Self-Management Education

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Helen Jones RN, MSN, CDE Lori D. Berard RN, CDE Gail MacNeill BNSc, RN, MEd, CDE Dana Whitham RD, MS, CDE Catherine Yu MD, FRCPC, MHSc

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • Offer collaborative and interactive self-management education (SME) interventions as they are more effective than didactic SME.
  • Incorporate problem-solving skills for ongoing self-management of medical, social and emotional aspects of care into the traditional knowledge and technical skills content of educational interventions.
  • Design patient-centred learning to empower individuals to make informed decisions toward achievement of patient-chosen goals.
  • Individualize SME interventions according to type of diabetes and recommended therapy, the patient's ability and motivation for learning and change, and his or her culture and literacy level.
  • Provide ongoing SME and comprehensive healthcare collaboratively to make SME most effective.

Introduction

Self-management education (SME) is defined as a systematic intervention that involves active patient participation in self-monitoring (physiological processes) and/or decision making (managing) (1). It recognizes that patient-provider collaboration and the enablement of problem-solving skills are crucial to the individual's ability for sustained self-care (2).

Several meta-analyses have demonstrated that SME is associated with clinically important benefits in persons with type 2 diabetes, such as reductions in glycated hemoglobin (A1C) of 0.36% to 0.81% (1,3,4). Improved quality of life (QOL) for persons with either type 1 or type 2 diabetes also has been demonstrated (5), as have other important self-care outcomes in those with type 2 diabetes, such as sustained weight loss and cardiovascular (CV) fitness for up to 4 years (6). One systematic review involving both type 1 and type 2 diabetes found that, as measures progressed from immediate to long-term outcomes, percentage of improved outcomes reduced (immediate learning 78.6%, intermediate behaviour change 50.0%, long-term clinical improvement 38.5%) (7). A 5-year follow-up of a patient-centred type 2 diabetes SME program resulted in no worsening of A1C, whereas the A1C in the control group rose 1.3% over the 5 years (8).

Diabetes SME is evolving from a traditional didactic teaching program to one using a variety of educational, psychological and behavioural interventions, and a combination of didactic, interactive and collaborative teaching methods that are tailored to the individual's specific needs (9). The content and skill-training components of SME must be individualized according to the type of diabetes and recommended therapy, the patient's ability, barriers, motivation for learning and change, culture and literacy level, and available resources (4,10,11). Models for systematizing, organizing and/or guiding the development of SME programs (12,13)share a 5-step problem-solving process aligned with the empowerment protocol (14)based on the principle that adults are more likely to make and maintain behaviour changes if these changes are personally meaningful and freely chosen (14). In order to meet the definition of “self-management education,” problem-solving skills for ongoing self-management of medical, social and emotional aspects of care must be integrated into the traditional knowledge and technical skills content of educational interventions (2). These skills are needed to inform decisions and increase the individual's capacity and confidence to apply these skills in daily life situations (2). SME refers to any of the educational processes that provide persons with the knowledge, skills and motivation required to inform decisions and increase the individual's capacity and confidence to apply these skills in daily life situations. Self-management support (addressed in the Organization of Care chapter, p. S20) refers to policies and people that may support continuation of self-management behaviours across the lifespan but that are not specific to educational processes.

Self-identification of a problem or need for self-care behaviour by the individual is crucial to all cognitive-behavioural interventions (14,15). The healthcare provider's role is to collaboratively facilitate this awareness process (2). Standardized instruments, such as the Problem Areas in Diabetes (PAID) (16), Self-care Inventory-Revised (SCI-R 2005) (17)or Summary of Diabetes Self-Care Activities (18), may have value in this process (19), although they have been used mainly for research purposes.

Interventions targeting knowledge and skills

Basic knowledge and skill areas that are essential for SME are monitoring of relevant health parameters, healthy eating, physical activity, pharmacotherapy, prevention and management of hypo-/hyperglycemia, and prevention and surveillance of complications. Skill training should include using self-monitoring of blood glucose (SMBG), making appropriate dietary choices, incorporating an exercise regimen, using medications as recommended and adjusting medication (20,21).

