Running head: IMPROVING DIABETES

Improving Diabetes by Improving Diabetes Education in Primary Care
Loretta Wall, RN, BSN, MHI and April T. Hill, DNP, FNP, ENP
Arizona State University

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Abstract

Diabetes is a leading cause of morbidity in the world. About 42 million people worldwide
have diabetes. Poorly managed diabetes leads to long term complications and mortality.
Diabetes self-management education (DSME) has been effective in preventing or
delaying complications. The purpose of this project is to implement a diabetes selfmanagement education (DSME) program in primary care and to evaluate its impact on
glycemic control and diabetes knowledge in a selected group of adults 18 years or older
in a community-based practice.
.
Keywords: diabetes education, diabetes self-management, hemoglobin A1C, DSME and
structured diabetes education,

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Improving Diabetes by Improving Education
Diabetes is one the most common chronic diseases and is estimated to be the fifth
leading cause of death in the country (Chaney, 2015). This prevalent disease is associated
with the development of increasing mortality, morbidity and rising healthcare costs.
Optimal diabetes care requires active involvement of patients. However, in order to
engage, one must have an understanding of diabetes and how to manage it. Thus, diabetes
education is the cornerstone of diabetes management.
Problem Statement
The complexity of diabetes remains a challenge for many people. About 422
million people, worldwide, have diabetes and the prevalence of this disease continues to
rise (World Health Organization (WHO), 2016). In the United States, 29.1 million people
have diabetes (Center for Disease Control (CDC), 2014). In the state of Texas, alone, an
estimated 11% of adults have diabetes and 8% have pre-diabetes (Texas Department of
State Health Services (TDSHS), 2015). Medicaid has spent more than $280 million on
Texas beneficiaries with diabetes (TDSHS, 2015). In 2013, there were 5,262 diabetes
related deaths in Texas (TDSHS), 2015). In a person with diabetes, there is a higher risk
for serious health complications such as blindness, kidney failure, heart disease, stroke,
loss of limbs and a 50% higher risk of death than a person without diabetes (CDC, 2014).
Many of these complications are directly related to poor management of the disease
(healthypeople.org, 2015).
Quality diabetes control is essential to preventing long-term complications.
However, interventions aimed at managing this disease are often inefficient in many
health care settings and patient populations. Thus, there is a need for change. One key

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catalyst for change is diabetes self-management education.
Diabetes self-management education (DSME) provides individuals with
knowledge, skill and the ability to navigate the multitude of daily decisions and activities
necessary for better health outcomes (Powers, Bardsley, Cypress, Duker, Funnell, Fischl,
Maryniuk, et al., 2015). The objectives of DSME are to support informed decisionmaking, self-care behaviors, problem solving, and active collaboration with the health
care team to improve clinical outcomes, health status and quality of life (Powers,
Bardsley, Cypress, Duker, Funnell, Fischl, Maryniuk, et al., 2015). This education is
designed to address the patient’s health beliefs, cultural needs, current knowledge,
physical limitations, emotional concerns, family support, financial status, and any other
factors that may be an obstacle to successful diabetes self-management (Powers,
Bardsley, Cypress, Duker, Funnell, Fischl, Maryniuk, et al., 2015). A well-known health
initiative devoted to addressing issues spanning the diabetes continuum is the National
Diabetes Education Initiative (NDEI). NDEI is a trusted online destination that delivers
scientifically rigorous, evidence-based programs, curricula, and tools that enable
practicing clinicians to view clinical practice guidelines, pathophysiology, understand
rationale for early intervention with appropriate lifestyle and pharmacologic management
to arrest disease progression (NDEI.org, 2017). Another source for diabetes education is
American Association of Diabetes Educators. It is a multi-disciplinary professional
organization dedicated to improving diabetes care through innovative education,
management and support (AADE.org, 2017).

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Background and Significance
Diabetes mellitus is a metabolic disorder characterized by hyperglycemia with
disorders of carbohydrate, fat and protein metabolism (Sadeghian, Madhu, Kannan, &
Agrawal, 2016). This disorder is a result of defects in insulin secretion and/or insulin
action (Sadeghian, Madhu, Kannan, & Agrawal, 2016). It is associated with
microvascular and macrovascular disease, which can present as myocardial infarction,
stroke, end stage renal disease, retinopathy and foot ulcers (McCulloch, Nathan, Mulder,
2017). It is now one of the leading causes of mortality in the world. (WHO, 2016).
Hence, there is a need to gain control of this disease.
Diabetes self-management education (DSME) is critical in preventing or delaying
complications of diabetes (Haas, Maryniuk, Beck, Cox, Duker, Edwards, 2014; Wong,
Wong, Wan, Chan, Lam, 2015, Prezio, Pagan, Shuval, Culica, 2014). Researchers have
found that the benefits of DSME are improved knowledge, constructive self-care
behaviors, and better clinical outcomes such as lowered hemoglobin A1C levels,
decreased risk of major complications, weight loss, and enhanced quality of life (Gumbs,
2012). Many diabetes education programs exist. However, their effectiveness varies.
Regardless of race and culture, group based self-management educational programs
using structured guidelines have been significantly effective in improving glycemic
control (Sadeghian, Madhu, Agrawal, Kannan, Agrawal, 2016; Essein ,Otu, Umoh,
Enang, Hicks, Walley, 2017).
Structured group education is geared towards informed choice, empowerment,
shared decision making, patient-centered care and social learning theory while other
strategies suggest the importance of frequent interventions and regular follow-ups

