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Best and Promising Practices in Diabetes Education

Note to Readers

The Best and Promising Practices in Diabetes Education catalogue is intended to guide practice and is not intended to serve as a comprehensive text on diabetes management. Healthcare professionals must consider the needs, values and preferences of individual patients, use clinical judgement, and work with available human and healthcare service resources in their settings. This catalogue was developed using the best available evidence. It is incumbent upon healthcare professionals to stay current in this rapidly changing field.

Reproduction of the Catalogue

Reproduction of the Best and Promising Practices in Diabetes Education catalogue in whole or in part is prohibited without written consent of the publisher.

Website

This catalogue is available online at: diabetes.ca/bestpractices.

© Canadian Diabetes Association, 2008 June 2008

ACKNOWLEDGEMENTS

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he Canadian Diabetes Association would like to thank the following individuals and organizations for their tremendous support and cooperation in project activities.

· erry Schubert-Mackie, Timiskaming Health Unit K ­ New Liskeard, ON · Tammy Simpson (ex-officio), Chronic Disease Prevention Division, Public Health Agency of Canada ­ Ottawa, ON · Rajinder (Raj) Sohi, Surrey Memorial Hospital ­ Surrey, BC · Louise Tremblay, Director of Diabétaide Education Service, Diabète Québec ­ Montréal, QC Consultants: · ancy Dubois, Principal N · ean Harvey, Associate J · eather McGrath, Associate H · usan Moore, Associate S · lice Strachan, Associate A · ricia Wilkerson, Associate T Research Assistants: · Geneviève Dulude, Research Assistant · Daniel Kagedan, Research Assistant · arilyn Manceau, Research Assistant M Canadian Diabetes Association: · arah Khan, National Project Manager S · Josée Guimond, Director of Research Programs and Partnerships · Karen Philp, Acting Vice President of Research, Professional Education & Government Affairs

Primary Funder: · ublic Health Agency of Canada P Project Expert Advisory Committee: · ori Berard, Health Sciences Centre Diabetes L Research Group ­ Winnipeg, MB · Joan Canavan, Ontario Ministry of Health and Long-Term Care, Manager, Chronic Disease Management Programs, Provincial and Priority Programs ­ Toronto, ON · Sharlene Clarke, Yukon Diabetes Education Centre ­ Whitehorse, YK · Sandra Delon, Calgary Health Region, Chronic Disease Management ­ Calgary, AB · Joan Erickson, Interior Health Authority ­ Naramata, BC · Catherine Freeze, Chronic Disease Analyst, Government of Prince Edward Island ­ Charlottetown, PEI · Stewart Harris, Thames Valley Family Practice Dr. Research Unit, Chair of National Diabetes Management Strategy ­ London, ON · lizabeth (Betty) Harvey, St. Joseph's Health Care E London, Community Diabetes Clinic ­ London, ON · Nina Jetha, Lead, Canadian Best Practices Initiative, Public Health Agency of Canada ­ Ottawa, ON · Cynthia Keith, Capital Health District ­ Lower Sackville, NS · Aileen Knip, Grand Bend Community Health Centre ­ Grand Bend, ON · Karen McDermaid, Regina Qu'Appelle Health Region ­ Moosomin, SK

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Table of Contents

Acknowledgements 1 2 3 Background Catalogue Findings Best Practices

Culturally Tailored Diabetes Intervention for Mexican Americans Diabetes Education for Canadian Portuguese Adults with Diabetes Diabetes Health Connection Diabetes Outpatient Intensive Treatment (DO IT) Diabetes Personal Trainer Educational Video Game ­ Packy and Marlon Experience-Based Group Education Group-Based Counselling for Improved Coping Guided Self-Determination Group Session for Type 1 Diabetes Low Literacy Motivational Interviewing to Improve Weight Loss Nurse Short Message Pounds Off With Empowerment (POWER) Promotora Diabetes Intervention for Mexican Americans Stress Management Training for Patients with Type 1 Diabetes Structured Intensive Diabetes Education Program (SIDEP) Sweet Talk: Text-Messaging System X-PERT Program

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13 15 18 22 25 28 31 35 37 39 43 45 47 50 53 56 59 64

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Promising Practices

BITES (Brief Intervention in Type 1 diabetes ­ Education for Self-Efficacy) Control On Campus Computer-Based Remote Diabetes Education for School Personnel Diabetes Prevention Program (DPP): Adapted Lifestyle Change Participant Notebook Diabetes Self-Management Education Program for Medicaid Recipients Education and Telephone Case Management for Children with Type 1 Diabetes Empowerment Group Education Program Ethnic-Specific Diabetes Education Program (Turkish Immigrants in Rotterdam) Functional Insulin Treatment (FIT) Group Visits & Computer-Assisted Consultations for Adolescents with Type 1 Diabetes HyPOS Interactive Diabetes Educational Simulators Internet-Based Physical Activity Know Your Health Program at the Worksite MicoHealth Internet Diabetes Management Program Picture Flashcard Health Education Practical Education/Behaviour Modification Program Project Dulce REACH Detroit Family Intervention Self-Management Patient Education Simple Meal Plan Emphasizing Healthy Food Choices Simple Start Soul Food Light Symptom-Focused Management Talking Circles Telecare Therapeutic Education Urban Church-Based Program

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69 71 74 76 78 81 83 87 91 94 99 101 105 107 109 111 113 115 119 122 124 126 128 133 135 138 140

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Background

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Best and Promising Practices in Diabetes Education

Background

he Canadian Diabetes Association is a not-for-profit organization working to prevent type 2 diabetes and improve the quality of life for those affected by type 1, type 2 or gestational diabetes, through research, education, service and advocacy. Over two million Canadians are estimated to have diabetes, with certain populations at higher risk or unaware of having the condition. Furthermore, a significant growth in the number of Canadians diagnosed with diabetes is predicted over the next ten years. The Canadian Diabetes Association strongly believes that there is a clear and growing need for investments in strategies, policies and programs to prevent type 2 diabetes as well as to manage all types of diabetes in Canada. Current evidence indicates diabetes care delivered in a structured program of continuous education and comprehensive care is effective in improving health outcomes for individuals with diabetes.1 The increasing prevalence of diabetes as well as the recognition that education models are effective in improving health outcomes is challenging health professionals, government and funders as they develop and support effective diabetes education programs. Decision makers and program planners rely on evidence-based outcomes to guide their investment decisions that support people managing diabetes. Published literature is a key source of information however until this report, there was no comprehensive review of the evidence available on the effectiveness of diabetes education practices. With financial support from the Public Health Agency of Canada, the Canadian Diabetes Association embarked on a project to identify `best' and `promising' practices in diabetes education based on the best available evidence; to develop an assessment tool that would identify these practices, and to disseminate the findings to diabetes educators, healthcare professionals, government, and key decision makers and funders of diabetes education

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1 Canadian Diabetes Association

(2003) Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, 15.

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programs. The project was designed to also complement two existing key resources within the Association: "Standards for Diabetes Education in Canada (2005)2 and the "Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada". The project involved a review of the international literature to identify diabetes education practices that were evaluated and therefore could be classified as either `best' or `promising'. The results are not comprehensive, but rather an indication of diabetes education practices from around the world at a specific point in time. The process included the development of an assessment tool that allowed for the screening of identified practices emerging from the literature review and for the rating of each project as a `best' or `promising' practice according to a consistent set of criteria. A standard annotation template summarized the programs. The following catalogue summarizes the project findings. The Best and Promising Practices in Diabetes Education catalogue has successfully contributed to the field of diabetes education. First, it has created an accessible catalogue of best or promising practices that have been evaluated and show positive outcomes. Secondly, this project has increased our knowledge of evidence-based best and promising practices in diabetes education, and this will inform not only health professionals but also government decision makers and funders like our Association. Finally, the project has developed an assessment tool that can be used in future to update and enhance the catalogue as well as our knowledge of successful health outcomes achieved through diabetes education. With future refinements, the assessment tool could become the standard process for assessing diabetes education programs. The 45 best and promising practices identified through the project will lead to an increased use of evidence-based practices; this will increase the effectiveness of diabetes education efforts and ultimately improve health outcomes for Canadians living with diabetes. Ultimately, diabetes educators and healthcare providers decide which practice is best to implement for their community. This catalogue provides information that will help them judge how practical it is to implement a best or promising practice that meets the need of their community. They will decide which program will have the greatest impact and at the same time will fit within the mandate and capacity of their organization. They will continue to develop innovative diabetes education programs, or modify existing practices, to

2 Standards for Diabetes Education

in Canada represent the desired targets and goals of diabetes education (provided the identified resources are available) of the Diabetes Educator Section (DES) and the Canadian Diabetes Association.

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enhance the health outcomes of the people they support. Governments and organizations such as the Canadian Diabetes Association should consider increasing the capacity of organizations to undertake evidence-based evaluations of their programs, so that the capacity of the healthcare system to address the broad range of needs of people living with diabetes will be enhanced. Evidence-based, responsive diabetes education practices, programs and services for people with diabetes will result in better health outcomes, and ultimately benefit all Canadians who rely on our publicly funded healthcare system.

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Catalogue Findings

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Best and Promising Practices in Diabetes Education

Catalogue Findings

he summary section of the catalogue provides details about each of the 45 practices identified as `best' or `promising.' The description of each practice contains information to help users determine whether they are interested in adapting that practice for use in their community. Information from published journal articles, online sources and the program developers was collated into a standard annotation template and is presented in this catalogue. In addition, the annotation refers to which of the six Process Standards from the Standards for Diabetes Education in Canada developed by the Association's Diabetes Educator Section (DES) which were met by each practice. The six DES Process Standards are: 1. Diabetes education is based on ongoing, client centred needs assessment of individuals and or communities. 2. Plans for diabetes education are client-centered and ongoing. 3. Implementation of diabetes education is client-centered and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professionals involved. 6. The effectiveness and quality of diabetes education services are regularly evaluation and revised, as needed. The 18 programs assessed through the project as `best' are: BEST Culturally Tailored Diabetes Intervention for Mexican Americans (United States) Diabetes Education for Canadian Portuguese Adults with Diabetes (Canada) Diabetes Health Connection (United States) Diabetes Outpatient Intensive Treatment (DO IT) (United States) Diabetes Personal Trainer (United States) Educational Video Game ­ Packy and Marlon (United States) Experience-Based Group Education (Sweden) Group-Based Counselling for Improved Coping (Norway) Guided Self-Determination Group Session for Type 1 Diabetes (Denmark)

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Low Literacy (United States) Motivational Interviewing to Improve Weight Loss (United States) Nurse Short Message (South Korea) Pounds Off With Empowerment (POWER) (United States) Promotora Diabetes Intervention for Mexican Americans (Scotland) Stress Management Training for Patients with Type 1 Diabetes (Iran) Structured Intensive Diabetes Education Program (SIDEP) (Korea) Sweet Talk: Text-Messaging System X-PERT Program (United Kingdom) The 27 programs assessed through the project as `promising' are: PROMISING BITES (Brief Intervention in Type 1 Diabetes ­ Education for Self-Efficacy) (United Kingdom) Control On Campus (United States) Computer-Based Remote Diabetes Education for School Personnel (United States) Diabetes Prevention Program (DPP): Adapted Lifestyle Change Participant Notebook (United States) Diabetes Self-Management Education Program for Medicaid Recipients (United States) Education and Telephone Case Management for Children with Type 1 Diabetes (United States) Empowerment Group Education Program (Sweden) Ethnic-Specific Diabetes Education Program (Turkish Immigrants in Rotterdam) (The Netherlands) Functional Insulin Treatment (FIT) (Austria) Group Visits & Computer-Assisted Consultations for Adolescents with Type 1 Diabetes (Norway) HyPOS (Germany) Interactive Diabetes Educational Simulators (United Kingdom) Internet-Based Physical Activity (United States) Know Your Health Program at the Worksite (United States) MicoHealth Internet Diabetes Management Program (Canada) Picture Flashcard Health Education (United Kingdom) Practical Education/Behaviour Modification Program (United States) Project Dulce (United States) REACH Detroit Family Intervention (United States) Self-Management Patient Education (Germany) Simple Meal Plan Emphasizing Healthy Food Choices (United States) Simple Start (United States) Soul Food Light (United States) Symptom-Focused Management (United States) Talking Circles (United States) Telecare Therapeutic Education (Spain) Urban Church-Based Program (New Zealand)

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Best Practices

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Best and Promising Practices in Diabetes Education

18 `Best' Practices

Culturally Tailored Diabetes Intervention for Mexican Americans Diabetes Education for Canadian Portuguese Adults with Diabetes Diabetes Health Connection Diabetes Outpatient Intensive Treatment (DO IT) Diabetes Personal Trainer Educational Video Game ­ Packy and Marlon Experience-Based Group Education Group-Based Counselling for Improved Coping Guided Self-Determination Group Session for Type 1 Diabetes Low Literacy Motivational Interviewing to Improve Weight Loss Nurse Short Message Pounds Off With Empowerment (POWER) Promotora Diabetes Intervention for Mexican Americans Stress Management Training for Patients with Type 1 Diabetes Structured Intensive Diabetes Education Program (SIDEP) Sweet Talk: Text-Messaging System X-PERT Program

Culturally Tailored Diabetes Intervention for Mexican Americans

BRIEF PROGRAM OVERVIEW A culturally tailored intervention for Mexican Americans with type 2 diabetes. The program consists of eight weekly two-hour sessions and includes didactic content, cooking demonstrations and group support.

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group level THEORETICAL BASIS: Social Cognitive Theory and strategies to promote self-efficacy TARGET AUDIENCE: Mexican Americans

18-75 years of age

SETTING: Diabetes clinic COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

Development Date: 2004 Revision Date: Revised in 2005 Current Program Status: Being implemented by source

Program Description: The program consists of eight weekly two-hour group sessions that include didactic content, cooking demonstrations and group support. All sessions are held during a weekday in a conference room of a clinic. The content followed the National Diabetes Education Program and American Diabetes Association (ADA) guidelines and included pathophysiology of diabetes, complications, treatment modalities, and diet, exercise and self-management strategies. Discussions about self-monitoring of blood glucose and how to interpret results are also included, and content on stress and stress management, heredity and culture (including traditional Mexican American ideas of causes of diabetes). Participants are encouraged to bring a support person to the sessions. Efforts to foster self-efficacy are incorporated into both the didactic and group sessions, and included skill mastery of self-glucose monitoring, problem solving and verbal persuasion. Modelling is also accomplished through the use of the promotora (lay peer educators) and the cooking demonstrations.

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Program Goals: To improve self-management of diabetes Program Objectives: To improve behavioural outcomes of self-efficacy, diabetes knowledge and self-care measures, as well as body mass index (BMI), HbA1c levels and blood glucose. These are achieved by providing culturally relevant group education sessions. Program Implementation Steps: See program description above. Cultural modifications are as follows: · elivery of intervention, including all materials, D in Spanish; · acilitation of support groups by promotora F (Mexican American lay educators); · nclusion of opportunities for socializing and I problem solving during shared meals; · nclusion of cultural content; I · eaching and counselling of dietary change by T modification of ethnic foods and recipes; · eaching and counselling of activity change using T culturally appropriate activities such as walking and dancing; · se of low literacy level written materials; and U · ncouragement of attendance of support person. E Program Delivery Sources: According to ADA guidelines Outcome Evaluation Results: Intervention had a positive clinical and statistical effect on diabetes knowledge, weight and BMI. Improvements were also noted in self-efficacy scores, blood glucose and HbA1c levels, but these changes did not reach statistical significance. Program Reach: 10 participants in the group studied Community Supports: Involvement of promotora

Start-up Costs: Study was done with a $10,000 grant, which paid for all supplies including food, glucose monitors and strips, laboratory tests and time for the promotora, dietitian and research assistant. Ongoing Implementation Costs: Supplies, copying of educational materials, food for cooking demonstrations, time spent by dietitian and promotora in teaching the classes and answering phone questions and laboratory tests (borne by the patient in this study). Critical Points That Need to be Replicated: Group support was particularly effective, and subjects reported enjoying that as well as the cooking demonstrations and meal sharing. Use of the promotora was critical in this population and enhanced the cultural tailoring of the program. Generalizability: Concept of culturally tailoring a program and involving a lay person is generalizable to many populations. Lessons Learned: Encourage family members to attend, as they also need the education. Group support is an excellent strategy for teaching complex self-management behaviours such as glucose selfmonitoring.

PROGRAM CONTACT:

Deborah Vincent, PhD

University of Arizona College of Nursing 1305 N. Martin, PO Box 210203 Tucson, Arizona 85721-0203 Email: [email protected]

References: Vincent, D., Pasvogel, A., & Barrera, L. (2007). A feasibility study of a culturally tailored diabetes intervention for Mexican Americans. Biological Research for Nursing, 9(2), 130-141. Communication with Dr. Deborah Vincent.

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Diabetes Education for Canadian Portuguese Adults with Diabetes

BRIEF PROGRAM OVERVIEW The Diabetes Education for Canadian Portuguese Adults with Diabetes program provides individual and group support tailored to the Portuguese community. Information is provided in Portuguese to both adults with diabetes and their family members.

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual and group

levels

THEORETICAL BASIS: Theory of Planned

Behaviour

TARGET AUDIENCE: Portuguese adults SETTING: Healthcare settings COUNTRY OF ORIGIN: Canada LANGUAGE: Portuguese

DES PROCESS STANDARDS MET

Development Date: Developed in 1991 in a small community hospital in Toronto, Ontario Current Program Status: Being implemented by source

Program Description: The individual counselling and group education components of the program are conducted by Portuguese-speaking educators. Management goals and nutritional care plans are created and patient status and priorities assessed during the individual counselling sessions. Group education is provided over a total of 15 hours during three consecutive weekdays. Six of these 15 hours are spent covering nutritionrelated content. The group sessions follow a standard set of topics and are delivered by various members in the multidisciplinary team. The sessions are interactive and use many "visual aids, low literacy level education resources and hands-on interactive activities that highlight traditional Portuguese foods, practices and customs." The messages discussed during the group education sessions are reinforced during the individual counselling sessions.

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Program Goals: Increased intention to follow, and adherence to, nutrition recommendations and greater glycemic control. Program Implementation Steps: Three face-toface counselling sessions are held (with additional appointments as needed) over a three-month period; the first with the dietitian or nurse, the second with the dietitian and the third with the nurse. The three days of group sessions are provided by the diabetes educators (nurse and dietitian), pharmacist, registered physiotherapist, social worker and psychologist. The group sessions occurs between 8:30 a.m. and 3 p.m. for three days in a row. Content covered during the program includes interactive sessions about healthy eating (e.g., meal planning, reading food labels, traditional events and a cooking demonstration), physical activity, diabetes complications, medication management and stress management. Program Delivery Sources: There are two endocrinologists, eight diabetes educators (four nurses and four dietitians) and a social worker on the core team at the Diabetes Education Centre. A physiotherapist, pharmacist and psychologist are also involved in the program's delivery. Process Evaluation: In December 1996, pilot focus groups were held to explore patients' perception of the cultural appropriateness of the program. Ongoing information is collected about the number of participants in the program and their attendance at the various individual and group sessions. In addition, patient's complete evaluation forms at the end of group education programs and the results are reported to a quality committee each year (this has been occurring since 1991). Information has also been collected about non-participation; the study authors state that having the three consecutive days of classes affected recruitment.

Outcome Evaluation Results: Since 1991, formal evaluations of nutrition and self-care behaviour indicators have been tracked and reported to the hospital's quality committee and board. HbA1c levels decreased from 7.4% (±1.6) at baseline to 6.9% (±1.3) at the end of the three-month period. Other changes measured and noted include changes in attitudes, subjective norms, intentions to adhere to nutrition recommendations, and self-reported nutrition adherence. Critical Points That Need to be Replicated: The following were identified by the program contact as the factors that work really well with the program: · nvolvement of professional interpreters, staff I who speak the language and diabetes educator nurse and dietitian who are familiar with and responsive to the cultural practices and cultural foods; · nformation provided in a comfortable learning I environment for patients; · se of education tools that are culturally specific U and written in a `universal Portuguese' (sensitive to differences of people from Brazil, Portugal, Africa, and other past colonies of Portugal); · se of materials that are suitable to participants U with diverse education and literacy backgrounds (visual tools and relevant literature); · se of education methods that work well for U the cultural group (i.e., interactive, hands-on, practical advice, visual aids, food and organ models [3D]); · Ongoing follow-up with patients; and · roviding continuity of care (the same healthcare P professional is involved for the individual visits). Description of Contextual Factors: The program was developed and studied in an urban and culturally diverse area in Toronto, Ontario. This area has the largest Portuguese-speaking population in Canada.

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Materials Available for Program Adaptation: The journal article referenced below outlines the individual counselling and group education sessions, and provides detailed information about the duration of time spent, the content, the provider, the teaching method and the teaching tools used. Lessons Learned: The program contact indicated patients of similar cultural backgrounds readily share their personal experiences with their illness/health (this is not seen within mixed heterogeneous groups).

It is important to teach the program material in the language that the individual speaks at home; this reduces attrition (even if patients understand English). It is necessary to have access to a well-equipped kitchen. Program funding needs to be sustained in order to maintain programs such as these; providers cannot rely on volunteers for program sustainability.

PROGRAM CONTACT:

Margaret De Melo, Practice Leader­ Clinical Nutrition

Toronto Western Hospital, University Health Network Diabetes Education Centre 1 West Wing 443 399 Bathurst Street Toronto, Ontario M5T 2S8 Phone: (416) 603-5800, ext 5973 Fax: (416) 603-5210 Email: [email protected]

References: Gucciardi, E., DeMelo, M., Lee, R. N., & Grace, S. L. (2007). Assessment of two culturally competent diabetes education methods: Individual versus individual plus group education in Canadian Portuguese adults with type 2 diabetes. Ethnicity & Health, 12(2), 163-187.

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Diabetes Health Connection

BRIEF PROGRAM OVERVIEW The Diabetes Health Connection project is a randomized study of a diabetes selfmanagement intervention relative to a computer-assisted control condition. The intervention uses an in-person, computerassisted behaviour change program to facilitate healthful dietary and physical activity practices. Primary outcomes are dietary patterns and physical activity levels. In addition, the study is collecting biological outcomes (e.g., HbA1c and lipid levels). The program includes the development of an action plan to improve self-management of type 2 diabetes.

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Unknown TARGET AUDIENCE: Adults (ages 19-64) SETTING: Healthcare settings COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning.

Development Date: None noted Revision Date: None noted Current Program Status: Unknown

Program Description: The intervention was conducted outside of the primary care setting by research staff members ("Health Connection coaches") trained in motivational interviewing techniques. Seven coaches (interventionists) with varied credentials and experience were trained. Five coaches had master's degrees (in public health, health education, occupational therapy, genetic counselling or dietetics/nutrition), and two coaches had bachelor's degrees. Four coaches had at least two years of health

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education or patient counselling experience. Four coaches had experience working among populations with chronic illness, but none had experience coaching people with diabetes mellitus. Participants were randomly assigned to either the intervention or the "enhanced standard care" group. Randomization was conducted using an assignment sequence developed by the project statistician and performed within physician to control for potential provider effects. Health Connection coaches conducted individual sessions that involved a health behaviour assessment and an education program via computer for all participants, but the content of the visits differed by treatment condition. Intervention participants received a 30- to 40-minute computer-assisted, tailored self-management (TSM) session with multimedia, personalized feedback and goal setting focused on patient-selected strategies to improve physical activity and diet. The program generated a two-page printout for the participant, a one-page summary for his or her physician that included HbA1c and lipid data, and a more detailed printout that the coach used to counsel the participant. The coach reviewed the personalized behaviour change plan with the participant, and discussed the goals and strategies chosen to ensure that the action plan was achievable and was personally relevant. Participants were also given a strength training plan (tailored to specific ability levels) that included instructions on the use of Thera-Bands (Hygiene Corp, Akron, Ohio) to perform the strengthening exercises, as well as an illustrated instruction book and a videotape. The TSM participants also received brief follow-up telephone calls from their coach one and four weeks after the visit, to check on their progress and to revise goals and strategies as needed. Finally, a tailored newsletter was mailed to TSM participants three weeks after the second telephone call. Control participants randomized to enhanced standard care also had a one-on-one session with a coach but received a health risk appraisal (HRA) multimedia computer-assisted session that provided more general age- and sex-appropriate information on preventive

health measures (e.g., immunizations, wearing seat belts, and cancer screening). Control participants did not receive follow-up telephone calls or a newsletter. Physicians of control patients were sent the results of the HbA1c and lipid panels only, and laboratory data were sent electronically from the participating laboratory, so this did not require additional staff time. Program Goals: None stated Program Objectives: Effectiveness of the program was determined by improvements in measures of fat intake, physical activity, and HbA1c and lipid levels. Program Implementation Steps: · hysicians were recruited from the Denver, P Colorado, metropolitan area from both HMOs (health maintenance organizations) and nonmanaged care settings. Patients were recruited first with a letter and then by telephone; those who agreed to participate were sent consent forms by mail. · he intervention focused solely on dietary and T physical activity behaviours and took about 30-45 minutes to complete. In-depth assessment, feedback and action planning were included. · he program visits were held separately from T the primary care visit and were facilitated by a research staff "health coach." Visits ranged from two to three hours in length, including detailed assessment, CD-ROM completion, discussion and tailoring of the action plan, and skill-building activities (e.g., estimating food portions and strength training with Thera-Bands). · articipants were followed for 18 months with P diet and exercise goals set at the first appointment, and then revised two months later at a second appointment. Follow-up calls and a mailed newsletter were provided by the health coach. Program Delivery Sources: The program was delivered by research staff "health coaches" and health educators. Process Evaluation: None stated

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Outcome Evaluation Results: Outcomes were identified using the RE-AIM framework and included program adoption among physicians, reach across patient groups, implementation, and behavioural (fat intake and physical activity) and biological (HbA1c and lipid levels) effectiveness measures. The REAIM framework considers five dimensions that are important for evaluating the potential public health effects and generalizability of an intervention. The five components of the RE-AIM model (and their application to this program) are as follows: 1. Reach (the percentage and representativeness of primary care patients with diabetes mellitus who were willing to participate in a computer-assisted, self-management program); 2. Effectiveness (intervention effects on targeted outcomes, including behavioural and physiological measures, and whether effects were robust across patient subgroups and interventionists); 3. Adoption (the percentage and representativeness of primary care physicians willing to sponsor and refer their patients to this program); 4. Implementation (how consistently the various intervention components were delivered by diverse intervention personnel and to different patient subgroups); and 5. Maintenance (the extent to which patients continued their participation in the program). Maintenance also has indicants at the setting level (see http://www.re-aim.org), but such indexes were not available for this article. In terms of behaviour change outcomes, the TSM intervention seems reasonably robust across the range of patients, healthcare settings and interventionist factors investigated. Overall effects on behaviour change measures did not translate into treatment effects on HbA1c or lipid levels (this may have been partially due to the good baseline levels of these variables). This study provides encouraging findings in these areas, as neither sex nor ethnicity nor income nor other demographic variables (with the possible exception of age on physical activity levels) moderated the intervention effects.

Program Reach: Forty-two primary care physicians (34 from HMOs) participated, as did 217 adult patients with type 2 diabetes. In a related study, 335 patients participated. The mean age of participants was 61.0 ±10.7 years; 45% were female; 28% had a high school education or less; and 59% had an annual family income of $50,000. Seventy per cent were white or non-Hispanic; 14% were Hispanic and 12% were African American. Most had two or more chronic illnesses in addition to diabetes mellitus. Community Supports: None stated Partner Engagement: None stated Start-up Costs: None stated Ongoing Implementation Costs: The cost of the program was $547 (US) per person. Significant contributors to this cost were the health educator required to be present for the extended compterassisted activities, and the time associated with planning an individual physical activity resistance training component. This cost includes expenses to recruit participants and deliver the intervention. Description of Contextual Factors: Several studies have found that the areas of care least likely to be consistently provided are self-management support and patient-centred care. Both involve understanding patient perspectives, setting collaborative goals, and tailoring interventions for patients. Added to these challenges are disparities in both the care received and the health outcomes for minority and underserved patients compared to middle-class whites. Most primary care practitioners are not well trained to address these chronic illness self-management or behavioural counselling challenges, and few have either the resources or the time to make them priorities.

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Generalizability: Except for perhaps the initial lengthy meeting with a health counsellor, the program was designed to be generalizable and broadly applicable, relying to a large extent on computer technology. The fact that the meeting occurred in a centralized setting outside of the medical office visit can be viewed as facilitating generalizability and adoption (our perspective) or as limiting generalizability (one reviewer's perspective). The present program is probably most appropriate for facilities such as group practices, managed care organizations, Veterans Affairs settings, or practices that use disease management

services. This program would be well suited to those most concerned about program quality and consistent implementation. Other programs might be better suited when the goal is to reach the largest proportion of patients. Materials Available for Program Adaptation: None stated Lessons Learned: It is encouraging that intervention staff members with different backgrounds and experience were able to successfully implement the program. The use of computer-assisted interventions helps ensure that a program is consistently delivered.

PROGRAM CONTACT:

Russell E. Glasgow, PhD

Clinical Research Unit, Kaiser Permanente Colorado 335 Road Runner Lane Penrose, Colorado 81240 Email: [email protected]

References: Glasgow, R. E., Strycker, L. A., King, D. K., Toobert, D. J., Rahm, A. K., Jex, M., & Nutting, P. A. (2006). Robustness of a computer-assisted diabetes selfmanagement intervention across patient characteristics, healthcare settings, and intervention staff. The American Journal of Managed Care, 12(3), 137-145. Glasgow, R. E., Nelson, C. C., Strycker, L. A., & King, D. K. (2006). Using RE-AIM metrics to evaluate diabetes selfmanagement support interventions. American Journal of Preventive Medicine, 30(1), 67-73.

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Diabetes Outpatient Intensive Treatment

(DO IT)

BRIEF PROGRAM OVERVIEW The Diabetes Outpatient Intensive Treatment (DO IT) program is an interactive, 3.5-day group education and skills training experience. The program involves a specialist diabetes care team that works with patients to customize their care to result in improved diabetes self-management.

Best Practice

PROGRAM FOCUS: Type 1 or Type 2 diabetes PROGRAM LEVEL: Group level TARGET AUDIENCE: Adults SETTING: Healthcare setting COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing.

Development Date: None noted Revision Date: None noted Current Program Status: Being implemented by source

Program Description: The program involves a maximum of 12 patients in the group at a time. Patients begin their 3.5-day program with one-on-one meetings with the endocrinologist, exercise physiologist, registered dietitian, nurse educator and social worker. Patients also have a physical exam and lab work, and a daily physician session. Based on the specialist assessments, the team works with each patient to design a personalized nutrition, exercise and medication plan. The small group sessions are used to teach the following diabetes management techniques: · Interpreting blood glucose levels; · Spotting, avoiding and treating low blood glucose; · Responding to high levels;

3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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· · · · · · ·

A djusting and timing their medications; T aking care of their heart and kidneys; M anaging travel and sick days; M eeting nutritional goals; R emoving the guesswork from dining out; E xercising to maintain control; and R educing stress and staying motivated.

