OBJECTIVE -To identify and synthesize evidence about the effectiveness of patient, provider, and health system interventions to improve diabetes care among socially disadvantaged populations.RESEARCH DESIGN AND METHODS -Studies that were included targeted interventions toward socially disadvantaged adults with type 1 or type 2 diabetes; were conducted in industrialized countries; were measured outcomes of self-management, provider management, or clinical outcomes; and were randomized controlled trials, controlled trials, or before-and-after studies with a contemporaneous control group. Seven databases were searched for articles published in any language between January 1986 and December 2004. Twenty-six intervention features were identified and analyzed in terms of their association with successful or unsuccessful interventions.RESULTS -Eleven of 17 studies that met inclusion criteria had positive results. Features that appeared to have the most consistent positive effects included cultural tailoring of the intervention, community educators or lay people leading the intervention, one-on-one interventions with individualized assessment and reassessment, incorporating treatment algorithms, focusing on behavior-related tasks, providing feedback, and high-intensity interventions (Ͼ10 contact times) delivered over a long duration (Ն6 months). Interventions that were consistently associated with the largest negative outcomes included those that used mainly didactic teaching or that focused only on diabetes knowledge.CONCLUSIONS -This systematic review provides evidence for the effectiveness of interventions to improve diabetes care among socially disadvantaged populations and identifies key intervention features that may predict success. These types of interventions would require additional resources for needs assessment, leader training, community and family outreach, and follow-up. Diabetes Care 29:1675-1688, 2006D iabetes affects at least 171 million people worldwide and is dramatically increasing in many countries as a consequence of increased obesity, sedentary lifestyle, and aging populations (1). Certain population subgroups are at higher risk of acquiring diabetes including nonwhite ethno-racial groups and those with low socioeconomic status (SES) (2). These same groups are often at higher risk of late diagnosis, poor diabetes control and self-management, the development of diabetes-associated complications, and more frequent emergency room visits and hospitalizations (3-8).Interventions to improve diabetes outcomes can be directed at individuals with diabetes, health providers, or the health system. Patient-level interventions include those directed at improved selfmanagement, including medication taking, diet, exercise, self-monitoring, and appropriate use of health care services (9). Continuing professional education and knowledge translation activities are examples of strategies intended to improve health provider care (10 -13). Health system changes with the potential to improve access to care and quality...
Quantitative assessment of climatic and environmental health risks is necessary because changes in climate are expected. We therefore aimed to quantify the relationship between climatic extremes and mortality in the 5 largest Australian cities during the period [1979][1980][1981][1982][1983][1984][1985][1986][1987][1988][1989][1990]. We then applied the relationship determined between recent climatic conditions and mortality to scenarios for climate and demographic change, to predict potential impacts on public health in the cities in the year 2030. Data on mortality, denominator population and climate were obtained. The expected numbers of deaths per day in each city were calculated. Observed daily deaths were compared with expected rates according to temperature thresholds. Mortality was also examined in association with temporal synoptic indices (TSI) of climate, developed by principal component and cluster analysis. According to observed-expected threshold analyses, for the 5 cities combined, the annual mean excess of deaths attributable to temperature over the period [1979][1980][1981][1982][1983][1984][1985][1986][1987][1988][1989][1990] was 175 for the 28°C threshold. This sum of statistically significant differences from the 5 cities was the greatest excess found in association with any threshold considered in the range of temperatures that occur. Excess mortality for the hottest days in summer was greater than for the coldest days in winter. Temperature-mortality relationships were little modified by socio-economic status. TSI analyses produced similar results: using this method, the climate-attributable mortality in the 5 cities was approximately 160 deaths yr -1 , although this number was evenly distributed across summer and winter. Persons in the group aged 65 yr and older were the most vulnerable. After allowing for increases in population, and combining all age groups, the synoptic method showed a 10% reduction in mortality in the year 2030. We conclude that the 5 largest Australian cities exhibit climate-attributable mortality in both summer and winter. Given the scenarios of regional warming during the next 3 decades, the expected changes in mortality due to direct climatic effects in these major coastal Australian cities are minor.
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