Diabetes is becoming a worldwide epidemic. It is one of the biggest health challenges that the United Kingdom (UK) is facing today with one person being diagnosed with diabetes every 3 minutes (Diabetes UK, 2009). The latest data indicates that there are now 2.8 million of people with diabetes in UK and nine out of ten people diagnosed with diabetes are Type 2 diabetes (2.5 millions). According to health experts, UK is now facing a huge public health problem and the figure is set to rise to four million by the year 2025. (Diabetes UK, 2010).
The alarming increase in diabetes prevalence is a great cause of concern and has a devastating economic effect. Recent estimate shows that 10% of National Health System (NHS) spending equivalent to 9 billion pounds a year, 1 million pounds per hour goes on diabetes (Diabetes UK, 2008). The direct and indirect cost to the NHS of caring for people with Type 2 diabetes and its complications are staggering and will continue to rise with the increasing incidence of the disease. As a result of this health crisis and significant financial burden, the NHS needs to respond to this massive strain by looking at more effective and efficient ways of providing diabetes care. It is therefore of primary importance for our local primary care diabetes services to identify ways to deliver an effective quality care for people with diabetes to counter this worrying trend.
1.1 Diabetes Education
Diabetes education has been considered as one of the key components of diabetes care since the 1930s and has been increasingly recognised as an integral part of the disease (Atak & Arslan, 2005). Nicolucci et al (1996) demonstrated that people who have never received diabetes education had a striking fourfold increased risks of developing major diabetes complications. Furthermore, the study done by Rickiem et al (2002), showed that diabetes education has an overall positive effect on the health and psychosocial outcome. It helps to improve patients’ skills and knowledge on the condition and enables beneficial change in the behaviour. Diabetes education has a profound effect on glycemic control, quality of life and treatment satisfaction (clinical governance support team, 2004). Stratton et al (2000) suggested that improving Hba1c by just 1% through diabetes education can significantly reduce risk of complications.
In view of all the evidence, the importance of diabetes education has been highlighted and well advocated by the National Service Framework (NSF) and National Institute of Clinical Excellence (NICE, 2003) . The NSF emphasizes that diabetes education should be made available from the point of diagnosis onwards and proposes that education should involve a structured program for people who have been newly diagnosed. This has been encouraged by NICE which recommends that all patients received structured education at initial diagnosis and then on a regular basis according to need (NICE, 2003).
However there is insufficient evidence currently available to recommend a specific type of education or provide guidance on the setting for, or frequency of, sessions. In this context, how best to provide structured education to people with diabetes is an important question. NICE acknowledge the limited evidence to suggest which approach is most appropriate and state that to achieve maximum effectiveness, some principle of good practice should be in place(NICE, 2003).
According to NICE criteria, diabetes education should reflect the principle of adult learning, provided by trained educators including a DSN or practice nurse with diabetes experience, and a dietitian, use a variety of techniques to promote active learning, be accessible to the broadest range of people taking into account their ethnicity, culture and beliefs.
1.2 Aim of Diabetes Education
The National Institute for Health and Clinical Excellence (NICE, 2003) states that the aim of education for people with diabetes is: ‘To improve their knowledge and skills, enabling them to take control of their own condition and to integrate self-management into their daily lives.’
Diabetes education should allow people to engage in their own health to put what they’ve learned into action. Traditional health education can give them the information they need but the learning experience may not engage and empower them to use what they’ve learned in their daily lives. Education was focused on passive didactic format where patients do not interact with the educator and generally use a lecture or print format (Norris et al, 2001). Middleton et al (2006) found that its purpose was often unclear to both patients and health care professionals. The old model of education is outmoded and ineffective (Skinner et al, 2007). Education has now moved towards a collaborative format where patient actively participate in the learning process through small group discussion, role playing and other interactive techniques (Norris et al, 2001).
1.3 Patient Centered Approach and Empowerment
The National Service Framework for diabetes (DoH, 2001) standard 3 states that all people with diabetes will: ‘Receive a service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle’.
The purpose of diabetes education is clear. It should empower people with diabetes to make informed choices about their condition (Funnel and Anderson, 2003). Anderson et al (1991) at the Michigan Diabetes Research and Training Center (MDRTC) introduced empowerment into patient education in diabetes at the beginning of the 1990s in the US. They implemented empowerment group education programmes in diabetes (empowerment programme) and evaluated their programme. An improvement in self-efficacy and glycaemic control was reported among the patients who had participated in the programme compared to those in the wait-listed control group.
