th graders from 10 randomly selected schools were assigned to the intervention (computer-tailored intervention, n = 139) or control (no-intervention, n = 142) condition. Questionnaires were completed 1 week before and 3 months after the intervention. The computer-tailored intervention was completed during classes.

Results

Students had few problems with the diagnostic questions and with the use of a computer. About half of the students evaluated the advice as interesting and easy to understand and about 40% as personally relevant, easy to use and credible. Half of students evaluated the advice as too long and only 33% reported to have used the advice. The computer-tailored intervention was effective for increasing school related physical activity levels with on average 25 min per week (F = 3.4, P ≤ .05), but not for increasing total physical activity or leisure time physical activity.

Conclusions

A 1-h computer-tailored intervention offered during class-time has the potential to increase school related physical activity.

Practice implications

Although favourable effects of large scale implementation may be expected, some adaptations that might increase effectiveness should be investigated in the future.     

Glycemic control in young children with diabetes: The role of parental health literacy

Objective

This cross sectional study examined the relationship between parental health literacy (HL), diabetes related numeracy, and parental perceived diabetes self-efficacy on glycemic control in a sample of young children with Type 1 DM.

Methods

Seventy primary caregivers of children (age 3–9 years) with Type 1 DM were recruited and surveyed at diabetes outpatient clinic visits. Patients’ medical histories were obtained by medical chart review.

Results

Parental diabetes related numeracy (r = −.52, p < 01), but not reading skills (r = −.25, p = NS) were inversely correlated with the child's glycemic control (HbA1c). Parental perceived diabetes self-efficacy was also negatively correlated to their child's HbA1c (r = −.47, p < 01). When numeracy and parental perceived diabetes self-efficacy were included as predictors of HbA1c, the model was significant (F = 12.93, p < .01) with both numeracy (β = −.46, p < .01) and parental perceived diabetes self-efficacy (β = −.36, p = .01) as significant predictors of HbA1c.

Conclusions

Data from this study highlight the importance of considering the role of parental numeracy, in health outcomes for children with Type 1 DM.

Practice implications

Practitioners should assess parental health literacy and consider intervention when needed.     

Family involvement is helpful and harmful to patients’ self-care and glycemic control

Objective

We assessed the relationships between supportive and obstructive family behaviors and patients’ diabetes self-care activities and HbA_1C, and potential interaction effects and differences by demographic characteristics.

Methods

In a cross-sectional study, 192 adults with type 2 diabetes completed the Diabetes Family Behavior Checklist-II, the Summary of Diabetes Self-Care Activities, and a glycemic control (HbA_1C) test.

Results

Participants reported similar rates of supportive and obstructive behaviors that were positively correlated (rho = 0.61, p < 0.001). In adjusted analyses, supportive family behaviors were associated with adherence to different self-care behaviors (β = 0.20 to 0.50, p < 0.05), whereas obstructive family behaviors were associated with less adherence to self-care behaviors (β = −0.28 to −0.39, p < 0.01) and worse HbA_1C (β = 0.18, p < 0.05). Supportive behaviors protected against the detrimental effect of obstructive behaviors on HbA_1C (interaction β = −0.22, p < 0.001). Non-Whites reported more supportive and obstructive behaviors than Whites, but race did not affect the relationships between family behaviors and self-care or HbA_1C.

Conclusion

Involving family members in patients’ diabetes management may impede patients’ self-care and compromise their glycemic control unless family members are taught to avoid obstructive behaviors.

Practice implications

Our findings endorse interventions that help family members develop actionable plans to support patients’ self-care and train them to communicate productively about diabetes management.     

Type D personality is associated with low cardiovascular reactivity to acute mental stress in heart failure patients

Background

The distressed (Type D) personality is associated with adverse coronary heart disease outcomes, but the mechanisms accounting for this association remain to be elucidated. We examined whether myocardial and hemodynamic responses to mental stress are disrupted in Type D patients with chronic heart failure (HF).

