Background
Methods
Search strategy and data abstraction
Inclusion criteria
PICO | Inclusion Criteria | Exclusion Criteria |
---|---|---|
Population | Over 18 years | |
Diagnosed with diabetes, COPD, cardiovascular disease, chronic musculoskeletal pain and any additional comorbidities | At-risk patients (e.g. prediabetes) | |
SES described in terms of education, income, area or occupation. | ‘Disadvantaged’ (e.g. ethnic minority) population without quantifiable reference to SES. | |
Intervention | Includes a self-management support intervention incorporating at least 3 recognised elements of SM [7] | Single-component SMS intervention (e.g. education, medication adherence only). |
Comparison | Includes analysis of whether the response to the intervention differs according to SES. | No measurement of SES disparity in reporting of outcomes. |
Outcome | Reporting of outcomes which may be clinical, behavioural, psychosocial or related to participation/attrition. |
Search outcomes
Data abstraction
Author1 | Country and setting | Study design | Chronic Disease | Sample size | Intervention description, healthcare providers (HCPs), SM Components2 | Control | Outcomes measured | Follow up | Results | Quality rating |
---|---|---|---|---|---|---|---|---|---|---|
Rothman 2004 (Rothman 2005) | USA Public primary care clinics | RCT with subgroup analysis | Diabetes | 217 | Individual Phone and face-to-face SMS over 12/12 Pharmacist and nurse 1,2,3,5,6,7 | Single session with pharmacist | Hb A1c and blood pressure | 12/12 | HbA1c improved significantly from baseline for both I/C. For higher literacy participants group there was no difference between I/C but those with low literacy had a HbA1c change of −1.4% (adjusted), CI −2.3 to − 0.6%, p < 0.001, favouring intervention. BP improved in intervention group regardless of literacy, p = 0.006 | JBI 11/12 S/O 11/11 |
DeWalt 2012 (DeWalt 2006) | USA Hospital clinics | RCT with subgroup analysis | Chronic heart failure (HF) | 605 | Individual Education session then phone support for 12/12 Health educators 1,2,3,5,7,8 | Single 1–1 education session | All-cause hospitalisation, death, HF hospital admission, HFQOL | 12/12 | In low-literacy participants adjusted incident rate ratio (IRR) was 0.73 for all-cause hospitalisation and death and 0.48 for HF hospitalisation, favouring intervention; IRR for high literacy was 1.16 for all-cause and 1.34 for HF hospitalisation, favouring control. | JBI 10/12 S/O 11/11 |
Bosma 2011 (Lamers 2010) | Netherlands Public primary care clinics | RCT with subgroup analysis | Diabetes or COPD with mild to moderate depression. | 361 | Individual Home-based CBT and SMS for 6/52 Nurses 1,3,4,6,7,8 | Usual GP care | Depression primary outcome (Beck Depression Inventory); also health-related quality of life (QOL); control beliefs (mastery); self-efficacy. | 9/12 | Interaction between education level was significant (p < 0.05) or nearing significance (p < 0.10) at 3 and 9 months for all outcomes with no benefit for low educated. Clinically significant (> 50% improvement) in depression at 9 months for high educated only. | JBI 11/12 S/O 9/11 |
Moskowitz 2013 (Thom 2013) | USA Public primary care clinics | RCT with subgroup analysis | Diabetes | 299 | Individual Phone and face-to-face peer support over 6/12 Peer health coaches 1,3,4,5,6,8 | Usual GP care | HbA1c | 6/12 | HbA1C reduced by 1.07% (intervention) vs 0.3% (control), p = 0.01. HbA1c decrease was predicted by SM ability and medication adherence. Those with low SM ability benefited most; ethnicity and education did not differentially affect the outcome. | JBI 10/12 S/O 9/11 |
Powell 2010 | USA Hospital clinics | RCT with subgroup analysis | Heart failure | 902 | Group SMS classes over 12/12 Health professionals 1,2,3,4,5,6 | Education sheets plus phone follow-up | Death/HF hospitalisation, medication adherence, salt intake, SM ability, cardiac QOL, SF 36, depression. | 2.5 years | Depression, self-efficacy and salt intake improved in both intervention and control groups. Low income participants in the control group had a non-significant (p = 0.056) trend to earlier cardiac event (death/hospitalisation). | JBI 11/12 S/O 6/11 |
