PB Role Education in Dm2

Timm M, Rodrigues MCS, Machado VB. Adherence to treatment of type 2 diabetes...

English/Portuguese

J Nurs UFPE on line., Recife, 7(4):1204-15, Apr., 2013 1204

DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

ADHERENCE TO TREATMENT OF TYPE 2 DIABETES MELLITUS: A SYSTEMATIC REVIEW OF RANDOMIZED CLINICAL ESSAYS

ADERÊNCIA AO TRATAMENTO DE DIABETES MELLITUS TIPO 2: REVISÃO SISTEMÁTICA DE ENSAIOS CLÍNICOS RANDOMIZADOS

ADHERENCIA AL TRATAMIENTO DE LA DIABETES MELLITUS TIPO 2: UNA REVISIÓN SISTEMÁTICA DE ENSAYOS CLÍNICOS RANDOMIZADOS

Márcia Timm1, Maria Cristina Soares Rodrigues2, Valéria Bertonha Machado3

ABSTRACT

Objective: to review the scientific literature on strategies used to improve adherence to treatment and control of diabetes mellitus type 2 (DM2). Method: a systematic review of literature published between 2007 and 2011, guided by the question: What strategies of health education to improve adherence to treatment of patients with DM2? Were consulted Databases Medical Literature Analysis and Retrieval System Online, ScienceDirect / Elsevier and Cumulative Index to Nursing and Allied Health Literature. It proceeded to the thematic analysis of the selected articles. Results: emerged seven units of analysis: glycosylated hemoglobin, body weight and body mass index, blood pressure, lipid profile, lifestyle, knowledge of DM2; quality of life. Conclusion: Different strategies have positive effect on treatment adherence and control of T2DM.

Descriptors: Diabetes Mellitus Type 2; Patient Compliance; Review.

RESUMO

Objetivo: analisar a produção científica sobre estratégias utilizadas para melhorar a aderência ao tratamento e controle do diabetes mellitus tipo 2 (DM2). Método: revisão sistemática da literatura publicada no período entre 2007 e 2011, norteada pela questão: Que estratégias de educação em saúde melhoram a aderência ao tratamento de pacientes com DM2? Foram consultadas as Bases de dados Medical Literature Analysis and Retrieval System Online, ScienceDirect/Elsevier e Cumulative Index to Nursing and Allied Health Literature. Procedeu-se à análise temática dos artigos selecionados. Resultados: emergiram sete unidades de análise: hemoglobina glicada; peso corporal e índice de massa corpórea; pressão arterial sistêmica; perfil lipídico; estilo de vida; conhecimento acerca da DM2; qualidade de vida. Conclusão: diferentes estratégias apresentam efeito positivo na aderência ao tratamento e controle do DM2. Descritores: Diabetes Mellitus

Tipo 2; Cooperação do Paciente; Revisão.

RESUMEN

Objetivo: revisar la literatura científica sobre las estrategias utilizadas para mejorar la adherencia al tratamiento y el control de la diabetes mellitus tipo 2 (DM2). Método: se realizó una revisión sistemática de la literatura publicada entre 2007 y 2011, guiado por la pregunta: ¿Qué estrategias de educación sanitaria para mejorar la adherencia al tratamiento de los pacientes con DM2? Se consultaron las bases de datos análisis de la literatura médica y Online Retrieval System, ScienceDirect / Elsevier y Cumulative Index de Enfermería y Salud Aliada Literatura. Procedió al análisis temático de los artículos seleccionados. Resultados: emergieron siete unidades de análisis: la hemoglobina glicosilada, el peso corporal y el índice de masa corporal, presión arterial, perfil lipídico, estilo de vida, el conocimiento de la DM2, la calidad de vida. Conclusión: las diferentes estrategias tienen un efecto positivo sobre la adherencia al tratamiento y el

control de la DMT2. Descriptores: Diabetes Mellitus Tipo 2; Cumplimiento Del Paciente; Revisión. 1Nurse Specialist, State Department of Health of the Federal District, Special Student of Master's Degree in Nursing, University of Brasilia/UNB. Brasilia (Federal District), Brazil. E-mail: [email protected]; 2Nurse and Pharmacist, Professor, Graduate / Post-Graduate Program in Nursing, University of Brasilia/PPGENF/UNB. Brasilia (DF), Brazil. E-mail: [email protected]; 3Nurse, PhD, Graduate / Teacher invited of the Post-Graduate Program in Nursing and Post-Graduate in Health Sciences, University of Brasilia/UNB. Brasilia (DF), Brazil. E-mail: [email protected]