Program participants choose breakfast and lunch from a buffet under the guidance of the program dietitian, and have two supervised exercise sessions. At the end of their DO IT program session, patients leave with a record of their lab work, a copy of their medical findings, and documentation about the changes they have made to their diabetes care plan. Program Goals: Increased glycemic control and better self-care. Program Implementation Steps: The program is 3.5 days in length and runs at the Joslin Center from Monday to Thursday. Upon arrival, participants meet individually with each of the healthcare professionals on the team, and then have a physical exam and lab work done. An introductory group session is then held for participants to discuss their experiences. On the morning of the second day, the staff team meets to plan the customized approach for each patient. The approach focuses on achievable lifestyle changes and possible changes in medication regimens. On days 2 to 4, patients follow the program schedule between 7:30 a.m. and 4 p.m. Each day consists of a series of group and individual sessions. Participants are provided with breakfast and lunch buffets (from which they freely choose food under the guidance of the staff dietitian), two supervised exercise sessions, and a series of classes covering the diabetes management topics shown above. Blood glucose levels are checked (and discussed) before and after meals and exercise sessions, to encourage patient problem-solving skills and to reinforce the potential value of exercise and

good food choices. Participants have daily individual meetings with the program's physician. During these meetings, the patient and physician review the daily glucose values and the changes in the patient's lifestyle. At the end of the program, patients participate in a final group session to review the program and identify their individual action goals. Patients review their discharge plan individually with a nurse educator. Patients receive ongoing follow-up from the team nurse educator to address problems, receive support, and adjust the regimen as necessary. Program Delivery Sources: The DO IT collaborative team consists of an endocrinologist, an exercise physiologist, a registered dietitian, nurse educators, a social worker and a physician. Outcome Evaluation Results: Evaluation results show patients improve their HbA1c results by an average of almost 1.5 points, and patients with HbA1c readings greater than 10 have a reduction in their HbA1c levels by an average of 2.75 points, in the first three to six months. The program also reports decreased emergency room visits and hospitalizations by more than 50% in the year following participation in the DO IT program, and a 43% reduction in time lost from work and school. Program Reach: The program takes 12 patients in each Monday-to-Thursday round of the program. Community Supports: Participants are encouraged to bring their spouse, a family member or a friend with them to the program. The program provides the support person with not only the opportunity to learn more about the challenges of managing diabetes and to become part of the patient's support network, but also to seek insight from others who live with someone with diabetes. While patients are doing their daily sessions in the gym, the support persons meet as a group with a mental health specialist.

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Critical Points That Need to be Replicated: Polonsky et al (2003) state that the "careful combination of medical management with diabetes self-management training into an integrated, multidisciplinary program may have been critical." The authors also identify the "emphasis on patient participation and collaboration as well as a focus on group education" as a critical component of the DO IT program.

Description of Contextual Factors: The program occurs within the Joslin Diabetes Center. The Joslin Center is a global leader in diabetes research, care and education and is affiliated with Harvard Medical School.

PROGRAM CONTACT:

Richard A. Jackson, MD

Joslin Clinic One Joslin Place Boston, Massachusetts 02215 Phone: (617) 732-2628 Email: [email protected] Website: www.joslin.org

References: Polonsky, W. H., Earles, J., Smith, S., Pease, D. J., Macmillan, M., Christensen, R., et al (2003). Integrating medical management with diabetes self-management training: a randomized control trial of the diabetes outpatient intensive treatment program. Diabetes Care, 26(11), 3048-3053. DO IT website: http://www.dlife.com/dLife/do/ ShowContent/dlife_media/tv/_joslin_do_it_060705.html Joslin Diabetes Center website: http://www.joslin.org/ 755_1409.asp

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Best and Promising Practices in Diabetes Education

Diabetes Personal Trainer

BRIEF PROGRAM OVERVIEW The intervention was designed to enhance youth's motivation and capability for diabetes management. The term personal trainer was chosen to emphasize the development of strengths rather than the amelioration of deficits. The role of the personal trainer was to be a facilitator of the prescribed medical regimen, not to be a provider of medical advice.

Best Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Social cognitive and self regulation models with the application of principles from motivational interviewing, applied behaviour analysis and problem solving TARGET AUDIENCE: Youth (ages 11-16) SETTING: Home or public location

(if distance was a factor)

COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET 1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities.

Development Date: 2002 Revision Date: The program has not been revised per se; however, it served as a launching point for the development of a clinic-integrated, familybased behavioural intervention designed to improve disease management problem solving; improve parent- child cooperation and communication; reduce conflict regarding disease management; and facilitate appropriate sharing of disease management responsibility. Current Program Status: Being implemented by source

Program Description: The intervention was delivered in six semi-structured sessions, in the patient's home or in public locations, and supplemented with phone calls. The program

2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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was conducted over approximately two months by trained non-professionals. The initial intervention session was conducted with both the youth and a parent; subsequent sessions were with the youth only. Every attempt was made to facilitate the youth's use of existing family relationships and skills in a helpful way. The youth experienced skill development associated with identifying areas for improvement, selecting goals, and generating solutions, but was then instructed to identify ways a parent could assist and to share these ideas with a parent during the session. The first intervention visit included rapport building, program overview and review of blood glucose monitoring records. Youths were provided with an accelerometer and food diary, and instructed to wear the accelerometer at all times and record all food consumption for two weekdays and one weekend day. The second visit was designed to continue assessment and begin building motivation for behaviour changes. The youth and personal trainer reviewed the selfmonitoring data, noting frequency, duration and intensity of physical activity; frequency and timing of blood glucose monitoring and frequency; and timing and content of meals. A semi-structured interview guided by motivational interviewing principles was conducted to identify areas of difficulty and develop a list of potential goals. Youths rated their readiness to change on each goal and then selected their top three potential goals. The third visit took the youth through the steps of the behaviour change process. Youths discussed pros and cons of each potential goal, and analyzed antecedents and consequences of the potential target behaviours. The youth selected one goal to work on and was led through the process of developing a personal plan, including brainstorming and selecting strategies, addressing potential barriers, defining the parent's role in facilitating the plan, determining a method to record progress and anticipating expected outcomes. The final three visits focused on follow-up and continued skill development. Youths were assisted in analyzing the results, troubleshooting, problem solving

and revising their plan as needed, and facilitating their ability to work toward self-selected goals and assess progress. The process should reinforce and lead to increases in outcome and efficacy expectations. The personal trainers provided suggestions, encouragement and positive feedback. Program Goals: To enhance youths' motivation and capability for diabetes management Program Objectives: To incorporate the principles of motivational interviewing to enhance engagement and to use an individualized experiential learning approach. The objective of the study was to assess the cognitive, behavioural and physiological outcomes of a self-regulation intervention for youth with type 1 diabetes delivered by non-professionals and, given the important developmental changes that occur from preto middle adolescence, to assess differing intervention effects by age. Program Implementation Steps: See program description above. Program Delivery Sources: The interventionists received 80 hours of training in diabetes management, motivational interviewing, applied behaviour analysis, parent-child issues in diabetes management, safety, ethics and the intervention activities. Training activities included didactic sessions, reading materials, video, role plays, group activities and individual practice with feedback. Process Evaluation: Interventions were tape recorded and monitored to ensure intervention fidelity. A sample of intervention sessions was coded along relevant motivational interviewing dimensions (e.g., reflective listening, open-ended questions, empathy and egalitarianism) and specific intervention components; adequate competence and fidelity were observed for all trainers. Outcome Evaluation Results: HbA1c, the primary outcome, was assessed as per standard care protocol at the clinics. Significant effects were seen among middle adolescents (ages 14-16). Adherence was

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Best and Promising Practices in Diabetes Education

assessed using a modified version of the Diabetes Self Management Profile. The Self Efficacy for Diabetes Self Management scale and the Outcome Expectations of Diabetes Self Management Positive and Negative scales were administered. The Diabetes Quality of Life scale was also administered. All the above were measured at baseline and at each follow-up. Children and parents completed a questionnaire assessing their satisfaction with the program. Program Reach: Limited by the need for one-on-one interaction Start-up Costs/Ongoing Implementation Costs: Because the program was developed and implemented within an intramural research branch of the National Institutes of Health, specific start-up and maintenance costs cannot be calculated. The program was developed by investigators at the National Institute of Child Health and Human Development as part of their research mission, and research interns were trained by the investigators to implement the intervention. In a clinical setting, costs would include training of intervention staff (approximately 80 hours) and staffing costs for six sessions of approximately one hour each per patient plus five brief telephone calls. If conducted in the home as was done in our study, expenses for travel to patients' homes would also be incurred. However, the program could be conducted in clinical or other settings. Critical Points That Need to be Replicated: The program was well received by youths and their families. Youths responded well to the motivational interviewing style of interaction, were able to identify areas of diabetes management that they wanted to improve, and were able to learn and utilize the problem solving process. Youths and parents reported liking the process of setting, working on, monitoring progress on, and achieving a specific goal. As implemented, the program was more beneficial for middle adolescents than early adolescents.

Generalizability: For youth, best results were seen with the 14- to 16-year-old age group. Lessons Learned: Findings support the utility of trained non-professionals as interventionists. The staff implemented the intervention with fidelity and no issues occurred with the boundaries of their expertise. Based on the findings from the outcome evaluation, as well as qualitative feedback from parents, the program could be strengthened by including parents in the program in a more integrated, systematic way. In addition, the lengthy distances travelled by intervention staff to deliver the intervention in the home presents a barrier to large-scale implementation in terms of time and cost. Translation of the program to the clinical or other setting may increase feasibility.

PROGRAM CONTACT:

Tonja R. Nansel, PhD

6100 Executive Boulevard Room 7B13R, MS 7510 Bethesda, Maryland 20892-7510 Email: [email protected]

References: Nansel, T. R., Iannotti, R. J., Plotnick, L. P., Zeitzoff, L., Simons-Morton, B., & Cox, C. (2007). Short-term and one-year outcomes of a "diabetes personal trainer" intervention among youth with type 1 diabetes. Diabetes Care, 30, 2471-2477. Communication with Dr. Tonja Nansel.

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Educational Video Game ­ Packy and Marlon

BRIEF PROGRAM OVERVIEW Packy and Marlon is a video game designed to improve a young person's self-confidence, ability and motivation to undertake the rigorous self-care necessary to control type 1 diabetes.

Best Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Cognitive psychology,

education, health promotion, human computer interaction

TARGET AUDIENCE: Children (ages 8-16) SETTING: Home COUNTRY OF ORIGIN: United States LANGUAGE: English, Spanish or French

DES PROCESS STANDARDS MET

Development Date: 1994 Revision Date: Does not appear to have been revised since 1994 Current Program Status: Available to order through various video game distributors

Program Description: Packy and Marlon is a video game for the Super Nintendo Entertainment System (SNES). It models game challenges on diabetes challenges. To win, players must learn how to avoid enemies, select desirable items and engage in specific behaviours that will help their character stay healthy. Repetition is a key factor. Program Goals: To promote diabetes self-care among children Program Objectives: To use a highly engaging activity (video game) to allow children to learn by trial and error in the safety and privacy of their own home to increase self-efficacy with respect to diabetes management

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities.

2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Best and Promising Practices in Diabetes Education

Program Implementation Steps: The characters in Packy and Marlon are two adolescent elephant friends who have diabetes and are on their way to a diabetes summer camp. The player takes the role of Packy in a one-player game; Marlon is added when a second player joins. The characters must save their camp from rats and mice that have scattered the camp's food and diabetes supplies. Players help their character monitor blood glucose, take appropriate amounts of insulin, review a diabetes logbook and find foods containing the right number of food exchanges (bread, fruit, meat, milk, vegetable and fat) according to the meal plan for each meal and snack. Players also learn about selfcare and typical social situations related to diabetes by answering multiple-choice questions posed by camp counsellors throughout the games. The 24 levels of play take place in the camp's forests, playgrounds, rivers, mountains, haunted houses and lakes, with each level becoming increasingly more difficult to complete. There are six game levels in a day, and four days in all. Each game level involves a meal or a snack: breakfast, morning snack, lunch, afternoon snack, and dinner and bedtime snack. Players see a menu at the beginning of the level and must help their character find and eat the foods in that meal plan ­ or substitute equivalent food exchanges to keep the blood glucose in the normal range. Players can press a button to look at a food exchange calculator that identifies the exchanges in all foods included in the game, such as a bowl of cereal or a tuna sandwich, and press the button again to see a logbook of prior blood glucose results, insulin injections taken and food exchanges consumed.

Program Delivery Sources: Video game played in the home Process Evaluation: Children were asked how they enjoyed the game and were asked to rate their use on a four point scale from "don't like to play it at all" to "like to play it a lot." The amount of time spent playing the game was determined by asking the children a series of questions about the number of times they played the video game alone and with others during the past three months, and they also estimated how much time they spent playing in one session. Outcome Evaluation Results: Children in the treatment group enjoyed playing Packy and Marlon as much as the control group. Six months after receiving the game, 69% said they "like the video game" or "like it a lot." On average, participants who received the Packy and Marlon game reported playing it 34 hours during the six months of the study. They averaged 18 hours in the first three months and 16 hours during the second three months. Participants using the video game showed gains in self-efficacy, communication with parents about diabetes, and self-care behaviours. Urgent doctor visits for diabetes-related problems declined. There was no discernable effect on HbA1c. Program Reach: Unlimited Community Supports: None except to make children aware the game is available Start-up Costs: Cost of the games ­ available on Amazon.com ­ price ranges from $15.49 to $35.00

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Ongoing Implementation Costs: None Critical Points That Need to be Replicated: None noted Description of Contextual Factors: Applicable to children 8-16 years of age who have an SNES video game system and enjoy playing video games. Generalizability: As above Materials Available for Program Adaptation: Video game available for purchase

Lessons Learned: There is potential for improvement in youngsters with diabetes to improve their selfcare through video games, a popular pastime for young people of all socio-economic strata. It may be possible in the future to host the game online, and a clinician would then be able to monitor individual progress, which would include measures of attitude and motivation as well as connection to actual physical measurement devices such as a blood glucose meter. In such a program, the patient could directly apply lessons from the role-playing game experience to reallife diabetes therapy.

PROGRAM CONTACT:

Raya Systems Inc

2570 West El Camino Real, Suite 520 Mountain View, California 94040

Deborah Lieberman

5808 Ellison Hall University of California, Santa Barbara Santa Barbara, California 93106 Phone: (805) 893-7571 Fax: (805) 893-7995 Email: [email protected]

References: Brown, S. J., Lieberman, D. A., Germeny, B. A., Fan, Y. C., Wilson, D. M., & Pasta, D. J. (1997). Educational video game for juvenile diabetes: Results of a controlled trial. Medical informatics = Medicine et informatique, 22(1), 77-89.

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Best and Promising Practices in Diabetes Education

Experience-Based Group Education

BRIEF PROGRAM OVERVIEW This intervention investigated the effectiveness of an experience-based group educational program 24 months after baseline (most programs do not look at effects of educational interventions after three to six months). It also pinpointed mediators might play a role in helping people achieve desired metabolic outcomes. Concepts such as a person's sense of power to influence their situation, their self-efficacy and body awareness were some of the aspects of diabetes self-management that were examined. Development Date: Not stated Revision Date: Not stated Current Program Status: Being implemented by source; the program is running in Stockholm by the local diabetes chapter

Program Description: This program aims to investigate the effectiveness of an experience-based group education 24 months after baseline, which is longer than most education programs follow their participants. Different intervention targets were chosen to see if they would result in longer-term glycemic control. Targets include reflection and understanding or acknowledging the individual's competence to make decisions about everyday

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Empowerment, internal locus of control, self-efficacy TARGET AUDIENCE: Adults SETTING: Community at large COUNTRY OF ORIGIN: Sweden LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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care, which yields a sense of autonomy that helps individuals take charge of their own diabetes. The person then acts as an equal partner in planning and delivery of diabetes care, which in turn reflects the sense of power or influence the person has to influence their situation. Another intervention target is the role of body awareness/patient recognition of hyper- and hypoglycemic events. Program Goals: To reinforce the participants' experiences, and use these experiences as a basis for the acquisition of practical skills needed for self-management of diabetes Program Objectives: The study hypothesis is that an individual's body awareness and capability to make a correct guess of their current blood glucose level before measuring it would predict better glycemic control. Other hypothesis- positive effects of exercise and decreased body weight and negative effects of feelings of loneliness, high body mass index and feelings of anxiousness for diabetes-related to complications. Program Implementation Steps: The intervention is 12 months long, with a planned follow-up one year after completion. Blood glucose was monitored through the course. Groups met once a month and participants' self-monitoring diaries were shared with the group; this was an important foundation for the discussions. Materials included a video on how to live well with diabetes by exemplifying lifestyle changes, a dice game where questions had to be answered (no set answers were available; answers had to be negotiated by the players), a booklet or guide on how to manage diabetes (which contained logs of imaginary people who had typical faults in their diet or treatment, and also included information on diabetes complications and a personal plan for follow-up visits). The booklets were used to stimulate discussion of more appropriate regimens.

Participants were encouraged to "experiment" with different nutritional components and exercise, and to monitor their blood glucose reactions as a means to promote experience-based learning. The guiding principle throughout the group sessions was that any questions raised should be solved by the group rather than by the group leader. Program Delivery Sources: Education sessions are led by specially trained pharmacists, assisted by a diabetes nurse specialist. Pharmacists received a threeday intensive training course before the start of the sessions. The educational materials used in training the pharmacists were identical to those used by program participants (as described above). The pharmacists were instructed not to intervene with participants' medical regimens, but to refer them to their medical team. Continuous backup and support was provided by the pharmacist with regular follow-up group meetings every six months. The pharmacists kept a diary for each participant to record their learning experience throughout the program. Process Evaluation: A questionnaire was administered at the start of the study, and two years after baseline. Participants' comments on all the items related to personal perceptions about the condition, and quotes from these comments, are being used to further explain and/or exemplify certain results. Outcome Evaluation Results: Each patient's HbA1c was measured at baseline, and again after six, 12 and 24 months in both the intervention and control groups. A questionnaire was administered at the start of the study and two years after baseline. The intervention group decreased its HbA1c values significantly between zero and six months after baseline, as well as at the long-term follow-up at 24 months. The intervention produced no effects for measurements at 12 months.

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Best and Promising Practices in Diabetes Education

The following factors showed a significant difference between the control and intervention groups: being more satisfied with one's own knowledge about diabetes, exercising more in order to affect blood glucose levels, and being able to predict current one's blood glucose level before measuring it. Factors without a detectable influence were an ability to "feel in my body" where the current blood glucose level is, feeling in control of blood glucose levels, and a feeling that blood glucose levels change irrespective of personal efforts to influence it. Program Reach: Eighty-four participants were recruited for the study, with 77 randomized, resulting in a control group with 38 and an intervention group with 39 participants. At the end of the trial (24 months), the intervention group had 33 and the control group had 31 participants. Community Supports: The acknowledgements indicate that the study was supported by the Swedish Foundation for Health-Care Sciences and Allergy Research Grant, The National Corporation of Swedish Pharmacies and Uppsala University. Funding for the first author was received from the Knut and Alice Wallenberg Foundation in Stockholm, Sweden. Partner Engagement: Participants were self-referred; they responded to advertisements in local newspapers and flyers distributed through GPs' offices and the Stockholm Diabetes Association. The Ethics Committee at Uppsala University Medical Facility was also involved. Pharmacists were involved in the delivery of the program and the medical team supporting the participants was also involved.

Financial Supports: The program contact indicted that the calculated return on investment is two times. In Sweden, the pharmacy calculated that the perperson cost was 4,500 SEK for a full-year course; the pharmacy staff costs were in addition to this. The most important cost in the analysis was that of blood glucose monitoring. If that can be reduced by skilled patients, it would really make a difference (Tennvall, G. R, Rosenqvist, U., Nilsson, L. G. [1997]. It is worth concentrating on prevention of complications. An example from diabetic care. Läkartidningen, 94[34], 2817-2821.) Critical Points That Need to be Replicated: The most important finding was the significant role of subjective measures reflecting personal perceptions of participants in determining outcomes. This may help explain why improving knowledge about diabetes is not enough in itself, and why it is difficult to conceptually capture and measure predictors of success in diabetes patient education. Therefore, it is recommended that evaluation of patient education programs in the future should routinely include adequate assessment of subjective factors that potentially influence outcomes. Description of Contextual Factors: Participants were self-referred, responding to ads in newspapers and flyers. This probably introduced selection bias, as those people are motivated to improve their diabetes self-management. Generalizability: The results showed a decrease in HbA1c at six and 24 months, but not at 12 months. This shows that interventions can have postponed or fluctuating dynamics, suggesting that follow-up should not be discontinued a year after baseline, but rather involve several measurements later on to capture a possible late effect of the intervention. It seems that both biomedical and subjective factors played a role in accounting for the variance in the differential between baseline HbA1c and that measured at the two-year follow-up.

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Lessons Learned: The program contact indicates that the program has been implemented with the help of laypersons from the local diabetes chapter with some success. The study circle facilitators need two to three days of introduction so they understand the principles behind the program.

PROGRAM CONTACT:

Anna Sarkadi

Department of Public Health and Caring Sciences Uppsala University Uppsala Science Park, Uppsala SE-751 85 Sweden Phone: 46-18-611-35-67 Email: [email protected]

References: Sarkadi, A. (2001). The borderland between care and self-care. Comprehensive summaries of Uppsala dissertations from the Faculty of Medicine, 983. Univ.-bibl. Retrieved from Acta Universitatis Upsaliensis (Uppsala) website:http:// publications.uu.se/theses/91-554-4901-8/. Sarkadi, A., & Rosenqvist, U. (2004). Experience-based group education in type 2 diabetes: A randomised controlled trial. Patient Education and Counselling, 53(3), 291-298. Sarkadi, A., Vég, A., & Rosenqvist, U. (2005). The influence of participants' self-perceived role on metabolic outcomes in a diabetes group education program. Patient Education and Counselling, 58(2), 137-45. Vég, A. (2006). Teaching and learning in type 2 diabetes: The importance of self-perceived roles in disease management. Digital comprehensive summaries of Uppsala dissertations from the Faculty of Medicine, 169. Retrieved March 26, 2008 from Acta Universitatis Upsaliensis (Uppsala) website: http://urn.kb.se/ resolve?urn=urn:nbn:se:uu:diva-7122. Vég, A., Rosenqvist, U., & Sarkadi, A. (2006). Self management profiles and metabolic outcomes in type 2 diabetes. Journal of Advanced Nursing, 56(1), 1-11. Vég, A., Rosenqvist, U., & Sarkadi, A. Variation of patients' views on type 2 diabetes management over time. Diabetic Medicine (accepted). Vég, A., Rosenqvist, U., & Sarkadi, A. Long-term followup of participants from an experience-based group education program for type 2 diabetes (manuscript).

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Best and Promising Practices in Diabetes Education

Group-Based Counselling for Improved Coping

BRIEF PROGRAM OVERVIEW The Group-Based Counselling program is designed to be responsive to the "behavioural, cognitive and psychosocial needs of adults with both types of diabetes." The intervention occurs during nine group sessions and emphasizes patients' active role and responsibility for the management of their diabetes.

Best Practice

PROGRAM FOCUS: Type 1 and Type 2

diabetes

PROGRAM LEVEL: Group level THEORETICAL BASIS: Cognitive Behavioural

Therapy Approach

TARGET AUDIENCE: Adults SETTING: Healthcare settings COUNTRY OF ORIGIN: Norway

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: Not specified Revision Date: Not specified Current Program Status: Unknown

Program Description: The program is a nine-session group program built on the assumption that behaviour and emotions are in constant interaction with cognition and that these cognitions may be inaccurate, leading to excessive emotional reactions and a failure to cope effectively. Program Goals: To help participants cope more actively with diabetes Program Objectives: The counselling process focuses on the patient's active role and responsibility, and aims at stimulating: · Conscious reflection · Cognitive restructuring · Problem-solving skills · Skills in decision making

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Program Implementation Steps: A nurse specialist in diabetes care and experienced individuals with diabetes worked together as co-leaders to implement the nine group sessions. The content of the nine sessions was built on discussions and demonstrations about reducing stress, active coping, enhanced psychological well-being and optimal metabolic control. Topics covered during the sessions were: self-monitoring of blood glucose; stress, coping and self-care behaviour; coping profiles and strategies; relationships (with healthcare professionals and with family, friends and colleagues); stress management; goal setting; dietary and exercise self-care; and goal attainment and relapse prevention. The nine sessions were each 1.5 hours and took place over 12 months. Participants were also divided into subgroups that met different days of the week. Program Delivery Sources: The program was delivered by a diabetes nurse specialist and experienced persons with diabetes. Group participants also assisted during the process as facilitators. This involvement was purposely designed into the program to "enhance the reflection and thereby change the interpretation of living with diabetes."

Outcome Evaluation Results: Program participants indicated that they were more motivated to regulate their diabetes, had more faith in self-control, and in living well with diabetes and in general were more optimistic. Participants also indicated they receive knowledge and more understanding about how to seek support, and were more active. Pre/post results indicated participants were less self-blaming regarding their management of diabetes; this decrease was also seen during the 12-month follow-up. Participants were also able to maintain an acceptable HbA1c level throughout the 12-month time period.

PROGRAM CONTACT:

Bjorg Karlsen

School of Health and Social Work Education Stavanger University College P.O. Box 8002, N-4068 Stavanger, Norway Phone: +47-51-83-41-68 Fax: +47-51-83-41-50 Email: [email protected]

References: Karlsen, B., Idsoe, T., Dirdal, I., Rokne Hanestad, B., & Bru, E. (2004). Effects of a group-based counselling program on diabetes-related stress, coping, psychological wellbeing and metabolic control in adults with type 1 or type 2 diabetes. Patient Education and Counselling, 53, 299-308.

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Best and Promising Practices in Diabetes Education

Guided SelfDetermination Group Session for Type 1 Diabetes

BRIEF PROGRAM OVERVIEW This program is a 16-hour group training program that uses guided self-determination to support patient autonomy and motivation for diabetes management. The program focuses on increasing patient life skills.

Best Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Group level THEORETICAL BASIS: Self-Determination Theory and Stages of Change Theory TARGET AUDIENCE: Adults SETTING: Healthcare setting COUNTRY OF ORIGIN: Denmark

DES PROCESS STANDARDS MET 1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities.

2. Plans for diabetes education are client-centred and ongoing.

Development Date: Not mentioned Revision Date: Not mentioned Current Program Status: Unknown

Program Description: The program guides patients and professionals through mutual reflection using a number of semistructured worksheets. The five-stage process used during the 16-hour program (eight weeks for two-hour sessions) consists of: establishing an "I-you-sorted" relationship, self-exploration, selfunderstanding, action and feedback from action. Each program group has around 10 members. Professionals use mirroring, active listening, values clarification and I-you-sorted communication techniques during each session. The worksheets explore relationships, the patient's life with diabetes, patient reflections on their life between ideal and reality, and change work. Program Objectives: The following outcomes are expected from the guided self-determination program: higher autonomy support perceived from professionals, fewer problems related to diabetes,

3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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improved glycemic control, increased perceived competence in managing diabetes, increased frequency of self-measured blood glucose, and an increase in autonomous motivation. Program Implementation Steps: The groups run for eight weeks for two hours each session. The patient and the professional work out independent lists of issues they each perceive to be difficult for the patient. Together they select one to three issues to be further explored. For each issue selected, the patient looks at his or her current strategies and is challenged and supported by the nurse to develop alternative strategies. The sessions include information about diabetes management based on the needs noticed by the professionals or identified by the patient participants. A total of 20 worksheets explore relationships, the patient's life with diabetes, patients' reflections on their life between ideal and reality, and change work. Patients look at 15 diabetes self-management recommendations and identify their stage of change for each. Patients identify their goals for future diabetes care. For a one-year period, patients continue to meet with the nurse to assess their progress and to review their completed worksheets. Program Delivery Sources: The program was delivered by the researcher along with guided self-determination trained nurses. Outcome Evaluation Results: The study authors report that "results confirmed that the guided selfdetermination group sessions were effective, enabling patients in persistent poor glycemic control to improve their life skills over one year as measured by increase in perceived autonomy support from health professionals, higher frequency of self-measured blood glucoses, increase in perceived competence in managing diabetes, fewer diabetes-related problems and improved glycemic control. An evaluation of the worksheets also showed that the worksheets enhanced patients' awareness of an ability to express, pose, assess and solve personal difficulties in living with diabetes."

Program Reach: Ten participants are seen per 16-hour program cycle. Critical Points That Need to be Replicated: The worksheets combined with the professional communication skills are important elements for replication. It is vital for the program to involve nurses who have been trained in guided self-determination. Description of Contextual Factors: Participants in the study were 18- to 49-year-olds who had attended diabetes clinics at a Danish university hospital in 2000. Those patients with an average HbA1c greater than 8.0% were eligible for the study. Generalizability: The authors believe minor adjustments are needed to provide a version of the program for both type 1 and type 2 diabetes patients. Materials Available for Program Adaptation: The journal article referenced below outlines in greater detail the 20 worksheets used during the program.

PROGRAM CONTACT:

Vibeke Zoffmann

Institute of Public Health Department of Nursing Science University of Aarhus, Denmark Hoegh Guldbergsgade 6a. 8000 Aarhus C, Denmark Phone: +45-89-42-48-45 Fax: +45-89-42-55-00 Email: [email protected]

References: Zoffmann, V., & Lauritzen, T. (2006). Guided selfdetermination improves life skills with type 1 diabetes and HbA1c in randomized controlled trial. Patient Education and Counselling, 64, 78-86.

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Best and Promising Practices in Diabetes Education

Low Literacy

Best Practice

PROGRAM FOCUS: General PROGRAM LEVEL: Individual level THEORETICAL BASIS: Gagné's Theory of Learning and the Component Design Theory TARGET AUDIENCE: Adults (ages 19-64)

BRIEF PROGRAM OVERVIEW A computer-based multimedia application for individuals with diabetes ("Living Well with Diabetes"), which utilizes extensive audio and video to supply information, provide psychological support, and promote diabetes self-management skills without text or complex navigation. The application was available on touch-screen computers in clinical waiting areas for patients to utilize before appointments.

SETTING: Healthcare settings COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes.

Development Date: The study and program were funded by the Agency for Healthcare Research and Quality (AHRQ); funding began in 2000. The program was developed between 2000-2002. The design was based on "Diabetes and Your Eyes," a pilot project completed in 1999-2000. Revision Date: The program has not been revised since inception however, it is something the developers would very much like to do if they had the funding to do so. Current Program Status: The program is being implemented elsewhere.

