Effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes: a systematic review Therapeutic education among adults with type 2 diabetes: effects of a three-day intervention on perceived competence, self-management behaviours and glycaemic control Medication Adherence in Type 2 Diabetes: The ENTRED Study 2007, a French Population-Based Study Medication adherence in diabetes mellitus and self management practices among type-2 diabetics in Ethiopia Behavioural interventions for type 2 diabetes: an evidence-based analysis. Effectiveness of a self-management intervention with personalised genetic and lifestyle-related risk information on coronary heart disease and diabetes-related risk in type 2 diabetes (CoRDia): study protocol for a randomised controlled trial Impact of an education program on patient anxiety, depression, glycemic control, and adherence to self-care and medication in Type 2 diabetes A brief structured education programme enhances self-care practices and improves glycaemic control in Malaysians with poorly controlled diabetes. Multimorbidity in a cohort of patients with type 2 diabetes Effectiveness of a community pharmacist intervention in diabetes care: a randomized controlled trial. Effect of hospital-based telephone coaching on glycaemic control and adherence to management guidelines in type 2 diabetes, a randomised controlled trial. Adherence to Glyburide and Metformin and Associated Factors in Type 2 Diabetes in Isfahan, Iran Improvement in medication adherence and self-management of diabetes with a clinical pharmacy program: a randomized controlled trial in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital Adherence to diabetes control recommendations: impact of nurse telephone calls. Barriers and strategies for oral medication adherence among children and adolescents with Type 2 diabetes. The DiGEM trial protocol – a randomised controlled trial to determine the effect on glycaemic control of different strategies of blood glucose self-monitoring in people with type 2 diabetes [ISRCTN47464659] Medication adherence survey of drugs useful in prevention of dementia of Alzheimer's type among Indian patients. Randomised controlled trial of an automated, interactive telephone intervention to improve type 2 diabetes self-management (Telephone-Linked Care Diabetes Project): study protocol Mobile phone intervention for increasing adherence to treatment for type 2 diabetes in an urban area of Bangladesh: protocol for a randomized controlled trial Impact of hypoglycaemia on patient-reported outcomes from a global, 24-country study of 27,585 people with type 1 and insulin-treated type 2 diabetes. Measuring beliefs about taking hypoglycaemic medication among people with Type 2 diabetes. Nurse-led telecoaching of people with type 2 diabetes in primary care: rationale, design and baseline data of a randomized controlled trial Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan.
Executive summary Background As a chronic condition , the prevalence of Type 2 diabetes is increasing worldwide and adherence to oral medications , an essential component of self‐management , has been shown to improve glycaemic control . However compliance with oral medication adherence remains poor . Educating people with Type 2 diabetes is an important strategy to enhance self‐management ability , including medication‐taking behaviour . Objectives The overall objective of the review was to determine the effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes . Inclusion criteria Types of participants Studies involving adults over 18 years old with Type 2 diabetes , with or without co‐morbidities , currently taking oral hypoglycaemic medication without insulin treatment , and with aglycated haemoglobin ( HbA1c ) > 7.0 % prior to the intervention were considered . Aglycated haemoglobin ( HbA1c ) concentration of less than 7.0 % , is important in order to delay or prevent diabetes‐related complications . Participants could be from the primary , tertiary or acute care setting . Types of intervention The review focused on various forms of educational interventions delivered by healthcare professionals aim ed at improving participants ’ knowledge . Types of outcomes The review evaluated outcomes measuring oral hypoglycaemic adherence including HbA1c , fasting blood glucose levels and other relevant indicators . Types of studies Studies that were r and omized controlled trials ( RCTs ) or case‐control studies were considered . Search strategy A three‐stage search strategy was employed . Papers in English and between the years 1990‐2009 were search ed in the following data bases : CINAHL , Medline , Mosby 's Nursing Consult , PsycINFO , PubMed , ScienceDirect , Scopus , TRIP and Web of Science . Full text was retrieved when the titles and abstract s of studies fulfilled the inclusion criteria . Method ological quality Full papers were assessed for method ological quality independently by two review ers using critical appraisal checklists from the Joanna Briggs Institute ( JBI ) . A third review er was consulted whenever there were disagreements between the two review ers . Data collection / extraction Details of each study included in the review were extracted using st and ardized data extraction forms developed by JBI . Extraction was conducted independently by two review ers . Data synthesis Meta‐ analysis was not possible due to method ological and statistical heterogeneity of the included studies . Hence study findings are presented in narrative form . Results Seven studies included in the final review consisted of seven RCTs . Five studies concluded that the educational intervention was effective in promoting oral hypoglycaemic adherence compared to usual care . These included pharmacist‐led interventions , individual diabetes education provided by nurses and diabetes group education based on a self‐management approach . Similarities among these interventions were provision of information on oral hypoglycaemic medication and the need for regular education sessions . However , small sample s in some studies limited generalization of results . Conclusions Implication s for practice Increased knowledge of oral hypoglycaemic issues and reinforcement of the importance of medication adherence were useful in promoting adherence . Regular education sessions allow individuals to reinforce information and educators to identify barriers to medication adherence . Educational interventions focusing on self‐management strategies appear more likely to achieve positive outcomes . Implication s for research Further trials involving larger sample s and population s with poor glycaemic control are needed . The effects of educational interventions , influence of additional take‐home written material , the optimal interval length of follow‐up and duration of education sessions , and specific processes of individual or group education which have been identified as effective need further exploration The purpose of this study was to evaluate the impact of a three-day therapeutic education programme on perceived competence , self-management behaviours ( i.e. physical activity , diet and medication ) and glycaemic control among adults with type 2 diabetes . A total of 120 participants