Diabetes Self Care Program (7 steps to success)

1.2 Program philosophy and theoretical framework / underpinning evidence base

The impact of chronic disease and the growing awareness of the role played by people with chronic conditions in determining their own health outcomes have led to greater awareness of the role of self management in chronic disease. Similarly, the need to support people with chronic conditions to acquire self management skills and the confidence to apply theses skills in everyday living has led to the identification and incorporation of self management support and education in a range of chronic disease models including the National Chronic Disease Strategy ² and the National Service Improvement Framework for Diabetes ³.

Unlike acute medical conditions, chronic conditions are ongoing, with health outcomes and quality of life dependent on client self management and decision making and the availability of ongoing (versus short term) clinical care and support services. Client-centred approaches in chronic disease management place the person with the condition as the ‘expert’ rather than the health professional. This does not negate the need for expert or best practice clinical management but recognises that the person with the condition has the absolute power of veto over even the most efficacious clinical management plan.

Diabetes has been considered as one of the most complex of the chronic diseases, requiring the person with diabetes to juggle a range of daily clinical and lifestyle tasks in order to avoid the short and long term complications of diabetes. Diabetes self management education (DSME) aims to make the person with diabetes an active member of their diabetes team and ‘to improve health status by empowering the person with diabetes to:

Acquire knowledge (what to do)
Acquire skills (how to do it)
Develop confidence and motivation to perform appropriate self care behaviours (want to do it)
Develop problem solving and coping skills to overcome barriers to self care (can do it).’ ⁴

The role of diabetes educators is to support people with diabetes along this path by providing self management education and support, enabling them to master the tasks required for effective self care and to become an active participant in their diabetes management.

There is now a wide body of literature on chronic disease self management and on diabetes self management education. The following models and frameworks have been drawn on to develop the design, delivery and evaluation of the DSCP.

1.2.1 Chronic Care Model

The Chronic Care Model ⁵ identifies the following elements that are necessary to achieve high quality chronic disease care.

Health System – A culture of change that promotes safe, high quality care and re-orientation from an acute care to a chronic care service delivery model. Communication and data sharing between service providers to coordinate care as patients move between health care settings and providers.
Delivery System Design – Delivery of pro-active, effective and efficient clinical care and self management support that patients understand and that fits with their cultural background and learning styles.
Decision Support – Provision of evidence based clinical care that is shared with clients and the use of proven education methods.
Clinical Information Systems – Use of information systems that provide timely reminders for patients and clinicians, identify clients needing additional care and monitor outcomes (e.g., diabetes register and recall systems).
Self Management Support – Use of effective self management support strategies such as assessment, goal setting, action planning, problem solving and follow-up to empower clients and prepare them to manage their health and health care. Use of health service and community resources to provide ongoing self management support to clients.
The Community – Partnerships with community organisations to support and fill gaps in needed services and facilitating client participation.

The Model asserts that if these elements are in place the result will be ’informed activated patients interacting with prepared and pro-active clinical teams’ and, ultimately, improved health outcomes.

Chronic Care Model

Figure 1: Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice, Aug/Sept. 1998; 1:2-4

The Chronic Care Model, and the evidence base on which it has been developed, emphasises the client’s central role in managing their own health and health care and that effective self management support involves much more than simply imparting information. Proven strategies are essential to provide emotional support and strategies for living with a chronic illness along with information on the condition.

The Improving Chronic Care website ⁶ provides a wealth of information on chronic disease care, self management support and the supporting evidence base for the model.

The Diabetes Self Care Program (DSCP) is:

Based on health behaviour and education theory and evidence based clinical management guidelines.
Integrated with clinical care. Evidence based clinical management guidelines are discussed with participants in the DSCP to help them assess their individual risk factors and treatment and lifestyle options. With client consent, DSCP facilitators communicate with referring practitioners to obtain accurate and current referral information and report outcomes of their patient’s participation in the DSCP. The DSCP identifies triggers for referral to other members of the diabetes care team. The DSCP acknowledges the general practitioner as the usual care coordinator for people with type 2 diabetes.
Acknowledges the client as the most important member of their diabetes team and uses evidence based strategies to support effective self management.
Makes links to other health service and community based programs to extend and enhance available support for effective self care.

