Measuring continuity of care for diabetes: which visits to include?

OBJECTIVES: Continuity of care measures are widely used to evaluate the quality of health care delivery, but which visits are included vary across studies. Our objective was to determine how the provider specialties included affect continuity values, year-to-year stability, and association with emergency department (ED) visits. STUDY DESIGN: Retrospective study of Alabama Medicaid administrative data. METHODS: We included beneficiaries with diabetes who had at least 3 outpatient visits in each of 2018 and 2019 (N = 9578). We defined 3 provider groupings: all providers, diabetes-broad (primary care, cardiology, neurology, endocrinology, ophthalmology, nephrology, and psychiatry), and diabetes-narrow (primary care and endocrinology). Continuity of care was calculated using the Continuity of Care Index (COCI) for each provider grouping. We compared correlation between measures and from year to year using Spearman correlations, and we used multivariable logistic regression to determine association with ED visits. RESULTS: The mean COCI was 0.54 using visits with all providers, 0.64 with diabetes-broad providers, and 0.83 with diabetes-narrow providers. COCI with diabetes-narrow providers was moderately correlated with the broader sets of providers (Spearman ρ, 0.52-0.65). Comparing each participant's COCI in 2018 with that in 2019, the mean intraperson difference was similar (0.16-0.22), and correlation was moderate (Spearman ρ, 0.41-0.47) for each measure. COCI had similar weak association with ED visits using each provider grouping (odds ratio, 0.99; 95% CI, 0.98-0.99 for each 0.1-unit difference in COCI). CONCLUSIONS: Continuity values differed substantially depending on which provider specialties were included. The importance of this variation is uncertain, as continuity was weakly associated with ED visits using each of the measures.

Trends and Predictors of Glycemic Control Among Adults With Type 2 Diabetes Covered by Alabama Medicaid, 2011-2019.

INTRODUCTION: Despite advances in diabetes management, only one-quarter of people with diabetes in the US achieve optimal targets for glycated hemoglobin A1c (HbA1c), blood pressure, and cholesterol. We sought to evaluate temporal trends and predictors of achieving glycemic control among adults with type 2 diabetes covered by Alabama Medicaid from 2011 through 2019. METHODS: We completed a retrospective analysis of Medicaid claims and laboratory data, using person-years as the unit of analysis. Inclusion criteria were being aged 19 to 64 years, having a diabetes diagnosis, being continuously enrolled in Medicaid for a calendar year and preceding 12 months, and having at least 1 HbA1c result during the study year. Primary outcomes were HbA1c thresholds of <7% and <8%. Primary exposure was study year. We conducted separate multivariable-adjusted logistic regressions to evaluate relationships between study year and HbA1c thresholds. RESULTS: We included 43,997 person-year observations. Mean (SD) age was 51.0 (9.9) years; 69.4% were women; 48.1% were Black, 42.9% White, and 0.4% Hispanic. Overall, 49.1% had an HbA1c level of <7% and 64.6% <8%. Later study years and poverty-based eligibility were associated with lower probability of reaching target HbA1c levels of <7% or <8%. Sex, race, ethnicity, and geography were not associated with likelihood of reaching HbA1c <7% or <8% in any model. CONCLUSION: Later study years were associated with lower likelihood of meeting target HbA1c levels compared with 2011, after adjusting for covariates. With approximately 35% not meeting an HbA1c target of <8%, more work is needed to improve outcomes of low-income adults with type 2 diabetes.

Perceived discrimination in primary care: Does Payer mix matter?

INTRODUCTION: Previous literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race- or insurance-based discrimination. METHODS: Between 2015-2017, we assessed patient satisfaction and perceived race- and insurance-based discrimination using a brief, anonymous post-clinic visit survey. RESULTS: Participants included 3,721 patients from seven primary care clinics-three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race- and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race- and insurance-based discrimination in both public and private settings. CONCLUSION: Reports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race- and insurance-based discrimination in primary care.

Diabetes distress and self-reported health in a sample of Alabama Medicaid-covered adults before and during the COVID-19 pandemic.