Methods

Ninety-nine HF patients (mean age 65 ± 12 years; 75% men) underwent a public speech task, during which heart rate (HR) and blood pressure (BP) were recorded. Type D personality and its components negative affectivity (NA) and social inhibition (SI) were assessed with the DS14. General linear models with repeated measures and logistic regression were used to assess differences in stress response and recovery.

Results

Type D personality was associated with a reduced HR response (F_1,93 = 4.31, p < .05) independent of the use of beta adrenergic blocking agents and the presence of atrial fibrillation. There were no differences between HF patients with and without a Type D personality with respect to the BP response. Examining continuous NA and SI scores and their interaction (NA ∗ SI), revealed a significant association of NA ∗ SI with the SBP response (F_1,93 = 4.11, p < .05), independent of BP covariates. Results with respect to HR and DBP responses were comparable to the findings using the dichotomous Type D measure. No significant associations between Type D and recovery patterns were found.

Conclusion

HF patients with Type D personality may show an inadequate response to acute social stress, characterized by a blunted HR response.     

A process evaluation using a Self Determination Theory measure of the co-delivery of self management training by clinicians and by lay tutors

Objective

To evaluate the co-delivery style of lay and clinician co-tutors of courses for patients, and courses for clinicians to support their patients’ self-management skills.

Methods

Motivational style of course delivery was assessed in 37 patient course sessions and 14 clinician workshops by independent observers using four Self Determination Theory rating scales and ethnographic notes. Forty-five tutors and 35 attendees were interviewed about their experience of co-delivered courses.

Results

Lay and clinician tutors had similar motivational styles, with significant differences between the four motivational style scales; patient courses (F(3, 216) = 3.437, p = .018); and clinician courses (F(3, 78) = 3.37, p = .025).The courses were experienced as co productive in style as suggested during interviews, but adherence to manuals limited the tutors’ contributions. Lay and clinician tutors scored higher on providing structure and engaging participants than they scored on supporting autonomous decision making and involvement.

Conclusion

Co-delivery was a successful model, affording opportunities to demonstrate co-production skills.

Practice implications

There is more scope to enable lay and clinician tutors to use their respective expertise in supporting self-management, and for tutor training to encourage a less didactic delivery style.     

Validation of an Information–Motivation–Behavioral Skills model of diabetes self-care (IMB-DSC)

Objective

Comprehensive behavior change frameworks are needed to provide guidance for the design, implementation, and evaluation of diabetes self-care programs in diverse populations. We applied the Information–Motivation–Behavioral Skills (IMB) model, a well-validated, comprehensive health behavior change framework, to diabetes self-care.

Methods

Patients with diabetes were recruited from an outpatient clinic. Information gathered pertained to demographics, diabetes knowledge (information); diabetes fatalism (personal motivation); social support (social motivation); and diabetes self-care (behavior). Hemoglobin A1C values were extracted from the patient medical record. Structural equation models tested the IMB framework.

Results

More diabetes knowledge (r = 0.22 p < 0.05), less fatalistic attitudes (r = −0.20, p < 0.05), and more social support (r = 0.27, p < 0.01) were independent, direct predictors of diabetes self-care behavior; and through behavior, were related to glycemic control (r = −0.20, p < 0.05).

Conclusions

Consistent with the IMB model, having more information (more diabetes knowledge), personal motivation (less fatalistic attitudes), and social motivation (more social support) was associated with behavior; and behavior was the sole predictor of glycemic control.

Practice implications

The IMB model is an appropriate, comprehensive health behavior change framework for diabetes self-care. The findings indicate that in addition to knowledge, diabetes education programs should target personal and social motivation to effect behavior change.     

Mindfulness-based therapy: A comprehensive meta-analysis

Background

Mindfulness-based therapy (MBT) has become a popular form of intervention. However, the existing reviews report inconsistent findings.

Objective

To clarify these inconsistencies in the literature, we conducted a comprehensive effect-size analysis to evaluate the efficacy of MBT.

Data sources

A systematic review of studies published in journals or in dissertations in PubMED or PsycINFO from the first available date until May 10, 2013.

