Identification and selection of the studies

In total, 358 studies were identified (Figure 1). Of these, 37 duplicate articles were excluded, 321 studies being included for reading the title and abstract. Of those 321, 290 studies were excluded because they did not meet the objectives of the type of patient, type of study, educational intervention, location, or results found. Of the 31 remaining studies included for full text reading, 14 articles that did not meet the criteria established in the PICO strategy were excluded. Finally, seventeen studies meet the eligibility criteria for inclusion in this scoping review.

Figure 1 Flow diagram of study selection process 

Characteristics of studies included

Of the 17 studies included in the SR. The studies were carried in 11 countries; of these, 65% of the studies were conducted in high-income countries, the rest being from low- and middle-income countries. These studies were published between 2010 and 2020. In relation to the type of study, it was found that 13 of the studies were randomized controlled trials and four cluster-randomized trials. Sample sizes ranged from 76 to 1589, with a mean of 344. The included studies were followed up for different periods, ranging from the first month after the intervention to 24 months. Studies with follow-up at 3, 6, and 12 months predominated. Although educational interventions showed a wide diversity, common strategies were found, such as education for diabetes control, a diabetes adherence and empowerment program, activities that included the individual, family, and communities. Education focused on the knowledge of the disease, warning signs, diet, and self-care practices. Regarding the control group, it was evident that all studies included standard care, that is, usual care. Educational interventions for the management of adults with DM2 were identified, which were grouped into four large categories, with the goal of projecting a better understanding of this review and a more delimited guide that serves health professionals in the implementation of interventions that respond to the needs identified in their practical environments.

Therapeutic adherence

Therapeutic adherence has historically represented one of the most important elements in the care of patients with DM2 and, with it, the execution of adequate treatment and control of the disease. Therefore, different countries have focused their educational intervention programs on adequate therapeutic adherence and, with this, seek to contribute to the management of DM2.¹² Thus, as a study aimed to provide training to community health workers on the pathophysiology of the disease, risk factors for DM2, and lifestyle strategies with an impact on glycemic control (nutrition, exercise, physical activity, and prevention of diabetic complications), this educational intervention, which was received by the professionals who guided the patients with DM2, allowed a greater adherence to the treatment, which consequently brought the improvement of the blood glucose levels of the study participants.

In the United States, a study which carried two groups through an intervention using two guides on educational intervention for DM2 (one of the groups used the kit designed to improve diabetes education in the intervention, sessions were carried out that included updating on diabetes and instruction on techniques to improve communication in health, and the second group received guidance based on the National Health Program as an intervention. Diabetes Education to carry out discussions for the care of the disease) found that after these interventions in patients with diabetes, satisfaction with treatment presented significant results (3.93 [95% confidence interval (CI), 2.48-6.21]; p<0.001 versus 3.04 [95% CI, 1.93-4.77]; p<0.001), improving adherence to treatment.¹⁶⁾ Another study through the delivery of material created by an interdisciplinary group based on the American Diabetes Association and the American Association of Diabetes Educators, was carried out with an educational intervention in small groups with 45-minute sections, focused on the self-care of “healthy eating, being active, regular blood sugar control, taking medication on time, problem solving, risk reduction and healthy coping,” resulting in 2% adherence to medication for control of blood glucose levels by the participants.²⁷

Self-care and self-management in diabetes

The evidence has shown the high morbidity rate that diabetes mellitus represents. In this sense, the implementation of educational interventions that are focused on the proper management of it will consequently allow a positive impact on the self-care of patients. Thus, a study that applied the theory of self-efficacy in the self-care behavior with the feet in adults with DM2, allowed to obtain improvements in the performance and indirect experience of the physical and emotional states and verbal persuasion of the participants.¹⁷The application of this theory has shown significant results in self-care and knowledge of DM2 when comparing the intervention group to which the theory was applied and the control group that received standard treatment (p<0.01).¹⁶⁾ Structured education programs in primary health care settings have shown the effectiveness of self-care practices and a significant improvement of 33.5% [95% CI: 22.9-44.0].²⁷ This, therefore, shows foot care’s considerable relevance since it seeks to also impact the patient's own self-care and thereby improve knowledge about the disease, which has led to significant results at 6 at 12 months of intervention (p<0.01).²²⁾ On the other hand, adherence and empowerment are indicators that can present improvement through self-care practices. A study carried out in Brazil implemented a strategy of group education and family visits. This group education strategy produced better results in relation to glycemic control and diabetes self-care.¹⁸ Through educational interventions, it has also been shown that knowledge about diabetes significantly increased in the group that received the educational intervention versus the control group (where it decreased), with the difference-in-difference model (DID) equal to (0.91 [95% CI: 0.64-1.18], p<0.001).¹³ Likewise, a study found that community-based, peer-supported education shows a significant reduction in diabetes distress (p<0.001).¹⁵

