Supported self-management for people with type 2 diabetes: a meta-review of quantitative systematic reviews

This meta-review examines the effectiveness of self-management support strategies for people with type 2 diabetes. It provides insights into the best interventions and their impact on glycaemic control and other outcomes. The study includes data from 459 unique RCTs and highlights the importance of multi-component programs and adequate contact time for effective self-management support.

1Captieux M, et al. BMJ Open 2018;8:e024262. doi:10.1136/bmjopen-2018-024262
Open access
Supported self-management for peo
with type 2 diabetes: a meta-review
quantitative systematic reviews
Mireille Captieux,1 Gemma Pearce,2 Hannah L Parke,3 Eleni Epiphaniou,4
Sarah Wild,1 Stephanie J C Taylor,5 Hilary Pinnock1
To cite: Captieux M, Pearce G,
Parke HL, et al. Supported
self-management for people
with type 2 diabetes: a
meta-review of quantitative
systematic reviews. BMJ Open
2018;8:e024262. doi:10.1136/
bmjopen-2018-024262
► Prepublication history and
additional material for this
paper are available online. To
view these files, please visit
the journal online (http:// dx. doi.
org/10. 1136/bmjopen- 2018-
024262.
Received 17 May 2018
Revised 31 August 2018
Accepted 12 September 2018
1Usher Institute of Population
Health Sciences and Informatics,
The University of Edinburgh,
Edinburgh, UK
2Coventry University, Centre
for Advances in Behavioural
Science, Coventry, UK
3University of Exeter Biomedical
Informatics Hub, Exeter, Devon,
UK
4University of Nicosia,
Department of Social Sciences,
Nicosia, Cyprus
5Centre for Primary Care and
Public Health, Barts and the
London School of Medicine and
Dentistry, Queen Mary University
of London, London, UK
Correspondence to
Dr Hilary Pinnock;
Hilary. Pinnock@ed. ac.uk
Research
© Author(s) (or their
employer(s)) 2018. Re-use
permitted under CC BY.
Published by BMJ.
AbstrACt
Objectives Self-management support aims to give people
with chronic disease confidence to actively manage their
disease, in partnership with their healthcare provider. A
meta-review can inform policy-makers and healthcare
managers about the effectiveness of self-management
support strategies for people with type 2 diabetes, and
which interventions work best and for whom.
Design A meta-review of systematic reviews of
randomised controlled trials (RCTs) was performed
adapting Cochrane methodology.
setting and participants Eight databases were
searched for systematic reviews of RCTs from January
1993 to October 2016, with a pre-publication update in
April 2017. Forward citation was performed on included
reviews in Institute for Scientific Information (ISI)
Proceedings. We extracted data and assessed quality with
the Revised-Assessment of Multiple Systematic Reviews
(R-AMSTAR).
Primary and secondary outcome measures Glycaemic
control as measured by glycated haemoglobin (HbA1c)
was the primary outcome. Body mass Index, lipid
profiles, blood pressure and quality of life scoring were
secondary outcomes. Meta-analyses reporting HbA1c were
summarised in meta-forest plots; other outcomes were
synthesised narratively.
results 41 systematic reviews incorporating data
from 459 unique RCTs in diverse socio-economic and
ethnic communities across 33 countries were included.
R-AMSTAR quality score ranged from 20 to 42 (maximum
44). Apart from one outlier, the majority of reviews
found an HbA1c improvement between 0.2% and 0.6%
(2.2–6.5 mmol/mol) at 6 months post-intervention, but
attenuated at 12 and 24 months. Impact on secondary
outcomes was inconsistent and generally non-significant.
Diverse self-management support strategies were
employed; no single approach appeared optimally
effective (or ineffective). Effective programmes tended to
be multi-component and provide adequate contact time
(>10 hours). Technology-facilitated self-management
support showed a similar impact as traditional approaches
(HbA1c MD −0.21% to −0.6%).
Conclusions Self-management interventions using a
range of approaches improve short-term glycaemic control
in people with type 2 diabetes including culturally diverse
populations. These findings can inform researchers, policy-
makers and healthcare professionals re-evaluating the
provision of self-management support in routine care.
Further research should consider implementation an
sustainability.
IntrODuCtIOn
The burden of type 2 diabetes is a promi-
nent global health challenge currently esti-
mated to affect 415 million adults worldwide1
with greatestprevalenceamong socio-eco-
nomicallydeprived populationsand those
of African, Afro-Caribbean,South Asian
and Middle Eastern ethnicity.2 An increas-
ingly obese, sedentary, ageing population is
expected to drive this number up to an esti-
mated 642 million (one adult in 10) by 2040.2
Healthcare service providers, commissioners
and policy-makers must meet the increasingly
complex needs and expectations of diverse
patient populations with type 2 diabetes
despite limited resources.
Supported self-management aims to give
people with chronic disease confidence in
taking an active role in all aspects of their
strengths and limitations of this study
► Meta-reviews provide a high-level overview of ev
dence ideal for informing policy and health servi
development, but fine-grained detail is lost as ra
domised controlled trials (RCTs) are synthesised
systematic reviews and then meta-reviews.
