Experience-based group education in Type 2 diabetes: A randomised controlled trial

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Abstract

Few studies have demonstrated an effect of educational interventions on glycaemic control in persons with Type 2 diabetes longer than 3–6 months after baseline. We aimed to investigate the effectiveness of an experience-based group educational programme 24 months after baseline and to pinpoint mediators that might play a role in achieving desired metabolic outcomes. We conducted a randomised controlled trial inviting self-referred persons with Type 2 diabetes (N=77 randomised). The pharmacist-led, year-long intervention was based on participants’ experiences of glucose regulation during the monthly group discussions. We measured HbA1c at 0, 6, 12, and 24 months and a questionnaire was administered at baseline and final follow-up. Our findings indicated that participating in the intervention programme significantly decreased HbA1c by 0.4% at 24 months after baseline. Initial HbA1c, satisfaction with own diabetes-related knowledge, and treatment were found directly related to glycaemic outcomes. The intervention group exercised more in order to lower blood-glucose levels and was also more able to predict current blood-glucose levels before measuring it. Experience-based group education was effective in decreasing participants’ HbA1c 1-year after completed intervention. Early effect of the intervention was followed by relapse after 12 months and a new, significant decrease at 24 months; this dual course implies that follow-up of educational interventions should involve several consecutive measurements to capture possible late effects. Both biomedical and subjective factors played a role in accounting for the variance of HbA1c at 2-year follow-up after baseline.

Introduction

Patient education is a well-established component of modern diabetes management [1]. However, there is no consensus on how effective educational efforts should be planned and put into practice to achieve long-term effects.

In a recent meta-analysis on randomised trials on patient education in Type 2 diabetes, the authors demonstrated that the longer the follow-up after an educational intervention, the lesser the effect on HbA1c [2]. The greatest effects were observed between 0 and 3 months after the intervention, to fade away entirely by 12 months. Few studies demonstrate an effect on glycaemic control longer than 6 months after educational intervention, whereas most educational programs achieve these early effects [3]. Consequently, it would appear that most interventions will help in the short run, but as time passes, whatever caused the initial effect seems to vanish in the reality of everyday life [2], [4]. The question that arises then is whether it is possible to achieve long-term glycaemic control through patient education by choosing better intervention targets.

Reflection and understanding are concepts that underline the pivotal role that persons with diabetes have in achieving effective daily management of their disorder. Acknowledging the individual’s competence to make decisions about everyday care yields a sense of autonomy, which is assumed to help individuals “take charge of their own diabetes” [5]. This initiative, in turn, results in the individual acting as an equal partner in the planning and delivery of diabetes care. In this perspective, the concept of empowerment can be viewed as both the goal and the means of patient education in diabetes. Supporting these assumptions is the evidence that internal locus of control [6], reflecting the individual’s sense of power to influence his or her situation, and health-care staff attitudes conducive to autonomy [7] have predicted a decrease of HbA1c in diabetes educational programs. In a randomised controlled study of persons with arthritis, self-efficacy was distinguished as the mediating factor in educational intervention and improved disease outcomes along with decreased physician costs [8].

Another intervention target with as yet unknown potential is the role of body awareness that has been studied in relation to Type 1 diabetes where training programs for patient recognition of hyper- and hypoglycaemia have proved useful for daily disease management [9]. Price described the process [10] in which persons with Type 1 diabetes learned to manage their illness during the first year after diagnosis by developing skills of “body listening” and interpreting the signs and clues their bodies gave them. Whether training body awareness has the potential of improving glycaemic control has not been examined, however. In an explorative interview study the interviewees described a “feeling in the body,” a way of knowing what was going on with their blood-glucose levels and why, as a helpful instrument for controlling their diabetes [11].

In this paper we present a randomised controlled trial of an experience-based group educational program. The intervention targeted several of the above mentioned subjective aspects of diabetes self-management and our aim was to investigate the effectiveness of the intervention as well as attempt to pinpoint mediators [12] that might have played a role in achieving desired metabolic outcomes. We hypothesised that body awareness and a capability to make a correct guess of the current blood-glucose level before measuring it would predict better glycaemic control. Other hypotheses tested included positive effects of exercise and decreased body weight and negative effects of feelings of loneliness, high body mass index (BMI) and feelings of anxiousness for diabetes-related complications [13]. Educational background, age, and sex were basic variables which we planned to initially include in all statistical testing. Planned analyses included one-way ANOVA, regression- and repeated-measures analyses, and independent sample t-tests.

Section snippets

The intervention

The intervention was a 12-month long group educational program led by specially trained pharmacists, assisted by a diabetes nurse specialist on the first two occasions. The programme had been pilot-tested [14] and we also conducted a trial for implementing the intervention at a number of pharmacies around Sweden to test its feasibility for mass education [13].

The training of the pharmacists (by co-author U.R.) to become facilitators comprised a 3-day intensive course where the main objective

Results

The intervention and control groups did not differ on age, sex, BMI, employment, and marital status (Table 2, Table 3). The intervention group, however, was found to have longer diabetes duration compared with the control group (5.9 years versus 2.6 years). Probably therefore, the intervention group also included more persons who were on both oral hypoglycaemic agents and insulin.

Discussion and conclusions

Our results indicate several points of interest. The most important implication of this study is that the experience-based educational intervention under study has produced a significant decrease in the HbA1c levels of the intervention group. The intervention group had a greater decrease in HbA1c both at 6 and 24 months after baseline, with the latter finding being significant in that few studies of educational programs have demonstrated long-term effects on metabolic control [2]. Those that

Acknowledgments

This study was supported by the Swedish Foundation for Health-care Sciences and Allergy Research Grant No. V2000 225, the National Corporation of Swedish Pharmacies, and Uppsala University. Funding for the first author, Anna Sarkadi, have been thankfully received from the Knut and Alice Wallenberg Foundation in Stockholm, Sweden, grant nr. KAW 2001.0303.

References (24)

  • A Sarkadi et al.

    Study circles at the pharmacy: a new model for diabetes education in groups

    Pat. Educ. Couns.

    (1999)
  • I DeWeerdt et al.

    Determinants of active self-care behaviour of insulin treated patients with diabetes: implications of diabetes education

    Soc. Sci. Med.

    (1990)
  • National Diabetes Advisory Board. Quality recognition for diabetes patient education programs: review criteria for...
  • S Norris et al.

    Effectiveness of self-management training in Type 2 diabetes

    Diab. Care

    (2001)
  • S Norris et al.

    Self-management education for adults with Type 2 diabetes: a meta-analysis of the effect on glycemic control

    Diab. Care

    (2002)
  • S Brown

    Meta-analysis of diabetes patient education research: variations in intervention effects across studies

    Res. Nurs. Health

    (1992)
  • R.M Anderson et al.

    Learning to empower patients

    Diab. Care

    (1991)
  • N White et al.

    Management of obese patients with diabetes mellitus: comparison of advice education with group management

    Diab. Care

    (1986)
  • G Williams et al.

    Supporting autonomy to motivate patients with diabetes for glucose control

    Diab. Care

    (1998)
  • K Lorig et al.

    Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health-care costs

    Arthritis Rheum.

    (1993)
  • D Cox

    Blood-glucose awareness training (BGAT-2)

    Diab. Care

    (2001)
  • M Price

    An experimental model for learning diabetes self-management

    Qual. Health Res.

    (1993)
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