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p r i m a r y c a r e d i a b e t e s 2 ( 2 0 0 8 ) 113–120

avai lab le at www.sc iencedi rec t .com

journa l homepage: ht tp : / /www. int l .e lsev ierhea l th .com/ journa ls /pcd /

eview

iabetes self-management education: A reviewf published studies

arie Clark ∗

entre for Behavioural & Social Sciences in Medicine, Division of Medicine, UCL, Charles Bell House,7-73 Riding House Street, London W1W 7EJ, UK

r t i c l e i n f o

rticle history:

eceived 19 October 2007

eceived in revised form

8 March 2008

ccepted 28 April 2008

ublished on line 25 June 2008

a b s t r a c t

Diabetes self-management is seen as the cornerstone of care for all individuals with diabetes

who want to achieve successful health-related outcomes and is considered most effective

when delivered by a multidisciplinary team with a comprehensive plan of care. There is a

growing body of literature on both educational and psychosocial interventions, aimed at

helping individuals to better manage their diabetes. However, the progress of this research

and its implications for clinical practice remain unclear and sometimes controversial. This

eyword:

paper therefore aims to further clarify this literature by considering published evidence for

the effectiveness of self-management education, including community-based peer support

iabetes self-management groups and ongoing home telephone support.

© 2008 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

ontents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1132. Is self-management education effective? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1143. Community-based peer-support groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1164. Ongoing home support via telephone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175. The role of emerging health technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

6. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. Introduction

iabetes and its complications pose a considerable pub-ic health burden. Although developments in medicine andharmacology have significantly advanced the treatment andanagement of diabetes in recent years, in clinical prac-

∗ Tel.: +44 20 7679 9464; fax: +44 20 7679 9028.E-mail address: Marie.Clark@ucl.ac.uk.

751-9918/$ – see front matter © 2008 Primary Care Diabetes Europe. Puoi:10.1016/j.pcd.2008.04.004

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

tice optimal diabetes control remains difficult to achieve andnumerous studies have documented that suboptimal control

of blood glucose, blood pressure and lipids remains com-mon in people with diabetes. This apparent contradictionmay be seen to reflect the central role that individuals withdiabetes themselves play in determining their health status,

blished by Elsevier Ltd. All rights reserved.

e t e s 2 ( 2 0 0 8 ) 113–120

Table 1 – Guiding principles for revision of DSMEstandards

1. Diabetes education is effective for improving clinicaloutcomes and quality of life, at least in the short-term

2. DSME has evolved from primarily didactic presentations tomore theoretically based empowerment models

3. There is no one ‘best’ education program or approach;however, programs incorporating behavioural andpsychosocial strategies demonstrate improved outcomes.Additional studies show that culturally andage-appropriate programs improve outcomes and thatgroup education is effective

4. Ongoing support is critical to sustain progress made byparticipants during the DSME program

5. Behavioural goal-setting is an effective strategy to support

114 p r i m a r y c a r e d i a b

and the challenges associated with supporting their effortsto self-manage their condition. Suboptimal health-relatedbehaviours, including physical inactivity, high calorie intake,inadequate blood glucose self-monitoring, and low adherenceto medication regimens are well-established risk factors forpoor health outcomes and the development of future com-plications. The goal therefore of diabetes self-managementeducation (DSME) is to help patients to take control of theirown condition by improving their knowledge and skills tomake informed choices for self-directed behaviour change,enabling them to integrate self-management into their dailylives and ultimately to reduce the risk of complications [1].More broadly, DSME aims to help people to cope with the men-tal and physical demands of their illness, given their uniqueeconomic, cultural and social circumstances.

