By itself, pharmacologic management does not ensure improvement in long-term patient-oriented outcomes such as the quality of life or all-cause mortality. Additional nonpharmacologic interventions are needed to empower individuals to improve their quality of life [ 2 ].

Yet, a majority of these individuals remain nonadherent to lifestyle guidelines [ 3 ]. The Diabetes Score questionnaire is a behavior change tool designed to improve lifestyle factors such as diet and exercise in individuals with diabetes online suppl. Material; for online suppl. material, see www.

This instrument consists of 10 questions pertaining to physical activity, nutrition, and self-care. Each question is rated by patients on a scale from 0 to 10 points based on the level of adherence. A total score ranging from 0 to is obtained by adding the points from the 10 individual questions.

The questionnaire has been carefully designed for clinical use. All items are actionable and behaviorally oriented. Thus, items that cannot be changed directly by patients themselves, such as blood glucose levels or BMI, are excluded. This is in contrast to the traditional biomedical approach to self-management, which has failed to yield meaningful results [ 4 ].

All regions of the world are experiencing an epidemic of obesity and type 2 diabetes [ 7 ]. Diabetes tends to be underdiagnosed and undertreated [ 8 ]. Glycemic levels are suboptimally controlled despite advances in diabetes therapy [ 10 ].

There is an urgent need for a practical, low-cost patient decision aid for diabetes self-management. We aimed to evaluate the Diabetes Score questionnaire in a clinical context.

In particular, we sought to assess whether Diabetes Score correlates with better glycemic control among adult patients with diabetes. A cross-sectional questionnaire survey was conducted at a primary care clinic in the city of Al Ain, United Arab Emirates, in Researcher-administered structured brief interviews were conducted with otherwise healthy, community-dwelling, adult individuals with type 2 diabetes in an ambulatory setting.

Inclusion criteria for recruitment of subjects in the study were age 18 years or greater and an established diagnosis of type 2 diabetes mellitus. Exclusion criteria included any mental or hearing deficits and other severe medical conditions such as mobility restrictions that would impede participation in the study.

A minimum sample size of 47 subjects was deemed sufficient to detect a correlation of 0. A trained researcher H. conducted all the interviews to ensure consistency and reliability.

Patients in the clinic waiting area were offered information about the study, and voluntary informed consent was requested. Preprinted questionnaire forms were used to collect data in a structured format.

Demographic age, gender, occupation, and education and clinical weight, recent blood glucose, and HbA1C data were recorded. Statistical data analysis was conducted using the current version of SPSS Statistics version 26; IBM SPSS Inc. In addition to descriptive measures, statistical tests for bivariate correlation, t test, and multivariate regression were performed.

Reliability analysis was assessed using the alpha Cronbach model. Factor analysis was used to evaluate principal components subscales for diet, exercise, and self-care. An alpha level of 0. A total of 60 adult patients with type 2 diabetes mellitus participated in the study. The sample was representative of a wide range of diabetic patients Table 1.

The ages ranged from 43 to 70 years mean 56; standard deviation [SD], 5. A broad range of occupations electricians and engineers to farmers and carpenters and educational backgrounds mean years of formal education, 13; SD, 2. The mean Diabetes Score was Patients were more adherent to dietary items than to exercise or physical activity Fig.

There was no significant difference between male and female patients in terms of glycemic control A1C 6. Comparison of these 2 groups showed that better Diabetes Scores were associated with significantly lower BMI and improved glycemic control Table 2.

The questionnaire data were analyzed for reliability and acceptability. Reliability analysis for internal consistency yielded a Cronbach alpha of 0. Diabetes Score was associated with better glycemic control among adult patients with type 2 diabetes.

The questionnaire showed fair evidence of construct validity, internal consistency, reliability, and patient satisfaction. We found that patients were more likely to comply with dietary guidelines than with exercise.

This is consistent with previous research showing the impact of diabetes on the ability to exercise [ 14 ]. Foot care was often neglected, indicating an area for self-improvement.

Self-reported adherence to diabetes medications was high in our survey indicating awareness of its importance. Knowledge of diabetes self-management has tended to remain low despite counseling by dieticians and diabetes educators [ 9 ].

In resource-limited settings such as developing countries, where the largest numbers of diabetes patients reside, frequent blood tests and physician visits may not be feasible. Innovative approaches are needed to focus on low-cost, nonpharmacological interventions such as lifestyle change [ 16 ].

Previous diabetes questionnaires have tended to be lengthy and complicated, making them unsuitable for use in clinical settings [ 11, 13 ]. Many questionnaires were designed for gathering data for research purposes, rather than for improving patient care.

Thus, a questionnaire is needed that can be used not only for measuring adherence to diet and exercise but also for discussing targets and monitoring progress. Unfortunately, many questionnaires include items that are not directly modifiable or actionable. Some items are not evidence based such as frequent checking blood glucose in type 2 diabetes controlled with oral medications.

The Diabetes Score questionnaire fills this critical gap. It is a brief, behavioral checklist designed specifically to empower patients to take control of their lifestyle.

In the context of diabetes education, the concept of empowerment is thus based on several assumptions:.

A helping hand In order for people with diabetes to become actively involved in their own care, it is important for the nurse to equip them with the information needed for effective self-management. The person with diabetes also needs to understand the healthcare system and how to utilise it when necessary.

This can only be achieved if the education programme contains all the relevant topics to improve knowledge. As shown in the extended list Table 1 , these topics should include knowledge about diabetes, dietary composition particularly with regard to reducing saturated fats , their impact on blood glucose levels, as well as the effect of other lifestyle issues such as exercise, smoking cessation, alcohol intake and illness.

How and why insulin needs to be adjusted to accommodate these factors also need to be explained. The importance of attending the diabetes clinic and eye appointments should be clearly emphasised.

