Diabetes Self-Management

Introduction

Diabetes as a health burden has increased globally, so much that its prevalence and magnitude are of great public concern in both developed and developing countries. In fact, in some countries, it is such a serious health issue that affects a significant percentage of the population, in some cases, as high as 10% (Zinman et al., 2015). Considering its seriousness, a universal health objective is to reduce diabetes-related health complications and deaths, particularly through glucose level monitoring and control. As the disease is difficult to control, diabetes patients are at increased risk of health complications and death, particularly due to regimen non-adherence. For this reason, it is important for patients to be involved in their own care if treatment goals are to be achieved. In fact, great success is realized when patients play a bigger role in diabetes care. In this vein, adherence to regimen treatment such as oral hypoglycemic agents is emphasized. For maintenance of a sufficient glycemic control, it is imperative for diabetes patients to adhere to a self-management plan that entails exercise, frequent glucose level monitoring, dietary modifications, optimal medication administration, and constant education. A collaborative and interactive approach is necessary for it brings together family members, healthcare providers, patients, and other stakeholders in optimally supporting and encouraging behavioral changes to effectively manage this chronic condition (Mayberry & Osborn, 2012). This paper discusses the concept of diabetes self-management and how to assess patient skills, knowledge, and health literacy in the management of the current chronic condition. 

Problem Statement

As Powers et al. (2015) present, diabetes requires performance an array of complex care decisions and the making of crucial self-management decisions on a daily basis. In this respect, diabetes self-management (hence contextual education) is important because it “provides the foundation to help people with diabetes navigate these decisions and activities as has been shown to improve health outcomes” (Powers et al., 2015: p. 1; Utah Department of Health, 2015: p.21). While various actors in healthcare delivery have a big role to play in the process, it is even more important to ensure that diabetes patients receive self-management education and resources that they may need so that overall issues like cultural needs, health beliefs, family support, physical limitations, health literacy, medical history, current knowledge, and financial status are addressed, especially for the manner they may affect patients’ own ability to self-manage their condition. Diabetes self-management education could not be more important in the regard as it supports patients in terms of problem solving, optimal decision-making, collaboration with other actors, and general self-care behaviors (Peyrot et al., 2013; Tang et al., 2014).

Assessment of Patient’s Knowledge and Health Literacy

In the context of diabetes self-management, a patient’s knowledge and health literacy measures and dictates the ability to not only correctly read and comprehend medical instructions, but also act as such may direct (Moss, 2014). Health literacy in this context includes the ability to obtain as well as process and comprehend basic information as would be needed in making appropriate and optimal health decisions. Therefore, it goes without saying that limited knowledge and health literacy can only culminate in poor self-management of the condition, a fact that has been well illuminated in literature (Berkman et al., 2011). In fact, health literacy has been shown to be a stronger predictor of health outcomes than factors such as education level, employment status, income, race, and age among others. Health literacy helps patients in many ways, for instance, in evaluating information, analyzing relative risks in the process of self-care/self-management, calculating dosages, locating health information, and interpreting test results just to mention but a few. Imperatively, aspects like visual literacy, computer literacy, information literacy, oral(language) literacy, and numerical literacy are elevated in this regard. Overall, patient’s knowledge and health literacy can be assessed through validated instruments, examples of which include TOFHLA (Test of Functional Health Literacy in Adults), LAD (Literacy Assessment for Diabetes, and NVS (Newest Vital Sign) (Moss, 2014). The suitability of each of these instruments varies from one population to another so they must be selected appropriately. 

Cultural Considerations

The fact that diabetes is a chronic condition underscores the significance of contextual self-management education as it helps promote behavior and skills that enable patients to optimize life quality and reduce other possible risks. According to the American Association of Diabetes Educators (2015), the most effective approach to delivering Diabetes Self-Management Education (DSME) is one that recognizes the unique nature of every individual, hence the unique needs of every diabetes patient. In this vein, it is widely recognized that how individuals learn, comprehend, and utilize information to a great extent depends on social support systems and personal life experiences, elements that are in turn influenced by culture (Haas et al., 2011).

In planning and delivering diabetes self-management education, there is need for cultural sensitivity as this allows the provision of culturally competent and sensitive education. Here, cultural sensitivity entails awareness of a patient’s cultural beliefs, values, language, customs, actions, and thoughts, which without doubt affect the decisions they make in the context of self-care/self-management. Besides taking into account what patients are likely to think and do as may be considered culturally appropriate, it is important for educators to communicate appropriately, more precisely cross-culturally even as they offer DSME to diverse populations. This would be crucial in enhancing patient understanding on how to manage their condition(s). Whether the focus is specifically on the administration of oral hypoglycemic agents or other aspects of general management of diabetes as a chronic condition, it is important for educators and healthcare givers to offer support, care, and education(information) to patients in a manner that acknowledges and respects the cultural perceptions and understanding of health (as may be unique to every individual). Additionally, information should be appropriately conveyed and support/care designed and delivered in such a manner that proactively considers patients’ challenges to self-management. Contextual goals should also be designed in a culturally appropriate manner. It is also imperative to utilize educational resources and materials that are appropriate in terms of learning readiness, literacy level, age, and culture.