► A comprehensive search strategy in line with a p
defined protocol was used to gather a large evid
base examining the impact of diverse self-manag
ment support interventions on different type 2 d
betes populations from 1993 to 2017.
► Individual RCTs may be included in multiple
tematic reviews; this precludes meta-analysis
means that that some RCTs may be over-represe
ed in our synthesis; we have identified and repor
this overlap.
► The researchteamencompassedpublichealth,
statistics, epidemiology, primary care and hea
psychology expertise, enabling a multi-discipli
approach to interpretation.
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disease management, and health behaviours,3 in partner-
ship with their care-providers.4 It is promoted as a strategy
that can cost-effectively enable patients to contribute to
the improvement of their own outcomes and plays a key
role in the WHO’s Innovative Care for Chronic Condi-
tions (ICCC) framework.5 The increasing literature in this
area may overwhelm decision-makers seeking to under-
stand how best to support patients with type 2 diabetes.6
A meta-review of systematic reviews can provide a broad,
high-level, over-arching synthesis of the existing evidence
base in a single manuscript to inform policy, research and
practice.6 The review questions were: Do self-manage-
ment support interventions improve glycaemic and other
physiological outcomes for people with type 2 diabetes in
comparison to usual care? What works, for whom and in
what contexts?
MethODs
We adapted Cochrane methodology to conduct a meta-re-
view of systematic reviews of randomised control trials
(RCTs) examining self-management support in people
with type 2 diabetes.7 Reporting follows the Preferred
Reporting Items for Systematic Reviews and Meta-Anal-
yses (PRISMA) guidelines.8 The initial search (January
1993 to June 2012), undertaken as part of the Practical
Systematic Review of Self-Management Support for long-
term conditions (PRISMS) meta-review,9 was updated in
October 2016, and a pre-publication update completed
in April 2017. Meta-reviews cannot be registered with the
International Prospective Register of Ongoing System-
atic Reviews (PROSPERO) but the PRISMS protocol is
available online: https://www. journalslibrary. nihr. ac. uk/
programmes/ hsdr/ 11101404/#/.
Data sources and search strategy
The participants, interventions, comparators, outcomes
and settings (PICOS) search strategy8 (table 1) combined
terms for: ‘self-management support’ AND ‘diabetes’ AND
‘systematic review’ and limits specified (human subjects,
English language,published after 1st January 1993)
(online supplementary table 1). We searched MEDLINE,
EMBASE, CINAHL, PsychINFO, AMED, BNI, Cochrane
Database of Systematic Reviews and Database of Abstrac
for Reviews of Effectiveness (DARE). A forward citation
was carried out on all included reviews in ISI Proceedings
(Web of Science) at the time of the database searches and
subsequently as a pre-publication update. This approach
is an efficient way to update searches.10
Table 1 PICOS search strategy and sources for the review
Definition
Population Adults with type 2 diabetes from all social and demographic settings. Multi-condition studies included i
possible to extract type 2 diabetes data separately.
Intervention Self-management support interventions.
We defined self-management as: 'The tasks that individuals must undertake to live with one or more
chronic conditions. These tasks include having the confidence to deal with medical management, role
management and emotional management of their conditions’.3 This definition implies action on the part of
the individual.
We defined self-management support interventions as ‘any interventions that facilitates self-
management’, that is, professional or non-professional care-givers collaboratively assisting individuals
to manage the medical, role or emotional components of their type two diabetes. Interventions that
solely provide one-way instructions to participants were not classified as self-management support
interventions.
We specified that supported self-management interventions would be multi-component, so that a
mono-component intervention (eg, exercise training) would be excluded unless it also offered (say) sel
management education giving people confidence to exercise in everyday life.
Comparator Generally usual care or less intense self-management interventions.
Outcomes Primary: HbA1c, Secondary: biomedical markers: body mass index/weight, lipids, complications. Patien
reported: quality of life. Intermediate: self-efficacy, self-management behaviours.
Settings Any healthcare settings.
Study Design Systematic review of randomised control studies.
Dates Initial database search: January 1993 to August 2012; Update search October 2016; Pre-publication
forward citation April 2017.
Databases MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, BNI, Cochrane Database of Systematic Reviews,
Database of Abstracts of Review of Effects and ISI Proceedings (Web of Science).
Forward citations On all included systematic reviews. Bibliographies of eligible reviews.
In progress studies Abstracts were used to identify recently published trials.
Other exclusions Previous versions of updated reviews.
Papers not published in English.
