title: Comparison of Community Health WorkerLed Diabetes Medication Decision-Making Support for Low-Income Latino and African American Adults With Diabetes Using E-Health Tools Versus Print Materials The Effects of a Web-Based Intervention on Psychosocial Well-Being Among Adults Aged 60 and Older With Diabetes Telecommunication Support for Rural Women With Diabetes Online Diabetes Self-Management Program Changes in Diabetes Distress Related to Participation in an Internet-Based Diabetes Care Management Program and Glycemic Control Efficacy of a Web-Based Intervention With Mobile Phone Support in Treating Depressive Symptoms in Adults With Type 1 and Type 2 Diabetes: A Randomized Controlled Trial Web-Based Depression Treatment for Type 1 and Type 2 Diabetic Patients REDEEM: A Pragmatic Trial to Reduce Diabetes Distress An Internet-based diabetes self-care intervention tailored to self-efficacy. Online disease management of diabetes: Engaging and Motivating Patients Online With Enhanced Resources-Diabetes (EMPOWER-D), a randomized controlled trial The diabetes network internet-based physical activity intervention: a randomized pilot study. The burden of treatment failure in type 2 diabetes. The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results. A randomized comparison of online- and telephone-based care management with internet training alone in adult patients with poorly controlled type 2 diabetes. Do Internet-Based Support Interventions Change Perceptions of Social Support?: An Experimental Trial of Approaches for Supporting Diabetes Self-Management
abstract: Adults with type 2 diabetes mellitus often struggle with their antihyperglycemic medication regimens . To improve medication management , providers must ensure that their patients underst and potential benefits , harms , and burdens of available options and elicit patients ' preferences and barriers to taking medications . Patients who are actively involved in treatment decision making tend to be more satisfied with their health care , be more adherent to treatment , and have improved clinical outcomes ( 13 ) . Such discussion s , however , can be too time-consuming for clinic visits . For inner-city low-income African American and Latino adults , low health literacy and limited English proficiency are often additional barriers ( 4 ) that reduce the exchange of information and decrease patient participation during primary care visits ( 58 ) . This contributes to less optimal treatment decisions and lower patient satisfaction , leading to poor medication adherence and outcomes ( 3 , 911 ) . There is therefore an urgent need for cost-effective approaches to enable low-re source health systems to help these high-risk population s gain information and decision support so that they can more actively participate in and improve satisfaction with their treatment decision making . Since 2000 , the REACH ( Racial and Ethnic Approaches to Community Health 2010 ) Detroit Partnership , a coalition of community , health system , and academic partners , has used community-based participatory research principles to guide development , implementation , and evaluation of interventions to meet this need among African American and Latino adults with diabetes in Detroit , Michigan . These interventions have built on evidence that community health workers ( CHWs ) are effective in improving diabetes outcomes , particularly among racial and ethnic minority communities ( 12 ) . CHW interventions train community members to work as bridges between their ethnic , cultural , or geographic communities and health care providers ( 13 ) . Two cohorts of participants in our previous CHW-led diabetes self-management support interventions  improved hemoglobin A1c ( HbA1c ) levels and diabetes distress compared with usual care ( 14 , 15 ) . An important next step in increasing the potential effect of CHWs and other lay health care workers is to develop and test effective tools they can use to better present evidence -based information to patients and to help patients make better self-management decisions ( 16 ) . Little is known about the effectiveness of different approaches for nontraditional care providers , such as CHWs , to deliver health information to ethnic minority and low-literacy population s ( 17 ) . By definition , CHWs and other lay workers do not have medical expertise and thus rely on effectively sharing printed educational and support material s with patients as part of their coaching and counseling efforts . Decision aids can increase satisfaction with treatment decisions and result in treatments that better reflect patients ' preferences ( 18 , 19 ) . There is also evidence that tailored health messages are more effective than generic group messages ( 20 , 21 ) , including for patients with diabetes ( 22 , 23 ) . Tailoring individualizes information and behavior change strategies to reach each person based on characteristics unique to that person derived from an individual assessment and related to the outcome of interest ( 24 ) . Software programs that are being developed to