Temporary closures of outpatient health facilities and transitions to virtual care during the COVID-19 pandemic interrupted the care of millions of patients with diabetes contributing to worsening psychosocial factors and enhanced difficulty in managing type 2 diabetes mellitus. We explored associations between COVID time period and self-reported diabetes distress on self-reported health among a sample of Alabama Medicaid-covered adults with diabetes pre-COVID (2017-2019) and during-COVID (2020-2021). Method: In this cross-sectional study, we surveyed a population-based sample of adults with type 2 diabetes covered by the Alabama Medicaid Agency. Participants were dichotomized into pre-COVID (March 2017 to October 2019) vs during-COVID (October 2020 to May 2021) groups. Participants with missing data were removed from analyses. We assessed diabetes related stress by the Diabetes Distress Scale. We measured self-reported health using a single item with a 5-point Likert scale. We ran logistic regressions modeling COVID time period on self-reported poor health controlling for demographics, severity of diabetes, and diabetes distress. Results: In this sample of 1822 individuals, median age was 54, 74.5% were female and 59.4% were Black. Compared to pre-COVID participants, participants surveyed during COVID were younger, more likely to be Black (64.1% VS 58.2%, p=0.01) and female (81.8% VS 72.5%, p<0.001). This group also had fewer individuals from rural areas (29.2% VS 38.4%, p<0.001), and shorter diabetes duration (7 years VS 9 years, p<0.001). During COVID individuals reported modestly lower levels of diabetes distress (1.2 VS 1.4, p<0.001) when compared to the pre-COVID group. After adjusting for demographic differences, diabetes severity, and diabetes distress, participants responding during COVID had increased odds of reporting poor health (Odds ratio [OR] 1.41, 95% Confidence Interval [CI] 1.11-1.80). Discussion: We found respondents were more likely to report poorer health during COVID compared to pre-COVID. These results suggest that increased outreach may be needed to address diabetes management for vulnerable groups, many of whom were already at high risk for poor outcomes prior to the pandemic.

Development of a Multicomponent Intervention to Decrease Racial Bias Among Healthcare Staff.

BACKGROUND: Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists). METHODS: Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback. RESULTS: Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to -0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether "it was made clear how to apply the presented content in practice" and "this module was worth the time spent" was ≥4.1 for all modules. CONCLUSIONS: There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.

Assessing Hispanic/Latino and Non-Hispanic White Social Determinants of Obesity Among a Community Sample of Residents in the Rural Southeast US.

Employing an ecological approach, we sought to identify social determinants of obesity among Hispanics/Latinos and non-Hispanic whites living in the Southeast US. Data on social determinants of obesity (individual, family, community and cultural/contextual) were collected from 217 participants [106 Hispanics/Latinos; 111 non-Hispanic whites]; height and weight  were objectively measured. We compared prevalence of overweight and obese between ethnic groups and BMI values within each group by social determinants. Hispanics had a 1.9-fold increase (OR 1.93, 95% CI: 1.05-3.55) in overweight prevalence compared to non-Hispanic whites after adjusting for age and gender. We found positive estimates between unfavorable family-level determinants and BMI among Hispanic/Latinos. In contrast, non-Hispanic whites who reported unfavorable neighborhood characteristics had higher BMI's. Findings highlight the need for targeted approaches for the prevention and control of obesity.

The Mediating Role of Self-Efficacy in the Association Between Diabetes Education and Support and Self-Care Management.

RESULTS: A total of 1,318 participants were included in the study (mean age = 52.9 years, SD = 9.6; 72.5% female, 56.4% Black, 3.1% Hispanic). Diabetes education was associated with increases in self-care activity scores related to general diet, physical activity, glucose self-monitoring, and foot care; care coordination was associated with glucose self-monitoring. In addition, mediation analysis models confirmed that improvements in self-efficacy led to improved self-care activities scores, mediating the association of diabetes education and self-care activities. CONCLUSIONS: Diabetes education and self-efficacy were associated with better self-care. Receiving diabetes education led to a higher likelihood of engaging in self-care activities, driven in part by increases in self-efficacy. Future interventions that aim to improve diabetes self-management behaviors can benefit from targeting self-efficacy constructs and from the integration of diabetes education in the care coordination structure.

Primary care visits and ambulatory care sensitive diabetes hospitalizations among adult Alabama Medicaid beneficiaries.

