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Can J Diabetes 36 (2012) 214e217
Canadian Journal of Diabetesjournal homepage:
www.canadianjournalofdiabetes.com
Perspectives in Practice
Patients’ Perspectives on Their Use of Diabetes Education Centresin Peel-Halton Region in Southern Ontario
Enza Gucciardi MHSc, PhD a,*, Vivian Wing-Sheung Chan HBSc, PhD(c) b, Brian Kam Chuen Lo BASc c,Mariella Fortugno BASc d, Stacey Horodezny BAA, RD e, Susan Swartzack BScN, MPA, RN f
a School of Nutrition, Ryerson University, Toronto, CanadabDepartment of Psychology, University of Waterloo, Waterloo, Canadac School of Nutrition, Ryerson University, Toronto, Canadad School of Nutrition, Ryerson University, Toronto, Canadae Trillium Health Centre, Toronto, CanadafMississauga Halton Local Health Integration Network, Toronto, Canada
a r t i c l e i n f o
Article history:Received 6 February 2012Received in revised form6 February 2012Accepted 6 February 2012
Keywords:attendancediabetes education centresdiabetes mellitusdiabetes self-management educationpatient satisfaction
Mots clés:fréquentationcentres d’enseignement sur le diabètediabète sucréenseignement sur la prise en charge dudiabète par le patientsatisfaction des patients
* Address for correspondence: Enza Gucciardi, ANutrition, Ryerson University, 350 Victoria Street,Canada.
E-mail address: [email protected] (E. Gucciardi
1499-2671/$ e see front matter � 2012 Canadian Diahttp://dx.doi.org/10.1016/j.jcjd.2012.07.009
a b s t r a c t
Objective: This study aimed to explore patient utilization of and barriers to attending diabetes educationcentres (DEC) in Southern Ontario, Canada.Methods: Internet questionnaires were completed by 221 individuals living with diabetes in the Peel-Halton region of Ontario.Results: Approximately 67% of respondents attended a DEC. The majority reported gaining a betterunderstanding and ability to manage diabetes. Regular DEC follow-up was relatively low. Reasons forfinding DEC visits unhelpful include a lack of individualized or tailored services, insensitive staff, andperceiving no benefits from attending. Common reasons for individuals never attending a DEC includediabetes education being provided by primary care physicians (PCPs), lack of DEC promotion from PCPs,patients’ perception of knowledge and confidence in managing the disease, and inconvenient DEClocation and program scheduling.Conclusions: DEC utilization appears to improve patients’ perception of their ability to manage diabetes.Creating better partnerships between PCPs andDECs could improve referrals to and patient participation atDECs. Delivering more accessible and patient-oriented services could improve patient retention at DECs.
� 2012 Canadian Diabetes Association
r é s u m é
Objectifs : Cette étude avait pour but d’explorer la fréquentation et les obstacles à la fréquentation descentres d’enseignement sur le diabète (CED) chez les patients du sud de l’Ontario, au Canada.méthodes : Les questionnaires en ligne ont été remplis par 221�individus atteints de diabète de la régionde Peel et Halton en Ontario.Résultats : Approximativement 67�% des répondants ont fréquenté un CED. La majorité a rapporté avoiracquis une meilleure compréhension et de meilleures habiletés de prise en charge du diabète. Le suivirégulier en CED a été relativement faible. Les raisons justifiant l’inutilité des visites en CED incluent unmanque de services individualisés ou personnalisés, l’insensibilité du personnel et la perception de ne tireraucun avantage à fréquenter les CED. Les raisons fréquemment rapportées par les individus pour ne jamaisfréquenter un CED incluent le fait que l’enseignement sur le diabète est fourni par les médecins de soinsprimaires (MSP), lemanquedepromotiondesCEDpar lesMSP, laperceptiondespatients sur la connaissanceet la confiance liés à la prise en charge de la maladie, et l’emplacement et l’horaire inappropriés des CED.Conclusions : La fréquentation des CED semble améliorer la perception des patients sur leur habileté deprise en charge dudiabète. La création d’unmeilleur partenariat entre lesMSP et les CEDpourrait améliorerl’orientation et la participation du patient au programme des CED. Une offre de services plus accessibles etorientés vers le patient pourrait améliorer la fidélisation des patients à la fréquentation des CED.