SYSTEMATIC REVIEW ARTICLE

mailto:[email protected]




English/Portuguese


DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

Diabetes Mellitus (DM) is related to the risk

of micro and macrovascular damage, as well

as to significant morbidity, reduced life

expectancy and decreased quality of life.¹ It

is an important and growing public health

problem worldwide. The estimate of the

worldwide prevalence of diabetes for 2010

was 6.4%, affecting 285 million adults by 2030

and will reach 7.7%, affecting 439 million.2

In a cohort study of one million U.S. adults

followed for 26 years, diabetes was associated

with nearly twice the risk of all-cause

mortality, i.e., in men or women with

diabetes at 50 years of age was Estimated

death, on average, five years earlier than in

those without the disease. It is important to

note that the risk factors are common to

diabetes and cancer, as in other chronic

diseases, including body mass index (BMI),

physical activity, smoking, alcohol and diet.

Thus, the basis for the treatment and

management of diabetes include measures

regarding diet, pharmacological therapy,

patient education practices and self-care.4

The knowledge in diabetes, especially for

self-care skills such as blood glucose

monitoring, foot care and self-administration

of insulin, need to be assessed regularly.5

Therefore, an aspect of essential importance

in relation to the treatment and control of

chronic diseases is the grip.

Adherence to the medication regimen is

generally defined as the extent to which

patients follow medication prescriptions,

however, reflects health-related behaviors

that go beyond ingest drugs. When education

programs are combined with disease-specific

self-management and treatment adherence

regular, significant improvement is observed

in the behavior of health promotion.7

In Brazil, the Ministry of Health (MoH)

launched in August 2011, the 'Strategic Action

Plan for the Fight of Chronic

Noncommunicable Diseases (NCDs) 2011-2022',

the context in which it appears DM2. This plan

aims to promote the development and

implementation of effective public policies,

integrated, sustainable and evidence-based

prevention and control of NCDs and their risk

factors, and strengthen health services

focused on care to patients with diseases

chronic.8

Therefore, based on the foregoing has

focused on a subject continuously being

investigated through studies based on

evidence, since the thematic adherence to

treatment and control of chronic diseases

such as type 2 diabetes, strategy is crucial to

promote health, as it is part of effective

public policies to relieve the health system,

given the significant impact of the disease,

thus justifying the realization of this study.

Thus, drew up to analyze the scientific

literature on strategies used to improve

adherence to treatment and control of type 2

diabetes mellitus.

To carry out the research we opted for

Systematic Literature Review, in order to

identify and analyze studies that presented

scientific evidence to support decision making

and the improvement of clinical practice in

the thematic focus of the screen.

This study was originated in the discipline

"Safety of Medicines in Health Care" Program

Graduate in Nursing, University of Brasilia,

and in the period from October 2011 to July

2012.

In healthcare practice in a Diabetes Clinic

of the hospital's public health system of the

Federal District has seen the occurrence of

complications related to inadequate

adherence to treatment and control of T2DM.

This fact has motivated the search for

evidence-based knowledge in order to support

actions that can contribute to the

improvement of metabolic control of diabetes

and its attendant complications. Thus, the

realization of the discipline made opportune a

deepening knowledge through literature

review, which is categorized as narrative

(traditional) and systematic.

Systematic reviews (RS) summarize the

results of multiple primary research, using

strategies to reduce bias, is an important tool

to support decision making in health. His

preparation consists of the following steps:

defining the purpose, question formulation,

literature search and selection, assessment

and data analysis, and presentation of

results.9

Thus, in drafting the guiding question of

this study we used the PICO strategy, which is

the acronym for problem or population (P),

Intervention (I), comparison (C) and outcome

(Outcome). In evidence-based practice (EBP)

these four elements are essential in preparing

the question of pesquisa9, thus applied in this

research: Population / Problem: Patients with

type 2 diabetes mellitus; Intervention /

Exposure / Risk factor: Education, health,

education of patients with DM2; comparison /

control: NA; Outcome: Outcome / Results /

Impact: Health education of patients with

T2DM promotes improved treatment

INTRODUCTION

METHOD


English/Portuguese


DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

adherence and, consecutively, the metabolic

control of diabetes. This strategy led to the

delineation of the following question: What

strategies of health education improves

adherence to treatment of individuals with

T2DM?

