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Six-month evaluation of a diabetes self-awareness intervention
Abstract
The purpose of this pilot study was to evaluate the effectiveness of a self-awareness intervention in promoting increased awareness of body cues associated with various levels of glycemia and in enhancing well-being in persons with Type I diabetes and hypoglycemia unawareness. Study results indicated that participants could identify more cues of normal blood glucose; experienced fewer blood glucose levels below 3.5 mmol/L, fewer hypoglycemia unawareness-related events, and improved glycemia; but reported lower diabetes quality of life. The self-awareness intervention represents an innovative theory-based approach for helping clients with Type I diabetes and hypoglycemia unawareness to achieve positive health outcomes.
... Education Before-and-After. There were 20 studies in this category: 8 in unselected populations with T1D (4,21-27) and 12 in participants with IAH at baseline (9,(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38). Eight studies (22,23,24,26,29,30,33,34) were long-term, durations ranging between 1 and 3 years. ...
... There were 20 studies in this category: 8 in unselected populations with T1D (4,21-27) and 12 in participants with IAH at baseline (9,(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38). Eight studies (22,23,24,26,29,30,33,34) were long-term, durations ranging between 1 and 3 years. ...
... Twelve studies in people with IAH were small: between 5 and 30 people in 11 studies (9,(28)(29)(30)(32)(33)(34)(35)(36)(37)(38), although 1 study had .100 people (31). ...
Objective:
Impaired awareness of hypoglycemia (IAH) increases the risk of severe hypoglycemia (SH) sixfold and affects 30% of adults with type 1 diabetes (T1D). This systematic review and meta-analysis looks at the educational, technological, and pharmacological interventions aimed at restoring hypoglycemia awareness (HA) in adults with T1D.
Research design and methods:
We searched The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, Social Sciences Citation Index, PsycINFO, and CINAHL from inception until 1 October 2014. Included studies described HA status at baseline. Outcome measures were SH rates, change in HA, counterregulatory hormone responses, and glycemic control.
Results:
Forty-three studies (18 randomized controlled trials, 25 before-and-after studies) met the inclusion criteria, comprising 27 educational, 11 technological, and 5 pharmacological interventions. Educational interventions included structured diabetes education on flexible insulin therapy, including psychotherapeutic and behavioral techniques. These were able to reduce SH and improve glycemic control, with greater benefit from the latter two techniques in improving IAH. Technological interventions (insulin pump therapy, continuous glucose monitoring, and sensor-augmented pump) reduced SH, improved glycemic control, and restored awareness when used in combination with structured education and frequent contact. Pharmacological studies included four insulin studies and one noninsulin study, but with low background SH prevalence rates.
Conclusions:
This review provides evidence for the effectiveness of a stepped-care approach in the management of patients with IAH, initially with structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioral therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, in those with persisting need.
... It is believed that these strategies, such as selfawareness of salient body cues, can be taught. A fundamental concept in self-awareness is that while health professionals are experts in diabetes, individuals are expert in their particular disease (Hernandez et al., 2003). Redman (2004) states that, ―to deal effectively with chronic illness patients must learn bodily cues, emotional triggers, and their own unique response patterns and must match their decisions with their own desired quality of life, rather than one predetermined by the healthcare system (p. ...
... Self-awareness enhances the management of disease by recognizing that something is amiss and the individual is able to seek appropriate medical attention (Hernandez et al., 2003). In the case of cardiovascular disease, self-awareness can have a profound effect on the individual's outcome. ...
... Components of programs that foster self-awareness such as those in the Hernandez et al. (2003) study includes the formation of an alliance between practitioner and individual, introduction of the concept, and group and individual activities such as self-learning logs where they would document their experiences. In this pilot study of 25 adults, self-monitoring of blood glucose levels which permitted individuals to correlate feelings and beliefs with objective results was used throughout the intervention. ...
... Other measures. A learning assessment and program evaluation were completed by an external consultant at the end of the final (eighth) SAI session and 6 months post-intervention.The results of this two-part evaluation are published elsewhere (Hernandez, Hume, & Rodger, 2003). ...
... Results are presented for all post-intervention time points, but the focus of the present analysis is the 12-month and 18-month findings, since the 6-month findings are published elsewhere (Hernandez et al., 2003). Results of the study outcome measures are summarized in Table 2. ...
