The concept of diabetes self-management comprises several activities aimed to alleviate disease symptoms: medication intake, physical exercise, and diet. Additionally, it implies patients’ knowledge about various manifestations of their disorder such as elevated blood glucose levels (García, Brown, Horner, Zuñiga, & Arheart, 2015; Orly et al., 2017). In combination, health literacy and individual behavioral patterns determine clinical outcomes.
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Blood Glucose Self-Monitoring
Blood glucose tracking is the basis of diabetes self-management because the awareness of its levels allows correcting health-related behaviors. The studies associated with this subtheme aimed to explore the links between self-monitoring and long-term clinical outcomes (Laxy et al., 2014), as well as such biomarkers as HbA1c and body mass index (BMI) (Lavelle et al., 2016). Laxy et al. (2014) used objective and self-reported data from the population-based KORA-A study (n = 1,002) and the MONICA project (n = 4,940), while Lavelle et al. (2016) studied 19 adult patients with diabetes. Thus, the limitation of the latter study was the small sample size and the consequent inability to generalize findings.
The limitation of the former study is the difficulty in verifying the credibility of self-reported information. Still, both research projects found a direct, positive link between blood glucose self-monitoring and clinical manifestations of diabetes, suggesting a valuable contribution of diabetes self-management education (DSME) to patient outcomes.
Compliance with a healthy diet is directly related to individual weight outcomes and, thus, is an essential diabetes self-management activity. The studies exploring this subtheme aimed to investigate the links between weight change and self-management motivation (Traina, Slee, Woo, & Canovatchel, 2015), as well as establish the needs of patients with diabetes and evaluate the effectiveness of targeted education programs (Dehkordi & Abdoli, 2017).
Dehkordi and Abdoli (2017) conducted 18 interviews with 15 participants, and Traina et al. (2015) examined the overall sample of 1182 subjects. Thus, the results of the latter study were easier to generalize, yet its major limitation was the specific nature of the implemented patient-centered intervention, which might not lead to similar results in real-world settings. Overall, the studies demonstrated the importance of weight management in the treatment of diabetes, showing the need to select appropriate educational content.
Similarly to diet, physical activity is regarded by researchers as an essential activity in diabetes self-management. The given subtheme is mentioned in the studies by Laxy et al. (2014), and Reyes, Tripp-Reimer, Parker, Muller, and Laroche (2017). Reyes et al. (2017) explored the differences between diabetes self-management patterns in patients with insufficient and good glucose control and aimed to identify their educational needs.
They assessed eight multicultural focus groups comprising up to 15 patients from rural areas. Thus, the findings may be not generalizable to non-rural populations. Reyes et al. (2017) found that participants tended to be physically inactive due to comorbidities, lack of motivation, and other physical symptoms. They concluded that education programs must consider patients’ differences.
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Many patient-related factors can affect one’s compliance with self-management recommendations. They include motivation, the overall level of health literacy, as well as individual socio-cultural features. It is important to consider this concept in research because it indirectly affects clinical outcomes in patients with diabetes.
Motivation is a psychological variable influencing individuals’ behaviors and desire to improve their health. The subtheme is widely discussed in the study Traina et al. (2015) and touched upon in the research by Huxley et al. (2015). Both of them focused on the investigation of diabetes self-management predictors such as weight loss, perceived self-efficacy, overall treatment satisfaction, and others.
The sample in the study by Huxley et al. (2015) was smaller compared to that examined by Traina et al. (2015) and comprised just adult 27 participants. Huxley et al. (2015) found that DSME helps increase knowledge and reduce HbA1c levels, yet they failed to identify all motivational predictors leading to better outcomes. Contrary, Traina et al. (2015) concluded that interventions aimed at weight loss were associated with greater treatment adherence motivation. Considering controversies in findings, a further investigation of motivation as a self-management efficacy factor is required.
Health Literacy and Educational Level
A person’s knowledge about the disease and overall health substantially defines their health-related and health-seeking behaviors. This subtheme is addressed in the studies by Niknami et al. (2018) who investigated the associations between health literacy, diabetes self-management, and clinical outcomes, as well as Orly et al. (2017) who analyzed the effectiveness of individual patient education (patient-practitioner communication) in altering self-management behaviors of patients with low educational levels. Niknami et al. (2018) used data collected from 347 individual patient surveys, while Orly et al. (2017) compared two sample groups (control and intervention) comprised of 90 individuals each.
