Diabetes education groups reduce resistance to treatment.
Introduction
It is well recognized that adoption of self-management skills (i.e. the learned ability to perform an act competently) by patients with diabetes is necessary to enable them to manage their illness[1],[2].The National Institute for Clinical Excellence (NICE), recognizes that the delivery of a structured self-management education program for people with diabetes should form the cornerstone of the management of this chronic condition[3],[4]. This principle is now accepted as being part of care delivered to people with diabetes. NICE recommends that education should be provided by an appropriately qualified multidisciplinary team to groups of people with diabetes, unless group work is considered unsuitable for an individual. Diabetes education can also be undertaken on an individual basis, by a health care provider such as a nurse[5], by peer to peer training[6] or computer based learning[7]. Over time, the emphasis of these educational programs has changed from a didactic approach to one which encourages sharing and empowerment of the participants[8]. While the educational approach needs to be in concordance with the individual patient's needs, it is clear that programs incorporating behavioral and psychosocial strategies demonstrate improved outcomes[9],[10]. Group education may be especially useful for minority ethnic groups of lower socio economic status[11].
It has been demonstrated that the more patient lifestyle changes are needed the higher the likelihood that patients will be resistant to treatment[12]. This is particularly true when there are no clear-cut symptoms, as is the case in most patients diagnosed with diabetes. The resistance of people with diabetes to treatment and its reasons are poorly understood. The patient often understands the need for treatment or change and even intends to make the change, but in practice does not make the necessary changes. This may be explained in part by the Transtheoretical Model of change[13], not only regarding their readiness to make a change, but also in terms of their self-efficacy and belief in their ability to make that change
Adults with type 2 diabetes who have participated in group-based education programs show improved diabetes control (fasting blood glucose and glycosylated hemoglobin and knowledge of diabetes in the short (four to six months) and longer-term (12 to 14 months), whilst also having a reduced need for diabetes medication. There is also some evidence that group-based education programs may lead to reduced blood pressure and body weight, and increase self-empowerment, quality of life, self-management skills and treatment satisfaction. However, as only a small number of studies evaluated those outcomes[14]. Opinions differ about which outcomes are most important in evaluation of diabetes self-management education (DSME) and there is a need to integrate the individual level outcome with that of the family and larger community[15].
The aim of our study was to measure the effectiveness of diabetic patient empowerment groups both in the short and medium term using a questionnaire that measures resistance to treatment, and to examine the associations between resistance to treatment, demographic variables and family support.
Methods
Setting: The prospective study was conducted in Maccabi Healthcare Services (MHS), the second largest Health Maintenance Organization in Israel, insuring 1.9 million members countrywide. According to the Israeli National Health Insurance Act, MHS may not bar any citizen who wishes to join it, and therefore every section in the Israeli population is represented in MHS. All members' interactions i.e., visits, hospitalizations, laboratory tests, and dispensed medications, are downloaded daily to a central computerized database. Throughout the country we offer a structured group intervention for our patients with diabetes to empower them by providing knowledge ,tools and support. The intervention is based on a patient empowerment model using cognitive behavioral strategies[16]. Diabetic patients are identified and offered a course run by a specially educated team consisting of a diabetes nurse, a dietician and a social worker. The course comprises of eight meetings over a period of two months and spouses are invited to participate. To date, approximately 10% of the 100,000 MHS members who suffer from diabetes have participated in these workshops.
Study population and recruitment: The study was conducted over a period of one year, between September 2007 to September 2008. Participants in the study were recruited from selected diabetes intervention groups conducted in MHS during this period. All participants in the groups were invited to take part in the study. All group participants were contacted in advance by telephone, and the study was explained to them. Those who were interested were asked to arrive 30 minutes earlier to the first group meeting. When they arrived they signed a consent form after receiving an explanation by the study nurse, and filled the initial questionnaire.
Data collection: This study was based on information obtained from several sources. A questionnaire was administered to all participants, which included demographic and personal information and measured resistance to treatment. The Resistance to Treatment Questionnaire (RTQ) is a validated, four theme, 40 item questionnaire which identifies the core reasons for non-adherence which are lack of faith or dissatisfaction with the treatment or with the medical team, emotional reasons, specific problems or constraints and factors connected to despair and failure13. The questionnaire can be administered in approximately ten minutes. Resistance patterns and their intensity can be mapped for each patient. Patient weight, height, blood pressure and waist circumference were collected by the study nurse. Data regarding patient blood tests and weight and blood pressure at one year follow-up were obtained from MHS computerized medical records. Data from patients were collected on the first meeting of the groups (T0), on the last meeting of the group (8 weeks later) (T1)and 6 months later (T2). Data from medical records were obtained one year after completion of the group (T3).
