Self-management education (SME) is defined as a systematic intervention that involves active patient participation in self-monitoring (physiological processes) and/or decision making (managing) (1). It recognizes that patient-provider collaboration and the enablement of problem-solving skills are crucial to the individual's ability for sustained self-care (2).
Several meta-analyses have demonstrated that SME is associated with clinically important benefits in persons with type 2 diabetes, such as reductions in glycated hemoglobin (A1C) of 0.36% to 0.81% (1,3,4). Improved quality of life (QOL) for persons with either type 1 or type 2 diabetes also has been demonstrated (5), as have other important self-care outcomes in those with type 2 diabetes, such as sustained weight loss and cardiovascular (CV) fitness for up to 4 years (6). One systematic review involving both type 1 and type 2 diabetes found that, as measures progressed from immediate to long-term outcomes, percentage of improved outcomes reduced (immediate learning 78.6%, intermediate behaviour change 50.0%, long-term clinical improvement 38.5%) (7). A 5-year follow-up of a patient-centred type 2 diabetes SME program resulted in no worsening of A1C, whereas the A1C in the control group rose 1.3% over the 5 years (8).
Diabetes SME is evolving from a traditional didactic teaching program to one using a variety of educational, psychological and behavioural interventions, and a combination of didactic, interactive and collaborative teaching methods that are tailored to the individual's specific needs (9). The content and skill-training components of SME must be individualized according to the type of diabetes and recommended therapy, the patient's ability, barriers, motivation for learning and change, culture and literacy level, and available resources (4,10,11). Models for systematizing, organizing and/or guiding the development of SME programs (12,13)share a 5-step problem-solving process aligned with the empowerment protocol (14)based on the principle that adults are more likely to make and maintain behaviour changes if these changes are personally meaningful and freely chosen (14). In order to meet the definition of “self-management education,” problem-solving skills for ongoing self-management of medical, social and emotional aspects of care must be integrated into the traditional knowledge and technical skills content of educational interventions (2). These skills are needed to inform decisions and increase the individual's capacity and confidence to apply these skills in daily life situations (2). SME refers to any of the educational processes that provide persons with the knowledge, skills and motivation required to inform decisions and increase the individual's capacity and confidence to apply these skills in daily life situations. Self-management support (addressed in the Organization of Care chapter, p. S20) refers to policies and people that may support continuation of self-management behaviours across the lifespan but that are not specific to educational processes.
Self-identification of a problem or need for self-care behaviour by the individual is crucial to all cognitive-behavioural interventions (14,15). The healthcare provider's role is to collaboratively facilitate this awareness process (2). Standardized instruments, such as the Problem Areas in Diabetes (PAID) (16), Self-care Inventory-Revised (SCI-R 2005) (17)or Summary of Diabetes Self-Care Activities (18), may have value in this process (19), although they have been used mainly for research purposes.
Interventions targeting knowledge and skills
Basic knowledge and skill areas that are essential for SME are monitoring of relevant health parameters, healthy eating, physical activity, pharmacotherapy, prevention and management of hypo-/hyperglycemia, and prevention and surveillance of complications. Skill training should include using self-monitoring of blood glucose (SMBG), making appropriate dietary choices, incorporating an exercise regimen, using medications as recommended and adjusting medication (20,21).
In general, education sessions provided to patients with diabetes have resulted in positive changes in diabetes-related knowledge (22), as well as psychological (23–26)and behavioural ( 23,27) domains. With respect to A1C, most trials involving group-based education have shown sustained A1C reductions (i.e. between 4 and 12 months), ranging from 0.4% to 0.7% (22,23,26,28). The Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) trial, a structured group education program for persons with newly diagnosed type 2 diabetes, resulted in greater improvements in weight loss, smoking cessation and positive improvements in illness beliefs up to 12 months after diagnosis; however, no significant effect on A1C was noted at 12-month follow-up (25).
In those studies that used print-based education, significant changes in behaviours related to physical activity (27), stage-of-change progression (29), weight loss (27)and improvements in glucose control (30)have been noted. Randomized trials of computer- or video-based education models have demonstrated improvements in at least 1 behaviour change related to healthy eating and physical activity ( 7,31).