1.2.2 Goals and outcomes for diabetes education

The report Outcomes and Indicators for Diabetes Education – A National Consensus Position (Outcomes and Indicators Framework) ⁷ provides a framework for the design and evaluation of diabetes education programs. Three overarching goals for diabetes education were identified in this report that resulted from a review of relevant literature, survey of service providers, extensive consultation with consumers, service providers and policy makers and a national stakeholder forum:

Optimal adjustment to living with diabetes
Optimal physical (health) outcomes
Optimal (public and personal) cost effectiveness.

The outcomes associated with the attainment of these goals were identified as:

Knowledge / understanding (including the application of knowledge)
Self management
Self determination
Psychological adjustment
Clinical outcomes
Cost effectiveness.

The above outcomes were defined as the results of diabetes education. Indicator areas were identified for each outcome. Indicators are defined in the Report as the units of information that can measure progress towards achievement of the result.

The Final framework of goals, outcomes and indicator areas for diabetes education, taken from the Outcomes and Indicators report 20007:44) identifies the outcomes in order of direct influence by diabetes education.

Diabetes education was deemed to have the greatest impact on diabetes knowledge, with self management, self determination and psychological adjustment as the outcomes next most impacted by diabetes education. While the difficulty of measuring (isolating) the impact of diabetes education on clinical outcomes and cost effectiveness was noted, the report identified the importance of cross linking these outcomes measures with other diabetes education outcome measures.

The DSCP is outcomes focused and uses evidence based strategies to achieve the goals and outcomes identified for diabetes education. In particular, self management, self determination and psychological adjustment, underpinned by knowledge and understanding, are key outcome areas determining the content and delivery of the DSCP.

Monitoring and evaluation of the DSCP is based on the identified diabetes education outcomes.

1.2.3 Chronic disease self management and diabetes self care behaviours

There are two widely accepted models for generic chronic disease self management support. The chronic disease education models arising from Stanford University ⁸ and the Flinders Human Behaviour & Health Research Unit ⁹ identify common tasks that a person needs to achieve in order to successfully manage a chronic condition.

Stanford University

Flinders Human Behaviour & Health Research Unit

Recognising and responding to symptoms
Using medications
Managing acute episodes and emergencies
Maintaining good nutrition
Maintaining adequate physical activity
Not smoking
Using relaxation and stress reducing techniques
Interacting appropriately with health care providers
Seeking information and using community resources
Adapting work and other role functions
Communicating with significant others
Managing negative emotions and psychological response to illness

Know about the condition and various treatment options

Be actively involved in decision making in relation to treatment and management of the condition
Follow the treatment plan developed with health care providers
Monitor symptoms and take appropriate action to manage and cope with symptoms
Manage the physical, emotional and social impact of the condition on their life
Adopt a lifestyle that promotes health and does not worsen symptoms.

The Stanford Model is underpinned by self efficacy theory which is premised on the following: belief in one’s ability to perform a task is a good predictor of motivation and behaviour; self efficacy can be enhanced through skills mastery, goal attainment, modelling and social persuasion; improved self efficacy leads to improved behaviour, motivation, thinking patterns and emotional well being. The Flinders Model also identifies the Transtheoretical Model as a useful model to guide health professional interventions which should be characterised by collaborative goal definition; targeting, goal setting and planning; training and support for individuals to change; active and sustained follow-up. The Stanford Model focuses on peer leadership and generic skill development while the Flinders Model is clinician led and is designed to be integrated with medical management.

The self management tasks identified by these authors are congruent with the self care behaviours identified in a technical review undertaken by American Association of Diabetes Educators (AADE) as being key behaviours for effective diabetes self management ⁴.

AADE Diabetes Self Care Behaviours

Healthy eating
Being active
Monitoring
Taking medication
Problem solving
Healthy coping
Reducing risks

With permission from the AADE, the Australian Diabetes Educators Association (ADEA) has adopted the AADE self care behaviours and published them in Diabetes Self Care – the 7 Steps to Success ¹.

The self care behaviours provide an easily understood framework and a common language for people with diabetes and diabetes educators to discuss health behaviours and their associated risks and benefits.

The seven core modules of the DSCP are structured around the seven self care behaviours. Self care behaviour, not information, is the primary focus of the DSCP.

1.2.4 Health Behaviour and Health Education Theory

Health behaviour and health education theories provide frameworks in which to consider why knowledge may not be translated into action, why people may or may not adhere to treatment recommendations and strategies that can be utilized to support behaviour change.

