Sharon A. Brown

Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited.

This paper reports a follow-up of previous meta-analysis research conducted by the author on the effects of diabetes patient education on patient outcomes. An expanded sample of studies and psychological outcome variables were added to the previously studied variables of patient knowledge, self-care behaviors (compliance and skill performance) and metabolic control. The purpose was to determine: (1) the effects of patient education on specific outcome variables; and (2) the relationships between effects of education and characteristics of the studies and/or subjects. Following an extensive literature search, a total of 82 studies were found which met the inclusion criteria for this analysis; 68% were published and 32% were unpublished. Homogeneity analyses of specific patient outcome variables yielded the following results: knowledge effects ranged from 0.49 to 1.05; self-care behavior effects from 0.17 to 0.57, with insulin injection and weight loss associated with the smallest effect sizes; metabolic control from 0.16 to 0.41; and psychological outcomes 0.27. Mean age of the subjects was negatively correlated with knowledge and cholesterol, indicating that the older the mean age of the subjects, the lower the effects of patient education on these variables. Findings of this meta-analysis on the expanded data set were consistent with the previous meta-analysis and lend support to the effectiveness of diabetes patient education in improving patient outcomes.

A meta-analysis of nurse practitioners and nurse midwives in primary care.

This meta-analysis was an evaluation of patient outcomes of nurse practitioners (NPs) and nurse midwives (NMs), compared with those of physicians, in primary care. The sample included 38 NP and 15 NM studies. Thirty-three outcomes were analyzed. In studies that employed randomization to provider, greater patient compliance with treatment recommendations was shown with NPs than with physicians. In studies that controlled for patient risk in ways other than randomization, patient satisfaction and resolution of pathological conditions were greater for NP patients. NPs were equivalent to MDs on most other variables in controlled studies. In studies that controlled for patient risk, NMs used less technology and analgesia than did physicians in intrapartum care of obstetric patients. NMs achieved neonatal outcomes equivalent to those of physicians. Limitations in data from primary studies precluded answering questions of why and under what conditions these outcomes apply and whether these services are cost-effective.

Effects of educational interventions in diabetes care: a meta-analysis of findings.

Forty-seven studies on the effects of patient teaching on knowledge, self-care behaviors, and metabolic control were analyzed using meta-analysis. Variables, such as type of patient instruction, type of research design, and overall quality of the study, also were analyzed. The 236 effect sizes had an unweighted mean of 0.91 (SD = 0.75) and a weighted mean of 0.33 (SD = 0.01). The weighted mean effect size for studies with control groups (N = 27) was 0.40 (SD = 0.05), and the weighted mean effect size for studies using the one group pretest-post-test design (N = 20) was 0.53 (SD = 0.05). Homogeneity analyses resulted in weighted mean effect size estimates for knowledge subvariables ranging from 0.41 to 0.91; for skill performance, 0.25 to 0.38; for compliance, 0.24 to 1.01; and for metabolic control, 0.06 to 0.84. Experimental mortality was the only variable significantly correlated with the overall weighted mean effect size, r = .52, p = .002. The results of this study clearly support the notion that patient teaching has positive outcomes in diabetic adults. Furthermore, methodological issues were important factors which influenced these findings.

Interventions to Promote Diabetes Self-Management: State of the Science

PURPOSE The purpose of this paper is to review the diabetes education literature that has emerged over the past 20 years to determine what we currently know about diabetes self-management interventions and their effectiveness in producing improved health outcomes. METHODS Findings of studies that were reported prior to 1990 were compared with findings of studies that have been conducted since 1990 to determine what recent changes and patterns in diabetes self-management education have occurred. Future directions in diabetes self-management research and practice were projected from these findings. RESULTS Most studies lacked adequate descriptions of the interventions tested, which precludes replication or application of the most effective strategies to clinical practice. Trends in interventions have evolved from education only to education plus behavioral models, with more attention given to interventions specifically for minority populations. The interventions that have been designed and tested seem to be longer, with more emphasis on simple, practical approaches to diabetes self-management. CONCLUSIONS The literature supports the effectiveness of diabetes education and behavioral interventions in improving psychosocial and health outcomes. The question of how to best achieve these improved outcomes continues to need further exploration.

