Sustaining short-term improvements over the long-term: Results from a 2-year diabetes self-management support (DSMS) intervention
Introduction
Diabetes self-management is central to effective diabetes care [1], [2], [3], [4]. Optimal diabetes self-management calls for initial diabetes self-management education (DSME) followed by ongoing diabetes self-management support (DSMS) [4]. According to the National Standards of Diabetes Education, DSME is defined as “the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care,” and DSMS as “activities to assist the individual with diabetes to implement and sustain the ongoing behaviors needed to manage their illness” [4].
While compelling evidence demonstrates the positive impact of DSME interventions on diabetes-related health outcomes [5], [6], [7], [8], [9], without continued follow-up and support, these gains are not sustained over the long-term [2]. The short-lived benefits achieved from DSME programs may be attributed to characteristics of current models for DSME. First, DSME programs are typically time-limited. In fact, a meta-analysis of 31 RCTs examining the impact of DSME programs on glycemic control found 61% of studies (n = 19) described interventions that lasted 6 months or less [5]. Not surprisingly, short-term DSME programs will most likely produce short-term improvements. For instance, in a pilot study of 44 adults with type 2 diabetes in a primary care setting, Bastiaens et al. [10] examined the impact of a 5-session DSME program with one follow-up contact (at 3-months) on body mass index (BMI), glycemic control and quality of life (QOL). At 12-month follow-up, the group showed significant improvements in BMI, glycemic control, and QOL. However, at 18-month follow-up, the only improvement that persisted was for BMI suggesting the need for continued self-management support [10].
Current DSME models also tend to be structured and curriculum-driven [11], [12], [13], [14], often overlooking the heterogeneity of self-management needs and priorities across patients. These standardized interventions consist of a set number of sessions delivered in a pre-determined sequence with each session devoted to a specific self-management topic [11], [12], [13], [14]. While a standardized curriculum may be useful in the initial acquisition of core self-management concepts, this DSME model is not compatible with the complex and ever-changing challenges patients encounter over the long-term. In “real-world” settings, patients do not experience living with diabetes in a sequential order or in discrete categories.
To sustain diabetes-related health gains, effective models for long-term DSMS need to be ongoing and accessible to patients over the course of their lives in addition to being flexible to the unique and continually evolving needs of each patient. Thus, patient empowerment is an approach that is ideally suited for long-term DSMS [15], [16], [17], [18]. The principles of patient empowerment underscore (1) the proactive role of the patient in making daily self-management decisions, (2) a collaborative patient–provider relationship which assumes the provider in an advisory role to the patient who exercises final control of self-management decisions, and (3) the importance of patient-selected self-management goals in initiating and sustaining meaningful behavior change [19]. An empowerment-based DSMS model is designed to accommodate individual differences in self-management needs and to be responsive to how these needs change over time.
To test this empowerment-based DSMS model, this study specifically recruited participants who had received previous DSME (inclusion criteria). To ensure that all participants had a similar level of baseline knowledge, we provided participants with 6 months of mailed DSME designed to reinforce and/or enhance DSME received in the past. The 6-month DSME enhancement period was followed by Lifelong Management (LM), a 24-month empowerment-based DSMS intervention delivered in a group setting. While we recognize that 24 months is still considered “time-limited,” theoretically, this model could be designed to be ongoing with no defined endpoint. The objectives of this study were two-fold:
- 1.
To examine the short-term impact of a 6-month DSME enhancement period on clinical, self-care, and psychosocial outcomes.
- 2.
To examine the long-term impact of a 24-month empowerment-based DSMS intervention on sustaining the health-related gains achieved from previous DSME and a short-term, 6-month DSME enhancement period.
Section snippets
Participants and recruitment
This study received approval from the University of Michigan Institutional Review Board and recruited African-American (AA) adults with type 2 diabetes living in the greater Ypsilanti, Michigan area. Recruitment strategies included posting flyers in local organizations, community and health centers; taking out newspaper advertisements, and making invited presentations at local AA churches. Those interested in participating were instructed to call a toll-free number to undergo eligibility
Characteristics of the sample
Table 1 presents the demographics of the sample. At baseline, we recruited 89 participants. At the end of the 6-month intervention, we retained 77 participants (attrition rate 13%); and at the end of the 24-month LM intervention, we retained 60 participants yielding an attrition rate of 33% (below the expected rate of 40% from baseline to 30-months). Participants were between the ages of 40 and 84 years with a mean of 62 years (SD = 10.2). Thirty percent (n = 18) were men; 70% (n = 42) were women and
Discussion
Lifelong Management (LM) is an empowerment-based model ideally suited for long-term DSMS because it is designed to be patient-driven and flexible to the unique needs, priorities, and life circumstances of each individual. This study examined the long-term impact of the 24-month LM intervention on sustaining the self-management gains achieved from previous DSME and a short-term, 6-month DSME enhancement period.
According to our findings, not only did the LM intervention sustain improvements
Conflict of interest
There are no conflicts of interest.
Acknowledgments
This study was supported by a K23 patient-oriented career development award from National Institutes of Health, K23 DK068375, National Institutes of Diabetes and Digestive and Kidney Diseases, and by a grant NIH P60 DK20572 from the National Institute of Diabetes and Digestive and Kidney Diseases.
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2018, International Journal of Nursing StudiesCitation Excerpt :The benefits were deemed to extend to other Asian populations who perceive blood glucose self-monitoring as a distressing and expensive activity (Chan et al., 2009; Ong et al., 2014; Tan and Magarey, 2008). Contrary to the findings of earlier work using usual care as control groups, there were no significant improvements in medication adherence and exercise (Peña-Purcell et al., 2011; Tang et al., 2012). This might be explained by satisfactory levels of both medication use and exercise at the baseline in the current sample, potentially leaving little room for improvement in response to intervention.