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3Captieux M, et al. BMJ Open 2018;8:e024262. doi:10.1136/bmjopen-2018-024262
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study selection
Table 1 gives the definitions that we used to identify relevant
reviews: in summary, we included reviews of interventions that
supported individuals to actively manage the medical, role or
emotional components of their type 2 diabetes.3 4 Following
training, title and abstracts from the original PRISMS search
were screened using the exclusion criteria online supple-
mentary table 2 (HLP) with a 10% random check (GP, EE)
with 96% agreement; the update search was screened (MC)
with a 1% check (GP) with 97% agreement. Disagreements
were discussed with a third reviewer (HLP, SJCT or SW)
until consensus was reached. The full texts were screened
(original: HLP, GP, EE, update: MC) with 10% check in the
original review (HLP or SJCT) with 89% agreement, and
100% checked in the update (HLP) with 93% agreement.
Any disagreements were resolved in discussion with a third
reviewer (HLP, SJCT or GP).
Data extraction and quality assessment
Using a piloted form, data were extracted on: review
rationale, review methodology, inclusion criteria, partic-
ipant demographics and intervention details, outcomes
and conclusions as synthesised by the review authors.
Only data provided in systematic reviews were extracted;
data were not extracted from individual RCTs within
systematic reviews. Data extraction was undertaken (HLP
original; MC update) with a 10% check of extraction and
quality assurance (GP, EE) and a 100% check of numer-
ical data extracted (GP, HLP). Methodological quality was
assessed (HLP, MC) using the R-AMSTAR tool (Revised -
A MeaSurement Tool to Assess systematic Reviews)11 with
a 10% check (GP, EE). Papers were defined as very high
quality if their score was≥40, high quality if their score
was≥35, medium quality if their score was≥30 and low
quality if their score was less than 30. Publication bias, if
reported in systematic reviews, was noted.
Data synthesis and analysis
The primary outcome was HbA1c (or other measure of
glycaemic control). Secondary outcomes included: other
biomedical markers of disease (blood pressure (BP), lipid
profile, weight and body mass index (BMI); quality-of-life;
intermediate outcomes (health behaviour or self-efficacy).
In addition to the definition of self-management and
self-management support that were used to select relevant
studies (table 1), we also used the PRISMS Taxonomy of
Self-Management Support12 to identify self-management
components within systematic reviews, even if the term
‘self-management’ was not used explicitly. The taxonomy
also provided a consistent language to describe the inter-
ventions in the included RCTs and to identify components
used. Meta-analysis is inappropriate at the meta-review
level because of overlap of RCTs included in the system-
atic reviews; therefore narrative synthesis was undertaken.
For the primary outcome (HbA1c), the summary data
from the meta-analyses in the included reviews were illus-
trated using meta-forest plots.
Patient and public involvement and stakeholder eng
Our lay collaborator, people with long-term conditions,
representatives of patient organisations as well as profes-
sional stakeholders (clinicians, healthcare managers and
policy-makers)contributed to workshopsthroughout
the PRISMS programmeof reviews.9 Their opinions
informed the decision about the focus of core review
At an end of project workshop, patients and other stake-
holders provided feedback on the findings, informed
our interpretation and suggested practical approaches to
dissemination.
results
The PRISMA diagram (figure 1) details the search
and selection process. We identified 28 143 reference
(14 839 in the original PRISMS search and 13 304 in
the 2016 update). After screening, 41 systematic reviews
were included in the review: 17 papers from the orig
inal review,13–2224 papers from the update23–46
; and two
identified from other sources47 48
; in addition, two of the
originally included systematic reviews were replaced b
updates.49 50 See online supplementary table 3 for the
reviews excluded at the Update full text screening. There
were 459 unique RCTs reported in the included system-
atic reviews; the overlap of RCTs between the reviews is
illustrated in online supplementary figure 1.
summary of included reviews
The 41 included systematic reviews encompassed RCT
from 33 countries: Argentina, Australia, Austria, Bahrain,
Canada, China, Costa Rica, Croatia, Cuba, Denmark,
Finland, Germany,Hong Kong, Iceland, India, Iran,
Ireland, Israel, Italy, Japan, Mexico, New Zealand, South
Korea, Spain, Sweden, Taiwan, Thailand, the Nether-
lands, Turkey, UK, USA, Vietnam and the West Indies
Year of publication ranged from 2001 to 2016, with the
RCT publications ranging from 1981 to 2015 (online
supplementary table 4). The majority of reviews (26/39)
included a meta-analysis,13–15 19 22–24 27–33 35–38 40 45–48 51–53
with the remaining 15 presenting a narrative synthesis.
Interventionduration and follow-up duration were
not always clearly defined. Where recorded, the average
number of sessionsranged from 1 to 10 sessions,
average contact time ranged from 30 min to 58 hours
over 6 weeksto 2 years(online supplementarytable
4).15–18 21 24 26 28 31 32 35 36 40–48 51–54
Twenty-one systematic
reviews explicitly documented the follow-up duration of
their included RCTs.19 22 24 25 27 29–37 39 40 45 46 48 52 53
The
modal follow-up ranged from immediately after the inter-
vention to 5 years.
