The investigators conducted a comparative effectiveness randomized controlled trial comparing a family model diabetes self-management education and support intervention (Family-DSMES) and a standard model DSMES intervention (Standard-DSMES). The trial included 550 persons with type 2 diabetes mellitus (PWD) and 550 of their family members/support persons. PWD were randomly assigned to either the Family-DSMES arm or the Standard-DSMES arm. In the Family-DSMES arm, the family members/support persons of the PWD took part in the educational sessions. In the Standard-DSMES arm, the family members/support persons did not participate in educational sessions or goal setting. Both interventions were delivered in a group setting via telehealth. Baseline, immediate post-intervention (12 weeks) and 6 months post-intervention data were collected from PWD and family members/support persons in both study arms. In both study arms, we obtained a medical records release to abstract the primary outcome at 12 months post-intervention and 18 months post-intervention for PWD. The primary outcome was change in Hemoglobin A1c between baseline and immediate post-intervention among PWD.
Approximately 11% of the United States population has type 2 diabetes mellitus, including 12% of Arkansas's population. Diabetes self-management education and support (DSMES) is recommended for people with diabetes (PWD) to support necessary self-management practices and improve health outcomes. Systematic reviews have documented the efficacy of family models of DSMES. To our knowledge, there has been no randomized comparison of the effectiveness of a family model and standard model of DSMES that: 1) evaluates curricula that incorporate elements required for program accreditation/recognition; 2) is implemented among general/diverse populations using curricula that is not culturally adapted; and 3) evaluates outcomes in PWD and family members/support persons. This study addressed important gaps in knowledge by comparing a family-based model of DSMES (Family-DSMES) to standard (individual focused) DSMES (Standard-DSMES). Family-DSMES included PWD and their family members/support persons in educational sessions which explicitly addressed diabetes self-management within a family context, educating both patients and family members/support persons, family goal setting to support the PWD, understanding supportive and non-supportive behaviors, and family behavioral changes. The overarching research question was "Compared to Standard-DSMES, does Family-DSMES yield improved outcomes among diverse patients with type 2 diabetes mellitus and their family members/support persons?" The primary outcome was change in hemoglobin A1c (HbA1c) between baseline and post-intervention among PWD. Secondary outcomes for PWD included other biometric outcomes (body mass index, and blood pressure), behavioral outcomes (diabetes self-care behaviors and medication adherence), and psychosocial outcomes (diabetes management self-efficacy, diabetes-related distress, diabetes-related support, family involvement in diabetes management, and diabetes-related quality of life). We also examined the duration of treatment effects by comparing outcomes collected at 6 months post-intervention, 12 months post-intervention, and 18 months post-intervention using HbA1c data extracted from electronic medical records. PWD were randomly assigned to either the Family-DSMES arm or the Standard-DSMES arm. Family-DSMES was delivered in group sessions via telehealth by a certified diabetes care and education specialist (CDCES) to patients and their family members. The intervention included 10 hours of education delivered over 10 weeks in one-hour sessions. Family members in the Family-DSMES arm took part in educational sessions and data collection. Standard-DSMES was delivered in group sessions via telehealth by a CDCES to patients only. The intervention included 10 hours of education delivered over 10 weeks in one-hour sessions. Family members took part in data collection but did not take part in educational sessions. We recruited participants through eight primary care clinics across the state of Arkansas. Initial eligibility was determined through medical record abstraction. Patients who were deemed potentially eligible were sent a recruitment letter from their clinic and the Principal Investigator with an explanation of the study, followed up with a phone call from study staff or being approached in the clinic to discuss interest in the study. Potentially eligible and interested PWD were asked to identify a family member/support person to participate in the study with them, who were also contacted by study staff to assess interest and eligibility. Inclusion criteria for PWD included: 1) adults ≥18 years of age; 2) have HbA1c ≥7.0%; 3) speak English; and 4) have an eligible family member/support person willing to take part in the study. For this study, a family member/support person was defined as "a person living in the same household and/or assisting the patient with household matters." Enrolled family members/support persons were also required to be ≥18 years of age and speak English. Exclusion criteria for PWD included: 1) received formal DSMES in the prior three years; 2) have a condition that makes it unlikely for them to be able to follow the study protocol, such as a terminal illness; and 3) have plans to move out of the area within 18 months. The enrollment visit took place in a private room at the clinic of the PWD. The enrollment visit was scheduled by study staff at a time where both the person with diabetes and family member/support person could attend. PWD were provided with a study information sheet to review, and to ensure eligibility, a point-of-care measurement of HbA1c was completed. After the HbA1c results confirmed eligibility, study staff met with the PWD and their family member/support person to explain each element of the informed consent. Both the PWD and family member/support person provided written informed consent.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
NONE
Enrollment
1,100
Family Diabetes Self-Management Education and Support demonstrates the effectiveness of family-centered models of DSMES that explicitly address diabetes self-management within a family context by educating both patients and family members and focusing on family motivational interviewing, family goal setting, understanding supportive and non-supportive behaviors, and family behavioral changes.
