Use the “DPI Proposal Template” and the Develop a Literature Review assignment from DNP-820 to develop a draft of a literature review (Chapter 2) for your DPI Project Proposal. The literature review (Chapter 2) is required to be a minimum of 30 pages. You have already completed some of this review in previous courses. No less than 85% of the articles must have been published in the past 5 years. Articles selected must further provide strong, relatable support for the proposal.
Use the following guidelines to create your draft Literature Review (Chapter 2):
In type 2 diabetes mellitus patients ages 18 and above, can education on medication adherence and lifestyle modifications on their routine office visits improve the fasting blood glucose?
1. Using the PICOT question format, identify at least three empirical or scholarly articles (25 articles total) related to the theme in the PICOT question.
2. Use the “Research Article Chart” resource located in the Topic Materials as a guide to: (a) analyze and synthesize the literature into your paper, (b) state the article title, (c) identify the author, (d) state the research question(s), (e) identify the research sample, (f) explain the research methodology, (g) identify the limitations in the study, (h) provide the research findings of the study, and (i) identify the opportunities for practice implementation. For scholarly, nonempirical articles, state the article title and author, and provide a brief contextual summary of the article.
3. Identify at least three subthemes that relate to each theme (six subthemes total).
4. Identify at least three empirical or scholarly articles related to each subtheme (18 articles total). At least one article must demonstrate a quantitative methodology.
5. Write statements that synthesize the three studies for each subtheme based on the information you stated above. You will write six synthesis statements.
Improvement of Fasting Blood Glucose in Type 2 Diabetes Mellitus
Introduction and Background
The project’s PICOT question is the main focus of this review, and it is as follows: In type 2 diabetes mellitus patients aged 18 and above, can education on medication adherence and lifestyle modifications on their routine office visits improve the fasting blood glucose?
The purpose of the project is to determine whether patient education on medication adherence and lifestyle modifications during a patient’s routine visits could improve their fasting blood glucose. Fasting blood glucose (FBG) is the measure of blood glucose levels after eight hours without food and drinks other than water. The parameter is used as a test for diabetes. Adherence to antidiabetic medications and lifestyle modifications could affect FBG as its level is determined by the body’s ability to produce and utilize insulin, the type of the meal, and size of the meal taken last. Patient education provides patients with the right information and strategies to improve their adherence and lifestyle modifications towards the improvement of their FBG. As such, the review focused on studies that have been conducted previously concerning the impact of patient education on medication adherence and lifestyle changes on patient’s FBG levels. The review was organized in themes and subthemes that allowed for the synthesis of the studies based on these themes.
The studies reviewed were surveyed from online databases such as EBSCOhost, PubMed, and ProQuest, which were also accessible through the Google Scholar search engine. The search strategy entailed the use of search terms such as patient education AND improvement of fasting blood glucose, the impact of patient education on fasting blood glucose, and patient education on medication adherence and lifestyle changes AND patient outcomes. Out of the thousands of hits returned from these databases, only thirty articles were included in the review based on their relevance to the PICOT question, publication date between 2013 and 2019, published in English, and available in full text or detailed abstract that gave insights of the entire study.
According to Bruce, Acheampong, & Kretchy (2015), patients with diabetes have had poor adherence to medications and lifestyle modifications despite the risk posed to their quality of health. The reviewed literature proposed the gap in medication adherence and lifestyle modifications such as incorporating physical activity and nutritional changes as critical aspects in improving outcomes such as FBG (Rusdiana & Amelia, 2018). As such, patient education sufficed as one strategy of improving medication adherence and lifestyle modifications as it would ensure that patients have a good understanding of their role in the management of the condition (Zheng, Liu, Liu, & Deng, 2019). Patient education appeared as a critical intervention of solving the issue of medication incompliance among type 2 diabetes patients. The problem has evolved to its current form through the patients’ belief that they can stop medications since they do not have any diabetic symptoms (Bruce et al., 2015). Also, inadequate patient education on the importance of adhering to medications as well as lifestyle changes has resulted in the current problem which contributes to poor health outcomes and elevated FBG (Awodele & Osuolale, 2015).