Quality assessment
The quality of the reviews ranged from 2047 to 4224 from a
R-AMSTAR total of 44 (online supplementary table 4 and
5). Four systematic reviews were very high quality,18 24 26 27
12
were judged high quality,14 15 19 23 28 35 37 43 45 48 52 53
15 reviews
were judged medium quality13 17 22 29–31 33 36 38 39 41 42 44 46 54
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and 10 were low quality.16 20 21 25 32 34 40 47 51 55
Total number
of patients in each review ranged from 64 to 33 124. Overall
nine systematic reviews stated no publication bias had
been found.14 23 29 36 38–40 45 48
Bolen et al found publication
bias but noted no change after sensitivity analysis, 12 iden-
tified possible publication bias13 15 19 24 25 28 30 33 37 39 43 46
and
16 did not assess publication bias16 17 20–22 31 32 34 41 42 47 51–55
;
three reviews stated insufficient studies to carry out mean-
ingful assessment of publication bias.18 26 27
Overview of results
Does supported self-management improve outcomes for
people with type 2 diabetes?
Primary outcome: HbA1c
Thirty-five of 41 systematic reviews assessed glycaemic
control, 24 of these presented meta-analyses of HbA1c
data (online supplementary table 6). Follow-up periods
varied between 0 and 24 months and were undefined in
eight of the 22 reviews.13 15 23 28 30 33 37 38
Eleven system-
atic reviews presented narrative findings on glycaemic
control.17 20 21 25 26 34 41 42 44 54 55
Ten of the 11 narrative reviews
were low or medium quality17 20 21 25 34 41 42 44 54 55
while
18 of the 24 meta-analyseswere medium or high
quality.13–15 19 23 28–31 33 35–38 45 48 52 53
All but one meta-analysis53 found a statistically signif-
icant improvement in HbA1c following a self-manage-
ment intervention (figure 2). The HbA1c decrease in 17
of these reviews was less than 0.5% (5 mmol/mol); three
reviews reported a decrease between 0.5% (5 mmol/
mol) and 1% (11 mmol/mol).19 22 28One low-quality
review reported an decrease of 1.2% (13 mmol/mol)
with wide confidence intervals.40 Three reviews reported
effect sizes (thus were not included in the meta-forest
plot) showing a significant reduction in HbA1c.30 45 47
Six
of the 11 narrative reviews confirmed a positive effect on
HbA1c17 20 21 25 34 41
; five reported an inconsistent effect
on HbA1c.
The comparator group in the RCTs varied both within
and between systematic reviews and ‘usual care’ was not
always specified. Two reviews performed sub-set analyses
based on the nature of the control intervention.38 48Both
found a greater mean difference (intervention/control)
when control was usual care than when the control was a
minimal self-management intervention. However, class
fying reviews based on whether they specified a usual car
comparator as opposed to a minimal care interventio
showed no obvious pattern in HbA1c (online supplemen-
tary figure 2a,b).
short-term, medium-term and long-term hbA1c outc
Where follow-up times were differentiated in the system-
atic reviews, they are illustrated in figure 3a-c. This
series of forest plots illustrates that the effect on HbA1c
attenuated with time; a statistically significant effect
persisted for 6 months in four of six reviews19 24 27 52
and
for 12 months in three of six reviews.24 45 52Attridge et
al (the highest quality systematic review 42/44) was one
of two reviews showing an improvement in HbA1c that
persisted at 24 months follow-up.24 52 Fewer RCTs were
included in the meta-analyses for long-term outcomes;
at the 24 month follow-up, only one meta-analysis
included data from more than 4 RCTs.14 Three narra-
tive reviews17 21 22
reported decreasing effectiveness over
time.
secondary outcomes
Biomedical markers
Nine systematic reviews presented meta-analysis data
biomedical markers13 15 24 27 35 48 52 53
; eight presented
narrative data.17 21 25 26 34 42 44 54
Self-management support
generally had no significant effect on BMI, weight and
Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
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BP (online supplementarytable 4 and 6), though
one positive review considered that effective interven-
tions involved regular contact, reinforcement or short
follow-up periods.31
► Seven of eight meta-analysesfound a non-signifi-
cant decrease in BMI or weight.13 15 23 24 27 52 53
One
found evidence of a small sustained decrease in BMI
(0.51 kg/m2) that was attenuated but still significant
at 12 months.48 Two reviews found evidence of a small
but statisticallysignificantdecreasein weight.35 47
Narrative results17 21 26 42 44 54
were similarly inconsistent
with only two showing a short-term improvement.21 26
► No statistically significant evidence of BP change was
found in three meta-analyses.24 52 53Three found a
clinically small but statistically significant decrease in
systolic BP.35 47 48
The majority of narrative syntheses
also showedinsignificantimprovementsor mixed
results.17 21 25 26 42 44
► Meta-analysisof lipid profiles showed non-signif-
icance,24 27 52 53 clinically small change,48 or were
conflicting.35 Narrative reviews generally found no
effect25 42 44
or small improvements.17 34
Patient-reported quality-of-life
Four systematicreviewspresentedmeta-analysisdata
for quality of life24 46 48 52 and four provided narra-
tive results.18 20 21 53 None showedan adverseeffect,
most showed mixed, neutral or non-significant
improvements,18 20 21 24 48 52 53
though one meta-analysis
showed beneficial effects.46 There was some evidence
from narrative syntheses to suggest that aspects of qualit
of life improved in response to group, peer or intensive
interventions.18 20 21 53
There was significant heterogeneity
in the RCTs with a variety of validated and un-validated
questionnaires, tools and scales, making it difficult for
review authors to draw firm conclusions.24
self-efficacy and health behaviour change outcomes
Two studies performed meta-analysis of self-efficacy. The
showedinconsistent24 or short-termpositiveeffects.52
Narrative reviews (n=5) generally reported short-term
positive effects in a few RCTs,25 26 34 42
and one showed
unclear evidence.18
Health behaviour change outcomes encompassed diet,
physical activity,self-measurementof blood glucose,
recognition of complications, foot care and medication
adherence behaviours. Three meta-analyses found a smal
but statistically significant improvement.32 47 52In nine
narrative reviews, there was evidence regarding improve-
ment in diet16 20 21 25 34 44
or physical activity16 21 25
; however,
overall the evidence was conflicting. Mixed results were
reported on changes in foot-care behaviours,16 18 20 43
though one review of intensive tailored foot-care educa-
tion showed benefit, compared with basic foot-care
education.43
Figure 2 Meta-Forest plot of mean difference in HbA1c (variable time-points).