Review methods

A total of 209 studies (n = 12,145) were included.

Results

Effect-size estimates suggested that MBT is moderately effective in pre-post comparisons (n = 72; Hedge's g = .55), in comparisons with waitlist controls (n = 67; Hedge's g = .53), and when compared with other active treatments (n = 68; Hedge's g = .33), including other psychological treatments (n = 35; Hedge's g = .22). MBT did not differ from traditional CBT or behavioral therapies (n = 9; Hedge's g = − .07) or pharmacological treatments (n = 3; Hedge's g = .13).

Conclusion

MBT is an effective treatment for a variety of psychological problems, and is especially effective for reducing anxiety, depression, and stress.     

Effects of patient education and therapeutic suggestions on cataract surgery patients: A randomized controlled clinical trial

Objective

This paper describes a randomized controlled single blind study testing the effects of a patient education intervention combined with positive therapeutic suggestions on anxiety for cataract surgery patients.

Methods

84 patients participated in the study. Physiological and behavioral indicators of anxiety were compared between a regularly treated control and an intervention group receiving an audio CD containing information, relaxation, and positive imagery.

Results

We found that the intervention group was calmer throughout the four measurement points of the study (p = .004; d = 0.71) and they were more cooperative (p = .01; d = 0.60) during the operation. The groups did not differ in sleep quality before the day of the operation, heart rate during the procedure, and subjective Well-being.

Conclusion

Findings indicate that preoperative information combined with positive suggestions and anxiety management techniques might reduce patient anxiety in the perioperative period of cataract surgery, but further research is needed to investigate the benefits of such interventions and to uncover the underlying mechanisms.

Practice implications

Patient education interventions providing additional anxiety management techniques are recommended for use prior to cataract surgery.     

The impact of a multimedia informational intervention on psychosocial adjustment among individuals with newly diagnosed breast or prostate cancer: A feasibility study

Objective

To examine the impact of an 8-week cancer multimedia informational intervention on health-related outcomes among individuals newly diagnosed with cancer.

Methods

Using a pre-/post-quasi-experimental design, participants with breast or prostate cancer (n = 250) were conveniently recruited from four oncology ambulatory clinics and completed questionnaires at three points (enrolment, 1–2 weeks post-intervention, and 3 months later).

Results

Repeated-measure analyses showed that, when compared to controls, the intervention significantly improved satisfaction with cancer information over time for women (p < .001), prevented deterioration in functional quality of life (p = .030) and marginally improved perceived oncologist informational support (p = .051). There were no significant differences in psychosocial adjustment among men. Unlike previously suggested, the intervention did not have a differential impact according to levels of personal resources (self-esteem, mastery, and optimism). However, for all outcomes and regardless of group, participants high in personal resources reported better adjustment across time.

Conclusion

Even though the hypotheses were only partially supported, the findings provide preliminary evidence that multimedia interventions can be supportive.

Practice implications

With increasing numbers of new cancer diagnoses, cancer survivors and more limited health care resources, further research is needed to evaluate potential benefits of health information technology in providing support to individuals facing cancer.     

Predictors of adolescent smoking cessation and smoking reduction

Objective

To investigate the processes of change, demographic, health- and smoking-related predictors of both smoking cessation and smoking reduction in adolescents.

Methods

Data were drawn from a sample of 755 adolescent smokers who participated in a study testing the efficacy of a text messaging-based intervention for smoking cessation. Demographic, health- and smoking-related variables were assessed at baseline. Five processes of smoking cessation, derived from the Transtheoretical Model and the Social Cognitive Theory, as well as outcome measures were assessed at 6-month follow up. Univariate and multivariate regression analyses were conducted to identify baseline and process variables to predict smoking abstinence and smoking reduction.

Results

Male gender (OR = 0.43, p < .01), lower alcohol consumption (OR = 0.90, p = .05) and a lower number of cigarettes smoked per day at baseline (OR = 0.87, p < .01) predicted smoking abstinence. Baseline physical activity predicted smoking reduction (OR = 1.04, p = .03). None of the examined process variables significantly predicted smoking abstinence. The process variable “counter-conditioning” predicted smoking reduction (OR = 1.46, p = .03).