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undertaken over an extended period of time, to promote enduring change (Long &
Gambling, 2011; Dineen, et al., 2014).
Recent collection of evidence is available to support the effectiveness of diabetes
self-management education on diabetes. A randomized controlled trial was done to
determine the success of a community-based group intervention in reducing the levels of
hemoglobin A1c and long-term health risks (Lynch, Liebman, Ventrelle, Avery,
Richardson, 2014). The intervention was culturally tailored and was more effective than
usual care at improving glycemic control (Lynch, et al., 2014).
A different randomized study, conducted in internal medicine practices, general
medical practices and group practices, assessed the efficacy of three different diabetes
management interventions. (Piatt, Anderson, Brooks, Songer, Siminerio, Korytkowski, &
Zgibor, 2010). The interventions included: Chronic Care Model, a Provider Only
intervention and Usual Care practices. The study revealed sustained improvements in
A1C, non-HDLc, and blood pressure at 3-year follow-up (Piatt, et al., 2010).
In continued efforts to promote better diabetes control, internet-based selfmanagement programs have been explored. A randomized controlled trial of computerbased self-management interventions revealed only a small positive effect on blood
glucose control (Pal, Eastwood, Michie, Farmer, Farmer, Barnard, Peacock, 2013).
However, mobile phone interventions appear to have larger effects (Pal, Eastwood,
Michie, Farmer, Farmer, Barnard, & Peacock, 2013).
Local health departments used a change facilitation model to implement quality
improvement projects that focused on two major themes: increasing community outreach
to patients and providers and improving internal operations related to the delivery of

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diabetes self-management education services (Dearinger et al., 2013). Core components
of the change model include quality improvement team development and on-site training.
This training enabled the local health departments to gather data on patient needs and
preferences and implement projects specific to their community. This improved the
delivery of their diabetes self-management education services. Ultimately, it improved
the number of patients receiving educational services (Dearinger et al., 2013).
Culturally tailored diabetes education can lead to significant improvements in selfcare, as well. It is important to understand traditions in cultures and that just talking about
diet and exercise is not enough to produce lifestyle changes (Carter, Berkley, Barba,
Kautz, & Donald, 2013). Culturally appropriate health education is basically tailored to
the cultural or religious beliefs or linguistic skills of the community being approached
(Attridge, Creamer, Ramsden, Cannings,-John, & Hawthorne, 2014). A systematic
literature review of RCTs was done to assess the effectiveness of culturally appropriate
health education in people with diabetes. The results showed that there was glycemic
control and increased knowledge of diabetes following culturally appropriate health
education (Attridge, et al., 2014).
An education program was developed for people with diabetes mellitus already on
insulin to enable effective self-management, improve confidence, reduce hypoglycemia
and enable peer group support (Fairfield, Amin, & James, 2014). The curriculum was
evidence based and tailored to the individual needs of groups. The structured education
included use of a trained and competent diabetes educator; a written curriculum; quality
assurance and regular audits. The content covered: understanding insulin action;
monitoring blood glucose; understanding the influence of food and activity on blood

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glucose levels; reducing the risk of hypoglycemia and its management and managing
illness and travel. This team-led program resulted in an improvement in glycemic control
as evidenced by decreased hemoglobin A1C, increased patient satisfaction and
confidence.
Internal Evidence
In a primary care practice in southwestern U.S. with a high number of patients
presenting with uncontrolled diabetes, health care providers must make a valid effort to
encourage and empower individuals to self-manage their diabetes. Internal evidence from
fieldwork reveals more than 70% of patients with diabetes has an HbA1c 0f 7.0% or
higher. Some obstacles to adherence include access to medications, the inability to
consistently stick to a diet plan, lack of exercise and lack of understanding the link
between the food they consume and hemoglobin A1C.
There are methods for risk assessment, screening and patient education. Currently,
a local primary care clinic in Texas, does not have a risk assessment or a screening tool
for clients with diabetes. Additionally, there is no process in place to provide consistent
structured patient education for individuals with diabetes.
New policies and interventions need to be developed and implemented to improve
individuals’ participation in self-care behaviors, self-management and ultimately clinical
outcomes. In light of diabetes self-management education being paramount to the
improvement of an individuals’ quality of life, it would be interesting to know what is the
most effective diabetes self-management education method. This inquiry has led to the
clinically relevant PICOT question, “In adults with diabetes, how does a structured

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diabetes self-management education compared to current practice of usual diabetes
education affect HbA1c over 3 months?”
Search Strategy
Databases searched for the literature review included Cochrane, Cumulative Index
of Nursing and Allied Health Literature (CINAHL), PubMed, and Academic Search
Premier. The focus of the search strategy was to find literature to support the PICOT
question. Keywords included; Education and Diabetes self-management; Diabetes Selfmanagement And Education AND Efficacy; Self-management education efficacy and
diabetes; Structured diabetes education and effectiveness; Diabetes education and
verbal; Diabetes education and improving clinical outcomes and structured; Diabetes
Education AND self efficacy; DSME AND A1C; Structured diabetes education and
clinical outcome. The searches were restricted to peer-reviewed journals written in
English and published from 2010 to 2017. Initial yields were produced, abstracts and
results were examined to determine relevancy to the clinical question. Studies included
evaluated the relationship between diabetes self-management education and improving
clinical outcomes. Those excluded were articles that involved individuals without the
diagnosis of diabetes, provided unclear documentation, inconclusive evidence, or were
impertinent to this review.
The Cochrane Database (Appendix D) was assessed, yielding 5731 reviews. The
CINAHL database was assessed (Appendix A), yielding 34 reviews. PubMed (Appendix
B) was assessed, yielding 368 reviews. Academic Search Premiere database (Appendix
C) was reviewed, yielding 2939 reviews. A total of 71 articles were collected from these
searches, and then critically examined according to the level of evidence and clinical

