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A study designed to improve glycemic control without hypoglycemia in elderly people living with type 2 diabetes utilized mobile phones for the intervention[12]. Participants received a glucometer that downloaded to a hospital-based server and based on the data, patient-specific messages were generated and sent to their mobile phone. Text messages included instructions about changes to medications based on blood glucose values and reminders to check blood glucose as instructed. The intervention group had significantly lower hemoglobin A1C (HA1C) values compared to two control groups at six months follow-up. Participants in the intervention group did have higher rates of hypoglycemia than participants in the two control conditions, but the difference was not statistically significant[12].

Support for diabetes management has been provided through text messaging using mobile phones. A sample of 18 African American people living with type 2 diabetes completed a 4 wk text message diabetes program[13]. Participants were required to receive a daily medication reminder, question about medication adherence, question about foot care, and appointment reminders for diabetes-related visits. Participants could also receive additional diabetes management text reminders if desired. A certified diabetes educator (CDE) phoned participants weekly to obtain feedback on the experience and make adjustments to the personalized text message. The CDE did not provide any education, counselling, or clinical support for participants. Qualitative interviews revealed that the text message program reinforced the importance of self-management, increased awareness of diabetes, and improved feelings of control over diabetes[13].

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A mobile diabetes intervention study examined the effect of mobile phones and patient and provider portals for individualized patient treatment and communication on HA1C levels[14]. Participants with type 2 diabetes enrolled in the one year study and utilized a patient-coaching system consisting of a mobile diabetes management software application that allowed them to enter diabetes self-care data including blood glucose values, carbohydrate intake, and medications. After entering this data into mobile phones, participants received automated, real-time educational, behavioral, and motivational messages related to entered data. The intervention also included a web portal consisting of a secure messaging center for patient and provider communication, personal health record, a learning library, and logbook to review entered data. Researchers found a statistically significant improvement in HA1C levels in the intervention group compared to a usual care control group. The study did not evaluate how the mobile intervention affected behavior leading to blood glucose changes. How the intervention affected medication adherence, physical activity, quantity and quality of patient-provider communication, and treatment intensification are important variables which should be considered in future studies[14].

A second randomized controlled trial aimed at reducing distress and enhancing effective management of type 2 diabetes compared three interventions to reduce diabetes distress and improve self-management[16]. The study enrolled 392 participants who were randomly assigned to computer-assisted self-management, computer-assisted self-management plus diabetes distress-specific problem-solving, or a computer-administrated minimal support intervention. Computer-assisted self-management included a web-based diabetes self-management improvement program that allows patients to select goals for medication adherence, diet, or exercise and monitor those goals. Participants in this group also had access to a forum to ask questions of diabetes experts and received phone calls from an interventionist to monitor progress and problems. The second group received this same computer-assisted self-management plus problem-solving therapy specifically for diabetes distress. The third intervention group received a computer-delivered health risk appraisal and diabetes information regarding healthy living, diet, and physical activity. Significant decreases in diabetes distress, emotional burden, and regimen distress occurred in all three groups with no significant between-group differences. The study did not include a usual care control group so the effect of attention alone could not be measured[16].

Similarly, a three-arm randomized controlled trial compared computer-assisted diabetes self-management, computer-assisted diabetes self-management plus human support, and enhanced usual care[2]. Participants in the computer-assisted diabetes self-management program (DSMP) selected achievable goals in the areas of medication adherence, physical activity, and food choices. They were able to view displays of their biophysical data, record progress toward goals, participate in a moderated forum, and view diabetes self-management information. Participants in this group also received periodic motivational calls. The computer-assisted plus human support group received the same computer intervention and received follow-up calls from an interventionist and opportunities to attend group educational sessions. The internet interventions significantly improved health behaviors including eating habits and adherence to medications compared to usual care over the 12 mo study period. All three conditions moderately improved self-efficacy, problem-solving, and HA1C[2].

A quasi-experimental design study was conducted to compare a web-based diabetes education program with a traditional classroom diabetes education program for newly diagnosed adults with type 2 diabetes[3]. The web-based program included six education modules covering diabetes basics, dietary management, exercise, medications, stress management, and foot care. The website also included a password-protected space where participants could enter glucose levels and see a display of those levels, calculate caloric content of meals consumed, record activities, and measure daily stress levels. Participants in the control group attended one hour lectures every week for three consecutive weeks in a group setting consisting of 30 to 40 participants that were taught by a diabetes care specialist nurse, dietician, and physician. Diabetes knowledge, care behaviors, and glycemic control were compared for the intervention and control groups at baseline, six weeks, and three months. Diabetes care knowledge significantly increased in both intervention and control groups from baseline to six weeks, but not from six weeks to three months. Diabetes care behaviors significantly increased in both groups from baseline to six weeks and also significantly increased from six weeks to three months in the intervention group. HA1C levels for the intervention group significantly decreased from baseline to six weeks, but not from six weeks to three months. No differences in HA1C were found in the control group. Limitations of this study include the small sample size (31 participants) and the lack of random group assignment. Participants in the intervention group were required to have the ability to use the internet which prevented random assignment. The improvement in diabetes care behaviors and HA1C in the intervention group offers promise for using web-based diabetes education as a substitute for group education[3].

A randomized controlled trial evaluated an online diabetes management system for patients with uncontrolled type 2 diabetes[20]. A usual care control group was compared to an intervention group that utilized an online disease management program that included wireless uploading of glucose readings, individualized diabetes summary status reports, nutrition and exercise logs, insulin records, online messaging with the health care team, advice and medication management from a nurse care manager and dietician, and personalized educational information. Participants in the intervention group had significantly lower HA1C levels at 6 mo compared to the control group, but at 12 mo, the difference was no longer significant. As in other studies, participants who utilized the online system more often achieved greater benefits[20].

Second, novel LMC Skills, Confidence and Preparedness Index (SCPI) tool was used to assess skills and self-efficacy in core behaviours central to diabetes self-management such as healthy eating, blood glucose monitoring, being active, healthy coping, medication adherence, problem solving and reducing risk [11, 45]. The SCPI tool had been previously validated, where its construct validity for different ages, ethnicity, gender and level of education was established [32]. Additionally, the validity of the tool for use in different settings is established by the fact that, as a new tool, the questions reflect the current recommended self-management regimen for diabetes patients, and this has not been fully explored by previous tools [45]. It has excellent readability and reliability. Permission was obtained to use the tool. The SCPI tool consists of three subscales: skills, confidence and preparedness. The skills subscale was used to assess perceived ability to perform the self-management activities mentioned above. The confidence subscale was used to assess self-efficacy in being able to perform the skills. The preparedness scale was not used in this study because this subscale assesses the readiness of patients to implement behavioural changes following an educational session; which was not applicable in the present study.

Participants in this study possessed lower skills related to planning for physical exercise in order to avoid hypoglycemia and adjusting medication to reach targeted blood glucose levels. This result corroborates previous findings [52]. The ability to manage and make appropriate adjustment to multiple regimens often determines success with other core areas of diabetes self-management and glycemic control [51]. For instance, studies have reported that due to the fear of hypoglycemia, patients have resorted to unhealthy behaviours (such as reducing or eliminating medication dose, inappropriate food choices and /or avoiding physical activities) that increase glucose levels [53]. Diabetic patients have an increased risk of developing hypoglycemia particularly when treated with insulin or insulin secretagogues [53]. Hence, they should be provided with regular refresher courses and continuous training on blood glucose levels awareness and strategies to balance exercise which could promote glycemic control and adherence to self-management. be457b7860