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What were the optimal components of self-management
support interventions?
Self-management support interventions was coded into
the 14 categories of the PRISMS taxonomy of self-man-
agement support12 (table 2). The most commonly used
components were information about the condition and
its management (32 reviews), psychological strategies (24
reviews) and lifestyle advice and support (24 reviews). No
component emerged as ‘essential’ or ‘optimal’, and six
reviews advised multicomponent self-management strate-
gies.16 20 26 31 35 47
Two reviews concluded that components
aimed at increasing motivation and changing attitudes
were more important than enhancing knowledge.21 29
Intensity of the intervention
Generally, review authors concluded that intensity of the
intervention influenced effectiveness. Five reviews iden-
tified that effective interventions provided moderate/
high frequency of contacts,27 28 44 47 52
though only two
gave specific guidance (‘over 11 hours’48 ; ‘23.6 hours’
to achieve1% (10.9 mmol/mol)HbA1c reduction’.22
Nine reviews recommended longer duration of inter-
ventions,19 24 30 31 35 36 46 47 52 however,guidance for
optimal duration varied from 3 months,24 36 over
6 months19 31 52to 2 years35 with regular reinforcement
identified as important in seven studies.21 31 33 36 40 47 51
Two
studies found intense short duration interventions to be
more effective if reinforcement was provided.14 27
Mode of delivery
Mode of delivery is an over-arching dimension of the
PRISMS taxonomy.Diverse interventionswere deliv-
ered by a broad range of professionals and lay people to
groups, individuals, in person or remotely with varyin
durations and intensities. There were many permutations
of delivery within and between systematic reviews, bu
with no clear evidence of an optimal mode of delivery or
delivery provider (online supplementary table 4).
We identified seven reviews reporting technology-facil-
itated self-management support.23 27 30 33 34 37 39
The focus
on technology is a recent development with the earliest
reviews published in 2013.27 33 34
Four looked at self-man-
agement education through tele-health,23 30 33 37
one eval-
uated mobile apps,37 two tested online programmes34 39
and one included a range of technological intervention.27
Meta-analyses23 27 30 33 37 showed an improvementin
HbA1c similar to traditional modes of delivery.
There were conflicting findings about the relative bene-
fits of different forms of technological support, however,
mobile app use (with/without an internet/multimedia
approach) appeared to perform well.23 27 30 37
There were
mixed results on whether unidirectional or bidirectional
data transfer was better.23 30 Younger patients may do
better.30 37
For whom are self-management support interventio
successful?
The reviews encompassedinterventions delivered
to individuals with a broad range of demographic,
cultural and clinical characteristics. People with poore
glycaemic control show greater benefit from self-man-
agement support than those whose control is already
good.17 28 35 40 41 44 48 51 53
specific cultural groups
Nine reviews looked at culturally ‘targeted’ interventions
(ie, generic interventions adapted to target a specific
group)17 19 24 25 29 40 41 45 55 three reviewedculturally
‘tailored’ interventions19 24 45
(ie, interventions compre-
hensively redesigned to fit the needs and characteristics
of a cultural community56
). Eight of the interventions
targeted minority ethnic groups.17 19 24 25 29 40 45 55
Figure 3 Meta-Forest plot of mean difference in HbA1c
according to duration of follow-up a: Mean difference in
HbA1c at follow-up ≤ 6months b: Mean difference in HbA1c
at follow-up >6months to ≤ 12months c: Mean difference
in HbA1c at follow-up >12months to ≤24months. RCT,
randomised controlled trial.