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relevancy. thirteen final articles were chosen for inclusion in this review: Systematic
reviews, randomized controlled trials, and meta analyses.
Critical Appraisal and Synthesis
Thirteen studies were included in this literature review, all of which were
evaluated using Melnyk and Fineout-Overholt's (2010) hierarchy of rapid critical
appraisal. Many of the studies answered the PICOT question and are within the last five
years. Most of the studies are of high level of evidence. The articles ranged from level I
to level VII evidence, with eleven of the thirteen studies ranking as levels I and II.
(Appendix F). Although the one level VII article is not considered the strongest evidence,
it offers important guidelines provided by experts on the topic of diabetes education. This
information will be valuable in the development of an evidence-based project (EBP)
focusing on improving clinical outcomes by improving diabetes education.
Most of the participants were between ages 40-60 years old and equally represent
male and female. There is broad ethnic representation across studies. Globally, other
countries are represented. The sample sizes are ranged from 88 to 520,345. Tools to
measure outcomes varied across studies. However, 11 out of 14 measured HbA1C
(Appendix F).
The instruments used are widely accepted and valid. The consistent measurements
were those used measure HbA1c, self-efficacy, diabetes and distress (Appendix F).
Measurements are valid and reliable as demonstrated by high construct validity reported
as a Cronbach’s alpha. (Appendix E). Of the final 14 studies, nine were randomized
controlled trials, three systematic reviews, one meta-analysis and one cross-sectional
analysis. Seventeen variables were selected for inclusion in the synthesis table based on

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relevance to the PICOT question (Appendix F).
Many studies found significant relationships between structured DSME and
improved hemoglobin A1C. Some studies found significant relationships between
culturally tailored education and improved HbA1C, diabetes knowledge and selfefficacy. Few studies found relationships between DSME and improved quality of life.
Conclusion
The current standard of care is inconsistent and ineffective in managing diabetes
as evidenced by the rising burden of the disease. This literature review revealed that the
cornerstone of diabetes management is diabetes education. This literature review revealed
that multi-faceted, structured diabetes self-management education and culturally tailored
diabetes education were more effective than usual practices. These approaches improve
HbA1c, self-management skills, self-efficacy, diabetes knowledge and quality of life.
Theoretical Framework
Self-efficacy is defined as people's beliefs about their capabilities to produce
designated levels of performance that exercise influence over events that affect their lives
(Bandura, 1994). Self-efficacy beliefs determine how people feel, think, motivate
themselves and behave. A person who is self-efficacious approaches difficult situations
as challenges to be mastered instead of threats to be avoided. An efficacious individual
approaches situations with assurances that can be controlled. In order to have adequate
control over diabetes, one must have robust sense of efficacy to sustain the perseverant
effort needed to succeed in maintaining a health lifestyle. The selected theory that
describes the interrelated concepts and behaviors of this body of evidence is Self-efficacy
theory (Appendix G).

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Conceptual Framework

Ongoing self-care is necessary for effective management of diabetes. This is often
achieved through diabetes self-management education. Healthcare providers must use
evidence-based healthcare delivery models, such as the chronic care model (CCM), to
improve outcomes for people with diabetes. The Chronic Care Model (Appendix H) is an
organizing framework for improving chronic illness care by providing a multifaceted
framework of six interrelated elements. The idea of CCM is that quality care is not
isolated. It creates a culture and mechanisms that promote safe, high quality care; it
assures the delivery of effective, efficient clinical care and self-management support;
promotes clinical care that is consistent with scientific evidence and patient preferences;
organizes patient and population data to facilitate efficient and effective care; empowers
and prepares patients to manage their health and health care; and mobilizes community
resources to meet the needs of patients (AADE, 2014)
The theoretical/conceptual framework presents a systematic way of understanding
events, behaviors and/or situations. The selected framework will describe a set of
interrelated concepts, definitions, and propositions that explain or predict events or
situations by specifying relationships among variables.
This model can be applied to an evidence-based project. The CCM has proven to
be effective in sustaining diabetes self-management programs. It could be incorporated in
primary care by facilitating patient-centered care, patient empowerment and selfmanagement support as it relates to diabetes. The CCM could help with assembling
diabetes management protocol, tools and education materials that are user-friendly,
culturally tailored and at the appropriate literacy level for people with diabetes.

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Evidence-Based Model
The chosen evidence base model is that of Translating Evidence into Clinical
Practice (Appendix I). This conceptual model is a systematic process grounded in change
theory, research utilization and standardized nomenclature (Pipe, Wellik, Buchda,
Hansen & Martyn, 2005). It facilitates the translation of research into practice (Pipe, et
al.). There are six phases: assessing the need for change; linking the problem with
interventions and outcomes; synthesizing the best evidence; designing a change in
practice; implementing and evaluating the practice; and integrating and maintaining the
practice change (Pipe, et al.).
Applying Evidence to Practice/Methods
Primary care providers can improve management of diabetes by improving
diabetes self-management education. The evidence suggests that usual care is not
sufficient in helping patients gain glycemic control. The evidence shows that structured
and culturally tailored diabetes self-management education is effective in improving
diabetes knowledge, self-efficacy, clinical outcomes and quality of life. The stakeholders
include the providers, the healthcare workers and patients.
The first three phases of the EBP model were accomplished through fieldwork,
the exhaustive search of evidence, and the critical appraisal and synthesis of that
evidence. The design phase began with me utilizing the evidence to design a practice
change for the primary care clinic.
The practice design was submitted and approved by Arizona State University
Institutional Review Board committee. The setting was a primary care clinic in
Mansfield, TX. The participants were scheduled for an office visit for pre-intervention

