Impact of Diabetes Self-Management Education on A1C Levels Among Black/African Americans: A Systematic Review

Abstract

Purpose:

The purpose of this systematic review was to examine the impact of diabetes self-management education (DSME) programs on A1C levels of Black/African American adults with type 2 diabetes.

Methods:

Authors followed PRISMA guidelines and searched PubMed and CINAHL databases to identify articles published from 2000 to date. The primary outcome was A1C and participation in a DSME program among Black/African Americans with diabetes.

Results:

Nine high-quality randomized control trials (RCTs) were included in this review. Sample sizes ranged between 48 and 211. Studies reported Black/African American samples ranging from 23% to 57% (n = 4), 4 reported 100%, and 1 reported 96%. Most (56%) reported a statistically significant decline in A1C levels postprogram, whereas 44% noted insignificant changes. All the studies compared the DSME intervention effect to a control group or another type of diabetes self-management program.

Conclusion:

The results suggest that DSME programs can be effective at lowering A1C levels in Black/African American adults; however, more research with larger sample sizes of Black/African Americans is warranted. The availability of meta-analyses and more RCTs could also further strengthen the external validity of this review. Additionally, future studies focused on A1C outcomes within DSME programs not combined with other self-management interventions among Black/African Americans can advance science regarding the impact of DSME programs among this disparate population.

More than 34.1 million adults in the United States are currently diagnosed with type 2 diabetes, which represents 13% of the nation’s adult population¹ and is ranked the seventh leading cause of death.² The prevalence of diabetes increases with age; those over 65 years have a 26.8% likelihood of receiving the diagnosis.² Such rates are alarming because diabetes can accelerate comorbid health conditions like stroke, kidney failure, cardiovascular problems, loss of eyesight, and vascular complications.^1,3 Thus, providing education about self-management is one strategy for reducing the prevalence and complications associated with diabetes.

The Black/African American population is increasingly being sought to participate in diabetes self-management education (DSME) programs due to their elevated diabetes prevalence rates and higher susceptibility to related complications.³ Black/African American diabetes prevalence rate for confirmed diagnosis in a 2017 to 2020 study was 12.4% compared to 8.9% for their non-Hispanic White counterparts.⁴ In addition, compared to non- Hispanic White adults, Black/African Americans experience 2.5 times higher incidences of diabetes-related hospitalizations and complications,⁵ such as heart failure, kidney disease, nerve damage, and amputations.⁶ Health disparities in diabetes and its related complications among minority groups like the Black/African population can be attributed to individual, social determinants of health, health care system challenges,⁷ and structural racism.⁸ The disparities warrant consideration of effective interventions to reduce racial/ethnic health inequities.⁹ DSME programs among Black/African American adults improve sociocultural interactions that promote reduction of racial/ethnic disparities.¹⁰ It is necessary to evaluate how effective DSME programs are in impacting AIC levels among the Black/African American adults with diabetes.

Black/African American adults with diabetes, and other individuals, can mitigate health outcomes of this disease through self-management, for example, dietary changes, physical activity, pharmacological options, and consistent blood glucose level monitoring.³ One aim of self-management is the regulation of A1C level. A1C is a measure that analyses blood glucose control over the prior 3 months.⁹ DSME can enhance a patient’s management of diabetes by improving blood glucose control⁸ by at least 1%.¹¹ Poor blood glucose control increases an individual’s susceptibility to complications. Prior studies indicate that DSME programs are effective in helping patients lower their A1C levels, make more positive lifestyle choices, improve their overall quality of life, adopt healthier coping habits, and prevent or manage diabetes-related complications.¹¹ Adults who have never received DSME are 4 times more likely to develop health complications related to diabetes compared to those who have received DSME.¹² DSME programs encourage patients to be actively involved in managing the disease by providing information and skills necessary for behavioral adjustments in collaboration with health providers.¹²

Currently there is a gap in the literature, attributable to health disparities, that analyzes the efficacy of DSME programs based on A1C among Black/African American adults. Therefore, the aim of this systematic review is to examine the impact of DSME programs on A1C levels among the Black/African American population.