It could be argued that those who are thus empowered benefit both psychologically and in terms of maintaining long-term metabolic control. This approach to diabetes management, as Cavan argues, shifts from a purely traditional medical model to the provision of effective educational interventions to facilitate successful self-care, with immediate medical needs met at diagnosis and at intervals thereafter Figure 1.

However, not everyone with diabetes may be comfortable with taking responsibility for their lives. In such cases, the individual may prefer a more direct approach.

As Funnell et al assert:. The choice remains with the patient, even when the choice is to decline power. Patients who choose to remain the passive recipients of care are responsible for that choice and its consequences.

The medical model In the medical model, treatment goals and plans often ignore the emotional, spiritual, social and cognitive aspects of living with a chronic disease such as diabetes Arnold et al, During a medical visit, there may be opportunities to see a nurse or dietitian.

Consequently, the medical model may well lead to conflict between healthcare professionals and people with diabetes.

Furthermore, the medical model does not necessarily meet the psychological needs of the person with diabetes. For example, the diagnosis of diabetes is often a shock and frequently devastating to the individual.

Failure to effectively address this important aspect of psychological care may lead to poor self-esteem and low motivation to adopt self-care behaviour Jacobson et al, Moving towards empowerment A major goal of patient empowerment is to improve adherence to agreed self-care regimens.

People with diabetes are often unsure whether they can achieve the set goals. To become empowered, they need information, assurance, support and caring. The motivational interview model developed by Rollnick et al aims to assist healthcare professionals in helping patients manage their illness experience.

The adapted steps see below , extracted from the work of Rollnick et al , may be applied in full or in part, depending on where the individual is located in the process.

Many people with diabetes have misconceptions about their condition. They may associate diabetes with complications and fatalistic outcome. Such information enables the nurse to respond in an empathic manner. Exchanging information The amount of information given to a person with diabetes should be based on assessment and negotiation.

When the person is ready for more information, it should be provided in an unbiased, non-judgmental manner. Where diabetes medications are concerned, their action, any possible side-effects, and storage should be explained in a style that is readily understood by the person with diabetes.

The present and the future This strategy allows people with diabetes to discuss their expected outcomes as a result of undertaking the prescribed self-care activities. Expected outcomes may include weight loss, normal blood glucose level, and prevention of complications.

Any concerns for the future should be addressed in a compassionate and non-judgmental manner. Although the approach to asking the questions is neutral and non-judgmental, they do not necessarily produce a desired outcome.

Conclusion The empowerment philosophy clearly represents a shift in attitude for both patients and healthcare professionals. In the context of diabetes, there is perhaps an understandable apprehension that allowing people with this condition to learn about the care and education they should receive may give rise to an increasingly demanding population of patients.

It cannot be denied that healthcare professionals who routinely practice empowerment have seen the emergence of well-informed people with diabetes, who are aware of their rights. Frank and honest information about the lack of resources and other factors that impede the delivery of appropriate care will result in a better-informed population who have a significant effect on our healthcare providers and political figures.

Consequently, people with diabetes are our best allies in our fight to deliver the optimum level of care. Facilitating empowerment to people with diabetes and their families is therefore well worth the time and energy required to achieve it.

Anderson RM Is the problem of non-compliance all in our heads? The Diabetes Educator 11 1 : 31—34 Arnold M, Butler P, Anderson RM et al Guidelines for facilitating a patient empowerment program. The Diabetes Educator 21 4 : —12 Cavan D Giving power to the patients.

Modern Diabetes Management 2 4 : 15—16 Department of Health National Service Framework for Diabetes: Standards. DoH, London Department of Health The National Service Framework for Diabetes: Delivery Strategy. DoH, London Falk-Rafael AR Advocacy and empowerment: dichotomous or syncronomous concepts?

Topics : Diabetes , Health Informatics. Policies and ethics. Skip to main content. Authors: Nicola Brew-Sam 0. Nicola Brew-Sam Regensburg, Germany View author publications. Diabetes Apps for Self-Management. Sections Table of contents About this book Keywords Authors and Affiliations About the author Bibliographic Information Publish with us.

Buy it now Buying options eBook EUR Price includes VAT Germany. Softcover Book EUR Tax calculation will be finalised at checkout. Licence this eBook for your library. Learn about institutional subscriptions. Table of contents 18 chapters Search within book Search.

Front Matter Pages I-XXIV. Introduction Nicola Brew-Sam Pages Background on Diabetes Self-Management Nicola Brew-Sam Pages Defining and Categorizing Diabetes Apps for Self-Management Nicola Brew-Sam Pages Diabetes App Use — Previous mHealth Research Nicola Brew-Sam Pages Anteceding Factors of Diabetes App Use Nicola Brew-Sam Pages Summarizing mHealth Research Gaps I: Alternative Theory is Needed Nicola Brew-Sam Pages

Ávila L, Cerón D, Ramos R, Velázquez L. Association of family support and knowledge about the disease with glycemic control in diabetic patients.

Rev Med Chil. Article Google Scholar. Chen M-F, Wang R-H, Lin K-C, Hsu H-Y, Chen S-W. Efficacy of an empowerment program for Taiwanese patients with type 2 diabetes: A randomized controlled trial.

Appl Nurs Res. Cunha M, André S, Granado J, Albuquerque C, Madureira A. Empowerment and Adherence to the Therapeutic Regimen in People with Diabetes. Procedia Soc Behav Sci. Elsevier B. Imazu MFM, Faria BN, De Arruda GO, Sales CA, Marcon SS.

Effectiveness of individual and group interventions for people with type 2 diabetes. Rev Lat Am Enfermagem. Freire P. Pedagogia do Oprimido. São Paulo: Paz e Terra; Cortez DN, Torres H de C, Reis IA, Macedo MML, Souza DAS. Complications and the time of diagnosis of diabetes mellitus in primary care.

Acta Paul Enferm. Torres H de C, Reis IA, Maia MA. Professional workshops help fill gaps in diabetes self-management. Diabetes Voice. Campbell M, Thomson S, Ramsay C, MacLennan G, Grimshaw J.

