AbstractBackground: Previous systematic reviews comparing group-based education programs with individual care have demonstrated promising results in terms of health outcomes for people with type 2 diabetes mellitus (T2DM). However, these are out-dated, with searches failing to account for the last eight years of published literature. Additionally, previous reviews have not investigated whether specific attributes of group-based interventions account for improved patient outcomes. Given the widely acknowledged role of self-management in T2DM, the experiences and motivations of individuals who choose to attend group education programs are largely under-explored. Further, there is evidence that Accredited Practising Dietitians (APDs) in Australia are underutilizing group-based education for people with T2DM; however the reasons for this are currently unknown.
Aims and Objectives: The overarching aim of this thesis is to assess which attributes of group-based education programs for the management of T2DM contribute to effectiveness. The objectives were to assess the effectiveness of these programs and explore the impact of various program attributes on intervention effectiveness, to identify and compare how group-based education programs are developed in practice, and to obtain the opinions of group facilitators and participants on the attributes that affect the success of group-based education. Additional objectives of this thesis were to develop and assess the feasibility and acceptability of a group-based education program for the management of T2DM, to understand individuals’ experiences of these programs, explore their motivation for self-management, and to explore the utilization of group-based education, as well as preferences for practice and training, among APDs.
Methods: A systematic review with meta-analyses and meta-regression was completed to assess whether group-based education programs for the management of T2DM are effective at improving clinical, lifestyle and psychosocial outcomes in adults in both the short (6 months) and long term (greater than 12 months) when compared with usual care, waiting list control, or individual interventions. The primary outcome was glycated haemoglobin (HbA1c) levels, while secondary outcomes were fasting blood glucose (FBG), body weight, body mass index (BMI), waist circumference, systolic and diastolic blood pressure, blood lipid levels, diabetes knowledge, depression scores and physical activity levels. Further, this study investigated the impact of various attributes on intervention effectiveness, and assessed the completeness of reporting of included studies using the Template for Intervention Description and Replication (TIDieR), which aims to improve the reporting and ultimately the replicability of interventions. In addition, three further studies have been conducted to investigate the feasibility of a group-based education program developed using robust formative evaluation methods (including semi-structured interviews with facilitators and participants of existing chronic disease group programs), and to explore the experiences and motivations of participants in the feasibility study (through additional semi-structured interviews). Finally, an investigation of the utilization of group-based education by APDs was conducted using an online survey.
Results: The results of the systematic review, which included 53 publications describing 47 studies, favoured group-based education when compared to controls for the primary outcome (HbA1c) at six to ten months (MD= 0.31%; 95%CI:-0.48, -0.15; 30 studies, n=4107), 12-14 months (MD= 0.33%; 95%CI:-0.49, -0.17; 27 studies, n= 4384), 18 months (MD= 0.72%; 95%CI:-1.26, -0.18; 3 studies, n=194), and 36-48 months (MD= 0.93%; 95%CI:-1.52, -0.34; 5 studies, n=1436) post-baseline. The results of the pooled analyses also favoured group-based education for some secondary outcome measures including FBG after a year, body weight and waist circumference in the shorter term; triglyceride levels at both short and long term follow up; and diabetes knowledge, depression scores and physical activity in the short term. The analyses found no statistically significant effect for group-based interventions when measuring BMI, blood pressure, total or HDL cholesterol, quality of life or energy intake at short or long term measures. Furthermore, the results indicated that the group-based interventions with greater effects on HbA1c appear to be those that: are conducted in primary care settings; that provide materials to participants; have less than 10 sessions provided either in less than one month, or over seven to 12 months or 13 to 60 months; provide either 8 hours or less or over 31 hours of contact time; and include individuals with HbA1c levels greater than 7%. The assessment of the completeness of reporting of the included studies using the TIDieR checklist suggested that group-based education interventions for T2DM are often incompletely reported.
The results of the feasibility study and qualitative investigation, which used thematic analysis underpinned by self-determination theory (SDT), found that factors such as peer identification, normalisation, and group interactions may substantially influence the effectiveness of group-based education interventions for the management of T2DM and may improve motivation for self-management. Additionally, the results of these studies support the use of patient-centred programs focusing on group interactions rather than the didactic presentation of content. Lastly, the results of the survey of APDs indicated that they are currently underutilizing group-based education programs for the management of T2DM, with the primary reasons likely to be a lack of training provided to APDs in the area, limited access to facilities suitable for groups, the perceived poor cost effectiveness of these programs, and the lack of evidence-based practice guidelines for the group-based management of persons with T2DM.
Conclusions: The series of studies completed for this thesis have resulted in numerous implications for practice and future research directions. Key implications of the research include: the primary focus of the group facilitator should be on encouraging group interactions and group discussions to allow group participants to benefit from peer identification and normalisation; group-based education interventions for the management of T2DM can be effective at improving health outcomes at any length, session number, number of contact hours, and number of participants per group; group-based education programs which are patient-centred and non-didactic are efficacious; group-based education programs can be effective when facilitated by single disciplines, multidisciplinary teams or health professionals with peer supporters; and group-based education programs for the management of T2DM may benefit from the use of self-determination theory (SDT) as a framework for intervention design to enhance participant motivation. Primarily, future research in the area of group-based education for the management of T2DM should further assess the influence of group interactions on health outcomes. Additionally, researchers working in the area should design and publish their results using the TIDieR checklist in order to improve the completeness of reporting and replicability of interventions. Finally, further research into the Medicare Chronic Disease Management group items should be completed in order to determine whether the rebates provided can result in financially viable group-based education programs; and the development of evidence-based practice guidelines for the group-based management of persons with T2DM by APDs may increase the number of groups being facilitated by dietitians which could improve the health outcomes of individuals with diabetes.
|Date of Award||11 Feb 2017|
|Supervisor||Elizabeth Isenring (Supervisor), Rae Thomas (Supervisor) & Dianne Reidlinger (Supervisor)|