To Adapt or Not to Adapt: The Association between Implementation Fidelity and the Effectiveness of Diabetes Self-Management Education.

Self-management education (SME) is a key determinant of diabetes treatment outcomes. While SME programs are often adapted for implementation, the impact of adaptations on diabetes SME effectiveness is not well documented. This study evaluated the impact of the implementation fidelity of diabetes SME programs on program effectiveness, exploring which factors influence implementation fidelity. Data from 33 type 2 diabetes SME program providers and 166 patients were collected in 8 countries (Austria, Belgium, Germany, Ireland, UK, Israel, Taiwan and USA). Program providers completed a questionnaire assessing their adherence to the program protocol and factors that influenced the implementation. Patients answered a pre-post questionnaire assessing their diabetes-related health literacy, self-care behavior, general health and well-being. Associations between implementation fidelity and outcomes were estimated through logistic regressions and repeated measures MANOVA, controlling for potential confounders. Adaptations of the program protocol regarding content, duration, frequency and/or coverage were reported by 39% of the providers and were associated with better, not worse, outcomes than strict adherence. None of the factors related to the participants, facilitating strategies, provider or context systematically influenced the implementation fidelity. Future research should focus on individual and contextual factors that may influence decisions to adapt SME programs for diabetes.

When knowing is not enough: Emotional distress and depression reduce the positive effects of health literacy on diabetes self-management.

OBJECTIVES: Adequate self-management activities are important predictors of diabetes outcomes. As diabetes literacy and self-efficacy are strong predictors of diabetes self-care, self-management education programs focus essentially on these factors. This study investigated whether emotional distress or depression moderates the relation between health literacy, self-efficacy and diabetes self-care behaviors. METHODS: 128 people with type 2 diabetes were recruited in hospitals, through general practitioners and via a diabetes website, and completed a questionnaire assessing health literacy, self-efficacy, diabetes-related distress, depression and self-care behaviors. RESULTS: Multiple regression analysis confirms that health literacy and self-efficacy significantly predict reported self-care behaviors. Additional regression analyses reveal that distress or depression do not predict self-care behaviors directly, but moderate the effect of health literacy, which has a weaker impact in patients experiencing distress or depression. In contrast, distress and depression do not moderate the effect of self-efficacy on diabetes self-care behaviors. CONCLUSION: Emotional distress, whether related to diabetes or not, prevents patients from acting on their competence to perform adequate self-management behaviors. PRACTICE IMPLICATIONS: Diabetes Professionals should pay more attention to the patients' affective state and its influence on self-care. Psychological support should be integrated in the care for people suffering from type 2 diabetes.

Assessment of implementation fidelity in diabetes self-management education programs: a systematic review.

OBJECTIVE: As diabetes requires extensive self-care, self-management education is widely recommended to enhance the effectiveness and reduce the costs of treatment. While a variety of diabetes self-management (DSM) programs are available, the conditions for their effective implementation are not well documented. This paper reviews the literature on implementation fidelity (IF), the degree to which programs are delivered as intended, as a factor influencing the effectiveness of diabetes education. METHODS: Medical, psychological and educational research databases were searched to identify published studies on diabetes education describing the implementation process. Studies detailing the intervention adherence/fidelity/integrity were included to assess the way key elements of IF were addressed. RESULTS: From an initial 418 abstracts, 20 published papers were retained for an in-depth analysis focusing on the components of IF. Intervention content was mainly assessed through observation, whereas intervention dose was more often assessed through self-report measures. Only one study addressed the relationship between IF and intervention effectiveness. CONCLUSION: Despite the importance of IF to achieve program outcomes, IF of DSM programs remains largely under-investigated. PRACTICE IMPLICATIONS: The results of this review suggest that reports on DSM education should systematically describe how the program was implemented. The impact of IF on program outcomes needs further investigation.