were included in this r and omized , wait list control group trial . The results confirm that therapeutic education may be a powerful healthcare intervention to improve lifestyle and health status of people with type 2 diabetes . We observed that the education programme used in this study generated positive changes in glycaemic control and adherence to physical activity and diet after three months follow-up . Furthermore , the intervention positively impacted participants ’ perceived competence towards physical activity and diet . The latter finding is of particular importance , given that perceived competence has been found to be involved in long-term adherence to self-management behaviours Background Adherence to prescribed medications is a key dimension of healthcare quality . The aim of this large population -based study was to evaluate self-reported medication adherence and to identify factors linked with poor adherence in patients with type 2 diabetes in France . Methodology The ENTRED study 2007 , a French national survey of people treated for diabetes , was based on a representative sample of patients who cl aim ed reimbursement for oral hypoglycaemic agents and /or insulin at least three times between August 2006 and July 2007 , and who were r and omly selected from the data base of the two main National Health Insurance Systems . Medication adherence was determined using a six-item self-administered question naire . A multinomial polychotomous logistic regression model was used to identify factors associated with medication adherence in the 3,637 persons with type 2 diabetes . Principal Findings Thirty nine percent of patients reported good medication adherence , 49 % medium adherence and 12 % poor adherence . The factors significantly associated with poor adherence in multivariate analysis were socio-demographic factors : age < 45 years , non-European geographical origin , financial difficulties and being professionally active ; disease and therapy-related factors : HbA1c>8 % and existing diabetes complications ; and health care-related factors : difficulties for taking medication alone , decision making by the patient only , poor acceptability of medical recommendations , lack of family or social support , need for information on treatment , reporting no confidence in the future , need for medical support and follow-up by a specialist physician . Conclusions In a country with a high level of access to healthcare , our study demonstrated a substantial low level of medication adherence in type 2 diabetic patients . Better identification of those with poor adherence and individualised suitable recommendations remain essential for better healthcare management Background : Type-2 diabetes mellitus and its complication are becoming more prevalent in Ethiopia . Evidence abound that the most important predictor of reduction of morbidity and mortality due to diabetes complication is the level of glycemic control achieved . Aims : The aim is to assess adherence to anti diabetic drug therapy and self management practice among type-2 diabetic patient in Ethiopia . Patients and Method : The study consists of two phases . A cross-sectional review of r and omly selected 384 case notes of type-2 diabetic patient that attend diabetes mellitus clinic over 3 month and cross-sectional interview , with pre tested adherence and self management and monitoring tool question er of 347 consecutive patients that attend in Jimma university specialized hospital diabetic clinic . Result : Oral hypoglycemic agent were prescribed for 351(91.4 ) of the patient while insulin and oral hypoglycemic agent was prescribed in 33(8.6 % ) . About 312 ( 88.9 % ) patients on oral hypoglycemic agent were on mono therapy , the most frequently prescribed oral hypoglycemic agent was glibenclamide 232(74.3 % ) and metformine 80(25.7 % ) . Only 41.8 % of the patient had adequate glycemic control . The main external factors for non adherence were lack of finance ( 37.1 % ) followed by perceived side effect of drug 29.2 % . Only 6.5 % patient who missed their medications disclosed to physician during consultation . The knowledge and practice of critical component of diabetes self management behavior were generally low among the patient studied . Conclusion : Majority of the patient with type 2 diabetes in Ethiopia are managed by OHA monotherapy mainly glybenclamide and metformine . While the current prescribing strategy do not achieve glycemic control on majority of the patient . This is due to poor adherence with the prescribed drug regimen and poor knowledge and practice of successful self management UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis  BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine whether behavioural interventions are effective in improving glycemic control in adults with type 2 diabetes . BACKGROUND Diabetes is a serious chronic condition affecting millions of people worldwide and is the sixth leading cause of death in Canada . In 2005 , an estimated 8.8 % of Ontario 's population had diabetes , representing more than 816,000 Ontarians . The direct health care cost of diabetes was $ 1.76 billion in the year 2000 and is projected to rise to a total cost of $ 3.14 billion by 2016 . Much of this cost arises from the serious long-term complications associated with the disease including : coronary heart disease , stroke , adult blindness , limb amputations and kidney disease . Type 2 diabetes accounts for 90 - 95 % of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older , prevalence in younger population s is increasing due to a rise in obesity and physical inactivity in children . Data from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) has shown that tight glycemic control can significantly reduce the risk of developing serious complications in type 2 diabetics . Despite physicians ' and patients ' knowledge of the importance of glycemic control , Canadian data has shown that only 38 % of patients with diabetes have HbA1C levels in the optimal range of 7 % or less . This statistic highlights the complexities involved in the management of diabetes , which is characterized by extensive patient involvement in addition to the support provided by physicians . An enormous dem and is , therefore , placed on patients to self-manage the physical , emotional and psychological aspects of living with a chronic illness . Despite differences in individual needs to cope with diabetes , there is general agreement for the necessity of supportive programs for patient self-management . While traditional programs were didactic models with the goal of improving patients ' knowledge of their disease , current models focus on behavioural approaches aim ed at providing patients with the skills and strategies required to promote and change their behaviour . Several meta-analyses and systematic review s have demonstrated improved health outcomes with  self-management support programs in type 2 diabetics . They have all , however , either looked at a specific component of self-management support programs ( i.e. self-management education ) or have been conducted in specific population s. Most review s are also qualitative and do not clearly define the