All trials evaluating a culturally appropriate education module (which incorporated cultural or religious beliefs, were offered in the patient's native language, adapted dietary advice to reflect cultural traditions and the patient's needs, and/or involved family members) have noted improvements in diabetes-related knowledge, self-management behaviours and clinical outcomes, with A1C reductions ranging from 0.5% to 1.8% (32–35). These findings demonstrate the importance of creating culturally relevant educational materials.
Interventions for content and materials geared toward patients with low literacy and numeracy can be successful in improving outcomes, such as A1C, self-efficacy and blood pressure (BP) (36). Training healthcare professionals in specific communication skills to address low literacy can also be effective (37,38).
While the majority of randomized controlled trials (RCTs) examining skill-training interventions used face-to-face individual sessions (39–43), some have used face-to-face group sessions (44), a combination of face-to-face group and individual sessions (26)and video-based programs for home viewing (45). One study that compared insulin-initiation skills training provided in a group vs. an individual setting found no difference in A1C, rate of hypoglycemia, BP, lipid profile or QOL between the 2 approaches; however, differences in weight gain and time spent in follow-up appointments or calls favoured individual training sessions (44). Most interventions were delivered by nurses (26,39,43,44)or diabetes educators (42). In general, skill-training interventions demonstrated positive changes or no significant differences in outcomes compared to control. For example, contrasting results were found in the 2 trials examining the impact of SMBG skills training: 1 study found an improvement in A1C, low-density lipoprotein cholesterol (LDL-C), body mass index (BMI) and self-care activities with skills training (40), whereas the other found no difference in A1C and BMI but an improvement in total cholesterol (TC) and TC to high-density lipoprotein cholesterol (HDL-C) ratio (41).
The acquisition of knowledge should be augmented with behavioural interventions to achieve longer-term change in self-care behaviours (3,23,25,46). Behavioural interventions had a larger effect size (ES) on self-management behaviours (ES −0.92) and on metabolic outcomes (ES 0.63) than knowledge-based or other psychological interventions (9). The more appropriate term may be “cognitive behavioural” interventions, which include cognitive restructuring, problem solving, cognitive-behavioural therapy (CBT), stress management, goal setting and relaxation. All of these recognize that personal awareness and alteration of causative (possibly unconscious) thoughts and emotions are essential for effective behaviour change (47).
Several trials have found various cognitive-behavioural interventions to be effective in lowering A1C (4,15,48), improving QOL (49,50)and increasing self-care behaviours (15,23), whereas others have shown mixed results (3,46). Interventions that combine strategies for knowledge acquisition and self-care management (25,46)have been proven to be more effective in increasing knowledge, self-efficacy and self-care behaviours and in achieving metabolic control than programs that are didactic and knowledge oriented alone (4,9,15,51). Cognitive-behavioural interventions share common elements, including a patient-centred approach, shared decision making, the development of problem-solving skills, and the use of action plans directed toward patient-chosen goals (23,25,52).
A trusting, collaborative patient-healthcare professional relationship is also important for improving self-care behaviours (4). Frequent communication is a key indicator for successful interventions, whether done by a multidisciplinary team in a hospital or a community setting (33,53). Effective patient-clinician communication may improve adherence to recommendations (54). Communication technologies, such as e-Health and telemedicine with videoconferencing and teletransmission of home glucose monitoring, show promise for delivering individualized messages over an extended time period (52). Using a combination of different instructional methods that consistently incorporate an interactive component has been found to have somewhat more favourable effects than didactic programs (9,53).
Family and social support has positively impacted metabolic control and self-care behaviours (32,33,55). In both type 1 and type 2 diabetes, interventions that have targeted the family's ability to cope with stress have resulted in fewer conflicts, and having partners involved in care has been found to impact glycemic control (55).
Family and culturally tailored interventions are particularly relevant in minority communities. Several RCTs and systematic reviews have demonstrated that culturally competent healthcare interventions have resulted in lower A1C levels and improvements in diabetes-related knowledge and QOL (32,33,49).
Both individual and group settings have been used for cognitive-behavioural interventions, but there is no definitive conclusion as to which setting is superior (9,23). In general, group settings have been found to be more effective for weight loss and short-term glycemic control, whereas group interventions combined with individual follow-up sessions have resulted in lower A1C levels than either setting alone (10). Connecting with community partners and other chronic care model programs has proven to be a successful adjunct to cognitive-behavioural interventions (49,52,56). RCTs have concluded that different behavioural strategies are needed at different times to sustain behaviour change in the long term (56,57).