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HbA1c check and Diabetes Knowledge Test (DKT). The DSME session was followed. It
included diabetes educational videos and compiled sources for a DSME leaflet. This was
followed by a post-test. Three months later, another HbA1c was drawn.
Outcomes/ Results
Data was collected, coded and entered into SPSS. With collaboration with a
statistics consultant, descriptive statistics non-parametric tests were run to analyze data
and produce figures and tables. Frequencies reported on all ordinal and nominal data. The
sample consisted of 60% male and 40% female. Descriptive statistics was reported on all
scale data. The average age of the participants is 72 (SD = 8.34) and the ages ranged from
65 to 82 years of age. There were clinical and statistical significant improvements in
diabetes knowledge post intervention (p=0.043). There were clinical significant
improvements in HbA1c values (P=1.00) post intervention.
Impact/Discussion
By implementing DSME programs in primary care and monitoring HbA1c,
patients should gain improved diabetes knowledge, self-efficacy and glycemic control.
Patients, providers and the health care system will see significant benefits from focusing
on the implementation of evidence-based diabetes education program.
Some strengths of the project include, the patients, provider and the office staff seemed
very receptive to the practice change. However, there were some barriers: time and
available staff. For sustainability, the office may have to set aside a specific day to do the
education sessions or hire more people. Policy and procedural changes could help with
the consistent provision of diabetes education in primary care.

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Conclusion
The DNP project demonstrated that implementing DSME in primary care can
improve diabetes knowledge and glycemic control. These results seem to be is in line
with the current literature. Patients and health care providers should consider DSME
interventions in the primary care settings. This can improve patient knowledge about DM
self-management and ultimately, improve health outcomes. This DNP project paves the
way for future research that should focus on a larger sample across different populations.

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2 diabetes mellitus. Cochrane Database of Systematic Reviews, 3, 1-49.
doi:10.1002/4651858.afr008776.pub2

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control in type 2 diabetes using weekly intensive multifactorial interventions:
Structured glucose monitoring, patient education, and adjustment of therapy.
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Pipe, T., Wellik, K., Buchda, V., Hansen, C., Martyn, D. (2005). Implementing
evidenced based nursing practice. Urology Nursing, 25(5), 365-370.

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(2015). Diabetes self-management education and support in type 2 diabetes: A joint
position statement of the American diabetes association, the American association of
diabetes educators, and the academy of nutrition and dietetics. The Diabetes
Educator, 41(4), 417-429. doi:10.1177/01457215588904

IMPROVING DIABETES

22

Prezio, E., Pagan, J., Shuval, K., Culica, D. (2014). The community diabetes education
(CoDE) program cost-effectiveness and health outcomes. American Journal of
Preventive Medicine, 47(6), 771-779. doi.org/10.1016/j.ampre.2014.08.016

Sadeghian, H., Made, S., Agrawal, O., Kannan, A., & Agrawal, K. (2016). Effects of a
self-management educational program on metabolic control in type 2 diabetes.
Turkish Journal of Medical Sciences, 46, 719-726. doi:10.3906/sag-1501-115

Texas Department of State Health Services. (2015). 2013 diabetes fact Sheet—Texas .
Retrieved from https://www.dshs.texas.gov/diabetes/tdcdata.shtm

Wong, C., Wong, W., Wan, W., Chan, F., & Lam, C. (2016). Effect of a structured
diabetes education programme in primary care on hospitalizations and emergency
department visits among people with type 2 diabetes mellitus: Results from the
patient empowerment programme. Diabetes Medicine, 33(10), 1427-1436.
doi:10.1111/dme.12969

Wooley, D. S., & Kinner, T. J. (2016). Comparing perceived self-management practices
of adult type 2 diabetic patients after completion of a structured ADA certified
diabetes self-management education program with unstructured individualized nurse
practitioner led diabetes self-management education. Applied Nursing Research, 32,
171-176..doi.org/10.1016/j.apnr.2016.07.012

World Health Organization. (2016). 10 facts on diabetes. Retrieved from
http://www.who.int/features/factfiles/diabetes/en/

IMPROVING DIABETES

23

Appendix A
CINAHL

IMPROVING DIABETES

24

Appendix B
Pubmed

IMPROVING DIABETES

25

Appendix C
Academic Search Premiere

IMPROVING DIABETES

26

Appendix D
Cochrane

IMPROVING DIABETES

27

Appendix E

Evaluation Table
Citation

Theory/
Conceptual
Framework

Design/ Method

Attridge, et al.
(2014). Culturally
appropriate health
education for people
in ethnic minority
groups with type 2
diabetes mellitus.

Chronic care
model

Design:
Systematic
Review
Purpose: To
assess the
effectiveness of
culturally
appropriate health
education for
people in ethnic
minority groups
with type 2
diabetes mellitus.

