Document Type : Original Article
Authors
1 Student Research Committee, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran, Nursing and Midwifery Sciences Development Research Center, Najafabad Branch, Islamic Azad University, Najafabad, Iran
2 Nursing and Midwifery Sciences Development Research Center, Najafabad Branch, Islamic Azad University, Najafabad, Iran Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
4 Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
Abstract
BACKGROUND: A key step for improving the effectiveness of diabetes self‑management
education (DSME) is to identify its restrictors.
OBJECTIVES: The aim of this study was to explore the restrictors of the effectiveness of DSME.
METHODS: This descriptive qualitative study was conducted in March 2016–2017. Participants
were 16 DSME providers (viz., physicians, nurses, nutritionists, and psychologists) and nine DSME
receivers (viz., patients and their family members) – 25 in total. Semi‑structured interviews were held
for data collection. Interviews were transcribed word by word and analyzed through conventional
content analysis approach proposed by Graneheim and Lundman.
RESULTS: The restrictors of the effectiveness of DSME were categorized into three main categories
and 11 subcategories, namely patients’ limited welcoming of DSME classes (allocating limited time
for participation in DSME classes, inadequate knowledge about diabetes mellitus [DM] importance,
inappropriate educational environment, and financial problems), unfavorable adherence to
treatments: serious challenge (inattention to educations, poor motivation for adherence to medical
recommendations, and inattention to the psychological aspects of DM), and the difficulty of adult
education (the difficulty of changing health‑related attitudes and behaviors, mere information
delivery during education, adults’ physical and perceptual limitations, and diabetes educators’ limited
competence in adult education).
CONCLUSION: The findings of the present study provide an in‑depth understanding about the
restrictors of the effectiveness of DSME. DM management authorities and policymakers can use
these findings to develop strategies for improving the effectiveness of DSME.
Keywords
- American Diabetes Association. Standards of medical
care in diabetes 2020. Diabetes Care 2020;43:S1. Available
from: https://care.diabetesjournals.org/content/diacare/
suppl/2019/12/20/43.Supplement_1.DC1/Standards_of_
Care_2020.pdf. [Last accessed on 2020 Oct 14].
2. Cho NH, Shaw JE, Karuranga S, HuangY, da Rocha Fernandes JD,
Ohlrogge AW, et al. IDF Diabetes Atlas: Global estimates of
diabetes prevalence for 2017 and projections for 2045. Diabetes
Res Clin Pract 2018;138:271-81.
3. International Diabetes Federation (IDF). Diabetes Atlas. Brussels,
Belgium: International Diabetes Federation; 2019. Available
from: https://www.diabetesatlas.org/upload/resources/
material/20200302_133351_IDFATLAS9e-final-web.pdf. [Last
accessed on 2020 Oct 14].
4. Fasil A, Biadgo B, Abebe M. Glycemic control and diabetes
complications among diabetes mellitus patients attending at
University of Gondar Hospital, Northwest Ethiopia. Diabetes
Metab Syndr Obes 2019;12:75-83.
5. Duncan I, Ahmed T, Li QE, Stetson B, Ruggiero L, Burton K,
et al. Assessing the value of the diabetes educator. Diabetes Educ
2011;37:638-57.
6. Taghipour A, Moshki M, Mirzaei N. Determination of effective
factors on self-care behaviors in women with diabetes referring
to Mashhad health centers. Iran J Health Educ Health Promot
2017;5:328-35.
7. Reisi M, Mostafavi F, Javadzade H, Mahaki B, Tavassoli E,
Sharifirad G. Impact of health literacy, self-efficacy, and outcome
expectations on adherence to self-care behaviors in Iranians with
type 2 diabetes. Oman Med J 2016;31:52-9 - 8. Didarloo A, Shojaeizadeh D, Asl RG, Habibzadeh H, Niknami S,
Pourali R. Prediction of self-management behavior among Iranian
women with type 2 diabetes: Application of the theory of reasoned
action along with self-efficacy (ETRA). Iran Red Crescent Med J
2012;14:86.
9. Pourverdi S, Mohammadi Shahboulaghi F, Kashaninia Z,
Rezasoltani P. Effects of self-management program on glycemic
control in patients with type 2 diabetes and glycosylated
hemoglobin. J Holistic Nurs Midwifery 2015;25:19-28.