The obtained research evidence suggests that health literacy is directly correlated with diabetes self-management and clinical outcomes (Niknami et al., 2018) and that education interventions specifically targeted at vulnerable populations have a significant value in improving individuals’ behaviors (Orly et al., 2017). Further, researchers recommend investigating whether the lack of general or diabetes-related health literacy affects adherence more.
The subtheme includes such features as socioeconomic status and cultural beliefs linked to health and contributing to healthcare disparities. The topic was explored in the studies by Reyes et al. (2017), Debussche et al. (2018) who analyzed the effectiveness of community-based diabetes self-management education in an adult, lower-income population (n = 151), and Rovner, Casten, and Harris (2013) who evaluated how cultural background affects diabetes self-management in 110 older African Americans.
Concerning the subtheme, Debussche et al. (2018) and Reyes et al. (2017) observed that socioeconomic status defines one’s access to preventive care, healthier foods, and feasibility of continual engagement in physical exercise and stress management.
Similarly, Rovner et al. (2013) noted that the lack of diabetes knowledge and adherence to self-management recommendations might be determined by African Americans’ socio-cultural background. The latter study has a methodological limitation as it employs the convenience sample technique and focuses on senior individuals. The study by Debussche et al. (2018) is not randomized enough as well, which means that the investigation of the effects of a targeted DSME should be further repeated by using a more diverse population.
Self-Management and Patient Outcomes
Proper diabetes self-management can potentially lead to multiple favorable results including improved quality of life, and enhanced clinical outcomes such as BMI and HbA1c.
Quality of Life
Since DMSE is expected to enhance the overall health condition of patients with diabetes, it is considered to affect the quality of life favorably. This subtheme is explored by Dehkordi and Abdoli (2017), and Al-Khaledi et al. (2018) who focused on the given issue directly. The latter study employed a sample of individuals from Kuwait. Al-Khaledi et al. (2018) found that proper diabetes self-management is an independent factor linked to a better quality of life, while obesity is correlated with poor physical health composite.
Moreover, it is observed that the female gender is associated with a poorer physical health composite of the quality of life than the male gender. These findings have implications for designing education programs targeted at specific populations’ needs. At the same time, the main limitation of the study by Al-Khaledi et al. (2018) was the non-inclusion of immobile and severely morbid patients in the sample, possibly leading to the overestimation of results.
The level of HbA1c is a primary measure in individuals’ glycemic control. Some studies (Flood, Hawkins, & Rohloff, 2017; Lavelle et al., 2016; García et al., 2015, Brunisholz et al., 2015; and others) demonstrated that DSME leads to its significant reduction over time. Most of the research projects were directly devoted to the investigation of DSME effects on this clinical outcome.
Among them was the study by Flood et al. (2017), which analyzed the overall sample of 90 indigenous participants from rural Guatemala who underwent interventions in a low-resource setting. The findings of this research were consistent with results obtained by other researchers mentioned in the discussion of the related concept, yet it has a major methodological limitation as Flood et al. (2017) did not compare the obtained data with a control group. Overall, their findings can be generalized only to similar rural populations.
A lot of patients with diabetes are either overweight or obese and, therefore, the reduction in BMI is often one of their main self-management goals. However, the findings regarding the effectiveness of DSME in reducing weight are controversial. The study by Bowen et al. (2016), which explored the effects of nutrition-focused education on the overall sample of 150 patients with type 2 diabetes, showed a statistically significant weight loss in program participants over three months.
At the same time, the studies by García et al. (2015) and Huxley et al. (2015) did not observe significant changes in participants’ BMI. Additionally, Reyes et al. (2017) noted that the inability to control/reduce their weight through self-management practices is one of the main sources of individuals’ distress and frustration, which are the barriers to intervention adherence. Therefore, there is a need to investigate further the links between individual characteristics and BMI outcomes in patients.
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Healthcare practitioners can inform patients about diabetes self-management activities during both individual and group sessions. The latter education format has such advantages as cost- and time-efficiency yet may fail to take into account individual needs in diverse patients to a similar extent as in face-to-face instruction.