Methods

The search strategy was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2021 guidelines¹³ (see Figure 1 for an overview of the search process). The electronic search identified studies indexed in PubMed and CINAHL databases in January 2023 using medical search headings (Mesh), Boolean operators, truncations, and synonyms. Tables 1 and 2 include the full search queries and Mesh terms applied to each database. All the search results were exported to EndNote (Version 20.3) reference citation manager.

Figure 1.

PRISMA flow chart showing data extraction process.

Table 1.

PubMed Search Query

(((("diabetes self management education"[Title/Abstract] OR "self management education"[Title/Abstract] OR "DSME"[Title/Abstract] OR diabetes self management support[Title/Abstract]) OR (DSMS[Title/Abstract])) OR (DSME/S[Title/Abstract])) OR (DSMES[Title/Abstract])) AND (("type 2 diabetes"[Title/Abstract] OR "type 2 diabetes mellitus"[Title/Abstract] OR "diabetes"[Title/Abstract] OR "T2DM"[Title/Abstract] OR "type 2 diabetes mellitus"[Title/Abstract] OR "non insulin dependent diabetes mellitus"[Title/Abstract] OR "NIDDM"[Title/Abstract] OR "type 2 diabetes"[Title/Abstract] OR "Diabetes Mellitus"[MeSH Terms:noexp] OR "diabetes mellitus, type 2"[MeSH Terms:noexp])) AND (("HbA1c"[Title/Abstract] OR "A1c"[Title/Abstract] OR "glycemic control"[Title/Abstract] OR "hemoglobin a1c protein human"[Supplementary Concept])) AND (("african american"[Title/Abstract] OR "Black"[Title/Abstract])) AND (("Adult"[Title/Abstract] OR "adults"[Title/Abstract] OR "Adult"[MeSH Terms]))

Table 2.

CINAHL Search Query

AB Diabetes Self management Education OR TI Diabetes Self management Education OR AB Self management Education OR TI Self management Education OR AB DSME OR TI DSME OR TI Diabetes Self management Support OR AB Diabetes Self management Support OR TI DSMS OR AB DSMS OR TI DSMES OR AB DSMES AND MH Diabetes Mellitus OR MH Diabetes Mellitus, Type 2 OR AB Diabetes AND MH Glycemic control OR MH Hemoglobin A, Glycosylated OR TI Glycemic control OR TI Hemoglobin A, Glycosylated OR AB Glycemic control OR AB Hemoglobin A, Glycosylated AND MH Black Persons OR MH African American OR TI Black OR TI African American OR AB Black OR AB African American AND MH adults OR AB adults OR TI adults

The initial search resulted in 39 total articles. No publication date restrictions were included, and articles retrieved were from the year 2000 to 2023. Six duplicate records were removed prior to screening. Records were further screened to only include meta-analysis, randomized control trials (RCTs), and systematic reviews, leading to removal of 20 additional articles. Thus, 13 articles were retained for further review.

Studies included were published in English and reported on a DSME program administered to individuals or groups through the internet, over the phone, or during in-person interactions. The DSME interventions included were delivered as independent interventions or paired with other interventions within a study. The primary variable of interest was to assess changes in A1C after DSME program participation. Studies included contained either an intervention group and a comparison group or a control group. Studies retained comprised only Black/African Americans or mixed populations including Black/African Americans. Studies excluded did not assess A1C as an outcome measure at the end of the study and examined Black/African American populations outside the United States.

Thirteen full text articles were analyzed with the application of the inclusion and exclusion criteria. Four of 13 studies were excluded for the following reasons: did not have data on a DSME,¹⁴ A1C not accessed as an outcome,¹⁵ excluded a postprogram A1C measure,¹⁶ and contained a British population.¹⁷ This exclusion process resulted in 9 articles reviewed for this systematic review.

Results

Study Characteristics, Samples, and Settings

All the studies were RCTs.^18
-26 Studies conducted within the United States with participants who had a diagnosis of type 2 diabetes were selected. Table 3 provides an overview of the sample characteristics, outcomes, and overall quality of each included study. Studies had participants across a range of settings that included community health centers,^19,21,22 academic medical centers,^24,25 home-based settings,^18,26 a community clinic,²² and the emergency department.²⁰

Table 3.