PURPOSE: To describe patterns of care use for Alabama Medicaid adult beneficiaries with diabetes and the association between primary care utilization and ambulatory care sensitive (ACS) diabetes hospitalizations. METHODS: This retrospective cohort study analyzes Alabama Medicaid claims data from January 2010 to April 2018 for 52,549 covered adults ages 19-64 with diabetes. Individuals were characterized by demographics, comorbidities, and health care use including primary, specialty, mental health and hospital care. Characteristics of those with and without any ACS diabetes hospitalization are reported. A set of 118,758 observations was created, pairing information on primary care use in one year with ACS hospitalizations in the following year. Logistic regression analysis was used to assess the impact of primary care use on the occurrence of an ACS hospitalization. RESULTS: One third of the cohort had at least one ACS diabetes hospitalization over their observed periods; hospital users tended to have multiple ACS hospitalizations. Hospital users had more comorbidities and pharmaceutical and other types of care use than those with no ACS hospitalizations. Controlling for other types of care use, comorbidities and demographics, having a primary care visit in one year was significantly associated with a reduced likelihood of ACS hospitalization in the following year (odds ratio comparing 1-2 visits versus none 0.79, 95% confidence interval 0.73-0.85). CONCLUSIONS: Program and population health interventions that increase access to primary care can have a beneficial effect of reducing excess inpatient hospital use for Medicaid covered adults with diabetes.

Social support and diabetes distress among adults with type 2 diabetes covered by Alabama Medicaid.

AIMS: Diabetes distress affects approximately 36% of adults with diabetes and is associated with worse diabetes self-management and poor glycaemic control. We characterized participants' diabetes distress and studied the relationship between social support and diabetes distress. METHODS: In this cross-sectional study, we surveyed a population-based sample of adults with type 2 diabetes covered by Alabama Medicaid. We used the Diabetes Distress Scale assessing emotional burden, physician-related, regimen-related and interpersonal distress. We assessed participants' level of diabetes-specific social support and satisfaction with this support, categorized as low or moderate-high. We performed multivariable logistic regression of diabetes distress by level of and satisfaction with social support, adjusting for demographics, disease severity, self-efficacy and depressive symptoms. RESULTS: In all, 1147 individuals participated; 73% were women, 41% White, 58% Black and 3% Hispanic. Low level of or satisfaction with social support was reported by 11% of participants; 7% of participants had severe diabetes distress. Participants with low satisfaction with social support were statistically significantly more likely to have severe diabetes distress than those with moderate-high satisfaction, adjusted odds ratio 2.43 (95% CI 1.30, 4.54). CONCLUSIONS: Interventions addressing diabetes distress in adults with type 2 diabetes may benefit from a focus on improving diabetes-specific social support.

Area based stratified random sampling using geospatial technology in a community-based survey.

BACKGROUND: Most studies among Hispanics have focused on individual risk factors of obesity, with less attention on interpersonal, community and environmental determinants. Conducting community based surveys to study these determinants must ensure representativeness of disparate populations. We describe the use of a novel Geographic Information System (GIS)-based population based sampling to minimize selection bias in a rural community based study. METHODS: We conducted a community based survey to collect and examine social determinants of health and their association with obesity prevalence among a sample of Hispanics and non-Hispanic whites living in a rural community in the Southeastern United States. To ensure a balanced sample of both ethnic groups, we designed an area stratified random sampling procedure involving three stages: (1) division of the sampling area into non-overlapping strata based on Hispanic household proportion using GIS software; (2) random selection of the designated number of Census blocks from each stratum; and (3) random selection of the designated number of housing units (i.e., survey participants) from each Census block. RESULTS: The proposed sample included 109 Hispanic and 107 non-Hispanic participants to be recruited from 44 Census blocks. The final sample included 106 Hispanic and 111 non-Hispanic participants. The proportion of Hispanic surveys completed per strata matched our proposed distribution: 7% for strata 1, 30% for strata 2, 58% for strata 3 and 83% for strata 4. CONCLUSION: Utilizing a standardized area based randomized sampling approach allowed us to successfully recruit an ethnically balanced sample while conducting door to door surveys in a rural, community based study. The integration of area based randomized sampling using tools such as GIS in future community-based research should be considered, particularly when trying to reach disparate populations.