SME reinforcers and technological innovation
Incorporating booster sessions enhances the effectiveness of SME interventions (9). While healthcare providers play an essential role in SME delivery, patients are largely responsible for the majority of their own diabetes management. Historically, healthcare providers have been challenged with providing continued self-management support between visits. More recently, however, the availability of several different technologies (e.g. the internet, web-based education, text messaging [58–62], email, automatic telephone reminders , telehealth/telephone education [64–67]and reinforcement [68–72]) has provided an effective and time-efficient means of providing this ongoing support.
Several small trials have demonstrated improved outcomes when utilizing these technologies, reminder systems and scheduled follow-ups compared to controls. Outcomes include increased frequency of SMBG (58,63,71), improved adherence to treatment algorithms (31), improved self-efficacy (64–66)and QOL (70), as well as improved clinical outcomes, including reductions in A1C (59–62,65,69,73)and weight (67,68). However, 1 study of online diabetes education found no improvement in outcomes with the use of reinforcement methods (74).
A meta-analysis of studies examining the use of telemonitoring, home monitoring, telecare and telemedicine demonstrated a significant impact at the behavioural, clinical and structural levels (75). These strategies also resulted in significant reductions in A1C and diabetes-related complications, patient empowerment and improved patient understanding. However, the magnitude of the effect varied across studies and appeared to be dependent on the background characteristics of the patient population (e.g. ability for self-management, medical condition), sample selection and the approach to the treatment of control subjects.
Professional and peer delivery
Peer facilitators may augment multidisciplinary team practices in providing SME and/or social support, especially when developed as culturally relevant behavioural interventions for underserved populations (35). Two studies of the 6-week Diabetes Self-Management Program (DSMP) demonstrated the feasibility, but mixed effectiveness, of peer delivery of this standardized diabetes education program in Hispanic (71)and non-Hispanic populations (76). The DSMP was associated with significant A1C reductions in the Hispanic group (−0.4%) but not in the non-Hispanic group. Significant improvements in other outcomes, including decreased health distress, improved global health, decreased depressive symptoms, improved self-efficacy and improved communication with physicians, were noted in both groups (71,76). In another study, a culturally tailored outreach and education program delivered by trained community health workers (CHW) was associated with significant improvements in self-care behaviours and similar A1C reductions compared to nurse-led case management and standard clinic care (77). Of note, the dropout rate was significantly lower in the CHW group (28% vs. 50% in the standard group), suggesting that the CHW may provide a trusted, culturally relevant and sustainable component to standard diabetes care (77).
The superiority of peer-delivered programs over similar programs delivered by health professionals has not been demonstrated in general populations with type 2 diabetes. A large study found that a peer-support intervention (i.e. 9 group sessions over 2 years) was not effective when targeted at all patients with type 2 diabetes (78). Another large study comparing specialist (nurse and physician) delivery to peer delivery of a 6-week, structured, interactive diabetes education program found no significant differences in either knowledge or A1C outcomes between the groups. However, the specialist group scored significantly higher in process and participant evaluations (79). Studies of the incremental effect of peer educators show much variability in terms of behaviour change and clinical outcomes (80,81). The specifics of training requirements for peer educators have not been clarified, and significant variations in training, scope of practice and issues of governance remain.
No particular delivery strategy (e.g. video, web-based/online, phone, face-to-face, mixed) appears to result in consistently superior outcomes in persons with type 2 diabetes; however, larger effect sizes have been noted with strategies that involve personal contact with healthcare providers, either via face-to-face interactions or by telephone (9). A combination of didactic and interactive teaching methods, as well as group and individual sessions, appears to be most effective for persons with type 2 diabetes (9).
Since 2004, there has been a clear increase in the use of multifaceted programs that incorporate behavioural/psychosocial interventions, as well as knowledge and skills training, with a marked reduction in didactic educational programs that focus on knowledge or skill acquisition only (3). Interventions that include face-to-face delivery, a cognitive-behavioural method and the practical application of content are more likely to improve glycemic control (11,48). The most effective behavioural interventions involve a patient-centred approach, shared decision making, the enablement of problem-solving skills and the use of action plans directed toward patient-chosen goals. Steps to success in SME are summarized in Figure 1.