Open Access Research Health education for …...statistical presentation of results from reviews All...
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1 Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857 Open Access Health education for patients with acute coronary syndrome and type 2 diabetes mellitus: an umbrella review of systematic reviews and meta-analyses Xian-liang Liu, 1,2,3 Yan Shi, 1 Karen Willis, 4 Chiung-Jung (Jo) Wu, 5,6,7,8 Maree Johnson 9,10 To cite: Liu X, Shi Y, Willis K, et al. Health education for patients with acute coronary syndrome and type 2 diabetes mellitus: an umbrella review of systematic reviews and meta-analyses. BMJ Open 2017;7:e016857. doi:10.1136/ bmjopen-2017-016857 ► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http://dx.doi. org/10.1136/bmjopen-2017- 016857). Received 16 March 2017 Revised 7 July 2017 Accepted 7 July 2017 For numbered affiliations see end of article. Correspondence to Xian-liang Liu; [email protected] Research ABSTRACT Objectives This umbrella review aimed to identify the current evidence on health education-related interventions for patients with acute coronary syndrome (ACS) or type two diabetes mellitus (T2DM); identify the educational content, delivery methods, intensity, duration and setting required. The purpose was to provide recommendations for educational interventions for high-risk patients with both ACS and T2DM. Design Umbrella review of systematic reviews and meta- analyses. Setting Inpatient and postdischarge settings. Participants Patients with ACS and T2DM. Data sources CINAHL, Cochrane Library, Joanna Briggs Institute, Journals@Ovid, EMBase, Medline, PubMed and Web of Science databases from January 2000 through May 2016. Outcomes measures Clinical outcomes (such as glycated haemoglobin), behavioural outcomes (such as smoking), psychosocial outcomes (such as anxiety) and medical service use. Results Fifty-one eligible reviews (15 for ACS and 36 for T2DM) consisting of 1324 relevant studies involving 2 88 057 patients (15 papers did not provide the total sample); 30 (58.8%) reviews were rated as high quality. Nurses only and multidisciplinary teams were the most frequent professionals to provide education, and most educational interventions were delivered postdischarge. Face-to-face sessions were the most common delivery formats, and many education sessions were also delivered by telephone or via web contact. The frequency of educational sessions was weekly or monthly, and an average of 3.7 topics was covered per education session. Psychoeducational interventions were generally effective at reducing smoking and admissions for patients with ACS. Culturally appropriate health education, self- management educational interventions, group medical visits and psychoeducational interventions were generally effective for patients with T2DM. Conclusions Results indicate that there is a body of current evidence about the efficacy of health education, its content and delivery methods for patients with ACS or T2DM. These results provide recommendations about the content for, and approach to, health education intervention for these high-risk patients. INTRODUCTION Acute coronary syndrome (ACS) is the leading cause of death worldwide. The risk of high mortality rates relating to ACS is markedly increased after an initial cardiac ischaemic event. 1 Globally, 7.2 million (13%) deaths are caused by coronary artery disease (CAD), 2 and it is estimated that >7 80 000 persons will experience ACS each year in the USA. 3 More- over, about 20%–25% of patients with ACS reportedly also have diabetes mellitus (DM); predominantly type two diabetes mellitus (T2DM)). 4 5 Patients with ACS and DM have an increased risk of adverse outcomes such as death, recurrent myocardial infarction (MI), readmission or heart failure during follow-up. 6 Longer median delay times from symptom onset to hospital presentation, have been reported among patients with ACS and DM than patients with ACS alone. 7 DM is now considered to confer a risk equiv- alent to that of CAD for patients for future MI and cardiovascular mortality. 8 Mortality Strengths and limitations of this study ► This umbrella review is the first synthesis of systematic reviews or meta-analyses to consider health education-related interventions for patients with acute coronary syndrome (ACS) or type two diabetes mellitus (T2DM). ► These results provide recommendations about the content of a health education intervention for patients with ACS and T2DM. ► The diversity of the educational interventions seen in the reviews included in this umbrella review may reflect the uncertainty about the optimal strategy for providing health education to patients. ► This umbrella review found no reviews focused on patients with ACS and T2DM—the intended target group; instead, all of the systematic reviews and meta-analyses focused on only one of these two diseases. on May 29, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2017-016857 on 16 October 2017. Downloaded from
Transcript of Open Access Research Health education for …...statistical presentation of results from reviews All...
1Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Health education for patients with acute coronary syndrome and type 2 diabetes mellitus: an umbrella review of systematic reviews and meta-analyses
Xian-liang Liu,1,2,3 Yan Shi,1 Karen Willis,4 Chiung-Jung (Jo) Wu,5,6,7,8 Maree Johnson9,10
To cite: Liu X, Shi Y, Willis K, et al. Health education for patients with acute coronary syndrome and type 2 diabetes mellitus: an umbrella review of systematic reviews and meta-analyses. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2017- 016857).
Received 16 March 2017Revised 7 July 2017Accepted 7 July 2017
For numbered affiliations see end of article.
Correspondence toXian-liang Liu; liu. xianliang@ myacu. edu. au
Research
AbstrACtObjectives This umbrella review aimed to identify the current evidence on health education-related interventions for patients with acute coronary syndrome (ACS) or type two diabetes mellitus (T2DM); identify the educational content, delivery methods, intensity, duration and setting required. The purpose was to provide recommendations for educational interventions for high-risk patients with both ACS and T2DM.Design Umbrella review of systematic reviews and meta-analyses.setting Inpatient and postdischarge settings.Participants Patients with ACS and T2DM.Data sources CINAHL, Cochrane Library, Joanna Briggs Institute, Journals@Ovid, EMBase, Medline, PubMed and Web of Science databases from January 2000 through May 2016.Outcomes measures Clinical outcomes (such as glycated haemoglobin), behavioural outcomes (such as smoking), psychosocial outcomes (such as anxiety) and medical service use.results Fifty-one eligible reviews (15 for ACS and 36 for T2DM) consisting of 1324 relevant studies involving 2 88 057 patients (15 papers did not provide the total sample); 30 (58.8%) reviews were rated as high quality. Nurses only and multidisciplinary teams were the most frequent professionals to provide education, and most educational interventions were delivered postdischarge. Face-to-face sessions were the most common delivery formats, and many education sessions were also delivered by telephone or via web contact. The frequency of educational sessions was weekly or monthly, and an average of 3.7 topics was covered per education session. Psychoeducational interventions were generally effective at reducing smoking and admissions for patients with ACS. Culturally appropriate health education, self-management educational interventions, group medical visits and psychoeducational interventions were generally effective for patients with T2DM.Conclusions Results indicate that there is a body of current evidence about the efficacy of health education, its content and delivery methods for patients with ACS or T2DM. These results provide recommendations about the content for, and approach to, health education intervention for these high-risk patients.
IntrODuCtIOnAcute coronary syndrome (ACS) is the leading cause of death worldwide. The risk of high mortality rates relating to ACS is markedly increased after an initial cardiac ischaemic event.1 Globally, 7.2 million (13%) deaths are caused by coronary artery disease (CAD),2 and it is estimated that >7 80 000 persons will experience ACS each year in the USA.3 More-over, about 20%–25% of patients with ACS reportedly also have diabetes mellitus (DM); predominantly type two diabetes mellitus (T2DM)).4 5 Patients with ACS and DM have an increased risk of adverse outcomes such as death, recurrent myocardial infarction (MI), readmission or heart failure during follow-up.6 Longer median delay times from symptom onset to hospital presentation, have been reported among patients with ACS and DM than patients with ACS alone.7
DM is now considered to confer a risk equiv-alent to that of CAD for patients for future MI and cardiovascular mortality.8 Mortality
strengths and limitations of this study
► This umbrella review is the first synthesis of systematic reviews or meta-analyses to consider health education-related interventions for patients with acute coronary syndrome (ACS) or type two diabetes mellitus (T2DM).
► These results provide recommendations about the content of a health education intervention for patients with ACS and T2DM.
► The diversity of the educational interventions seen in the reviews included in this umbrella review may reflect the uncertainty about the optimal strategy for providing health education to patients.
► This umbrella review found no reviews focused on patients with ACS and T2DM—the intended target group; instead, all of the systematic reviews and meta-analyses focused on only one of these two diseases.
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was significantly higher among patients with ACS and DM than among patients with ACS only following either ST segment elevation myocardial infarction (STEMI) (8.5% (ACS and DM) vs 5.4% (ACS)) or unstable angina/non-STEMI (NSTEMI) (2.1% (ACS and DM) vs 1.1% (ACS)).9 ACS and T2DM are often associated with high-risk factors such as low levels of physical exercise, obesity, smoking and unhealthy diet.10 Some of these and other risk factors, specifically glycaemia, high blood pressure (BP), lipidaemia and obesity, are frequently addressed by health education interventions.10
Health education interventions are comprehensive programmes that healthcare providers deliver to patients aimed at improving patients’ clinical outcomes through the increase and maintenance of health behaviours.11 Along with education about, for example, medication taking, these programmes seek to increase behaviours such as physical exercise and a healthy diet thus reducing patient morbidity or mortality.11 Most diabetes educa-tion is provided through programmes within outpatient services or physicians’ practices.12 Many recent educa-tion programmes have been designed to meet national or international education standards13–15 with diabetes education being individualised to consider patients’ existing needs and health conditions.16 Patients with T2DM have reported feelings of hopelessness and fatigue with low levels of self-efficacy, after experiencing an acute coronary episode.17
Although there are numerous systematic reviews of educational interventions relating to ACS or T2DM, an umbrella review providing direction on educational interventions for high-risk patients with both ACS and T2DM is not available, indicating a need to gather the current evidence and develop an optimal protocol for health education programmes for patients with ACS and T2DM. This umbrella review will examine the best avail-able evidence on health education-related interventions for patients with ACS or T2DM. We will synthesise these findings to provide direction for health education-related interventions for high-risk patients with both ACS and T2DM.
An umbrella review is a new method to summarise and synthesise the evidence from multiple systematic reviews/meta-analyses into one accessible publication.18 Our aim is to systematically gather, evaluate and organise the current evidence relating the health education interventions for patients with ACS or T2DM, and proffer recommenda-tions for the scope of educational content and delivery methods that would be suitable for patients with ACS and T2DM.
MethODsData sourcesThis umbrella review performed a literature search to identify systematic reviews and meta-analyses examining health education-related interventions for patients with ACS or T2DM. The search strategies are described in
online supplementary appendix 1. This umbrella review searched eight databases for articles published from January 2000 to May 2016: CINAHL, Cochrane Library, Joanna Briggs Institute, Journals@Ovid, EMBase, Medline, PubMed and Web of Science. The search was limited to English language only. The following broad MeSH terms were used: acute coronary syndrome; angina, unstable; angina pectoris; coronary artery disease; coronary artery bypass; myocar-dial infarction; diabetes mellitus, type two; counseling; health education; patient education as topic; meta-analysis (publication type); and meta-analysis as a topic.
Inclusion criteriaParticipantsAll participants were diagnosed with ACS or T2DM using valid, established diagnostic criteria. The diagnostic standards included those described by the American College of Cardiology or American Heart Association,3 National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand,19 WHO20 or other associations.
Intervention typesFor this umbrella review, health education-related inter-ventions refer to any planned activities or programmes that include behaviour modification, counselling and teaching interventions. Results considered for this review included changes in clinical outcomes (including BP levels, body weight, diabetes complications, glycated haemoglobin (HbA1c), lipid levels, mortality rate and physical activity levels), behavioural outcomes (such as diet, knowledge, self-management skills, self-efficacy and smoking), psychosocial outcomes (such as anxiety, depression, quality of life and stress) and medical service use (such as medication use, healthcare utilisation and cost-effectiveness) for patients with ACS or T2DM. These activities or programmes included any educational inter-ventions delivered to patients with ACS or T2DM. The interventions are delivered in any format, including face-to-face, telephone and group-based or one-on-one, and the settings include community, hospital and home. The interventions were delivered by nurses (including diabetes nurse educators), physicians, community health-care workers, dietitians, lay people, rehabilitation thera-pists or multidisciplinary teams.
Study typesOnly systematic reviews and meta-analyses were included in this review.
eligibility assessmentThe title and abstract of all of the retrieved articles were assessed independently by two reviewers (XL-L, YS) based on the inclusion criteria. All duplicate articles were identi-fied within EndNote V.X721 and subsequently excluded. If the information from the titles and abstract was not clear, the full articles were retrieved. The decision to include an article was based on an appraisal of the full text of all retrieved articles. Any disagreements during this process
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were settled by discussion and, if necessary, consensus was sought with a third reviewer. We developed an assess-ment form in which specific reasons for exclusion were detailed.
Assessment of methodological qualityThe methodological quality and risk of bias were assessed for each of the included publications using the Assess-ment of Multiple Systematic Reviews (AMSTAR),22 inde-pendently by the same two reviewers (see table 1). The AMSTAR is an 11-item tool, with each item provided a score of 1 (specific criterion is met) or 0 (specific crite-rion is not met, unclear or not applicable).22 23 An overall score for the review methodological quality is then calcu-lated as the sum of the individual item scores: high quality, 8–11; medium quality, 4–7 or low quality, 0–3.23 If the required data were not available in the article, the orig-inal authors were contacted for more information. The low quality reviews (AMSTAR scale: 0–3) were excluded in this umbrella review.
Data extractionData were independently extracted by two reviewers using a predefined data extraction form. For missing or unclear information, the primary authors were contacted for clarification.
statistical presentation of results from reviewsAll of the results were extracted for each included system-atic review or meta-analysis, and the overall effect esti-mates are presented in a tabular form. The number of systematic reviews or meta-analyses that reported the outcome, total sample (from included publications) and information of health education interventions is also presented in tables 2 and 3.24 A final ‘summary of evidence’ was developed to present the intervention, included study synthesis, and indication of the findings from the included papers (table 4).24 This umbrella review calculated the corrected covered area (CCA) (see online supplementary appendices 2 and 3). The CCA statistic is a measure of overlap of trials (the repeated inclusion of the same trial in subsequent systematic reviews included in an umbrella systematic review). A detailed description of the calculation is provided by the authors who note slight CCA as 0%–5%, moderate CCA as 6%–10%, high CCA as 11%–15% and very high CCA is >15%.25 The lower the CCA the lower the likelihood of overlap of trials included in the umbrella review.
synthesising the results and rating the evidence for effectivenessThe statements of evidence were based on a rating scheme to gather and rate the evidence across the included publi-cations.26 The statements of evidence were based on the following rating scheme: sufficient evidence, sufficient data to support decisions about the effect of the health education-related interventions.26 A rating of sufficient evidence in this review is obtained when systematic reviews or meta-analyses with a large number of included articles
or participants produce a statistically significant result between the health education group and the control group.26 Some evidence, is a less conclusive finding about the effects of the health education-related interventions26 with statistically significant findings found in only a few included reviews or studies. Insufficient evidence, refers to not enough evidence to make decisions about the effects of the health education-related interventions, such as non-significant results between the health education group and the control group in the included systematic reviews or meta-analyses.26 Insufficient evidence to determine, refers to not enough pooled data to be able to determine whether of the health education-related interventions are effective or not based on the included reviews.26
resultsCharacteristics of included reviewsThe selection process and number of studies at each step was illustrated as presented in figure 1. The data-base search yielded 692 publications, with removal of 197 duplicates and 371 articles that did not meet the inclu-sion criteria, 124 full-text articles were retrieved after applying the methodological quality rating (AMSTAR scale), and three studies27–29 were removed due to low scores ≤3 on the AMSTAR scale. Fifty-one systematic reviews or meta-analyses30–80 conducted between 2001 and 2016 and published in English were included (figure 1; tables 1–3); 15 relating to ACS. The overlap of the trials included in the 15 reviews and meta-analyses related to ACS was slight (CCA=2.6%). For the 36 systematic reviews relating to T2DM, the overlap of trials within these 35 reviews and meta-analyses (one review47 did not report the included studies) was slight (CCA=2.1%). None of the articles included patients with both ACS and T2DM. The umbrella review involved a total of 2 77 493 patients, including 2 25 034 patients with coronary heart disease or ACS (one article did not report the total sample) and 52 459 patients with T2DM (16 papers did not report the total sample). The average sample size of included arti-cles was 8161 (range, 536–68 556) participants, however, 63 studies related to ACS and 177 studies related to T2DM were included in more than one systematic review or meta-analysis (see online supplementary appendices 2 and 3 and CCA statistics). The sample of these studies would therefore be included more than once. Of the included systematic reviews or meta-analyses, 11 were published in The Cochrane Library. Nine of the articles described meta-analyses, 29 articles described systematic reviews and the remaining 13 articles were described as systematic reviews and meta-analyses or meta-regressions or narrative reviews.
Electronic database searches were conducted for all systematic reviews or meta-analyses, with an average of 6 databases searched (range, 2–16). The dates searched ranged widely from inception of the database through December 2014. Most of the included reviews were randomised controlled trials (RCTs), and an average of
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Tab
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al64
CA
Yes
Yes
CA
No
Yes
Yes
Yes
NA
No
No
5
Item
1: ‘
Was
an
"a p
riori"
des
ign
pro
vid
ed?’
,Sou
rce:
She
a et
al22
; Ite
m 2
: ‘W
as t
here
dup
licat
e st
udy
sele
ctio
n an
d d
ata
extr
actio
n?’;
Item
3: ‘
Was
a c
omp
rehe
nsiv
e lit
erat
ure
sear
ch p
erfo
rmed
?’;
Item
4: ‘
Was
the
sta
tus
of p
ublic
atio
n (ie
, gre
y lit
erat
ure)
use
d a
s an
incl
usio
n cr
iterio
n?’;
Item
5: ‘
Was
a li
st o
f stu
die
s (in
clud
ed a
nd e
xclu
ded
) pro
vid
ed?’