The value of DSME is evident from research which suggestsfor example, that patients who never received DSME had aremarkable fourfold increased risk for major diabetes com-plications compared with patients who received some formof DSME [2]. It is of concern therefore that, in its Guidance forthe use of patient-education models for diabetes, NICE recognizedthat while most people with diabetes in the UK are offerededucation at least at the time of diagnosis, ‘the length, con-tent and style of educational options varies greatly betweenservices; some of the educational programmes offered areunstructured, very few have been formally evaluated, and fewindividuals who deliver education have been formally trainedfor this purpose’ [1]. Similarly, a 2006 survey conducted by theHealthcare Commission shows that people in England withdiabetes are not being offered sufficient information abouttheir condition to help them to self-manage it better, only 11%of respondents had attended an educational course on dia-betes and how to live with the condition and, alarmingly, 17%of all respondents did not even know if they had type 1 or type2 diabetes [3].

Accordingly, in the UK, the National Service Frameworkfor Diabetes [4] has incorporated as Standard 3 ‘EmpoweringPeople with Diabetes’, the aim being to enhance personal con-trol over the day-to-day management of diabetes to ensurethe best possible quality of life for each individual and thedevelopment of a service in which self-management is seenas the cornerstone of effective diabetes care. An empoweredpatient is one who has the knowledge, skills, attitudes andself-awareness necessary to influence their own behaviourand that of others to improve the quality of their lives. Accord-ingly, empowerment can be seen as a fundamental outcomeof diabetes education and self-management education as anessential patient empowerment strategy [5].

Likewise, in its National Standards for Diabetes Self-Management Education (DSME), the American Diabetes Asso-ciation recognized self-management education as ‘the cor-nerstone of care for all individuals with diabetes who wantto achieve successful health-related outcomes’ [40]. In thismodel DSME is seen as most effective when delivered bya multidisciplinary team with a comprehensive plan ofcare. Importantly, in a more recent review of the current

DSME standards [6], five overriding principles were identi-fied based on existing evidence, and these were used toguide the review and revision of the current DSME standards(Table 1).

self-management behaviours

From Funnell et al. [6].

In light of this, there is a growing body of literature,which reports research on both educational and psychosocialinterventions, aimed at helping individuals to better managetheir diabetes. However, the progress of this research and itsimplications for clinical practice remain unclear and some-times controversial. This paper therefore will seek to furtherclarify this literature by considering published evidence forthe effectiveness of self-management education, includingcommunity-based peer support groups and ongoing hometelephone support.

2. Is self-management education effective?

The key findings of the following studies on the effectivenessof self-management education are summarised in Table 2. Evi-dence for the effects of formal patient education programmes,designed to promote self-management, in adults with type 2diabetes was considered by [7]. These programmes were deliv-ered in either individual or group sessions, and their contentwas determined by the educator. Three meta-analyses, sevenprimary studies and seven systematic reviews were identi-fied. The literature consistently supported patient educationas a component of diabetes care. From the meta-analysesthe following observations were made: lower quality stud-ies tended to produce higher effect sizes; knowledge andskill performance was more improved in patient educationprogrammes of longer duration; knowledge and skill effectscontinued to improve over the longer term (to at least 1 year),however weight loss improvements depleted over the sametime period; improvements in metabolic control peaked atbetween 1 and 6 months and then declined after 6 months,the opposite trend occurred with psychological outcomes;effect sizes for knowledge and disease status were smaller forthose over the age of 40 compared to younger patients. Theauthors note that knowledge and skills are necessary but notsufficient to ensure good diabetes control in the long term.From the evidence available, it was not possible to concretely

establish whether patient education is effective at promotingself-management in the long term to prevent/delay diabeticmorbidity and mortality or improve patient quality of life.There was no consistent pattern of effect based on type of

p r i m a r y c a r e d i a b e t e s 2 ( 2 0 0 8 ) 113–120 115

Table 2 – Effectiveness of self-management education

Study Group studied (N) Strength of evidence Outcome

Corabian and Harstall [7] Type 2 diabetes Systematic review (included 3meta-analyses, 7 primary studies, 7systematic reviews)

No firm conclusion regardingeffectiveness of DSME onself-management

Hampson et al. [8] Adolescents with type 1diabetes

Systematic review (included 64 studies, 12were RCTs)

Improvements in psychosocial outcomeslarger than those for glycaemic control

Norris et al. [9] Type 2 diabetes Systematic review (included 72 RCTs) DSME effective in short-term but furtherresearch needed to assess long-termeffectiveness