Conclusions

Baseline predictors of smoking cessation differ from predictors of smoking reduction. Dynamic or modifiable variables play an important role in predicting adolescent smoking cessation.

Practice implications

Counter-conditioning might be an important element in adolescent smoking cessation interventions.     

The perception of shared medical decision making of expert and lay people: Effects of observing a movie clip depicting a medical consultation

Objective

To test for differences between experts and lay people in assessment of the degree to which a doctor engaged in a shared decision making (SDM) with a patient using the OPTION scale and a movie clip as stimulus material.

Methods

A segment of the movie ‘Wit’, depicting the communication of the diagnosis and the therapy proposed of a cancer, was shown to (a) university students with no knowledge about doctor–patient communication; (b) nurses working in medicine departments; (c) advanced medical students; (d) hospital physicians. The participants were asked to complete the OPTION scale which measures the extent to which physicians involve patients in medical decisions. An analysis of variance was used to compare OPTION scores across the four groups and to compare males and females.

Results

Being female [F_(1,190) = 11.9; p < .001] and being familiar with medical issues [F_(3,190) = 11.09; p < .001] were both significantly associated with a negative evaluations of the doctor's ability to involve the patient in the SDM.

Conclusion

Lay people and males (including male experts), are less demanding regarding SDM abilities.

Practice implications

A more systematic use of videos and the OPTION scale as validated outcome measure could be helpful educational strategy for the teaching of SDM.     

Randomised controlled trial of a pedometer-based telephone intervention to increase physical activity among cardiac patients not attending cardiac rehabilitation

Objective

To determine the effectiveness of a pedometer-based telephone intervention on the physical activity levels of cardiac patients who did not attend a CRP.

Methods

A randomised controlled trial was conducted with 215 patients referred to a CRP but who could not or chose not to attend. The 6-week intervention included self-monitoring of physical activity using a pedometer and step calendar; and behavioural counselling and goal setting sessions. Data were collected at baseline, 6 weeks and 6 months.

Results

Study groups did not differ significantly at baseline. After 6 weeks, improvements in total physical activity time (p = 0.027), total physical activity sessions (p = 0.003), walking time (p = 0.013) and walking sessions (p = 0.002) in the intervention group were significantly greater than the control group after adjusting for baseline differences, and remained significant at 6 months.

Conclusion

The findings that the pedometer-based telephone intervention was successful in increasing physical activity levels in cardiac patients who did not attend a CRP could result in major health benefits for this group of people.

Practical implications

The pedometer-based telephone intervention could be offered as an effective and accessible option for patients not attending a CRP to increase and maintain their physical activity levels after hospitalisation.     

The health competence measurement tool (HCMT): Developing a new scale to measure self-rated “health competence”

Objectives

To develop and test a tool for measuring health competence.

Methods

In order to measure this attribute, we used a sequential exploratory mixed methods design in rural and urban communities in Cameroon. In the qualitative phase, 67 clients constituted 10 focus groups to elicit themes related to health competence. In the quantitative phase, self-rated items were tested on 300 participants and on a random selection of 25 participants 2 weeks later.

Results

The internal consistency for the subscales derived varied from 0.61-0.81. Older (F[45, 339.1] = 1.2; p = 0.031) and more educated (F[3, 22.6] = 2.1; p = 0.004) people were more likely to score higher on the scale. Interviewers also contributed to the variance (F[5, 37.6] = 3.6; p < 0.001). Test–retest reliability was 0.66. The final scale with 15 items is made up of three subscales: knowledge of disease, how to stay in good health and health information.

Conclusion

We present a new self-rated scale for health competence with good psychometric properties. It circumvents the need to be literate, but requires well trained interviewers. We recommend that it be tested in other settings.

Practice implications

This tool should be used to appraise individual and community health education needs with minor context specific modifications.     

