Marit By Rise

Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis

BackgroundDiabetes self-management education (DSME) can be delivered in many forms. Group based DSME is widespread due to being a cheaper method and the added advantages of having patient meet and discuss with each other. assess effects of group-based DSME compared to routine treatment on clinical, lifestyle and psychosocial outcomes in type-2 diabetes patients.MethodsA systematic review with meta-analysis. Computerised bibliographic database were searched up to January 2008 for randomised controlled trials evaluating group-based DSME for adult type-2 diabetics versus routine treatment where the intervention had at least one session and =/>6 months follow-up. At least two reviewers independently extracted data and assessed study quality.ResultsIn total 21 studies (26 publications, 2833 participants) were included. Of all the participants 4 out of 10 were male, baseline age was 60 years, BMI 31.6, HbA1c 8.23%, diabetes duration 8 years and 82% used medication. For the main clinical outcomes, HbA1c was significantly reduced at 6 months (0.44% points; P = 0.0006, 13 studies, 1883 participants), 12 months (0.46% points; P = 0.001, 11 studies, 1503 participants) and 2 years (0.87% points; P < 0.00001, 3 studies, 397 participants) and fasting blood glucose levels were also significantly reduced at 12 months (1.26 mmol/l; P < 0.00001, 5 studies, 690 participants) but not at 6 months. For the main lifestyle outcomes, diabetes knowledge was improved significantly at 6 months (SMD 0.83; P = 0.00001, 6 studies, 768 participants), 12 months (SMD 0.85; P < 0.00001, 5 studies, 955 participants) and 2 years (SMD 1.59; P = 0.03, 2 studies, 355 participants) and self-management skills also improved significantly at 6 months (SMD 0.55; P = 0.01, 4 studies, 534 participants). For the main psychosocial outcomes, there were significant improvement for empowerment/self-efficacy (SMD 0.28, P = 0.01, 2 studies, 326 participants) after 6 months. For quality of life no conclusion could be drawn due to high heterogeneity. For the secondary outcomes there were significant improvements in patient satisfaction and body weight at 12 months for the intervention group. There were no differences between the groups in mortality rate, body mass index, blood pressure and lipid profile.ConclusionsGroup-based DSME in people with type 2 diabetes results in improvements in clinical, lifestyle and psychosocial outcomes.

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.

Same description, different values. How service users and providers define patient and public involvement in health care.

Background  Patient and public involvement in health care is important, but the existing definitions of the concept do not integrate the stakeholders’ own perceptions.

Making and Maintaining Lifestyle Changes after Participating in Group Based Type 2 Diabetes Self-Management Educations: A Qualitative Study

Background Disease management is crucial in type 2 diabetes. Diabetes self-management education aims to provide the knowledge necessary to make and maintain lifestyle changes. However, few studies have investigated the processes after such courses. The aim of this study was to investigate how participants make and maintain lifestyle changes after participating in group-based type 2 diabetes self-management education. Methods Data was collected through qualitative semi-structured interviews with 23 patients who attended educational group programs in Central Norway. The participants were asked how they had used the advice given and what they had changed after the course. Results Knowledge was essential for making lifestyle changes following education. Three factors affected whether lifestyle changes were implemented: obtaining new knowledge, taking responsibility, and receiving confirmation of an already healthy lifestyle. Four factors motivated individuals to maintain changes: support from others, experiencing an effect, fear of complications, and the formation of new habits. Conclusion Knowledge was used to make and maintain changes in diet, medication and physical activity. Knowledge also acted as confirmation of an already adequate lifestyle. Knowledge led to no changes if diabetes appeared “not that scary” or if changes appeared too time consuming. Those involved in diabetes education need to be aware of the challenges in convincing asymptomatic patients about the benefits of adherence to self-management behaviour.

Occupational rehabilitation programs for musculoskeletal pain and common mental health disorders: study protocol of a randomized controlled trial

BackgroundLong-term sick leave has considerably negative impact on the individual and society. Hence, the need to identify effective occupational rehabilitation programs is pressing. In Norway, group based occupational rehabilitation programs merging patients with different diagnoses have existed for many years, but no rigorous evaluation has been performed. The described randomized controlled trial aims primarily to compare two structured multicomponent inpatient rehabilitation programs, differing in length and content, with a comparative cognitive intervention. Secondarily the two inpatient programs will be compared with each other, and with a usual care reference group.Methods/designThe study is designed as a randomized controlled trial with parallel groups. The Social Security Office performs monthly extractions of sick listed individuals aged 18–60 years, on sick leave 2–12 months, with sick leave status 50% - 100% due to musculoskeletal, mental or unspecific disorders. Sick-listed persons are randomized twice: 1) to receive one of two invitations to participate in the study or not receive an invitation, where the latter “untouched” control group will be monitored for future sick leave in the National Social Security Register, and 2) after inclusion, to a Long or Short inpatient multicomponent rehabilitation program (depending on which invitation was sent) or an outpatient cognitive behavioral therapy group comparative program. The Long program consists of 3 ½ weeks with full rehabilitation days. The Short program consists of 4 + 4 full days, separated by two weeks, in which a workplace visit will be performed if desirable. Three areas of rehabilitation are targeted: mental training, physical training and work-related problem solving. The primary outcome is number of sick leave days. Secondary outcomes include time until full sustainable return to work, health related quality of life, health related behavior, functional status, somatic and mental health, and perceptions of work. In addition, health economic evaluation will be performed, and the implementation of the interventions, expectations and experiences of users and service providers will be investigated with different qualitative methods.Trial registrationClinicalTrials.gov: NCT01926574.