; Ite
m 6
: ‘W
ere
the
char
acte
ristic
s of
the
in
clud
ed s
tud
ies
pro
vid
ed?’
; Ite
m 7
: ‘W
as t
he s
cien
tific
qua
lity
of t
he in
clud
ed s
tud
ies
asse
ssed
and
doc
umen
ted
?’; I
tem
8: ‘
Was
the
sci
entifi
c q
ualit
y of
the
incl
uded
stu
die
s us
ed a
pp
rop
riate
ly in
fo
rmul
atin
g co
nclu
sion
s?’;
Item
9: ‘
Wer
e th
e m
etho
ds
used
to
com
bin
e th
e fin
din
gs o
f stu
die
s ap
pro
pria
te?’
; Ite
m 1
0: ‘W
as t
he li
kelih
ood
of p
ublic
atio
n b
ias
asse
ssed
?’; I
tem
11:
‘Was
the
con
flict
of
inte
rest
sta
ted
?’C
A, c
anno
t an
swer
; NA
, not
ap
plic
able
.
Tab
le 1
C
ontin
ued
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
6 Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Tab
le 2
C
hara
cter
istic
s an
d in
terv
entio
ns o
f inc
lud
ed s
yste
mat
ic r
evie
ws
and
met
a-an
alys
is in
volv
ed p
atie
nts
with
AC
S
Firs
t au
tho
r, ye
ar; j
our
nal
Pri
mar
y o
bje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns
on…
.)S
tud
ies
det
ails
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
w
ere
in b
old
)‘−
': N
o c
hang
e‘↑
': In
crea
se‘↓
': D
ecre
ase
Syn
thes
is
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Dev
i, 20
1544
; The
C
ochr
ane
Lib
rary
Life
styl
e ch
ange
s an
d
med
icin
es
man
agem
ent
Num
ber
of
stud
ies:
11
com
ple
ted
tr
ials
(12
pub
licat
ions
);Ty
pes
of
stud
ies:
RC
Ts;
Tota
l sa
mp
le: 1
392
par
ticip
ants
All
inte
rnet
-bas
ed
inte
rven
tions
√ B
EH
A (-
)√
CV
R (-
)√
DIE
T (-
) √
EX
ER
CIS
E
(-) □ M
ED
√ P
SY
(-)
√ S
MO
KIN
G
(-) □ S
ELF
Die
titia
ns;
exer
cise
sp
ecia
lists
; nur
se
pra
ctiti
oner
s;
phy
siot
hera
pis
t re
hab
ilita
tion
spec
ialis
ts, o
r d
id
not
des
crib
e.
Num
ber
of
sess
ion:
w
eekl
y or
mon
thly
or
uncl
ear;
Tota
l co
ntac
t ho
urs:
unc
lear
.D
urat
ion:
from
6
wee
ks t
o 1
year
Str
ateg
ies:
inte
rnet
-bas
ed
and
mob
ile p
hone
-bas
ed
inte
rven
tion,
suc
h as
em
ail
acce
ss, p
rivat
e-m
essa
ging
fu
nctio
n on
the
web
site
, on
e-to
-one
cha
t fa
cilit
y,
a sy
nchr
onis
ed g
roup
ch
at, a
n on
line
dis
cuss
ion
foru
m, o
r te
lep
hone
co
nsul
tatio
ns; o
r vi
deo
fil
es;
Form
at: o
ne-o
n-on
e ch
at
sess
ions
; ‘as
k an
exp
ert’
gr
oup
cha
t se
ssio
ns;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt
sett
ings
, p
ostd
isch
arge
, ot
her
− C
linic
al o
utco
mes
; −
Car
dio
vasc
ular
ris
k fa
cto
rs;
− L
ifest
yle
chan
ges;
− C
omp
lianc
e w
ith
med
icat
ion;
− H
ealth
care
util
isat
ion
and
cos
ts;
↓ A
dve
rse
inte
rven
tion
effe
cts
Met
a-an
alys
is
used
Rev
iew
M
anag
er
soft
war
e
Bar
th, 2
01569
; Th
e C
ochr
ane
Lib
rary
Sm
okin
g ce
ssat
ion
Num
ber
of
stud
ies:
40
RC
Ts;
Typ
es o
f st
udie
s: R
CTs
;To
tal
sam
ple
: 792
8 p
artic
ipan
ts
Psy
chos
ocia
l sm
okin
g ce
ssat
ion
inte
rven
tions
□ B
EH
A□
CV
R□
DIE
T□
EX
ER
CIS
E□
ME
D□
PS
Y√
SM
OK
ING
□ S
ELF
Car
dio
logi
st;
gene
ral
pra
ctiti
oner
p
hysi
cian
or
stud
y nu
rse
Num
ber
of
sess
ion:
w
eekl
y or
2–3
tim
es
per
wee
k;To
tal c
ont
act
hour
s: u
ncle
ar.
Dur
atio
n: fr
om
8 w
eeks
to
1 ye
ar
Str
ateg
ies:
face
-to-
face
, te
lep
hone
con
tact
, writ
ten
educ
atio
nal m
ater
ials
, vi
deo
tap
e, b
ookl
et o
r un
clea
r;Fo
rmat
: one
by
one
coun
selli
ng; t
elep
hone
ca
ll; g
roup
mee
tings
or
uncl
ear;
The
ore
tica
l ap
pro
ach:
TT
M, S
CT
Inp
atie
nt
sett
ings
, p
ostd
isch
arge
, ot
her
↑ A
bst
inen
ce b
y se
lf-re
po
rt o
r va
lidat
edM
eta-
ana
lysi
s us
ed R
evie
w
Man
ager
so
ftw
are
Kot
b, 2
01459
; P
LoS
One
Pat
ient
s’
outc
omes
Num
ber
of
stud
ies:
26
stud
ies;
Typ
es o
f st
udie
s: R
CTs
;To
tal
sam
ple
: 408
1 p
artic
ipan
ts
Tele
pho
ne-d
eliv
ered
p
ostd
isch
arge
in
terv
entio
ns
□ B
EH
A√
CV
R□
DIE
T□
EX
ER
CIS
E□
ME
D□
PS
Y□
SM
OK
ING
□ S
ELF
Die
titia
ns;
exer
cise
sp
ecia
list;
hea
lth
educ
ator
s; n
urse
s an
d p
harm
acis
ts
Num
ber
of
sess
ion:
3–
6 se
ssio
ns/
tele
pho
ne c
alls
and
w
as g
reat
er t
han
six
calls
in fi
ve s
tud
ies;
or
unc
lear
;To
tal c
ont
act
hour
s: 4
0 –1
80 m
ins
or u
ncle
ar;
Dur
atio
n: 1
.5–
6 m
onth
s or
unc
lear
Str
ateg
ies:
tel
epho
ne
calls
;Fo
rmat
: unc
lear
, did
not
d
escr
ibe
the
form
at;
The
ore
tica
l ap
pro
ach:
un
clea
r
Unc
lear
, did
not
d
escr
ibe
the
sett
ing
↓ A
ll-ca
use
hosp
ital
isat
ion;
− A
ll-ca
use
mo
rtal
ity;
↓
Dep
ress
ion;
− A
nxie
ty;
↑ S
mok
ing
cess
atio
n,↓
Sys
tolic
blo
od
pre
ssur
e;−
LD
L-c
Met
a- a
naly
sis
used
Rev
iew
M
anag
er
soft
war
e
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
7Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Firs
t au
tho
r, ye
ar; j
our
nal
Pri
mar
y o
bje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns
on…
.)S
tud
ies
det
ails
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
w
ere
in b
old
)‘−
': N
o c
hang
e‘↑
': In
crea
se‘↓
': D
ecre
ase
Syn
thes
is
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Ghi
si, 2
01450
; P
atie
nt E
duc
atio
n an
d C
ouns
elin
g
Kno
wle
dge
, he
alth
b
ehav
iour
ch
ange
, m
edic
atio
n ad
here
nce,
p
sych
osoc
ial
wel
l-b
eing
Num
ber
of
stud
ies:
42
artic
les;
Typ
es o
f st
udie
s:
30 w
ere
exp
erim
enta
l: 23
RC
Ts
and
7 q
uasi
-ex
per
imen
tal;
and
11
obse
rvat
iona
l an
d 1
use
d
a m
ixed
-m
etho
ds
des
ign.
Tota
l sam
ple
: 16
079
p
artic
ipan
ts
Any
ed
ucat
iona
l in
terv
entio
ns√
BE
HA
(+)
√ C
VR
(++
)√
DIE
T (+
++
) √
EX
ER
CIS
E
(++
)√
ME
D (+
+)
√ P
SY
(++
)√
SM
OK
ING
(+
)□
SE
LF
Nur
ses
(35.
7%),
a m
ultid
isci
plin
ary
team
(31%
), d
ietit
ians
(14.
3%)
and
a c
ard
iolo
gist
(2
.4%
)
Num
ber
of
sess
ion:
1–
24 o
r un
clea
r.To
tal c
ont
act
hour
s: 5
–10
min
to
3 ho
urs
as w
ell a
s a
full
day
of e
duc
atio
nD
urat
ion:
1–
24 m
onth
; fro
m
dai
ly e
duc
atio
n to
ev
ery
6 m
onth
s
Str
ateg
ies:
did
not
d
escr
ibe
the
stra
tegi
es;
Form
at: g
roup
(88.
1%)
educ
atio
n w
as d
eliv
ered
b
y le
ctur
es (4
0.5%
), gr
oup
d
iscu
ssio
ns (4
0.5%
) and
q
uest
ion
and
ans
wer
p
erio
ds
(7.1
%).
Ind
ivid
ual
educ
atio
n (8
8.1%
), in
clud
ing
ind
ivid
ual
coun
selli
ng (5
0%),
follo
w-
up t
elep
hone
con
tact
s (3
1%) a
nd h
ome
visi
ts
(7.1
%);
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt
sett
ings
− K
now
led
ge;
− B
ehav
iour
;−
Psy
cho
soci
al
ind
icat
ors
Nar
rativ
e sy
nthe
sis
Bro
wn,
201
337;
Eur
opea
n Jo
urna
l of
Pre
vent
ive
Car
dio
logy
Mor
talit
y,
mor
bid
ity,
HR
QoL
and
he
alth
care
co
sts
Num
ber
o
f st
udie
s:
24 p
aper
s re
por
ting
on 1
3 R
CTs
;Ty
pes
of
stud
ies:
RC
Ts;
Tota
l sam
ple
: 68
556
p
artic
ipan
ts
Pat
ient
ed
ucat
ion
□ B
EH
A√
CV
R□
DIE
T□
EX
ER
CIS
E□
ME
D□
PS
Y□
SM
OK
ING
□ S
ELF
Nur
ses
or o
ther
he
alth
care
p
rofe
ssio
nals
.
Num
ber
of
sess
ion
and
dur
atio
n: fr
om
a to
tal o
f 2 v
isits
to
a 4
-wee
k r e
sid
entia
l st
ay r
einf
orce
d w
ith
11 m
onth
s of
nur
se
led
follo
w-u
pTo
tal c
ont
act
hour
s: u
ncle
ar
Str
ateg
ies:
face
-to-
face
ed
ucat
ion
sess
ions
, te
lep
hone
con
tact
and
in
tera
ctiv
e us
e of
the
in
tern
et;
Form
at: g
roup
-bas
ed
sess
ions
, ind
ivid
ualis
ed
educ
atio
n an
d fo
ur u
sed
a
mix
ture
of b
oth
sess
ions
;T
heo
reti
cal a
pp
roac
h:
uncl
ear
Inp
atie
nt
sett
ings
, oth
er−
Mo
rtal
ity,
− N
on-
fata
l MI,
− R
evas
cula
risa
tio
ns,
− H
osp
ital
isat
ions
, −
HR
Qo
L,−
With
dra
wal
s/d
rop
outs
;−
Hea
lthca
re u
tilis
atio
n an
d c
osts
Met
a- a
naly
sis
used
Rev
iew
M
anag
er
soft
war
e
Dic
kens
, 201
345;
Psy
chos
omat
ic
Med
icin
e
Dep
ress
ion
and
dep
ress
ive
sym
pto
ms
Num
ber
of
stud
ies:
62
ind
epen
den
t st
udie
sTy
pes
of
stud
ies:
RC
Ts;
Tota
l sam
ple
: 17
397
Psy
chol
ogic
al
inte
rven
tions
√ B
EH
A (-
)□
CV
R□
DIE
T□
EX
ER
CIS
E□
ME
D√
PS
Y (-
)□
SM
OK
ING
√ S
ELF
(-)
A s
ingl
e he
alth
p
rofe
ssio
nal o
r b
y a
unid
isci
plin
ary
team
Num
ber
of
sess
ion:
14
.4 (r
ange
, 1–1
56);
Tota
l co
ntac
t ho
urs:
var
ying
from
10
to
240
min
Dur
atio
n: u
ncle
ar
Str
ateg
ies:
face
-to-
face
se
ssio
ns, t
elep
hone
co
ntac
t or
unc
lear
;Fo
rmat
: gro
up o
r un
clea
r;T
heo
reti
cal a
pp
roac
h:
uncl
ear
Unc
lear
, did
not
d
escr
ibe
↓ D
epre
ssio
n;−
Ad
vers
e ca
rdia
c ou
tcom
es;
− O
ngoi
ng c
ard
iac
sym
pto
ms
Uni
varia
te
anal
yses
usi
ng
com
pre
hens
ive
met
a-an
alys
is,
mul
tivar
iate
m
eta-
regr
essi
on
usin
g S
PS
S
V.15
.0
Tab
le 2
C
ontin
ued
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
8 Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Firs
t au
tho
r, ye
ar; j
our
nal
Pri
mar
y o
bje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns
on…
.)S
tud
ies
det
ails
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
w
ere
in b
old
)‘−
': N
o c
hang
e‘↑
': In
crea
se‘↓
': D
ecre
ase
Syn
thes
is
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Ald
crof
t, 2
01120
; Jo
urna
l of
Car
dio
pul
mon
ary
Reh
abili
tatio
n &
P
reve
ntio
n
Hea
lth
beh
avio
ur
chan
ge
Num
ber
of
stud
ies:
sev
en
tria
lsTy
pes
of
stud
ies:
six
ra
ndom
ised
co
ntro
lled
tria
ls
and
a q
uasi
-ex
per
imen
tal
tria
lTo
tal
sam
ple
: 536
p
artic
ipan
ts
All
psy
choe
duc
atio
nal
or b
ehav
iour
al
inte
rven
tion
□ B
EH
A√
CV
R (-
)□
DIE
T□
EX
ER
CIS
E□
ME
D√
PS
Y (-
)□
SM
OK
ING
□ S
ELF
Ap
pro
pria
tely
tr
aine
d h
ealth
care
w
orke
rs
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s: u
ncle
ar;
Dur
atio
n:
2–12
mon
ths
Str
ateg
ies:
did
not
d
escr
ibe
the
stra
tegi
es;
Form
at: g
roup
set
ting,
co
mb
inat
ion
of g
roup
and
on
e-on
-one
ed
ucat
ion
and
on
e-on
-one
form
at o
nly;
The
ore
tica
l ap
pro
ach:
TT
M, i
nter
actio
nist
rol
e th
eory
, Ban
dur
a’s
self-
effic
acy
theo
ry, G
ord
on’s
re
lap
se p
reve
ntio
n m
odel
and
a c
ogni
tive
beh
avio
ural
ap
pro
ach
Unc
lear
, did
not
d
escr
ibe
↓ S
mo
king
rat
es;
med
icat
ion
use;
− S
upp
lem
enta
l o
xyg
en u
se;
↑ P
hysi
cal a
ctiv
ity;
↑ N
utrit
iona
l hab
its
Met
a-an
alys
is
and
nar
rativ
e p
rese
ntat
ion
Bro
wn,
201
170;
The
Coc
hran
e Li
bra
ry
Mor
talit
y,
mor
bid
ity,
HR
QoL
and
he
alth
care
co
sts
Num
ber
o
f st
udie
s:
24 p
aper
s re
por
ting
on 1
3 st
udie
s.Ty
pes
of
stud
ies:
RC
Ts;
Tota
l sam
ple
: 68
556
p
artic
ipan
ts
Pat
ient
ed
ucat
ion
√ B
EH
A (-
)√
CV
R (-
)□
DIE
T√
EX
ER
CIS
E
(-)
√ M
ED
□ P
SY
□ S
MO
KIN
G□
SE
LF
Nur
se o
r d
id n
ot
des
crib
eN
umb
er o
f se
ssio
n an
d d
urat
ion:
tw
ovi
sits
to
4 w
eeks
re
sid
entia
l11
mon
ths
of n
urse
le
d fo
llow
-up
T ota
l co
ntac
t ho
urs:
unc
lear
Str
ateg
ies:
face
-to-
face
se
ssio
ns, t
elep
hone
co
ntac
t an
d in
tera
ctiv
e us
e of
the
inte
rnet
;Fo
rmat
: fou
r st
udie
s in
volv
ed g
roup
ses
sion
s,
five
invo
lved
ind
ivid
ualis
ed
educ
atio
n an
d t
hree
use
d
bot
h se
ssio
n ty
pes
, with
on
e st
udy
com
par
ing
the
two
app
roac
hes;
The
ore
tica
l ap
pro
ach:
d
id n
ot d
escr
ibe
Pos
tdis
char
ge,
othe
r−
To
tal m
ort
alit
y;−
Car
dio
vasc
ular
− m
ort
alit
y;−
No
n-ca
rdio
vasc
ular
m
ort
alit
y;−
To
tal c
ard
iova
scul
ar
(CV
) eve
nts;
− F
atal
and
/or
non-
fata
l MI;
− O
ther
fata
l and
/or
non-
fata
l CV
eve
nts
Met
a-an
alys
is
used
Rev
iew
M
anag
er
soft
war
e
Gou
ldin
g,
2010
51; J
ourn
al
of A
dva
nced
N
ursi
ng
Cha
nge
mal
adap
tive
illne
ss
Num
ber
of
stud
ies:
13
stud
ies;
Typ
es o
f st
udie
s: R
CTs
;To
tal s
amp
le:
uncl
ear
Inte
rven
tions
to
chan
ge m
alad
aptiv
e ill
ness
bel
iefs
√ B
EH
A (-
)□
CV
RD
IET
□ E
XE
RC
ISE
□ M
ED
√ P
SY
(-)
□ S
MO
KIN
G□
SE
LF
Car
dio
logi
st,
nurs
e,
psy
chol
ogis
t or
d
id n
ot d
escr
ibe.