Sample size calculator for cluster randomized trials. Comput Biol Med. Funnell MM, Tang TS, Anderson RM. From DSME to DSMS: Developing empowerment-based diabetes self-management support.

Diabetes Spectr. Cecílio SG. Dissertação: Adequação Cultural: Etapa complementar à tradução e adapatação de instrumentos em saúde. Belo Horizonte: Universidade Federal de Minas Gerais; Torres HC, Virginia AH, Schall VT.

Validation of Diabetes Mellitus Knowledge DKN-A and Attitude ATT Questionnaires. Rev Saude Publica. Torres H de C, Franco LJ, Stradioto MA, Hortale VA, Schall VT. Evaluation of a diabetes education program. Chaves FF, Reis IA, Pagano A, Torres H de C. Translation, cultural adaptation and validation of the Diabetes Empowerment Scale-Short Form.

Kroese DP, Brereton T, Taimre T, Botev ZI. Why the Monte Carlo method is so important today. Wiley Interdiscip Rev Comput Stat. R Development Core Team. R: A Language and Environment for Statistical Computing.

Vienna: R Found. Comput; Schulz KF, Altman DG, Moher D, Jüni P, Altman DG, Egger M, et al. CONSORT Statement: Updated guidelines for reporting parallel group randomised trials. J Clin Epidemiol. Wong CKH, Wong WCW, Lam CLK, Wan YF, Wong WHT, Chung KL, et al. Effects of patient empowerment programme PEP on clinical outcomes and health service utilization in type 2 diabetes mellitus in primary care: An observational matched cohort study.

PLoS One. Littlewood K, Cummings D, Lutes L, Solar C. Psychometric Properties of the Family Support Scale adapted for African American Women with Type 2 Diabetes Mellitus. Ethn Dis. PubMed Google Scholar. Birditt KS, Newton N, Hope S. J Gerontol Ser B Psychol Sci Soc Sci. Huang M-C, Hsu C-C, Huang-Sen W, Shyi-Jang S.

Prospective Randomized Controlled Trial to Evaluate Effectiveness of Registered Dietitian—Led Diabetes Management on Glycemic and Diet Control in a Primary Care Setting in Taiwan.

Yang YS, Wu YC, Lu YL, Kornelius E, Lin YT, Chen YJ, et al. Adherence to self-care behavior and glycemic effects using structured education. J Diabetes Investig. Dempster M, McCarthy T, Davies M.

Psychological adjustment to Type 2 diabetes and relationship quality. Diabet Med. Investigation of the relationship between patient empowerment and glycaemic control in patients with type 2 diabetes: a cross-sectional analysis. BMJ Open. Nuti L, Turkcan A, Lawley MA, Zhang L, Sands L, McComb S.

The impact of interventions on appointment and clinical outcomes for individuals with diabetes: a systematic review. Download references. This study was financially supported by Minas Gerais State Research Support Foundation FAPEMIG - Grant APQ Programa Hiperdia Minas under the coordination of Dr.

Heloísa de Carvalho Torres. The grant had no role in the study design, data collection, data analysis, data interpretation, writing of the manuscript, or decision to submit the manuscript. No potential conflict-of-interest relevant to this article was reported. We hereby declare that the data and research materials can be obtained by email to the corresponding author.

We also declare that the dataset supporting the conclusions of this manuscript will be available in a proper repository. DNC: Collaborated in the design and development of the project, the collection, analysis, and interpretation of the data, in writing the article, provided a relevant critical review of the intellectual content.

IAR, HCT: Collaborated in the design and development of the project, in the relevant critical review of the intellectual content, and in the final approval of the version to be published.

MMLM, DASS, JCS, GSA: Collaborated in the collection, analysis, and interpretation of the data, in writing the article, and provided a relevant critical review of the intellectual content. All authors read and approved the final manuscript. Daniel Nogueira Cortez: Professor in Federal University of São João del-Rei Divinópolis Campus and Ph.

D in School of Nursing, Federal University of Minas Gerais, Brazil. Maísa Mara Lopes Macedo, Débora Aparecida Silva Souza and Jéssica Caroline dos Santos: Master degree in School of Nursing, Federal University of Minas Gerais, Brazil.

Gesana Sousa Afonso: Nursing, School of Nursing, Federal University of Minas Gerais. Ilka Afonso Reis: Professor in Institute of Exact Sciences, Federal University of Minas Gerais, Brazil. Heloísa de Carvalho Torres: Professor in School of Nursing, Federal University of Minas Gerais, Brazil and Coordinator of the Research Group in Management, Education and Health Evaluation.

Daniel Nogueira Cortez, Maísa Mara Lopes Macedo, Débora Aparecida Silva Souza, Jéssica Caroline dos Santos, Gesana Sousa Afonso and Ilka Afonso Reis: Member of the Research Group in Management, Education and Health Evaluation in Federal University of Minas Gerais, Brazil.

The study was approved by the Ethics Committee, following the national and international standards, under record: CAAE The participants signed an informed consent agreement. Federal University of São João del-Rei Centro Oeste Campus , Divinópolis, Brasil.

School of Nursing, Federal University of Minas Gerais, Belo Horizonte, Brazil. Institute of Exact Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil. Universidade Federal de São João Del-Rei, Sebastião Gonçalves Coelho Street, , sala You can also search for this author in PubMed Google Scholar.

Correspondence to Daniel Nogueira Cortez. Open Access This article is distributed under the terms of the Creative Commons Attribution 4. Reprints and permissions. Cortez, D. et al. Evaluating the effectiveness of an empowerment program for self-care in type 2 diabetes: a cluster randomized trial.

BMC Public Health 17 , 41 Download citation. Received : 18 May Accepted : 13 December Published : 06 January Anyone you share the following link with will be able to read this content:.

