Diabetes education is an integral part of the management of diabetes. The overall goal of diabetes education is to assist the person to integrate diabetes successfully into their concept of self and fit the management tasks into their lifestyle in order to achieve and maintain an integrated sense of self, appropriate self-care, a balanced lifestyle and optimum diabetic control. That is, to deliver holistic patient-centred diabetes care. As indicated in the preface, I prefer to use the term ‘patient’ as ‘well as person with diabetes’ in this book. Some people with diabetes object to being referred to as patients but in my experience the majority refer to themselves as patients and/or diabetics. Significantly, the International Alliance of Patient Organisations (IAPO 2005) uses the term ‘patients’.

IAPO recognised that patients’, families’ and carers’ needs and priorities differ among countries and diseases and described five key principles of patient-centred care:

Holistic patient-centred education and care is consistent with these principles and has a core aim of preventing disease and/or disease progression and promoting positive health to achieve the best possible outcomes (Bastable 1997). Patient education describes the theory and skills the individual needs to learn and encompasses establishing goals to be achieved and conditions in which learning can take place (Redman 2001). Thus, diabetes education is a planned, interactive process using a combination of methods to help people learn relevant information and develop appropriate health behaviours. Significantly, people who learn to and effectively manage their health and make appropriate lifestyle choices use fewer resources and make more effective use of available resources (Tankova et al. 2001).

Standardised patient education and self-management guidelines (a representative list is presented at the end of the chapter) act as important frameworks in which the IAPO principles can be met. However, some may be limited in their effectiveness because they rely on traditional teaching methods, primary and tertiary care is not well-integrated, and the programmes and services often only reach a small number of people (Wagner et al. 2002). Effective chronic disease management consists of:

• Delivering care according to evidence-based guidelines and protocols.
  
• Well designed service practices such as appointment systems, follow up procedures, referral processes, Alert systems, and education programmes suitable to the needs of the target population.
  
• A focus on prevention and supporting patients to self-manage and make relevant behaviour changes by using education methods that facilitate problem-solving and empowerment (Anderson et al. 2002; Anderson & Funnell 2005). Ideally this includes a process for identifying people who do not meet targets.
  
• Ensuring health care providers are educated, competent and supported to undertake their roles, that they function in a complementary, collaborative team, and there are clear links among service providers and resources. Health professionals may need training in health coaching methods.
  
• Education programmes that meet the needs of the relevant population and provide opportunities for continuing education for patients and health professionals. A recent review of >30 randomised controlled trials of diabetes education found only half the education interventions included behavioural components (setting goals, counselling techniques or problem-solving), only one third assessed psychosocial factors (beliefs, self-efficacy, mastery, or locus of control), and significant improvements in knowledge was only demonstrated in one-fifth of the studies (Knight & Donan 2006). These findings suggest most current diabetes education programmes are not holistic or patient-centred, despite the rhetoric.
  
• Accurate clinical and investigative procedures.
  
• Appropriate information is generated, documented and communicated including chronic disease registers, referral systems, patient reminders, outcome monitoring and care planning.
  
• Continuous quality improvement and audit processes that include patients in the design as well as the evaluation and not only as the subject of the evaluation.

Key education and behaviour theories that can be applied to diabetes education include:

• The Health Belief Model, which can suggest best content, topics and information sequencing.
  
• Self-efficacy, the education should build confidence, for example, by ensuring people achieve successes however small and that these are acknowledged.
  
• Locus of control; if people feel they are not in control they may require more support, for example, coaching and carer/family support.
  
• Cognitive Dissonance Theory; design interventions that make people feel unhappy or dissatisfied with their current behaviour and reinforce to prevent relapse.
  
• Diffusion Theory; ensure the intervention is consistent with the individual’s belief system and values.
  
• Stages of Change; design strategies that fit the individual stages and where the individual is at each stage.
  
• Adult education theories; use existing knowledge and problem-solving techniques.

Diabetes education is a lifelong process and information needs change as health status changes, new technology and medicines become available, and new models of service delivery emerge. Significantly, there is a poor correlation between knowledge and behaviour. Scare tactics and negative information lower mental and emotional well being and might lead to denial and/or non-adherence (Knight & Donan 2006).