interventions of interest , making findings difficult to interpret . Moreover , heterogeneity in the interventions has led to conflicting evidence on the components of effective programs . There is thus much uncertainty regarding the optimal design and delivery of these programs by policymakers . EVIDENCE -BASED ANALYSIS OF EFFECTIVENESS : RESEARCH QUESTIONS Are behavioural interventions  effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics ( e.g. delivery of intervention , length of intervention , mode of instruction , interventionist etc . ) ? INCLUSION CRITERIA English Language Published between January 1996 to August 2008 Type 2 diabetic adult population ( > 18 years)R and omized controlled trials ( RCTs ) Systematic review s , or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control ( HbA1c ) with extractable data Studies with a minimum of 6-month follow up EXCLUSION CRITERIA Studies with a control group other than usual care Studies with a sample size < 30 Studies without a clearly defined intervention OUTCOMES OF INTEREST PRIMARY OUTCOME glycemic control ( HbA1c ) SECONDARY OUTCOMES systolic blood pressure ( SBP ) control , lipid control , change in smoking status , weight change , quality of life , knowledge , self-efficacy , managing psychosocial aspects of diabetes , assessing dissatisfaction and readiness to change , and setting and achieving diabetes goals . SEARCH STRATEGY A search was performed in OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , The Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1996 and August 2008 . Abstract s were review ed by a single author and studies meeting the inclusion criteria outlined above were obtained . Data on population characteristics , glycemic control outcomes , and study design were extracted . Reference lists were also checked for relevant studies . The quality of the evidence was assessed as being either high , moderate , low , or very low according to the GRADE methodology . SUMMARY OF FINDINGS The search identified 638 citations published between 1996 and August 2008 , of which 12 met the inclusion criteria and one was a meta- analysis ( Gary et al. 2003 ) . The remaining 11 studies were RCTs ( 9 were used in the meta- analysis ) and only one was defined as small ( total sample size N=47 ) . SUMMARY OF PARTICIPANT DEMOGRAPHICS ACROSS STUDIES : A total of 2,549 participants were included in the 11 identified studies . The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years . Most studies reported gender with a mean percentage of females of approximately 67 % . Of the eleven studies , two focused only on women and four included only Hispanic individuals . All studies evaluated type 2 diabetes patients exclusively . STUDY CHARACTERISTICS : The studies were conducted between 2002 and 2008 . Approximately six of 11 studies were carried out within the USA , with the remaining studies conducted in the UK , Sweden , and Israel ( sample size ranged from 47 to 824 participants ) . The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality ( based on the Consort Checklist ) . Differences in quality were mainly due to method ological issues such as inadequate description of r and omization , sample size calculation allocation concealment , blinding and uncertainty of the use of intention-to-treat ( ITT ) analysis . Patients were recruited from several setting s : six studies from primary or general medical practice s , three studies from the community ( e.g. via advertisements ) , and two from outpatient diabetes clinics . A usual care control group was reported in nine of 11 of the studies and two studies reported some type of minimal diabetes care in addition to usual care for the control group . INTERVENTION CHARACTERISTICS : All of the interventions examined in the studies were mapped to the 2007 Self-management Mapping Guide . The interventions most often focused on problem solving , goal setting and encouraging participants to engage in activities that protect and promote health ( e.g. modifying behaviour , change in diet , and increase physical activity ) . All of the studies examined comprehensive interventions targeted at least two self-care topics ( e.g. diet , physical activity , blood glucose monitoring , foot care , etc . ) . Despite the homogeneity in the aims of the interventions , there was substantial clinical heterogeneity in other intervention characteristics such as duration , intensity , setting , mode of delivery ( group vs. individual ) , interventionist , and outcomes of interest ( discussed below ) . DURATION , INTENSITY AND MODE OF DELIVERY : Intervention duration s ranged from 2 days to 1 year , with many falling into the range of 6 to 10 weeks . The rest of the interventions fell into categories of ≤ 2 weeks ( 2 studies ) , 6 months ( 2 studies ) , or 1 year ( 3 studies ) . Intensity of the interventions varied widely from 6 hours over 2 days , to 52 hours over 1 year ; however , the majority consisted of interventions of 6 to 15 hours . Both individual and group sessions were used to deliver interventions . Group counselling was used in five studies as a mode of instruction , three studies used both individual and group sessions , and one study used individual sessions as its sole mode of instruction . ( ABSTRACT Background Many patients with type 2 diabetes fail to achieve good glycaemic control . Poor control is associated with complications including coronary heart disease ( CHD ) . Effective self-management and engagement in health behaviours can reduce risks of complications . However , patients often struggle to adopt and maintain these behaviours . Self-management interventions have been found to be effective in improving glycaemic control . Recent developments in the field of genetics mean that patients can be given personalised information about genetic- and lifestyle-associated risk of developing CHD . Such information may increase patients ’ motivation to engage in self-management . The Coronary Risk in Diabetes ( CoRDia ) trial will compare the effectiveness of a self-management intervention , with and without provision of personalised genetic- and lifestyle-associated risk information , with usual care , on clinical and behavioural outcomes , the cognitive predictors of behaviour , and psychological wellbeing . Methods / Design Participants will be adults aged 25–74 years registered with general practice s in the East of Engl and , diagnosed with type 2 diabetes , with no history of heart disease , and with a glycated haemoglobin level of ≥6.45 % ( 47 mmol/mol ) . Consenting participants will be r and omised to one of three arms : usual care control , group self-management only , group self-management plus personalised genetic- and lifestyle-associated risk information . The self-management groups will receive four weekly 2-hour group sessions , focusing on knowledge and information sharing , problem solving , goal setting and action planning to promote medication adherence , healthy eating , and physical activity . Primary outcomes are glycaemic control and CHD risk . Clinical data will be collected from GP records , including HbA1c , weight , body mass index , blood pressure , and HDL and total cholesterol . Self-reported health