Literature Review of Studies and Quality Assessment

Author(s) AND Year	Sample size	Setting	Study design	Population & location	Intervention vs control	Duration (mo)	Intervention	Control	A1C mean change	A1C change significance or P < .05^a	Attrition rate	Jadad score
Krousel-Wood et al¹⁸ (2008)	76	Home-based & clinical settings	RCT	47% Black New Orleans, LA	I: 37; C: 39	3	DSME and home-based exercise program	DSME	I: –0.7, C: –0.7	Not Significant (P value not provided)	19%	3
Lynch et al²² (2019)	211	Community clinics	RCT	100% African Americans Chicago, IL	I: 106; C: 105	18	Lifestyle improvement through food and exercise + DSME	Group-based DSME	I: –0.58, C: –0.33	Significant I: P < .01, C: P = .048	6%	4
Miller et al²⁵ (2012)	52	Ohio State University Medical Center	RCT	23% African American Columbus, OH	I: 27; C: 25	3	Mindfulness-based eating awareness training	Smart Choices: a group-based DSME	I: –0.83, C: –0.67	Significant I: P < .001, C: P = .008	24%	3
Magee et al²⁰ (2015)	101	ED	RCT	96% Black Washington, DC	I: 51; C: 50	1	Usual ED care + survival skills DSME	Usual ED care	I: –1.3, C: –0.4	Significant I: P < .001, C: P = .12	20%	3
Presley et al²³ (2020)	97	Community health care system	RCT	100% African Americans Birmingham, AL	I: 62; C: 35	6	Community-based DSME + 6 mo of mHealth-enhanced peer support, including 12 weekly phone calls, then 3 monthly calls	Community-based DSME	I: 0.5, C: 0.7	Not significant P = .21 (only 1 P value provided)	19%	2
Rovner et al²⁶ (2020)	101	Home treatment sessions	RCT	100% African Americans Philadelphia, PA	I: 50; C: 51	12	Occupational therapy behavioral intervention	DSME	I: –0.91, C: –0.54	Significant I: P = .001, C: P = .048	18%	4
Spencer et al¹⁹ (2011)	164	Community or local health system	RCT	57% African Americans Detroit, MI	I: 72; C: 92	6	REACH Detroit community activities + community health worker-led DSME	REACH Detroit community activities + 6-mo delayed DSME	I: –0.8, C: 0.0	Significant I: P < .01	18%	4
Tang et al²¹ (2015)	106	Community center	RCT	100% African Americans Ann Arbor, MI	I: 54; C: 52	15	3-mo DSME followed by 12 mo of peer-led diabetes self-management support	3-mo DSME	I: 5.5, C: 1.1	Not significant I: P = .10, C: P = .71	40%	5
Williams et al²⁴ (2023)	48	Academic medical center location	RCT	40% Black Columbus, OH	I: 26; C: 22	12	Share Our Strength’s Cooking Matters program + DSMES	Intervention after an 18-wk wait period	I or C: 0.27	Not significant P = .292	10%	2

Statistical significance was P = .05.

Abbreviations: C, control; DSME, diabetes self-management education; DSMES, diabetes self-management education and support; ED, Emergency department; I, intervention; RCT, randomized control trial; REACH, Racial and Ethnic Approaches to Community Health.

Studies included had a total of 956 adult participants (sample sizes ranged from 48 to 211 per study). Four studies reported 100%^21
-23,26 Black/African American representation, 1 study reported 96%,²⁰ and the other 4 studies reported a range from 23% to 57%.^18,19,24,25 Attrition rates ranged between 6%²² and 40%²¹ for all the sudies. The duration of each study ranged from 3 months or less,^18,20,25 6 months,^19,23 or between 12 and 18 months.^21,22,24,26 A1C was the primary outcome investigated in all the studies. However, 3 studies^18,20,25 also investigated other variables as additional primary outcomes.