Norris et al. [10] Type 2 diabetes Systematic review (included 31 RCTs) Immediate post-interventionimprovement in glycaemic control notsustained at 1–3 months follow-up

Norris et al. [11] Both type 1 and type 2diabetes

Systematic review (includedself-management interventions incommunity settings)

Beneficial effects on glycaemic control foradults in community settings andchildren/adolescents in home settings

Gary et al. [12] Type 2 diabetes (2720) Systematic review (included 18 RCTs) Blood glucose levels in intervention groupsignificantly reduced compared tocontrols

NICE [1] Both type 1 and type 2diabetes

NICE technology appraisal (included 4studies for type 1, 8 studies for type 2, 4studies for both types 1 and 2)

Focused DSME may have some effect inimproving glycaemic control and qualityof life but little evidence of longer termimpacts

Sarkisian et al. [13] Older African Americanor Latino adults

Systematic review (included 8 RCTs) Immediate post-interventionimprovement in glycaemic control notsustained at 6 months follow-up

Steed et al. [14] Both type 1 and type 2diabetes

Systematic review (included 36 studies,54% type 2 diabetes, 11% type 1 diabetes,35% both)

Depression improved followingpsychosocial intervention but quality oflife showed greater improvementfollowing DSME

Ellis et al. [15] Both type 1 and type 2diabetes (2439)

Systematic review (included 21 RCTs) Modest but significant difference inglycaemic control at initial and 24-weekfollow-up

Deakin et al. [16] Type 2 diabetes (1532) Cochrane systematic review (included 11studies)

Group-based DSME is effective inimproving glycaemic control, knowledge,weight and requirement for diabetes

olled

iimbide

eafdracmeiingaf

DSME: diabetes self-management education; RCT: randomized contr

ntervention, duration, setting or other characteristics, thust was not possible to identify which intervention strategy is

ost effective for improving diabetes control. A number ofarriers to diabetes self-management were identified includ-

ng patient characteristics, socio-environmental context, theisease itself, and patients’ interaction with diabetes care andducation providers.

Hampson et al. [8] conducted a systematic review of theffects of psychosocial and educational interventions (whichim to improve knowledge, skills and self-management)or adolescents with type 1 diabetes. Sixty-four studies,escribing 62 interventions, met the inclusion criteria. A nar-ative description of all 64 studies was completed, as wells a meta-analysis of results from the RCTs. The studiesovered a wide variety of interventions, the most com-on being skills training, followed by dietary interventions,

motional/psychological interventions and family-relatednterventions. In many cases, the individual delivering thentervention was not specified; where the professional was

amed, these were most likely to be nurses (32.3%), psycholo-ists (32.3%) or doctors (27.4%). Effects were measured acrossnumber of outcomes, with the greatest number of reports

or glycaemic control. Twelve RCTs used glycaemic control as

medications

trial.

an outcome measure, reporting an average effect size of 0.33.However, there was significant heterogeneity between theindividual results of these RCTs which was eliminated whentwo studies which produced large effect sizes were removed.Without these two studies, the mean improvement in gly-caemic control was reduced substantially (from 0.33 to 0.08).Improvements in psychosocial outcomes were larger thanthose for blood glucose control (mean effect size 0.37). Report-ing on economic outcomes was minimal, but the studies didprovide tentative evidence that psychosocial and educationalinterventions can lead to a reduction in health services util-isation. Of 12 studies that focused on individuals with poormetabolic control, only 2 showed significant reductions in hos-pitalisation after intervention.

Norris et al. have conducted the most extensive reviewsof the evidence for the effectiveness of self-managementeducation in diabetes. Norris et al. [9] conducted a system-atic review of randomized controlled trials (RCTs) for theeffectiveness of self-management training in type 2 diabetes.