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats
used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level I
Strengths:
High Quality
evidence
Weakness:
Risk of bias is
high
Practice:

Sample: N= 7
IV1: CAE
Glycemic
Funnel
DV1 –
n=1,000
IV2: Usual
control:
Plots
HbA1cRandom – improved
Setting: Primary
diabetes
Laboratory
healthy care
education
measurements effects
after CAE
Model
centers or hospital DV1
of HbA1C
(MD: Self-efficacy:
Meta
clinics; (USA,
Glycemic
0.4%;(95%
Stanford SE
analyses
Canada, South
control
CI: -.5 to scale
Africa, New
(Change in
.2)
DV2:Redu
Diabetes SC
Zealand, Australia HbA1C)
ction in
Heterogeneity of
behaviors:
Gender: Male &
DV2:
Triglycerid
studies
female (%
Triglycerides Summary of
es ;(95%
Diabetes Selfunclear)
DV3: Total
CI: -40 to Risk of bias was
Care
AA; British South Cholesterol
8)
judged to be high for
Activities;
Asians; Surinam
DV4:
DV3many outcomes.
BIPQ
Asians; Mexican
Knowledge
Neutral
American; Peurto DV5: BMI
effects on
Ricans; American DV6: QOL
total
Somoans, Native
cholesterol
Americans
DV4 –
Selection
criteria: RCTs of
Knowledge
ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

28

Citation

Theory/
Conceptual
Framework

Design/ Method

Essein, et al.,
(2017). Intensive
Patient Education
improved Glycaemic
Control in Diabetes
Compared to
conventional
education: a RCT in
a Nigerian Tertiary
Care Hospital
Funding: Novartis &
Biofem – Funders
had no role in study
design or data
collection.

Chronic Care
Model

Design
Unblinded,
parallel-group
RCT
Purpose:
Evaluate whether
an intensive &
systematic DSME
program, using
structured
guidelines
improved
glycemic control
compared to
existing ad hoc pt
education.

culturally
appropriate health
education for
people >16y.o
with T2DM;
named ethnic
minority; uppermiddle-income or
high income
countries.
Sample/ Setting

n=118
Setting: Cross
river state
Nigeria; Teaching
hospital,
endocrinology
clinic.
F-71; M-47
Inclusion: >18y.o;
HbA1C .8.5%
Able to engage n
moderate
exercise; free of
eye disease

improved

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

IV-Intensive
Pt Education
IV 2 –
Conventional
education
DV-HbA1c

HbA1C
measurements
obtained by
nurses using
Clover A1c
Analyzer

Data
Analysis
(stats
used)
SAS with
two-sided
hypothesis
testing &
significan
ce at the
0.05 level

Findings/
Results

Intensive
Group
HbA1C 1.8% (95%
CI= -2.4 to
-1.2) lower
than
convention
al group

Level/Quality
of Evidence;
Decision for
practice/
Level II
Strengths :
Robust results
demonstrating
improved
clinical
outcomes
Weakness:
The trial had
only 6 month
f/u pd. Unclear
on how
generalizable
the results are
bc of pt
population
Practice: Can
be used in
practice to

ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

29

improve clinical
outcomes.

Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats
used)

Findings/
Results

Fairfield, et al.,
(2014). ‘Getting
there’: the impact of
structured insulin
management
education in a high
ethnic ix population
with type 1 and type
2 diabetes

Self Efficacy

Design
NICE guidelines
Purpose: develop
an education
program for
people with type 1
or 2 diabetes to
enable effective
self-management,
improve
confidence ,
reduce
hypoglycemia &
enable peer group
support.

n= 40; 68% male;
age 35-82y.o
Caucasian: 18;
Asian: 22
Setting: Cross
river state
Nigeria; Teaching
hospital,
endocrinology
clinic.
Inclusion: Type 1
or 2 diabetes; on
medications; Able
to speak and
understand
English

IV:DAFNE
for T1DM
IV2:
DESMOND
for T2DM
DV1-A1C
DV2 Lipids
DV3 BP
DV4 Quality
of life

DV 1 – blood
work
DV 2: Blood
work
DV 3: BP cuff

SAS with
two-sided
hypothesis
testing &
significan
ce at the
0.05 level

Improved
HgA1C
Increased
pt
satisfaction
&
confidence

There are no
conflicts of interest
declared
Funding-unclear

DV4:Pt feedback;
no scale was
used

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level VII
Strengths: The
curriculum
showed
improvements
in clinical
outcomes,
Weakness:
Mix group
(type1 & 2);
Different
medications.
Low level of
evidence.
Practice: it has
practice
implications
however, this
article has low

ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

30

Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Ferguson, et al.,
(2015). Does
diabetes selfmanagement
education in
conjunction with
primary care
improve glycemic
control in Hispanic
Patients .
Funding- unclear
Potential for
publication bias
Citation

Chronic care
Model

Design:
Systematic
Review & Metaanalysis of
PubMED,
Cochrane Library,
CINAHL
Purpose: Test the
effect of DSME
interventions in
Hispanic adults
with T2DM

N= 24
n= 2784
Hispanic
Mean age: 47.970.3
Setting: Diabetic
Clinic MA, TX,
NY, CA,PR
Inclusion: Pre &
post intervention;
Change in A1C

IV1: DSME
individual
IV2 DSME
group
IV3-DSME
telephone/ele
ctronic
IV4: DSME
multimodal
DV: HbA1C

Glycemic
control
measured by
blood draw:
Hb A1C

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Gonzalez, I., et al.
(2015). Long-term
effects of an
intensive=practical
diabetes education
program and selfcare

Chronic Care
Self efficacy
Cognitive
behavior

Cross sectional
study, repeated
measure design.
Purpose
Purpose: Long
term effects of
DEP

Data
Analysis
(stats
used)
PRISMA
guidelines
.
Subgroup
analyses
Funnel
plot
Failsafe N
test
CMA