The RS was conducted with the purpose of

identifying education interventions for type 2

diabetes patients on self-management and

self-monitoring of the disease, aiming to

adherence to medication and lifestyle change,

affecting thereby improving metabolic control

and reducing possible complications.

To ensure the quality of the RS, we used

the protocol Preferred Reporting Items for

Systematic reviews and Meta-Analyses (PRISMA

statement), which is a minimal set of items

for reporting the RS and meta-analyzes based

on evidences.10

Were defined as inclusion criteria for

selection of articles on the study: research

published in English, Portuguese and Spanish

between 2007 and 2011, the original articles

of randomized controlled trials; texts

available in full online; studies involving adult

patients and elderly, and research actions

that addressed health education for self-care

in DM2, aiming to treatment adherence.

The exclusion criteria were: research

involving patients with type 1 diabetes,

studies with a qualitative approach; articles

published before the year 2007; research on

other diseases associated with diabetes,

gestational diabetes and ethnic approach;

editorial, expert opinion, consensus , study

protocols, clinical guidelines, reviews, short

communications, monographs, reviews,

theoretical studies and economic evaluation.

To find and select items with potential

eligibility descriptors were used in Portuguese

and English. Thus, the following descriptors

were used, according to its definition in the

Health Sciences Descriptors (MeSH): diabetes

mellitus type II, health education, medication

adherence, and adherence to drug treatment,

medication adherence, and self-care. For

databases Medical Literature Analysis and

Retrieval System Online (MEDLINE ®) via

PubMed, ScienceDirect / Elsevier and

Cumulative Index to Nursing and Allied Health

Literature (CINAHL ®) were used the

following key words, defined according to

their description in the Medical Subject

Headings Terms ( MeSH): diabetes mellitus

type 2, health education, medication

adherence, adherence, self-care.

The descriptors / keywords defined in the

search for sources of information were placed

with and without quotation marks, using

Boolean connectors AND, OR and NOT.

To synthesize the data of selected articles

used a previously developed instrument

capable of ensuring that all the relevant data

were extracted. Therefore, we adopted the

instrument validated by Ursi,11 which was

completed according to analysis variables of

each selected article, covering five topics:

identification of the article; institution

headquartered in the study, type of

publication, methodological characteristics of

the study; assessment methodological rigor.

The revised instrument of each article was

archived in a database, using the computer

program for Windows ® Word version 2010.

The RS now held synthesizes 16 randomized

clinical trials on the adherence of patients to

treatment in view of improving metabolic

control in T2DM.

Figure 1 shows the flowchart of the search

result in information sources, selection and

inclusion of articles in the original RS,

according to the protocol PRISMA statement.10

The publications are analyzed originating

from 12 countries, three continents of the

world, distributed as follows: 53.0% (n = 9) in

Europe, 29.4% (n = 5) and Asia 17.6% (n = 2)

Latin America. All items are captured in

English language publications. Proceeded to

read the manuscript, followed by the data

extraction and synthesis of instrumento11

analysis variables used in this study. The data

presented in Figure 1 integrates the results of

the papers according to the authors, year of

publication, location and size of the study

sample. It is noteworthy that among the

publications analyzed, seven are treated in

multicenter studies.12-8.