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s: u
ncle
ar;
Dur
atio
n: 4
day
s to
2
wee
ks o
r un
clea
r
Str
ateg
ies:
face
-to-
face
se
ssio
ns, t
elep
hone
co
ntac
t an
d w
ritte
n se
lf-ad
min
iste
red
;Fo
rmat
: unc
lear
;T
heo
reti
cal a
pp
roac
h:
Com
mon
Sen
se M
odel
, Le
vent
hal’s
fram
ewor
k
Inp
atie
nt
sett
ings
, p
ostd
isch
arge
, ot
her
− B
elie
fs (o
r o
ther
ill
ness
co
gni
tio
n);
− Q
oL;
− B
ehav
iour
;−
Anx
iety
or
dep
ress
ion;
− P
sych
olog
ical
wel
l-b
eing
;−
Mod
ifiab
le r
isk
fact
ors;
pro
tect
ive
fact
ors
A d
escr
iptiv
e d
ata
synt
hesi
s
Hut
tune
n-Le
nz,
2010
56; B
ritis
h Jo
urna
l of H
ealth
P
sych
olog
y
Sm
okin
g ce
ssat
ion
Num
ber
of
stud
ies:
a t
otal
of
14
stud
ies
wer
e in
clud
edTy
pes
of
stud
ies:
RC
Ts;
Tota
l sa
mp
le: 1
792
par
ticip
ants
Psy
choe
duc
atio
nal
card
iac
reha
bili
tatio
n in
terv
entio
n
□ B
EH
A□
CV
R□
DIE
T□
EX
ER
CIS
E□
ME
D□
PS
Y√
SM
OK
ING
(-
) □ S
ELF
Car
dio
logi
st,
nurs
e p
sych
olog
ist
or
did
not
des
crib
e
Num
ber
of
sess
ion:
4–
20 o
r un
clea
r.To
tal c
ont
act
hour
s: 1
0–72
0 m
ins
or u
ncle
arD
urat
ion:
4–
29 w
eeks
or
uncl
ear
Str
ateg
ies:
face
-to-
face
co
unse
lling
, sel
f-he
lp
mat
eria
ls; h
ome
visi
t,
boo
klet
, vid
eo a
nd
tele
pho
ne c
onta
ctFo
rmat
: ind
ivid
ual o
r un
clea
rT
heo
reti
cal a
pp
roac
h:
soci
al le
arni
ng t
heor
y; A
SE
m
odel
; TTM
; beh
avio
ural
m
ultic
omp
onen
t ap
pro
ach
Inp
atie
nt
sett
ings
, p
ostd
isch
arge
, ot
her
↑ P
reva
lent
sm
oki
ng
cess
atio
n,↑
Co
ntin
uous
sm
oki
ng
cess
atio
n,−
Mor
talit
y
Sub
grou
p m
eta-
anal
ysis
was
us
ed s
oftw
are
Tab
le 2
C
ontin
ued
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
9Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Firs
t au
tho
r, ye
ar; j
our
nal
Pri
mar
y o
bje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns
on…
.)S
tud
ies
det
ails
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
w
ere
in b
old
)‘−
': N
o c
hang
e‘↑
': In
crea
se‘↓
': D
ecre
ase
Syn
thes
is
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Aue
r, 20
0834
; C
ircul
atio
nM
ultip
le
card
iova
scul
ar
risk
fact
ors
and
all-
caus
e m
orta
lity
Num
ber
o
f st
udie
s:
27 a
rtic
les
rep
ortin
g 26
st
udie
sTy
pes
of
stud
ies:
16
clin
ical
co
ntro
lled
tria
ls
and
10
bef
ore-
afte
r st
udie
sTo
tal s
amp
le:
2467
pat
ient
s in
CC
Ts
and
38,
581
p
atie
nts
in
bef
ore-
afte
r st
udie
s
In-h
osp
ital
mul
tidim
ensi
onal
in
terv
entio
ns
of s
econ
dar
y p
reve
ntio
n
□ B
EH
A□
CV
R√
DIE
T (-
)√
EX
ER
CIS
E
(-)
√ M
ED
√ P
SY
(-)
√ S
MO
KIN
G
(-) □ S
ELF
Car
dia
c nu
rses
; p
hysi
cian
, or
did
no
t d
escr
ibe
Num
ber
of
sess
ion:
1–
5 or
unc
lear
;To
tal c
ont
act
hour
s: 3
0–24
0 m
ins
or u
ncle
ar;
Dur
atio
n:
4 w
eeks
–12
mon
ths
Str
ateg
ies:
Writ
ten
mat
eria
l; au
dio
tap
es;
pre
sent
atio
ns; f
ace-
to-
face
;Fo
rmat
: gro
up o
r un
clea
r;T
heo
reti
cal a
pp
roac
h:
uncl
ear
Inp
atie
nt
sett
ings
↓ A
ll-ca
use
mo
rtal
ity;
↓ R
ead
mis
sio
n ra
tes;
− R
einf
arct
ion
rate
s
Sta
ta V
.9.1
Bar
th, 2
00836
;Th
e C
ochr
ane
Lib
rary
Sm
okin
g ce
ssat
ion
Num
ber
of
stud
ies:
40
tria
ls;
Typ
es o
f st
udie
s: R
CTs
;To
tal s
amp
le:
7682
pat
ient
s
Psy
chos
ocia
l in
terv
entio
n√
BE
HA
(++
+)
√ C
VR
(++
)□
DIE
T□
EX
ER
CIS
E□
ME
D√
PS
Y (+
)√
SM
OK
ING
(+
++
)√
SE
LF(+
++
)
Car
dio
logi
st,
nurs
e, p
hysi
cian
or
stu
dy
nurs
e
Num
ber
of
sess
ion:
1–
5 or
unc
lear
;To
tal c
ont
act
hour
s: 1
5 m
ins–
9 ho
urs
Dur
atio
n: w
ithin
4
wee
ks o
r d
id
not
rep
ort
on t
he
dur
atio
n
Str
ateg
ies:
face
-to-
face
; in
form
atio
n b
ookl
ets,
au
dio
tap
es o
r vi
deo
tap
esFo
rmat
: gro
up s
essi
ons
or
ind
ivid
ual c
ouns
ellin
g;T
heo
reti
cal a
pp
roac
h:
TTM
Inp
atie
nt
sett
ings
↑ A
bst
inen
ce b
y se
lf-re
po
rt o
r va
lidat
edM
eta-
anal
ysis
us
ed R
evie
w
Man
ager
so
ftw
are
Fern
and
ez,
2007
48;
Inte
rnat
iona
l Jo
urna
l of
Evi
den
ce-B
ased
H
ealth
care
Ris
k fa
ctor
m
odifi
catio
nN
umb
er o
f st
udie
s: 1
7 tr
ials
;Ty
pes
of
stud
ies:
ra
ndom
ised
, q
uasi
-RC
Ts
and
clu
ster
ed
tria
ls;
Tota
l sa
mp
le: 4
725
par
ticip
ants
Brie
f str
uctu
red
in
terv
entio
n√
BE
HA
(-)
□√ C
VR
(-)
□ D
IET
□ E
XE
RC
ISE
□ M
ED
□ P
SY
□ S
MO
KIN
G√
SE
LF (-
)
Cas
e m
anag
er;
die
ticia
ns; h
ealth
ed
ucat
or; n
urse
s;
psy
chol
ogis
t;
and
res
earc
h as
sist
ants
Num
ber
of
sess
ion:
sup
por
tive
coun
selli
ng r
ange
d
from
1 t
o 7
calls
for
the
dur
atio
n of
the
st
udy;
Tota
l co
ntac
t ho
urs:
var
ied
from
10
to
30 m
ins;
Dur
atio
n: u
ncle
ar
Str
ateg
ies:
writ
ten,
vis
ual,
aud
io, t
elep
hone
con
tact
;Fo
rmat
: did
not
des
crib
e;T
heo
reti
cal a
pp
roac
h:
theo
retic
al b
ehav
iour
ch
ange
prin
cip
les
Unc
lear
, did
not
d
escr
ibe
↓ S
mo
king
;−
Cho
lest
ero
l lev
el;
− P
hysi
cal a
ctiv
ity;
↑ D
ieta
ry h
abit
s;↓
Blo
od
sug
ar le
vels
;−
BP
leve
ls;
↓ B
MI;
− In
cid
ence
of
adm
issi
on
Coc
hran
e st
atis
tical
p
acka
ge R
evie
w
Man
ager
Bar
th, 2
00635
; A
nnal
s of
B
ehav
iour
al
Med
icin
e
Sm
okin
g ce
ssat
ion
Num
ber
of
stud
ies:
19
tria
ls;
Typ
es o
f st
udie
s: R
CTs
;To
tal s
amp
le:
2548
pat
ient
s
Psy
chos
ocia
l in
terv
entio
ns√
BE
HA
(++
+)
√ C
VR
(++
)□
DIE
T□
EX
ER
CIS
E□
ME
D□
PS
Y□
SM
OK
ING
√ S
ELF
(++
+)
Unc
lear
, did
not
d
escr
ibe
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s: u
ncle
ar;
Dur
atio
n: u
ncle
ar
Str
ateg
ies:
face
-to-
face
, te
lep
hone
con
tact
or
uncl
ear;
Form
at: u
ncle
ar;
The
ore
tica
l ap
pro
ach:
un
clea
r
Unc
lear
, did
not
d
escr
ibe
↑ A
bst
inen
ce;
↓ S
mo
king
sta
tus
Dat
a an
alys
es
wer
e ca
rrie
d
out
in R
evie
w
Man
ager
V.4
.2
Tab
le 2
C
ontin
ued
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
10 Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
25.6 (range, 7–132) studies was included per systematic review or meta-analyses. Of the total, 818 unique (non-re-peated) studies were included in all of the reviews or meta-analyses, 286 included patients with ACS and 532 included patients with T2DM (see online supplementary appendix 2 and 3). The included reviews assessed the risk of bias using the Cochrane risk of bias tool (22 publica-tions), JADA quality score (7 publications), Joanna Briggs quality assessment tool (2 publications), PEDro scale (1 publication), RCT Critical Appraisal Skills Programme (1 publication) and the SIGN-50 checklist (1 publication).
Methodological quality of included systematic reviews and meta-analysesThe methodological quality of the included publications is presented in table 1. Thirty (58.8%) publications were classified as high quality (scores 8–11) and 21 (41.2%) publications were classified as medium quality (scores 4–7). Twenty-five (49%) reviews specifically provided an a priori design, while the use of such a design was unclear for 26 (51%) publications. The inclusion of other forms of literature (such as grey literature) was described in 18 (35%) reviews. Only 14 out of 51 (27%) reviews included a table of included and excluded studies. Only two (4%) reviews did not provide a characteristics table of the included papers. The scientific quality of the included papers was evaluated and documented in 47 (92%) reviews. The scientific quality of the included studies was used appropriately to formulate conclusions in 47 (92%) reviews. The methods to combine the results of the included studies were appropriate in 43 (86%) reviews. Publication bias was assessed in only 19 (37%) reviews. Finally, conflicts of interest were reported in 47 (92%) reviews.
Characteristics of health educational interventionsThe description of the health educational interventions followed the Workgroup for Intervention Develop-ment and Evaluation Research reporting guidelines for behaviour change interventions.81 The characteristics of the recipients, setting, delivery methods, intensity, dura-tion and educational content of health educational inter-ventions for patients with ACS or T2DM are summarised in tables 2 and 3. The delivery strategies for health educa-tion included face-to-face, internet-based, phone-based, videotape, written educational materials or mixed. The format included one-on-one (individualised), group or both. Face-to-face sessions were the most common delivery formats, and many education sessions were also delivered by telephone/web contact or individualised counselling. The number of sessions, total contact hours and dura-tions varied, and there was limited information about the intensity of health education for patients provided. The frequency of educational sessions was weekly or monthly, and an average of 3.7 topics was covered per education session. Nurses and multidisciplinary teams were the most frequent educators, and most education programmes were delivered postdischarge.Fi
rst
auth
or,
year
; jo
urna
l
Pri
mar
y o
bje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns
on…
.)S
tud
ies
det
ails
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
w
ere
in b
old
)‘−
': N
o c
hang
e‘↑
': In
crea
se‘↓
': D
ecre
ase
Syn
thes
is
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Cla
rk, 2
00541
; A
nnal
s of
Inte
rnal
M
edic
ine
Mor
talit
y, M
IN
umb
er o
f st
udie
s: 6
3 ra
ndom
ised
tr
ials
;Ty
pes
of
stud
ies:
RC
Ts;
Tota
l sam
ple
: 21
295
pat
ient
s
Sec
ond
ary
pre
vent
ion
pro
gram
mes
□ B
EH
A□
CV
R√
DIE
T (-
)√
EX
ER
CIS
E
(-) □ M
ED
√ P
SY
(-)
□ S
MO
KIN
G□
SE
LF
Nur
se,
mul
tidis
cip
linar
y te
am o
r d
id n
ot
des
crib
e
Num
ber
of
sess
ion:
1–
12 o
r un
clea
rTo
tal c
ont
act
hour
s: d
id n
ot
des
crib
eD
urat
ion:
0.7
5–48
mon
ths
Str
ateg
ies:
face
-to-
face
, te
lep
hone
con
tact
and
ho
me
visi
t;Fo
rmat
: gro
up a
nd
ind
ivid
ual o
r un
clea
r;T
heo
reti
cal a
pp
roac
h:
uncl
ear
Inp
atie
nt
sett
ings
, p
ostd
isch
arge
, ot
her
↓ M
ort
alit
y,↓
MI,
− H
osp
italis
atio
n ra
tes
Per
form
ed
anal
yses
by
usin
g R
evie
w
Man
ager
V.4
.2
and
Qua
litat
ive
Dat
a S
ynth
esis
Sm
okin
g, s
mok
ing
cess
atio
n; C
VR
, car
dio
vasc
ular
risk
fact
ors;
PS
Y, p
sych
osoc
ial i
ssue
s (d
epre
ssio
n, a
nxie
ty);
DIE
T, d
iet;
EX
ER
CIS
E, e
xerc
ise;
ME
D, m
edic
atio
n; B
EH
A, b
ehav
iour
al c
harg
e (in
clud
ing
lifes
tyle
m
odifi
catio
n); S
ELF
, sel
f-m
anag
emen
t (in
clud
ing
pro
ble
ms
solv
ing)
; DR
, dia
bet
es r
isks
; CH
D, c
oron
ary
hear
t d
isea
se; C
AD
, cor
onar
y ar
tery
dis
ease
; CH
W, c
omm
unity
hea
lth w
orke
r; H
bA
1c, g
lyca
ted
hae
mog
lob
in; B
P,
blo
od p
ress
ure;
LD
L, lo
w-d
ensi
ty li
pop
rote
in c
hole
ster
ol; S
MS
, sho
rt m
essa
ge s
ervi
ce; B
CTs
, beh
avio
ural
cha
nge
tech
niq
ues;
LE
A, l
ower
ext
rem
ity a
mp
utat
ion;
PR
IDE
, Pro
ble
m Id
entifi
catio
n, R
esea
rchi
ng o
ne's
rou
tine,
Id
entif
ying
a m
anag
emen
t go
al, D
evel
opin
g a
pla
n to
rea
ch it
, Exp
ress
ing
one'
s re
actio
ns a
nd E
stab
lishi
ng r
ewar
ds
for
mak
ing
pro
gres
s; A
SE
, att
itud
e so
cial
influ
ence
-effi
cacy
; CV
RF,
car
dio
vasc
ular
risk
fact
ors;
PA
, p
hysi
cal a
ctiv
ity; E
DU
, pat
ient
ed
ucat
ion;
GP,
gen
eral
pra
ctic
e; R
CTs
, ran
dom
ised
con
trol
led
tria
ls; C
CTS
, con
trol
led
clin
ical
tria
ls; H
RQ
oL, h
ealth
-rel
ated
qua
lity
of li
fe; Q
oL, q
ualit
y of
life
; MI,
myo
card
ial in
farc
tion;
CA
D,
coro
nary
art
ery
dis
ease
; CA
BG
, cor
onar
y ar
tery
byp
ass
graf
t su
rger
y; B
MI,
bod
y m
ass
ind
ex; S
BP,
sys
tolic
blo
od p
ress
ure;
DB
P, d
iast
olic
blo
od p
ress
ure;
HD
L-c,
hig
h-d
ensi
ty li
pop
rote
in c
hole
ster
ol; T
TM, t
rans
theo
retic
al
mod
el; S
CT,
soc
ial c
ogni
tive
theo
ry; H
BM
, hea
lth b
elie
f mod
el; S
AT, s
ocia
l act
ion
theo
ry.
In t
he e
duc
atio
nal c
onte
nt: ‘
+’:
min
or fo
cus;
‘++
’:mod
erat
e fo
cus;
‘++
+’ m
ajor
focu
s; ‘-
’=un
clea
r wha
t th
e in
tens
ity o
f the
ed
ucat
ion
was
for
any
top
ic.
In t
he o
utco
mes
: arr
ow u
p (‘
↑’) f
or im
pro
vem
ent,
arr
ow d
own
(‘↓’)
for
red
uctio
n; a
das
h (‘−
’) fo
r no
cha
nge
or in
conc
lusi
ve e
vid
ence
. Prim
ary
outc
omes
wer
e in
bol
d.