In general, education sessions provided to patients with diabetes have resulted in positive changes in diabetes-related knowledge (22), as well as psychological (23–26)and behavioural ( 23,27) domains. With respect to A1C, most trials involving group-based education have shown sustained A1C reductions (i.e. between 4 and 12 months), ranging from 0.4% to 0.7% (22,23,26,28). The Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) trial, a structured group education program for persons with newly diagnosed type 2 diabetes, resulted in greater improvements in weight loss, smoking cessation and positive improvements in illness beliefs up to 12 months after diagnosis; however, no significant effect on A1C was noted at 12-month follow-up (25).

In those studies that used print-based education, significant changes in behaviours related to physical activity (27), stage-of-change progression (29), weight loss (27)and improvements in glucose control (30)have been noted. Randomized trials of computer- or video-based education models have demonstrated improvements in at least 1 behaviour change related to healthy eating and physical activity ( 7,31).

All trials evaluating a culturally appropriate education module (which incorporated cultural or religious beliefs, were offered in the patient's native language, adapted dietary advice to reflect cultural traditions and the patient's needs, and/or involved family members) have noted improvements in diabetes-related knowledge, self-management behaviours and clinical outcomes, with A1C reductions ranging from 0.5% to 1.8% (32–35). These findings demonstrate the importance of creating culturally relevant educational materials.

Interventions for content and materials geared toward patients with low literacy and numeracy can be successful in improving outcomes, such as A1C, self-efficacy and blood pressure (BP) (36). Training healthcare professionals in specific communication skills to address low literacy can also be effective (37,38).

While the majority of randomized controlled trials (RCTs) examining skill-training interventions used face-to-face individual sessions (39–43), some have used face-to-face group sessions (44), a combination of face-to-face group and individual sessions (26)and video-based programs for home viewing (45). One study that compared insulin-initiation skills training provided in a group vs. an individual setting found no difference in A1C, rate of hypoglycemia, BP, lipid profile or QOL between the 2 approaches; however, differences in weight gain and time spent in follow-up appointments or calls favoured individual training sessions (44). Most interventions were delivered by nurses (26,39,43,44)or diabetes educators (42). In general, skill-training interventions demonstrated positive changes or no significant differences in outcomes compared to control. For example, contrasting results were found in the 2 trials examining the impact of SMBG skills training: 1 study found an improvement in A1C, low-density lipoprotein cholesterol (LDL-C), body mass index (BMI) and self-care activities with skills training (40), whereas the other found no difference in A1C and BMI but an improvement in total cholesterol (TC) and TC to high-density lipoprotein cholesterol (HDL-C) ratio (41).

Cognitive-behavioural interventions

The acquisition of knowledge should be augmented with behavioural interventions to achieve longer-term change in self-care behaviours (3,23,25,46). Behavioural interventions had a larger effect size (ES) on self-management behaviours (ES −0.92) and on metabolic outcomes (ES 0.63) than knowledge-based or other psychological interventions (9). The more appropriate term may be “cognitive behavioural” interventions, which include cognitive restructuring, problem solving, cognitive-behavioural therapy (CBT), stress management, goal setting and relaxation. All of these recognize that personal awareness and alteration of causative (possibly unconscious) thoughts and emotions are essential for effective behaviour change (47).

Several trials have found various cognitive-behavioural interventions to be effective in lowering A1C (4,15,48), improving QOL (49,50)and increasing self-care behaviours (15,23), whereas others have shown mixed results (3,46). Interventions that combine strategies for knowledge acquisition and self-care management (25,46)have been proven to be more effective in increasing knowledge, self-efficacy and self-care behaviours and in achieving metabolic control than programs that are didactic and knowledge oriented alone (4,9,15,51). Cognitive-behavioural interventions share common elements, including a patient-centred approach, shared decision making, the development of problem-solving skills, and the use of action plans directed toward patient-chosen goals (23,25,52).