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Table 2 Intervention components coded by Practical Systematic Review of Self-Management Support for long-term conditions taxonomy
Intervention Components Systematic Reviews Tailoring Other
[A1] Information about the condition and its
management
32 reviews:
.14–19 21–31 33 34 39–45 48 51–55
Culturally/linguistically appropriate17 19 24 25 45 48 55
Low literacy17 19 25mental illness.26
Personalised43:
Remote22 23 25 27 30 33 34 39–41 45 48
Educational video/DVD/cassette15 24 25 31 43
:
[A12] Psychological strategies 24 reviews14–16 18 19 23 25 26 28 29 31 32 34–36 38–40 42 44 46
48 51 53
:
Linking to existing cultural strategies e.g. prayer25 48 Remote elements15 23 34 39 40
:
[A14] Lifestyle advice and support 24 reviews15 16 19 20 22–25 27–29 31 34 37 38 40 44–46 48 51 53–55
: Ethnic foods19 25
Culturally relevant24 45 48
Local lifestyle programme24
Tailored dietary plans produced by computers27
Online peer groups/personal coaching.54 55
Mobile text messages23 27 37
[A13] Provision of social support 17 reviews18 19 24 25 27 28 34–36 38–40 42 45 48 52 54
: Inclusion of family.19 25 35 40 52 54 Online social support.27 34 35 39 42 48
Peer phone calls36 42 48 54
:
Video conference45
[A6] Practical support with adherence
(medication or behavioural)
14 reviews:
Telephone/HCP outreach15 24 25 27 38 43–45 55
Rewards/financial incentives23 35
Mobile phone text prompts.23 26 27
Mobile phones23 26 27
:
[A9] Training to communicate with healthcare
professionals
Five reviews25 26 42 54 55
:
[A5] Feedback monitoring Five reviews23 27 35 37 39
: Remote23 27 37 39
:
[A3] Provision of agreement on specific clinical
action plans/rescue med
Four reviews25 27 34 35
: Computer-generated plan after 30 min
assessment.27 34
[A7] Provision of equipment (A7) Four reviews25 26 37 43 48
: Using pedometer app37
[A10] Training rehearsal for everyday activitiesTwo reviews14 35
:
[A2] Signposting to available resources Two reviews34 53
:
[A4] Regular clinical review Two reviews31 37
: Remote37:
[A11] Training rehearsal for practical self-
management
Two reviews22 55
:
[A8] Provision of easy access to advice or
support when needed
Not specifically mentioned
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Culturally targeted interventions delivery used bilin-
gual healthcare professional teams,29 community health
workers/peer educators24 25 29 45
or bilingual comput-
er-based learning/social networking24 (table 2, online
supplementary table 4). All five meta-analyses showed
evidence of short-term and medium-term improvement
in HbA1c19 24 29 40 45
though long-term benefit was incon-
sistent (figures 2 and 3a-c)
The three reviews that focused on culturally tailored
interventionsconcluded that tailoring should build
on prior research or experience of the community and
their characteristics.19 24 45
Choi et al, in the context of a
Chinese ethnic majority, suggested that didactic group
lectures might be more effective and culturally accept-
able to Chinese populations than the ‘Western’ participa-
tory self-management approaches.24 40
The one review that compared cultural tailoring to
cultural targetingconcluded that interventionswere
most beneficial when tailored, and when delivered using
a range of options by multiple educators.45 Peer educators
were identified as a way to target existing interventions or
inform development of a tailored intervention.24 29 45 55
specific medical groups
Targeted interventions can improve foot care behaviour
in those at risk of foot ulceration,43 or aspects of quality
of life for people with end-stage diabetic kidney failure18
;
however, a self-managementsupport intervention
targeting severe mental illness for people with diabetes
was ineffective.26
In what contexts is self-management support best delivered?
The systematic reviews reported interventions
carried out in a range of different settings: commu-
nity,44 45 55outpatients,15 18 home-based, inpatient and
remote delivery.23 39Sixteen systematic reviews included
a range of these settings,19 22 24 25 27–30 33–37 43 47 52
and was
not reported in 17 reviews.13 14 16 17 20 21 26 32 38 40–42 46 48 51 53 54
Setting was not analysed as a variable in any of the reviews,
therefore, we cannot conclude that interventions in one
setting were more effective than another.
DIsCussIOn
This meta-review synthesises evidence from 41 system-
atic reviewsand 459 RCTs across33 countries with
diverse settings and healthcare systems. There is consis-
tent evidence that supported self-management improves
glycaemic control in people with type 2 diabetes with the
effect attenuating over time. The impact on secondary
outcomes (BP, BMI, lipid profiles, quality of life), self-ef-
ficacy and self-managementbehaviourswas generally
non-significant. A wide variety of self-management support
strategies were employed; most commonly information
about the condition and its management; psychological
strategies; lifestyle advice and support; and provision of
social support. Improvement in HbA1c was demonstrated
in diverse cultural groups, with interventions that were
culturally, linguistically and socially appropriate. Effective
interventions were delivered in a variety of settings, by a
range of professionals and peer educators. Technology is
increasingly being used and appears to be equally effec-
tive as traditional modes of delivery.
strengths and limitations
Meta-reviews enable high-level over-arching summaries
of evidence and are therefore ideal for informing health
service policy, but an inherent limitation is the loss of fine
detail.57 Individual RCTs were not reviewed nor authors
contacted for further information, so data relied on the
quality of the systematic review publications, which in
turn relied on the quality of RCT data. At each step, it
was possible for assumptions to be made and detail
be lost. Systematic reviews had their own aims and their
own selection criteria, which were not always completely
aligned with the aims of this review.