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Program Description: The application ("Living Well with Diabetes") was available on touch-screen computers in clinical waiting areas for patients to utilize before appointments. The intervention includes audio/video sequences to communicate information, provide pyschological support and promote diabetes self-management skills without extensive text or complex navigation. Lesson content include an introduction to diabetes, blood glucose management, oral medications and insulin, nutrition and physical activity, depression and stress, oral hygiene and the prevention of complications (including eye, foot, cardiovascular and kidney disease). Users were advised to begin with the introductory lesson; however, they could choose lessons in any order (visual cues indicated which lessons had been viewed). Each lesson targeted a specific self-care objective according to Gagne's Theory of Learning and the Component Design Theory. For each objective, a learning hierarchy was developed based on relevent verbal information (diabetes facts), intellectual skills (procedures for appropriate diabetes care) and cognitive strategies (suggestions for a healthy lifestyle). Each lesson incorporated Gagne's events for instruction, including obtaining the user's attention, stating the objective, reviewing previous learning, providing learning guidance, evaluating user performance and providing feedback. The design included intervention tailoring (based on previous computer experience and learning style) as well as message tailoring of information (targeting communication to African Americans and Latinos). Local professionals provided instructional narration. The software included video recordings of individuals with diabetes who provided unscripted testimonials related to diabetes, emphasizing barriers to care, challenges and personal solutions they or family members have encountered. While the lesson plans for the English and Spanish versions were very similar through translation, different testimonials from various subjects were used to relate both languageand culture-appropriate information to the users. The program was available on touch-screen personal computers. Navigation was provided through a simplified interface, including forward/backward buttons for user control. Advanced features included

pop-up supplementary text information or additional testimonials related to the current screen concept. After each lesson, approximately 10 randomly sequenced multiple-choice questions were presented for reinforcement. Individuals who answered questions incorrectly received immediate audio feedback. The average time for lesson completion ranged from 10 to 20 minutes. Individuals using the program had higher perceived susceptibility to complications but no change in glycemic control. The intervention did result in significant improvement in HbA1c among patients with low health literacy and poor glycemic control. Program Goals: To supply information, provide psychological support and promote diabetes selfmanagement skills to individuals with low health literacy skills Program Implementation Steps: Personal computers with touch screens were placed in waiting areas of public health clinics. Headphones were also made available. Program Delivery Sources: Public health clinics Process Evaluation: The group has continued to collect and process data on computer use. Outcome Evaluation Results: Another trial with the software is currently in progress (2008). This will measure behavioural and clincal outcomes in diabetes care. Program Reach: The program is ongoing and has almost unlimited reach as the computers are available to everyone who uses the public clinic. Community Supports: The public clinic supported the program implementation through their willingness to set up computer kiosks. Start-up Costs: The cost of a PC computer, and access to the software

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Best and Promising Practices in Diabetes Education

Ongoing Implementation Costs: The program implementation does not require Internet access. The only ongoing cost is routine PC maintenance. Critical Points That Need to be Replicated: Simplicity of the computer application and connection to healthcare practitioners is associated with higher usage. Description of Contextual Factors: The program was implemented in public clinics in Chicago and targeted individuals with low health literacy levels in a diverse population. Generalizability: There are several mechanisms by which the multimedia program may impact users. Prominent features of the educational application include video-recorded patient testimonials and interactive assessments that provide immediate feedback to users. Realistic role models may encourage vicarious learning through imitation. Also, skill building of glucose monitoring, insulin injection and lifestyle modification are promoted. These testimonials highlight the benefits of self-care and discuss potential solutions to barriers. The additional use of positive feedback may increase self-efficacy through testimonial and narrator encouragement. The psychological impact of these features may be explained by various social and psychological health behaviour change models, including Bandura's Social Cognitive Theory and Rosenstock's expanded Health Belief Model. The use of video-recorded testimonials including persons with visual defects, kidney disease, amputations and other complications of diabetes may increase viewers' perceived susceptibility to complications. However, behavioural change may occur if perceived benefits and barriers are subsequently addressed, particularly for those individuals having a greater sense of competence to implement change. Lessons Learned: The program has been very popular with patients who want to understand diabetes. The patients like the video stories of others discussing

issues related to diabetes; they like the realism. They also appreciate the basic approach to diabetes instruction. Some like the quizzes at the end of the modules. The practitioners feel the program is helpful for those newly diagnosed and those transitioning to insulin therapy. Implementation and getting the program integrated into clinical workflow is key for sustainability. Having touch-screen computer programs is not sufficient for success: it also needs to be well integrated into personnel work patterns. This is especially true where financial support for research disappears as soon as that rersearch has been completed. There needs to be someone who will make sure that patients with diabetes have access to the computer when needed, and see the information that is most appropriate for them. A process also needs to be in place to allow providers the opportunity to recommend specific information on the computer for patient viewing. Additional Notes: The intervention also addresses the digital divide. This disparity not only represents differential access to computer technology and the Internet, but it also describes personal characteristics that separate users from non-users of electronic information. Access to technology will not effectively enable dissemination of consumer health information if the content is unreadable. The developed multimedia addresses many of the needs and preferences of low-income and underserved Americans concerning content ­ information provided on a basic health literacy level, content for nonEnglish speakers, and culturally defined content. The implementation of touch-screen monitors offers an alternative to keyboard and mouse for computer input, which may hold value for individuals who are older, have lower health literacy or have less computer experience. From the author's experience, there are several challenges to moving forward with computer-based interventions. Despite efforts to improve computer

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usability, there is less use by participants with lower health literacy. As the technology was installed in the clinical setting, an unexpected issue arose: the optimal location for computer accessibility is often uncertain. Having computers visible, freely available and accessible (from the guidelines of the Americans with a Disabilities Act) is a challenge in crowded waiting areas. Unfortunately, privacy is sacrificed when a computer is more centrally located within a clinic. Finally, the availability of computers may be limited if people have to wait for others to finish using a computer, or if one malfunctions. Prompting, instruction, repetition and support are key factors in computer use. Staff encouragement and initial assistance improve acceptance; however, changing staff behaviours in a busy clinical environment is

challenging. Bilingual research assistants provide brief initial instructions to users, which is helpful particularly in locations lacking bilingual staff. Multimedia audiovisual prompting is found to be necessary for continued use. However, repeated sessions may require external prompting by staff, either through verbal reminders or provider recommendations for computer-based learning. Recent experience indicates much greater user and acceptance when a volunteer or family member helps to navigate the computer. To improve usability, additional personal and organizational barriers must be addressed in conjunction with provider involvement. This may increase the impact of computer-based education on behavioural and clincal outcomes.

PROGRAM CONTACT:

Ben Gerber, MD, MPH

Section of Health Promotion Research, M/C 275 University of Illinois at Chicago 1747 West Roosevelt Road Chicago, Illinois 60608 Phone: (312) 996-8872 Fax: (312) 413-8950

References: Gerber, B. S., Brodsky, I. G., Lawless, K. A., Smolin, L. I., Arozullah, A. M., Smith, E. V., et al (2005). Implementation and evaluation of a low-literacy diabetes education computer multimedia application. Diabetes Care, 28(7), 1574-1580.

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Best and Promising Practices in Diabetes Education

Motivational Interviewing to Improve Weight Loss

BRIEF PROGRAM OVERVIEW Motivational interviewing is a brief intervention approach that is demonstrated to promote better long-term outcomes for a range of health outcomes with preliminary support as an adjunct to behavioural obesity treatment. Motivational interviewing produced significantly improved glycemic control, better treatment adherence and a trend toward greater short-term weight loss in a pilot study of diabetic women.

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group education

program followed by individual sessions

THEORETICAL BASIS: Motivational

interviewing

TARGET AUDIENCE: Overweight women SETTING: Healthcare setting COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: 2007 Revision Date: Unknown Current Program Status: Being implemented by source

Program Description: All participants received a 42-session weight management program that met weekly for six months and then monthly for six months. Weight loss induction was emphasized in the first six months and weight maintenance in the subsequent 12 months. Five individual motivational interviewing sessions were offered with the first session before starting the group therapy program and then at three, six, nine and 12 months. Sessions lasted 45 minutes and were delivered by licensed clinical psychologists who had received structured training in motivational interviewing. Each session followed a semi-structured interview

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format of motivational interviewing adapted for weight management. Program Goals: To add motivational interviewing to a behavioural weight control program to improve weight loss and glycemic control Program Delivery Sources: The group sessions were delivered by a multidisciplinary team that included a behaviourist, nutritionist, exercise physiologist and diabetes educator. Licensed clinical psychologists who had received structured training in motivational interviewing delivered the motivational interviewing sessions. Process Evaluation: Ongoing clinical supervision of motivational interviewing skills and intervention protocol fidelity monitoring were combined in weekly supervision sessions. All sessions were audio taped, and randomly selected audiotapes were reviewed weekly by two clinical psychologists using a standardized coding format modelled on other studies of motivational interviewing proficiency. Outcome Evaluation Results: Women in motivational interviewing lost significantly more weight at six months and 18 months. Increased weight losses with motivational interviewing were mediated by increased adherence to the behavioural weight control program. Significantly greater HbA1c reductions were observed in those undergoing motivational interviewing at six months. African American women experienced significantly smaller weight loss than white women. The extended impact of motivational interviewing differed by race, with greater long-term enhancement of weight loss with motivational interviewing for white women than for African American women.

Program Reach: Group size averaged 14 individuals Start-up Costs: Training and meeting facilities Ongoing Implementation Costs: Time and ongoing training Description of Contextual Factors: The participants' body mass index was 27-50kg/m2 but they were generally healthy otherwise and able to walk for exercise. Lessons Learned: Further research is necessary to identify parameters that may be associated with or promote a positive response to motivational interviewing for weight management in ethnically diverse samples, as well as mechanisms responsible for facilitating behavioural change. Further evaluation of motivational interviewing for weight management among men and the non-diabetic population is also necessary.

PROGRAM CONTACT:

Delia Smith West, PhD

UAMS College of Public Health 4301 West Markham Street, #820 Little Rock, Arkansas 72205 Email: [email protected]

References: West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care, 30(5), 1081-1087.

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Best and Promising Practices in Diabetes Education

Nurse Short Message

BRIEF PROGRAM OVERVIEW A nurse educational intervention program using the Internet and a short message service (SMS) by cellular phone improved levels of HbA1c and two-hour post-meal glucose levels for 12 weeks in patients with type 2 diabetes.

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level TARGET AUDIENCE: Adults (ages 19-64) SETTING: Unlimited for patient COUNTRY OF ORIGIN: South Korea

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved.

Development Date: 2003 Revision Date: Unknown Current Program Status: Unknown

Program Description: Before the intervention, each patient was instructed for 30 minutes by a researcher about inputting data into a website. Patients logged into the website whenever it was convenient for them. They sent their self-monitored blood glucose levels and drug information, including the kinds and dosages of insulin and oral anti-diabetic medication that they used for diabetes control. The data was transported to a server system and automatically displayed on the individual's electronic chart. Patients were able to see recommendations from nurses and physicians as well as laboratory data. The nurse could view information on each patient including blood glucose levels, medication and details of some events that were provided by the patient. They could also view basic personal history, including historical data, family history, smoking habits, body mass index (BMI), blood pressure and baseline laboratory data. After integrating the above information, the nurse sent back optimal recommendations to each patient, weekly, via SMS by cellular phone or Internet. Recommendations included "Please decrease

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long-acting insulin by two units" or "Lack of exercise may be the cause of aggravated glucose level" or "Your glucose control seems to be good." All medication adjustments were communicated to the subject's diabetes doctor. If a patient did not forward a blood glucose level for more than one week, a warning message was sent. Program Goals: To maintain blood glucose levels within a normal range Program Delivery Sources: The program was delivered by Internet and cellular phone. Process Evaluation: Unknown Outcome Evaluation Results: An Internet-based intervention by a nurse can improve HbA1c levels in patients with type 2 diabetes. Program Reach: Program reach would be dependent on the amount of nursing resources available to be able to collect, interpret and act on the data submitted. The program is also limited to those who have Internet access and a cellular phone. Partner Engagement: A program nurse works closely with the patient's physician.

Start-up Costs: Unknown Ongoing Implementation Costs: Unknown Critical Points That Need to be Replicated: This program was effective in South Korea. South Korea is one of the most developed countries in terms of Internet networking. Nearly all families have their own computers and cellular phones, and can access the Internet via modem or high-speed network systems that exist in South Korea. Generalizability: Given the appropriate technology, this program could be adapted to youth given their comfort and familiarity with the Internet and SMS. Lessons Learned: For clarification, it would be useful to use a cost-analysis model to determine the expense of a clinic visit versus the use of a web-based management system. Additional Notes: Language is assumed to be South Korean, although attempts to connect with the researcher were unsuccessful.

PROGRAM CONTACT:

Hee-Seung Kim, PhD

College of Nursing, The Catholic University 505 Banpodong, Socho-gu, Seoul 137-701 South Korea Email: [email protected]

References: Kim, H. S., Yoo, Y. S., & Shim, H. S. (2005). Effects of an Internet-based intervention on plasma glucose levels in patients with type 2 diabetes. Journal of Nursing Care Quality, 20(4), 335-340.

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Best and Promising Practices in Diabetes Education

Pounds Off With Empowerment

(POWER)

BRIEF PROGRAM OVERVIEW POWER is a 12-month randomized clinical trial comparing an "intensive-lifestyle" intervention (modelled after the NIH Diabetes Prevention Program), and a "reimbursablelifestyle" intervention (intensive lifestyle intervention delivered in the time allotted for Medicare reimbursement for diabetes education related to nutrition and physical activity) with usual care as a control.

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Behavioral Community

Psychology

TARGET AUDIENCE: Adults (ages 19-64)

living in rural areas

SETTING: Rural communities and

healthcare settings

COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET 2. Plans for diabetes education are client-centred and ongoing.

Development Date: 2004 Revision Date: Revised in 2005 Current Program Status: Being implemented by source

Program Description: The program uses behavioural strategies for weight loss and physical activity, such as self-monitoring of diet and physical activity and additional behavioural strategies, to assist with achieving weight loss goals tailored to individual needs in a culturally appropriate manner. The intensive intervention group met for one-hour sessions with a study nutritionist; they met weekly for the first four months of the core curriculum, every other week for the next two months, and once a month for the remaining six months. The reimbursable-lifestyle intervention was a condensed version that was delivered in four one-hour sessions over the 12-month study and included three group sessions and one individual session. The intervention emphasized low-

3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved.

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calorie/low-fat diet, moderate physical activity, and self-monitoring tools for healthy eating and physical activity. Program Goals: The study goal was to achieve and maintain a 10% weight loss over 12 months. The program goal was 25% of calories from dietary fat, and a minimum of 150 minutes of physical activty per week with an intensity similar to brisk walking. Program Objectives: To provide an intervention on risk factors for diabetes complications among African Americans and Latinos with type 2 diabetes Program Implementation Steps: The implementation steps were as follows: · stablished partnerships with community health E centres. · taged recruitment, which consisted of medical S record review, a pre-screening telephone call and two screening visits. · mplementation of the intensive lifestyle I intervention. Program Delivery Sources: Physicians were encouraged to refer their patients to the program. The program was delivered by health educators, researchers and nutritionists. Process Evaluation: None stated Outcome Evaluation Results: Modest weight loss occurred at six months and was statistically significantly greater among the intensive-lifestyle participants compared with the usual-care participants. At 12 months, a significantly greater proportion of intensive-lifestyle participants compared with usualcare participants had lost at least two kilograms. There was no statistically significant weight loss observed among reimbursable-lifestyle participants.

Program Reach: The first eight sessions of the "Lifestyle Change Program" of the NIH/NIDDKfunded primary prevention trial, and the Diabetes Prevention Program were used as the weight management intervention. The POWER study researchers made minimal modifications to these materials: simplification of the language and layout; inclusion of regionally and culturally appropriate examples; inclusion of information specific to persons with diabetes; and replacement of diabetes prevention commentary with prevention of diabetes complications. Community Supports: The program was marketed directly to physicians in the community, and was promoted as a partnership between the researchers at the university and the local health centre. Partner Engagement: Community health centres were pivotal partners during the development and delivery of the POWER study. Start-up Costs: Unknown Ongoing Implementation Costs: The program needs ongoing implementation support from health education and nutrition staff. Critical Points That Need to be Replicated: Successful recruitment strategies for recruiting overweight adults with diabetes from rural, medically underserved communities to a weight management intervention were found to include: partnering with community health centres, hiring staff from the community, positive reinforcement and social supportiveness, monitoring progress and free transportation.

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Best and Promising Practices in Diabetes Education

Description of Contextual Factors: The program was implemented at two primary healthcare centres in rural counties in the United States. The 12-month randomized clinical trial was a collaborative effort between the University of South Carolina and the South Carolina Primary Health Care Association. The study was conducted with older adults, primarily African Americans, who had physician-diagnosed type 2 diabetes and who lived in rural medically underserved communities in South Carolina.

Lessons Learned: The study authors emphasize the importance of planning that attends to the needs of the target population. Support from key stakeholders within the organization set a foundation for strong and lasting programs by ensuring compatibility with existing organizational goals. The program should be couched in local terms and language, and should carefully adhere to local customs and values.

PROGRAM CONTACT:

Elizabeth J. Mayer-Davis, PhD

Department of Epidemiology and Biostatistics Arnold School of Public Health University of South Carolina Columbia, South Carolina 29208 Phone: (803) 251-7874 Email: [email protected]

References: Mayer-Davis, E. J., D'Antonio, A., Martin, M., Wandersman, A., Parra-Medina, D., & Schulz, R. (2001). Pilot study of strategies for effective weight management in type 2 diabetes: Pounds off with empowerment (POWER). Family & Community Health, 24(2), 27-35. Mayer-Davis, E. J., Smith, S. M., Kirkner, G., Levin Martin, S., Parra-Medina, D., Schultz, R. (2004). Pounds off with empowerment (POWER): A clinical trial of weight management strategies for black and white adults with diabetes who live in medically underserved rural communities. American Journal of Public Health, 94(10), 1736-1742. Parra-Medina, D., D'Antonio, A., Smith, S. M., Levin, S., Kirkner, G., Mayer-Davis, E., et al. (2004). Successful recruitment and retention strategies for a randomized weight management trial for people with diabetes living in rural, medically underserved counties of South Carolina: The POWER study. Journal of the American Dietetic Association, 104(1), 70-75.

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Promotora Diabetes Intervention for Mexican Americans

BRIEF PROGRAM OVERVIEW This randomized controlled trial determined the effectiveness of an intervention led by promotoras (community lay leaders) on glycemic control, diabetes knowledge, and diabetes health beliefs of Mexican Americans with type 2 diabetes living in a major city on the Texas-Mexico border.

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Community level for

Mexican Americans

THEORETICAL BASIS: Theory of self-efficacy by Bandura with some adaptations from Stages of Change Theory as well as Theory of Community Empowerment and the Diabetes Health Belief Measure (DHBM) TARGET AUDIENCE: Mexican-American

adults (ages 40 or older)

SETTING: Community (recruited from

faith-based organizations)

COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

Development Date: 1995 Revision Date: In 2000, the total number of hours was decreased from 20 hours (class series with eight sessions/series) to 16 hours. Current Program Status: Since 2000, participation by community members has increased by approximately 5% per year (in each class series).

Program Description: This program is conducted by community lay leaders called promotoras who have been trained in diabetes education. Program Goals: To determine the effectiveness of an intervention led by community lay workers (promotoras) on the glycemic control, diabetes knowledge and diabetes health beliefs of Mexican Americans with type 2 diabetes living in a major city on the TexasMexico border

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Best and Promising Practices in Diabetes Education

Program Objectives: The objectives are as follows: 1. Participants in the intervention will have lower HbA1c levels than the participants in the usualcare control group at six months post-baseline. 2. Participants in the intervention group will have higher scores on the Diabetes Knowledge Questionnaire (DKQ) than the participants in the usual-care control group at three and six months post-baseline. 3. Participants in the intervention group will have stronger health belief scores on the Diabetes Health Belief Measure (DHBM) than the participants in the usual-care control group at three and six months post-baseline. Program Implementation Steps: The trial was implemented at a Catholic faith-based community clinic in a major city on the Texas-Mexican border. The six-month intervention was developed with collaboration from clinic promotoras and patients. A team of two promotoras delivered eight weekly twohour participative group classes and telephone followup to the intervention participants. The classes were available in English and Spanish, and were developed by a certified health educator in conjunction with the promotoras. They met the curriculum guidelines of the American Diabetes Association, were interactive, had hands-on demonstrations and handouts, and included diabetes self-management goal setting and attainment progress reports. The promotoras contacted the participants by telephone biweekly to answer any questions or concerns, reinforce the education process and promote behaviour change. After the classes ended, inspirational faith-based health behaviour change postcards were mailed biweekly for 16 weeks to the intervention group participants. This study had three Spanish classes with 23 participants in each, and one English class with six participants. Program Delivery Sources: The promotoras were bilingual clinic employees who had received 60 hours of training on diabetes self-management. Process Evaluation: Every series of classes has "participant satisfaction surveys done regularly. However, the associated clinical outcomes HbA1c, etc are not being tracked.

Outcome Evaluation Results: Glycemic control was measured using HbA1c levels, which were drawn at a local community diabetes educational agency by trained staff. The DKQ was used (English and Spanish) to measure diabetes knowledge including the respondents' understanding of the cause of diabetes, types of diabetes, self-management skills and complications of diabetes. The bilingual DHBM was used to measure participants' belief in their ability to manage diabetes. The HbA1c levels were measured and the DKQ and DHBM questionnaires were done at baseline, three and six months post-baseline. The mean HbA1c levels decreased for the intervention group and increased for the control group over the six-month study period. There were no significant differences at three months. The DKQ score mean change of the intervention group was significantly higher than that of the control group at the six-month assessment. Based on the DHBM, the participants did not experience an increase in their belief about their ability to manage diabetes, although the intervention group demonstrated more knowledge and better control of their HbA1c levels. Program Reach: The clinic provides primary care services to 12,000 patients, 2,000 of whom have type 2 diabetes. Ninety per cent of the clinic's clients are self-reported Mexican Americans. Sample size calculations determined 63 participants were needed per group so, in anticipation of an attrition rate of 20%, sample size increased to 75 per group. Of the clinic's patients, 160 were eligible and interested, and 150 met inclusion criteria. These were then randomized into an intervention and a usual-care control group Community Supports: The protocol was approved by the clinic's administrative officers and the university's committee for the protection of human subjects. Partner Engagement: The program was conducted at a Catholic faith-based community clinic in a major city on the Texas-Mexico border. Acknowledgements note that the Paso del Norte Health Foundation through the Centre for Border Health Research supported the study

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through a grant. The author was with the University of Texas at the time the study was reported Start-up and implementation Costs: Approximately 16 hours of labour time for the promotora at approximately $10 = $160 for each eight-week (two hours per class) series of classes. Learner materials cost approximately $100, for a total expense of $260 per class series. Critical Points That Need to be Replicated: Retention is very important and this was promoted by providing: 1. transportation to the classes and assessment interview; 2. a class attendance incentive credit per class that was applied to the participant's clinic account; 3. a small token gift; and 4. a gift certificate at each of the three assessment interviews that was redeemable at a major local discount store. Description of Contextual Factors: In this study, the promotoras provided multi-component patient self-management education and follow-up contact to Mexican Americans, rather than just helping with the work as in previous studies. They were able to deliver the material in a culturally sensitive manner and at the appropriate level, using relevant food items, recommending appropriate physical activity, and acknowledging and integrating the Mexican American beliefs of divine fatalism. There was a concerted effort to reinforce the relationships between faith and diabetes self-management. Generalizability: This is a unique setting with a specific target group, so the results have limited generalizability. However, a key outcome is the use of promotoras to deliver the content, and the spiritualbased health outcomes­oriented postcards.

Materials Available for Program Adaptation: Materials (handouts, videos, flip charts) are commercially produced by NovoNordisk, El Paso Diabetes Association, Eli Lilly or Centro San Vicente Community Health Center in El Paso, Texas. Each pharmaceutical company can be contacted individually online. Centro San Vicente can be contacted online through the Director of Patient Education. Lessons Learned: The following lessons can be gleaned from this study: · romotoras are an effective way to deliver patient P education that is culturally and linguistically competent. · he spirituality of Hispanic clients needs to be T addressed in all patient education programs to enhance outcomes. · uch more intervention research needs to be M conducted to reduce Hispanic health disparities in the US.

PROGRAM CONTACT:

Josefina Lujan

University of Texas University of Texas at El Paso 1101 North Campbell El Paso, Texas 79902 Email: [email protected]

References: Lujan, J., Ostwald, S. K., & Ortiz, M. (2007). Promotora diabetes intervention for Mexican Americans. The Diabetes Educator, 33(4), 660-670.

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Best and Promising Practices in Diabetes Education

Stress Management Training for Patients with Type 1 Diabetes

BRIEF PROGRAM OVERVIEW Patients with type 1 diabetes referred from a research centre attended an eight-week training program on stress management for three months. Significant reductions in blood pressure (max.) and pulse rate were observed.

Best Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Group level TARGET AUDIENCE: Adults (ages 16-30) TARGET AUDIENCE: Mexican Americans

18-75 years of age

SETTING: Community at large COUNTRY OF ORIGIN: Iran LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

Development Date: Published in 2006 Revision Date: No revision has taken place. Current Program Status: The program is used as a routine process for individuals with diabetes who attend the diabetes clinic.

Program Description: Control of type 1 diabetes, because of its need for frequent insulin injections, fasting blood glucose control, lifestyle modification and diet changes, can in itself be a stressful event for patients. Patients with type 1 diabetes referred from a research centre attended an eight-week training program on stress management for three months. Significant reductions in blood pressure (max.) and pulse rate were observed. The program included "homework" tasks with most classes that took the curriculum content into action. Program Goals: To identify the effect of stress management training on glycemic control in type 1 diabetes patients Program Objectives: To create a diabetes clinic in Isfahan

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning.

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Program Implementation Steps: The patients in the study group attended training classes on stress management for three months while the control group did not. Each class lasted for two hours with 10-15 participants; each participant took part in eight sessions. The classes were held using discussion method and mutual talk under supervision of an experienced psychiatrist. The participants were asked to perform homework for each session and report the results in the next session.

Table 1.0 The curriculum of classes of stress management

SESSION DURATION (H) 1st week 2 CONTENT

Outcome Evaluation Results: Results show a clinically significant beneficial effect of stress management training on glycemic control among patients with type 1 diabetes. It is recommended that this type of training be considered as an addition to the treatment program in patients with type 1 diabetes. Trained patients showed significantly improved ways of coping. HbA1c changed from 11.7 ±2.9 and 10.9 ±2.1 before training, to 8.5 ±1.7 and 10.3 ±2.1 after intervention, in trained and control groups respectively, and the changes were

TASK Some question about stress and stressor

The nature of stress. The physiological and psychological response to any demand Some degree of stress is essential for life The nature of stressors Personality factors Environmental factors The effects of stress Stress may lead directly and indirectly to illness The type of illness from stress. The type A personality Stress-related aspects of diet Diet management Lifestyle changes Improving one's skills Establishing routines Personality changes Intentionally changing the stressful aspects of one's personality Improving one's self-concept Becoming more assertive Improve one's self-concept Thought stopping Developing close friendships Type A behaviour can be reduced Muscle relaxation training Physical activity using physical activity as a stress management technique Swimming, running, dancing, skiing, and other individual sports are appropriate A regular physical activity program

2nd week 3rd week

2 2

To determine the environmental stresses To list the individual stresses

4th week

2

Report the change of their diet during next week Listing tasks in order of their importance

5th week

2

6th week

2

If they will success to reduce stress by personality change during next weeks

7th week 8th week

2 2

Try to do MRT 2-3 times every day for at least 20 min for each session Report their program for daily physical activity

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significant in the study group (p<0.001). In addition, the difference between means of HbA1c in the two groups was statistically significant at the end of the study (p<0.001). Findings of this study show that well-designed training programs concerning the techniques of stress management can affect the way patients with type 1 diabetes cope with stress. At the end of the research, patients in the study group applied negative coping methods with a significantly decreased frequency, and there was a significant difference between the case and control groups in this area. These educational courses also actuated the patients in the study group to apply positive methods of coping more frequently when compared with the control group. Program Reach: Thirty people participated in the intervention group. Description of Contextual Factors: Stress was described as a universal reaction to type 1 diabetes that, when addressed, shows positive results. Generalizability: This program is not recommended for those under the age of 16. Stress management training can play a considerable role in improving glycemic control among patients with type 1 diabetes. These training programs should be considered as an important component of comprehensive treatment programs for the type 1 patient.

Materials Available for Program Adaptation: An eight-week curriculum outline is available along with a 26-item stress management questionnaire with 17 positive and 9 negative items. Lessons Learned: Program results lead to the recommendation that stress management training, as conducted in this study, be included as an addition to the typical treatment program for patients with type 1 diabetes. Findings of this study show that welldesigned training programs concerning the techniques of stress management can affect the way patients with type 1 diabetes cope with stress. At the end of the research, patients in the study group applied negative coping methods with a significantly decreased frequency, and there was a significant difference between the case and control groups in this area. These educational courses also actuated the patients in the study group to apply positive methods of coping more frequently when compared with the control group.

PROGRAM CONTACT:

Abbas Attari

Behavioural Sciences Research Centre, Khorshid Hospital Ostandari St., PO Box 81465-993 Isfahan, Iran Phone: +98-311-222-2135 Email: [email protected]

References: Attari, A., Sartippour, M., Amini, M., & Haghighi, S. (2006). Effect of stress management training on glycemic control in patients with type 1 diabetes. Diabetes Research and Clinical Practice, 73(1), 23-28.

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Structured Intensive Diabetes Education Program (SIDEP)

BRIEF PROGRAM OVERVIEW The Structured Intensive Diabetes Education Program (SIDEP) is a group education program delivered by an interdisciplinary team (consisting of a diabetologist, certified diabetes educator [nurse or dietitian], ophthalmologist, rehabilitation therapist, pharmacist, psychologist, family physician and rehabilitation medicine doctor. The SIDEP program was delivered over four years and consisted of a 30-hour curriculum during the patients' hospital stay, outpatient follow-up (two weeks after discharge and every three months after) and an annual three-hour group education session.

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group level THEORETICAL BASIS: Cognitive-Behavioural

Therapy Approach

TARGET AUDIENCE: Adults SETTING: Healthcare setting COUNTRY OF ORIGIN: Korea

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved.

Development Date: None noted Revision Date: None noted Current Program Status: Unknown

Program Description: The curriculum was delivered over a course of five days for six hours each day while the patient was in the hospital. Curriculum content included information about diabetes, metered self-glucose monitoring, injection techniques, sick-day care, meal planning, physical activity, foot inspection and management of low blood glucose. For each of the five days, the curriculum incorporated a one-hour lunch buffet with a dietitian

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and a one-hour exercise session (the first day focused on teaching and the subsequent four days focused on practising the exercise). The dietary component of the program used the Food Pyramid guidelines and recommended restricting total fat intake to less than 30% of daily energy intake (saturated fat intakes between 8% and 10%, cholesterol intakes to less than 300 mg/day and a healthy body weight. Study authors report that "the curriculum content was structured to address the knowledge, skills and attitudes that would encourage, support and promote self-management skills leading to long-term behaviour maintenance" (Ko, S.H. et. al., 2007). Participants attended the outpatient clinic at two weeks after discharge and every three months after. During each outpatient clinic, the participant's adherence to lifestyle behaviours was assessed by an educational nurse, and a physician met with the patient and adjusted medication as needed. Three-hour group education sessions were held each year to review self-management and provide education about new topics (e.g., glucose-lowering agents, obesity and dyslipidemia). Program Goals: The primary outcome was glycemic control. The secondary outcome was the patient's adherence to lifestyle modification and maintenance of self-care behaviour. Program Implementation Steps: The curriculum was delivered over five straight days, for six hours each day, while the patient was in the hospital. After discharge from the hospital, participants visited the outpatient clinic two weeks after their discharge, and then every three months throughout the four-year study period. Three-hour group education sessions were held each year for the program participants during the study period.