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Abstract Background The prevalence of type 2 diabetes mellitus is increasing substantially worldwide, leading to serious economic effects, complications and deaths. Knowledge of diabetes self-management has tended to remain low despite counseling by dieticians and diabetes educators [ 9 ].

In resource-limited settings such as developing countries, where the largest numbers of diabetes patients reside, frequent blood tests and physician visits may not be feasible. Innovative approaches are needed to focus on low-cost, nonpharmacological interventions such as lifestyle change [ 16 ].

Previous diabetes questionnaires have tended to be lengthy and complicated, making them unsuitable for use in clinical settings [ 11, 13 ]. Many questionnaires were designed for gathering data for research purposes, rather than for improving patient care.

Thus, a questionnaire is needed that can be used not only for measuring adherence to diet and exercise but also for discussing targets and monitoring progress.

Unfortunately, many questionnaires include items that are not directly modifiable or actionable. Some items are not evidence based such as frequent checking blood glucose in type 2 diabetes controlled with oral medications. The Diabetes Score questionnaire fills this critical gap.

It is a brief, behavioral checklist designed specifically to empower patients to take control of their lifestyle. The 10 items in the questionnaire are simple and actionable.

The questionnaire is easy to score, and its results are intuitively understandable unlike other questionnaires with complicated scoring. Despite widespread efforts at diabetes education in clinics and the community, most patients do not receive adequate instruction [ 3 ].

Diabetes Score is designed to be used as an educational tool during counseling by a healthcare professional. Physicians and nurses can engage patients, set targets, and measure progress using Diabetes Score.

It can thus form a component of a comprehensive chronic disease care process Fig. By focusing on patient empowerment, Diabetes Score can be a part of a holistic framework for diabetes care [ 16 ].

Diabetes treatment algorithm using Diabetes Score. The study was limited by the context of a single clinic located in an urban setting. Language may be an issue as some patients had limited literacy. However, a bilingual researcher experienced in this setting conducted the interviews.

Further studies using a prospective study design are needed to confirm these findings. The Diabetes Score is a brief, behavioral questionnaire for lifestyle self-management in diabetes.

Results from this study indicate that higher Diabetes Score correlates with better glycemic control. The questionnaire has favorable internal consistency and reliability. It appears to be useful for discussing and promoting healthy nutrition, increasing physical activity, and engaging in self-care among adult patients with type 2 diabetes.

Written informed consent was obtained from the participants, and no personally identifiable information such as names or addresses was recorded. Financial incentives were not provided to the subjects for participation in the study. The study was carried out in accordance with the Helsinki Declaration Principles.

The safety, privacy, and voluntary participation of subjects were respected at all times. The study was supported by an internal university research grant College of Medicine and Health Sciences Faculty Grant.

contributed to design, conception, manuscript drafting, critical analysis, and final approval. contributed to data collection, manuscript drafting, critical analysis, and final approval. Data that support the findings of this study are available from the corresponding author upon reasonable request.

Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Dubai Diabetes and Endocrinology Journal. Advanced Search. Skip Nav Destination Close navigation menu Article navigation.

Volume 27, Issue 4. Materials and Methods. Statement of Ethics. Conflict of Interest Statement. Funding Sources. Author Contributions. Data Availability Statement. Article Navigation. Research Articles November 16 Empowering Patients for Healthy Nutrition, Physical Activity, and Self-Care Using the Diabetes Score Questionnaire Subject Area: Endocrinology , Further Areas.

Muhammad Jawad Hashim Department of Family Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates. physicianthinker gmail. This Site. Google Scholar. Halla Mustafa Halla Mustafa. Dubai Diabetes Endocrinol J 27 4 : — Article history Received:.

Cite Icon Cite. toolbar search Search Dropdown Menu. Education has long been recognised as the cornerstone of the diabetes management regimen Hurley and Shea, For example it has been reported that undertaking a self-care management regimen is more difficult than dealing with the diagnosis of diabetes Anderson, It is, therefore, important for the nurse to be aware of how complex the treatment regimen can be, particularly for individuals with type 1 diabetes mellitus.

Their lives revolve around a temporal regularity in which insulin doses must be calculated and administered at precise times. Meals, exercise, rest and monitoring of blood glucose parameters must be planned and performed to match those times when insulin levels are expected to drop or peak.

In the context of diabetes education, the concept of empowerment is thus based on several assumptions:. A helping hand In order for people with diabetes to become actively involved in their own care, it is important for the nurse to equip them with the information needed for effective self-management.

The person with diabetes also needs to understand the healthcare system and how to utilise it when necessary. This can only be achieved if the education programme contains all the relevant topics to improve knowledge. As shown in the extended list Table 1 , these topics should include knowledge about diabetes, dietary composition particularly with regard to reducing saturated fats , their impact on blood glucose levels, as well as the effect of other lifestyle issues such as exercise, smoking cessation, alcohol intake and illness.

How and why insulin needs to be adjusted to accommodate these factors also need to be explained. The importance of attending the diabetes clinic and eye appointments should be clearly emphasised.

It could be argued that those who are thus empowered benefit both psychologically and in terms of maintaining long-term metabolic control. This approach to diabetes management, as Cavan argues, shifts from a purely traditional medical model to the provision of effective educational interventions to facilitate successful self-care, with immediate medical needs met at diagnosis and at intervals thereafter Figure 1.

However, not everyone with diabetes may be comfortable with taking responsibility for their lives. In such cases, the individual may prefer a more direct approach. As Funnell et al assert:. The choice remains with the patient, even when the choice is to decline power.

Patients who choose to remain the passive recipients of care are responsible for that choice and its consequences. The medical model In the medical model, treatment goals and plans often ignore the emotional, spiritual, social and cognitive aspects of living with a chronic disease such as diabetes Arnold et al, During a medical visit, there may be opportunities to see a nurse or dietitian.

Consequently, the medical model may well lead to conflict between healthcare professionals and people with diabetes. Furthermore, the medical model does not necessarily meet the psychological needs of the person with diabetes. For example, the diagnosis of diabetes is often a shock and frequently devastating to the individual.