behaviours , including medication adherence , healthy eating and physical activity , and cognitive outcomes will be assessed by question naire . Measures will be taken at baseline , 3 months ( question naire only ) , 6 months and 12 months post-baseline . Discussion This study will determine whether the addition of personalised genetic- and lifestyle-associated CHD risk information to a group self-management intervention  improves diabetes control and CHD risk compared with group self-management and usual care . Effectiveness of the combined intervention on health behaviours cognitions theorised to predict them , and psychological outcomes will also be investigated . Trial registration This study has been registered at Clinical Trials.gov ; registration identifier NCT01891786 , registered 28 June 2013 Background : Diabetes mellitus ( DM ) requires continuous medical care , patients ’ self-management , education , and adherence to prescribed medication to reduce the risk of long-term complications . The aim of this study was to assess the benefits of an education program on diabetes , patient self-management , adherence to medication , anxiety , depression and glycemic control in type 2 diabetics in Saudi Arabia . Material s and Methods : This was a prospect i ve study , conducted among 104 diabetic patients at a major tertiary hospital in Riyadh , Saudi Arabia , between May 2011 and October 2012 .  Education material s given to diabetic patients included pamphlets/h and outs written in Arabic , the national language . Special videotapes about DM were made and distributed to all participants . In addition , specific educational programs through the diabetes educators and one-on-one counseling sessions with the doctor were also arranged . Patients were interviewed using a structured interview schedule both during the baseline , and after 6 months of the program . The interview schedule included , socio-demographics , clinical characteristics , diabetes self-management , adherence to medication , anxiety , and depression . Glycemic control was considered poor , if hemoglobin A1c ( HbA1c ) was ≥ 7 % . Results : The mean age of the study population was 57.3 ± 14.4 years . Seventy one were males ( 68.3 % ) and 33 ( 31.7 % ) were females . After six months of the diabetes education program , there were significant improvements in patients ’ dietary plan ( P = 0.0001 ) , physical exercise ( P = 0.0001 ) , self-monitoring of blood glucose ( SMBG ) ( P = 0.0001 ) , HbA1c ( P = 0.04 ) , adherence to medication ( P = 0.007 ) , and depression ( P = 0.03 ) . Conclusions : Implementation of education programs on diabetes among type 2 diabetic patients is associated with better outcomes such as their dietary plan , physical exercise , SMBG , adherence to medication , HbA1c and depression We assessed the effectiveness of a brief structured diabetes education programme based on the concept of self-efficacy on self-care and glycaemic control using single-blind study design . One hundred and sixty-four participants with poorly controlled diabetes from two setting s were r and omized using computer-generated list into control ( n = 82 ) and intervention ( n = 82 ) groups , of which 151 completed the study . Monthly interventions over 12 weeks addressed the self-care practice s of diet , physical activity , medication adherence and self-monitoring of blood glucose ( SMBG ) . These self-care practice s were assessed at Weeks 0 and 12 using pre- and post- question naires in both groups together with glycated haemoglobin A1c ( HbA1c ) and diabetes knowledge . In the intention-to-treat analysis ( n = 164 ) , the intervention group improved their SMBG ( P = < 0.001 ) , physical activity ( P = 0.001 ) , HbA1c ( P = 0.03 ) , diabetes knowledge ( P = < 0.001 ) and medication adherence . At Week 12 , HbA1c difference adjusted for SMBG frequency , medication adherence and weight change remained significant ( P = 0.03 ) compared with control group . For within group comparisons , diabetes knowledge ( P = < 0.001 ) , HbA1c level ( P = < 0.001 ) , SMBG ( P = < 0.001 ) and medication adherence ( P = 0.008 ) improved from baseline in the intervention group . In the control group , only diabetes knowledge improved ( P = < 0.001 ) . These findings can contribute to the development of self-management diabetes education in Malaysia ABSTRACT Background : People with type 2 diabetes frequently have a variety of related and unrelated chronic conditions . These additional conditions have implication s for patient education , treatment burden and disease management . Objectives : The aim of this study was to examine the nature of multimorbidity , and its impact on GP visits , polypharmacy and glycaemic control as measured by HbA1c , in a cohort of patients with type 2 diabetes attending general practice in Irel and . Methods : A cohort of 424 patients with type 2 diabetes enrolled in a cluster r and omized controlled trial based in Irish general practice was examined . Patient data included : medical conditions , HbA1c , health service utilization , socio-economic status and number of prescribed medications . Results : 90 % of patients had at least one additional chronic condition and a quarter had four or more additional chronic conditions . 66 % of patients had hypertension ; 25 % had heart disease ; and 16 % had arthritis . General practitioner visits and polypharmacy increased significantly with increasing numbers of chronic conditions . When comparing patient self-report with medical records , patients who reported a higher proportion of their conditions had better glycaemic control with a significantly lower HbA1c score . Conclusion : There was a high prevalence of multimorbidity in these patients with type 2 diabetes and the results suggest that glycaemic control is related to patients ’ awareness of their chronic conditions . The variety of conditions emphasizes the complexity of illness management in this group and the importance of maintaining a generalist and multidisciplinary approach to their clinical care WHAT IS KNOWN AND OBJECTIVE There is little evidence from well- design ed r and omized controlled trials of the impact of community pharmacist intervention on the clinical management of patients with type 2 diabetes . It is also not known how sustainable any observed effects on glycaemic control are , over time . This study was initiated to address both these issues . METHODS A 6-month , r and omized , controlled parallel-group trial in 66 community pharmacies was conducted in Belgium . Patients were r and omly assigned to receive usual pharmacist care ( n = 135 ) or a predefined pharmacist intervention ( n = 153 ) . The intervention mainly focused on correct medication use , medication adherence and healthy lifestyle promotion . Primary outcome was glycaemic control , as measured by fasting plasma glucose and HbA1c . Sustainability of changes in glycaemic control was assessed by additional glucose measurements 18 months after the end of the study . RESULTS AND DISCUSSION The intervention significantly reduced HbA1c ( between-group difference : 0·5 % , P = 0.009 ) . The largest impact on HbA1c was observed when pharmacotherapy changes ( i.e. , type and /or dose of hypoglycaemic