Program Delivery Sources: The program was delivered by a group of professional health providers with expertise in diabetes. The team consisted of a diabetologist, certified diabetes educator (nurse or dietitian), ophthalmologist, rehabilitation therapist, pharmacist, psychologist, family physician and rehabilitation medicine doctor. Process Evaluation: The study researchers kept track of participants' participation in the outpatient clinics and the group education sessions. The education nurse tried to reach by phone or email each patient who did not participate in the clinic every three months. Outcome Evaluation Results: Mean value and changes in HbA1c levels over the four-year study period were the primary outcome measure. HbA1c levels dropped from a mean of 9.4 ±2.0 to 7.1 ±1.5 after six months of involvement in the SIDEP group. After four years in the study, HbA1c levels were 1.5% lower in the SIDEP group. This is significantly lower than the HbA1c levels in the control group. In addition to measuring glycemic control, a questionnaire was administered each year to measure participants' dietary habits, physical activity and their frequency of blood glucose self-monitoring. Participants in the SIDEP group had significantly higher scores for dietary habits, physical activity and blood glucose self-monitoring frequency than the control group. Close to 60% of the SIDEP group participants (59.4%) were physically active more than three to four times/week at the end of the fouryear study period (compared to 30.6% of the control group). This improvement was not seen to be related to healthy eating in the majority of SIDEP participants. Program Reach: During the four-year study period, 160 patients participated.

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Community Supports: Family members of the program participants were encouraged to attend the curriculum sessions. Critical Points That Need to be Replicated: The study authors suggest providing a re-education program as part of the group session to emphasize the healthy eating and physical activity messages. The annual education was suggested by the authors as a key factor that could have impacted the significant differences seen in HbA1c levels between the SIDEP and control groups at 36 and 48 months.

Generalizability: The study took place in Korea. Ko, S.H. et al (2007) report that "many more Koreans with diabetes are treated with lifestyle modifications and oral glucose-lowering agents than are treated with insulin." This difference may impact the generalizability of the program to Canada.

PROGRAM CONTACT:

Yu-Bai Ahn, MD, PhD

Associate Professor, Division of Endocrinology and Metabolism Department of Internal Medicine St. Vincent's Hospital The Catholic University of Korea 93, Ji-Dong, Paldal-Gu, Suwon 442-723, South Korea Email: [email protected]

References: Ko, S. H., Song, K. H., Kim, S. R., Lee, J. M., Kim, J. S., Shin, J. H., et al. (2007). Long-term effects of a structured intensive diabetes education program (SIDEP) in patients with type 2 diabetes mellitus ­ a 4-year follow-up study. Diabetic Medicine: A Journal of the British Diabetic Association, 24(1), 55-62.

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Sweet Talk: Text-Messaging System

BRIEF PROGRAM OVERVIEW Sweet Talk is a novel motivational support network that uses text messages through a mobile phone to deliver a theoretically guided behavioural intervention to support young people (ages eight to 18) with type 1 diabetes. The hypothesis was that automatically delivered daily scheduled text messages to reinforce diabetes self-management goals that had been set in the clinic would increase diabetes self-efficacy, promote adherence with intensive insulin therapy (IIT) and improve glycemic control without significantly increasing traditional patient contact and health professional resources.

Best Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Goal Setting Theory, Social Support Theory, and Social Cognitive Theory TARGET AUDIENCE: Youth (ages 8-18) SETTING: Telehealth (adapted) COUNTRY OF ORIGIN: Scotland LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: Patients were recruited between October 2002 and February 2003. The study was then 12 months long. Revision Date: Unknown Current Program Status: Appears to be operational

Program Description: The central component of Sweet Talk is an automated, scheduled text-messaging system designed to offer regular support to patients with diabetes to optimize their self-management and control. Goal setting at clinic visits were reinforced by daily text messages from the Sweet Talk software

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system, containing personalized goal-specific prompts and messages tailored to patients' age, sex and insulin regimen. Pediatric patients attending clinics in Tayside, Scotland, were invited to participate if they were aged between eight and 18 years, had had type 1 diabetes for more than one year and were on conventional insulin therapy (CIT; two or three daily injections of pre-mixed insulin). Sweet Talk fulfils the identified need for a socially acceptable, low-cost behavioural support intervention that can be integrated into routine clinic care. Patients agree to a `contract' listing personal diabetes self-management goals during the diabetes consultation and, based on these goals and the patient's age, sex and diabetes regimen, Sweet Talk schedules the automated delivery of a series of appropriately tailored messages, including a weekly reminder of the goal set in clinic, and a daily message providing tips, information or reminders to reinforce this goal. Sweet Talk delivers a unique form of individualized `push support' by delivering automated text messages related to patients' goals and profiles. It has the potential to overcome the major limitations to current

Table 1.0 Examples of Sweet Talk text messages

Message categories Insulin injections Blood glucose testing Healthy eating Exercise Carbohydrate counting Pump therapy Example messages Don't 4get 2 inject! Why not try another BG meter­check out with the team next time ur in clinic Fruit, celery or carrot sticks, pretzels, plain popcorn make healthy snax Boost ur daily activity ­ play ur favourite music and dnz! Do you have any `carb counting' questions for the DiaBTs doctors or dietician? Y not check out a website 4 kids who use pumps­www.kidsrpumping.com n if u see any good ideas­txt us and we'll pass them on

approaches to diabetes education and support ­ cost and time to both patient and professional, limited reach and availability of programs, and the need for ongoing support to maintain behaviour change in the long term ­ by fulfilling the RE-AIM criteria, devised for behavioural support programs for young people with type 1 diabetes. Sweet Talk demonstrated reach, with more than 70% of the eligible clinic population participating (comparing favourably with randomized control trials of either IIT or behavioural interventions), and appeared to engage a difficultto-reach group of young people. Sweet Talk also demonstrated efficacy with improved psychological measures. Program Goals: To enhance self-efficacy, facilitate uptake of intensive insulin therapy and improve glycemic control in pediatric patients with type 1 diabetes, through the use of a tailored text-messaging support system based on individual goals Program Implementation Steps:

do your injections check your dose s???? need insulin 21

injecting enough insulin?

doc tors c reate `goa l mes s a ges '

kids can ask doctors questions, send in their information and get replies wherever they are

k i d s re c e i ve a `go a l ' me s s ag e e ve r y d a y

doctors can use information to understand their patients and improve the messages for everyone

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Best and Promising Practices in Diabetes Education

Program Delivery Sources: All patients continued with conventional care delivered by a multidisciplinary team, including 3­4-monthly clinic visits and access to an emergency hotline. Members of the diabetes team received training on goal setting from the team psychologist, and all patients allocated to the Sweet Talk intervention participated in goal setting at clinic visits. They were also given a card detailing the functions of the text-messaging service, emphasizing that it was not for emergency use. Process Evaluation: The development of the Sweet Talk software package was evaluated separately. Additionally, a semi-structured interview at the end of the study was conducted to determine perceptions of the text-messaging service. Of patients receiving Sweet Talk, 81% felt that it had helped their diabetes self-management during the year of the study. At the end of the study, 90% of patients wanted to continue receiving messages. Ninety-seven per cent of patients liked the frequency of messages received (one or two daily), but 20% complained about receiving the same message repeatedly. Outcome Evaluation Results: HbA1c did not change in patients on conventional therapy without or with Sweet Talk (10.3 ±1.7 vs. 10.1 ±1.7%), but improved in patients randomized to intensive therapy and Sweet Talk (9.2 ±2.2%, 95% CI -1.9, -0.5, p<0.001). Sweet Talk was associated with an improvement in diabetes self-efficacy (conventional therapy 56.0 ±13.7, conventional therapy plus Sweet Talk 62.1 ±6.6, 95% CI +2.6, +7.5, p=0.003) and self-reported adherence (conventional therapy 70.4 ±20.0, conventional therapy plus Sweet Talk 77.2 ±16.1, 95% CI +0.4, +17.4, p=0.042). When surveyed, 82% of patients felt that Sweet Talk had improved their diabetes selfmanagement, and 90% wanted to continue receiving messages. Sweet Talk was associated with improved self-efficacy and adherence, engaging a difficult-to-reach group of young people. While Sweet Talk alone did not improve glycemic control, it may have had a role in supporting the introduction of intensive insulin therapy.

Introducing intensive insulin therapy in combination with coping-skills training programs appears particularly successful. The data did not show any increase in adverse outcomes (diabetic ketoacidosis [DKA], hypoglycemia and weight gain) in patients assigned to IIT in combination with Sweet Talk, suggesting that this is an effective method of improving the patient's adjustment to this complex regimen. However, patients randomized to IIT with Sweet Talk had more episodes of DKA than the other groups: one episode occurred in a patient on basal bolus therapy and six episodes occurred in five patients opting for pump therapy, mostly occurring within the first month of initiation and associated with viral illness. Two of these patients subsequently discontinued pump therapy. These results are in line with more recent studies in which there was no increase in adverse outcomes (DKA, hypoglycemia and weight gain) with early use of intensive therapy. There was a step-wise increase in clinic visits across the three study groups over the year of the study, but this remained within the clinic protocol of seeing patients 3­4 times monthly and may be seen as a positive result of the text-message clinic reminders sent to patients allocated to Sweet Talk before each clinic visit. There was an increase in hotline contacts in those using IIT with Sweet Talk compared with those using CIT with Sweet Talk (p=0.01), but overall calls from study patients were lower than recorded in the previous year. As predicted, both groups receiving Sweet Talk support showed improvement in diabetes selfefficacy (p=0.003), self-reported adherence (p=0.04) and diabetes social support from the diabetes team (p<0.001). Adjustment for multiple testing was not performed and, while this may cast doubt on the borderline significant results, it is unlikely to have affected the very significant results. Furthermore, the majority of patients felt that Sweet Talk had helped their diabetes self-management and wanted to continue receiving text messages after the study period ended.

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Program Reach: Sweet Talk demonstrated reach, with more than 70% of the eligible clinic population participating (comparing favourably with randomized control trials of either IIT or behavioural interventions), and appeared to engage a difficult-toreach group of young people. Ongoing Implementation Costs: Limited details available, but each participant was provided with a cell phone and a phone card. As well, as a minimal cost per text message was incurred. Critical Points That Need to be Replicated: It is critically important to use well-tested messages in the text, to set goals initially with the patient in order to tailor the messages accordingly, and to provide a cell phone and phone card in order to ensure equal access. Description of Contextual Factors: · ext messaging has rapidly become a socially T popular form of communication. It is personal, highly transportable and widely used, particularly in the adolescent population. · lycemic control in young people with type 1 G diabetes in Scotland and Europe is poor, placing many at high risk of complications associated with diabetes. Intensive insulin therapy (IIT; multiple daily injections or pump therapy [continuous subcutaneous insulin infusion]) improves glycemic control when coupled with increased health professional support (frequent clinic visits and telephone contact). This is possible in wellresourced studies, but difficult to translate into routine clinical practice. · hile conventional behavioural support W interventions have been shown to affect the uptake of IIT, they require significant resources and patient commitment, frequently do not attract young people, and are not routinely incorporated into clinical practice. There is therefore a need to find ways of supporting, educating and motivating young people with type 1 diabetes. The challenge is to develop validated, innovative support systems

that appeal to young people, encourage uptake of IIT, and are practical and feasible to deliver within existing health resources. Generalizability: Scheduled, tailored text messaging offers an innovative means of supporting adolescents with diabetes and could be adapted for other healthcare settings and chronic conditions. Sweet Talk also demonstrated efficacy with improved psychological measures. However, one of the greatest strengths of the program lies in the nature of the intervention, which could be easily adopted, implemented and maintained by any interested diabetes team: it is intuitive to use, costs for text messages to patients are low (approximately two pence/text) and the system requires little health professional time for ongoing maintenance and use. It is envisaged that the database of text messages created for this study could be personalized by each diabetes clinic, to control content at a local level and reflect individual clinic protocols, philosophies and approach. The results of this study should be of interest to healthcare professionals and policy makers, as the text-message database could be easily adapted to suit other chronic disease models and engage other age groups. Materials Available for Program Adaptation: · ttp://texting4health.org/slides/Stanford%20 h Sweet%20Talk%20Franklin%20-Numbered%20 slides.pdf · atabase of 400 Text Messages D Lessons Learned: Sweet Talk was associated with improved self-efficacy and adherence, engaging a difficult-to-reach group of young people. While Sweet Talk alone did not improve glycemic control, it may have had a role in supporting the introduction of intensive insulin therapy. Scheduled, tailored text messaging offers an innovative means of supporting

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adolescents with diabetes and could be adapted for other healthcare settings and chronic conditions. While there was no difference in glycemic control between patients on conventional insulin therapy alone and those receiving conventional therapy plus Sweet Talk support, there was an overall difference in HbA1c of approximately 1% between these groups and patients who received intensive insulin therapy and Sweet Talk. This is clinically important, as it confers a 43% reduction in risk of retinopathy progression.

PROGRAM CONTACT:

Dr. Claudia Pagliari

Senior Lecturer in Primary Care General Practice Section Division of Community Health Sciences The University of Edinburgh 20 West Richmond Street Edinburgh EH8 9DX, UK Phone: (0131) 650-9464 Fax: (0131) 650-9119 Email: [email protected]

Victoria Franklin

Maternal and Child Health Services Ninewells Hospital Dundee DD1 9SY, UK Email: [email protected]

References: Franklin, V. L., Waller, A., Pagliari, C., & Greene, S. A. (2006). A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes. Diabetic Medicine: A Journal of the British Diabetic Association, 23(12), 1332-1338. Franklin, V., Waller, A., Pagliari, C., & Greene, S. (2003). "Sweet Talk": Text messaging support for intensive insulin therapy for young people with diabetes. Diabetes Technology & Therapeutics, 5(6), 991-996.

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X-PERT Program

Best Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group level THEORETICAL BASIS: Empowerment Theory

and Discovery Learning Theory

BRIEF PROGRAM OVERVIEW The Diabetes X-PERT program is a patientcentred, group-based self-management program delivered in six weekly two-hour sessions. The program is designed to develop participant skills and build confidence to enable patients to make informed decisions about their diabetes self-care.

TARGET AUDIENCE: Adults SETTING: Community venues COUNTRY OF ORIGIN: United Kingdom LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Current Program Status: Implemented by the source and others

Program Objectives: To develop skills and build confidence to enable patients to make informed decisions about their diabetes self-care Program Description: Program sessions were held in locations within the community. On average the group consisted of 16 participants and four to eight carers for each program. The journal article states that the X-PERT program works to "develop skills and build confidence, to enable patients to make informed decisions regarding their diabetes self-care." During the published randomized control trial study, the X-PERT Program was designed and delivered in community locations by a diabetes research dietitian (T.A.D.) who took on the role of a diabetes educator. "Separate sessions were held for Urdu-speaking South Asian

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Best and Promising Practices in Diabetes Education

participants, where a translator was present." The weekly sessions that comprise the X-PERT program are: · Week 1: What is diabetes? · Week 2: Weight management · Week 3: Carbohydrate awareness · Week 4: Supermarket tour · Week 5: Possible complications of diabetes · Week 6: Questions and evaluation · Goal Setting: Lifestyle experiment Program Delivery Sources: A diabetes educator is needed to deliver the session material. Process Evaluation: Process evaluation has been gathered to track the implementation reach (56 programs have been delivered to 840 people with diabetes) but also to gather participant feedback about the program. Sample comments from patients provided by Dr. Deakin are: · This is the first time in 10 years of being a " diabetic that anybody has told me these things." · Very glad to be offered the course, much " appreciated (Thank you NHS!). Feel much encouraged in dealing with myself and more understanding with latest knowledge." · I am more at ease with diabetes from what I have " learnt and able to control it better." · I was very impressed ­ the sessions had been " delivered in a manner that had obviously gone beyond that required to make them understandable." · Don't feel as frightened as I did...feel more " confident in myself...things explained so that anybody & everybody can understand." · This course was really helpful in helping me " understand diabetes as all demonstrations were in laymen's language ­ program should have been implemented years ago." Outcome Evaluation Results: Research results show that the X-PERT program significantly improves glycemic control, reduces the requirement for medication, reduces blood pressure, reduces body weight, reduces waist circumference, improves lipid levels, increases fruit and vegetable intake, reduces

total and saturated fat intake, increases physical activity levels, increases treatment satisfaction, increases well-being through food-related quality of life and increases patient empowerment. Program Reach: About 16 people participate in each six-week cycle of the program. Community Supports: Community organizations provide meeting space for the six weekly sessions. Start-up Costs: To start up the X-PERT program, the Licence Agreement would need to be purchased from the program developers. The Licence Agreement would grant permission to meet the needs of the population by making approved adaptations to: · he X-PERT Tutors Manual (structured t curriculum); · he X-PERT (participant) Handbook; and t · he X-PERT Train the Trainers course. t The Licence Agreement would also grant permission for a working party to deliver the adapted X-PERT Train the Trainer Course (TTC) to healthcare professionals and then for those professionals to deliver the X-PERT Program to the local population with diagnosed diabetes. The only costs in addition to the Licence Agreement would be for the initial training and the purchase of the X-PERT visual aids. Ongoing Implementation Costs: Ongoing costs for the program would be for the staffing complement to deliver the program. Critical Points That Need to be Replicated: The X-PERT Program is an empowering structured education program based on vision and discovery learning. It's a complex intervention and Dr. Deakin indicates that it is therefore difficult to tease out the active ingredients. Based on the comments from program participants, it appears that the success of the program is based on the non-didactic nature, emphasis on self-management and use of visual aids. Vision is the common language and it doesn't matter what literacy skills patients have ­ they are able to benefit and increase their knowledge, skills and confidence in diabetes self-management. Dr. Deakin notes that she

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has also undertaken a Cochrane Systematic Review of group-based education programs and there appears to be a real advantage in offering group-based education. Description of Contextual Factors: The X-PERT program has been implemented extensively throughout the UK. New Zealand and the Republic of Ireland are both interested in purchasing a Licence Agreement for X-PERT Program implementation. The Republic of Ireland has undertaken a pilot and found it to be equally beneficial for their population. Generalizability: The program has been successfully implemented in a number of communities throughout the UK and Ireland. In addition to the main X-PERT program, the materials have been adapted for a Junior X-PERT version targeting youth under 11 years and those 11-16 years. Pilot research has been conducted for the revised implementation. The program has also been adapted for use with adults with type 1 diabetes. An interactive CD-ROM and DVD has been created to provide structured patient education to those who cannot or do not wish to attend group sessions. Once the Licence Agreement for the program is purchased, the program developer will work with the purchaser to assist in revisions to adapt the program materials for the specific needs of various populations. Materials Available for Program Adaptation: The X-PERT Program curriculum is available for purchase. The curriculum contains the following: · he aim of the structured patient education T program and learning objectives; · list of the materials and visual aids required and A the learning styles used; · full script of the six-week program; A

· patient registration form and register template; A · etailed lesson plans; D · valuation program to ensure that outcomes are E audited; · uality assurance program to assess the Q environment, structure, process content, use of materials, program delivery, and evaluation and outcome data; and · atient handouts and a CD-ROM to allow for the P printing of handouts as required. Lessons Learned: According to Dr. Deakin, the lesson learned from the X-PERT program is that when empowering, patient-centred group-based education for people with diabetes replaces traditional clinical care based on the medical model, the transformation in people's ability to self-manage their diabetes is outstanding. This leads to improved patient clinical, lifestyle and psychosocial outcomes, and increased treatment satisfaction for both people with diabetes and healthcare professionals. This is likely to reduce demand on healthcare resources in the future.

PROGRAM CONTACT:

Dr. Trudi Deakin

X-PERT Team Culpan House, Burnley General Hospital Casterton Ave., Burnley, Lancashire BB10 2PQ, UK Phone: +44 (0) 79-21-50-7003 Email: [email protected]

References: Deakin, T. A., Cade, J. E., Williams, R., & Greenwood, D. C. (2006). Glycemic control: The Diabetes X-PERT program makes a difference. Diabetic Medicine, 23 944-954. X-PERT program website: www.xpert-diabetes.org.uk Correspondence with Dr. Trudi Deakin.

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Promising Practices

4

Best and Promising Practices in Diabetes Education

27 `Promising' Practices

BITES (Brief Intervention in Type 1 Diabetes ­ Education for Self-Efficacy) Control On Campus Computer-Based Remote Diabetes Education for School Personnel Diabetes Prevention Program (DPP): Adapted Lifestyle Change Participant Notebook Diabetes Self-Management Education Program for Medicaid Recipients Education and Telephone Case Management for Children with Type 1 Diabetes Empowerment Group Education Program Ethnic-Specific Diabetes Education Program (Turkish Immigrants in Rotterdam) Functional Insulin Treatment (FIT) Group Visits & Computer-Assisted Consultations for Adolescents with Type 1 Diabetes HyPOS Interactive Diabetes Educational Simulators Internet-Based Physical Activity Know Your Health Program at the Worksite MicoHealth Internet Diabetes Management Program Picture Flashcard Health Education Practical Education/Behaviour Modification Program Project Dulce REACH Detroit Family Intervention Self-Management Patient Education Simple Meal Plan Emphasizing Healthy Food Choices Simple Start Soul Food Light Symptom-Focused Management Talking Circles Telecare Therapeutic Education Urban Church-Based Program

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Best and Promising Practices in Diabetes Education

BITES

Promising Practice

(Brief Intervention in Type 1 Diabetes ­ Education for Self-Efficacy)

BRIEF PROGRAM OVERVIEW A brief psycho-educational intervention for patients with type 1 diabetes developed by a multidisciplinary team (composed of a consultant diabetologist, a diabetes specialist nurse, a specialist diabetes dietitian and a clinical health psychologist) and delivered in 20 hours over 2.5 days. The randomized control trial (RCT) for this program was implemented between 2003 and 2007. The results from the RCT have not yet been reported.

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Group level THEORETICAL BASIS: Social Cognitive/

Learning Theory

TARGET AUDIENCE: Adults (ages 19-64) SETTING: Healthcare settings COUNTRY OF ORIGIN: United Kingdom LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved.

Development Date: 2003 Current Program Status: Being implemented by source

Program Description: The program was developed as a psychoeducational program that is acceptable to people with diabetes, feasible and cost-effective in practice. BITES is delivered as a 2.5-day course over a six-week period to allow participants time to practise and reflect between sessions. A diabetes specialist

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nurse and a specialist diabetes dietitian facilitated sessions. The BITES program is based on adult learning principles and uses cognitive behavioural techniques. During the 2.5-day course, participants explore coping, control and strategies for prioritizing. Imaginative insulin use, carbohydrate estimation, glycemic index as well as pre- and post-meal blood glucose monitoring are promoted. Participants are encouraged to self-adjust their insulin doses according to their carbohydrate intake and level of activity. Changing negative to positive thoughts and maintaining changes are discussed. Participants are introduced to a fictitious individual with diabetes whom they mentor throughout the course and discuss helping them around the change cycle. Home reflection and sharing, rather than simple provision of information, are components of the course. Program Goals: The goal of BITES is to motivate and enable patients to strive for blood glucose values as normal as possible. All those agreeing to participate are asked to convert to a basal bolus insulin regimen based on two injections of isophane insulin (morning and evening) and meal-related rapid-acting insulin. Insulin dose adjustment skills are based on the Dusseldorf and DAFNE (Dose Adjustment For Normal Eating) principles of treatment to target glucose and matching insulin to carbohydrate portions. The nutritional emphasis is on normal eating and unrestricted patient choice. Program Implementation Steps: Participants are recruited from those attending a single specialist diabetes service in a hospital setting. Eligibility criteria are as follows: · Type 1 diabetes for longer than 12 months; · ultiple injection therapy for at least two months; M and · Minimum age of 18 and ability to read and write. Participants attend two-full day and one-half day sessions of instruction with homework sessions between. Program Delivery Sources: The program is delivered by a diabetes specialist nurse and a specialist diabetes dietitian.

Outcome Evaluation Results: No outcome measures have been reported as yet; however, HbA1c and severe hypoglycemia were going to be measured as primary outcomes at three, six and 12 months. The following secondary measures are measured at three, six and 12 months: blood pressure, weight, height, total cholesterol, triglycerides and a psychological questionnaire. The psychological questionnaire consists of the following scales: Short Form 36, Illness Perception Questionnaire (IPQ), Diabetes Knowledge Test (DKT), Diabetes Empowerment Scale (DES), Diabetes Treatment Satisfaction Questionnaire (DTS-Q), Hypoglycemia, Fear Scale (HFS), Diabetes Health Profile (DHP) and the Diabetes Self-Managing Adherence Questionnaire (DSMA-Q). Program Reach: The program study recruited 120 participants: 60 for the intervention group and 60 for the control group. Participants were recruited from the Diabetes Centre of York Health Services NHS Trust. Materials Available for Program Adaptation: There is a workbook that all participants work through during the class sessions and on their own at home. The workbook encourages participants to keep track of their daily comments and complete practical exercises.

PROGRAM CONTACT:

Dr. Jonathan Thow

York Hospital Wigginton Road York YO318HE, UK Email: [email protected]

References: George, J. T., Valdovinos, A. P., Thow, J. C., Russell, I., Dromgoole, P., Lomax, S., et al (2007). Brief intervention in type 1 diabetes ­ education for self-efficacy (BITES): Protocol for a randomised control trial to assess biophysical and psychological effectiveness. BMC Endocrine Disorders, 7, 6.

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Control On Campus

BRIEF PROGRAM OVERVIEW Control on Campus is a program for college students with type 1 diabetes. It includes a comprehensive 92-page guide that provides up-to-date information on diabetes management tailored to the needs and perspectives of a college student. Participants in the program attend three sessions during which the topics in Control on Campus were presented. Participants were also invited to attend one individual session with the group facilitator to discuss issues of personal interest.

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Group with one

individual session and an individual resource

THEORETICAL BASIS: Expanded Health Belief, and Model and Social Learning Theory TARGET AUDIENCE: College students with

type 1 diabetes

SETTING: Post-secondary school COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing.

Revision Date: Unknown Current Program Status: Being used as part of a larger program

Program Description: Control on Campus is the name of the intervention program presented to students as well as the name of the guide. The 92-page guide contains information on nutrition, blood glucose, insulin and pattern management, exercise, stress, alcohol, ketones, sick-day management and long-term goal setting. These topics were chosen as representative of the most pertinent issues for college students. In accordance with social learning theory, each chapter includes behavioural objectives, age-appropriate activities, hands-on activities, creative homework assignments to reinforce knowledge and interesting graphics to keep the reader's attention.

3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Students attend three group sessions for two hours each over three consecutive weeks. Refreshments are provided at each session, as are incentives for goals that were met and homework or activities that were completed. Participants are also asked to attend one individual session with the group facilitator (a registered dietitian/certified diabetes instructor) to discuss issues of personal interest. Students are told this session was mandatory. The intervention allowed time for students to discuss emotional issues concerning diabetes and to brainstorm ways to deal with these issues. Behavioural norms are discussed relative to perceived peer pressure to drink alcohol, what others think of testing their blood glucose and what they believed others thought about their nutrition or exercise habits. An effort was made to strengthen students' intentions by having them set goals, giving verbal reminders and helping them access ways to incorporate their accomplishments or behaviours into their lifestyles. Behavioural capabilities are enhanced by the inclusion of hands-on activities. Reinforcements are provided, such as verbal praise for participating in discussions and completing activities, small weekly prizes for completing homework or attaining goals, and vicarious reinforcement by observing the rewards of good diabetes management reaped by the role model. Program Goals: To increase knowledge about management of type 1 diabetes in college students (the study noted that there is minimal research on college students with type 1 diabetes) Program Objectives: To provide a supportive environment in which students could meet and interact with others who had diabetes, which resulted in an increase in knowledge and awareness

Program Implementation Steps: Students were recruited from those who had visited the university health centre for diabetes care or those who were known to have diabetes received a letter of invitation to attend. Sessions were offered in three consecutive weeks, two hours per session, and the individual session was described to participants as being mandatory. Program Delivery Sources: The group facilitator was a registered dietitian/certified diabetes educator. Process Evaluation: The resource was a 92-page guide (described above). The content of the guide had been evaluated by 12 diabetes experts including certified diabetes educators, registered dietitians, registered nurses, diabetes researchers and students with diabetes. Outcome Evaluation Results: Reporting of HbA1c values and diabetes knowledge were measured and both showed improvement as a result of the intervention. Participants also reported feeling more support on campus after the intervention, appeared to have overcome their fears associated with testing their blood glucose, reported an increased frequency of blood glucose testing and were more likely to test when they felt their blood glucose level was low. Program Reach: The test group was comprised of 21 students. The group size would be limited only by the number of instructors available to ensure appropriate student: instructor ratios. Community Supports: The intervention was supported within the university community through the provision of space and instructors.

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Ongoing Implementation Costs: Unknown, although participants were given prizes and incentives, and were paid $50 upon completion of the whole program in the research study Critical Points That Need to be Replicated: None stated

Description of Contextual Factors: Limited to application with college age students Generalizability: Generalizable to college age students with type 1 diabetes

PROGRAM CONTACT:

Patricia A. Kendall, PhD

Food Science and Human Nutrition Department Colorado State University Fort Collins, Colorado 80523 Email: [email protected] Phone: (970) 491-1945 Fax: (970) 491-7252

References: Wdowik, M. J., Kendall, P. A., Harris, M. A., & Keim, K. S. (2000). Development and evaluation of an intervention program: "Control on Campus". The Diabetes Educator, 26(1), 95-104.

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Computer-Based Remote Diabetes Education for School Personnel

BRIEF PROGRAM OVERVIEW A web-based diabetes information system to educate school personnel about diabetes information and the necessary responses to diabetes related incidents. The material combined audiovisual material with information from the American Diabetes Association publication Caring for Children with Diabetes. Development Date: Not stated Revision Date: Unknown Current Program Status: Unknown

Program Description: This is a web-based diabetes information system to educate school personnel about diabetes information and the necessary responses to diabetes-related incidents. The web-based material was organized and linked so participants could easily move from one part to another, and included audio and video clips to illustrate the text material. The video material included a demonstration of an injection and discussion of appropriate foods. Audio clips included children talking about food, exercise and feelings that may accompany low blood sugar. The text of the web-based material was based on information from the American Diabetes Association publication Caring for Children with Diabetes, along with audiovisual material.

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Individual level TARGET AUDIENCE: Elementary school

personnel

SETTING: Online (web-based system) COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

3. Implementation of diabetes education is client-centred and facilitates learning. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Program Objectives: To increase educator knowledge about diabetes care Program Implementation Steps: Participants worked through the computer-based diabetes instruction program in one session (with no subject taking longer than 45 minutes). Process Evaluation: The computer-based group satisfaction scores were significantly higher than the paper-based group.

Outcome Evaluation Results: The computer-based group participants had significantly higher scores on the knowledge test than the paper-based group. Program Reach: Since the training was provided online, there is the potential to reach a great number of educators. In addition, the program is more cost effective in the long run using an online system rather than paper documentation.

PROGRAM CONTACT:

Doreen Radjenovic, PhD, ARNP, CDE

Department of Nursing College of Health, University of North Florida Jacksonville, Florida Email: [email protected]

References: Radjenovic, D., & Wallace, F L. (2001). Computer-based . remote diabetes education for school personnel. Diabetes Technology & Therapeutics, 3(4), 601-607.