Health literacy and interpersonal interactions as predictors of maternal perception of ambulatory care for low-income,Latino children

Objective

This study explores whether maternal HL (MHL) and maternal perception of health care provider (HCP) interpersonal interactions predict maternal perception of quality of pediatric ambulatory care received.

Methods

This cross-sectional study included 124 low-income Latina mothers of children 3 months to 4 years. Maternal HL, perception of maternal-HCP interpersonal interactions, and perception of pediatric ambulatory care were measured using well-validated surveys.

Results

In adjusted hierarchical regression models, HCP fail to speak clearly (β = −.225, 95% CI −13.998, −1.960, p = .01) and explain results (β = .344, 95% CI 3.480, 13.010, p = .001) predicted perception of quality of developmental guidance received. Explaining results (β = .422, 95% CI 5.700, 14.089, p = <.001), working out treatment together (β = .441, 95% CI 6.657, 13.624, p < .001) and MHL (β = −.301, 95% CI −7.161, −2.263, p < .001) predicted perception of family centeredness of care.

Conclusions

Speaking with clarity, explaining results fully and working with the mother to determine a child's plan of care is most predictive of whether she feels her child is receiving high quality pediatric ambulatory care services.

Practice implications

Interventions that target mother and provider interaction may improve perception of care.     

Patient–clinician information engagement increases treatment decision satisfaction among cancer patients through feeling of being informed

Objective

Examine how patient–clinician information engagement (PCIE) may operate through feeling informed to influence patients’ treatment decision satisfaction (TDS).

Methods

Randomly drawn sample (N = 2013) from Pennsylvania Cancer Registry, comprised of breast, prostate and colon cancer patients completed mail surveys in the Fall of 2006 (response rate = 64%) and Fall of 2007. Of 2013 baseline respondents, 85% agreed to participate in follow-up survey (N = 1703). Of those who agreed, 76% (N = 1293) completed follow-up surveys. The sample was split between males and females. The majority of participants were White, over the age of 50, married, and with a high school degree. Most reported having been diagnosed with in situ and local cancer.

Results

PCIE was related to concurrent TDS (β = .06) and feeling informed (β = .15), after confounder adjustments. A mediation analysis was consistent with PCIE affecting TDS through feeling informed. Baseline PCIE predicted feeling informed (β = .04) measured 1 year later, after adjustments for baseline feeling informed and other confounders. Feeling informed was related to concurrent TDS (β = .35) after confounder adjustment and follow-up TDS (β = .13) after baseline TDS and confounder adjustment.

Conclusion

Results suggest PCIE affects TDS in part through patients’ feeling informed.

Practice implications

PCIE may be important in determining patients’ level of feeling informed and TDS.     

Communicating consequences of risky behaviors: Life expectancy versus risk of disease

Objective

We investigate (1) whether presenting consequences of health-related behaviors in terms of life expectancy, rather than risk of disease, improves recall and (2) if yes, through which underlying mechanisms; (3) whether these effects hold for both low- and high-numeracy people and (4) in two countries with different cultural environments and medical systems.

Methods

Experiment within a computerized survey on probabilistic samples in the United States (n = 513) and Germany (n = 534).

Results

When consequences of health-related behaviors were presented in terms of changes in life expectancy, recall was better than when they were presented in terms of risks of a disease both after 10 min, Cohen's h = .51, F(1,543) = 34.12, p = .001, and after 3 weeks, h = .62, F(1,543) = 48.98, p = .001. This was so for participants of both high and low numeracy, and in both countries. The improved recall seems to be due to better imaginability of changes in life expectancy.

Conclusions

Consequences of health-related behaviors are easier to imagine and are recalled better when expressed as changes in life expectancy rather than as changes in risk of diseases.

Practice implications

When communicating with patients about medical risks, we recommend using concepts that they can readily relate to their own everyday experiences.     

Consumer health information technology in an adult public health primary care clinic: A heart health education feasibility study

Objective

To explore the feasibility and short term outcomes of using an interactive kiosk integrated into office flow to deliver health information in a primary care clinic.