10. Ghannadi S, Amouzegar A, Amiri P, Karbalaeifar R,
Tahmasebinejad Z, Kazempour-Ardebili S. Evaluating the effect
of knowledge, attitude, and practice on self-management in type 2
diabetic patients on dialysis. J Diabetes Res 2016;2016:1-7.
11. Niknami M, Mirbalouchzehi A, Zareban I, Kalkalinia E,
Rikhtgarha G, Hosseinzadeh H. Association of health literacy
with type 2 diabetes mellitus self-management and clinical
outcomes within the primary care setting of Iran. Aust J Prim
Health 2018;24:162-70.
12. Madmoli M, Abbaszade Aliabad M, Madmoli M, Khodadadi M,
Papi Ahmadi F. The effect of some factors on self-care in diabetic
patients: A systematic review. J Genetics Genetic Eng 2019;3:21-5.
13. Moayed MS, Amoozadeh B, Parandeh A. Assessing health-care
needs of patients with diabetes in Iran’s health-care system:
A modified Delphi method study. J Educ Health Promot 2020;9:42.
14. Tang PY, Fisher EB. Enhancing Peer Support Interventions in
Diabetes Care. Behavioral Diabetes. 1rd ed.: Springer Nature.
2020. p417-37. Available from: https://link.springer.com/
chapter/10.1007/978-3-030-33286-0_27. [Last accessed on 2020
Oct 14].
15. American Diabetes Association. Facilitating behavior change and
well-being to improve health outcomes: Standards of medical care
in diabetes-2020. Diabetes Care 2020;43:S48-65.
16. Larijani B. The Epidemic of Diabetes in Iran: Salamatnews;
2015. Available from: http://www.salamatnews.com/
news/168404. [Last accessed on 2020 Aug 02].
17. Farmahini FarahaniM, PurfarzadZ, GhorbaniM, Ghamari ZareZ,
Ghorbani F. The impact of multimedia software support on
the knowledge and self-care behaviors of patients with type 2
diabetes: A randomized clinical trial. J Caring Sci 2016;5:111-20.
18. Mohebbi B, Sadeghi R, Tol A, Mahmoudi Majdabadi M. The
Effect of educational intervention on barriers of living with
diabetes in awareness and belief, lifestyle, adaptation, and
support dimensions among patients with type 2 diabetes mellitus:
Application of the basnef model. Iran J Diab Metab 2016;16:49-62.
19. Solhi M, Hazrati S, Shabani M, Nejaddadgar N. Use of PRECEDE
model for self-care educational need assessment among diabetic
patients. J Diab Nurs 2017;5:295-306.
20. Sadeghi R, Rezaeian M, Khanjani N, Iranpour A. The applied of
health belief model in knowledge, attitude and practice in people
referred for diabetes screening program: An educational trial.
J Rafsanjan Univ Med Sci 2015;13:1061-72.
21. Moshki M, Dehnoalian A, Alami A. Effect of precede-proceed
model on preventive behaviors for type 2 diabetes mellitus in
high-risk individuals. Clin Nurs Res 2017;26:241-53.
22. Alavi NM, Ahmadi F, Ghofranipour F, Babaei G, Rajab A. Design
and study of the effect of implementation of result-oriented care
and treatment pattern in patients with Diabetes mellitus. Feiz
2000;28:1-10.
23. Alirezaei Shahraki R, Sahaf R, Abolfathi Momtaz Y. Effects of
nationwide program for prevention and control of diabetes
initiated by the ministry of health on elderly diabetic patients’
knowledge, attitude and practice in Isfahan. Iran J Ageing
2019;14:84-95.
24. Mostofizadeh N, TavalaeiZavareh MS. Evaluation of knowledge,
attitude, and practice of diabetic adolescents aged 10-14 years who
referred to diabetes clinic in Imam Hossein Hospital, Isfahan, Iran.
J Diabetes Nurs 2020; 8:1011-16.
25. Akhoundan M, Shadman Z, Soleymanzadeh M ,
Khoshniat Nikoo M, Larijani B. Designing a questionnaire to
evaluate diabetic patients’ knowledge of Ramadan fasting and
its determinant factors. Iran J Diabetes Metab 2014;13:331-9.
