Abstract
Background
Long-term conditions (LTCs) are prevalent in socio-economically deprived populations. Self-management interventions can improve health outcomes, but socio-economically deprived groups have lower participation in them, with potentially lower effectiveness. This review explored whether self-management interventions delivered to people experiencing socio-economic deprivation improve outcomes.
Methods
We searched databases up to November 2022 for randomized trials. We screened, extracted data and assessed the quality of these studies using Cochrane Risk of Bias 2 (RoB2). We narratively synthesized all studies and performed a meta-analysis on eligible articles. We assessed the certainty of evidence using GRADE for articles included in the meta-analysis.
Results
The 51 studies included in this review had mixed findings. For the diabetes meta-analysis, there was a statistically significant pooled reduction in haemoglobin A1c (−0.29%). We had moderate certainty in the evidence. Thirty-eight of the study interventions had specific tailoring for socio-economically deprived populations, including adaptions for low literacy and financial incentives. Each intervention had an average of four self-management components.
Conclusions
Self-management interventions for socio-economically deprived populations show promise, though more evidence is needed. Our review suggests that the number of self-management components may not be important. With the increasing emphasis on self-management, to avoid exacerbating health inequalities, interventions should include tailoring for socio-economically deprived individuals.
Keywords: chronic disease, public health, systematic review
Background
Long-term conditions (LTCs) are any health problem requiring active, ongoing management over at least a year, where there is no cure.1 LTCs affect approximately 43% of the adult population in England and are more prevalent in socio-economically deprived groups.2 The least affluent social class has a 60% higher prevalence of LTCs than the most affluent social class.1 Major socio-economic inequalities in the distribution of LTCs exist even when accounting for common risk factors such as smoking, diet and exercise.3
Individuals with LTCs have greater care needs than the general population.4 Around 70% of all health and social care funding goes to supporting people with LTCs.1 In England, people with LTCs account for around 70% of hospital bed days.4 Consequently, improving the self-management capacity of individuals has been a proposed solution to reduce the strain LTCs place on health systems.4 Evidence has shown that self-management approaches can improve clinical outcomes and reduce health service utilization.5,6
According to Barlow and colleagues, self-management can include (i) providing information about the condition, (ii) drug management, (iii) symptom management, (iv) management of psychological consequences, (v) lifestyle changes, (vi) Social support and (vii) communication with doctors.7 Self-management interventions aimed at the general population are less effective in people experiencing deprivation and may help maintain existing inequalities.8 This could be because people experiencing socio-economic deprivation are less likely to engage with the intervention.8 In addition, self-management involves taking a proactive approach, such as accessing preventative services, which is reduced in this population.9 Those experiencing deprivation have reported feeling less able to ask their doctor questions.10 These, along with other unexplored factors, impact the ability of interventions to effectively improve self-management in this population.
Whilst we know self-management interventions overall are less effective for people experiencing socio-economic deprivation, it has not been explored whether self-management interventions targeted specifically at this population are effective. By exploring tailored interventions, we may identify intervention active components for this population.
Aims
This review aimed to explore whether self-management interventions targeted at people experiencing socio-economic deprivation are effective at improving outcomes. The second aim was to explore how interventions are tailored and activate components is explored.
Methods
Protocol registration
The protocol was registered on PROSPERO on 8 December 2021 (CRD42021289674), available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289674.
Information sources and search strategy
We used previous reviews8,11,12 as a guiding point to develop a comprehensive list of search terms (Supplementary Material 1). The search was run in AMED, EMBASE, Medline, PsycINFO and CINAHL plus on 15 December 2021. We updated the search on 14 November 2022. The screening of titles, abstracts and full texts was undertaken independently by two authors (TO and MA). Any disagreements were resolved in collaboration with the multi-disciplinary team of authors. Data extraction and quality assessment were undertaken by TO, and all were checked by MA.
Eligibility criteria
For studies to be eligible, the population must be adults, with a least one LTC and be experiencing socio-economic deprivation. Indicators of socio-economic deprivation considered in this review include education, income and area-level indicators (such as the index of multiple deprivation).13 The intervention must primarily be focused on self-management. The design must be an intervention study with a comparator population such as a randomized control trial (RCT).
The exclusion criteria were (i) the study population did not capture a dimension of socio-economic deprivation, (ii) palliative patients, (iii) no full text in English and (iv) review articles, editorials and conference proceedings. Qualitative studies were excluded from this review, but identified papers have been analysed separately to explore the barriers and facilitators of self-management in this population.14 Self-management of LTCs occurs within a unique socio-economic and public health context. Therefore, suitable interventions are likely to differ widely between lower and high-income countries.15 Whilst exploring self-management of LTCs in lower income countries is important, it requires its own discussion beyond the scope of this review. Therefore, we excluded studies set in low-income countries.
Critical appraisal (risk of bias)
We evaluated the risk of methodological bias using version 2 of the Cochrane tool for assessing the risk of bias in randomized trials (RoB2) and version 2 for cluster-RCTs (RoB2 CRT).16,17 We assessed each domain using information from the trials’ main published journal articles, published protocols, clinical trial registries and supplementary appendices, when available.
Data extraction
We created three data extraction tables on the study characteristics, intervention characteristics (modelled after the template for intervention description and replication (TiDier) guidelines18) and the self-management components.
Narrative synthesis
Due to the heterogeneity of studies included in this review, the main results are presented as a narrative summary. We tabulated and compared positive study outcomes against a selection of study and intervention characteristics.
Meta-analysis
Studies with the same outcome were screened for inclusion in a random-effects meta-analysis. Studies had to contain data on the mean change from baseline to end for both the intervention and control groups, and the standard deviations (SD). If the SDs were not reported, we converted the standard error (SE) or 95% confidence intervals.19 If a study did not report this data and was not available from the authors, it was excluded from the meta-analysis. To measure heterogeneity, I2 was the preferred measure because Q’s power is reduced when the studies are unbalanced in sample size.20 We assessed publication bias using a contour-enhanced funnel plot and Egger’s test. In this review, only diabetes studies were eligible.
GRADE
The GRADE methodology was used to assess the certainty of the body of retrieved evidence from the studies included in the meta-analysis. We assessed GRADE using developed checklists21 and using a series of guidelines by Guyatt and colleagues, 2011.22–26
Results
Study selection
After full-text screening, 49 articles met the inclusion criteria. The updated search brought this total up to 51 studies. Figure 1 summarizes the selection process.
Fig. 1.
PRISMA study selection process.
Study characteristics
The study characteristics are outlined in Table 1. Almost all the trials took place in the USA. The sample sizes varied from 25 to 5599 participants. Common dimensions of socio-economic deprivation in the included samples were low income or uninsured participants or the study setting was in an area of high deprivation. Most studies had predominantly African American or Hispanic/Latino study samples.
Table 1.
Study characteristics
| Ref | Author, date | Country | Follow-up time | Long term condition | Population socioeconomic status | Sample size (intervention/control) | Mean age (SD) | n Female (%) | Primary ethnicity (%) | Outcome | Results summary | P value |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 27 | Anderson et al., 2010 | USA | 12 months | Type 2 diabetes | Area of deprivation: patients are at or below 200% of the federal poverty level | 295 (146/149) | NP | 171 (58) | African American and Hispanic/Latino | Mean HbA1c value | The difference in HbA1c between the intervention and control group was not significant | 0.63 |
| 28 | Arora et al., 2013 | USA | 6 months | Type 2 diabetes | Area of deprivation: low-income patients of a safety-net hospital | 128 (64/64) | 50.7 (10.2) | 82 (64) | Hispanic/Latino (87) | Mean change in HbA1c (%) | The intervention group had a −0.45 (95% CI: −0.27 to 1.17) greater decrease in HbA1c levels compared to control | 0.230 |
| 29 | Baig et al., 2015 | USA | 6 months | Type 2 diabetes | Area of deprivation: low-income neighbourhood | 100 (50/50) | 53.7 (11.6) | 81 (81) | Hispanic/Latino (97.9) | Mean change in HbA1c (%) | The intervention group had a −0.21 (CI: −0.98 to 0.55) greater decrease in HbA1c levels compared to control | >0.05 |
| 30 | Berry et al., 2016 | USA | 15 months | Type 2 diabetes | Low income: annual household income <200% of federal poverty guidelines | 80 (40/40) | 51.4 (8.5) | 72 (89.3) | African American (77.4) | Mean change in HbA1c (%) | Patients in the experimental group decreased their HbA1C significantly more than the control group | 0.001 |
| 31 | Chamany et al., 2015 | USA | 12 months | Type 1 and 2 diabetes | Low income | 941 (443/498) | 56.3 (11.7) | 599 (63.7) | Hispanic/Latino (67.7) | Mean change in HbA1c (%) | The intervention group had a 0.4% greater mean decrease in HbA1c compared to the control group | 0.01 |
| 32 | Clancy et al., 2007 | USA | 12 months | Type 2 Diabetes | Inadequately insured patients | 186 (96/90) | 56.1 | 134 (72%) | African American (82.8) | Mean change in HbA1c (%) | There was no difference in HbA1c change between the groups over 12 months | NP |
| 33 | Davis et al., 2010 | USA | 12 months | Type 2 diabetes | Area of deprivation: rural, medically underserved and low income | 165 (85/80) | 59.9 (9.4)/59.2 (9.3)** | 123 (75%) | African American (75.3/72.5) | Mean change in HbA1c (%) | The improvement in HbA1c was greater in the intervention group compared with usual care | 0.004 |
| 34 | Fitzpatrick et al., 2022 | USA | 6 months | Type 2 diabetes | At least one of the four social risks (food insecurity, unstable housing, difficulty paying for medical care and lack of transportation) | 110 (56/54) | 53.3 (12) | 77 (70) | Multi-ethnic | Mean change in HbA1c (%) | Within each group, there was a clinically significant reduction in HbA1c. −0.72% in the intervention group and −0.54% in the control | Between-group difference not reported |
| 35 | Fortmann al., 2017 | USA | 6 months | Type 2 diabetes | Low income, uninsured and low educational attainment | 126 (63/63) | 48.43 (9.80) | 94 (75%) | Hispanic/Latino (100) | Mean change in HbA1c (%) | There was a significant time-by-group interaction effect for HbA1c, indicating that over time, the intervention group had greater glycaemic control compared to the control group | 0.03 |
| 36 | Frosch et al., 2011 | USA | 6 months | Type 2 diabetes | Low income and underinsured | 201 (100/101) | 56.7 (8.3)/54.3 (8.9) | 97 (48.3%) | Hispanic/Latino (55.80) | Mean change in HbA1c (%) | There was an overall decrease in HbA1c values for both groups. However, there was no significant interaction effect of group by time | 0.49 |
| 37 | Gary et al., 2009 | USA | 24 months | Type 2 diabetes | ‘Socioeconomically disadvantaged’ | 488 (235/253) | 58 (11) | 358 (73) | African American (100) | Mean change in HbA1c (%) | There were no within-group or between-group differences in HbA1c change | 0.44 |
| 38 | Greenhalgh et al., 2011 | UK | 6 months | Type 2 diabetes | Socio-economically deprived area | 157 (79/78) | 58 (12) | 110 (70) | Multi-ethnic | Mean change in HbA1c (%)* | There was no significant difference in the within-group change in HbA1c between the intervention and control | 0.364 |
| 39 | Hill-briggs et al., 2011 | USA | 9 months | Type 2 diabetes | Low income | 56 (29/27) | 61.3 (10.9) | 33 (58.9) | African American (100) | Mean change in HbA1c (%) | The intervention group had a larger reduction in HbA1C change | 0.02 |
| 40 | Lynch et al., 2014 | USA | 6 months | Type 2 diabetes | Low income | 61 (30/31) | 54.1 (10.0) | 41 (67.2) | African American (100) | Mean change in HbA1c (%)* | There was no significant difference in HbA1c reduction between the groups | 0.10 |
