Preferences of Persons with Type 2 Diabetes for Diabetes Self-Management Education Interventions: An Exploration

Objectives: Treatment preferences affect treatment engagement, adherence and outcomes. There is limited knowledge of patients’ preferences for Diabetes Self-Management Education (DSME). This study explored the preferences of Canadians with diabetes for components, mode and dose for implementing DSME interventions. Methods: A cross-sectional design was used. Adults with diabetes completed a questionnaire to assess participants’ preferences for components ( i.e. content), mode ( i.e. teaching strategies, delivering formats) and dose ( i.e. number and length of sessions) of DSME. Descriptive statistics were used to analyze the data. Results: Participants (n = 100) were middle-aged men and women, who had diabetes for 6.1 years and previously received (95.0%) DSME. They indicated preference for DSME to include a combination of educational, behavioral and psychological components; to be delivered in individual, face-to-face sessions (4 sessions, 60 minutes each, given monthly) that allowed discussion with one diabetes educator to develop and carry out a care plan. Conclusions: Diabetes educators may consider eliciting patient’s preferences and tailoring DSME to fit patients’ preferences. Delivering interventions that are consistent with patients’ preferences increases their motivation to engage in intervention, satisfaction and adherence to treatment and achievement of desired outcomes.

• Type 2 Diabetes
• Preferences
• Diabetes Self-Management Education
• Interventions
• DSME
• Diabetes Education

1. Introduction

Type 2 diabetes is a chronic disease that affects a large number of adults worldwide. Its prevalence in Canada is increasing at an alarming rate. It is estimated that 6.8% of adult Canadians (about 2.4 million) had diabetes in 2009. By 2019, that number is expected to increase to 3.7 million [1] . The target of diabetes management is to achieve glycemic control and to maintain blood glucose, blood pressure, and cholesterol levels, and weight within acceptable ranges in order to prevent diabetes chronic complications such as heart diseases, stroke, kidney diseases, eye problems, and foot ulcers [1] [2] .

People with diabetes are responsible for the management of their disease on a daily basis. They have to actively engage in multiple self-management activities to achieve glycemic control and prevent complications. Self-management activities include: carefully selecting food, engaging in regular physical activity, self-monitoring of blood glucose, taking medications (oral pills or insulin injection) as prescribed and adjusting the medications dose as needed, managing stress and emotional distress, screening complications, and implementing strategies to prevent the occurrence of complications [1] . Diabetes self-management education (DSME) refers to the process of teaching people with diabetes about the application of self-management activities [3] . The goal of DSME is to assist in acquisition of the knowledge, skills and abilities necessary for practicing diabetes self-management [4] . DSME provides people with diabetes the knowledge and skills needed to make lifestyle changes required to successfully manage this disease, and provides the critical elements to assist people with diabetes to guide these decisions and activities; it has been demonstrated to improve clinical outcomes [5] [6] [7] .

Although DSME is highly recommended and accessible, patients with diabetes demonstrate low utilization and high attrition rates from DSME programs. These suboptimal rates may be related to low satisfaction, and the format for delivering the educational sessions; in fact, patients found the content not quite responsive to their specific self-management needs [8] [9] . In other words, DSME programs, as designed, may not fit with patients’ preferences. Yet, evidence indicates that preferences affect motivation to engage in and adhere to treatment, satisfaction with treatment and consequently outcomes achievement [10] . Preferences denote patients’ choices of intervention, that is, the intervention they want to receive to manage the presenting clinical problem [11] .

A key element of patient-centered care is involving patients in the development of interventions in a way that is consistent with their preferences [12] [13] . Accordingly, it is necessary to account for patient preferences in designing educational and behavioral interventions aimed at enhancing self-management in diabetes [14] - [19] . A few recent studies examined patients’ perception of interventions for diabetes self-management [20] [21] [22] . These studies targeted patients with different socio-cultural backgrounds and assessed their views of specific aspects of education or support interventions. The results showed that most diabetes patients report an interest in receiving diabetes self-management education, but preferences for strategies of delivery of self-management support (telephone support, group medical visits, one-on-one peer support, and Internet-based support etc.) vary by ethnicity, language proficiency, and self-reported health literacy. Healthcare providers should consider offering a range of diabetes self-management education and support services to meet the needs of their diverse patient populations. However, there is limited knowledge of the preferences of Canadian persons with diabetes for the following aspects of DSME interventions: components or types of intervention (i.e. education, psychological, behavioral), mode of delivery (i.e. teaching strategies; formats for delivery); dose (i.e. number, duration, and frequency of sessions), and type of interventionist responsible for implementing the interventions. Understanding patients’ views on these aspects is essential for designing DSME interventions that are acceptable to and consistent with the preferences of persons with diabetes. Offering interventions that are responsive to their preferences is expected to improve their motivation to participate actively in the intervention activities, adherence or performance of self-management activities, and consequently improvement in outcomes [11] [12] .