On a practical level, diabetes education is often divided into:

• Survival skills – the initial information necessary to begin the self-care journey and be safe at home (described later in the chapter). Given the increasing prevalence of diabetes survival skills should actually commence before diagnosis and target at risk populations or the whole population. For example, programmes developed by the National Public Health Institute in Helsinki designed to be delivered in primary care achieved reductions in three key diabetes and cardiovascular risk factors: BMI, waist circumference, and diastolic blood pressure after one year. People who achieved reductions in four or more risk factors had a lower risk of developing diabetes. This suggests diabetes educators need to take a population based approach to diabetes education as well as providing individual education and management.
  
• Basic knowledge – information that builds on survival information and enables the individual to understand diabetes and its management and their role in diabetes management generally, and self-care in particular.
  
• Ongoing education – the continued acquisition of new information, including changes in technology and management practices as they emerge. A key aspect of delivering new information is helping the individual decide how it applies to them. That is, the information must be personalised to their particular life context.

Acquiring survival skills and undertaking relevant diabetes self-management usually requires changes in established behaviours. Understanding the individual’s readiness to make relevant changes and identifying their personal barriers to change is central to behavioural change interventions. Several models have been developed that attempt to describe the behaviour change processes. These include:

• The Health Belief Model (HBM) (Becker & Maiman 1975).
  
• Social Learning Theory (SLT) (Bandura 1986).
  
• Theory of Reasoned Action and Planned Behaviour (TRA) (Ajzen & Fishbein 1980).
  
• The Transtheoretical Model of Change (Stages of Change) (SOC) (Prochaska & DiClemente 1983).
  
• Empowerment Model (Anderson & Funnell 2000).
  
• Coaching models such as the Health Care Australia Coaching Model (Linder et al.2003; Gale 2007), which are based on positive psychology and focus on helping people form the intention to change and supporting them to make and sustain changes. This is different from telephone or Internet coaching models that aim to help individual’s achieve management targets. For example, by prompting them to have various tests or recommending that they ask their doctor about treatment changes (Vale et al. 2003; Young et al. 2007).
  
• The Ecological Model, which focuses on identifying key resources and supporting self-management (RSSM) is an approach that grounds diabetes self-management in the context of the individual’s social and environmental situation (Fisher et al. 2005). It enables the skills and choices of the individual to be integrated with the services and support they receive from their social environment, which includes family and friends, health services, and wider community services. The ecological approach determines the impact various factors in the individual’s environment have on their self-care ability.
  
• Complementary medicine (CAM) models focus on finding the ‘doctor within’ and enhancing the individual’s innate capacity for healing. CAM models suggests health professionals are most effective when ‘. . . we give the doctor who resides in each patient a chance to go to work’. (Schweitzer, in Cousins 2005, p. 78).

There are several common elements among these models: individual behaviours result from perceived benefit of and perceived barriers to change (HBM); expected outcomes and readiness to make changes (SOC); self-efficacy and perceived ability to control the behaviour (SCT); perceptions of social and cultural norms (TRA and CAM); individual innate capacity (doctor within) (CAM). Coaching involves helping people identify ways of changing (pathway thinking). In addition, these models all rely on understanding people with diabetes’ explanatory models for diabetes, their lived experience of diabetes, and how they negotiate complicated health care systems with their contradictory language, focus on ‘control’, discipline, regular surveillance by a range of health professionals, and transferring a great deal of responsibility for diabetes care to the individual.

Health professionals need to understand the multiplicity of factors that influence people’s explanatory models, including their own influence. For example, Type 2 diabetes is frequently described as a ‘lifestyle disease,’ which has a hidden subtext, for example, self-induced disease and blame, media advertising promotes foods such as ‘guilt-free chocolate’. The ‘voice’ in which health professionals seek or deliver information as well as the actual words they use affect learning. Three health professional voices have been described:

• The ‘doctor’ voice used when the health professional is seeking information from the patient.
  
• The ‘educator’ voice used when imparting information to the patient.
  
• The ‘fellow human’ voice used when encouraging and supporting people.

People with diabetes are more likely to respond to the fellow human voice. They often try to reduce the judgmental connotations inherent within words by developing their own explanations for diabetes.

Effective communication is central to teaching and learning and the patient’s role in health-related decision-making. Communication means many things. In the context of diabetes education it is the art of asking good questions and listening to the answers.

