THE ROLE OF THE

DIABETES EDUCATOR
1. Therapeutic Patient Education

Therapeutic Patient Education is a priority of healthcare & fundamentals to integrate

people in prevention & control of non-communicable diseases.
-World Health Organization

Therapeutic Patient Education is education managed by healthcare providers trained

in the education of patients and designed to enable a patient(or a group of patients &
families)to manage the treatment of their condition & prevent avoidable complications,
while maintaining or improving quality of life.

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Therapeutic Patient Education

Aim Benefits
• Changing Health Behaviors
To acquire the competencies to help
• Improving Health Status
patients to self-manage their non-
• Improving Patient Compliance
communicable disease.
• Reduction of Personal , Economic &
Social costs.

ENVIRONMENT
In order to improve care, educators need to put themselves in place of people with
diabetes –considering their culture and how diabetes impacts their lives &
relationships.

Optimal diabetes care is best achieved by collaboration between people with diabetes,
their family members & healthcare teams that are adequately resourced & motivated
to work together.

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Therapeutic Patient Education -
DAWN Model for Diabetes & Its Goal

Diabetes Attitudes ,Wishes and Needs (DAWN) :

The DAWN program is an international partnership effort to improve outcomes of

diabetes care by increasing the focus on the person behind the disease, especially the
psychosocial and behavioral barriers to effective diabetes management.
w Promote active self-management.
w Enhance psychological care.
w Enhance communications between people with diabetes & healthcare providers .
w Promote communication & co-ordination between health care professionals.
w Reduce barriers to effective therapy .

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Therapeutic Patient Education -
DAWN Model for Diabetes & Its Goal

Me: Being able to cope with my condition, and

living a full, healthy, and productive life.
SOCIETY
Family and Friends: Emotional and practical
support in all aspects of my condition.
RE AND TREA
L CA TM
ICA EN
M
E D T Community:
AND FRIEN
M ILY DS Medical Care & Treatment: Access to quality
FA
diagnosis, treatment, care and information.
Work/School: Support for, and understanding
ME
of, my condition.
Living: Having the same opportunities to enjoy
life as everybody else.
Society: A healthcare system, government, and
public that are willing to listen, change, and be
supportive of my condition.

The DAWN needs model 2011, DAWN Study 2011 DAWN

Youth Study 2008; DAWN2 Dialogue Events 2011

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2. Multidisciplinary Team

5
Multidisciplinary Team - For People With Diabetes

In addition to physicians(e.g. primary care ,endocrinologist, obstetrician

–gynecologist,ophthalmologist). This team could include –

§ Diabetes Educators Endocrinologist Diabetes

§ Nurse Practitioners Educator

§ Podiatrists
§ Optometrists Pharmacist Podiatrist
Patient
§ Dental Care Professionals
§ Dietitians
Dietician
§ Community Health Workers
§ Mental Health Professionals
§ Pharmacist Exercise Internist, Ophthalmologist
Counselor Nurse Practitioner,
Mental Health Profession
§ Exercise Counselor

American Diabetes Association, Diabetes Car. 2008;31(suppl1):S12-S54.

6
 Multidisciplinary Team

Working
collaboratively
to foster
supportive
relationships

Strong and
The patient at committed
the centre of organizational
decision-making and team
leadership

Successful
interdisciplinary
team

Clear and open Diversity in

communication expertise, with
within the team team members
and with tailored to local
patients circumstances

Shared goals
and approaches
to ensure
consistency of
message

sciencedirect.com
7
Multidisciplinary Team - Goals & Benefits

GOALS: Multidisciplinary approach should be focused on integrated

management with multiple treatment goals including -
w Glucose, blood pressure & lipid control.
w Life style management .
w Regular appointments .
w Screening for the prevention of T2DM morbidities.

