title: Diabetes self-management arrangements in Europe: a realist review to facilitate a project implemented in six countries.
abstract: BACKGROUND
  Self-management of long term conditions can promote quality of life whilst delivering benefits to the financing of health care systems. However, rarely are the meso-level influences, likely to be of direct relevance to these desired outcomes, systematically explored. No specific international guidelines exist suggesting the features of the most appropriate structure and organisation of health care systems within which to situate self-management approaches and practices. This review aimed to identify the quantitative literature with regard to diabetes self-management arrangements currently in place within the health care systems of six countries (The United Kingdom, The Netherlands, Norway, Spain, Bulgaria, and Greece) and explore how these are integrated into the broader health care and welfare systems in each country.
  
  
  METHODS
  The methodology for a realist review was followed. Publications of interest dating from 2000 to 2013 were identified through appropriate MeSH terms by a systematic search in six bibliographic databases. A search diary was maintained and the studies were assessed for their quality and risk of bias.
  
  
  RESULTS
  Following the multi-step search strategy, 56 studies were included in the final review (the majority from the UK) reporting design methods and findings on 21 interventions and programmes for diabetes and chronic disease self-management. Most (11/21, 52%) of the interventions were designed to fit within the context of primary care. The majority (11/21, 52%) highlighted behavioural change as an important goal. Finally, some (5/21, 24%) referred explicitly to Internet-based tools.
  
  
  CONCLUSIONS
  This review is based on results which are derived from a total of at least 5,500 individuals residing in the six participating countries. It indicates a policy shift towards patient-centred self-management of diabetes in a primary care context. The professional role of diabetes specialist nurses, the need for multidisciplinary approaches and a focus on patient education emerge as fundamental principles in the design of relevant programmes. Socio-economic circumstances are relevant to the capacity to self-manage and suggest that any gains and progress will be hard to maintain during economic austerity. This realist review should be interpreted within the wider context of a whole systems approach regarding self-care support and chronic illness management.
authors.forename: Antonis A
authors.initials: AA
authors.lastname: Kousoulis
authors.forename: Evridiki
authors.initials: E
authors.lastname: Patelarou
authors.forename: Sue
authors.initials: S
authors.lastname: Shea
authors.forename: Christina
authors.initials: C
authors.lastname: Foss
authors.forename: Ingrid A
authors.initials: IA
authors.lastname: Ruud Knutsen
authors.forename: Elka
authors.initials: E
authors.lastname: Todorova
authors.forename: Poli
authors.initials: P
authors.lastname: Roukova
authors.forename: Mari Carmen
authors.initials: MC
authors.lastname: Portillo
authors.forename: María J
authors.initials: MJ
authors.lastname: Pumar-Méndez
authors.forename: Agurtzane
authors.initials: A
authors.lastname: Mujika
authors.forename: Anne
authors.initials: A
authors.lastname: Rogers
authors.forename: Ivaylo
authors.initials: I
authors.lastname: Vassilev
authors.forename: Manuel
authors.initials: M
authors.lastname: Serrano-Gil
authors.affiliation: Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Voutes, P,O, Box 2208, Heraklion 71003, Greece. lionis@galinos.med.uoc.gr.
authors.forename: Christos
authors.initials: C
authors.lastname: Lionis
mesh_terms: D003920:Diabetes Mellitus / Q000628:therapy*; D005060:Europe; D057220:Health Literacy; D006801:Humans; D010353:Patient Education as Topic; D012648:Self Care