Seventy-two studies, reported in 84 articles were included,the purpose of the interventions were broadly categorisedas knowledge/information, lifestyle behaviours, skill devel-opment and coping skills. Where follow-up was short (less

e t e s

116 p r i m a r y c a r e d i a b

than 6 months) self-management training was associatedwith improvements in knowledge, frequency or accuracy ofblood glucose self-monitoring, self-reported dietary habitsand glycaemic control. Variable effects were reported forlipids, physical activity, weight and blood pressure. In studieswith longer follow-up, interventions using regular reinforce-ment were sometimes more effective in improving glycaemiccontrol. The studies showed no evidence of effectiveness fordisease-related events or mortality.

Norris et al. [10] performed a meta-analysis of RCT datafor the effects of diabetes self-management education on gly-caemic control. Thirty-one studies met their inclusion criteria,which entirely or mostly evaluated self-management edu-cation in people with type 2 diabetes. The review collecteddata on diabetes self-management education regardless oftype, setting, educator, method of delivery, duration orintensity. When outcomes were measured on completionof the intervention, self-management education was foundto improve glycaemic control (average change of 0.76%, CI0.34–1.18). Increased contact time between educator andpatient increased the effect of self-management education.However, effects were not sustained between 1 and 3 monthsfollowing completion of the intervention. It was concludedthat although self-management training improved diabetescontrol at immediate follow-up, the benefit declined between1 and 3 months after the intervention ceased, suggesting thatlearned behaviours can change overtime. It is important tonote however, that since there was significant heterogene-ity between the results of the trials reported, which may beexplained by differences between the interventions evaluated,a meta-analysis may not have been the appropriate method-ology in this instance.

A further systematic review on the effectiveness andcost-effectiveness of diabetes self-management educationin community settings [11] evaluated evidence for a num-ber of different interventions, differing in terms of content,educator, follow-up period and method of delivery. The out-comes of interest were classified as physiological, knowledge,skills, psychosocial outcomes and healthcare system out-comes. Self-management education had beneficial effects onglycaemic control for adults in community gathering settings,and children and adolescents in home settings. Few studiesreported on non-physiological outcomes in community andhome settings; while there was some evidence of improve-ment in these outcomes the findings were not consistentlypositive. The evidence was insufficient to assess the effective-ness of self-management education delivered in recreationalcamps and the workplace.

Gary et al. [12] reported results from a meta-analysis ofRCTs evaluating the effects of behavioural and educationalinterventions on body weight and glycaemic control in peo-ple with type 2 diabetes. The meta-analysis was conductedwith the findings of 18 RCTs, involving a total of 2720 patients.The interventions varied substantially in terms of content, fre-quency and setting, leadership, mode of instruction, topics,follow-up and outcomes. Nurses were most often involved in

delivering the intervention (39%), with dieticians (26%), physi-cians (17%) and other professionals (13%) also reported asinterventionists. The main topic of most interventions wasdiet (70%); topics also covered included exercise (57%), medi-

2 ( 2 0 0 8 ) 113–120

cations (35%) and self-monitoring (26%). Blood glucose levelswere significantly reduced compared with controls (pooledeffect size −0.43). The largest effect sizes were reported instudies with higher quality scores, larger sample sizes, physi-cian interventionists and in which the topic areas focused onmedications and exercise. Group and individual approachesproduced similar results. Educational interventions producedsmall, but non-significant, weight loss effects.

