Discussion
Patients need a structured group education program when they are newly diagnosed with type 2 diabetes. Evidence from research showed that such structured programs are able to limit the patients’ weight loss and smoking incidences, which are helpful in managing the diabetes conditions.
At the same time, the structured education program is beneficial because it is effective in improving the patients’ beliefs about diabetes such that they become more responsive to treatment and other intervention programs (American Diabetes Association, 2013).
It is also useful to note that while the education program achieves its intended purpose of changing attitudes, it does not make any significant impact on actual incidences of diabetes as measured by haemoglobin A levels in research findings by Davies et al. (2008) and Adolfsson, Walker-Engström, Smide, and Wikblad (2007).
Although quality of life may not improve, the structured group education program that relies on experts is influential in improving patient satisfaction with treatment as they become more knowledgeable about diabetes and improve their physical activity levels.
On the other hand, structured individual-based lifestyle education (SILE) programs show remarkable improvements in haemoglobin A levels (Adachi et al., 2013; Tan, Magarey, Chee, Lee, & Tan, 2011).
Education targeted on community, culture and cultural events, such as the Ramadan focused education in diabetes, are effective as they are contextually relevant to patients’ situations. Not only do patients learn about their need to embrace dietary flexibility and insulin adjustment, but they also learn about hypoglycaemia, which then acts as a motivating factor for lifestyle change.
It is also instrumental in overcoming cultural biases (Bravis et al., 2010). Indeed, the culturally tailored diabetes educational interventions (CTDEI) improve glycaemic control among ethnic minorities as influenced by the settings of the intervention.
When using the CTDEI, care givers must also consider the influences of baseline haemoglobin A level and time of haemoglobin A measured as these also impact on the measured value (Nam, Janson, Stotts, Chesla, & Kroon, 2012; Moher, Liberati, Tetzlaff, & Altman, 2009).
Increase in knowledge appears as the only guaranteed result of single education and self-management, structured programme, with biomedical and lifestyle outcomes being circumstantial (Khunti et al., 2012).
In fact, as Cooper, Booth, and Gill (2008) concluded, diabetes education does not guarantee lasting benefits of glycaemic control, but it is very effective in changing patient attitudes such that they develop a positive outcome of the disease. The fact holds for education interventions carried out for different lengths between six months and two years.
The reinforcement of the education programme is essential to achieve lasting behavioural changes as Sperl-Hillen et al. (2013) concluded. This happens because conventional individual education leads to sustained improvements in self-efficiency and reduces diabetes related stress more than usual care does, but then the effects only last within the period of education (Moriyama et al., 2009; Wu et al., 2011)
In addition, the complexities of the education program do not have significant influences on the outcome, but they have a salient effect on the cost of education. The UK X-PERT programme performs as well as the UK DAFNE and the Italian BASICs, despite the other two being expensive and labour intensive (Cooper et al., 2008).
Moreover, group based diabetes self-management education (DSME) allows patients to meet and discuss with each other, which significantly contributes to better outcomes on clinical, lifestyle, and psychosocial aspects (Steinsbekk, Rygg, Lisulo, Rise, & Fretheim, 2012).
The consideration here is that the effects of the DSME are affected by ethnicity, sex, and other socioeconomic characteristics of the patients (Gucciardi, Chan, Manuel, & Sidani, 2013). Meanwhile, locally developed education programs could be less effective than programs specifically developed for studies mainly due to the lack of appropriate control features (Rygg, Rise, Gønning, & Steinsbekk, 2012; Whittemore & Knafl, 2005).
All education programs must focus on the patient because patients control behaviour choices and activities that influence their experience of diabetes. However, patients must have the necessary knowledge to properly self-manage their diabetes.
In this regard, intervention programs that focus on the patient empowerment and incorporate a means of collaborative learning to improve patient’s knowledge will be the ones that succeed as shown by Heinrich, Schaper, and de Vries (2010). When there is adequate knowledge of diabetes, patients are able to change their dietary behaviour, irrespective of the type of diabetes they have or their present treatment method.
In this regard, knowledge becomes a universal requirement for successful self-management of the disease and would be important in any education program targeting diabetes patients. As an isolated intervention, education improves self-care and metabolic control variables (IKarakurt & Kaşıkçı, 2012).
In resource constrained and pressured environments, the same educational interventions used in other settings may not work appropriately. Therefore, they should be modified to take care of the possibilities of task shifting for the experts tasked with the job of educating patients. Group motivational interviewing for the health experts and their patients helps in this case (Mash, Levitt, Steyn, Zwarestein, & Rollnick, 2012).
Implication
The effectiveness of self-care education depends on the components of self-care available in the education program and their ease of monitoring.
The combination of DSME and patient-centred care should offer care providers enough options to influence both broad and specific impacts on their diabetes patients. Working within the DSME program features to suit the context of application along parameters such as socioeconomic and cultural backgrounds, resource availability and intended outcomes can potentially make the program more effective.
The development of self-management diabetes education in Singapore will benefit from the findings that show the effectiveness of structured diabetes education. Practitioners should be aware of the potential differences in outcome between locally prepared programs and study-specific programs in terms of their effectiveness (Im & Chang, 2012).
Limitation
Despite the extensive consultation on the subject of diabetes education, there is still limited knowledge of the intervention features of DSME that actually promote behaviour change and then go on to improve clinical outcomes.
Much of what is presented in the paper covers the DSME as a whole and would, therefore, need additional research to obtain a measurable result for the five intervention features associated with DSME, together with other related features that researchers see as having positive effects on patient outcomes.
Recommendation
Future studies on self-care activities of diabetes patients should look into the efficacy aspect, in addition to the overall difference in pre- and post-intervention periods.
Evidence from the research and the subsequent discussion calls for planners of the education for diabetes patients to take care of environmental variables, patient specific challenges, when obtaining standardized results. This would then make it easier for evaluators to compare different interventions and eliminate comparison errors that may arise due to contextual differences.
Education programs need to cover a larger period of time to capture a varied number of changes in patients. In addition, there should be more divergent sample groups to provide extensive case coverage.
Conclusion
Structured individual-based lifestyle programs (SILE) are the way forward because they lead to great improvement in haemoglobin A1c as compared to usual care. Moreover, a culturally tailored diabetes educational intervention (CTDEI) is a better approach to use when targeting ethnic minorities.
This would go well with the Singaporean context, where there are ethnic majority and minority groups that may not have similar care opportunities. In addition, as a cost-intervention measure group, intervention would be a preferred mode of delivery for Singapore Diabetes Centres that are mostly running a busy schedule with a high patient volume. However, this should only happen due to budget constraints.
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