Smeulders 2010 (Smeulders 2006) | Netherlands Hospital clinics | RCT with subgroup analysis | Chronic heart failure | 317 | Group Stanford CDSMP for 6/52 Nurse and peer leader 1,2,3,4,5,6,7,8 | Usual care | Cardiac QOL (Kansas City Cardiomyopathy Questionnaire) | 12/12 | Short-term improvement in cardiac QOL in intervention group but not at 6 or 12/12. Lower educated patients improved more than higher educated (p = 0.018) throughout the follow-up period. | JBI 10/12 S/O 7/10 |
Jonker 2012 | Netherlands Elderly daycare facility | RCT with subgroup analysis | Frail elderly; unspecified chronic disease (mean of 2 CDs) | 63 (intervention group) | Group Stanford CDSMP for 6/52 Nurses 1,2,3,4,5,6,7,8 | Waitlist | Depression, valuation of life, control beliefs (mastery); self-efficacy, cognitive function. | 6/12 | Mastery (p = 0.01) and Depression (p = 0.05) scores improved from baseline in the intervention group at 6/12 (small effect size); subgroup analysis showed improvements in mastery (p < 0.05) were limited to the lower educated and those with better cognitive function. | JBI 6/12 S/O 5/11 |
Nour 2006 | Canada Public community health centres | RCT with subgroup analysis | Arthritis and housebound | 58 (intervention group) | Individual Home-based CBT and SMS for 8/52 Allied HCPs 1,3,4,5,6,8 | Waitlist | Health behaviour changes, arthritis score, pain/fatigue scores, mastery, depression, self-efficacy. | 8/52 | Increased frequency of exercise (p < 0.001) and relaxation (p = 0.05) in intervention group but not for those with depression or perceived low SES. | JBI 5/12 S/O 5/11 |
Govil 2009 | USA Insurance funded clinics | Cohort study | Cardiovascular disease | 785 | Individual and group 3/12 lifestyle programme Range of HCPs 1,3,4,5,6,7,8 | None | Blood pressure, lipids, exercise tolerance, BMI, depression, adherence. | 3/12 | Outcomes improved significantly p < 0.05 across all education and income levels. Adherence and attendance similar across all groups. Baseline measures were significantly lower in low educated. | JBI 9/11 |
Author2 | Country and setting | Study Design | Chronic Disease | Sample size | Intervention | Variables measured | Results | Quality rating |
---|---|---|---|---|---|---|---|---|
Poduval 2018 (Murray 2017) | UK Urban public primary care practices | Subgroup analysis of RCT | Diabetes | 299 (intervention group) | Comparing 2 internet SM programmes +/− support Predictors of use | Gender, age, ethnicity, education. | No difference in frequency of programme use or registration according to any demographic predictors. User characteristics were reflective of the overall target population of the area. | JBI 12/12 S/O 10/11 |
Thorn 2011 (Day 2010) | USA Rural public primary care practices | Subgroup analysis of RCT | Chronic pain | 109 | Low-literacy pain SM (education and CBT) groups. Drop-out predictors | Demographics, literacy, pain catastrophising, disability, depression, QOL, pain intensity/interference. | Dropout before programme started was associated with low education (p < 0.02), low literacy (p < 0.05) and catastrophising (p < 0.01); failure to complete programme associated with income (under/over $13,000 – p < 0.01) and low education (p < 0.02). | JBI 12/12 S/O 9/11 |
Dattalo 2012 (Boult 2011) | USA Primary care (both insured and public patients) | Subgroup analysis of RCT | Multimorbid chronic disease | 241 | Stanford CDSMP Completion predictors | Demographics, health status, health activities, patient activation, patient-rated quality of care. | 22.8% of eligible adults completed (attended at least 5 of 6 sessions). Attendance was associated with dissatisfaction with GP (OR = 2.8) and having higher SF-36 physical health scores (OR = 2.3). Age, sex, education, race and SES were not significant. | JBI 11/12 S/O 5/11 |
Cauch-Dudek 2014 | Canada National database analysis | Cohort | Diabetes –first 8/12 post diagnosis | 46,553 | Any type of DSME Participation predictors | Age, sex, immigrant status, comorbidity, mental illness, rural residence, SES | 22% of people attended DSME within 8/12 of diagnosis. Non- attendance was associated with older age, lower SES, recent immigration or physical/mental health comorbidity (all p < 0.001). | JBI 10/11 |
