Monica SørensenI; Henny-Kristine Korsmo-HaugenI; Marina MagginiII; Silke KuskeIII; Andrea IcksIII; Ulrike RotheIV; Jaana LindströmV; Jelka ZaletelVI; on behalf of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)
IThe Norwegian Directorate of Health, Oslo, Norway
IICentro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy
IIIHeinrich Heine University, German Diabetes Center, Düsseldorf, Germany
IVDresden University of Technology, Dresden, Germany
VNational Institute for Health and Welfare, Helsinki, Finland
VINational Institute of Public Health, Ljubliana, Slovenia
AIM. To present the most common quality criteria in health promotion interventions in type 2 diabetes mellitus (T2DM).
METHODS. A systematic literature search was conducted to identify review articles, health technology assessments and policy reports of evaluated health promotion interventions in T2DM. A descriptive analysis of study characteristics and evaluation criteria are presented.
RESULTS. Seven studies met the inclusion criteria. The findings indicate that the most common health promotion interventions used in T2DM are initiatives targeting health care professionals. The main ambition of the programs was to increase the collaboration between health care professionals and patients, and between health care centres, program managers and community stakeholders.
CONCLUSIONS. This investigation extends our knowledge of the most common health promotion interventions in T2DM and which structure, process and outcome measurements that are reported in such interventions. Future research could usefully explore how the effectiveness of multicomponent and complex interventions may be evaluated and extend the association of these factors into other settings and in relation to other lifestyle related chronic diseases.
Key words: health promotion, diabetes mellitus, type 2, quality indicators
Type 2 diabetes mellitus (T2DM) constitute a major and growing burden on health care systems globally . People with chronic conditions are their own principal caregivers and health care professionals, regardless of degree of specialization, ought to act as consultants supporting patients in their self-management role. Diabetes is a social problem that demands for re-education and reorientation of health care professionals and health care settings, readiness from policy makers and relevant stakeholders, as well as robust national policies and strategies developed, owned and monitored by national authorities.
Health promotion, as defined by the Ottawa Charter for Health Promotion in 1986 , refers to the process of "enabling people to increase control over, and to improve, their health". In the 4th International Conference on Health Promotion in 1997, The Jakarta Declaration was set out, and gave the following five key prerequisites of success for health promotion strategies :
build healthy public policy;
create supportive environments;
strengthen community action;
develop personal skills;
reorient health services.
Health promotion strategies in T2DM may consist of one or a combination of programs targeting health-and dietary education, self-management, psychological support, or constitute initiatives targeting health care professionals or community stakeholders, and in addition have an intention to increase partnership across sectors. Also, patient empowerment is an upmost important and central topic in health promotion interventions. The EU-funded EMPHATiE project  defines patient empowerment as follows: […patients to become "co-managers" of their condition in partnership with health professionals; and to develop self-confidence, self-esteem and coping skills to manage the physical, emotional and social impacts of illness in everyday life].
Mechanisms that explain success or failure of such initiatives remains mainly unclear or unknown, as there exists no consensus or validated framework to evaluate the structure, process and outcome indicators among complex interventions. Even more so, patient perspectives, experiences, values and preferences are seldom taken into account when it comes to evaluation, as anticipated in health promotion interventions.
The overall aim of the systematic literature search was to bring attention to the most commonly used health promotion interventions in T2DM, and to provide a deeper understanding of the scope of such interventions and how they are evaluated in order to present quality indicators of good practices.