The theoretical foundation of this project was based on Bandura’s Self-Efficacy Model, which focuses on patients’ abilities to make changes and maintain them for positive changes in their lives (Martos-Méndez, 2015). According to Self-Efficacy Model, patients’ beliefs to make changes and maintain them is based on their self-confidence which indicates motivation to make appropriate behavioral changes (Mohebi, Azadbakht, Feizi, Sharifirad, & Kargar, 2014). The theory of self-efficacy is based on some aspects that are critical for them to learnt and develop new behaviors such as mastery of skills, modeling of skills from others, social persuasion and support from others, arousal of the emotions that a situation may create, and environment (Amer, Mohamed, Elbur, Abdelaziz, & Elrayah, 2018). As such, this theory presents a basis for patient education as an intervention to address FBG levels for patients with type 2 diabetes. While the model suggests that self-efficacy would not be effective alone in achieving the intended outcomes, it is apparent that patients would require specific plans to enhance the success of their situations. This would mean that patients would have to be proactive in adhering to medications and making lifestyle changes by taking specific actions since patient education would not meet their self-efficacy needs solely (Sleath et al., 2016).
Review of Literature
The studies included were reviewed based on the themes discussed as follows.
Patient Education for the Improvement of Patient Outcomes
The studies demonstrated that patient education was essential for the improvement of patient outcomes associated with type 2 diabetes (Burke, Sherr, & Lipman, 2014; Martin & Lipman, 2014). Mokabel et al. (2017) posited that a diabetes education program for the patients would help to improve their knowledge on the importance of medication adherence and lifestyle modifications which are integral in diabetes management. This theme had three common subthemes that were common across several studies in the review.
Rusdiana & Amelia (2018) conducted a quasi-experimental study to determine the impact of diabetes education on FBG and Hba1c levels in patients with type 2 diabetes. The research question in the study focused on whether a diabetes self-management education program would have any effect on FGB levels based on the behavioral changes imparted by the providers. The study included a sample of 80 patients with type 2 diabetes in three primary health care centers. The findings suggested that Hba1c and FBG levels reduced significantly after the post-tests indicating that the changes the patients implemented were effective.
In a cohort study, Lavelle et al. (2017) sought to answer the research question of whether self-management education in the home brought about changes in the way the patients viewed the management of the condition. The study included 19 home visits to patients with type 2 diabetes, which constituted patient education on nutrition, self-management, and proper monitoring. The findings indicated that home-based educational programs on diabetes would foster behavior changes regarding lifestyle changes and result in an improvement in health indicators such as FBG levels.
In a similar study, Kenney et al. (2016) conducted a pre- and post-evaluation study that involved a home-based education program on management and prevention dubbed Together on Diabetes (TOD). The study aimed to answer the research question on whether a home-based educational program has positive impacts on health indicators and self-management. The program enrolled a sample of 225 support individuals and 256 youths with type 2 diabetes. The program was found to be effective and efficacious in reducing the risk of diabetes among the American Indian youth based on the information and education they received regarding prevention and management.
The studies provided similar evidence on the outcome of behavioral changes among patients with type 2 diabetes as the first step towards the improvement of health indicators (García, Brown, Horner, Zuñiga, & Arheart, 2015). Based on the articles, it was essential for the patients to change their behaviors for them to follow the information provided in the educational programs. As such, the studies supported the need for patient education to improve FBG as it would be supported by positive behavior changes by the patient based in the information provided (Burke et al., 2014; Li, Elliott, Klein, Ur, & Tang, 2017). However, an important gap that would require further research was the inadequacy of evidence on the association between education and behavior change. Another subtheme associated with patient outcomes is the improvement of medication adherence.
Improved Medication Adherence
In a randomized controlled trial (RCT), Vervloet et al. (2014) argued that patient education is an effective strategy for improving medication adherence among patients with type 2 diabetes. The study’s research question was whether patient education and medication monitoring were effective in improving medication adherence. The sample consisted of 69 patients per group who were the intervention and control groups. The study found that adequate and effective education on diabetes complications, the importance of medications, and monitoring of medications were critical to improving adherence.
In a mixed-methods cross-sectional study, Aloudah et al. (2018) assessed the adherence of oral hypoglycemic agents as well as the factors that influence adherence among patients with type 2 diabetes. A total of 400 participants were obtained from a previous study that reported high adherence in patients who received adequate support and education. The study highlighted the challenges facing medications adherence in this population and recommended patient education as a way of improving adherence and associated outcomes.
Barba et al. (2017) conducted an observational, cross-sectional study to identify and compare the perspectives of type 2 diabetes patients, pharmacies, and physicians on the factors associated with the improvement and persistence of medication adherence. The study had a sample size of 963 patients with type 2 diabetes, 419 pharmacists, and 998 physicians to determine their views on medication adherence. The study found that a stronger relationship between patients and pharmacists or physicians would enhance adherence rates, monitoring, and persistence to antidiabetic medications. The relationships were found to be critical for patient education as they would promote discussions with the patients on the need to adhere to medications.
