Role of diabetes self-management education in improving self-care behavior among adult type 2 diabetics: A systematic review and meta-analysis

Mamta Gehlawat; Goutham Thumati; Sreenivas Gundala

doi:10.4103/mjhs.mjhs_71_22

SYSTEMATIC REVIEW AND META-ANALYSIS

Year : 2023 | Volume : 11 | Issue : 1 | Page : 9-16

Role of diabetes self-management education in improving self-care behavior among adult type 2 diabetics: A systematic review and meta-analysis

Mamta Gehlawat, Goutham Thumati, Sreenivas Gundala
Department of Community Medicine, GMC, Siddipet, Telangana, India

Date of Submission	01-Aug-2022
Date of Decision	02-Oct-2022
Date of Acceptance	20-Oct-2022
Date of Web Publication	02-Feb-2023

Correspondence Address:
Mamta Gehlawat
Department of Community Medicine, 2^nd Floor, GMC Siddipet, Ensanpally, Siddipet - 502103, Telangana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_71_22

Abstract

Background: Type 2 diabetes mellitus (T2DM) is a crucial public health issue causing physical, financial, and psychosocial crises globally.
Objectives: To estimate the effectiveness of diabetes self-management education (DSME) on self-care behavior among T2DM patients.
Materials and Methods: A systematic review and meta-analysis of intervention trials promoting self-care behavior among T2DM patients was done by searching MEDLINE, Clinicaltrials.gov, Microsoft Academics, ScienceDirect, ICTRP, OAISTER, LILACS and CINAHL to identify eligible trials starting from inception till August 26, 2021. Studies which did not have a self-care behavior intervention, couldn't be found or translated in English, didn't have control arm or had multiple study arms, had <30 study participants per arm, or included adolescent or pregnant individuals were excluded. Data screening, extraction, and analysis were done with help of Rayyan software, Microsoft Excel and JASP software. Cochrane risk of bias tool was used to assess bias in the studies.
Results: The search yielded 4023 results, of which 20 studies were included in meta-analysis. Our main outcome was “change in self-care behaviour score” owing to the DSME intervention. The pooled standardized mean difference in self-care behaviour was 1.38 (95% confidence interval 0.50–2.27, I² ¼ 99.2, P < 0.001) with Dersimonian and Laird random effects method.
Conclusion: Owing to the paucity of studies in low- and middle-income countries, further studies are needed to evaluate the DSME effectiveness in preventing diabetes related complications and enhancing patients' quality of life.

Keywords: Diabetes, diabetes self-management education, review, self-care, self-management

How to cite this article:
Gehlawat M, Thumati G, Gundala S. Role of diabetes self-management education in improving self-care behavior among adult type 2 diabetics: A systematic review and meta-analysis. MRIMS J Health Sci 2023;11:9-16

How to cite this URL:
Gehlawat M, Thumati G, Gundala S. Role of diabetes self-management education in improving self-care behavior among adult type 2 diabetics: A systematic review and meta-analysis. MRIMS J Health Sci [serial online] 2023 [cited 2023 Oct 4];11:9-16. Available from: http://www.mrimsjournal.com/text.asp?2023/11/1/9/369044

Introduction

More than 450 million individuals in the world suffer from diabetes today, which is projected to cross 700 million by 2050.^[1] Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke, and lower limb amputation.^[2] In 2019, an estimated 1.5 million deaths were directly caused by diabetes. Diabetes is a chronic disease that requires a person to undertake a multitude of daily self-management decisions and activities. Diabetes can be treated and its consequences avoided or delayed with diet, physical activity, medication, and regular screening and treatment for complications.^[3]

Diabetes self-management education (DSME) is the process of facilitating the knowledge, skill, and ability necessary for diabetes self-care and has been shown to improve health outcomes.^[4] DSME programs are designed to address the patient's health beliefs, cultural needs, current knowledge, physical limitations, emotional concerns, family support, financial status, medical history, health literacy, numeracy, and other factors that influence each person's ability to meet the challenges of self-management.^[5],[6]

Despite proven benefits and general acceptance, the number of patients who are referred to and receive DSME are disappointingly small. This lacuna necessitates the generation of more scientific evidence on effectiveness of DSME to halt the day-to-day increasing morbidity and mortality due to Type 2 diabetes by adding to insights of diabetes health care providers. This systematic review and meta-analysis aims to estimate the effectiveness of DSME on self-care behavior among T2DM patients.

Materials and Methods

A systematic review registered in international prospective register of systematic reviews (PROSPERO) was conducted following^[7],[8] preferred reporting items for systematic reviews and meta-analyses (PRISMA) recommendations. This systematic review and meta-analysis (SRMA) was conducted to explore improvement in self-care behaviour scores following DSME-based interventions. We searched for intervention studies with control groups, where a summarized self-care score was available as behavioral outcome after a minimum of 3 months follow-up postintervention.