Glycemic control of diabetes

The versatility of measures such as web applications for the education of patients with DM2 that have allowed a significant reduction in HbA1C (p=0.004).¹⁵ A study with the intervention with web portals showed a mean decrease in glycated hemoglobin of 1.9% in contrast to standard care 0.7%, which has a variance of 1.2% (p=0.001) at 12 months.²⁴ The literature has been consistent in demonstrating the positive results of group programs for education in patients with DM2. Two studies showed significant results (p<0.001) in the reduction of glycated hemoglobin compared to other interventions, such as home visits, or standard care.^16,21 Interventions in structured groups have also made it possible to improve the knowledge of patients in relation to DM2, and with this, they have prevented the elevation of HbA1C.²⁰⁾ The inclusion of cultural aspects in educational interventions in a Latino population residing in the United States achieved a significant reduction in the HbA1C difference at 3 months (p=0.043), followed by a reduction difference at 6 months (p=0.05) and finally at 18 months (p=0.009).¹² Similarly, a culturally adapted self-care coaching intervention for racial/ethnic minority populations showed significant improvement in blood glucose levels.²²⁾ Likewise, the individualized educational intervention in a study carried out in Austria showed significant reductions in weight and cholesterol, but it did not significantly influence metabolic control measured by HbA1C after one year.²⁵ With this, physical activity advice as an educational intervention has been effective in promoting a significant reduction in HbA1C 0.5% (p<0.01). Additionally, it has left positive results in glycemic control and the health of patients with DM2.²³ These types of activities that provide accompaniment and support in lifestyle have shown that it is possible to obtain a significant reduction in HbA1C (p=0.02) and in random blood glucose levels (p=0.03), compared to standard care. Thus, approaching the patient as an integral being through empowerment and commitment undoubtedly allows for even more successful interventions for diabetes self-management.^19,26)

Nursing and its role in educational interventions in patients with DM2

In the development of educational interventions, the multidisciplinary health team plays a fundamental role. However, it is recognized that nursing professionals have a differentiated scope within the team. Patient-centered interventions, which have the execution and accompaniment of the nursing staff, have allowed patients to self-identify their challenges and thus together be able to develop different strategies to overcome them.²⁶⁾ It has also been shown that the educational strategies that are stimulated by other educational components outside the standard, and that guide the restructuring of behaviors, through education on the disease process, prescribed medication, diet, prescribed exercise, and improvement in coping with the disease by nursing professionals in the care of patients with DM2, it has generated encouraging results.²⁸ A study showed the importance of having professionals who have vast experience in education on DM2 through various structured and individualized educational interventions. The participants and their caregivers improved autonomy, allowing greater metabolic control and achievement of their long-term therapeutic goals.¹⁴⁾ Educational interventions have shown a great role in the care of diseases. The evidence showed that the performance of the nursing professional in the execution of these interventions prevents the increase in HbA1C in patients with diabetes. This is possible through the training of groups with patients with DM2, through familiarization and training in diabetic education for the identification of risk factors, and the non-compliance with pharmacological treatment when compared to other educating agents.²⁰

Risk of bias of the studies included

The results of the analysis of the quality of the included studies is presented in Table 2, performed based on the parameters evaluated by RoB 1 in the 17 included studies. 88% described adequate random sequence generation^{12-16,18-20,22-28} and 23% described allocation concealment.^17,24,25,28 Only two articles described blinding of participants and staff,^12,28 and 23% described blinding of outcome assessment.^12,14,20,28 Regarding the risk of selective reporting of results, it was shown that 76% described the proposed results from the beginning^{12-14,16-18,20-22,25-28} (Figure 2 and Table 2). According to the JBI, the level of evidence of the 17 studies was 1C.

Figure 2 Methodological quality of individual studies