A search strategy was developed and conducted to identify studies that assessed health promotion interventions in patients with T2DM, by a librarian at the Norwegian Directorate of Health. The electronic databases searched were: MEDLINE (Ovid), EMBASE, PubMed, Cochrane Database of Systematic Reviews (CDSR), DARE and NHS Economic Evaluation Database (EED). Various combinations of the following search terms and Medical Subject Headings (MeSHs) were used:
for type 2 diabetes: Diabetes Mellitus, Type 2 (MeSH) OR Diabetes Mellitus, Maturity Onset (MeSH) OR Diabetes Mellitus, Adult Onset OR Diabetes Mellitus, Slow Onset OR Diabetes Mellitus, Stable OR Diabetes Mellitus, Non Insulin OR DM2 OR NIDDM OR Non Insulin Dependent Diabetes Mellitus OR Non Insulin Dependent Diabetes Mellitus Type 2 OR Diabetes Insulin Independent OR Mellitus OR Chronic Disease (MeSH) OR Chronic illness OR Chronic Ill OR Chronic Sick;
for health promotion intervention: Benchmarking (MeSH) OR Benchmarking Practice OR Benchmarking Analysis OR Health Promotion (MeSH) OR Health Promotion Model OR Health Campaign (MeSH) OR Program Evaluation (MeSH) OR Program Model OR Program Method OR Program Measure OR Program Analyses OR Program Question OR Program Review OR Program Effectiveness OR Program Efficacy OR Program Sustainability OR Program Appropriateness OR Program Feasibility OR Wellness Program.
All articles published in English, Norwegian, Swedish and Danish from January, 2010 through March, 2015, with at least one search term from each of the categories mentioned in bullet points above, were included for consideration. No additional sources i.e. cross-matching reference lists and forward citation search were sought. A full record of the systematic literature search can be found in Appendix I (available online as Supplementary Material at www.iss.it/anna).
Study selection and eligibility criteria
Qualitative, quantitative or mixed method systematic reviews, meta-analyses, guidelines, review articles, narrative syntheses, HTAs and policy statements that evaluated non-pharmacological health promotion interventions in patients with T2DM were considered eligible, as well as the following inclusion criteria:
participants: studies where the majority, or all of the patients had T2DM; age > 18 years;
types of interventions: non-pharmacological health promotion interventions, initiatives, strategies, programs, activities and projects that could be defined as health promotion according to the Ottawa Charter for Health Promotion. Interventions were considered eligible for inclusion if they consisted of one or a combination of the following components, provided individually, in a group, or by telemedicine: Dietary and/or physical activity education; self-management education; psychological and behavioural support; restructuring and/or re-education of health care professionals; initiatives to increase the quality of health professionals' care or health care systems; new and intelligent use of clinical information systems; regular publication and revision of local health promotion strategies and quality indicators; increased usage of community resources and cooperation to promote health where patients live; and interventions that aim for an increased partnership across local sectors to promote health;
setting: studies considered relevant were conducted in Europe, North America or Oceania, in primary and/or secondary care, within local communities − urban or districts − or as part of national strategies. Studies had to define a practice that incorporated environmental, organizational, social, economical, educational, individual, and/or local context of the target population.
Exclusion criteria entailed: unpublished articles and conference abstracts; studies based on a pay-forperformance, computational- and model structure; studies evaluating preventions strategies, surgical and pharmacological interventions; experimental studies and epidemiological investigations; studies where participants had personality disorders, and studies that did not report evaluation- or quality criteria of the intervention.
Two reviewers independently assessed titles and abstracts of all the relevant publications and made decisions on inclusion. Discrepancy in opinion was discussed and no third party was required in the process of study selection. Full-texts were sought and read for all articles that met the inclusion criteria (except one study that was unavailable in full text ). In the case of duplicate reports related to the same study, both articles were evaluated to extract the maximum amount of information.
Data was extracted by one author, and checked for accuracy by a second investigator. For each article design, authors and year of publication, as well as type of intervention, evaluation method and reported quality criteria were extracted.
Of the 313 articles screened by title and abstract, seven were identified as being relevant for inclusion [5-11]. The reasons for excluding 306 studies fell within four main criteria as outlined in Figure 1. Two hundred and seventy-three publications were immediately rejected as they did not address health promotion interventions in T2DM. Additional 19 studies were excluded as they did not meet our inclusion criteria on study design, patient population and geographical location [12-30].
Table 1presents the characteristics of the included studies and provides a detailed description of the health promotion interventions as described by the study authors. The seven final studies were published between 2010 and 2015 and consisted mainly of articles performing a review of the literature. Initiatives from the included articles target and evaluate health care professional reorganization and education, collaborative partnerships, communities, policymakers, patients, and technological applications and platforms. A range of approaches to reach quality improvement were reported, such as outreach cardiac specialist services, utilisation of multidisciplinary teams, education of health care professionals and evaluation of technology applications.
