Self Management
Twelve-month outcomes of an Internet-based diabetes self-management support program

https://doi.org/10.1016/j.pec.2011.07.024Get rights and content

Abstract

Objective

Internet-based programs offer potential for practical, cost-effective chronic illness self-management programs.

Methods

We report 12-month results of an Internet-based diabetes self-management program, with and without additional support, compared to enhanced usual care in a 3-arm practical randomized trial. Patients (n = 463) were randomized: 77.3% completed 12-month follow-up. Primary outcomes were changes in health behaviors of healthy eating, physical activity, and medication taking. Secondary outcomes were hemoglobin A1c, body mass index, lipids, blood pressure, and psychosocial factors.

Results

Internet conditions improved health behaviors significantly vs. usual care over the 12-month period (d for effect size = .09–.16). All conditions improved moderately on biological and psychosocial outcomes. Latinos, lower literacy, and higher cardiovascular disease risk patients improved as much as other participants.

Conclusions

The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact. However, 12-month magnitude of effects was small, suggesting that different or more intensive approaches are necessary to support long-term outcomes. Research is needed to understand the linkages between intervention and maintenance processes and downstream outcomes.

Practice implications

Automated self-management interventions should be tailored and integrated into primary care; maintenance of patient self-management can be enhanced through links to community resources.

Introduction

With the increased prevalence of diabetes [1], there is increasing need for diabetes self-management support that has the ability to reach large numbers of adults [2]. Traditional clinical approaches, such as physician counseling and group-based diabetes education programs [3], have inadequate reach, and have not been sufficient to support long-term behavior changes [4], [5], [6]. In addition, primary care offices generally do not have the resources or time to provide diabetes self-management education and follow-up support [7], [8]. Widespread use of the Internet provides an opportunity to expand the reach of diabetes education programs, and to provide continuous support and tools for achieving necessary changes in multiple lifestyle behaviors, such as healthful eating, regular physical activity, and managing medications [9], [10].

Despite reviews suggesting that computerized interactive behavioral health change interventions can be effective [4], [11], [12], questions remain about whether these programs will prove equitable in terms of access to services, or whether the “digital divide” may increase disparities and about their longer term effects and overall public health impact [13]. From an ecological perspective on health behavior change [14], it is also not known whether website use and outcomes are influenced by factors such as individual characteristics, especially factors such as level of computer use and health literacy and numeracy; social network/social support; and community/environmental influences.

Evidence from our previous research indicates that effective diabetes self-management interventions (a) incorporate the patient as an active participant in setting goals, (b) are based on behavioral and social-ecological theory, (c) emphasize problem solving and use of supportive resources, and (d) provide proactive follow-up support [15], [16], [17]. Translating these important principles into interactive components in an electronic or virtual environment is complex. Furthermore, integrating such programming with primary care activities is important. With the growing emphasis on telemedicine and electronic health records, integrating Internet-based diabetes self-management activities with primary care is a logical step. Whether web-based approaches can eliminate or substantially reduce the need for personal and social support is unclear, and research is needed to understand the right formula of human and computerized support to produce sustained, long-term behavior change [18].

In this paper we follow up on our earlier publications [19], [20] to report 12-month results of a three-arm pragmatic randomized trial to evaluate an Internet-based, computer-assisted diabetes self-management (CASM) intervention compared to a CASM plus human support (CASM+) condition. BOTH versions of the intervention were offered in English and Spanish, and compared to enhanced usual care (EUC). Initial results at a 4-month follow-up revealed relatively high levels of website use as well as dietary and exercise behavior improvements relative to the enhanced usual care comparison condition, but only modest and non-significant improvements in biological outcomes relative to the EUC condition [19], [20].

Our primary purposes in this article are to expand upon our earlier immediate treatment results to: (a) report longer-term (12-month) results, including engagement, attrition, behavior change, biological impacts, and psychosocial outcomes; (b) using the RE-AIM model, investigate if the earlier, promising engagement and initial behavior change results were maintained and translated into broader public health outcomes at 12 months; and (c) investigate potential effects of moderator variables hypothesized to impact the outcomes of the intervention (e.g., health literacy or numeracy, age, racial or ethnic differences, and level of baseline computer use).

Section snippets

Methods

A patient-randomized practical effectiveness trial [21] evaluated two Internet-based diabetes self-management programs relative to EUC. The interventions were (a) self-administered, computer-assisted self-management (CASM), based on social-ecological theory [22] and the “5 As” self-management model [23] and (b) the CASM program with the addition of enhanced social support (CASM+). EUC provided computer-based health risk appraisal feedback and recommended preventive care behaviors using the same

Participants and preliminary analyses

A total of 463 patients participated. Recruitment and participant details have been reported elsewhere [19]. We recruited a diverse sample across age, gender, ethnicity (21% Latino), race (14% African American), and education and income levels (Table 2). There were no significant differences among outcomes on baseline characteristics. Distributions of all variables were normal with the exceptions of fat intake and physical activity, which were leptokurtotic. To obtain normal distributions for

Discussion

The primary purpose of this paper was to investigate the longer-term (12-month) effects of the My Path program relative to a relatively stringent enhanced usual care condition. Overall, improvement was seen in most measures, but between-group differences were largely non-significant. The patterns of change varied across outcomes. On the behavioral outcomes, the CASM and CASM+ conditions improved significantly more than the EUC condition across 12 months, but effect sizes indicated that

Conflict of interest

All authors declare no conflicts of interest.

Acknowledgment

This study was supported by grant DK35524 from the National Institute of Diabetes and Digestive and Kidney Diseases.

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