The art and science of diabetes education: a culture out of balance

Discrepancies in persons with dementia, family members, and physician perspectives of dementia treatment: a descriptive study

BACKGROUND

This study aims to reconsider diagnostic approaches to dementia where pharmacological approaches are not available to reverse the pathological changes caused by dementia.

METHODS

A questionnaire survey was conducted with 524 physicians specialising in dementia management in Aichi, Japan, with 163 (31.1%) valid responses. The survey gathered information on the perceived merits and demerits of the early diagnosis of dementia and the priorities in treating those with mild cognitive impairment (MCI), mild dementia, and moderate or advanced dementia. In the interview survey, 27 outpatients with mild Alzheimer's disease (76.2 ± 7.6 years old; Mini-Mental State Examination score 23.3 ± 2.7 points; 21 women, six men) and 24 family members (12 spouses, 12 children) were asked about their priorities in treatment.

RESULTS

A total of 61.3% of physicians answered that persons with dementia having more time to accept the diagnosis is a merit of early diagnosis, while 61.3% answered that the possibility of causing anxiety was a demerit. Around 45% of the physicians chose the option 'maintaining cognitive function' as the first priority in cases of MCI and mild dementia, while 39.3% considered it the last priority in moderate or advanced cases. About 22.2% of persons with dementia and 37.5% of their families assigned the highest priority to 'maintaining cognitive function', whereas 37.0% of persons with dementia prioritised 'maintaining quality of life for them and their families'.

CONCLUSIONS

Although it is important to build therapeutic alliances among persons with dementia, their families, and physicians by sharing a common perspective for better treatment of dementia, this study suggested that the three parties do not always share the same vision. Future research is needed to determine how to build therapeutic alliances for better approaches to dementia, especially to ensure that timely diagnosis is beneficial for persons with dementia and their families.

Tedious, Tiresome, and Dull: An Unrecognized Problem That We Can Solve

Editor's Note: This article is adapted from the virtual address Dr. Polonsky delivered as the recipient of the American Diabetes Association's (ADA's) Outstanding Educator in Diabetes Award for 2020. He delivered the address in June 2020 during the Association's 80th Scientific Sessions, held online as a result of the coronavirus disease 2019.

'It's an important part, but I am not quite sure that it is working': educators' perspectives on the implementation of goal-setting within the 'DAFNE' diabetes structured education programme

AIM

To explore educators' perspectives on the implementation of goal-setting and action-planning strategies within a structured diabetes self-management education programme.

METHODS

Ten semi-structured interviews were conducted with diabetes self-management education providers delivering the 'Dose Adjustment for Normal Eating' (DAFNE) programme to people with Type 1 diabetes throughout Ireland. A pre-designed topic guide, focused on exploring educators' experiences of delivery and application and views on usefulness of goal-setting strategies, was used in all interviews. The interviews were recorded, transcribed and analysed using thematic analysis.

RESULTS

Five main themes were identified: 'people need a plan', discussing perspectives on goal-setting's value; 'the power of the group', highlighting the impact a group format has on goal-setting practices; 'diversity and individuality', discussing differences in DAFNE participants' and educators' engagement with goal-setting; 'goal-setting's fit', exploring perspectives on how well goal-setting fits within diabetes self-management education and follow-up care; and 'feelings of inadequate psychological knowledge', addressing challenges experienced in the delivery of goal-setting components.

CONCLUSION

While educators saw benefits in the implementation of goal-setting and planning strategies within diabetes self-management education, concerns about how well goal-setting currently fits within diabetes self-management education and follow-up care were evident. Additionally, many educators experienced the delivery of goal-setting and action-planning strategies as challenging and would value additional training opportunities.

Type 2 Diabetes Education and Support in a Virtual Environment: A Secondary Analysis of Synchronously Exchanged Social Interaction and Support

Background

Virtual environments (VEs) facilitate interaction and support among individuals with chronic illness, yet the characteristics of these VE interactions remain unknown.

Objective

The objective of this study was to describe social interaction and support among individuals with type 2 diabetes (T2D) who interacted in a VE.

Methods

Data included VE-mediated synchronous conversations and text-chat and asynchronous emails and discussion board posts from a study that facilitated interaction among individuals with T2D and diabetes educators (N=24) in 2 types of sessions: education and support.

