Using path analysis to model the process of change in HbA1c among African Americans and Latinos in a community health worker diabetes intervention

ObjectiveTo examine which components of a culturally tailored community health worker (CHW) intervention improved glycemic control and intermediate outcomes among Latina/o and African American participants with diabetes.MethodsThe sample included 326 African American and Latina/o adults with type 2 diabetes in Detroit, MI. CHWs provided interactive group diabetes self-management classes and home visits, and accompanied clients to a clinic visit during the 6-month intervention period. We used path analysis to model the processes by which each intervention component affected change in diabetes self-efficacy, diabetes-related distress, knowledge of diabetes management, and HbA1c.ResultsThe group-based healthy lifestyle component was significantly associated with improved knowledge. The group-based self-management section was significantly associated with reduced diabetes-related distress. Intervention class attendance was positively associated with self-efficacy. Diabetes self-management mediated the reductions in HbA1c associated with reductions in diabetes distress.ConclusionsPath analysis allowed each potential pathway of change in the intervention to be simultaneously analyzed to identify which aspects of the CHW intervention contributed to changes in diabetes-related behaviors and outcomes among African Americans and Latinas/os.Practice Implications: Findings reinforce the importance of interactive group sessions in efforts to improve diabetes management and outcomes among Latina/o and African American adults with diabetes.     

Secondary prevention with college drinkers: evaluation of an alcohol skills training program

This study evaluated secondary prevention approaches for young adults (N = 36, mean age 23 years) at risk for alcohol problems. Subjects were randomly assigned to cognitive-behavioral alcohol skills training, a didactic alcohol information program, or assessment only. The skills program included training in blood alcohol level estimation, limit setting, and relapse prevention skills. All subjects maintained daily drinking records during the 8-week intervention and for 1 week at each follow-up. Repeated measures MANOVA found a significant reduction over 1-year follow-up in self-reported alcohol consumption for the total sample. For all drinking measures, the directional findings consistently favored skills training. Despite overall reductions, most subjects continued to report occasional heavy drinking.     

Retraining social and adaptive living skills in severely head injured adults.

To assess the effectiveness of an intensive, multidisciplinary rehabilitation program upon social and adaptive living skills, and to study the relationship of cognitive functioning to those skills, 10 severely head-injured adults who were treated in the program were matched with 10 waiting-list control subjects. The mean improvement shown by the treated subjects in social and adaptive living skills were all in the expected direction and all greater than the mean changes of control subjects, though not significantly so. Cognitive changes showed no consistent patterns. A striking bimodal distribution in the results for social and adaptive living skills suggests that future researchers should consider employing single-subject methodology coupled with a knowledge of the patterns and events that occur during each individual's recovery sequence.     

Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND): process modelling of pilot study

OBJECTIVE: To determine the effects of a structured education program on illness beliefs, quality of life and physical activity in people newly diagnosed with Type 2 diabetes. METHODS: Individuals attending a diabetes education and self-management for ongoing and newly diagnosed (DESMOND) program in 12 Primary Care Trusts completed questionnaire booklets assessing illness beliefs and quality of life at baseline and 3-month follow-up, metabolic control being assessed through assay of HbA1c. RESULTS: Two hundred and thirty-six individuals attended the structured self-management education sessions, with 97% and 64% completing baseline and 3-month follow-up questionnaires. At 3 months, individuals were more likely to: understand their diabetes; agree it is a chronic illness; agree it is a serious condition, and that they can affect its course. Individuals achieving a greater reduction in HbA1c over the first 3 months were more likely to agree they could control their diabetes at 3 months (r=0.24; p=0.05), and less likely to agree that diabetes would have a major impact on their day to day life (r=0.35; p=0.006). CONCLUSION: Pilot data indicate the DESMOND program for individuals newly diagnosed with Type 2 diabetes changes key illness beliefs and that these changes predict quality of life and metabolic control at 3-month follow-up. PRACTICE IMPLICATIONS: Newly diagnosed individuals are open to attending self-management programs and, if the program is theoretically driven, can successfully engage with the true, serious nature of diabetes.     

Training peers to provide ongoing diabetes self-management support (DSMS): results from a pilot study

ObjectiveThis study determined the feasibility of training adults with diabetes to lead diabetes self-management support (DSMS) interventions, examined whether participants can achieve the criteria required for successful graduation, and assessed perceived efficacy of and satisfaction with the peer leader training (PLT) program.MethodsWe recruited nine African-American adults with diabetes for a 46-h PLT pilot program conducted over 12 weeks. The program utilized multiple instructional methods, reviewed key diabetes education content areas, and provided communication, facilitation, and behavior change skills training. Participants were given three attempts to achieve the pre-established competency criteria for diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy.ResultsOn the first attempt 75%, 75%, 63%, and 75% passed diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy, respectively. Those participants who did not pass on first attempt passed on the second attempt. Participants were highly satisfied with the program length, balance between content and skills development, and preparation for leading support activities.ConclusionFindings suggest that it is feasible to train and graduate peer leaders with the necessary knowledge and skills to facilitate DSMS interventions.Practical implicationsWith proper training, peer support may be a viable model for translating and sustaining DSMS interventions into community-based settings.     

Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6-17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist's asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.     

A medication self-management program to improve adherence to HIV therapy regimens

This study examined whether a self-management intervention based on feedback of adherence performance and principles of social cognitive theory improves adherence to antiretroviral dosing schedules. Forty-three individuals with HIV/AIDS who were starting or switching to a new protease inhibitor regimen were randomly assigned to be in a medication self-management program or usual care control group. The self-management program included skills development exercises, three monthly visits for medication consultations, and monthly feedback of adherence performance using electronic monitors on medication bottles. Participants also completed a 40-item questionnaire that measured self-efficacy to take medications, on schedule, in a variety of situations. Logistic regression analysis indicated that individuals in the self-management group were significantly more likely to take 80% or more of their doses each week than individuals in the control group (n=29, OR=7.8, 95% CI=2.2-28.1). Self-management training with feedback of adherence performance is a potentially useful model for improving adherence to complex regimens in HIV/AIDS care.     

Improving empowerment,motivation, and medical adherence in patients with poorly controlled type 2 diabetes: A randomized controlled trial of a patient-centered intervention

ObjectiveTo test whether an intervention consisting of four patient-centered consultations improves glycemic control and self-management skills in patients with poorly regulated type 2 diabetes (T2DM), compared to a control group receiving usual care.MethodsUnblinded parallel randomized controlled trial including 97 adults diagnosed with T2DM ≥ 1 year and hemoglobin A1c (HbA1c) levels ≥ 8.0% (64 mmol/mol). Consultations incorporated tools supporting self-reflection, learning processes, and goal setting. Primary outcome was HbA1c. Secondary outcomes were autonomy support, motivation, self-management skills, and well-being.ResultsAverage HbA1c decreased slightly in both groups. Autonomy support and frequency of healthy eating were significantly higher in the intervention group. Most participants in the intervention group chose to set goals related to diet and physical exercise. Implementation of the intervention was inconsistent.ConclusionDespite increased autonomy support and individual goal-setting, the intervention was not superior to usual care in terms of glycemic control. More research is needed on how individual preferences and goals can be supported in practice to achieve sustainable behavior changes.Practice ImplicationsThe intervention promoted participant engagement and supported exploration of participants’ challenges and preferences. Further exploration of more flexible use of tools adapted to individual contexts is recommended.     

Sex differences in weight loss among adults with Type II diabetes mellitus

The treatment of choice for Type II or non-insulin-dependent diabetes mellitus is a behavioral program for the management of weight. However, compliance with this lifelong dietary regimen is often poor. In the current investigation male and female adults with diagnosed Type II diabetes were randomly assigned to either a behavior modification, a cognitive modification, a cognitive-behavior modification, or a control group. Patients were evaluated in terms of weight, percentage of body fat, and glycosylated hemoglobin measures. Men lost signficantly more weight than women and subjects in the behavior modification group lost more weight and demonstrated greater decreases in diabetes control than subjects in the cognitive-behavior modification, cognitive, and control groups. A significant interaction indicated that diabetic men may benefit more from behavioral weight reduction programs than diabetic women. Several explanations for these findings are considered.This work was supported by Grants K04 HL 00809 and R01 AM 27901 from the National Institutes of Health to Robert M. Kaplan.     

Effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management for people with type 2 diabetes. A randomized controlled trial

ObjectiveDetermine the effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management behaviors for Australian adults with type 2 diabetes.MethodsUsing intention to treat analysis and generalized estimating equations, this randomized controlled trial of 395 adults determined change in HbA1c at 3 and 6 months between the intervention and control group. Secondary outcomes included change in nutrition, physical activity, blood lipid profile, body mass index, quality of life, self-efficacy, medication taking and program acceptability.ResultsNo significant difference was observed between the intervention or control group for HbA1c at 3 months (P = 0.23) or 6 months (P = 0.22). Significant improvements were seen in consumption of vegetables at 3 months (P < 0.001) and 6 months (P = 0.04); fruit at 3 months (P = 0.046) and discretionary sweet foods at 3 months (P = 0.02). No other significant effects seen. The intervention demonstrated high rates of acceptability (94.0%) and minimal withdrawal (1.5%).ConclusionsDTEXT was an acceptable text message intervention that improved some nutritional behaviors in people with type 2 diabetes, but did not significantly improve HbA1c or other outcomes. Further research is required to optimize DTEXT.Practice implicationsDTEXT provides an acceptable, feasible form of self-management support that may complement existing diabetes care.     