Improved medication adherence was presented as a primary patient outcome associated with patient education as patients learned the strategies to monitor and adhere to their medications (Joshi, Joshi, & Cheriyath, 2017). The studies’ unifying aspect was the support for diabetes education for the patients to understand their medications and the benefits of adherence (Adisa & Fakeye, 2013). As such, the findings suggested that the intervention of patient education on medication adherence could improve FBG as the medications are essential in regulating blood glucose levels. An inconsistency identified from the studies related to the need to provide specific patient education on medication adherence as a common issue with this population rather than general diabetes education. An associated subtheme with medication adherence was lifestyle modifications, which include changes in nutrition and physical activity.
Adachi et al. (2014) focused on the effects of lifestyle modifications achieved through lifestyle education programs for type 2 diabetes patients in an RCT. The study had a sample size of 193 adults with type 2 diabetes from 20 Japanese clinics. The intervention group received four sessions of nutritional education, and the results were compared with the control group. The study demonstrated that Hba1c levels improved following the lifestyle education program than the levels registered with general diabetes education and care. This suggested that the program was effective in improving Hba1c levels more than the usual care and support.
In a systematic review and meta-analysis, Su, McBride, Zhou, & Kelley (2016) reviewed 92 studies that focused on the effects of telemedicine on the management of diabetes. The review sought to determine whether nutritional counseling in telemedicine help in the improvement of patient outcomes related to diabetes. The findings of the review indicated that several studies demonstrated the effectiveness of nutritional counseling on SMS, telephone, and video chats rather than telemedicine, which was not associated with any significant differences. This highlighted the importance of nutritional counseling for type 2 diabetes patients regarding their diets through phone calls, texts, or video calls.
Portillo et al. (2017), in a mixed-methods cross-national study, focused on the interventions of diabetes self-management to improve patient outcomes in a European setting. The sample comprised 749 participants from across the countries included in the study. The findings of the study demonstrated that self-management education for patients with diabetes would enhance their ability to make and maintain lifestyle changes that would be suitable for the management of the disease. As such, the study showed that community and voluntary organizations provided support to diabetes patients to encourage them to make lifestyle changes.
The articles demonstrated that lifestyle modifications were key outcomes of patient education for patients with type 2 diabetes, including nutritional and physical activity changes (Austin, 2013). As such, this project would benefit patients with type 2 diabetes in learning how to make lifestyle changes associated with nutrition and physical activity as significant factors in the management of diabetes. However, no research gaps or inconsistencies were notable from the studies. Based on the review of the improvement of patient outcomes, the outcomes could be associated with improved self-management.
Improvement of Self-Management and Reduction of Diabetic Symptoms
Improvement of self-management among type 2 diabetes patients was a common theme across the studies included in the review. Kent et al. (2013) argued that improved self-management of diabetes would reduce the complications and symptoms associated with diabetes. Moradi, Mojadam, Shojaeizadeh, Ghazanfari, & Haghighizadeh (2017) and Schnell, Klausmann, Gutschek, Garcia-Verdugo, & Hummel (2017) supported this argument by proposing a precede-model based education and the use of color in monitoring glucose levels for patients to enhance their self-management abilities. A common subtheme was the improvement of self-monitoring and reduction of FBG as a result of effective monitoring and self-management (Ba-Essa, Mobarak, Alghamdi, & Al-Daghri, 2015).
Self-Monitoring of Blood Glucose and Improved Fasting Blood Glucose
Several articles supported the need for effective self-monitoring of blood glucose levels, which is a major factor in self-management. Sodipo et al. (2017) conducted a randomized control study to assess the effect of self-monitoring blood glucose on patient outcomes such as reduced FBG. With a sample of 120 patients with diabetes, the study found that self-monitoring blood glucose improved FBG levels as the patient were able to track their levels. Kirk & Stegner (2014) also demonstrated that self-monitoring enhances the self-management of diabetes since the patients develop routines and behaviors that focus on improved outcomes.
The review indicated that patient education is a critical intervention in improving FBG levels as it helps patients to adhere to medications and make lifestyle modifications that help regulate blood glucose levels. The studies supported patient education based on two major themes, which included the improvement of patient outcomes and self-management.
Adachi, M., Yamaoka, K., Watanabe, M., Nishikawa, M., Kobayashi, I., Hida, E., & Tango, T. (2013). Effects of lifestyle education program for type 2 diabetes patients in clinics: a cluster randomized controlled trial. BMC public health, 13(1), 467. Fakeye, T. O. (2013). Effect of number and type of antidiabetes medications on adherence and glycemia of ambulatory type 2 diabetes patients in southwestern Nigeria. Pharmacy Practice, 11(3), 156-165.