| 41 | Lynch et al., 2018 | USA | 12 months | Type 2 diabetes | Low income | 211 (106/105) | 55.0 (10.3) | 148 (70.1) | African American (100) | Mean change in HbA1c (%) | While the HbA1c change was greater in the intervention group than the comparison group, the difference was not statistically significant | 0.52 |
| 42 | Nelson et al., 2017 | USA | 12 months | Type 2 diabetes | Low income: household income of less than 250% of the federal poverty level | 287 (145/142) | 52.5 (9.3) | 140 (48.8) | Multi-ethnic | Mean change in HbA1c (%) | There was no significant difference in the mean HbA1c change in the intervention group compared to the control group | 0.54 |
| 43 | Pérez-Escamilla et al., 2015 | USA | 12 months | Type 2 diabetes | Low income | 211 (105/106) | 56.3 (11.8) | 155 (73.5) | Latino/Hispanic (100) | Mean change in HbA1c (%) | The intervention led to a greater reduction in HbA1c, compared to the control | 0.021 |
| 44 | Philis-Tsimikas et al., 2011 | USA | 4 months | Type 2 diabetes | Underinsured, low income | 207(104/103) | 52.2 (9.6)/49.2 (11.8) | 146 (70.5) | Mexican American (100) | Mean change in HbA1c (%) | The intervention group had a significant decrease in HbA1c, from baseline to month 4 (−1.7%, P = 0.001). The control group had a non-significant reduction of −1.1% (P = 0.14) | Between-group difference not reported |
| 45 | Protheroe et al., 2016 | UK | 7 months | Type 2 diabetes | Residents from an area of deprivation | 76 (39/37) | 64.7 (11.2)/61.5 (10.1) | 38 (50) | NP | Mean change in HbA1c values | No difference in HbA1c change between the groups | 0.183 |
| 46 | Pyatak et al., 2018 | USA | 6 months | Type 1 and 2 diabetes | Low income/education—self-reported household income was below 250% of the federal poverty level or neither parent had a bachelor’s degree | 81 (41/40) | 22.6 (3.5) | 51 (63) | Hispanic/Latino (78) | Mean change in HbA1c (%) | The intervention group had greater improvement in HbA1c compared to the control group | 0.01 |
| 47 | Rosal et al., 2005 | USA | 6 months | Type 2 diabetes | Low-income | 25 (15/10) | 62.6 (8.6) | 20 (80) | Hispanic/Latino (100) | Mean change in HbA1c (%) | The HbA1c decrease was larger in the intervention group compared to control | 0.005 |
| 48 | Rosal et al., 2011 | USA | 12 months | Type 2 diabetes | Low income | 252 (124/128) | NP | 93 (76.6) | Hispanic/Latino—Puerto Rico (87.7) | Mean change in HbA1c (%) | The intervention effect was not significant | >0.293 |
| 49 | Ruggiero et al., 2014 | USA | 12 months | Type 2 diabetes | Low income | 266 (134/132) | 53.15 (12.36) | 183 (68.8) | African American (52.6) and Hispanic/Latino (47.4) | Mean change in HbA1c (%) | No intervention effect was found, and no differences were found for A1C | NP |
| 50 | Schillinger et al., 2009 | USA | 12 months | Type 2 diabetes | Low income and underinsured | 339 (113/112/114) | 56.1 (12.0) | 200 (59.0) | Multi-ethnic | Patient assessment of chronic illness care (PACIC) | Both the intervention groups showed a greater improvement in PACIC compared to control | For ATSM: P < 0.0001 For GMV: P = 0.04 |
| 51 | Schoenberg et al., 2017 | USA | 7 months | Type 2 diabetes | Area of poverty | 41 (20/21) | 58.24 (10.77) | 30 (65.85) | Anglo-white (100) | Mean change in HbA1c (%) | There was no overall difference in HbA1c change over time | 0.22 |
| 52 | Seligman et al., 2018 | USA | 6 months | Type 2 diabetes | Food insecure—food bank recipients | 568 (285/283) | 54.8 (11.4) | 384 (68.3) | Hispanic/Latino (52.1) | Risk difference in mean HbA1c (%) at follow-up | No evidence of a difference in HbA1c at follow-up | 0.16 |
| 53 | Shea et al., 2006 | USA | 12 months | Type 2 diabetes | Medicare beneficiaries | 1665 (844/821) | 70.82 (6.63) | 1040 (62.82) | Multi-ethnic | Mean change in HbA1c (%) | The intervention group had a greater reduction in mean HbA1c level compared to control | 0.006 |
| 54 | Sixta and Ostwald, 2008 | USA | 6 months | Type 2 diabetes | Low income | 131 (63/68) | 56.3 | 93 (71) | Mexican American | Mean change in HbA1c (%)* | There was no difference in the HbA1c level over the study period, within both the intervention and control group | NP |
| 55 | Skelly et al., 2009 | USA | 9 months | Type 2 diabetes | Rural, low income | 180 (60/60/60) | 67 | 180 (100) | African American (100) | Mean change in HbA1c (%) | There were no differences in the amount of decline between the 3 study arms | NP |
| 56 | Spencer et al., 2018 | USA | 18 months | Type 2 diabetes | Area of deprivation residents | 222(60/89/73) | 48.9 (10.6) | 135 (60.8) | Latino | Mean change in HbA1c (%) | From 6 to 12 months, improvements in HbA1c were sustained for participants randomized to the enhanced intervention group (n = 60) (−0.63% [95% CIs: −1.06 to −0.19]; P < 0.01) but not the regular intervention or the control groups | NP |
| 57 | Talavera et al., 2021 | USA | 6 months | Type 2 diabetes | Low education and low income | 456 (225/231) | 55.72 (9.82) | 290 (63.7) | Hispanic/Latino (96.5) | Mean change in HbA1c (%) | The group × time interaction effect (−0.32, 95% CI: −0.49 to −0.15) indicated greater improvement in HbA1c level over 6 months in the intervention group compared to control | <0.01 |
| 58 | Thom et al., 2013 | USA | 6 months | Type 2 diabetes | Low income | 299 (148/151) | 55 | 156 (52.2) | Multi-ethnic | Mean change in HbA1c (%) | Patients in the intervention group had a 0.77% greater decrease in HbA1c levels at 6 months compared to control | 0.01 |
| 59 | Wang et al., 2018 | USA | 6 months | Type 2 diabetes | Low income, underinsured and uninsured | 26 (11/9/6) | 56.4 | 16 (62) | African American/Black (65.38) | Mean change in HbA1c (%) | At 6 months, there were no statistically significant group differences in HbA1c level change | 0.44 |
| 60 | Wayne et al., 2015 | Canada | 6 months | Type 2 diabetes | Low income | 97 (48/49) | 53.2 (11.3) | 70 (72) | Black-Caribbean (40) | Mean change in HbA1c (%) | There was no between-group differences in mean HbA1c change from baseline to 6 months | 0.48 |
| 61 | Whittemore-2020 | Mexico/USA | 6 months | Type 2 diabetes | Low income | 47 (26/21) | 55.35 (8.75) | 31 (68) | Hispanic/Latino | Mean change in HbA1c (%) | There was little difference of changes between the groups | 0.11 |
| 62 | Aikens et al., 2022 | USA | 12 months | Depression | Low-income | 204 (108/96) | 48.6 (12.2) | 165 (80.8) | Caucasian (74.1) | Depressive symptom severity (Patient Health Questionnaire 9) | The intervention group’s mean PHQ-9 total had a greater reduction compared to the control | 0.004 |
| 63 | Apter et al., 2019 | USA | 12 months | Asthma | Area of deprivation: residents of a neighbourhood in which 20% of households had incomes of less than the federal poverty level | 301 (151/150) | 49 (13) | 270 (89.7) | African American (75.4) | Mean difference in Asthma Control Questionnaire score | The intervention had greater reduction in ACQ score, but the difference was not statistically significant | NP |
| 64 | Krieger et al., 2015 | USA | 12 months | Asthma | Low income: household income of less than 250% of the federal poverty level (2007) | 366 (177/189) | 41.3 | 268 (73.2) | Multi-ethnic | ‘Symptom-free days’ over 2 weeks | The intervention group had significantly greater and clinically meaningful increases in symptom-free days compared to control | <0.001 |
| 65 | Martin et al., 2009 | USA | 3 months | Asthma | Low income | 42 (20/22) | 33 (9) versus 37 (8) | 29 (69.05) | African American (92.86) | Asthma self-efficacy score | Self-efficacy increased in the intervention group and either remained the same or decreased in the control group, controlling for baseline variables | <0.001 |
| 66 | Young et al., 2012 | USA | 6 months | Asthma | Income less than or equal to 200% of the federal poverty level | 98 (49/49) | 44.6 (15.8) | 75 (76.5) | White (92.9%) | Patients’ asthma control (Asthma Control Test (ACT)) | Results did not indicate a significant difference between the control and intervention groups | NP |
| 67 | Evans-Hudnall et al., 2014 | USA | 4 weeks | Stroke | Low income and education and underinsured | 52 (27/25) | 56.03 (9.9)/46.95 (10.74) | 20 (38.5%) | African American (57) | Tobacco use (Behavioral Surveillance Survey [BRFSS]) | There was a greater proportion of patients with treatment-compliant tobacco use in the intervention group compared to control | 0.01 |
| 68 | Kronish et al., 2014 | USA | 6 months | Stroke | Low income | 600 (301/299) | 63 (11) | 354 (59) | Multi-ethnic: Hispanic/Latino and African American (86) | Proportion of sample who achieved a composite outcome of control of blood pressure lipids and regular use of antithrombotic medication | There was no difference in the proportion of intervention and control participants who at 6 months had attained their composite control measure | 0.98 |
| 69 | Tiliakos et al., 2013 | USA | 6 months | Rheumatoid arthritis | Low income | 104 (52/52) | 53.55 | 82 (79) | African American (90) | Proportion of patients who achieved 20% improvement from baseline according to the American College of Rheumatology (ACR20) | The test for interaction between intervention group and time was not statistically significant | 0.7 |
| 70 | Eakin et al., 2007 | USA | 6 months | Two or more chronic conditions | Low income | 200 (101/99) | 50 (13)/49 (13) | 157 (78.5%) | Hispanic/Latino (80.2/1.1) | Dietary behaviour (Kristal Fat and Fibre Behavior Questionnaire [FFB]) | The intervention group showed a significantly greater improvement in dietary behaviour compared to the control group | P = 0.003 |
| 71 | Kangovi et al., 2017 | USA | 6 months | Two or more chronic conditions | Area with high poverty rate, underinsured/publicly insured | 302 (150/152) | 56.3 (13.1) | 228 (75.5) | African American (94.7) | Mean change in score of participant’s chosen parameter (HbA1c, BMI, SBP and number of cigarettes per day) | There were positive differences in the 6-month change in chronic disease parameters, favouring the intervention arm | 0.08 |
| 72 | Kennedy et al., 2013 | UK | 12 months | Irritable bowel syndrome, chronic obstructive pulmonary disease or type 2 diabetes | Area of high deprivation | 5599 (2295/3304) | NP | 2990 (53.5) | White (96.7) | Change in shared decision making (health care climate questionnaire) | There was no difference between the groups | 0.66 |
| 73 | McKee et al., 2011 | USA | 6 months | Hypertension and type 2 diabetes | Low income | 55 (31/24) | 61.2 (11.2)/58.6 (7.9) | 36 (65.45) | Hispanic/Latino (72.73) | Change in proportion at goal for HbA1c (≤7%)* | A significantly larger proportion of the intervention group was at goal for HbA1c compared to control | 0.049 |
| 74 | Mercer et al., 2016 | UK | 12 months | Two or more chronic conditions | Socio-economically deprived area (Scottish Index of Multiple Deprivation) | 152 (76/76) | 52 | 85 (55.92) | NP | Mean change in patient-reported health-related quality of life (EQ-5D-5L). | Positive improvements in quality of life favoured the intervention group at 12 months. However, the overall effect size was not significant | 0.15 |
| 75 | Riley et al., 2001 | USA | 1 month | 1 or more chronic diseases | Low income | 28 (15/13) | 58 (9.5) | 23 (82) | Anglo-white (55) | Use of social-environmental resources (Chronic Illness Resources Survey [CIRS]) | The intervention group had increased their use of social-environmental resources significantly more than those in the control group | <0.03 |
| 76 | Swerissen et al., 2006 | Australia | 6 months | Chronic diseases (general) | Low income | 474 (320/154) | 66 (9.52) | 355 (74.9) | Multi-ethnic (Greek, Vietnamese, Chinese, Italian) | Health status (self-rated health) | At 6 months, the intervention group had a better mean self-rated health score compared to control | 0.000 |
| 77 | Willard-grace-2015 | USA | 12 months | Hypertension and/or hyperlipidaemia and/or diabetes | Low income, uninsured or publicly insured | 441 (224/217) | 52.7 (11.1) | 244 (55.3) | Latino/Hispanic (70.1) | Composite clinical outcome measure—proportion of treatment group with improvement in either HbA1C, SBP or LDL according to predefined thresholds | Participants in the intervention arm were more likely than those in the control group to achieve the primary composite measure | 0.02 |
Of the 51 studies, there were three cluster RCTs, 15 pilot studies and 33 RCTs. Three RCTs had three arms, making 54 unique interventions in total. Most trials looked at diabetes (n = 35). In addition, eight were on general chronic conditions or multi-morbidity, four on asthma, two on secondary stroke prevention, and one each for arthritis and depression.
Intervention details
Table 2 describes the interventions. In addition, 25 of the 51 studies (49.0%) were underpinned by at least one named behaviour change theory. The most common were social cognitive theory (n = 8), the transtheoretical model (n = 5) and self-efficacy theory (n = 6). The 54 intervention arms were delivered either face to face (n = 23, 42.6%), remotely (n = 9, 16.7%) or a combination of both (n = 22, 40.7%). Few made use of smartphone applications (n = 2, 3.7%). In addition, 29 (53.7%) of the intervention arms were delivered to participants individually. The rest were delivered to groups (n = 12, 22.2%) or used a combination of individual and group delivery (n = 11, 20.4%). The most common intervention providers were community health workers (CHWs). They were also referred to as peer leaders, lay leaders and peer supporters (n = 22). Other intervention providers included nurses, health educators and dieticians.
Table 2.