Diabetes risk scores for Hispanics living in the United States: A systematic review.

AIM: Undiagnosed diabetes is more prevalent among racial/ethnic minorities in the United States (U.S.). Despite the proliferation of risk scores, few have been validated in Hispanics populations. The aim of this study is to systematically review published studies that developed risk scores to identify undiagnosed Type 2 Diabetes Mellitus based on self-reported information that were validated for Hispanics in the U.S. METHODS: The search included PubMed, EMBASE, Cochrane and CINAHL from inception to 2016 without language restrictions. Risk scores whose main outcome was undiagnosed Type 2 diabetes reporting performance measures for Hispanics were included. RESULTS: We identified three studies that developed and validated risk scores for undiagnosed diabetes based on questionnaire data. Two studies were conducted in Latin America and one in the U.S. All three studies reported adequate performance (area under the receiving curve (AUC) range between0.68and 0.78). The study conducted in the U.S. reported a higher sensitivity of their risk score for Hispanics than whites. The limited number of studies, small size and heterogeneity of the combined cohorts provide limited evidence of the validity of risk scores for Hispanics. CONCLUSIONS: Efforts to develop and validate risk prediction models in Hispanic populations in the U.S are needed, particularly given the diversity of thisfast growing population. Healthcare professionals should be aware of the limitations of applying risk scores developed for the general population on Hispanics.

Effectiveness of Non-Primary Care-Based Smoking Cessation Interventions for Adults with Diabetes: A Systematic Literature Review.

Diabetes is a chronic disease that affects over 25 million adults, many of whom are smokers. The negative health impact of diabetes and comorbid smoking is significant and requires comprehensive interdisciplinary management. The National Diabetes Education Program has identified specific providers, known as PPOD, who include pharmacists, podiatrists, optometrists, and dentists, as key individuals to improve diabetes-related clinical outcomes. These providers are encouraged to work together through interdisciplinary collaboration and to implement evidence-based strategies as outlined in the PPOD toolkit. The toolkit encourages healthcare providers to ask, advise, and assist patients in their efforts to engage in risk reduction and healthy behaviors, including smoking cessation as an important risk factor. While individual PPOD providers have demonstrated effective smoking cessation interventions in adults with other acute and chronic systemic diseases, they lack specific application and focus on adults with diabetes. This literature review examines the current role of PPOD providers in smoking cessation interventions delivered to adults with diabetes.

Challenges to Healthy Eating Practices: A Qualitative Study of Non-Hispanic Black Men Living With Diabetes.

PURPOSE: The purpose of this study was to explore current dietary practices and perceived barriers to healthy eating in non-Hispanic black men with type 2 diabetes. METHODS: Four 90-minute focus groups held in September and October 2011 were led by a trained moderator with a written guide to facilitate discussion on dietary practices and barriers to healthy eating. Participants were recruited from the diabetes database at a public safety-net health system in Jefferson County, Alabama. Two-independent reviewers performed content analysis to identify major themes using a combined deductive and inductive approach. RESULTS: There were 34 male participants aged 18 years and older. Mean years living with diabetes was 9.6 ± 5.9. Sixty-two percent of participants perceived themselves to be in fair or poor health. Participants' self-reported eating practices did not always relate to hunger. Internal cues to eat included habit and response to emotions, and external cues to eat included media messaging, medication regimens, and work schedules. Men identified multiple barriers to healthy eating including hard-to-break habits, limited resources and availability of food at home and in neighborhood grocery stores, and perceived poor communication with health care professionals. CONCLUSION: Non-Hispanic black men acknowledged the importance of healthy eating as part of diabetes self-management but reported various internal and external challenges that present barriers to healthy eating. Tailored strategies to overcome barriers to healthy eating among non-Hispanic black men should be developed and tested for their impact on diabetes self-management.

Evaluation of a workshop to improve residents' patient-centred obesity counselling skills.