Results

VE interactions consisted of communication techniques (how individuals interact in the VE), expressions of self-management (T2D-related topics), depth (personalization of topics), and breadth (number of topics discussed). Individuals exchanged support more often in the education (723/1170, 61.79%) than in the support (406/1170, 34.70%) sessions or outside session time (41/1170, 3.50%). Of all support exchanges, 535/1170 (45.73%) were informational, 377/1170 (32.22%) were emotional, 217/1170 (18.55%) were appraisal, and 41/1170 (3.50%) were instrumental. When comparing session types, education sessions predominately provided informational support (357/723, 49.4%), and the support sessions predominately provided emotional (159/406, 39.2%) and informational (159/406, 39.2%) support.

Conclusions

VE-mediated interactions resemble those in face-to-face environments, as individuals in VEs engage in bidirectional exchanges with others to obtain self-management education and support. Similar to face-to-face environments, individuals in the VE revealed personal information, sought information, and exchanged support during the moderated education sessions and unstructured support sessions. With this versatility, VEs are able to contribute substantially to support for those with diabetes and, very likely, other chronic diseases.

Bringing person-centeredness and active involvement into reality

Purpose

– The purpose of this paper is to examine the use and applicability of cultural probes – an explorative participatory method to gain insights into a person’s life and thoughts – to achieve person-centeredness and active involvement in self-management education for people with chronic illness.

Design/methodology/approach

– An education toolkit inspired by the ideas of cultural probes was developed and feasibility tested in 49 education settings in Denmark. Questionnaires, interviews, and observations were used to collect data, which were analysed using descriptive statistics, analysis of variance, and systematic text condensation.

Findings

– Educators emphasized the applicability of the toolkit, and between 69 and 82 per cent of educators reported that the toolkit supported them in facilitating person-centred education and active involvement to a high or very high degree. Most educators (81 per cent) reported that they would like to apply the toolkit again in future education to a high or very high degree. Five categories of educator experiences were identified: interaction and activity; person-centeredness; group dynamics and synergy; openness; and light and cheerful atmosphere. Educators talked significantly less in situations where the toolkit was applied. This indicates the ability of the toolkit to facilitate talk among participants and thereby let participants become the focal point of education. Applying cultural probes in patient education targeting people with chronic illness seems to be a useful method to achieve patient-centeredness and active involvement in patient education and to support educators in facilitating this process.

Originality/value

– Introducing fully flexible education toolkits inspired by cultural probes may, in the future, lead to improved self-management patient education among people with chronic illness.

Cuidado e Empoderamento: a construção do sujeito responsável por sua saúde na experiência do diabetes

A partir da análise da literatura sobre a abordagem do empoderamento do paciente no campo da diabetologia, discute-se o impacto dessa perspectiva sobre os significados das transformações nas relações de cuidado, explorando as implicações para a posição ocupada por profissionais da saúde e pacientes. Consideram-se as dificuldades e os incômodos apontados pelos profissionais da saúde frente às mudanças requeridas pelo empoderamento do paciente. Esses dados são problematizados por meio de um enfoque antropológico, apoiando-se nas elaborações sobre o contraste entre a lógica da escolha e a lógica do cuidado, e considerando a diferença entre as representações dos agentes da biomedicina e dos pacientes a partir da oposição entre os modelos indivíduo/pessoa. O percurso analítico é concluído com a constatação da necessidade de relativizar a ideia de que o empoderamento do paciente representa o incremento do individualismo nas relações de assistência à saúde, o que contribui para matizar as reflexões que os cientistas sociais têm desenvolvido acerca da tendência atual de atribuir ao indivíduo a responsabilidade pela própria saúde.

Therapeutic alliance in mental health nursing: an evolutionary concept analysis

The concept of therapeutic alliance is relevant in contemporary mental health care, as the consumer-led recovery movement promotes the development of collaborative relationships, and is focussed on the consumer's individual concept of wellbeing. An evolutionary concept analysis was undertaken to establish a contemporary interpretation of therapeutic alliance for mental health nursing. The CINAHL, Scopus and PsycINFO databases were searched for articles (n = 322), with 52 deemed appropriate for analysis. Therapeutic alliance is characterised by mutual partnerships between nurses and consumers, and is dependent on a humanistic healthcare culture. Therapeutic alliance is associated with enhanced consumer outcomes and experiences with care.

The factors that limit activities of certified diabetes educators in Japan: a questionnaire survey

Background

The certified diabetes educator (CDE) is a qualification awarded to health professionals with specialized knowledge, skills, and experiences in diabetes management and education. To clarify whether CDEs consider themselves to be working sufficiently, in other words, making sufficient use of their specialized skills or not, a questionnaire survey was conducted.

The participants were persons involved in diabetes-related educational seminars and medical personnel engaged in diabetes care at the National Center for Global Health and Medicine. They were asked to complete a questionnaire regarding self -perception of CDE’s activities and to describe the reasons for their answers.