RESULTS


English/Portuguese


DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

Figure1. Flowchart of the search results in the databases consulted, screening, eligibility

and inclusion of articles in the systematic review.

nº Authors Year Location of study Sample size

1 Adolfsson et al.12 2007 Sweden n= 88

2 Yoo et al.19 2007 Korea n= 48

3 Kim 20 2007 Korea n= 51

4 Davies et al.13 2008 England and Scotland n= 762

5 Hornsten et al.14 2008 Sweden n= 104

6 Chen et al.21 2008 China n= 89

7 Torres et al.22 2009 Brazil n= 104

8 Braun et al.15 2009 Germany n= 155

9 Kerssen et al.23 2009 Netherlands n= 25

10 Mollaoglu et al 24 2009 Peru n= 50

11 Heinrich et al.16 2010 Netherlands n= 584

12 Kang et al.25 2010 China n= 56

13 Shi et al.26 2010 China n= 157

14 Rubak et al.17 2011 Denmark n= 628

15 Salinero-Fort et al.18

2011 Spain n= 608

16 Rygg et al.27 2011 Norway n= 146

Figure 2. Distribution of the studies reviewed, according to the authors, year of publication,

place of fulfillment and sample size. Brasília - DF, 2012. Source: originates search

Units of analysis - synthesis extracted

It was found that the main variables

investigated in the studies analyzed were

related to glycated hemoglobin (A1C), blood

pressure (SBP), body weight, body mass index

(BMI) and lipid profile. There were also used

questionnaire of lifestyle, knowledge DM2,

quality of life, treatment satisfaction, and

self-management questionnaire assessing self-

efficacy. Figure 2 shows the distribution of

these variables, with respective periods in

which they were developed.


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DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

nº Variables and analysis realization

1 A1C, IMC, questionnaire to evaluate the knowledge, self-efficacy and satisfaction

with everyday life. Period: 1 year.12

2 A1C, fasting glycaemia, BMI, waist circumference, visceral fat thickness. Period: 9

months.19

3 A1C, BMI, blood glucose. Period: 12 weeks. 20

4 A1C, PAS, body weight and lipid profile, lifestyle, psychosocial measures, depression

score, quality of life. Period: 1 year and 4 months.13

5 A1C, IMC, PAS and lipid profile. Period: 5 years.4

6 A1C, PAS, weight, lipid profile, glucose, renal, eye screening and feet. Period: 1

year.21

7 A1C, IMC, knowledge in DM2, attitudes, self-management and quality of life. Period:

6 months.22

8 A1C, IMC, questionnaire of satisfaction with treatment and knowledge in DM2. Test

of cognitive function and practical skill. Period: 1 year.15

9 A1C, the patient noted the viability of components that have been discussed during

the session. The nurse pointed out the obstacles that she felt were present for the

patient. Period: 6 months.23

10 A1C and lipid profile, glucose and glycosuria. Duration: 8 weeks.24

11 A1C, IMC, PAS, lipid profile, questionnaire of self-management, quality of life and

knowledge in DM2. Period: 2 years.16

12 A1C, IMC, lipid profile, family support, knowledge and attitudes, behavior of self-

care in DM2. Period: 6 months.25

13 Evaluation of self-efficacy in glycemic control. Period: 5 months.26

14 A1C, IMC, PAS, lipid profile, number of visits to health services. Questionnaire for

physical activity, smoking, self-care in DM2. Period: 1 year.17

15 A1C, IMC, PAS and lipid profile. Period: 2 years.18

16 A1C, PAS lipid profile, weight, patient knowledge questionnaire, abilities and

confidence in self-management and questionnaire of quality of life and satisfaction

with treatment. Period: 2 years and 6 months.27

Figure 3. Distribution of variables and analysis presented and study period, according to studies analyzed.

Brasília - DF, 2012. Source: originates search

The studies showed a diversity of

approaches in health education, with

individual or group dynamics, use of teaching

strategies and encouragement to changes in

lifestyle and visit al home, entering the family

in the education process. Besides the analysis

variables, some studies used questionnaires as

instruments for measuring results. Figure 3

presents the strategies of intervention in the

studies analyzed.

nº Intervention

1 Approach to group of five patients. The momentum was of empowerment.12

2 Lifestyle modification (self-efficacy), with 16 meetings of 60 minutes.19

3 Used the cell phone and the internet to send small messages (SMS).20

4 Education using the theory of self-efficacy. 13

5 Reflective discussions groups.14

6 Program 1 - individual counseling. Program 2 - was given a booklet with guidance.21

7 Group meeting, using dynamic exercises, involving theoretical and practical knowledge. The individual approach was made in such a way as to educate them through dialogue.22

8 Program adapted to the demands of older people; It consists of seven meetings lasting 45 min. more intensive Training of practical abilities.15