... Self-report of diabetes life satisfaction, measured on a visual analogue scale, increased significantly between baseline and the 6-and 18-month follow-up time points. In addition, the external consultant found that participants reported high levels of confidence and satisfaction with the SAI activities at 6-month follow-up (Hernandez et al., 2003).The DQOL may not have been an appropriate measure for this sample as it was developed and tested on younger patients (< 40 years of age) who had minimal or no complications (DCCT Research Group, 1988), whereas the present sample had a median age of 54 and did have complications. In future research, multiple quality-of-life measures will be incorporated, both generic (e.g., the SF-36 [Ware & Sherbourne, 1992]) and diabetes-specific (e.g., DSQOLS [Bott, Overmann, Muhlhauser, & Berger, 1998]), once the English-language version of the DSQOLS has been validated. ...
The purpose of this prospective before-and-after study was to determine whether there are psychosocial and physical benefits of a self-awareness intervention for adults with type 1 diabetes and hypoglycemia unawareness (HU). A total of 29 adults participated in the self-awareness intervention of 8 sessions, each lasting 3 hours. Psychosocial (integration, diabetes quality of life) and physical (number of body cues, HU-related events, HbA1c) measures were taken at baseline and at 6, 12, and 18 months post-intervention. Post-intervention the participants detected more cues of euglycemia and hypoglycemia and experienced significant increases in integration and metabolic control (HbA1c). The number of HU-related events was not decreased and diabetes quality-of-life results were unstable. A self-awareness intervention can have physical and psychosocial benefits and has implications for diabetes education. This intervention needs to be tested in a multi-centre randomized control trial.
... The insights gained during one grounded theory study point to the need for additional grounded theory research and have resulted in a program of grounded theory research for at least one nurse researcher (Olshansky, 1996). Alternatively, hypotheses from the new middle-range theory can be tested in quantitative research, including nursing intervention research (Hernandez, Hume, & Rodger, 2003, 2008Hernandez, Laschinger, Rodger, Bradish, & Rybansky, 2004;Hernandez & Williamson, 2004). ...
Glaserian grounded theory is a powerful research methodology for understanding client behaviour in a particular area. It is therefore especially relevant for nurse researchers. Nurse researchers use grounded theory more frequently than other qualitative analysis research methods because of its ability to provide insight into clients' experiences and to make a positive impact. However, there is much confusion about the use of grounded theory.The author delineates key components of grounded theory methodology, areas of concern, and the resulting implications for nursing knowledge development. Knowledge gained from Glaserian grounded theory research can be used to institute measures for enhancing client-nurse relationships, improving quality of care, and ultimately improving client quality of life. In addition, it can serve to expand disciplinary knowledge in nursing because the resulting substantive theory is a middle-range theory that can be subjected to later quantitative testing.
... More importantly, self-efficacy can be increased through performance mastery, modeling, and social persuasion (Bandura;Lorig et al., 1996). Self-efficacy has been demonstrated to result in improved diabetes control (Hernandez, Hume, & Rodger, 2003;Holman & Lorig, 2004;Lorig, Ritter, & Gonzales, 2003;Whittemore, 2000). The culturally tailored intervention used in this study integrated strategies for enhancing self-efficacy, such as using demonstration and return demonstration of selfglucose monitoring to enhance skill mastery. ...
The purpose of this article is to report the results of a culturally tailored diabetes intervention for Mexican Americans on physical activity and to report the results of a focus group with intervention participants.
Seventeen Mexican American subjects with type 2 diabetes participated in the study. The study used a pretest/posttest control group design with 10 subjects in each group (N = 20). Outcome measures included the number of steps walked weekly, weight, and body mass index (BMI). Pedometers were used to measure the daily number of steps in the intervention group. A focus group provided data on participant satisfaction.
Results suggest a positive effect of the intervention on physical activity level, weight, and sense of control over diabetes self-management. Intervention participants had a statistically significant increase in the number of steps walked per day and a statistically significant mean weight loss of five pounds. Focus group results indicate that participants were satisfied with the culturally tailored intervention and that they and their families benefited from the intervention.
A culturally tailored diabetes self-management program may result in improved outcomes for Mexican Americans with type 2 diabetes.
... In a recent study using an empowerment-based psychosocial intervention in type 2 diabetic patients, the researchers concluded that the intervention improved quality of life and improved glycemic control (Pibernik-Okanovic and others 2004). A similar study testing a collaborative alliance between patient and caregivers in a Canadian setting revealed that patients with type 1 diabetes could achieve better glycemic control when encouraged to attend to bodily cues and set goals for change (Hernandez and others 2003). These findings support results of the current study in which the emphasis was on patient empowerment. ...