BACKGROUND: Primary care physicians are being asked to counsel their patients on obesity and weight management. Few physicians conduct weight loss counselling citing barriers, among them a lack of training and confidence. Our objective was to pilot test the effectiveness of a 3-h interactive obesity-counselling workshop for resident physicians based on motivational interviewing (MI) techniques. DESIGN: This study used a pretest/post-test cross-sectional design. A convenience sample of resident physicians was invited to participate. Participating resident physicians completed a preintervention and postintervention questionnaire to assess their knowledge, beliefs and confidence in obesity counselling. MI techniques taught in the intervention were evaluated by audio recording interviews with a standardised patient (SP) pre intervention and post intervention. Audio recordings were transcribed and coded by two independent coders using a validated assessment tool. Paired t tests were used to assess preintervention and postintervention differences. RESULTS: Eight-six residents attended the workshop. At baseline, the majority (71%) felt that there is not enough time to counsel patients about obesity and only 24% felt that residency trained them to counsel. After the intervention, knowledge and confidence in counselling increased (p<0.001). Among the 55 residents with complete pre-post SP interview data, MI adherent statements increased from a mean of 2.88 to 5.42 while the MI non-adherent statements decreased from 6.73 to 2.33 (p<0.001). CONCLUSIONS: After a brief workshop to train physicians to counsel on obesity-related behaviours, residents improved their counselling skills and felt more confident on counselling patients. Future studies are needed to assess whether these gains are sustained over time.

Diabetes Connect: Developing a Mobile Health Intervention to Link Diabetes Community Health Workers With Primary Care.

Community health worker (CHW) interventions can help improve diabetes self-management and health outcomes. There is limited evidence on how to effectively integrate CHW programs with primary care efforts. Mobile health technology (mHealth) can connect CHWs to members of the health care team and enhance care. We tested a model for the integration of a CHW-delivered mHealth intervention to improve diabetes self-management. Seventy-two African American patients with diabetes were followed using the mHealth tool. This project partnered an academic institution, a safety-net clinic, and African American churches. The integration of mHealth technology into CHW programs was successfully achieved and readily accepted.

Physical Activity Patterns of Latina Immigrants Living in Alabama.

BACKGROUND: Latinos are the fastest growing minority group in the Southeastern USA. Latinos living in the USA have a higher prevalence of obesity, metabolic diseases, and physical inactivity compared to non-Latino Whites, particularly Latina women. The objective of this study is to assess the patterns of physical activity (PA) in overweight Latina immigrants in Alabama using a self-report and an accelerometer. METHODS: Participants included foreign-born Latina women age ≥19 years with BMI ≥25 kg/m(2). The Global Physical Activity Questionnaire was used to assess self-reported physical activity. Accelerometers were used as an objective measure of physical activity. RESULTS: Among 44 overweight/obese Latina immigrants (mean age 36.6 years and BMI 33.3 kg/m(2)), 36.4 % met PA recommendations by self-report while only 20.5 % met recommendations according to the accelerometer. Self-report sedentary activity was underestimated (186 min/day self-report vs. 575 min/day accelerometer) while moderate activity was overestimated (34 min/day self-report vs. 15 min/day accelerometer). While the number of years living in the USA was positively associated with vigorous activity (r=0.32, p= 0.03), the number of years living in Alabama tended to be positively associated with sedentary activity and negatively associated with moderate activity. CONCLUSIONS: Latina immigrants living in Alabama overestimated the amount of time spent in moderate PA and underestimated time spent in sedentary activity.

Development of a theory-based, peer support intervention to promote weight loss among Latina immigrants.

BACKGROUND: Obesity rates are disproportionately high among Latinas living in the United States. Few community-based weight management studies have focused on Latina immigrants living in emerging Latino communities. The purpose of this study was to develop and pilot test a theory-based, promotora-delivered, peer support weight loss intervention for Latina immigrants to be administered in a community setting. We employed participatory methods to develop an 8-week program grounded in self-determination theory. Overweight Latina immigrants were recruited to participate in a quasi-experimental pilot study. Data collected pre and post-intervention included height, weight, fasting lipids, glucose, dietary practices, physical activity and depressive symptoms. RESULTS: Twenty-two women completed the intervention. Mean age was 36, mean time in the U.S. was 12 years; the majority was from Mexico. Mean BMI was 33; 68% had a family history of diabetes. The intervention resulted in statistically significant weight loss (mean 2.1 kg, SD 2.6, p < 0.001); mean change in weight remained significant when compared with that of a historical control group (-2.1 kg vs 1.10 kg, p < 0.01) but was attenuated at 6 months. Levels of moderate physical activity increased significantly (p < 0.05) and dietary practices improved (p < 0.01) and remained significant at 6 months. Notably, depressive symptoms also improved (p = <0.001). CONCLUSIONS: This theory-based, promotora-delivered intervention resulted in significant weight loss among a sample of Latina immigrants at 8 weeks. Future studies are needed to test the impact of an extended peer support intervention on long-term weight management. TRIAL REGISTRATION: National Clinical Trials: NCT02344212. Registered 21 January 2015.