Culturally Competent Diabetes Education for Mexican Americans: The Starr County Study

PURPOSE Few culturally competent health programs have been designed for Mexican Americans, a group that bears a disproportionate burden of Type 2 diabetes. In Starr County, a Texas-Mexico border community, investigators designed and tested a culturally competent intervention aimed at improving the health of this target population. The purpose of this article is to describe the development process of this diabetes education and support group intervention. METHODS The development stages were (1) community assessment, (2) intervention design, (3) selection or development of outcomes, (4) pilot testing, and (5) a randomized clinical investigation. RESULTS Focus group participants identified knowledge deficits regarding diabetes and self-management strategies, and suggested characteristics of an effective intervention for Mexican Americans. Outcome measures included metabolic control indicators, a newly developed knowledge instrument, and an existing health belief instrument. Preliminary analyses indicated that the intervention was successful in significantly improving metabolic control in the target population. CONCLUSIONS Developing successful diabetes interventions for minority groups requires a number of stages, careful planning, assessment of cultural characteristics of the target population, and a systematic approach to implementation.

Promoting Weight Loss in Type II Diabetes

OBJECTIVE To examine strategies—behavioral therapies, exercise, diet, anorectic drugs, surgery, or a combination of strategies—used for promoting weight loss in people with type II diabetes. RESEARCH DESIGN AND METHODS Meta-analysis was used to synthesize research of promoting weight loss in the population. Literature search strategies involved reviewing bibliographies, conducting computer searches and surveys of relevant masters degree programs, and contacting representatives of the Centers for Disease Control. The final sample consisted of 89 studies involving 1,800 subjects. Data were extracted on 80 variables characterizing the sample of studies/subjects and on 23 outcome variables, including weight, metabolic control, lipids, and other physiological parameters. RESULTS Diet alone had the largest statistically significant impact on weight loss (−20 lb) and metabolic control (−2.7% in glycosylated hemoglobin). All diets significantly improved fasting blood sugar. Behavioral programs alone had a statistically significant impact on weight loss (−6.4 lb) and metabolic control (−1.5%) but effects were < for diet alone. Data from the few exercise studies indicated that weighted average effects for exercise on weight loss (−3.4 lb) and metabolic control (−0.8%) were < diet alone. Behavioral therapy plus diet plus exercise was associated with statistically significant effect size estimates for weight loss (−8.5 lb) and metabolic control (−1.6%). Diet alone achieved better results. Effects of weight promotion strategies, in general, were smaller in experimental studies and for individuals over age 55. CONCLUSIONS Dietary strategies are most effective for promoting short-term weight loss in type II diabetes. A number of gaps exist in the extant literature—descriptions of subjects, interventions, or longitudinal outcomes beyond 12 months after intervention.

A Community-Based, Culturally Sensitive Education and Group-Support Intervention for Mexican Americans With NIDDM: A Pilot Study of Efficacy

The purpose of this study was to determine the feasibility of providing a diabetes patient education and group-support intervention that was directed by a Mexican-American clinical nurse specialist (CNS), dietitian, and community worker; consistent with national standards; and designed for the Mexican-American culture. In a rural Texas-Mexico border community, subjects with diabetes were randomly selected to participate in the intervention, and a family member of each subject participated as a support person. The intervention involved 8 weeks of educational sessions with instruction on nutrition, blobd glucose self-monitoring, exercise, and other diabetes self-management topics, and provided group support. Group discussion was facilitated using a series of Spanish-language videotapes that had been developed and previously tested in the target Mexican-American community. Results suggested statistically significant improvements in diabetes knowledge, fasting blood sugar levels, and glycosylated hemoglobin levels. The study documented the feasibility and potential benefits of the intervention.

