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Table 2 An overview of the studies included in the review

From: Diabetes self-management arrangements in Europe: a realist review to facilitate a project implemented in six countries

Country Initiative Relevant citations Definition Goals to be obtained Overall studies participants Main research findings Setting Professionals roles
UK Local Diabetes Centres (within The Diabetic Retinopathy Screening Service for Wales) Dennis et al, 2000[14] Education, Community based service, Real and virtual specialist support service, Enhanced all-Wales screening service. Behaviour change. Locally implemented Some elements (funding, structure have been successful in promoting self-management, but some need revising (education, behavioural change). There are 3 models of diabetes education in Wales. More to be invested in this area in the years to come. Primary Care Patient education a requirement of all providing services to patients with diabetes. Staff encouraged to set an example.
UK DAFNE (Dose Adjustment For Normal Eating) Jack, 2001; DAFNE Study Group, 2002; Shearer et al, 2004; Speight et al, 2010; Lawton et al, 2010; Rankin et al, 2011; Leelarathna et al, 2011; Keen et al, 2012; Gunn et al, 2012; Rankin et al, 2012 [1524] A course teaching flexible intensive insulin treatment combining dietary freedom and insulin adjustment (delivered in 35 hours over 5 consecutive days). Dietary freedom. 715 Improved quality of life (p < 0.001) and glycaemic control (p < 0.0001) in people with type 1 diabetes without worsening severe hypoglycaemia or cardiovascular risk. Has the potential to be a cost-saving initiative. The impact of a single DAFNE course on glycaemic control remains apparent in the long term (4 years). DAFNE delivered in routine clinical practice is associated with a range of benefits and certain clinical and psychosocial characteristics are associated with better outcomes. Results show significant reductions in total, quick acting and basal insulin (all p < 0.0005) doses in patients undergoing DAFNE training. Secondary Care - Diabetes Clinics Diabetes specialist nurses and dieticians who attended a training course.
UK LAY (Look After Yourself programme) Cooper et al, 2003a; Cooper et al, 2003b; Cooper et al, 2008 [2527] Theoretically constructed on the premise that knowledge acquisition alone does not necessarily promote self-directed action. Rather, systems of motivation and the teaching of skills (practical, physical, conceptual, emotional, social and personal) are stressed. Behaviour change, empowerment-based education. 89 Associated with only limited benefits in glycaemic control (only significant in 6 months, p < 0.005), but there were significant educational (p < 0.002) and psychological benefits. Primary Care/ Hospital Diabetes specialist nurses trained in the programme.
UK Portsmouth Primary Care Trust, Self-management programmes for people with diabetes Cradock, 2004 [28] Structured self management programmes, delivered to groups of patients, to assist in helping people be clearer about how they can make changes that will reduce their risk of diabetes complications and cardiovascular disease. Behaviour change. Locally implemented Engaging with patients in a group situation appears to be beneficial. The programme has run since 2001 and the evidence is that it is working (3 practices added group follow-up). Primary Care Nurses and dieticians. Training around empowerment, counselling and communication skills.
UK UCL-DSMP (University College London-Diabetes Self Management Programme) Steed et al, 2005 [29] Group-based programme consisting of five 2.5 hour sessions held weekly for five weeks, plus one booster session of 2.5 hours held three months after the end. Behaviour change, quality of life. 124 At immediate post-intervention and three-month follow-up the intervention group showed significant improvement relative to controls on self-management behaviours (p < 0.01), quality of life (p < 0.01) and illness beliefs (p < 0.05). A trend towards improved HbA1c was also observed (p < 0.01). Outpatient clinics, hospital Diabetes specialist nurses and dieticians.
UK Librae Franklin et al, 2006 [30] Software package in the form of ‘diabetes diary’ (validated algorithm) to input data related to patients’ daily diabetes self-management. Individual responsibility, Educational predictive tool. 15 The modelled values of ‘Librae’ correlated well with the continuous blood glucose monitoring data (positive mean 0.35 mmol/L), but clinically unacceptable errors occurred at extremes of blood glucose levels. Diabetes Clinic No direct health care professional input.