9 Education program in individual sessions; reinforcement to adherence to medicinal products; change of lifestyle; self-monitoring of blood glucose.23

10 The intervention consisted of three sessions of 40 min., a hospital and two home visits, between 4 and 8 weeks after discharge. Approach on the influences on metabolic control.24

11 Individual query using the motivational interview lasting about 20 minutes each session.16

12 Three sessions of individual education, two days in a group session, a monthly session for 25 to 30 min phone.25

13 Group sessions with one to two hours per week for four weeks.26

14 Individual approach, three 45 min. queries using the motivational interview.17

15 10 individual sessions were about 40 min.18

16 The program was conducted in 15 hours, three sessions with a week interval between each one.27

Figure 4. Interventions in health education, according to studies analyzed. Brasília - DF, 2012. Source:

originates search


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DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

To analyze the results and effectiveness of

the strategies, studies conducted to compare

the intervention and control groups, according

to the variables already described, through

statistical analysis, considering p <0.05 for

statistically significant difference. Figure 4

presents a summary of these results.

nº Results

1 Not obtained significant results of A1C or BMI. There has been significant improvement in knowledge and confidence in DM2 (p=0.012).12

2 There was significant difference in A1C (p=0,003).19

3 There was a significant reduction in A1C (p<0,05).20

4 The A1C did not present significant changes. There was significant reduction in smoking (p = 0.033) and increased physical activity (p = 0.046).13

5 The A1C was significant difference (p < 0.001).14

6 The average A1C level variation during the holiday period rose in both groups and was statistically higher in the program 1 (p = 0.03). PAS was significantly lower in Group 1 program.21

7 The A1C was significant difference (p = 0.002), in addition to the significant improvement in knowledge on DM2 (0,017).22

8 A1C difference was significant (p = 0.02), reduced the incidence of hypoglycemia (p = 0.009) and hyperglycemia (p = 0.01), knowledge improved significantly in both groups, with no difference between them.15

9 The sample size was insufficient to make conclusions regarding the effect of A1C levels program.23

10 There was significant difference in A1C (p < 0.05), total cholesterol, LDL and triglycerides (p<0,05).24

11 There was no significant improvement of the A1C after the intervention. The knowledge score was significantly higher (p<0.05).16

12 There were no significant changes in A1C, however, with significant change in knowledge (p = 0.005).25

13 The glycemic control and self-efficacy were significantly higher (p < 0.05). Has not evaluated the A1C.26

14 Improvement in both groups compared to PAS, blood lipids, A1C and BMI, without significant differences between the groups.17

15 A1C difference was significant (p = 0.01), and PAS (p < 0.01).18

16 There was no significant difference of A1C between groups. There was a significant increase in knowledge in DM2 (p = 0.004), and in the proportion of participants who shied away from fatty food (p = 0.052) and inspection of the feet (p = 0.002).27

Figure 5. Distribution of the results, the second study examined. Brasília - DF, 2012. Source:

originates search

The information found in the 16 studies

analyzed variables presents measurement

results and analysis of statistical significance

in the process of educating patients with DM2,

described below.

Level of glycated hemoglobin (A1C) -

among the 16 articles analyzed, the majority

(n = 15, 93.8%) used the A1C to assess the

effects of educational interventions, but only

in seven (46.6%) was obtained with

statistically significant results for this

variable.14,15,18,19,20,22,24

Weight and BMI-measurement of these

variables were evaluated in thirteen articles

(81.3%), with no statistically significant

difference was obtained regarding the

variable weight.

Systemic Blood Pressure (SBP) - Seven

studies (43.8%) assessed levels of SBP,

significant changes were found in two studies

for this variable after the interventions.

Lipid-nine studies (56.3%) assessed levels of

total cholesterol, triglycerides, low-density

lipoprotein (LDL), high density lipoprotein

(HDL), and only two studies (22.2%) showed

significant results.

Lifestyle-management and self-care

behaviors, such as blood glucose monitoring,

diet, physical activity and smoking were

evaluated by nine of the studies (56.3%), and

only three (33.3%) showed significant results.

Knowledge about the DM2-knowledge about

T2DM was evaluated in six (37.5%) of the

work, with five of these differences

demonstrated statistically significant between

groups for this variable. However, when

analyzing compared with A1C, only one was

statistically significant results.22

Quality of life was assessed by

questionnaire in three of the articles analyzed

(18.8%), and revealed no significant changes.