Search strategy and eligibility criteria

We searched the domestic and foreign databases of MEDLINE, Clinicaltrials.gov, Microsoft Academics, Science Direct, ICTRP, OAISTER, LILACS, and CINAHL to identify eligible trials starting from inception till August 26, 2021. The search strategy for MEDLINE was “((type 2 diabetes [Title/Abstract]) AND (intervention [Title/Abstract])) AND (self-care [Title/Abstract])”. Similar search strategies were used for searching through various databases with improvision as needed as per the available online interface. Cross-referencing was done from the selected articles to not miss any eligible studies.

Studies were included if they had an intervention and a control group (e.g., prospective comparative studies, randomized controlled trials, nonrandomized controlled trials, prospective cohort studies, controlled before-after studies, and pretest posttest studies); participants were adults with type 2 diabetes mellitus (T2DM) and had behavioral change outcome measure (e.g., summary of diabetes self-care activities [SDSCA] summary score). Studies from other languages were translated wherever possible, with the help of Google translate online software and assessed for eligibility in our study.

Studies were excluded if study follow-up duration was lesser than 3 months; study participants were hospitalized patients or pregnant women; participants had type 1 diabetes; studies giving special emphasis to comorbidities other than diabetes (such as depression or disabilities); study had <30 participants in each arm at baseline, or more than 1 intervention arm; or if control group received more than usual care.

Selection of studies

Primary screening with title and abstract of all articles was done individually by MG and GT and any disagreement was resolved by meeting and discussion to reach consensus. Secondary screening by reading full text of all articles was done individually by MG and GT and any disagreement was resolved by decision of the third reviewer SG. Finally, in-depth study of each article was done by all the reviewers to look at the particulars of study results and data reported in the studies to include them in the systematic review and meta-analysis by study eligibility and consensus of the reviewers. PRISMA checklist and guidelines were followed throughout the study process.

Data extraction

All citations identified through the search were imported into a shared Mendeley bibliography, and the data extracted from all eligible publications were recorded in a structured evidence table. Rayyan online software^[9] (a collaboration and research tool by Rayyan Systems Inc.) was used for the data extraction after importing the studies from the Mendeley bibliography into Rayyan. Key data extracted were sociodemographic, intervention data, and outcome in the terms of self-care behavior change.

Quality assessment

All the selected studies were assessed for quality by using Risk of Bias tool^[10] from Cochrane. Separate tools were used to assess Randomised controlled trials and other intervention study types with the guidance of the Cochrane collaboration.

Analytical strategy and statistical methods

All the analysis of the extracted data was done using JASP software.^[11] Standardized mean difference from each study was used as the effect size to obtain a forest plot and a pooled estimate. Dersimonian and Lairds method^[12] was used to obtain the measure of the standardized mean difference for the meta-analysis. Test of heterogeneity was done to detect heterogeneity. The analysis was based on random effect's model as the test of heterogeneity revealed I² of >75% in all evaluations. No subgroup analysis was conducted.

Publication bias was detected by the use of funnel plot using the standard error and effect size of the included studies. Egger's test of regression^[13] was employed to detect the publication bias by funnel plot.

Results

As depicted by the PRISMA flow diagram in [Figure 1]; 4023 study articles were found in the initial search; 2489 of which were excluded before screening due to duplication, no results or no intervention in the articles. 1534 resultant articles were screened by going through their title and abstracts, and 1224 articles were excluded due to presence of wrong study type, wrong study population, absence of behaviour outcome or no outcome details. Remaining 310 articles were now screened by full article reading and 244 articles were further removed for not satisfying criteria like presence of control arm, DSME based intervention etc. Finally, 20 out of 86 articles were included in the systematic review and meta-analysis after in-depth review of the results and data reported in the studies.

Figure 1: PRISMA flow diagram. PRISMA: Preferred reporting items for systematic reviews and meta-analyses

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Out of the 20 studies [Table 1], 11 were randomised control trial (RCTs) (one cluster RCT included) and 9 were Non-Randomised Controlled Trial (NRCT) intervention studies (two prepost, three experimental, three quasi experimental and one randomised prospective type study). All the studies were published between the years 2009 and 2020. Out of the studies, six were conducted in Iran, four in China, three in USA, two in Taiwan and five others in Germany, Brazil, India, Vietnam and Turkey. Among the studies, different types of DSME based interventions were used which were nursing staff based, peer-led, telemedicine based, SMS based, mobile app based or other types. Seven studies used SDSCA as the scale to measure self-care behaviour while other studies used different scales such as DSCS, DSMQ and other self-care questionnaires.