DSME Plan

Successful DSME ought to be a collaborative and interactive process through which patients are equipped with relevant basic knowledge on how to manage diabetes while remaining focused on their own goals and self-identified challenges.  True as it were, it places emphasis on decision-making as well as problem-solving particularly in relation to self-care skills and competencies in the context of diabetes. Such include proper dental care, physical activity, glucose level monitoring, and healthy eating just to mention but a few. A good diabetes self-management education plan in the current conversation would be that which emphasizes on community support and convenient locations as well as cultural relevance. A key objective of such a plan would be to reach people whose access to regular or formal healthcare is limited. Those facing language barrier, or lack the option of school-, clinic-, worksite-, or home-based diabetes management education would be considered. Importantly, the plan would be based on the empowerment philosophy whereby emphasis is placed on an interactive as well as collaborative approach in achieving self-directed behavioral change in patients.

The plan is rooted in an empowerment philosophy as well as various theoretical frameworks and behavioral and/or educational strategies that have emerged as helpful and effective in the self-management of diabetes. In this vein, the theory of self-determination would be applied to achieve contextual empowerment, for indeed it postulates that autonomy/self- motivation is likely to result if individuals consider the behaviors they are urged to adopt to be personally meaningful. Autonomy support as a theoretical framework explored by Williams et al. (1998) would be used to devise educational interventions in which healthcare providers and various sources of social support would, as per the needs, feelings, and priorities of diabetes patients, provide only relevant information as opposed to controlling the behaviors of patients.  A wide body of literature supports this aspect of the DSME plan for it indicates that diabetes patients given autonomy motivation by their healthcare providers have greater internal motivation to regulate their glucose levels and develop other relevant skills for self-managing diabetes (Williams & Zeldman, 2002). Imperatively, the problem-based learning strategy would be used in patient education encompassing aspects such as exercise and dietary behavior. This education strategy is learner-centered (rightly patient-centered in this case) and it fosters health education that is age- and culturally appropriate. Such education would focus on patient issues as opposed to the general educational curriculum or agenda of various healthcare actors.

Evaluation

Following the DSME, patients can be evaluated to determine if they have mastered necessary skills and competencies. In essence, the focus of evaluation in this respect would be the patients’ knowledge and health literacy as far as the self-management of diabetes is concerned. Appropriate items (based on the Likert Scale) could be developed to assess skills and competencies in relation to reading as well as comprehending basic instructions, for instance as may be contained in hospital handouts (on self-management). How well can patients extract information and understand it? How well can they communicate the information? Are they able to apply new information even to changing circumstances?  Such items can be designed and used to evaluate patients’ ability to extract or receive quantitative information and process it accordingly as to be able to ultimately use in decision making. Evaluation items can include those with multiple-choice questions where upon answering correctly the patient is awarded points for each correct answer.

 Diabetes-specific skills, competency, and knowledge could be tested using items designed with false and true questions centered on different aspects of the implied elements (skills, competency, and knowledge). Such include glycemic monitoring, exercise, health diet, healthy coping, risk reduction, and problem solving. The items would be optimally developed based on available scales on diabetes knowledge (Heisler et al., 2005). Adherence to care/management instructions would, of course, be a clear indicator of patients’ knowledge and general health literacy.

References

American Association of Diabetes Educators (2015). Cultural Considerations in Diabetes Education. AADE Practice Synopsis. Author. 

Berkman, N.D., Sheridan, S.L, Donahue, K.E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: an updated systematic review. Annals of Internal Medicine, 15(3):97-107.

Haas, L., Maryniuk, M., & Beck, J. (2012). National Standards for Diabetes Self-Management Education and Support. Diabetes Care,35(11):2393-2401.

Heisler, M., Piette, J.D., Spencer, M., Kieffer, E., Vijan, S. (2005). The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management. Diabetes Care, 28(4):816–22.

Mayberry, L. S., Osborn, C. Y. (2012). Family support, medicationadherence, and glycemic control among adults with type 2diabetes. Diabetes Care, 35(6): 1239–1245.

Moss, T.R. (2014).The Impact of Health Literacy on Clinical Outcomes for Adults with Type 2 Diabetes Mellitus.Advances in Diabetes and Metabolism, 2(1): 10-19.

Peyrot M, Kovacs Burns K, & Davies M. (2013). Diabetes Attitudes Wishes and Needs 2 (DAWN2): A multinational, multi-stakeholder study of psychosocial issues and person-centered diabetes care. Diabetes Research and Clinical Practice, 99 (5):174-184.

Powers, M.A.,  Bardsley, J., Cypress, M., Duker, P., Funnell, M.M., Fischl, A.H., Maryniuk, M.D., Siminerio, L., & 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. The Diabetes Educator, 20 (10): 1-14.

Tang, T.S., Funnell, M., & Sinco, B. (2014). Comparative effectiveness of peer leaders and community health workers in diabetes self-management support: results of a randomized controlled trial. Diabetes Care, 37(8) :1525-1534.

Utah Department of Health (2015). Utah Diabetes Self-Management Education: A guidance map for understanding evidence-based diabetes self-management education (DSME) programs. Author.

Williams, G.C., Rodin, G.C., Ryan, R.M., Grol­nick, W.S, Deci, E.L. (1998). Autonomous regulation: the motivational basis of adherence to medical regimens. Health Psychology, 17 (4) :269–276.

Williams, G.C., & Zeldman, A. (2002). Patient-centered diabetes self-management education. Curr Med, 2(3) :145–152.

Zinman, B., Wanner, C., & John, M. (2015). Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. New England Journal of Medicine, 373:2117–2128.