Research Quality

The quality of the RCTs was assessed methodically using the Jadad scale, an instrument developed and validated by Jadad et al²⁷ and evaluated in other studies.^28-30 Quality assessment is important in identifying any internal factors of a study that may affect its generalizability to other settings.³¹ A score was assigned to each study (see column in Table 3), with each point given or excluded (for a maximum possible score of 5) based on the following criteria: presence of randomization, appropriateness of the randomization process, presence of blinding, appropriateness of the blinding method used, and if the number and reasons for participant withdrawals were provided. Only 1 study received a score of 5,²¹ reflecting the need to improve the quality of studies in this area. Randomization was present in all the studies, but 1 study²³ did not provide enough details to determine if the method used was appropriate. Blinding or masking was reported in 4 out of the 9 studies.^19,21,22,26 Two studies did not provide reasons for participant withdrawals, which resulted in a lower Jadad score.^24,26 The average score for all the 9 studies was 3.3. To further promote rigor in assessing the research quality, a bias assessment was conducted.

Bias Assessment

Cochrane’s collaboration tool assessed the risk for bias in the studies.³² Any biases present in a study interfere with its true findings and ultimately threaten its internal/external validity.³¹ Biases can emerge from a study’s process of selecting participants, delivering the interventions, or the overall engagement of participants in the study.³¹ The Cochrane bias tool was selected because it is the most recommended tool for assessing the risk of bias in RCTs,³³ which improves the accuracy of reported findings in clinical trials.³⁴ The tool is scored based on assessment judgments made for the different domains of bias for each study.³⁴ Risk of bias assessment judgments for the included studies were separately completed for each domain as shown in Figures 2 and 3. The percentile score for each domain is generated by the tool, based on the selected risk of bias assignment for each study, with scores ranging from 0% to 100%.³² Risk of bias assignment as “high risk,” “low risk,” or “some concerns” covered 5 domains of bias arising from randomization process, deviations from planned interventions, missing outcome data, outcome measurement, and selection of reported results.³² All the studies were least biased in deviations from planned interventions and in selection of reported results. The highest bias level was evident in the missing outcome data domain due to varying attrition rates within the studies. The overall risk of bias among the 5 domains assessed for all the studies leaned toward “some concerns” (60%) and “low risk” (40%).

Figure 2.

Risk of bias assessment using the Cochrane assessment tool (summary with domains).

Figure 3.

Risk of bias assessment using the Cochrane assessment tool (bar graph).

Key Findings

Five studies^{19,20,22,25,26} reported statistically significant declines in A1C levels postintervention in DSME programs, and 4 studies reported insignificant changes in A1C levels after participation in a DSME program.^18,21,23,24 A statistical alpha level of P < .05 was used to interpret significant findings. All the studies compared the intervention effect of the DSME program to a control group or another type of diabetes self-management intervention. Other diabetes self-management programs used for comparisons to the DSME included home-based exercise programs,¹⁸ lifestyle improvement through food and exercise,²² mindfulness-based eating awareness training,²⁵ mHealth-enhanced peer support,²³ occupational therapy behavioral intervention,²⁶ REACH Detroit community activities,¹⁹ and Share Our Strength’s Cooking Matters program.²⁴

Discussion

This systematic review investigated the effectiveness of DSME programs in impacting A1C levels among Black/African American adults with diabetes. The overall aim of the review was to gain insight about this topic and provide recommendations for future interventions among this population. The results indicate that DSME programs significantly reduce A1C levels among Black/African American adults with diabetes. These findings provide some evidence of the efficacy of DSME programs in lowering A1C levels among Black/African American adults with diabetes.

Other studies have also yielded comparable results of significant reductions in A1C levels of participants engaged in DSME programs.^35
-39 These other studies^35
-39 examined A1C levels among populations that were not primarily Black/African American. Hildebrand et al’s³⁷ study, conducted among an adult Latino population diagnosed with type 2 diabetes, was a systematic review and meta-analysis. In addition to the significant A1C findings, the study’s results noted greater A1C decline among programs that were 6 months long and enrolled participants whose baseline A1C levels were above 8%.³⁷ Another study by Yuan et al,³⁵ which also reported decrease in A1C, was a RCT conducted for 3 months among a Chinese population. The 76 adults were randomly assigned to receive the DSME intervention (n = 36) or standard medical advice (n = 40).³⁵ Although this study included a different population and had a shorter duration, it was equally effective at lowering A1C levels.