Adjei-Boakye 2018 | USA National telephone survey | Cross-sectional | Diabetes | 84,179 | Any type of diabetes SM education (DSME) Participation predictors | Race, education, marital status, income, sex, health insurance, BMI, insulin use, self-care behaviour. | 53.7% reported attending DSME, with attendance less likely amongst men (adjusted OR = 0.85), Hispanics (aOR = 0.81), high school only (aOR = 0.71) or less than high school educated (aOR = 0.51), income <$15,000 (aOR = 0.70) or < $25,000 (aOR = 0.81) and the uninsured (aOR = 0.87). Attending DSME was significantly associated with adherence to SM behaviours. | JBI 8/8 |
Glasgow 2018 | USA Database analysis (health insurance organisation) | Cross-sectional | Diabetes | 2603 | Internet SM programme Participation predictors | Socio-demographics, reason for declining service, HbA1c BP, BMI, lipids, SF36, ADL, number of comorbidities | Participants were likely to be younger (p = 0.041); not Latino (p = 0.002); earning >$30,000 (p < 0.0001), greater than high school educated (p < 0.0001), non-smokers (p < 0.0001) with lower blood pressure (p = 0.028). Self-selected participants were the most likely to be white, better educated and healthier. | JBI 8/8 |
Horrell 2017 | USA National database analysis | Cross-sectional | Multimorbid chronic disease | 19,365 | Stanford CDSMP Participation and completion predictors | Enrolment and completion of CDSMP compared to high/low SES area | 83.6% of participants lived in the least impoverished areas (< 25% of population below poverty line) and 0.3% of participants lived in the most impoverished areas (> 50% below poverty line). SE area was significantly correlated with ethnicity and education level. Course completion was not associated with SES – poorer people had a higher (but non-significant) completion rate. | JBI 8/8 |
Hardman 2018 | Australia Rural community health centre | Cross-sectional | Chronic pain | 186 | Tailored pain SM Drop-out predictors | Demographics, self-efficacy, pain catastrophising, opioid dose, comorbidities. | Early dropout associated with social stressors (p = 0.002/0.029, OR = 0.08/0.30); pain causal beliefs (p = 0.005, OR = 5.01) and pain catastrophising (p = 0.048, OR = 1.03) Low income significant in bivariate analysis (p = 0.011) only. | JBI 8/8 |
Kure-Beigel 2016 | Denmark Urban community health centre | Mixed:Cross-sectional + qualitative | Diabetes, COPD or CVD | 104 | Tailored SMS Drop-out predictors | Education, age, gender, cohabitation, whether 1st meeting cancelled. | Non-completion associated with younger age (below 60) (p = 0.03, OR = 3.38). Non-significant trend of lower education associated with lack of completion. Qualitative study suggested comorbidity and low job control in low educated were factors. | JBI 8/8 |
Santorelli 2017 | USA State-wide telephone survey (New Jersey) | Cross-sectional | Diabetes | 4358 | Any type of DSME Participation predictors | Age, sex, race, income. | 42% reported attending DSME, with attendance less likely amongst lower educated (high school or less), Hispanic or ‘other’ ethnicity, those diagnosed under 2 years ago (all p < 0.001); the uninsured (p < 0.004) and those without a HCP visit for diabetes in the past year (p < 0.002). DSME attendance was not correlated to the number of certified DSME courses available in the area. | JBI 6/8 |
Study | Theory behind intervention | Individual or group? | Intensity and duration | SES adaptions made (if any) | Demographics and SES status of population1 | SES subgroup Comparison | Results (in terms of SES only) | Dropout by group and SES | Impact on disparity |
---|---|---|---|---|---|---|---|---|---|
Rothman 2004 | CDSM in low SES groups is best managed by a multidisciplinary approach that is tailored to the patient’s needs and barriers. | Individual | 2–4 phone or direct contacts a month (mean 38 min/month) over 12/12 | Literacy adaptions, practical help to address barriers | Age: 56y mean Sex: 42%M Race: 67%EM Edu: 62% < 12 yrs. Income:74% < $20,000 Literacy: 38% ≤ 6th grade3 | Literacy – above/below 6th grade. Correlated to education, income and insurance status. | Significant HbA1c improvement with intervention for low literacy group only; high literacy group did not differ between I/C. | Dropout low both before (study refusals) and during intervention; no difference for I/C or SES. | Reduced |