A trusting, collaborative patient-healthcare professional relationship is also important for improving self-care behaviours (4). Frequent communication is a key indicator for successful interventions, whether done by a multidisciplinary team in a hospital or a community setting (33,53). Effective patient-clinician communication may improve adherence to recommendations (54). Communication technologies, such as e-Health and telemedicine with videoconferencing and teletransmission of home glucose monitoring, show promise for delivering individualized messages over an extended time period (52). Using a combination of different instructional methods that consistently incorporate an interactive component has been found to have somewhat more favourable effects than didactic programs (9,53).

Family and social support has positively impacted metabolic control and self-care behaviours (32,33,55). In both type 1 and type 2 diabetes, interventions that have targeted the family's ability to cope with stress have resulted in fewer conflicts, and having partners involved in care has been found to impact glycemic control (55).

Family and culturally tailored interventions are particularly relevant in minority communities. Several RCTs and systematic reviews have demonstrated that culturally competent healthcare interventions have resulted in lower A1C levels and improvements in diabetes-related knowledge and QOL (32,33,49).

Both individual and group settings have been used for cognitive-behavioural interventions, but there is no definitive conclusion as to which setting is superior (9,23). In general, group settings have been found to be more effective for weight loss and short-term glycemic control, whereas group interventions combined with individual follow-up sessions have resulted in lower A1C levels than either setting alone (10). Connecting with community partners and other chronic care model programs has proven to be a successful adjunct to cognitive-behavioural interventions (49,52,56). RCTs have concluded that different behavioural strategies are needed at different times to sustain behaviour change in the long term (56,57).

SME reinforcers and technological innovation

Incorporating booster sessions enhances the effectiveness of SME interventions (9). While healthcare providers play an essential role in SME delivery, patients are largely responsible for the majority of their own diabetes management. Historically, healthcare providers have been challenged with providing continued self-management support between visits. More recently, however, the availability of several different technologies (e.g. the internet, web-based education, text messaging [58–62], email, automatic telephone reminders [63], telehealth/telephone education [64–67]and reinforcement [68–72]) has provided an effective and time-efficient means of providing this ongoing support.

Several small trials have demonstrated improved outcomes when utilizing these technologies, reminder systems and scheduled follow-ups compared to controls. Outcomes include increased frequency of SMBG (58,63,71), improved adherence to treatment algorithms (31), improved self-efficacy (64–66)and QOL (70), as well as improved clinical outcomes, including reductions in A1C (59–62,65,69,73)and weight (67,68). However, 1 study of online diabetes education found no improvement in outcomes with the use of reinforcement methods (74).

A meta-analysis of studies examining the use of telemonitoring, home monitoring, telecare and telemedicine demonstrated a significant impact at the behavioural, clinical and structural levels (75). These strategies also resulted in significant reductions in A1C and diabetes-related complications, patient empowerment and improved patient understanding. However, the magnitude of the effect varied across studies and appeared to be dependent on the background characteristics of the patient population (e.g. ability for self-management, medical condition), sample selection and the approach to the treatment of control subjects.

Professional and peer delivery

Peer facilitators may augment multidisciplinary team practices in providing SME and/or social support, especially when developed as culturally relevant behavioural interventions for underserved populations (35). Two studies of the 6-week Diabetes Self-Management Program (DSMP) demonstrated the feasibility, but mixed effectiveness, of peer delivery of this standardized diabetes education program in Hispanic (71)and non-Hispanic populations (76). The DSMP was associated with significant A1C reductions in the Hispanic group (−0.4%) but not in the non-Hispanic group. Significant improvements in other outcomes, including decreased health distress, improved global health, decreased depressive symptoms, improved self-efficacy and improved communication with physicians, were noted in both groups (71,76). In another study, a culturally tailored outreach and education program delivered by trained community health workers (CHW) was associated with significant improvements in self-care behaviours and similar A1C reductions compared to nurse-led case management and standard clinic care (77). Of note, the dropout rate was significantly lower in the CHW group (28% vs. 50% in the standard group), suggesting that the CHW may provide a trusted, culturally relevant and sustainable component to standard diabetes care (77).

