Learning to Live With Diabetes: Educative Intervention for Improving Self-Management

Purpose: Diabetes is a big public health problem worlwide. It is estimated that there are 415 million of people with this non comunicable disease and it could increase to 642 million in twenty five years. In Mexico the prevalence of previously diagnosed diabetes in 2016 was 9.4%. The increase of 2.2% relative to 2012 was not significant and only observed in patients older than 60 years however is pending to know total prevalence of this natonal survey. As hyperglycemia is one of the main characteristics of this disease, the presence of microvascular and macrovascular complications is one of the greatest risks. Complications have increased in Mexico and are the main cause of hospitalization, morbidity and mortality increasing health care costs. To delay or reduce these complications, glycemic control becomes essential and self-care behaviors are necessary. These behaviors include healthy eating, physical activity, glucose monitoring, medications, problem solving, healthy coping and risk reduction. The improvement of glycemic control through self-care management in adults in Mexico is urgent. The Mexican health system has recognized the importance of diabetes management through different strategies implemented in the health sector, it has improved the access to care and treatment, however, national studies show an inadequate glycemic control of people with diabetes. Because of the foregoing, it is evident the need to implement an intervention in patients with type 2 diabetes to improve their self-care and glycemic control, so it was proposed to implement a pilot educational intervention that provides them with cognitive skills and support for the management of their diabetes. Purposes a) to test the feasibility of the educational intervention (including its acceptability, and further refine intervention materials and study procedures) for improving self-care behaviors in low income Mexican people with type 2 diabetes; b) To test the initial efficacy of the intervention on participants with T2DM on the following outcomes from Time 1 (Baseline-0 months), Time 2 (Post Intensive Intervention-2 months), and Time 3 (After 3 months on their own-5 months): The primary outcome included glycated hemoglobin (A1c) from Time 1 to Time 3. The secondary outcomes included adiposity (waist circumference, triceps and subscapular skinfolds) and weight status (body mass index [BMI]), and diabetes self-management behaviors (Stanford Diabetes Questionnaire) from Time 1 to Time 2 and Time 1 to Time 3.

Methods: The study used a two-group (experimental group = 25 participants and control group = 25 participants) repeated measures design to evaluate the feasibility of the intervention with participants of Mexican heritage from Tampico, México. The experimental group received an intervention focused on type 2 diabetes self-management weekly for 8 weeks and then had 3 months on their own. The control group received usual care. Data collection was at Time 1 (Baseline-0 months), Time 2 (Post Intensive Intervention-2 months), and Time 3 (After 3 months on their own-5 months). The control group received usual care. Inclusion criteria for participants was age 18 to 60 years old; self-identification as Mexican heritage; fluent in Spanish; diagnosed with T2DM for at least 1 year; and receive their medical care at the Community Health Center and had received permission from their health care provider to join the study. Participants were excluded if they were found to have a heart murmur, congenital heart disease, family history of sudden death, difficulty walking or exercising or history of psychological problems that would prevent participation in group classes. The intervention was based on social cognitive theory, which posits that learning and practicing new behaviors and coping skills enhance self-efficacy, which, in turn, increases the probability that new behaviors will be maintained. The diabetes group visits were developed according to the American Diabetes Association Clinical Practice Guidelines from one author in this study. Each experimental patient received 8 weekly classes over 2 months in Spanish. Two nurses interventionists with experience teaching participants with diabetes were trained. The modules have been tested in English in the U.S. and have been highly successful and have been translated into Mexican Spanish. The classes included understanding diabetes and A1C goals, exercise goals, weight goals, cholesterol and blood pressure goals, portion control, fast food, and sweetened beverages, improving diabetes self-management goals using social problem solving, improving nutrition goals using social problem solving, and improving exercise goals using social problem solving. After informed consent, we collected the following data in a private room in the same order: height, weight, waist circumference, triceps and subscapular skinfolds, finger stick A1C, and self-management and self-efficacy questionnaires. Data collection took total of 45-60 minutes for each patient. Data analysis included descriptive and inferential statistics in the SPSS program. Ethical consideration were according to Helsinki declaration.

Results: This study showed the fifty participants were from 36 to 60 (M = 49.84; SD = 5.76) years of age. Seventy-six percent (n = 38) were female and 24% (n = 12) were male. Educational preparation was mainly 42% (n = 21) with primary school and 36% (n=18) with secondary school. In clinical data: From Time 1 to Time 3 (p = .518) there were no significant differences in hemoglobin A1C. The intervention group started at 9.92% and decreased to 8.73% and the control group started at 9.08% and decreased to 8.32%. Both groups decreased from Time 1 to Time 3, however, the intervention group decreased 1.19% and the control group decreased 0.76%. There was a significant difference at Time 2 (p < .001) and Time 3 (p = .057) in that the intervention group had fewer episodes of hyperglycemia compared to the control group in the past week. There was a significant difference at Time 2 (p = .009) and Time 3 (p = .011) in the intervention compared to the control group felt more confident that they knew what to do when their blood sugar went higher or lower than it should be.

Conclusions: Short educative interventions in people with diabetes can increase self-efficacy and self-management mainly in glycemic control (A1c) but not in anthropometric measurements which need more time to produce changes. This study need to be replicated in order to explore other factors.Key words: intervention, diabetes, self-management.