� 2012 Canadian Diabetes Association
ssistant Professor, School ofToronto, Ontario, M5B 2K3,
).
betes Association
Table 1Demographic characteristics
Characteristics n (%) ormean � (SD)
Sex (n¼203)Male 104 (51.2)Female 99 (48.8)
Age group (n¼206)18e34 years 14 (6.8)35e49 years 31 (15.0)50e64 years 79 (38.3)65e74 years 45 (19.8)75e84 years 35 (17.0)84 years of age and older 1 (1.0)
Type of diabetes (n¼220)Type 1 diabetes 30 (13.6)Type 2 diabetes 180 (81.8)Prediabetes 7 (3.2)
When first diagnosed with diabetes (n¼217)Within 1 year 23 (10.6)1e5 years ago 62 (28.6)6e10 years ago 51 (23.5)11 or more years ago 81 (37.3)
Mean number of other health problems (n¼221) 2.64 � 1.80Annual household income (n¼190)Under $20,000 25 (13.2)$20,000e$29,999 20 (10.5)$30,000e$39,999 17 (8.9)$40,000e$59,999 29 (15.3)$60,000e$79,999 15 (7.9)$80,000e$99,999 20 (10.5)$100,000 and Over 34 (17.9)
Highest level of education reached (n¼184)Less than high school 25 (13.6)Competed high school 54 (29.3)Completing undergraduate university or college degree 10 (5.4)Competed undergraduate university or college degree 78 (42.4)Completing postgraduate university degree 1 (0.5)Completed postgraduate university degree 16 (8.7)
Country born in (n¼208)Canada 110 (52.9)Other 98 (47.1)
SD, standard deviation.
E. Gucciardi et al. / Can J Diabetes 36 (2012) 214e217 215
Introduction
Diabetes mellitus is a chronic illness that requires a lifelongcommitment to complex lifestyle modifications. Diabetes self-management education (SME) is recommended by the CanadianDiabetes Association (CDA) as a valuable resource that empowerspatients to participate in themanagement of their diabetes (1). SMEfacilitates an understanding of the disease, its management, andthe development of technical and problem-solving skills requiredto attain andmaintain glycemic (blood sugar) control. It is generallyprovided by nurses and dietitians at Diabetes Education Centres(DECs). Individuals who understand how to manage their diabetesare more likely to engage in regular self-care, resulting in betterhealth (2).
Despite the documented benefits of SME in assisting patientswith self-management, studies suggest that SME delivered at DECshave been underutilized in Ontario (3,4). A recent study conductedby Shah and Booth (4) investigating the predictors and effective-ness of diabetes SME in Ontario revealed that only 30% of the 781study participants attended DECs across Ontario.
There is a large body of United States (US)-based literature thathas investigated the under utilization of DECs by studying patient-perceived barriers. These studies have found that patient barriersto DEC attendance include accessibility issues (i.e., transportationdifficulties, inconvenient location or program scheduling), longclass hours and lack of insurance coverage for SME (5,6). Othercommon barriers to attending DECs include patients’ attitudes,such as misunderstanding the seriousness of diabetes (5), skepti-cism concerning the benefits of SME (7) and greater prioritiesbesides diabetes management (7). Finally, elements of the deliverystructure of SME, such as the lack of individual tailoring, languagebarriers, and culturally inappropriate programming, can affect theuse of DECs (6,8).
Due to the scarce Canadian literature, an exploration of patients’utilization of DECswithin a Canadian context is necessary to identifyappropriate strategies to improve thedeliveryof, access toanduseofSME in Canada. This article discusses patients’ perspectives on theiruse of DECs in the Peel-Halton region in Southern Ontario. Findingsare based on a survey conducted between August and December2008 in the Peel-Halton region of Southern Ontario (excludingBrampton). Study participants completed either a hard copy or aninternet survey posted on the Mississauga Halton Local HealthIntegration Network’s website (Survey Monkey). The survey wasadvertised locally in community newspapers, and by DEC staff andaffiliated healthcare professionals.
Key questions focused on frequency in attending DECs andbarriers to attendance, and were pilot tested on 3 patients for easeand comprehension. Slight modifications were made accordingly.All analyses were conducted using SPSS version 14.0 (IBM, Chicago,IL). Frequency counts and percentages were tabulated for allresponses. Open-ended questions, “Other” responses, were sortedinto categories and themes by 2 of the authors (VC and BL). Anydiscrepancies were resolved by the first author (EG).
Results
Utilization patterns of DEPs
Sample characteristics are presented in Table 1. Among the 221respondents, two-thirds of the participants had used DEC services(66.7%); a similar percentage of participants were aware of the DECin their region (64.5%). Participants had first attended DECs becausethey had recently been diagnosed with diabetes (67.9%), had poorglucose control (9.3%), needed to start insulin treatment (7.9%), hadexperienced a change in diabetes treatment (5.7%) or had an illnessor infection (2.1%). Of these respondents, 38.1% attended regular
follow-up appointments, 32.4% attended only when they felt theyneeded to and 29.5% had attended just one appointment. Afterattending a DEC, most participants reported a “much better” or “alittle more” understanding about the nature of diabetes (92.5%).They also reported a better understanding of how to keep them-selves healthy (90.4%), and how to cope with their diabetes (88%)compared to before their visit(s).
Patient-perceived barriers to attending DECs
Figure 1 summarizes reasons for patients not finding DECservices helpful. Reasons for never attending a DEC as reported bystudy participants are listed in Table 2 and include: receiving dia-betes education fromprimary care physicians (PCPs) (48.4%), lack ofDEC promotion from PCPs (32.3%), having enough information andsupport to self-manage their diabetes (21.0%), inconvenientprogram scheduling (11.3%), lack of parking (6.5%) and long waitlists (6.5%) (Table 2).