Following the valuation of patient educational interventions for people with type 2 diabetes during the 21st century, Deakin et al (2006) showed that there is a trend to actively involve patients in their care in accordance with the empowerment philosophy. The investigator compared group education programmes with routine diabetes care and found that group-based programmes involving patient empowerment has positive effect on biomedical and psychological out come.
The concept of empowerment requires an initial understanding of what the treatment pathway is trying to achieve and is continual information sharing process encompassing learning and behaviour change which aims to allow the patient to take responsibility for their own condition. (Meetoo and Gopaul, 2004)
For empowerment to be effective it is important for patients to have the appropriate information to enable them to make informed choices, if they have the capability and desire to do so. They need to be able to agree plans and set goals with the support of the care team. To do so, it is important for them to understand their disease.The NSF set to ensure that people with diabetes are empowered to enhance their personal control on a day to day management of the condition. Implications for service planning were highlighted detailing how NHS will need to develop, review and audit education program to empower people with diabetes, (DoH, 2001)
People are more likely to make behavioural changes if they are facilitated through patient centered care rather than imposed by care based on the medical model of delivery (DoH, 2001a).The philosophy of practice which support patient centered approached for diabetes education is well documented in chapter 3 of the DoH publication structured patient education in diabetes: report from the patient education working group (DoH, 2005).
Specific strategies that grew out of the patient centered model included the following:
affirming that the person with diabetes is responsible for and in control of the daily self-management of diabetes;
educating patients to promote informed decision making rather than adherence/compliance;
learning to set behavioural goals so that patients can make changes of their own choosing;
integrating clinical, psychosocial, and behavioural aspects of diabetes self-management;
affirming the participants as experts on their own learning needs;
affirming the ability of participants to determine an approach to diabetes self-management that will work for them;
affirming the innate capacity of patients to identify and learn to solve their own problems;
respecting cultural, ethnic, and religious beliefs of the target population;
creating opportunities for social support; and
Providing ongoing self-management support.
Overall the diabetes education must provide knowledge and skills, be tailored to the needs of the individual and include skills-based approaches to education. It should support people with diabetes to adopt and maintain a healthy lifestyle, prevent and manage diabetes related complications that will result in improved quality of life and self-management. Healthcare professionals are encouraged to work in partnerships in the decision-making process to support the individual to manage his or her condition.
1.4 Effectiveness of Diabetes Group Education
The manner in which education is delivered can be the subject of much debate. Education can be delivered in a one to one session or in group settings.
Diabetes group education has been seen as an effective intervention since 1970 (Mensing, 2003). Traditionally, it was more of a medical model where patients handed their medical problem for the doctors to cure. They are told what to do and expecting good results (Calabretta, 2002). As the process of group education has evolved over time, diabetes education has changed from a medical didactic presentation to more of theoretical, patient centered and empowerment model.
Diabetes group education is now seen as a first line approach to improve diabetes outcome. With the increase in number of people diagnosed with diabetes, more education is being delivered now in groups as compared to the past. The environment should support and reinforce self management and patients and their health care should work in collaborative way. Self management can only be successful in a well organised and coordinated diabetes service where patients are supported to make informed choices (Norris et al, 2001). Several reviews and meta- analyses provide valuable information on the effectiveness of group education. Mullen et al( 1985) found that patient knowledge about their medication significantly improved in group education, one to one counselling , written and other audiovisual material. Norris et al (2002) suggest that the literature in diabetes education is divided although there may be more positive effect on group education as compared to the individual one.
Deakin et al(2006) showed that there is some evidence to support group-based diabetes self-management education as an effective way to improve knowledge and glycemic control and to reduce BP, body mass index (BMI), and the need for diabetes medication. However, a number of issues arise when reviewing the literature on the relative effectiveness of group education compared to individual ones. Some researchers make comparison difficult by focusing on different outcome rather than the delivery format whereas others compare it with usual program without considering the relative effectiveness (Mensing,2003). Wilson (1997) noted that it is not easy to figure out whether the outcome is from an educational approach based on a specific theory or from intervention applied to a specific setting and population. Given these issues and limitation, it is difficult to draw conclusion about group effectiveness. More evaluation research must be done in this field to answer these questions.