UK Diabetes Manual Sturt, Hearnshaw et al, 2006; Sturt, Taylor et al, 2006; Sturt et al, 2008; Lindenmeyer et al, 2010 [3134] A self-management 1:1 educational intervention aimed at improving biomedical and psychosocial outcomes. Behavioural change, skills and confidence for self-management. 257 A small improvement in patient diabetes-related distress (p = 0.012) and confidence to self-care over 26 weeks, but no significant difference in HbA1c (p = 0.39). The programme requires close communication and openness towards collaborative approaches to improve skills and confidence for self-management. Primary Care 2-day training for nurse to deliver the programme; telephone-support in weeks 1,5,11; 12-month follow-up.
UK DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) Skinner et al, 2006; Davies et al, 2008; Ockleford et al, 2008; Skinner et al, 2008; Gillett et al, 2010; Skinner et al, 2011; Khunti et al, 2012 [3541] Structured education program on illness beliefs, quality of life and physical activity. Behavioural change, illness awareness, lifestyle outcomes. 1660 Newly diagnosed individuals are open to attending self-management programs. Positive improvements in beliefs about illness and weight loss. Structured group education is essential. Combining illness beliefs into discrete clusters may be more useful in understanding patterns of responding to illness. The intervention is likely to be cost effective compared with usual care. A single programme for people with newly diagnosed type 2 diabetes showed no difference in HbA1c (P = 0.81) or lifestyle outcomes at 3 years, but illness belief score differed significantly (p = 0.01). Primary Care Specific guidelines for trained educators. The amount of time educators talk provides practical marker for the effectiveness of the process.
UK The diabetes X-PERT programme Deakin et al, 2006; Deakin et al, 2009; Choudhury et al, 2009 [4244] 6-week structured education programme based on theories of patient empowerment and discovery learning, to develop skills and confidence leading to increasing diabetes self-management and sustain improvement. Personal responsibility, lifestyle and psychosocial outcomes. 191 Attendance rates 58%. Participation in the X-PERT Programme by adults with T-2D was shown at 14 months to lead to improved glycaemic control, reduced total cholesterol level, body weight, BMI & waist circumference, reduced requirement for diabetes medication, increased consumption of fruit and vegetables, enjoyment of food, knowledge of diabetes, self-empowerment, self-management skills and treatment satisfaction (all self-reported). Primary Care The programme trains health-care professionals to deliver it to people with diabetes.
UK BITES (Brief Intervention in Type 1 diabetes, Education for Self-efficacy) George et al, 2007; George et al, 2008 [45, 46] Brief (2.5 days) psycho-educational intervention Patient empowerment 114 At 12 months, had no significant impact on HbA1c (p = 0.94) or severe hypoglycaemia, but improved diabetes treatment satisfaction (p = 0.006) and patient empowerment. Secondary Care Nurses and dieticians. Multidisciplinary teams.
UK Diabetes Virtual Clinic Armstrong et al, 2008; Jennings et al, 2009; Powell et al, 2009; Armstrong et al, 2012 [4750] Internet-based self-management tool for diabetes allowing patients to communicate with their health professionals, find information about their condition and share support and advice with others through peer-to-peer discussions. User-centred approach, Support for patients to become effective self-managers 22 The pilot study did not identify evidence of an impact on HbA1c (p = 0.53), improving quality of life or self-efficacy in patients who used insulin pump therapy. Users found participation reassuring. They rated peer interaction (53%) as the most desirable and the most useful of the features available. Hospital clinics (online community) Online “ask an expert” sessions conducted with diabetes specialists not directly involved with the patients care.
