Alliance to Reduce Disparities in Diabetes

Chicago Team at the 2014 Midwest Regional Meeting of the Society of General Internal Medicine

Diabetes Empowerment Program: Changes in patient self-confidence, diabetes self-management, and health outcomes

Midwest Regional Meeting of the Society of General Internal Medicine
September 4-5, 2014
Chicago, IL

Authors
Peek, M.E., Geary, N., Gao, Y., Rowell, D.J., O’Neal, Y., Roberson, T.S., Whyte, J.L., Bergeron, N., & Chin, M.H.

Introduction
African-Americans disproportionately suffer from diabetes and its complications. Although culturally tailored education can improve diabetes self-management and health outcomes among this population, little prior work has combined diabetes education with patient/provider communication training to empower African-American patients to better manage their disease.

Methods
As part of a larger intervention, we developed the Diabetes Empowerment Program, a 10-week program that combined culturally-tailored diabetes education with skills training in patient/provider communication and shared decision-making. The education classes were modeled after the BASICS diabetes curriculum, and were adapted based on principles of health literacy and adult learning theory. Session length was adjusted to reduce the volume of information shared per session and audio visual aids supplemented written materials.  The shared-decision making classes focused on building patients’ skills and confidence in asking more questions, giving more information, clarifying/restating what the doctor says, and communicating health care preferences. The classes utilized role-play, narrative, group interaction and problem-solving. Following the 10-week session, patients were invited to join a monthly support group for ongoing learning, skills building and social support. Patients were recruited to participate in the classes from two university clinics and four federally qualified health centers.

We utilized in-person surveys to measure the following: 1) patients’ self-confidence about shared decision-making and diabetes self-management (i.e. decision-making empowerment and diabetes self-efficacy), 2) patient’s behaviors regarding diabetes self-management behaviors and shared decision-making (i.e. patients’ perceived involvement in care, blood sugar testing, exercise, healthy eating, and foot care), and 3) intermediate health outcomes (i.e. HbA1c, systolic blood pressure, weight and LDL cholesterol). Data were collected at baseline, immediately following the intervention (post), 3-months, and 6-months post intervention.

We used linear mixed models to assess changes between baseline data and three follow-up points, controlling for age, gender, education, health insurance, number of years since diabetes diagnosis, self-reported health status, and co-morbidities (e.g. stroke, asthma, hypertension, hyperlipidemia).

Results
Among the 118 patients (with at least one follow-up data point), the mean age was 57 years, 78% were female, 97% were African American and 40% were uninsured or Medicaid-insured. The average baseline HbA1c was 8.8%.

Patients’ self-confidence about diabetes care significantly improved after program participation in decision-making empowerment and diabetes self-efficacy (Table 1).  Significant improvements in diabetes self-management behaviors were also observed after program participation. Patients perceived themselves to be more involved in their care, and reported higher frequencies of exercising, testing blood sugar, and doing foot examinations. No significant findings were observed in healthy eating.

After program participation, significant changes in intermediate health outcomes were also observed. There was a significant decrease in HbA1c from baseline, which was sustained at the 6-month follow-up. Additionally, a significant decrease in weight was observed at the 6-month follow-up. No significant changes in LDL values or systolic blood pressure were observed.

Discussion
Our findings suggest that combining culturally-tailored diabetes education with skills training in patient/provider communication can be an effective strategy to improve self-confidence and behaviors in self-management and shared decision-making, and also improve diabetes-related health outcomes. Such strategies may serve to reduce diabetes disparities among African-Americans.

Table. 1 Changes in self-confidence, diabetes self-management behaviors, and intermediate health outcomes in the Diabetes Empowerment Program

Outcome

Time

Adjusted mean (CI)

p-value

Decision-making empowermenta

 

baseline

80.9 (76.8,85.1)

 

post

92.2 (87.7,96.7)

<0.001

3-month

89.2 (83.4,95.0)

0.002

6-month

90.6 (85.1,96.1)

<0.001

Diabetes self-efficacy a

 

baseline

67.0 (60.6,73.4)

 

post

76.6 (69.8,83.5)

<0.001

3-month

69.7 (61.0,78.4)

0.47

6-month

81.3 (72.9,89.7)

<0.001

Patients' perceived involvement in care a

 

baseline

68.0 (58.1,77.9)

 

post

77.9 (67.2,88.6)

0.03

3-month

81.2 (67.6,94.8)

0.02

6-month

82.8 (69.9,95.6)

0.008

Exercise b

 

baseline

3.1 (2.3,3.8)

 

post

3.5 (2.8,4.3)

0.10

3-month

3.1 (2.2,4)

0.86

6-month

4 (3.1,4.9)

0.01

Blood sugar testing b

 

baseline

4.4 (3.6,5.1)

 

post

5.2 (4.4,6)

0.01

3-month

5 (3.9,6)

0.22

6-month

5 (3.9,6)

0.24

Foot care b

 

baseline

4.3 (3.6,4.9)

 

post

5 (4.3,5.7)

0.01

3-month

4.6 (3.7,5.5)

0.43

6-month

5.1 (4.2,6)

0.03

HbA1c

baseline

8.8 (8.1,9.4)

 

post

8.1 (7.4,8.8)

<0.001

3-month

8.1 (7.3,8.9)

0.02

6-month

8.1 (7.3,8.9)

0.04

Weight (pounds)

baseline

245.6 (226.1,265.1)

 

post

246.2 (226.4,265.9)

0.85

3-month

239.4 (218.6,260.2)

0.20

6-month

231.4 (209.9,252.9)

0.02

a Scale from 0 to 100, low to high
Number of days per week