NICE (2003) has highlighted the effectiveness of group education sessions .For healthcare professionals, group sessions are considered as the most cost-effective way of delivering education. In the present financial climate, and with the increase in the numbers of people with newly diagnosed diabetes, it could be argued that group education is the only way forward if healthcare professionals are to be able to provide education for the majority of people with diabetes. A group approach to patient education makes sense from what we already know about the positive effects of peer support and the inadequacies of the brief medical appointment.
The potential benefit of an effective group education programme for people with type 2 diabetes is to enhance skill and knowledge, to make positive behavioural changes for better metabolic outcome, psychological outcome and improve quality of life.
1.5 The Two National Programs for people with type 2 Diabetes : XPERT AND DESMOND
Most people diagnosed with diabetes are offered some sort of education, at least when they are diagnosed (NICE, 2008). However, there is still much debate over the educational approach that is most effective in delivering such crucial health information in a way that leads to measurable changes in patient behaviour and improved clinical outcomes.
The two national group education programs available for adults with type 2 diabetes are (DESMOND) and X-PERT program. Both are patient centered, meet the NICE key criteria, flexible in their content and adaptable to patient’s educational and cultural background. However, the two structured group varies in their cost implication and duration of the program. Depending upon primary care trust funding funding, avaibility of health care professionals and what best suits patients, either DESMOND or X_PERT are chosen to be delivered by the primary care trust.
1.51 XPERT DIABETES PROGRAM
The X-PERT diabetes programme is a six-week professionally-led programme based on the theories of patient empowerment and patient activation. The X-PERT course is designed to be delivered to anyone diagnosed with diabetes It aims to increase knowledge, skills and confidence leading to informed decisions regarding diabetes self-management (Deakin &Whitham,2010). Participation in the X-PERT Programme by adults with type 2 diabetes has been shown at 14 months to have led to improved glycaemic control, reduced total cholesterol level, improved body mass index and waist circumference, reduced requirement for diabetes medication, increased consumption of fruit and vegetables, increased enjoyment of food, and improved knowledge of diabetes, self-empowerment, self-management skills and treatment satisfaction (Deakin et al, 2006).
Contents of the X-PERT Diabetes Programme include:
What is diabetes?
The eatwell plate and energy balance.
Carbohydrate awareness and glycaemic index.
The benefits of physical activity.
Supermarket tour and understanding food labels.
Possible complications of diabetes and their prevention.
Lifestyle experiment.
Are you an X-PERT? Game.
Care Planning: the lifestyle experiment.
There is a one off cost to run X-PERT and this is approximated to £1400.
1.52 DESMOND
The DESMOND programme was launched in 2004, and is currently the most familiar education programme provided in the UK. It was developed as a collaborative project involving a multidisciplinary, multicentre collaborative team which agreed upon a core set of philosophical principles to the use of ‘informed choice’ as the key to ’empowerment’. They drew the program on three theoretical approaches: the common-sense model of illness, social learning theory, and use of a discovery learning process (DESMOND, 2004).
DESMOND aims to educate patients about type 2 diabetes. It provides resources for them to manage their disease, and offer a group-based opportunity to meet and share experiences with others in the same situation .The DESMOND programme is facilitated by two health care professionals who have been formally trained.
The course is usually delivered for 6 hours and is based on a formal curriculum. It is offered either as a 1-day or 2 half-day sessions and accommodates 6-10 patients in one group.
DESMOND helps to promote the understanding of type 2 diabetes, allowing the patients to be more knowledgeable about the condition and what can benefit their long-term health. It encourages patient to work together with the health care professionals to take an active role in the management of their type 2 diabetes. It helps patients to see their illness in a well define way which drives them for positive changes.
The program content includes:
Thoughts and feelings of the patients around their condition.
Understanding diabetes and glucose: what actually happens in the body.
Understanding the risk factors and complications associated with diabetes.
Understanding monitoring and medications.
How to take control: Food Choices and Physical Activity.
Future care plan.
DESMOND was piloted in 15 English PCTs between January and May 2004 (Skinner, 2006). Initial abstracts of preliminary research findings were presented at the Diabetes UK annual conference in 2005. Pilot data indicated the DESMOND course for newly diagnosed individuals changed important illness beliefs. At three month follow-up there was a reported improvement in quality of life and metabolic control. DESMOND was revised following feedback from all involved parties.