BENEFITS -
w Minimize patient’s health risks through assessment ,intervention and
surveillance.
w Identify problems early & initiate timely treatment

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Multidisciplinary Team

Multidisciplinary Team provide direct care for people with diabetes with complex needs
that include

w People newly diagnosed with Type 1 diabetes.

w People with Type 1 diabetes (for carbohydrate counting and /or continuous blood
glucose monitoring ).
w Children with diabetes.
w Pregnant women and those planning a pregnancy.
w Patients with significant and ongoing cardiovascular or peripheral vascular disease .
w Young patients with diabetes of an undefined nature.
w Patients with active foot ulcers or uncontrolled neuropathic pain.
w Patients with diabetes and renal disease or retinopathy requiring active management
or complex monitoring.
w People whose risk factors for complications have been unsuccessfully controlled in
primary care.
w Patients with recurrent hypoglycemia.
w Patients with neuropathy ,especially autonomic neuropathy .
w Inpatient care.

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3. Diabetes Education

Diabetes Education is a key component of diabetes management…

A real life guidance, coaching & support proven to help people understand exactly how to
best manage their diabetes & to feel less alone while doing it.

Aim of Diabetes Education

To achieve optimum levels of knowledge regarding diabetes & its consequences.
Ensure patient have the necessary skills & confidence to successfully manage their
diabetes.
Intensive Self – Management :
• A person with diabetes will understand the impact of factors such as food intake,
exercise , stress & medication on blood glucose & importance of foot care, regular
checkup of eye ,glucose level blood ,blood pressure.
• Make appropriate adjustments to maintain glucose within a target level.
Foster Behavior Change : A person with diabetes need to know what they should be doing
now, in order to best manage their condition & forestall its possible ramifications.
Diabetic Education helps by designing a specific plan for each person that includes the
tools & support to help make the plan easy to follow.

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4. Diabetes Educator

Who Are Diabetes Educators ?

Diabetes Educators are healthcare professionals trained specifically to coach patients with
diabetes through their own self-care & focus on all aspects of diabetes care & are also
skilled in counseling ,education & communication.

Role of Diabetes Educator

Diabetes Educators are an integral part of the diabetes management team.
w The diabetes educator has a complex role that combines the clinical ,educational &
psychological components of diabetes care.
w To help people with diabetes learn to manage their disease.
w To allow them to make able choices & take actions based on informed judgment.
w To improve the quality of life of diabetic patient.

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Diabetes Educator

Knowledge & Skills Required For Diabetes Educator

w Broad-based knowledge of diabetes ,pathogenesis ,diagnosis, prevention,
complications & management.
w Technical skills such as injection technique ,blood glucose monitoring & foot care.
w Interpersonal skills such as empathy , communications, assertiveness, flexibility &
resourcefulness.
w Presentations ,writing & interviewing skills, understanding the education process for
adults & children.
w Understanding of behavior change and education strategies.

Diabetes Educators help people with diabetes to -

w Learn basic information about diabetes and its management.
w Understand how to use diabetes devices ,such as blood glucose meters ,insulin pens
,insulin pumps & continuous glucose monitors.
w Adopt healthy eating habits through nutrition education ,including meal-planning,
weight-loss strategies & other disease- specific nutrition counseling.
w Develop problem- solving strategies and skills to self-manage diabetes.
w Monitor blood glucose & learn how to interpret & appropriately respond to the
results.
w Understand how their medications work, including their action, side effects ,efficacy,
toxicity, prescribed dosage and more.
w Develop skills for handling stressful situations.

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Diabetes Educator

Who should see a Diabetes Educators ?

w Everyone should see a Diabetes Educators even people with pre-diabetes. Diabetes
Educator can provide initial information what can happen in the future & what to look
out for if something goes wrong.
w For people with type 1 diabetes, Diabetes Educators can help them to manage their
medication, meal plans, eye care & looking after their feet.
w For people with type 2 diabetes, Diabetes Educators can help them with prolong
needing medication & help them to make the transition to medication when the
insulin producing cells in their pancreas stop producing insulin.

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Diabetes Educator

Career Opportunities Expanding Roles

In-Hospital Diabetes Management Lobbying for advantages for people

Outpatient Diabetes Education Center with diabetes (policies ,cost of care,
Corporate Health non-discrimination).
Education Encouraging support groups as well
Research Development as diabetes associations.
Sales (pharmaceutical companies) Increasing community awareness.
Government Sector Increasing awareness of the
CDE in Primary Care importance of the diabetes
CDE in Endocrinologist Office Setting educators.
Wellness Centers. Promoting diabetes education as an
Pharmacies independent profession.

