Diabetes: Revisiting ‘back-to-basics’ education helps poor self-management

1 July 2013

A Christchurch randomised-control trial found people struggling with managing their diabetes made significant improvements after a one-day education session. FIONA CASSIE talks to Lisa Whitehead about the research team’s findings and their ‘hunch’ that combining cognitive behaviour therapy with education could be even more effective.

Revisiting ‘back to basics’ diabetes education for people with long-standing, poorly managed diabetes is welcomed and makes a difference, Christchurch research has found.

In fact, research leader Dr Lisa Whitehead says a number of participants told researchers that it was the first time they received any basic education about diabetes.

The two-year study on enhancing the self-management of diabetes was led by the University of Otago’s Centre for Postgraduate Nursing Studies and focused on people who struggle to maintain glycaemic control (HbA1c ≥ 7%).

The 118 people recruited into the study were randomised into three groups: one group of 34 people were offered a day of education on diabetes; another group of 39 people a day that combined education with acceptance and commitment therapy (ACT – a form of cognitive behavioural therapy); and the final control group of 45 people received usual care. The data collected included questionnaires on health and wellbeing, illness perception, and self-management, as well as HbA1c at baseline and at three and six months.

Hunch’ that therapy could make longer term impact

The study found that the education intervention had a statistically significant impact (p-value .019) on the participants’ blood glucose levels compared to the control. The combined education and therapy intervention had a lesser impact (p-value .062) but Whitehead and her team have a ‘hunch’ that this intervention may have greater impact in the long-term and still want to explore that intervention further.

“We know that education can be effective. We know that after education, people will change their diet, improve their blood glucose monitoring, and have an increased knowledge around being ‘hypo’ or hyper’ glycaemic.”

“But the hunch is that it will wear off and the changes are unlikely to last.”

The team believes that given the combined education/therapy intervention did have an impact, and they want to explore further whether delivering that intervention in a different way could see it making a greater and longer lasting impact than education alone.

The ACT intervention included some mindfulness training and exploring of people’s attitudes and beliefs around diet and medication and any difficult thoughts and feelings about having diabetes. The idea was that addressing some of those attitudes could help the participants improve their emotional well-being and lead to better diabetes self-management and ultimately improved glycaemic control. Keeping glucose control within the recommended range (3.5-6.5 per cent) is known to significantly delay the onset and progression of diabetes-related complications

Return to basics

The education intervention offered the basics on diabetes and its management and the nurses employed to deliver the education intervention were initially worried that the package was “too basic”, says Whitehead.

But the qualitative feedback from the participants was that the package’s content and level was pitched just right and was “exactly what they wanted”.

“They wanted to go back to basics and lots of people told us they had never had them (the basics) before.”

“It shows that you really need to go back, repeat, and follow-up to check the client’s knowledge of diabetes,” says Whitehead. “And even if these people have been given the basics at some point, they told us they really appreciated the refresher session.”

Both the education group and the education/therapy group reported back positively on their particular interventions.

Quakes and out-of-date blood tests

The researchers began recruiting participants in early 2010 and found it challenging to get participants even before the quakes hit the city, with only 300 responses to the more than 1500 letters sent out.

The team was seeking people who had less than optimal glycaemic control – and not just people who had a one-off incident but people who had been over the threshold for some time with at least two over the optimum level HbA1c test results.

Whitehead says setting blood sugar level criteria for participants uncovered an unexpected hiccup, as a number of practices were unable to supply a recent HbA1c level for their patients.

“We were surprised to find that,” says Whitehead. “We had to request quite a few practices to do an up-to-date test.”

She says the researchers also found it really difficult to recruit a representative number of Māori and Pacific participants for the study, despite trying a number of different tacks, including approaching churches. As a result, the team was looking more closely at making the information provided to participants more appealing and how to better approach and engage potential participants.

The quakes also impacted on recruitment in the latter end of the research, with people unwilling to add one more thing to their already busy lives. And running the intervention sessions at its central city multi-story building also caused difficulties for some people. But of the recruits who were signed up to the project when the quakes hit, very few people dropped out.

Inevitably, when participants were interviewed for the qualitative part of the study, they talked about the quakes and their impact on their diet, exercise, and stress levels, and these findings were being analysed by a Masters student as a related but separate piece of research.

Whitehead says while the quakes were not an ideal time to run a randomised controlled trial, the researchers were pleased with the final outcome.

“We’re really pleased that given everything that went on we found a significant result for education and moving towards a significant result for the combined education and ACT intervention”.

The University of Otago is now looking to publish its findings and considering follow-up research to further explore ACT’s long-term effectiveness on improving self management for people with poor diabetes control.

* Dr Lisa Whitehead, director of the University of Otago’s Centre for Postgraduate Nursing Studies, was lead investigator of the study which was one of the research projects funded under the $2.7m STAR (Strategy to Advance Research) Fund designed to build research capability in nursing and allied health disciplines.