UK Birmingham Own Health telephone care management service Jordan et al, 2011 [2] Telephone-based care service (nurse-delivered motivational coaching and support for self-management and lifestyle change) for patients with poorly controlled diabetes. Behavioural, lifestyle change. 473 The intervention is effective in reducing HbA1c levels (p = 0.0004), blood pressure and BMI in people with diabetes. Study design had limitations (controls matched from a retrospective cohort). Primary Care (telephone-based) Specifically trained nurses as Care Managers.
UK Whole Systems Model Bower et al, 2012 [12] Self-management support through an evidence-based ‘whole systems’ model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care. Behaviour change, Whole System Approach Designed Protocol paper only Primary Care Multidisciplinary approach
Netherlands CBGT (Cognitive Behavioural Group Training) Snoek et al, 2001; van der Ven et al, 2005a; van der Ven et al, 2005b [5153] 4 weeks cognitive behavioural small group training aimed at modifying dysfunctional beliefs, reducing negative emotions and enhancing self-care practices. Behavioural change 131 Following CBGT, mean HbA1c dropped by 0.8% at 6 months from baseline (p = 0.36), while emotional well-being was preserved. CBGT was successful in improving self-efficacy (p = 0.01), diabetes-related distress (p = 0.01) and mood (p < 0.001) at 3 months’ follow-up, but not in improving glycaemic control. Outpatient setting Diabetes nurse specialist and psychologist.
Netherlands Theory-driven Intervention Schreurs et al, 2003 [54] Action plans to enhance self-management provided to disease-homogeneous groups of patients. Planning of behaviour, goal-setting 24 The majority of participants were satisfied with the programme and positive about most of the intervention aspects (evaluation scores ranged 3.03-4.05/5). Patients of older age, lower education, or no current employment responded best to the intervention. Outpatient department, hospital Specialised nurses trained by cognitive behavioural therapists, techniques applicable in the daily care.
Netherlands Di@alog Study Roek et al, 2009 [55] Web-based self-management programme for insulin titration in T2DM patients. Personal responsibility, glycaemic control Designed, 248 Protocol paper only Primary Care (web based) General Practitioner and practice nurse more conscious of the treatment process.
Netherlands Diabetes Coach Nijland et al, 2011 [56] Web-based application for supporting the self-care of patients with type 2 diabetes. Empowered patients 50 Long diabetes duration a factor for increased engagement (p = 0.03). Factors influencing increased use of eHealth technologies: (1) avoiding selective enrollment, (2) making use of participatory design methods, and (3) developing push factors for persistence. Primary Care (web based) Multidisciplinary teams, patient-nurse email exchange.
Netherlands DIEP.info (Diabetes Interactive Education Programme) Heinrich et al, 2012 [57] Web-based type 2 diabetes self-management education programme aimed at improving knowledge, encouraging active patient participation and providing supportive self-management tools. Knowledge improvement 674 The effect evaluation showed a significant intervention effect (p < 0.01) on knowledge. The user evaluation showed high satisfaction with the programme’s content, credibility and user-friendliness. However, it is not fully used as intended. Web-based Active role and clear instructions for health care professionals.
Norway Diabetes Self Management Education Rygg et al, 2010; Rygg et al, 2012 [58, 59] Locally developed group based education. Knowledge improvement, skills 168 The controls in locally developed ongoing diabetes self-management education programs prevented an increase (0.3%) in HbA1c and can have an effect in patients with higher levels. Locally developed education programmes seem to have less effect than interventions developed for studies. Hospital Led by diabetes nurses, and input by physician, physiotherapist and a lay person.
Spain eHealth platform Fico et al, 2011; Fioravanti et al, 2011 [60, 61] Technological platform for diabetes disease management. Web usability to induce self-care 23 High usability and satisfaction (score 4.7/6). Web-based Clinicians, market analysis and technology experts.
Bulgaria DEPB (Diabetes Education Program in Bulgaria) DEBM, 2001[7] A large-scale unified structured educational programme for insulin-treated diabetic patients. Education, knowledge improvement, empowered patients 1037 56 educational centres. Trained patients cope better with their condition. Regional centers (potential for primary care) Endocrinologist, nurse.