Diabetes Self-Management Education and Support demonstrates the effectiveness of individual model DSMES that explicitly address diabetes self-management within an individual context by educating individual patients on individual motivational interviewing, individual goal setting, and individual behavioral changes.
University of Arkansas for Medical Sciences Northwest
Fayetteville, Arkansas, United States
Hemoglobin A1c (HbA1c)
A Siemens DCA Vantage analyzer was utilized to collect HbA1c from participants via finger stick blood collection (except for 12 months post-intervention and 18 months post-intervention, which was collected through medical record abstractions).
Time frame: Baseline, immediate post-intervention, 6 months post-intervention, 12 months post-intervention, 18 months post-intervention
Body Mass Index (BMI)
Participant height (without shoes) was collected using a stadiometer and participant weight (without shoes) was collected using a calibrated digital scale. Height and weight were used to compute a continuous measure of BMI (kilograms per square meter).
Time frame: Baseline, immediate post-intervention, 6 months post-intervention
Systolic Blood Pressure
Blood pressure was measured with a digital blood pressure device with the participant seated and arm elevated to place the cuff approximately at heart height. Two blood pressure measurements were taken, waiting at least one minute between readings. The two measurements were averaged and recorded.
Time frame: Baseline, immediate post-intervention, 6 months post-intervention
Diastolic Blood Pressure
Blood pressure was measured with a digital blood pressure device with the participant seated and arm elevated to place the cuff approximately at heart height. Two blood pressure measurements were taken, waiting at least one minute between readings. The two measurements were averaged and recorded.
Time frame: Baseline, immediate post-intervention, 6 months post-intervention
Glucose
Through finger prick blood collection, point of care tests were used to collect non-fasting blood glucose.
Time frame: Baseline, immediate post-intervention
Total Cholesterol
Through finger prick blood collection, point of care tests were used to collect lipids using a commercial lipid panel kit and Cholestech LDX analyzer.
Time frame: Baseline, immediate post-intervention
High-Density Lipoproteins (HDL)
Through finger prick blood collection, point of care tests were used to collect HDL using a commercial lipid panel kit and Cholestech LDX analyzer.
Time frame: Baseline, immediate post-intervention
Triglycerides
Through finger prick blood collection, point of care tests were used to collect triglycerides using a commercial lipid panel kit and Cholestech LDX analyzer.
Time frame: Baseline, immediate post-intervention
Low-Density Lipoproteins (LDL)
Through finger prick blood collection, point of care tests were used to collect LDL using a commercial lipid panel kit and Cholestech LDX analyzer.