automatically embed tailored content into portable e-health Web applications show promise in improving health behaviors and outcomes ( 25 , 26 ) . To date , however , most e-health applications have been design ed for use by patients with relatively high literacy and the skills to navigate them ( 27 ) . Do more sophisticated , tailored , interactive e-health tools increase the effectiveness of CHW outreach with underserved patients compared with reliance on printed educational material s alone ? We addressed this question by developing and evaluating a personally tailored , interactive diabetes medication decision aid ( iDecide [ in English ] or iDecido [ in Spanish ] ) design ed for CHWs to deliver on tablet computers with 3 G wireless access to African American and Latino adults with diabetes and low health literacy . We then evaluated the effectiveness of iDecide in improving key diabetes outcomes compared with CHW delivery of the same evidence -based information , without tailoring , through print consumer booklets developed by the Agency for Healthcare Research and Quality ( AHRQ ) . Methods Setting This study was developed and implemented by using community-based participatory research principles ( 28 ) in partnership with the REACH Detroit Partnership and the Community Health and Social Services Center ( CHASS ) , a federally qualified health center in Southwest Detroit serving more than 13000 patients with 47099 visits in 2012 ( 29 ) . The University of Michigan and CHASS institutional review boards approved the study . Content of AHRQ Consumer Guides The AHRQ guides ( Pills for Type 2 Diabetes and Premixed Insulin for Type 2 Diabetes ) ( 30 , 31 ) provide information on diabetes and summarize the effectiveness of currently available medication classes  ( oral and insulin ) on HbA1c . They also provide information on administration methods , costs , medication adverse effects , risks for diabetes complications , suggested questions to discuss with health care providers , and prompts to make notes of any questions for the doctor . The booklets include pictures of patients and tables and graphs summarizing information . Content of iDecide The development process and content of the iDecide program have been described in detail elsewhere ( 32 ) . Briefly , we used community-based participatory research and user-centered design ( 33 , 34 ) principles to iteratively develop and refine the iDecide tool . iDecide is available in English and Spanish , can be delivered via tablet computers , and enables navigation by the CHW and participant to selectively explore issues most important to the participant . The iDecide program is organized into 4 main sections and includes the same content as the AHRQ consumer guides . However , its information is presented in a more graphical style suited to patients with low literacy . Table 1 summarizes key differences between the presentation of information in iDecide and the printed material s. The first section illustrates , through animations , how diabetes affects the way glucose is processed in the body and how different medication classes , foods , and physical activity affect blood glucose . The second section includes pictographs showing participants ' own risk for diabetes complications ( tailored according to their baseline HbA1c ) and enabling participants to explore how their risk for different complications changes with their HbA1c levels . In the third section , participants review their current diabetes medications and barriers to taking the medications they had reported on the baseline survey . This section includes an interactive issue card approach to help elicit patient preferences and priorities about different medication characteristics ( for example , cost , adverse effects , effects on weight , and dosing schedules ) ( 22 , 35 ) . The fourth section prompts participants to set goals and develop specific action plans to address identified barriers or other concerns and identify specific questions and concerns to discuss with their doctor about their medications or making lifestyle changes . Personal information from the baseline assessment is interwoven throughout the program ( high-depth tailoring within sentences ) . Motivational interviewingbased , tailored discussion prompts encourage autonomy-supportive CHWpatient interactions at key points with open-ended questions and values exploration to help participants discover their motivation , overcome barriers to change , and develop an action plan ( 36 ) . Table 1 . Comparison of Content and Mode of Delivery Between the iDecide Study Group and the Printed Material s Group Recruitment and R and omization From September 2011 to August 2012 , potentially eligible participants were identified from a computer-generated list of CHASS patients with physician-diagnosed type 2 diabetes . Inclusion criteria required a HbA1c value greater than 7.5 % in the previous 6 months or expressed concerns about current diabetes medications during the screening assessment . Exclusion criteria were age younger than 21 years , terminal health conditions , self-reported alcohol or drug abuse , and conditions ( such as blindness and dementia ) that would impede meaningful participation . Pregnant women and individuals who reported that they could not be contacted by telephone were also excluded . Introductory letters were sent in timed batches . Research staff then telephoned patients and screened them for eligibility . Interested eligible patients met with research staff , who facilitated completion of written informed consent , administered baseline surveys in English or Spanish , and measured HbA1c and blood pressure . Participants received a stipend of $ 20 after each assessment . Within 1 to 14 days , participants were scheduled for a visit with a CHW ( at home , the clinic , or another agreed-upon place ) . At the beginning of the CHW visits , participants were registered into the iDecide program and r and omly assigned by the computer program , through use of a r and om-sequence algorithm , into 1 of 2 study groups . There were no differences between the steps to participate in either study group . Patients , research staff , and CHWs were blinded to r and omization results through completion of all baseline measures up to the start of the intervention . Data assessors remained blinded to group assignment throughout the study . CHW Intervention for Both Study Groups All participants received an initial one-on-one , face-to-face session with a CHW and a copy of the printed material s to take home . The iDecide sessions lasted approximately 2 hours , and the sessions using printed material s lasted Purpose The purpose of this study is to investigate the impact of a 6-month Web-based intervention on the psychosocial well-being of older adults with diabetes . Methods This study was a r and omized controlled trial ( N = 62 ) comparing the effects of a 6-month Web-based intervention plus usual care with usual care alone among adults aged 60 years or older with diabetes . The outcomes included quality of life , depression , social support , and self-efficacy . Results The intervention group showed significant improvement , F(4.48 ) = 4.03 P = .007 , when compared with the control group on measures of depression , quality of life , social support , and self-efficacy when controlling for all baseline outcome variables ( age , gender , and number of years with diabetes ) . Conclusions These findings provide support for the conclusion that a Web-based intervention is effective in improving the psychosocial well-being of participants at a 6-month follow-up . Future research needs to investigate the long-term effectiveness of Web-based interventions for sustaining psychosocial well-being , including factors that may affect quality of life , such as diabetes-specific beliefs , attitudes , social support , and disease-specific coping skills PURPOSE The Women to Women Diabetes Project tested the use of telecommunication technology to deliver diabetes education and social support to rural women with diabetes . The aims were to ( 1 ) test the effects of the computer intervention in providing support , information , and education on selected outcomes , and ( 2 ) evaluate the women 's attitudes toward and satisfaction with the intervention and the support provided . METHODS Thirty women were r and omized into computer and noncomputer groups and participated for 10 months . For 5 months , one group participated in a self-help support and educational group via the computer ; the other group continued to use their usual modes of support and communication .  Psychosocial well-being scales were administered and attitudes were surveyed . RESULTS Improving health and higher educational levels positively influenced measures of social support and quality of life .  Women who were married or who reported greater support had higher scores on the Personal Re source Question naire . The women expressed positive effects of the computer-based support group on their lives . CONCLUSIONS The intervention was enthusiastically accepted , and could be conducted effectively in isolated rural areas OBJECTIVE We hypothesized that people with type 2 diabetes in an online diabetes self-management program  , compared with usual-care control subjects , would 1 ) demonstrate reduced A1C at 6 and 18 months , 2 ) have fewer symptoms , 3 ) demonstrate increased exercise , and 4 ) have improved self-efficacy and patient activation . In addition , participants r and omized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement . RESEARCH DESIGN AND METHODS A total of 761 participants were r and omized to 1 ) the program  , 2 ) the program with e-mail reinforcement , or 3 ) were usual-care control subjects ( no treatment ) . This sample included 110 American Indians/Alaska Natives ( AI/ANs ) . Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups . RESULTS At 6 months , A1C , patient activation , and self-efficacy were improved for program participants compared with usual care control subjects ( P < 0.05 ) . There were no changes in other health or behavioral indicators . The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects . The subgroup with initial A1C > 7 % demonstrated stronger improvement in A1C ( P = 0.01 ) . At 18 months , self-efficacy and patient activation were improved for program participants . A1C was not measured . Reinforcement showed no improvement . CONCLUSIONS An online diabetes self-management program is acceptable for people with type 2 diabetes . Although the results were mixed they suggest 1 ) that the program may have beneficial effects in reducing A1C , 2 ) AI/AN population s can be engaged in and benefit from online interventions , and 3 ) our follow-up reinforcement appeared to have no value Background : This article investigated how changes in diabetes distress relate to receiving care management through an Internet-based care management ( IBCM ) program for diabetes and level of participation in this program . Further , it examined the relationship between diabetes distress and changes in glycemic control . Methods : We enrolled patients of the Veterans Affairs Boston Healthcare System with diabetes who had hemoglobin A1c ( HbA1c ) levels of ≥9.0 % . Subjects were r and omized to usual care ( n = 52 ) or IBCM ( n = 52 ) for 1 year . We measured diabetes distress at baseline and quarterly thereafter using the  Problem Areas in Diabetes ( PAID ) question naire . Glycemic control was determined by baseline and quarterly HbA1c . For subjects r and omized to IBCM , we measured participation by observing frequency and consistency of their usage of the IBCM patient portal over 12 months . Linear mixed models were used to analyze THE data . Results : PAID scores declined over time for both treatment groups . Among subjects r and omized to IBCM , the decline in PAID scores over time was significant for sustained users of the IBCM patient portal but not for nonusers . Moreover , subjects whose usage of the patient portal was sustained throughout the study had lower PAID scores at baseline . With respect to changes in glycemic control , HbA1c reduced individual differences in PAID scores by 44 % ; a lower baseline HbA1c was associated with lower baseline PAID scores , and over time , the decrease in HbA1c was associated with further decreases in the PAID score . Conclusions : Participation in IBCM varies by initial diabetes distress , with people with less distress participating more . For people who participate , IBCM further mitigates diabetes distress . There is also a relationship between achievements in glycemic control and subsequent lowering of diabetes distress . Future research should identify how to maximize fit between patient needs and the provisions of IBCM , with the aim of increasing patient engagement in the active management of their health using this care modality . A key to maximizing fit might be first addressing metabolic control aggressively and then using IBCM for sustainment of health OBJECTIVE Depression is common in diabetes and linked to adverse health outcomes . This study evaluated the efficacy of a guided web-based intervention in reducing  depression in adults with type 1 and type 2 diabetes . RESEARCH DESIGN AND METHODS A total of 260 participants with diabetes and elevated depressive symptoms ( Center for Epidemiologic Studies Depression Scale [ CES-D ≥23 ] ) were r and omly assigned to the GET.ON  Mood Enhancer Diabetes ( a guided self-help intervention , n = 130 ) or a brief online unguided psychoeducation program for depression ( n = 130 ) . The primary outcome was depressive symptoms severity ( CES-D ) . The secondary outcomes included diabetes-specific emotional distress ( Problem Areas in Diabetes [ PAID ] scale ) and participant satisfaction ( adaption CSQ-8 ) . Data were collected at baseline and 2 months after r and omization . To identify differences in outcome between the groups , we used analyses of covariance with the baseline CES-D score as covariate on both intent-to-treat ( ITT ) and per- protocol ( PP ) basis . RESULTS Compared with the control group , the intervention group showed significantly less depressive symptom severity at posttreatment based on ITT ( d = 0.89 ) and PP analyses ( d = 1.00 ) . The intervention participants displayed a significantly larger reduction in diabetes-specific emotional distress ( d = 0.58 , ITT ) . The intervention appeared to be acceptable to the participants ; 95 % ( n = 121 ) would recommend the training to a friend with diabetes in need of psychological help . CONCLUSIONS A guided , web-based intervention to reduce depression in adults with type 1 and type 2 diabetes  is effective in reducing both depressive symptoms and diabetes-specific emotional distress OBJECTIVE Comorbid depression is common in patients with type 1 and type 2 diabetes , adversely affecting quality of life , diabetes outcomes , and mortality . Depression can be effectively treated with cognitive behavior therapy ( CBT ) . The Internet is a new and attractive method for delivering CBT intervention on a large scale at relatively low costs . This study evaluated the effectiveness of Web-based CBT for depression treatment in adults with type 1 or type 2 diabetes , with minimal guidance . RESEARCH DESIGN AND METHODS A r and omized controlled trial was conducted in the Netherl and s in 255 adult diabetic patients with elevated depressive symptoms . Primary outcomes were depressive symptoms . Secondary outcomes were diabetes-specific emotional distress and glycemic control . Assessment s were at baseline , after treatment , and at the 1-month follow-up . RESULTS The Web-based CBT was effective in reducing depressive symptoms by intention-to-treat analyses ( P = 0.04 , d = 0.29 ; clinical improvement 41 % vs. 24 % P < 0.001 ) and by per- protocol analyses ( P < 0.001 , d = 0.70 ; clinical improvement , 56 % vs. 24 % P < 0.001 ) . The intervention reduced diabetes-specific emotional distress ( P = 0.03 ) but had no beneficial effect on glycemic control ( P > 0.05 ) . CONCLUSIONS Web-based CBT depression treatment is effective in reducing depressive symptoms in adults with type 1 and type 2 diabetes . In addition , the intervention reduces diabetes-specific emotional distress in depressed patients OBJECTIVE To compare three interventions to reduce diabetes distress ( DD ) and improve self-management among non– clinical ly depressed adults with type 2 diabetes mellitus ( T2DM ) . RESEARCH DESIGN AND METHODS In REDEEM , 392 adults with T2DM and DD were r and omized to computer-assisted self-management ( CASM ) , CASM plus DD-specific problem solving ( CAPS ) , or a computer-administered minimal supportive intervention . Primary outcomes were Diabetes Distress Scale ( DDS ) total , the Emotional Burden ( EB ) and Regimen Distress ( RD ) DDS subscales , and diet , exercise , and medication adherence . RESULTS Significant and clinical ly meaningful reductions in DD ( DDS , EB , and RD ) and self-management behaviors occurred in all three conditions ( P < 0.001 ) , with no significant between-group differences . There was , however , a significant group × baseline distress interaction ( P < 0.02 ) , in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions . RD generated the most distress and displayed the greatest distress reduction as a result of intervention . The pace of DD reduction varied by patient age : older patients demonstrated significant reductions in DD early in the intervention , whereas younger adults displayed similar reductions later . Reductions in DD were accompanied by significant improvements in healthy eating , physical activity , and medication adherence , although not by change in HbA1c . CONCLUSIONS DD is malleable and highly responsive to intervention . Interventions that enhance self-management also reduce DD significantly , but DD-specific interventions may be necessary for patients with high initial levels of DD . Future research should identify the minimal , most cost-effective interventions to reduce DD and improve self-management The main objective of this study was to assess whether self-efficacy ( SE ) could function as a moderator of the effect of a tailored Internet-based intervention aim ed at increasing self-reported diabetes self-care behaviours . In a two-group , 1-month interval pre-test-post-test r and omized controlled trial , participants ( N = 64 ) were assigned at r and om to either a group that received an intervention on the area of self-care ( blood glucose monitoring , diet management or physical activity ) for which the reported SE was lowest ( LSE group ) or to a group that received an intervention on area of self-care for which the reported SE was highest ( HSE group ) . Improvements in self-care were observed for both groups , but the HSE group improved more . Self-care also increased for those areas that the intervention did not target . Furthermore , SE levels decreased from baseline to follow-up . This study suggests that SE can function as a moderator in a behavioural intervention for diabetes self-care , and hence that initial level of SE provides relevant information for tailoring such interventions OBJECTIVE To evaluate an online disease management system supporting patients with uncontrolled type 2 diabetes . MATERIAL S AND METHODS Engaging and Motivating Patients Online With Enhanced Re sources for Diabetes was a 12-month parallel r and omized controlled trial of 415 patients with type 2 diabetes with baseline glycosylated hemoglobin ( A1C ) values ≥7.5 % from primary care sites sharing an electronic health record . The intervention included : ( 1 ) wirelessly uploaded home glucometer readings with graphical feedback ; ( 2 ) comprehensive patient-specific diabetes summary status report ; ( 3 ) nutrition and exercise logs ; ( 4 ) insulin record ; ( 5 ) online messaging with the patient 's health team ; ( 6 ) nurse care manager and dietitian providing advice and medication management ; and ( 7 ) personalized text and video educational ' nuggets ' dispensed electronically by the care team . A1C was the primary outcome variable . RESULTS Compared with usual care ( UC , n=189 ) , patients in the intervention ( INT , n=193 ) group had significantly reduced A1C at 6 months ( -1.32 % INT vs -0.66 % UC ; p<0.001 ) . At 12 months , the differences