Intervention details
| Author, date | Theory | Materials and procedures | Intervention provider(s) | Mode(s) of delivery | Setting(s) | Frequency | Low SES tailoring | Planned fidelity assessment | Actual fidelity | Financial incentives |
|---|---|---|---|---|---|---|---|---|---|---|
| Anderson et al., 2010 | No | Patients received unscripted phone calls on disease management followed by mailed educational materials | Nurses were trained by a ‘master trainer’ who was an expert in commercial disease self-management | Telephone: individual | Centralised call centre | If HbA1c > 9, weekly calls, 7 < HbA1c < 9 or HbA1c < 7 with HTN/depression/retinopathy/neuropathy bi-weekly calls and HbA1c < 7 monthly calls | Educational materials were available in English and Spanish and at fourth grade reading level | Nurses documented phone encounters on patients’ electronic heath record. Intervention fidelity monitored through chart review by project co-ordinator | NP | $25 gift card to a local store after completing their 6- and 12-month assessments |
| Arora et al., 2013 | No | Participants received unidirectional, SMS text messages sent. text messages were based on content from the National Diabetes Education Program | Automated | Text messages: individual | Remote | Two daily text messages (9 am and 5 pm) over 6 months. Each text is a 160-character phrase | Texts were available in English and Spanish at fifth grade reading level. If needed patients were financially compensated ($20 per month) to upgrade to an unlimited messaging plan on the phones | No | NP | $175 during 6 months for time and travel costs associated with study follow-up visits |
| Baig et al., 2015 | Self-determination theory, social cognitive theory and the transtheoretical model (stages of change) | Patients received a faith-based diabetes self-management education program (DSME) | Trained, lay leaders, who either had diabetes themselves or knew a friend or family member with diabetes. Lay leaders underwent three 3 hour training sessions on coaching skills through modelling, program content, feedback and role play | Face to face: group | Churches | Eight sessions weekly, 90 min each | The DSME was faith based and culturally tailored. Lay leaders were bilingual in English and Spanish | Members of the academic team observed the class leaders during the first 8-week class and then periodically to ensure intervention fidelity using standard processes including checklists and direct observation | NP | No |
| Berry et al., 2016 | No | Patients received group diabetes self-management education | Health nurse practitioner, a physician, a postdoctoral fellow and a trained interventionist | Face to face: group | Community health centre | Five sessions—one session every 3 months | NP | NP | NP | No |
| Chamany et al., 2015 | Self-efficacy theory and the transtheoretical model (stages of change) | Patients were mailed a ‘welcome’ packet that included print materials on diabetes self-management and healthy retention incentives such as pedometers. Also, they received self-management support via telephone | Health educators who received 20 h of training in delivering behavioural counselling by phone. Health educators also attended a 10 h American Diabetes Association–recognized diabetes self-management program. They were supervised by a team consisting of a nurse-certified diabetes educator, internal medicine physician and clinical health psychologist thoroughly weekly case meetings | Telephone: individual | Remote | Four calls (one every 3 months) over 12 months if baseline HbA1c was in the >7.0% and <9.0%, or eight calls over 12 months if HbA1c was >9.0% | The health educators were bilingual in English and Spanish, and the print materials were adapted for low literacy | Fidelity to the protocol was enhanced by the use of telephone log sheets for documenting details of every call. Also, every study participant had a protocol flow sheet with exact dates by which protocol activities had to occur | NP | No |
| Clancy et al., 2007 | No | Patients received group medical visits | The groups were co-led by an internal medicine physician and a registered nurse, modelling the format of Cooperative Health Care Clinics (CHCC). They were trained by a senior internist who had previous experience in group visits. Also, the previous trainer for CHCC providers, gave a 3 h educational training session to clinic staff | Face to face: group | Clinic | 2 h group sessions, delivered monthly over 12 months | No | No | NP | A visit deposit fee per visit of $15 for intervention patients and $45 for control group patients |
| Davis et al., 2010 | Health belief model and transtheoretical model (stages of change) | Patients received remote DSME, with content based off the ‘Pounds Off With Empowerment’ materials, the ADA (American Diabetes Association guidelines) and the Michigan Diabetes Research and Training Center’s Life with Diabetes Curriculum | A self-management education team, consisting of a nurse/certified diabetes educator and a dietitian | Face to face: group and video conferencing: group and individual | Academic health centre (for the providers) and primary care clinic (for the patients) | Over 12 months, there were 13 sessions in total, with two being held in the first month (one group and one individually). Sessions were monthly thereafter. 10 sessions were group based, and the remaining three were individual | Modifications included considerations for a low-literacy and a rural population | No | NP | Participants were given a gift card for each of the three completed visits |
| Fitzpatrick et al., 2022 | No | Patients received resource navigation in addition to a problem-solving based, ADA recognized DSME programme | Community health workers (CHWs) who were already embedded in culturally specific community-based organizations. CHWs received 20 h of training in diabetes, delivering the DSME programme and addressing social needs | Face to face and telephone: individual | Patients’ homes or community settings (churches, cafes, libraries) | 9 modules were delivered over the 6 months on a weekly and bi-weekly basis. Resource navigation support was provided as needed | The DSME curriculum was adapted for low literacy. All materials were available in English and Spanish and the CHWs were ethnically diverse | A random selection of CHW visits were audio-recorded and reviewed as a check for fidelity | NP | Participants were given a $50 gift card for completing the 6-month follow-up |
| Fortmann et al., 2017 | No | Patients received an m-health SMS-text-based self-management intervention. Text message content was based on the Project Dulce DSME curriculum. The text bank included 119 different messages, less than 160 characters in length | Bilingual study co-ordinator | Text messages: individual | Remote—texts were sent out via a contracted patient health management technology platform | At the start of the intervention period, texts were 2–3 times per day at standardized h. Frequency tapered off as the study progressed | Patients who did not have a mobile-phone with texting capability were provided free of charge. Those with their own phones had the costs of the additional texts covered by the study ($12/month). Texts were in English and Spanish | No | NP | Participants received incentives at baseline, 3-month and 6-month assessment |
| Frosch et al., 2011 | No | Patients received one 24-min-long DVD program with an accompanying booklet called ‘Living with Diabetes: Making Lifestyle Changes to Last a Lifetime’, which was developed by the Foundation for Informed Medical Decision Making. Patients could also receive additional telephone support | A nurse educator trained in patient-centred approaches to diabetes management and motivational enhancement | Mail and telephone: individual | Patients receive the calls and material remotely, from their homes | Five phone calls in total. Call 1 being up to 60 min. Calls 2 and 3 up to 30 min. Calls 4 and 5 up to 15 min. Patients could receive no more than 150 min (2.5 h) worth of telephone support. The time interval between calls was at the discretion of the patients and nurse educator | The nurse educator was bilingual in English and Spanish | To improve fidelity, patients received a call 1 week after enrolment in the study to remind them to review the intervention materials provided and again to schedule a telephone session. Fidelity was assessed as the number of phone sessions each patient underwent | 73.0% completed five sessions of telephone coaching. The mean (SD) number of sessions completed was 4.0 (1.9) | No |
| Gary et al., 2009 | PRECEED-PROCEED Framework | Patients received individualised care and self-management support, in the form of intervention action plans (IAPs) based on a clinical algorithm | Both nurse case managers (NCMs) ad community health workers (CHWs) received 6 weeks’ worth of training. CHWs continued to have weekly meetings with the project co-ordinator to reinforce initial training and go over any problems | Face to face and telephone: individual | Clinic, patients' homes, community settings or remote | NCMs conduct a minimum of one face-to-face clinic visit per patient per year. CHWs conducted home visits at least 3 times a year. However, the frequency and intensity of the intervention for each patient is guided by the algorithm which triages them according the diabetes control level. For example, those with ‘poor control’ will receive weekly contact versus every other week for those with optimal control | CHWs are also African American | No | NP | No |
| Greenhalgh et al., 2011 | No | Participants took part in a semi-structured, informal group story-telling intervention, each session based around themes. Participants shared the experiences self-managing diabetes as it related to the group-selected theme | The story-telling facilitator (bilingual health advocate [BHA]) was a non-clinical professional or volunteer trained in the sharing stories model. Medical professionals such as a dietician, exercise specialist or diabetes nurse were invited to one-off sessions on a case-by-case basis | Face to face: group | Informal community settings | Each session lasted 2 h and was held every 2 weeks for 6 months | BHAs were bilingual, groups were offered in Bengali, Tamil, Punjabi, Urdu, Gujaratis and English. Those with mobility needs were offered minicab transport, allowing ‘housebound’ patients the opportunity to join the study | A researcher attended all but 8 of the 72 story-sharing sessions and checked that they followed the established protocol and format | NP | No |
| Hill-briggs et al., 2011 | D’Zurilla and Nezu problem-solving therapy | Patients received a diabetes and CVD education session and problem-solving training sessions. Patients also received two workbooks: ‘Diabetes and Your Heart Facts & Information Workbook’ and ‘Hitting the Targets for Diabetes and Your Heart: Your Problem-Solving Workbook’ | The interventionists underwent training and followed prepared manuals | Face to face: group | NP | One education session and 8 problem-solving training sessions, each lasting 90 min, delivered biweekly | The sessions and materials (workbooks) were adapted for accessibility and usability in low literacy and functionally impaired populations. The workbooks made use of colours (red vs green) and symbols to simplify concepts | All sessions were audiotaped, and randomly selected audiotapes were reviewed | NP | No |
| Lynch et al., 2014 | Information processing model. | Participants received a community-based, group intervention that focused on diet and physical activity, and follow-up peer support | Classes were facilitated by a registered dietitian, who was assisted by two peer supporters. Peer supporters trained weekly for 8 weeks (2 h per week) with a psychologist, dietitian and health educator. Training sessions familiarized the peer supporters with goal setting and the nutrition education materials | Face to face: group and telephone: individual | Local city park building near the recruitment clinic | 18, 2 h LIFE classes, which were weekly for the first 3 months and every other week for the second 3 months. Telephone support was weekly | Peer supporters were also African American and had diabetes or hypertension. They came from the same community as the participants | No | NP | No |
| lynch et al., 2018 | Cognitive-behavioural models of behaviour change and information processing model | Participants received group-based DSME and individualized peer support. The bulk of the LIFE intervention curriculum focused on diet change and goals. It was based on a modified plate method referred to as ‘the Plate of LIFE’. Participants also received educational materials and workbooks | The intervention team for each group session consisted of a registered dietitian, a group facilitator and 1–2 peer supporters. A clinical psychologist supervised peer supporters. Peer supporters completed 8 h of training. They were trained to reinforce progress on goals with verbal praise and apply simplified motivational interviewing and problem-solving techniques. Peer supporters provided telephone support | Face to face: group and telephone: individual | Community settings near the main clinic | 28, 2 h group sessions over 12 months: weekly for the first 4 months, biweekly for the second 4 months and monthly for the third 4 months. Two additional maintenance sessions were held at months 15 and 18. Telephone support was delivered at the same frequency | Peer supporters were also African American and the curriculum was culturally tailored. To address literacy barriers, the sessions and materials made use of graphics, simplified food lists, and physical demonstrations and hands-on activities to reinforce more abstract concepts. Numeracy barriers were addressed by repeated visual and tangible exercises counting out carb portions (using real food) | Yes: fidelity was monitored using checklists developed for each session to assess content delivery. Group sessions were recorded using a digital voice recorder. The project director reviewed fidelity data and provided feedback | NP | US$100 for each of the three full assessment and $25 for brief assessments |
| Nelson et al., 2017 | Self-efficacy theory | Patients received home visits where their current diabetes self-management was assessed using a structured interview. Community health workers (CHWs) worked with participants to set health goals and develop an action plan. Participants also received complimentary educational materials | Community health workers (CHWs) who received 60 h of mandatory training in health coaching and motivational interviewing by a professional health coach and training in how to use a blood pressure monitor. Each CHW passed a competency test prior to intervention delivery | Face to face: individual | Participants’ homes | 4 mandatory home visits that took place 0.5, 1.5, 3.5 and 7 months after enrolment. There was a fifth optional visit at month 10 | The CHWs were bilingual in English and Spanish and educational materials were available in both languages. Materials were also adapted for those with low literacy | Yes: CHWs completed an encounter form after each visit. The forms were reviewed monthly by a certified diabetes educator to ensure that each participant receives the required components of the intervention | NP | US$25 at both baseline and 12-month assessment |
| Pérez-Escamilla et al. 2015 | Transtheoretical model (stages of change) and problem solving theory | Participants received home visits were they were taught the DIALBEST curriculum in modules and received a tailored self-management plan | Community healthcare workers (CHWs) (nurse and medical assistant) who were employed by a community-based non-profit organization. They received 65 h of core training and 25 h of supplementary training by an interdisciplinary team of academics and practitioners in topics such as diabetes pathology, lifestyle strategies for glycaemic control, motivational interviewing, communication skills and social determinants of health | Face to face: individual | Participants’ homes | 17 visits over a 12-month period. Visits were weekly during the first month, biweekly during months 2 and 3, and monthly until month 12 | CHWs were bicultural/bilingual in English and Spanish. The curriculum was designed to be both culturally and health literacy appropriate. The self-management plans were individually tailored to meet the participants’ socio-economic circumstances | Yes: an ancillary study was conducted to audit the CHW progress notes and phone records to document intervention fidelity | Over half of the participants (51%) received the scheduled 17 visits, with an average duration of 87.8 (18.2) min per home visit | No |
| Philis-Tsimikas et al., 2011 | No | Participants received diabetes self-management education based on the Project Dulce ‘Diabetes among friends’ curriculum | Peer educators (PE) known as ‘promotoras’. They were individuals with diabetes, identified as ‘natural leaders’ from a patient population. Over a 3-month period, they received 40 h of training in the curriculum, group instruction, mediation and behaviour change techniques | Face to face: group and telephone: individual | NP | 8, 2 h group classes, delivered weekly and then monthly support groups. Telephone contact was made before each class to increase attendance | PEs were bilingual in English and Spanish | Yes: to ensure the fidelity of intervention delivery, all classes were audio-recorded and reviewed using checklists to monitor the delivery or omission of curriculum component | NP | Yes: participants were given small gift cards at each of the three assessment points (amount not disclosed) |
| Protheroe et al., 2016 | No | Patients received an individualized self-management plan, following an interview with a lay health trainer, along with follow-up telephone support and a printed pamphlet. The interview identified areas for improvement in their health | Lay health trainers (LHTs) received training from the research team on evidence-based diabetes care and appropriate lifestyle advice | Face to face and telephone: individual | NP and remote | 1 interview took place at the start of the intervention period, followed by up to 3 2-monthly support phone calls | Pamphlets were adapted for low health literacy | No | NP | No |