De Walt 2012 | People with low literacy have knowledge deficits. SMS should be adapted for their needs and provide ongoing support until mastery is achieved. | Individual | Education session + ongoing phone support for 12/12 (mean 14 calls) | Literacy adapted, intervention length varied depending on need. | Age: 60y mean Sex: 52% M Race: 61% EM2 Edu: 26% < 12 yr Income: 68% < $25,000 Literacy: 41%3 low | Literacy (S-TOFHLA). Education and subjective SES also assessed in subgroups but were weaker predictors than literacy. | Phone support more effective in low literacy group, control intervention (education session) favoured high literacy. Literacy was a stronger predictor than education/income. | Dropout equal for I/C groups and did not differ by literacy. | Reduced |
Bosma 2010 | SMS is focussed on increasing control and returning responsibility to the patient | Individual | 2-10x1hr face-to-face sessions (mean 4) for 6/52 | Extra sessions if needed | Age: 70y mean Sex: 49% M Edu: 33% primary only | Education level (primary; some high school; completed high school). | No benefit for low educated. Gains only in higher educated groups. | Increased dropout from intervention in low educated. | Increased |
Moskowitz 2013 | Low SES patients have more challenges with SM and need assistance with literacy, depression and social support. | Individual | 0–29 phone or direct contacts (median 5) over 6/12 | Patients choose own coach, language and ethnicity catered for | Age: 56y mean Sex: 49%M Race: 55% EM Edu: 36% < 12 yr | Education (less than high school; high school; some college; college degree). | Benefit for those with low medication adherence and SM ability. Education level did not affect outcome. | Dropout low both before (study refusals) and during intervention; no difference for I/C or SES. | No change |
Powell 2010 | SMS groups aim to motivate people to participate in their care by teaching SM skills. | Group | 18x2hr over 12/12 | No | Age: 63y mean Sex: 53%M Race: 40% EM Edu: 44% ≤ 12 yr Income: 52% < $30,000 | Education (high school or less; above high school) and income (above/below $30000) | No improvement overall but low- income patients in intervention group had non-significant improvement on one outcome. | Dropout high both before and during intervention (in intervention group only); not reported by SES. | No change (n.s.reduction) |
Smeulders 2010 | The CDSMP aims to increase patient responsibility for SM by increasing self-efficacy. | Group | 6 × 2.5 h over 6/52 | No | Age: 67y mean Sex:72% M Edu:64% < 12 yr | Education (under or over 12 yr education). | Low educated improved more than high educated in cardiac QOL outcomes. | Dropout high before intervention (study refusals) but no difference during intervention between I/C. | Reduced |
Jonker 2012 | SMS works by increasing self-efficacy and improving one’s control over life and health. | Group | 6 × 2.5 h over 6/52 | No | Age: 82y mean Sex: 10%M Edu: 50% ≤ 9 yr | Education (over/under 9 years) | Lower educated improved on mastery (p < 0.05) but no other benefits from multiple outcomes. | Low dropout rate (but programme part of day-care centre activities). | Reduced (one outcome) |
Nour 2006 | Arthritis SM is achieved by Increasing knowledge and adopting health behaviours. | Individual | 6-7x1hr over 8/52 | No | Age: 77y mean Sex: 10%M Edu: 47% < 9 yr Perceived SES: 12% ‘financially insecure’ | Education (over/under 9 years) and perceived SES | Overall minor gains, but not for those with depression or perceived low SES. | Low dropout rate | Increased |
Govil 2009 | SMS aims to make lifestyle changes and improve health habits. | Both | 104 h over 3/12 (4 h, 2x/week) | No | Age: 60y mean Sex: 67%M Race: 5% EM Edu: 4% < 12 yr Income: 22% < $25,000 | Education (high school or less; some college; college degree; postgrad degree). | All benefited equally – no difference across education levels, although lower educated had lower baseline measures. | High attendance, low dropout, unrelated to SES | No change |
Study | Study question | Outcome | Intervention Description | SES adaptions made (if any) | SES status of population | Results (in terms of SES) | Impact on disparity |
