Self-Management Education for Adults With Type 2 Diabetes
A meta-analysis of the effect on glycemic control
Article Figures & Tables
Figures
- Figure 1—
Systematic review flow diagram. n = number of studies. Cinahl is the Nursing and Allied Health database; ERIC, Educational Resources Information Center database; RCT, randomized controlled trial.
- Figure 2—
GHb, stratified by follow-up interval. Net change in GHb is shown for each individual study, with lines extending from the symbols representing 95% CIs. Pooled results are for each follow-up interval, with r = 0.5.
Tables
- Table 1—
Characteristics of eligible clinical trials
Study No. of patients Duration of intervention (months) Total contact time (h) Follow-up intervals (months)* Care delivered to the intervention group Agurs-Collins, 1997 (78) 64 6 28 0, 3 Additional care† Bloomgarden, 1987 (79) 345 19 NR 0 UC Brown, 1999 (49) 247 12 NR 0 UC Campbell, 1996 (38) 238 12 NR −1‡, −1 Additional care de Bont, 1981 (29) 148 6 NR 0 Additional care de Weerdt, 1989 (39) 558 1 12 6 UC d’Eramo-Melkus, 1992 (45) 82 3 14 0, 3 UC Estey, 1990 (80) 60 2.5 1 0 Additional care Falkenberg, 1986 (28) 46 3 16 6 Additional care Franz, 1995 (57) 247 1.5 1.5 1.5, 4.5 Additional care Glasgow, 1995 (50) 206 9 1 3 UC Glasgow, 1992 (53) 102 2.5 NR 3 UC Hawthorne, 1997 (73) 201 NR NR 6 UC Heller, 1988 (81) 87 6 7.5 −1, 0, 6 Additional care Kaplan, 1985 (27) 76 2.5 20 15.5 Additional care Korhonen, 1987 (30) 80 12 NR −1, −1, 0 UC Mazzucca, 1986 (31) 532 6 3.6 12 UC McCulloch, 1983 (41) 44 6 NR −1, 0 Additional care Mulrow, 1987 (42) 120 10 NR 1 Additional care Perry, 1997 (54) 70 6 NR 0 UC Raz, 1988 (47) 51 12 NR 0 UC Ridgeway, 1999 (40) 58 6 9 0, 6 UC Scott, 1984 (55) 60 1 NR 0 UC Trento, 1998 (82) 120 12 4 0 UC Tu, 1993 (75) 31 1 NR 1.5 UC Turnin, 1992 (56) 105 6 9 0 UC Uusitupa, 1993 (51) 86 27 NR −1, 0 UC White, 1986 (48) 41 6 10 0 Additional care Wing, 1986 (32) 50 10 NR −1, 3 Additional care Wing, 1988 (68) 20 10 NR −1, 2 Additional care Wise, 1986 (43) 88 6 2 6 UC Total N 4,263 - Table 2—
Summary of demographic, setting, intervention, and design characteristics of included studies
Variable Mean Demographics Age (years) 55 (35–67) Using insulin (%) 16 (0–100) Baseline GHb 9.4 (6.1–12.9) Race/ethnicity (% NR) 77 Setting (%) United States 45 Clinic 88 Home 9 Senior center 3 Intervention Focus (%) Lifestyle 44 Knowledge 23 Skills (SMBG and foot care) 3 Coping skills 0 Mixed 30 Provider (%) Nurse 13 Dietitian 13 Physician with team 25 Team (nurse, dietitian, etc.) 20 Lay health care worker 3 Self (e.g. computer-assisted instruction) 7 NR 20 Duration (median) (months) 6 (1.0–27) Number of contacts (median) 6 (1–36) Total contact time (hours) 9.2 (1–28) Individual (%) 32 Collaborative (%) 87 Theory-based (%) 39 Computer-assisted instruction (%) 6 Interface with primary care (%) 13 (65% NR) Design and quality Recruitment (%) Random 3 Volunteers 58 Entire eligible population 19 Unclear 19 Comparison group: % Patients receiving usual care 58 Completion rate ≥80% 65 -
Data are means (range) or %, unless otherwise indicated. NR, not reported; SMBG, self-monitoring of blood glucose.