Data from commonly cited RCTs were included in
several systematic reviews so that their findings will
presented in multiple meta-analyses;we recognised
this by cataloguing the overlap in RCTs included in the
systematic reviews (see online supplementary figure 2
For example, one RCT was captured in seven meta-anal-
yses.58 The Forest plots thus illustrate the findings from
each meta-analysis rather than summarising them. At
meta-review level we were unable to exclude or control
for publication bias, but we noted any assessments o
publication bias by the review authors.
The update was completed with input from the majority
of the original PRISMS team (GP, HP, SJCT and HLP)
who were thus able to ensure fidelity to the original
methodology. Title and abstract screening was carried
out by one reviewer, increasing the risk of missing rele-
vant papers. Structured training, and random duplicate
checking (95% agreement) was undertaken to maintain
quality. The multi-disciplinary team encompassed public
health, statistics, epidemiology, primary care and health
psychology expertise, and met regularly to discuss results
and aid interpretation.
Interpretation of findings
Impact of self-management on glycaemic control
Improvement in glycaemic control is a consistent and
important finding. According to the UK Prospective
Diabetes Study, each absolute 1% (11 mmol/mol)
decrease in HbA1c is associated with reduction of 21
for any diabetes-related end point and 37% for micro
vascular complications.Therefore, an improvement
between 0.25% and 0.5% (3 mmol/mol to 5 mmol/mol)
(the the most common outcome in this meta-review) is
modest, but clinically significant59 and could make useful
inroads into the projected burden of diabetes. This may
underestimatethe impact of supported self-manage-
ment, as many reviews accepted minimal intervention
(such as behavioural weight programme or education)
as a comparator, which may have had some effect in the
control group.13 15 19 22 24 27 28 35–37 52 53
This heterogeneity
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of comparator, however, reflects the diverse healthcare
contexts in which interventions will be implemented
as type 2 diabetes education or other self-management
components may be routinely available in some settings
but not in others.
Impact of self-management on secondary outcomes
Self-managementdid not consistentlyimprove other
physiological targets of diabetes care. This may be a
consequence of a narrow focus on glycaemic control,
inadequate intensity of interventions or limited ongoing
reinforcement. Further research on strategies that might
improve this broader range of outcomes is warranted.
Implementation: what works, for whom and in what contexts
Implementation is challenging and only a minority of
people with diabetes receive self-management support.2
Time pressures in routine practice may mean that infor-
mation is provided in convenient,standardisedbut
potentially ineffective formats (eg, leaflets, didactic group
lectures),21 which take no account of cultural beliefs,
personal preferences or individual psychological adjust-
ment to their diagnosis.
It was not possible to definitively pinpoint the optimal
composition, intensity or mode or delivery of supported
self-management, though many studies concluded that
effectiveprogrammeswere multi-componentand of
adequateintensity(>10 hours).Attenuationof effect
(see figure 2A–C), and the observation that prolonged
duration and/or reinforcement are features of effective
interventions resonates with the concept of ‘supported
self-management’ as an approach to delivering ongoing
care rather than a discrete time-limited intervention.
Flexibility is likely to be important,17 where a preferred
self-management support strategy is co-constructed with
individuals. People’s fluctuating motivation to manage
their diabetes as they progress and oscillate through
different physical and psychological phases related to
their life, health and disease severity adds complexity
to this situation. This may be best addressed by offering
access to more intensive components (eg, comprehen-
sive self-management education courses) according to
readiness to receive rather than chronological time since
diagnosis.
Echoing recommendationsin other diseaseareas,9
authors of our included reviews highlighted the need to
tailor interventions to individuals or diverse social and/
or cultural groupings. Characteristics of target commu-
nities, the range of professionals, peer educators, third
sector agencies and local resources available, as well as
the patients’ existing interaction with the diabetes care
services should be considered when designing/devel-
oping a self-management support programmes or evalu-
ating an existing programme.