The superiority of peer-delivered programs over similar programs delivered by health professionals has not been demonstrated in general populations with type 2 diabetes. A large study found that a peer-support intervention (i.e. 9 group sessions over 2 years) was not effective when targeted at all patients with type 2 diabetes (78). Another large study comparing specialist (nurse and physician) delivery to peer delivery of a 6-week, structured, interactive diabetes education program found no significant differences in either knowledge or A1C outcomes between the groups. However, the specialist group scored significantly higher in process and participant evaluations (79). Studies of the incremental effect of peer educators show much variability in terms of behaviour change and clinical outcomes (80,81). The specifics of training requirements for peer educators have not been clarified, and significant variations in training, scope of practice and issues of governance remain.

Delivery

No particular delivery strategy (e.g. video, web-based/online, phone, face-to-face, mixed) appears to result in consistently superior outcomes in persons with type 2 diabetes; however, larger effect sizes have been noted with strategies that involve personal contact with healthcare providers, either via face-to-face interactions or by telephone (9). A combination of didactic and interactive teaching methods, as well as group and individual sessions, appears to be most effective for persons with type 2 diabetes (9).

Figure 1
Steps to success in SME.

CHW, community health worker. PAID, Problem Areas in Diabetes scale.

Conclusions

Since 2004, there has been a clear increase in the use of multifaceted programs that incorporate behavioural/psychosocial interventions, as well as knowledge and skills training, with a marked reduction in didactic educational programs that focus on knowledge or skill acquisition only (3). Interventions that include face-to-face delivery, a cognitive-behavioural method and the practical application of content are more likely to improve glycemic control (11,48). The most effective behavioural interventions involve a patient-centred approach, shared decision making, the enablement of problem-solving skills and the use of action plans directed toward patient-chosen goals. Steps to success in SME are summarized in Figure 1.

Recommendations

  1. People with diabetes should be offered timely diabetes education that is tailored to enhance self-care practices and behaviours [Grade A, Level 1A (3,11,53)].
  2. All people with diabetes who are able should be taught how to self-manage their diabetes [Grade A, Level 1A (53)].
  3. SME that incorporates cognitive-behavioural educational interventions, such as problem solving, goal setting, and self-monitoring of health parameters, should be implemented for all individuals with diabetes [Grade B, Level 2 (11,23,48,82)].
  4. 4. Interventions that increase patient participation and collaboration in healthcare decision making should be used by providers [Grade B, Level 2 (53)].
  5. For people with type 2 diabetes, SME interventions should be offered in small group and/or one-on-one settings, since both may be effective [Grade A, Level 1A (83,84)].
  6. In both type 1 and 2 diabetes, interventions that target families' ability to cope with stress or diabetes-related conflict should be included in educational interventions when indicated [Grade B, Level 2 (55)].
  7. Technologically based home blood glucose monitoring systems may be integrated into SME interventions in order to improve glycemic control [Grade C, Level 3 (75,85)].
  8. Culturally appropriate SME, which may include peer or lay educators, may be used to increase diabetes-related knowledge and self-care behaviours and to decrease A1C [Grade B, Level 2 (32,34,77)].
  9. Adding literacy- and numeracy-sensitive materials to a comprehensive diabetes management and education program may be used to improve knowledge, self-efficacy and A1C outcomes for patients with low literacy [Grade C, Level 3 (36)].

Abbreviations:
A1C, glycated hemoglobin; SME, self-management education.