Another study by Celik et al,³⁶ which reported significant decrease in A1C levels, was a systematic review among English-speaking participants in London. The study investigated and validated the efficacy of DSME programs primarily delivered through online platforms.³⁶ A fourth study by Azmiardi et al³⁸ was a systematic review and meta-analysis of studies conducted among populations in 8 countries. The DSME program paired with peer support was effective at lowering A1C levels, but also, statistically significant effects were identified among studies that enrolled participants with baseline A1C levels below 8.5%, had a sample size less than 100, and were 6 months or longer in duration.³⁸ An important contribution of this study was that it provided some design recommendations. Bekele and colleagues³⁹ conducted a systematic review and meta-analysis and reported a significant reduction in A1C among studies that were less than 4 months long.³⁹ Overall, these studies report significantly favorable effects of DSME programs on A1C among different populations. These studies further validate the efficacy of DSME programs and provide additional recommendations for program durations and participant sample characteristics that strengthen replication of A1C outcomes.

Although these current findings indicate positive effects of DSME programs on A1C levels, it is also important to acknowledge that 4 of the 9 studies^18,21,23,24 reviewed reported insignificant changes in A1C levels after participation in the DSME program. Insignificant effects of DSME programs on A1C levels have also been noted in other studies. Cunningham et al’s³ study, a systematic review and meta-analysis, investigating the impact of DSME programs on A1C among Black/African Americans found no statistically significant effects. Another RCT study by Rygg et al⁴⁰ conducted in Norway reported no changes in A1C levels of its 146 participants after a yearlong DSME program. Despite no statistically significant changes in A1C levels, the DSME program in Rygg et al⁴⁰ was credited with preventing participants’ A1C levels from increasing beyond their baseline levels. This perspective does support the current authors’ review of findings about DSME programs and the impact on AIC levels, especially in instances when A1C levels either decreased or are maintained with interventions. However, the perspective does not provide a strong basis for the continued implementation of DSME programs that aim to decrease A1C levels among Black/African American populations and are not successful in achieving lower levels.

Limitations

One limitation of this review is the smaller sample sizes of Black/African American participants. Despite the rigorous search strategy within the selected databases, only 9 RCTs met the inclusion criteria. The availability of meta-analyses and more RCTs with larger Black/African American sample sizes could further strengthen the external validity of this review. A second limitation was smaller sample sizes or short duration of DSME program interventions that may have affected the ability to detect significant effects in A1C levels. A third limitation was the evaluation of A1C outcomes within DSME programs that were combined with additional self-management interventions. Such variations of DSME program pairings make it challenging to identify an effective program design in this population and replicate the findings for additional research. A fourth limitation is that not all the studies reported A1C outcomes by race or subgroup analyses. The findings of this review yield insight into areas warranting improvement to increase the effectiveness of DSME programs on A1C levels among Black/African American adults with diabetes. Impactful DSME programs can help lower diabetes prevalence and complication rates and bridge health iniquities among the Black/African American population.

Conclusion

Five out of 9 studies in this review reported a significant decline in A1C levels after participation in a DSME program, thus supporting that DSME programs can help reduce AIC levels among Black/African Americans with diabetes. However, more RCTs and meta-analyses with larger Black/African American sample sizes are needed to further investigate and strengthen these findings. Furthermore, future DSME programs not combined with additional self-management interventions among Black/African Americans can help guide other researchers on the impact level of DSME programs on A1C levels in this population. DSME programs support better self-management of diabetes and its complications and reduce health disparities among the Black/African American population.

Footnotes

Acknowledgements

The authors would like to thank the University of Kentucky for providing electronic resources and platforms to facilitate this review. The content is solely the responsibility of the authors.

Declaration of Conflicting Interests

The authors have no conflicts of interest to report.

ORCID iD

Hilda M. Okeyo

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