were not significant ( -1.14 % INT vs -0.95 % UC ; p=0.133 ) . In post hoc analysis , significantly more INT patients had improved diabetes control ( > 0.5 % reduction in A1C ) than UC patients at 12 months ( 69.9 ( 95 % CI 63.2 to 76.5 ) vs 55.4 ( 95 % CI 48.4 to 62.5 ) ; p=0.006 ) . CONCLUSIONS A nurse-led , multidisciplinary health team can manage a population of diabetic patients in an online disease management program . INT patients achieved greater decreases in A1C at 6 months than UC patients , but the differences were not sustained at 12 months . More INT than UC patients achieved improvement in A1C ( > 0.5 % decrease ) . Trial registered in clinical trials.gov : # NCT00542204 OBJECTIVE Because of other competing priorities ,  physical activity ( PA ) is seldom addressed in a consistent way in either primary care or diabetes education . This 8-week pilot study evaluated the short-term benefits of an Internet-based supplement to usual care that focused on providing support for sedentary patients with type 2 diabetes to increase their PA levels . RESEARCH DESIGN AND METHODS A total of 78 type 2 diabetic patients ( 53 % female , average age 52.3 years ) were r and omized to the Diabetes Network ( D-Net ) Active Lives PA Intervention or an Internet information-only condition .  The intervention condition received goal - setting and personalized feedback , identified and developed strategies to overcome barriers , received and could post messages to an on-line " personal coach , " and were invited to participate in peer group support areas . Key outcomes included minutes of PA per week and depressive symptomatology . RESULTS There was an overall moderate improvement in PA levels within both intervention and control conditions , but there was no significant improvement in regard to condition effects . There was substantial variability in both site use and outcomes within the intervention and control conditions . Internal analyses revealed that among intervention participants , those who used the site more regularly derived significantly greater benefits , whereas those in the control condition derived no similar benefits with increased program use . CONCLUSIONS Internet-based self-management interventions for  PA and other regimen areas have great potential to enhance the care of diabetes and other chronic conditions . We conclude that greater attention should be focused on methods to sustain involvement with Internet-based intervention health promotion programs over time OBJECTIVE In type 2 diabetes , therapies to maintain blood glucose control usually fail after several years . We estimated the glycemic burden that accumulates from treatment failure and describe the time course and predictors of failure . RESEARCH DESIGN AND METHODS A prospect i ve , population -based study using retrospective observational data . We identified all 7208 complete courses of treatment with nondrug therapy , sulfonylurea monotherapy , metformin monotherapy , and combination oral antihyperglycemic therapy between 1994 and 2002 , inclusive , among members of the Kaiser Permanente Northwest Region . We calculated mean cumulative glycemic burden , defined as HbA(1c)-months > 8.0 or 7.0 % for each treatment . We then measured the likelihood that the next HbA(1c ) would exceed 8.0 and 7.0 % after HbA(1c ) exceeded each of ten hypothetical treatment thresholds . Finally , we estimated multivariate logistic regression models to predict when HbA(1c ) would continue to deteriorate . RESULTS In this well-controlled population , the average patient accumulated nearly 5 HbA(1c)-years of excess glycemic burden > 8.0 % from diagnosis until starting insulin and about 10 HbA(1c)-years of burden > 7.0 % . Whenever patients crossed the American Diabetes Association-recommended treatment threshold of 8.0 % , their next HbA(1c ) result was as likely to be < 8.0 as > 8.0 % . Multivariate prediction models had highly statistically significant coefficients , but predicted < 10 % of the variation in future HbA(1c ) results . CONCLUSIONS Clinicians should change glucose-lowering treatments in type 2 diabetes much sooner or use treatments that are less likely to fail . An action point at 7.0 % or lower is more likely to prevent additional deterioration than the traditional action point of 8.0 % BACKGROUND A prerequisite to translating research findings into practice is information on consistency of implementation , maintenance of results , and generalization of effects . This follow-up report is one of the few experimental studies to provide such information on Internet-based health education . METHODS We present follow-up data 10 months following r and omization on the " Diabetes Network ( D-Net ) " Internet-based self-management project , a r and omized trial evaluating the incremental effects of adding ( 1 ) tailored self-management training or ( 2 ) peer support components to a basic Internet-based , information-focused comparison intervention .  