Skip to main content
SpringerLink
Log in

Effect of Problem-Solving-Based Diabetes Self-Management Training on Diabetes Control in a Low Income Patient Sample

  • Original Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Lower socioeconomic status is associated with excess disease burden from diabetes. Diabetes self-management support interventions are needed that are effective in engaging lower income patients, addressing competing life priorities and barriers to self-care, and facilitating behavior change.

Objective

To pilot test feasibility, acceptability, and effect on disease control of a problem-based diabetes self-management training adapted for low literacy and accessibility.

Design

Two-arm randomized controlled trial powered to detect a 0.50% change in A1C at follow-up with a 2-sided alpha of 0.05 in a pooled analysis.

Participants

Fifty-six urban African-American patients with type 2 diabetes and suboptimal blood sugar, blood pressure, or cholesterol control recruited from a diabetes registry within a university-affiliated managed care organization.

Interventions

A group, problem-based diabetes self-management training designed for delivery in an intensive and a condensed program format. Three intensive and three condensed program groups were conducted during the trial.

Main Measures

Clinical (A1C, systolic blood pressure [SBP], diastolic blood pressure [DBP], LDL and HDL cholesterol) and behavioral (knowledge, problem solving, self-management behavior) data were measured at baseline, post-intervention, and 3 months post-intervention (corresponding with 6–9 months following baseline).

Results

Adoption of both programs was high (>85% attendance rates, 95% retention). At 3 months post-intervention, the between-group difference in A1C change was −0.72% (p = 0.02), in favor of the intensive program. A1C reduction was partially mediated by problem-solving skill at follow-up (ß = −0.13, p = 0.04). Intensive program patients demonstrated within-group improvements in knowledge (p < 0.001), problem-solving (p = 0.01), and self-management behaviors (p = 0.04). Among the subsets of patients with suboptimal blood pressure or lipids at baseline, the intensive program yielded clinically significant individual improvements in SBP, DBP, and LDL cholesterol. Patient satisfaction and usability ratings were high for both programs.

Conclusions

A literacy-adapted, intensive, problem-solving-based diabetes self-management training was effective for key clinical and behavioral outcomes in a lower income patient sample.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2

Similar content being viewed by others

References

  1. Saydah S, Lochner K. Socioeconomic status and risk of diabetes-related mortality in the U.S. Public Health Rep. 2010;125:377–88.

    PubMed  Google Scholar 

  2. LaVeist TA, Thorpe RJ Jr, Galarraga JE, Bower KM, Gary-Webb TL. Environmental and socio-economic factors as contributors to racial disparities in diabetes prevalence. J Gen Intern Med. 2009;24:1144–8.

    Article  PubMed  Google Scholar 

  3. Funnell MM, Brown TL, Childs BP, Haas LB, Hosey GM, Jensen B, Maryniuk M, Peyrot M, Piette JD, Reader D, Siminerio LM, Weinger K, Weiss MA. National standards for diabetes self-management education. Diabetes Care. 2010;33(Suppl 1):S89–96.

    Article  PubMed  Google Scholar 

  4. Hill-Briggs F, Gary TL, Hill MN, Bone LR, Brancati FL. Health-related quality of life in urban African Americans with type 2 diabetes. J Gen Intern Med. 2002;17(6):412–9.

    Article  PubMed  Google Scholar 

  5. Institute of Medicine. Priority areas for national action: Transforming health care quality. Washington, D.C.: National Academies Press; 2003.

    Google Scholar 

  6. Sentell TL, Halpin HA. Importance of adult literacy in understanding health disparities. J Gen Intern Med. 2006;21:862–6.

    Article  PubMed  Google Scholar 

  7. Hill-Briggs F. Problem solving in diabetes self-management: a model of chronic illness self-management behavior. Ann Behav Med. 2003;25:182–93.

    Article  PubMed  Google Scholar 

  8. Davidson KW, Falzon L: Cochrane Behavioral Medicine Field. About The Cochrane Collaboration (Fields) 2007, Issue 3. Article. No. CE000146.

  9. Hill-Briggs F, Gemmell L. Problem solving in diabetes self-management and control: a systematic review of the literature. Diabetes Educ. 2007;33:1032–50.

    Article  PubMed  Google Scholar 

  10. Glasgow RE, Fisher L, Skaff M, Mullan J, Toobert DJ. Problem solving and diabetes self-management: investigation in a large, multiracial sample. Diabetes Care. 2007;30:33–7.

    Article  PubMed  Google Scholar 

  11. D'Zurilla TJ, Nezu AM. Problem-solving Therapy. 3rd ed. New York: Springer; 2007.

    Google Scholar 

  12. Schumann K, Sutherland J, Majid H, Hill-Briggs F. Evidence-based behavioral treatments for diabetes: Problem-solving therapy. Diabetes Spectrum, in press.

  13. Hill-Briggs F, Renosky R, Lazo M, et al. Development and pilot evaluation of literacy-adapted diabetes and CVD education in urban, diabetic African Americans. J Gen Intern Med. 2008;23:1491–4.

