Commentary by:

Russell Rothman, MD, Associate Professor, Internal Medicine and Pediatrics, Vanderbilt University; Director, Van­derbilt Program on Effective Health Communication; Deputy Director, Prevention and Control Division, Vanderbilt Diabetes Research and Training Center, Nashville, TN

Definitions

Literacy: Includes reading and writing skills (print literacy), listening and speaking skills (oral literacy), cultural and conceptual knowledge, and numeracy. These are functional skills, requiring that individuals receive, understand, and interpret information and then act on that information in an appropriate manner.

Numeracy: Broadly, this is the ability to understand and use numbers and math skills in daily life. It includes perform­ing basic calculations, interpreting graphs and labels, understanding time, money, and probability, and deducing which math skills are needed in a given situation.

Impact on health

Over the past 10 to 15 years, many studies have shown the impact of literacy on health outcomes. This effect generally persists after controlling for other factors, including level of education. Literacy and numeracy skills are particularly important in the self-management of diabetes. Patients with diabetes are expected to perform many tasks — from interpreting nutritional labels to adjusting insulin — that may be affected by literacy or nu­meracy.

Interpreting nutritional labels

Study: Participants were shown various products from the grocery store and were asked several questions based on the information included in the standard nutrition facts panel.

Findings: Many patients — even those who reported regularly reading food labels — had difficulty answering the questions. Knowledge gaps involved serving size, servings per container, calculations based on intake, and percent daily values. It was also found that overweight patients and those with chronic conditions (including diabetes) per­formed worse than average on these tests.

Understanding portion sizes

Study: Participants were asked to serve what they considered a normal serving of various foods and drinks.

Findings: The phenomenon of “portion distortion” was readily apparent, with widely variable estimates of serving sizes. Estimates remained high, even after participants were given information about serving size (eg, 8 oz for one serving of juice). Furthermore, the ability of participants to accurately estimate serving size was associated with literacy and numeracy skills.

Diabetes self-management skills

A follow-up study presented participants with a quiz related to various aspects of diabetes self-management. Patients had difficulties with:

•   Serving size

•   Carbohydrate counting

•   Calculations with fractions or
decimals

•   Calculations involving multiple steps

•   Titration of medications or insulin

Improving communication

Although tools for assessing literacy and numeracy skills are available, improving communication and simplifying instruc­tions for all patients is recommended. To improve communication (print or spoken):

•   Use low-literacy materials

•   Avoid jargon

•   Focus on key concepts and actions

•   Avoid detailed discussion of anatomy and physiology (unless requested by patient)

It is important to confirm that a patient understands the new concept or instructions that were presented. This can be accomplished using the teach-back technique. If the patient does not fully understand, then the clinician or edu­cator must clarify the concept (not simply restate what was previously said), then close the loop by again asking the patient to explain the new concept or instructions. Limited evidence suggests that using this technique results in improved outcomes (eg, glycemic control).

Improving care of vulnerable patients

Rothman and colleagues conducted a study that looked at the role of literacy within a comprehensive management pro­gram. After an initial educational session, participants were randomized to usual care or intensive disease-management intervention, which was customized to literacy level. Although all patients who were randomized to the intensive inter­vention benefited (shown by, eg, improved blood pressure [BP] and glucose control), the greatest benefit was seen among low-literacy patients.

Skills and Resources for Self-Management

Interview with:

Edwin Fisher, MD, Professor of Health Behavior and Health Education, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, and Global Director, Peers for Progress

Diabetes self-management:
a 24/7 job

During the course of a year, patients spend an average of 6 hr with health professionals. This means that patients are managing their diabetes on their own for more than 8700 hr/yr — hence the need for ongoing diabetes self-manage­ment support.

Setting goals and building on success

Because the management of diabetes is a life-long endeavor, patients need to remain engaged and invested for the long haul. Allowing patients to choose which aspects of management they want to address and having them set attain­able goals increases the likelihood of success, which is important for continued motivation.

Self-management skills

For self-management to be successful, patients must not only set their own goals but have the knowledge, skill sets, and support that will allow them to achieve those goals.

The basics

•   Physical activity

•   Diet/nutrition

•   Medication

To be successful at making behavior changes, patients need to know not only what to do (eg, 30 min of physical activ­ity a day, 5 days a week), but how to do it. This requires a deeper understanding of their skills and resources.