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5. Components Of Diabetes Educator Training

w Teaching & Learning Skills

w Communication Skills
w Application of Research Findings

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Components Of Diabetes Educator Training -
Teaching & Learning Skills

Teaching skills are integral to the role of the diabetes educator.

Diabetes educators should do more than hand out information; they should have a good
understanding of the principles of the education process & apply these principles in
practice.

Goals : To provide the participant with the knowledge & skills of the education process.

Elements Of The Teaching/Learning Process:

Assessment: Describe how to undertake a learning need assessment .
Planning : Discuss how to develop an effective learning program & Discuss the need
for programme content to be culturally sensitive.
Implementation:
• Demonstrate active listening skills.
• Demonstrate use of open-ended questions.
• Demonstrate positive feedback.
• Discuss how to manage group dynamics.
Evaluation : The various methods of evaluation include:
• Questions & answers
• Pre & post-knowledge & skills test.
• Simulation/ demonstrations
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Components Of Diabetes Educator Training -
Teaching & Learning Skills

Methods of Learning
Learning By Observing : Processes which could be utilized include lectures , videos &
films ,demonstrations of a task, procedure or equipment.
Learning By Contributing : The learning process are dependent on the interaction
among people.
Examples include : Brainstorming , Discussions , Role Play , Exercises.
• Brainstorming : helpful to explore attitudes, help them problem solving.
• Discussions : helpful to change attitudes ,compare experiences , develop
commitment etc.
• Role-Play : the individual practices a face to face situation that presents real life;
practicing occurs in a safe environment & participants can gain insight into their own
and other’s behaviors or needs.
• Exercises : participants are asked to perform certain tasks or activities in a small
group or individually .This could meet several learning objectives

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Components Of Diabetes Educator Training -
Teaching & Learning Skills

Difference Teaching Methods - Group Based Training

This could be small or large group.
Examples : Lectures, Videos & Films ,Demonstration ,Brainstorming, Discussions, Role
play & Exercise.

w Formal Lectures : A formal lecture is a presentation given to an audience with little

interaction or feedback. This method allows for education of large groups of
participants & a large amount of information is conveyed in a short period.
w Group Discussions :Knowledge, ideas & opinions on a particular subject are freely
exchanged between participants & the educator. Useful in most learning programs &
allows for open flexible learning .
w Demonstrations : A demonstration is a session where a skill is learned ,following a
formal procedure e.g. description / demonstration of a skill under supervision such
as injection technique ,urine or blood glucose testing techniques, foot care etc. It is
important that the demonstration is clearly visible to all participants.

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Components Of Diabetes Educator Training -
Teaching & Learning Skills

Different Teaching Methods - Group Based Training….

w Brainstorming, Discussions, Role-play & Exercises :
Allow for group interaction & participation to take place .These sessions need to be
well guided.

Group-based teaching could be suitable to teach people with diabetes & their
families about:
w Diabetes
w Healthy eating habits
w Foot care
w Managing a diabetes diary
w Managing every day life with diabetes
w Sick days
w Exercise
w Life-style Change

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Components Of Diabetes Educator Training -
Teaching & Learning Skills

Different Teaching Methods – One-On-One Training

Individual Training : To encourage the participants to acquire new skills & habits in a
practical way.
It allows participants to progress at their own pace.
Useful for reviewing progress & discussing specific matters or subjects.
Provides an opportunity for individual counseling & guidance.
This form of teaching is suitable when teaching the person with diabetes on –
w Individual eating plans
w Insulin injection techniques
w Storing of insulin

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Components Of Diabetes Educator Training -
Teaching & Learning Skills

Different Teaching Methods - Text Based Training

Handouts ,insulin diaries ,eating plans & information on foot care could be text-
based.
Charts & pictures could be displayed in the clinic setting .
Posters should give an instant clear message.
Lettering should be large & clear enough to be read at a distance.
Words ,illustrations & diagrams can be used to convey the message.