Tab
le 2
C
ontin
ued
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
11Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Tab
le 3
C
hara
cter
istic
s an
d in
terv
entio
ns o
f inc
lud
ed s
yste
mat
ic r
evie
ws
and
met
a-an
alys
is in
volv
ed p
atie
nts
with
T2D
M
Firs
t au
tho
r, ye
ar; j
our
nal
Prim
ary
obje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns o
n….)
Stu
die
s d
etai
ls
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
wer
e in
bo
ld.)
‘−':
No
cha
nge
‘↑':
Incr
ease
‘↓':
Dec
reas
eS
ynth
esis
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Cho
i, 20
1640
; Dia
bet
es
Res
earc
h an
d C
linic
al
Pra
ctic
e
Gly
caem
ic e
ffect
Num
ber
of
stud
ies:
53
stud
ies
(5 in
Eng
lish,
48
in C
hine
se);
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: unc
lear
Dia
bet
es e
duc
atio
n in
terv
entio
n□
BE
HA
√ D
IET
(-)
□ D
R□
EX
ER
CIS
E□
GC
□ M
ED
□ P
SY
□ S
MO
KIN
G√
SE
LF (-
)
Unc
lear
, did
not
des
crib
eN
umb
er o
f se
ssio
n:
uncl
ear;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
30–
150
min
or
unc
lear
Str
ateg
ies:
face
-to-
face
, writ
ten
mat
eria
ls;
tele
pho
ne c
onta
ct a
nd
hom
e vi
sit;
Form
at: u
ncle
ar;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
t d
isch
arge
, oth
er↓
Hb
A1c
STA
TA V
.12
and
R
evie
w M
anag
er V
.5.3
Cre
amer
, 201
642; D
iab
etic
M
edic
ine
Suc
cess
ful o
utco
mes
and
to
sug
gest
dire
ctio
ns fo
r fu
ture
res
earc
h
Num
ber
of
stud
ies:
33;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 745
3 p
artic
ipan
ts
Cul
tura
lly a
pp
rop
riate
he
alth
ed
ucat
ion
√ B
EH
A (-
)√
DIE
T (-
)√
DR
(-)
√ E
XE
RC
ISE
□ G
C□
ME
D□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
CH
Ws,
clin
ical
pha
rmac
ists
d
ietic
ians
, nur
ses,
p
odia
tris
ts, p
hysi
othe
rap
ists
an
d p
sych
olog
ists
Num
ber
of
sess
ion:
1–
10 o
r un
clea
r;To
tal c
ont
act
hour
s:
uncl
ear;
Dur
atio
n: fr
om a
sin
gle
sess
ion
to 2
4 m
onth
s
Str
ateg
ies:
face
-to-
face
; p
hone
con
tact
;Fo
rmat
: gro
up s
essi
ons
(10
stud
ies)
, ind
ivid
ual
sess
ions
(13)
or
a co
mb
inat
ion
of b
oth;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↓ H
bA
1c,
− H
RQ
oL,
− A
dve
rse
even
ts,
− B
P,−
BM
I,−
Lip
id le
vels
,−
Dia
bet
es c
omp
licat
ions
,−
Eco
nom
ic a
naly
ses,
m
orta
lity
and
dia
bet
es
know
led
ge,
− E
mp
ower
men
t,−
Sel
f-ef
ficac
y an
d s
atis
fact
ion
Met
a-an
alys
is u
sing
the
R
evie
w M
anag
er s
tatis
tical
p
rogr
amm
e
Hua
ng, 2
01655
; Eur
opea
n Jo
urna
l of I
nter
nal
Med
icin
e
Clin
ical
mar
kers
of
card
iova
scul
ar d
isea
seN
umb
er o
f st
udie
s: 1
7 st
udie
s;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: u
ncle
ar
Life
styl
e in
terv
entio
ns□
BE
HA
√ D
IET
(-)
√ C
VR
(-)
√ E
XE
RC
ISE
(-)
□ G
C□
ME
D□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
Nur
se, p
harm
acis
t or
unc
lear
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s:
uncl
ear;
Dur
atio
n:
6 m
onth
s–8
year
s
Str
ateg
ies:
unc
lear
;Fo
rmat
: ind
ivid
ual;
grou
p
and
mix
edT
heo
reti
cal a
pp
roac
h:
uncl
ear
Unc
lear
, did
not
d
escr
ibe
Car
dio
vasc
ular
ris
k fa
cto
rs
such
as,
− B
MI,
↓ H
bA
1c,
− B
P,↓
Leve
l of c
hole
ster
ol
Rev
iew
Man
ager
V.5
.1
Che
n, 2
01539
; Met
abol
ism
-C
linic
al a
nd E
xper
imen
tal
Clin
ical
mar
kers
Num
ber
of
stud
ies:
16
stud
ies;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: per
stu
dy
rang
ed fr
om 2
3 to
257
5
Life
styl
e in
terv
entio
n√
BE
HA
(-)
□ D
IET
√ C
VR
(-)
□ E
XE
RC
ISE
□ G
C√
ME
D (-
)□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
Unc
lear
, did
not
des
crib
eN
umb
er o
f se
ssio
n:
mon
thly
;To
tal c
ont
act
hour
s:
uncl
ear;
Dur
atio
n:
<6
mon
ths−
8 ye
ars
Str
ateg
ies:
unc
lear
;Fo
rmat
: ind
ivid
ual;
grou
p
and
mix
ed;
The
ore
tica
l ap
pro
ach:
un
clea
r
Unc
lear
, did
not
d
escr
ibe
Car
dio
vasc
ular
ris
k fa
cto
rs
incl
udin
g↓
BM
I,↓
Hb
A1c
,↓
SB
P, D
BP,
− H
DL-
c an
d L
DL-
c
All
anal
yses
wer
e p
erfo
rmed
usi
ng
Com
pre
hens
ive
Met
a-A
naly
sis
stat
istic
al
soft
war
e
Terr
anov
a, 2
01572
;D
iab
etes
, Ob
esity
and
M
etab
olis
m
Wei
ght
loss
Num
ber
of
stud
ies:
10
ind
ivid
ual s
tud
ies
(from
13
pap
ers)
;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: r
angi
ng
from
27
to 5
145
par
ticip
ants
Life
styl
e-b
ased
-onl
y in
terv
entio
n√
BE
HA
(-)
√ D
IET
(-)
□ D
R (-
)√
EX
ER
CIS
E (-
)□
GC
□ M
ED
□ P
SY
□ S
MO
KIN
G√
SE
LF (-
)
Die
ticia
n; d
iab
etes
ed
ucat
or; g
ener
al p
hysi
cian
; m
ultid
isci
plin
ary
team
or
nutr
ition
ist;
nur
se
Num
ber
of
sess
ion:
1–
42;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
ran
ged
from
16
wee
ks t
o 9
year
s
Str
ateg
ies
and
fo
rmat
: fa
ce-t
o-fa
ce in
div
idua
l or
grou
p-b
ased
ses
sion
s, o
r a
com
bin
atio
n of
tho
se.
One
stu
dy
del
iver
ed
the
inte
rven
tion
via
the
tele
pho
neT
heo
reti
cal a
pp
roac
h:
uncl
ear
Unc
lear
, did
not
d
escr
ibe
↓ W
eig
ht c
hang
e;−
Hb
A1c
Met
a-an
alys
es—
Rev
iew
M
anag
er a
nd m
eta-
regr
essi
on a
naly
sis—
Sta
ta
vers
ion.
Pill
ay, 2
01571
; Ann
als
of
Inte
rnal
Med
icin
eH
bA
Ic le
vel
Num
ber
of
stud
ies:
13
2;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: u
ncle
ar
Beh
avio
ural
pro
gram
me
√ B
EH
A (-
)√
DIE
T (-
)□
DR
√ E
XE
RC
ISE
(-)
√ G
C (-
)√
ME
D (-
)□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
Trai
ned
ind
ivid
uals
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s:
rang
e, 7
–40.
5 ho
urs;
Dur
atio
n: 4
or
mor
e w
eeks
Str
ateg
ies:
unc
lear
;Fo
rmat
: unc
lear
;T
heo
reti
cal a
pp
roac
h:
uncl
ear
Inp
atie
nt s
ettin
gs,
pos
t d
isch
arge
, oth
er−
Hb
A1c
;↓
BM
ITh
e an
alys
is w
as
cond
ucte
d b
y us
ing
a B
ayes
ian
netw
ork
mod
el
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
12 Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Firs
t au
tho
r, ye
ar; j
our
nal
Prim
ary
obje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns o
n….)
Stu
die
s d
etai
ls
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
wer
e in
bo
ld.)
‘−':
No
cha
nge
‘↑':
Incr
ease
‘↓':
Dec
reas
eS
ynth
esis
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Pal
, 201
467; D
iab
etes
Car
eH
ealth
sta
tus,
ca
rdio
vasc
ular
ris
k fa
ctor
s an
d Q
oL
Num
ber
of
stud
ies:
20
pap
ers
des
crib
ing
16
stud
ies;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 357
8 p
artic
ipan
ts
Com
put
er-b
ased
sel
f-m
anag
emen
t in
terv
entio
ns□
BE
HA
□ D
IET
□ D
R□
EX
ER
CIS
E□
GC
□ M
ED
□ P
SY
□ S
MO
KIN
G√
SE
LF
Unc
lear
, did
not
des
crib
eN
umb
er o
f se
ssio
n:
1–8;
Tota
l co
ntac
t ho
urs:
10
min
– 6
hour
s;D
urat
ion:
8
wee
ks–1
2 m
onth
s
Str
ateg
ies:
onl
ine/
web
-b
ased
; Pho
ne c
onta
ctFo
rmat
: ind
ivid
ual;
grou
p
and
mix
edT
heo
reti
cal a
pp
roac
h:
TTM
, soc
ial e
colo
gica
l th
eory
, SC
T an
d s
elf-
det
erm
inat
ion
theo
ry
Unc
lear
, did
not
d
escr
ibe
− H
RQ
oL,
↓Hb
A1c
,−
Dea
th;
↓Cog
nitio
ns, b
ehav
iour
s,−
Soc
ial s
upp
ort,
↓Car
dio
vasc
ular
ris
k fa
ctor
s,−
Com
plic
atio
ns,
−E
mot
iona
l out
com
es,
−H
ypog
lyca
emia
,−
Ad
vers
e ef
fect
s,−
CE
and
eco
nom
ic d
ata
Met
a-an
alys
is u
sing
R
evie
w M
anag
er s
oftw
are
or n
arra
tive
pre
sent
atio
n
Ric
ci-C
abel
lo, 2
01473
; B
MC
End
ocrin
e D
isor
der
sK
now
led
ge, b
ehav
iour
s an
d c
linic
al o
utco
mes
Num
ber
of
stud
ies:
37
stud
ies;
Typ
es o
f st
udie
s:
alm
ost
two-
third
s of
th
e st
udie
s w
ere
RC
Ts,
27%
stu
die
s w
ere
qua
si-e
xper
imen
tal
des
ign.
Tota
l sam
ple
: unc
lear
DS
M e
duc
atio
nal
pro
gram
me
□ B
EH
A√
DIE
T(+
++
)□
DR
√ E
XE
RC
ISE
(++
+)
√ G
C(+
++
)√
ME
D(+
+)
√ P
SY
(++
)□
SM
OK
ING
□ S
ELF
Die
titia
n; n
urse
; psy
chol
ogis
t;
phy
sici
an; r
esea
rch
team
or
sta
ff
Num
ber
of
sess
ion:
13
.1;
Tota
l co
ntac
t ho
urs:
0.
25–1
80 h
ours
;D
urat
ion:
0.2
5–48
mon
ths
Str
ateg
ies:
face
-to-
face
; te
leco
mm
unic
atio
n; b
oth
Form
at: o
ne o
n on
e;
grou
p a
nd m
ixed
The
ore
tica
l ap
pro
ach:
un
clea
r
Pos
tdis
char
ge, o
ther
−D
iab
etes
kno
wle
dg
e;−
Sel
f-m
anag
emen
t;−
Beh
avio
urs;
−C
linic
al o
utco
mes
; ↓G
lyca
ted
hae
mog
lob
in;
−C
ost-
effe
ctiv
enes
s an
alys
is
Met
a-an
alys
es a
nd
biv
aria
te m
eta-
regr
essi
on
wer
e co
nduc
ted
with
Sta
ta
V.12
.0
Saf
fari,
201
474; P
rimar
y C
are
Dia
bet
esG
lyca
emic
con
trol
.N
umb
er o
f st
udie
s: 1
0;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: 9
60
pat
ient
s
An
educ
atio
nal
inte
rven
tion
usin
g S
MS
√ B
EH
A (-
)□
DIE
T□
DR
□ E
XE
RC
ISE
√ G
C (-
)√
ME
D (-
)□
PS
Y□
SM
OK
ING
□ S
ELF
Unc
lear
, did
not
des
crib
eN
umb
er o
f se
ssio
n:
wee
kly;
or
two
mes
sage
s d
aily
or
uncl
ear;
Tota
l co
ntac
t ho
urs:
un
clea
r.D
urat
ion:
3
mon
ths–
1 ye
ar
Str
ateg
ies:
SM
S: s
end
ing
and
rec
eivi
ng d
ata.
R
ecei
ve d
ata
thro
ugh
text
-m
essa
ging
by
pat
ient
s on
ly. U
sed
a w
ebsi
te a
long
w
ith S
MS
;Fo
rmat
: Unc
lear
;T
heo
reti
cal a
pp
roac
h:
Unc
lear
.
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↑Gly
caem
ic c
ont
rol
Com
pre
hens
ive
Met
a-an
alys
is S
oftw
are
V.2.
0
Od
nole
tkov
a, 2
01466
; Jo
urna
l of D
iab
etes
&
Met
abol
ism
Cos
t-ef
fect
iven
ess
(CE
)N
umb
er o
f st
udie
s: 1
7 st
udie
s;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: u
ncle
ar
Ther
apeu
tic e
duc
atio
n√
BE
HA
(-)
□ D
IET
□ D
R□
EX
ER
CIS
E□
GC
□ M
ED
□ P
SY
□ S
MO
KIN
G√
SE
LF (-
)
Gen
eral
phy
sici
an;
nutr
ition
ists
or
uncl
ear
Num
ber
of
sess
ion:
~
16;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
unc
lear
Str
ateg
ies:
face
-to-
face
or
unc
lear
;Fo
rmat
: ind
ivid
ual a
nd
grou
p le
sson
s;T
heo
reti
cal a
pp
roac
h:
uncl
ear
Inho
spita
l or
uncl
ear
−C
EIn
crem
enta
l cos
t-ef
fect
iven
ess
ratio
Att
ridge
, 201
433; T
he
Coc
hran
e Li
bra
ryH
bA
Ic le
vel,
know
led
ge
and
clin
ical
out
com
esN
umb
er o
f st
udie
s:
33 t
rials
;Ty
pes
of
stud
ies:
RC
Ts
and
qua
si-R
CTs
;To
tal s
amp
le: 7
453
par
ticip
ants
'Cul
tura
lly a
pp
rop
riate
' he
alth
ed
ucat
ion
√ B
EH
A (-
)√
DIE
T (-
)□
DR
√ E
XE
RC
ISE
(-)
√ G
C (-
)□
ME
D□
PS
Y√
SM
OK
ING
(-)
□ S
ELF
CH
Ws;
die
ticia
ns; e
xerc
ise
phy
siol
ogis
ts; l
ay w
orke
rs;
nurs
es; p
odia
tris
ts a
nd
psy
chol
ogis
ts
Num
ber
of
sess
ion:
on
e se
ssio
n to
24
mon
ths;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
the
m
edia
n d
urat
ion
of
inte
rven
tions
was
6
mon
ths
Str
ateg
ies:
Form
at: g
roup
in
terv
entio
n m
etho
d,
one-
to-o
ne s
essi
ons
and
a m
ixtu
re o
f the
tw
o m
etho
ds.
Or
a p
urel
y in
tera
ctiv
e p
atie
nt-c
entr
ed
met
hod
The
ore
tica
l ap
pro
ach:
em
pow
erm
ent
theo
ries;
b
ehav
iour
cha
nge
theo
ries,
TTM
of b
ehav
iour
ch
ange
and
SC
T
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↓Hb
A1c
;−
HR
Qo
L;−
Ad
vers
e ev
ents
;−
Mor
talit
y;−
Com
plic
atio
ns; −
Sat
isfa
ctio
n;
↑Em
pow
erm
ent;
↑Sel
f-ef
ficac
y;−
Att
itud
e; k
now
led
ge;
−B
P;
−B
MI;
↓Lip
id le
vels
;−
Hea
lth e
cono
mic
s
Met
a-an
alys
es u
sed
R
evie
w M
anag
er s
oftw
are
Vugt
, 201
375; J
ourn
al o
f M
edic
al In
tern
et R
esea
rch
Hea
lth o
utco
mes
Num
ber
of
stud
ies:
13
stud
ies;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 381
3 p
atie
nts
BC
Ts a
re b
eing
use
d in
on
line
self-
man
agem
ent
inte
rven
tions
√ B
EH
A (-
)□
DIE
T□
DR
□ E
XE
RC
ISE
□ G
C□
ME
D□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
Hea
lthca
re p
rofe
ssio
nal
Num
ber
of
sess
ion:
6
wee
kly
sess
ions
or
uncl
ear;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
unc
lear
Str
ateg
ies:
onl
ine/
web
-b
ased
;Fo
rmat
: unc
lear
;T
heo
reti
cal a
pp
roac
h:
self-
effic
acy
theo
ry, s
ocia
l su
pp
ort
theo
ry, T
TM, S
CT,
so
cial
-eco
logi
cal m
odel
an
d c
ogni
tive
beh
avio
ural
th
erap
y
Pos
tdis
char
ge−
Hea
lth
beh
avio
ur c
hang
e;−
Psy
cho
log
ical
wel
l-b
eing
;−
Clin
ical
par
amet
ers
Unc
lear
Tab
le 3
C
ontin
ued
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
13Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Firs
t au
tho
r, ye
ar; j
our
nal
Prim
ary
obje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns o
n….)