References

  1. 1 J. Chodosh S.C. Morton W. Mojica Meta-analysis: chronic diseases self-management programs for older adults Ann Intern Med 143 2005 427 458
  2. 2 T. Bodenheimer K. Lorig H. Holman Patient self-management of chronic disease in primary care JAMA 288 2001 3470 3475
  3. 3 L. Minet S. Moller V. Lach Mediating the effect of self-care management intervention in type 2 diabetes: a meta-analysis of 47 randomised controlled trials Patient Educ Couns 80 2010 29 41
  4. 4 T. Gary J. Genkinger E. Guallar Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes Diabetes Educ 29 2003 488 501
  5. 5 J. Cochrane V.S. Conn Meta-analysis of quality of life outcomes following self-management training Diabetes Educ 34 2008 815 823
  6. 6 Look AHEAD Research group Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial Arch Intern Med 170 2010 1566 1574
  7. 7 S.A. Boren T.L. Gunlock J. Schaefer Reducing risks in diabetes self-management: a systematic review of the literature Diabetes Educ 33 2007 1053 1077
  8. 8 A. Hornsten H. Stenlund B. Lundman H. Sandstrom Improvements in HbA1c remain after 5 years: a follow up of an educational intervention focusing on patients' personal understandings of type 2 diabetes Diabetes Res Clin Pract 81 2008 50 55
  9. 9 L. Fan S. Sidani Effectiveness of diabetes self-management education intervention elements: a meta-analysis Can J Diabetes 33 2009 18 26
  10. 10 S.L. Norris J. Lau C.H. Smith Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control Diabetes Care 25 2002 1159 1171
  11. 11 S. Ellis T. Speroff R. Dittus Diabetes patient education: a meta analysis and meta-regression Patient Educ Couns 52 2004 97 105
  12. 12 S. Wolfe R.E. Glasgow A. Krist Putting it together: finding success in behavior change through integration of services Ann Fam Med 3 suppl 2 2005 s20 s27
  13. 13 F. Hill-Briggs L. Gemmell Problem solving in diabetes self-management and control: a systematic review of the literature Diabetes Educ 33 2007 1032 1050
  14. 14 M. Funnell R. Nwankwo M.L. Gillard Implementing an empowerment-based diabetes self-management education program Diabetes Educ 31 2005 53 56
  15. 15 K. Ismail E. Maissi S. Thomas A randomised controlled trial of cognitive behaviour therapy and motivational interviewing for people with type 1 diabetes mellitus with persistent sub-optimal glycemic control: a diabetes and psychological therapies study Health Technol Assess 14 2010 1 101
  16. 16 W. Polonsky L. Fisher J. Earles Assessing psychosocial distress in diabetes: development of the diabetes distress scale Diabetes Care 28 2005 626 631
  17. 17 K. Weinger H. Butler G. Welch A. LaGreca measuring diabetes self-care: a psychometric analysis of the Self-Care Inventory-revised with adults Diabetes Care 28 2005 1346 1352
  18. 18 D. Toobert S. Hampson R. Glasgow The Summary of Diabetes Self-Care Activities measure: results from 7 studies and a revised scale Diabetes Care 23 2000 943 955
  19. 19 A. Sigurdardottir R. Benediktsson H. Jonsdottir Instruments to tailor care of people with diabetes J Adv Nurs 65 2009 2118 2130
  20. 20 Canadian Diabetes Association H. Jones Building Competency in Diabetes Education: The Essentials 2008 Canadian Diabetes Association Toronto, ON
  21. 21 American Association of Diabetes Educators Standards for outcome measures of diabetes self-management Diabetes Educ 29 2003 804 816
  22. 22 S.F. Scain R. Friedman J.L. Gross A structured educational program improves metabolic control in patients with type 2 diabetes: a randomized controlled trial Diabetes Educ 35 2009 603 611
  23. 23 B. Kulzer N. Hermanns H. Reinhecker Effects of self-management training in type 2 diabetes: a randomized prospective trial Diabetic Med 24 2007 415 423