Failure to effectively address this important aspect of psychological care may lead to poor self-esteem and low motivation to adopt self-care behaviour Jacobson et al, Moving towards empowerment A major goal of patient empowerment is to improve adherence to agreed self-care regimens. People with diabetes are often unsure whether they can achieve the set goals.

To become empowered, they need information, assurance, support and caring. The motivational interview model developed by Rollnick et al aims to assist healthcare professionals in helping patients manage their illness experience. The adapted steps see below , extracted from the work of Rollnick et al , may be applied in full or in part, depending on where the individual is located in the process.

Many people with diabetes have misconceptions about their condition. They may associate diabetes with complications and fatalistic outcome. Such information enables the nurse to respond in an empathic manner.

Exchanging information The amount of information given to a person with diabetes should be based on assessment and negotiation. When the person is ready for more information, it should be provided in an unbiased, non-judgmental manner. Where diabetes medications are concerned, their action, any possible side-effects, and storage should be explained in a style that is readily understood by the person with diabetes.

The present and the future This strategy allows people with diabetes to discuss their expected outcomes as a result of undertaking the prescribed self-care activities. Expected outcomes may include weight loss, normal blood glucose level, and prevention of complications.

Any concerns for the future should be addressed in a compassionate and non-judgmental manner. Although the approach to asking the questions is neutral and non-judgmental, they do not necessarily produce a desired outcome. Conclusion The empowerment philosophy clearly represents a shift in attitude for both patients and healthcare professionals.

In the context of diabetes, there is perhaps an understandable apprehension that allowing people with this condition to learn about the care and education they should receive may give rise to an increasingly demanding population of patients. It cannot be denied that healthcare professionals who routinely practice empowerment have seen the emergence of well-informed people with diabetes, who are aware of their rights.

Frank and honest information about the lack of resources and other factors that impede the delivery of appropriate care will result in a better-informed population who have a significant effect on our healthcare providers and political figures. Consequently, people with diabetes are our best allies in our fight to deliver the optimum level of care.

Facilitating empowerment to people with diabetes and their families is therefore well worth the time and energy required to achieve it.

Anderson RM Is the problem of non-compliance all in our heads?

Article PubMed Google Scholar. Zoffmann V, Kirkevold M. Realizing Empowerment in Difficult Diabetes Care: A Guided Self-Determination Intervention. Qual Health Res. Rossi MC, Lucisano G, Funnell M, Pintaudi B, Bulotta A, Gentile S, et al. Interplay among patient empowerment and clinical and person-centered outcomes in type 2 diabetes.

The BENCH-D study. Bravo P, Edwards A, Barr PJ, Scholl I, Elwyn G, McAllister M. Conceptualising patient empowerment: a mixed methods study.

BMC Health Serv Res. BMC Health Services Research. Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, et al.

National standards for diabetes self-management education and support. Ávila L, Cerón D, Ramos R, Velázquez L. Association of family support and knowledge about the disease with glycemic control in diabetic patients. Rev Med Chil. Article Google Scholar.

Chen M-F, Wang R-H, Lin K-C, Hsu H-Y, Chen S-W. Efficacy of an empowerment program for Taiwanese patients with type 2 diabetes: A randomized controlled trial. Appl Nurs Res. Cunha M, André S, Granado J, Albuquerque C, Madureira A.

Empowerment and Adherence to the Therapeutic Regimen in People with Diabetes. Procedia Soc Behav Sci. Elsevier B.

Imazu MFM, Faria BN, De Arruda GO, Sales CA, Marcon SS. Effectiveness of individual and group interventions for people with type 2 diabetes. Rev Lat Am Enfermagem.

Freire P. Pedagogia do Oprimido. São Paulo: Paz e Terra; Cortez DN, Torres H de C, Reis IA, Macedo MML, Souza DAS.

Complications and the time of diagnosis of diabetes mellitus in primary care. Acta Paul Enferm. Torres H de C, Reis IA, Maia MA. Professional workshops help fill gaps in diabetes self-management.

Diabetes Voice. Campbell M, Thomson S, Ramsay C, MacLennan G, Grimshaw J. Sample size calculator for cluster randomized trials. Comput Biol Med. Funnell MM, Tang TS, Anderson RM. From DSME to DSMS: Developing empowerment-based diabetes self-management support. Diabetes Spectr. Cecílio SG. Dissertação: Adequação Cultural: Etapa complementar à tradução e adapatação de instrumentos em saúde.

Belo Horizonte: Universidade Federal de Minas Gerais; Torres HC, Virginia AH, Schall VT. Validation of Diabetes Mellitus Knowledge DKN-A and Attitude ATT Questionnaires. Rev Saude Publica. Torres H de C, Franco LJ, Stradioto MA, Hortale VA, Schall VT.

Evaluation of a diabetes education program. Chaves FF, Reis IA, Pagano A, Torres H de C. Translation, cultural adaptation and validation of the Diabetes Empowerment Scale-Short Form.

Kroese DP, Brereton T, Taimre T, Botev ZI. Why the Monte Carlo method is so important today. Wiley Interdiscip Rev Comput Stat. R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna: R Found. Comput; Schulz KF, Altman DG, Moher D, Jüni P, Altman DG, Egger M, et al.

CONSORT Statement: Updated guidelines for reporting parallel group randomised trials. J Clin Epidemiol. Wong CKH, Wong WCW, Lam CLK, Wan YF, Wong WHT, Chung KL, et al. Effects of patient empowerment programme PEP on clinical outcomes and health service utilization in type 2 diabetes mellitus in primary care: An observational matched cohort study.

PLoS One. Littlewood K, Cummings D, Lutes L, Solar C. Psychometric Properties of the Family Support Scale adapted for African American Women with Type 2 Diabetes Mellitus.