Stu
die
s d
etai
ls
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
wer
e in
bo
ld.)
‘−':
No
cha
nge
‘↑':
Incr
ease
‘↓':
Dec
reas
eS
ynth
esis
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Guc
ciar
di,
2013
52; P
atie
nt
Ed
ucat
ion
and
Cou
nsel
ing
Hb
AIc
leve
l,phy
sica
l ac
tivity
and
die
t ou
tcom
esN
umb
er o
f st
udie
s: 1
3 st
udie
s;Ty
pes
of
stud
ies:
R
CTs
and
com
par
ativ
e st
udie
s;To
tal s
amp
le: u
ncle
ar
DS
ME
inte
rven
tions
.□
BE
HA
√ D
IET
(++
+);
□ D
R√
EX
ER
CIS
E (+
++
);□
GC
√ M
ED
(+);
√ P
SY
(+)
□ S
MO
KIN
G√
SE
LF (+
+)
Die
titia
ns (n
=7/
13);
Mul
tidis
cip
linar
y te
am
(n=
7/13
); N
urse
(n=
5/13
);C
omm
unity
pee
r w
orke
r (n
=3/
13)
Num
ber
of
sess
ion:
lo
w in
tens
ity:
<10
ed
ucat
ion
sess
ions
(n
=7)
; hig
h in
tens
ity:
≥10
educ
atio
n se
ssio
ns
(n=
6);
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
<6
mon
ths
(n=
7/13
); ≥6
mon
ths
(n=
6/13
)
Str
ateg
ies:
face
-to-
face
(n=
13/1
3); w
ritte
n lit
erat
ure:
(eg,
han
db
ook)
(n
=4/
13);
tele
pho
ne
(n=
4/13
); au
dio
visu
al
(n=
1/13
)Fo
rmat
: one
-on-
one:
(n
=11
/13)
; gro
up (n
=9/
13)
The
ore
tica
l ap
pro
ach:
S
AT; e
mp
ower
men
t B
ehav
iour
cha
nge
mod
el;
mod
ifica
tion
theo
ries;
p
harm
aceu
tical
car
e m
odel
; Beh
avio
ur c
hang
e th
eory
; PAT
HW
AYS
p
rogr
amm
e; s
ymp
tom
- fo
cuse
d m
anag
emen
t m
odel
; mot
ivat
iona
l in
terv
iew
ing
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge−
Hb
A1c
leve
ls,
− A
nthr
opom
etric
s,−
Phy
sica
l act
ivity
;−
Die
t ou
tcom
es
A r
ecen
tly d
escr
ibed
m
etho
d
Pal
, 201
368; T
he C
ochr
ane
Lib
rary
Hea
lth s
tatu
s an
d H
RQ
oLN
umb
er o
f st
udie
s: 1
6 st
udie
s;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: 3
578
par
ticip
ants
Com
put
er-b
ased
dia
bet
es
self-
man
agem
ent
inte
rven
tion
□ B
EH
A√
DIE
T (-
)□
DR
√ E
XE
RC
ISE
(-)
√ G
C (-
)√
ME
D (-
)√
PS
Y (-
)□
SM
OK
ING
□ S
ELF
Nur
se o
r ot
her
heal
thca
re
pro
fess
iona
lsN
umb
er o
f se
ssio
n:
uncl
ear;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
1 s
essi
on–
18 m
onth
s
Str
ateg
ies:
onl
ine/
web
-b
ased
; pho
ne c
onta
ctFo
rmat
: unc
lear
;T
heo
reti
cal a
pp
roac
h:
uncl
ear
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
− H
RQ
oL;
− D
eath
fro
m a
ny c
ause
;↓H
bA
1c;
− C
ogni
tions
;−
Beh
avio
urs;
−S
ocia
l sup
por
t;−
Bio
logi
cal m
arke
rs;
− C
omp
licat
ions
Form
al m
eta-
anal
yses
and
na
rrat
ive
synt
hesi
s
Nam
, 201
262; J
ourn
al o
f C
ard
iova
scul
ar N
ursi
ngG
lyca
emic
con
trol
Num
ber
of
stud
ies:
12
RC
Ts;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 149
5 p
artic
ipan
ts
Dia
bet
es e
duc
atio
nal
inte
rven
tions
(no
dru
g in
terv
entio
n)
□ B
EH
A√
DIE
T (-
)□
DR
√ E
XE
RC
ISE
(-)
√ G
C (-
)√
ME
D (-
)√
PS
Y (-
)□
SM
OK
ING
√ S
ELF
(-)
Nur
ses
(36%
), d
ietic
ians
(3
6%),
dia
bet
es e
duc
ator
s (5
%),
othe
r p
rofe
ssio
nals
(9
%) a
nd n
on-p
rofe
ssio
nal
staf
f (14
%)
Num
ber
of
sess
ion:
1
mon
th o
r le
ss;
1–3
mon
ths
and
12
mon
ths;
Tota
l co
ntac
t ho
urs:
m
ost
stud
ies
did
not
d
escr
ibe,
or
from
1
sess
ion
to m
ore
than
30
hou
rs;
Dur
atio
n: fr
om 1
se
ssio
n to
12
mon
ths,
fr
eque
ncy:
1 s
essi
on t
o 25
wee
kly
or b
iwee
kly
educ
atio
n
Str
ateg
ies:
tea
chin
g or
co
unse
lling
; hom
e-b
ased
su
pp
ort
and
vis
ual a
ids
Form
at: g
roup
ed
ucat
ion
or a
com
bin
atio
n of
gro
up
educ
atio
n an
d in
div
idua
l co
unse
lling
; or
only
in
div
idua
l cou
nsel
ling;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↓Hb
A1c
leve
lM
eta-
anal
ysis
Ste
insb
ekk,
201
276; B
MC
H
ealth
Ser
vice
s R
esea
rch
Clin
ical
, life
styl
e an
d
psy
chos
ocia
l out
com
esN
umb
er o
f st
udie
s: 2
1 st
udie
s (2
6 p
ublic
atio
ns)
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 283
3 p
artic
ipan
ts
Gro
up-b
ased
ed
ucat
ion
Did
not
des
crib
e th
e co
nten
t of
the
in
terv
entio
n
Com
mun
ity w
orke
rs;
die
ticia
n; la
y he
alth
ad
viso
rs
nurs
e an
d n
utrit
ioni
st
Num
ber
of
sess
ion
and
to
tal c
ont
act
hour
s: 3
0 ho
urs
over
2.
5 m
onth
s, 5
2 ho
urs
over
1 y
ear
and
36
or
96 h
ours
ove
r 6
mon
ths
Dur
atio
n: 6
mon
ths
to
2 ye
ars
Str
ateg
ies:
face
-to-
face
;Fo
rmat
: 5 t
o 8
par
ticip
ants
gro
up t
o 40
p
atie
nts
grou
pT
heo
reti
cal a
pp
roac
h:
emp
ower
men
t m
odel
and
th
e d
isco
very
lear
ning
th
eory
, the
SC
T an
d t
he
soci
al e
colo
gica
l the
ory,
th
e se
lf-ef
ficac
y an
d
self-
man
agem
ent
theo
ries
and
op
eran
t re
info
rcem
ent
theo
ry
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↓Hb
A1c
,↑L
ifest
yle
out
com
es,
↑Dia
bet
es k
now
led
ge,
↑Sel
f-m
anag
emen
t sk
ills,
↑Psy
chos
ocia
l out
com
es,
↓Mor
talit
y ra
te,
↓BM
I,↓B
lood
pre
ssur
e;↓L
ipid
pro
file
Met
a-an
alys
is u
sing
R
evie
w M
anag
er V
.5
Am
aesh
i, 20
1232
; Pod
iatr
y N
owIn
crea
sing
goo
d fo
ot
heal
th p
ract
ices
tha
t w
ill
ultim
atel
y re
duc
e LE
A
Num
ber
of
stud
ies:
ei
ght
stud
ies;
Typ
es o
f st
udie
s: R
CT
or c
linic
al c
ontr
olle
d
tria
l (C
CT)
;To
tal s
amp
le: u
ncle
ar
Foot
hea
lth e
duc
atio
nFo
od c
are
Pod
iatr
ist,
psy
chol
ogis
t or
un
clea
rN
umb
er o
f se
ssio
n:
uncl
ear;
Tota
l co
ntac
t ho
urs:
b
etw
een
15 m
in a
nd
14 h
ours
;D
urat
ion:
3–3
0 m
onth
s
Str
ateg
ies:
face
- to
-fac
e;Fo
rmat
: in
thre
e of
the
st
udie
s, e
duc
atio
nal
inte
rven
tions
wer
e d
eliv
ered
to
the
par
ticip
ants
in g
roup
s,
whi
le t
he o
ther
five
p
rovi
ded
ind
ivid
ualis
ed
(one
-to-
one)
foot
ca
re e
duc
atio
n to
the
p
artic
ipan
ts;
The
ore
tica
l ap
pro
ach:
un
clea
r
Unc
lear
, did
not
d
escr
ibe
↓ LE
A;
↑Sel
f-ca
reN
arra
tive
synt
hesi
s
Tab
le 3
C
ontin
ued
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
14 Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Firs
t au
tho
r, ye
ar; j
our
nal
Prim
ary
obje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns o
n….)
Stu
die
s d
etai
ls
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
wer
e in
bo
ld.)
‘−':
No
cha
nge
‘↑':
Incr
ease
‘↓':
Dec
reas
eS
ynth
esis
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Lun
Gan
, 201
157;
JBI L
ibra
ry o
f Sys
tem
atic
R
evie
ws
Ora
l hyp
ogly
caem
ic
adhe
renc
eN
umb
er o
f st
udie
s:
seve
n st
udie
s;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: u
ncle
ar
Ed
ucat
iona
l int
erve
ntio
ns√
BE
HA
(-)
√ D
IET
(-)
□ D
R√
EX
ER
CIS
E (-
)√
GC
(-)
√ M
ED
(-)
√ P
SY
(-)
□ S
MO
KIN
G√
SE
LF (-
)
Nur
ses;
pha
rmac
ists
; ot
her
skill
ed h
ealth
care
p
rofe
ssio
nals
Num
ber
of
sess
ion:
1–
12 o
r un
clea
r;To
tal c
ont
act
hour
s:
2.5
hour
s or
unc
lear
;D
urat
ion:
4–1
2 m
onth
s
Str
ateg
ies:
face
- to
-fac
e;Fo
rmat
: gro
up a
nd
ind
ivid
ual;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↓ H
bA
1c,
− M
edic
atio
n ad
here
nce;
↓Blo
od g
luco
se;
− T
able
t co
unt;
− M
edic
atio
n co
ntai
ners
;−
Dia
bet
es c
omp
licat
ions
;−
Hea
lth s
ervi
ce u
tilis
atio
n
Nar
rativ
e su
mm
ary
form
Bur
ke, 2
01138
; JB
I Dat
abas
e of
S
yste
mat
ic R
evie
ws
and
Im
ple
men
tatio
n R
epor
ts
Hb
AIc
leve
l,BP
Num
ber
of
stud
ies:
11
RC
Ts a
nd 4
qua
si-
exp
erim
enta
l tria
ls;
Typ
es o
f st
udie
s: R
CTs
an
d q
uasi
-exp
erim
enta
l tr
ials
;To
tal s
amp
le: 2
240
pat
ient
s
Gro
up m
edic
al v
isits
√ B
EH
A (-
)√
DIE
T (-
)□
DR
□ E
XE
RC
ISE
√ G
C (-
)√
ME
D (-
)□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
End
ocrin
olog
ists
; DM
nur
se;
fam
ily p
hysi
cian
; nut
ritio
nist
an
d r
ehab
the
rap
ist
Num
ber
of
sess
ion:
1–
4 or
unc
lear
;To
tal c
ont
act
hour
s:
2–4
hour
s or
unc
lear
;D
urat
ion:
1 s
essi
on t
o 2
year
s
Str
ateg
ies:
face
-to-
face
;Fo
rmat
: gro
up a
nd
ind
ivid
ual;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↓Hb
A1c
;−
Sys
tolic
and
dia
sto
lic B
P;
−LD
L m
easu
rem
ents
Met
a-an
alys
is
Ram
adas
, 201
177;
Inte
rnat
iona
l Jou
rnal
of
Med
ical
Info
rmat
ics
Hb
AIc
leve
lN
umb
er o
f st
udie
s: 1
3 d
iffer
ent
stud
ies;
Typ
es o
f st
udie
s: R
CTs
an
d q
uasi
-exp
erim
enta
l st
udie
s;To
tal s
amp
le: u
ncle
ar
Web
-bas
ed b
ehav
iour
al
inte
rven
tions
√ B
EH
A (-
)√
DIE
T (-
)□
DR
□ E
XE
RC
ISE
√ G
C (-
)√
ME
D (-
)□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
Die
ticia
n; e
ndoc
rinol
ogis
t;
phy
sici
ans;
res
earc
hers
or
rese
arch
sta
ff m
emb
ers
and
st
udy
nurs
e
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s:
uncl
ear;
Dur
atio
n: r
ange
d
bet
wee
n 12
and
52
wee
ks, w
ith
an a
vera
ge o
f 27
.2±
18.3
wee
ks
Str
ateg
ies:
em
ail a
nd
SM
S t
echn
olog
ies
that
wer
e co
mm
only
us
ed t
oget
her
with
the
w
ebsi
tes
to r
einf
orce
the
in
terv
entio
n, a
nd w
ebsi
te,
prin
t m
ater
ial
Form
at: u
ncle
ar;
The
ore
tica
l ap
pro
ach:
W
agne
r's
Chr
onic
Car
e M
odel
; sel
f-ef
ficac
y th
eory
/soc
ial s
upp
ort
theo
ry; T
TM; H
BM
; SC
T
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
− S
elf-
mo
nito
ring
blo
od
su
gar
,−
Wei
ght
loss
,−
Die
tary
beh
avio
ur,
− P
hysi
cal a
ctiv
ity
Not
sta
tistic
ally
com
bin
ed
and
re-
anal
ysed
Min
et, 2
01061
; Pat
ient
E
duc
atio
n an
d C
ouns
elin
gG
lyca
emic
con
trol
Num
ber
of
stud
ies:
47
stud
ies;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: unc
lear
Sel
f-ca
re m
anag
emen
t in
terv
entio
ns√
BE
HA
(-)
□ D
IET
□ D
R□
EX
ER
CIS
E□
GC
□ M
ED
□ P
SY
□ S
MO
KIN
G√
SE
LF (-
)
Cas
e nu
rse
man
ager
; gro
up
faci
litat
or; n
urse
ed
ucat
or;
mul
tidis
cip
linar
y te
am;
phy
siol
ogis
t; p
hysi
cian
; pee
r co
unse
llor;
res
earc
her
and
p
harm
acis
t
Num
ber
of
sess
ion:
3–
26;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
4 w
eeks
to
4 ye
ars
Str
ateg
ies:
face
-to-
face
; ho
me
visi
t; p
hone
cal
ls;
Form
at: g
roup
and
in
div
idua
l;T
heo
reti
cal a
pp
roac
h:
uncl
ear
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↓ H
bA
1cM
eta-
anal
yses
and
met
a-re
gres
sion
use
d S
tata
's
met
a co
mm
and
Haw
thor
ne, 2
01054
; D
iab
etic
Med
icin
eE
ffect
s of
cul
tura
lly
app
rop
riate
hea
lth
educ
atio
n
Num
ber
of
stud
ies:
10
tria
ls;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 160
3 p
atie
nts
Cul
tura
lly a
pp
rop
riate
he
alth
ed
ucat
ion
□ B
EH
A√
DIE
T (-
)□
DR
√ E
XE
RC
ISE
(-)
□ G
C□
ME
D□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
Exe
rcis
e p
hysi
olog
ists
; d
ietic
ians
; dia
bet
es n
urse
s;
link
wor
kers
and
pod
iatr
ists
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s:
uncl
ear;
Dur
atio
n: 1
ses
sion
to
12 m
onth
s
Str
ateg
ies:
face
-to-
face
; vi
sual
aid
s, le
aflet
s an
d
teac
hing
mat
eria
ls;
Form
at: g
roup
ap
pro
ach,
on
e-to
-one
inte
rvie
ws
and
a
mix
ed a
pp
roac
h;T
heo
reti
cal a
pp
roac
h:
SAT
, Em
pow
erm
ent
Beh
avio
ur C
hang
e M
odel
, S
CT,
Man
agem
ent
mod
el
and
the
The
ory
of P
lann
ed
Beh
avio
ur
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
−Q
oL;
↓Hb
A1c
;−
BP
;↑K
now
led
ge;
− B
MI;
↓ Li
pid
leve
ls,
− D
iab
etic
com
plic
atio
ns,
− M
orta
lity
rate
s, h
osp
ital
adm
issi
ons,
hyp
ogly
caem
ia
Met
a -a
naly
sis
usin
g th
e R
evie
w M
anag
er a
nd
narr
ativ
e re
view
Fan,
200
947; C
anad
ian
Jour
nal o
f Dia
bet
esK
now
led
ge, s
elf-
man
agem
ent
beh
avio
urs
and
met
abol
ic c
ontr
ol
Num
ber
of
stud
ies:
50
stud
ies;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: unc
lear
DS
ME
inte
rven
tion
√ B
EH
A (-
)□
DIE
T□
DR
□ E
XE
RC
ISE
□ G
C□
ME
D√
PS
Y (-
)□
SM
OK
ING
√ S
ELF
(-)
Unc
lear
, did
not
des
crib
eN
umb
er o
f se
ssio
n:
10 (r
ange
1–2
8);
Tota
l co
ntac
t ho
urs:
17
con
tact
hou
rs
(ran
ge 1
– 52
); ≤1
0 (4
6%);
11–2
0 (2
1%);
>20
(33%
);D
urat
ion:
22
wee
ks
(ran
ge 1
–48)
; ≤8
wee
ks
(26%
); 9–
24 w
eeks
(3
7%);
>24
wee
ks
(37%
)
Str
ateg
ies:
Onl
ine/
web
-b
ased
(4%
); vi
deo
(2%
); fa
ce-t
o-fa
ce (6
0%);
pho
ne
cont
act
(4%
); M
ixed
(3
0%).