Data
Analysis
(stats
used)

Findings/
Results

DV: At > 6
month A1C
reduction
was -.25
(95% CI, .42 to 0.07)
Most
successful
DSME =
Culturally
tailored
Findings/
Results

level of
evidence.
Level/Quality
of Evidence;
Decision for
practice/
Level I
Strengths:
RCTs
Weakness:
Interventions
represent large
variability in
DSME design;
Heterogeneity;
limited
published
studies.
Practice: Usable
Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level III
Strengths:
Results support
hypothesis;
Significant
decrease
inA1C;
measures of

N=1
IV-DEP
ECODI scale
NonDV1:
n= 40: 57.5%
DV1-HbA1c
SDSCA
parametric HbA1c –
Female: 23; Male: DV2:
Diabetes Care
data were
lower at 6
17
knowledge of Profile
analyzed
mo & 12
Setting: Diabetes
Diabetes
Confidence in
with
mo f/u
outpatient clinic
Diabetes SelfMcNemar P<-.000 SD
= 1.28
San Cecillio
Care
’s test
University
Blood work
ANOVA
DV2:
ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

31

No conflicts of
interests declared

Hospital in Spain
Inclusion: T1DM
on insulin
Exclusion:
physical
impairment;
psychological
impairment; been
recently
diagnosed; not
being a native
Spanish speaking.

Funded by the
Regional Ministry of
Health Andalusia,
Spain

Citation

Theory/
Conceptual
Framework

Hermanns, N.
(2013). The effect of
a diabetes education
programme
(PRIMAS) for
people with type
1diabetes: Results of
a randomized trial.

Self Efficacy

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

SPSS
software

Perceived
barriers
decreased
Knowledge
increased –
Mean value
increased(S
D =1.24)

Data
Analysis
(stats
used)
95%
confidenc
e interval
– 0.4%
-SYSTAT

Findings/
Results

clinical
significance
Weaknesses:
Small sample
size
Practice:
Practice
implications
because the
study shows
improved
clinical
outcomes
Level/Quality
of Evidence;
Decision for
practice/
Level II
Strengths:
Modest
improvements
in clinical
outcomes
Weakness: Not
blinded; .
Practice: it has
practice
implications
however, this
article has low
level of
evidence.

n= 160
IV:PRIMAS
DV 1 – blood
DV1: 0.4
Design
Multi-center
participants
IV2: DTTP
work
% greater
Setting:
DV 2: SelfRandomized trial
DV1-A1C
reduction
Outpatient clinics DV2 self
care behavior
- SYSTAT
of DV2:
Purpose: develop in Germany
DV 3:
management
HbA1c in
an education
Inclusion: Type 1 DV3 Distress DiabetesPRIMAS;
HbA1C
program for
Age>18 & <75
related distress
DV4 Selfunchanged
people with type 1 y,o
scale
efficacy
in DTTP
or 2 diabetes to
BMI >20&<40
DV4: Diabetes
Funding: Grant of
DV3: enable effective
HbA1c>7&<13
Self efficacy
Berlin Chemie
PRIMAS =
self-management, Informed consent;
scale
AG/Menarini
greater
improve
Ability to
Diagnostics; No role
decrease in
confidence ,
understand &
in PRIMAS study
distress
reduce
speak German.
DV 4:
design, data
hypoglycemia &
Exclusion:
collection &
enable peer group Psychological or
PRIMAS =
ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

analysis, decision to
publish or
preparation of the
manuscript.

32

support.

psychiatric
disorder;
dementia;
cognitive
impairment;
Somatic disease;
Pregnancy.

greater
increase in
self
efficacy

Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats
used)

Findings/
Results

Piatt, et al. (2010).
3-Year Follow-up of
Clinical and
Behavioral
Improvements
following a
Multifaceted
Diabetes Care
intervention

Chronic care
Model
Self-efficacy

Design
RCT – 4 phases;
cross sectional
Purpose: To
determine if
improvements
observed in
clinical,
behavioral, &
psychosocial
outcomes
measured in 12
months following
multifaceted
diabetes care
intervention were
sustained at 3-yar
follow up

n= 11primary care
n= 42 providers
n = 119 patients
Setting: Supurb of
Pittsburgh,
Pennsylvania; 11
Primary care
practices
Demograph: HS
education; FT
employment or
PT employment
Income level
>$20,000/yr;
Home ownership
Inclusion:
diabetes; A1C >
7%; informed
consent;

IV1: Chronic
care model
IV2: Provider
intervention
only
IV3: Usual
Care
DV1:
Glycemia
DV2: BP
DV3: Self
Monitoring
blood glucose
DV4: A1c

Clinical testing
Questionnaire
– Modified
Diabetes Care
Profile
World Health
Organization
(Ten) Quality
of Well being
Index
BP cuff
Blood work laboratory.
A1C DCS 200
analyzer;
Cholestech
LDX system

Paired t
tests
McNemar
SAS

DV1;Glyce
mic
improveme
nt – (0.5%)
DV2 BP
control (4.8%)
DV3: Self
monitor
blood
glucose
(86.7%100%)
DV4: A1c
improveme
nt p=.09)
Non-HDLc
P=0.1)

Funding: United
States Air Force
Conflicts unclear

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level II
Strengths:
Chronic care
model; 3
groups; Primary
care offices; 4
phases; crosssectional
;confirm
multifaceted
interventions
Weakness:
Small sample
size
University
institutional
review board
did not permit
contacts with

ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

33

Citation

Theory/
Conceptual
Framework

Design/ Method

Pimazoni-Netto, et
al. (2011). Rapid
Improvement of
Glycemic Control in
Type 2 Diabetes
Using weekly
intensive
multifactorial
interventions:
structured glucose
monitoring, patient
education, and
adjustment of
therapy

Chronic Care
Self efficacy
Cognitive
behavior

Design: Proof of
concept RCT
Purpose: to test
the hypothesis
that more frequent
adjustment of
therapy, combined
with a
multifactorial
interdisciplinary
approach could
result in a more
rapid glycemic
control

Exclusion:
Gestational
diabetes,
adolescents,
comparative drug
effectiveness, type
1 diabetes, studies
of Caucasian
women, diabetes
pathology
Sample/ Setting

n= 63 pts
outpatient
Setting: Sao
Pauo, Brazil
Inclusion: 3575y.o A1C>8
Exclusion:
Noncompliance

pts
articles.
Practice: Very
useful; study
done in primary
care practices

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

IV-intensive
treatment
DV-WMG
DV2: SD
DV3:A1C

Accuchek
Performa
Roche
Bloodwork

Data
Analysis
(stats
used)
Computer
analysis
(SMBG);
onside
compariso
n. WMG,
SD, A1C.
perform
X2 test to
assess null
hypothesis

Findings/
Results

DV1:
Significant
changes in
WMG,
DV2: SD
&
DV3A1C
occurred
more
rapidly in
intensive
treatment
group.

Level/Quality
of Evidence;
Decision for
practice/
Level II
Strengths:
Results support
hypothesis;
Significant
decrease inA1C
Weaknesses:
Small sample
size; short
duration of
study;
Practice:
Practice
implications
because the
study shows
improved
clinical
outcomes

Support from
Federal University;
Diabetes Education
& Control Group of
ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

34

the Kidney &
Hypertension
Hospital
Authors; APN
consultant for
Roche, Bayer; Brazil
Consultant for
Abbott Diabetes;
MTZ consultant for
Novartis, Pfizer

Citation

Theory/
Conceptual
Framework

Rygg, et al. (2011).
Efficacy of ongoing
group based diabetes
self-management.

Self-efficacy

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats
used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level II
Strengths:
Intervention
group showed
better diabetes
knowledge,
improved selfmanagement
skills ;
Weakness:
Participants had
lower A1Cs
than expected.
articles.

n= 146
IV1: DSME
In A1C
A1C
Design
DV1:
RCT – open
50%men
IV2: Usual
Laboratory
90%
improveme
pragmatic,
age: 40-75
Care
Measures:
power and nt – (DV2: Patient
parallel group;
Female: 50%
DV1: A1C
a 0.05
0.5%)
Activation
randomized by
Male: 50%
DV2: Self
significan BP control
Funding: Cenral
(-4.8%)
Measure
computer
Setting; Central
management
ce level
Purpose: To
PAM
Norway Health
Self
Norway
DV3: Quality (PAM) (Self
determine if
score of
Authorities
monitor
reporting
of Life
Inclusion:
improvements
blood
questionnaires. 6.0(S.D
Diabetes duration DV4:
observed in
11.1)
There are no
glucose
Diabetes
)
1month to 10
DV3: Medical Analysis
clinical,
potential conflicts of
(86.7%Knowledge
years.
outcomes
of
behavioral, &
interests relevant to
100%)
DV5: BP
study short
covarianc
psychosocial
this article.
outcomes
Form-36
e
A1c
ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

35

measured in 12
months following
multifaceted
diabetes care
intervention were
sustained at 3-yr
follow up

(SF36)
DV4: 12-item
questionnaire
DV5: BP cuff

Paired ttest
Test of
proportion
s
SPSS

improveme
nt p=.09)
Non-HDLc
P=0.1)

Data
Analysis
(stats
used)
Microsoft
Excel
SPSS
Chisquare
Independe
nt t-test
McNemar
’s test
Generaliz
ed
estimation
equations

Findings/
Results

Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Sadeghian, et al.,(
2016). Effects of
self-management
educational program
on metabolic control
in type 2 diabetes

Self-care theory

Design: RCT;
parallel group trial
Purpose: to
evaluate the
efficacy of a selfmanagement
educational
program on
metabolic control
in type 2

n= 306
Mean age= 45.42
(32-60)
47male; 58.3%
female
Setting: Diabetic
Clinic at Guru
Teg Bahadur;
India hospital,
Inclusion:
HbA1C>8%
T2DM
Informed consent
Registered for
clinic for 1st time
Exclusion:
Pregnancy
Gestational
diabetes
Malignancy

IV-Group
education
DV- Self
management
practices

Questionnaires
Clinical
examination
Investigations

Bias: unclear
Funding unclear

Significant
improveme
nt in
HbA1c
(P=.0001)

Practice:
Locally
developed
programs may
be less effective
than program
developed for
studies
Level/Quality
of Evidence;
Decision for
practice/
Level II
Strengths study
proved selfmanagement
program
improves
metabolic
control
Weakness
Practice

ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

Citation

Theory/
Conceptual
Framework

36

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data
Analysis
(stats
used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level II
Strength: high
level of
evidence
HbA1C
Weakness:
Small sample
size