Peers for Progress

Affiliation: American Academy of Family Physicians Foundation

Mission: To promote peer support programs around the world

Goals: To develop a state of the art for peer support; to connect peer support programs around the world; to build the evidence base for peer support; to encourage the inclusion of peer support programs in health systems and health policy.

Effects on morbidity

That self-management programs improve outcomes has been well established. Self-management programs have been associated with improved BP, hemoglobin A1C, and quality of life in academic, clinical, and community settings. There also is emerging data that they are associated with reduced morbidity and cost of acute care. Furthermore, these programs have been shown to be cost effective, with an estimated cost per quality life-year of $39,000 (which is within what is normally considered to be reasonable).

Patient Empowerment

Commentary by:

Martha Funnell, MS, RN, CDE, Research Investigator and Diabetes Nurse-Educator, Department of Medical Edu­cation, University of Michigan Medical School, Ann Arbor

Meeting patients’ needs

Patient empowerment does not simply involve being a cheerleader for patients; we must also provide them with the skills, information, and support that they need — and before those needs can be met, they must be identified. One way to identify and meet those needs is to base education on the patient’s questions and concerns. Another important element is to provide explanations that are relevant to patients’ lives and that they can apply in meaningful ways.

Keeping it simple

Although diabetes is a complex disease, simple explanations often are effective. Most patients neither want nor need to understand diabetes at the same level of detail as do health professionals. The goal is to provide explanations and information that help patients to manage their diabetes on a daily basis.

Technology in Diabetes
Education: TeleHealth

Interview with:

J. Terry Saunders, PhD, Assistant Professor, Medical Education in Internal Medicine, University of Virginia; Direc­tor, Virginia Center for Diabetes Professional Education, Charlottesville

Joyce Green-Pastors, RD, MS, CDE, Assistant Professor, Medical Education in Internal Medicine, University of Vir­ginia, Charlottesville

Outreach to rural populations

Access to healthcare and health education often is limited in rural areas. Yet some of these areas have high incidences of type 2 diabetes. Therefore, providing effective education (as efficiently as possible) is a challenging but critical task.

Telemedicine technology

Web-based technology that allows two-way communication (audio and visual) between sites at a distance.

Virginia’s TeleHealth program

Needs assessment: Researchers identified areas of the state where the incidence of diabetes is particularly high.

Target regions: Two rural areas were selected. Both are relatively remote and largely underserved, and have limited access to resources, including diabetes educators.

Satellite sites: A number of locations have been established in small hospitals, health departments, and community clinics. Patients and their families are encouraged to attend the educational programs.

Format: Each program is 2 hr long and includes a lecture portion, question and answer sessions, and interactive exer­cises. Participants are emailed materials in advance, which will be used during the program.

Facilitation: At each remote site, a trained facilitator is present to help conduct the session and encourage people to ask questions (or ask them on the patients’ behalf).

Content: The Diabetes Patient Education Program has two modules: One is a basic introduction to diabetes; the other focuses on nutrition. A pilot program on diabetes prevention uses the Power to Prevent curriculum from the Na­tional Diabetes Education Program of the National Institutes of Health (NIH).

Program assessment

Participant feedback: Participants report high levels of satisfaction and find the program useful.

Follow-up: Limited. At this point, the program is structured as an educational program only (as opposed to a comprehen­sive self-management program).

Impact: Knowledge — A test is administered before and after the program to assess baseline knowledge gaps and comprehen­sion of the program material. Behavior change — At the end of the program, participants are asked whether they intend to make any behavior changes. Most list two to three behaviors that are consistent with the information discussed in the pro­gram. At this time the program does not follow up with the participants to determine whether those behaviors were changed or implemented successfully.

Future expansion

In the era of healthcare reform, innovative programs such as these may have the opportunity for growth and expan­sion. In some states, telemedicine programs already are reimbursed; reimbursement for tele-education programs may come next.

What is needed to initiate
similar programs

•   Cooperation with multiple agencies

•   Access to telemedicine technology

•   Access to support staff or volunteers to build and facilitate the program

•   Needs assessment

•   Identification of target regions and individual sites where the programs can be held

•   Considerable amount of planning and coordination

Access to telemedicine technology

Most academic centers have offices of telemedicine, which may not be fully utilized. In addition, the technology has been adopted in some rural areas to help improve access to healthcare. But even if the technology is in place, work is required to organize the program and design the modules so that the information can be effectively conveyed using the tele-education format.