Form
at: o
ne-o
n-on
e (3
2%);
grou
p (4
0%);
mix
ed
(28%
)T
heo
reti
cal a
pp
roac
h:
uncl
ear
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↑ D
iab
etes
kno
wle
dg
e,↑
Sel
f-m
anag
emen
t b
ehav
iour
s;↓
Hb
A1c
Com
pre
hens
ive
met
a-an
alys
is (V
.2.0
)
Tab
le 3
C
ontin
ued
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
15Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Firs
t au
tho
r, ye
ar; j
our
nal
Prim
ary
obje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns o
n….)
Stu
die
s d
etai
ls
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
wer
e in
bo
ld.)
‘−':
No
cha
nge
‘↑':
Incr
ease
‘↓':
Dec
reas
eS
ynth
esis
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Duk
e, 2
00946
; The
C
ochr
ane
Lib
rary
Met
abol
ic c
ontr
ol,
dia
bet
es k
now
led
ge a
nd
psy
chos
ocia
l out
com
es
Num
ber
of
stud
ies:
ni
ne s
tud
ies;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 135
9 p
artic
ipan
ts
Ind
ivid
ual p
atie
nt
educ
atio
n√
BE
HA
(-)
□ D
IET
□ D
R√
EX
ER
CIS
E (-
)√
GC
(-)
□ M
ED
√ P
SY
(-)
□ S
MO
KIN
G□
SE
LF
Dia
bet
es e
duc
ator
s an
d
die
ticia
nsN
umb
er o
f se
ssio
n:
1–6;
Tota
l co
ntac
t ho
urs:
20
min
–7
hour
s;D
urat
ion:
4
wee
ks–1
yea
r
Str
ateg
ies:
face
to
face
; te
lep
hone
;Fo
rmat
: ind
ivid
ual;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs−
Hb
A1c
;−
Dia
bet
es c
om
plic
atio
ns;
− H
ealth
ser
vice
util
isat
ion
and
he
alth
care
cos
ts;
− P
sych
osoc
ial o
utco
mes
;−
Dia
bet
es k
now
led
ge; p
atie
nt
self-
care
beh
avio
urs;
− P
hysi
cal m
easu
res;
m
etab
olic
Met
a-an
alys
is
Ala
m, 2
00930
; Pat
ient
E
duc
atio
n an
d C
ouns
elin
gG
lyca
emic
con
trol
and
p
sych
olog
ical
sta
tus
Num
ber
of
stud
ies:
35
tria
ls;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 143
1 p
atie
nts
Psy
cho-
educ
atio
nal
inte
rven
tions
√ B
EH
A (-
)□
DIE
T□
DR
□ E
XE
RC
ISE
□ G
C□
ME
D√
PS
Y (-
)□
SM
OK
ING
□ S
ELF
Gen
eral
ists
; psy
chol
ogic
al
spec
ialis
ts; o
r d
id n
ot r
epor
t th
e sp
ecia
list
Num
ber
of
sess
ion:
1–
16;
Tota
l co
ntac
t ho
urs:
20
min
–28
hou
rs;
Dur
atio
n: a
bou
t 13
.7
(±11
.06)
wee
ks
Str
ateg
ies:
face
to
face
; te
lep
hone
cal
ls;
Form
at: g
roup
form
at; a
si
ngle
form
at a
nd u
sed
a
com
bin
atio
n;T
heo
reti
cal a
pp
roac
h:
TTM
; mot
ivat
iona
l in
terv
iew
ing
Inp
atie
nt s
ettin
gs,
othe
r↓
Hb
Alc
;↓
Psy
cho
log
ical
dis
tres
sM
eta-
anal
ysis
Khu
nti,
2008
58; D
iab
etic
M
edic
ine
Kno
wle
dge
and
b
iom
edic
al o
utco
mes
Num
ber
of
stud
ies:
ni
ne s
tud
ies;
Typ
es o
f st
udie
s: R
CTs
an
d R
CT
was
follo
wed
b
y a
bef
ore-
and
-aft
er
stud
y;To
tal s
amp
le: 1
004
pat
ient
s
Any
ed
ucat
iona
l in
terv
entio
n□
BE
HA
√ D
IET
□ D
R□
EX
ER
CIS
E□
GC
□ M
ED
□ P
SY
□ S
MO
KIN
G□
SE
LF
Unc
lear
, did
not
des
crib
eN
umb
er o
f se
ssio
n:
uncl
ear;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
3–1
2 m
onth
s
Str
ateg
ies:
face
-to-
face
;Fo
rmat
: gro
up a
nd
ind
ivid
ual;
The
ore
tica
l ap
pro
ach:
un
clea
r
Unc
lear
, did
not
d
escr
ibe
− K
now
led
ge;
− P
sych
olo
gic
al a
nd
bio
med
ical
out
com
e m
easu
res
Unc
lear
Love
man
, 200
860; H
ealth
Te
chno
logy
Ass
essm
ent
Clin
ical
effe
ctiv
enes
s.N
umb
er o
f st
udie
s: 2
1 p
ublis
hed
tria
ls;
Typ
es o
f st
udie
s: R
CTs
an
d C
CTs
;To
tal s
amp
le: u
ncle
ar
Ed
ucat
iona
l int
erve
ntio
ns√
BE
HA
(++
)√
DIE
T (+
++
)□
DR
√ E
XE
RC
ISE
(++
+)
√ G
C (+
++
)□
ME
D□
PS
Y□
SM
OK
ING
√ S
ELF
(++
+)
Com
mun
ity w
orke
rs;
dia
bet
es r
esea
rch
tech
nici
an; d
iab
etes
nur
se,
die
ticia
ns; e
duc
atio
nalis
t;
med
ical
stu
den
ts; n
urse
s;
pha
rmac
ists
; phy
sici
an o
r p
hysi
cian
ass
ista
nt
Num
ber
of
sess
ion:
tw
o to
four
inte
nsiv
e ed
ucat
ion
of
1.5–
2 ho
urs
follo
wed
-up
with
ad
diti
onal
ed
ucat
ion
at, 3
and
6
mon
ths;
Tota
l co
ntac
t ho
urs
and
dur
atio
n:
abou
t 15
0 m
ins
over
6
mon
ths
or 6
1–52
hou
rs o
ver
1 ye
ar
Str
ateg
ies:
face
-to-
face
;Fo
rmat
: gro
up a
nd
ind
ivid
ual;
The
ore
tica
l ap
pro
ach:
co
gniti
ve-b
ehav
iour
al
stra
tegi
es; p
edag
ogic
al
prin
cip
le
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
− D
iab
etic
co
ntro
l out
com
es;
− D
iab
etic
end
poi
nts;
− Q
oL a
nd c
ogni
tive
mea
sure
s
Nar
rativ
e re
view
Wen
s, 2
00878
; Dia
bet
es
Res
earc
h an
d C
linic
al
Pra
ctic
e
Imp
rovi
ng a
dhe
renc
e to
med
ical
tre
atm
ent
reco
mm
end
atio
ns
Num
ber
of
stud
ies:
ei
ght
stud
ies;
Typ
es o
f st
udie
s: R
CTs
an
d c
ontr
ollin
g b
efor
e an
d a
fter
stu
die
sTo
tal s
amp
le: 7
72
pat
ient
s
Inte
rven
tions
aim
ed a
t im
pro
ving
ad
here
nce
to
med
ical
tre
atm
ent
√ B
EH
A (-
)√
DIE
T (-
)□
DR
√ E
XE
RC
ISE
(-)
√ G
C (-
)√
ME
D (-
)□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
Dia
bet
es e
duc
ator
; nur
se o
r d
id n
ot d
escr
ibe
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s:
uncl
ear;
Dur
atio
n:~
9 m
onth
s or
un
clea
r
Str
ateg
ies:
face
-to-
face
; te
lep
hone
;Fo
rmat
: fac
e-to
-fac
e;
grou
p b
ased
and
te
lem
edic
ine;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
− A
dhe
renc
e;−
Hb
A1c
;−
Blo
od g
luco
se
Coc
hran
e R
evie
w
Man
ager
sof
twar
e
Haw
thor
ne, 2
00853
; The
C
ochr
ane
Lib
rary
Hb
AIc
leve
l, kn
owle
dge
an
d c
linic
al o
utco
mes
Num
ber
of
stud
ies:
a
tota
l of 1
1 tr
ials
;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: 1
603
pat
ient
s
Cul
tura
lly a
pp
rop
riate
(or
adap
ted
) hea
lth e
duc
atio
n√
BE
HA
(-)
√ D
IET
(-)
□ D
R√
EX
ER
CIS
E (-
)√
GC
(-)
□ M
ED
□ P
SY
√ S
MO
KIN
G (-
)□
SE
LF
Die
ticia
ns, d
iab
etes
nur
ses,
ex
erci
se p
hysi
olog
ists
; lin
k w
orke
rs; p
odia
tris
ts;
psy
chol
ogis
t an
d a
nd n
on-
pro
fess
iona
l lin
k w
orke
r
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s:
uncl
ear;
Dur
atio
n: 1
ses
sion
to
12 m
onth
s
Str
ateg
ies:
face
-to-
face
; b
ookl
et;
Form
at: g
roup
in
terv
entio
n m
etho
d; o
ne-
to-o
ne in
terv
iew
s; m
ixtu
re
of t
he t
wo
met
hod
s; p
urel
y in
tera
ctiv
e p
atie
nt-c
entr
ed
met
hod
; sem
i-st
ruct
ured
d
idac
tic fo
rmat
and
co
mb
inat
ion
of t
he t
wo
app
roac
hes
The
ore
tica
l ap
pro
ach:
S
AT; E
mp
ower
men
t B
ehav
iour
Cha
nge
Mod
el;
Beh
avio
ur C
hang
e Th
eory
; S
CT,
Man
agem
ent
Mod
el
and
the
The
ory
of P
lann
ed
Beh
avio
ur
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↓Hb
A1c
↑ K
now
led
ge
sco
res
− O
ther
out
com
e m
easu
res
Nar
rativ
e p
rese
ntat
ion
and
m
eta-
anal
ysis
Tab
le 3
C
ontin
ued
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
16 Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Firs
t au
tho
r, ye
ar; j
our
nal
Prim
ary
obje
ctiv
es(t
o a
sses
s ef
fect
of
inte
rven
tio
ns o
n….)
Stu
die
s d
etai
ls
Inte
rven
tio
nO
utco
mes
(pri
mar
y o
utco
mes
wer
e in
bo
ld.)
‘−':
No
cha
nge
‘↑':
Incr
ease
‘↓':
Dec
reas
eS
ynth
esis
met
hod
sE
duc
atio
nal c
ont
ent
Pro
vid
erN
umb
er o
f se
ssio
n(s)
, del
iver
y m
od
e, t
ime,
set
ting
Nie
ld, 2
00763
; The
C
ochr
ane
Lib
rary
Met
ablic
con
trol
Num
ber
of
stud
ies:
36
artic
les
(18
tria
ls);
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 146
7 p
artic
ipan
ts
Die
tary
ad
vice
□ B
EH
A√
DIE
T□
DR
□ E
XE
RC
ISE
□ G
C□
ME
D□
PS
Y□
SM
OK
ING
□ S
ELF
Exe
rcis
e p
hysi
olog
ist;
d
ietit
ian;
gro
up fa
cilit
ator
; nu
triti
onis
t; n
urse
ed
ucat
or;
and
phy
sici
an
Num
ber
of
sess
ion:
1–
12;
Tota
l co
ntac
t ho
urs:
20
min
–22
hour
s;D
urat
ion:
11
wee
ks–
6 m
onth
s or
unc
lear
Str
ateg
ies:
face
-to-
face
;Fo
rmat
: gro
up a
nd
ind
ivid
ual;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
− W
eig
ht;
− D
iab
etic
co
mp
licat
ions
;−
Hb
A1c
;−
QoL
;−
Med
icat
ion
use;
− C
ard
iova
scul
ar d
isea
se r
isk
Met
a-an
alys
is
Zab
alet
a, 2
00779
; Brit
ish
Jour
nal o
f Com
mun
ity
Nur
sing
Clin
ical
effe
ctiv
enes
sN
umb
er o
f st
udie
s: 2
1 st
udie
s;Ty
pes
of
stud
ies:
co
ntro
lled
tria
ls;
Tota
l sam
ple
: unc
lear
Str
uctu
red
gro
up d
iab
etes
ed
ucat
ion
√ B
EH
A (-
)√
DIE
T (-
)□
DR
√ E
XE
RC
ISE
(-)
√ G
C (-
)□
ME
D√
PS
Y (-
)□
SM
OK
ING
□ S
ELF
Dia
bet
es n
urse
ed
ucat
or;
phy
sici
an's
ass
ista
nt a
nd
phy
sici
ans
Num
ber
of
sess
ion:
4–
6 or
unc
lear
;To
tal c
ont
act
hour
s:
6–12
hou
rs o
r un
clea
r;D
urat
ion:
1–6
mon
ths
or u
ncle
ar
Str
ateg
ies:
face
-to-
face
;Fo
rmat
: gro
up;
The
ore
tica
l ap
pro
ach:
un
clea
r
Pos
tdis
char
ge−
Hb
A1c
A t
abul
ativ
e sy
nthe
sis
Dea
kin,
200
543; T
he
Coc
hran
e Li
bra
ryC
linic
al, l
ifest
yle
and
p
sych
osoc
ial o
utco
mes
Num
ber
of
stud
ies:
14
pub
licat
ions
, rep
ortin
g 11
stu
die
s;Ty
pes
of
stud
ies:
R
CTs
, and
CC
Ts;
Tota
l sam
ple
: 153
2 p
artic
ipan
ts.
Gro
up-b
ased
ed
ucat
iona
l p
rogr
amm
esD
id n
ot d
escr
ibe
the
cont
ent
of t
he
inte
rven
tion
Hea
lth p
rofe
ssio
nals
, lay
he
alth
ad
viso
rsN
umb
er o
f se
ssio
n:
uncl
ear;
Tota
l co
ntac
t ho
urs:
fr
om 6
to
52 h
ours
;D
urat
ion:
3 h
ours
per
ye
ar fo
r 2
year
s an
d 3
or
4 h
ours
per
yea
r fo
r 4
year
s
Str
ateg
ies:
unc
lear
;Fo
rmat
: gro
up;
The
ore
tica
l ap
pro
ach:
th
e D
iab
etes
Tre
atm
ent
and
Tea
chin
g P
rogr
amm
e (D
TTP
); em
pow
erm
ent
mod
el; a
dul
t le
arni
ng
mod
el, p
ublic
hea
lth
mod
el, H
BM
and
TTM
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge↓M
etab
olic
co
ntro
l; ↑D
iab
etes
kno
wle
dg
e;↑Q
oL;
↑Em
pow
erm
ent/
self-
effic
acy
Sum
mar
ised
sta
tistic
ally
Verm
eire
, 200
580; T
he
Coc
hran
e Li
bra
ryIm
pro
ving
ad
here
nce
to t
reat
men
t re
com
men
dat
ions
Num
ber
of
stud
ies:
21
artic
les;
Typ
es o
f st
udie
s:
RC
Ts; c
ross
-ove
r st
udy;
con
trol
led
tria
l; co
ntro
lled
bef
ore
and
af
ter
stud
ies;
Tota
l sam
ple
: 413
5 p
atie
nts
Inte
rven
tions
tha
t w
ere
aim
ed a
t im
pro
ving
the
ad
here
nce
to t
reat
men
t re
com
men
dat
ions
□ B
EH
A□
DIE
T□
DR
□ E
XE
RC
ISE
√ G
C (-
)√
ME
D (-
)□
PS
Y□
SM
OK
ING
□ S
ELF
Nur
se, p
harm
acis
t an
d o
ther
he
alth
care
pro
fess
iona
lsN
umb
er o
f se
ssio
n:
uncl
ear;
Tota
l co
ntac
t ho
urs:
un
clea
r;D
urat
ion:
unc
lear
Str
ateg
ies:
face
-to-
face
; te
lep
hone
; hom
e vi
sit;
vi
deo
; mai
led
ed
ucat
iona
l m
ater
ials
;Fo
rmat
: unc
lear
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
tdis
char
geD
irec
t in
dic
ato
rs, s
uch
as↓B
lood
glu
cose
leve
l;−
Ind
irect
ind
icat
ors,
suc
h as
p
ill c
ount
s;−
Hea
lth o
utco
mes
A d
escr
iptiv
e re
view
and
su
bgr
oup
met
a-an
alys
is
Gar
y, 2
00349
; Dia
bet
es
Ed
ucat
orB
ody
wei
ght
and
gl
ycae
mic
con
trol
Num
ber
of
stud
ies:
63
RC
Ts;
Typ
es o
f st
udie
s:
RC
Ts;
Tota
l sam
ple
: 272
0 p
atie
nts
Ed
ucat
iona
l and
b
ehav
iour
al c
omp
onen
t in
terv
entio
ns
□ B
EH
A√
DIE
T (-
)□
DR
√ E
XE
RC
ISE
(-)
√ G
C (-
)√
ME
D (-
)□
PS
Y□
SM
OK
ING
□ S
ELF
Nur
se (3
9%);
die
titia
n (2
6%);
phy
sici
an (1
7%);
othe
r or
not
sp
ecifi
ed (2
3%);
othe
r p
rofe
ssio
nal (
13%
); p
sych
olog
ist
(9%
); ex
erci
se
psy
chol
ogis
t (9
%) a
nd h
ealth
ed
ucat
or (4
%)
Num
ber
of
sess
ion:
un
clea
r;To
tal c
ont
act
hour
s:
uncl
ear.