  24. 24 J.A. Sturt S. Whitlock C. Fox Effects of the Diabetes Manual 1:1 structured education in primary care Diabet Med 25 2008 722 731
  25. 25 M.J. Davies S. Heller T.C. Skinner Effectiveness of the diabetes education and self-management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial BMJ 336 2008 491 495
  26. 26 C. Wattana W. Srisuphan L. Pothiban Effects of a diabetes self-management program on glycemic control, coronary heart disease risk, and quality of life among Thai patients with type 2 diabetes Nurs Health Sci 9 2007 135 141
  27. 27 J. Christian D. Bessesen T. Byers Clinic based support to help overweight patients with type 2 diabetes increase physical activity and lose weight Arch Intern Med 168 2008 141 146
  28. 28 J. Wens E. Vermeire H. Hearnshaw Educational interventions aiming at improving adherence to treatment recommendations in type 2 diabetes: a sub-analysis of a systematic review of randomised controlled trials Diabetes Res Clin Pract 79 2008 377 388
  29. 29 G. Dutton B. Provost F. Tan A tailored print-based physical activity intervention for patients with type 2 diabetes Prev Med 47 2008 409 411
  30. 30 H.S. Chen T.E. Wu T.S. Jap Improvement of glycaemia control in subjects with type 2 diabetes by self-monitoring of blood glucose: comparison of two management programs adjusting bedtime insulin dosage Diabetes Obes Metab 10 2008 34 40
  31. 31 P.A. Dyson S. Beatty D.R. Matthews An assessment of lifestyle video education for people newly diagnosed with type 2 diabetes J Hum Nutr Diet 23 2008 353 359
  32. 32 R. Whittemore Culturally competent interventions for Hispanic adults with type 2 diabetes: a systematic review J Transcult Nurs 18 2007 157 166
  33. 33 C. Samuel-Hodge T. Keyserling S. Park A randomized trial of a church-based diabetes self-management program for African Americans with type 2 diabetes Diabetes Educ 35 2009 439 454
  34. 34 K. Hawthorne Y. Robles R. Cannings-John Culturally appropriate health education for type 2 diabetes in ethnic minority groups: a systematic and narrative review of randomized control trials Diabet Med 27 2010 613 623
  35. 35 J. Lujan S. Ostwald M. Ortiz Promotora diabetes intervention for Mexican Americans Diabetes Educ 33 2007 660 670
  36. 36 E.F. Van Scoyoc D.A. deWalt Interventions to Improve diabetes outcomes for people with low literacy and numeracy: a systematic literature review Diabetes Spectrum 23 2010 228 237
  37. 37 K. Cavenaugh K.A. Wallston T. Gerretsadik Addressing literacy and numeracy to improve diabetes care Diabetes Care 32 2009 2149 2155
  38. 38 C. Osborn K. Cavenaugh K.A. Wallston Diabetes Numeracy: an overlooked factor in understanding racial disparities in glycemic control Diabetes Care 32 2009 1614 1619
  39. 39 W.J. Borges S.K. Ostwald Improving foot self-care behaviors with Pies Sanos West J Nurs Res 30 2008 325 341
  40. 40 A. Duran P. Martin I. Runkle Benefits of self-monitoring blood glucose in the management of new-onset type 2 diabetes mellitus: the St. Carlos Study, a prospective randomized clinic-based interventional study with parallel groups J Diabetes 2 2010 203 211
  41. 41 A.J. Farmer A.N. Wade D.P. French Blood glucose self-monitoring in type 2 diabetes: a randomised controlled trial Health Technol Assess 13 2009 iii-iv, ix-xi,1–50.
  42. 42 M. Moriyama M. Nakano Y. Kuroe Efficacy of a self-management education program for people with type 2 diabetes: results of a 12 month trial Jpn J Nurs Sci 6 2009 51 63
  43. 43 A.H. Skelly J. Carlson J. Leeman Controlled trial of nursing interventions to improve health outcomes of older African American women with type 2 diabetes Nurs Res 58 2009 410 418