    Article  PubMed  Google Scholar 

  14. Hill-Briggs F, Lazo M, Renosky R, Ewing C. Usability of a diabetes and cardiovascular disease education module in an African American, diabetic sample with physical, visual, and cognitive impairment. Rehabil Psychol. 2008;53:1–8.

    Article  Google Scholar 

  15. Centers for Disease Control and Prevention. Scientific and technical information simply put. 2nd ed. Atlanta: Office of Communication, Centers for Disease Control and Prevention, 1999.

  16. Doak CC, Doak LG, Root JH. Teaching patients with low literacy skills. 2nd ed. Philadelphia, PA: J.B. Lippincott Company; 1996.

    Google Scholar 

  17. National Cancer Institute. Clear and simple: Developing effective print materials for low-literate readers. Bethesda, MD, U.S: Department of Health and Human Services; 1994.

    Google Scholar 

  18. Williams AS. Accessible diabetes education materials in low-vision format. Diabetes Educ. 1999;25:695–8, 700, 702.

  19. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2010;33(Suppl 1):S11–S61.

    Article  Google Scholar 

  20. Wilkinson GS. Wide Range Achievement Test Administration Manual. Wilmington, DE: Wide Range, Inc.; 1993.

    Google Scholar 

  21. Beck AT, Steer RA, Brown GK. BDI-Fast Screen for Medical Patients Manual. The Psychological Corporation, 2000.

  22. Hill-Briggs F, Gemmell L, Kulkarni B, Klick B, Brancati FL. Associations of patient health-related problem solving with disease control, emergency department visits, and hospitalizations in HIV and diabetes clinic samples. J Gen Intern Med. 2007;22:649–54.

    Article  PubMed  Google Scholar 

  23. Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care. 2000;23:943–50.

    Article  PubMed  CAS  Google Scholar 

  24. Peyrot M. Causal modeling: theory and applications. J Pediatr Psychol. 1996;21:3–24.

    Article  PubMed  CAS  Google Scholar 

  25. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41:582–92.

    PubMed  Google Scholar 

  26. Malouff JM, Thorsteinsson EB, Schutte NS. The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clin Psychol Rev. 2007;27:46–57.

    Article  PubMed  Google Scholar 

  27. Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Diabetes Educ. 2003;29:488–501.

    Article  PubMed  Google Scholar 

  28. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care. 2002;25:1159–71.

    Article  PubMed  Google Scholar 

  29. Kazdin AE. Research Design in Clinical Psychology. 4th ed. New Jersey: Allyn and Bacon; 2003.

    Google Scholar 

  30. Glazier RH, Bajcar J, Kennie NR, Willson K. A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Diabetes Care. 2006;29:1675–88.

    Article  PubMed  Google Scholar 

  31. Leichter SB, Dreelin E, Moore S. Integration of clinical psychology in the Comprehensive Diabetes Care Team. Clin Diabetes. 2004;22:129–31.

    Article  Google Scholar 

Download references

Acknowledgements

This research was funded by NHLBI grant K01 HL076644, American Diabetes Association grant 7-06-IN-07, General Clinical Research Center grant M01RR000052 from the NIH National Center for Research Resources, and NIDDK Diabetes Research and Training Center grant P60 DK079637. Portions of the study results were presented at the American Diabetes Association Scientific Sessions, Orlando, Florida, June 2010 and the World Congress on Chronic Care, Amsterdam, Netherlands, November, 2007. We gratefully acknowledge the dedication of our research participants and staff.

(ClinicalTrials.gov Identifier Number NCT00201110)

Conflict of Interest

The authors have no conflicts of interest to disclose.

Author information

Authors and Affiliations

  1. Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Felicia Hill-Briggs PhD, Angela Doswell BA, Yi-Ting Chang ScM, David Levine MD, ScD, Nae-Yuh Wang PhD & Frederick L. Brancati MD, MHS

  2. Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

    Felicia Hill-Briggs PhD & David Levine MD, ScD

  3. Johns Hopkins University School of Nursing, Baltimore, MD, USA

    Felicia Hill-Briggs PhD & Martha N. Hill PhD

  4. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Mariana Lazo MD, ScM & Frederick L. Brancati MD, MHS

  5. Department of Sociology, Loyola University of Maryland, Baltimore, MD, USA

    Mark Peyrot PhD

  6. Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Nae-Yuh Wang PhD

  7. Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Suite 2–600, 2024 E. Monument Street, Baltimore, MD, 21287, USA

    Felicia Hill-Briggs PhD

Authors
  1. Felicia Hill-Briggs PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mariana Lazo MD, ScM
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mark Peyrot PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Angela Doswell BA
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yi-Ting Chang ScM
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Martha N. Hill PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. David Levine MD, ScD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Nae-Yuh Wang PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Frederick L. Brancati MD, MHS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Felicia Hill-Briggs PhD.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Online Appendix

Project DECIDE (Decision-making Education for Choices In Diabetes Everyday) Intervention Description (PDF 49 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hill-Briggs, F., Lazo, M., Peyrot, M. et al. Effect of Problem-Solving-Based Diabetes Self-Management Training on Diabetes Control in a Low Income Patient Sample. J GEN INTERN MED 26, 972–978 (2011). https://doi.org/10.1007/s11606-011-1689-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-011-1689-6

KEY WORDS

Search

Navigation