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- Table 3—
Change in glycated hemoglobin after self-management training in type 2 diabetes
Study Baseline GHb First follow-up interval* Second follow-up interval* Third follow-up interval* Months Net change GHb Months Net change GHb Months Net change GHb Agurs-Collins, 1997 (78) 10.0 0 −.80 3 −2.60 — — Bloomgarden, 1987 (79) 6.6 0 −0.40 — — — — Brown, 1999 (49) 12.4 0 −2.00 — — — — Campbell, 1996 (38) 11.9 −1 −0.50 −1 −2.30 — — de Bont, 1981 (29) 9.2 0 −0.04 — — — — de Weerdt, 1989 (39) 9.2 6 −0.24 — — — — d’Eramo-Melkus, 1992 (45) 10.9 0 −1.87 3 −1.59 — — Estey, 1990 (80) 6.1 0 −0.40 — — — — Falkenberg, 1986 (28) 7.3 6 0.00 — — — — Franz, 1995 (57) 8.3 1.5 −0.30 4.5 −0.20 — — Glasgow, 1995 (50) 7.9 3 −0.10 — 0.00 — — Glasgow, 1992 (53) 7.4 3 −0.10 — — — — Hawthorne, 1997 (73) NR 6 −0.34 — — — — Heller, 1988 (81) 12.7 −1 −0.70 0 −1.60 6 −0.50 Kaplan, 1985 (27) 7.5 15.5 −0.24 — — — — Korhonen, 1987 (30) 9.2 −1 −0.13 −1 −0.40 0 −0.04 Mazzucca, 1986 (31) 9.4 12 −0.78 — — — — McCulloch, 1983 (41) 12.9 −1 −0.80 0 −1.40 — — Mulrow, 1987 (42) 9.5 1 0.00 — — — — Perry, 1997 (54) 8.7 0 −0.40 — — — — Raz, 1988 (47) 9.6 0 −2.20 — — — — Ridgeway, 1999 (40) 12.3 0 −0.99 6 −0.14 — — Scott, 1984 (55) 8.7 0 −0.50 — — — — Trento, 1998 (82) 7.3 0 −0.21 — — — — Tu, 1993 (75) NR 1.5 −0.46 — — — — Tumin, 1992 (56) 10.8 0 −0.80 — — — — Uusitupa, 1993 (51) 7.8 −1 −0.30 0 −0.20 — — White, 1986 (48) 11.3 0 0.40 — — — — Wing, 1986 (32) 10.5 −1 0.68 3 0.51 — — Wing, 1988 (68) 10.5 −1 0.49 2 1.06 — — Wise, 1986 (43) 8.7 6 −0.80 — — — — - *
↵* Follow-up is from the last educator-patient contact, in months.
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- Table 4—
Meta-analysis results
Study group and follow-up interval Number of studies Q significance level Point estimate (net change in GHb [%]) 95% CI All studies During or immediately after the intervention 20 <0.05 −0.76 −1.18 to −0.34 1–3 months 9 >0.10 −0.26 −0.73 to 0.21 ≥4 months 8 >0.10 −0.26 −0.48 to −0.05 All studies where the comparison group receives usual care During or immediately after the intervention 12 <0.05 −0.91 −1.40 to −0.42 1–3 months 4 >0.10 −0.11 −0.57 to 0.36 ≥4 months 5 >0.10 −0.28 −0.52 to −0.05 Appendix—Additional characteristics of eligible clinical trials of the effectiveness of self-management education in type 2 diabetes
Study Age (years) Baseline Control GHb Patients on insulin (%) In U.S. (yes/no) Intervention Care delivered to the control group Intervention No. of contacts Total contact time (hours) Individual or group Didactic or collaborative Theory-based (Y,N) Sampling Completion rate >80% (Y,N) Agurs-Collins, 1997 (78) 62 10.0 50 Y Didactic + participatory sessions: diet and activity One class + mailed information L 18 28 G C Y V Y Bloomgarden, 1987 (79) 58 6.6 100 Y Classes on general diabetes issues UC M 9 NR G C N E N Brown, 1999 (49) 54 12.4 25 Y Weekly sessions + group support UC M 26 NR G Unclear N V NR Campbell, 1996 (38) 56 11.9 0 N Individual sessions Two group sessions K 10 NR G C N V N de Bont, 1981 (29) 55 9.2 1.5 N Individual sesions + home visits: low-fat diet Same intervention, with