Trinidad and Tobago Specific Modules>Trinidad and Tobago Specific Modules>

DEFINITION

• Ongoing process through which people with diabetes obtain the knowledge, attitudes, and skills necessary to make daily decisions about their medications, physical activity, meal plan and other psychosocial challenges that impact their blood glucose levels, other risk factors, and quality of life.
• Includes evidence-based clinical knowledge, behavior strategies, and educational theory

EPIDEMIOLOGY

• Clinical measures improved by diabetes education: Hemoglobin A1c (1.9% reduction over 4 to 6 months) blood pressure (5mmHg reduction over 4 to 6 months), weight loss (1.6 kg. over 12 to 14 months) (Duke).
• Provided primarily by nurses and dieticians, some pharmacists, clinicians, and community health workers.

CLINICAL TREATMENT

• Principles provide a framework for how to approach all patients. Can be used as needed. See Interventions and Follow-up sections.
• Empowerment: facilitating and supporting the patient's capacity to make informed decisions about their own care. The approach is patient centered, not authoritarian.
• Adult learning: patients learn best if they: 1) believe the information is important for them; 2) address the impact of past experiences that help or hinder learning; 3) have control over the learning experience.
• Determine what the patient knows about diabetes, what they want to learn, and their learning style.
• Transtheoretical model of health behavior change: patients are at different stages of readiness to change and need specific interventions to move to the action stage. Help the patient choose realistic goals based on their readiness to change.
• Health belief model: helps to predict or explain health behaviors based on attitudes and beliefs of individuals with respect to: 1) their susceptibility to the disease; 2) the severity of disease and its complications; 3) the perceived benefits and costs; 4) confidence in their ability to make a change (self-efficacy). The approach is to: 1) explore the patient's views on how serious their diabetes is and how they they think it will affect them; 2) identify the risks and benefits of self care; and 3) evaluate their level of confidence.

• Goal setting: 1) define goals in collaboration with the patient; 2) be specific ("What steps will you take to lose weight?"), measurable ("How often will you do this?"), and realistic ("On a scale of 1 to 10, how likely are you to follow this plan?"). Examples of goals: I will walk 3 times a week for 15 minutes. I will stop eating snacks after dinner.
• Problem solving: 1) brainstorm options, pick the best option, and evaluate the effectiveness of the option. This can be used to help patients set their goals.
• Motivational interviewing: a directive, patient-centered style of counselling that uses reflective listening and explores ambivalence to help patients change difficult behaviors; 1) reflective listening helps the patient clarify behaviors they want to change and lets them know you have heard what they said; 2) identifying ambivalence about the change helps the patient change their behavior; 3) helps patients define a goal that has a greater chance for success
• The first two interventions can be used during an office visit and require minimal training. Motivational interviewing takes more time and training.

FOLLOW UP

• Diabetes education is not effective if done only once. It always requires follow-up. Frequency, timing and location of follow-up will vary.
• Immediate Follow-up: Teach by answering patients' questions: What questions do you have today about your diabetes? What worries you most about your diabetes? What would you like to learn today about your diabetes? Tell me one thing you want to make sure we address today.
• Evaluate goals: What's working? What isn't working? What problems are you having with your plan? Who can help and support you? Where can you get help?
• Set new goals: What would you like to work on for your next visit?
• Always look for and celebrate success, no matter how small.

EXPERT COMMENTS

• Clinicians are responsible not only for making recommendations but also for seeing that patients are optimally educated about evidence based care.
• Patients are responsible for the execution of recommendations on a day-to-day basis.
• Listen more, talk less; the patient knows what works for them. The task is to help THEM come up with their own solutions, giving information as needed, and supporting their efforts.
• Build on success: What has worked for you in the past? How did you lose weight the last time?

Basis for Recommendations

• Anderson RM, Funnell MM; Patient empowerment: Myths and misconceptions.; Patient Educ Couns; 2009; Vol.
  ISSN: 1873-5134;
  PUBMED: 19682830
  Rating: Basis for recommendation
  Comments:Excellent discussion of the use and misuse of empowerment.
  
  
• Bodenheimer T, Handley MA; Goal-setting for behavior change in primary care: an exploration and status report.; Patient Educ Couns; 2009; Vol. 76; pp. 174-80;
  ISSN: 1873-5134;
  PUBMED: 19560895
  Rating: Basis for recommendation
  Comments:Review of the literature on goal setting. Did not look at outcomes. Goal setting was performed by clinicians during the visit, non-clinicians after a visit, or computer-based programs.
  
  
• Duke SA, Colagiuri S, Colagiuri R; Individual patient education for people with type 2 diabetes mellitus.; Cochrane Database Syst Rev; 2009; Vol. CD005268;
  ISSN: 1469-493X;
  PUBMED: 19160249
  Rating: Basis for recommendation
  Comments:This systematic review suggests a benefit of individual education on glycaemic control when compared with usual care in a subgroup of those with a baseline HbA1c greater than 8%. In the small number of studies comparing group and individual education, there was an equal impact on HbA1c at 12 to 18 months.
  
  
• Russell SS; An overview of adult-learning processes.; Urol Nurs; 2006; Vol. 26; pp. 349-52, 370;
  ISSN: 1053-816X;
  PUBMED: 17078322
  Rating: Basis for recommendation
  Comments:Description of the of adult learning theory in clinical practice.
  
  
• Deakin TA, McShane CE, Cade JE, Williams R.; Group based training for self-management strategies in people with type 2 diabetes mellitus. ; Cochrane Database of Systematic Reviews; 2005; Vol. Issue 2. Art. No.: CD003417. DOI: 10.1002/14651858.CD003417.pub2; pp.
  Rating: Basis for recommendation
  Comments:Adults with type 2 diabetes who have participated in group-based training programmes show improved diabetes control (fasting blood glucose and glycated haemoglobin) and knowledge of diabetes in the short (four to six months) and longer-term (12 to 14 months) . There is some evidence that group-based education programmes may increase self-empowerment, quality of life, self-management skills and treatment satisfaction.
  
  
• Miller WR, Rollnick S; Motivational Interviewing: Preparing People to Change Addictive Behavior; The Guilford Press; 2002; Vol.
  Rating: Basis for recommendation
  Comments:This is the original publication on motivation interviewing- it describes the process in detail.
  
  
• Prochaska JO, Velicer WF; The transtheoretical model of health behavior change.; Am J Health Promot; 1997; Vol. 12; pp. 38-48;
  ISSN: 0890-1171;
  PUBMED: 10170434
  Rating: Basis for recommendation
  Comments:Description and use of the transtheoretical model.
  
  

REFERENCES

RELATED MODULES

• Introduction to Diabetes