Different Teaching Methods- Technology Based Training

Computer-based training
Interactive video
The Compact Disc (C.D.)
E-learning-Internet based training

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Components Of Diabetes Educator Training -
Communication Skills

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Components Of Diabetes Educator Training -
Communication Skills

Healthcare professional’s attitude & skills -

Vital for successful educational interventions:
w Active listening
w Reflective listening
w Empathy
w Encourage & reinforce positively
w Value a person’s active participation

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Components Of Diabetes Educator Training -
Communication Skills

The Calgary-Cambridge Approach to Communication Skills Teaching :

Suzanne Kurtz & Jonathan Silverman have developed a model of the consultation,
encapsulated within a practical teaching tool ,the Calgary Cambridge Observation Guides.

The Guides define the content of a communication skills curriculum by delineating &
structuring the skills that have been shown by research & theory to aid educator-patient
communication .

The Guides also make accessible a concise & accessible summary for facilitators &
learners alike which can be used as an aide-memoire during teaching sessions.

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Components Of Diabetes Educator Training -
Communication Skills

The Framework of the Calgary –Cambridge Guide

w Initiating the session w Gathering information w Physical examination
w Explanation & Planning w Closing the session
Initiating the session
Preparation
Establishing initial rapport
Providing Building the
Identifying the reasons for the consultation
structure relationship
Gathering information
Make Using
organization Exploration of the patient’s problems to discover the appropriate
overt Biomedical perspective Patient’s perspective non-verbal
Attending Background information - context behaviour
to flow Developing
Physical examination rapport
Involving
Explanation and planning the patient
Providing the correct type and amount of information
Aiding accurate recall and understanding
Achieving a shared understanding: incorporating the patient’s illness framework
Planning: shared decision - making
Closing the session
Ensuring appropriate point of closure
Forward planning

The Calgary–Cambridge Guide. From Kurtz, S., et al. (2005) Teaching and Learning Communication Skills in Medicine, 2nd edn. Radcliffe Publishing, Oxford

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Components Of Diabetes Educator Training -
Application of Research Findings

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Components Of Diabetes Educator Training -
Application of Research Findings

w Research in diabetes mellitus is a scientific method aimed at seeking new knowledge

that will continue towards the improvement of quality of life & care of people living
with this condition .
w Research is an essential aspect of the diabetes educator’s role.
w The process of research is aimed to :
Generate new knowledge
Provide results that can be generalized (applicable to similar patients or
situations)
Challenge the current situation or practice
Inform policy makers & service delivery practitioners.
Diabetes Educators should be able to :
Access & review relevant literature ,including guidelines & protocols, to find out
what has already been said about an issue.
Determine whether the findings or recommendations relate to their area of
practice & can be implemented .

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6. Diabetes Self –Management Education

Self-Management
Self-Management is the cornerstone of overall diabetes management.
Persons with diabetes will achieve optimal outcomes only if they are willing to and capable
of managing their condition adequately on a daily basis.

Goals :The primary goal is to improve the quality of life in persons with diabetes. This will
also assist in understanding :
• The burden of diabetes ( personal, economic & psychosocial costs).
• The needs of effective self-management skills.
• Ways to facilitate access to services.
• Ways to facilitate transition of care from childhood to adulthood.

Good self-management reduces costs of care by reducing morbidity.

The diabetes educator must aim at being advocate for children /people with diabetes to
reduce discrimination against them at school, the workplace & in society.

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Diabetes Self –Management Education

Self-Management - Patient Education

CONSIDER individual needs ,wishes & health beliefs .
TEACH skills to facilitate behavior change ,to develop coping skills & to optimize
outcomes.
PROVIDE emotional support ,collaborative & partnership approach ,mutual
understanding of roles & responsibilities.

Patients are encouraged to learn these 7 Self – Management Skills

Healthy Eating
Being Active
Monitoring
Healthy Coping
Reducing Risks
Problem Solving
Taking Medication

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Diabetes Self –Management Education

The SMART Goals For Diabetes Management

SMART Goals for diabetes management is a tool that has helped people with diabetes
experience
Specific : Select one clear action that you want to accomplish.
Measurable : Determine how you will quantify your progress so you can track it
Attainable : Set a goal that will challenge you, but something that is not impossible to
achieve .
Relevant : Determine what you can commit to & make sure it is within reach.
Time Based : Define the time frame for the goal.