NICE [1] reported evidence for the clinical and cost effec-tiveness of structured patient education in diabetes care[1]. Education was defined in terms of three main objec-tives: (i) control of vascular risk factors; (ii) management ofdiabetes-associated complications; and (iii) quality of life. Edu-cation for people with type 1 diabetes was evaluated in fourstudies; only one measured education alone, and found nosignificant impact on blood glucose levels. The remainingstudies, which measured education as part of an intensifiedtreatment programme, found improvements in blood glucoselevels and diabetes complications over the short and longterm. Treatment intensification programmes, however, werealso associated with increased frequency of hypoglycaemicepisodes. Eight studies focused on the effects of general self-management education for people with type 2 diabetes. Inonly three of these were significant differences in blood glu-cose levels between control and intervention groups reported;in all three studies, the intervention was delivered over along period and had the shortest time between the end ofthe intervention and follow-up. The studies provide some evi-dence that general self-management education can improvebody mass index, use of medications, quality of life and dia-betes knowledge. Seven trials of focused self-managementeducation in people with type 2 diabetes were reviewed. Nodifferences were found for blood pressure, body mass indexor weight, cholesterol or triglyceride levels. Two trials testedinterventions that combined exercise with dietary education,both reporting significant improvements in blood glucose lev-els. One of these studies also measured quality of life, whichwas found to be significantly improved in the interventiongroup compared with control. Two cost-effectiveness analy-ses were identified, both from the USA and limited in termsof their generalisability. One reported that a behavioural inter-vention addressing diet and exercise was more cost-effectivethan a general educational intervention in adults with type 2diabetes. The second found that a dietary self-managementprogramme led to improvements in intermediate health out-comes in adults with type 1 and 2 diabetes, at a cost of $137 perperson. A cost-utility analysis of the dose adjustment for nor-mal eating (DAFNE) programme was submitted to NICE, whichreported a cost saving of £2679 over 10 years. A re-evaluationof this data, based on more conservative assumption of inter-vention effects, came to a reduced net saving of £536.

Sarkisian et al. [13] assessed the effectiveness of self-careinterventions for improving glycaemic control or health-related quality of life in older African American or Latinoadults with diabetes. Eight RCTs were identified, which eval-uated the following: educational group sessions, exercise

classes, diet counselling sessions, support group meetings,weekly pharmacist appointments, diabetic education, follow-up phone calls, standard or nutritional diabetic educationprogrammes, group discussions, one-to-one diabetic edu-

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ation and bicultural community health work. Outcomesf interest were: glycaemic control, diabetes-related symp-oms or self-rated quality of life. Out of the eight trials, fiveeported improved glycaemic control. However, where a 6-

onth follow-up was conducted, improvements were notustained in two studies and were only partially sustainedn a third. Four trials reported on quality of life; only in oneas there a difference in end scores between intervention

nd control groups (this was a very small trial, involving only4 patients in total). Positive trials had the following char-cteristics: poor glycaemic control at baseline; interventionas tailored either culturally or to age; use of group coun-

elling or support; involvement of family. The authors raiseoncerns about the methodological quality of the trials; manyad high drop-out rates and only one conducted analysis onn intention-to-treat basis.

A systematic review of the psychosocial outcomes of edu-ation, self-management and psychological interventions iniabetes was conducted by Steed et al. [14]. Educational inter-entions are those where patients only receive information;elf-management interventions aim to promote adherencey teaching practical or psychosocial skills, or by addressingttitudes and beliefs; and psychological interventions pri-arily address negative mood states. Thirty-six studies were

ncluded, with 54% conducted with type 2 diabetic patients,1% with type 1, and 35% with both. The interventions eval-ated typically contained a number of components (withn average of three components); the most common ele-ent was general education, which was included in 75%

f the studies. Five studies evaluated effects on psychologi-al well-being, with only one reporting that the interventionself-management) led to significant improvements in bothegative and positive mood. In four out of the six RCTshat measured depression outcomes, the intervention led tomprovements compared to control; three of these studiesere conducted with psychological interventions (and withatients that had high baseline levels of stress and/or depres-ion). Anxiety was improved in only two out of seven RCTs,hich evaluated psychological stress management and an

ducational intervention. Improvements in quality of life wereot found using generic measures, but were reported in stud-

es measuring disease-specific quality of life; improvements inhis outcome were most common for self-management inter-entions. In all but one study, short-term quality of life effectsere sustained at longer term follow-up; this contrasts withndings for glycaemic control, where effects tend to regressver time. Methodological problems, including small sampleizes and poor description of the interventions, limit the inter-retation of results and the conclusions that can be drawnrom them.