Table 1: Study characteristics and results of intervention studies included in the systematic review and meta-analysis (n=20)

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Risk of bias tool from Cochrane^[10] was used to estimate the quality of studies as depicted in [Figure 2] and [Figure 3]. Among the RCTs, seven studies had low risk of bias while four studies had uncertain risk of bias. Among the NRCTs, eight studies had low risk of bias while one study had moderate risk of bias. None of the studies included in the meta-analysis was found to have high risk of bias.

Figure 2: Risk of Bias assessment for RCTs (n = 11). *Cochrane ROB tool for Cluster RCTs used for this study. L: Low, U: Unclear and H: High risk of bias, RCT: Randomized controlled trial

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Figure 3: Risk of Bias assessment for Non-RCTs (n = 9), RCT: Randomized controlled trial, L: Low, M: Moderate risk of bias

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Our main outcome was “change in self-care behaviour score” owing to the DSME intervention for which we estimated the pooled and standardized mean difference WMD with Dersimonian and Laird random effects method. Analysis was first run separately for RCT and NRCT type studies to obtain different forest plots and pooled standardized mean difference values which are represented in [Figure 4] and [Figure 5]. Later combined Forest and Funnel plots were obtained from analysis [Figure 6] and [Figure 7] to find out the pooled standardized mean difference and publication bias from various studies included in our SRMA.

Figure 4: Forest and Funnel Plots for RCTs (n = 11), RCT: Randomized controlled trial

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Figure 5: Forest and Funnel Plots for Non-RCTs (n = 9). RCT: Randomized controlled trial

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Figure 6: Forest Plot (n = 20)

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Figure 7: Funnel Plot (n = 20)

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The pooled standardized mean difference in self-care behaviour was 1.38 (95% confidence interval 0.50–2.27, I² ¼ 99.2, P < 0.001) which shows a small but significant difference owing to effectiveness of DSME interventions among T2DM.

Funnel plot with Egger's method as depicted in [Figure 7] shows a gap in the bottom right quadrant of the funnel plot indicating presence of publication bias in the studies. The publication bias was not found to be significant by Egger's test (P = 0.356).

Discussion

This systematic review and meta-analysis was undertaken to estimate the effectiveness of DSME interventions on self-care behaviour of T2DM patients. This study obtained a small but significant positive sustained change in the self-care behaviour of T2DM patients following the DSME interventions.

In a systematic review done by Mikhael et al.^[34] in 2020 in Middle East countries, four of the included studies used a summary score for diabetes self-care behaviour and all of them showed improvement because of DSME in intervention group compared to control group.

Ernawati et al. in 2021^[35] systematic review from Indonesia also found improvement in self-care behaviours as an outcome in few of their included studies.

In our review, 14 out of 20 included studies showed statistically significant improvement in summary self-care behavior scores. When analysed separately, both RCTs and NRCTs showed small but significant improvement as evident by the pooled standardized mean difference in [Figure 4] and [Figure 5]. When combined together also, the 20 studies showed a statistically significant improvement in the pooled standardized mean difference. This evidence strengthens the role of DSME in improvement of self-care behaviors among T2DM patients. This review includes studies from various ethnicities, countries, and population groups and overall estimate shows a positive effect of DSME based culturally appropriate interventions on day-to-day self-care behaviors of T2DM patients.

This study emphasizes the importance of such culturally tailored and population specific DSME interventions to bring about sustained changes in the self-management of diabetes by patients. “Prevention is better than cure,” this statement can't prove any more valuable than it is in diabetes disease care. All the morbid conditions which can follow a poorly controlled diabetes can be avoided easily by adopting to proper self-care behaviour practices as taught in DSME. We appeal to clinicians all over the world to involve DSME in the treatment and care of every diabetic to improve their quality of life and researchers to generate more evidence till this is achieved globally.

Strengths

The following factors make this study findings robust-Studies with <30 participants per arm weren't included as small studies can produce most extreme results; standardized mean difference was used for pooled estimate; random effect's model was used for the analysis to accommodate heterogeneity; RCTs as well as NRCTs were included in order to not miss out on such study findings and were both analysed separately as well; NonEnglish language studies were also included by translating them with Google translate software; Studies from different global databases were included in the review; and gray literature or unpublished literature was also included from many databases.

Limitations

This study has many limitations, some of them being-Subgroup analysis has not been done; A detailed qualitative and sensitivity analysis has not been done; intervention studies without a control group have not been included; and only summary score has been taken for this review and not the individual behavior scores.

Conclusion

To the best of our knowledge, this systematic review is one of the very few to compile evidence on the effectiveness of DSME in improving self-care behavior. DSME can help diabetics take control, prevent and delay T2DM-related complications, however, a lacuna of evidence is apparent from the low- and middle-income countries in connection to DSME and self-care behavior-related research.

Trial registration

Registered in PROSPERO database. CRD42021275367.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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