Ethn Dis. PubMed Google Scholar. Birditt KS, Newton N, Hope S. J Gerontol Ser B Psychol Sci Soc Sci. Huang M-C, Hsu C-C, Huang-Sen W, Shyi-Jang S. Prospective Randomized Controlled Trial to Evaluate Effectiveness of Registered Dietitian—Led Diabetes Management on Glycemic and Diet Control in a Primary Care Setting in Taiwan.

Yang YS, Wu YC, Lu YL, Kornelius E, Lin YT, Chen YJ, et al. Adherence to self-care behavior and glycemic effects using structured education. J Diabetes Investig. Dempster M, McCarthy T, Davies M. Psychological adjustment to Type 2 diabetes and relationship quality.

Diabet Med. Investigation of the relationship between patient empowerment and glycaemic control in patients with type 2 diabetes: a cross-sectional analysis. BMJ Open.

Nuti L, Turkcan A, Lawley MA, Zhang L, Sands L, McComb S. The impact of interventions on appointment and clinical outcomes for individuals with diabetes: a systematic review. Download references. This study was financially supported by Minas Gerais State Research Support Foundation FAPEMIG - Grant APQ Programa Hiperdia Minas under the coordination of Dr.

Heloísa de Carvalho Torres. The grant had no role in the study design, data collection, data analysis, data interpretation, writing of the manuscript, or decision to submit the manuscript. No potential conflict-of-interest relevant to this article was reported.

We hereby declare that the data and research materials can be obtained by email to the corresponding author. We also declare that the dataset supporting the conclusions of this manuscript will be available in a proper repository. DNC: Collaborated in the design and development of the project, the collection, analysis, and interpretation of the data, in writing the article, provided a relevant critical review of the intellectual content.

IAR, HCT: Collaborated in the design and development of the project, in the relevant critical review of the intellectual content, and in the final approval of the version to be published.

MMLM, DASS, JCS, GSA: Collaborated in the collection, analysis, and interpretation of the data, in writing the article, and provided a relevant critical review of the intellectual content. All authors read and approved the final manuscript. Daniel Nogueira Cortez: Professor in Federal University of São João del-Rei Divinópolis Campus and Ph.

D in School of Nursing, Federal University of Minas Gerais, Brazil. Maísa Mara Lopes Macedo, Débora Aparecida Silva Souza and Jéssica Caroline dos Santos: Master degree in School of Nursing, Federal University of Minas Gerais, Brazil.

Gesana Sousa Afonso: Nursing, School of Nursing, Federal University of Minas Gerais. Ilka Afonso Reis: Professor in Institute of Exact Sciences, Federal University of Minas Gerais, Brazil. Heloísa de Carvalho Torres: Professor in School of Nursing, Federal University of Minas Gerais, Brazil and Coordinator of the Research Group in Management, Education and Health Evaluation.

Daniel Nogueira Cortez, Maísa Mara Lopes Macedo, Débora Aparecida Silva Souza, Jéssica Caroline dos Santos, Gesana Sousa Afonso and Ilka Afonso Reis: Member of the Research Group in Management, Education and Health Evaluation in Federal University of Minas Gerais, Brazil.

The study was approved by the Ethics Committee, following the national and international standards, under record: CAAE The participants signed an informed consent agreement. Federal University of São João del-Rei Centro Oeste Campus , Divinópolis, Brasil.

School of Nursing, Federal University of Minas Gerais, Belo Horizonte, Brazil. Institute of Exact Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil. Universidade Federal de São João Del-Rei, Sebastião Gonçalves Coelho Street, , sala You can also search for this author in PubMed Google Scholar.

Correspondence to Daniel Nogueira Cortez. Open Access This article is distributed under the terms of the Creative Commons Attribution 4. Reprints and permissions. Cortez, D. et al. Patients as a whole become the focus of the visit and the encounter, rather than just their diabetes.

The Chronic Care Model has been tested as an effective approach for chronic illness care. The empowerment philosophy is in keeping with this approach to care. It involves establishing partnerships with individual patients and creating truly patient-centered practices.

The benefits for patients include better communication with providers, greater satisfaction with care, improved metabolic and psychosocial outcomes, and emotional well-being. The benefits for providers include achievement of recommended standards of care, improved outcomes, and greater professional satisfaction.

Funnell, MS, RN, CDE, is a clinical nurse specialist and Director for Administration at the Michigan Diabetes Research and Training Center in the Division of Endocrinology and Metabolism, Department of Internal Medicine, and Robert M.

Anderson, EdD, is a professor of medical education in the Department of Medical Education at the University of Michigan in Ann Arbor. Work on this article was supported in part by grant number NIH5P60 DK and 1 R18 0K from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.

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Volume 22, Issue 3. Previous Article Next Article. Models of Care and Education. Self-Management Education and Support for Patient Empowerment.

Practice Design for Empowerment and Self-Management. Making the Shift. Article Information. Article Navigation. Features July 01 Empowerment and Self-Management of Diabetes Martha M. Funnell, MS, RN, CDE ; Martha M.

Funnell, MS, RN, CDE. This Site. Google Scholar. Robert M. Anderson, EdD Robert M. Anderson, EdD. Clin Diabetes ;22 3 — Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest.

IN BRIEF A gap currently exists between the promise and the reality of diabetes care. Table 1. View large. View Large.

In addition, during patient visits, providers can:. Offer referrals to a diabetes education program and a registered dietitian. Listen to patient-identified fears and concerns. Take advantage of teachable moments that occur during each visit.

Establish a partnership with patients and their families to develop collaborative goals. Provide information about behavior change and problem-solving strategies. Assist patients in solving problems and overcoming barriers to self-management.

Support and facilitate patients in their role as self-management decision-makers. Supplement self-management support with information technology.

Diabetes Educ. Diabetes Care. Pract Diabetol. In Evidence-Based Diabetes Care. J Gen Intern Med. In Practical Psychology for Diabetes Clinicians. Ann Behav Med. In Psychology in Diabetes Care.