We highlight the educational approaches

that achieved significant results in A1C, which

used the following strategies: education-based

program of lifestyle changes (diet, exercise,

smoking cessation and medication adherence),

counseling, stress management and support,

using the principles of self-efficacy (using

achievable goals); educational intervention

focusing on personal understanding of the

disease, based on empowerment, reflective

discussions with groups; combination of

theoretical and practical knowledge; program

tailored to the demands of elderly people; as

well as association approach in group and

individual visits.

The main limitations of the studies cited by

the authors of the publications analyzed


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DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

referred to the sample12,14,15,22-5,27 size to the

difficulty of changing strategy and breaking

paradigms, as well as the difficulty of

assessing diabetes education,12 beyond the

short follow-up period.22

The studies analyzed in this RS reinforce

that health education is a useful resource to

face limitations on treatment adherence.

Example is a study that investigated factors

influencing adherence, emphasizing patient

understanding about treatment regimen and

its benefits, side effects, medication costs,

the complexity of the scheme, as well as

emotional well-being of the patient. The

results emphasize the importance of effective

communication between patients and

professionals to overcome barriers to

adherence. 28

The educational intervention focusing on

personal understanding provides an

opportunity to reflect on one's own perception

of the seriousness of the disease and the

possibility of influencing its course. Thus, the

management of people with diabetes requires

multidisciplinary skills and active participation

of paciente.5 Nurses, especially, as an

educator plays an important role in health

promotion, disease prevention and control,

community and general population. 29

Issues highlighted in the studies analyzed

refer to the habits and lifestyle of patients

with DM2, considered of fundamental

importance. The panorama of modern society

that sets the phenomenon of medicalization

gaining importance and medicine is often seen

as the most effective means of obtaining

health, especially in the control of chronic

diseases such as diabetes and hypertension.

Thus, adherence to non-pharmacological

measures, such as regular exercise, changes in

eating patterns and weight control, is a major

challenge to managers of the Unified Health

System (SUS), health teams and people with

chronic diseases, users of the system. In this

sense, one cannot ignore that established

habits for many years are not easy to change,

so health professionals cannot expect

immediate adherence to the plan of care

established.

The multiple attributes specific

psychosocial diabetes, including self-efficacy,

understanding care, distress related to the

disease are strongly associated with self-

management and glycemic control. Thus, the

applicability of an education program is

necessary to consider the psychosocial

complexity of T2DM.32

The ability of the patient manage their

disease depends on the awareness of the need

for self-monitoring, ability to interpret the

results and appropriate response, and these

manifestations influenced by subjective

experience of life and aspects culturais.³³

These facts were evidenced in the results of

RS, in prominently six studies in T2DM

knowledge, obtaining significant improvement

for this variable in five of these, however,

when evaluated together it appears that only

one yielded significant effect on A1C. Thus, it

is observed that education and knowledge

acquisition assist the patient in making

decisions about their choices and attitudes,

however, not in isolation ensure adherence to

treatment and adequate metabolic control.

In a study that focused on the family's

perspective, adherence to treatment of

people with type 2 diabetes was considered

low, with many factors influencing it, as the

subjective perception of the disease,

socioeconomic status, imposition of treatment

regimens, diet, quality of care provided in

health institutions, among outros.34 Thus,

understanding the perception of family is

extremely relevant to contextualized

interventions that are integrated with

therapeutic education of patients with T2DM,

without disregarding the environment in which

he lives and family dynamics.

One of the interventions demonstrated in

this RS, which has achieved significant results,

with improved metabolic values of patients,

using the following strategies: repetition of

topics from education three times, schedule

according to the needs of patients and home

visits. One factor influencing the results was

the willingness of patients and their families

to get directions.24

Another facet evidenced in studies that RS

is that the improvement in adherence to drug

therapy can be achieved through a continuing

education program, by encouraging the

patient on regular monitoring of blood glucose

level, simplifying the regimen, with decreased

number of medications and reduce

treatment35 costs. It is recommended that a

continuing education program is offered for

people with diabetes to achieve and maintain

normal metabolic values.24 O SUS has focused

on these issues by promoting strategies such

as the enrollment of patients in control groups

in T2DM, in which are implemented education

about the disease,36,37 guidelines for self-

monitoring, regular consultations and

provision of medicines and supplies.