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Diabetes Self –Management Education

SMART GOALS GUIDE

What exactly needs to be accomplished?

Specific Why do we want to accomplish this goal?

How will we know we have succeeded?

Measurable How much change needs to occur?
How many actions or cycles will it take?

Do we have the resources to achieve the goal?

Attainable Is the goal a reasonable stretch?
Is the goal likely to bring success?

Is this a worthwhile goal?

Relevant Will it be meaningful to management/the team?
Can we commit to achieving this goal?

What is the deadline for reaching the goal?

Time-bound When will we begin taking action?

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 PSYCHOSOCIAL &
BEHAVIOURAL APPROACHES
1. Reasons for Failure of Diabetes Treatment

Non-Compliance : Non- Late Insulin Initiation : One fourth

compliance is believed common of the patients refuse or
reason for treatment failure in discontinue the current insulin
diabetic patients ,leading to the therapy due to psychological
absence of metabolic control & concerns.
accelerating diseased –related
compliance.

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Reasons for Failure of Diabetes Treatment

1.1 General Reasons For Non-Compliance

Fear of Adverse Effect : It is difficult for patients to follow a treatment that produces
discomfort .

Lack of knowledge about the drug : A high risk of non-compliance exists for patients
who do not fully understand how a medication will improve their health as opposed to
patients who are familiar with the mechanism of action of the drug & can visualize the
long-term effects of compliance.

Cognitive Impairments : Many elderly patients have cognitive impairments that may
affect their ability to understand or follow recommendation regarding their medication.

Complex Drug Regimens or Multiple Dosing : Compliance has been shown to drop as
the number of medications taken daily increases & if the medication regimen is too
complex .The patient may be confused & may not fully comply.

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Reasons for Failure of Diabetes Treatment

1.2 Solutions to Non-compliance

Several useful strategies can help to improve compliance :-

Simplifying the Medication Regimen: The simpler the regimen is ,the higher the rate of
compliance is.

Educating the Patient About the Disease : Patients need to be properly educated in a
clear & concise way about their disease states & the need for treatment.

Explaining Potential Side Effects : Health professional should discuss with patients not
only the potential side effects associated with a drug, but the importance of consulting
with their physician if an adverse effect becomes intolerable so that an alteration drug
may be substituted .

Encouraging the Use of Patient Reminder Aids : Another reason why many patients fail
to take their medication is that they simply forget .For those patients who have difficulty
remembering , remembering aids may be helpful.

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2.Psychosocial Reasons for Non-Compliance

Diabetes Distress
Depression
Anxiety
Eating Disorders

Psychosocial reasons related to the failure of diabetes treatment need adequate

consideration.

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 2.Psychosocial Reasons for Non-Compliance

2.1 Diabetes Distress

Diabetes distress is the emotional distress resulting from living with diabetes & the
burden of relentless daily self-management.
Higher levels of diabetes distress significantly impact medication-taking behaviors.
Linked to higher A1C, lower self-efficacy, poorer dietary & exercise behavior .
Significant negative emotional reaction to :
- Diabetes diagnosis
- Worry & fear regarding health
- Financial & behavioural burden of living with diabetes. Feeling of life
being controlled Feeling not being
Fear, angst or by DM supported
- Onset of complications despair about
living with DM
by Healthcare
Providers
- Impact on lifestyle of self-management demands Fear of failing at Social isolation
keeping up with or feeling lack of
- Lack of support in managing diabetes Diabetic Care social support

Burden of living
with chronic
Diabetes Other quality
of Life issues
disease Distress

Gonzales et al. Diabetes Care 2011 Picture Reference :Translational Pediatrics

36
 Psychosocial Reasons for Non-Compliance

2.2 Depression
Depression is the most common psychiatric disorder witnessed in the diabetes community.
Typical Depressive Symptoms (minimum of two weeks)
- Lowered/Depressed mood
- Lack of interest & pleasure in usual activities
- Lack of energy
- Difficulty concentrating
- Low self-esteem
- Irritability
- Trouble with eating
Causes of Depression
- Trouble with sleep
w Non-diabetes specific
- Feelings of worthlessness or guilt
contributors may include stressful
- Recurrent thoughts about death or suicide life circumstances, substances use
- Isolation & a personal or family history of
Associated with poor self-care ,complications & mortality. depression .
Increase risk for obesity ,sedentary life-style, smoking. w Diabetes-specific contributors
may include the chronic nature of
the condition & complex
management regimen.