Time frame: Baseline, immediate post-intervention
Medication Adherence (ARMS-D)
The Adherence to Refills and Medications Scale for Diabetes Medicines (ARMS-D) was used to measure patient's adherence to their medications (if prescribed). The ARMS-D uses 12 items to assess self-reported adherence to diabetes medications. Item responses range from 1 (none of the time) to 4 (all of the time) and are summed to produce an overall adherence score with a possible range of 12-48, with higher scores representing more problems with medication adherence.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Efficacy (DMSES)
The Diabetes Management Self-Efficacy Scale (DMSES) was used to measure patient's confidence in managing their diabetes. The DMSES assesses self-reported confidence in managing multiple aspects of their diabetes. The item reponses range from 1 (not at all confident) to 10 (totally confident) and are averaged to generate composite scores, with higher scores indicating higher levels of self-efficacy.
Time frame: Baseline, immediate post-intervention
Diabetes-Related Distress (PAID-5)
The Problem Areas in Diabetes scale (PAID-5) was used to measure diabetes-related distress. The PAID-5 consists of 5 items to assess self-reported diabetes-related emotional distress, including feeling scared or depressed. Item responses range from 0 (not a problem) to 4 (serious problem) and are summed to produce an overall composite score, with a total score of 8 or higher indicating possible diabetes-related emotional distress.
Time frame: Baseline, immediate post-intervention
Diabetes-Related Quality of Life (DIDP)
The Diabetes Attitudes Wishes and Needs (DAWN2) study Impact of Diabetes Profile (DIDP) was used to measure the perceived impact of diabetes on patients' quality of life. The DIDP consists of 6 items to assess self-reported impacts on quality of life, including physical health, financial situation, and relationships with others. Item responses range from 1 (very negative impact) to 7 (very positive impact) and are reverse scored and averaged to generate composite scores, with lower scores indicating greater positive impact and higher scores indicating greater negative impact.
Time frame: Baseline, immediate post-intervention
Diabetes-Related Helpful Family Involvement (FIAD-helpful)
The Family and Friend Involvement in Adults' Diabetes (FIAD) scale was used to measure participants' perception of helpful involvement of their friends and family in managing their diabetes. Item responses range from 1 (never in the past month) to 5 (twice or more each week) and are averaged to generate composite scores for helpful family involvement, with higher scores indicating more frequent helpful involvement.
Time frame: Baseline, immediate post-intervention
Diabetes-Related Harmful Family Involvement (FIAD-harmful)
The Family and Friend Involvement in Adults' Diabetes (FIAD) scale was used to measure participants' perception of harmful involvement of their friends and family in managing their diabetes. Item responses range from 1 (never in the past month) to 5 (twice or more each week) and are averaged to generate composite scores for harmful family involvement, with higher scores indicating more frequent harmful involvement.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Follow Healthful Eating Plan
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants followed a healthful eating plan over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Follow Personal Eating Plan
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants followed their personally tailored eating plan over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Fruits and Vegetables
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants ate five or more servings of fruits and vegetables over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Fatty Foods
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants ate high fat foods such as red meat or full-fat dairy over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Physical Activity
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants participated in at least 30 minutes of continuous physical activity over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Specific Exercise
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants participated in a specific exercise session (such as swimming, walking, biking) over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Blood Sugar Test
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants tested their blood sugar over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Blood Sugar Test Recommended by Provider
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants tested their blood sugar the number of times recommended by their healthcare provider over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Check Feet
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants checked their feet over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Inspect Shoes
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed how often participants inspected the inside of their shoes over the past week. Item responses range from 0 days to 7 days, with higher scores indicating more frequent behavior (more days in the past week). Items in the SDSCA scale were analyzed separately.
Time frame: Baseline, immediate post-intervention
Diabetes Self-Care Behaviors (SDSCA): Smoking
Items from the Summary of Diabetes Self-Care Activities (SDSCA) were used to assess engagement in diabetes self-care behaviors over the past week. This item assessed whether participants had smoked in the past week (yes=1; no=0). Items in the SDSCA scale were analyzed separately. The mean estimates of this outcome are presented on the odds scale from logistic generalized estimating equation models.
Time frame: Baseline, immediate post-intervention
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