Abstract

Title: Diabetes self-Management Education in Community Gathering for Adults with Type-

2 Diabetes in Tiruvallur, Chennai, India.

Introduction:

Over the next decade it has been projected that the total number people with diabetes will elevate to

200 million in world .The intended health promotion program will help patients with type 2

diabetes to develop self management skills and becoming empowered to avoid diabetic

complications, as there is no cure for it. Research studies have shown that if blood glucose level is

not maintained, it will lead to stroke, cataract and other cardio vascular diseases.

Aims:

Diabetes self-management education is an interactive, collaborative process that can equip adults

with basic knowledge to manage their type 2 diabetes while focusing on their self-identified

problems and goals. It emphasizes problem solving and decision making as they relate to core

diabetes self-care skills such as healthy eating, physical activity, proper dental care, and monitoring

blood glucose level.

Objectives:

The intended program will help type 2 diabetes patients, irrespective of their racial or ethnic

backgrounds, to develop appropriate diabetes management knowledge and skills. Among the

participants, blood sugar level will improve, potentially leading to a decrease in diabetes-related

complications and premature death.

Discussion:

To tackle the problem of diabetes, there are so many programs running at primordial and primary

level in India, but less at tertiary level .So, this community based program will let target population

to become empowered, it is especially important for reaching people who have limited access to

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formal healthcare, do not speak native language, or may not have the option of home-, clinic-,

school-, or worksite-based diabetes education.

Conclusion:

According to the studies conducted, community based diabetes self-management education program

has been proved to be effective in halting diabetes related complication. In addition, program can be

bolstered by taking other determinants of health in consideration and making modifications in

existing social and government policies .Moreover, it will help in its sustainability.

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Introduction:

Diabetes is a group of disorders sharing the common features of sustained high blood sugar level.

Diabetes cannot be cured; it is a common, serious, chronic disease (WHO). It affects health and

life expectancy, has major financial and social impacts and its more prevalent form (type2) is

preventable diseases. The less prevalent (type 1) is one of the most common chronic diseases of

childhood, it is usually genetic. But type 2 results from excess of weight and physical inactivity

and in turns can be prevented (Shah et al, 2004).

International scenario:

Diabetes prevalence has reached epidemic proportions worldwide as we enter the new

millennium. According to the W.H.O, ‘there is an apparent epidemic of diabetes which is

strongly related to lifestyle and economic change’. Over the next decade the projected number

will exceed 200 million and mostly will have type-2 diabetes. There are approximately 1.3

million people in the U.K who are known to have type 2 diabetes ,this figure will rise to 3

million by 2010 ( Wild et al 2004; WHO, diabetes ).

Indian scenario:

There are about 40 million people affected by diabetes (U.N, 2004). Most Indians develop

diabetes at an early age and have greater incidence of obesity. The prevalence is escalating at

enormous pace. According to WHO (India), there were 46 million people with diabetes in 2007.

As economic progression is directly proportional to urbanization, there is a hike in the number of

people with diabetes in India (Ramachandra et al, 2000).

It’s also estimated that the diabetes prevalence will increase from 6% to 9% in 2025 as a result of

increased life expectancy, where the aged population (50 and above) will increase from 16% to

24% between 2007 and 2025 (U.N, 2004).

Sequel of diseases:

Type 2 diabetes is also linked with other non-communicable diseases. Various research studies

concluded that it is a major risk factor for other associated conditions. Odds and risk ratio

associated with diabetes as risk factor for cataract (Pradeep et al., 2002) {OR -8.5, C.I – 3.63 to

20.12}, Neuropathy (Ashok et al. 2002) {OR-1.4, C.I- 1.20 to 6.40}, Stroke (Ramachandra et

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al ,1999){OR- 1.7 ,C.I 1.1 to 2.6}. In addition, attributable risk of 4% for stroke, 2% for

neuropathy and 32% for cataract cases shows that all these post complications can be avoided if

individual haven’t acquired diabetes (Ramachandra et al). Diabetes also accounted for 11.57

million year of life lost and for 22.63 million DALY’s during year 2007 (WHO, India).

From the meta-analysis of epidemiological studies conducted in India. It has been observed that

prevalence rate in urban is almost thrice as compared to rural areas (Sandeep et al. 2002;

Ramachandra et al., 2000).

