Management> Lifestyle and education>

DEFINITION

• Any condition that interferes with a patient's ability to learn about or manage their diabetes.
• Barriers can be related to the patient, clinician, or environment.

EPIDEMIOLOGY

• People with inadequate health literacy were twice as likely to have poor glycemic control and retinopathy (Schillinger)
• Diabetes-related numeracy is a strong predictor of A1c and may help explain racial disparities in glycemic control (Osborn; Cavanaugh)
• Half of patients taking insulin reported they would be more likely to take their injections regularly if another product was available to reduce the pain (Rubin).
• 41% of patients with diabetes report poor psychological well-being which affected diabetes care (Peyrot).
• Depression is a common comorbidity among persons with diabetes that affects diabetes care.

CLINICAL TREATMENT

• Literacy: 1) use picture-based handouts, repetition, short teaching sessions covering one topic at a time, written instructions to share with literate caregiver or family member; 2) ask patient how they like to learn (e.g. reading, videos, music, games or skits). Vanderbilt Diabetes Literacy and Numeracy Education Toolkit (DLNET) is a good resource.
• Cultural: 1) important to know health beliefs, foods, complementary and alternative medicines that are culture-based; 2) include members from target culture in planning of educational tools; 3) provide cultural sensitivity training for all staff
• Physical Impairments: 1) vision:  large print or audio tools, computer aides; 2) hearing: written material, bring a friend or family member, computer assisted learning ;3) manual dexterity: observe glucometer use and insulin injection technique, choose meters that are easier to use, use insulin pens or prefilled syringes
• Pain: 1) short sessions, repetition; 2) pain medication may interfere with ability to pay attention; 3) discomfort of pricking blood for glucometer testing can be minimized by alternating fingers
• Emotional: 1) shock, anger, denial and feeling overwhelmed are common; let the patient talk for a few minutes at the beginning of the visit and use reflective listening (see overview of patient education module); 2) screen patients for depression; 3) stressful living conditions (e.g. crime, financial problems, alcohol, verbal and sexual abuse or neglect) and consider referral to mental health and/or social work
• Health beliefs: patients do not see the importance of learning about diabetes because they do not understand the risks associated with an asymptomatic disease; discuss during the visit or refer for education.
• Social stigma: patients may feel reluctant to share their illness with others for fear of discrimination which hinders their ability to optimally self-manage their diabetes; encourage patient to talk about their concerns; support groups may be helpful.
• Lack of social support: 1) help patients identify their support system; 2) family and friends may not always be helpful; other forms of social support include internet-based or telephone peer support and volunteer organizations (e.g, church, diabetes associations, or service groups).
• Socially disadvantaged: especially benefit from literacy interventions, participatory decision-making, and social support.

• Diabetes educators may have more time than physicians for assessment and teaching.
• Perceived or actual differences in teaching content and philosophy (e.g. targets for metabolic control) between doctor and diabetes educator; educational curriculum or patient handouts should be developed as a team
• Patients are more likely to attend education sessions if they are recommended by their doctor.

• Lack of certified diabetes educators: not enough to meet patients' need. Solution: train clinic staff or lay people from churches, diabetes association; hang posters or show videos in the waiting room; hand out single topic written materials related to patients' questions or concerns; initiate group medical visits which include education (Deitrick).
• Logistical: inconvenient time or place and lack of transportation. Solution: extended hours, diabetes clinics where the patient can see the doctor and diabetes educator the same day, teaching in the community (i.e. churches, women's or men's groups, schools).
• Lack of community resources: cannot get medications due to cost or transportation; no one to help with insulin administration; poor eating due to lack of help with food shopping or preparation. Solution: help the patient identify and recruit neighbors, relatives, or church members who can help with these tasks; make a list of volunteer organizations in the community who can help.

• Fear of needles: demonstrate injection technique, use ultra fine needles, pen injectors.
• Fear of hypoglycemia: emphasize incidence of serious hypoglycemia is low if administered appropriately
• Fear of weight gain: reinforce healthy eating and physical activity.
• Feeling of failure: emphasize the progressive nature of the disease and that majority of people with diabetes will eventually need insulin.

FOLLOW UP

• Review knowledge and skills: Is the patient remembering and acting on the information you are giving them?
• Continue to explore barriers: What is making it difficult for you to.... take your medicine, monitor your blood sugar?

EXPERT COMMENTS

• Addressing barriers to patient education are especially important for patients who are not meeting glycemic targets despite optimizing medical therapy.
• Consider individual teaching and frequent follow-up for patients with significant barriers.
• Patients often hear conflicting information on diabetes; coordinate with your team to develop consistent messages about diabetes care.
• A supportive clinician-patient relationship is key to successful learning and health behavior change.

REFERENCES