A cognitive training intervention improves modality-specific attention in a randomized controlled trial of healthy older adults

Age-related deficits in cognitive and sensory function can result in increased distraction from background sensory stimuli. This randomized controlled trial investigated the effects of a cognitive training intervention aimed at helping healthy older adults suppress irrelevant auditory and visual stimuli. Sixty-six participants received 8 weeks of either the modality-specific attention training program or an educational lecture control program. Participants who completed the intervention program had larger improvements in modality-specific selective attention following training than controls. These improvements also correlated with reductions in bimodal integration during selective attention. Further, the intervention group showed larger improvements than the control group in non-trained domains such as processing speed and dual-task completion, demonstrating the utility of modality-specific attention training for improving cognitive function in healthy older adults.     

Results of a self-management program added to standard physical therapy in chronic neck pain

ObjectiveTo evaluate the effectiveness of a self-management treatment added to a physical therapy program compared to a physical therapy program in patients with chronic neck pain.MethodsFifty-three patients with chronic neck pain were randomly allocated to a physical therapy intervention (control group) or an individualized self-management combined with physical therapy intervention (experimental group). Both interventions were developed over a four-week period. Outcome measures included were Disability, Fear-Avoidance Beliefs, Health-Related Quality of Life, Pain, and Anxiety and Depression. All outcomes were measured before and after the treatment and at three-month follow-up.ResultsThere were not significant differences between groups at baseline. After the intervention both groups obtained better results in the Neck Disability Index but there were not significant differences between them (p > 0.05). At follow-up, the self-management group obtained significant better results compared to the control group (95 % CI: -5.20(-6.8 to -1.5), p = 0.032).ConclusionsAn individualized self-management program added to a physical therapy program led to a greater improvement in disability at 3 months follow up compared to a physical therapy program alone. Catastrophizing, pain, and health-related quality of life improved significantly after the intervention and at follow-up compared to the standard care alone.Practical implicationsThis study indicates that physical therapy for patients with chronic neck pain preferably should include self-management education.     

You Can Control Asthma: evaluation of an asthma education program for hospitalized inner-city children

A self-management education program was designed for staff nurses to offer children while they received medical care for asthma in the hospital. The program uses videotapes, written activity books and nurse discussion with the patient. Evaluation was conducted to assess program feasibility and impact. Pre- and post-tests of 40 children age 6-12 years revealed that the children had statistically significant increases in knowledge of and expected response to early warning signs of acute asthma, and in their sense of personal control (Health Locus of Control). Parents reported an increased use of asthma self-management techniques for acute episodes of asthma. Medical record review for a 15 month pre- and post-period indicated reductions in emergency room use. Inpatient hospital based education offers a critical opportunity to introduce asthma management skills, especially to children not reached by more traditional programs.     

Tuning in to kids: an emotion‐focused parenting program—initial findings from a community trial

This study evaluated a new group parenting program, Tuning in to Kids, which taught emotion coaching skills to parents of preschool children. In a randomized control trial, 218 primary caregiver parents of children aged 4.0–5.11 years completed questionnaires assessing parent emotion socialization (emotion coaching vs. emotion dismissing), parent emotional competence, parent wellbeing and child behavior. Assessment occurred at preintervention and 10 weeks later. Parents randomized to the intervention condition (n=107) attended a 6‐session parenting program. Results showed parents in the intervention condition reported significant increases in emotion coaching and significant reductions in emotion dismissing with their children. Child behavior was also reported to improve. Of those with clinical levels of behavior difficulties, more than half were no longer at clinical level postprogram. These findings suggest that an emotion‐focused parenting intervention may assist parents to learn emotion‐coaching skills that have been linked to improved child behavior. © 2009 Wiley Periodicals, Inc.     