Chennai as an evidence of rising prevalence:

Chennai is perhaps the only city in India, where a series of population based studies have been

conducted, which has enabled investigators to compare the prevalence rates. Studies done in the

same urban (Tiruvallur) area for past 15 years have shown a rise in prevalence from 8.3% to

14.3% from 1995 to 2005. Thus there was 72.3% rise in the prevalence (Sandeep et al. 2002,

Mohan et al, 2003).

Fig .1(Source, Sandeep et al. 2002)

With such high prevalence, there will be large number of people suffering from diabetes and its

complications. We will target retired people with diabetes and help them to manage the condition

by educating them. Targeting retired people will help us to overcome the problem of ‘population

paradox’ (Rose 1992).

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Strategies:

1. Community based health promotion [Diabetes Self Management Education Program

(DSMEP)]

2. Secondary prevention (Rose, 1992)

Secondary prevention will help to identify those who have already developed the disease and to

halt progress. It will be accompanied by an awareness program, life style changes and supportive

environment all through community bases. This will focus on entire population or community as

whole. The goal of Diabetes Self Management Support Program (DSMEP) will be to empower

people in the community using risk and health oriented approach (Downie et al., 2004) to avoid

post-complications of the diseases. This program will provide knowledge, information and

support for the development of necessary management skills and will work with the people to let

them choose their own agendas with health professionals as facilitators. There is also evidence

from meta-analysis of different studies that group-based education programs are significant in

reducing blood pressure and body weight, and increase self-empowerment, quality of life, self-

management skills and treatment satisfaction (Deakin et al., 2005; Hawthorne K., 2008;

Renders, 2000). Moreover, reviews have shown that, for every five patients attending a group-

based education program one patient is expected to reduce diabetes medication and post-

complication (Deakin et al., 2005; Norris et al., 2002).

Model used:

Proceed-Precede model (Green & Kreuter, 1991, 1999) will be used to begin the planning

process, by assessing the target audience at multiple levels. This model will help to recognize

multiple determinants of health (Marmot and Wilkinson, 1999) and the program will be started

with an assessment of the quality of life and social problems, as ultimate goals, of which health

is a contributory factor.

1. Social, epidemiological, environmental and educational assessment will be done to

understand the perceived needs of the community, prioritized them and setting program

goals.

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2. Administrative and policy assessment – Information gathered from the previous steps

will help us to identify key resources needed, policies and regulation that could affect the

program.

3. Evaluation:–

Process evaluation- before implementing the program we will do an evaluation to

gauge the extent to which program is carried out according to action plan

Outcome evaluation- At the end we will look at whether the intervention has

affected health and knowledge of patients in the expected way

Identifying the needs and priorities of community to set goals:

The target group (patients already with diabetes) priorities will be assessed prior to

implementation of interventions because the structure and scope of program will be developed

according to the needs of the intended program participants. Besides, the program for pregnant

women will be different from a retired diabetic patient. For gaining people’s support, conduct

focus group and semi-structured interviews will be conducted with prospective program

participants and their families. This will help to understand the current level of basic diabetes

knowledge of prospective participants, assessing their environmental and personal barriers to

improved Diabetes Self Management Self Education Program (DSMEP) participation (like-

Transport and time limits, child care needs , cultural and community practices , poor access to

clinical care , lack of social support , food quality and physical activity opportunity)

Existing partners and key stakeholders will also be identified and will be engaged in the

program. Various stake holders could be:

Adult residents with type 2 diabetes

Existing diabetes education and general program in clinical and community settings

Physicians

Other health professionals like diabetes educator

Community health worker

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Local and national diabetes organizations

Community leaders

Local media( television, radio , newspapers , internet)

Community gathering places for DSMEP

The program will be delivered at the locations which will be acceptable and easily accessible for

the participants. Community centers, faith-based institutions, libraries, and private facilities (e.g.,

Diabetes risk reduction centers) will be the potential sites (Reff????). To evade poor outcomes

unacceptable and inaccessible places will be avoided and transportation will be provided for the

participants to attend DSME classes.