Patient participation in mental healthcare: When is it difficult? A qualitative study of users and providers in a mental health hospital in Norway

Background: In western countries, patient participation is requested in policies on mental health services. Participation is built on ideas of democracy and individual responsibility. Mental illness has, however, been characterized by its irrational features. Aim: To investigate mental health service users’ and providers’ views on patient participation during episodes of mental illness. Methods: Qualitative interview study with 20 users and 25 staff from a mental health hospital in central Norway. Results: Both users and professionals saw poor illness phases as an obstacle to patient participation. Lack of insight, lack of verbal ability and difficulty cooperating made participation difficult. During such phases, patient participation was redefined. There was a shift in responsibility where professionals took charge through strategies of providing information, motivating patients and reducing choices. Respect and dignity were maintained and not redefined. Conclusions: In poor phases of mental illness, patient participation was redefined and weighed against what was perceived to be the patient’s best interest.

Changes among male and female visitors to practitioners of complementary and alternative medicine in a large adult Norwegian population from 1997 to 2008 (The HUNT studies)

BackgroundThe aim was to investigate changes in the prevalence and characteristics of male and female visitors to practitioners of complementary and alternative medicine (CAM) in a large adult population from 1997 to 2008.MethodsTwo cross sectional adult total population health surveys from Central Norwegian (the Nord-Trøndelag Health Studies (HUNT)). In 1997 42,277 and in 2008 50,713 respondents were included. Variables included demographics (age, education, working status), lifestyle (daily smoker, did hard physical activities), health status (self-rated health status, recent complaints, chronic complaints, psychiatric complaints, a range of diseases) and health care use (visit general practitioner, chiropractor). A test of difference between the results of multivariable logistic regression models for each year, including all variables, was used to analyse changes from 1997 to 2008.ResultsIn 1997 9.4% (95%CI 9.1-9.6) of the population had visited a CAM practitioner in the last 12 months and this increased to 12.6% (12.3-12.9) in 2008 (p < 0.001 for difference). Prevalence of CAM use in females was almost twice as high as that in males both years. For males, the significant changes from 1997 to 2008 (p < 0.05) were an increase in odds of visiting for those under 50 years, who had a recent complaint, were widower or did hard physical activities. There was a decrease for males who had a university degree, psychiatric complaint or hay fever. For females there was an increase in the odds for those under 50 years, who had a recent complaint or chronic complaint. It was a decrease for females with reported fair global health, psychiatric complaint, hay fever or if they had visited a chiropractor.ConclusionThe increase in visits was mainly among younger people of both genders with more limited complaints. A larger proportion of the more healthy part of the population is increasing their visits to CAM practitioners.

Cross-Cultural Comparison of Visitors to CAM Practitioners in the United States and Norway

OBJECTIVES The United States and Norway are among the countries that have the highest total expenditure on health per capita and also high utilization of complementary and alternative medicine (CAM). However, these countries have fundamentally different health care systems. The aim was therefore to compare characteristics of adults who have seen a CAM practitioner during the last year in the United States and Norway. METHODS Data from the National Health Interview Survey in the United States from 2002 and the Level of Living survey in Norway from 2002 were used. Both surveys were nationally representative household surveys of the noninstitutionalized civilian population. The data consist of 6612 individuals from Norway and 31,044 individuals from the United States. RESULTS In the United States, 7.4% of the population had seen a CAM practitioner during the last 12 months compared to 8.7% in Norway (p < 0.001 for difference). In both the United States and Norway, seeing a CAM practitioner was most strongly associated with seeing other health care practitioners and having experienced better or worse self-reported health in the last year. Being male and a daily smoker reduced the odds of seeing a CAM practitioner in both countries. In the United States, but not Norway, having higher education was strongly associated with seeing a CAM practitioner. Higher education was the variable with the biggest difference between the two countries. CONCLUSIONS This study indicates that in a country that provides health care services for all based on need regardless of personal income (Norway), the utilization of CAM practitioners is higher and less associated with use of other health care providers than a country with low government expenditure on health (the United States).

Reasons for participation in group-based type 2 diabetes self-management education. A qualitative study

Aims: To investigate reasons for participating in group-based diabetes self-management education (DSME) for patients with type 2 diabetes. Methods: A qualitative study using focus groups and individual semi-structured interviews was conducted with 22 patients attending seven different groups in Central Norway. Results: Patients with diabetes described two main reasons for attending DSME; experiencing practical problems and feeling insecure. These reasons differed by affecting the patients in two ways — practically or emotionally. Practical problems and feeling insecure both originated from lack of or contradictory information and from lack of contact with other patients with diabetes. This affected the patients’ everyday lives in important areas such as diet, medication, social settings and lifestyle changes. Conclusions: The underlying reason for participating in a DSME was the participants’ experience of having insufficient information about their diabetes, which led to practical problems and emotional insecurity. Being aware of the patients’ reasons for participating can help professionals keep a focus which is more consistent with patients’ needs.

Patient education – Which parts of the content predict impact on coping skills?

Aims: Studies investigating the effect of patient education usually evaluate whole educational programmes. The aim of this study was to describe the content of several locally developed educational programmes and investigate which parts predicted improved coping skills in the participants. Method: A prospective observational study investigating the content of several educational programmes and the participants’ coping skills 4 months afterwards. Results: The content of 35 different educational programmes was described. The programmes lasted on average 12 hours. The main focus was increased knowledge about the disease and improved coping skills. Programmes developed locally and tailored to the specific participant group in collaboration between services users and health professionals led to improved coping skills. The participants’ level of activity was the strongest predictor for improved coping skills (adjOR = 4.1 (95% CI 1.5–11.2) p = 0.007). Conclusions: The group process during patient education might be more important for improving coping skills than the content of the programme. Future patient education programmes should focus on group processes and improving participants’ activity.