Patient education interventions for colorectal cancer patients with stoma: A systematic review

ObjectivesTo describe the various types of patient education interventions for colorectal cancer patients with stoma and to examine their effects on quality of life, psychosocial skills and self-management skills.MethodsA systematic review was performed. Six electronic databases were searched. Inclusion criteria were: studies about patient education applying quantitative methods including digestive stoma adults with colorectal cancer. The primary outcome was quality of life. Secondary outcomes were psychosocial and self-management skills.ResultsThirteen studies were identified and included. Five studies examined quality of life and three reported improvements. Patient education improved some psychosocial and self-management skills. Contrasting findings were reported for specific-disease quality of life, emotional distress, length of hospital stay, stoma complications and readmission rate.ConclusionsPatient education has a positive impact on some psychosocial and self-management skills, indicating that this area should be developed. Contrasting findings were reported for quality of life. Methodologies are heterogeneous making it difficult to produce evidence-based guidelines. This article proposes tools to carry out further studies on this subject and to improve understanding.Practice implicationFurther education intervention for stoma patients with colorectal cancer should be standardized in terms of intervention, duration and outcome measures to compare intervention and determine best practice.     

Patients' understandings of heart attack: implications for prevention of recurrence

To assess the efficacy of self-management programs it is important to know what behavioural changes take place. This paper assesses whether including self-treatment guidelines (action plans) in a self-management program for adult asthmatics, leads to greater behavioural changes than a program without these guidelines. Patients were randomised into a self-treatment group (n=123) or an active control group (n=122). All subjects received self-management training. Discussed topics included the pathophysiology of asthma, medication and side-effects, triggers, symptoms, smoking, physical exercise, and compliance. The only difference was that the self-treatment group received instructions about self-treatment of exacerbations and the control group did not. At 1 year of follow-up asthma-specific self-efficacy expectancies, outcome expectancies, and asthma-specific knowledge improved significantly in all patients. Only self-treatment group patients demonstrated favourable changes in generalised self-efficacy, social support, and self-treatment and self-management behaviour, in case of a hypothetical scenario of a slow-onset exacerbation. We conclude that our self-management program is effective in changing the behavioural variables, and including self-treatment guidelines (action plans) has added benefit.     

Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial

Objective

To evaluate the efficacy of ongoing group based diabetes self-management education (DSME) for patients with type 2 diabetes.

Methods

146 patients were randomised to either group education or waiting list control. Primary outcomes were A1C and patient activation measured with patient activation measure (PAM).

Results

There were no differences in the primary outcomes between the groups at 12 months, but the control group had an increase in A1C of 0.3% points during follow-up. Diabetes knowledge and some self-management skills improved significantly in the intervention group compared to the control group. A sub group analysis was conducted for the quartile with the highest A1C at baseline (>7.7, n = 18 in both groups). There were significant improvements within the intervention group at 12 month follow-up for both A1C and PAM and a trend for better outcome in the intervention group compared to the control.

Conclusions

The locally developed ongoing diabetes self-management education programs prevented an increase in A1C and can have an effect on A1C in patients with higher A1C level.

Practice implications

Locally developed programs may be less effective than programs developed for studies.     

Development, content, and process evaluation of a short self-management intervention in patients with chronic diseases requiring self-care behaviours

Many patients with asthma, diabetes, and heart failure do not succeed in integrating the required self-management behaviours into their lives, and fail to attain optimal disease control. The purpose of this study was to describe the development of a theory-driven intervention to enhance self-management that would be appreciated and accepted by participants and providers. Based on self-regulation theory and proactive coping, the program emphasised goal-setting and the planning of behaviour. In five 2h group sessions, participants first decided upon their own goal and behaviours they wanted to change. Next, they wrote an action-plan to implement these behavioural intentions. Behavioural rehearsal and self-monitoring took place between the sessions. Participants and nurse providers evaluated the intervention positively. Evaluations were unrelated to patients' health at baseline, or to feelings of self-efficacy regarding self-management. But patients of older age, lower education, or no current employment responded best to the intervention.     

Cognitive behavioural group training (CBGT) for patients with type 1 diabetes in persistent poor glycaemic control: who do we reach?

Approximately a quarter of adults with type 1 diabetes do not succeed in achieving satisfactory glycaemic control, partly due to problems with the demanding self-management regimen. To improve glycaemic control, interventions with a cognitive behavioural approach, aimed at modifying dysfunctional beliefs, reducing negative emotions and enhancing self-care practices are a potentially successful tool. Little is known about the reach of such an approach. This article describes characteristics of participants in a randomized, controlled trial of cognitive behavioural group training for patients with type 1 diabetes in poor glycaemic control. Results show that outpatients from seven hospitals in the area of Amsterdam, selected on long-standing high HbA1c and volunteering to participate, report high levels of psychological distress and depressive symptoms. Furthermore, self-care behaviours were perceived as important, but burdensome. Diabetes-specific self-efficacy was relatively low. It is concluded that this selected group of adults with type 1 diabetes would potentially benefit from a cognitive-behavioural intervention in order to reduce negative emotions, enhance diabetes self-efficacy, self-care behaviour and glycaemic outcomes.