Findings

Fewer than 40% of the responding CDEs in each of the professions surveyed were satisfied with the current state of their activities and contributions as a CDE. For CDEs, “lack of labor” is the most concerning issue that limits their satisfactory activities as CDEs, followed by “condition of facilities”. Other factors such as insufficient “interprofessional teamwork”, “limited personal ability”, “mismatched allocation”, and “low recognition for CDEs” also limited their activities.

Conclusion

Many CDEs perceived they are not working sufficiently. Further efforts should be made to support CDEs to improve their working conditions.

Personnel and participant experiences of a residential weight-loss program. A qualitative study

Background

Residential weight-loss programs aim to help persons with obesity lose weight and maintain a long-term healthy lifestyle. Knowledge is needed on the different actors’ perceptions and experiences from such programs. The aim of this study was to describe how personnel argued for and perceived a residential weight-loss program, to investigate how the participants experienced the program, and to contrast these perspectives.

Methods

This qualitative study took place in an 18-week residential weight-loss program. Exercise, diet, and personal development were the main components in the program. Data was collected through participant observation and individual and focus group interviews with participants and personnel.

Results

Program personnel characterized persons with obesity in specific terms, and these formed the basis of the educational aims, teaching principles, and content of the program. According to personnel, persons with obesity typically had problems acknowledging their own resources, lived unstructured lives, had a distorted relationship to food, experienced a range of social problems and featured a lack of personal insight. Program participants reported enthusiasm about their experiences of exercise and appreciated measures of success with the exercise program. They had, however, very different experiences regarding the usefulness and appropriateness of the parts of the program focused on social and personal development. Some felt that weight loss required an engagement with personal development while others viewed it as unnecessary and inappropriate.

Conclusion

The reliance in personnel accounts on particular characteristics of persons with obesity as a rationale for the program might lead to stigmatizing and stereotyping. Program activities focused on social and personal development need to be better understood by participants if they are to be viewed as helpful. To achieve this personnel must carefully consider how these parts of the program are communicated and conducted.

Partnering with diabetes educators to improve patient outcomes

Diabetes is a chronic, progressive disease that affects millions worldwide. The paradigm of diabetes management has shifted to focus on empowering the person with diabetes to manage the disease successfully and to improve their quality of life. Diabetes self-management education is a collaborative process through which people with diabetes gain the knowledge and skills needed to modify their behavior and to self-manage successfully the disease and its related conditions. Diabetes educators are health care professionals who apply in-depth knowledge and skills in the biological and social sciences, communication, counseling, and pedagogy to enable patients to manage daily and future challenges. Diabetes educators are integral in providing individualized education and promoting behavior change, using a framework of seven self-care behaviors known as the AADE7 Self-Care Behaviors™, developed by the American Association of Diabetes Educators. The iterative process of promoting behavior change includes assessment, goal setting, planning, implementation, evaluation, and documentation. Diabetes educators work as part of the patient's health care team to engage with the patient in informed, shared decision making. The increasing prevalence of diabetes and the growing focus on its prevention require strategies for providing people with knowledge, skills, and strategies they need and can use. The diabetes educator is the logical facilitator of change. Access to diabetes education is critically important; incorporating diabetes educators into more and varied practice settings will serve to improve clinical and quality of life outcomes for persons with diabetes.

The effects of education with printed material on glycemic control in patients with diabetes type 2 treated with different therapeutic regimens

BACKGROUND/AIM

Diabetes mellitus (DM) is considered to be an epidemic, chronic and progressive disease. The treatment of DM reqiures substantial effort from both the diabetes treatment team and a patient. Patient education is one of the treatment elements. The most efficacious form and content of education has not yet been established. However, every DM education must include introduction to a substantial number of facts about diabetes. The aim of our study was to estimate the levels of DM knowledge and glycemic control in Serbian patients with DM type 2 as well as to estimate the effects of education using printed material on the levels of glycemic control and knowledge about DM. Also, the effects of education on glycemic control and the level of knowledge in differently treated patients were estimated.

METHODS

The patients with DM type 2 (n = 364), aged 40 to 65 years, from three regional health centers, were randomized for the study. After informed consent, patients filled out the questionnaire, and were checked for HbA1c and fasting blood glucose. Finally, booklet "Healthy lifestyle with diabetes mellitus type 2" was given to them. The same procedure was repeated after 3, 6 and 18 months.

