BackgroundBrief automated messages have the potential to support self-management in people with type 2 diabetes, but their effect compared with usual care is unclear.ObjectiveTo examine the effectiveness of interventions to change lifestyle behavior delivered via automated brief messaging in patients with type 2 diabetes.MethodsA systematic literature review of controlled trials examined the impact of interventions, delivered by brief messaging, and intended to promote lifestyle change in people with type 2 diabetes, on behavioral and clinical outcomes. Bibliographic databases searched included Medline, Embase, CINAHL, PsycINFO, and ISI WoK. Two reviewers independently screened citations. We extracted information on study risk of bias, setting (high versus low- and middle-income countries) and intervention characteristics (including use of theory and behavior-change techniques). Outcome measures included acceptability of the interventions and their impact on 1) determinants of lifestyle behavior (knowledge about diabetes, self-efficacy, attitudes towards self-management), 2) lifestyle behavior (diet, physical activity), and 3) clinical and patient-reported outcomes. Where possible, we pooled data using random-effects meta-analyses to obtain estimates of effect size of intervention compared to usual care.ResultsWe identified 15 trials (15 interventions) meeting our inclusion criteria. Most interventions were delivered via short message service text messaging (n=12) and simultaneously targeted diet and physical activity (n=11). Nine interventions consisted of unidirectional messages, whereas six consisted of bidirectional messages, with patients receiving automated tailored feedback based on self-reported data. The acceptability of the interventions, and their impact on lifestyle behavior and its determinants, were examined in a low proportion of trials, with heterogeneous results being observed. In 13 trials (1155 patients) where data were available, there was a difference in glycated hemoglobin of -0.53% (95% CI -0.59% to -0.47%) between intervention groups compared to usual care. In five trials (406 patients) there was a non-significant difference in body mass index of -0.25 kg/m2 (95% CI -1.02 to 0.52). Interventions based on unidirectional messages produced similar effects in the outcomes examined, compared to those based on bidirectional messages. Interventions conducted in low- and middle-income countries showed a greater impact than those conducted in high-income countries. In general, trials were not free of bias and did not use explicit theory.ConclusionsAutomated brief messages strategies can improve health outcomes in people with type 2 diabetes. Larger, methodologically robust trials are needed to confirm these positive results.

Background Competent end-of-life care is an essential component of total health care provision, but evidence suggests that it is often deficient. This study aimed to evaluate the knowledge and attitudes about key end-of-life issues and principles of good death among doctors in clinical settings. Methods A cross-sectional study was conducted among allopathic medical doctors working in in-ward clinical settings of tertiary care hospitals in Sri Lanka using a self-administered questionnaire with open- and close-ended questions as well as hypothetical clinical scenarios. Univariate and logistic regression analysis were used to identify the independent factors associated with knowledge and attitudes. Results Of the responders who had not been a caregiver for a terminally ill relative (n = 390), 57.9% were men with a mean age of 36.5 years (SD = 8.2). Compared to undergraduate (65.6%; n = 256), only 27.4% (n = 107) had received end-of-life care training at postgraduate level. Only 65.9% of doctors favoured disclosing terminal prognosis to patients; 27.7% of doctors were aware of advance directives; 14.6% were aware of the correct time of death when certifying brain death; 70.3% felt more comfortable in withholding than withdrawing life-sustaining treatment; 61.3% were aware of do-not-attempt cardiopulmonary resuscitation (DNACPR) decisions while 26.7% felt reluctant to administer it; 15.1% thought that all life-sustaining therapy should be withdrawn with a DNACPR decision; and only17.9% were able to name the four principles of medical ethics while 57.9% could not name a single. Participants scored a mean of 9.2 (SD = 3.9) of a maximum 14 points when tested on principles of a ‘good death’. Doctors who had pursued postgraduate studies were more likely to be aware of breaking bad news (adjusted-Odds-Ratio:1.99; 95%CI = 1.19–3.32), advance directives (adjusted-OR: 4.15; 95%CI = 2.49–6.94), aware of certifying the correct time of death (adjusted-OR:2.37; 95%CI = 1.33–4.2) and less reluctant to make DNACPR decisions (adjusted-OR:1.74; 95%CI = 1.13–2.68). Doctors who had worked in ICU were more comfortable withholding than withdrawing treatment (adjusted-OR:1.99; 95%CI = 1.2–3.31). Conclusions Knowledge and attitudes about end-of-life care, good death and principles of medical ethics among doctors in Sri Lanka were suboptimal. Structured training of end-of-life care needs to be integrated within curricula and in-service training.

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