Griffin S, Wagner EH, Eijk JT, Assendelft WJ: Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev.

Curr Diabetes Reps. Pract Diabetol Int. Diabetes Spectrum. Jt Comm J Qual Improv. American Diabetes Association. View Metrics. Email alerts Article Activity Alert. Table of contents 18 chapters Search within book Search. Front Matter Pages I-XXIV. Introduction Nicola Brew-Sam Pages Background on Diabetes Self-Management Nicola Brew-Sam Pages Defining and Categorizing Diabetes Apps for Self-Management Nicola Brew-Sam Pages Diabetes App Use — Previous mHealth Research Nicola Brew-Sam Pages Anteceding Factors of Diabetes App Use Nicola Brew-Sam Pages Summarizing mHealth Research Gaps I: Alternative Theory is Needed Nicola Brew-Sam Pages Empowerment as an Antecedent of Diabetes App Use Nicola Brew-Sam Pages Summarizing mHealth Research Gaps II: Empowerment and Diabetes App Use Nicola Brew-Sam Pages Summarizing Model on Empowerment and Diabetes App Use Nicola Brew-Sam Pages Research Questions and Hypotheses Nicola Brew-Sam Pages Overview of the Research Design Nicola Brew-Sam Pages Study 1 — Diabetes App Features Corresponding to Indicators of Empowerment: An App Feature and Quality Analysis Nicola Brew-Sam Pages Study 2 — Interviews on App Use for Diabetes Self-Management and the Relevance of Empowerment Nicola Brew-Sam Pages Study 3 — An Online Survey on Empowerment as an Antecedent of Diabetes App Use Nicola Brew-Sam Pages Discussion and Deriving Research Gaps Nicola Brew-Sam Pages Learning from Research Results — Implications for Research and Diabetes Care Practice Nicola Brew-Sam Pages Summarizing Research Limitations Nicola Brew-Sam Pages Conclusion Nicola Brew-Sam Pages Back Matter Pages

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Search for stores near:. Find out when it's back ×. Email address. Diabetes Selfcare Management - A patient-empowerment manual Edited by Sarah Cuschieri , Charles Savona-ventura. Learn More. This product requires a minimum order of 1. Final Sale. No returns or exchanges. This item will be shipped by appointment through our delivery partner.

Ship to me Checking availability…. For example it has been reported that undertaking a self-care management regimen is more difficult than dealing with the diagnosis of diabetes Anderson, It is, therefore, important for the nurse to be aware of how complex the treatment regimen can be, particularly for individuals with type 1 diabetes mellitus.

Their lives revolve around a temporal regularity in which insulin doses must be calculated and administered at precise times. Meals, exercise, rest and monitoring of blood glucose parameters must be planned and performed to match those times when insulin levels are expected to drop or peak.

In the context of diabetes education, the concept of empowerment is thus based on several assumptions:. A helping hand In order for people with diabetes to become actively involved in their own care, it is important for the nurse to equip them with the information needed for effective self-management.

The person with diabetes also needs to understand the healthcare system and how to utilise it when necessary. This can only be achieved if the education programme contains all the relevant topics to improve knowledge. As shown in the extended list Table 1 , these topics should include knowledge about diabetes, dietary composition particularly with regard to reducing saturated fats , their impact on blood glucose levels, as well as the effect of other lifestyle issues such as exercise, smoking cessation, alcohol intake and illness.

How and why insulin needs to be adjusted to accommodate these factors also need to be explained. The importance of attending the diabetes clinic and eye appointments should be clearly emphasised.

It could be argued that those who are thus empowered benefit both psychologically and in terms of maintaining long-term metabolic control. This approach to diabetes management, as Cavan argues, shifts from a purely traditional medical model to the provision of effective educational interventions to facilitate successful self-care, with immediate medical needs met at diagnosis and at intervals thereafter Figure 1.

However, not everyone with diabetes may be comfortable with taking responsibility for their lives. In such cases, the individual may prefer a more direct approach.

As Funnell et al assert:. The choice remains with the patient, even when the choice is to decline power. Patients who choose to remain the passive recipients of care are responsible for that choice and its consequences.

The medical model In the medical model, treatment goals and plans often ignore the emotional, spiritual, social and cognitive aspects of living with a chronic disease such as diabetes Arnold et al, During a medical visit, there may be opportunities to see a nurse or dietitian.

Consequently, the medical model may well lead to conflict between healthcare professionals and people with diabetes. Furthermore, the medical model does not necessarily meet the psychological needs of the person with diabetes.

For example, the diagnosis of diabetes is often a shock and frequently devastating to the individual. Failure to effectively address this important aspect of psychological care may lead to poor self-esteem and low motivation to adopt self-care behaviour Jacobson et al, Moving towards empowerment A major goal of patient empowerment is to improve adherence to agreed self-care regimens.

People with diabetes are often unsure whether they can achieve the set goals. To become empowered, they need information, assurance, support and caring. The motivational interview model developed by Rollnick et al aims to assist healthcare professionals in helping patients manage their illness experience.

The adapted steps see below , extracted from the work of Rollnick et al , may be applied in full or in part, depending on where the individual is located in the process.

Many people with diabetes have misconceptions about their condition. They may associate diabetes with complications and fatalistic outcome. Such information enables the nurse to respond in an empathic manner.

Exchanging information The amount of information given to a person with diabetes should be based on assessment and negotiation. When the person is ready for more information, it should be provided in an unbiased, non-judgmental manner.

Where diabetes medications are concerned, their action, any possible side-effects, and storage should be explained in a style that is readily understood by the person with diabetes.

The present and the future This strategy allows people with diabetes to discuss their expected outcomes as a result of undertaking the prescribed self-care activities. Expected outcomes may include weight loss, normal blood glucose level, and prevention of complications.

Any concerns for the future should be addressed in a compassionate and non-judgmental manner. Although the approach to asking the questions is neutral and non-judgmental, they do not necessarily produce a desired outcome. Conclusion The empowerment philosophy clearly represents a shift in attitude for both patients and healthcare professionals.