The Outcomes and Indicators Framework identified self management and self determination as two outcome areas most impacted on by diabetes education, after knowledge and understanding. The following theories provide insight into these concepts and practical strategies to achieve these outcomes.

The Health Belief Model ¹⁰ identifies that in order to adopt a behaviour (e.g., engage in self care practices), a person must believe they are at risk of an adverse event (e.g., diabetes complications), that the consequences of the event are severe and that the event can be avoided by a particular treatment or engaging in a particular behaviour. The likelihood of a person adopting the behaviour depends on how they perceive the benefits as opposed to the barriers (or costs) of adopting the behaviour.

Self Determination Theory ⁷ describes autonomous motivation versus controlled motivation – doing something because one wants to do it versus being coerced to do it (including health professional pressure or pressure to appease a health professional). Autonomous motivation is associated with greater likelihood of success in adopting and sustaining a behaviour and is associated with the absence of threats and external rewards. An autonomous environment offers choice and the opportunity to discuss and acknowledge feelings.

Self efficacy is one of the five domains of self determination identified in the Outcomes and Indicators Framework. Self efficacy is also one of the key constructs of Social Cognitive Theory ¹⁰. People develop self efficacy through experiencing success.

Social Cognitive Theory embodies the following strategies for health behaviour interventions:

Providing opportunities for social support
Promoting capability and mastery through skills training
Modelling positive outcomes of healthy behaviours
Describing outcomes of change that are meaningful to individuals
Promoting individual regulation of goal directed behaviour through providing opportunities for decision making, self monitoring, goal setting, problem solving and intrinsic (self) reward
Providing opportunities for observational learning and opportunities to learn from credible models (e.g., peers)
Supporting self initiated rewards / incentives
Approaching behaviour change in small steps and being specific about the change
Providing training in problem solving and stress management, including the opportunity to practice skills in challenging situations.

The Transtheoretical Model ¹⁰ identifies the various stages of change that individuals move through in order to adopt and maintain a behaviour: pre-contemplation; contemplation; preparation; action; and maintenance. Other important concepts of the Transtheoretical Model are decisional balance (the benefits versus the costs of changing) and self efficacy (confidence that one can engage in healthy behaviours across a range of challenging situations versus temptation to engage in unhealthy behaviours). The Model also clearly identifies that different strategies are required for each ‘stage of change’ and applying strategies suitable for one stage at another may be counter productive. Given the range of self care behaviours that people with diabetes are required to contemplate, it is important to recognise that individuals may be at different stages of readiness for each one.

Individual care plans provide the basis for DSCP participants to assess their current self care behaviours. Care plans are discussed in the context of recommended targets, the relevance of the targets to diabetes health outcomes and treatment and lifestyle options to achieve the targets.

DSCP activities are designed to encourage self assessment and self reflection and to develop skills that can be used on an ongoing basis to monitor diabetes and self care needs.

DSCP participants are encouraged to build self efficacy through engaging in ‘goal setting’ assist with barrier identification and problem solving skills.

The group structure of the DSCP provides social support from peers as well as peer learning and modelling opportunities.

DSCP participants determine their own goals and their own pathway through the DSCP which offers a ‘menu’ of choices according to participant determined priorities. Having attended an introductory module, participants determine which of the seven self care modules they will attend.

1.2.5 Delivery of diabetes education

A Cochrane Review ¹¹ examining the impact of group training in diabetes self care concluded that group programs impacted favourably on a range of clinical diabetes outcomes.

The NHMRC Patient Education Guideline for Type 2 Diabetes ¹² identifies the following:

Both group and one-to-one diabetes client education provided on a face to face basis have a positive impact on knowledge, lifestyle change and some aspects of psychological outcomes.
Interventions delivered over the longer term and those with regular reinforcement are more effective than one-off or short term interventions.
Multidisciplinary team delivery may provide better client outcomes.

The DSCP is designed to be conducted as a group education program with entry to the group program being the preferred pathway for clients with type 2 diabetes who meet eligibility criteria. Group programs offer opportunities for problem solving, peer learning and modelling as outlined above as well as service efficiencies with respect to providing DSME for people with type 2 diabetes.

Wherever possible, the DSCP should be delivered by a multidisciplinary team of health professionals with recognised skills and experience in diabetes education and care and all of whom are familiar with and committed to the goals and philosophy of the program.

The module outlines may also be used by diabetes educators as the framework for individual interventions.

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