RESULTS

There was a significant improvement in HbA1c levels after 3 months (8.00 +/- 1.66% vs 9.06 +/- 2.23%, p < 0.01) and after 6 months (7.67 +/- 1.75% vs 9.06 +/- 2.23%, p < 0.01). There was no further improvement in HbA1c levels after 18 months (7.88 +/- 1.46% vs 7.67 +/- 1.75%, p > 0.05). There was a significant improvement in the average test score (percent of correct answers per test sheet) after three monts (64.6% vs 55.6%, p < 0.01). There were no further statistically significant changes in the general level of DM knowledge after 6 months (65.0 +/- 32.5% vs 64.5 +/- 33.7%, p > 0.05) and after 18 months (64.8 +/- 32.7 vs 64.5 +/- 33.7%, p > 0.05). There was a significant diffrence in educational intervention response in DM type 2 patients on different therapeutic regimens.

CONCLUSION

Education with printed material led to improvement in glycemic control and level of DM knowledge in our patients. Education with printed material may be a useful adjunct to DM treatment and should be structured according to the treatment modality.

Diabetes in sub-saharan Africa: kenya, mali, mozambique, Nigeria, South Africa and zambia

Until a few years ago, a limited number of epidemiologists or public health experts mentioned the words “diabetes.” As new lifestyles, imported dietary practices, and globalization take roots in the developing world, as Africa is, today, diabetes and its complications are considered an epidemic in Africa, compelling African governments to start paying more attention to its impact as thousands of Africans run the risk of dying young. The potential severity of diabetes is such that some epidemiologists predict that its economic impact and death toll will surpass the ravages of HIV and AIDS in the near future. On the African sub-continent, present literature and the work of the World Diabetes Foundation have highlighted three countries, namely, Mali, Mozambique, and Zambia. However, the conditions in South Africa, Kenya, and Nigeria, some of the most developed areas of the continent, provide a clue to how people are coping and how governments are responding to diabetes and its full impact. This study is, therefore, a meta-summary of the incidence and prevalence of today's emerging silent killer or diabetes in Sub-Saharan Africa. The theme is that time is running out for Africa and that, as was for HIV/AIDS, by the time the governments wake up and stop denying the catastrophic potential of the epidemic, diabetes will simply overwhelm the continent's resources, and the world will witness the death of millions of Africans. The last section is a call for action against diabetes in terms of advocacy, promotion of awareness, and public health policies that empower people to diabetes self-management.

"It's a wild thing, waiting to get me": stance analysis of African Americans with diabetes

PURPOSE

This mixed methods study uses a unique approach from social science and linguistics methodologies, a combination of positioning theory and stance analysis, to examine how 20 African Americans with type 2 diabetes make sense of the practices that led to recurrent emergency department visits to identify needs for more effective intervention.

METHODS

In a purposive sample of postemergency department visit interviews with a same-race interviewer, people responded to open-ended questions reflecting on the decision to seek emergency department care. As applied to diabetes education, positioning theory explains that people use their language to position themselves toward their disease, their medications, and the changes in their lives. Transcriptions were coded using discourse analysis to categorize themes. As a form of triangulation, stance analysis measured language patterns using factor analysis to see when and how speakers revealed affect, attitude, and agentive choices for action.

CONCLUSION

Final analysis revealed that one third of the sample exhibited high scores for positive agency or capacity for decision-making and self-management, while the rest expressed less control and more negative emotions and fears that may preclude self-management. This approach suggests a means to tailor diabetes education considering alternative approaches focused on communication for those facing barriers.

Diabetes educators in safety-net practices: a qualitative study

PURPOSE

The purpose of this study was to explore the issues and challenges faced by certified diabetes educator (CDE) trainees in providing diabetes self-management education to patients in safety-net practices.

METHODS

Semi-structured interviews were conducted with CDE trainees and a CDE mentor in 2 primary care practices. Transcripts were analyzed using a content-driven immersion-crystallization approach to identify major themes.

RESULTS

Four major themes emerged from the qualitative interview data: (1) patient recruitment approaches, (2) patient barriers to attending diabetes education classes, (3) teaching challenges, and (4) CDE integration into the practices.

CONCLUSIONS

This study underscores the need for diabetes educators and other health education professionals to be creative and flexible in delivering self-management education to patients in underserved settings. The complexity of diabetes care and the self-care responsibilities placed on the patient reinforce the need for a team approach such as that proposed in the medical home model and should include certified diabetes educators.

The narrative-autobiographical approach in the group education of adolescents with diabetes: a qualitative research on its effects

OBJECTIVE

To introduce a narrative-autobiographical approach in the care and education of adolescents with type-1 diabetes and observe the effects of this novel approach on adolescents' self-awareness, concern for self-care, and well-being.

