Effectiveness of an intervention to improve diabetes self-management on clinical outcomes in patients with low educational level.

OBJECTIVE: To determine whether an intervention based on patient-practitioner communication is more effective than usual care in improving diabetes self-management in patients with type 2 diabetes with low educational level. METHODS: 12-month, pragmatic cluster randomised controlled trial. Nine physicians and 184 patients registered at two practices in a deprived area of Granada (Andalusia, Spain) participated in the study. Adult patients with type 2 diabetes, low educational level and glycated haemoglobin (HbA1c) > 7% (53.01 mmol/mol) were eligible. The physicians in the intervention group received training on communication skills and the use of a tool for monitoring glycaemic control and providing feedback to patients. The control group continued standard care. The primary outcome was difference in HbA1c after 12 months. Dyslipidaemia, blood pressure, body mass index and waist circumference were also assessed as secondary outcomes. Two-level (patient and provider) regression analyses controlling for sex, social support and comorbidity were conducted. RESULTS: The HbA1c levels at 12 months decreased in both groups. Multilevel analysis showed a greater improvement in the intervention group (between-group HbA1c difference= 0.16; p=0.049). No statistically significant differences between groups were observed for dyslipidaemia, blood pressure, body mass index and waist circumference. CONCLUSIONS: In this pragmatic study, a simple and inexpensive intervention delivered in primary care showed a modest benefit in glycaemic control compared with usual care, although no effect was observed in the secondary outcomes. Further research is needed to design and assess interventions to promote diabetes self-management in socially vulnerable patients.

Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care.

BACKGROUND: In the last decades the presence of social inequalities in diabetes care has been observed in multiple countries, including Spain. These inequalities have been at least partially attributed to differences in diabetes self-management behaviours. Communication problems during medical consultations occur more frequently to patients with a lower educational level. The purpose of this cluster randomized trial is to determine whether an intervention implemented in a General Surgery, based in improving patient-provider communication, results in a better diabetes self-management in patients with lower educational level. A secondary objective is to assess whether telephone reinforcement enhances the effect of such intervention. We report the design and implementation of this on-going study. METHODS/DESIGN: The study is being conducted in a General Practice located in a deprived neighbourhood of Granada, Spain. Diabetic patients 18 years old or older with a low educational level and inadequate glycaemic control (HbA1c > 7%) were recruited. General Practitioners (GPs) were randomised to three groups: intervention A, intervention B and control group. GPs allocated to intervention groups A and B received training in communication skills and are providing graphic feedback about glycosylated haemoglobin levels. Patients whose GPs were allocated to group B are additionally receiving telephone reinforcement whereas patients from the control group are receiving usual care. The described interventions are being conducted during 7 consecutive medical visits which are scheduled every three months. The main outcome measure will be HbA1c; blood pressure, lipidemia, body mass index and waist circumference will be considered as secondary outcome measures. Statistical analysis to evaluate the effectiveness of the interventions will include multilevel regression analysis with three hierarchical levels: medical visit level, patient level and GP level. DISCUSSION: The results of this study will provide new knowledge about possible strategies to promote a better diabetes self-management in a particularly vulnerable group. If effective, this low cost intervention will have the potential to be easily incorporated into routine clinical practice, contributing to decrease health inequalities in diabetic patients. TRIAL REGISTRATION: Clinical Trials U.S. National Institutes of Health, NCT01849731.

[Study of migratory grief in immigrant patients seen in primary care clinics. Presentation of a migratory grief evaluation questionnaire]. / Estudio del duelo migratorio en pacientes inmigrantes que acuden a las consultas de atención primaria. Presentación de un cuestionario de valoración del duelo migratorio.

OBJECTIVES: To validate a questionnaire designed to show the existence of migratory grief (MG) and its dimensions in the immigrant population, and to study its relationship with certain sociodemographic variables. DESIGN: A descriptive, cross-sectional, multicentre study. EMPLACEMENT: Consultations in Primary Health Care. PATIENTS: The study included 290 Primary Health Care immigrant patients over 18-years old. There were 12 rejections due to, lack of time, absence of a translator, and lack of understanding. PRINCIPAL MEASUREMENTS: An MG questionnaire with 17 questions was employed, carrying out a factor analysis with final extraction of 4 factors explaining 52.1% of overall variance. Sociodemographic variables were collected: gender, age, marital status, nationality, social network, time in Spain, legal and work situation and communication difficulties. Multivariate analysis was performed using the sociodemographic variables. RESULTS: Four factors were found (fear, homesickness, concern and loss of identity), showing that non-communality was < 0.30 and considering that the 4 factors represent the group of variables from the questionnaire. After analysing the correlations between the different factors, it was observed that concern is related to fear and homesickness, this latter being independent from fear. The loss of identity had a low correlation with other factors. Cronbach's alpha showed good consistency in factors 1, 2 and 3. Some sociodemographic variables are associated with the presence of each factor. CONCLUSIONS: We present a validated instrument to study and characterise MG, adapted to study the different dimensions of the grief in immigrant population.