| Pyatak et al., 2018 | Social-ecological model of health behaviour and complexity theory | Participants received an adaptation of the Lifestyle Redesign OT intervention framework, which involves a manualized, individually tailored intervention, composed of 7 flexible modules | Two licensed occupational therapists (OTs) who received 20 h of training in the intervention manual, 12 h of training in motivational interviewing and 20 h training in diabetes self-management education. An endocrinologist and a licensed clinical social worker were available on an as-needed basis for issues identified that were outside the main scope of the intervention | Face to face: individual | Participants’ homes and community settings | 12 biweekly sessions averaging 1 h each, over 6 months. Timings were flexible; however, the aim was to deliver an intervention dose of between 10 and 16 h per participant | NP | Intervention fidelity was maintained through three strategies. First, therapists documented intervention dose, timing and treatment activities in notes completed after each session. Second, approximately 10% of sessions were observed by a second therapist trained in the intervention protocol, who completed a fidelity checklist and shared feedback with the treating therapist. Third, all team members trained in the intervention met weekly to facilitate problem-solving and prevent intervention drift | Fidelity monitoring showed that the therapists had 96% adherence to the intervention’s key components | Yes: received US$25 at baseline and US$50 at follow-up |
| Rosal et al., 2005 | Social cognitive theory | Participants received an interactive self-management education program. The program involved direct instruction and modelling through a soap opera, skill-building activities, personalized goal setting and skill reinforcement activities | A nutritionist, nurse and intervention assistant were trained in the intervention’s theoretical and delivery models, intervention goals, counselling skills and use of materials | Face to face: individual and group | A community room 3 blocks from the health centre and 2 blocks away from the elder service | One initial 1 h individual session, followed by 10 weekly 2.5 to 3 h group sessions and two 15-min individual sessions that occurred during the 10-week period immediately prior to the group session | The intervention team was bilingual and the interventions used the traffic light concept and visual aids as a means of simplifying educational messages | No | NP | Participants were offered incentives equivalent to US$90 for completing the assessment spread out over the three assessment points |
| Rosal et al., 2011 | Social cognitive theory | Participants received an interactive self-management education program. The program involved direct instruction and modelling through a soap opera, skill-building activities, personalized goal-setting and skill reinforcement activities | The intervention delivery team consisted of two leaders and an assistant (either a nutritionist or health educator and trained lay individuals or three lay individuals). The intervention staff received approximately 40 h of extensive training in accordance with a protocol that covered diabetes self-management, the theoretical foundation of the intervention and group management skills | Face to face: individual and group | Participants home (first individual session only) and community settings such as senior centres and local YMCAs | One 1 h individual session followed by 11 weekly 2.5 h group sessions and 8 monthly group sessions. Each group session included a 10-min one-to-one session for each participant with one of the intervention teams | The intervention was culturally and language tailored (English and Spanish). The content was adapted for low literacy by simplifying concepts, minimizing didactic instruction and using picture and colour-coded based guides | Yes: fidelity checklists monitored delivery or omissions of intervention components. Supervision of interventionists included a review of completed checklists following the sessions | NP | No |
| Ruggiero et al., 2014 | Transtheoretical model (stages of change) and empowerment theory | Patients received a self-care coaching intervention. The aim was to help the patients learn the necessary information and skills to make informed self-care goals and changes, using the 5As framework and motivational interviewing as the primary coaching methods. They were also provided with written materials matched to their stage of change in the framework | Medical assistants served as medical assistant coaches (MACs). In addition to the standard medical assistant training, they received more than 40 h of initial project training and ongoing boosters. They were trained by the multidisciplinary team in diabetes self-management, behavioural counselling strategies guided by the theory, motivational interviewing and the 5As framework | Face to face and telephone: individual | The clinic and remote | Face-to-face clinic visits were delivered quarterly during routine diabetes visits at the clinic and were less than 30 min in length. Telephone follow-ups were monthly and less than 15 min in length | MACs were of the same ethnicity (African American or Hispanic/Latino) as the patients at their clinic, educational materials were culturally tailored, written at a fifth grade or below reading level and were available in both English and Spanish | Yes: the PI and project coordinator reviewed and tracked intervention reports, notes and charts. There was occasional direct observation by a trained research assistant and periodic PI observation of the ongoing training | The majority of patients did not receive the intended dose of the intervention | US$20 cash for baseline assessment and US$25 cash for the two follow-up assessments |
| Schillinger et al., 2009 | Self-efficacy theory | Patients received individual action plans and took part in collaborative goal setting. This was achieved through an Automated Telephone Self-Management Support System (ATSM), where patients responded to automated queries regarding their self-care. Action plans and interactions are linked to the patients' clinic record | IDEALL clinical staff, including the nurse diabetes care managers for the ATSM, were trained in model protocols, motivational interviewing and communication techniques for patients with limited literacy | Telephone: individual | Remote—patients received calls in their homes | Weekly calls over 39 weeks (9 months). Each call takes between 6 and 10 min to complete | Intervention was delivered in English, Spanish or Cantonese | No | NP | US$15 and US$25 at baseline and 1-year follow-up, respectively. No additional incentive to answer calls |
| Patients received individual action plans and took part in collaborative goal setting. This was achieved through Group Medical Visits (GMVs). The visits involved discussing concerns, problems or progress with the plans and modelling of self-management behaviours | IDEALL clinical staff for GMV included a physician, pharmacist and health educator. In addition to the training described above, they received training in group facilitation techniques | Face to face: group | NP | Monthly visits of 9 months, each lasting approximately 90 min | Intervention was delivered in English, Spanish or Cantonese. Participants were given bus tokens to assist with transportation costs | No | NP | US$15 and US$25 at baseline and 1-year follow-up, respectively | ||
| Schoenberg et al., 2017 | No | Patients received a hybrid model of diabetes self-management classes (with goal setting) combined with care navigation based on the chronic care model | Trained community health workers (CHWs) | Face to face: group | Field office | The 6 classes took place every 2 or 3 weeks | The classes were culturally appropriate and material was delivered at a fifth grade or below reading level | No | NP | US$25 at both baseline and follow-up assessment |
| Seligman et al., 2018 | No | Patients received food packages and DSME modelled on the American Association of Diabetes Educators AADE7 Self-Care Behaviours and adapted from components of the Type 2 Diabetes BASICS curriculum | Food bank staff, volunteers and health educators. Educators were food bank staff trained in curriculum delivery by a registered nurse and diabetes educator. Staff also received training in the following subjects: diabetes pathophysiology, screening, evaluation and treatment, client privacy and HIPAA regulations, universal precautions and sharps safety, medical waste handling and use of specific study equipment | Face to face: group | Food bank | 2 mandatory group classes in the first 2 months of the intervention period, each lasting between 2 and 2.5 h. Optional ‘drop-in’ monthly sessions were available for the next 4 months and were 60 to 90 min long. Participants could receive 11 food packages picked up twice monthly over the 6-month intervention period | Classes and material were available in English and Spanish. The DSME curriculum and intervention was tailored to address literacy, numeracy, transportation barriers and costs, food-access barriers and food insecurity | No | No | US$15 gift cards at each assessment |
| Shea et al., 2006 | Social cognitive theory | Patients received telehealth case management via a home telemedicine unit (HTU), which consisted of a web-enabled computer with video conferencing capabilities | Nurse case managers and dieticians conducted the tele-health visits | HTU video: individual | Remote | Every 4–6 weeks across a 5-year period | The intervention providers for ethnic minority patients were bilingual in English and Spanish and were Hispanic/Latino or African American so advice could be tailored to the patients cultural background | No | NP | No |
| Sixta and Ostwald, 2008 | No | Patients received a diabetes self-management course, according to a scripted course curriculum | Promotores, employed by the clinic, led the course sessions in pairs, supervised by nurses. The nursing director oversaw quality control and promotores' education and training | Face to face: group | Community clinic | 10, 1.5 h sessions held weekly | The course curriculum was presented in Spanish, was culturally sensitive and used pictures to aid understanding | No | NP | No |
| Skelly et al., 2009 | No | Patients received a symptom-focused diabetes intervention (teaching and counselling) based on the University of California, San-Francisco symptom management model. Half of patients also received a telephone booster, reinforcing the content and strategies of the home visit | Nurses | Face to face and telephone: individual | Patient homes and remote | The 4 home visits were 60 min and took place bimonthly. The 4 telephone boosters took place 3 months after the last visit and occurred every 2–3 weeks. Each call averaged 15 min in length | The teaching was individualized and made specific to each patient home and community. Also, the visits took place at the patients' homes to avoid transport-related barriers | No | NP | No |
| Spencer et al., 2018 | Social cognitive theory | Participants received an empowerment-based group diabetes self-management education (DSME) classes, based on the Racial and Ethnic Approaches to Community Health (REACH) curriculum for Latinos. In addition, they received home visits and accompanied clinic visits | Community health workers (CHWs), who underwent more than 160 h of CHW training, more than 80 h of diabetes education, including home visit experiences, training in human subjects protocols, behaviour modification strategies, cultural competency and community-based participatory research | Face to face: group and individual | Community locations, participants homes and clinics and remote | Eleven 2 h group DSME sessions held every 2 weeks, two 60-min home visits each month and 1 accompanied clinic visit over a 6-month period | The CHWs were Latinas, bilingual in English and Spanish and were from the same community/area as the participants | No | NP | No |
| After the initial 6 month CHW intervention patients could receive ongoing emotional and behavioural support | Peer leaders (PLs) recruited by the CHWs. They received 46 h of training over 12-weeks and monthly booster sessions over the 12 month intervention period | Face to face: group and telephone: individual | Community locations and remote | Group drop-in sessions held weekly over a 12-month period. PLs made calls to any participants who had not attended three sessions in a row | Peer leaders were from the same community as participants but had already done the DSME curriculum previously | No | No | No | ||
| Talavera et al., 2021 | No | Patients received a team-based integrated care and behavioural intervention based on the 5As framework. It consisted of a medical visit, behaviour visit, group DSME classes and care co-ordination. The DSME class curriculum materials were developed as an adaptation of the Pasos Adelante/Steps Forward intervention | The team consisted of a physician/medical provider, a specialty behaviour health provider and a peer health educators | Face to face: individual (medical and behaviour visits) and group (self-management classes) | The partnership clinic | 4 medical and behaviour visits over a 6-month period and six 2 h DSME self-management classes | All intervention providers were bilingual in English and Spanish and Latino. DSME classes emphasized visuals and minimal text to accommodate varied levels of literacy | Yes: the number of medical and behavioural visits and DSME classes were tracked. DSME classes were audiotape recorded and reviewed by a trained research assistant who used a checklist to evaluate coverage of key content and ensure delivery as intended. The behavioural health providers completed a checklist based on the 5As framework after each visit | No major deviations. Fidelity by the 5As framework showed the following: Assess (99%), Advise (96%), Agree (78%), Assist (75–97%, depending on the topic) and Arrange (79%). 47 participants received no intervention contact | No |
| Thom et al., 2013 | No | Patients received peer health coaching | Peer health coaches who were patients at the clinic, who had an HbA1c level of less than 8.5% within the past 6 months. They received 36 h of training over 8 weeks, conducted by two of the research investigators. Trainees who passed both a written and an oral examination became peer coaches. Trainees received US$150 for completing the training, regardless of if they passed | Face to face and telephone: individual | The public health clinic and remote | Telephone contact must be at least twice a month and in-person contact at least 2 times during the 6-month intervention period | Peer coaches were from the same clinic/community and spoke either English or Spanish | No | NP | Patients received US$10 after baseline data collection |
| Wang et al., 2018 | Social learning theory and self-regulation theory | In addition to usual diabetes care and education, participants received lifestyle-based intervention sessions and tracked progress using a series of mobile apps (Diabetes Connect app and LoseIt!) | Lifestyle counsellors were trained using publicly available materials and a digital optical disc and printed training materials from the Group Lifestyle Balance (GLB) program and the Look AHEAD intervention | Face to face and mobile: group and individual | Community centre | 11 group sessions: weekly for month 1, biweekly for months 2 and 3, and monthly for months 4 to 6—and an individual session after month 3. Each session was 1 to 2 h | All intervention materials were modified to be at ninth grade reading level. Also, participants without a smartphone were lent one for the study duration | A checklist was used for each group and individual session to track the content delivered. The principal investigator (PI) attended at least 80% of the group sessions for both paper and mobile groups to ensure treatment fidelity | NP | No |
| In addition to usual diabetes care and education, participants received lifestyle-based intervention sessions and tracked progress using CalorieKing food and exercise journals | All intervention materials were modified to be at ninth grade reading level. | |||||||||
| Wayne et al., 2015 | Intervention described as theory driven but details not provided | Participants received health coaching with additional mobile phone support, based on a behaviour change curriculum co-designed by the study authors. The app used was the Connected Wellness Platform (CWP) provided by NexJ Systems, Inc | Health coaches who were behaviour change counselling specialists, with expertise in chronic disease management. They were either certified exercise physiologists or personal trainers. All coaches attended weekly seminars and meeting prior to and throughout the trial for training in the curriculum | Mobile app and face to face: individual | Remote | App communication was 24 h a day/7 days a week basis | Participants were provided with a Samsung Galaxy Ace II mobile phone during the intervention period. Also, the health coaching curriculum was adapted for the socio-economic context and ethnocultural backgrounds | No | Mean contact time between participants and health coaches was 38 min/week (SD 25) | No |
| Whittemore-2020 | Social cognitive theory, Empowerment theory and Health Action Process Approach Model (HAPA) | Participants received education sessions supplemented by text messages | The group session coordinators were a registered nurse and social worker who received one week's worth of training. The training program consisted of content on the program and its theoretical underpinnings, the pathophysiology and treatment of type 2 diabetes, and the social determinants of health in Mexico City | Face to face: group, text messages and telephone calls: individual | In 5 Seguro Popular clinics | Seven group sessions, which were followed up by a phone call every 2 weeks and daily text messages | Texts were written at a third to fourth grade reading level, with simple pictures to enhance understanding. For those unable to receive texts, the text content and pictures were printed on card. The group sessions were made to be culturally relevant and appropriate for adults with low health literacy. Group activities were tailed to the cultural and socioeconomic context of participants | A 5-item fidelity checklist and attendance were completed by the group session leaders. Also, approximately 35% of sessions were observed by a trained research assistant to ensure protocol fidelity | Average group session attendance was 89%. 100% of participants received texts at 6 months (96% at 3 months). 88% received picture messages at 6 months (83% at 3 months) | Participants received department store gift cards after each data collection point—$200 Mexican pesos (∼$10 USD) at baseline, $300 Mexican pesos (∼$15 USD) at 3 months and $400 Mexican pesos (∼$20 USD) at 6 months |