Research consistently demonstrates low patient-health professional concordance about management decisions (Heisler et al. 2003; Parkin & Skinner 2003; Skinner et al. 2007), which health professionals frequently attributed to patients not recalling the content of the consultation. However, Skinner et al. (2007) demonstrated that both patient and health professional recall is poor. Significantly, Skinner et al. found some decisions patients and health professionals recalled were not evident in recordings of their conversations and there were discrepancies between the details even when both groups recalled the general topics discussed.

Parkin & Skinner (2003) found patients were more likely to recall talking about diet and less likely to recall discussing moods or emotions. Conversely, health professionals were more likely to recall discussing mood and emotions. They found complete disagreement between patients and health professionals in 19.6% of encounters and about decisions made 20.7% of the time. That is, the ‘the two parties seem to recall different consultations’. Patients may forget a great deal of what they are told, but it appears health professionals forget a great deal about what they said.

Likewise, Rushford et al. (2007) found women hospitalised with a cardiac condition recalled receiving information about medication, smoking cessation, and exercise but very few recalled receiving information about resuming gardening, sexual activity, and driving. Obese inactive women only recalled a limited amount of information about diet and activity and only some women with diabetes recalled receiving information about medicines. Older women were least likely to recall advice.

Teaching is a communication process involving planning, implementing and evaluating information to be learned. Teaching can be delivered individually or in groups and involves:

• Creating an environment in which learning can occur. This includes establishing a relationship with the person and finding their ‘doctor within’.
  
• Assessing learning needs and learning style or styles. The learning needs are used to set goals and plan the teaching. Assessment is an essential first step because patients and health professionals have different ideas about what is important (Woodcock & Kinmouth 2001). Barriers and facilitators to learning and being able to use the information can be identified and the teaching can build on past experience, existing knowledge, and address misconceptions.
  
• Prioritising learning needs.
  
• Setting goals with the individual or group to be achieved that are agreed with the individual or group and are achievable and measurable.
  
• Identifying the teaching method most likely to enhance learning and the materials needed to deliver the teaching. This can be as simple as a stick to draw in the sand with or as complex as a sophisticated lecture room. In group settings a range of teaching strategies need to be used to accommodate different learning styles.
  
• Delivering the teaching using strategies most likely to facilitate learning.
  
• Having the insight to ‘Seize the day’ and teach at a teachable moments as the movie The Dead Poet’s Society portrayed so poignantly.
  
• Evaluating the outcome. Evaluation is an essential aspect of quality improvement and should not only focus on patient outcomes (knowledge and behaviour). Teacher performance and the overall teaching programme should also be evaluated. There are different forms of evaluation depending on the purpose of the evaluation see recommended reading at the end of the chapter. When planning the evaluation, the data collection process and validity of any tools used need to be considered.

Thus, there is considerable overlap among teaching, storytelling, and counselling. In the context of diabetes education where the underlying goal is often to achieve and/or maintain behaviour change, the teacher must find the most effective way to invite the individual to see themselves and their role in a different way and find ways to help the individual help him or herself. Thus, education is a sophisticated form of marketing. It is a challenge selling the product ‘diabetes’, with all that entails and the meanings the word holds for individuals and society, to a usually reluctant buyer.

Health professional training in how to deliver patient-centred education and care may improve performance and patient satisfaction with and active engagement in their care (Lewin et al. 2001).

Diabetes education can be delivered individually and is equally effective delivered in groups including initiating insulin (Plank et al. 2004; Yki Jarvinen et al. 2007). However, people still need to be able to apply the information to their personal situation and have the opportunity to practice relevant behaviours. Group education provides a form of peer support and often helps people feel less alone in the problems they face and feelings about diabetes, which can have positive health benefits. Internet based education programmes are also effective for younger and older people especially when they are interactive and emphasise behavioural and motivational strategies (Bond et al. 2007).

Health professionals are often also patient advocates, in fact patient advocacy is listed as in Role and Scope of Practice for the Credentialed Diabetes Educator in Australia (Australian Diabetes Educators Association (ADEA) 2007). Specific advocacy actions for diabetes educators and nurses include helping people obtain relevant health care, advocating for services, and interceding with other health professionals on the individual’s behalf. Health advocacy is a complex process and nurses are often hindered in their advocacy by issues such as a sense of powerlessness, lack of support form colleagues, lack of time, and insufficient knowledge and skills (Negarandeh et al. 2006).