Enhancing the (cost-) effectiveness of diabetes self-management education: A comparative assessment of different educational approaches and conditions for successful implementation
Diabetes is one of the most common non-communicable diseases (NCDs). According to the newest data of the IDF´s DIABETES ATLAS (Whiting, Guariguata et al. 2013) there are almost 32 MIO diabetes cases (in the adult population between 20 and 79 years of age) in the European Union of which almost 50% are undiagnosed. Another 37 MIO EU citizens have impaired glucose tolerance (IGT) a form of pre-diabetes. Diabetes and diabetes related conditions can impose severe health risks. In 2012 almost 272 TSD people died EU wide from diabetes related causes. Diabetes is as well of economic importance, since throughout the EU the diabetes related expenditures amounted in 2012 to more than 82 BIL Euros.
Scientific evidence of the last decades shows that many diabetic outcomes can be influenced by appropriate diagnosis, therapy and disease management. Modern diabetes management regimens emphasise, a side from medical and therapeutic interventions, especially diabetes self-management (DSM) education as a strategic a corner stone (Mensing et al. 2007 in Diabetes Care).
The diabetes literacy project is an international EU funded 7th Framework Programme project that focuses on specific aspects of DSM in the EU member states (MS) (http://www.diabetesliteracy.eu/). It is coordinated by the University of Louvain. The other operative partners are the Technische Universität Dresden, University College Dublin, Universiteit Maastricht, University of Shouthampton, The Regents University of California and Clalith Health Services (Israel). The Ludwig Boltzmann Institut for health promotion research (LBIHPR) is the Austrian Partner of the project. The operative partners lead the different work packages (WP) of the project. (1) National diabetes strategies will be investigated using an internet survey and a document review. (2) Knowledge on cost effectiveness will be substantiated by using bottom up costing methods. (3) To assess the impact of organizational factors as well as health literacy on the delivery of DSM programs a literature review will be undertaken and HL measures will be included in the pre-post evaluation study. (4) Implementation fidelity of DSM Programs will be assessed by questioning key informants of DSM service providers using a specifically developed assessment tool. (5) Questions regarding how to best design web-based materials for the growing population of patients with basic literacy and computer skills will be addressed by developing a web based DSM tool and a qualitative and quantitative study thereof. (6) Dissemination strategies of project results to scientists, politicians and other stakeholders will be developed within a stakeholder analysis.
The WP let by the LBIHPR has the aim to evaluate the effectiveness of four different kinds of DSM programs: individual educations (in one-on-one sessions), group educations (DSM classes with a professional educator), IT based educations and self-help groups.
The foundation of the LBIHPR´s work package of evaluating and comparing DSM programs, is a rationale for which outcomes should be included in effectiveness measures. Therefore, the field’s most prominent outcome classification framework that was developed by the AADE (American Association of Diabetes Educators), is primarily used. This framework (AADE7) regards behavioural outcomes as the prime outcome of DSM programs and differentiates seven self-care behaviours (American Association of Diabetes Educators, 2008). With this AADE7 framework as core the LBIHPR developed a project specific outcome classification system in order to further emphasize additional outcome categories like “patient empowerment” and “health outcomes” that may as well be regarded as important dimensions of DSM program effectiveness.
The objectives of the LBIHPR WP are:
- To assess the effectiveness of existing individual, group, and IT based diabetes self-management education and self-help programs.
- To compare the relative effectiveness of existing individual, group, and IT based diabetes self-management education and self-help programs.
- To assess in how far individual training is more effective than group based or IT based education or self-help programs
The LBIHPR will use a pre-post evaluation study design in order to assess and compare program effectiveness of existing DSM programs.
The WP consists of 7 different tasks :
- A Literature review on effectiveness of diabetes self-management interventions that has already been performed and resulted in a project specific outcome classification system.
- Protocol development to identify eligible and comparable DSM programs. This intervention identification protocol has already been set up a
- Protocol development of a survey protocol containing instrument application, definition of the study population and guidelines for sampling.
- Instrument development based on the outcome classification system and the AADE7 framework. This involves an interactive process with other WP´s.
- Get ethical approval or exempt from ethics commission.
- Data collection: Data collection will be carried out by national partners, following the LBIHPR´s survey protocol.
- Analysis and reporting.
- Publication in peer-reviewed journal
Research ethics is prominently addressed in the projects grant agreement with the EU and is therefore reflected in the projects official description of work (DOW). An ethical subcommittee (ESC) was set up for the project; this subcommittee will monitor the ethical issues that will arise within the project. Any empirical research within the project has further to be approved by the appropriate national/local/institutional ethic commission.
Status / Timeline
Pre-Post differences for all four intervention types will provide evidence on relative effectiveness of the different types of DSM education. Especially for the hypothesis that the individual approach is more effective than group based, IT based or self-help approaches.
Planned Products / Publications
The LBIHPR will produce 2 deliverables, both are defined as publications:
- A report on a Diabetes Self-Management Outcome Framework (LBIHPR-Workingpaper)
- A peer-reviewed publication on the effectiveness of individual, group and IT based diabetes self-management education and self-help programs, based on the comparative study.
Röthlin, F., Pelikan, J.M., Ganahl, K. on behalf of the diabetes literacy consortium (2016):
Development of a Diabetes Self-Management Outcome Framework (DSMOF) for the Diabetes Literacy Project. Working Paper No. 13 of the LBIHPR. Vienna. Austria.
Jürgen M. Pelikan (PI), Florian Röthlin, Kristin Ganahl, Sandra Peer, Lukas Baumann
Video Diabetes Literacy: