It is now time to synthesize the evidence by identifying patterns, strengths, and limitations of evidence entries contained in your Summary of Evidence Table. Review Appendix H, Synthesis and Recommen

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It is now time to synthesize the evidence by identifying patterns, strengths, and limitations of evidence entries contained in your Summary of Evidence Table. Review Appendix H, Synthesis and Recommendation Tool, to summarize best evidence recommendations to address the PICO question.

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It is now time to synthesize the evidence by identifying patterns, strengths, and limitations of evidence entries contained in your Summary of Evidence Table. Review Appendix H, Synthesis and Recommen
Summary Evidence Table EBP Question: For type II diabetics in impoverished communities, is the implementation of self-management effective? impoverished community. Author and Date Title of Article Population, size (n) Setting Type of Evidence Description of Intervention Outcome Measures Findings that Help Answer the EBP Question Limitations Evidence Level and Quality Implications for Proposed Project Authors: Margaret A. Powers, Joan Bardsley, Marjorie Cypress, Paulina Duker, Martha M. Funnell, Amy Hess Fischl, Melinda D. Maryniuk, Linda Siminerio, & Eva Vivian Publication Date: 5 June 2015 Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics N/A N/A Literature Review This is a study of a given phenomenon through a thorough survey of peer-reviewed articles. Quality of life. Type II diabetes is a burdensome and complex disease that demands individuals to make rational health decisions to maintain a healthy lifestyle. The implementation of self-management is therefore effective for diabetics in rural communities where they would have difficulty accessing healthcare resources. This literature review did not incorporate a section highlighting the limitation. Nonetheless, there are minor differences between the findings of these articles. The findings of this article are consistent and hence adequate to be used in the project. This article will help build on the research concerning the importance of introducing self-management care for diabetes type II in impoverished communities. Authors: Morgan Griesemer Lepard, Alessandra L. Joseph, April A. Agne & Andrea L. Cherrington Publication Date: 7 May 2015 Diabetes Self-Management Interventions for Adults with Type 2 Diabetes Living in Rural Areas: A Systematic Literature Review N/A N/A Literature Review This is a study of a given phenomenon through a thorough survey of peer-reviewed articles. Rates of type II diabetes The authors found that in impoverished communities, there are higher rates of type II diabetes due to limited access to diabetes education, health services, and community resources. However, interventions such as collaborative goal-setting and motivational support are likely to enhance the metabolic control of a diabetic. Possible publication bias. Difficulty comparing data from several articles. The interventions analyzed were of different lengths and designed for several cultural groups hence making it difficult to compare the studies. The evidence provided by this article is sufficient, however, the inconsistencies in the results in different articles interfere with the validity of the results. The findings from this article will be used to build on the research since the results indicate that there is a positive impact of self-management care for diabetics in rural communities. Authors: Roger Carpenter, Toni DiChiacchio & Kendra Barkera Publication Date: 10 Jan 2019 Interventions for self-management of type 2 diabetes: An integrative review N/A N/A Integrative review It is a methodology that summarizes past theoretical and empirical literature to offer a comprehensive comprehension of a phenomenon. HbA1c level. A significant amount of literature showed that self-management has a short-term improvement in distress reduction and glycemic control. Due to the exhaustive nature of the existing evidence on this phenomenon, it is difficult to be informed about the entire body of literature on this topic. The evidence offered by this article is inadequate because different articles reveal different results on the efficacy of self-management in diabetes care. Implications remain inconclusive. Authors: Fadli, F. Publication Date: 2022 The Impact of Self-Management-Based Care Interventions on Quality of Life in Type 2 Diabetes Mellitus Patients: A Philosophical Perspective N/A N/A Literature Review This is a study of a given phenomenon through a thorough survey of peer-reviewed articles. The quality of life of type 2 diabetes mellitus patients. Most articles indicated an increase in the quality of life and self-care behaviors among type 2 diabetes patients after being subjected to self-management interventions. Some articles did not indicate a major difference in the quality of life among diabetics utilizing self-management in impoverished communities. The article provides valid evidence because most of the articles reviewed provided similar results. Since this article indicates a positive relationship between self-management and diabetics in impoverished societies, it will be used to build research on the topic. Authors: Burd, C., Gruss, S., Albright, A., Schumacher, P. & Alley, D. Publication Date: 28 Jan 2022 Translating knowledge into action to prevent type 2 diabetes: Medicare expansion of the National Diabetes Prevention Program lifestyle intervention. Over 3,000 adults RCT groups Literature Review This is a study of a given phenomenon through a thorough survey of peer-reviewed articles. Rate of Diabetes Type II among groups using medicine and self-management. The self-management group indicated a 71% rate of reducing the effects of diabetes type II while the group using metformin indicated a 31% likelihood of managing the disease. Racial inequality because a majority of the respondents were not at a high risk of developing diabetes type 2. High-quality evidence because there are expert opinions from Medicaid Innovation Center. Results will help answer the EBP question and build on the research. Authors: Yamaoka, K., Nemoto, A., & Tango, T. Publication Date: 19 June 2019 Comparison of the Effectiveness of Lifestyle Modification with Other Treatments on the Incidence of Type 2 Diabetes in People at High Risk: A Network Meta-Analysis n=113 Online research PUBMED database Meta- analysis An epidemiological, formal, and quantitative study design is utilized to systematically analyze the findings of past research on a given topic. Quality of life of diabetics. Findings indicate that self-management through lifestyle modifications help prevent the progression of type 2 diabetes. The type of education training utilized was ununiform among different studies. The study only used PUBMED in the review. Good quality of evidence because the sample used was adequate. However, some articles provide inconsistent results. The findings will be used to supplement the findings of other articles on the same topic. Authors: Kerrison, G., Gillis, R. B., Jiwani, S. I., Alzahrani, Q., Kok, S., Harding, S. E., Shaw, I. & Adams, G. G. Publication Date: 16 Apr 2017 The Effectiveness of Lifestyle Adaptation for the Prevention of Prediabetes in Adults: A Systematic Review Population: 1,780 studies n:9 studies Electronic Databases such as CENTRAL, Cochrane, PsycINFO, EMBASE, MEDLINE, CINAHL Systematic Review Summary of literature that use reproducible and explicit methods to synthesize, critically appraise, and search a particular issue. Glycemic control, weight changes, BMI, and physical exercise capacity. Self-management such as changing lifestyle behaviors helps minimize the incidence of diabetes type 2. Minor differences in the findings of the studies. High-quality evidence These results will help formulate the final project’s report on the efficacy of self-management in individuals with diabetes type II. Authors: Walker, R. J., Strom Williams, J., & Egede, L. E. Publication Date: April 2016 Influence of Race, Ethnicity, and Social Determinants of Health on Diabetes Outcomes N/A N/A Systematic Review Summary of literature that use reproducible and explicit methods to synthesize, critically appraise, and search a particular issue. Quality of life Even though the findings of this article do not address the evidence-based question directly, it helps highlight factors that might affect certain groups from receiving treatment such as economic classes. Limited evidence on how ethnicity and race affect the quality of health outcomes of diabetics in impoverished communities. The evidence provided is of moderate quality. The findings of this article could be used to explain some of the factors that prevent diabetics in impoverished communities from accessing medical care services. This will help indicate a need for the implementation of self-management. Authors: Delahanty, L. M., Peyrot, M., Shrader, P. J., Williamson, D. A., Meigs, J. B., Nathan, D. M., & DPP Research Group. Publication Date: 2013 Pretreatment, Psychological, and Behavioral Predictors of Weight Outcomes Among Lifestyle Intervention Participants in the Diabetes Prevention Program (DPP) n: 274 DPP community centers Randomized clinical trial Assigning respondents to different groups (control group and treatment group) that receive different treatments. Weight loss. Self-efficacy, healthy diets, and greater exercise helped 40.5% of the participants in the Diabetes Prevention Program (DPP) achieve their weight loss goal. The participants in this study did not fully represent all diabetics trying to lose weight. The evidence provided is high quality. These findings show that self-management could help diabetes manage the disease. Authors: Whittemore, R., Vilar-Compte, M., De La Cerda, S., Marron, D., Conover, R., Delvy, R., & Pérez-Escamilla, R. Publication Date: 23 August 2019 Challenges to diabetes self-management for adults with type 2 diabetes in low-resource settings in Mexico City: a qualitative descriptive study n: 20 adults 3 Seguro Popular primary care clinics in Mexico City Qualitative descriptive study This approach systematically describes a phenomenon. Glycemic targets. Factors that interfere with the efficacy of self-management in diabetics include lack of resources, mental health issues, cultural beliefs, and lack of family support. The sample was in a single geographical location hence it does not mirror the situation in other impoverished regions. High-quality evidence. The findings could be used in the project to show how self-management helps patients in impoverished societies manage the disease. References Burd, C., Gruss, S., Albright, A., Zina, A., Schumacher, P., & Alley, D. (2020). Translating knowledge into action to prevent type 2 diabetes: Medicare expansion of the National Diabetes Prevention Program lifestyle intervention. The Milbank Quarterly, 98(1), 172-196. Carpenter, R., DiChiacchio, T., & Barker, K. (2019). Interventions for self-management of type 2 diabetes: an integrative review. International journal of nursing sciences, 6(1), 70-91. Delahanty, L. M., Peyrot, M., Shrader, P. J., Williamson, D. A., Meigs, J. B., Nathan, D. M., & DPP Research Group. (2013). Pretreatment, psychological, and behavioral predictors of weight outcomes among lifestyle intervention participants in the Diabetes Prevention Program (DPP). Diabetes care, 36(1), 34-40. Fadli, F. (2022). The Impact of Self-Management-Based Care Interventions on Quality of Life in Type 2 Diabetes Mellitus Patients: A Philosophical Perspective. medRxiv. Kerrison, G., Gillis, R. B., Jiwani, S. I., Alzahrani, Q., Kok, S., Harding, S. E., … & Adams, G. G. (2017). The effectiveness of lifestyle adaptation for the prevention of prediabetes in adults: a systematic review. Journal of diabetes research, 2017. Lepard, M. G., Joseph, A. L., Agne, A. A., & Cherrington, A. L. (2015). Diabetes self-management interventions for adults with type 2 diabetes living in rural areas: a systematic literature review. Current diabetes reports, 15(6), 1-12. Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Hess Fischl, A., … & Vivian, E. (2015). Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes care, 38(7), 1372-1382. Walker, R. J., Williams, J. S., & Egede, L. E. (2016). Influence of race, ethnicity, and social determinants of health on diabetes outcomes. The American journal of the medical sciences, 351(4), 366-373. Whittemore, R., Vilar-Compte, M., De La Cerda, S., Marron, D., Conover, R., Delvy, R., … & Pérez-Escamilla, R. (2019). Challenges to diabetes self-management for adults with type 2 diabetes in low-resource settings in Mexico City: a qualitative descriptive study. International journal for equity in health, 18(1), 1-10. Yamaoka, K., Nemoto, A., & Tango, T. (2019). Comparison of the effectiveness of lifestyle modification with other treatments on the incidence of type 2 diabetes in people at high risk: a network meta-analysis. Nutrients, 11(6), 1373.
It is now time to synthesize the evidence by identifying patterns, strengths, and limitations of evidence entries contained in your Summary of Evidence Table. Review Appendix H, Synthesis and Recommen
Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals Synthesis and Recommendations Tool Appendix H EBP Question: Strength Number of Sources (Quantity) Synthesized Findings With Article Number(s) (This is not a simple restating of information from each individual evidence summary—see directions) Level Overall Quality Rating (Strong, good, or low) Level I Experimental studies Level II Quasi-experimental studies Level III Nonexperimental, including qualitative studies Level IV Clinical practice guidelines or consensus panels Level V Literature reviews, QI, case reports, expert opinion Where does the evidence show consistency? Where does the evidence show inconsistency? Best evidence recommendations (taking into consideration quantity, consistency, and strength of the evidence): Based on your synthesis, select the statement that best describes the overall characteristics of the body of evidence? ☐ Strong & compelling evidence, consistent results Recommendations are reliable; evaluate for organizational translation. ☐ Good evidence & consistent results Recommendations may be reliable; evaluate for risk and organizational translation. ☐ Good evidence but conflicting results Unable to establish best practice based on current evidence; evaluate risk, consider further investigation for new evidence, develop a research study, or discontinue the project. ☐ Little or no evidence Unable to establish best practice based on current evidence; consider further investigation for new evidence, develop a research study, or discontinue the project. See Chapter 11, Lessons from Practice, for examples of completed tools. Directions for use of the Synthesis and Recommendations Tool Purpose: This tool guides the EBP team through the process of synthesizing the pertinent findings from the Individual Evidence Summary (Appendix G), sorted by evidence level, to create an overall picture of the body of the evidence related to the PICO question. The synthesis process uses quantity, strength (level and quality), and consistency to generate best evidence recommendations for potential translation. Overall quality rating and total number of sources: Record the overall quality rating and the number of sources for each level (strong, good, or low), ensuring agreement among the team members. Synthesized findings: This section captures key findings that answer the EBP question. Using the questions below, generate a comprehensive synthesis by combining the different pieces of evidence in the form of succinct statements that enhance the team’s knowledge and generate new insights, perspectives, and understandings into a greater whole. The following questions can help guide the team’s discussion of the evidence: How can the evidence in each of the levels be organized to produce a more comprehensive understanding of the big picture? What themes do you notice? What elements of the intervention/setting/sample seem to influence the outcome? What are the important takeaways? Avoid repeating content and/or copying and pasting directly from the Individual Evidence Summary Tool. Record the article number(s) used to generate each synthesis statement to make the source of findings easy to identify. Using this synthesis tool requires not only the critical thinking of the whole team, but also group discussion and consensus building. The team reviews the individual evidence summary of high- and good-quality articles, uses subjective and objective reasoning to look for salient themes, and evaluates information to create higher-level insights. They include and consider the strength and consistency of findings in their evaluation. Where does the evidence show consistency/inconsistency? EBP teams must consider how consistent the results are across studies. Do the studies tend to show the same conclusions, or are there differences? The synthesized evidence is much more compelling when most studies have the same general results or point in the same general direction. The synthesized evidence is less compelling when the results from half the studies have one indication, while the findings from the other half point in a different direction. The team should identify the points of consistency among the evidence as well as areas where inconsistency is apparent. Both factors are important to consider when developing recommendations or determining next steps. Best evidence recommendations: In this section, the EBP team takes into consideration all the above information related to strength, quantity, and consistency of the synthesized findings at each level to generate best practice recommendations from the evidence. Consider: What is the strength and quantity of studies related to a specific evidence recommendation? Is there a sufficient number of high-strength studies to support one recommendation over another? Are there any recommendations that can be ruled out based on the strength and quantity of the evidence? Does the team feel the evidence is of sufficient strength and quantity to be considered a best evidence recommendation? Recommendations should be succinct statements that distill the synthesized evidence into an answer to the EBP question. The team bases these recommendations on the evidence and does not yet consider their specific setting. Translating the recommendations into action steps within the team’s organization occurs in the next step (Translation and Action Planning Tool, Appendix I). Based on the synthesis, which statement represents the overall body of the evidence? Choose the statement that best reflects the strength and congruence of the findings. This determination will help the team to decide next steps in the translation process. When evidence is strong (includes multiple high-quality studies of Level I and Level II evidence), compelling, and consistent, EBP teams can have greater confidence in best practice recommendations and should begin organizational translation When most of the evidence is good (high-quality Level II and Level III) and consistent or good but conflicting, the team should proceed cautiously in making practice changes. In this instance, translation typically includes evaluating risk and careful consideration for organizational translation. The team makes practice changes primarily when evidence exists that is of high to good strength. Never make practice changes on little to no evidence (low-quality evidence at any level or Level IV or Level V evidence alone). Nonetheless, teams have a variety of options for actions that include, but are not limited to, creating awareness campaigns, conducting informational and educational updates, monitoring evidence sources for new information, and designing research studies. The exact quantity of sources needed to determine the strength of the evidence is subjective and depends on many factors, including the topic and amount of available literature. The EBP team should discuss what they consider sufficient given their knowledge of the problem, literature, and setting © 2022 Johns Hopkins Health System/Johns Hopkins School of Nursing Page | 5

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