The most frequent type of health promotion intervention detected was initiatives that targeted health care professionals. In fact, in five out of seven studies health care professionals were the only, or one of several target groups [7-11]. The health promotion interventions targeting health care professionals were delivered with an emphasis on multidisciplinary teams , improvement models to change practice , projects aiming to increase health care professionals adherence to clinical practice guidelines , workforce development , quality improvement programmes in primary care  and education of health care professionals .
Mainly, structure and process indicators were reported in the evaluation of the health promotion interventions. The structure and process indicators encompassed use, or change in use of: health care services [9-11]; screening [9, 10]; clinical variables ; medication use ; and provision of the care- or programme processes [6, 8, 10, 11]. Only one eligible study emphasized patients' clinical outcome variables as an evaluation indicator .
Overall, the main ambition of the programs was to increase the collaboration between health care professionals and patients, and between health care centres and program managers and community stakeholders. This was reported as community engagement and self-governance by culturally adjusted disease self-management education , continuous quality improvement of health centres system efficiency and system development through increased dialog with health care staff and program managers , or increased partnership learning collaborative to improve chronic disease management , development of patient feedback possibilities and tools for shared decision support , and reorganization of services and work force development . Lastly, use of technological applications and platforms were suggested to improve prevention, management, monitoring, and quality of communication between patients with lifestyle-related chronic diseases and practitioners .
Health promotion in T2DM consists of several interrelated, multicomponent and complex interventions targeting patients, health care professionals and policy makers. Our results confirm that the most common health promotion intervention in T2DM is initiatives targeting health care professionals. Evaluation methods to assess the population based impact of these programs in the world of busy, understaffed public health clinics, diverse health systems, or community settings are limited. Applicable quality indicators of health promotion initiatives pay attention to the representativeness of settings and context of the target population, covering among others, socio-economy, health literacy, different levels of disease determinants, organization of health care, and the economical promoters in the community. By taking into consideration these variables and limitations, the external validity of interventions could be increased and give solid advises to policy makers and program initiators when developing strategies to improve community or national health.
Table 1 shows the evaluation criteria and indicators reported from the selected studies. These characteristics must be interpreted with caution, as they by no means give the full picture of indicators used in health promotion interventions. One of the limitations of this investigation is that we restricted our search to review articles in order to cover our primary goal of getting a brief overview of initiatives that target not only the patients, but also engage health care professionals, policy makers and local society. An implication of this is that the generalisability of findings may be restricted to very specific populations and regional settings.
Medical and economical effects of health promotion initiatives are commonly reported in observational studies, however incorporation of primary research was beyond the scope for this article. Well written examples of the possible impact of a quality improvement project and the lessons learned from implementing quality indicators in primary care are reported by Mata-Cases et al  and Bodicoat et al , who presents the results from a fifteen year continuous quality improvement program in type 2 diabetes mellitus in primary care in Catalonia, Spain (the GEDAPS program).
On the other hand, strict inclusion- and exclusion criteria are strengths of this work. Interventions targeting people with diabetes with the intention to increase quality of care lacking the health promotion perspective of defining and attending local context, were dismissed.
In conclusion, this literature search identified the most common health promotion interventions in diabetes reported in review articles and policy statements. More research on the long term effectiveness of complex intervention strategies is needed, and will merit rigorous evaluation to aid implementation in other contexts. Making necessary local adjustments considering an intervention's overall public health impact and take local decisions about its own challenges and resources, communities may aim for increased effectiveness of their health care services.
This publication arises from the Joint Action CHRODIS, which has received funding from the European Union, in the framework of the Health Programme (2008-2013). Sole responsibility lies with the authors and the Consumers, Health, Agriculture and Food Executive Agency is not responsible for any use that may be made of the information contained therein. We would like to thank Astrid Merete Nøstberg at the Norwegian Directorate of health for performing the systematic literature search.
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Address for correspondence:
Helsedirektoratet, Pb 7000 St. Olavs plass
0130 Oslo, Norway.
Submitted on invitation.
Accepted on 9 June 2015.
Conflict of interest statement: There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.
The supplementary material is available in pdf: [Supplementary material]