The purpose of this study is to examine effects of a nurse-physician collaborative approach to care of patients with type 2 diabetes and to determine possible effect sizes for use in computing sample sizes for a larger study. Forty patients from a family practice clinic with type 2 diabetes were randomly assigned to control or experimental groups. The control group received standard care, whereas the experimental group received standard care plus home visits from a nurse, as well as consultation with an exercise specialist and/or nutritionist. Follow-up continued for 3 months. Clinical end points included standard measures of diabetes activity as well as quality-of-life indicators. Focus group interviews were used to explore patients' responses to the program. Although findings were not statistically significant, a trend toward small to moderate positive effect sizes was found in glycosylated hemoglobin and blood pressure. Quality of life measures also showed a trend toward small to moderate, but nonsignificant, improvements in physical functioning, bodily pain, vitality, social and global functioning, energy, impact of diabetes, and health distress. Focus group interviews indicated a very positive response from patients, who expressed feelings of empowerment. In this study, patients treated with nurse-physician collaboration demonstrated small, but nonsignificant, improvements in blood chemistry after only 3 months. Physical and social functioning, energy, and bodily pain also showed a small improvement. Changes in awareness of effects of diabetes on health and an expressed sense of self-efficacy suggest that effects could be sustainable over the longer term.
Statement: This dissertation is submitted to the RCN Institute in part fulfilment of the MSc in Nursing and has been conducted and presented solely by myself. I have not made use of other people's work (published or otherwise) and presented it here, without acknowledging the source of all such work. Word count is 20.004 Date _________________ ________________________________ Brynja Ingadóttir 2 Abstract The aim of the study was to explore what it is like to have a complex regimen prescribed when living with a chronic disease like diabetes, and what happens in patients' relationship with healthcare professionals when they do not adhere to the treatment regimen. The research approach was phenomenology, and the research method unstructured interviews or dialogues. The findings were constructed from 16 dialogues with 11 persons with diabetes, whom were seen as co-researchers. The data analysis was guided by the Vancouver School of Doing Phenomenology. The findings reveal a dynamic experience, full of conflicts, which can be understood as a constant attempt to live a normal and fulfilling life by balancing the regimen with physical and psychosocial wellbeing. Empirical knowledge is juggled with own experience to gain understanding and place oneself within the context of the disease as well as social context. Strict adherence to the regimen may threaten the person's need for autonomy. Extreme periods of self-deception give way to a sense of responsibility, defining what constitutes quality of life and struggling to integrate a modified treatment regimen with it. Respecting the disease without letting it dominate one's life is the key for successful integration. Different desires are in conflict, 'to do right' competes with the desire to be normal or give in to temptations that disturb blood-sugar control. Finally, overcoming fear is an important part of the experience; the remote fear of diabetes complications as well as the daily fear of hypoglycaemia and the truth. The participants in this study described how healthcare professionals use different communication approaches, enabling or disabling, that influence the adherence experience for better or worse. 3 It is concluded that the lived experience of adherence and non-adherence is a complex, dynamic and multistructured phenomenon, which the dominant biomedical model that tends to guide healthcare professionals' practices fails to describe sufficiently. It is deeply ethical in nature, it involves two parties, the patient and the healthcare professional, and conflicts may be created in their interaction, between the three ethical principles that guide practice: respect for autonomy, beneficence and justice. The challenges that meet the person with diabetes are dealt with by negotiating with oneself and healthcare professionals can provide support with authentic dialogues, based on respect and trust. Further studies on the issue of adherence are needed in order to enhance understanding and improve the healthcare services provided for patients who have difficulties with the management of their disease. 4
The purpose of this meta-analysis was to meet the need to quantify the influence of diabetes self-management training on quality of life (QOL) of adult diabetes patients.
Extensive literature searching located published and unpublished diabetes self-management intervention studies that measured QOL outcomes among at least 5 subjects with type 1 or 2 diabetes. Data were extracted from primary study reports which included interventions designed to improve diabetes self-management and adequate data to calculate effect sizes. Random-effects meta-analytic procedures were used to estimate overall effects between treatment and control groups at outcome assessment and between baseline and outcome data for both treatment subjects and control subjects.
Exhaustive searching yielded 20 comparisons across 1892 subjects. The comparisons between treatment and control group outcomes following interventions yielded an effect size of 0.281. The comparisons between treatment group at baseline and outcome measurement yielded an effect size of 0.312 to 0.313. Each of these effect sizes were statistically significant, meaning that the hypothesis that interventions to improve diabetes self-management results in increased QOL was supported. Control subjects did not experience improved QOL while participating in studies.
These findings document that people with diabetes experience improved QOL from participation in diabetes self-management training programs. Future diabetes self-management intervention studies should include quality of life outcomes so that this important outcome can be further studied. After more primary studies are available, future meta-analyses can explore important moderator analyses.
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