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A systematic literature review of the effectiveness of diabetes education of school personnel

Key Messages Offer collaborative and interactive self-management education and support. Incorporate problem solving, goal setting and self-monitoring of health parameters for ongoing self-management of clinical and psychosocial aspects of care.

  • You are strongly encouraged to access diabetes self-management education and support when you are first diagnosed, as well as during times when there are changes in your diabetes treatment, general health or life circumstances;
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Design and implement person-centred learning to facilitate informed decision-making and achievement of individual goals. Individualize self-management education interventions according to the type of diabetes and recommended therapy within the context of the individual's ability for learning and change, culture, health beliefs and preferences, literacy level, socioeconomic status and other health challenges.

Create and offer self-management support that reflects person-centred goals and needs. Key Messages for People with Diabetes A variety of diabetes education and support programs are available to you. These may include group classes and individual counselling sessions, as well as strategies that use technology e.

Internet-based computer programs, mobile phone apps. You are strongly encouraged to access diabetes self-management education and support when you are first diagnosed, as well as during times when there are changes in your diabetes treatment, general health or life circumstances. Work with your diabetes team to: Establish a trusting and collaborative relationship Set goals for caring for your diabetes and health, and Identify strategies to help you manage your diabetes. Introduction The dynamic nature of diabetes and its impact on multiple aspects of one's life requires individuals to make frequent and ongoing self-management decisions.

Therefore, the title of this chapter has been modified to include self-management education SME and self-management support SMSin recognition of the growing evidence and benefit of SMS for individuals living with diabetes, particularly when combined with SME 1.

SME is a process to facilitate individuals in decision-making, resulting in improvements in variables, such as knowledge, attitudes and self-efficacy, as well as improvements in healthy behaviours and clinical outcomes 2.

It also recognizes that patient-provider collaboration, approaches and the development of problem-solving skills are crucial for sustained self-care 4. The goal of SME and SMS is to foster opportunities for people with diabetes to become informed and motivated to continually engage in effective diabetes self-management practices and behaviours.

To date, a growing body of research evidence indicates that the combination of both SME and SMS is most advantageous for improving glycemic control, self-efficacy, self-care behaviours i.

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Self-Management Education Several meta-analyses have demonstrated that SME is associated with clinically important benefits in people with diabetes, such as reductions in glycated hemoglobin A1C 1 and improvements in cardiovascular CV risk factors and reductions in foot ulcerations, infections and amputations 1.

A large population-based cohort study of 27,278 people with type 2 diabetes and no known previous cardiovascular disease CVD found that attending structured diabetes education was associated with a reduction in: A large retrospective cohort study of 26,790 individuals who had had at least 1 diabetes education session demonstrated lower diabetes-related health-care expenditures after 12 months compared to individuals who did not receive diabetes education 13.

Improved quality of life has also been demonstrated 14in addition to sustained weight loss and CV fitness for up to 4 years following education 15. SME also improved short- and long-term 1 year self-efficacy and reduced diabetes-related stress 16.

Defining SME Diabetes SME has evolved from traditional didactic teaching to a variety of educational, psychological and behavioural interventions, and collaborative teaching methods, tailored to the individual's specific needs 17.

SME comprises any educational processes that provide individuals with the knowledge and skills to inform decisions and increase their capacity and confidence to apply these skills in daily life situations 4. Interventions and strategies for ongoing self-management of medical, behavioural and emotional aspects of care may be integrated into knowledge and technical skills training 1.

A review of 18 systematic reviews found that educational interventions that emphasize knowledge, emotional and behaviour support, coping strategies and self-management training were associated with improved glycemic control at all ages 1.

Additionally, SME strategies that incorporate individual goal setting 16collaboration, problem solving 18patient empowerment strategies 12 and tailored education 1 were effective in improving glycemic control and self-care outcomes for individuals with diabetes. Furthermore, SME results in positive changes in diabetes-related knowledge 19as well as psychological 20β€”23 and behavioural 20,24 domains.

Basic knowledge and skills for SME include monitoring of relevant health parameters, healthy eating, physical activity, pharmacotherapy, prevention and management of hypo- and hyperglycemia, and prevention and surveillance of complications. Skill training includes self-monitoring of blood glucose SMBG ; making healthy dietary choices; incorporating physical activity; stress management; and medication adherence and adjustment 25,26.

Finally, research demonstrates that combining complex cognitive and affective emotional interventions to support the detection of problems, identify possible causes and generate corrective actions, were most effective in improving glycemic control 27.