Moreover, from the perspective of an

individualized care plan, with reinforcement

approach, we can provide a better result in

DISCUSSION


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DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

short term and maintain control of

glicemia.36 this approach, studies have shown

a more pronounced decrease in A1C in the

first three months intervention, favorable

aspect to controlling the disease.

In the context of individualized approach is

necessary to consider whether gender

differences for the success of men's accession

process to the pursuit of knowledge. One

strategy is to promote health education in

different spaces in which they find

themselves, in order to enable accessibility,

independence and effective tips. 38

In order to measure the results of

operations and compliance with treatment,

most studies have assessed the impact on A1C

as a key measure of the impact of the control

DM.39 This has been demonstrated in other

systematic reviews, where most of the studies

included biomarkers, especially A1C, to

measure the results. Whereas the reference

values of the laboratory A1C is 6.5% currently

A1C may also contribute as a parameter for

the diagnosis of DM.42

The intensity of treatment and differential

treatment may be a key to obtain substantial

effects. Among the methods of individual

education approach used by two of the 16

studies was motivational interviewing. It is an

education strategy for the management of

self-care and behavior change counseling,

basic skills, such as glucose monitoring, insulin

administration, guidance on diabetes and its

complications, characteristics of nutritional

therapy are taught with emphasis on priorities

patient's life and their own internal

motivations, configuring itself as a useful

strategy for adherence to therapy. In

implementing this strategy by studies that RS

was a training team, considering the

necessary capacity to conduct training

properly this method. The motivational

interviewing training included the use of

specific skills, eg, empowerment,

ambivalence, balanced decision schedule, the

visual analog scale, the phase shift and

reflective listening. 17

Other interventions used method of

empowerment and education through dialogue

and education strategies. Finally, a tool that

can be used is the use of computer technology

to assist in the monitoring of compliance with

medication and is considered a reliable

method. Remember the medication through

the cell phone, personal digital assistant and

pillbox with system call can help patients who

have more difficulty following the regimen.6

Thus, the results of the studies presented

highlight the need for education of the

patient with DM2, and demonstrate specific

interventions to improve adherence, observed

in clinical practice.

Despite the ongoing effort to control the

DM2, design and epidemiological data indicate

that the number of individuals affected by the

disease continues to grow worldwide. Public

policies and health professionals have sought

a better way to help individuals with chronic

diseases such as diabetes type 2, to control

their disease, thereby avoiding a devastating

impact on their lives, their families and the

public health system of countries.

Chronic diseases require continuous care

throughout life, which necessitates guidance

for self-care and adherence to treatment. In

this context, we emphasize the fundamental

role of interdisciplinary education and health

promotion.

At RS showed that the measurement of A1C

is an important tool for assessing adherence to

treatment, and may be regarded as an

objective fact of the result of metabolic

control of type 2 diabetes. However, due to

the diversity of educational interventions in

T2DM and psychosocial complexity of the

disease, the evidence found in this review

indicates that the combination of different

strategies has a positive effect on adherence

to treatment and control of T2DM. There

needs to be ongoing evaluation and a critical

look at the forms of education and counseling

on health, identifying through research well

structures if the programs undertaken

currently have efficient results.

Finally, the subject discussed in this review

shows up as an important and ongoing theme

in investigative research agenda in public

health, in order to present an epistemological

corpus that drives decision-making based on

evidence. Despite the limitations pointed out

by the researchers of the articles analyzed,

this RS contributes relevant in order to assist

in the formulation of methodological design of

future studies in order to minimize the

limitations noted by the authors.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740652/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740652/


English/Portuguese


DOI: 10.5205/reuol.3188-26334-1-LE.0704201318 ISSN: 1981-8963

Submission: 2013/02/23 Accepted: 2013/03/08 Publishing: 2013/04/01

Corresponding Address

Márcia Timm Condomínio Jardim Europa II Av. São Francisco / Conj. E1 / casa: 27 Grande Colorado CEP: 73105-904 — Brasília (DF), Brazil

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