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Effect of a community-based diabetes self-management empowerment program on mental health-related quality of life: a causal mediation analysis from a randomized controlled trial.

Sugiyama T, Steers WN, Wenger NS, Duru OK, Mangione CM - BMC Health Serv Res (2015)

Bottom Line: Also, among studies supporting the favorable effects of DSME on mental HRQoL, the direct effect of DSME that is independent of improved glycemic control has never been investigated.In the causal mediation analysis, the intervention had a direct effect on MCS-12 improvement (1.7 points, 95% CI: 0.2 to 3.2) with no indirect effects mediated via HbA1c change (-0.1 points, 95% CI: -0.4 to 0.1), social support (0.1 points), and perception of empowerment (0.1 points).This favorable effect on mental HRQoL may be a separate clinical advantage of this DSME intervention.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 3rd Floor, 911 Broxton Ave, Los Angeles, California, 90024, USA. tsugiyama-tky@umin.ac.jp.

ABSTRACT

Background: There is a paucity of evidence supporting the effectiveness of diabetes self-management education (DSME) in improving mental health-related quality of life (HRQoL) for African American and Latinos. Also, among studies supporting the favorable effects of DSME on mental HRQoL, the direct effect of DSME that is independent of improved glycemic control has never been investigated. The objectives of this study were to investigate the effect of community-based DSME intervention targeting empowerment on mental HRQoL and to determine whether the effect is direct or mediated by glycemic control.

Methods: We conducted secondary analyses of data from the Diabetes Self-Care Study, a randomized controlled trial of a community-based DSME intervention. Study participants (n = 516) were African Americans and Latinos 55 years or older with poorly controlled diabetes (HbA1c ≥ 8.0%) recruited from senior centers and churches in Los Angeles. The intervention group received six weekly small-group self-care sessions based on the empowerment model. The control group received six lectures on unrelated geriatrics topics. The primary outcome variable in this secondary analysis was the change in Mental Component Summary score (MCS-12) from the SF-12 Health Survey between baseline and six-month follow-up. We used the change in HbA1c during the study period as the main mediator of interest in our causal mediation analysis. Additionally, possible mediations via social support and perceived empowerment attributable to the program were examined.

Results: MCS-12 increased by 1.4 points on average in the intervention group and decreased by 0.2 points in the control group (difference-in-change: 1.6 points, 95% CI: 0.1 to 3.2). In the causal mediation analysis, the intervention had a direct effect on MCS-12 improvement (1.7 points, 95% CI: 0.2 to 3.2) with no indirect effects mediated via HbA1c change (-0.1 points, 95% CI: -0.4 to 0.1), social support (0.1 points), and perception of empowerment (0.1 points).

Conclusions: This Diabetes Self-Care Study empowerment intervention had a modest positive impact on mental HRQoL not mediated by the improvement in glycemic control, as well as social support and perception of empowerment. This favorable effect on mental HRQoL may be a separate clinical advantage of this DSME intervention.

Trial registration: ClinicalTrial.gov NCT00263835.

No MeSH data available.


Related in: MedlinePlus

Comparison of conceptual models. A. Original research question of Diabetes Self-Care Study – effect of the DSME intervention on glycemic control. B. First research question of our research – total effect of the DSME intervention on mental health-related quality of life (mental HRQoL). C. Second and third research questions of our research – direct effect of the DSME intervention on mental HRQoL separate from indirect effect via glycemic control (second research question) or other mediators (third research question). DSME = Diabetes self-management education. Total Effect = Direct Effect + Indirect Effect.
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Fig1: Comparison of conceptual models. A. Original research question of Diabetes Self-Care Study – effect of the DSME intervention on glycemic control. B. First research question of our research – total effect of the DSME intervention on mental health-related quality of life (mental HRQoL). C. Second and third research questions of our research – direct effect of the DSME intervention on mental HRQoL separate from indirect effect via glycemic control (second research question) or other mediators (third research question). DSME = Diabetes self-management education. Total Effect = Direct Effect + Indirect Effect.

Mentions: Self-management is an integral part of controlling diabetes. For example, optimal glucose control in most cases requires patients to maintain healthy eating and appropriate exercise. Diabetes self-management education (DSME) has been described as “a collaborative process through which people with or at risk for diabetes gain the knowledge and skills needed to modify behavior and successfully self-manage the disease and its related conditions [7]”. There is considerable evidence that DSME improves glycemic control, albeit modestly (Figure 1A) [8,9]. In addition, several researchers have hypothesized that DSME improves psychological aspects through a positive attitude toward health and increased diabetes self-efficacy (Figure 1B). For example, Kirk et al. reported that exercise consultation compared to standard care improved the mental health subscale of SF-36 5 weeks after the intervention in a small randomized controlled trial (RCT) among patients with Type 2 diabetes (T2DM) [10] However, other studies of DSME showed either no effect or worsened mental HRQoL [11-13]. A few systematic reviews and meta-analyses attempted to assess the effect of DSME on generic and diabetes-specific quality of life measures [9,14]; however, they could draw no conclusion related to quality of life due to heterogeneity of included studies or a paucity of studies measuring quality-of-life. In summary, both the type and extent of the effect of DSME on mental quality of life among patients with diabetes remain unclear. Evidence within African American and Latino populations is particularly scarce.Figure 1


Effect of a community-based diabetes self-management empowerment program on mental health-related quality of life: a causal mediation analysis from a randomized controlled trial.

