Effectiveness of Multilevel and Multidomain Interventions to Improve Glycemic Control in U.S. Racial and Ethnic Minority Populations: A Systematic Review and Meta-analysis

Abstract

BACKGROUND Racial and ethnic disparities in type 2 diabetes outcomes are a major public health concern. Interventions targeting multiple barriers may help address disparities. PURPOSE To conduct a systematic review and meta-analysis of diabetes self-management education (DSME) interventions in minority populations. We hypothesized that interventions addressing multiple levels (individual, interpersonal, community, and societal) and/or domains (biological, behavioral, physical/built environment, sociocultural environment, and health care system) would have the greatest effect on hyperglycemia. DATA SOURCES We performed an electronic search of research databases PubMed, Scopus, CINAHL, and PsycINFO (1985–2019). STUDY SELECTION We included randomized controlled trials of DSME interventions among U.S. adults with type 2 diabetes from racial and ethnic minority populations. DATA EXTRACTION We extracted study parameters on DSME interventions and changes in percent hemoglobin A1c (HbA1c). DATA SYNTHESIS A total of 106 randomized controlled trials were included. Twenty-five percent (n = 27) of interventions were exclusively individual-behavioral, 51% (n = 54) were multilevel, 66% (n = 70) were multidomain, and 42% (n = 45) were both multilevel and multidomain. Individual-behavioral interventions reduced HbA1c by −0.34 percentage points (95% CI −0.46, −0.22; I2 = 33%) (−3.7 [−5.0, −2.4] mmol/mol). Multilevel interventions reduced HbA1c by −0.40 percentage points (95% CI −0.51, −0.29; I2 = 68%) (−4.4 [−5.6, −3.2] mmol/mol). Multidomain interventions reduced HbA1c by −0.39 percentage points (95% CI −0.49, −0.29; I2 = 68%) (−4.3 [−5.4, −3.2] mmol/mol). Interventions that were both multilevel and multidomain reduced HbA1c by −0.43 percentage points (95% CI −0.55, −0.31; I2 = 69%) (−4.7 [−6.0, −3.4] mmol/mol). LIMITATIONS The analyses were restricted to RCTs. CONCLUSIONS Multilevel and multidomain DSME interventions had a modest impact on HbA1c. Few DSME trials have targeted the community and society levels or physical environment domain. Future research is needed to evaluate the effects of these interventions on outcomes beyond HbA1c.