Data analysis
Data analysis was conducted using SPSS. Descriptive analyses were conducted for all demographic and clinical variables. Analyses for RTQ were conducted using parametric paired analyses.
Results
Participants were recruited from 26 diabetes empowerment groups. Of 210 participants in these groups, 198 agreed to participate in the study and completed the first questionnaire. The second questionnaire was completed by 154 participants(78%), and the third, 6 months later, was completed by 138 participants(69.6%). The population was equally distributed between genders (51% males) and most (78%) were married – 7% single, 9% divorced, and 6% widowed. Fifty eight percent were Israeli born, while non-Israeli born participants originated from 21 different countries, Including Turkey, Bulgaria, Yemen, The U.S., Argentina and Azerbaijan. Educational levels of participants were distributed in similar patterns to the Israeli population distribution – 8% had completed primary education, 40% secondary, 52% had post-secondary qualifications, of these 27% tertiary education. Participants were aged between 32 and 80, and 83% were aged over 50 (mean 58, SD 9.7).
As previously mentioned, resistance to treatment was measured using the RTQ, which is designed to assess resistance in four different realms. Table 1 describes the results of resistance to treatment in all realms before and after participation in the groups, analyzed using paired analysis. In the paired analyses we included only participants who had both questionnaires completed, and for whom we had clinical data available.
There was no significant difference in resistance to treatment either before or after the interventionbetween genders with the exception of factors connected to despair and failure. Women showed significantly more resistance to treatment due to despair than males (2.09 compared with 1.84, p=0.05) but this difference disappeared after treatment. There were also no differences between participants who were married, single, divorced or widowed. We did, however, find that resistance to treatment was associated with age. Before the intervention, the older the participant, the lower the resistance to treatment, in the realms of emotional reasons (r=-0.35, p<0.001), specific difficulties (r=-0.26, p<0.01) and general resistance (r=-0.21, p<0.01). After the group only resistance due to specific difficulties remained significantly lower for older participants, although the association was weaker (r=-.021, p<0.05). There was no association between length of illness and resistance to treatment.
Some of the questions asked in the RTQ relate to the extent to which people with diabetes share information with their family, and the degree to which they feel their family assist them with their diabetes care. The majority (94% and 95% respectively) stated both before and after the intervention that their spouse knows they have diabetes. Of these, two thirds (66 and 67%) stated that their spouse assists them to care for their diabetes. In regards to their children, however, there was a statistically significant increase in both those who stated that their child/children know they have diabetes (85% to 91%) but specifically in the proportion of those who stated that their children assist them (36% to 53% after the intervention, p<0.001). We found statistically significant associations between resistance to treatment in all realms and the perception that they are assisted by their spouses and their children. Before the intervention, participants who felt that their spouse assists them had lower resistance scores for dissatisfaction with treatment (1.95 vs 2.23, p<0.05), emotional (1.97 vs 2.43, p<0.01), specific difficulties (2.49 vs 3.04, p<0.01), despair and failure (1.75 vs 2.50, p<0.001), and general resistance (2.04 vs 2.56, p<0.001). After the intervention these differences were smaller although they remained statistically significant – with the exception of dissatisfaction with treatment (1.78 vs 2.21, p=0.07). We also found that before the intervention, a high perceived support from children, was associated with lower resistance to treatment (in the realms of specific difficulties (p<0.05), despair and failure (p<0.005) and total resistance (p<0.05).After the intervention all realms were associated with this (all p<0.001): Those who felt their children assisted them with their treatment had significantly lower resistance to treatment scores.
As stated, we also examined the changes in clinical variables immediately after the group and one year after participation in the groups. Table 2 describes the changes in these clinical variables.