The acquisition of knowledge may be augmented with cognitive behavioural interventions to achieve longer-term change in self-care behaviours 7,20,22,28. These include cognitive restructuring, problem solving, cognitive behavioural therapy CBTstress management, goal setting and relaxation techniques. All of these recognize that personal awareness and alteration of causative possibly unconscious thoughts and emotions are essential for effective behaviour change 29.

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Cognitive behavioural interventions share common elements, including a patient-centred approach, shared decision-making, the development of problem-solving skills, and the use of action plans directed toward patient-chosen goals, 20,22,30 and may be used in both individual and group settings 17,20. In general, group settings are more effective for short-term glycemic control, whereas group interventions combined with individual follow-up sessions result in lower glycated hemoglobin A1C levels than either setting alone 31.

Cognitive-behavioural interventions are effective in lowering A1C 8,32,33improving quality of life 34,35 and increasing self-care behaviours 20,32although other studies show mixed results 7,28. A network meta-analysis found that 11 or more hours of behavioural interventions for type 2 diabetes were associated with a reduction of A1C of at least 0. The reduction in A1C was even greater in those with baseline A1C levels greater than 7. Interventions that combine strategies for knowledge acquisition and self-care management 22,28 appear to be more effective in increasing knowledge, self-efficacy and self-care behaviours and in achieving metabolic control than didactic and knowledge-oriented programs alone 8,17,32,36.

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A growing number of studies demonstrate that early diabetes SME is effective in improving glycemic control 1. However, statistically and clinically significant improvements in A1C were seldom maintained after 3 months without additional SMS 1. Frequent communication is key for successful interventions, whether by an interprofessional, in-hospital diabetes team or a community setting 37,38. Effective individual health-care provider communication may improve adherence by decreasing barriers to overall diabetes management 39.

Many systematic reviews demonstrate that access to an interprofessional team for diabetes education is associated with improvements in glycemic control, lipids and blood pressure BP 1. Furthermore, expanding the role of educators, to include medication management, support and monitoring of individuals with diabetes, is associated with improvements in glycemic control, cholesterol and BP 1. Evidence on the use of new technology to support SME in diabetes is still emerging. The current literature suggests that virtual environments provide a feasible and useful platform for diabetes education and support for people with diabetes as well as educators 41,42.

SME delivered via the Internet is effective at improving measures of glycemic control and diabetes knowledge in adults with type 2 diabetes compared with usual care 1,41. Internet-delivered diabetes education may increase access for many individuals and they can engage in self-paced learning. New online materials may need to be added for ongoing engagement 41.

A systematic literature review of the effectiveness of diabetes education of school personnel.

However, there was no evidence of benefit for other biological, cognitive, behavioural or emotional outcomes 43. Mobile applications, especially text messaging, may also be used as educational tools for improving outcome among people with type 2 diabetes 2,44.

In a meta-analysis of 13 trials, a difference in A1C of 0. The acceptability of such approaches are mixed as some report high satisfaction, while others report participants requesting to stop the messages before the end of the intervention, and low acceptability for challenging interfaces or inexperienced participants with mobile web use 2. Age, diabetes duration, A1C, and type and length of the intervention may also have implications on the effectiveness of such approaches 44.

Tailoring SME to the individual is paramount. Family and culturally tailored interventions are particularly relevant in minority communities. Several randomized controlled trials and systematic reviews demonstrate that culturally competent health-care interventions result in lower A1C levels and improvements in diabetes-related knowledge and quality of life 34,37,48. Family and social support positively impact metabolic control and self-care behaviours 37,48,49. In both type 1 and type 2 diabetes, interventions that target the family's ability to cope with stress result in fewer conflicts, and having partners involved in care positively impacts glycemic control 49.

Studies identifying program characteristics associated with greater success for minority populations show larger reductions in A1C with individual and face-to-face delivered educational programs and peer educators, than with group-based diabetes education programming 46,51.

Key Messages

Additionally, content and materials geared toward people with low literacy and numeracy can be successful in improving outcomes, such as A1C, self-efficacy and BP 52.

Training healthcare professionals about health literacy, numeracy and clear communication principles to address low literacy can also be effective 53,54.

Finally, self-identification of problems or need for self-care improvement by the individual is critical to all cognitive-behavioural interventions 32,55. The health-care provider's role is to collaboratively facilitate this awareness or identification of issues 4. S27 refers to policies and people that support self-management behaviours across the lifespan, and are not necessarily specific to educational processes.

Although historically, diabetes educators have provided SMS, educators are increasingly challenged to offer and maintain SMS, such as frequent and ongoing supportive follow up and case management due to expanding caseloads, complexity of individual diabetes care and limited time and resources 6.