agents ) initiated by the physician were sustained with pharmaceutical care : HbA1c was reduced by 1·05 % in the intervention group , whose medication was changed , compared with a reduction of 0·02 % in the therapy-modification only , group . It was also found that the diabetes education program result ed in improved self-management and better knowledge of diabetes . Eighteen months after the end of the formal study period , the mean HbA1c of the intervention group did not differ significantly from the control group ( 7·4 % vs. 7·2 % ) . WHAT IS NEW AND CONCLUSION This study provides new evidence , from a r and omized controlled trial , of the beneficial  effect of community pharmacist intervention in the clinical management of type 2 diabetic patients . However , questions remain about the sustainability of the observed improvements BACKGROUND Failure to achieve treatment targets is common among people with type 2 diabetes . Cost-effective treatments are required to delay the onset and slow the progression of diabetes-related complications . AIMS This study aim ed to measure the effect of a 6-month telephone coaching intervention on glycaemic control , risk factor status and adherence to diabetes management practice s at the intervention 's conclusion ( 6 months ) and at 12 months . METHOD This r and omised controlled trial recruited 94 adults with type 2 diabetes and an HbA1C > 7 % from the Diabetes Clinic of St Vincent 's Hospital Melbourne . People who were non-English speaking , cognitively impaired , severely hearing impaired or without telephone access were excluded . Participants were r and omised to receive usual care plus 6 months of telephone coaching focusing on achieving treatment targets and complication screening , or usual care only . The primary outcome was HbA1C at 6 months ; secondary outcomes included other physiological and monitoring measures . RESULTS Significant interaction effects were observed between group and time at 6 months , demonstrating improvement in HbA1C , fasting glucose , diastolic blood pressure and physical activity . The intervention 's effect on these parameters was not sustained at 12 months . Intervention group participants also improved compliance with foot examinations and pneumococcal vaccination by 6 months and retinal screening by 12 months . CONCLUSIONS Telephone coaching improved glycaemic control and adherence to complication screening in people with type 2 diabetes , for the duration of its delivery , but these effects were not maintained on withdrawal of the intervention . Strategies that assist patients to sustain these benefits are required The purpose of this study was to determine the adherence to oral hypoglycemic medications and associated factors in type 2 Diabetes Mellitus patients who were referred to the Isfahan Endocrinology and Metabolism Research Centre ( IEMRC ) . Convenience sampling was used to enroll 248 patients with type 2 diabetes in a prospect i ve study at IEMRC from January 2007 to January 2008 . Patients had to be on a stable dose of oral hypoglycemic medications ( glyburide and metformin ) or for 3 months prior to the study and willing to participate in consultation sessions with a pharmacist . Pill count and self report methods were used to measure the adherence .  Mean ( SD ) of patients studied was 56.6 ( 8.9 ) years and 62 % were females . The mean ( SD ) duration of diabetes in the study patients was 10.8 ( 6.1 ) years and 81.9 % of them were literate with basic education . Non-adherence rates to metformin and glyburide were recorded in 39.7 % and 35.3 % of the study population respectively . Lower HbA1C levels and higher education were associated with higher adherence rates . Forgetfulness , confusion , fasting , adverse effects , complexity of medication regimen and disruption of routines were most commonly reported causes of non adherence . Prevalence of adherence to these two medications did not differ significantly between pill count ( 62.3 % ) and self report ( 62.8 % ) , ( p > 0.05 ) . Adherence rates did not vary by pill count and self report significantly . It was concluded that good adherence to medications was associated with a lower HbA1C profile ; so it seems that pill count is a useful method in the clinical practice to identify non-adherent patients . Further studies are needed to find out efficient interventions to improve the patient ’s adherence OBJECTIVE : To evaluate the impact of a clinical pharmacy program on health outcomes in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital in Brazil . METHOD : A r and omized controlled trial with a 6-month follow-up period was performed in 70 adults , aged 45 years or older , with type 2 diabetes who were taking insulin and who had an HbA1c level ≥8 % . Patients in the control group ( CG ) ( n = 36 ) received st and ard care , patients in the intervention group ( IG ) ( n = 34 ) received an individualized pharmacotherapeutic care plan and diabetes education . The primary outcome measure was change in HbA1c . Secondary outcomes included diabetes and medication knowledge , adherence to medication , insulin injection and home blood glucose monitoring techniques and diabetes-related quality of life . Outcomes were evaluated at baseline and 6 months using question naires . RESULTS : Diabetes knowledge , medication knowledge , adherence to medication and correct insulin injection and home blood glucose monitoring techniques significantly improved in the intervention group but remained unchanged in the control group . At the end of the study , mean HbA1c values in the control group remained unchanged but were significantly reduced in the intervention group . Diabetes-related quality of life significantly improved in the intervention group but worsened significantly in the control group . CONCLUSION : The program improved health outcomes and result ed in better glycemic control in patients with type 2 diabetes undergoing insulin therapy BACKGROUND Type 2 diabetes mellitus is increasing in incidence and research has shown that normalization of blood glucose levels can moderate the risk of microvascular and neurological complications . AIM The purpose of this study was to investigate the effect of nurse telephone calls on glycosylated haemoglobin ( HbA1c ) levels and adherence to diabetes control recommendations . METHODS A r and omized design with control and experimental groups being assessed pre- and post intervention was used to assess the effectiveness of nurse telephone calls .  