Ellis et al. [15] reported a meta-analysis and meta-egression of the effect of diabetes patient education onlycaemic control. The use of meta-regression in this studys an important addition, not often reported in the literature,

hich allows for analysis of which variables within an edu-ational intervention best explains the variance in glycaemic

ontrol. Twenty-one RCTs describing 28 educational interven-ions were identified, involving a total of 2439 patients. Thenterventions varied with regard to teaching method, con-ent, intervention duration, number of sessions and overall

( 2 0 0 8 ) 113–120 117

time period. For example, the studies included the follow-ing teaching methods: didactic, goal setting (dictated andnegotiated), situational problem solving and cognitive re-framing. In the majority of the interventions (n = 20), studyparticipations were patients with type 2 diabetes. Therewas a statistically significant (but modest) difference in gly-caemic control between intervention and control groups atinitial follow-up and at 24 weeks. Meta-regression revealedthat interventions which included face-to-face delivery, usedcognitive reframing teaching methods and included exer-cise content were more likely to improve glycaemic control.Those three areas collectively explained 44% of the variancein glycaemic control. The authors note however that thismeta-analysis is limited by the small number of available stud-ies.

Deakin et al. [16] in a systematic review for the CochraneCollaboration assessed the effectiveness of group-based self-management strategies for people with type 2 diabetes.Outcomes of interest were clinical, lifestyle and psychosocial,in both short-term (4–6 months) and long-term (more than 12months) follow-up. To be included in the review, the sessionshad to be delivered to groups of six people or more. Fourteenpublications, involving 11 different studies, were identified.These described a range of different approaches, varying inintensity, location, the person delivering the programme, andwhether or not family members also participated. Group-based training led to a significant short-term lowering ofsystolic blood pressure. It also reduced the need for dia-betes medication, and significantly improved fasting bloodglucose levels, glycated haemoglobin, and diabetes knowledgeat both short- and long-term follow-up. There was also evi-dence of improved self-efficacy, self-management, treatmentsatisfaction and quality of life (at longer term follow-up only).Effectiveness did not appear to vary according to whether thecourse was delivered in primary or secondary care, who deliv-ered it (as long as they were adequately trained) or the size ofthe group.

3. Community-based peer-support groups

There is some evidence to suggest that individuals withdiabetes also can improve their self-management skillsthrough classes led by non-clinician peers and structured toimprove their understanding of their illness and confidenceor “self-efficacy” regarding self-management. A successfulprogram for achieving these goals in patients with chronicarthritis has been developed by Lorig et al. at Stanford Uni-versity [17]. In the UK, the ‘Expert Patient Programmes’,based on the work of Lorig, are lay-led and focus on areassuch as developing individuals’ confidence to access ser-vices [18]. Ongoing research is evaluating the impact ofthis intervention on diabetes treatment outcomes in theUK but evaluations in the UK and the US indicate that itproduces lasting reductions in symptoms, physician visits,and costs relative to patients receiving usual care [19,20].

Community-based groups such as these may be particu-larly important in settings where diabetes patients havedifficulty accessing care within traditional health care set-tings.

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118 p r i m a r y c a r e d i a b

4. Ongoing home support via telephone

Self-management support provided through regular tele-phone follow-up improves diabetes patients’ outcomes. In onestudy among elderly type 2 men [21], monthly calls by a nurse-educator improved glycaemic control, and a more recent studyhad similar results [30]. These studies are consistent with thebroader literature on telephone care, showing that telephonecalls can improve the health of chronically ill patients [22,23]and may even serve as an effective alternative to face-to-faceconsultations [24].

5. The role of emerging health technologies

A variety of novel technologies has been developed to sup-port diabetes patients’ efforts at self-care and provide analternative to traditional education occurring within outpa-tient clinics [25]. Interactive software accessed on a personalcomputer using CD-ROMs or other hardware represents onestrategy for delivering behaviour change interventions effi-ciently and effectively in the context of busy primary carepractices. These systems can be placed in clinic waiting roomswhere they can reach large numbers of patients, require mini-mal staffing, and provide patients with self-paced and tailorededucational messages [26]. Glasgow et al. [27] developed aclinic-based touch-screen computer system to assist indi-viduals with diabetes in assessing their health behaviours,self-management goals, and barriers to goal attainment. Peo-ple using the computer system had improvements in theirdietary intake and lower cholesterol levels compared to similarpatients who did not [28].