Methods

Fifty-one adults with BMI ≥25 were randomly assigned to use a kiosk with attached devices to receive a six-week healthy eating/weight monitoring (intervention) or general health/BP monitoring (attention-control) program. Outcomes were measured at baseline, 8 weeks (post) and three month follow-up.

Results

Participants completed an average of 2.73 weekly sessions, with transportation and time given as limiting factors. They found the kiosk easy to use (97%), liked the touchscreen (94%), and would use the kiosk again (81%). Although there were no differences between groups, the 27 completing all assessments showed reduced weight (p = .02), and decreased systolic (p = .01) and diastolic BP (p < .001) at follow-up. Although healthy eating behaviors increased, the change was not statistically significant.

Conclusion

Using a kiosk within a clinic setting is a feasible method of providing health information and self-monitoring. Multi-session educational content can provide beneficial short-term outcomes in overweight adults.

Practice implications

A kiosk with attached peripherals in a clinic setting is a viable adjunct to provider education, particularly in medically underserved areas.     

Walking on prescription: The utility of a pedometer pack for increasing physical activity in primary care

Objective

This study used a multi-method approach to examine the effectiveness of a pedometer-based intervention delivered by health professionals for increasing walking.

Methods

Pedometer packs were distributed to 374 patients who undertook a 12-week walking programme. Changes in walking were assessed at three months (using self-reported step-counts [n = 139] and questionnaire data [n = 104]) and at six months (using patient questionnaire data [n = 112]). Qualitative data were collected at both time points to identify underlying mechanisms.

Results

After 12 weeks patients had increased their step-counts by 4532 steps/day (p < .001) and at six months were achieving 2977 more steps/day (equivalent to around 30 min/day) than at baseline. Over half the patients reported achieving this target on at least 5 days/week. Qualitative data indicated that the pedometer pack was perceived to be most effective when patients were ready to change and when ongoing support was made available.

Conclusion

These findings support the use of pedometer-based interventions in primary care and suggest that the pedometer pack could lead to sustainable changes in walking. Further investigation, using a randomised controlled trial design, is warranted.

Practice implications

Provision of social support and accurate identification of patient readiness to change are important considerations in future implementation of the intervention.     

Autonomic dysfunction and arterial stiffness in female overactive bladder patients and antimuscarinics related effects

Objectives

To investigate the characteristics of autonomic function and arterial stiffness of OAB women, their relations with urodynamic parameters, and the impact of antimuscarinics on the above parameters.

Study design

A total of 85 OAB women and another 65 women without OAB were selected. Forty-two OAB women who enrolled before March 2009 were treated with tolterodine for 12 weeks, and another 43 OAB women who enrolled thereafter were treated with solifenacin.

Main outcome measures

The differences of the heart rate variability, cardio-ankle vascular index (CAVI) and ankle-brachial pressure index (ABI) between OAB and asymptomatic women, and their changes after 12 weeks’ antimuscarinics for OAB women.

Results

OAB women had higher low frequency/high frequency ratios (LF/HF) (OAB: 1.5 ± 1.1 vs. the control: 1.1 ± 0.7, P = 0.04). Nonetheless, CAVI and ABI did not differ between OAB and the control group. The square root of the mean squared differences of successive NN intervals (RMSSD) is associated with nocturia (Spearman's ρ = 0.23, P = 0.049), LF is associated with urgency episodes (Spearman's ρ = 0.28, P = 0.01), and maximum urethral closure pressure is negatively associated with CAVI (Spearman's ρ = −0.26, P = 0.02). After 12 weeks’ treatment, a decrease of RMSSD, HF, CAVI and an increase of LF/HF were found in the tolterodine group but not in the solifenacin group.

Conclusions

OAB women have higher severity of autonomic dysfunction with sympathetic predominance. Tolterodine may improve arterial stiffness but may deteriorate autonomic dysfunction to more sympathetic predominance. Thus, tolteridine should be used for OAB with caution in women with preexisting symptoms of autonomic dysfunction.