Technology may be a promising mode of delivery,
which, in our included reviews, seemed similarly effec-
tive to traditional approaches. Intuitively, they may be
seen as offering convenient options for hard-to-reach
groups such as economically active younger people o
marginalised populations reluctant to attend multiple
lengthy appointments or formal group self-management
programmes. Self-monitoring and professional feedback
(potentially facilitated by tele-health) may offer other
theoretical advantages. In the context of hypertension
(another asymptomatic long-term condition in which the
key medical aim of self-management is to prevent compli
cations) qualitative evidence suggests that self-monitoring
of physiological parameters can bridge the gap between
a lay perspective (treating symptoms) and medical objec-
tive (improving clinical measurements)promoting a
collaborative approach to self-management.60
Implications for research
Studies of self-managementof type 2 diabetesare
well-represented in the literature and findings are based
on a mature and diverse database. Future RCTs shou
shift from establishing short-term effectiveness (reduced
HbA1c) to exploring how to sustain self-management
support in routine care. Longer term studies suggested
attenuation of effect, but it is not clear whether this
the result of loss of effect of the intervention (implying
the need for ongoing support) or the gradual increas
of HbA1c over time making it more difficult to control.61
Behaviour change interventions commonly show attrition
over time and need reinforcing.62 The recognised benefit
of achieving early control in reducing longer term micro-
vascular outcomes supports provision of self-managemen
support despite this attenuation.63 These areas require
further characterisation in studies designed for follow-up
of long-term outcomes.
The shift in focus to implementation demands an
understanding of the influence of context (policy incen-
tives, healthcare setting, existing approach to self-ma
agement, availability of resources) and the development
of locally adaptable implementation strategies promoting
sustainable support for diabetes self-management. The
PRISMS taxonomy of self-management support12 worked
well as a framework for clarifying description of self-man-
agement support initiatives in the different reviews and
could act as an inventory of potential self-manageme
support strategies. Consideration of the taxonomy ma
facilitate learning from self-management strategies used
in other long-term conditions. For example, proactive
written ‘action plans’ are pivotal in asthma self-manage-
ment64 but used less commonly in type2 diabetes, althoug
could be applicable as ‘sick day rules’ for metformin.65
Qualitativeevidencesuggeststhat self-management
support needs to evolve over time. Initial support ma
need to focus on enabling people to accept the diagnosis;
the optimal time to focus on lifestyle change may be when
a person has made a conscious decision to take control
over their condition.9 Included reviewsrarely used
outcomes such as patient activation66 or self-efficacy that
might have informed the process of behaviour change
suggesting a fruitful research agenda in exploring how
people relate to their type 2 diabetes diagnosis and how
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that influences the optimal timing, delivery, components
and overall direction of their self-management.
While tailoring to cultural groups was addressed by the
included reviews, other groups were under-represented,
for example, the frail elderly, people with multi-morbidity,
people affected by substance misuse, disability and mental
health problems. Self-management in populations with
limited access to healthcare services either due to depri-
vation, rurality, geography,occupation,transiencyor
incarceration are contexts that could benefit from further
exploration. The potential of technology as a mode of
delivering supported self-management is an important
research agenda. As in other disease areas,60 67our find-
ings suggestthat technologicallysupportedself-man-
agement is at least as effective as traditional face-to-face
approaches; there is need for methodologically rigorous
mixed-methods evaluation of the potential advantages
to healthcare services and individuals of employing this
mode of interaction.
COnClusIOn
Self-management support, using a range of strategies,
improves glycaemic control at least in the short term; the
effect on other clinical indicators such as blood pressure
is inconsistent. Tailored interventions enable targeted
approaches that are culturally, socially and demograph-
ically sensitive to the individual and their community.
Implementing an adaptable self-management programme
offering tailored sustainable self-management support
for individuals with type 2 diabetes, which is accessible
throughout their diabetes journey will require a whole
systems approach that involves active involvement of poli-
cy-makers, healthcare providers, patients and third sector
organisations. Existing assets must be identified, and new
services designed where gaps exist.
Acknowledgements We thank Ms Christine Hunter, lay collaborator to the
PRISMS project, representatives from stakeholder groups who contributed to the
development of the project and the project workshops and Richard Parker, senior
statistician at the Clinical Trials Unit, Usher Institute, University of Edinburgh.
Contributors SJCT and HP initiated the idea for the PRISMS study, led the
development of the protocol, securing of funding, study administration, data
analysis and interpretation of results. EE, HLP and GP were systematic reviewers
who undertook searching, selection of papers and data extraction with SJCT, HP
and SW in the original PRISMS review. MC undertook the updating of the PRISMS
review with GP, HLP, HP and SJCT. All authors had full access to all the data, and
were involved in interpretation of the data. MC wrote the initial draft of the paper
with HP and GP to which all the authors contributed. SJCT and HP are study
guarantors.
Funding PRISMS was funded by the National Institute for Health Research Health
Services and Delivery Research Programme (project number 11/1014/04). HLP
was supported by a Primary Care Research Career Award from the Chief Scientist’s
Office of the Scottish Government at the time of the PRISMS study. MC is supported
by an Academic Fellowship in General Practice from the Scottish School of Primary
Care.
Disclaimer The views expressed in this article are those of the author(s) and not
necessarily those of the NHS, the NIHR, or the Department of Health and Social Care
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data are included in the supplementary t
Open access This is an open access article distributed in accordance w
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which p
others to copy, redistribute, remix, transform and build upon this work f
purpose, provided the original work is properly cited, a link to the licenc
and indication of whether changes were made. See: https:// creativecom
licenses/by/ 4.0/.
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