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Evaluation of Diabetes Self-Management Education

Program at Mercy Philadelphia Hospital
Rachel Yik Han Chan

Outline
u Background/

problem

u Purpose, hypothesis
u Objectives
u Methodology
u Results
u Discussion
u Conclusion

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What is
n

Diabetes?
n
n

Metabolism disorder
Early mortality & high levels of
morbidity

Complications
n
n
n
n
n
n

Heart disease
Stroke
Hypertension
Blindness
Eye problems
Kidney disease

n
n
n
n
n

Nervous system disease

Amputations
Pregnancy complications
Hyperosmolar (nonketotic)
coma
Depression

Increased incidence of diabetes

n In

2009, 120,000 people with DM in Philadelphia (ADA,

2009)
n In

2010, 18.8 million people were estimated to have

diagnosed diabetes (CDC, 2012)

n 7.0

million had undiagnosed diabetes (CDC, 2012)

n Diabetes

will affect 5.4% of the adult population in the

world by 2025 (Rasekaba et al., 2012)

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Health, social and economic

consequences
Health
n

Life expectancy is shorter (Caspersen et al., 2012)

n

Older adults with DM develop significant comorbidities

DM is the leading cause of ESRD in 2007 (CDC, 2010)

n

44% of new ESRD cases

Social
n

Late middle aged DM (Caspersen et al., 2012)

n
n

Poorly educated
Low-income households

Health, social and economic

consequences, cont.
Economic
n Total

cost of $174 billion in 2007 (Caspersen et al.,

2012)
n Average

medical expenses was 2.3 times as high

(Caspersen et al., 2012)

n Annual

medical and societal costs will increase

72% to $514 billion by 2025 (Rowley & Bezold, 2012)

What can we do?

Interventions are needed to slow down the
progression of DM population!
n Rowley

and Bezold (2012)

Significant lifestyle changes would be needed

n Proactive prevention and continuous access to
management of chronic diseases
n

Nutrition education
Evert et al. (2014):
n American
n

Diabetes Association

self-management, education, and treatment plan with their

health care provider

n Nutrition

therapy is considered a key component

n Individuals

with DM had the most difficulty on

determining what to eat

Knowles (1978):
n Andragogy
n

Concept and process of adult learning

Types/ formats of diabetes

education
n Dose

Adjustment for
Normal Eating (DAFNE)
programme (Murphy et al.,
2010)

n Conventional

education

approach (Sperl-Hillen et al.,

2013)

n Belief, attitude,

subjective norms, and

enabling factors
(BASNEF) model
(Sharifirad, Najimi, Hassanzadeh,
Azadbakht, 2011)

n Diabetes

SelfManagement Education
(Evert et al., 2014) (Davis et al.,
2012) (Haas et al., 2012)

Role of dietitians
n

Effects of dietitian coaching in combination with annual

endocrinologist follow-up (Battista et al., 2012)
n

Intervention group lowered A1C, weight, BMI, waist circumference

Dietitian visits is an independent predictor for diabetic diet

consumption among subjects with type 2 diabetes (Patel M.,
Patel I., Patel Y. & Rathi S., 2012)
n

77% receive dietary advice from family physicians

n

35% were able to keep their A1C levels below 7%

Successful DM education programs

n DAFNE

Improved glycemic control and quality of life

n Reduce outpatient appointments and prevent diabetes
complications (Owen & Woodward, 2012)
n

n DSME

39% of patients followed a meal plan recommended by a

dietitian, compared to only 12.5% of patients at baseline
(Hayek et al., 2013)
n Combination of DSME and a physical activity program
n Weight loss of 5.4 kg and 75% achieved the physical
activity goal(Guyse et al., 2011)
n

Successful DMSE
n

Self-management education intervention

n
n

Improved A1C level

Saved an average of $551 per active patient per year at the
hospital
Reduced hospital visits (Micklethwaite et al., 2012)

Daily walk and diet education intervention program

n

4-week group classes

Ongoing nutrition self-management and physical activity

Significant decrease of A1C at the 16 week follow-up assessment

(Van Rooijen, A.J., Viviers, C.M. & Becker, P.J., 2010)

Background-cont.
Mercy Philadelphia Hospital's Diabetes Education Program
offers individuals with diabetes support and help in
managing the disease and living a healthy lifestyle,
including:
n

Insulin Instruction

Eye & Foot Care

Comprehensive Diabetes
Management

Self Glucose Monitoring

Side Effects of Medication

Management of Sick Days

Achieving and Maintaining

Positive Thinking

Coping Mechanisms

Nutrition Counseling

n
n
n

Stress Management
Exercise
Warning Signs of Other
Diabetes-related Problems

Objectives
n

To evaluate the nutrition education component of diabetes

outpatient education program at Mercy Philadelphia Hospital

By having participants of the program fill out a pretest and

post-test before and after participating in the nutrition
education classes

Purpose
n

To evaluate the outpatient diabetes education program for its

effectiveness in helping participants to gain confidence in
making dietary changes to manage diabetes