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Diabetes Prevention Program (DPP): Adapted Lifestyle Change Participant Notebook

BRIEF PROGRAM OVERVIEW A case management approach for high-risk, minority patients with type 2 diabetes, which uses a seven-module participant handbook and provider script (revised from the Diabetes Prevention Program Lifestyle Change Participant Notebook). The program combines face-to-face contact and telephone support with a nurse case manager. Current Program Status: Implemented by the source

Program Description: The edited version of the Diabetes Prevention Program consists of a seven-module (51-page) participant handbook and appropriately modified provider script. The edited version focuses on the following core areas: provision of basic knowledge regarding diabetes and its complications, individual goal setting for diet and exercise, basic education regarding the calorie and fat content of various foods, guidance in choosing exercises appropriate to age and physical condition, techniques for self-monitoring, specific strategies for shopping

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level TARGET AUDIENCE: Minority patients SETTING: Healthcare setting (primary

care clinic)

COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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and eating out, relapse prevention, and individual coaching to monitor progress, address obstacles and increase motivation. The program also includes culturally specific food pyramids. Program Goals: The goals of the intervention were to achieve increased exercise levels, a weight loss of 7% and appropriate modification of the patient's diet. Program Implementation Steps: At the patients' first visit with the nurse case manager, patients learn more about diabetes and the associated risk of complications, and also complete a physical activity and dietary questionnaire. Participants have monthly individual meetings at the clinic with the nurse case manager, and receive telephone calls every two weeks between meetings for support with diet and exercise, glucose monitoring, medication compliance, and discussions about their progress. The seven modules cover: · eek 1: Welcome to the program, getting started W being active, move those muscles · eek 2: Being active: a way of life W · eek 3: Getting started: losing weight W · eek 4: Be a fat detective: three ways to eat less fat W · eek 5: Healthy eating: take charge of what's W around you · eek 6: Four keys to healthy eating out W · eek 7: The slippery slope of lifestyle change W During the seventh visit, patients complete the physical activity and dietary questionnaires again. Program Delivery Sources: The program is implemented by a nurse case manager. Process Evaluation: Participants reacted positively to the intervention and identified the food pyramid and social support from the nurse as beneficial.

Outcome Evaluation Results: The program was shown to result in significant weight loss and positive dietary change within the target population of low-income minority patients. Improvements in HbA1c were also seen in program participants. Description of Contextual Factors: The program was implemented among low-income minority patients in urban America. Materials Available for Program Adaptation: The following information can be downloaded from the University at Buffalo website (fammed.buffalo.edu/ intensiveNurseCM.html): · odified Diabetes Prevention Program Participant M Notebook · odified Diabetes Prevention Program Instructor M Scripts · odified Diabetes Prevention Program Diet Help M · tandard Fat Counter S · tandard Ethnic Food Pyramid S

PROGRAM CONTACT:

J. Steven Cramer, MD, MSc

Department of Family Medicine School of Medicine and Biomedical Sciences State University of New York Buffalo 2447 Sheridan Drive Tonawanda, New York 14150 Email: [email protected]

References: Cramer, J. S., Sibley, R. F Bartlett, D. P., Kahn, L. S., & ., Loffredo, L. (2007). An adaptation of the diabetes prevention program for use with high-risk, minority patients with type 2 diabetes. The Diabetes Educator, 33(3), 503-508. University at Buffalo website: fammed.buffalo.edu/ intensiveNurseCM.html

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Diabetes SelfManagement Education Program for Medicaid Recipients

BRIEF PROGRAM OVERVIEW To develop, implement and evaluate a diabetes self-management education (DSME) program for Medicaid recipients. The continuous quality improvement process was used to identify the problem, collect and analyze data.

Promising Practice

PROGRAM FOCUS: General PROGRAM LEVEL: Individual level THEORETICAL BASIS: Diabetes-related costs

were predicted using the Gilmer model

TARGET AUDIENCE: Medicaid recipients

(adults) who have had diabetes for at least one year and have been enrolled in Medicaid for 11 continuous months

SETTING: Community at large for the

specific target group

COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

Development Date: 2001 Revision Date: The program has not been revised. Current Program Status: The program was intended to be a demonstration project to show State Medicaid that money could be saved. The state legislators liked the concept and gave it a high score; however, it was not funded due to the shortfall in the State budget. Hence the program was not continued further until funding was available. The program contact indicated that the program has been expanded to serve underserved communities through the help of Eli Lilly in Phase II. The results of Phase II have been published in the CDC journal Preventing Chronic Disease, and it is successfully ongoing. The program has also been expanded to Phase III, which is a pilot project similar to Phase I, disseminating DSME to underserved communities via telemedicine (results waiting to be published).

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1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Program Description: This program was created due to the increasing Medicaid budgets for diabetes care and a growing financial crisis. A number of partners worked together to test strategies that had the potential to reduce costs. (The Arkansas Diabetes Prevention and Control Program along with Eli Lilly and Company formed a coalition of public and private partners, including the Arkansas Department of Human Services, the Arkansas Foundation for Medical Care, Health Information Design, the Arkansas Chapter of the American Diabetes Association and the Arkansas Minority Health Commission.) The coalition wanted to implement a diabetes selfmanagement education (DSME) program and evaluate its effectiveness in improving diabetes care and decreasing overall healthcare costs among Medicaid recipients with diabetes. The DSME program consists of a one-hour initial assessment of individual needs followed by 12 hours of group education on nutrition and self-management. Details of the program are in the Program Implementation section. Program Goals: To develop and implement a Diabetes Self-Management Education (DSME) program, and to evaluate its effectiveness to improve diabetes care and decrease overall healthcare costs among Medicaid recipients with diabetes Program Objectives: Evaluation objectives were to: 1. assess changes in key clinical measures; 2. assess changes in healthcare use and expenditures among participants who received DSME compared to those who did not receive DSME; and 3. use predictive models to project the impact of DSME on three-year diabetes-related cost and 10-year disease event rates among the program participants. Program Implementation Steps: An initial assessment was conducted and then participants received 12 hours of diabetes education, including three hours of medical nutritional education. Education was provided over three visits: an initial visit shortly after the educational needs assessment, a second visit scheduled at six months and a final visit after a period of one year from the first visit. Diabetes education was provided

through group sessions, and the curriculum addressed 10 content areas: diabetes disease processes; nutrition; physical activity; medications; monitoring/using results; acute complications; chronic complications; goal setting and problem solving; psychosocial adjustment; and pre-conception care, pregnancy, and gestational diabetes. Program Delivery Sources: DSME is provided by a registered nurse and a registered dietitian who followed the American Diabetes Association Educators core curriculum for diabetes education. Process Evaluation: During each visit, educators administer a questionnaire to document the participant's demographic characteristics, self-care skills, preventative care practices and healthcare use. Outcome Evaluation Results: Key clinical measures including HbA1c, systolic and diastolic blood pressures, weight and body mass index, are collected at the initial and final visits (baseline and 12 months). Questionnaires and clinical data are entered into DiaTrac, an electronic data management system managed by Control Diabetes Services (CDS). Over one year, mean HbA1c declined by 0.45% among the DSME participants who completed the full program. Changes in HbA1c and systolic blood pressure were statistically significant. No changes were observed in mean weight or body mass index. An estimated saving in diabetesrelated cost over thee years was $415 per program completer. Over 10 years, completers are estimated to experience 12% fewer coronary heart disease events and 15% fewer micro vascular disease events using the United Kingdom Prospective Diabetes Study Risk Models. Program Reach: Efforts to retain the 212 participants during the one-year period include follow-up telephone contacts and postcard reminders. As a result, 184 (87%) attended the midyear visit and 157 (74%) attended the year-end visit. Community Supports: Funding for the program was provided by Eli Lilly and Company (unrestricted grant). Support was also received from the Arkansas

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Department of Human Services and from Control Diabetes Services. Partner Engagement: In response to increasing costs among Medicaid recipients with diabetes, the Arkansas Medicaid director called for proposals to test strategies with the potential to reduce costs. The Arkansas Diabetes Prevention and Control Program, along with Eli Lilly and Company, formed a coalition of public and private partners, including the Arkansas Department of Human Services, the Arkansas Foundation for Medical Care, Health Information Design, the Arkansas Chapter of the American Diabetes Association and the Arkansas Minority Health Commission. Start-up Costs: The initial set-up cost in 2002 was approximately $10,000, not including staff salaries. Program organizers anticipated reimbursement from Medicaid starting six months into the program (once it is recognized by the ADA), which would have covered ongoing costs from that time on. Ongoing Implementation Costs: The ongoing costs will be offset by reimbursement from clients, either from private insurance or from public insurers such as Medicare or Medicaid. Critical Points That Need to be Replicated: Based on these findings, the authors indicate that the state Medicaid director and other key stakeholders are exploring ways to sustain the DSME program for Medicaid recipients. They believe State Medicaid program administrators should seriously consider providing reimbursement for diabetes education in an attempt to lower increasing Medicaid costs. Description of Contextual Factors: The Medicaid recipients who agreed to participate in the program engaged in more care-seeking behaviour than nonparticipants, and may not be representative of the overall population of Medicaid recipients with diabetes. This program was directed to a specific population ­ Medicaid recipients ­ so it may not be applicable to the general population. Generalizability: This study clearly demonstrated decreased healthcare use among Medicaid recipients,

indicating that the cost of the program and the program delivery will likely be offset by short- and long-term savings in healthcare use. Limitations included the small number of DSME participants and short duration of follow-up for a condition with relatively slow progression. The Medicaid recipients who agreed to participate in the program engaged in more care-seeking behaviour than non-participants, and may not be representative of the overall population of Medicaid recipients with diabetes. Improved diabetes management on lipid values may have been overestimated as the lipid values were not assessed but estimated from a comparable population. Lessons Learned: A diabetes education program such as DSME can be successful in decreasing participants' healthcare use. Development and implementation of the program requires initial funding support (in this case, received from Eli Lilly), motivated staff to lead the project, and buy-in from hospitals/clinics to agree to implement this program. The biggest challenge was sustaining the program. In this case, they couldn't (at least for Medicaid recipients in the state) because of funding issues.

PROGRAM CONTACT:

Appathurai Balamurugan

Arkansas Department of Health and Human Services PO Box 1437, Slot H-32 Little Rock, Arkansas 72203-1437 Phone: (501) 661-2000 Email: [email protected]

References: Balamurugan, A., Ohsfeldt, R., Hughes, T., & Phillips, M. (2006). Diabetes self-management education program for Medicaid recipients: A continuous quality improvement process. The Diabetes Educator, 32(6), 893-900.

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Education and Telephone Case Management for Children with Type 1 Diabetes

BRIEF PROGRAM OVERVIEW The study compared three nursing interventions and their impact on glycemic control among children with type 1 diabetes. The combination of standard care, education groups and telephone case management was shown to improve adherence behaviours.

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Individual and group

levels

TARGET AUDIENCE: Children and their

families

SETTING: Healthcare setting and home COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: Study published in 2005 Current Program Status: Implemented by source

Program Description: The program provides a combination of standard care consisting of quarterly visits with the nurse practitioner and endocrinologist, a one-time education session instructing families about basic diabetes management skills, and a series of telephone follow-up case management (typically five to 15 minutes in length) providing telephone support between the clinic visits (weekly for the first three months or until the first clinic visit and then bimonthly calls for the following three months). Program Implementation Steps: For the telephone call, the study coordinator connected with the designated parent of children less

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than 13 years, and with both the teen and parent for those over 13 years. A standard telephone protocol is used for telephone case management calls, which reviews blood sugar, safety issues related to low and high blood sugar, problem-solving skills, diet and meal planning, and changing insulin dose. Parenting and behaviour management skills are also discussed with parents as needed. Program Delivery Sources: A number of health professionals are involved in the full complement of activities (an endocrinologist, a diabetes nurse or nurse practitioner, a dietitian and a social worker or family therapist). Outcome Evaluation Results: HbA1c levels decreased modestly (but not significantly) by 0.5 points, from 10.0% to 9.5%. There were significant improvements relating to positive adherence (ADH checklist) on the six items targeting the use of problem-solving skills

and the five items that target adherence to basic safety behaviours. There were also significant improvements noted on the TEAM checklist. (The TEAM checklist is a clinician checklist used to evaluate a child's ability to assume age-appropriate behaviours related to diabetes management, and the parents' ability to provide age-appropriate supervision of their child's diabetes management.) Critical Points That Need to be Replicated: The authors suggest that the trans-theoretical model of behaviour change may offer interesting insights into the complexity of behaviour change pursued in the study. Instead of expecting to move patients from a pre-contemplative stage through to action and maintenance, the authors suggest moving patients along the continuum of behaviour change as a realistic approach.

PROGRAM CONTACT:

Carol J. Howe, RN, MScN

Division of Endocrinology and Diabetes The Children's Hospital of Philadelphia 34th Street and Civic Center Blvd Philadelphia, Pennsylvania 19104 Phone: (215) 590-1000

References: Howe, C. J., Jawad, A. F Tuttle, A., Moser, J., Preis, C., ., Buzby, M., & Murphy, K. M. (2005). Education and telephone case management for children with type 1 diabetes: A randomized controlled trial. Journal of Pediatric Nursing, 20(2): 83-95.

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Empowerment Group Education Program

BRIEF PROGRAM OVERVIEW In this program, 101 patients were randomly assigned either to empowerment group education (intervention group) or to routine diabetes care (control group). Out of these, 42 patients in the intervention group and 46 in the control group completed the one-year follow-up. Before the intervention and at the one-year follow-up, the patients answered a 27-item questionnaire, and weight, body mass index (BMI) and HbA1c were measured. The questionnaire comprised three domains: confidence in diabetes knowledge, self-efficacy and satisfaction with daily life.

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group level TARGET AUDIENCE: Adults (ages 19-74) SETTING: Healthcare settings (primary

health care)

COUNTRY OF ORIGIN: Sweden LANGUAGE: Articles in English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved.

Development Date: Article published in 2006 Revision Date: Unknown Current Program Status: Unknown

Program Description: Volunteer physicians and diabetes specialist nurses facilitated a series of group sessions for patients with type 2 diabetes over a one-year period that focused on an empowerment model. Patients are considered to be empowered ``when they have knowledge, skills, attitudes and self-awareness necessary to influence their own behaviour and that of others in order to improve the quality of their lives.''

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Program Goals: To utilize an empowerment group education approach with type 2 diabetes patients in order to increase their confidence in diabetes knowledge, self-efficacy, satisfaction with daily life, BMI and glycemic control compared with the impact of routine diabetes care on the same factors at a oneyear follow-up Program Objectives: At the individual level, empowerment can be viewed as a process whereby people gain mastery and take control over their own lives. It is a process ``whereby groups or individuals are enabled to change a situation, given skills, resources, opportunities and authority to do so.'' The patients are considered to be empowered ``when they have knowledge, skills, attitudes and self-awareness necessary to influence their own behaviour and that of others in order to improve the quality of their lives.'' Program Implementation Steps: · ach group consisted of at least five and at most E eight patients for the group education. · he minimum number of empowerment group T education sessions was four and the maximum was five (mean value: 4.7), including one follow-up session given within seven months. The sessions lasted 2.5 hours at each centre. · he first education session started with a T presentation and discussion of patients' expectations. The patients were encouraged to identify problems related to their diabetes. The facilitator supported this process by actively involving all the patients and by inviting each of them to talk about their own specific problems. This helped the patients feel comfortable to ask questions. · t each session, different themes dealing with selfA care and diabetes were approached. The themes were: general issues concerning the condition, treatment, prevention of complications, blood glucose monitoring, diet, physical activity and daily foot care. The introduction to the different themes started with an open question, e.g., ``What do you know about...?'' ``What do you think about...?'' The facilitators' purpose was to work in partnership with the patients. Further,

the facilitators' tasks were to meet the patients' needs and to respond to their concerns regarding diabetes. The patients were encouraged to share their experiences with each other. · ach session ended by encouraging patients to E reflect upon the behavioural changes they needed to undertake in their own self-care within the specific area. After the first session, each session started with a discussion of patients' experiences and reflections since the last session. Support for and barriers to making behavioural changes were discussed. The aim of the education was to enable patients to reach their short- and long-term goals. · ontact time between the facilitators and the C patients was approximately 12.5 hours during the year. Program Delivery Sources: The seven physicians and 12 diabetes specialist nurses who volunteered to become facilitators in empowerment group education were prepared for their task in the following way: Preparation began by asking the volunteer physicians and diabetes specialist nurses to simulate being diabetes patients for two consecutive days and to follow a diabetes regimen, in order to increase their understanding of living with diabetes. After this simulation, they participated in a two-day empowerment workshop arranged by the Diabetes Education and Research Centre (LUCD), Karolinska Hospital, Sweden. The program presented in the workshop was based on work conducted at the Michigan Diabetes Research and Training Centre (MDRTC) in the US. The workshop was designed to provide prospective facilitators with the theoretical framework of empowerment, motivation and learning principles. The practical part of the workshop included training as facilitators in individual counseling using videotaping. Participants practiced problem solving, identifying feasible changes, supports for and barriers to making these changes, setting shortand long-term goals and making a plan to reach these goals. It was pointed out that empowerment education involves teamwork between equals, and stresses patients' ability and responsibility to make their own choices and decisions. The role of the facilitator was to coach and support patients in discovering

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and developing their own resources for change and control. After the workshop, the facilitators practiced using the empowerment approach in real situations. They acted as facilitators using the new approach in a pilot group with at least four diabetes patients in four group sessions. A researcher working on the study participated as an observer in at least one of the pilot group sessions at each of the seven primary care centres. The researcher videotaped three of these group sessions. The observations showed that the facilitators should improve their listening skills, their way of posing questions, problem solving, goal setting, and supporting patients in their behavioural changes and medical treatment. Based on these observations, feedback was given in meetings with the facilitators at each primary care centre. "To further emphasize the importance of the required skills and to apply their new skills, two halfday follow-up meetings were conducted within a twomonth interval before the intervention started. At the first half-day follow-up meeting, videotapes from three of the training group sessions were presented, followed by a discussion of the empowerment philosophy and how to properly apply the approach. At the second meeting, the content of the empowerment group education was discussed. Moreover, the facilitators received a written document stressing the essence of empowerment and a set of guidelines to use during the study period. Process Evaluation: The overall aim was to gain insight into and understand how physicians and nurses view the implementation of empowerment group education (EGE) in diabetes. Prior to the study, the physicians and nurses attended a twoday empowerment workshop. Further, they had implemented the empowerment approach in two groups of patients with type 2 diabetes. Three to nine months later, they (five physicians and 11 nurses from six family practices) participated in focus group interviews to evaluate the implementation of the EGE. The interviews were audio taped, transcribed and analyzed using the constant comparative method. The main result showed a conflict in roles. The physicians and nurses knew their role in the traditional approach

but not with respect to the empowerment approach, which they needed to grow into. At the same time, as they started a new way of working, their role had changed from being an expert to being a facilitator. They felt secure as experts; as facilitators, they needed support in their educational process. To implement EGE, they required support both from the family practice and from a supervisor in direct connection with the EGE. Patients participating in the study were interviewed after completing the program. Data from these interviews confirmed that the facilitators had acted in accordance with the empowerment approach. Outcome Evaluation Results: At one-year follow-up, the level of confidence in diabetes knowledge was significantly higher in the intervention group than in the control group (p<0.05). No significant differences were found in self-efficacy, satisfaction with daily life, BMI or HbA1c between the intervention and control groups. The empowerment group education did improve patients' confidence in diabetes knowledge and helped them maintain glycemic control despite the progressive nature of the disease. Program Reach: There were 42 patients in the intervention group and 46 in the control group, none of whom had ever participated in a group diabetes education program. Out of the 42 patients in the intervention group, 29 (69%) participated in every group session and 13 (31%) missed one of the sessions. Critical Points That Need to be Replicated: · hose facilitating the empowerment process need T to be well trained, experienced and comfortable in this role. · articipants in this type of program need to be P ready to accept empowerment. · ith diabetes being a lifelong condition, one-year W follow-up is not nearly long enough. Description of Contextual Factors: The past 50 years of education for people with diabetes have seen different views on patients' involvement in

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diabetes care. At the beginning of the 1980s, diabetes education focused chiefly on medical facts about the condition. Care providers of diabetes education acted as experts and had full responsibility for patients' care. However, this was not found to be an effective way of helping individuals with diabetes manages their self-care. In the 1990s, more emphasis was placed on the learning process in diabetes education, specifically on learning how to learn. This resulted in a shift in the role of care providers. The new role was to act as facilitator, thus coaching and supporting the patients.

Materials Available for Program Adaptation: Survey tools such as the 27-item study specific questionnaire are available. Lessons Learned: · ata from focus group interviews with the D participating facilitators showed that they felt they needed more time to practice the approach before they could say they had mastered it. · one-year follow-up is too short. Several years of A follow-up are needed. · he results of this study are not enough to T recommend a change in the approach to diabetes care.

PROGRAM CONTACT:

Eva Thors Adolfsson

Email: [email protected] Diabetes Nursing Research Group Email: [email protected] Email: [email protected] Website: http://www.medsci.uu.se/diabnurse/ eng/research.htm

References: Adolfsson, E. T., Smide, B., Gregeby, E., Fernström, L., & Wikblad, K. (2004). Implementing empowerment group education in diabetes. Education Counselling, 53(3), 319324. Adolfsson, E. T., Walker-Engstrom, M. L., Smide, B., & Wikblad, K. (2007). Patient education in type 2 diabetes: A randomized controlled 1-year follow-up study. Diabetes Research and Clinical Practice, 76(3), 341-350.

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Ethnic-Specific Diabetes Education Program (Turkish

BRIEF PROGRAM OVERVIEW

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual (some group) THEORETICAL BASIS: Health Education

Immigrants in Rotterdam)

(Belief) Model

TARGET AUDIENCE: Ethnic populations SETTING: Primary care COUNTRY OF ORIGIN: The Netherlands LANGUAGE: English and Spanish

First-generation Turkish immigrants to the Netherlands (Rotterdam) with type 2 diabetes (who met study inclusion criteria), from one of seven family practices, were segmented into an intervention or control group and participated in seven individual and three group diabetes education sessions over a nine-month period. Three principles (peer education, tailoring and the Health Education Model) drove the project, which resulted in a significant reduction of HbA1c levels in women with an HbA1c level >7% at baseline. No other significant changes resulted.

DES PROCESS STANDARDS MET

2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved.

Development Date: Published in 2005 Revision Date: Unknown Current Program Status: Unknown

Program Description: Participants attended seven individual sessions and three group sessions over a nine-month period. During the individual sessions, the educators were assigned to investigate the patient's attitude regarding important diabetes-related behaviour (e.g., diet, exercise and medical

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drug compliance) according to the model, in order to prioritize the therapeutic goals. During the individual sessions, patients were invited to arrange an appointment with a dietitian to discuss dietary rules and with the patient's partner to discuss social support. In each session, the therapeutic goals were reevaluated and adjusted based on the patient's personal experiences and problems hampering attainment of the goals. The first group session was mainly to discuss experiences, and the patients received general information about diabetes. During the second group session, the treatments of diabetes and self-care behaviours were discussed. Main topics in the third group session were prevention of diabetes-related complications and care of the feet (this intervention and also the results of behavioural outcome measures are described in detail elsewhere). Program Goals: To improve glycemic control and cardiovascular risk factors in Turkish patients with type 2 diabetes through an ethnically tailored diabetes education program Program Objectives: Although not stated as objectives, the specific measures used to determine success were plasma glucose, total cholesterol, HDL cholesterol and triglyceride levels, blood pressure and body mass index (BMI). The education component focused on the attainment of self-care skills and behavioural change strategies. Program Implementation Steps: To be included in the program, the following inclusion criteria were evident: An inventory of all type 2 diabetes patients who were being treated for their diabetes by the GP exclusively was received from computer-based patient records and, if available, disease registers. Patients were identified as type 2 diabetics if they were specifically marked in the patient records as having type 2 diabetes, or if they were using oral anti-diabetic medication or insulin. Patients were considered Turkish on the basis of their surname, as assigned by a Turkish assistant. All Turkish patients with type 2

diabetes who were younger than 75 years and being treated for diabetes by their GP were eligible. Patients were excluded if they were too ill to follow the intervention program (according to their GP), or were planning to go abroad for more than six months during the study period. A Turkish-speaking assistant, who was not aware of which group the patients were allocated, approached the patients to invite them to participate. The planned nine-month program included seven individual educational sessions and three group sessions. The individual sessions consisted of four sessions with the educator and patient together, and three `triangle' sessions with the GP, educator and patient present, to discuss the three-month assessment of the patient's glycemic control and cardiovascular risk factors. Patients were encouraged to have one of the individual sessions with the dietitian and one with the partner present, although this was not obligatory. Afterwards, the educator and patient discussed the triangle sessions. During the intervention, group sessions were organized separately for men and women. The educators were allowed to adjust the number of the education sessions according to the needs of the individual patient. Individual and group sessions took place in the general practice. Program Delivery Sources: Two health educators of Turkish origin, who spoke both Turkish and Dutch fluently, were regarded as representatives of the target population (peers). They were trained educators and had experience in education in a primary care setting. They received additional training about diabetes management. The health educators were supervised by a Dutch psychologist. Outcome Evaluation Results: Compared with the control group, mean HbA1c in the intervention group decreased by 0.3% (95% CI -0.8 to 0.2). A significant decrease in HbA1c was observed in women with HbA1c >7% at baseline (-0.9%; 95% CI -1.73

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to -0.09) but not in the other subgroups studied. Serum lipid concentrations, blood pressure and BMI remained unchanged in the intervention group. It was concluded that ethnic-specific diabetes education by Turkish female educators has no obvious beneficial effect on glycemic control or cardiovascular risk profile. More focus on specific patient selection and gender equality between educators/patients may prove worthwhile. Plasma glucose, total cholesterol, HDL cholesterol and triglycerides were measured every three months with the 950 AT ORTHO diagnostics. HbA1c was determined by the Variant-1 Biorad. LDL cholesterol was calculated using the Friedewald formula. All blood samples were taken in the fasting state using venous blood samples. The research assistants were instructed to measure systolic and diastolic blood pressure (Korotkoff V) on the left arm of the seated patient twice with a two-minute interval using a mercurial blood pressure monitor, and to calculate the mean of the two measurements. Weight and height were measured to calculate the BMI. The main effect parameter was a change in HbA1c between baseline measurement and one-year followup. Power calculations were based on the assumption that the study should be able to detect a clinically relevant improvement in HbA1c of 0.6% in the intervention group, based on an intention-to-treat analysis. With a 5% significance level and a power of 90%, 50 patients were required in each group. To adjust for potential confounding variables, multivariate linear regression analyses were carried out with change from baseline as the outcome variable. The HbA1c at baseline, gender, age, years since diagnosis, mode of treatment, and the indicators of diabetes care were considered as potential confounders. Because essential data were missing for some patients due to loss to follow-up, researchers first carried out an intention-totreat analysis, followed by an intention-to-treat analysis on the dataset obtained by multiple imputations for missing data. (Multiple imputations for non-response

replace each missing value by two or more plausible values.) There were no significant differences in the change in HbA1c and fasting plasma between patients in the intervention and control groups. Compared with the control group, mean HbA1c in the intervention group decreased by 0.3% (95% CI -0.8 to 0.2) and fasting plasma glucose decreased by 0.9 mmol/L (95% CI -2.2 to 0.3). Adjustment for baseline value (HbA1c), patient features (age, gender, years since diagnosis and use of medication) or practice features did not substantially alter these findings. Program Reach: In the one program cycle described in the research study, 104 participants were recruited and, of those, 38 attended the sessions and participated in the follow-up. Community Supports: A nutritionist assisted in one of the three group sessions. Critical Points That Need to be Replicated: In the program the gender of the educator matched with that of the participants; for some ethnic populations, this may be an important consideration. Peer educators found, "Turkish male patients may feel less inclined to take advice regarding behavioural changes from women" Uitewaal, P (2005). Description of Contextual Factors: The characteristics of this specific group of Turkish diabetes patients, such as low education and a traditional way of living, were not only taken into account but were instrumental in tailoring the program. This was particularly important because type 2 diabetes has a high prevalence among certain ethnic groups in Western society. Together with aging of the population, it is expected that the prevalence of type 2 diabetes will further increase in these groups in the coming decade. This education program was tailored to the traditions and specific habits of Turkish patients with diabetes. In addition,

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the program was carried out by Turkish female health educators. Generalizability: This ethnically tailored program was based on the generalized elements of known Dutch diabetes education programs (e.g., what is diabetes, general advice on diet, physical exercise and self-care). Lessons Learned: Diabetes education is an essential part of diabetes care. Problems with communication and cultural differences may hinder delivery of optimal diabetes care to ethnic groups. Attention to gender equality should be considered in future studies, possibly by making the contents of the message more gender specific.

PROGRAM CONTACT:

P.J.M. Uitewaal

Department EGG, Municipal Health Service The Hague, Netherlands Phone: +31-0-70-353-71-94 Email: [email protected]

References: Uitewaal, P. J., Voorham, A. J., Bruijnzeels, M. A., Berghout, A., Bernsen, R. M., Trienekens, P. H., et al. (2005). No clear effect of diabetes education on glycemic control for Turkish type 2 diabetes patients: A controlled experiment in general practice. The Netherlands Journal of Medicine, 63(11), 428-434.

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Functional Insulin Treatment (FIT)

BRIEF PROGRAM OVERVIEW FIT is a structured outpatient education program on perceived control over diabetes and health-related beliefs. FIT is thought to influence the perception of self-efficacy in diabetes, in contrast to conventional treatment based on scheduled rigid food intake and insulin delivery. FIT allows flexible eating providing independent control of glycemia.

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Group level THEORETICAL BASIS: No theory; based on solution focus and goal model of neurolinguistic programming TARGET AUDIENCE: Adults (ages 17+) SETTING: Healthcare settings COUNTRY OF ORIGIN: Austria LANGUAGE: Austrian and English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: 1983 Revision Date: Continuously being improved documented with each new edition of the patient manual (1987, 1988, 1989, 1993, 1995, 1997) Current Program Status: Being implemented by source and elsewhere

Program Description: The FIT program is focused on everyday criteria for choices of insulin dosages and thus on the patient's ability to execute newly gained flexible treatment in everyday life while preventing acute and late complications. FIT involves 35 hours of structured comprehensive outpatient group training. FIT requires selective use of insulin, either for fasting, eating or correcting high blood glucose values. Systematic correction of high blood glucose with short-acting insulin was taught as an essential element to keep blood glucose levels closer to normal range. Moreover, patients were taught secondary adaptation of insulin-

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dose algorithms by learning everyday criteria for evaluating and adapting basal, prandial and corrective insulin dosage. Practical exercises or insulin games based on the aforementioned theoretical contents were performed. The FIT program focuses on the patient's ability to execute and self-adjust treatment to everyday life and prevents acute and late complications. It also includes individual counselling as follow-up and from that, recommendations were made as needed for further group teaching models, which included a weekend FIT module update, hypertension training, hyperlipidemia training, a pregnancy and birth preparation course, a module on hypoglycemia unawareness and a slimming course (Slim and FIT). Program Goals: To improve care and competence with modular outpatient group education Program Implementation Steps: FIT involves 35 hours of structured instruction with individualized followup. FIT was preceded by group instruction in basic diabetes education including pathology of diabetes, nutrition, individual therapy goals, dosage selfadjustment, late and acute complications of diabetes, and prevention and treatment. Program Delivery Sources: The team involved inpatient care, rehabilitation and in conducting the study was approved for conformity with international quality management and assurance standards.