| Aikens et al., 2022 | No | Patients and their nomination ‘care partner’ (CP) received depression self-management advice via an automated interactive voice response (IVR) telephone system | Automated: the structured algorithm determines which pre-recorded queries patients hear | Telephone: individual | Remote | Over a 12-month period, patients received calls weekly, with each call lasting 5 to 10 min | NP | No | No | After each of the three planned assessments, patients, their CPs and in-home supporters were offered a $50 cash card for attendance. Patients could receive up to $150 during the study |
| Apter et al., 2019 | No | Patients received one-off training in patient portal use on how to locate a laboratory test result, check an upcoming doctor’s appointment, schedule an appointment, locate medication lists, find their immunization record, request a prescription refill and send a secure message. They also received home visits for care coordination and to promote their online patient portal use and familiarity with health information technology | Community health workers (CHWs) who were trained as lay health educators | Face to face: individual | Patients’ homes | Four visits over 6 months at weeks 2–4, 4–7, 6–11 and 23–27 | CHWs were from the same community as the patients | No | NP | No |
| Krieger et al., 2015 | Social-cognitive theory and self-regulation theory | Participants received home-based asthma education, support and service coordination. Through motivational interviewing, they developed a tailored asthma self-management plan | Community health workers (CHWs) with personal experience of asthma. They received 80 h of classroom training followed by biweekly training sessions. A health educator and nurse provided clinical support and a manager provided oversight | Face to face, telephone and email: individual | Patient homes | 1 initial visit/assessment at baseline, followed by 4 follow-up visits 0.5, 1.5, 3.5 and 7 months later. Additional telephone and email support was on an as-needed basis | CHWs could speak Spanish and English and were from the same community as participants | The project nurse conducted monthly audits of home visit records. The project manager or nurse observed at least 1 home visit per month per CHW and rated it with a structured tool | 90% of identified problems on each participant’s asthma problem list were addressed with the correct protocol, 86% of mandatory protocols were discussed and 83% of active problems were addressed at each visit | US$35 and US$50 for completing baseline and exit data collection |
| Martin et al., 2009 | Self-efficacy theory and social learning theory | Patients received group education sessions and home visits and co-developed an asthma self-management plan. Sessions and home visits involved environmental restructuring, problem solving, and asthma related goal setting as mechanisms for improving self-management skills. | A social worker led the group sessions with the support from community health workers (CHWs). CHWs delivered the home visits. CHWs were trained to establish relationships with participants, successfully implement home visits, and teach basic asthma facts, skills, and self-management techniques. The social worker was trained to effectively lead self-management group sessions and to supervise the CHWs. Altogether both the CHWs and social worker received 113 h of training. CHWs were evaluated by study investigators using a standardized role-play scenario to determine their readiness. | Face to face: individual and group | Primary care clinic (group sessions) and patients’ homes | 4 group sessions (2 h each) and 4 to 6 CHW home visits over a 12-week period | NP | CHWs and investigators met weekly throughout the study implementation phase to review documentation | CHWs reported covering all the required areas of asthma education, with the most emphasis on controller medications and taking medications correctly | Participants received US$25 after attending each group session and were mailed US$10 after each home visit |
| Young et al., 2012 | Self-efficacy theory | Patients receive counselling based off materials from the Indian Health Services’ patient-counselling model and the pharmacist–patient consultation program, which formed the communication guide | Trained pharmacists who were certified in the National Asthma Educator Certification Board Exam. Pharmacists were trained by a patient–provider communication expert | Telephone: individual | Remote—patients received calls in their homes | Three phone calls over a 3-month period | NP | During the intervention, pharmacists were evaluated during the intervention by a health communication scientist to examine their fidelity. Using the standardized counselling framework as a guide, the scientist reviewed and commented on the pharmacists’ adherence to the protocol | NP | Participants were reimbursed $75 for study participation: $50 at the beginning and $25 at study completion |
| Evans-Hudnall et al., 2014 | No | Patients received self-care sessions, with content based on the AHA (American Heart Association’s) guidelines and the 5As framework and cognitive behavioural therapy (CBT) | A health educator with a bachelor’s degree in health education and several years’ experience conducting chronic illness self-care education sessions. They also received training in stroke-specific health problems and CBT techniques | Face to face and telephone: individual | Intensive care unit and remotely in patient's homes | One face-to-face session at the start of the program and two phone calls, one every 2 weeks, for 4 weeks. Each session was 30–45 min | The health educator made sure to recommend free and easily accessible resources to aid in the adoption and maintenance of the specified goals. Materials were culturally tailored based on the religiosity and collectivism constructs prevalent amongst African Americans and Hispanics | No | NP | No |
| Kronish et al., 2014 | No | Participants received a peer-led stroke prevention group–based workshop adapted from the Chronic Disease Self-Management Program. After each session, participants were required to make an action plan with a goal | Peer leaders who received 5 days of training in the Stanford Program’s philosophy and methods. The trainers observed the first course and 20% of subsequent courses taught by new peer leaders | Face to face: group | Community settings | 6 weekly workshops, each 90 min in length | Peer leader were from similar socio-economic backgrounds as the participants. Workshops and materials were available in both English and Spanish. Concepts were taught in terms lay people could understand | No | NP | No |
| Tiliakos et al., 2013 | No | Patients received an arthritis self-management program (ASMP). The ASMP was supplemented by a printed educational manual | An instructor | Face to face: group | The hospital | Weekly 2 h sessions over 6 weeks | The education manual was at an eighth grade reading level | No | NP | No |
| Eakin et al., 2007 | No | Patients received a lifestyle intervention based off of the 5As framework advocated in multiple behavioural risk factor interventions (Ask, Assess, Advise, Agree, Arrange) | An experienced health educator | Face to face, telephone and newsletters: individual | Clinic or patient’s home for face-to-face visits, depending on patient preference | Two face-to-face visits lasting 60–90 min, 3 months apart. Three phone calls, two after the first visit (2 and 6 weeks after) and one after the second visit (2 weeks after). Three newsletters were also sent | Tailoring included the use of visual aids for low literacy, cultural adaptations and materials translated into Spanish. Health educators were also bilingual | Fidelity was assessed by tracking the delivery of the intervention protocol, including the number of intervention sessions delivered, and the percentage of patients who set goals on physical activity and dietary behaviour change | Of the 101 intervention participants, 48 (47.5%) received two visits, 39 (38.6%) received one and 14 (13.9%) could not be contacted for visits or calls. 46 (45.5%) received the three follow-up phone calls, 29 (28.7%) received two calls, 9 (8.9%) received one call and three (3.0%) were never reached for follow-up-calls | No |
| Kangovi et al., 2017 | Goal setting theory | Participants underwent a collaborative goal-setting session, followed by ongoing support. The follow-up support included tailored coaching, social support, advocacy and navigation to community resources. Participants co-developed tailored action plans for their chosen goals with community health workers. They could also attend group support sessions | Research assistants and primary care providers provided the collaborative goal-setting and were offered a 60-min training session. Community health workers (CHWs) delivered the follow-up support. They underwent a month-long college accredited training course covering topics such as action planning and motivational interviewing. CHWs were supervised by a manager, who was typically a master’s level social worker | Face to face: group and individual, text and telephone: individual | Primary care clinic (weekly support group), participants’ homes and community settings | 1 collaborative goal-setting session at baseline. Follow-up support from CHWs was delivered at least once weekly through various forms of communication. The support groups were weekly, but optional over the 6-month period | Collaborative goal setting made use of visual aids. Each individual plan was developed with the social determinants of health in mind | Research assistants were observed during an initial training period to assess fidelity to the collaborative goal-setting scripts. Managers assessed fidelity of the CHW support component through a recurring series of weekly assessments such as chart review, quarterly day-long observation, calls to patients to hear about their experience and a performance dashboard | Patients and CHWs created an average of 4.6 action plans over the course of their 6-month relationship. These action plans most commonly related to health behaviour changes (58.9%) and psychosocial issues (23.5%) | US$10 pre-paid gift card upon completion of the baseline survey, US$20 upon completion of baseline laboratory testing and US$30 upon completion of the 6-month follow-up assessment |
| Kennedy et al., 2013 | Normalization process theory | Patients received a whole systems model of self-management support compared within routine primary care. The patient-centred approach to the routine management of long-term conditions focuses on providing skills, resources and motivation to patients | Primary care providers (doctors, nurses, technicians) received 2 days of training by two facilitators. The training teaches three core skills: (i) assessment of the individual patient’s self-management support needs, in terms of their current capabilities and current illness trajectory; (ii) shared decision making using the PRISMS (Patient Report Informing Self-Management Engagement) tool; (iii) facilitating patient access to support | Face to face: individual | General practice | NP | NP | Yes: fidelity checks took place after training | There were varying levels of implementation in routine practice: information guidebooks were readily used (88% of clinicians reporting use, 51% ‘regularly’) whereas the PRISMS tool was least used (42% reporting no use) | No |
| McKee et al., 2011 | No | Patients received home-based self-management support focused on goal setting for behaviour change and targeted health/risk communications related to improving the ‘ABCs’ (A1c, BP and cholesterol). They also received enhanced care navigation via a tele-monitoring system, whereby home readings of blood glucose and blood pressure were sent to their primary care provider | Home health nurse (HHNs) took part in workshops to enhance skills in promoting self-management, covering selected health behaviour counselling techniques (motivational interviewing) to control primarily blood pressure, as well as glucose and lipids. The program manager was a nurse certified diabetes educator. Also, clinicians were educated to meet the clinical guidelines for HbA1c and blood pressure | Face to face and telemonitoring equipment—individual | Patient homes | NP | Intervention delivered in English or Spanish | No | 25 out of 31 patients received the entire protocol. There were 10.4 home nursing visits over an average of 75.2 days (SD = 35.6), or 10.7 weeks | Participants received modest incentives for completing the research interviews, but not for home visits or telemonitoring (amount not provided) |
| Mercer et al., 2016 | No | Patients received a whole-systems care intervention which included longer consultations and additional patient self-management support packs containing materials such as a cognitive behavioural therapy-derived self-help booklet | General practitioners who received training over 3 half days on how to use the longer CARE Plus structured consultations to carry out a holistic assessment. This included identification of patient concerns and priorities, a focus on self-management and agreeing on a care plan. They also had 20–30 min of mindfulness-based stress reduction | Face to face: individual | General practitioner | 12-month period | NP | Yes: intervention fidelity was estimated from the details recorded on the CARE Plus care plan by practitioners and the patient-reported questionnaire data | Intervention patients received longer initial consultations, with a mean length of 36.9 min (SD 9.8), according to the care plan, and a mean of 34.1 min (12.7) according to the patient report. Mean time per patient in the CARE Plus consultation was 69.2 min (SD 30.18). Practitioners reported giving the self-management pack to 97% of patients | £5 gift voucher on completion of each questionnaire |
| Riley et al., 2001 | Social cognitive theory, social-ecological theory and self-efficacy theory | Participants met with a health educator to set self-management goals, identify barriers, and supports to self-management and problem-solve. Health educators provided feedback on the CIRS score and helped to identify social-environmental resources relevant to that goal. After setting up the self-management plan, participants received follow-up support | Health educator | Face to face, telephone and newsletters: individual | Participants’ homes and remote | One visit at the start of the intervention, followed by the first newsletter immediately after. One, follow-up, 5 min, phone call took place 1 week after the visit. The second tailored newsletter was sent 5 weeks after the visit | NP | Yes: using RE-AIM Framework | All intervention components were implemented 100% as intended, with the exception that one participant did not receive the follow-up phone call | No |
| Swerissen et al. 2006 | Social learning theory | Participants received the Chronic Disease Self-Management Program developed at Stanford University | Peer leaders who received 20 h of training from two master trainers prior to leading the program | Face to face: group | Community settings such as senior citizens clubs, churches and community health centres | 6 weekly sessions, each session being 2.5 h long | The peer leaders were bilingual. All programs were delivered in participants’ first language (Chinese, Italian, Greek or Vietnamese) | No | NP | No |
| Willard-grace-2015 | No | Patients receive health coaching during a three-stage medical visit which consisted of a pre-visit, a collaborative medical check-up with a clinician and a post-visit session | Medical assistants retrained as health coaches. They received 40 h of training in collaborative communication, disease-specific knowledge, medication adherence, developing actions plans and knowledge of community and clinic resources | Face to face and telephone: individual | Community clinic for face-to-face visits and remotely from patients’ homes | The clinic visits were at least once every 3 months and telephone follow-ups were at least monthly over a 12-month period | The health coaches were bilingual in English and Spanish, self-identified as Latina and had not received a 4-year college education | Number of health coach interactions per patient | Mean = 12.4, (SD = 7.4) | Participants received $10 for taking part in a 45-min pre-randomization interview |
Thirty-eight of the intervention arms had outlined their specific tailoring for socioeconomically deprived groups (70.4%). The most common modification was adapting the reading material for low literacy and numeracy, for example, setting the materials at the US fourth or fifth grade reading levels (ages 9 to 11) (n = 16, 29.6%), including visual aids and diagrams to simplify abstract and complex concepts (n = 8, 14.8%) and using colour codes for health guides (n = 3, 5.6%). Materials were provided in both English and Spanish to accommodate the high numbers of Hispanic and Latino participants (n = 27, 54.0%). Also, many interventions (n = 22, 40.7%) were delivered by bilingual CHWs or peer leaders from the same ethnicity and community as the intervention participants, who provided culturally tailored advice based on their experiences. Finally, some of the text-messaged-based interventions had financial provisions to cover the cost of texts or provided participants a mobile phone for the study duration (n = 4, 7.4%). Only two (3.7%) of the face-to-face interventions had tailoring that addressed transportation barriers, for example, by providing free bus tokens or minicab transportation. These modifications were often used in combination with one another.
Of the seven self-management components (Table 3), the most frequently used was ‘lifestyle changes’ (n = 46, 85.2%), with most intervention arms focusing on diet and physical activity. This was followed by ‘symptom management’ (n = 40, 74.1%), mainly about blood glucose monitoring. Both ‘information’ and ‘drug management’ were common (both n = 36, 66.7%). Drug management involved medication reminders, aids such as pill boxes and sessions explaining how and why to take each drug. ‘Management of psychological consequences’ (n = 33, 61.1%) focused on stress management. ‘Social support’ (n = 32, 59.3%) usually involved sessions on family and home barriers to self-management. Families could also attend group sessions and home visits. The least used component was ‘Communication’. Only 18 (33.3%) interventions explicitly had elements involving communication strategies with primary care providers.
Table 3.
