Group education for patients with type 2 diabetes – needs, experiences and effects
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Group education for patients with type 2 diabetes—needs, experiences and effects Diabetes mellitus is an increasing health problem worldwide. The total number of people with diabetes is projected to double in the next two decades, to 366 million in 2030 (Wild et al., 2004). Type 2 diabetes accounts for about 90% of all cases of diabetes (Horton, 2008). In Norway, approximately 90 000 to 120 000 people have been diagnosed with diabetes, and a similar number likely remain undiagnosed (Stene et al., 2004). Living with diabetes places demands on lifestyle, diet, physical activity, and/or medical treatment, with the aim of preventing acute and long-term complications. Most of these demands are managed by patients themselves and require a great deal of knowledge. Group-based diabetes self-management education (DSME) is an important source of such knowledge and are frequently offered to patients. The overall aim of this thesis was to investigate the needs of, the experiences of, and the effects on patients participating in DSME and the effects of DSME programs. This was done in four studies. In Paper I, the effects of a locally-developed, group-based DSME for patients with type 2 diabetes mellitus in Helse Nord-Trøndelag HF was studied. The study included 73 participants with intervention and 73 controls. The group based education, which included lectures and discussions between participants, lasted 15 hours and, was conducted over three days. The education covered important facts, treatment, diet, and physical activity for diabetes. The glycated hemoglobin (A1c) levels of participants in the educational seminar stayed the same, while those of the control group increased. This indicated that the education prevented an increase in A1c, but the difference was not substantial enough to be statistically significant 12 months after the intervention. Participants who attended the education showed, however, increased knowledge of diabetes after both six and 12 months and their coping increased, examplified by improvments in foot examinations appearing at 12 months. Furthermore, sub-analyses of participants in the intervention group demonstrated that those who had the highest blood glucose levels at the starting point improved their A1c and their coping with everyday living compared with participants with well-regulated glucose levels. The study in Paper II explored reasons for participating in group-based type 2 diabetes self-management education. Through interviewing 22 participants who were about to begin the program, two main reasons for participation were found: experiencing practical problems with everyday living and feeling insecure about the disease and its possible consequences. Both practical problems and feelings of insecurity were derived from insufficient or contradictory information and from a lack of contact with other persons with type 2 diabetes. This affected important areas of patients’ everyday lives, including diet, use of medicine, social setting, and lifestyle. The study in Paper III investigated how the 22 participants from Study II made and maintained lifestyle changes just after and six months after participating in DSME. The results showed two factors affecting whether lifestyle changes were implemented: new knowledge and taking responsibility for their diabetes self-care. Four factors motivated the informants to maintain changes: fear of complications, support from others, experiencing the effects of lifestyle changes, and having developed the changes they had made into a habit. In Paper IV, a systematic review, 21 RCT studies were identified, in which 2833 adults with type 2 diabetes were participating. Four out of ten participants were male and the avarage age at start was 60 years, duration of their diabetes was eight years on average, with eight out of ten using medicine to help manage the disease. It was found that participation in group-based diabetes education helped participants increase control over their diabetes (fasting glucose and A1c), as well as increase their knowledge of diabetes, both in the short and long terms. The results also showed that group-based educational programs for people with type 2 diabetes led to improvements in clinical, lifestyle, and psychosocial outcomes. There were no differences between the intervention and control groups in regard to mortality, blood pressure, or lipid profile. Conclusion Patients with type 2 diabetes attended DSME due to practical problems and emotional insecurity in living with their disease. After participating in the education, patients used the new acquired knowledge along with a realization of their own responsibility in making lifestyle changes. Fear of complications, perceived support, experiencing effects of lifestyle changes, and having developed the changes they had made into a habit motivated the participants to maintain their new lifestyle. Locally-developed ongoing diabetes self-management education can prevent an increase in A1c and may contribute to a reduction in A1c for those with the highest levels of blood sugar. The research in the field demonstrates that group-based diabetes self-management education can improve clinical, lifestyle and psychosocial outcomes.
UtgiverNorges teknisk-naturvitenskapelige universitet, Det medisinske fakultet, Institutt for samfunnsmedisin
SerieDoktoravhandlinger ved NTNU, 1503-8181; 2012:278
Dissertations at the Faculty of Medicine, 0805-7680; 572