Such support may include frequent follow up by a health-care provider, diabetes coaching, peer support or community health workers, linkages with community support groups or interest groups. To date, a growing body of research evidence indicates that combining SME and SMS is most advantageous for improving glycemic control, self-efficacy and self-care behaviours, and reducing diabetes distress and foot complications 1,6,16. Although the delivery strategy for SMS appears to be dependent on the population and context, evidence suggests that frequent interactions with text message systems on mobile phones when combined with the Internet to relay blood glucose records are associated with improved glycemic control 1,43,44,70.

Additional systematic reviews of healthy behaviour programs for those living with type 2 diabetes found that web-based programs are effective in increasing physical activity 43,71decreasing dietary fat intake 43 and improving overall dietary intake 42. A systematic literature review of the effectiveness of diabetes education of school personnel, several small trials demonstrate improved outcomes when utilizing reminder systems and scheduled follow ups compared to controls.

Outcomes include improving SMBG 60,65,71,72improved adherence to treatment algorithms 73improved self-efficacy 6,66β€”68 and quality of life 74as well as improved clinical outcomes, including reductions in A1C 61β€”64,67,70,75,76 and weight 69,77. The superiority of peer-delivered programs over similar programs delivered by health professionals is yet to be demonstrated in general populations with type 2 diabetes 79,80.

Studies of the incremental effect of peer educators show variability in terms of behaviour change and clinical outcomes 81,82. Although training and scope of practice of peer leaders or community support workers is not clearly articulated in the literature, some examples exist for which the role has been successfully created, implemented and evaluated in clinical and community settings 78,83.

Tailoring SMS An SMS intervention that is most readily available for tailoring includes frequent follow up with a diabetes educator 84. A telephone-based support intervention 4 phone calls in one yearfollowing education, to reach a lower-income minority population living a systematic literature review of the effectiveness of diabetes education of school personnel diabetes, found that participants who receive telephone contact have an A1C 0.

Community health workers may also play an important role in tailoring SMS interventions to ethnically diverse populations. Peer support and community health workers may offer SMS and engage with individuals with diabetes in the community setting, primarily in faith-based settings, community health centres and at community events 83.

Finally, diabetes coaching is emerging as a promising SMS intervention that offers opportunities for personalized support, depending on an individual's self-management needs and preferences.

Conclusions Evidence supports the beneficial effect of SME on diabetes clinical, emotional and behavioural outcomes. Interventions that include face-to-face delivery, a cognitive-behavioural method and the practical application of content are more likely to improve glycemic control 33,45,86.

Recommendations People with diabetes should be offered timely SME that is tailored to enhance self-care practices and behaviours [Grade A, Level 1A 1,7,9,10,38,45 ].

All people with diabetes who are able should be taught how to self-manage their diabetes [Grade B, Level 2 16,38,40 ]. SME that incorporates cognitive-behavioural educational interventions, such as problem solving, goal setting, self-monitoring of health parameters and dietary modifications and physical activity, should be implemented for all able individuals with diabetes [Grade B, Level 2 18,20,33,42,45,71,86,87 ].

Interventions that increase participation and collaboration of the person with diabetes in health-care decision-making should be used by health-care providers [Grade B, Level 2 38 ]. Support for self-management should be offered to assist individuals in implementing and maintaining diabetes self-management [Grade B, Level 2 1 ] by offering any of the following: In both type 1 and type 2 diabetes, interventions that target the family's ability to cope with stress or diabetes-related conflict should be included in educational interventions when indicated [Grade B, Level 2 49 ].

Technologies, such as Internet-based computer programs and glucose monitoring systems, brief text messages and mobile apps, may be used to support self-management in order to improve glycemic control [Grade A, Level 1A 44,70 for type 2 diabetes; Grade B, Level 2 1 for type 1 diabetes].

Culturally appropriate SME and SMS, which may include peer or lay educators, may be used to increase diabetes-related knowledge and self-care behaviours and to improve glycemic control [Grade A, Level 1A 46,47,50 ].

Key Messages for People with Diabetes

Adding literacy- and numeracy-sensitive materials to comprehensive diabetes management education and support programs may improve knowledge, self-efficacy and A1C outcomes for people with low literacy [Grade C, Level 3 52 ].

S27 Monitoring Glycemic Control, p. S47 Diabetes and Mental Health, p. S130 Type 1 Diabetes in Children and Adolescents, p. PLoS Med 6 6: For more information, visit www. Sherifali reports investigator-initiated funding from AstraZeneca.