Image Source: TheDiabetesCouncil.com

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 Psychosocial Reasons for Non-Compliance

• The ‘vicious cycle of depression’

Lack of social interaction

Lack of exercise or physical exertion
Unhealthy behaviour such as
smoking or binge drinking
Diet of processed foods Bi-directional relationship
between behaviours
and depression
(most often depression
leads to behaviours)
Increase

s
ete s Stres
Diab Depression
Lethargy
Lack of motivation
Poor diabetes management Extreme mood swings
Diabetes-related complications Low energy
Indecisiveness

The cyclical nature of the

relationship between depression and
diabetes (adapted from Diabetes UK)
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 Psychosocial Reasons for Non-Compliance

2.3 Anxiety Disorders

• Having diabetes may place people at increased risk of developing anxiety disorders .
• Common diabetes-specific concern:
-Fears related to hyperglycemia.
-Not meeting blood glucose targets.
-Insulin Injections
-Infusion
-Fear of hypoglycemia
• General anxiety is a predictor of injection-related anxiety & fear of hypoglycemia.

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 Psychosocial Reasons for Non-Compliance

2.4 Eating Disorders

• Diabetes is likely associated with an increased risk Eating disorders comprise a group of diagnosable
of eating problems . conditions , characterised by preoccupation with food
• Eating disorders in people with diabetes are ,body weight & shape, resulting in disturbed eating
associated with sub-optimal diabetes self- behaviors with or without disordered weight control
management & outcomes & impaired behaviors (e.g. food restrictions ,excessive exercise,
psychological well-being. vomiting, medication misuse).
• Eating disorders are associated with early onset of They include –
diabetes complications & higher morbidity &
mortality. - Anorexia
• Early warning signs : - Bulimia
- Frequent bouts of & hospitalizations for poor
blood sugar control.
- Anxiety about or avoidance of being weighed.
- Widely fluctuating blood sugar levels without
obvious reason.
- Severe family stress

Image Source – ADW Diabetes

40
Psychosocial Reasons for Non-Compliance

Anorexia Bulimia
- Severe food restrictions - Recurrent episodes of
,fasting ,excessive exercise eating large amount of
or use of laxatives. food followed by
- Obsessed with weight compensatory behaviors
control such as forced vomiting .
- Abnormally low body - Similar to anorexia ,weight
weight for age ,sex , & shape play a central role
developmental stage & in self-evaluation.
physical health . - In contrast to anorexia ,
- Disturbance in self- weight is in the normal
perceived weight or shape. ,overweight or obese
range.

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 3. Psychosocial Reasons for Late
Insulin Initiation

• One-fourth of the patients refuse or discontinue the current insulin therapy due to
psychological concerns.
- Psychological Insulin Resistance :
Fear of injections & pain
Fear of becoming insulin-dependent
Fear of more severe evolution of diabetes
- Health Concerns :
Concerns about hypoglycaemia & weight gain
- Lifestyle Issues :
Need to comply with a more complex self-monitoring
Time consuming & inconvenient
Poor adherence while travelling

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 4. Psychosocial & Behavioural Care -
General Considerations

• Psychosocial & Behavioural care should be integrated with a collaborative, person-

centered approach.

• Psychosocial screening & follow-up includes :

- Attitudes about diabetes
- Expectations for medical management & outcomes.
- Affect or mood
- General & diabetes-related quality of life
- Available resources : financial ,social
- Psychiatric history

• Consider assessment for symptoms of diabetes distress, depression ,anxiety ,disordered

eating behaviors .