  44. 44 H. Yki-Jarvinen L. Juurinen M. Alvarsson Initiate insulin by aggressive titration and education (INITIATE): a randomized study to compare initiation of insulin combination therapy in type 2 diabetic patients individually and in groups Diabetes Care 30 2007 1364 1369
  45. 45 M.A. Krousel-Wood L. Berger X. Jiang Does home-based exercise improve body mass index in patients with type 2 diabetes? Results of a feasibility trial Diabetes Res Clin Pract 79 2008 230 236
  46. 46 G. Magwood J. Zapka C. Jenkins A review of systematic reviews evaluating diabetes interventions. Focus on quality of life and disparities Diabetes Educ 34 2008 242 265
  47. 47 K. Ismail K. Winkley S. Rae-Hesketh Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes Lancet 363 2004 1589 1597
  48. 48 K. Weinger E. Beverly Y. Lee The effect of a structured behavioral intervention in poorly controlled diabetes Arch Intern Med 171 2011 1990 1998
  49. 49 M. Kim H. Han H. Song A community-based, culturally tailored behavioral intervention for Korean Americans with type 2 diabetes Diabetes Educ 35 2009 986 994
  50. 50 D. Toobert R. Glasgow L. Strycker Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes Int J Behav Nutr Phys Act 4 2007 1479 1481
  51. 51 K. Mulcahy M. Maryniuk M. Peeples Diabetes self-management education core outcomes measures Diabetes Educ 29 2003 768 803
  52. 52 T. Gambling A. Long The realisation of patient-centered care during a 3 year proactive telephone counselling self-care intervention for diabetes Patient Educ Couns 80 2010 219 226
  53. 53 S.L. Norris M.M. Engelgau K.M.V. Narayan Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials Diabetes Care 24 2001 561 587
  54. 54 S. Nam C. Chesla N.A. Stotts Barriers to diabetes management: patient and provider factors Diabetes Res Clin Pract 923 2011 1 9
  55. 55 T.A. Armour S.L. Norris L. Jack Jr. The effectiveness of family interventions in people with diabetes mellitus: a systematic review Diabet Med 22 2005 1295 1305
  56. 56 G. Piatt R. Anderson M. Brooks 3-Year follow-up of clinical and behavioural improvements following a multifaceted diabetes care intervention: results of a randomized controlled trial Diabetes Educ 36 2010 301 309
  57. 57 B. Thoolen D. Ridder J. Bensing Beyond good intentions: the role of proactive coping in achieving sustained behavioural change in the context of diabetes management Psychol Health 24 2009 237 254
  58. 58 D.A. Hanauer K. Wentzell N. Laffel Computerized automated reminder diabetes system (CARDS): e-mail and SMS cell phone text messaging reminders to support diabetes management Diabetes Technol Ther 11 2009 99 106
  59. 59 K.H. Yoon H.S. Kim A short message service by cellular phone in type 2 diabetic patients for 12 months Diabetes Res Clin Pract 79 2008 256 261
  60. 60 H.S. Kim A randomized controlled trial of a nurse short-message service by cellular phone for people with diabetes Int J Nurs Stud 44 2007 687 692
  61. 61 H.S. Kim H.S. Jeong A nurse short message service by cellular phone in type-2 diabetic patients for six months J Clin Nurs 16 2007 1082 1087
  62. 62 H.S. Kim M.S. Song Technological intervention for obese patients with type 2 diabetes Appl Nurs Res 21 2008 84 89
  63. 63 J.A. Graziano C.R. Gross A randomized controlled trial of an automated telephone intervention to improve glycemic control in type 2 diabetes Adv Nurs Sci 32 2009 E42 E57
  64. 64 R.S. Weinstock G. Brooks W. Palmas Lessened decline in physical activity and impairment of older adults with diabetes with telemedicine and pedometer use: results from the IDEATel study Age Ageing 40 2008 98 105