Automated telephone systems can allow for frequentfollow-up with patients who have difficulty accessing clinic-based services or who lack the computer supports necessaryfor more “high-tech” interventions. Chronically ill patientscan provide valid and reliable information using their touch-tone telephone during automated monitoring calls. Piette[29,30] found that low-income English- and Spanish-speakingdiabetes patients receiving bi-weekly automated calls withtelephone nurse follow-up responded to the calls consistentlyover the 12-month study period, used the calls to accessself-care education, and reported information that identifiedindividuals at greatest risk for developing problems. The inter-vention improved patients’ blood glucose self-monitoring,foot care, weight self-monitoring, and medication adherence[30]. The study also found improvements in patients’ glucosecontrol, diabetes-related symptoms, and symptoms of depres-sion.

Internet-based diabetes self-care support has the potentialto reach large numbers of people with little extra cost, andeven computer novices are willing to use Internet-based dia-betes education programs [31,32]. Such systems can enhancethe educational experience by using audio and video andare potentially available 24 h per day. Internet-based dia-

betes supports also can allow patients to communicate withtheir clinicians, experts in self-care, or one another. Oneof the most definitive studies of Internet-based diabetessupports [33] evaluated a web-based self-management pro-

2 ( 2 0 0 8 ) 113–120

gram in which participants were encouraged to log on toa specially designed website, review their progress towardsself-management goals, and access other services such as anon-line log of their progress and personal counselling andsupport. At follow-up, both patients using the website andcomparison-group patients improved in their self-reportedphysical activity levels, however there were no significant dif-ferences between the two groups. Intervention patients whoused the system more frequently reported greater change inphysical activity than those who used it less often.

Murray et al. [34] conducted a Cochrane systematic reviewto assess the effects of interactive health communicationapplications (ICHAs) for people with chronic disease [34].ICHAs were described as “computer-based, usually web-based, packages for patients that combine health informationwith at least one of social support, decision support, orbehaviour change support.” Twenty-four RCTs met their inclu-sion criteria of which six examined diabetes. Primary outcomemeasures included knowledge, social support, self-efficacy,emotional outcomes, and behavioural and clinical outcomes.ICHAs were found to improve knowledge, social support,health behaviours and clinical outcomes. There was insuf-ficient data to determine impact on emotional outcomesor cost-effectiveness. Results indicated probable positiveeffects on self-efficacy, but more data is needed to clarifythis.

6. Conclusion

Diabetes self-management education is a multi-faceted pro-cess involving much more than helping patients to monitortheir blood glucose or take their medication as prescribed [35].As patients’ health status and need for support changes overtime, diabetes self-management education must reflect thisand be an ongoing process rather than a one-time event. Anumber of randomized controlled trials of the effectiveness ofself-management education in individuals with diabetes havebeen conducted. Despite numerous limitations in methodol-ogy and heterogeneous population characteristics, evidencesupports the effectiveness of self-management education inindividuals with diabetes, particularly in the short-term. How-ever, reviews have demonstrated sharp declines in benefitsonly a few months after interventions ended. This finding mir-rors well-established patterns of relapse after interventionsin other areas for e.g. weight loss [36] and smoking cessation[41]. Among the demographic and intervention characteris-tics examined, only duration of the intervention was found topredict a programme’s success.

In general, group and individual approaches appear to pro-duce similar effects. Individual sessions may be helpful topatients in improving their self-care, although group sessionsled either by clinicians or other patients can also be effective.Telephone care can be a vital link between patients and theirhealth care providers for ongoing self-management support,especially when patients experience difficulty accessing face-

to-face services. Automated telephone calls can extend thereach of self-management education when staffing is limitedor patients need frequent monitoring and behaviour changesupports.

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Overall, self-management education is most likely to beuccessful when it is part of a comprehensive and coordinatedpproach to diabetes care [37]. Further research is needed tossess the effectiveness of self-management interventions onong-term sustained glycaemic control, cardiovascular diseaseisk factors, and ultimately microvascular and cardiovascularisease and quality of life.

onflict of interest statement

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