METHODS

Ninety-four adolescents with type-1 diabetes attending one 9-day summer camp in 2004, 2005, or 2006 participated in structured daily self-writing proposals on diabetes, integrated with daily interactive self-management education. After some months, we sent participants interview-like questionnaires, and two independent researchers performed a qualitative analysis of the 50 answers that were mailed back.

RESULTS

Writing about the discovery of diabetes was, for many, a stressful experience, but with a strong liberating effect. One relevant point was change, which occurred: (a) in the perception of self; (b) in the relationship with others; (c) in the relationship with the disease.

CONCLUSIONS

The integration of autobiography in diabetes camps, by adding the value of sharing individual stories to the liberating power of self-writing, can allow the adolescents to overcome their feelings of diversity, and can initiate several changes reflecting increased self-efficacy, maturity, acceptance of the disease and responsibility in self-management.

PRACTICE IMPLICATIONS

Self-writing is feasible and well accepted, and provides healthcare professionals a proper way to patient-centered care.

Optimizing patient education for people with obesity: possible use of the autobiographical approach

OBJECTIVE

To review recent results of the current approaches to the education of obese people, focusing on the motivation for healthy behaviors, and to present the narrative-autobiographical approach as a possible tool in the education of obese people.

METHODS

Our overview will necessarily be partial, and limited to some studies that succeeded in improving the motivation for healthy lifestyles in people with overweight or obesity. We will also describe the use of the autobiographical approach in the "Io-muovo-la-mia-vita" project.

RESULTS

Many studies have induced relevant behavioral changes, mainly by using intensive interventions. Weight loss maintenance has been difficult and usually has required pro-active follow-up interventions. The use of self-writing may allow overweight and obese people to reveal their inner feelings to themselves and to peers, and may reinforce their motivation for self-care.

CONCLUSIONS

The association of weight loss with intensive interventions, and the need for follow-up pro-active interventions to maintain results make one wonder whether the inner motivation of participants is usually fostered as recommended.

PRACTICE IMPLICATIONS

The narrative-autobiographical approach appears to be a proper way to patient centered care, but for an effective practice, the human and relational attitudes of healthcare professionals should be integrated with specific educational skills.

Assessing the value of diabetes education

PURPOSE

The purpose of this study was to evaluate the impact of diabetes self-management education/training (DSME/T) on financial outcomes (cost of patient care).

METHODS

Commercial and Medicare claims payer-derived datasets were used to assess whether patients who participate in diabetes education are more likely to follow recommendations for care than similar patients who do not participate in diabetes education, and if claims of patients who participate in diabetes education are lower than those of similar patients who do not.

RESULTS

Patients using diabetes education have lower average costs than patients who do not use diabetes education. Physicians exhibit high variation in their referral rates to diabetes education.

CONCLUSIONS

The collaboration between diabetes educators and physicians yields positive clinical quality and cost savings. The analysis indicates that quality can be improved, and cost reduced, by increasing referral rates to diabetes education among low-referring physicians, specifically among men and people in disadvantaged areas. More needs to be done to inform physicians about ways to increase access to diabetes education for underserved populations.

Diabetes management and self-care education for hospitalized patients with cancer

Managing diabetes can be a daunting task for patients with cancer. Empowerment-based diabetes education and motivational interviewing are complementary approaches. Oncology nurses may feel unprepared to teach patients and their families about self-care for diabetes, but they provide individualized information on symptom management of cancer throughout hospitalization and at discharge. The essential self-care issues include food, exercise, medication, blood glucose monitoring, prevention, recognition and treatment of hypoglycemia and hyperglycemia, and when and how to get additional medical and educational support. This patient-centered model of diabetes education differs from the older "compliance" model that covers many universal rules for all patients, which are predetermined by the nurse. Informing nurses about their role in care of patients with cancer and diabetes is critical.

Management of the metabolic syndrome and type 2 diabetes through lifestyle modification

Sustainable lifestyle modifications in diet and physical activity are the initial, and often the primary, component in the management of diabetes and the metabolic syndrome. An energy-prudent diet, coupled with moderate levels of physical activity, favorably affects several parameters of the metabolic syndrome and delays the onset of diabetic complications. Weight loss, albeit not an absolute prerequisite for improvement, is a major determinant and maximizes effectiveness. Adopting a healthy lifestyle pattern requires a series of long-term behavioral changes, but evidence to date indicates low long-term adherence to diet and physical activity recommendations. This calls for greater research and public health efforts focusing on strategies to facilitate behavior modification.