Sugiyama T, Steers WN, Wenger NS, Duru OK, Mangione CM - BMC Health Serv Res (2015)

Comparison of conceptual models. A. Original research question of Diabetes Self-Care Study – effect of the DSME intervention on glycemic control. B. First research question of our research – total effect of the DSME intervention on mental health-related quality of life (mental HRQoL). C. Second and third research questions of our research – direct effect of the DSME intervention on mental HRQoL separate from indirect effect via glycemic control (second research question) or other mediators (third research question). DSME = Diabetes self-management education. Total Effect = Direct Effect + Indirect Effect.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4375843&req=5

Fig1: Comparison of conceptual models. A. Original research question of Diabetes Self-Care Study – effect of the DSME intervention on glycemic control. B. First research question of our research – total effect of the DSME intervention on mental health-related quality of life (mental HRQoL). C. Second and third research questions of our research – direct effect of the DSME intervention on mental HRQoL separate from indirect effect via glycemic control (second research question) or other mediators (third research question). DSME = Diabetes self-management education. Total Effect = Direct Effect + Indirect Effect.
Mentions: Self-management is an integral part of controlling diabetes. For example, optimal glucose control in most cases requires patients to maintain healthy eating and appropriate exercise. Diabetes self-management education (DSME) has been described as “a collaborative process through which people with or at risk for diabetes gain the knowledge and skills needed to modify behavior and successfully self-manage the disease and its related conditions [7]”. There is considerable evidence that DSME improves glycemic control, albeit modestly (Figure 1A) [8,9]. In addition, several researchers have hypothesized that DSME improves psychological aspects through a positive attitude toward health and increased diabetes self-efficacy (Figure 1B). For example, Kirk et al. reported that exercise consultation compared to standard care improved the mental health subscale of SF-36 5 weeks after the intervention in a small randomized controlled trial (RCT) among patients with Type 2 diabetes (T2DM) [10] However, other studies of DSME showed either no effect or worsened mental HRQoL [11-13]. A few systematic reviews and meta-analyses attempted to assess the effect of DSME on generic and diabetes-specific quality of life measures [9,14]; however, they could draw no conclusion related to quality of life due to heterogeneity of included studies or a paucity of studies measuring quality-of-life. In summary, both the type and extent of the effect of DSME on mental quality of life among patients with diabetes remain unclear. Evidence within African American and Latino populations is particularly scarce.Figure 1

Bottom Line: Also, among studies supporting the favorable effects of DSME on mental HRQoL, the direct effect of DSME that is independent of improved glycemic control has never been investigated.In the causal mediation analysis, the intervention had a direct effect on MCS-12 improvement (1.7 points, 95% CI: 0.2 to 3.2) with no indirect effects mediated via HbA1c change (-0.1 points, 95% CI: -0.4 to 0.1), social support (0.1 points), and perception of empowerment (0.1 points).This favorable effect on mental HRQoL may be a separate clinical advantage of this DSME intervention.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 3rd Floor, 911 Broxton Ave, Los Angeles, California, 90024, USA. tsugiyama-tky@umin.ac.jp.

ABSTRACT

Background: There is a paucity of evidence supporting the effectiveness of diabetes self-management education (DSME) in improving mental health-related quality of life (HRQoL) for African American and Latinos. Also, among studies supporting the favorable effects of DSME on mental HRQoL, the direct effect of DSME that is independent of improved glycemic control has never been investigated. The objectives of this study were to investigate the effect of community-based DSME intervention targeting empowerment on mental HRQoL and to determine whether the effect is direct or mediated by glycemic control.

Methods: We conducted secondary analyses of data from the Diabetes Self-Care Study, a randomized controlled trial of a community-based DSME intervention. Study participants (n = 516) were African Americans and Latinos 55 years or older with poorly controlled diabetes (HbA1c ≥ 8.0%) recruited from senior centers and churches in Los Angeles. The intervention group received six weekly small-group self-care sessions based on the empowerment model. The control group received six lectures on unrelated geriatrics topics. The primary outcome variable in this secondary analysis was the change in Mental Component Summary score (MCS-12) from the SF-12 Health Survey between baseline and six-month follow-up. We used the change in HbA1c during the study period as the main mediator of interest in our causal mediation analysis. Additionally, possible mediations via social support and perceived empowerment attributable to the program were examined.

Results: MCS-12 increased by 1.4 points on average in the intervention group and decreased by 0.2 points in the control group (difference-in-change: 1.6 points, 95% CI: 0.1 to 3.2). In the causal mediation analysis, the intervention had a direct effect on MCS-12 improvement (1.7 points, 95% CI: 0.2 to 3.2) with no indirect effects mediated via HbA1c change (-0.1 points, 95% CI: -0.4 to 0.1), social support (0.1 points), and perception of empowerment (0.1 points).

Conclusions: This Diabetes Self-Care Study empowerment intervention had a modest positive impact on mental HRQoL not mediated by the improvement in glycemic control, as well as social support and perception of empowerment. This favorable effect on mental HRQoL may be a separate clinical advantage of this DSME intervention.

Trial registration: ClinicalTrial.gov NCT00263835.

No MeSH data available.


Related in: MedlinePlus