When comparing males and females, before the intervention there were no gender differences in BP values, but after the intervention females had significantly lower values than males (p=0.05 for both SBP and DBP). Diabetes control (as measured by HbA1C) was slightly better among males than females (before the interventions 7.64 vs 7.10, p=0.085, and after the interventions 7.26 vs 6.85, p=0.078). A year later these differences disappeared (7.13 vs 6.96). We also conducted paired analyses for the reduction in HbA1C by gender. For both genders there was a statistically significant reduction for both genders after the intervention (males – 7.64 vs 7.27, p<0.01, females 7.13 vs 6.85, p<0.05). Males also continued to reduce their HbA1C levels a year later (7.15, p<0.01). There were no significant differences between males and females in LDL either before or after the intervention. Females had a higher HDL than males both before, immediately after and a year after the group (T0: 50.14 vs 42.08, p<0.001, T1: 49.14 vs 42.75, p=0.001, T3: 48.35 vs 42.75, p<0.01). Females also had a significantly higher BMI than males before the group (31.41 vs 29.61, p<0.05) and a year later (30.95 vs 29.37, p=0.069). The only statistically significant association with increasing length of illness and clinical values was that of a higher level of HbA1c both before and after the intervention.
We examined the data for possible correlations between resistance to treatment and the observed changes in HbA1C. We found a statistically significant negative correlation between the proportion of change in HbA1C one year after the group, and emotional resistance (r=-0.26, p<0.01), resistance due to specific difficulties (r=-0.21, p<0.05) and general resistance (r=-0.22, p<0.05). For all three categories the lower the resistance to treatment at the end of the group, the more likely they were to improve diabetes control.
Discussion and Conclusion
Main findings: We found that the resistance to treatment of patients who participated in our support groups was reduced and that this improvement was maintained six months later. Younger patients had higher scores for resistance to treatment before the intervention. This difference disappeared after the intervention except for the realm of specific difficulties with diabetes management. We were able to show that the lower the resistance to treatment scores the better glycemic control one year later. In addition we showed that there was a sustained reduction in blood pressure among the patients who participated in the groups. Participation in the groups also improved participants’ perception of support from family members. Participants also were more able to involve family members in their care, particularly younger patients.
Strengths and weaknesses: This study managed to achieve a high rate of recruitment among the participants of twenty six different diabetes care empowerment groups. In addition 78% and 69.6% of the study subjects answered the questionnaires at the end of the group sessions and 6 months later respectively. It may be that the patients that did not answer the questionnaire six months after the group meetings benefited less from the groups and the longer term findings may be over optimistic. The intervention groups were a convenience sample and not randomly selected. However, the large number of different groups reduces the possibility that the results are related to a particular group leader and increase the possibility that the results reflect the group processes.
What this study adds to previous research: Unlike a technology such as a new drug there is not sufficient uniformity in behavioral interventions. In addition, Effectiveness of behavioral interventions for diabetes self-management is difficult to standardize. . Each report in the literature includes a description of the specific group. However the numbers, ages, gender, stage and type of diabetes of participants tends to be varied as is the training of the group leaders which varies widely from lay people to healthcare workers who might be undergoing ongoing training and support in order to understand the group dynamics. In addition the aim of the groups might be different. Some groups may focus on the sharing of knowledge while others like ours may concentrate more on interpersonal challenges of the participants. A Cochrane study found fourteen publications describing 11 studies involving 1532 participants. The results of the meta-analyses in favour of group-based diabetes education programs were reduced glycatedhaemoglobin at four to six months (1.4%; 95% confidence interval (CI) 0.8 to 1.9; P < 0.00001), at 12-14 months (0.8%; 95% CI 0.7 to 1.0; P < 0.00001) and reduced systolic blood pressure at four to six months (5 mmHg: 95% CI 1 to 10; P = 0.01). Interestingly a different Cochrane review reports that in the small number of studies comparing group and individual education, there was an equal impact on HbA1c at 12 to 18 months. Our study produced similar findings but in addition we show a possible mechanism for this improvement which is a reduction in resistance to treatment which may have led to an increase in support from family members.
Conclusions:The findings from this study support the use of group education for diabetes self-management. The RTQ appears to be a useful tool for the measurement of diabetes related behavioral interventions. This is the first such study that has used this tool to measure reduction of patient resistance to treatment within diabetes education groups. Based on this questionnaire we show that group interventions empower all patients and especially younger patients. The groupsalso encourage patients to share the burden of care with family members. Reduced resistance to treatmentwas correlated with improved glycemic and blood pressure control. Future evaluations of behavioral interventions for diabetes care need to be based on standardized intervention and measurement methods. This is increasingly important in view of the increasing number of patients with diabetes and the scarcity of resources to treat them.
Practice implications: All patients and especially younger patients should be encouraged to participate in education groups irrespective of the duration of disease.
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