American Diabetes Association

43
 Psychosocial & Behavioural Care -
General Considerations

4.1 Screening Recommendations

1. Include routine psychosocial assessment as part of ongoing diabetes care using a collaborative,
person-centered approach .
2. Psychosocial issues should be understood through a life-course lens, understanding that life
circumstances and therefore the needs of the person with diabetes,will change over time.
3. Screening & follow-up should include attitudes, expectations, mood, general and diabetes-related
quality of life , resources and psychiatric history.
4. Screening that reaches the level of clinical significance requires referral to appropriate care
providers.
5. Routinely screen for depression, diabetes-related distress ,anxiety ,disordered eating behaviors.
6. Older adults should be considered a high priority population for screening & treatment.

4.2 When to Screen

• At diagnosis
• Regularly scheduled visits
• Changes in medical status
• During hospitalization
• When new-onset complications occur
• Whenever problems are identified with:
- Glucose control
- Quality of life
- Self –management

Source- Standards of Medical Care in Diabetes.Diabetes Care 2017

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 5. Implementation of Team Based/Person -
Centered Care

Collaborative Care Model

• Physician, case manager, educator & mental health consultant(psychiatry, psychology) within the
practice.
• Active monitoring with ongoing exchange of information re: medical & psychosocial outcomes.
• Active re-alignment of regimen to meet person needs & to reach desired health outcomes.

Embedded behavioural Specialist

• Psychologist, Social Worker, Psychiatrist at the clinic site
• In practice or consultant , member of the multidisciplinary team
American Diabetes Association

6.Psychosocial Interventions for Diabetes

Multidisciplinary team to administer educational modules & address compliance :

-Patient-centered assessment of the reasons for non-compliance.
-Collaborative efforts of the patient & healthcare provider to tackle the difficulties related to poor
compliance or initiation of insulin.
-Providing care for mental disorders such as depression , anxiety & eating disorders (pharmacology
and /or psychological therapy : cognitive behavioural ,interpersonal or problem solving )

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7. Psychosocial & Behavioural Approaches

Diabetes & its treatment are strongly associated with patient's health behavior, as well as their lifestyle &
socioeconomic status. So new ways to communicate with patients are required in order to support their
health behaviors. These methods empower patients to take responsibility for their own health &
lifestyle. These approaches involve cooperation between the patient with diabetes & health care
professionals.
Interventions that incorporate behavioural & cognitive dimensions are most effective in changing health
– related behaviors.
Trans theoretical Model of Behavior Change.
Motivational Interviewing
Social Learning Theory
Health Belief Model
Empowerment
Self-Efficacy Theory

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 Psychosocial & Behavioural Approaches

7.1 The Trans theoretical Model (TTM)

• Trans theoretical Model of behavior change by Prochaska & Diclemente ,offers a well –established &
research –based framework for understanding ,measuring ,evaluating & intervening in behavior
change .
• TTM suggests that health behavior change involves progress through six stages of change .
• Precontemplation
• Contemplation
Six Stages of Behavior Change Model
• Preparation
No awareness / intention of behavior
• Action Precontemplation
change
• Maintenance
• Termination Contemplation
Aware of needed behavior change, planning for
change but have not yet committed to change

Begin planning to make behavior change and

Preparation
are committed to following through

Have implemented intended behavior modications

Action in an effort to change behavior

Maintaining behavior change and trying to

Maintenance prevent termination of behavior change

Failure to maintain intended

Termination behavior change

Transtheoretical Model stages of behavior change. Note Adapted from : Prochaska J, DiClemente C.
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 Psychosocial & Behavioural Approaches

7.2 Motivational Interviewing (Miller And Rollnick)

Motivational Interviewing is an empathic, client centered ,yet directive counseling style.
Its goal is to explore & resolve ambivalence about changing behaviors.

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 Psychosocial & Behavioural Approaches

Motivational Interviewing
There are four distinct principles that guide the practice of MI :
1 Express Empathy
w Expressing empathy towards the clients shows acceptance &
increases the chances of developing a rapport .
w Acceptance enhances self –esteem.
w Skillful reflective listening is fundamental. Motivational Interviewing:
2 Develop Discrepancy 4 Principles
w Developing discrepancy enables the clients to see that their (Miller & Rollnick, 2002)
present situation does not necessarily fit into their values and
what they would like in the future.
w Express Empathy
w The clients rather than the helpers should present the
arguments for change . w Develop Discrepancy
3 Roll with Resistance w Roll with Resistance
w Rolling with resistance prevents a breakdown in communication w Support Self-Efficacy
between clients & helpers & allows the clients to explore their
views.
w Avoid arguing for change
w Do not directly oppose resistance
w Resistance is a signal for the helpers to respond differently.
4 Support Self-efficacy
w Self –efficacy is a crucial component to facilitating change .If the
clients believe that they have the ability to change ,the
likelihood of change occurring is greatly increased.
w Client’s belief in the possibility of change is an important
motivator