In the context of diabetes, there is perhaps an understandable apprehension that allowing people with this condition to learn about the care and education they should receive may give rise to an increasingly demanding population of patients.

It cannot be denied that healthcare professionals who routinely practice empowerment have seen the emergence of well-informed people with diabetes, who are aware of their rights.

Frank and honest information about the lack of resources and other factors that impede the delivery of appropriate care will result in a better-informed population who have a significant effect on our healthcare providers and political figures.

Consequently, people with diabetes are our best allies in our fight to deliver the optimum level of care. Facilitating empowerment to people with diabetes and their families is therefore well worth the time and energy required to achieve it.

Anderson RM Is the problem of non-compliance all in our heads? The Diabetes Educator 11 1 : 31—34 Arnold M, Butler P, Anderson RM et al Guidelines for facilitating a patient empowerment program. All regions of the world are experiencing an epidemic of obesity and type 2 diabetes [ 7 ].

Diabetes tends to be underdiagnosed and undertreated [ 8 ]. Glycemic levels are suboptimally controlled despite advances in diabetes therapy [ 10 ]. There is an urgent need for a practical, low-cost patient decision aid for diabetes self-management.

We aimed to evaluate the Diabetes Score questionnaire in a clinical context. In particular, we sought to assess whether Diabetes Score correlates with better glycemic control among adult patients with diabetes.

A cross-sectional questionnaire survey was conducted at a primary care clinic in the city of Al Ain, United Arab Emirates, in Researcher-administered structured brief interviews were conducted with otherwise healthy, community-dwelling, adult individuals with type 2 diabetes in an ambulatory setting.

Inclusion criteria for recruitment of subjects in the study were age 18 years or greater and an established diagnosis of type 2 diabetes mellitus. Exclusion criteria included any mental or hearing deficits and other severe medical conditions such as mobility restrictions that would impede participation in the study.

A minimum sample size of 47 subjects was deemed sufficient to detect a correlation of 0. A trained researcher H. conducted all the interviews to ensure consistency and reliability.

Patients in the clinic waiting area were offered information about the study, and voluntary informed consent was requested. Preprinted questionnaire forms were used to collect data in a structured format.

Demographic age, gender, occupation, and education and clinical weight, recent blood glucose, and HbA1C data were recorded. Statistical data analysis was conducted using the current version of SPSS Statistics version 26; IBM SPSS Inc.

In addition to descriptive measures, statistical tests for bivariate correlation, t test, and multivariate regression were performed.

Reliability analysis was assessed using the alpha Cronbach model. Factor analysis was used to evaluate principal components subscales for diet, exercise, and self-care. An alpha level of 0. A total of 60 adult patients with type 2 diabetes mellitus participated in the study. The sample was representative of a wide range of diabetic patients Table 1.

The ages ranged from 43 to 70 years mean 56; standard deviation [SD], 5. A broad range of occupations electricians and engineers to farmers and carpenters and educational backgrounds mean years of formal education, 13; SD, 2.

The mean Diabetes Score was Patients were more adherent to dietary items than to exercise or physical activity Fig. There was no significant difference between male and female patients in terms of glycemic control A1C 6. Comparison of these 2 groups showed that better Diabetes Scores were associated with significantly lower BMI and improved glycemic control Table 2.

The questionnaire data were analyzed for reliability and acceptability. Reliability analysis for internal consistency yielded a Cronbach alpha of 0. Diabetes Score was associated with better glycemic control among adult patients with type 2 diabetes.

The questionnaire showed fair evidence of construct validity, internal consistency, reliability, and patient satisfaction.

We found that patients were more likely to comply with dietary guidelines than with exercise. This is consistent with previous research showing the impact of diabetes on the ability to exercise [ 14 ].

Foot care was often neglected, indicating an area for self-improvement. Self-reported adherence to diabetes medications was high in our survey indicating awareness of its importance. Knowledge of diabetes self-management has tended to remain low despite counseling by dieticians and diabetes educators [ 9 ].

In resource-limited settings such as developing countries, where the largest numbers of diabetes patients reside, frequent blood tests and physician visits may not be feasible. Innovative approaches are needed to focus on low-cost, nonpharmacological interventions such as lifestyle change [ 16 ].

Previous diabetes questionnaires have tended to be lengthy and complicated, making them unsuitable for use in clinical settings [ 11, 13 ]. Many questionnaires were designed for gathering data for research purposes, rather than for improving patient care.

Thus, a questionnaire is needed that can be used not only for measuring adherence to diet and exercise but also for discussing targets and monitoring progress. Unfortunately, many questionnaires include items that are not directly modifiable or actionable.

Some items are not evidence based such as frequent checking blood glucose in type 2 diabetes controlled with oral medications. The Diabetes Score questionnaire fills this critical gap. It is a brief, behavioral checklist designed specifically to empower patients to take control of their lifestyle.

The 10 items in the questionnaire are simple and actionable. The questionnaire is easy to score, and its results are intuitively understandable unlike other questionnaires with complicated scoring. Despite widespread efforts at diabetes education in clinics and the community, most patients do not receive adequate instruction [ 3 ].

Diabetes Score is designed to be used as an educational tool during counseling by a healthcare professional. Physicians and nurses can engage patients, set targets, and measure progress using Diabetes Score. It can thus form a component of a comprehensive chronic disease care process Fig.

By focusing on patient empowerment, Diabetes Score can be a part of a holistic framework for diabetes care [ 16 ]. Diabetes treatment algorithm using Diabetes Score.

The study was limited by the context of a single clinic located in an urban setting. Language may be an issue as some patients had limited literacy.

However, a bilingual researcher experienced in this setting conducted the interviews. Further studies using a prospective study design are needed to confirm these findings.

The Diabetes Score is a brief, behavioral questionnaire for lifestyle self-management in diabetes.