Technology in Diabetes Self-Management:
Going Wireless

Interview with:

Stephen Ponder, MD, Professor of Pediatrics, Texas A&M University, College of Medicine, College Station, TX

Wireless technology and the
Internet: How can it help
improve diabetes self-
management?

•   Simplify access to information

•   Automate information retrieval

•   Engage patients in their self-management

•   Decrease work for providers (freeing their time for other tasks)

GlucoMON technology

This automated diabetes management system connects to a glucose meter (proprietary) to collect data about a pa­tient’s blood glucose (BG) levels. It then sends the data wirelessly (an Internet connection is not necessary) to a se­cure location, where it can be organized and sent back to the patient in a simple to understand, color-coded format. The data is time-synchronized with the atomic clock, so there is no time distortion of the BG measurements.

Features include:

•   Simple presentation of BG data, facilitating pattern recognition

•   Trend alerts (via email or text message)

•   Automated reminders for patients

“We can’t manage thousands of people’s blood glucose data. We can’t play air traffic control... [The information] has to go back to the user, who decides its utility and whether to share the information with the provider.”

Effects on behavior and outcomes

Use: On average, patients check their BG levels 7.5 times/day. This has been sustained over time and occurs without intervention from the provider. Users report high degrees of satisfaction.

Patient population: The technology has been used by patients with type 1 diabetes, type 2 diabetes, and gestational di­abetes.

BG control: A randomized controlled study, which enrolled children <12 yr of age, found that use of this technology was associated with improved levels of A1C: a 1% decrease among those whose initial A1C was ³8% and a 0.5% decrease among those whose initial A1C was <8%.

Diabetes House Call

House calls to remote areas are now possible using the Internet video-phone service, Skype. Although these clinician-patient interactions do not substitute for in-person visits (eg, recommended annual evaluations), they allow more fre­quent contact with patients and improve patient satisfaction and self-management. In Texas, this service is fully reim­bursed by a number of payors.

“Blood sugars are nothing but the end result of numerous actions.”

Healthy Families

Technology: Interactive wireless mobile platform with educational modules (diabetes and asthma) uses text messag­ing to elicit information from and push information to patients.

Content: Once an individual signs up for the service (by texting “healthy” to 25827), they receive text messages ask­ing them about their health goals. Over time, the system “learns” about the person and his or her health goals and concerns. Small amounts of relevant information are then sent, via text messages, to that person. In some cases, the system sends reminders intended to improve self-management or facilitate proactive measures.

Diabetes Self-
Management Education in Diverse Populations

Interview with:

Maria B. Castellanos, RN, CDE, Nurse Educator, Kaiser Permanente, Orange, CA

Beware of one’s own prejudices…

… That is, one’s preset ideas about how people behave and about their capacity for change. A patient-centered approach to di­abetes self-management education (DSME) and support requires that clinicians and educators hand over much of the control to their patients, allowing them to set the agenda and make decisions.

ABCs of Diabetes 

•   A: A1C

•   B: Blood pressure

•   C: Cholesterol

This program was developed by the American Diabetes Association and the American College of Physicians and is promoted by the National Diabetes Education Program, the World Health Organization, and the International Diabe­tes Federation. Print and online resources provide simple explanations of important concepts related to diabetes and self-management, and they help structure tangible healthcare plans.

Leaving the visit without knowing one’s ABCs is like driving a car blindfolded.

Clinical impact

By using the ABCs of diabetes as a guide for DSME, patients understand the importance of tracking their A1C, BP, and cho­lesterol levels. The patients are able to recognize how the changes that they are implementing affect these levels — and what that means for their health. This is critical for sustaining behavior change. Using the example of BG monitoring, if patients do not understand the importance of monitoring or do not know how to lower their BG levels if they are high, they are less likely to monitor their BG levels and less likely to achieve good glycemic control.

Home BG monitoring

Providing patients with home BG meters with the capacity to upload the data to a computer and training them how to use them facilitates individualized goal setting and management. Clinicians should review the data from the monitors on a regular basis. Action plans can then be made collaboratively, based on the individual’s glycemic control and targets.

The emotional response to a
diagnosis of diabetes

Upon diagnosis, the question “am I going to die?” enters the minds of most, if not all, patients. Subsequently, a grieving process (which may last ³6 mo) is normal. This process may be prolonged if patients are not given the opportunity to dis­cuss their fears and concerns with clinicians, and clinical depression may develop.