A larger randomised controlled trial was conducted involving 824 adult patients in 207 general practices in 13 primary care sites in the United Kingdom. The results showed that compared to patients who did not undergo the DESMOND programme there were greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but there were no differences in haemoglobin A1C levels up to 12 months after diagnosis (Davies et al,2008). The author feels that it is difficult to compare DESMOND to X-PERT because of the different populations (newly diagnosed diabetes compared with established diabetes) and because the study concerned multiple sites and educators. In response to the Hba1c the author commented that it is usual for noticeable reductions to occur in levels shortly after diagnosis and in terms of showing a difference in levels between groups, patients with newly diagnosed type 2 diabetes may be the most difficult in which to demonstrate this(Davies et al,2008). To investigate this further, a follow-up was carried out three years later.
743 participants were eligible for follow-up at 3years. Biomedical data were collected from 604 (81.3%) and questionnaire data from 536. Those followed up were older, had a higher BMI , higher waist circumference and higher depression score than those who were not. The result indicates a lack of difference in biomedical and lifestyle measure but the author reckoned that this is not unexpected as drift towards pre intervention values is commonly observed (Khunki et al, 2010) . However accumulated effects, which were not significant individually, did manifest themselves as a difference in UKPDS score. The differences in illness belief scores show that attending DESMOND results in positive changes in understanding of diabetes, which are sustained at 3 years.Therefore attending a single course at diagnosis is beneficial, but patients need to continue receiving ongoing support to help them to manage their diabetes.
The study done on cost effectiveness for DESMOND found that per patient cost of providing the DESMOND Newly Diagnosed or Foundation programme compares very favourably to the provision of oral glycaemic agents(Gillet et al, 2010). The therapeutic benefit of the DESMOND structured education programme is effective as a once-off intervention to help lower biomedical markers as well as having a positive impact on peoples health beliefs and health outcomes (Gillet et al, 2010). Although it is likely that the one off DESMOND intervention is cost effective, it must be noted that the DESMOND programme was never intended as a one off intervention. Moreover, in the real world, costs of delivering the DESMOND programme are likely to vary considerably across primary care trusts. The main variables affecting the cost are the number of educators trained, the grade of healthcare professional delivering courses, venue cost, ratio of demand to head of population (including participation rate), number of patients per course, and overhead rates. It hopes to promote understanding of type 2 diabetes, allowing patients to be more knowledgeable about what will positively benefit their long-term health as they live with the condition.
1.6 Diabetes Conversation Map:
Recently, healthy interaction in collaboration with Diabetes UK, sponsored by Lilly company, has introduced Diabetes Conversation Maps in UK. Diabetes Conversation Maps was created in 2005 in Canada and since then over 60% of diabetes educators has been trained for the program. It was next launched in America in 2006 and now over 20,000 health professionals have been trained. Diabetes Conversation Map serves as a facilitation tool to engage individuals in conversations around their condition and usually last for 2 hours. (Healthyi, 2005)
Diabetes Conversation Map is an educational tool which has transformed healthcare education throughout the world by engaging people in meaningful conversations about their health(Healthyi, 2005). The American Diabetes Association (ADA) believes that it is one of the most important innovation in a decade. Conversation Mapâ„¢ education tools have been developed by Healthy Interactions. They are built on the philosophy that people respond better when they are engaged, empowered, and draws their own conclusions as to why they need to change behaviours (ADA, 2006). In this way, that will be an impact on their overall health as opposed to didactic interventions where patients are told what to do by a healthcare professional. The Diabetes Conversation Map methodology creates an experience whereby patients develop their own self-management solution that accounts for their individual challenges and situation. The patients, in turn, then “own” the solution because it is theirs. They are subsequently much more likely to embrace and implement the change needed to improve their condition
The main philosophy is that people will act on their own conclusions by engaging themselves in an experience(Healthyi, 2005). It allows them to explore health facts through dialogue and enable decision making. Conversation map shapes the way in which people are motivated for positive behavioural change.