Theory:

The program will be based on theory of community building (Minkler 1999) and community

organization theory (Rothman 2001), as this program is intended to be user led, facilitated with

the help of health professional and empowering people (Wallerstein, 1992) to gain mastery over

their lives in context to improving equity and quality of life. The community will become more

empowered, will work on specific issue linked with other groups, to take wider action and

ultimately will be engaged in collective political and social action. Involvement in self group or

action group will provide opportunities for further personal development and individuals can

become more critically aware of the wider social forces that are acting on them and their

community (Wallerstein, 1992). In contrast, this model of community organization can be too

much problem-based (seeking solutions to predefined problems), and may have its roots from

approaches that were significantly dependent upon outside technical expertise and professional

support. In addition, community building on empowerment is conceptually attractive, but

difficult to deliver. It requires high level of trust and commitment between those involved, and a

willingness by health promotion workers to relinquish power.It can be challenging, if

marginalized and disenfranchised groups in the society are considered (Sidell et al., 2003).

There can be other determinants of health (Marmot and Wilkinson, 1999) for the target group

because these can indirectly influence their health. They can be:

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Social stratification factors - Age , sex , hereditary factors

Personal behaviour factor – smoking , physical inactivity , psychological factor(stress)

Social and community factor- ethnicity, religion , family , peer group

Living conditions – access to health services , source of livelihood ,access to leisure

facilities , regional location

General economic, cultural and environmental conditions – Environment , Advertising ,

Housing tenure.

Type of program

An amalgamation of lifestyle change and supportive environment for managing the condition

will be used in the program. The program will focus on skills building activities ,where we will

contribute to modify life style factors including maintenance of Body Mass Index (25 or less) ,

eating healthy diet rich in cereal fibres and polyunsaturated fats and low saturated and trans fat

and glycemic load, exercising regularly, abstaining from smoking and consuming moderate

alcohol. Research shows that ,if above factors are adopted, the chance of developing type-2

diabetes will be alleviated by 90% (Tuomilehto et al., 2001; Wing et al., 2001; Knowler et al.,

2002; Frank et al., 2001).

The program will also incorporate skills for enhancing self-efficacy (e.g. personal goal setting,

collective problem-solving to overcome self-identified barriers to diabetes self-management) and

overcoming psychosocial factors that may hinder diabetes self-management, lessons that teach

participants skills for advocating environmental changes that support diabetes self-management

will also be taken into consideration ( access to quality food).

Risk factors:

There are some factors that are associated with an increased risk of type-2 diabetes like obesity,

previous gestational diabetes, hypertension, family history of type-2 diabetes and some ethnical

groups are more at risk. Persons with "pre-diabetes" are also at high risk: they have abnormal

blood glucose levels but not in the range of diabetes. Pre-diabetes often precedes the

development of type-2 diabetes (Orozco et al., 2008). Excess body fat is the single most

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important determinant of type-2 diabetes. Weight control would be the most effective way to

reduce the risk of type-2 diabetes (Frank et al., 2001).

Structure and scope of the program

This program will incorporate following four diabetes self care behaviour that have been proved

effective by systematic reviews conducted (Deakin et al., 2005). These are:

Healthy eating

Physical activities

Monitoring sugar level in blood

Taking medication

Existing DSMEP curricula and diabetes education material that has been determined to be

effective through evidence based research will be searched. Then it will be modified in

accordance to participant’s background like literacy level, health beliefs, cultural beliefs and

other determinants of health. We will also make decisions on items relating to curriculum

delivery, including class size, frequency, and length; lesson format; and educational strategies for

teaching adults (such as engaging participants through culturally appropriate examples). If the

program is less culturally relevant (Sidell et al., 2003) to the participants, it may result in low

attendance rates. To increase the program attraction, it will be ensured that its culturally

inclusive, sensitive and supportive, that instructor understands participants’ health beliefs,

cultural norms, and values (Downie et al., 2004), conveys information in participants’ preferred

language (Sidell et al., 2003) and at an appropriate reading level, integrate ethnic food

preferences into nutrition education and cooking demonstrations, and feature individuals of the

same racial or ethnic group in graphics and videos.

However, just educating regarding the above four self management techniques will not be

enough because there can be several other factors (Downie et al., 2004; Sidell et al., 2003)

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which do not allow the participants to adopt these factors easily even if they will be eager.

These can be:

Social norms: Inactive lifestyles have become a “social norm”. Surveys have showed that

people spend their leisure time as sedentary lifestyle (Brown et al 2003).

Personal factors: Older adults may feel out of shape, have physical disabilities, or may not want

to walk alone (King, 2001).

External factors: Research shows that environmental factors have a remarkable effect on

activity levels. People are more likely to engage in physical activities if the sources (such as

Parks) are near to them (Casper et al., 1990; King, 2001; Sallis et al., 1990).