Tang, et al. (2014).
Self care
Design: RCT
n= 116
IV1- Peer
Laboratory:
Longitud- Both PL &
Comparative
Setting:
lead DSME
HbA1c,
inal
Communit
Purpose:
Effectiveness of peer
cholesterol
analysis
y leader led
compare peer lead University of
IV2:
Community
Leaders and
Michigan
to
vs community
worker
Community Health
Age: 48-50
improved
health worker
Workers in Diabetes
Inclusion: at least DV1- HbA1c
patient
outreach
DV2 CV
Self-Management
21 y.o
outcomes.
intervention in
disease risk
Support
Regular health
PL- HB1c:
sustaining
Funding: Peers for
(-0.6 –
DV3: distress
care provider
improvements in
Progress grant from
6.6mml).
Self-identified as
A1c
American Academy
(P=0.0004)
Latino
of Family Physicians
CHW: -0.3
Exclusions:
Foundation,
to -3.3)
physical
National institute of
P=0.234
limitations
Diabetes &
Terminal health
Digestive, CDC;
Psychiatric illness
Funding sources had
excessive alcohol
no role in the study
or illicit drug use
design, data
collection,
administration of
interventions,
analysis,
interpretation or
reporting of data or
decision to submit
findings for
ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

publications.
Citation

Vos, et al.,(2016).
Diabetes selfmanagement
education after preselection of patients.
Funding: European
Foundation for the
study of diabetes
The authors declare
they have no
competing interests.

37

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Self care

Design: RCT
:influencing
follow up use of
DSME

n=88
age: <75 y
Setting:
Netherlands
Inclusion: <75y;
Dx with T2DM
b/t 3-5 months
Exclusion: High
self-management
capabilities;
Insignificant
cognition;

IV- DSME
DV1Behavior
DV2 = Hb
A1C
DV3 Quality
of life

Blood work
SemaS: Self
management
screening
EQ-5D tool
Short-Form 36
ADDQOL

Data
Analysis
(stats
used)
GEE
ANCOVA

Findings/
Results

Improved
clinic
outcome:
improved
Quality of
life, BP, &
HbA1c

Level/Quality
of Evidence;
Decision for
practice/
Level II
Strength:
Results yielded
improved
clinical
outcomes.
Weakness:
Small sample
size

ADDQOL= Audit of Diabetes-Dependent Quality of Life; BP: Blood pressure CAE: Culturally appropriate education; CI: confidence interval; CMA=
Comprehensive meta-analysis; CHW: Community health worker; CT = controlled trial; CV= Cardiovascular DEP: Diabetes education program. DSME=
Diabetes self-management education; DTTP: diabetes teaching and treatment program. ES: effect size; GE = group education; HbA1C= glycosylated
hemoglobin; mo: month; N= no of studies; n= no of participants; PRiH (Peurto Rican identified Hispanic); PRIMAS: self-management oriented education
program. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analysis. QOL: Quality of Life; RCT= randomized control trial; NICE:
National Institute for Health and care Excellence. SDSCA- Summary of Diabetes Self-care activities; SYSTAT: Systat software. WMG – weekly mean
glycemia; T2DM: Type 2 Diabetes Mellitus

IMPROVING DIABETES

38

Appendix F

Synthesis Table
Author

Attridge Essien

Fairfield

Ferguson Gonzalez

Hermanns Johnson PimazoniNetto

Piatt

Rygg

Sadeghian Tang

Vos

Year

2014

2017

2014

2015

2015

2013

2017

2011

2010

2011

2016

2014

2016

Design/Level of
evidence

SR/II

RCT/II

Guideline
s/VII

SR&MA/
I

CS/III

RCT/II

SR/I

RCT/II

RCT/II

RCT/II

RCT/II

RCT/II

RCT/II

118

40

2784

40

160

520345

63

119

146

306

116

88

>17
Mean=
52.7

35-82
Mean=
58y

Mean
47.9-70.3
y

Mean:
32.8

18-75

45-65

35-75

64-69

40-75

32-60

48-50

<75 y

71/47

32%/68% Majority
Female

23/17

138/22

46.7%/5
3.3

18/45

91/28

50%/50 58.3%/47
%
%

68/48

N/A

Multiethnic,

Caucasian Hispanic
18; Asian:
22

unclear

German

Peurtorican

N/A

‘Nonw
hite” =
5

White
Indian
Norweg
ian

Latino

Dutch

Nigeria

Spain

Germany

USA

Brazil

USA

Norway India

USA

Netherla
nds

Demographics
Sample Size 1000
Age >16
(Years)
Female/Male Unclear
% F/M
Race Multiethnic

Country US,
Nigeria
Canada,
South
Africa,
New
Zealand,
Australia

USA

Tools
DSME: Diabetes Self-Management Education; N/A: Not available; RCT: randomized controlled trial; SE: Self efficacy scale; SR: Systematic review; US: United
State;USA: United States of America;

IMPROVING DIABETES

A1c Lab
SE Scale X
Behaviors X
Distress scale X

X

Telephone Survey
Questionnaire

39

X

X

X
X
X

X
X
X
X

X

X

X
X

X
X

X
X

X

Interventions
DSME X
Group structure
Culturally X
tailored
Online
Usual Care X
Telephone

X

X
X

X
X

X

X
X
X

X

X

X

X
X
X

X

X

X

X

X
X
X
X

X

X
X

X

X

X

X

Outcomes
HbA1c
Self-Efficacy
Knowledge X
Quality of Life X

X

X

X

X
X

X

X
X

X

X

DSME: Diabetes Self-Management Education; N/A: Not available; RCT: randomized controlled trial; SE: Self efficacy scale; SR: Systematic review; US: United
State;USA: United States of America;

IMPROVING DIABETES

40

Appendix G

IMPROVING DIABETES

41

Appendix H

IMPROVING DIABETES

42

Appendix I
EBP Model

IMPROVING DIABETES

43