Diabetes self-management interventions for adults with type 2 diabetes living in rural areas: a systematic literature review.

In rural communities, high rates of diabetes and its complications are compounded by limited access to health care and scarce community resources. We systematically reviewed the evidence for the impact of diabetes self-management education interventions designed for patients living in rural areas on glycemic control and other diabetes outcomes. Fifteen studies met inclusion criteria. Ten were randomized controlled trials. Intervention strategies included in-person diabetes (n = 9) and telehealth (n = 6) interventions. Four studies demonstrated between group differences for biologic outcomes, four studies demonstrated changes in behavior, and three studies demonstrated changes in knowledge. Intervention dose was associated with improved A1c or weight loss in two studies and session attendance in one study. Interventions that included collaborative goal-setting were associated with improved metabolic outcomes and self-efficacy. Telehealth and face-to-face diabetes interventions are both promising strategies for rural communities. Effective interventions included collaborative goal-setting. Intervention dose was linked to better outcomes and higher attendance.

Diabetes Connect: African American Women's Perceptions of the Community Health Worker Model for Diabetes Care.

Community health worker (CHW) interventions have potential to improve diabetes outcomes and reduce health disparities. However, few studies have explored patient perspectives of peer-delivered diabetes programs. The purpose of this qualitative study is to investigate possible benefits as well as risks of CHW-delivered peer support for diabetes from the perspectives of African American women living with type 2 diabetes in Jefferson County, Alabama. Four ninety-minute focus groups were conducted by a trained moderator with a written guide to facilitate discussion on the topic of CHWs and diabetes management. Participants were recruited from the diabetes education database at a safety-net hospital. Two independent reviewers performed content analysis to identify major themes using a combined deductive-inductive approach. There were 25 participants. Mean years with diabetes was 11.2 (range 6 months to 42 years). Participants were knowledgeable about methods for self-management but reported limited resources and stress as major barriers. Preferred CHW roles included liaison to the healthcare system and easily accessible information source. Participants preferred that the CHW be knowledgeable and have personal experience managing their own diabetes or assisting a family member with diabetes. Concerns regarding the CHW-model were possible breaches of confidentiality and privacy. The self-management strategies and barriers to management identified by participants were reflected in their preferred CHW roles and traits. These results suggest that African American women with diabetes in Alabama would support peer-led diabetes education that is community-based and socially and emotionally supportive.

Internet interventions to support lifestyle modification for diabetes management: a systematic review of the evidence.

BACKGROUND: The Internet presents a widely accessible, 24-h means to promote chronic disease management. The objective of this review is to identify studies that used Internet based interventions to promote lifestyle modification among adults with type 2 diabetes. METHODS: We searched PubMed using the terms: [internet, computer, phone, smartphone, mhealth, mobile health, web based, telehealth, social media, text messages] combined with [diabetes management and diabetes control] through January 2013. Studies were included if they described an Internet intervention, targeted adults with type 2 diabetes, focused on lifestyle modification, and included an evaluation component with behavioral outcomes. RESULTS: Of the 2803 papers identified, nine met inclusion criteria. Two studies demonstrated improvements in diet and/or physical activity and two studies demonstrated improvements in glycemic control comparing web-based intervention with control. Successful studies were theory-based, included interactive components with tracking and personalized feedback, and provided opportunities for peer support. Website utilization declined over time in all studies that reported on it. Few studies focused on high risk, underserved populations. CONCLUSION: Web-based strategies provide a viable option for facilitating diabetes self-management. Future research is needed on the use of web-based interventions in underserved communities and studies examining website utilization patterns and engagement over time.