The specific objectives of this study were to describe the acceptability and preferences of adult Canadians with type 2 diabetes for the following aspects of DSME interventions: components (i.e. education, psychological, behavioral), mode of delivery (i.e. teaching strategies, use of teaching aids, formats, follow-up modes, timing, group size), dose (i.e. number, length and frequency of sessions), and type of instructors responsible for providing DSME.

2. Methods

Design, sampling and sample size: A cross-sectional design was used to examine preferences for DSME interventions. Eligible and consenting participants were requested to attend a data collection session to complete study questionnaires assessing the variables of interest. The sample of convenience included 100 patients with type 2 diabetes. This sample size was adequate to address the descriptive objective of this study.

Setting and participants: The study took place in primary healthcare settings including a family health team (FHT) centre and Toronto Chronic Diseases Centre (TCDC) after getting the local ethics approval. Participants referred by their family physicians to receive care from internists and diabetes educators at diabetes management teams in the two centers in Toronto. The target population consisted of adult patients with type 2 diabetes. Persons were eligible if they: 1) had a confirmed diagnosis of type 2 diabetes; 2) were 18 years of age or older; 3) able to read and understand English; and 4) non-institutionalized, residing in the catchment area served by the clinics.

2.1. Variables Measures

Participants’ socio-cultural and clinical characteristics. The socio-cultural characteristics included age, gender, education, employment status, and were assessed with standard questions. The clinical characteristics involved: duration of diabetes, metabolic control levels including hemoglobin A1c (HbA1c), blood pressure, low-density lipoprotein (LDL) and body mass index (BMI), and prior exposure to diabetes education. The researcher obtained the latest HbA1c and LDL laboratory reports from the participants’ medical records, after securing their consent. The researcher assessed blood pressure with an Omron blood pressure monitor, on the participant’s right arm, while in a seated position, and recorded the systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings. The researcher also measured the participant’s weight and height with a standard standing measuring scale, after calibrating it. BMI was calculated by measuring participants’ weight (kg) and height (m) and applying the formula {weight (kg)/height (m)²} to compute BMI. Participants indicated the actual number of years they have been diagnosed with diabetes (i.e. duration of diabetes) and whether or not they have had received diabetes education and information related diabetes management (prior exposure to diabetes education).

Preferences for DSME interventions. The researcher developed a set of questions to assess participants’ preferences for DSME intervention types, teaching strategies and methods, delivery formats and approaches, teaching aids use, follow-up modes, dose, timing for providing the intervention sessions, group size, and instructor involvement. The items were derived from the literature review previously conducted [3] [4] . The questions were pilot tested for comprehension with 5 persons with type 2 diabetes and 2 nurses. Minor changes were made based on their feedback to clarify the description of different aspects of the DSME interventions. The content of the questions is detailed next.

Intervention types were: 1) educational intervention, which refers to interventions in which patients with diabetes primarily receive information from healthcare providers and aim to improve patients’ knowledge of diabetes self-management; 2) behavioral intervention, which refers to interventions that focus on active skills training and emphasize acquisition of skills associated with lifestyle changes and implementation of a diabetes self-management regimen, such as diet, physical activity, blood glucose monitoring, foot care, and weight management; 3) psychological intervention, which refers to interventions in which the primary goal is to address stress and negative mood states, and to promote coping skills such as relaxation exercises and social support; and (4) combination of all 3 intervention types.

Teaching strategies used to convey DSME content included: 1) written material in the form of brochure/pamphlet that can be handed out to patients; 2) online/web based; 3) video; and 4) lecture presentation; and 5) interactions with instructor.

Teaching methods for providing DSME were divided into: 1) didactic lecture, where the educator conveyed diabetes-related information to patients, the didactic lectures were often characterized by limited interaction between instructor and participants and may involve a combination of distributing written materials, watching a video or attending formal individual or group sessions; 2) discussion sessions, which consisted primarily of active patients’ involvement in the learning process through exchange of information; 3) hands-on practice of the skills learned such as self-monitoring of blood sugar, choosing food items, and insulin injection; and 4) development of a care plan, where participants worked with the educator to develop and carry out a care plan (e.g. using problem solving or individualized goal-setting negotiation).