Process Evaluation: The Diabetes Treatment Satisfaction Questionnaire was used, which includes questions on treatment satisfaction as well as measures of perceived frequency of high and low blood glucose. Outcome Evaluation Results: FIT included the feeling of independence from situational control while selfmanaging diabetes. After an average of three years after FIT structured education, the patients were increasingly freed from the feeling of being under the control of the physician and treatment-related restrictions. Together with higher perceived selfefficacy, high treatment satisfaction and significant improvement of glycemic control, this contributed to a feeling of empowerment. HbA1c values showed glycemic improvement 38 months after FIT training. Program Reach: Unlimited depending on availability of educators Start-up Costs: Personnel and rooms for 40 hours of structured patient education Ongoing Implementation Costs: The education of an experience FIT educator takes about one year. Critical Points That Need to be Replicated: The enthusiasm of the certified diabetes educators or physicians, expertise, and the patient manual, which is available in English

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Materials Available for Program Adaptation: All program materials are available in English. Lessons Learned: The outpatient procedure is much cheaper and easier to carry out. The modular system is necessary to achieve optimal hypertension and hyperlipidemia control.

PROGRAM CONTACT:

Kinga Howorka, MD, MPH

Professor of Internal Medicine MBA Applied Biomedicine Medical University Vienna Center of Biomedical Engineering and Physics Waehringer Guertel 18, AKH 4L A-1090 Vienna, Austria Phone: +43-1-40400-3981 Fax: +43-1-40400-3988 Email: [email protected] Website: www.diabetesfit.org

References: Howorka, K. (2004). Benchmarking benefits generated by a certification process in health care environment: Seven years' experience with ISO 9001 ­ management system in diabetes bioengineering research and education. Master thesis for Professional Master of Business Administration in Applied Biomedicine, Donau University Krems (Supervisor: Dipl.-Ing. Thomas Brand, Academic advisor: Univ.-Prof. Dr.med. Dr. phys. Dieter Falkenhagen.) Howorka, K., Pumprla, J., Gabriel, M., Feiks, A., Schlusche, C., Nowotny, C., Schober, E., Waldhoer, T., & Langer, M. (2001). Normalization of pregnancy outcome in pregestational diabetes through functional insulin treatment and modular outpatient education adapted for pregnancy. Diabetic Medicine, 18, 965-972. Howorka, K., Pumprla, J., Schlusche, C., Wagner-Nosiska, D., Schabmann, A., & Bradley, C. Dealing with ceiling baseline treatment satisfaction level in patients with diabetes under flexible, functional insulin treatment: Assessment of improvements in treatment satisfaction with a new insulin analogue. Research Group on Functional Rehabilitation and Group Education, Institute of Biomedical Engineering and Physics Howorka, K., Pumprla, J., Wagner-Nosiska, D., Grillmayr, H., Schlusche, C., & Schabmann, A. (2000). Empowering diabetes out-patients with structured education: Short-term and long-term effects of functional insulin treatment on perceived control over diabetes. Journal of Psychosomatic Research, 48(1), 37-44.

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Group Visits & Computer-Assisted Consultations for Adolescents with Type 1 Diabetes

BRIEF PROGRAM OVERVIEW A structured educational and counselling program administered over a course of 15 months for adolescents 11­17 years old, and their parents. The program focused on three main aspects: (i) patient experience and peer support, (ii) parental experience and family functioning, and (iii) knowledge of diabetes. The effects of the program were measured by generic and diabetes-specific questionnaires that focused on functional health and well-being, and diabetes-related quality of life. Metabolic control was assessed by measuring HbA1c.

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Individual level

(computer aspect), group level

TARGET AUDIENCE: Youth (ages 11-17) and

families

SETTING: Healthcare setting (hospital) COUNTRY OF ORIGIN: Norway LANGUAGE: Article published in English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: The study was conducted between March 2000 and June 2001. Revision Date: Unknown Current Program Status: Unknown

Program Description: The program focused mainly on the adolescent's active participation, discussing the impact of the

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Topics of the group visit sessions and computer-assisted consultations in the structured programme for adolescents with type 1 diabetes

SESSION First session TIME 0 months 3 months TYPE OF CONSULTATION Group visit Individual consultation (computer-assisted follow-up) FOCUS Diabetes self-management and coping strategies; at home, at school, and in spare-time activities Identifying knowledge, skills and motivational aspects in relation to diabetes self-management. Introduction to internet, useful links to educational and promotional web sites, and to blood glucose profile tools Physiological and psychological development during puberty, and impact of these issues on treatment regimen, treatment targets and self-management Parental bonding, parental involvement, family support and peer support Personal goals and priorities and discussions in relation to individual blood glucose profiles. Experiences with web-based communication and educational sites Self-efficacy and diabetes self-management Personal goals and priorities, coping strategies, self-efficacy and responsibility. Assessment of barriers to self-management, and introduction to personal quality improvement strategies and tools

4 months

Meeting for the parents

Second session

6 months 9 months

Group visit Individual consultation (computer-assisted follow-up) Group visit Individual consultation (computer-assisted follow-up)

Third session

12 months 15 months

OBJECTIVES Group visits 1. Meeting Ways of coping with the disease (coping strategies)

DETAILS OF CONTENT Topic 1: Me and my diabetes ­ what is a good life like for me Topic 2: Freedom is the opportunity to have several alternatives

THE EDUCATIONAL PROCESS AND METHODOLOGY

The education and counselling process was aimed at stimulating reflection and the adolescents' and parents' active participation in the groups Through supportive counselling from health professionals, and dialogue with others, the adolescents and parents might get hold of alternative ways of handling disease-related issues, and facilitate new roles in family relations 2. Meeting Topic 3: Me and the others ­ who The structure of each session: Family and peers ­ is influencing my choices -Welcome. Group rules and roles within the group Technical and emotional Topic 4: Freedom is about setting my -Introduction. Presenting the objectives and content of each support own goals, and drawing my own lines session -Topic of the day - didactic activity 3. Meeting Topic 5: Who am I ­ and who -Self-monitoring, pizza, and blood sample test (HbA1c) Self-efficacy, self-perceptions would I actually like to be? -Reflecting and discussing real-life situations and experiences of control, competence and Topic 6: Freedom is to be in charge -Summing up mastery of my own life Computer-assisted consultations The education and counselling process was aimed at providing adolescents with information, re-education and support in relation to individual needs.

Topic 1: Identifying knowledge, skills and motivational aspects in relation to diabetes self-management Topic 2: Introduction to internet, useful links to educational and communicational web sites, and to blood glucose-profile tools

Every second consultation was scheduled as individual computer-assisted consultation and every second as group visit Focus was on problem-based and emotional and experienceoriented dialogs and tasks The internet was used as a technical and didactic tool

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condition on daily life, family and peer support, problem-solving skills and sharing of personal experience. The parents were given an opportunity to meet with parents in the same situation, to discuss parental involvement and control in daily diabetes management, supportive communication patterns in the family, physiological and psychological changes during puberty, and areas of conflict in parentadolescent relationships. Younger (11­13 years) and older (14­17 years) adolescent groups discussed the same issues, but specific examples of coping demands and daily life situations varied according to the group's age. The three 45-minute individual consultations scheduled during the intervention period allowed the diabetes nurse specialist to review the adolescent's knowledge, skills and motivation for diabetes care and self-management. Assessment of motivation and readiness to learn was included as an essential part of the teaching-learning process to facilitate communication with the adolescents about issues of concern to their lives, self-management activities and treatment regimen. The computer-assisted consultations provided an opportunity for the diabetes nurse specialist to present the adolescents with useful links to educational and communicational websites and blood glucose profile tools. Every three months, each member of the control group attended a 30-minute traditional outpatient appointment with the diabetes team in the outpatient clinic, involving a physician and a diabetes nurse specialist. In this meeting, adolescents (with or without accompanying parents) discussed insulin delivery, treatment targets and other issues concerning treatment and care. Program Goals: To improve the quality of life and glycemic control in adolescents with type 1 diabetes through a series of group visits and computer-assisted consultations Program Objectives: Group visits were combined with individual computer-assisted consultations to take advantage of the effects of group dynamics on the learning process. The group visits also gave an opportunity to build up a social network, facilitating

peer support that has been reported to be beneficial in previous research. In contrast, the patient-provider relationship was strengthened by the three individual consultations. More specifically, the group visits were geared to the development of coping strategies and providing technical and emotional support in family and peers, while building the adolescent's self-efficacy, and self-perceptions of control, competence and mastery. The education and counselling process was aimed at providing adolescents with information, reeducation and support in relation to individual needs. Program Implementation Steps: At intervals of three months, separate group visits for the adolescents and their parents and individual computer-assisted consultations for the adolescents were scheduled. Patients and parents participated in separate groups. The three 45-minute individual consultations allowed the diabetes nurse specialist (DNS) to review the adolescent's knowledge, skills and motivation for diabetes care and self-management. Assessment of motivation and readiness to learn was included as an essential part of the teaching-learning process to facilitate communication with the adolescents about issues of concern to their lives, self-management activities and treatment regimen. The computerassisted consultations provided an opportunity for the DNS to present useful links to educational and communication websites and blood glucose profile tools to the adolescents. The tables on the following page from Graue et al. (2005) describe this further. Program Delivery Sources: Each of the three threehour group visits (four to nine participants per group) followed a structured program involving a physician, DNS, clinical psychologist, dietitian and social worker in various parts of the program. An older, experienced adolescent with diabetes (about three or four years older than the participants) participated as a co-leader of each group. Process Evaluation: The adolescents' and parents' satisfaction with the intervention program was evaluated by a 15-item questionnaire designed for this study. The response options were measured on a visual analogue scale marked with six or 10 numerical

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scale points. At each extreme were written statements representing the opposite extreme responses, ranging from `to a small extent' to `to a large extent' (on a 1-6 scale), or `lower levels of satisfaction' to `higher levels of satisfaction' (on a 1-10 scale). Assessment of patient satisfaction was anonymous, implying that satisfaction could not be related to the other outcomes in the study. The adolescents and parents participating in the group visits reported a high degree of satisfaction with the program. On a scale from 1 (lower levels of satisfaction) to 10 (higher levels of satisfaction), the mean scores were 7.1 (SD 1.9) for the adolescents and 8.7 (SD 1.1) for the parents. They found peer support especially useful. The opportunity to meet with others in the same situation and to share their own thoughts was perceived positively by both adolescents and parents. On a scale from 1 (to a small extent) to 6 (to a large extent), the mean scores were 4.1 (SD 1.4) for adolescents and 5.3 (SD 0.7) for parents. Outcome Evaluation Results: Two-sample t-tests showed a significant difference between the intervention and control groups for diabetes-related impact (not significant after Bonferroni correction). There was a significant group-by-age interaction for diabetes-related impact, implying that the difference in mean post-test scores between the groups was agedependent. There was also a significant group-by-age interaction for diabetes-related worry. Two-sample t-tests were also performed for the generic measurement, and revealed a significant difference between the intervention and control groups in family activities (not significant after Bonferroni correction). There were significant group-by-age interactions for general behaviour and mental health. The family cohesion score decreased with age, and there was a significant group by gender interaction.

Two-sample t-tests showed no significant difference between intervention and control groups in HbA1c. Regression analyses showed no relationships between HbA1c and any of the explanatory variables except for baseline scores. In older adolescents (aged 14-17 years), HbA1c decreased significantly (p=0.019, mean 0.63, 95% CI 0.1, 1.1) in the intervention group, but not in the control group. In younger adolescents (aged 11-13 years), HbA1c increased significantly (p=0.046, mean 0.56, 95% CI 0.0, 1.1 ) in the control group, but not in the intervention group. Program Reach: In this research study, 45 participants completed the intervention and evaluation component over a 15-month period, from a total possible population in the outpatient clinic of 116. Thirty-eight of these adolescents were in the control group. Critical Points That Need to be Replicated: A multi-dimensional approach seems necessary that includes both an individual and group aspect. Family involvement enhances the impact for both the adolescent and the family. Tailored education methods and age-appropriate content and, more importantly, the maturity level of the adolescent are key. Generalizability: The program was well received by patients and parents, and might therefore be suitable for implementation in the clinical routine. The effectiveness of the program in influencing the adolescents' perceptions of burden of the condition on daily life and psychosocial health domains was established. Lessons Learned: There is growing agreement among healthcare providers that it is important to focus on health-related quality of life issues, with assessment of the subjective burden of disease and symptoms, and not merely on the presence of objectively identifiable problems. Research has demonstrated that psychosocial factors play an integral role in the management of diabetes in both children and adults. Although this intervention was adapted to fit the age range of the participants, the program was mainly effective for HRQOL (health-related quality of life) in the older adolescents (above approximately 14

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years of age), with a noticeable opposite effect in the younger ones. This difference suggests that a certain level of cognitive and emotional maturity is needed to take advantage of an interactive educational and counselling program that includes discussion of treatment, and ways to handle daily life situations and worries related to the condition. Excessively pushing adolescents with diabetes toward autonomy in selfcare and having them assume diabetes responsibilities too soon might increase the risk of their developing problems with treatment adherence and poorer glycemic control. Adolescents lost during follow-up in both the intervention and control groups had significantly lower scores on self-reported self-esteem and general health in the generic measurement, a worse perception of diabetes-related impact, and higher HbA1c. These adolescents appeared to have less self-confidence and perceived a greater impact of the condition than did the other participants. This suggests that there might be problems in reaching adolescents with these particular problems. Parental involvement in diabetes management might create conflict in the parent-child relationship. Family conflict and lack of cohesiveness are linked to poor diabetes self-management. Adolescents and their parents need to change their roles during the transition from childhood to adulthood, and learn alternative ways of addressing disease-related issues and sharing diabetes responsibility. Targeted intervention might be important in establishing family involvement and interaction centred on diabetes tasks before negative behaviours become established. However, interventions requiring family involvement might also

increase the level of conflict in some instances. In this study, there was a significant gender by intervention effect in family cohesion, suggesting the need for special consideration of the effects in families with girls. To interfere as little as possible with the adolescents' school work and social activities, researchers chose to include relatively infrequent hospital visits (every third month) compared with the frequency of visits used in other intervention studies. The frequency of visits needs to be considered seriously if an intervention program is intended to last beyond a brief study period. Even with the moderate intensity of this program, a certain number of adolescents chose not to participate or were lost during follow-up, giving the intervention a completion rate of 39 of 55 patients, or 71%.

PROGRAM CONTACT:

Marit Graue

Department of Paediatrics Haukeland University Hospital N-5021 Bergen, Norway Email: [email protected]

References: Graue, M., Wentzel-Larsen, T., Hanestad, B. R., & Sovik, O. (2005). Evaluation of a program of group visits and computer-assisted consultations in the treatment of adolescents with type 1 diabetes. Diabetic Medicine: A Journal of the British Diabetic Association, 22(11), 15221529.

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HyPOS

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Group level THEORETICAL BASIS: Bio-psycho-

behavioural

BRIEF PROGRAM OVERVIEW HyPOS is an education program specifically designed for patients with type 1 diabetes who have problems with low blood glucose (hypoglycemia). HyPOS focuses on avoiding low blood glucose values, informing patients about the causes of hypoglycemia unawareness, modifying health beliefs that contribute to frequent low blood glucose readings, improving the detection and recognition of hypoglycemic warning symptoms, and emphasizing the need for immediate and sufficient treatment of low blood glucose values.

TARGET AUDIENCE: Adults (ages 18-70) SETTING: Healthcare settings COUNTRY OF ORIGIN: Germany LANGUAGE: German

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: 2006 Revision Date: Not applicable Current Program Status: Being offered by source

Program Description: HyPOS consists of five lessons. Each lesson lasts for approximately 90 minutes and takes place weekly. Lesson topics are as follows: Lesson 1: Understanding hypoglycemic problems Lesson 2: Hypoglycemia awareness Lesson 3: Treatment of hypoglycemia Lesson 4: Insulin therapy and hypoglycemia Lesson 5: Living with hypoglycemia

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HyPOS focuses not only on the detection of symptoms of low blood glucose, but also on patients' views regarding the causes and consequences of hypoglycemia as well as individual glycemic targets, in order to modify dysfunctional treatment goals or health beliefs. In addition, the importance of immediate treatment of hypoglycemia is stressed and possible reasons for delayed hypoglycemic treatment are analyzed. With the aid of insulin templates, patients are encouraged to analyze their individual insulin therapy with special regard to low blood glucose events. Patients also discuss coping with activities that may pose a risk of hypoglycemia: for example, physical exercise, alcohol consumption and eating unusual foods. Social aspects of hypoglycemia such as regulations concerning driving licences, occupational restrictions and dangers of hypoglycemia are other relevant topics. Participants are allowed to bring a family member or an affiliated person to the fifth lesson. Program Goals: To help patients avoid low blood glucose by optimization of insulin therapy. Program Objectives: To provide education on avoiding low blood glucose values, causes of hypoglycemia, modifying health beliefs that contribute to low blood glucose readings, improve the detection and recognition of hypoglycemic warning symptoms, and emphasize the need for immediate and sufficient treatment of low blood glucose values Program Implementation Steps: Patients are recruited from outpatient medical practices run by a diabetologist and a diabetes educator or diabetes nurse. The program is offered in a study centre over five consecutive weeks. Program Delivery Sources: Program deliverers are diabetologists or diabetes educators who have completed an intensive 18-lesson training course to instruct them on how to deliver the program. Process Evaluation: To ensure treatment integrity, onsite visits were made to one-third of the study centres during the intervention phase. Study centres were also contacted by phone during the intervention phase and a telephone hotline was set up in case problems arose.

Outcome Evaluation Results: Hypoglycemic awareness significantly improved. The threshold for detection of low blood glucose and the treatment of low blood glucose increased significantly. The number of undetected hypoglycemic episodes and the rate of mild hypoglycemia dropped significantly. The numbers of severe events per patient per year and very severe hypoglycemic episodes were lower, but these differences were not significant. Program Reach: The study included 164 patients, 80 of whom received the treatment. Critical Points That Need to be Replicated: In Germany, diabetes education for type 1 patients is part of standard treatment; therefore, much of the basic information was omitted from HyPOS, resulting in a shorter duration. HyPOS focuses exclusively on low blood glucose values, as glucose self-monitoring is part of the standard treatment of patients with type 1 diabetes. Description of Contextual Factors: Unknown Generalizability: HyPOS demonstrates additional benefits in terms of improving impaired hypoglycemic awareness, reducing mild hypoglycemia, detecting low blood glucose and treating low blood glucose. HyPOS is an effective tool that can complement the treatment of patients who have impaired hypoglycemia awareness.

PROGRAM CONTACT:

N. Hermanns

Forschungsinstitut der Diabetes Akademie Megentheim Postfach 1144 FIDAM D-97961 Germany Email: [email protected]

References: Hermanns, N., Kulzer, B., Kubiak, T., Krichbaum, M., & Haak, T. (2007). The effect of an education program (HyPOS) to treat hypoglycaemia problems in patients with type 1 diabetes. Diabetes/Metabolism Research Reviews, 23(7), 528-538.

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Interactive Diabetes Educational Simulators

BRIEF PROGRAM OVERVIEW AIDA is a software program used to simulate glucose-insulin interaction and insulin dosage & dietary adjustment in diabetes mellitus. The purpose of AIDA is to create a learning environment for communicating and training intuitive thinking. In this respect, AIDA appears most appropriate for recreating clinical situations (rather than trying to predict best outcome). AIDA incorporates a compartmental model that describes glucose-insulin interaction in patients who lack endogenous insulin secretion. It contains a single extracellular glucose compartment into which glucose enters via both absorption from the intestine and glucose production from the liver. The AIDA v4 model also contains separate compartments for plasma and `active' insulin, the latter being responsible for glycemic control while insulin is removed from the former by liver degradation. AIDA is not meant to replace advice from an experienced diabetes educator or physician. Rather, the software endeavours to empower patients with greater knowledge and experience.

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Health Belief Model TARGET AUDIENCE: Adults (ages 19-64) COUNTRY OF ORIGIN: United Kingdom LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Development Date: The original AIDA system was developed in 1991-92. Revision Date: The program was revisited in 1995, at which time a dedicated data entry screen was added and the whole system was streamlined and upgraded. This allowed for a robust and suitable widespread distribution via the Internet. In 1996, a beta-release version was formally tested by approximately 60 patients and medical users. As a result of their feedback, further refinements were made to the system, particularly related to technical issues to help ensure that the software would run on as wide a variety of PC hardware as possible. In June 1996, AIDA was officially launched on the Internet. Current Program Status: Being implemented by source

Program Description: AIDA is a software program (available without charge from www.2aida.org) that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, self-learning and research purposes. It is intended as an educational support tool. The interactive and dynamic nature of the simulations adds a real-life dimension to the web-based educational material, and the software is complemented by a substantial amount of supporting information on the website. The AIDA v4 software comes with 40 educational case scenarios, each of which represents a `snapshot' of the metabolic status of a typical patient with respect to type 1 diabetes. It is easy for users to add or create further case scenarios, as required. Program Goals: The goal is to have patients with diabetes, and their caregivers (both healthcare and personal), understand and manage their glucose levels through case studies. There are two distinct aspects to the evaluation of the program, each with its own goal.

One involves a prospective randomized control trial (RCT) in Italy undertaken to evaluate the educational utility of AIDA in small group teaching sessions. The second component is an ongoing process evaluation that involves a questionnaire-based survey to those who download the program. The goals of it are: (i) to establish what people have thought about the AIDA software, (ii) to assess the utility of the program, and (iii) to ascertain how much people have actually used it. Program Objectives: For the questionnaire-based survey, three ancillary study objectives were: 1. to identify any problems that users may have experienced with the software since its launch, with the intention being for any critical problems to be addressed in future upgrades; 2. to identify features that users felt were important to have incorporated in later releases of the program; and 3. to establish the feasibility of undertaking such a post-release diabetes software survey primarily via electronic mail. For the RCT methodology for evaluating the teaching utility of interactive educational diabetes simulators, main outcome measures were to help subjects: 1. improve knowledge of how to tailor the insulin dose to the specific needs of the subject; 2. improve morning and postprandial selfmonitoring of blood glucose levels; 3. improve forward thinking (ability to answer "what-if" type questions); 4. improve well-being and self-confidence; 5. reduce the number of hypoglycemic episodes; 6. improve HbA1c levels; and 7. achieve a feeling of "empowerment." Secondary outcome measures were to: 1. increase social behaviour and interpersonal co-operation about diabetes; 2. help to increase confidence with a computer; 3. increase physiological knowledge; and 4. establish sample sizes required for a possible future larger-scale, multi-centre study.

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Program Implementation Steps: In a pilot prospective RCT, six lessons (once per week) were held for both the intervention and control groups, consisting of a conventional lesson with slides and transparencies. At the end of the six lessons, followed by a "washout" period of four weeks, the intervention group entered a partial cross-over phase with the simulator during a further six-week block of lessons. LESSoN 1: Learn how to match insulin and food intake. LESSoN 2: Learn about regulation of blood glucose levels overnight. LESSoN 3: Learn about the role of the renal threshold of glucose and role of exercise. LESSoN 4: Learn about the avoidance and treatment of hypoglycemia. LESSoN 5: Learn about behaviour in case of shift work or travel abroad. LESSoN 6: Learn how to manage blood glucose in unforeseen circumstances. Program Delivery Sources: The program can be downloaded by anyone and used as a self-management tool or as a teaching tool by professionals. Process Evaluation: There is an ongoing collection of subjective feedback that provides anecdotal evidence of the utility of the software. In 2002, 400 responses were received from more than 54 countries, with nearly half coming from the US, UK and Canada. Of these, 208 were received from patients with diabetes, 50 from doctors, and 49 from relatives of patients, with fewer responses coming from students, diabetes educators, nurses, pharmacists and other end users. The semi-automated analysis adopted for this study reaffirmed the feasibilty of using the Internet to obtain free-text comments, at no real cost from a substantial number of users. Based on ongoing process evaluations, the caveats/warnings have been strengthened even further at the AIDA website, with reinforcement of the limitations of the

software now appearing with a dedicated warning on the pop-up window that is displayed when anyone tries to download the program. AIDA continues to be developed and evolves in response to user feedback. Indeed, one of the important original aims of this survey was to discover what users wanted from future versions of the software. The major demand on the part of users seemed to be for extra/novel functions. These would let users input a wider range of data, including an expansion of dietary information and insulin regimens, as well as incorporate the effects of other variables on blood glucose levels. Many of the "wish list" features suggested by respondents concerned the inclusion of new functions within the program. Broadly speaking, these fell into three main categories. The main request was a desire to have greater variation when inputting insulin injections into the simulator. Suggestions included the facility to inject larger doses and a wider variety of regimens. Users also wanted the inclusion of various parameters that might affect blood glucose levels. These were factors such as exercise, stress and variations in food intake, besides carbohydrate levels. Furthermore, a smaller proportion wanted the program to allow the input of oral hypoglycemic agents, thereby more closely reflecting typical diabetes management in people with type 2 diabetes. Outcome Evaluation Results: An RCT methodology for evaluating the teaching utility of interactive educational diabetes simulators has been developed (2000). A prospective, clinical RCT ran at the Ospedale di Marino in Italy in 2002. Results have not been found for this research. Based on user surveys, perhaps the most striking point to emerge from this feedback survey is the positive motivational effect of AIDA in getting users to think more about how they can improve their glycemic control, and adapt the knowledge gained in simulations to their own lives in consultation with their healthcare team. Program Reach: In the 10 years since its web launch, well over 700,000 visits have been logged at the AIDA websites, and more than 200,000 copies of the program have been downloaded free of charge. Further copies have been made available in the past on disk by

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the system developers and from the British Diabetes Association (now called Diabetes UK) in London, UK. Description of Contextual Factors: Time restrictions on educator/physician-patient consultations, or lack of access to such educational sessions, may mean that some people with diabetes are not equipped with sufficient knowledge and skills to manage their own condition. The working hypothesis underlying the use of a program such as AIDA v4 is that a diabetes simulator might be able to go some way toward helping to fill this knowledge gap. This is substantiated to some extent by the very high percentage of respondents who reported finding the program both educationally valuable (96.5%) and a useful adjunct to managing their condition (97%). Generalizability: Possibly AIDA could be well utilized to include group-based teaching sessions led by a diabetologist or diabetes educator. This approach, which has been trialled by Tatti and Lehmann in one centre in Italy, might facilitate learning for those who are unfamilar with using computers, and might introduce the program to more individuals who may be able to benefit from it. Other possible applications of the software include use by undergraduate and nursing students to aid further understanding of the difference between insulin and dietary regimens and resulting blood glucose levels. Because the program is based on Internet and computer use, there is some hesitation about using it by people who are less computer-savvy, and there are definite access issues with respect to computer hardware. However, as younger generations are exposed to computer tecnology from a very young age, this fear and limited access will undoubtedly wane over time. Materials Available for Program Adaptation: The AIDA program can be downloaded at no cost from www.aida2.org. Lessons Learned: 1. Educators are encouraged to invest time in learning about the AIDA program in order to identify how they can best work with the program to teach their patients in their particular setting. The most important items to improve

the outcome of the lessons seem to be the preparation of the teacher, consideration of how to import preliminary information to help patients understand the pathophysiology of diabetes, the optimum selection of topics to be covered, the arrangement of the lessons, how to involve each of the participants, and how to deal with questions. Other important topics include how to spot and deal with some of the difficulties that may be encountered by participatns who apparently seem uninterested, obtaining feedback from the lessons and practical ideas on how to lead a class. 2. The implication of the feedback from user surveys is that a substantial proportion of people with diabetes who responded to the questionnaire might like to see computer technology incorporated further into their diabetes management. More research would need to be carried out to determine the optimum large-scale use that might be made of such software. 3. With future versions of AIDA, the plan is to make the software even easier to use, with a standard Windows graphical user interface and mouse control. This should help to ensure that even those who do not rate themselves as knowledgeable with computers should still be able to make good use of the program. 4. The program is neither flashy nor colourful, nor is it simple to learn and use. It requires patience. The user manual should be read before proceeding.

References: Lehmann, E. D. (1998). Preliminary experience with the internet release of AIDA ­ an interactive educational diabetes simulator. Computer Methods and Programs in Biomedicine, 56(2), 109-132. Lehmann, E. D., Chatu, S. S., & Hashmy, S. S. H. (2007). Retrospective pilot feedback survey of 200 users of the AIDA version 4 educational diabetes program. Diabetes Technology & Therapeutics, 9(1). Tatti, P., & Lehmann, E. D. (2001). A randomisedcontrolled clinical trial methodology for evaluating the teaching utility of interactive educational diabetes simulators. Diabetes, Nutrition & Metabolism, 14(1), 1-17.

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Internet-Based Physical Activity

BRIEF PROGRAM OVERVIEW The D-NET Active Lives Program is an Internet-based supplement to usual care that focuses on providing support for increasing physical activity including goal setting, personalized feedback, identification and strategies to overcome barriers, online "personal" coach, peer support and online chat, and online database for personal physical activity (PA).

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Social-Ecological Model of Diabetes Self-Management TARGET AUDIENCE: Adults SETTING: Online COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing.

Current Program Status: The online site is no longer available.

Program Description: Participants who were assigned to the intervention received an eight-week personalized physical activity program tailored to their individual needs. The intervention was based on a multi-level social-ecological model of diabetes self-management and follow-up support for behaviour change. Participants were assessed online for their physical activity level and received specific feedback on their baseline activity level in relation to national guidelines for regular moderate-level physical activity. Participants were then led through a "5 Steps to Action" planning process, in which they first identified the benefits of physical activity (i.e., personal motivators) and next selected a physical activity goal to gradually increase the number of days per week and minutes per day that they would engage in moderateintensity physical activity. Subsequent steps included selecting

3. Implementation of diabetes education is client-centred and facilitates learning.

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two preferred physical activities from an "activity exploration" checklist, scheduling days of the week and times of day that they would do these activities, and identifying two personal barriers to physical activity from a barriers checklist. Both individual barriers selected and associated tips for overcoming personal barriers were always available on the website for review and printout. Participants were encouraged to log on to the website at least once a week to review their physical activity plan and to use the website's physical activity resources, personal coach, and peer-to-peer support areas. Participants also had online access to a private personal database, from which they could enter and track their total minutes of physical activity per day as well as generate graphs of their progress. The database also contained a resource area with a collection of physical activity ­ specific how-to articles, tips and motivational stories. Online personal coach counseling and support was also available. Program Objectives: To increase participant weekly physical activity (minutes per week) and to decrease depressive symptoms

Evaluation Results: The article reports no significant change in depressive symptoms. Overall moderate improvement was seen in PA levels in both groups; no significant differences in PA were seen between groups. Further analyses showed that people in the intervention group who used the site more frequently derived greater benefits in PA that were not seen in the control group. There was a steep decline in usage in both groups during the course of study. Those in the intervention group were more satisfied than those in the control group. Lessons Learned: The authors conclude that the study identified important lessons about Internetbased self-management programs. "Although there were no significant between-condition differences in outcomes, this mode of delivery appears effective for increasing activity levels among those patients who use the service with sufficient regularity." There was a steep decline in usage over time, which is not unique to this study. The authors also state that the "findings regarding depressive symptomatology were instructive and generally encouraging. Intervention participants reported improvements in depressive symptoms, which are in contrast to reports of Internet use being associated with increased symptoms of depression."