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 Psychosocial & Behavioural Approaches

7.3 Social Learning Theory (Albert Bandura’s Theory )

• Social Learning Theory is determined by the relationship between cognitive factors, environmental factors and
behavior factors .
Cognitive Factors
(also called “Personal Factors”)
w Knowledge
w Expectations
w Attitudes

DETERMINES
Environmental Factors HUMAN
w Social Norms behavioural Factors
BEHAVIOR
w Access in Community w Skills
w Influence on Others w Practice
(ability to change own environment) w Self-Efficacy

Social Learning Theory emphasizes learning by observing & modeling of others.

People learn through observing other’s behavior, attitude, emotion reaction & outcomes of behaviors.
Conditions for effective modeling :
Attention– To learn something new, learners should pay attention to the features of behaviors of the model.
Retention – Remembering details of the behavior including symbolic coding ,mental images .
Reproduction– Reproducing the actual performances of the behavior that the learner observed .
Motivation– In order to be succeeding in observational learning ,the learner should be motivated to reproduce the behavior .

• Social Learning Theory – Application in People With Diabetes :

- Sharing the experiences.
- Diabetes Acceptance
- Autonomy in diabetes management
- Development of skills
- Well – being Reference : Bandura ,A.(1997).Self-efficacy: The exercise of control. New York : W.H.Freeman.
Bandura ,A.(1988).Organizational Application of Social Cognitive Theory.
Australian Journal of Management . Source :www.idfdiabetesschool.org
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7.4 Health Belief Model

This model was developed by Hochbaum, Rosenstock & Kegels in 1950.A tool that predicts a
person’s health behaviors

Health Belief Model: Rosenstock (1974); Strecher & Rosenstock (1997)

Perceived
susceptibility

Perceived
Dermographic severity
variables
(e.g. age,
gender, Perceived Likelihood
benefits of
ethnicity, behavior
personality
knowledge Perceived
and SES) barriers

Cues to action

Self Efficacy

Perceived Susceptibility – The person only changes his/her behavior if he/she believes that he/she is in danger.
Perceived Severity – The probability for changing behavior depends on how serious he/she considers the
consequences are.
Perceived Benefits –The person only changes his/her behavior if it brings benefits.
Perceived Barriers –Changing health behavior can cost physical, psychological or even social efforts .
Cues to action –External events or information can prompt the need to change health behavior.

Reference: www.idfdiabeteschool.org
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7.5 Empowerment
• Empowerment – A New Approach to the Treatment of Diabetes .
• Patient Empowerment is a therapeutic technique focused on the patient ,in which the patient becomes
willing & able to take responsibility for their own life .
• In this process patients gain the necessary knowledge to influence their own behavior to improve the
quality of their lives.
• The three main pillars of empowerment in diabetes are :
1. Diabetes is a patient –managed disease.
2. Patients should be capable to make decisions based on the information provided by the health team
3. Patients should identify & implement their own treatment goals, which have a real impact on their lives.

Stages of the Empowerment Therapy

Stage 1 Identify the Problem
Stage 2 Explain Feelings & Meanings
Stage 3 Build a Plan
Stage 4 Action
Stage 5 Experience & Assess the Execution

Aim of the Empowerment Therapy :

To provide the patient with critical thinking skills & the ability to make autonomous, informed decisions.

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7.6Self - Efficacy Theory

• Self –efficacy is one of the factors involved in successful self-care of diabetic patients.

• Self-efficacy defined as the person’s trust to its abilities for exploring a behavior.

• Self-efficacy affects person’s motivation & pushes it to try & continue the behavior.

• Self-efficacy consists of the people’s trust to themselves in executing a special act.

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Thank You