Dur
atio
n: 1
mon
th t
o 19
.2 m
onth
s
Str
ateg
ies:
unc
lear
;Fo
rmat
: unc
lear
;T
heo
reti
cal a
pp
roac
h:
SAT
, con
trac
ting
mod
el
and
pat
ient
em
pow
erm
ent
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge−
Gly
caem
ic c
ont
rol;
− W
eig
htS
uffic
ient
dat
a w
ere
com
bin
ed u
sing
met
a-an
alys
is
Nor
ris, 2
00265
; Dia
bet
es
Car
eTo
tal G
Hb
Num
ber
of
stud
ies:
31
stud
ies
Typ
es o
f st
udie
s:
RC
Ts.
Tota
l sam
ple
: 426
3 p
atie
nts
Sel
f-m
anag
emen
t ed
ucat
ion
√ B
EH
A (-
)√
DIE
T (-
)□
DR
□ E
XE
RC
ISE
□ G
C□
ME
D□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
Die
titia
n; la
y he
alth
care
w
orke
r; n
urse
; phy
sici
an w
ith
team
; sel
f (eg
, com
put
er-
assi
sted
inst
ruct
ion)
and
te
am (n
urse
, die
titia
n, e
tc)
Num
ber
of
sess
ion:
6
(1–3
6);
Tota
l co
ntac
t ho
urs:
9.
2 (1
–28)
hou
rs;
Dur
atio
n: 6
(1.0
–27
) mon
ths
Str
ateg
ies:
onl
ine/
web
-b
ased
; vid
eo; f
ace-
to-
face
; pho
ne c
onta
ct;
Form
at: g
roup
; ind
ivid
ual
and
mix
ed;
The
ore
tica
l ap
pro
ach:
un
clea
r
Inp
atie
nt s
ettin
gs,
pos
t d
isch
arge
, oth
er↓T
ota
l GH
bM
eta-
anal
ysis
and
met
a-re
gres
sion
Nor
ris, 2
00164
; Dia
bet
es
Car
eC
linic
al o
utco
mes
, kn
owle
dge
, met
abol
ic
cont
rol
Num
ber
of
stud
ies:
72
stud
ies
(84
pap
ers)
;Ty
pes
of
stud
ies:
R
CTs
;To
tal s
amp
le: u
ncle
ar
Sel
f-m
anag
emen
t tr
aini
ng
inte
rven
tions
√ B
EH
A (-
)√
DIE
T (-
)□
DR
□ E
XE
RC
ISE
□ G
C□
ME
D□
PS
Y□
SM
OK
ING
√ S
ELF
(-)
CH
Ws;
nur
se; o
r ot
her
heal
thca
re p
rofe
ssio
nals
Num
ber
of
sess
ion:
1–
16;
Tota
l co
ntac
t ho
urs:
~
22 h
ours
;D
urat
ion:
~26
mon
ths
Str
ateg
ies:
onl
ine/
web
-b
ased
; vid
eo (2
%);
face
-to
-fac
e; p
hone
con
tact
;Fo
rmat
: gro
up; i
ndiv
idua
l an
d m
ixed
;T
heo
reti
cal a
pp
roac
h:
SAT
; Fis
hbei
n an
d A
jzen
H
BM
Inp
atie
nt s
ettin
gs,
pos
tdis
char
ge, o
ther
↑Kno
wle
dg
e;↑L
ifest
yle
beh
avio
urs;
−
Psy
cho
log
ical
and
Qo
L o
utco
mes
;↑
Gly
caem
ic c
ont
rol;
− C
ard
iova
scul
ar d
isea
se r
isk
fact
ors
Out
com
es a
re s
umm
aris
ed
in a
qua
litat
ive
fash
ion
Tab
le 3
C
ontin
ued
Con
tinue
d
on May 29, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-016857 on 16 O
ctober 2017. Dow
nloaded from
17Liu X, et al. BMJ Open 2017;7:e016857. doi:10.1136/bmjopen-2017-016857
Open Access
Acute coronary syndromeThe educational content for patients with ACS covered cardiovascular risk factors in eight reviews (53.33%), psychosocial issues in eight reviews (53.33%), smoking cessation in six reviews (40.00%), exercise in five reviews (33.33%), behavioural change in five reviews (33.33%), diet in four reviews (26.67%), self-management in three reviews (20.00%) and medication in one review (6.67%). Two reviews only included smoking cessation and cardio-vascular risk factors. The most common educational providers were nurses and a multidisciplinary team. Six studies31 36 48 51 56 69 (6/15, 40%) described the theoretical approach that underpinned the education intervention.
type 2 diabetes mellitusThe educational content for patients with T2DM included diet in 23 reviews (63.89%), behavioural change in 21 reviews (58.33%), self-management in 20 reviews (55.56%), exercise in 17 reviews (47.22%), glycaemic regulation in 16 reviews (44.45%), medication in 13 reviews (36.11%), psychosocial issues in 9 reviews (25.00%), smoking cessation in 2 reviews (5.56%), cardiovascular risk factors in 2 reviews (5.56%) and DM risks in 1 review (2.78%). The most common providers were dieticians, nurses and a multidisciplinary team. The number of sessions, total contact hours and durations varied. Thirteen reviews30 33 43 49 52–54 60 64 67 75–77 (13/36, 36.11%) described the theoretical approach that under-pinned the education intervention.
effect of interventionsThe outcomes of the included systematic reviews and meta-analyses are summarised in table 4.
Patients with ACsThree major types of health education-related interven-tions were used for patients with ACS: general health education (only included general health information), psychoeducational interventions and secondary preven-tion educational interventions (including strategies to promote a healthy lifestyle, manage medications and reduce cardiovascular complications) as well as inter-net-based interventions.
General health educationThe findings are based on our synthesis of the findings from six systematic reviews.37 48 50 51 59 70 Overall, there were mixed effects of general health education on behavioural change or clinical outcomes in patients with ACS. There was some evidence of a positive effect of general health education on knowledge, behaviour, psychosocial indica-tors, beliefs and risk factor modification, but no effects for key clinical outcomes, such as cholesterol level, hospi-talisation, mortality, MI and revascularisation. The results for health-related quality of life, healthcare utilisation and costs were mixed; several reviews reported a significant change, and other reviews reported no significant change for these outcomes. Only one review focused on tele-phone-based health education. There is some evidence that Fi
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dom
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pro
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+’:
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Tab
le 3
C
ontin
ued
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Table 4 Summary of evidence from quantitative research syntheses
Intervention
Number of systematic reviews/meta-analysis, total participants
First author, year Primary results/findings
Rating the evidence of effectiveness
Patients with acute coronary syndrome
General health education Six/161 997 patients (Goulding et al, 201051 did not give the total sample size)
Ghisi, 201450 Knowledge 91% studies* Some evidence
Behaviour 77%/84%/65% studies*
Psychosocial indicators 43% studies*
Brown, 201337 Mortality
MI
Revascularisations
Hospitalisations
HRQoL
Withdrawals/dropouts
Healthcare utilisation and costs
Brown, 201170 Total mortality
MI
CABG
Hospitalisations
HRQoL 63.6% studies*
Healthcare costs 40% studies*
Withdrawal/dropout
Goulding, 201051
Beliefs 30.08% studies*
Secondary outcomes
Fernandez, 200748
Smoking
Cholesterol level
Multiple risk factor modification
Kotb, 201459 All-cause hospitalisation
All-cause mortality
Smoking cessation
Depression
Systolic blood pressure
Low-density lipoprotein
Anxiety
Psychoeducational interventions
Six/37 883 patients Barth, 201569 Abstinence by self-report or validated
Sufficient evidence
Dickens, 201345 Depression
Aldcroft, 201131 Smoking cessation
Physical activity
Huttunen-Lenz,201056
Prevalent smoking cessation
Continuous smoking cessation
Total mortality
Barth, 200836 Abstinence by self-report or validated
Smoking status
Barth, 200635 Abstinence
Smoking status
Continued
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Intervention
Number of systematic reviews/meta-analysis, total participants
First author, year Primary results/findings
Rating the evidence of effectiveness
Secondary prevention educational interventions (including Internet-based secondary prevention)
Three/25 154 patients Devi, 201544 Mortality Some evidence
Revascularisation
Total cholesterol
HDL cholesterol
Triglycerides
HRQOL
Auer, 200834 All-cause mortality
Readmission rates
Reinfarction rates
Smoking cessation rates
Clark, 200541 Mortality
MI
Quality of life Most of the included studies*
Patients with T2DM
General health education Five/2319 patients (Choi et al, 201640; Loveman et al, 200860; Zabaleta et al, 200779 did not give the total sample size)
Choi, 201640 HbA1c Some evidence
Saffari, 201474 Glycaemic control
Duke, 200946 HbA1c
BP
Knowledge, psychosocial outcomes and smoking habits
No data
Diabetes complications or health service utilisation and cost analysis
No data
Loveman, 200860
Diabetic control outcomes
46.15% studies*
Weight 66.67% studies*
Cholesterol or triglycerides
40.00% studies (+)
Zabaleta, 200779
HbA1c 4.8% studies*
Culturally appropriate health education
Eight/20 622 patients (Ricci-Cabello et al, 201473 and Gucciardi et al, 201352 did not give the total sample size)
Creamer, 201642 HbA1c Some evidence
HRQoL
AEs No AEs
Ricci-Cabello, 201473
HbA1c
Diabetes knowledge 73.3% studies*
Behaviours 75% studies*
Clinical outcomes Fasting blood glucose, HbA1c and BP improved in 71%, 59% and 57% of the studies
Table 4 Continued
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Intervention
Number of systematic reviews/meta-analysis, total participants
First author, year Primary results/findings
Rating the evidence of effectiveness
Attridge, 201433 HbA1c
Knowledge scores
Clinical outcomes
Other outcome measures Showed neutral effects
Gucciardi, 201352
HbA1c levels 3 of 10 studies*
Anthropometrics 3 of 11 studies*
Physical activity One of five studies*
Diet outcomes Two of six studies*
Nam, 201262 HbA1c level
Hawthorne, 201054
HbA1c
Knowledge scores
Khunti, 200858 Knowledge levels Only one study reporting a significant improvement
Biomedical outcomes Only one study reporting a significant improvement
Hawthorne, 200853
HbA1c
Knowledge scores
Other outcome measures
Lifestyle interventions+ behavioural programme
Six/10 440 patients (Huang et al, 201655; Pillay et al, 201571 and Ramadas et al, 201177 did not give the total sample size)
Huang, 201655 HbA1c Some evidence
BMI
LDL-c and HDL-c
Chen, 201539 HbA1c
BMI
SBP
DBP
HDL-c
Terranova, 201572
HbA1c level
Weight
Pillay, 201571 HbA1c levels
BMI
Ramadas, 201177
HbA1c 46.2% studies *
Gary, 200349 Fast blood sugar
Glycohaemoglobin
HbA1
HbA1c
Weight
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Intervention
Number of systematic reviews/meta-analysis, total participants
First author, year Primary results/findings
Rating the evidence of effectiveness
Self-management educational interventions
Nine/19 597 patients (Minet et al, 201061; Fan et al, 200947 and Norris et al, 200164 did not give the total sample size)
Pal, 201467 Cardiovascular risk factors
Sufficient evidence
Cognitive outcomes
Behavioural outcomes Only one study reporting a significant improvement
AEs No AEs
Vugt , 201375 Health behaviours 7 of 13 studies *
Clinical outcomes measures
Nine studies *
Psychological outcomes Nine studies *
Pal , 201368 HbA1c
Depression
Quality of life
Weight
Steinsbekk, 201276
HbA1c
Main lifestyle outcomes
Main psychosocial outcomes
Minet, 201061 Glycaemic control
Fan, 200947 Diabetes knowledge
Overall self-management behaviours
Overall metabolic outcomes
Overall weighted mean effect sizes
Deakin, 200543 Metabolic control (HbA1c)
Fasting blood glucose levels
Weight
Diabetes knowledge
SBP
Diabetes medication
Norris, 200265 Total GHb
Norris, 200164 Knowledge
Self-monitoring of blood glucose
Self-reported dietary habits
Glycaemic control
Therapeutic education One/total sample: unclear Odnoletkova, 201466
Cost-effectiveness Overall high in studies on prediabetes and varied in studies on T2DM
Insufficient evidence
Foot health education One/total sample: unclear Amaeshi32 Diabetes complications Some evidence
Incidence of LEA
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telephone-based health education during cardiac rehabil-itation might improve all-cause hospitalisation, anxiety, depression, smoking cessation and systolic BP, but there is no evidence for improvements in all-cause mortality and reductions in low-density lipoprotein cholesterol.59
Psychoeducational interventionsStrategies for psychoeducational interventions have a specific focus on smoking cessation and depression. The findings are based on synthesis of results from six publi-cations.31 35 36 45 56 69 There is sufficient evidence that psycho-educational programmes are effective at decreasing smoking, achieving smoking abstinence and reducing depression. One review reported no effect on smoking cessation31 or total mortality.56
Secondary prevention educational interventionsThe following statements are based on our synthesis of results from three papers.34 41 44 There is some evidence that secondary prevention educational interventions reduce MI readmission rates and improve quality of life, but the intervention was ineffective in reducing revascularisation, cholesterol levels and improving smoking cessation rates. The results are mixed for mortality and re-infarction rates; two reviews34 41 found positive effects on mortality, while one review44 did not.
Patients with t2DMTen types of health education-related interventions were used for patients with T2DM: culturally appro-priate health education (tailored to the religious beliefs, culture, literacy and linguistics of the geographical area), dietary advice, foot health education, group medical visits (a group education component taught by health profes-sionals), general health education (only included general health information), improving the uptake and mainte-nance of medication regimes (eg, promoting the use of oral hypoglycaemic medications), lifestyle interventions (specific focus on dietary changes and increased physical activity, or stress management), psychoeducational inter-ventions and self-management educational interventions (activities that promote or maintain the behaviours to manage T2DM often based on the National Standards for Diabetes Self-Management Education13) and thera-peutic education (collaborative process needed to modify behaviour and more effectively manage risk factors).
Culturally appropriate health educationFindings are based on our synthesis of results from eight publications.33 42 52–54 58 62 72 Overall, there was some evidence of the effects of culturally appropriate health education on clinical outcomes for T2DM. There was sufficient
Intervention
Number of systematic reviews/meta-analysis, total participants
First author, year Primary results/findings
Rating the evidence of effectiveness
Group medical visit One/2240 patients Burke, 201138 HbA1c Some evidence
BP and DBP
SBP
Cholesterol—LDL
Psychoeducational intervention
One/1431 patients Alam, 200930 HbA1c Some evidence
Psychological status
Interventions aimed at improving adherence to medical treatment recommendations
Three/4907 patients (Lun Gan et al, 201157 did not give the total sample size)
Lun Gan, 201157
Oral hypoglycaemic adherence
Five of seven studies *
Some evidence
Wens et al., 200878
Adherence General conclusions could not be drawn
Vermeire, 200580
HbA1c
Dietary advice One/1467 patients Nield, 200763 Glycaemic control (addition of exercise to dietary advice)
Insufficient evidence to determine
Weight Limited data
Diabetic microvascular and macrovascular diseases
Limited data
*Intervention group is significantly better than control group, for example, ‘91% studies ’ means 91% studies reported a significant better compared with control group.AEs, adverse events; BMI, body mass index; BP, blood pessure; CABG, coronary artery bypass graft surgery; HbA1c, glycated haemoglobin; HRQoL, health related quality of life; LDL-c, low-density lipoprotein cholesterol; LEA, lower extremity amputation; MI, myocardial infarction; RCTs, randomised controlled trials; SBP, systolic blood pressure, DBP, diastolic blood pressure, HDL-c, high density lipoprotein cholesterol; T2DM, type two diabetes mellitus.
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evidence that culturally appropriate health education improves HbA1c reduction and knowledge scores. There is some evidence that physical activity and clinical outcomes (blood glucose, HbA1c, BP) were improved. There were no data relating to adverse events during the intervention and follow-up (such as hypoglycaemic events and mortality), and there was insufficient evidence about improvements in quality of life.
General health educationThe statements are based on our synthesis of results from five papers.40 46 60 74 79 Overall, there were mixed effects of general health education programmes on clin-ical outcomes for T2DM, including HbA1c, cholesterol level and triglyceride level. There was some evidence of the effectiveness of general health education on the manage-ment of glycaemia, weight reduction and some diabetes management outcomes (HbA1c, diabetes complica-tions). There were no data supporting the effectiveness of general health education on reduced health service utilisation, diabetes complications, improved knowledge, psychosocial outcomes or smoking habits.
Lifestyle interventionsThe following statements are based on our synthesis of results from six reviews.39 49 55 71 72 77 Overall, there were mixed effects of the lifestyle interventions on cholesterol
level, HbA1c level and body weight. There is some evidence that lifestyle interventions or behavioural programmes are effective for blood glucose and BP management, but they were ineffective for reductions in HbA1c scores.71 72
Uptake and maintenance of medication regimesThe statements are based on our synthesis of results from three publications.57 78 80 There is some evidence of the effectiveness of increased uptake and maintenance of medication regimes for taking medications for HbA1c regulation including oral hypoglycaemic agents.
Self-Management educational interventionsThe statements are based on our synthesis of results from nine reviews.43 47 61 64 65 67 68 75 76 Overall, there was sufficient evidence of the effects of self-management education inter-ventions on HbA1c level, knowledge, lifestyle outcomes and main psychosocial outcomes. However, there was insufficient evidence of the benefits of this education inter-vention on depression, quality of life and body weight.
