6.9% of adult population suffers from diabetes in the US. However, the percentage of African American population with diabetes is almost double. According to the National health interview survey almost 13% of all African American over the age of 18 have diabetes (minority.health.hhs.gov). Additionally, as opposed to other population groups, more African Americans suffer from diabetes related serious complications. It has been documented that a well developed educational intervention program improves patient’s understanding of disease, self management proficiency and disease outcome. However, there is a need for development of novel and potent intervention strategies especially adapted for racial/ethnic minority and patients from lower socioeconomic background. In addition to being not adequately aware of diabetes self care, a lot of patients’ believe that they have no say in their own diabetes treatment and management plan.
Researchers from the University of Chicago developed an empowerment based intervention program that combined diabetes education targeted towards African American diabetic population and training in shared decision making process (Peek, et al. 2012). Twenty one patients were recruited for the study. All the patients were African American, with the average age of group being 61. The patients had been diagnosed with diabetes for 5-7 years. An interdisciplinary team of clinicians, dieticians, nurse practitioners, psychologists, pharmacists etc from the University of Chicago developed the “evidence based, theoretical model” of education that was specifically modified to suit the needs of the targeted group (Peek, et al. 2012). The curriculum was developed by using the principles of the BASICS diabetes intervention program (Powers, Carstensen, Colon, Rickheim, & Bergenstal, 2006). According to the principle of the BASIC program, the following area are covered: basic knowledge of diabetes (physiology of the disease, treatment strategy, complication of medications), lifestyle modification (diet and physical activity) and self care management of the disease (glucose testing, symptoms of hyper and hypo- glycemia).The curriculum was, however, very finely tuned to fit the needs and requirements of the study population. The mode of the study was observational. The time-table of the intervention program was modified from the original BASICS schedule. The intervention program was offered as ten weekly classes which were modified in real time. The first six sessions covered the education principles regarding management and self care, the next three sessions dealt with concept of shared decision making and the last session was a review session that offered additional learning opportunities.
The researchers incorporated audiovisual tools to improve the understanding of the study group, used interactive role playing to emphasize more complex principles. The participants provided feedback following each session and reviewed the key topics at the end of each session. The education session on lifestyle modification addressed the cooking and eating habits of the study population. A mock grocery store was created to practice the nutritional skills of the patients. The dietary patterns of the patients were modified to make them healthier while ensuring long term adherence could be achieved. Similarly, recommendations for physical activity were made to suit the need of elderly and often overweight patients’. Low cost resources such as elastic bands, community center with workout facilities were identified that could be utilized as a means for long term sustainable care.
The second part of the empowerment based intervention program was based on the idea of shared decision making (Peek, et al. 2010). Shared decision making is the method of involving the patient as a partner and active participant in making treatment and medical care choices. The program was built upon the researchers’ prior work with African American diabetes patients and addressed the beliefs and cultural norms and attempted to improve the negotiation and communication skills of the patients. The study group was educated on some skills applicable to the shared decision making course. These include seeking, providing and verifying correct and appropriate information to ensure patients’ understanding of their disease state. More importantly, the patients were also taught to voice their opinion and share the decision making by explaining their preference for treatments and tests. According to the authors the three features of shared decision making involved debate, discuss and decide.
Audiovisual tools were used in every step of the program. A game titled “Who wants to have a say” in their healthcare was developed; with diabetes education and shared decision making process as the categories. This game identified the various factors that positively and negatively affected the shared decision making process. Patients’ provided examples (good and bad) of communication methods with their health care provider, which improved the patients’ confidence with regarding to getting involved in their own care.
At the end of the ten week classes and then 3 and 6 months later, the patients’ were tested for weight, blood glucose, HbA1C, cholesterol level and asked to complete a survey. Even with their small sample size, the study demonstrated positive outcomes in many of the research criteria. The authors found that the study group population was able to improve nutritional pattern by adhering to healthy food plan. The means scores were 3.4 in the beginning vs. 5.2 at the end of the program. The patients’ level of physical activity and exercise improved over the course of study peaking at 6 months’ after study completion. The patients’ also exhibited improvements in self glucose monitoring and self foot care. The authors found that the HbA1C values at 3 months (8.24 at baseline vs. 7.33 after 3 months’) and cholesterol levels at 6 months (HDL levels of 51.2 at the beginning of the program vs. 61.8 after 6-month) demonstrated a statistically significant improvement as opposed to the beginning of study(Peek, et al. 2012). This suggested that patients’ were motivated to consciously change their behavior. The patient’s reported feeling more empowered in participating in shared decision making. However, when asked specifically to rate their own and physician’s progress in SDM process, they could not report any improvement. This simply demonstrated that it would be especially difficult to overcome the social, cultural and psychological barrier to the process of involved and shared decision making. The intervention program was generally received well by the participants. The patients’ adhered to the study outline, demonstrated good attendance in the study session and believed that program was useful and helpful.
The main limitations of the study were its small sample size and that the study was not a randomized trial. A selection bias could skew the results to more positive outcomes. The initial patient assessment of shared decision making was very high. The patients’ understanding improved after the program and as a result no improvement was observed post study assessment. The researchers, possibly for the first time, demonstrate that modifying diabetes education to the patients’ needs and beliefs and combining it with shared decision-making is a useful approach towards an intervention program with positive outcome.
References
Peek, M.E., Harmon, S.A., Scott, S.J., Eder, M., Roberson, T.S., Tang, H., & Chin, M.H. Culturally tailoring patient education and communication skills training to empower African-Americans with diabetes. Translational Behavioral Medicine. 2012 Sep;2(3):296-308. doi: 10.1007/s13142-012-0125-8.
Powers, M.A., Carstensen, K., Colon, K., Rickheim, P., Bergenstal, R.M (2006). Diabetes BASICS: education, innovation, revolution. Diabetes Spectrum. 19:90–98. doi: 10.2337/diaspect.19.2.90
Peek, M.E., Odoms-Young, A., Quinn, M.T., Gorawara-Bhat, R., Wilson, S.C., & Chin, M.H (2010). Racism in healthcare: Its relationship to shared decision-making and health disparities: a response to Bradby. Social Science Medicine. 71(1):13-7.
Minority health (2012). Retrieved from http://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=51&ID=3017