Participants were 320 adult type 2 diabetes patients from participating primary care offices , mean age 59 ( SD = 9.2 ) , who were relatively novice Internet users . RESULTS All intervention components were consistently implemented by staff , but participant website usage decreased over time . All conditions were significantly improved from baseline on behavioral , psychosocial , and some biological outcomes ; and there were few differences between conditions . Results were robust across on-line coaches , patient characteristics , and participating clinics . CONCLUSIONS The basic D-Net intervention was implemented well and improvements were observed across a variety of patients , interventionists , and clinics . There were , however , difficulties in maintaining usage over time and additions of tailored self-management and peer support components generally did not significantly improve results AIMS Care management may improve the quality of diabetes care by enhancing contact between high-risk patients and their providers . This prospect i ve , longitudinal , r and omized trial sought to investigate whether telephone or online care management improves diabetes-related outcomes over time compared with usual care supplemented with Internet access and training . SUBJECTS AND METHODS One hundred fifty-one adult subjects with type 2 diabetes mellitus and an elevated hemoglobin A1c ( A1c ) level ( ≥8.5 % ) were r and omly assigned to  online care management ( n=51 ) , telephone-based care management ( n=51 ) , or Web training ( n=49 ) groups . Online and telephone participants interacted with a care manager through a diabetes education and care management Web site and by telephone , respectively . The Web training group was provided with online diabetes self-management re sources but no care management support . The primary outcome measure was A1c measured every 3 months for a year . RESULTS A1c declined significantly and substantially in all groups over 12 months . A1c declined linearly at a rate of 0.32 % ( P<0.0001 ) per quarter for the online group , 0.36 % ( P<0.0001 ) for the telephone group , and 0.41 % for the Web training group ( P<0.0001 ) . The rate of change over time did not differ significantly among groups . The groups converged at 12 months with average absolute A1c difference of -1.5 % . The number of interactions with care providers was not significantly associated with the change in A1c . Blood pressure , weight , lipid levels , and diabetes distress did not differ among groups over time . CONCLUSIONS Online , telephone-based care management , and Web training for diabetes patients with elevated A1c were each associated with a substantial improvement in A1c over a 1-year period . Internet access and training alone may be as effective as care management in patients with poorly controlled diabetes Internet-based support groups are a rapidly growing segment of mutual aid programs for individuals with chronic illnesses and other challenges . Previous studies have informed us about the content of online exchanges between support group members , but we know little about the ability of these interventions to change participants ' perceptions of support . A r and omized trial of 160 adult Type 2 diabetes patients provided novice Internet users with computers and Internet access to 1 of 4 conditions :  (  a ) diabetes information only , ( b ) a personal self-management coach , ( c ) a social support intervention , or ( d ) a personal self-management coach and the support intervention . After 3 months , individuals in the 2 support conditions reported significant increases in support on a diabetes-specific support measure and a general support scale . Participants ' age was significantly related to change in social support , but intervention effects were still significant after accounting for this relationship . This report is a critical first step in evaluating the long-term effects of  Internet-based support for diabetes self-management . The discussion identifies directions for future research
target: Interventions with a duration of 2 - 6 months providing professional-led support with asynchronous and synchronous communication appeared to be associated with significant well-being outcomes .
  While the meta-analyses demonstrated nonsignificant results for depression and distress scores , this review has shown that there is a potential for Web-based interventions to improve well-being outcomes in type 2 diabetes .
background: BACKGROUND Poor diabetes self-care can have a negative impact on psychological well-being and quality of life .
  Given the scarcity of traditional psychological support and the barriers to uptake of and attendance at face-to-face education programs , Web-based interventions are becoming a popular approach to provide an additional platform for psychological support in long-term conditions .
  However , there is limited evidence to assess the effect of Web-based psychological support in people with type 2 diabetes .
  OBJECTIVE This systematic review is the first review to critically appraise and quantify the evidence on the effect of Web-based interventions that aim to improve well-being in people with type 2 diabetes .