Other health education-related interventionsOther health education-related interventions for patients with T2DM included therapeutic education, foot health education, group medical visits, psychoeducational inter-ventions and dietary advice. Statements for all of these
Figure 1 Flow chart of the systematic reviews and meta-analyses selection process.
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interventions are based on our synthesis of results from one review.
There is some evidence that foot health education is effec-tive in reducing the incidence of lower extremity amputa-tion.32 There is some evidence that group medical visits are effective for improving HbA1c and systolic BP manage-ment.38 There is also some evidence that psychoeducational programmes are effective for improving HbA1c regula-tion and psychological status.30
Finally, there is insufficient evidence that dietary advice improves glycaemic and weight management or reduces microvascular and macrovascular diseases.63 There is also insufficient evidence for the cost-effectiveness of therapeutic education for patients with T2DM.66
DIsCussIOnThis umbrella review identified 51 systematic reviews or meta-analyses (15 for ACS and 36 for T2DM) that assessed the outcomes of various aspects (such as the duration, contact hours, educational content, delivery mode) of the delivery of health education-related inter-ventions relevant to high-risk patients with ACS and T2DM. Health education has become an integral part of the management for people with ACS and T2DM. The most appropriate focus of the education provided to patients with ACS and T2DM remains largely undefined in the literature. For example, it remains unknown if the focus should be primarily on cardiovascular risk factors, blood glucose monitoring or all educational components for patients with both conditions.70 76 In addition, should cardiovascular risk factors be the focus during the acute inpatient stay with other educational needs such as the smoking cessation occurring within the primary care or outpatient settings.31 69 70
It remains challenging to determine the specific strategy or format that is the most effective delivery mode for patients with ACS or T2DM. There is very limited evidence to guide clinicians on the duration, contact hours, educational content, delivery mode, total length and setting of health education programme for cardiac patients.50 For patients with DM, one study reported that more successful programme were longer than 6 months (longer duration), consisted of greater than 10 contact sessions (high intensity) and were one-on-one sessions with individualised assessment.82
use of theoretical orientation to develop educational interventionFor patients with ACSUse of theory when designing behavioural change interventions may also influence effectiveness.75 Health education using a cognitive behavioural strategy is most consistently effective in changing maladaptive illness beliefs,51 and studies using more than two behavioural change strategies reported significant differences between the intervention and control groups.31 In one review, a significant change in smoking cessation was not
observed in subgroup analyses between studies that did or did not report using a theory in intervention planning56; however, the authors did not suggest that using a theory in programme planning should be disregarded but reported that examining actual theories or mechanisms underlying health education programmes is required.56 Owing to the considerable overlap between different theories and the detailed description of the theoretical approach in only approximately 40% of the included papers, it is difficult to determine the most effective theoretical approach, but many models can be used with success, such as the health belief model (HBM), social cognitive theory (SCT) and transtheoretical model (TTM).56 67 69 75 Three reviews31 41 44 noted that some included studies used behavioural strat-egies such as goal setting. These strategies were found to be beneficial for patients with coronary heart disease.
For patients with T2DMAlthough the theoretical approach underpinning the health education programme was not always described, 13 of the 36 reviews (36.11%) related to T2DM reported the theoretical approach used in their included studies. The most common theories were SCT (including self-efficacy), empowerment theories (eg, empowerment behaviour change model, self-determination and autonomy motiva-tion theory, middle-range theory of community empower-ment) and TTM. There is evidence that health education interventions based on a theoretical model are likely to be effective.43 Vugt et al suggested that self-care educa-tion programmes should be based on theories and that theory-based self-care interventions are more effective than non-theory-based programmes.75 83 Theories could help to specify the key target health behaviours and behavioural change techniques required to generate the desired outcomes.75 The decision regarding the theory should be based on the aim of the programme and factor for intervention.77 Only one review reported that a theoretical approach underpinning the health educa-tion programme is not necessary for better outcomes.76 Fourteen reviews30 33 40 46 52 57 60 63 64 67 68 73 75 77 reported that goal setting was conducted in the included studies. Goal setting by patients, health professionals or mutually agreed goals were linked to improved patient outcomes.
educational contentFor patients with ACSMost reviews reported that the educational content of the interventions was comprehensive. The most common topics, of the average 3.7 topics per education session, were behavioural change, cardiovascular risk factors management, exercise, psychosocial issues and smoking cessation. An underlying principle of health education for patients with ACS is that knowledge is necessary, but not enough to develop health behaviours and change risk factors.31 50 Age, cognitive factors, environmental factors and social and economic background are also important considerations.50 While interventions using a behavioural programme, telephone-based content or
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self-care are effective for smoking cessation, there was insufficient evidence to support that any type of educa-tional programme was more efficacious than the others.69 Psychoeducation, which is defined as multimodal, educa-tionally based, self-management interventions,31 led to enhanced physical activity levels within 6–12 months when added to cardiac rehabilitation (CR) and was more effective than an exercise programme or health educa-tion alone.31 56 Moreover, psychoeducational interven-tions were more effective for patients with ACS than other types of health education.31 56
For patients with T2DMThe educational content for patients with T2DM focused more on behavioural change, diet, exercise, glycaemic regulation, medication and self-management. Health education that was self-management was more effective for patients with T2DM.40 47 In addition, based on the current evidence, the educational content should be culturally sensitive, especially for patients with T2DM33 42 54; cultur-ally appropriate diabetes health education may have a greater impact on the management of glycaemia and reduce diabetes complications.77 The educational inter-ventions for patients with T2DM focused primarily on HbA1c, lipid levels, quality of life and body weight. HBM and SCT were the most common theories used in the included reviews.
teaching strategies and outcomesFor patients with ACSMost reviews reported that the education was provided using multiple teaching methods and in multiple settings. Nurses and multidisciplinary teams were the most frequent people providing education, and most education programmes were delivered postdischarge. Although face-to-face sessions were the most common delivery format, many education sessions were also deliv-ered by telephone or through individualised counselling. Telephone-based health education appeared to be effec-tive for reducing hospitalisations, systolic BP, smoking rates, depression and anxiety.59 The educational interven-tions for patients with ACS focused primarily on clinical outcomes (hospitalisation and mortality), modifiable risk factors (BP, low-density lipoprotein levels and smoking cessation) and other psychological outcomes (anxiety and depression).
For patients with T2DMMixed health education programmes generally included group sessions combined with educator-facilitated indi-vidual sessions, covering basic knowledge and prob-lem-solving skills. These programmes produced greater benefits and larger effect sizes for blood glucose reduc-tion and knowledge levels in patients with T2DM.47 In contrast, individual education programmes have been reported as more effective in achieving outcomes than group-based education. This may be because educa-tion programmes might be more efficient at addressing
personal needs, with greater participant engagement.73 However, one systematic review reported that individual and group patient education demonstrated similar outcomes among patients with T2DM.46
Although face-to-face sessions were the most common delivery format, many education sessions were also deliv-ered by telephone or individualised counselling. Face-to-face health education programmes were most effective for enhancing blood glucose regulation and knowledge levels, while mixed delivery models (face-to-face, phone contact, online or web-based or video) produced a moderate effect for knowledge levels.47 Another review reported that face-to-face health education programmes generated a greater benefit for metabolic management than those delivered using electronic communication technology.73
Nurses (including diabetes nurses educators), commu-nity workers, dieticians and multidisciplinary teams were the most frequent educators, and most of the education programmes were delivered postdischarge. Some reviews indicated that health education programmes delivered by a group of different educators, with some degree of education reinforcement at additional points of contact, may provide the best results.60 76 However, based on two studies that reported HbA1c at 12 months, it is indi-cated that the outcomes in studies with only a diabetes nurse as the educator also tended to do better than the outcomes in studies with a multidisciplinary team, while the biggest effect was seen when a dietician was the only educator.76 Health education programmes delivered by one person may focus more on the patient's ability than the educational content or quality of the health educa-tion programmes.76 However, no clear conclusion can be drawn whether having one educator delivering the inter-vention is best due to few information.60
Delivery, timing and follow-upFor patients with ACSMost educational sessions were delivered weekly. Few reviews provided information regarding the duration of education interventions; when the duration was reported, it varied from 4 weeks to 48 months. These findings suggest that there is a significant gap in the evidence in relation to the duration, contact hours, educational content, optimal delivery mode, total length and setting of health educa-tion programmes for cardiac patients.50 For patients with ACS, one systematic review that included 7 studies with a total of 536 participants reported that studies with education lasting at least 6 months resulted in the most significant changes in the primary outcomes (such as behavioural change, smoking cessation)31 and that at least 12 months of follow-up is needed to evaluate the impact of telephone-based education.59 Another review reported that the intensity of education programmes is important for efficacy regarding smoking cessation: inter-ventions with a very low intensity and brief interventions do not have a significant effect,69 and programmes for smoking cessation among patients with coronary heart
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disease should last >1 month.69 Most of the reviews were provided for patients with ACS in inpatient settings and then within postdischarge settings, five reviews31 36 45 48 59 did not explicitly state the settings in which the health education-related interventions were provided.
For patients with T2DMEducation sessions were delivered weekly or monthly. Longer health education programmes for T2DM (>6 months) produced larger effects for all primary outcomes (such as HbA1c).47 Health education lasting >3 months resulted in the largest effect size compared with health education of a shorter duration (<3 months).33 For HbA1c, the effect size at 6 months seemed to be signifi-cantly greater than at 3 and 12 months; in other words, the effect size peaked at 6 months.62 In general, health education of a greater intensity (longer duration and more sessions) was more effective for blood glucose reduction and knowledge levels among patients with T2DM.47 74 Compared with health education programmes covering only one topic, programmes that included multiple or mixed educational topics yielded consistently greater benefits in blood glucose reduction and knowl-edge levels.47 In addition, health education programmes combined with specific behavioural change strategies (such as self-care strategies) seemed more effective than other programmes.47 Health education-related
interventions were mainly delivered in hospital settings, primary care settings, diabetes centres or communi-ty-based settings, although six reviews32 39 55 58 67 72 did not explicitly state the delivery settings.
recommendations about health education interventions for patients with ACs and t2DMThese results from included systematic reviews and meta-analyses help to provide recommendations about the content of a health education intervention for patients with ACS and T2DM, requiring further evalua-tion. Future development of educational programmes for patients with ACS and T2DM by healthcare profes-sionals should consider the needs of people with these diseases.37 40 42 70 Based on the results and findings from this umbrella review, recommendations are made in table 5. The acute life-threatening nature of ACS requires that increased emphasis should be placed on cardiovas-cular risk factors in any combined education programme. Both ACS and T2DM have common lifestyle factors such as inactivity and high fat diet requiring modifications.
Overall completeness and applicability of evidenceThis overview potentially provides an estimate with the lowest level of bias for the impact of health education-re-lated interventions for patients with ACS or T2DM and could be regarded as an all-inclusive summary of the
Table 5 Recommendations of health education programmes for patients with ACS and T2DM
Patients with ACS Patients with T2DM Both ACS and T2DM
Theoretical approach SCT, empowerment theories.
HBM; SCT. HBM; SCT and empowerment theories
Behavioural strategies Goal setting Goal setting Goal setting
Educational content Behavioural change (such as smoking cessation), cardiovascular risk factors, exercise, medication and psychosocial issues
Behavioural change, diet, exercise, glycaemic control, medication and self-management
Behavioural change (such as smoking cessation), cardiovascular risk factors, diet, exercise, glycaemic control, medication, psychosocial issues and self- management
Healthcare professionals to deliver Nurse or multidisciplinary team
Multidisciplinary team; dietitian or nurse
Nurse or multidisciplinary team
Teaching approaches Strategies Face to face; telephone or mixed
Face-to-face, written materials; telephone or mixed
Face-to-face, written materials; telephone contact or mixed
Format Individual (one by one) or mixed
Individual (one by one) or mixed
Individual (one by one) or mixed
Delivery timing Contact hours More than 30 min per time per week
More than 30 min per time per week
More than 30 min per time per week
Duration At least 6 months About 6 months At least 6 months
Duration of follow-up At least 12 months At least 12 months At least 12 months
Settings Inpatient and postdischarge settings
Hospital settings and primary care settings
Inpatient and postdischarge settings
ACS, acute coronary syndrome; T2DM, type two diabetes mellitus; SCT, social cognitive theory; HBM, health belief model.
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current evidence base for health education for these patients. While this umbrella review identified evidence for each of the types of health education, there was only a small number of reviews within some categories (such as psychoeducational intervention30 and dietary advice63), and these studies were not very informative. This umbrella review also found no reviews that system-atically analysed varying doses of health education; therefore, could not examine the dose-response effects. There was insufficient information about the evaluated doses (total contact hours and duration of education) to enable comparison of the benefits of differences in the magnitude of the doses across the different research. This umbrella review found no reviews focused on patients with ACS and T2DM; instead, all of the systematic reviews and meta-analyses focused on only one of these diseases.
Quality of the evidenceThe methodological quality of the included systematic reviews and meta-analyses varied. All of the included reviews or meta-analyses were of moderate-to-high meth-odological quality, as assessed using AMSTAR. However, only 30 (58.8%) systematic reviews or meta-analyses were rated as high quality and only 3 (5.9%) systematic reviews or meta-analyses43 53 69 adequately met all 11 AMSTAR criteria. This indicates that some of the reviews included in this umbrella review may have limitations in their design, conduct and/or reporting that could have influ-enced the findings when considered both individually and collectively.32 65
The quality of the primary studies in the included systematic reviews or meta-analyses also varied. The main sources of bias were inadequate reporting of allocation concealment and randomisation processes, as well as lack of outcome blinding.33 42 69 70 This bias in the methodolog-ical quality led to lower quality assessments, which varied by results within each included review. Other reasons for lower methodological quality included heterogeneity in, or inconsistency of, the effect and imprecise findings. Heterogeneity between studies in this umbrella review was described in terms of the intervention, participant characteristics and length of follow-up. Heterogeneity was an important factor indicating the complexity of the health education interventions.56 The variability in the approaches, tools or scales used to measure outcomes between the included studies are likely to introduce some heterogeneity.30 The heterogeneity of the educational interventions seen in the reviews included in this umbrella review may reflect the uncertainty about the optimal strategy for providing health education to patients.37 In addition, 240 studies were included more than once in the included reviews and meta-analyses. However, the overall overlap of studies among reviews and meta-anal-yses-related ACS and T2DM was slight, CCA of 2.6% and 2.1%, respectively.25
This umbrella review is the first synthesis of systematic reviews or meta-analyses to take a broad perspective on health education-related interventions for patients with
ACS or T2DM. Given that health education is complex, the biggest challenge for systematic reviews or meta-anal-yses of health education is accounting for the potential clinical heterogeneity in health education-related inter-ventions (content and delivery approaches) and the population of patients who receive health education. To facilitate comparisons across systematic reviews of health education and the efficient future update of this umbrella review, future reviews or meta-analyses need high-quality research and to standardise their design and reporting, including the reporting of included study characteristics, assessment criteria for risk of bias, outcomes and methods to synthesise evidence synthesis.
COnClusIOnsFor clinicians providing educational interventions to indi-viduals with ACS and T2DM, the results from this review provide a contemporaneous perspective on current evidence on the effectiveness of health education (its content and delivery methods) for this high-risk patient group. The current evidence compiled by this umbrella review supports current international clinical guidelines, that theoretically based education interventions lasting 6 months, delivered in multiple modes (face to face, phone contact, online or web-based or video), and with individualised education delivered weekly, are more likely to generate positive outcomes. This review also supports health education-related interventions provided by health professionals, including nurses and multidisciplinary teams, delivering content including specific clinical factors for ACS and T2DM (BP, glycaemic level and medi-cation), modifiable risk factors (unhealthy diet, inactivity and smoking) and other psychological factors (anxiety and depression). These health education interventions could be delivered postdischarge, such as rehabilitation centres, primary care centres and the community and should be at least 6 months in duration. The effective-ness of these programmes was based on HbA1c levels, knowledge, psychosocial outcomes, readmission rates and smoking status rather than clear evidence of reduced mortality, MI or short-term and long-term complications. In addition, psychoeducational interventions were more effective for patients with ACS, and health education that was culturally appropriate or taught self-management was more effective for patients with T2DM. We also found that longer durations and high-intensity health education provided in an individualised format were more helpful for patients with ACS or T2DM.
The fact that none of the included reviews included patients with both ACS and T2DM indicates a clear need for further rigorous experimental studies with patients with both diseases. Future research that includes these aspects of education are likely to determine the effec-tiveness of educational interventions focusing on cardio-vascular and DM risk factors and complications within patients with ACS and T2DM.
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Author affiliations1Tenth People's Hospital, Tongji University, Shanghai, China2School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Brisbane, QLD, Australia3School of Nursing, Jinggangshan University, Ji'An, China4Melbourne Health, La Trobe University, Melbourne, Victoria, Australia5School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Australia6School of Nursing, Queensland University of Technology (QUT), Brisbane, Australia7Royal Brisbane and Women’s Hospital (RBWH), Australia8Mater Medical Research Institute-University of Queensland (MMRI-UQ), Australia9Faculty of Health Sciences, Australian Catholic University, North Sydney, NSW, Australia10Ingham Institute of Applied Medical Research, Sydney, NSW, Australia
Acknowledgements We would like to thank the authors of the original articles who provided additional unpublished data.
Contributors Study conception and design: XL-L, MJ, KW, C-JW, YS. Data collection: XL-L, YS. Data analysis: XL-L, YS, MJ, KW, C-JW. Manuscript drafts: XL-L, MJ, C-JW, KW, YS.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The lead author is a recipient of an Australian Catholic University Faculty of Health Sciences Tongji University Cotutelle PhD Scholarship.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Open Access This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http:// creativecommons. org/ licenses/ by/ 4. 0/
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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