Self-management components
| Self-management components based on Barlow et al., 2002 | Other details including medical treatment | Control description | References for additional material | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Author, year | Information | Drug management | Symptom management | Management of psychological consequences | Lifestyle changes | Social support | Communication | |||
| Anderson et al., 2010 | Yes: during the brief clinical assessment | Yes: problem-solving discussions around medication adherence | Yes: glucose monitoring and reviewing home results | Yes: stress management | Yes: diet, exercise, smoking cessation and developing specific goals | No | No | No | Usual care | |
| Arora et al., 2013 | Yes: educational texts and trivia questions on diabetes myths | Yes: medication reminder texts | Yes: texts containing glucose monitoring, blood pressure monitoring, foot care information | No | Yes: texts containing healthy living challenges, which were specific daily challenges related to diet and food choices such as not drinking juice | Yes | No | No | Usual care | |
| Baig et al., 2015 | Yes: participants were given information about diabetes | No | No | No | Yes: participants were taught healthy Mexican recipes and at-home exercises not requiring special equipment. They were informed of church sponsored exercise programs. Also taught a cognitive approach to behavioural problem solving including goal setting, anticipating obstacles, stimulus control and behavioural alternatives | Yes: social support gained from the group setting | No | No | Enhanced usual care including, one 90-min lecture on diabetes self-management | 84 |
| Berry et al., 2016 | Yes: teaching patients to understand the complications of diabetes | No | Yes: teaching patients to understand blood pressure, cholesterol and blood glucose–monitoring goals before meals, after meals and long-term (A1C). Also, understanding the importance of proper foot self-examination and foot care | No | Yes: teaching patients to understand the importance of nutrition and exercise goals | No | No | Patients could also have their medications reviewed and an individual medical examination during the group sessions | Individual appointment with a nurse or physician once every 3 months for 15 months | |
| Chamany et al., 2015 | No | Yes: calls addressed problem solving and self-efficacy regarding medication adherence and patients were sent supportive retention aids such as a 7-day pill box, which they were encouraged to use over the phone | No | Yes: calls could address stress management as an optional topic, depending on the participants’ preferences | Yes: calls addressed self-efficacy and problem solving regarding physical activity and exercise. Patients were also sent items such as pedometers and were encouraged to use them over the phone | No | No | No | Control patients were given the same print materials and retention items | 85 |
| Clancy et al., 2007 | Yes: visits discussed the complications of diabetes | Noon to | Yes: visits discussed foot care | Yes: visits discussed the emotional aspect of diabetes | Yes: visits discussed healthy eating strategies, nutrition, and exercise | No | No | Vaccinations, foot examinations, medication adjustments. Laboratory orders and referral for retinal exams also took place during the group visits | Usual care in the tradition patient–physician dyad | |
| Davis et al., 2010 | No | Yes: the video conferencing included a session titled ‘Know Your Medicines’ | Yes: Session titled ‘Foot Care Basics & Know Your Numbers’. Also, participants were given logs to self-monitor their blood glucose | Yes—sessions titled ‘Stick With It: Positive Thinking’ and ‘Stress Management’ | Yes: the program includes goal setting and sessions titled ‘Welcome and Health Eating’, ‘Keeping well and healthy’, ‘Be a Food Detective’, ‘Healthy Eating Out’ and ‘Shop Smart’. The last session was in-person at a local grocery shop | Yes: session titled ‘Community Resources, Social Support’ | No | Optional retinal examinations | Control patients were given one 20-min diabetes education session, using ADA materials, conducted individually. They were also given access to usual care and community resources, including care managers for goal setting and education | |
| Fitzpatrick et al., 2022 | Yes: modules outlined information on diabetes | Yes: modules covered medication adherence | Yes: modules outlined clinical targets for blood glucose, HDLs, LDLs and blood pressure | No | Yes: modules covered lifestyle changes such as healthy eating and physical activity | No | No | No | Control patients were emailed diabetes materials monthly and received navigation support for medical and social resources. The received 2 follow-ups over a 6-month period | 86 |
| Fortmann et al., 2017 | NP | Yes: example text, ‘Tick, tock. Take your medication at the same time every day!’ | Yes: participants received a blood glucose meter, test strips and instructions on use. Example texts for monitoring prompts include ‘Time to check your blood sugar. Please text back your results’; 1 value >250 or <70 mg/dL or 3 values between 181 and 250 mg/dL prompted a study coordinator to call the participant to assess possible reasons for hyperglycaemia/hypoglycaemia | NP | Yes: example text, ‘Use small plates! Portions will look larger, and you may feel more satisfied after eating’ | Yes: example text, ‘Get the support you need family, friends and support groups can help you to succeed’ | NP | No | Control patients also received the 15-min diabetes educational video developed by Scripps, a blood glucose meter and testing strips, with instructions. Afterwards they continued with usual care which included visits with a primary care physician, certified diabetes educator and group DSME, although the use of the services was dependent on physician and patient initiative | OTHER PROJECT DULCE INTERVENTIONS INCLUDED IN THIS STUDY |
| Frosch et al., 2011 | NP* | NP | NP | NP | Yes: during the coaching intervention the nurse educator collaborated with participants to identify desired and attainable behavioural goals that could have a positive impact on their diabetes management. Together a behavioural plan was developed and monitored | NP | NP | NP | Control patients received a 20-page brochure entitled ‘4 Steps to Control Your Diabetes for Life’, which was developed by the National Diabetes Education Program of the National Institutes of Health | |
| Gary et al., 2009 | Yes: CHWs gave patients feedback on their blood pressure and blood glucose results during home visits and provided health education that would be followed up in the IAPs | Yes: IAPs could address medication adherence such as problems understanding the prescribed regime or obtaining the drugs. Follow-up actions by the CHW involved home visits to organize and monitor pill-taking behaviour | Yes: there were IAPs on foot care and home visits involved blood glucose monitoring | No | Yes: there were nutrition and physical activity IAPs. Also, during home visits CHWs could review patients’ fridges/cabinets and take them on grocery field trips to educate them on health food choices. CHWs could also facilitate group walking exercises | Yes: during home visits CHWs could involve family members and teach supportive behaviours such as how to perform glucose monitoring for a patient with poor eyesight | No | NCMs oversaw any aspect of the intervention requiring nursing expertise such as participating in the upward titration of insulin dose and prompting the physician regarding sub-optimal care patterns | The minimal intervention involved telephone calls every 6 months to remind patients of preventive screenings and a written summary of healthcare utilization was sent to their primary care provider. They also received diabetes-related educational material in the mail | 87 |
| Greenhalgh et al., 2011 | Yes: exchanging diabetes knowledge during sessions | Yes: themes such as ‘medication’ | Yes: stories around foot care and symptom management | Yes: discussions around the emotional impact of diagnosis and the affect it has on identity | Yes: discussions/stories around diet and exercise | Yes: themes such as ‘feeding the family’ and discussions around ‘mobilising a care network’. The group setting also provided social opportunities | Yes: themes such as ‘dealing with doctors’ | No | Participants received a nurse-led group diabetes education sessions held in the hospital or community settings | 88 |
| Hill-Briggs et al., 2011 | No | Yes: the education session covered the self-management behaviours of taking medications | Yes: the education session covered control of blood sugar, blood pressure, and cholesterol and self-monitoring | Yes: one of the problems solving sessions covers how to take control of stress and emotion through adaptive thinking techniques | Yes: the education session covered eating healthy and getting physical activity | No | No | No | Control patients received a condensed version of the intervention. 1 education session and 1 problem solving session | |
| Lynch et al., 2014 | No | No | Yes: LIFE classes covered blood glucose self-monitoring | No | Yes: LIFE classes focused on helping participants adapt a low-sodium, moderate-carbohydrate DASH (Dietary Approaches to Stop Hypertension) diet. Participants received a nutrition education workbook and a daily food log. They also received a pedometer and were told to set a step goal. LIFE classes included a peer supporter led moderate aerobic activity along with music | Yes: LIFE classes and telephone calls also provided emotional and social support | No | No | Two 3 h self-management training classes taught by an African American community health worker. One class focused on diabetes self-management and the other on nutrition | |
| lynch et al., 2018 | No | Yes: materials covered medication adherence | Yes: participants were given glucometers and glucose test strips and a daily log to monitor results. The sessions covered information on hyperglycaemia and hypoglycaemia | Yes: materials covered healthy coping | Yes: the core of the sessions DSME curriculum was focused on healthy eating such as carbohydrate counting, reading food labels, a grocery shop tour and eating more vegetables and wholegrains etc. They used a modified version of the plate method. They were also given food logs. Participants were given resistance bands and a 10-min resistance band workout was included in every group session. They were also given an accelerometer and were encouraged to track steps and meet the 10 000 steps per day goal. Peer supporters provided encouragement through telephone follow-ups | Yes: peer supporters provided social support. The group sessions had a dedicated ‘listening session’ where participants could share their struggles as well as their communal wisdom and expertise | No | No | 2 DSME sessions, delivered in the clinic, by a registered dietician in the first 6 months of the study period. Control participants also received glucometers | 89 |
| Nelson et al., 2017 | Yes: two of the mandatory education topics were ‘what is diabetes?’ and ‘treating diabetes’ | Yes: one of the mandatory education topics was ‘diabetes medications’ | Yes: two of the mandatory education topics were ‘signs and symptoms of low and high blood sugar’ and ‘blood glucose monitoring’ | NP | Yes: two of the mandatory topics were ‘food and diabetes’ and ‘diabetes and physical activity’. Optional topics/activities included attending a community kitchen or a CHW-led grocery shopping tour to demonstrate how to make economical yet healthy food choices | Yes: CHWs mobilized social support for participants by encouraging family and other members of participants’ support networks to help participants by encouraging lifestyle changes and medication adherence, attending clinic visits and providing emotional support | NP | CHWs facilitated coordination with primary care and case managers and encouraged participants to visit their provider for regular check-ups | Usual care, including medical care, community resources and one CHW visit after 12 months | 90 |
| Pérez-Escamilla et al. 2015 | Yes: visit 2 was an ‘intro to diabetes’. 3 subsequent visits addressed complications of diabetes | Yes: visits discussed medication adherence, especially visit 7 ‘medications’ | Yes: visits discussed diabetes complications and home glucose monitoring. They were also given a glucometer and glucose test strips | Yes: visit 11 focused on mental health | Yes: visit 10 focused on physical activity. Visits 3, 4, 5, 6, 9 and 15 focused on nutrition and related topics such as portion size and food labels. Visit 9 involved an onsite grocery shopping activity | Yes: family members, if present, were allowed to sit in during the home visits | No | CHWs had weekly meetings with the health management coordination team at the clinic, to update them on self-management barriers faced by the participants. The medical providers were able to provide feedback and suggestions | Usual care—physicians were expected to check HbA1c levels every 3 months and to conduct yearly foot, urine and eye examinations. Control participants received glucometers and glucose test strips with instructions on use. They were able to purchase medications at a discounted cost. Also, referrals to the clinic dietician were provided when needed | |
| Philis-Tsimikas et al., 2011 | Yes: the curriculum covered diabetes and its complications | Yes: the curriculum medication adherence and cultural myths/beliefs interfering with management such as, fear of using insulin and nopales, such as Mexican prickly pear cactus, as cures | Yes: participants were given glucometers and test strips. The curriculum covered blood glucose monitoring and cultural myths/beliefs interfering with monitoring such as relying on urine | Yes: the curriculum covered emotional experiences | Yes: the curriculum covered diet and exercise | Yes: during classes, participants could share their experience and receive advice and social support from each other | No | PE's had access to laboratory results and if they noticed that a participant was not meeting treatment guidelines, they encouraged them to seek further help from their primary care provider but did not offer medical advice themselves | Usual care and free glucometer and test strips | |
| Protheroe et al., 2016 | Yes: discussed perceptions of risk from diabetes | NP | NP | NP | Yes: discussed advantages and disadvantages of behaviour change | NP | NP | LHTs advised participants about essential health care tests and checks they should receive regularly as advised by Diabetes UK | Usual medical care, including a review by their family doctor at least once every 12 months | |
| Pyatak et al., 2018 | Yes: modules 2 and 7 deal with what diabetes is, its treatment and long-term complications | Yes: module 4 ‘Activity and health’ (flexible based on participants' needs) | Yes: module 4 ‘Activity and health’ (flexible based on participants' needs) | Yes: module 6, ‘Emotions and Wellbeing’ deals with emotions such anxiety, depression, anger, guilt, denial, fear; coping with diabetes burnout and self-destructive behaviours; promoting well-being and developing positive coping strategies | Yes: module 4 ‘Activity and health’ (flexible based on participants’ needs) deals with establishing and maintaining health-promoting habits and routines such as carbohydrate counting skills | Yes: module 5 ‘Social Support’ deals with managing diabetes in social situations, dealing with ‘diabetes police’, family-household life, peer relationships and intimate relationships. In some sessions, OTs engaged with family members to resolve social support problems identified by the participant | Yes: module 3 ‘Access and Advocacy’ deals with accessing health care and self-advocacy and communication in health care and community settings | No | Attention control—included an initial home visit and 11 follow-up phone calls, delivered biweekly. Phone calls followed a script and a staff member delivered a standardized set of educational materials published by the National Diabetes Education Program and MyPlate.gov | 91 , 92 |
| Rosal et al., 2005 | Yes: session topics included enhancing understanding of basic facts about the disease | Yes: session topics included the role of medications and adherence | Yes: session topics included adherence to daily blood glucose self-monitoring and understanding of values | Yes: session topics included stress management | Yes: session topics included dietary guideline education, menu planning and a supermarket tour. Topics also included physical activity with an emphasis on walking | Yes: session topics included family support. Family members could attend sessions as a way to elicit home-based support/approval for the participant | No | No | Control participants were given a simple booklet describing the importance of lifestyle factors in diabetes management and providing recommendations for diet, PA and blood glucose monitoring | |
| Rosal et al., 2011 | Yes: session 2 covers ‘what is diabetes’, other session also touched on diabetes complications | Yes: sessions cover medication adherence | Yes: participants were given glucometers and a tracking log. Sessions cover self-monitoring of blood glucose and management of hypoglycaemia | Yes: sessions covered stress management | Yes: participants were given a step counter and were encouraged to increase their daily steps. Sessions covered physical activity and various aspects of diet such as reading food labels and portion control. Reinforcement activities included cooking healthy meals during sessions, food bingo and a supermarket tour | Yes: family and friends could attend the group sessions | Yes: sessions covered topics such as communicating and keeping in touch with health care providers and what to ask them | No | Usual care | 93 |
| Ruggiero et al., 2014 | Yes: through the education materials provided | Yes: coaching content included medication adherence | Yes: coaching content included blood glucose self-monitoring and foot care | Yes: coaching content included healthy coping | Yes: coaching content included healthy eating, smoking cessation and physical activity | No | No | The MAC also supported the patient in arranging appointments and made referrals | Usual care, including regular visits with a primary health care provider, referrals for specialty care such as foot and eye examinations and basic education delivered by their physician. All participants were given the ‘Diabetes: You’re in Control’ educational booklet at the baseline | |