---|---|---|---|---|---|---|---|
Poduval 2018 | Can a DSME internet intervention engage people of differing demographics without increasing health inequity? | Use (more than 2 log-ins post registration) | Internet SM programme + email/text support and assistance to register and access site | Low literacy, developed with input from target population | Age: 58y mean Sex: 55.5%M Race: 55%EM Edu: 30% < 12 yr | No difference in use according to education. Users were reflective of the target population (inner London). | No change |
Thorn 2011 | Is pain SMS (CBT or education) effective in low SES groups and what are the predictors of engagement? | Initial participation and dropout | SMS groups CBT and education for 10 × 1.5 h over 10/52 | Literacy adaptations and teaching | Age: 53y mean Sex: 20%M Race: 79%EM Income:86% < $30,000 Literacy score: mean 21% (50% is population mean) | Non-attendance associated with low education, literacy and income; dropout associated with low income. | Increased |
Dattalo 2012 | Which subgroups of multimorbid older adults are most likely to attend CDSMPs? | Completion (attend 5 or more sessions) | Stanford CDSMP 6 × 2.5 h | None | Age: 67-95 yr Sex: 43%M Race: 51.8%EM Edu: 24% < 12 yr Other SES: 42% ‘financial strain’ | No effect of SES variables on course completion | No change. |
Cauch-Dudek 2014 | Are there disparities in utilisation of DSME soon after diagnosis? | Initial participation | Certified public health DSME programmes | Unspecified (multiple programmes) | All diabetics in Ontario, Canada diagnosed from Jan-June 2006 and followed up for 8/12. | Low SES area associated with increase in non-attendance, p < 0.001. | Increased |
Adjei Boakye 2018 | Are there are subgroups who do not participate in diabetes SM education (DSME)? | Initial participation | Diabetes SM education (DSME) - unspecified | Unspecified (multiple programmes) | Cross section of US population with diabetes | Non-participation associated with low education and low income; association stronger as education/income reduced. | Increased |
Glasgow 2018 | How representative of the diabetes population are those who participate or volunteer for an internet DSME study? | Initial participation | Internet DSME programme +/− support (phone calls and groups) | Available in 2 languages, no specific SES adaption | Age: 58y mean Sex: 50%M Race: 31%EM Edu: 34% ≤ 12 yrs. Income: 29% < $30,000 | Higher income and education increased chance of participation, especially for self-selected people | Increased |
Horrell 2017 | Do those in low income areas attend CDSMPs and how can we promote higher enrolment? | Initial participation and completion | Stanford CDSMP 6 × 2.5 h | None | USA attendees of CDSMP courses Age: 58y mean 83.6% of attendees lived in the least impoverished areas. | Lowest SE area was associated with low participation (0.3% of participants) but not with low completion. | Increased (participation) No change (completion) |
Hardman 2018 | Do the social determinants of health affect engagement with pain SMS programmes? | Dropout (attend 3 or less sessions) | CBT-informed tailored SMS, individual or group | Programme tailored to preference/need | Age: 55y mean Sex: 42%M Income: 82% on welfare benefit Other SES: 27% ‘social stressor’ | Income not significant post-regression but social stressors (substance abuse history, victim of abuse/assault) significantly associated with dropout. | Increased |
Kure-Beigel 2016 | Is there a social difference between those who do and don’t complete SMS programmes? | Course completion | Tailored SMS individual or group over 6–12 weeks | Programme tailored to preference/need | Age: 78% > 60 yrs. Sex: 50%M Edu: 57% < high school graduate | Education not significant post-regression but qualitative interviews suggested social factors (job/carer demands) were important. | No change - suggestive of increase |
Santorelli 2017 | What determines DSME participation and is it affected by the availability of DSME services? | Initial participation | DSME – unspecified type. | Unspecified (multiple programmes) | Survey sample of people living in New Jersey with diabetes | Lack of participation correlated with low education and ethnicity (p < 0.001) but not with income. | Increased |