To develop recommendations based on this evaluation

Hypothesis
n

After participating in the outpatient diabetes education

program at Mercy Philadelphia Hospital

Subjects of this program were expected to demonstrate

improved self-efficacy to use basic carbohydrate counting to
manage diabetes

As measured by scores on pretests and posttests that include

Diabetes Self-Efficacy Scales

Methodology
n

Quasi-experiment with pretest and post-test

Convenience population

Subjects
n
n
n

Participants from the program

Referred by physicians, nurses, registered dietitians, etc
Posters were posted in doctors offices, community calendar, or
churches in West and Southwest Philadelphia

Adults of both sexes and various ethnicities, socioeconomic

statuses and educational levels

Methodology (cont.)
n

Instrumentation
n Pretests and post-tests
n Self-efficacy scales modified from the Stanford Patient
Education Research Center
n To determine if subjects improved levels of confidence in
applying the nutrition knowledge
n Developed based on the objectives of the nutrition
education component of the program

Methodology (cont.)
n

Procedure
n
n

One series runs for 6 weeks

Discuss various topics:
n

Being active
Self-blood glucose monitoring

Reducing risks of diabetes mellitus (DM)

2 classes focus on healthy eating

Consents were obtained prior to distribution of pretests

Instructed subjects to not write their names on any

documents

Methodology (cont.)
n

Pretests- green papers

Post-tests- pink papers

Matching letters on each pair of tests

Anonymous

Indicate consent by checking a checkbox at the top of the

pretests

10 minutes

Content of nutrition education were the same

Pretest

Posttest

Results
n

Participants of outpatient diabetes education program in

February 2014
n
n

Two classes condensed to one

5 subjects

Every subject participated

Three indicated no changes in levels of confidence

Two subjects increased their levels of confidence

Mean score increased by 3.4%

Results
Change in Score between Pretest and Posttest.
Participant
E
D
M
S
F
Mean
!

Pre-test
33
36
27
40
40
35.2

Posttest
35
36
31
40
40
36.4

% change
6.1%
0%
14.8%
0%
0%
3.4%

Results
Change in Scores
45
40
35
30
Scores

25
Pretest

20

Posttest
15
10
5
0
E

Participant

Change in Scores by Participant.

Results
Mean Score By Question
6
5
Mean Score

4
3

Pretest

Posttest

1
0
1

3
4
5
6
Question Number
Mean Score By Question.

Result
n

Changes in self-efficacy scores were seen in all questions

except question 1 & 8
n
n

One subject decreased his/her score in self-efficacy

n

Q2: following his/her meal plan when he/ she has to share meals with
people who are not diabetic

One subject reported a 50% increase in self-efficacy

n

Q1: confidence level of eating every 4 to 5 hours daily

Q8: confidence level of controlling diabetes with a healthy meal plan

Q5: planning meals using carbohydrate counting

Both subjects who indicated changes in self-efficacy

n

Q4: finding amount of carbohydrate per serving on a nutrition label

Results
n

Participant E
n
n

Less confident eating a meal every 4-5 hours daily

More confident in
n

Choosing right foods for snacks

Exercise 30-60 minutes for 5 days a week

Finding amount of carb per serving on nutrition label

Participant M
n

More confident in
n Finding the amount of carb per serving
n
n

Plan meals using carbohydrate counting

Being able to manage diabetes when he/she eats out

Discussion
n

Inadequate data

Condensed two classes into one

Very small changes were observed between pretests and

post test scores

Results did not support hypothesis

Unexpected for the three subjects to indicate 0% changes in

self-efficacy after attending the class

Likely presented to their primary care as patients who

needed more education or guidance on controlling their med
conditions

Discussion cont.
n

Results skewed by differences between subjects perceptions

of disease management and their actual ability to manage
their medical conditions

One subject asked about butter vs. margarine

One subject was a newly diagnosed diabetic

One subject asked about amount of carbohydrate in alcohol

Carbohydrate counting activity

n

Subjects seemed to have more knowledge than others

Strength & Limitations

n

Strength
n

Limitations
n
n
n
n

Nonaccredited program

Small sample of population

Limited amount of data
Only one series of program was studied
Limited generalizability
n Only applicable to other DMSE program in local area

Threats to validity
n
n

Referred to DM program as inpatients from Mercy Philadelphia

Hospital
Lack of understanding of research

Application of results
n

Provide incentives to participate in research

Recruit subjects via email, phone calls, word-of-mouth, etc

Other measurement tools should be included

Effective instruments in measuring outcomes of type 2 diabetes

lifestyle programs

Psychological adjustments and motivation

Help Mercy Philadelphia Hospital Community Outreach

Center to improve the DM outpatient program
n

Adjust the nutrition education component

Specific recommendations

Suggestions for future research

n

Expand duration of the study

n
n

More data
Larger sample population

Implement research at different time of the year

Explore and include other measurement tools

n

Problem areas in diabetes (PAID)

n Psychological adjustment

Motivation and energy inventory (MEI)

n

Motivation to improve and manage their medical conditions

Suggestions for DM programs

n

Customized education
n

Based on personality, ethnicity, health literacy, and emotions

(Bagnasco et al., 2014)

n

Acknowledge needs/ preferences for nutrition education

(Muchiri, Gerike & Rheeder, 2012)
n

Knowledge deficit

Inappropriate dietary practices

Questions?