Social interaction: People are more likely to be active if they are with other persons (Balfour J.

and Kaplan., 2002; King, 2001).

TIMETABLE WITH PROJECT MILESTONES:

This program work will start on 1 January 2010 and will end on 30 July 2011. The

program will consist of multi phases.

I January 2010-----28February2010 Need assessment of key stake holders

1March----------30 July 2010 Providing self management education

1August2010---30 April 2011 Follow up

1 May 2011---- 30 July 2011 Outcome Evaluation

Resources that will be needed to successfully implementation

Office space for staff, Meeting space, audiovisual equipment,

Hard-copy educational materials for participants , Instructional materials ( food models,

cooking equipment)

Equipment for on-site assessments of physiological measures (body weight scales, blood

pressure cuffs, glucose meters)

Hard-copy and electronic promotional materials ( flyers, registration forms)

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Items serving as participant incentives ( water bottles)

Materials for interviews, surveys, and other modes of evaluation

And other possible resource would be Program coordinator to direct program planning and

manage the program, administrative staff to provide support to the program coordinator and

instructional staff, Instructional staff to provide DSME, advisory board composed of

committed partners and stakeholders to support the goals of the program.

Evaluation methods: (Scott and Welson, 1998; MacDonal et al., 2006 ; Issel, 2004;

Mulcahy et al., 2003)

Evaluation will be conducted before and after study. To assess whether program was

implemented as intended, we will collect data on quality and effectiveness of our activities

and following question will help us to assess it.

Process evaluation: assesses actions taken in pursuit of program outcomes

Is the advisory board representative of appropriate community stakeholders?

To what extent are program participants representative of the target audience?

Has the level of participation decreased over time?

What are the program costs, from a participant and from a delivery perspective?

Outcome Evaluation: refers to the assessment of program goals to determine if discernable

changes to behaviour, attitudes, or knowledge have been attained as a result of the

intervention (Mulchay et al., 2003).

To what extent have participants achieved their self-identified behavioral goals

(e.g., quitting tobacco use, eliminating candy consumption, taking a 10-minute walk

every day, specified taking steps to reduce stress, practicing proper oral health)?

To what extent have participants improved targeted physiologic measures such as

weight, blood pressure, cholesterol, blood glucose level?

How do participants rate the improvement in their overall quality of life as a result

of program participation?

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Evaluation challenges (Sidell et al., 2003)

The Cost Challenge: Program evaluation can be expensive

The Time Challenge: Evaluation efforts may be time consuming

The Expertise Challenge: As experts may be involved to analysis of the data collected

Potential sources of collecting data for above evaluations can be:

Participant registration and attendance records, participant satisfaction surveys, Interviews,

questionnaires, and focus groups with participant (Qualitative methods).Results from

physiologic measures—such as weight, blood pressure, and blood glucose level—taken on-

site at DSME classes (Quantitative methods)

Dissemination of the DSME program

The information obtained from the community assessment and input from the advisory board

will be used to develop promotional messages about the DSME program. Marketing materials

will be developed that describe the program and the benefits to participants; using the

audience’s native language and incorporating culturally appropriate symbols and key messages.

Post flyers in stores and community gathering places (e.g. faith-based institutions, schools,

community centres, ethnic centres, senior centres, supermarkets, libraries, healthcare centres,

fitness centres, pharmacies). Also, local faith-based leaders, tribal leaders, community health

workers and other respected community figures, will be engaged for promotion of DSME

program among members of the community. The program will also offer an “open house” or

informational class about the DSME before it begins, which will address questions that

potential participants may have, provide them with an overview of the program and introducing

them to staff.

Sustaining DSME program

Following steps will be taken for sustaining the program

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Encourage participants to share their experiences in order to reduce feelings of isolation

and learn from each other.

Help participants set goals that meet their individual needs.

Give incentives (e.g. food samples, useful handouts, free glucose test strips, door prizes)

at each class.

Incorporate the target population’s culture into program components.

Foster social support by encouraging participants to bring a “buddy” to classes.

Conclusion:

It’s clear from the range of literature that Group based training for self-management strategies in

people with type-2 diabetes mellitus are effective in halting post complications. But, sustaining

the program can be a daunting task; there can be several institutional, socioeconomic or political

structural, cultural, personal factors that may hamper it. The program can be more successful if

integrated with modification on macro economic and political structure.

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