Twenty patients were r and omly assigned to an intervention group and 16 to a control group . The goal of the intervention was to keep blood glucose concentrations close to the normal range ( HbA1c < 7 % ) . The intervention was applied to the intervention group for 12 weeks , and consisted of continued education and reinforcement of diet , exercise , medication adjustment recommendations , as well as frequent self-monitoring of blood glucose levels . Telephone intervention was performed twice per week for the first month and then weekly for the second and third month . Participants were requested to write self-management logs including blood glucose levels , diet and an exercise diary . A dietitian analysed the diet diaries and participants were informed about their results by telephone or mail . All medication adjustments were communicated to participants ' doctors . The HbA1c and diabetes adherence were measured before and after the intervention . RESULTS Patients in the intervention group had a mean decrease of 1.2 % in HbA1c levels and those in the control group had a mean increase of 0.6 % in HbA1c levels . The intervention group had greater diet and blood glucose testing adherence than the control group . CONCLUSION These findings indicate that a nurse telephone intervention can improve HbA1c , and diet and blood glucose testing adherence AIMS Examine barriers for taking  glucose-lowering oral medications  , associated baseline characteristics , strategies used , and the adherence impact in the Treatment Options for Type 2 Diabetes in Adolescents and Youth ( TODAY ) study . METHODS We studied youth prescribed oral diabetes medications over two years ( N = 611 , 583 , and 525 at 6 , 12 , and 24 months ) . Clinicians documented barriers ( e.g. forgetting , routines , other concerns ) in the sub sample that reported missed doses ( N = 423 [ 69.2 % ] , 422 [ 72.4 % ] , and 414 [ 78.9 % ] at 6 , 12 , and 24 months , respectively ) . Adherence strategies were also assessed ( e.g. family , schedule , reminder device ) using st and ard questions . Logistic regression was used to analyze associations with medication adherence . RESULTS Those missing doses were not different from the total sample ( 61.5 % female , 13.9 ± 2.0 years , > 80 % racial/ethnic minorities ) . No baseline demographic or clinical predictors of barriers to medication adherence were identified . Among those for whom barriers were assessed , " forgetting " with no reason named ( 39.3 % ) and disruptions to mealtime , sleep , and schedule ( 21.9 % ) accounted for the largest proportion of responses . Family support was the primary adherence strategy identified by most youth ( ≥50 % ) , followed by pairing the medication regimen with daily routines ( > 40 % ) ; the latter strategy was associated with significantly higher adherence rates ( p = 0.009 ) . CONCLUSIONS Family supported medication adherence was common in this mid-adolescent cohort , but self-management strategies were also in evidence . Findings are similar to those reported among youth with other serious chronic diseases . Prospect i ve studies of multi-component family support and self-management interventions for improving medication adherence are warranted . TRIAL REGISTRATION Clinical Trials.gov NCT00081328 Background We do not yet know how to use blood glucose self-monitoring ( BGSM ) most effectively in the self-management of type 2 diabetes treated with oral medication . Training in monitoring may be most effective in improving glycaemic control and well being when results are linked to behavioural change . Methods / design DiGEM is a three arm r and omised parallel group trial set in UK general practice s. A total of 450 patients with type 2 diabetes managed with lifestyle or oral glucose lowering medication are included . The trial compares effectiveness of three strategies for monitoring glycaemic control over 12 months ( 1 ) a control group with three monthly HbA1c measurements ; interpreted with nurse-practitioner ; ( 2 ) A self-testing of blood glucose group ; interpreted with nurse- practitioner to inform adjustment of medication in addition to 1 ; ( 3 ) A self-monitoring of blood glucose group with personal use of results to interpret results in relation to lifestyle changes in addition to 1 and 2.The trial has an 80 % power at a 5 % level of significance to detect a difference in change in the primary outcome , HbA1c of 0.5 % between groups , allowing for an attrition rate of 10 % . Secondary outcome measures include health service costs , well-being , and the intervention effect in sub-groups defined by duration of diabetes , current management , health status at baseline and co-morbidity . A mediation analysis will explore the extent to which changes in beliefs about self-management of diabetes between experimental groups leads to changes in outcomes in accordance with the Common Sense Model of illness . The study is open and has recruited more than half the target sample . The trial is expected to report in 2007 . Discussion The DiGEM intervention and trial design address weaknesses of previous research by use of a sample size with power to detect a clinical ly significant change in HbA1c , recruitment from a well-characterised primary care population , definition of feasible monitoring and behaviour change strategies based on psychological theory and evidence , and measures along the hypothesised causal path from cognitions to behaviours and disease and well being related outcomes . The trial will provide evidence to support , focus or discourage use of specific BGSM strategies BACKGROUND Good medication adherence is the cornerstone of therapeutic success . Alzheimer 's disease ( AD ) is the most common type of dementia and most patients are old and on multiple drugs , and good compliance therefore is even more important in this population . Dementia of Alzheimer 's type ( DAT ) at present is yet to find a cure . Anticholinesterases and N-methyl-D-aspartate blockers are specific anti-AD therapies available . Hypertension , diabetes , and dyslipidemia can contribute to cognitive worsening . Keeping hypertension , diabetes , and dyslipidemia in control can therefore possibly prevent further cognitive decline . METHODS Patients with subjective memory complaints ( n = 75 ) were chosen r and omly . Upon thorough neurological diagnostic work up for dementia , those with mild cognitive impairment/ question able dementia ( Clinical Dementia Rating = 0.5 ) or those with AD were recruited in this study ( n = 67 ) . Those with hypertension , diabetes , and deranged lipid profile were further interviewed if they were able to take medicines regularly or not . An attempt was made to know causes of non-compliance . RESULTS Forty-one percent of patients were not taking the drugs that have potential to prevent cardiovascular complications or ability to slow down cognitive decline in AD on regular basis . The lack of awareness , ignorance , medicines being " too expensive , " and the pressure of taking medicines regularly were cited as the reasons for non-compliance . Being illiterate and having low education contributed majorly to poor compliance in this study . CONCLUSION Compliance to drugs that have potential or real ability to slow down cognitive decline is low in elderly people with DAT Background An estimated 285 million people worldwide have diabetes and its prevalence is predicted to increase to 439 million by 2030 . For the year 2010 , it is estimated that 3.96 million excess deaths in the age group 20 - 79 years are attributable to diabetes around the world . Self-management is recognised as an integral part of diabetes care . This paper describes the protocol of a r and omised controlled trial of an automated interactive telephone system aim ing to improve the uptake and maintenance of essential diabetes self-management behaviours . Methods / Design A total of 340 individuals with type 2 diabetes will be r and omised , either to the routine care arm , or to the intervention arm in which participants receive the  Telephone-Linked Care ( TLC ) Diabetes program in addition to their routine care . The intervention requires the participants to telephone the TLC Diabetes phone system weekly for 6 months . They receive the study h and book and a glucose meter linked to a data uploading device . The TLC system consists of a computer with software design ed to provide monitoring , tailored feedback and education on key aspects of diabetes self-management , based on answers voiced or entered during the current or previous conversations . Data collection is conducted at baseline ( Time 1 ) , 6-month follow-up ( Time 2 ) , and 12-month follow-up ( Time 3 ) . The primary outcomes are glycaemic control ( HbA1c ) and quality of life ( Short Form-36 Health Survey version 2 ) . Secondary outcomes include anthropometric measures , blood pressure , blood lipid profile , psychosocial measures as well as measures of diet , physical activity , blood glucose monitoring , foot care and medication taking . Information on utilisation of healthcare services including hospital admissions , medication use and costs is collected . An economic evaluation is also planned . Discussion Outcomes will provide evidence concerning the efficacy of a telephone-linked care intervention for self-management of diabetes . Furthermore , the study will provide insight into the potential for more widespread uptake of automated telehealth interventions , globally . Trial Registration Background Mobile phone technologies including SMS ( short message service ) have been used to improve the delivery of health services in many countries . However , data on the effects of mobile health technology on patient outcomes in re source -limited setting s are limited . The aim of this study therefore is to measure the impact of a mobile phone SMS service  on treatment success of newly diagnosed type 2 diabetes in an urban area of Bangladesh . Methods / design This is a single-centred r and omized controlled intervention trial ( prospect i ve ) comparing st and ard-of-care with st and ard-of-care plus a mobile phone-based SMS intervention for 6 months . A total of 216 participants with newly diagnosed type 2 diabetes will be recruited . Data will be collected at the outpatient department of Bangladesh Institute of Health Science ( BIHS ) hospital at baseline and after 6 months . The primary outcome measure will be change in HbA1c between baseline and 6 months . The secondary outcome measures are self-reported medication adherence , clinic attendance , self-reported adoption of healthy behaviours , diabetes knowledge , quality of life and cost effectiveness of the SMS intervention .  The inclusion criteria will be as follows : diagnosed as patients with type 2 diabetes by the BIHS physician , using oral medication therapy , living in Dhaka city , registered with the BIHS hospital , using a mobile phone , willing to return for follow up after 6 months and providing written informed consent . Participants will be allocated to control and intervention arms after recruitment using a r and omization software . Data will be collected on socio-demographic and economic information , mobile phone use and habits , knowledge of prevention , management and complications of diabetes , self-perceived quality of life assessment , self-reported diseases , medical history , family history of diseases , medication history , medication adherence , health seeking behaviour , tobacco use , physical activity , diet , mental health status , life events and disability , anthropometric measurements of weight , height , blood pressure and blood tests for HbA1c . Discussion Mobile phone SMS services have the potential to communicate with diabetes patients and to build awareness about the disease , improve self-management and avoid complications also in re source -limited setting . If this intervention proves to be efficient and cost-effective in the current trial , large-scale implementation could be undertaken . Trial registration DRKS00005188 AIMS Data on the impact of hypoglycaemia on patients ' daily lives and diabetes self-management , particularly in developing countries , are lacking . The aim of this study was to assess fear of , and responses to , hypoglycaemia experienced by patients globally . MATERIAL S AND METHODS This non-interventional , multicentre , 4-week prospect i ve study using self- assessment question naires and patient diaries consisted of 27,585 patients , ≥18years , with type 1 diabetes ( n=8022 ) or type 2 diabetes ( n=19,563 ) treated with insulin for > 12months , at 2004 sites in 24 countries worldwide . RESULTS Increased blood glucose monitoring ( 69.7 % ) and seeking medical assistance ( 62.0 % ) were the most common responses in the 4weeks following hypoglycaemic events for patients with type 1 diabetes and type 2 diabetes , respectively . Approximately 44 % of patients with type 1 diabetes or type 2 diabetes increased calorie intake in response to a hypoglycaemic episode . Following hypoglycaemia , 3.9 % ( type 1 diabetes ) and 6.2 % ( type 2 diabetes ) of patients took leave from work or study . Regional differences in fear of , and responses to , hypoglycaemia were evident - in particular , a lower level of hypoglycaemic fear and utilisation of healthcare re sources in Northern Europe and Canada . CONCLUSIONS Hypoglycaemia has a major impact on patients and their behaviour . These global data for the first time reveal regional variations in response to hypoglycaemia and highlight the importance of patient education and management strategies AIMS Identifying patients ' beliefs about taking medication can inform interventions to support medication taking , and their evaluation . We set out to establish the range of these beliefs , and measure the frequency of commonly held beliefs and their correlation with intention to take medication and self-reported medication adherence . METHODS An exploratory survey among Type 2 diabetic patients aged 40 years or older , registered in general practice , used a question naire measuring a range of plausible beliefs about taking and intention to take medication developed from interviews where belief elicitation was guided by the Theory of Planned Behaviour . The Medication Adherence Report Schedule was used as a self-report adherence measure . RESULTS Question naires were returned by 121 ( 61.7 % ) people . The majority strongly agreed with statements about the benefits of taking medication . Negative beliefs that taking medication would 'cause unpleasant side effects ' and ' lead to weight gain ' were held by 32.8 [ corrected ] and 13.9 % of people , respectively . Beliefs about benefit were strongly associated with intention to take medication regularly . Two beliefs were associated with reduced medication adherence : ' changes to my daily routine would make it more difficult to take my diabetes medicines regularly ' ( P < 0.001 ) , and ' if I were to take my diabetes medicines regularly this would lead to my gaining weight ' ( P < 0.01 ) [ corrected ] CONCLUSIONS Use of a theoretical model to elicit and identify common beliefs about taking medication regularly underscores the importance of exploring weight-gain concerns and how to keep taking tablets when routines change . Beliefs associated with intention and taking medication will inform intervention development , implementation and evaluation in r and omized controlled studies Background Despite the efforts of the healthcare community to improve the quality of diabetes care , about 50 % of people with type 2 diabetes do not reach their treatment targets , increasing the risk of future micro- and macro-vascular complications . Diabetes self-management education has been shown to contribute to better disease control . However , it is not known which strategies involving educational programs are cost-effective . Telehealth applications might support chronic disease management . Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high method ological quality . “ The COACH Program ” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions . It proved to be effective in patients with coronary heart disease after hospitalization . Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed . Methods / Design R and omized controlled trial in patients with type 2 diabetes . Patients were selected based on their medication consumption data and were recruited by their sickness fund . They were r and omized to receive either usual care plus “ The COACH Program ” or usual care alone . The study will assess the difference in outcomes between groups . The primary outcome measure is the level of HbA1c . The secondary outcomes are : Total Cholesterol , LDL-Cholesterol , HDL-Cholesterol , Triglycerides , Blood Pressure , body mass index , smoking status ; proportion of people at target for HbA1c , LDL-Cholesterol and Blood Pressure ; self-perceived health status , diabetes-specific emotional distress and satisfaction with diabetes care . The follow-up period is 18 months . Within-trial and modeled cost-utility analyses , to project effects over life-time horizon beyond the trial duration , will be undertaken from the perspective of the health care system if the intervention is effective . Discussion The study will enhance our underst and ing of the potential of telehealth in diabetes management in Belgium . Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions . Trial registration Belgian number : B322201213625 . Clinical Trials.gov Identifier : BACKGROUND Glycemic goals ( hemoglobin A1c < 7 % ) are often not achieved in patients with type 2 diabetes despite the availability of many effective treatments and the documented benefits of glycemic control in the reduction of long-term microvascular and macrovascular complications . Several studies have established the important positive effects of pharmacist-led management on achieving glycemic control and other clinical outcomes in patients with diabetes . Diabetes prevalence and mortality are increasing rapidly in Jordan . Nevertheless , clinical pharmacists in Jordan do not typically provide pharmaceutical care ; instead , the principal responsibilities of pharmacists in Jordan are dispensing and marketing of medical products to physicians . OBJECTIVE To assess the primary clinical outcome of glycemic control ( A1c ) and secondary outcomes , including blood pressure , lipid values , self-reported medication adherence , and self-care activities for patients with type 2 diabetes in an outpatient diabetes clinic r and omly assigned to either usual care or a pharmacist-led pharmaceutical care intervention program . METHODS Patients with type 2 diabetes attending an outpatient diabetes clinic of a large teaching hospital were recruited over a 4-month period from January through April 2011 and r and omly assigned to intervention and usual care groups using the Minim software technique . The intervention group at baseline received face-to-face objective -directed education from a clinical pharmacist about type 2 diabetes , prescription medications , and necessary lifestyle changes , followed by 8 weekly telephone follow-up calls to discuss and review the prescribed treatment plan and to resolve any patient concerns . The primary outcome measure was glycemic control ( A1c ) , and secondary measures included systolic and diastolic blood pressure , complete lipid profile ( i.e. , total cholesterol , low-density lipoprotein cholesterol [ LDL-C ] , high-density lipoprotein cholesterol [ HDL-C ] , serum triglycerides ) , and self-reported medication adherence ( 4-item Morisky Scale ) and self-care activities ( Summary of Diabetes Self-Care Activities question naire ) . Data were collected at baseline and at 6 months follow-up . Changes from baseline to follow-up were calculated for biomarker values , and between-group differences in the change amounts were tested using the t test for independent sample s. A P value of < 0.05 was considered statistically significant . RESULTS A total of 77 of 85 patients ( 90.6 % ) r and omly assigned to the intervention group and 79 of 86 patients ( 91.9 % ) assigned to usual care had baseline and 6-month follow-up values . Compared with baseline values , patients in the intervention group had a mean reduction of 0.8 % in A1c versus a mean increase of 0.1 % from baseline in the usual care group ( P = 0.019 ) . The intervention group compared with the usual care group had small but statistically significant improvements in the secondary measures of fasting blood glucose , systolic and diastolic blood pressure , total cholesterol , LDL-C , serum triglycerides , self-reported medication adherence , and self-care activities . Between-group differences in changes in the secondary measures of HDL-C and body mass index were not significant . CONCLUSIONS Patients with type 2 diabetes who received pharmacist-led pharmaceutical care in an outpatient diabetes clinic experienced reduction in A1c at 6 months compared with essentially no change in the usual care group . Six of 8 secondary biomarkers were improved in the intervention group compared with usual care
Similarities among these interventions were provision of information on oral hypoglycaemic medication and the need for regular education sessions .
Implication s for practice Increased knowledge of oral hypoglycaemic issues and reinforcement of the importance of medication adherence were useful in promoting adherence .
Regular education sessions allow individuals to reinforce information and educators to identify barriers to medication adherence .
Educational interventions focusing on self-management strategies appear more likely to achieve positive outcomes .
EXECUTIVE SUMMARY Background As a chronic condition , the prevalence of Type 2 diabetes is increasing worldwide and adherence to oral medications , an essential component of self-management , has been shown to improve glycaemic control .
However compliance with oral medication adherence remains poor .
Educating people with Type 2 diabetes is an important strategy to enhance self-management ability , including medication-taking behaviour .
Objectives The overall objective of the review was to determine the effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes .
Aglycated haemoglobin ( HbA1c ) concentration of less than 7.0 % , is important in order to delay or prevent diabetes-related complications .