PROGRAM CONTACT:

H. Garth McKay, PhD

Oregon Research Institute 1715 Franklin Blvd. Eugene, Oregon 97403-1983 Email: [email protected]

References: McKay, H. G., King, D., Eakin, E. G., Seeley, J. R., & Glasgow, R. E. (2001). The diabetes network Internetbased physical activity intervention: A randomized pilot study. Diabetes Care, 24(8), 1328-1334.

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Know Your Health Program at the Worksite

BRIEF PROGRAM OVERVIEW The Know Your Health program provides educational materials to promote prevention and wellness. Know Your Health encourages patients to learn about their medical conditions and gives them tools to track doctor visits, prescriptions, and diet and exercise regimens.

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group level TARGET AUDIENCE: Adults SETTING: Worksite COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes.

Development Date: Not stated Revision Date: Not stated Current Program Status: Being implemented by source

Program Description: The program, which is provided by Pfizer, is used in a number of settings. This study looked at the effectiveness of the Know Your Health program in a large worksite. The program integrates established culturally sensitive health education practices for self-management of type 2 diabetes and hypertension. The purpose of the program is to help participants improve health by learning about prevention and wellness. Program Implementation Steps: The program as implemented in the study at the workplace consisted of a one-hour education session for patients with hypertension and a three-hour education session for patients with diabetes. Those participants with both diabetes and hypertension attended both sessions. The sessions were implemented on-site at the workplace. The workplace had an on-site fitness facility that program participants were encouraged to attend. Physical activity and healthy eating was

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promoted. Participants received tools to track their physician visits and a diet and exercise regimen. The program sessions were implemented by Pfizer-trained facilitators. Participants were encouraged to make changes to attain treatment goals. Program Delivery Sources: The program was delivered at the workplace by the Pfizer Know Your Health Program­trained facilitator. Process Evaluation: Participant attendance suggests that the program was favourably received: 76% attended the education session and more than 80% indicated they were satisfied with the program. Outcome Evaluation Results: Information collected during the study showed an increase in highercompliance behaviour, an increase in readiness to change and an increase in the proportion of participants who reached their goal during the study. Blood pressure reductions were also observed. The authors conclude that "the positive messages of the Know Your Health program empower patients to change their risks by making feasible changes."

Partner Engagement: Workplaces need to be supportive for this program to take place within their environment, and employees need to feel comfortable participating in this type of program at their workplace. Critical Points That Need to be Replicated: Know Your Health is a program provided by Pfizer. The Know Your Health information is available at the Pfizer website: www.communityhealthadvocacy.pfizer.com/ programs/know_health_blood.asp. The materials were presented in the US by a representative trained on the program from Pfizer. Description of Contextual Factors: This study was conducted within a large workplace and participants were predominantly male. Materials Available for Program Adaptation: The Pfizer website contains Know Your Health information that could be adapted.

PROGRAM CONTACT:

Robert Miceli, PhD

Global Statistics Pfizer, Inc. 235 E 42nd St. New York, New York 10017 Email: [email protected]

References: Thomas, P. D., & Miceli, R. (2006). Evaluation of the Know Your Health program for type 2 diabetes mellitus and hypertension in a large employer group. American Journal of Managed Care, 12(special issue): SP33-SP39. Pfizer website: www.communityhealthadvocacy.pfizer.com/ programs/know_health_blood.asp

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MicoHealth Internet Diabetes Management Program

BRIEF PROGRAM OVERVIEW An online diabetes management program that offers online access to a range of educational, planning, data-collection graphing and communication tools that promote improved self-management of diabetes. The randomized control trial (RCT) study conducted in Kitchener, Ontario, examined a comprehensive interactive internet program as an adjunct to the current diabetes education centre (DEC) program for the follow-up of patients with diabetes and as a solution for ongoing chronic disease management.

Promising Practice

PROGRAM FOCUS: General PROGRAM LEVEL: System level TARGET AUDIENCE: Adults (ages 19-64) SETTING: Healthcare settings COUNTRY OF ORIGIN: Canada LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes.

Development Date: Unknown Revision Date: Unknown Current Program Status: Being implemented by source

Program Description: There have been two clinical trials to measure the program's effectiveness. The "St. Mary's Hospital" clinical trial (reported in 2007) was a year-long study involving three regional hospitals that measured the outcomes of DEC clients who utilized the MedManager system for all of their post-education services. MedManager portal users experienced an improvement in biometric performance, as well as quality of life measures. A second trial (reported in 2004) showed positive

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results when MedManager's online program was tested to see if it would facilitate interaction between women with gestational diabetes and a nurse practitioner. Program Objectives: The objectives of the RCT study were to improve glycemic control, disease management behaviours, health status and patient satisfaction. Program Implementation Steps: The internet program consisted of a central data repository that the patient or healthcare provider could access via a confidential password. Patients had their own unique profile, where they were able to enter data on blood glucose measurements, diet, exercise, insulin and oral medications. A certified diabetes nurse, working under medical directives, had access to all patient profiles. The nurse was able to monitor data, give feedback and make recommendations about adjusting medications or other aspects of treatment. The nurse also provided individual education based on participants' needs. The patients understood that this program offered timely feedback but was not a substitute for any required emergency treatment. The program also offered a chatting/communication module, which enabled patientto-patient discussions. A bulletin board section was also used, enabling patients to post moderated messages, including recipes, information about diabetes supply items and other general information. Glucose meters and connection cables were provided for all participants of the RCT study to facilitate the downloading of blood glucose test results to their Internet patient profile. Process Evaluation: Process evaluation results reported show that: · 0% of patients agreed that MicoHealth helped 9 them communicate with the healthcare provider; · 00% found the online interface easy to 1 understand and follow; and 1 · 00% found MicoHealth assisted with their diabetes. Outcome Evaluation Results: The trial results showed that patients using the MicoHealth system experienced several statistically significant changes: 1. Improved triglyceride levels (2.30 to 1.90 mmol/L), while there was no change in the control group; 2. Lower HbA1c measure by three months (maintained for the remainder of the year)

3. Greater satisfaction at all follow-ups versus their baseline measure, while the control group showed no significant change. Program Reach: For the RCT study, a total of 57 participants completed the one-year study or came to their natural censored endpoint at three or six months because of staggered entry times. Twenty were randomized to the control group and 37 to the intervention group. Community Supports: Patients need to have Internet access and computer literacy. Description of Contextual Factors: The majority of the patients in both the RCT study control and intervention groups were cared for by generalists such as family physicians, internists or nurses. In addition, most of the RCT study patients were either newly diagnosed with type 2 diabetes or well managed. Two DECs in northern Ontario are beginning to implement the interactive chronic disease management software in their communities. Lessons Learned: Participants in both studies were current Internet users, so external validity and generalization are applicable to the diabetes population that currently uses Internet/computer technology.

PROGRAM CONTACT:

Researcher contact:

Online program contact:

MedManager Interactive Corp. 285 Weber St. N., Unit 3 Waterloo, Ontario N2J 3H8 Phone: (519) 747-2492 Website: www.micohealth.com

Dr. Erin Tjam

Director of Research St. Mary's Hospital Kitchener, Ontario Phone: (519) 749-6918 Email: [email protected]

References:

Tjam, E. Y., Sherifali, D., Steinacher, N., & Hett, S. (2006). Physiological outcomes of an Internet disease management program vs. in-person counselling: A randomized, controlled trial. Canadian Journal of Diabetes, 30(4):397-405. MedManager web site: http://www.micohealth.com solutions_evidence.cfm

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Picture Flashcard Health Education

BRIEF PROGRAM OVERVIEW Pictorial flashcard education combined with one-on-one teaching program can improve knowledge about diabetes, increase self-caring behaviour and affect some aspects of attitudes to diabetes and diabetes clinics. Development Date: 1991 Revision Date: Was adapted for Bangladeshi patients with diabetes in Cardiff, UK and used from 1998-2001 Current Program Status: Not being implemented

Program Description: Ten colour photographs were produced with the help of a dietitian, link workers and a professional photographer, enlarged to A3 size and laminated. Asian models, utensils and foods were used. Each photograph was designed to cover one or more predetermined teaching objectives. A standardized interview questionnaire was developed to use with the flash cards. The patients were shown the flash cards by the link worker together with a structured education package. They were taught to test their urine for sugar if they did not already do that. Program Goals: To increase knowledge, self-caring skills and attitudes toward diabetes Program Objectives: To use flash cards in conjunction with a health education program to increase patients' ability to monitor and interpret glucose results, understand the implications of poor glycemic control and take control of their diet

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level THEORETICAL BASIS: Social Cognitive TARGET AUDIENCE: Pakistani Moslem adults SETTING: Healthcare setting and/or home COUNTRY OF ORIGIN: United Kingdom LANGUAGE: Urdu and Punjabi

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Program Implementation Steps: Patients received oneon-one education in either a hospital outpatient clinic or a diabetic clinic. Interviews could also take place at the participant's home. All interviews took place in the language the patient was most comfortable using. Program Delivery Sources: A standardized interview questionnaire was developed to use with the flash cards, and the interviews were carried out by a link worker who was fluent in Urdu, Punjabi and English. She had no medical background but received informal in-house training at the Manchester Diabetes Centre and was taught to conduct a structured education package. Process Evaluation: Most patients were positive about the education they had received. Outcome Evaluation Results: All parameters of knowledge increased. Self-caring behaviour improved as measured by the regularity of glucose testing. Attitudinal views were more resistant to change, with patients still finding it hard to choose suitable foods at social occasions. HbA1c control improved as well. Program Reach: Ability to provide one-on-one instruction limited by staffing needs Community Supports: Interviewer with Urdu and Punjabi language skills Partner Engagement: This was part of the authors' masters thesis. Start-up Costs: Would involve training of staff in health education and phlebotomy, salaries for a healthcare worker with bilingual skills and a manager/ DSN, travel expenses and costs for development of materials, evaluation and follow-up Ongoing Implementation Costs: Travel and staffing Critical Points That Need to be Replicated: Flash cards were well accepted Description of Contextual Factors: Type 2 diabetes is up to four times more common in British South

Asians but their awareness is low. South Asians are also more susceptible to the associated renal and cardiac complications. Generalizability: The concept would be generalizable to many cultures. Materials Available for Program Adaptation: Flash cards Lessons Learned: · pportunistic health education works well in a O hard-to-reach community. · ne-on-one health education works better than O group health education. · atients need to have control over where they are P seen ­ community centre, home, GP's surgery. · t is necessary to obtain co-operation from other I healthcare providers to support the project. · he quality of the healthcare assistant/link worker T is vital to the success of the project ­ he/she needs to come from the community itself, have a respected position, and have the right skills, attitudes and motivation. · nlisting the co-operation of important E community leaders ­ religious and secular ­ is also very worthwhile. · honing patients to remind them of follow-up P appointments increases attendance.

PROGRAM CONTACT:

K. Hawthorne

Four Elms Surgery 103 Newport Road Cardiff CF2 1AF UK , Email: [email protected] Email: [email protected]

References: Hawthorne, K., & Tomlinson, S. (1997). One-to-one teaching with pictures ­ flashcard health education for British Asians with diabetes. The British Journal of General Practice: The Journal of the Royal College of General Practitioners, 47(418), 301-304. Direct communication with K. Hawthorne.

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Practical Education/ Behaviour Modification Program

BRIEF PROGRAM OVERVIEW A series of six sessions, with one followup session held at 12 months, focused on education/behaviour modification and held at a primary care clinic. The sessions consisted of didactic portions using the Life Skills program as the base.

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group level TARGET AUDIENCE: Adults SETTING: Healthcare setting ­ primary

care clinic

COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning.

Development Date: Not stated Revision Date: Not stated Current Program Status: Unknown

Program Description: The six weekly sessions were 1.5 hours in length. Classes were delivered by certified diabetes educators (one registered nurse and one registered dietitian). The program contained lecture guidelines, teaching slides and handouts to help average patients understand diabetes and its treatment and consequences. Healthy eating and exercise were emphasized to the participants as a way to control their diabetes. A follow-up session was held for patients at the 12-month point. Program Implementation Steps: The program began with an individual session for each participant with the instructors, to create individual diet and exercise prescriptions and set individual goals. Patients completed worksheets and contracts, to encourage participant involvement and personal responsibility in the program. The classes were structured to encourage participants to ask questions, share their own experiences and receive feedback

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from other patients and the instructors. During each monthly session, participants received their weight, blood pressure and lab results. The day before the class, patients received a phone call from the program organizers to remind them about the next session. Physicians also briefly attended each session to show their interest in the program and their patient's progress. Program Delivery Sources: The sessions were delivered by certified diabetes educators (a registered nurse and a registered dietitian). The clinic physicians also attended each session briefly. Process Evaluation: The study researchers kept track of participant attendance at each of the sessions. Ten patients dropped out of the intervention group due to illness, failure to attend classes or have adequate lab studies. Eighteen participants attended at least five of the six classes and completed the study. Outcome Evaluation Results: During the study, researchers measured glycemic control, lipoprotein cholesterol, health-related quality of life and the patients' cognitive knowledge of diabetes. The healthrelated quality of life was measured with the MOS SF-36 and the DRP questionnaires. The MOS SF-36 measures physical conditioning, social functioning, physical role functioning, emotional role functioning, mental health, vitality, bodily pain and general health perceptions. The DRP scale covers 19 symptoms. The Life Skills test was used to measure patients' cognitive knowledge of diabetes; this test uses a true or false/ picks the best answer format with 10 questions on diabetes and medications in general, 10 questions on dietary control of diabetes, 10 questions on diabetes-specific issues and 10 questions on exercise and monitoring. The study results showed that the intervention group had statistically significant improvements in glycemic control and total cholesterol at the end of the six-month time period and significant improvements in body weight at 12 months.

Program Reach: Each series of classes had 14 participants. Ongoing Implementation Costs: The authors indicate the program cost $95 per patient for educational materials and salaries. This estimate does not include the cost of lab tests. The physicians did not receive any compensation for their efforts. Critical Points That Need to be Replicated: The sessions were held at the patients' primary care setting, which was already familiar to them. Having the physicians attend each session (even periodically) demonstrated their interest in the patients' progress.

PROGRAM CONTACT:

Nathan A. Ridgeway, MD

Holston Professional Bldg 146 W Park Dr., Suite 9-I Kingsport, Tennessee 37660

References: Ridgeway, N. A., Harvill, D. R., Harvill, L. M., Falin, T. M., Forester, G. M., & Gose, O. D. (1999). Improved control of type 2 diabetes mellitus: A practical education/ behaviour modification program in a primary care clinic. Southern Medical Journal, 92(7), 667-672.

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Project Dulce

Promising Practice

PROGRAM FOCUS: General PROGRAM LEVEL: Individual level TARGET AUDIENCE: Underserved, ethnically

diverse population

BRIEF PROGRAM OVERVIEW PROJECT DULCETM is a diabetes care and education program that addresses the specific needs of underserved, ethnically diverse populations. The program is dedicated to "Diabetes Excellence Across Communities," with a mission of improving the lives of people with diabetes through culturally appropriate, community-based diabetes management, education and support programs.

SETTING: Community-based COUNTRY OF ORIGIN: United States LANGUAGE: English, Spanish and 10 other

languages DES PROCESS STANDARDS MET

2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: 1997 Revision Date: Unknown Current Program Status: Unknown

Program Description: The core of Project Dulce's approach to patient care, a chronic care model, is a nurse-led team consisting of a registered nurse/certified diabetes educator, medical assistant and dietitian who provide clinical care in collaboration with the patient's primary care provider. Peer educators who are persons with diabetes are trained to provide diabetes self-management education and support to their peers. Clincial standards and algorithms are used to guide treatment. An electronic diabetes registry is used to track patient care, monitor compliance with standards and report clinical outcomes. Project Dulce has conducted extensive socio-cultural research to adapt its group education curriculum and approach to address the needs of African American, Filipino and Vietnamese communities.

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Peer educators from each of these cultural groups provide diabetes education and support to respective communities. Patient handouts have been translated into numerous languages and the handouts are available. Program Goals: To address specific needs of underserved, ethnically diverse populations Program Objectives: To improve the lives of people with diabetes through culturally appropriate, community-based diabetes management, education and support programs Program Implementation Steps: The program involved a combination of nurse care management (NCM) and group education delivered by specially trained peer educators to achieve self-empowerment. The NCM component consisted of a nurse-led team with a registered nurse/certified diabetes educator (RN/CDE), bilingual/bicultural medical assistant and bilingual/bicultural dietitian who travelled to a different clinic site each day to see patients. The RN/ CDE had extensive experience in diabetes education and was further trained to use the protocols in Staged Diabetes Management (SDM) for glucose levels, lipid levels and hypertension management. Each participant underwent a two-hour baseline visit to assess demographic information, history of diabetes, weight, blood pressure, foot status, HbA1c, chemistry and lipid panel, results of liver function tests and proteinuria. At each subsequent visit, the RN/ CDE reviewed self-monitored blood glucose results, self-management, guidelines and goals; provided recommendations for changes in diabetes medications following SDM protocols; and ordered follow-up laboratory studies and return visits. Prescriptions were approved and signed by the primary care physician. For patients with complicated cases, follow-up visits were scheduled within two weeks. A medical assistant was responsible for translation (Spanish to English), recording of vital signs, phlebotomy and patient reminder calls. A bilingual dietitian was available for two 45-minute sessions per year for nutrition education. All patients had access to medications

and testing supplies through Medicaid. All patients had access to at least one screening retinal examination and podiatric care. All patients were referred to the empowerment/peer education program. Individuals with diabetes who exemplified the traits of a natural leader were identified from the clinic's patient population and trained initially using a program developed by the Latino Health Access Program. The peer educators were subsequently required to complete the Project Dulce training curriculum and meet established competencies before teaching classes on their own. The curriculum consisted of 12 twohour sessions (one per week). Classes were taught in the patients' and promotoras' native language and covered diabetes and its complications; the role of diet, exercise and medication; and the importance of self-monitoring of blood glucose. Classes included interactive sessions in which the patients discussed their personal experiences, fears and beliefs about diabetes. An emphasis was made to overcome noncongruent cultural beliefs such as the fear of using insulin or the use of nopales in an attempt to cure diabetes. Visual demonstrations enhanced the dietary and exercise components. All elements of American Diabetes Association (ADA)-recognized teaching programs were covered during the course of the classes. Program Delivery Sources: The NCM component consisted of a nurse-led team with a registered nurse/ certified diabetes educator (RN/CDE), bilingual/ bicultural medical assistant and bilingual/bicultural dietitian who travelled to different clinic sites each day to see patients. The RN/CDE had extensive experience in diabetes education and was further trained to use the protocols in Staged Diabetes Management. The peer education component (PEER) involved community healthcare workers who were provided with extensive training to be effective diabetes peer educators. They in turn trained individuals with diabetes who exemplified the traits of a natural leader and were identified from the patient population and trained.

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Process Evaluation: The literature refers to the program being evaluated on a regular basis. Outcome Evaluation Results: Details on Project Dulce's impact on health outcomes, behaviour change and cost effectiveness have been published in peer-reviewed journals. Significant improvements in HbA1c levels, total cholesterol, LDL cholesterol and diastolic blood pressure have been demonstrated. Accepted ADA standards of diabetes care, knowledge of diabetes, treatment satisfaction and culture-based beliefs were also improved. Program Reach: Underserved, ethnically diverse population who are involved in diabetes management with their primary care physician Community Supports: The program uses a multidisciplinary team in innovative ways that transfer tasks to those most able and qualified to perform them. The nurse case manager works alongside the primary care physician, using standardized procedures and protocols to perform many diabetes management tasks: reviewing labs, adjusting medications and ensuring clinic goals are met. Trained lay peer educators provide diabetes education and support that empowers individuals to manage their condition within their own cultural, social and educational framework of reference. The County of San Diego contracts with Project Dulce to manage the diabetes care of enrollees of their Medically Indigent Adult Program. Project Dulce has integrated depression care services as well as hypertension management in the model. Partner Engagement: At a minimum, diabetes management programs should engage pharmacists by including them in strategy sessions that draw upon their expertise in pharmacology and adherence, and provide them with an understanding of cultural issues that affect self-management.

Start-up Costs: Although Project Dulce participants experienced higher total costs in the first year of the intervention, these costs were almost completely attributable to the increased use of medications and diabetes testing supplies. However, in this medically indigent adult population, many drugs were initiated for the first time, contributing to the upfront costs of implementing the program. Expenditures on hospital and emergency department care declined, although the change was not statistically significant. Ongoing Implementation Costs: Although there are ongoing human resources costs, the cost is less than the cost of hospitalization and emergency care department use by patients with diabetes who do not have access to this program. Critical Points That Need to be Replicated: Medications and glucose testing strips were provided on the same day as the visit. The proper use and safety precautions of the medications and strips were explained in the patients' native language. It is likely that the immediate availability of medications was responsible for the dramatic improvement in clinical outcomes. Optometry and podiatry services were performed on-site, often on the same day as another scheduled visit. Trust was developed between the nurse team and the primary care providers. All members of Project Dulce were highly dedicated in caring for the enrolled patients. Whether this can be reproduced in other settings is unknown. Generalizability: A novel culturally appropriate community-based nurse care management/peer education diabetes care model leads to significant improvement in clinical diabetes care, self-awareness and understanding of diabetes in under-insured populations.

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Materials Available for Program Adaptation: Training programs and technical assistance are available. Project Dulce has prepared the materials, training programs and approach necessary to share the model with other health providers and communities. Training materials include: · "Diabetes Among Friends" curriculum to be taught by peer educators. The curriculum includes modules on hypertension and depression management. · Educational handouts in English, Spanish and 10 other languages. · Peer Education Training Program Manual. · Four- to five-day peer education Train-the-Trainer program. · Training for community health workers to be diabetes care advocates. · Operations Manual, including replicable copies of program forms and charts. · Professional education programs, ranging from a one-day "Basics of Diabetes" to five days of intensive training for health professionals to increase their diabetes management knowledge and skills.

Additional Notes: Project Dulce has trained individuals in health systems, community health centers, and community-based organizations throughout the US, including · Philadelphia, PA · New Jersey · Tennessee · Florida · Central Valley, California · Alameda County, CA · Los Angeles and Riverside Counties, CA For information or materials, please contact: Chris Walker Director, Project Dulce [email protected] 858-626-5664

PROGRAM CONTACT:

Anna Garay, MD

Chief Medical Director The Whittier Institute for Diabetes 9894 Genesse Ave. La Jolla, California 92037 Email: [email protected]

References: Philis-Tsimikas, A., Walker, C., Rivard, L., Talavera, G., Reimann, J. O., Salmon, M., et al. (2004). Improvement in diabetes care of underinsured patients enrolled in project dulce: A community-based, culturally appropriate, nurse case management and peer education diabetes care model. Diabetes Care, 27(1), 110-115.

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REACH Detroit Family Intervention

BRIEF PROGRAM OVERVIEW The purpose of the REACH Detroit Family Intervention is to work with African Americans and Latinos with type 2 diabetes and their families to improve blood sugar control by healthy eating, regular exercise and managing their diabetes. A total of 151 African American and Latino adults with diabetes were recruited from three healthcare systems in Detroit, Michigan to participate in the REACH Detroit Partnership diabetes lifestyle intervention. The curriculum, delivered by trained community residents, was aimed at improving dietary, physical activity and diabetes self-care behaviours.

Promising Practice

PROGRAM FOCUS: General PROGRAM LEVEL: Community level THEORETICAL BASIS: Community

development

TARGET AUDIENCE: African American and

Latino families, healthcare providers and community organizations

SETTING: Community at large and

healthcare settings

COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: 2000 Revision Date: Unknown Current Program Status: Being implemented by source

Program Description: Family Health Advocates (FHAs) were trained to work with the REACH families. REACH participants were referred to the project by their personal physicians from one of three healthcare systems in Detroit. The program was developed with Latino and African American cultures in mind. Latino families participated in El Camino a la Salud and African

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American families participated in The Journey to Health programs. REACH families also receive a new Internet computer and training that helped them get important information about diabetes and community programs in their own home. Program Goals: The following were identified as the program goals: · ncrease healthy eating and leisure-time physical I activity. · Enhance family-health provider relationships. · Increase access to quality health care. · mprove client's ability to control diabetes with I self-care. · ncrease access to community health promotion I resources. Program Objectives: To determine the effects of a community-based, culturally tailored, diabetes lifestyle program Program Delivery Sources: Seven FHAs were trained in patient empowerment techniques, diabetes selfmanagement, healthcare consumer skills, computer set-up, Internet search skills, diet and nutrition, and the benefits of physical activity. Approximately 150 clients with diabetes have been enrolled; 142 have completed in-home baseline health surveys. FHAs have begun group classes on diabetes with their clients. More than 40 clients have received an Internet computer device and one-on-one training on how to access health information on the Internet. The REACH Detroit website, with relevant health links and a database of community resources, was launched. FHAs are teaching group classes using a culturally tailored curriculum to increase healthful eating and physical activity among their clients. Outcome Evaluation Results: There were statistically significant improvements in post-intervention dietary knowledge and behaviours, and physical activity knowledge. A statistically significant improvement in HbA1c level was achieved among REACH Detroit program participants (p<0.0001) compared to a

comparison group in which no significant changes were observed (p=0.160). REACH participants were interviewed before they started The Journey to Health, and again after about six months and 12 months. Many REACH participants made important changes in their habits. These included eating more fruits and vegetables and drinking fewer fruit-flavoured drinks. More participants now take their recommended dose of medication, follow a healthful eating plan, test their blood sugar and check their feet. The study authors conclude that the findings indicate that a culturally tailored, diabetes lifestyle intervention delivered by trained community residents produced significant improvement in dietary and diabetes self-care related knowledge and behaviours as well as important metabolic improvements. Program Reach: A total of 151 participants were recruited for three family care systems. Start-up Costs: Unknown Ongoing Implementation Costs: Unknown Critical Points That Need to be Replicated: FHAs are dedicated to empower African American and Latino people who have type 2 diabetes as well as their families. By educating, supporting, demonstrating and providing health awareness, FHAs help families to diminish the risk of diabetes in future generations, prevent its devastating complications, and assist families in being better health consumers and establishing a better quality of life. FHAs work closely with doctors to help build strong, long-lasting doctorpatient relationships. FHAs also collect important data to track and evaluate the project's success and assist families in using an Internet-only computer device to seek healthcare information and resources that are available in the community through the REACH Website.

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Description of Contextual Factors: REACH Detroit is a community research partnership that works with African American and Latino families, healthcare providers and community organizations in eastside and southwest Detroit to prevent type 2 diabetes and health problems related to diabetes. REACH informs, educates and empowers families, communities and healthcare providers to prevent or better manage diabetes through one-on-one relationships, support groups and community-wide healthy lifestyle activities. REACH works in several African American and Hispanic communities in the city of Detroit.

PROGRAM CONTACT:

REACH Detroit Partnership Metropolitan Center for High Technology 2727 Second Ave., Rm 300 Detroit, Michigan 48201 Phone: (313) 961-1030 Website: www.reachdetroit.org

References: Feathers, J. T., Kieffer, E. C., Palmisano, G., Anderson, M., Janz, N., Spencer, M. S., et al. (2007). The development, implementation, and process evaluation of the REACH Detroit partnership's diabetes lifestyle intervention. The Diabetes educator, 33(3), 509-520. Feathers, J., Kieffer, E. C., Palmisano, G., Anderson, M., Sinco, B., Janz, N., et al. (2005). Racial and ethnic approaches to community health (REACH) Detroit partnership: Improving diabetes-related outcomes among African American and Latino adults. American Journal of Public Health, 95(9), 1552-1560. REACH Detroit Partnership website: www.reachdetroit.org

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Self-Management Patient Education

BRIEF PROGRAM OVERVIEW A six-session program based on selfmanagement rather than training about `symptom perception' designed to reduce problems related to low blood glucose (hypoglycemia), and increase hypoglycemia awareness.

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Group level TARGET AUDIENCE: Adults SETTING: Healthcare setting ­ inpatient

care setting

COUNTRY OF ORIGIN: Germany

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing.

Development Date: 2004 Revision Date: Revised in 2005 Current Program Status: Being implemented by source

Program Description: The program is delivered to groups of eight to 10 adults with type 1 diabetes. It consists of six lessons, each 45 minutes in length. The program curriculum as reported by Kubiak et al (2005) is as follows: · Lesson 1: Goal-setting, prior experiences with hypoglycemia, initial problem analysis and introduction of self-monitoring techniques · Lesson 2: Individual problem analysis and building up motivation to change · Lesson 3: Model of hypoglycemia perception and `circulus vitiosus' of impaired hypoglycemia awareness · Lesson 4: Individual glycemic goals, fear of hypoglycemia and diabetic complications

3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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· esson 5: Hypoglycemia in social context and L coping with hypoglycemia in daily life · esson 6: Goal attainment, feedback and strategies L for maintaining behaviour change. Program Delivery Sources: The program lessons were delivered by a postgraduate psychologist experienced in diabetes care and patient education. Outcome Evaluation Results: The prevalence of hypoglycemia-related problems decreased, hypoglycemia awareness remained constant (versus deteriorating in the control group), and HbA1c levels decreased significantly in both the intervention and control groups.

Program Reach: The group sessions were delivered to eight to 10 participants for each cycle. Description of Contextual Factors: The program was implemented in a hospital setting in Germany. Lessons Learned: The authors conclude that there is a "potential preventive effect of the program in addition to ameliorating hypoglycemia-related problems."

PROGRAM CONTACT:

Thomas Kubiak

Institute of Psychology, University of Greifswald Franz-Mehring-Str. 47 D-17487 Greifswald, Germany Phone: +49-3834-86-3751 Email: [email protected]

References: Kubiak, T., Hermanns, N., Schreckling, H. J., Kulzer, B., & Haak, T. (2006). Evaluation of a self-managementbased patient education program for the treatment and prevention of hypoglycaemia-related problems in type 1 diabetes. Patient Education and Counselling, 60(2), 228-234.

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Simple Meal Plan Emphasizing Healthy Food Choices

BRIEF PROGRAM OVERVIEW The Simple Meal Plan program is a program for people with type 2 diabetes that emphasizes "healthy food choices" (without emphasis on weight loss) instead of using the traditional exchange-based meal plan.

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level TARGET AUDIENCE: Urban African

Americans with low health literacy

SETTING: Healthcare setting (community

diabetes clinic)

COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

Development Date: Not noted Revision Date: Not noted Current Program Status: Unknown

Program Description: The Simple Meal Plan program uses instructional materials developed at the fifth and sixth grade reading level. The low-literacy educational material uses the American Diabetes Association's "Eating Healthy Foods" (with references to the quantity of food removed) combined with slightly modified information about the Food Guide Pyramid (modified to group high-starch and high-protein foods as recommended for persons with diabetes). The study authors indicate the "modified food guide pyramid was glossy and in full colour with line drawings of foods. Patients were instructed to limit use of sweets and fats, particularly saturated fat. Although food models were used, portion sizes were not discussed and weight loss was not emphasized." Program Goals: The study purpose was to determine whether a simpler meal plan that emphasizes "healthy food choices" (without emphasis on weight loss per se) would be as effective as the traditional exchange-based meal plan (emphasizing weight loss).

