Q 67What is the recommended delivery of education to promote understanding of Type 1 diabetes and improve initial self-management of newly diagnosed adults with stable Type 1 Diabetes?

Author/Title/Reference/YrCarpentier, W. S., Piziak, V. K., Bratcher, T., & Hejl, J. 1990, “Efficacy of diabetes education: classroom versus individualized instruction”, Hmo Practice., vol. 4, no. 1, pp. 30–33.
N=N=40, classroom based education =20, individualised learning =20
USA
Research DesignRandomised controlled trial
AimA pilot study to test the hypothesis that patients attending formal diabetes classes will have a greater increase in stages of concern (SC) and Levels of use (LU) with regard to practices of self care
PopulationThe population included in the study have a mix of type 1 and type 2 diabetes although this is unlikely to significantly influence scores for outcomes used
InterventionThe content of the diabetes management education program conforms to the National Standards for Diabetes Education as put forth by the National Diabetes Advisory Board.7 approximately 15 hours.
ComparisonUsual education. The time for individualised instruction (the control) varies, being determined by patient needs, but it ranges from 90 minutes to 3–4 hours
OutcomeChanges from baseline in SC and LU scores were measured by a second assessment was done approximately 1 week after completion of the educational program. The stages of concern scale is a 7 point scale ranging from (0) Awareness to (6) Refocusing. The level of use and behavioural Indices of Level are graded from (I) Non-use to (VI) Renewal
CharacteristicsAge =greater than 40 yrs, Male =33% diabetes =type 1 and type 2
ResultsThere was no statistically significant different enhancement of LU in either setting.
The results of the statistical tests of changes in SC medicated that classroom education was more effective than individualised instruction in enhancing the level of concern (p = 0.04)
There was no statistical evidence of a difference in technical skills between the two groups
Hierarchy of Evidence GradingIb
CommentsNo baseline comparison made between study groups
Lack of blinding may have led to outcome assessors grading more favourable for the people in the intervention group, thus increasing effect size.
No details given for baseline comparison and con founding factors may have influenced outcomes with unknown direction of bias
No validity and lack of replicability may have led to false outcomes being reported with unknown direction of bias
A nursing assessment interview form for diabetes was used by nurse educators to provide in- formation whereby the client could be assigned a score for both SC and LU. No validation given or replicability evaluation undertaken
Extra time devoted to education in the classroom setting as opposed to the individualised group may have confounded the results rather then simply the method of delivery
Larger samples should be sought in future studies.
Longer term outcomes after education ceased not assessed in whole study population
When the classroom mode of education is employed, there is a more efficient use of staff time and more cost effective use of facility space
Reference/Citation77
Author/Title/Reference/YrKim, J. Y. & Phillips, T. L. 1991, “The effectiveness of two forms of corrective feedback in diabetes education”, Journal of Computer-Based Instruction, vol. 18, no. 1, pp. 14–18.
N=N=24, feedback drill =12, normal drill =12 • USA
Research DesignRandomised controlled trial
AimThe purpose of this study was to investigate the effectiveness of two forms of corrective feedback utilised in a computer based drill developed for adults with diabetes
PopulationThe study used patients with type 1 or type 2 diabetes, although this difference is unlikely to have effected learning patterns
InterventionAn intervention with a computer drill to reinforce messages from an educational video. The intervention group received additional feedback and information on correct answers when reviewing scores on a test.
ComparisonThis was compared to a control where only the correct answer was shown
OutcomeThe main outcome was the knowledge of diabetes patients about topics relating to self care as defined by the number of correctly answered questions in a multiple choice test post the computer drill. This was evaluated immediately after the drill was completed
CharacteristicsAge =35 to 60 yrs, duration of diabetes =3 to 27 yrs
ResultsThe patients in the complex corrective feedback arm scored significantly better on the post drill test than those in the conventional drill arm (p=0.005). However changes from baseline knowledge not discernable
There were no significant differences in attitude ratings to the computer drill between the study arms
Hierarchy of Evidence GradingIb
CommentsOutcomes are measured by a multiple-choice quiz on diabetic self-care knowledge with 20 questions. This was piloted and the internal reliability of this was tested and found to be at 0.86. Satisfaction levels were measured by a self-completed Likert scale based questionnaire.
The lack of pre-test comparison of knowledge between the groups may have produced more positive results for the feedback mechanism drill than the standard drill if patients in this group had better baseline understanding, the only entry criteria was scoring 3 or less on a screening multiple choice test.
Lack of blinding may have led to more positive feedback being reported among people in the intervention arm as they may perceive to have benefited from a novel approach
Lack of blinding of assessors is unlikely to have effected score on diabetes knowledge as these were gained from self completed tests
Participants expressed very positive views with regard to experience with both computerised drills
Complex corrective feedback can stimulate better learning and may build more positive attitudes to the educational programme than simply providing the correct answer
Influence of baseline understanding not evaluated
May not be equally applicable to younger patients
Intensive education programme
Reference/Citation78
Author/Title/Reference/YrMensing, C. 2003, “National Standards for Diabetes Self-management Education”, Diabetes Care, vol. 26, no. Supplement 1, p. S149–S156.
N=Not applicable
Research DesignNational guidelines
AimAn update of extant standards for diabetes self management education (DSME) in the USA
PopulationMixed diabetes population
InterventionTask force represented a wide body of federal organisations and agencies including: American Diabetes Association, American Association of Diabetes Educators, American Dietetic Association, Veterans Health Administration, Centres for Disease Control and Prevention
ComparisonNot applicable
OutcomeNot applicable
CharacteristicsA technical team review subgroup undertook to critically review the literature for each standard it was convened in 1999 and held weekly conference calls to discuss findings
164 references were considered across the new standards, but no details of search strategy of appraisal mechanisms are given
The standards cover areas relating to both the organisation of DSME services and their practical content and provision
Exhaustive literature review showed behavioural and educational research is increasing, however more research is needed in this field to show improvement in patient outcomes
ResultsStandard 1: The DMSE entity will have documentation of its organisational structure, mission statement, and goals, and will recognise and support quality DMSE as an integral component of diabetes care
Standard 2: The DMSE entity will determine its target population, assess educational needs, and identify the resources necessary to meet the self management educational needs of the target populations
Demographic variables such as ethnic background, formal education level, reading ability, and barriers to participation in education, must be considered to maximise the effectiveness of self management education
Standard 3: An established system involving professional staff and other stakeholders will participate annually in a planning and review process that included data analysis and outcome measurements, and addresses community concerns
Standard 4: The DMSE entity will designate a coordinator with academic and or experiential preparation in programme management
Standard 5: DMSE will involve the interaction of the individual with diabetes with a multi-faceted education instructional team, which may include a behaviourist, exercise physiologist, ophthalmologist, optometrist, pharmacist, physician, podiatrist, registered dietician, registered nurse, other health care professionals, and paraprofessionals. The instructional team must consist of at least a registered dietician and a registered nurse
It is essential in this collaborative and integrated team approach that individuals with diabetes assume an active role in their care
Although there is no evidence demonstrating that on discipline is more effective tan another, the literature review favours current practice that utilises the registered nurse and registered dietician as key members of the multidisciplinary team preparing and assisting in the delivery of DSME
Based on expert consensus, there is support that the primary instructors on the diabetes team require specialised diabetes educational training beyond their basic academic preparation
Standard 6: The DSME instructors will obtain regular continuing education in the areas of diabetes management, behavioural interventions, teaching and learning skills, and counselling skills
Studies indicate that instructors without specialised training in diabetes, behavioural interventions, teaching and learning skills, and counselling skills, may not focus on patient behaviour change, ad therefore, clinical outcomes may not improve
Standard 7: A written curriculum, with criteria for successful learning outcomes shall be available. Assessed needs of the individual will determine which content areas listed below are delivered
-