  65. 65 P.M. Trief J.A. Teresi J.P. Eimicke Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project Age Ageing 38 2009 219 225
  66. 66 P.M. Trief J.A. Teresi R. Izquierdo Psychosocial outcomes of telemedicine case management for elderly patients with diabetes: the randomized IDEATel trial Diabetes Care 30 2007 1266 1268
  67. 67 M. Franciosi G. Lucisano F. Pellegrini ROSES: role of self-monitoring of blood glucose and Intensive education in patients with type 2 diabetes not receiving insulin. A pilot randomized clinical trial Diabet Med 28 2011 789 796
  68. 68 L. Wu A. Forbes A. White Patients' experience of a telephone booster intervention to support weight management in type 2 diabetes and its acceptability J Telemed Telecare 16 2010 221 223
  69. 69 R.A. Stone R.H. Rao M.A. Sevick Active care management supported by home telemonitoring in veterans with type 2 diabetes: the DiaTel randomized controlled trial Diabetes Care 33 2010 478 484
  70. 70 M. Jansa M. Vidal J. Viaplana Telecare in a structured therapeutic education programme addressed to patients with type 1 diabetes and poor metabolic control Diabetes Res Clin Pract 74 2006 26 32
  71. 71 K. Lorig P.L. Ritter F. Villa Spanish diabetes self-management with and without automated telephone reinforcement Diabetes Care 31 2008 408 413
  72. 72 E. Walker C. Shmukler R. Ullman Results of a successful telephonic intervention to improve diabetes control in urban adults: a randomized trial Diabetes Care 34 2011 2 7
  73. 73 G. Pare K. Moqadem G. Pineau Clinical effects of home telemonitoring in the context of diabetes, asthma, heart failure and hypertension: a systematic review J Med Internet Res 12 2010 e21
  74. 74 K. Lorig P.L. Ritter D.D. Laurent Online diabetes self-management program: a randomized study Diabetes Care 33 2010 1275 1281
  75. 75 M. Jaana G. Pare Home telemonitoring of patients with diabetes: a systematic assessment of observed effects J Eval Clin Pract 13 2007 242 253
  76. 76 K. Lorig P.L. Ritter F.J. Villa Community-based peer-led diabetes self-management: a randomized trial Diabetes Educ 35 2009 641 651
  77. 77 K. Babamato K.A. Sey V. Karlan Improving diabetes care and health measures among Hispanics using community health workers: results from a randomized controlled trial Health Educ Behav 36 2009 113 126
  78. 78 S.M. Smith G. Paul A. Kelly Peer support for patients with type 2 diabetes: cluster randomised controlled trial BMJ 342 2011 d715
  79. 79 A.K. Baksi M. Al-Mrayat D. Hogan Peer advisers compared with specialist health professionals in delivering a training programme on self-management to people with diabetes: a randomized controlled trial Diabet Med 25 2008 1076 1082
  80. 80 S.L. Norris F.M. Chowdhury K. Van Le Effectiveness of community health workers in the care of persons with diabetes Diabetic Med 23 2006 544 556
  81. 81 R. Perez-Escamilla A. Hromi-Fiedler S. Vega-Lopez Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: a systematic literature review J Nutr Educ Behav 40 2008 208 225
  82. 82 L. Steed D. Cooke S. Newman A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus Patient Educ Couns 51 2003 5 15
  83. 83 P.L. Rickheim T.W. Weaver J.L. Flader Assessment of group versus individual diabetes education: a randomized study Diabetes Care 25 2002 269 274
  84. 84 T. Deakin C.E. McShane J.E. Cade Group based training for self-management strategies in people with type 2 diabetes mellitus Cochrane Database System Rev 2 2005 CD003417
  85. 85 H.D. Tildesley A.B. Mazanderani S.A. Ross Effect of internet therapeutic intervention on A1C levels in patients with type 2 diabetes treated with insulin Diabetes Care 33 2010 1738 1740
 
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