The 6 components of the map are map visuals, facts, questions, group interaction, facilitator and action plan. The program is delivered to a small group of 3-10. It facilitates discussion, not lectures and must be delivered by trained health professionals. It benefits the patients as people are visual learners and like exploring and discovering their own answers. The map is fun and provides a process that patient use to internalise and personalise health information. For educators, it is simple to use, portable and non technology dependent. The program content includes basic facts about diabetes, healthy eating, self-monitoring of blood glucose, diabetes complications, and gestational diabetes
The evaluation done in Enfield showed that Diabetes Conversation Map offers several advantages (Monk, 2009). First and foremost, it enables better use of staff time as it requires one member of the healthcare team to facilitate the session, allowing more time for direct patient contact. In terms of financial implication, to run the education program, cost is very minimal. Hand-outs are provided for free from Diabetes Uk and Lilly company which can be photocopied. Although the non-attendance rate remains high in enfield, it was observed that the number of patients attending Conversation Map is better and most patient who come to the first session the other sessions. It is reported that patient get to know each other during the program which help to break down barriers and improve group dynamics (Monk , 2009). Overall, the evaluations done in Enfield area have been positive. However, the result could have been influenced by the fact that the evaluations were completed at the end of the session and handed to the facilitator.
In April 2008 a survey was done to assess the effectiveness of the Diabetes Conversation Map training sessions and initial impact on diabetes self-management education (Grenci, 2010). The survey results indicated that sixty-five percent of diabetes educators attribute improved patient self-management to the Diabetes Conversation Map tools. Eighty percent of healthcare professionals say that the tools make group facilitation more interactive and engaging. More than sixty percent say that there was an increase in patient interest in diabetes education and it boosts their willingness to learn.
When asked about the most effective method in helping patients to adopt positive behaviours and achieve good outcomes, forty percent of the diabetes educators believe that Diabetes Conversation Map session is most effective. Only twelve percent report that the traditional education means as effective in this survey. Ninety percent of those who have had firsthand experience with the tools suggest that they would recommend them to their peers (Grenci,2010).
In terms of metabolic outcome such as Hba1c, cholesterol, blood pressure, weight and patient satisfaction, so far there is no data available. However there will be an upcoming clinical trial called Interactive Dialogue to Educate and Activate (IDEA), which is sponsored by Merck, to identify outcomes using three separate treatment arms:, patients using the Conversation Map tools, patients using individual intervention without using the Conversation Map tools, patients using no formal diabetes education but the data will only be available in five years time. The data will be gathered on an annual basis over the duration of five years and the study will look into metabolic outcomes (A1C, blood pressure, cholesterol, weight) as well as patient and educator satisfaction, knowledge retention and several other behavioural markers of success(Merck , 2009).
Nevertheless, the group-based IDEA education method using the Conversation Map approach was executed as planned and showed promise to improve diabetes self-management behaviours. Clinical and behavioural outcome data are necessary and will be forthcoming.
1.7 Current Diabetes Group Education Program in NHS Bromley
To fulfil the NICE criteria and provide a quality diabetes care, the NHS Bromley chose to deliver DESMOND education program for all patients who are newly diagnosed patients. DESMOND has been ongoing for the past four years but the cost implication to deliver DESMOND is £5000 per year plus ongoing £5/person for the resources.
With a diabetes population of 13,000 and about 10-15 referrals received on a weekly basis for DESMOND, NHS Bromley is striving towards an enhanced Diabetes Service to meet the increased demands and to curb the economic burden.
In view of the strong positive feedback from diabetes educators in the US, the short duration of the program and the cost, NHS Bromley feel that Diabetes Conversation Map may be an alternative that could be used. As there is a lack of data for metabolic outcome and patient satisfaction, this study will be undertaken to evaluate which group education is more effective to be delivered at NHS Bromley.
2.0 Aim of the study:
The aim of the study is to evaluate the effectiveness of DESMOND Group education program versus Diabetes Conversation Map group education program for people who are newly diagnosed with type 2 diabetes at NHS Bromley.
It is a requirement of the NSF for diabetes that education is available to everybody with type 2 diabetes. At present, DESMOND is the most widely used programme available in the community setting, however this may not meet the needs of every local population. The Conversation Map tools may be an alternative or additional tool that could be used. In Enfield these have been used with success. The author is aware of work that has been ongoing to ensure that this method of education is fully compliant with the NICE criteria and is keen to implement this as soon as it is available.
2.1 Objectives:
To measure patient biomedical outcome before and 3 months after the delivery of both group educations
To assess patient satisfaction before and after the delivery of both group educations.
2.2 Hypothesis:
DESMOND and Diabetes Conversation Group Education will have different biomedical outcome
DESMOND and Diabetes Conversation Group education will have different patient satisfaction and quality of life outcome.
2.3 Study Design:
Questionnaire Survey involving both quantitative and qualitative design analysis.
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