Survey of people with type 2 diabetes shows the majority prefer diabetes education to be given during regular diabetes check-ups; other education preferences and opinions on self-care vary depending on patient characteristics
- Correspondence to Warren Gillibrand
Department of Nursing & Health Studies, School of Human and Health Sciences, Harold Wilson Building, Room HW3/28, University of Huddersfield, Queensgate, Huddersfeild HD1 3DH, UK;
Type 2 diabetes is classified globally as a pandemic affecting all populations, to such an extent, that nearly every human being will have some kind of reference to it. This paper contributes to a widening knowledge base, in a very important aspect of diabetes, related to patient education and its concomitant impact on the ability by a person with diabetes to self-manage their condition. It has been explored, investigated and recognised that high standard, individually tailored, psychosocially orientated patient education will have beneficial, clinical and cost-effective results on disease and quality of life (QoL) outcomes.1 Patient preferences as to type and mode of delivery of education have not been explored to any great depth in diabetes and indeed in other conditions. There is also a paucity of information regarding which aspects of self-management or self-care patients prefer, or do not prefer, to carry out in order to maintain optimal biophysical and psychosocial outcomes.
This research used a standard questionnaire survey design in people with type 2 diabetes attending diabetes services in primary care hospital out-patient settings. The aim was to investigate the association between preferences of patients to the setting of education, the educator and self-care activities. The questionnaire measured four different multinomial outcomes related to patient preferences and assessed potential determinants of preferences against age, gender, educational level, ethnicity and setting and other parameters. The questionnaire responses were analysed for descriptive outcomes, and logistic regression analysis was used to assess possible associations. These were expressed as ORs using a backward stepwise method. The main results were that in 994 questionnaires analysed, 80% of participants preferred diabetes education during their check up appointment, patients taking insulin preferred education by nurses, and patients with ‘eating disinhibition’ found taking medication and following a healthy diet as having the most burden. The main conclusion the authors make is that healthcare workers should aim to provide individualised education to people newly diagnosed with type 2 diabetes.
Methodological issues in survey design
The sample, it appears was one of convenience, taken from consecutive attending patients to their general practitioner or hospital specialist. There were considerably more respondents from primary than secondary care and indeed differences in demography, and diabetes-related measures, were noted by the authors. It is possible that this may have skewed the results; however, it is probably representative of the split in service delivery and therefore offers some validity.
In terms of the outcome measures within the questionnaire, these appear standard, with use of the European QoL Scale, the European QoL visual analogue scale and three subscales from the Diabetes Health Profile. There is some debate in the diabetes-related literature about the use of generic QoL scales in specific conditions, and there are validated diabetes specific QoL scales available, which might have produced more detailed and accurate responses for people with diabetes. Most research in diabetes focuses on one typology for robust validity reasons; however, it is interesting to note that one of the significant results was related to patients taking insulin, preferring the nurse to deliver education. On average, half of people with type 2 diabetes will become insulin requiring, related to duration and decreasing insulin production and sensitivity, and the authors acknowledge this in the discussion. Considering that all people with type 1 diabetes require insulin, it might have been interesting to compare preference of educator, in this type, as a subgroup analysis. The authors acknowledge some limitations which was essentially a very robust study; for example the very low percentage of non-Western ethnicity, which is not representative of the global prevalence of type 2 diabetes but possibly representative of the ethnic minority population in the Netherlands.
Important clinical recommendations for nursing practice
This research contributes some much needed information on patients' preference for education and self-management, as there is a distinct paucity of research in this area. Indeed, the authors make reference to a study which explored similar concepts, which is over 30 years old, and was conducted in a different context. The systematic review conducted by the American researchers probably provided some comparable recommendations to this research, and points towards patient preferences of non-medical educators and incorporated within their general diabetes care programme.
This study was conducted within a state/private funded healthcare system and because of its robust methods and adequate sample size, nurses should be able to take some important messages for their practice: individualise education for people with type 2 diabetes and assist the patients in improving their self-management by determining the most suitable exercise programme for them.
Clearly, given the few studies in this area, further research is needed into motivation and behaviour by people with type 2 diabetes, and also to evaluate how well nurses implement evidence-based interventions to progress these in their patients.