Discussion
In the Peel-Halton Region of Southern Ontario, the majority ofthose who were surveyed attended a DEC, and they were generallysatisfied with the services. Most respondents attended when theywere first diagnosed with diabetes, had poor glucose control, orneeded to start insulin. These 3 circumstances demonstratepatients’ need for SME or re-education on self-care practices.
DEC programming was not tailored to my
needs34%
Insensitive interactions with
DEC professionals22%
Perceived futility of the service
22%
Unmotivated or not a priority
11%
Condition is not considered as
severe11%
Figure 1. Reasons for not finding DEC visit(s) helpful (n¼9).
E. Gucciardi et al. / Can J Diabetes 36 (2012) 214e217216
Supporting this finding, a Canadian study found that recentlydiagnosed patients with diabetes were more likely to attend a DEC(4). Similarly, a US study found that patients used DECs when theywanted to know more about their diabetes, when their diabetesworsened, when they started a new medication or when they hada new physician (9).
The objectives of SME according to the CDA 2008 ClinicalPractice Guidelines for the Prevention andManagement of Diabetesin Canada is “to increase the individual’s involvement in, confi-dence with and motivation to control their diabetes, its treatmentand its effects on their lives” (1). It is promising to observe that themajority of the DEC participants in our study reported that theygained a better understanding of diabetes and increased theirability to manage and cope with their disease after attending a DEC.
The most common reasons for participants never attendinga DEC include already receiving diabetes education from their PCPs,a lack of DEC information received from PCPs, high perceivedpatient confidence in their existing self-management skills andknowledge and barriers accessing DECs (i.e., hours of operation,lack of parking and long wait lists). These findings are similar tothose found in the US literature (5e7). Our previous study exam-ining referral practices and factors influencing referrals by PCPs toDECs in the same geographic region identified similar patientaccessibility barriers as reported by PCPs (10). Some of the reasons
Table 2Reasons for never attending a DEC (check all that apply) (n¼62)
Reasons Frequencyn (%)
Your own doctor provides you with diabetes education 30 (48.4)Your doctor does not promote the diabetes centre 20 (32.3)Perceive enough information and support to self-manage 13 (21.0)Inconvenient program scheduling (i.e., no evening and
weekend appointments)7 (11.3)
Parking issues 4 (6.5)Long waiting list 4 (6.5)Diabetes not serious enough to visit a diabetes centre 3 (4.8)Program is not offered in a language you feel most comfortable
in speaking3 (4.8)
You are too ill to attend 3 (4.8)Location is hard to get to 3 (4.8)Diabetes education is a low priority for you 1 (1.6)
DEC, Diabetes Education Centre.
why PCPs did not refer patients to DECs in the previous studyoverlap with patients’ own reasons for nonattendance in thecurrent study, which include PCPs providing patients with diabeteseducation, long waiting lists, and inconvenient locations and timesof services (10). Despite the benefits reported for those who receiveSME, some individuals may have a high level of confidence inmanaging their disease and may be managing well and meetingtheir glycemic target, and therefore do not see further benefits ofSME. However, further research is warranted to examine physio-logical data to verify whether those who are confident in theirmanagement and feel that they do not need to attend a DEC, arewithin the recommended clinical targets for diabetes.
Overall, there seems to be a need for better promotion of DECs. Itis important for patients to note that SME offered by DECs is notintended to substitute clinical care provided by PCPs, but rather,should be seen as complementary services. An important intent ofDECs is to provide ongoing education and support for self-care. It iswell established that long-term regular use of SME is crucial ineffective management and reaching clinically recommendedtargets (11,12). As PCPs are the predominant source of diabetesinformation according to participants in our study, it would bebeneficial for patients if DECs develop partnerships with PCPs topromote DEC services and their benefits; increasing patients’awareness of DECs is key to increasing DEC utilization. Partnershipsshould also be established at the community level, such as withchurches, public recreational facilities, and media, to furtherincrease patients’ awareness of DEC services so that patientswho donot have a PCP can then self-refer to DECs (4). Furthermore, analternative SMEdeliverymodel should be considered to tackle somecommon logistical barriers such as inconvenient times and locationto ensure patients receive SME in a timely manner. For instance,mobile diabetes teams within primary care settings in NorthernOntario represent amodel that could be used in urban areas tomeetthe needs of patients with difficulties commuting to DECs (13).
The major limitations of our study were that it had a smallsample, the survey was available in English only, and it was con-ducted within a small region of Ontario, which all limit thegeneralizability of our finding to Canadians living with diabetes.However, our findings do provide insight into the current utiliza-tion of SME in Ontario and identifies barriers that deter attendance,which can direct strategies to improve SME delivery and uptake.Based on the survey results, future research in this area cancontribute to a better understanding of DEC usage by surveyinga larger and more representative canadian population, includingnon-English speakers, to further validate our findings. Lastly, usingqualitative approaches can provide comprehensive data on patient-perceived barriers that may not be reflected in researcher-designedsurveys.
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