low-carbohydrate diet L 4 NR I C N Unclear Y de Weerdt, 1989 (39) 44 9.2 100 N Collaborative education by health worker or patient UC K 4 12 G C Y V Y d’Eramo-Melkus, 1992 (45) 56 10.9 0 Y Didactic course + individual sessions UC M 12 14 G C Y V N Estey, 1990 (80) 55 6.1 0 N Group education + follow-up at home 3-day course, no follow-up M 4 1 I C N Unclear Y Falkenberg, 1986 (28) 66 7.3 0 N Small group sessions: problem solving 1-day didactic teaching K 8 16 G C Y R N Franz, 1995 (57) 57 8.3 16 Y Individual visits with dietician Basic nutrition care L 3 1.5 I C N V N Glasgow, 1995 (50) 62 7.9 67 Y Single visit: diet, goal-setting UC L 8 1 I C Y V Y Glasgow, 1992 (53) 67 7.4 27 Y Weekly sessions: problem-solving and self-efficacy UC L 10 NR G C Y V Y Hawthome, 1997 (73) 53 NR NR N Culturally appropriate flashcards, by lay health care worker UC M 1 NR I D Y V Y Heller, 1988 (81) 56 12.7 0 N Group sessions on weight loss Individual sessions with dietician L 5 7.5 G C N E Y Kaplan, 1985 (27) 54 7.5 26 Y Collaborative sessions on diet and activity Same intervention, discuss general diabetes issues L 10 20 G C Y V Y Korhonen, 1987 (30) 56 9.2 0 N Individual sessions on diet UC L 5 NR I C N E Y Mazzucca, 1986 (31) 58 9.4 70 Y Home visits UC K 2.4 3.6 G C N E N McCulloch, 1983 (41) 35 12.9 100 N Meal demonstrations Conventional diet teaching L 3 NR G C N V Y Mulrow, 1987 (42) 54 9.5 0 N Monthly small group meetings in diet and activity Unclear L 6 NR G C Y E N Perry, 1997 (54) 42 8.7 100 N Monthly meetings, feedback UC L 6 NR Unclear C N V Y Raz, 1988 (47) 53 9.6 0 N Didactic + small group sessions UC M 15 NR G D N Unclear Y Ridgeway, 1999 (40) 64 12.3 16 Y Monthly group sessions on behavioral modification UC K 6 9 G C Y E N Scott, 1984 (55) NR 8.7 0 N Group + individual sessions UC K 4 NR G D N V N Trento, 1998 (82) 61 7.3 0 N Group sessions on diet, activity and blood sugar UC M 4 4 G C N Unclear Y Tu, 1993 (75) 65 NR 89 Y Weekly telephone calls after hospital discharge UC M 4 NR I C N V Y Tumin, 1992 (56) 45 10.8 80 N Interactive computer program on diet UC L 36 9 I C N NR Y Uusitupa, 1993 (51) 53 7.8 0 N Individual sessions on diet, activity UC L 10 NR I C N V Y White, 1986 (48) 61 11.3 71 Y Psychologist-led group sessions on diet and activity Didactic teaching L 10 10 G C Y Unclear N Wing, 1986 (32) 54 9.9 50 Y Weight loss program with focus on blood sugar Behavioral weight control intervention M 18 NR G C N V Y Wing, 1988 (68) 53 10.5 0 Y Sessions on diet, activity and blood sugar Same intervention, but no problem-solving S 22 NR G C Y V Y Wise, 1986 (43) 56 8.7 0 N Computerized knowledge assessment program UC K 2 2 I C N V Y -
C, collaborative; D, didactic; E, entire accessible population recruited into the study; G, group; I, individual; K, knowledge; L, lifestyle; M, mixed; N, no; NR, not reported; R, recruitment of the study population by random sampling of the accessible population; S, skills teaching such as self-monitoring of blood glucose and foot care; UC, usual care; V, volunteers recruited into the study; Y, yes.
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In this Issue
July 2002, 25(7)