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Program Implementation Steps: Individual care is provided to patients by a team that includes nurses, dietitians, podiatrists and endocrinologists. Each patient's initial visit includes an extensive evaluation and education focused on self-care. After the initial visit, patients are scheduled for return visits at one, two and four weeks after the initial visit, and then at two, four and six months. All patients are routinely scheduled to see a dietitian at the initial visit and again at visits at one, two and four weeks with additional visits as needed; at each of these appointments, patients receive individualized, one-on-one instruction in separate sessions. During the sessions with the dietitian, the Simple Meal Plan approach was used with the intervention groups and the traditional exchange-based meal plan approach used with the control group participants. Program Delivery Sources: The Simple Meal Plan information was provided by the dietitian. Process Evaluation Results: Unfortunately, information on patient satisfaction was not gathered during the study with either meal plan. The authors state that "patients reported anecdotally that the healthy food choice meal plan was easy to understand, which contrasts with the difficulty patients may have with the exchange-based meal plan." The authors also indicate that while they did not evaluate ease of use, the dietitians reported anecdotally that the Simple Meal Plan was easier to teach. Outcome Evaluation Results: The primary outcomes measured were changes in glycemic control (HbA1c); secondary outcomes included changes in fat and sugar intake, body mass index, lipids and blood pressure. The randomized control trial study found that instruction in meal planning based only on the healthy food choices (Simple Meal Plan) was comparable with the traditional exchange-based meal plan system in terms of impact on food selection, glycemic control, weight, lipids and blood pressure. Participants in both groups had comparable fat and sugar intakes at baseline, and reported significant but comparable reductions in fat and sugar intake at follow-up.

Critical Points That Need to be Replicated: Simple Meal Plan materials would need to be developed to be reflective of the Canadian Diabetes Association guidelines for healthy eating and Canada's Food Guide. The authors note that a small number of study patients requested to switch from the Simple Meal Plan healthy food choice approach to the exchange-based meal plan for the purpose of weight management. Description of Contextual Factors: The program was implemented with urban African Americans with type 2 diabetes. Materials Available for Program Adaptation: The Simple Meal Plan materials would be helpful to assist in adaptation for use in Canada. Lessons Learned: The authors indicate that "as a result of this study, providers in the Grady Diabetes Clinic continue to use the exchange-based meal plan for those patients who desire a focus on food exchanges and portion sizes as a strategy to lose weight, but instruction in healthy food choices (Simple Meal Plan) without an emphasis on weight loss has become the standard approach to meal planning for all other patients."

PROGRAM CONTACT:

David C. Ziemer, MD

Emory University School of Medicine 69 Butler Street, S.E. Atlanta, Georgia 30303 Email: [email protected]

References: Ziemer, D. C., Berkowitz, K. J., Panayioto, R. M., El-Kebbi, I. M., Musey, V. C., Anderson, L. A., et al. (2003). A simple meal plan emphasizing healthy food choices is as effective as an exchange-based meal plan for urban African Americans with type 2 diabetes. Diabetes Care, 26(6), 1719-1724.

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Simple Start

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group and individual

levels

THEORETICAL BASIS: Unknown

BRIEF PROGRAM OVERVIEW Simple Start is a patient guidebook educating patients on the importance of glycemic targets and the action that should be taken to normalize glucose during the postprandial period.

TARGET AUDIENCE: Adults (ages 19-64) SETTING: Diabetes care centre COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

Development Date: 2007 Revision Date: Unknown Current Program Status: Being implemented by source

Program Description: The program consists of a patient reading a 15-page book, attending a 30-minute group education course reviewing the booklet and watching a DVD covering the same material as in the booklet. Simple Start is often used in addition to a general education class. The Simple Start program emphasizes the importance of testing and behaviour changes that one could make to lessen glucose excursions from normal. This includes adjusting portion sizes and carbohydrate content if a patient finds postprandial blood glucose values beyond current recommended guidelines. Program Goals: To educate patients about glycemic targets and dietary changes that could lessen glucose excursions Program Objectives: To use Simple Start as a supplement to a general education class to increase self-monitoring of blood glucose

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

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Program Implementation Steps: After attending a 30-minute class on general diabetes care, patients are given the Simple Start program, which includes a 30-minute review of the Simple Start material as well as a DVD and booklet that accompanies Simple Start. Program Delivery Sources: Programs are delivered by staff of the Diabetes Care Center.

Outcome Evaluation Results: Mean glucose in the 4-hour after-meal period was significantly lower in those who used the Simple Start resource in addition to the general diabetes education class. There was also a significant increase in self-monitoring of blood glucose. Program Reach: The study involved 30 patients in total, 15 of who used the Simple Start program in addition to the general diabetes education program.

PROGRAM CONTACT:

Gary Wolfe, RN

Diabetes Care Center 1260 South Main Street, Ste 201 Salinas, California 93901 Phone: (831) 769-9355 Fax: (831) 754-4955 Email: [email protected] Website: http://www.diabetescarecenter.com

References: King, A. B., Wolfe, G. S., & Armstrong, D. U. (2007). Evaluation of a patient education booklet's (Simple Start) effect on postprandial glucose control in type 2 diabetes. Diabetes Technology & Therapeutics, 9(3), 241-245.

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Soul Food Light

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group level THEORETICAL BASIS: Community

development

BRIEF PROGRAM OVERVIEW The program was a culturally specific dietary self-management program for African Americans with type 2 diabetes living in rural South Carolina. It reflected the ethnic beliefs, values, customs, food preferences, language, learning methods and healthcare practices of this group through four weekly classes in low-fat dietary strategies, five monthly peerprofessional group discussions and weekly telephone follow-up by a nurse case manager.

TARGET AUDIENCE: Mexican Americans 18-

75 years of age

SETTING: Diabetes clinic COUNTRY OF ORIGIN: United States LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved.

Development Date: Prior to 2002 Revision Date: Unknown Current Program Status: Unknown

Program Description: Four weekly classes on low-fat dietary strategies, five monthly peer-professional group discussions and weekly telephone follow-up. The culturally competent approach reflected the ethnic beliefs, values, customs, food preferences, language, learning methods and healthcare practices of southern African Americans. Program Goals: To test the effects of a culturally competent dietary self-management intervention on physiological outcomes and dietary behaviours for African Americans with type 2 diabetes in rural South Carolina

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Program Objectives: Increased knowledge and behaviour change related to one focused dietary change (low-fat diet) (deduced, not stated). Program Implementation Steps: (These steps not intended to be presented sequentionally.) 1. Potential participants were referred by their primary physician based on the following inclusion criteria: African American, type 2 diabetes, age 18 or older, no mental or physical limitations that would preclude participation in goup activities and discussion, and at least one indicator from a list of diabetes complications that are high risk and modifiable by diet. 2. Research assistants telephoned interested individuals and pre-screened them. 3. Physiological and dietary fat food habits were collected through questionnaires (these were read aloud to avoid embarrassment over any lack of literacy). 4. In the educational classes, the Diabetes Food Pyramid was used to teach healthy, low-fat food choices. 5. Practical and culturally competent strategies were provided for reducing fats.

6. Individualized goals were set. 7. In black cultural traditions, meals are social events with friends and families, so traditional African American meals were prepared with lowfat techniques and ingredients, and were served to participants and family members following most classes. Participation of family members was encouraged not only to integrate black cultural traditions associated with food but also to capitalize on the value of family and to provide transportation ­ a common barrier in rural areas. 8. Experiential teaching methods were used, such as assisting with meal preparation, reading food labels, and making food choices at a simulated church homecoming supper. 9. Four monthly one-hour peer-professional discussion groups provided professional group education with peer discussion. Groups began one month after educational classes and were facilitated by a nurse case manager who was certified as a diabetes educator. The nurse case manager monitored dynamics and was the expert for questions related to diabetes care.

INTERVENTION PLAN INTERVENTION SESSIONS FOLLOW-UP CONCLUDING SESSION

· Natureofdiabetes · Complicationsofdiabetes · Assessment Education Sessions · PlanninghealthymealswithDiabetesFoodPyramid · Eatingathome;grouppreparationofhealthyAfricanAmericanfoods · PurchasinghealthyAfricanAmericanfoods · Eatingawayfromhome:makinghealthychoicesofAfricanAmericanfoods Discussion Group Sessions · Opendiscussionofanytopic · Discussionofclasscontent · Swappinganddiscussionofparticipants'personallow-fatrecipes · DiscussionofhealthyAfricanAmericanfoodspreparedbyclassduringclass · Discussionofchoicemadeatasimulatedchurchhomecomingdinner · Weeklytelephonecalls · Singlehomevisit · Assessment

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In the first session, the Food Guide Pyramid was used as a major teaching tool. Participants were given a copy of the food pyramid and foods in each group were reviewed. Emphasis was placed on the appropriate number of servings for each food group in relation to individual weight; fewer servings were suggested for those who were overweight. Serving size was demonstrated with measuring cups, spoons and food models. Participants were directed to plan a healthy meal using the food models, and planned meals were then discussed to reinforce learning. To conclude the class, a traditional meal based on African American culture, but prepared with low-fat techniques and ingredients, was served to participants and family members. Recipes and techniques were shared with participants. The second class was a cooking class in which participants learned strategies to lower fat content by modifying cooking techniques and substituting low-fat foods in recipes. Family members were invited to attend and many actively participated. The third class focused on purchasing healthy foods. A video on reading food labels was shown. Participants practised reading food labels from pictorial samples of various foods and were taught strategies for grocery shopping. Healthy snacks were provided, and participants reviewed and discussed the labels and nutrient content of the snacks. In the final class, participants discussed strategies for eating away from home, such as church dinners and family gatherings. A church homecoming supper was simulated to help participants learn strategies for healthy eating away from home. Each of the classes was followed by a 30-minute discussion group led by the nurse case manager. The discussion groups enabled participants to verbalize emotions and barriers, to share successful and unsuccessful strategies in trying to manage changes, and to receive peer support and reinforcement for positive changes. Follow-up was provided by telephone calls and home visits. The nurse case manager made weekly telephone calls and scheduled at least one home visit with participants during the study. The aim was to elicit

participants' success at using information presented at the nutritional classes, to provide additional counselling as needed, to facilitate access to health and social services, to evaluate and solicit family support, and to provide early intervention for problems requiring medical attention. Weekly contact by the nurse case manager personalized the project and facilitated the development of a caring, collaborative nurse-participant relationship. Development of this relationship was viewed as integral to participants' continued participation and success in the study. Program Delivery Sources: The educational classes were taught by a local registered dietitian with experience in nutrition therapy for rural black residents with diabetes. A nurse case manager monitored group dynamics in the peer-professional discussion groups and was the expert for questions related to diabetes care. Process Evaluation: A feasibility study was undertaken initially with a convenience sample of 23 high-risk African American adults with diabetes recruited from a family practice office in rural South Carolina. This was based on previous focus group research. Outcome Evaluation Results: Body mass index (BMI) and dietary fat behaviours were significantly lowered in the experimental group. A trend in reduction of HbA1c and lipids was observed. Results suggest the effectiveness of a culturally competent dietary self-management intervention in improving health outcomes for southern African Americans, especially those at high risk due to high-fat diets and BMI >34 kg/mm2. The program attracted high-risk participants, retained high percentages in the program and achieved significant weight loss. It also showed an impact in changing dietary behaviours in a population with deeply embedded cultural traditions of high-fat foods and food preparaton techniques. These results were achieved in a rural environment where availability of low-cost, low-fat food choices is limited.

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Program Reach: The program involved 97 adult African Americans who were referred by their primary physician; 33% of those were lost through attrition. Final data analysis was completed on 65 participants. Community Supports: Churches helped to provide locations for meals. Partner Engagement: The community hospital contributed the time for dietary personnel who prepared foods for classes and classroom space. Start-up Costs: Initial expenses included the costs of traditional African American food models ($272), copies of the diabetes food pyramid ($25), the standard curriculum for type 2 diabetes education ($65), balance scales ($204), telephone calling cards ($45), the addition of a stove for the diabetes centre ($750). Ongoing Implementation Costs: Each participant received $15 for their attendance, plus Soul Food Light sweatshirts, small token gifts, and "door prizes" at each intervention and/or testing session. The intervention was very economical, using a nurse case manager employed for 12 hours a week and a hospital-based dietitian paid per class. A local physician facilitated access to clients and provided medical oversight for a nominal fee. Food supplies were purchased in bulk by the hospital, and costs of meals were minimal. The most expensive part of the intervention was the cost of the laboratory tests, even though the hospital lab performed these at a discounted cost. Critical Points That Need to be Replicated: A culturally competent approach is required (and has been demonstrated to be effective with Mexican Americans as well). Diabetes educators are a pivotal role for leadership. Description of Contextual Factors: The healthcare professional needs to be seen as an "insider" within the rural black community. Traditional Southern

cooking methods are high in saturated fats so practical alternatives were necessary. A low literacy level was prevalent. Traditional risk reduction approaches have not been effective with African Americans. Availability of low-cost, low-fat food choices is limited. There is a genetic predispositon to obesity in the population; as well, food is central in the culture and education levels are low. Blacks in South Carolina are approximately three times more likely to die from diabetes than whites, experience higher rates of complications, and are twice as likely to be hospitalized as are whites with diabetes. Generalizability: The results are widely applicable to South Carolina, which is 70% rural. "Other rural communities, even those with scarce resources, can replicate the diabetes education program elsewhere with southern African Americans." Lessons Learned: · Experiential approaches to learning were critical. · anguage differences with healthcare providers L and rural prejudices against "outsiders" were recognized as potential barriers ­ speaking the vernacular and idioms facilitated communication and marks one as an "insider." · nsider healthcare providers hold positions of high I esteem and trust in rural communities, and thus their advice is valued. · ecause of low literacy levels, the focus was on B one major dietary concept in order to improve the chances for success by simplifying the intervention and behaviour change required. · he peer-professional approach with the T discussion groups facilitates cultural translation of content, culturally competent learning methods, and emotional support from peers and family ­ it is the preferred group structure of southern African Americans. · evelopment of the relationship between the D nurse case manager and participant was integral to participants' continued participation and success.

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Additional Notes: An adaptation of the conceptual Model for Nursing Case Management for Rural Settings guided the study intervention. The model posits that the health-making function of the case management role improves physiological outcomes, diabetes self-management and costs of care, but only if high-risk, high-cost or high-volume clients are targeted. Community Mobilization theory was not named but was apparent in the approaches taken.

PROGRAM CONTACT:

Wanda Anderson-Loftin

University of South Carolina College of Nursing Columbia, South Carolina 29209 Email: [email protected]

References: Anderson-Loftin, W., Barnett, S., Bunn, P., Sullivan, P., Hussey, J., & Tavakoli, A. (2005). Soul food light: Culturally competent diabetes education. The Diabetes Educator, 31(4), 555-563. Anderson-Loftin, W., Barnett, S., Bunn, P., Sullivan, P., Hussey, J., & Tavakoli, A. (2002). Culturally competent diabetes education for southern rural African Americans with diabetes. The Diabetes Educator, 28(2), 245-257.

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Symptom-Focused Management

BRIEF PROGRAM OVERVIEW The program is a teaching and counselling intervention based on patient and nurse collaboration that focuses on self-management skills and behaviours necessary for individuals to successfully interpret and manage their diabetes symptoms. The program uses a series of four one-hour home visits (total contact time of four hours) and a telephone booster.

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level TARGET AUDIENCE: Older rural African

American women

SETTING: Home COUNTRY OF ORIGIN: United States LANGUAGE: English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: 2000 Revision Date: Ongoing based on feedback and evaluation efforts Current Program Status: Implemented by the source

Program Description: The four symptom modules address: symptoms related to high/low blood glucose; numbness and tingling in the feet and foot pain; stress, anxiety and worry; musculoskeletal aches and pains; and skin symptoms. For each module, the nurse and patient address self-care strategies related to the symptom, psychosocial strategies (e.g., coping skills, stress reduction, family support, community resources), medical management (e.g., discussing with the healthcare provider the need for medication adjustment, change in frequency or pattern of home monitoring) and prevention.

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Program Objectives: To improve participants' glycemic control, medication, diet, home glucose monitoring, self-care practices and perceptions of quality of life, and to decrease distress from symptoms Program Implementation Steps: The nurse meets individually with the patient for one hour for a total of four home visits. Program Delivery Sources: The program is delivered by diabetes education nurses. Process Evaluation: Process evaluation results indicate that participants are very satisfied with the program and that they prefer the in-home format due to difficulties with transportation. Participants identified the opportunity to ask questions and discuss their experiences with managing a symptom and problemsolve as very useful. Most participants had not received any other diabetes education other than that received during the home visit. Outcome Evaluation Results: HbA1c levels were reduced by 0.76% using four one-hour home visits (total contact time: 4 hours) and a telephone booster. This change was maintained over nine months, showing the sustainability of the intervention. Participants also significantly improved their self-care practices and perceptions of quality of life.

Ongoing Implementation Costs: Cost data has been collected and is currently being analyzed by the program developers. Critical Points That Need to be Replicated: The customized in-home support provided by the nurse and problem solving with the patient is critical to the program. "The intervention empowered participants through storytelling, shared experiences and mutual goal setting." Description of Contextual Factors: The program was implemented in a rural area with older African American women.

PROGRAM CONTACT:

Anne H. Skelly, PhD, RN, CS, FAANP

Professor School of Nursing University of North Carolina-Chapel Hill Chapel Hill, North Carolina 27599-7460 Office phone: (919) 966-3612 Office fax: (919) 843-9969 Research office phone: (919) 966-3295 Research office fax: (919) 843-8238 Email: [email protected]

References: Amoako, E., & Skelly, A. H. (2007). Managing uncertainty in diabetes: an intervention for older African American women. Ethnicity & Disease, 17(3), 515-521. Leeman, J., Skelly A. H., Burns, D., Carlson, J., & Soward, A. (2008). Tailoring a diabetes self-care intervention for use with older, rural African American women. The Diabetes Educator, 34(2), 310-317. Skelly, A. H., Carlson, J. R., Leeman, J., Holditch-Davis, D., & Soward, A. C. (2005). Symptom-focused management for African American women with type 2 diabetes: A pilot study. Applied Nursing Research, 18(4), 213-220. Correspondence with Dr. Skelly.

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Talking Circles

ww

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Individual level TARGET AUDIENCE: Aboriginal populations

BRIEF PROGRAM OVERVIEW The Diabetes Wellness Project used a 12-session educational curriculum that was designed for use among American Indian cultures and provided an integration of oral tradition, storytelling and Western medical information in a Talking Circle format.

SETTING: Community at large COUNTRY OF ORIGIN: United States LANGUAGE: English, Lakota and

Winnebago DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes.

Development Date: 2000 Revision Date: Unknown Current Program Status: Unknown

Program Description: During a diabetes wellness Talking Circle, the Talking Circle participants, who number between five and 20, sit in chairs placed in a circle. The Talking Circle facilitator leads, guides and maintains the group process by first creating a comfortable environment that emphasizes safety and confidentiality. Next, the Talking Circle facilitator welcomes everyone and asks someone in the group to offer a prayer to the Creator (higher being). The facilitator then delivers information on a specific type 2 diabetes topic from the curriculum. The Talking Circle is open to all; each participant is given the opportunity to speak and many told traditional stories and/or a story about their experiences. A Talking Circle participant, when speaking, may hold a feather, rock or other symbolic item. During this time, the speaker takes the lead in sharing experiences, stories and information with the group. While one person speaks, the facilitator and the other Talking Circle participants respect and support the speaker by honouring them, being present and

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attending to their words. After each person has had a chance to contribute, the facilitator summarizes the events and the Talking Circle is closed. Program Goals: The double aim is to impart knowledge related to diabetes risk factors and to improve self-management of type 2 diabetes. Program Implementation Steps: The outline of the Diabetes Wellness Project's 12-week curriculum is as follows: 1. Introduction 2. Diabetes perceptions 3. Diabetes facts and prevention 4. Diabetes secondary prevention 5. Nutrition basics 6. Nutrition preparation 7. Nutrition traditional foods 8. Healthy lifestyles ­ physical 9. Healthy lifestyles ­ emotional/spiritual 10. Healthy lifestyles ­ family 11. Healthy lifestyles ­ community 12. Closure Program Delivery Sources: The facilitators had expertise in the culture and were trained on Talking Circle facilitation and various aspects of type 2 diabetes as a condition. The facilitators wore many hats. The functions they fulfilled included coordinating the Talking Circle times and meeting places; ensuring that healthy food was served at each Talking Circle; recruiting and retaining Talking Circle participants; delivering educational curriculum; leading and expertly guiding the ensuing Talking Circle discussion in the old oral tradition; and collecting data and measurements. Process Evaluation: Each participant was interviewed about both their experience in the program and whether or not they altered their lifestyle as a result of the Talking Circles.

Outcome Evaluation Results: Talking Circle participants talked about recent changes in lifestyle, diet and physical activity. The Talking Circles were stated to be effective and accepted by Talking Circle participants. It is a desirable cultural tool for encouraging people to really talk to each other, listen to each other and support each other. Program Reach: Individuals living within a First Nations reservation Community Supports: Part of Aboriginal culture. Start-up Costs: Unknown, although likely limited to facilitator training and meeting costs Ongoing Implementation Costs: Minimal Critical Points That Need to be Replicated: It should be stressed that Talking Circle facilitators knew the Talking Circle participants personally. This played an important role in recruiting the participants, keeping them engaged and guiding the Talking Circle process. People interviewed in the research study said they had been invited personally to participate by the facilitator. In a small community, word of mouth is an effective vehicle. The Talking Circle was said to be a good thing and people joined. In addition, the Talking Circle was held at convenient times to accommodate busy schedules. Description of Contextual Factors: The community was Northern Plains American Indian reservations. Talking Circle is an ancient resource still used by numerous American Indian tribes to construct collective decisions and carry out a group process. The Talking Circle format created a culturally appropriate avenue to convey information to Talking Circle participants; oral tradition and storytelling provide the educational foundation. The Talking Circle format has been used to teach culture and traditions, and for health education and promotion. Noted past research

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has demonstrated congruence between the integration of health education and a cultural custom such as the Talking Circle. Generalizability: Accepted cultural methods of sharing information and supporting other individuals, such as Talking Circles, can be used as an effective method of sharing information and feelings about diabetes.

Materials Available for Program Adaptation: An outline of the curriculum and a list of questions asked during interviews upon completion of Talking Circle program are available. Lessons Learned: Talking Circles are a desirable tool for encouraging people to really talk to each other, listen to each other and support each other. However, researchers and health professionals should be aware that it might take years to structure and mobilize American Indian communities to successfully influence type 2 diabetes prevalence.

PROGRAM CONTACT:

Lorelei De Cora

SEVA Foundation ­ Native American Diabetes Project and Diabetes Wellness: American Indian Talking Circles Project

References: Struthers, R., Hodge, F S., Geishirt-Cantrell, B., & De Cora, . L. (2003). Participant experiences of talking circles on type 2 diabetes in two Northern plains American Indian tribes. Qualitative Health Research, 13(8), 1094-1115.

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Telecare Therapeutic Education

BRIEF PROGRAM OVERVIEW A telecare program was used as a replacement for face-to-face outpatient appointments. The telecare system may be useful in improving metabolic control, self-management knowledge and skills, and Diabetes Quality of Life (DQOL) scores, with lower patient and family costs compared to conventional intensive follow-up. This improvement was maintained at 12 months in both groups.

Promising Practice

PROGRAM FOCUS: Type 1 diabetes PROGRAM LEVEL: Individual level TARGET AUDIENCE: Adults (ages 19-64) SETTING: Healthcare settings COUNTRY OF ORIGIN: Spain LANGUAGE: English and Spanish

DES PROCESS STANDARDS MET

2. Plans for diabetes education are client-centred and ongoing. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes.

Development Date: Unknown Revision Date: Unknown Current Program Status: Unknown

Program Description: The telematic communication component used the GlucoBeep Patient Software. The GlucoBeep device is attached to the glucose meter and the device's loudspeaker is attached to the participant's telephone microphone. After the glycemic values are sent electronically, patients are invited to leave a one-minute message about their insulin doses and events. This data is uploaded by the diabetes team, which then provides appropriate counselling. There is also GlucoBeep Patient Software for use on the Internet, which provides the same information (this study looked at the GlucoBeep phone device). The study participants had nine telematic appointments with the GlucoBeep system and three outpatient appointments.

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Program Objectives: The study measured participants' metabolic control, self-management and quality of life at the beginning of the study, six months (end of study) and 12 months. Patient and family costs as well as health provider costs related to appointments were also evaluated. Program Delivery Sources: The program was delivered by healthcare providers. Process Evaluation: The study included 40 patients, 20 allocated to the telecare group and 20 allocated to the intensive conventional group. Participants in the telecare group spent an average of 15 hours to complete the follow-up (including nine thematic and three hospital visits, while the patients in the control group required an average of 48 hours to complete the face-to-face follow-up. In addition, the diabetes team spent an average of six hours for follow-up with the control group and only three hours with the telematic group. There were technical problems with the GlucoBeep system so the study authors conclude that this specific system was not considered sufficiently sound, practical or cost-effective, but they do conclude that an interactive telematic system integrated in an intensive follow-up period achieves similar improvements as found with face-to-face follow-up. Outcome Evaluation Results: Improvement in metabolic control was similar in both groups at six months (end of study) and at 12 months, with a decrease in the frequency of mild hypoglycemia. Both groups also showed a significant increase in the knowledge test DQK2 scores and in the proportion of participants who performed readjustments of insulin doses considering self-monitoring of capillary blood glucose after three or more daily adjustments. Patient costs were lower in the telematic group than in the control group in the length and cost of appointments, depending on where the patient lived.

Program Reach: The study included 40 patients, 20 allocated to the telecare group and 20 allocated to the intensive conventional group. Start-up Costs: Unknown Ongoing Implementation Costs: Unknown Description of Contextual Factors: Study participants were between the ages of 18-50, had had type 1 diabetes for at least two years, were being treated with at least three doses of insulin/day and had HbA1c >8%. Lessons Learned: The communication device used for telematic care needs to be reliable, sound and able to provide all of the data required by the diabetes team.

PROGRAM CONTACT:

M. Jansa

Diabetes Unit, Hospital Clinic 170 Villarroel St. 08036 Barcelona, Spain Email: [email protected]

References: Jansa, M., Vidal, M., Viaplana, J., Levy, I., Conget, I., Gomis, R., et al. (2006). Telecare in a structured therapeutic education program addressed to patients with type 1 diabetes and poor metabolic control. Diabetes Research and Clinical Practice, 74(1), 26-32.

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Urban Church-Based Program

BRIEF PROGRAM OVERVIEW The intervention was designed as a culturally relevant diabetes risk reduction program for Samoan community members within a Seventh Day Adventist Church. The study was facilitated by the pastor and the church's Health and Temperance Committee, and delivered by a diabetes nurse specialist and two Samoan women (a trained diabetes educator and an aerobics instructor). The intervention consisted of education sessions and fitness classes.

Promising Practice

PROGRAM FOCUS: Type 2 diabetes PROGRAM LEVEL: Group level TARGET AUDIENCE: Samoan adults SETTING: Church COUNTRY OF ORIGIN: New Zealand LANGUAGE: Samoan and English

DES PROCESS STANDARDS MET

1. Diabetes education is based on ongoing, client-centred needs assessments of individuals and/or communities. 2. Plans for diabetes education are client-centred and ongoing. 3. Implementation of diabetes education is client-centred and facilitates learning. 4. Diabetes education services partner with other resources and services required by individuals, support persons and/or communities affected by diabetes. 5. Diabetes education is provided according to the practice standards of the healthcare professional involved. 6. The effectiveness and quality of diabetes education services are regularly evaluated and revised, as needed.

Development Date: Not stated Revision Date: Not stated Current Program Status: Unknown

Program Description: A four-session awareness intervention that addressed the nature of diabetes, its symptoms and longterm consequences if uncontrolled was delivered by the Samoan diabetes educator. Participants were supported after the awareness sessions with exercise groups led by the Samoan aerobics instructor. Program Implementation Steps: Before the sessions began, two Samoan women were trained to deliver the program (one trained as a diabetes educator and the other as an aerobics instructor).

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The intervention consisted of four diabetes awareness sessions held as part of the Saturday church services. Materials used during the sessions included pamphlets, a video, flip charts and posters. All were uniquely designed for Pacific Islands people. The Samoan diabetes educator was the main presenter at each of the sessions and acted as an interpreter for the English portions of the intervention. The sessions addressed the nature of diabetes, its symptoms and long-term consequences if uncontrolled. After the awareness sessions, exercise groups were organized for program participants (featuring sitting exercises, low-impact aerobics, walking and sports). The exercise sessions were held every week for the first year of the program and twice a week after that. Exercise participation was encouraged with quarterly prizes for the best attendance, a major prize at the end of the year, reduced membership fees at a local gym and onsite exercise equipment at the church. The intervention also included cooking demonstrations provided during two blocks of four sessions. Program Delivery Sources: The program was delivered by a diabetes nurse specialist and one of two Samoan women who were members of the churches involved in the program. One of the women was trained in diabetes fieldwork and as a community diabetes educator; the other woman was trained as an aerobics instructor. Process Evaluation: Participation rates for each of the program components were tracked by the study authors. Significantly more women than men participated in the cooking sessions. Participation in the rest of the program components were similarly attended by both genders, except for the diabetes support group, which was also attended by significantly more females. Each of the program components was rated for its usefulness. None of the program components were reported as `not very useful' or `not at all useful.' The diabetes screening, blood pressure monitoring and anthropometric measurements were rated as useful or very useful by 93% to 97% of participants.

Outcome Evaluation Results: The study results show that there was no weight gain, a decrease in waist circumference, increased diabetes knowledge, increased exercise activities and reduced reported dietary fat intake among the intervention participants. Community Supports: The program could not have occurred without the support of the church leaders and the Samoan community. Critical Points That Need to be Replicated: Throughout the program, ongoing `networking' discussions were held with individual church leaders and members to ensure that the intervention remained culturally relevant. The program was delivered by members of the community. Description of Contextual Factors: The authors indicate that the church in the Pacific Islands community has become the centre and focus of life for many Pacific Islands people. Generalizability: The program has been expanded to additional churches with predominantly Pacific Islands congregations.

PROGRAM CONTACT:

Dr. David Simmons

Department of Medicine Middlemore Hospital Otahuhu, Auckland, New Zealand

References: Simmons, D., Fleming, C., Voyle, J., Fou, F Feo, S., & ., Gatland, B. (1998). A pilot urban church-based program to reduce risk factors for diabetes among western Samoans in New Zealand. Diabetic Medicine: A Journal of the British Diabetic Association, 15(2), 136-142. Simmons, D., Voyle, J. A., Fou, F Feo, S., Leakehe, L. ., (2004). Tale of two churches: Differential impact of a church-based diabetes control program among Pacific Islands people in New Zealand. Diabetic Medicine, 21(2), 122-128.

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Funding for this publication was provided by the Public Health Agency of Canada. The opinions in this publication are those of the authors and do not necessarily reflect the official views of the Public Health Agency of Canada.

Best and Promising Practices in Diabetes Education

The Canadian Diabetes Association works in communities across the country to promote the health of Canadians and eliminate diabetes through our strong nationwide network of volunteers, employees, healthcare professionals, researchers, partners and supporters. In the struggle against this global epidemic, our expertise is recognized around the world. The Canadian Diabetes Association: setting the world standard. diabetes.ca | 1-800-BANTING

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