The current diabetes education experience: Findings of a cross-sectional survey of adults with type 2 diabetes

Highlights

• Diabetes education varies in content, mode, setting, and provider type.

• Diabetes education access and uptake are low.

• Many persons with diabetes do not receive diabetes education at recommended times.

• For those who receive diabetes education, the amount (or dose) received is low.

• Often diabetes education does not include safety topics like when to see a doctor.

Abstract

Objective

To survey persons with type 2 diabetes (PWD) on their experiences with diabetes education to better understand what it means when a PWD says they have “had diabetes education.”

Methods

We conducted a cross-sectional descriptive study among a convenience sample of adult PWD receiving primary care and/or diabetes self-management education and support in a mid-Atlantic regional US healthcare system. Descriptive, bivariate, and regression analyses were used to describe and explore the diabetes education experience.

Results

Participants (n = 498) were majority female, African American, and non-Hispanic. Half reported having “had diabetes education.” Of those, 44% had only one session. Education was most often provided in clinical settings by a dietitian (68%) or doctor (51%), in one-on-one (70%) sessions. While most participants reported receiving core diabetes knowledge, fewer reported education on topics that are not related to their daily routine, such as what to do about diabetes medications when sick.

Conclusion

The self-reported diabetes education experience varies in content, modality, setting, and education provider. Education receipt is low, and for those who receive education, the amount is low.

Practical Implications

The diabetes education experience may fall short of the comprehensive US National Standards-recommended process. Innovative strategies are needed to address these gaps.

Introduction

Diabetes is a complex chronic medical condition which impacts over 34 million Americans [1]. To successfully manage this condition, the person with diabetes (PWD) must make multiple daily self-management decisions and perform complex health care activities. PWD spend an average of less than 20 min per visit 3–4 times a year with a health care provider and therefore must self-manage this condition the rest of their 6000+ waking hours [2]. Diabetes self-management education and support (DSMES) empowers PWD to adopt healthy self-care behaviors and problem-solving skills which are essential to living well with diabetes [3].

DSMES is defined as the ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care [4]. The Association of Diabetes Care and Education Specialists (ADCES) and the American Diabetes Association (ADA) delineate National Standards for DSMES in the US [5]. A comprehensive DSMES process incorporates the needs, goals, and life experiences of the PWD. The ADCES and ADA recognize four critical times for DSMES referral, namely at time of diagnosis, annually and/or when not meeting treatment targets, when complicating factors develop, and at transitions in life and care [4].

There is a robust evidence base which supports the value of DSMES. DSMES alone improves hemoglobin A1C (A1C) by as much as 1 unit (1.0%) in PWD [4], [6], [7], [8]. When DSMES is combined with intensive diabetes medications management facilitated by remote patient monitoring, even greater reductions in A1C have been shown [9], [10], [11], [12], [13], [14]. DSMES has a positive effect on other clinical, psychosocial, and behavioral outcomes [4], [7]. It has also been shown to be cost-effective via reduction in hospitalizations and by reducing estimated lifetime health care costs related to a lower risk for complications [9], [15].

Despite the strong body of evidence for the effectiveness of DSMES and recommendations for its utilization in the ADA’s Standards of Medical Care in Diabetes [16], it remains underutilized as a service in the US [17], [18], [19], [20], [21]. Underutilization has been attributed to barriers at multiple levels, including the health system/program, providers, PWD willingness to participate, and the environment [4]. While lack of insurance coverage has been identified as a barrier to DSMES, these services are underused even in insured populations [19], [21].

In a regional US health care system, the Certified Diabetes Care and Education Specialists (CDCES) have identified significant gaps in knowledge of diabetes self-care behaviors among PWD referred for services [9], [22]. Examples include a lack of understanding of how to recognize and treat low blood glucose (BG), how to self-administer insulin properly, the need for avoiding sugary beverages, the importance of checking BG levels, how to take diabetes medications safely, including on sick days, and when to call the doctor or go to the emergency room. Anecdotally, many PWD in the system reported either never having received any diabetes education or having not had an education update for many years. Even when the PWD reports that they have “had diabetes education,” significant deficits in knowledge and self-care skills often still exist.

To better design DSMES efforts to reach and engage PWD and to close knowledge gaps, it is important to understand the PWD experience of diabetes education. In this study, we conducted a diabetes education experience survey among adults with type 2 diabetes receiving primary care services and/or referred for DSMES in a mid-Atlantic regional US health care system. We sought to explore the variety of diabetes education experiences the members of such a cohort have had. The primary aim was to establish a baseline of patient experiences of diabetes education, including occurrence rates and dose of diabetes education, content areas taught, educator delivering the content, education modality, and education setting. In addition, the study aimed to determine whether any patient characteristics are predictive of receiving diabetes education and whether any education characteristics are predictive of diabetes outcomes, specifically A1C.