Describing the diabetes disease process and treatment options

-

Incorporating appropriate nutritional management

-

Incorporating physical activity into lifestyle

-

Utilising medications (if applicable) for therapeutic effectiveness

-

Monitoring blood glucose, urine ketones (where appropriate) and using results to improve control

-

Preventing, detecting, and treating acute complications

-

Preventing (through risk reduction behaviour), detecting, and treating chronic complications

-

Goal setting to promote health, and problem solving for daily living

-

Integrating psychosocial adjustment to daily life

-

Promoting preconception care, management during pregnancy, and gestational diabetes management (if applicable)

The literature support a core curriculum defines as a coordinated set of courses and educational experiences accomplish a set of outcomes
Standard 8: An individualised assessment, development of an education plan and periodic reassessment between participant and instructor will direct the selection of appropriate educational materials and interventions
The assessment includes relevant medical history, cultural influences, health beliefs and attitudes, diabetes knowledge, self management skills and behaviours, readiness to learn, cognitive ability, physical limitations, family support, and financial status
The bulk of literature supports the importance of attitudes and health beliefs in diabetes care outcomes
Standard 9: There shall be documentation of the individuals assessment education plan intervention, evaluation, ad follow up in the permanent confidential education record
Research suggests that the development of standardised procedures for documentation, training of health professionals to document appropriately, and the use of structured standardised forms based on current practice guidelines can improve documentation and may ultimately improve quality of care
Standard 10: The DSME entity will utilise a continuous quality improvement process to evaluate the effectiveness of the education experience provided, and determine opportunities for improvement
Monitoring participant progress (medical and behavioural) and best practices are critical to the success of DSME and can be used as a basis for quality improvement
Hierarchy of Evidence GradingIV
CommentsRecommendations on practical aspects and service delivery
Reference/Citation79

From: Appendix D, Evidence tables

Cover of Type 1 Diabetes in Adults
Type 1 Diabetes in Adults: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care.
NICE Clinical Guidelines, No. 15.1.
National Collaborating Centre for Chronic Conditions (UK).
Copyright © 2004, Royal College of Physicians of London.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.