iabetes Self-Management Education Programs:
The meta-analysis of 22 studies of psychosocial behaviors affecting diabetes self-management behaviors highlighted the importance of self-efficacy as one of the strongest predictors of self-management behavior. Therefore, it is imperative that diabetes educators incorporate learning opportunities that will enhance patients' self-efficacy. The most effective method for doing so is to allow opportunities for patients to experience successful task accomplishments. Diet teaching is often the area of diabetes self-management delivered in didactic format, compared with the performance-based approaches used with other skills such as blood glucose monitoring and medication administration. It is not surprising, then, that behaviors related to diet are especially associated with low self-efficacy (83). Thus, in addition to didactic instructional methods, teaching strategies such as motivational interview, role-play, and behavior modification interventions that are offered over longer periods of time are necessary to enhance self-efficacy (84).
Effective diabetes education involves a combination of art and science. The diabetes educator is expected to be current with the standards of clinical practice to design patient education programs that are scientifically derived and evidence based. Communicating effectively with patients in the context of a positive human relationship, however, is an art. It is imperative that diabetes educators possess proficiency in interpersonal communication skills and distinct character features to enhance effective rapport with their patients. Efficacious education should transcend mechanical transmission of information to attain a deeper level of knowledge and inspire sustainable behavior changes. Thus, through the assimilation of fundamental principles, reflecting and incorporating them into everyday activity, an individual with diabetes ensures active adherence to the treatment plan and manifests effective self-management results (85-86).
Diabetes self-management strategies allow the individual to make healthy food choices, incorporate physical activity into everyday lifestyle, monitor weight, set attainable goals, acquire social support, and develop skills in problem-solving. These are all necessary and fundamental involvements to keep the momentum of self-management continuous and effective (87). Research indicates that self-management and patient education programs are effective in improving diabetes management and metabolic control and enhancing quality of life. As a result of these studies, the Diabetes Self-Management Education (DSME) programs were developed. The DSME programs were designed to demonstrate that diabetes educators can deliver comprehensive models for diabetes self-management in primary care settings and significantly improve patient outcomes (88).
Diabetes educators are long-standing advocates for people at risk for and with diabetes, striving to create environments in healthcare systems, homes, schools, and communities that support diabetes care and prevention. Well positioned in their own communities, diabetes educators promote access to quality diabetes care and DSME, ensure healthy nutrition and physical activity choices, and provide social support to help individuals and families initiate and sustain lifestyle adaptations. Diabetes educators in all settings are critical members of the public health workforce (89).
If DSME is essential and beneficial, then one wonders why as little as one-third of patients with diabetes take advantage of this critically important health service (90). While there has been little direct research on factors affecting the use of DSME, there has been some relevant research. (91) asked diabetes educators their thoughts regarding patients who did not receive DSME. Reasons cited included several patient related factors, including lack of insurance coverage, unavailable funds, patient attitudes, low appreciation for DSME, logistical barriers, difficulty attending sessions, social network factors, and lack of family support. The role of the physician also was regarded as an important factor. Physician referrals were perceived to be a key motivator for patients; unfortunately, many physicians were not perceived to be supportive of DSME due to role conflict.
Although intensive patient education has been the most common strategy to facilitate diabetes self-management, education alone does not always result in behavior change that leads to sustained improvement in glycemic control (92). Frequent contact with the clinicians and diabetes education providers is required. Despite the association of the positive outcomes, DSME program effectiveness has been difficult to evaluate. Research to date has not determined which aspects of the program interventions are the most effective methods and which settings are the best for individuals to assimilate knowledge. Interactive approaches and behavior modification strategies that are incorporated into regular primary care visits in which patients participate in everyday self-management decision-making measures may be more effective than intensive educational programs. In addition, an educator who is familiar with the dietary practices of a given population might be more effective in conveying self-management strategies, due to acceptance by the group and the established trust (93-94-95). Although patients who received self-management education felt knowledgeable and empowered, they faced many challenges when they returned to the communities in which they lived and worked. As a result, strengthening ties with the community environments in which individuals managed their diabetes following diagnosis is imperative. Partnerships between the providers of care and the communities they serve may be valuable approaches. Thus, Building Community Supports for Diabetes Care was designed to extend self-management beyond the clinical setting and into the communities where people with diabetes live. This initiation targeted ethnic populations including African American, American Indian, and Latino populations. Armenians were not included in this project because Armenians are recognized as Caucasian or non-Hispanic Whites, not identifying them as an ethnic minority. Moreover, they are not evenly distributed across the States. Engaging a population living with substantial disadvantages such as lack of access to care, complex lifestyles, language barriers, cultural obstacles, and financial limitations were important steps toward reaching minorities. Lessons learned from the diabetes initiative was that goal setting and self-management techniques equip members of the patient care team to help patients to manage their chronic conditions by including them as partners in the healthcare team. Thus, nurses with additional training in patient focused care and community health such as parish, home health, and public health nurses are effective agents and integral members of the healthcare team in providing self-management support to persons with diabetes and link people in communities to healthcare delivery practices dedicated to addressing diabetes prevention and treatment. In addition, church congregations, employer work groups, charitable organizations, and professional associations can be partners in promoting health and preventing diabetes, too (96). Continued advocacy efforts by policy makers, however, are necessary to sustain the current diabetes self-management education benefits and expand the attempts to further promote healthy environments for people with and at risk for diabetes(97). The impact of diabetes self-management classes taught in Armenian on this population's glucose self-management (Alc levels), their overall health beliefs, and the impact of acculturation on their self-care behaviors has not been yet reported despite the fact that research has demonstrated that significant health disparities and higher rate of co-morbidities do exist in minorities (98).
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