Group DSME Settings
Group education may take place in a great variety of settings including primary care facilities, community centers, and patients’ homes. For example, the study by Debussche et al. (2018) implemented a community-based, peer-mediated education, while some other research projects (for instance, Dehkordi & Abdoli, 2017) focused on the experiences of patients who underwent DSME programs in clinical settings.
Additionally, Brunisholz et al. (2015) explored the sample of all patients with diabetes who underwent DSME in specialized education centers, certified by the American Diabetes Association. All of these studies aimed at determining the efficacy of DSME in improving patient outcomes. Nevertheless, Debussche et al. (2018) additionally revealed that the involvement of trained peer educators could help address the lack of human resources and increase vulnerable populations’ access to preventive care.
Individual DSME Settings
Similarly to group educational sessions, the individual ones may be conducted in clinical settings (Huxley et al., 2015; Orly et al., 2017; Bowen et al., 2016) and specialized educational centers (Brunisholz et al., 2015).
Moreover, some studies (García et al., 2015; Lavelle et al., 2016; Flood et al., 2017) conducted in-home education interventions. The latter DSME form can be characterized as more patient-centered, individualized, and targeted compared to group education although their content may be the same. Additionally, Lavelle et al. (2016) concluded that home-based one-on-one sessions allow identifying barriers to adherence better than in clinical settings.
Most of the reviewed studies revealed that DSME in any form results in moderate to significant improvements in patients’ clinical outcomes. In particular, Brunisholz et al. (2015) found that improved self-management leads to the enhancement of diabetes-associated biomarkers (namely, HbA1C, LDL, blood pressure, and others). These findings are consistent with the ones discussed in the previous section. Nevertheless, a clear differentiation between the effects of individual and group education was not provided in the literature, which indicates a research gap.
Factors of DSME Effectiveness
Based on the sum research results, it is possible to conclude that the outcome of group and individual intervention delivery depends on the ability to meet patients’ needs and interests, and the level of instructors’ knowledge. Thus, specific subthemes related to the concept of DSME effectiveness are content, needs assessment, and educators’ skills.
The relevance, quality, and intensity of content are directly linked to DSME effectiveness. Most of the reviewed studies analyzed interventions, addressing basic self-management practices, namely, “symptom awareness, glucose self-testing, and appropriate treatments” (García et al., 2015, p. 485; Lavelle et al., 2016), as well as the knowledge of links between various clinical manifestations of the disease and individual behaviors, such as nutrition and exercise (Bowen et al., 2016; Debussche et al., 2018). The subtheme is substantially explained in qualitative research by Dehkordi and Abdoli (2017).
The respondents in their study emphasized that it is essential for content to be specific, non-repetitive, well-structured, and detailed. Additionally, DSME participants observed that when the curriculum is excessively intensive, they may feel discouraged to maintain recommended self-management practices because of perceived complexity and the lack of understanding. These self-reported data give an insight into patients’ view of education content and provides implications for DSME program development.
Effective education always meets the interests and needs of students. Therefore, before beginning a DSME course, it is important to conduct patients’ needs assessment. The significance of individually tailored DSME is discussed by García et al. (2015), Flood et al. (2017), and Lavelle et al. (2016) who examined interventions implemented in patients’ homes. Though such education programs allow working with patients individually and, thus, identifying immediate environmental factors leading to better/worse self-management in them (Lavelle et al., 2016), group DSME can effectively address patient needs as well.
For instance, the importance of targeting education content towards particular interests of multicultural populations is demonstrated by Dehkordi and Abdoli (2017), Reyes et al. (2017), Rovner et al. (2013), and others. Based on the findings, it is possible to say that DSME carried out in heterogeneous groups may be less effective in terms of meeting participants’ needs than the one conducted in either more homogeneous groups or through individual sessions.
Instructors’ level of knowledge and skillfulness, as well as sensitivity towards patients’ needs, maybe a decisive factor in DSME outcomes. For instance, though without providing conclusive results regarding the issue, the study by Huxley et al. (2015) emphasized the importance of practitioners’ skills in determining how patients’ intermediate self-management outcomes are linked to improved overall, long-term DSME outcomes. Additionally, Orly et al. (2017) revealed that improved communication skills and the ability to deliver information following patients’ developmental levels could enhance their health-related behaviors. The findings indicate that besides theoretical knowledge, educators must have a wide range of competencies needed to motivate and empower patients in various settings.
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