| Schillinger et al., 2009 | Yes: health education messages in the form of narratives | Yes: medication adherence | Yes: self-monitoring of blood glucose and symptom queries | Yes: queries about psychosocial issues (e.g. coping, depressive symptoms, etc.) | Yes: queries on diet and physical activity | No | No | Care manager also facilitated referrals for preventive services (e.g. ophthalmologist, etc.) | Usual care | 94 , 95 |
| NP | NP | NP | NP | NP | Yes: group visits included social breaks | NP | During visits patients with unmet medical needs also received brief, individualized care | |||
| Schoenberg et al., 2017 | Yes: class one gives an over of diabetes and its effect on the body | Yes: class covers two medications taking, to avoid diabetes complications | Yes: class two cover blood-glucose self-monitoring. Class 5 covers avoiding feet, teeth, eyes, sick days, kidneys and blood pressure complications | Yes: class four covers stress management | Yes: class three covers healthy eating and class four covers physical activity | Yes: program covers working with family (class number not specified) | Yes: program covers working with health care providers (class number not specified) | Regarding medical appointments, CHW assisted in rescheduling, arranging transportation, finding dependent care options and motivating on follow-through | Usual care | |
| Seligman et al., 2018 | Yes: education materials were given with the food packages. Class topics included a disease overview | Yes: class topics included a diabetes medications overview, with medical professionals such as a registered nurse or physician as guest speakers | Yes: class topics included blood sugar monitoring | Yes: class topics included stress management and depression and healthy coping. Social workers and therapists were guest speakers for these topics | Yes: many classes covered aspects of healthy eating such as carbohydrate counting and reading food labels. Food packages contained diabetes-appropriate food and were accompanied with written healthy recipes. Classes also covered physical activity including exercise instructors as guest speakers | Yes: the class curriculum involved prompts to ask about questions family members had | No | Participants also received onsite HbA1c testing at months 3 and 6 and referrals to a primary care provider if they did not already have one | Wait list control | |
| Shea et al., 2006 | Yes: via the HTU patients had access to web-based diabetes educational materials | No—not explicitly | Yes: patients could upload their blood pressure and blood glucose measurements onto the HTU, where it could then be reviewed by their case manager. Patients also set HbA1c, cholesterol and blood pressure goals with their case manager during tele-health visits | No | Yes: nurse case managers supervised patients in setting behavioural goals such as smaller food portions. At each visit, the goal from the previous was reviewed and relevant praise and/or problem solving to barriers were discussed | Yes: patients and nurse case managers discussed strategies to overcome social barriers such as asking their partner to also cut out unhealthy foods such as ‘ice cream’ | No | No | Usual care by their primary care provider | 96 , 97 |
| Sixta and Ostwald, 2008 | Yes: patients were taught about the disease and related complications | No | Yes: patients were taught about blood glucose management | Yes: Patients were taught about disease ‘related emotions’ | Yes: patients were taught about healthy behaviours such as the effect of exercise and nutrition. Promotores assisted patients in setting/revising behaviour goals and assisted in follow-up and problem solving | No | Possibly—patients were taught about ‘multidisciplinary team management’ | No | Wait list and usual care | |
| Skelly et al., 2009 | Yes: patients were taught about disease symptoms and how they relate to diabetes | Yes: patients were taught about insulin/oral medication | Yes: patients were taught symptom management strategies and were given materials on the prevention of symptoms. Patients chose which strategies they wanted to use. Self-care practices taught include home glucose monitoring, foot care and checking urine for ketones if blood sugar was >240 | Yes: patients were taught several psychological strategies such as positive self-talk, positive coping strategies and stress reduction—abdominal breathing, visual imagery | Yes: physical activity and diet were addressed for example nurses went with patients to their kitchen to teach them how to read nutrition labels. Patients were given ‘homework’ and set goals at the end of each session | Yes: family members, if present, were invited to sit in during the home visits | Yes: patients were taught when to contact their healthcare provider, for example, to contact their healthcare provider if their readings were frequently >140 before meals | No | A weight and diet program consisting of four modules that addressed Weight Maintenance (two modules), Modifying Fat, and Modifying Sodium in the diet. The modules did not address symptoms directly | 98 |
| Spencer et al., 2018 | Yes: participants were taught information about diabetes | No | No | Yes: when patients set goals and identified problems, they were able to discuss the emotional impact of that problem with the CHWs. The curriculum also taught stress-lowering activities | Yes: the curriculum involved culturally appropriate diet and physical activity advice, including exercise videos. CHWs also help participants set goals using the 5-step goal-setting process ad developing and executing an action plan for that goal | Yes: the curriculum emphasises that healthy eating is beneficial for the whole family. A group session provided social support and role-playing support exercises to improve social support and communication with family members about diabetes self-management | Yes: CHWs helped participants improve communication skills with their providers and facilitated necessary referrals to other services. CHWs accompanied participants to one clinic visit with their primary health care provider | No | Enhanced usual care, including a 2 h class conducted by a research assistant covering how to interpret their clinical and anthropometric results | 99 |
| Yes: PLs addressed questions about diabetes and its care | No | No | Yes: PLs discussed psychosocial concerns with participants | Yes: using the same 5-step goal process as the CHWs. Group sessions were an opportunity to discuss challenges and problem solve | Yes: PLs helped participants take inventory of support sources | Yes: Pls helped participants in developing strategies to navigate the health care system | No | After the initial 6 months of the main intervention, participants randomized to CHW worker only group received monthly telephone calls from a CHW who had led their DSME group to check in and assess their progress | ||
| Talavera et al., 2021 | Yes: during medical visits, the medical provider reviewed patients laboratory results with them and their medical history. During the DSME classes, groups discussed diabetes pathophysiology in relation to cultural beliefs | Yes: medical providers and patients collaboratively discussed barriers to medication adherence during the medical visit. Medication adherence was also discussed during DSME classes | Yes: medical providers and patients collaboratively discussed home glucose self-monitoring during the medical visit | Yes: during the behaviour visit, patients collaboratively assessed emotional factors affecting diabetes self-management. The behaviour providers also provided psychoeducation. DSME classes involved discussions on psychosocial well-being (prevention and coping with depression, anxiety, diabetes distress, stress management and problem solving) | Yes: during the behaviour visits, patients created SMART goals and personal action plans. During DSME classes, groups discussed nutrition in the context of the traditional Latin diet and how to incorporate physical activity into everyday life | Yes: during the behaviour visit, patients discussed family barriers. Also, patients were refereed to social work/family services when needed. The DSME curriculum emphasized involving family in self-management and lifestyle activities | Yes: indirectly | Yes: medical visits also involved the development of a treatment plan. Care-coordination involved referrals to other health departments and community resources when needed | Control patients received primary care provider led usual care, with referrals to health education and behavioural health as needed | |
| Thom et al., 2013 | Yes: peer coaches and patients discussed current and target clinical values for HbA1c | Yes: peer coaches facilitated medication understanding and adherence | Yes: peer coaches discussed self-management skills such as using a glucometer and appropriate strategies for hypoglycaemia | Yes: peer coaches provided social and emotional support and helped patients with stress management | Yes: peer coaches assisted with lifestyle changes such as healthy eating and physical activity | Yes: peer coaches provided social support and shared stories about their own lives and families | Yes: peer coaches helped patient to navigate the clinic and could accompany the patient during a clinic visit | Yes: peer coaches provided information on community resources | Usual care, including referrals to a nutritionist and diabetes educator if needed | 100 |
| Wang et al., 2018 | No | Yes: covered in the usual care diabetes education | Yes: the usual care diabetes education covered risk and management of hyperglycaemic and hypoglycaemic situation and blood glucose self-monitoring. Participants also received a Bluetooth enabled glucometer linked to the Diabetes Connect app to track blood glucose | Yes: the lifestyle intervention sessions cover stress management and balancing thoughts | Yes: the lifestyle intervention sessions cover various aspects of exercise and healthy eating and includes a grocery shopping tour. Participants were provided with the LoseIt! App, a pedometer, a food scale and a weight scale to track calories, physical activity and weight | No | No | No | Control group received usual care and diabetes education from their primary care physicians and diabetes educators | |
| No | Yes: covered in the usual care diabetes education | Yes: the usual care diabetes education covered risk and management of hyperglycaemic and hypoglycaemic situation and blood glucose self-monitoring. Participants also received a regular glucometer to track blood glucose in a paper diary | Yes: the lifestyle intervention sessions cover stress management and balancing thoughts | Yes: the lifestyle intervention sessions cover various aspects of exercise and healthy eating and includes a grocery shopping tour. Participants were provided with the CalorieKing paper diary, a pedometer, a food scale and a weight scale to track calories, physical activity and weight | No | No | No | |||
| Wayne et al., 2015 | No—not explicitly | Yes: medication adherence was a goal emphasized by the health coaches | Yes: participants logged and monitored their blood glucose levels via the app | Yes: coaches emphasized stress management as goal for participants. Participants could also log and track their mood on the app | Yes: coaches guided participants in setting goals and making plans regarding diet (reducing carbohydrate intake) and increasing exercise frequency. Participants could also access free group exercise classes available at the local community health centre. Participants could log food intake and exercise frequency onto the app for the coaches to monitor and provide guidance when they diverged from their goals | No | Yes: a goal emphasized by health coaches was participant communication with primary care physicians and, generally, within the health system | No | Control participants received in-person health coaching only, with no additional mobile support | |
| Whittemore-2020 | Yes: session 1 focused on understanding diabetes | Yes: session 1 highlighted the need to take medication and session 5 focused on going diabetes medications | Yes: participants were given glucometers, test strips and lancets and were taught the need to self-monitor blood glucose and how this relates to carbohydrate intake | Yes: 4 of the sessions included stress management activities | Yes: throughout the sessions and texts/pictures participants were taught strategies to improve their diet such as how to read nutrition labels, menu planning with limited resources, food portion measurement and the ‘plate method’. Also, the benefits and precautions of physical activity were highlighted, and goals were encouraged through texts | Yes: family could be invited to sessions | Yes: session 5 covered how to talk to health care professionals | No | 100 | |
| Aikens et al., 2022 | Yes: pre-recorded messages contained information on depression symptoms | Yes: pre-recorded messages highlighted the importance of adhering to their anti-depressant regime and advice on how to do so and get refills | Yes: at the beginning of each pre-recorded call, patients answered PHQ-9 items to track their depression symptom severity, which then tailored the advice they were given | Yes | Yes: pre-recorded messages covered lifestyle advice such as physical activity and sleep | Yes: patients had an ‘in-home’ supporter and CP who lived outside the home. They provided social support. At the end of each IVR call, CPs were sent a structured report along with advice on how to support the patient with their depression | Yes: pre-recorded messages included advice on when and how to reach out to their physician | If patients reported suicidal feelings, the system alerted their primary care team | Control patients received enhanced usual care. While both they and their nominated CP received printed materials on depression self-management, they did not receive additional self-management support via the IVR | 101 |
| Apter et al., 2019 | Yes: CHWs taught patients how to search for health information online and access educational materials on the portal | Yes: CHWs explained the difference between controller and rescue medications, and proper inhaler use | Yes: CHWs drafted individualized asthma management plans with each patient and taught patients how to mitigate asthma triggers | No | Yes: signposting to relevant community resources such as smoking cessation and housing programs | Yes: CHWs also established relationships with patients’ families | Yes: CHWs taught patients how to chat with doctors via the portal, especially regarding exposure to key allergens and booking appointments | CHWs were involved in care navigation and referrals | Portal training only + usual care | 102 |
| Krieger et al., 2015 | Yes: visits covered asthma basics including asthma pathophysiology, when to seek emergency care and important vaccines | Yes: visits covered medication adherence including providing participants with a medication box; problem solving concerns about side effects, cost, access and getting to pharmacy; and CHWs assessing participants’ understanding of when to use controller medications | Yes: visits covered symptom management including peak flow monitoring—participants were given a peak flow monitor and diary and taught the correct technique; getting help during an asthma attack- CHWs demonstrated ‘Belly Breathing’ and other relaxation techniques | Yes: visits covered stress management | Yes: visits covered environmental control of the home and a cleaning checklist. Participants were given a vacuum, vacuum bag and cleaning kit | Yes: CHWs could engage family support during visits | Yes: visits covered working with the healthcare system including communication strategies, pointers and roleplay. If needed, CHWs could accompany participants to a medical appointment to act as a ‘cultural translator’ | CHWS made referrals to community resources for childcare, food, employment and citizenship assistance. CHWs also faxed visit details to the clinics for feedback | Usual care, information on community resources for asthma self-management and educational pamphlets. At the end of the study, participants in the control group received a home visit by a CHW and the intervention group resources | |
| Martin et al., 2009 | Yes: group session 1 covered asthma anatomy and physiology and understanding physiologic reactions to stressors. Home visit 3 covered asthma triggers | Yes: home visit 1 covered controller medications, spacers, inhalers | Yes: home visit 2 covered symptom recognition and management | Yes: group session 2 covered sociocultural definitions of stress; effects of stress on asthma management and an action plan to improvement ability to manage stress | Yes: groups session 3 and 4 and home visit 5 covered benefits of physical activity an action plan for physical activity. Home visit 4 covered smoking cessation and tobacco smoke avoidance | Yes: group session 4 covered discussions on current positive social support. All home visits also covered social support | Yes: home visit 2 covered communicating with providers. CHWs encouraged proactive communications between patients and their health care providers | No | 2 mailings covering the asthma education information presented at the group sessions for the intervention and a US$30 cheque | |
| Young et al., 2012 | No | Yes: pharmacists followed the communication guide to identity and address patient barriers to medication adherence. Pharmacists also used a series of questions to assess whether patients required additional education regarding inhaler technique | No | No | No | No | No | Pharmacists review their electronic health records. If they identified severe asthma related problems, they referred patients to their primary healthcare provider | Usual care, including mail receipt of a prescription refill with written instructions on medication use | |
| Evans-Hudnall et al., 2014 | Yes: Patients were given a detailed workbook on the signs and symptoms of stroke and risk factors for primary and secondary stroke | No | Yes: patients were given a detailed workbook on the signs and symptoms of stroke | Yes: patients were taught cognitive reframing techniques to minimize negative thoughts concerning their ability to change lifestyle habits. Also, they were taught deep breathing and guided imagery skills to help identify and decrease their stress levels | Yes: patients were given a dietary and exercise tracking form. Patients were asked to identify lifestyle habits that increased their risk for secondary stroke and how to assess change in these habits, including potential barriers and problem solving. Patients were taught stimulus control—removing environmental factors associated with unhealthy habits. Diet and exercise advice was tailored to each patient | Yes: patients were encouraged to engage friends and family members as a source of support to achieve their goals. They were also encouraged to set goals that focused on changing family lifestyle behaviours rather than individual change | No | The health educator facilitated phone calls to aid the patient in getting access to community resources | Usual care | |
