Capsule Commentary on Njeru et al., Diabetes Mellitus
Management Among Patients with Limited English Proficiency:
a Systematic Review and Meta-analysis
Amy Cunningham, PhD, MPH
Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
J Gen Intern Med 33(6):947
© Society of General Internal Medicine 2018
imited English proficiency (LEP) is associated with nu-
merous health disparities, including poorer glycemic con-
trol in LEP patients with diabetes.
In this issue, Njeru et al.
report findings from a systematic review and meta-analysis
of diabetes self-management education (DSME) interven-
tions in LEP populations. In their meta-analysis, DSME
interventions were associated with a significant lower he-
(− 0.84% [95% CI, − 0.97 to − 0.71]) than
usual care. Interventions lasting less than 6 months and
using in-person delivery were more likely to demonstrate
improvements in hemoglobin A
. Improvements in self-
efficacy, quality of life, and several other measures were
This systematic review and meta-analysis is the first to
examine the impact of DSME in LEP populations, and in-
cludes a sizable number of articles. The clinically significant
reduction in hemoglobin A
and positive effects on self-
efficacy and quality of life are encouraging findings that are
consistent with prior meta-analyses of DSME’seffectinthe
and in racial and ethnic minority groups.
The study also has several notable limitations. Nearly half of
the included studies were non-randomized designs. Addition-
ally, none of the interventions enrolled exclusively LEP par-
ticipants, and for nearly half of included studies, LEP partic-
ipation rates were Binferred^ from demographics tables or the
article text. Furthermore, nearly all studies (94%) offered LEP
accommodations, such as language-concordant staff or trans-
lated materials, but it was unclear which accommodations
were most helpful to participants. Finally, the overall hetero-
geneity of the interventions, including delivery methods and
intensity, precludes conclusions about the most effective
DSME designs for LEP populations.
The findings from Njeru et al.
suggest fruitful avenues for
future research. Overall, the LEP population in the USA is
very linguistically and culturally heterogeneous with substan-
tial variations in country of origin, education level, and socio-
Development and evaluation of DSME for
specific LEP sub-populations would strengthen the evidence
for DSME’s impact on LEP participants and clarify the most
effective intervention components for different groups. For
clinicians and health educators, understanding their local
LEP populations and working with community partners is
critical to designing linguistically and culturally appropriate
DSME to meet the needs of this vulnerable population.
Corresponding Author: Amy Cunningham, PhD, MPH; Department
of Family and Community Medicine Thomas Jefferson University,
Philadelphia, PA, USA (e-mail: Amy.Cunningham@jefferson.edu).
Compliance with Ethical Standards:
Conflict of Interest: The author declares that she does not have a
conflict of interest.
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Published online April 9, 2018