Teaching aids used to enhance the delivery of DSME intervention were: 1) power point slides to illustrate points or skills; 2) teaching tools such as food menu and labels; and 3) demonstration of how to use materials and supplies such glucometer and insulin pen. Participants were also asked if they prefer to not use any teaching aids.

Mode of delivery related to format and approach. Format reflected the number of participants attending a given intervention session including one-on-one teaching session, or group teaching session. Approach indicated the delivery of DSME intervention either by face-to-face on site or via telephone communication with diabetes educators, or a combination of these two approaches.

Follow-up modes represented participants’ preferences for ways to complete follow-up booster sessions after receiving DSME interventions; these were 1) on-site visit: patients come to the clinic and meet the diabetes educator in person to discuss relevant self-management information; 2) phone-call: diabetes educator contacts patients by phone; and 3) regular mail: patients complete pertinent self-management tools and documents and mail them back to the diabetes educator.

Dose of DSME intervention was described in terms of number of sessions; duration of each session; and frequency of sessions. Participants were required to indicate their preferences for each by writing down the respective numbers.

Group size preferred by participants was assessed by having them select the number of persons to include in a group teaching session, which ranged from 4 - 6, 7 - 15, 16 - 25, and 25 persons or more for each option in this study.

Timing indicated participant’s preferences for days of the week (weekdays or weekends) and time of the day (mornings, afternoons or evenings) on which the intervention sessions are offered.

Instructor involvement referred to the number of instructors (one or more) to facilitate the sessions and carry out the teaching activities. Instructor related to the type of healthcare providers responsible for facilitating the sessions such as: doctor, diabetes nurse educators, dietitians, other providers, and persons with diabetes.

2.2. Data Collection and Data Analysis

Eligible and consenting participants were requested to complete the questionnaire on their own.

Completing the questionnaires took about 20 minutes. The researcher checked the completed questionnaires to avoid missing data after participants completed them. The data analysis was carried out using SPSS (version 22.0) for Windows. Descriptive statistics were used to describe the sample in terms of socio-cultural and clinical characteristics, and preferences for the different aspects of DSME interventions.

3. Results

Participation rates. A total of 121 eligible patients with diabetes were invited to the study. Of these, 100 patients (82.6%) completed the study, and 21 patients (17.4%) declined participation. The reasons for refusal were time conflict with work or housework (n = 11, 52.4% of those who declined) and no interest in the study (n = 2, 9.5%); 8 (38.1%) patients gave no reason.

Participant’s socio-cultural characteristics. The participants’ characteristics are summarized in Table 1. Participants were adults with type 2 diabetes with an average age of 58.9 years (SD ± 10.1, range = 38 - 85). The years of formal education ranged between 6 and 19, with a mean of 14.09 years (SD = 2.37), with most having attended college or university. The sample consisted of slightly more men (55%) than women (45%). Most participants were married or partnered (72%), and employed (68%) either full-time or part-time. They varied in ethnicity with most self-identifying as South East Asians.

Participant’s clinical characteristics. As showed in Table 1, participants had diabetes for an average of 6.16 years (SD = 5.92); about one-third were newly diagnosed (<1 year) with diabetes. They had an average BMI of 30.08 kg/m² (SD = 5.84), LDL of 2.49 (SD = 1.25), SBP (120.44, SD = 13.26) and DBP (69.16, SD = 8.27). The mean FPG was 7.46 mmol/L (SD = 1.65) and HbA1c was 8.25% (SD = 1.66), Overall, more than 50% participants did not reach the glycemic control targets for HbA1c ≥ 7.0 (76%). The majority of participants (95%) indicated that they previously received diabetes education, mainly through attending diabetes education sessions (94%), and reading pamphlet/booklets (78%). Participants indicated engagement in the following diabetes management activities: taking oral medications (80%), using insulin (20%), having regular physical activities (95%), healthy eating (97%), self-monitoring of blood sugar (96%), and taking care of feet (96%).

Preferences of DSME interventions. Table 2 presents the percentage of participants indicating preferences for the DSME interventions’ types, mode and dose of delivery, and interventionists.

Preferences for intervention types: A small number of patients preferred educational (n = 14) and behavioral (n = 8) interventions, whereas the majority (78.0%) chose a combination of DSME interventions.

Preferences for teaching strategies: Participants expressed preference for more than one teaching strategy. Most participants (88%) preferred interactive learning with diabetes educators; 64% selected lectures presentation, and 58% chose

Table 1

Participant personal and clinic characteristics

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