| Kronish et al., 2014 | Yes: the workshop covered the biology of stroke and stroke treatments | Yes: the workshop stressed the importance of adherence to preventive medications to reduce stroke recurrence and provided suggestions for optimizing medication adherence | Yes: the workshop covered key symptom management related to blood pressure and cholesterol | No | No | Yes: participants could bring a family member, friend or home attendant to the workshops | Yes: the workshop covered working with your health care team, including communication | Participants were also given a list of local health providers, including those that accepted patients without health insurance | Usual care and wait list. Control participants received the workshop after a 1-year waiting period | 103 |
| Tiliakos et al., 2013 | Yes: class content included an overview of arthritis pathophysiology | Yes: class content included an overview of arthritis medications | Yes: class content covered appropriate use of injured joints | Yes: class content involved individualized relaxation programs | Yes: class content involved the development of individualized exercise programs | No | Yes: class content covered aspects of patient–physician communication | No | Usual care | 104 |
| Eakin et al., 2007 | No | No | No | No | Yes: patients set a self-management goal related to physical activity or healthy eating, and identified one or two types of social environmental resources they could use to help them reach their goal. Patients received a goal sheet that summarized their action plan. Phone calls addressed problem solving. Also, tailored newsletters reinforced these goals | Yes: family and friends were included as potential social-environmental resources | No | NA | Control patients were mailed a local area community resources guide and three newsletters on basic financial management | |
| Kangovi et al., 2017 | Yes: if participants wanted further disease education, CHWs navigated them to the appropriate clinician | Yes: the tailored action plans could include strategies for medication adherence | Yes: the tailored action plans could include strategies for symptom management such as blood glucose and blood pressure monitoring | Yes: the support groups discussed psychosocial stressors | Yes: the tailored action plans could include strategies for lifestyle changes such as increased physical activity, healthy eating and quitting smoking. CHW provided support such as food pantry visits with participants | Yes: the taction plans could involve strategies for involving family in the participants’ goal. Also, the support discussed relationships with friends and family members | Yes: the action plans could involve discussion pointers to bring up with the participant’s primary care provider | CHW also navigated participants towards appropriate community resources and sent progress reports to the participants primary care team | One time collaborate goal setting, followed by usual care | 105 , 106 |
| Kennedy et al., 2013 | NP | NP | NP | NP | NP | NP | NP | No | Wait list control | 107 |
| McKee et al., 2011 | NP | NP | Yes: Patients were leased Cardiocom telemonitoring equipment to send their daily self-monitored blood pressure and glucose readings. Results were transmitted to the program manager and formatted as weekly reports. The reports were sent to the primary care provider via secure clinical email for review and treatment modification if necessary | NP | NP | NP | NP | Primary care providers used weekly report to modify treatment plans | Usual care | |
| Mercer et al., 2016 | NP | NP | NP | Yes: mindfulness-based stress management CDs | NP | NP | NP | Practitioners were encouraged to link patients with relevant local resources and community services when appropriate | Usual care | 108 |
| Riley et al., 2001 | Yes: CIRS covers whether or not the participant has access to information about the condition | Yes: CIRS cover medication taking as a behaviour | No—not explicitly | No | Yes: CIRS covers behavioural targets such as eating more fruits and vegetables, getting more physical activity and quitting smoking | Yes: CIRS involves questions arounds family and friend support, e.g. ‘Have your family or friends exercised with you?’ | Yes: CIRS covers questions around support/communication with the participants’ healthcare team, e.g. ‘Has your doctor or other health care provider listened carefully to what you had to say about your illness?’ | No | Wait list control: received the intervention 1 month after the intervention group | |
| Swerissen et al., 2006 | No—not explicitly | No—not explicitly | Yes: the program manual covers symptom management | Yes: the program manual covers dealing with the emotions of chronic illness (e.g. anger and depression) and relaxation techniques | Yes: program covers exercise and healthy eating. There was weekly action planning and feedback on progress. Also, there was modelling of self-management behaviours and problem-solving strategies | Yes: program covers communication skills with friends and family | Yes: program covers communication skills with health care providers. The program emphasizes the critical role of the patient managing their own health in partnership with health professionals | No | Wait list control—participants received the intervention 6 months later | |
| Willard-grace-2015 | Yes: the health coach assesses the patient’s knowledge about HbA1c, systolic blood pressure (SBP) or low-density lipoprotein (LDL). They discuss the patient’s most recent results for these measures, their goal for these numbers and how to reach the goal | Yes: during the pre-visit, health coaches go through ‘medication reconciliation’ with the patient, which includes reviewing the medications under prescription, assessing patients knowledge of the purpose of the medications and identifying barriers to adherence | No—not mentioned explicitly | Yes: during the ‘post visit’, health coaches negotiate an ‘action plan’ with the patient, which includes strategies to reduce stress | Yes: the ‘action plan’ also addresses diet, exercise and other relevant lifestyle factors. The telephone follow-ups address barriers and problems with meetings these goals | No | Yes: during the medical visit the health coach acts as an advocate for the patient, helping them to remember questions or concerns raised during the pre-visit and praising the patients, relaying to the clinician steps the patient has taken to care for their health | Health coaches were also responsible for further referrals to specialists and resource navigation | Usual care, including access to clinic resources that would normally be available such as visits with a clinician, diabetes educator, nutritionist, chronic care nurse and educational classes | 109 , 110 |
Risk of bias
In 43 studies, there was a substantial risk of bias, mainly due to loss of follow-up (Figs. 2 and 3). For continuous outcomes, most studies had insufficient outcome data. Furthermore, there were sometimes large differences in the proportion of dropouts between the intervention and control groups. Following Cochrane’s RoB2 guidance, we did not assume that multiple imputation or ‘last observation carried forward’ corrected for bias due to missing outcome data, unless there was a sensitivity analysis showing that there was no relationship between missingness of data and its true value.
Fig. 2.
Risk of bias in randomized trials (RoB2).
Fig. 3.
Risk of bias for cluster-RCTs (RoB2 CRT).
After randomization, some studies had significant differences in key outcome variables and prognostic factors between the intervention and control, which was concerning. In the Cluster-RCTs, one study randomized clusters before individual participant recruitment, which was also a cause for concern. Due to the nature of self-management interventions, blinding to intervention status for participants was not possible for any of the studies.
For the diabetes studies, the outcome assessors were usually blinded, reducing risk of bias. For the study outcomes that were self-reported, these were deemed to be at risk of social desirability bias.
Synthesis
All studies
Overall, 22 intervention arms had a positive effect on their primary outcome compared to the control arms, while 27 did not. Three studies did not provide this information. Interventions delivered remotely and exclusively to individuals had a higher proportion of positive outcome results. There was no strong trend in the proportion of positive outcomes when comparing interventions according to specific SES tailoring, use of CHWs in intervention delivery, the number of self-management components used, use of a named theory, risk of bias or disease focus. Supplementary Material 2 enumerates the primary outcome results according to key study characteristics, as a means of exploring what the active intervention components for socio-economically deprived populations might look like.
Diabetes
The main outcome for diabetes studies was mean change in haemoglobin A1c (HbA1c). HbA1c is a biomarker which measures the level of glycated haemoglobin in the bloodstream. Achieving a lower level of HbA1c is associated with reductions in diabetes-related complications, reflecting improved self-management.27 For the 13 studies included in the random-effects meta-analysis using this outcome, we imputed the SD values for five. Figure 4 shows the forest plot. Improvements in diabetes control (i.e. reductions in HbA1c) favoured the intervention groups. The pooled mean difference shows that participants in the intervention groups had a 0.29% greater reduction in HbA1c than the control group participants. (95% CIs: −0.48 to −0.10). The Cochrane Q statistic (Q (12) = 16.84) indicated that the studies were homogenous (P = 0.16). This was reinforced by the I2 value of 32.46%, which suggests only moderate heterogeneity (25% > I2 > 50%).
Fig. 4.
Forest plot for diabetes self-management RCTs.
Publication bias
For the diabetes meta-analysis, there was not strong evidence of publication bias. Details on publication bias can be found in the Supplementary Material 3.
GRADE
Our certainty in the body of evidence for diabetes is moderate (Supplementary Material 4). The level of certainty was downgraded mainly due to risk of methodological bias, specifically, insufficient outcome data.
Discussion
Main finding of this study
For the diabetes meta-analysis (n = 13), the intervention groups had a 0.29% greater reduction in HbA1c than the control groups. This is similar to the results of another meta-analysis of diabetes self-management education programs in American ethnic minority groups.78 Some suggest that a HbA1c reduction of at least 0.50% is needed for clinical significance.79 Therefore, while the meta-analysis indicates that diabetes self-management interventions were more successful than the control treatment, the clinical improvements were modest at best. Overall, the quality of the body of evidence for diabetes self-management programs, as qualified by GRADE, was moderate.
Narratively, findings were mixed for multi-morbidity and other individual conditions. Across all studies, we tabulated and compared the proportion of positive results according to key intervention characteristics. There was a slightly higher proportion of interventions with positive results that were delivered remotely and exclusively to individuals compared to other delivery modes. While this may be a chance finding, it is in line with the results of a previous review of self-management support interventions.12 Interventions with a reported theoretical basis had a similar proportion of positive results compared to interventions with no reported or explicit theoretical basis. Few studies indicated why their chosen theory was the most appropriate for the intervention or provided evidence of mapping out the theoretical constructs onto the intervention components.
There was no apparent trend in the proportion of positive results when stratified by the number of self-management components. This is in line with the results of another review.12 Less than half the interventions in this review had fidelity checks and often the intervention descriptions were brief. A review of fidelity and engagement in self-management interventions concluded the need for proper fidelity assessments to determine which components are contributing towards the intervention effect or lack of effect.80
What is already known on this topic
Self-management interventions can improve clinical outcomes and reduce health service utilization in the general population. However, previous reviews and studies have shown that individuals from socioeconomically deprived backgrounds are less likely to reap the benefits of these interventions due to a number of factors such as lower intervention engagement.5,6,8–12
What this study adds
This systematic review is the first to synthesize evidence on the effectiveness of self-management interventions for long-term conditions in people experiencing socio-economic deprivation and the specific tailoring and components of these interventions. The main strength of this review is the comprehensiveness of the search strategy, both in the number of databases searched and the breadth of the keyword search. We expanded on terms for socio-economic status and social determinants to include synonyms for proxy measurements unlike previous reviews on this topic.8 We included disease-specific searches rather than solely using general terms for ‘long term conditions’. We also described the interventions in accordance with TiDier guidelines to aid future intervention replication and testing.
In light of the results of this review, we recommend that future intervention development should clearly state their theoretical basis. It is increasingly being recognized that public health interventions based on behaviour change theory are more likely to be effective than those lacking a theoretical basis.81 In addition, future interventions could incorporate the common socioeconomic tailoring methods identified in this review. However, adaptations beyond addressing language and literacy barriers are needed. Evaluations should explore which self-management components are most effective (not just most common) in interventions targeted at people experiencing socio-economic deprivation, potentially using factorial design methods. More trials based outside the USA and addressing long-term conditions other than diabetes are needed. Whilst it is important to address diabetes, this population has a range of LTCs, and research should focus on managing these as well as the complex interplay of having two or more LTCs (multimorbidity). Socio-economic deprivation is associated with a higher incidence of multimorbidity over a 15-year period.82 In addition, deprivation is associated with a higher prevalence of common LTCs, including diabetes, but also anxiety, depression, dyspepsia and coronary heart disease.83
Limitations of this study
The overall methodological quality of the studies included was poor. Although the Egger test for the meta-analysis indicated no publication bias, we limited our selection criteria to only include peer-reviewed articles available in English. There may have been relevant non-English or grey literature evidence not included in this review. Finally, meta-analysis was not possible for all the studies due to the large variation in outcomes. Therefore, we tabulated the results. However, this method does not account for the magnitude of the effect sizes or differences in sample size.
Conclusion
Self-management interventions of diabetes tailored for people experiencing socio-economic deprivation produces clinically modest but statistically significant reductions in HbA1c, which is promising. Narratively, other studies on multi-morbidity and other individual LTCs had mixed findings, and more evidence is needed. Self-management interventions in the general population with LTCs have previously been found less effective for people experiencing socio-economic deprivation, and this review highlights the importance of tailored, inclusive interventions in this population. Tailoring included adaptions for low literacy (e.g. visual aids), the involvement of community health workers or peer leaders, providing helpful materials if needed (e.g. mobile phone) and financial incentives, but more strategies could be developed. In terms of the self-management components of the interventions, our evidence suggests the number included may not be important, and other factors may matter more, such as the quality of each component. Self-management strategies and interventions are becoming an increasingly popular approach to LTC management; to avoid exacerbating health inequalities, these interventions should include adaptions for people experiencing socio-economic deprivation.
Conflict of interest
The authors have no conflict of interest to disclose.
Funding
The National Institute for Health and Care Research (NIHR) School for Primary Care Research (project reference 539). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Data availability
Data is available on reasonable request from Megan Armstrong, the principal investigator.
Supplementary Material
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Tosan Okpako, PhD Student
Abi Woodward, Research Fellow
Kate Walters, Professors
Nathan Davies, Associate Professor
Fiona Stevenson, Professors
Danielle Nimmons, GP and PHD Student
Carolyn A. Chew-Graham, Professors
Joanne Protheroe, Professors
Megan Armstrong, Lecturer
Contributor Information
Tosan Okpako, Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK; Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
Abi Woodward, Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
Kate Walters, Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
Nathan Davies, Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
Fiona Stevenson, Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
Danielle Nimmons, Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
Carolyn A Chew-Graham, School of Medicine, Keele University, Keele ST5 5BG, UK.
Joanne Protheroe, School of Medicine, Keele University, Keele ST5 5BG, UK.
Megan Armstrong, Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK.
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Associated Data
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Supplementary Materials
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Data Availability Statement
Data is available on reasonable request from Megan Armstrong, the principal investigator.