Metabolic effects of interventions to increase exercise in adults with type 2 diabetes

Aims/hypothesisThe aim of this meta-analysis was to integrate the results of primary research testing the effect of diabetes self-management interventions that included recommendations to increase exercise on metabolic outcomes among adults with type 2 diabetes.Materials and methodsExtensive literature searching strategies were used to identify published and unpublished intervention studies that measured glycated haemoglobin outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses.ResultsData were synthesised across 10,455 subjects from 103 research reports. The overall mean weighted effect size for two-group comparisons was 0.29 (higher mean for treatment than control). This effect size is consistent with a difference in HbA1c means of 0.45% (e.g. 7.38% for treatment subjects vs 7.83% for control subjects). For single-group studies, the overall mean weighted effect size was 0.32–0.34. Control group subjects experienced no improvement in metabolic control during participation in the studies. Interventions that targeted multiple health behaviours resulted in smaller effect size estimates (0.22) than interventions that focused only on exercise behaviours (0.45). Funded studies reported greater improvements in metabolic controls. Studies with a greater proportion of female subjects reported lower effect sizes. Baseline HbA1c and BMI were unrelated to metabolic outcomes.Conclusions/interpretationThese findings suggest that self-management interventions that include exercise recommendations improve metabolic control, despite considerable heterogeneity in the magnitude of the intervention effect. Interventions that emphasise exercise may be especially effective in improving metabolic control. Primary research testing interventions in randomised trials to confirm causal relationships would be constructive.

Gender and treatment differences in knowledge, health beliefs, and metabolic control in Mexican Americans with type 2 diabetes.

PURPOSE The purpose of this project was to describe metabolic control, knowledge, and health beliefs of Mexican Americans with type 2 diabetes. METHODS The study site was Starr County, Texas, a border community located on the Rio Grande River and bordering northern Mexico. Of the total sample of 360 persons, 252 agreed to participate in this intervention study and were randomized either to the treatment group or the control group that waited 1 year to begin the intervention. RESULTS The majority of individuals were Spanish-speaking females with a mean age of 54 years and a mean diabetes duration of 8 years. For those treated with diet only, males exhibited higher fasting blood glucose levels than females. Gender effects were seen for cholesterol level, with females exhibiting higher levels than males. Males expressed stronger perceptions of control and social support for diet. Bivariate relationships were found between acculturation and diabetes knowledge. The health belief subscales of control and impact on job together explained 16% of the variance in HbAlc values. CONCLUSIONS Males and females held differing beliefs about ability to control their diabetes and degree of social support for diet. The impact of gender differences on ability to integrate diabetes self-care and on effectiveness of diabetes programs has not been determined but should be considered in future research.

Lost productive work time after mild to moderate traumatic brain injury with and without hospitalization.

OBJECTIVE:Lost productivity after mild traumatic brain injury (TBI) is a large component of the economic costs of brain trauma in the United States. This is the first prospective study of employment after mild TBI to include patients not admitted to a hospital. METHODS:Concurrent inception cohorts of 210 working-age adults with mild to moderate TBI and 122 patients who sustained general trauma not involving the brain were recruited at a trauma center and followed up to 6 months later. Outcomes were time from injury until first day worked and problems reported after resuming work. RESULTS:Most patients who worked after their injury remained employed 6 months later in a similar capacity as before the injury. No consistent differences were demonstrated between employment outcomes of patients with mild TBI and those with general trauma. The majority of nonhospitalized patients with mild TBI did not work for at least 1 month and did not begin working until 1 to 3 months after injury. Most patients with moderate TBI remained unemployed at 6 months postinjury. Patients with lower preinjury occupational status tended to have longer work absences. CONCLUSION:Lost productive work time after nonhospitalized TBI may cause significant economic costs because these injuries are frequent. Contrary to the theory that brain injury is more disabling to patients in cognitively demanding occupations, patients with higher job status tended to begin work earlier. A technique is needed to screen patients with mild TBI for risk of employment problems. Rehabilitation after moderate TBI may help to minimize lost productivity.