26. Salehi F, Ahmadian L, Ansari R, Sabahi A. The role of information
resources used by diabetic patients on the management of their
disease. Med J Mashhad Univ Med Sci 2016;59:17-25.
27. Khozeimeh F, Tahani B, Saberi Z, Gholi A. Evaluation of
knowledge, attitudes and oral health-related nutritional
performance of diabetic patients referred to the diabetes research
center in Isfahan-Iran, 2016. Open Dent J 2019;13.
28. Khanpaye A, Madmoli Y, Riahipour B, Mohebifar M, Madmoli M,
Mahmoodi R, et al. Evaluation of knowledge, attitude and
performance regarding gestational diabetes mellitus among
women. J Res Med Dent Sci 2019;7:122-5.
29. Lawal M, Woodman A, Fanghanel J, Ohl M. Barriers to attendance
at diabetes education centres: Perceptions of education providers.
J Diab Nurs 2017;21:61-6.
30. Pamungkas RA, Chamroonsawasdi K, Vatanasomboon P,
Charupoonphol P. Barriers to effective diabetes mellitus
self-management (DMSM) practice for glycemic uncontrolled
type 2 diabetes mellitus (T2DM): A socio cultural context of
Indonesian communities in West Sulawesi. Europ J Investig
Health Psychol Educ 2020;10:250-61.
31. Poduval S, Marston L, Hamilton F, Stevenson F, Murray E.
Feasibility, acceptability, and impact of a web-based structured
education program for type 2 diabetes: Real-world study. JMIR
Diabetes 2020;5:e15744.
32. Mirzaei-Alavijeh M, Jalilian F, Karami-Matin B, Hosseini S,
Jouybari T, Mahboubi M, et al. Patient education in nursing:
Investigation the role of individual and organizational barriers.
Res J Appl Sci 2016;11:704-8.
33. Horigan G, Davies M, Findlay-White F, Chaney D, Coates V.
Reasons why patients referred to diabetes education programmes
choose not to attend: Asystematic review. Diab Med 2017;34:14-26.
34. Abazari P, Vanaki Z, Mohammadi E, Amini M. Inadequate
investment on management of diabetes education. J Res Med Sci
2012;17:792-8.
35. Mc Laughlin S, Chaney D, Belton A, Garst J. International
standards for education of diabetes health professionals. 1rd ed.
International Diabetes Federation. Brussels. 2015, pp. 7-14.
36. Adu MD, Malabu UH, Malau-Aduli AE, Malau-Aduli BS.
Enablers and barriers to effective diabetes self-management: A
multi-national investigation. PLoS One 2019;14:1-22.
37. ObirikorangY, Obirikorang C, Anto EO, Acheampong E, Batu EN,
Stella AD, et al. Knowledge of complications of diabetes mellitus
among patients visiting the diabetes clinic at Sampa Government
Hospital, Ghana: A descriptive study. BMC Public Health
2016;16:637.
38. Schäfer I, Pawels M, Küver C, Pohontsch NJ, Scherer M,
van den Bussche H, et al. Strategies for improving participation
in diabetes education. A qualitative study. PloS One 2014;9:1-7.
39. Hadi N, Rostami GN, Jafari P. study on the determining factors for
compliance to prescribed medication by patients with high blood
pressure. Jundishapur Scientific Medical Journal 2005;4:223-9.
40. Nazar CM, Bojerenu MM, Safdar M, Marwat J. Effectiveness
of diabetes education and awareness of diabetes mellitus in
combating diabetes in the United Kingdom; a literature review.
J Nephropharmacol 2016;5:110.
41. Davies M. Psychological aspects of diabetes management.
Medicine 2019;47:131-4.
42. American Diabetes Association. Standards of medical care in
diabetes-2020 abridged for primary care providers. Clin Diabetes
2020;38:10-38.
43. Abazari P, Vanaki Z, Mohammadi E, Amini M. Challenges of
training diabetes nurse educator in Iran. Iran J N Midwifery Res
2012;17:187. - 44. International Standard Classification of Education: ISCED.
Adult Education Definition 2011; UNESCO-UIS 2012. Available
from: http://uis.unesco.org/sites/default/files/documentts/
international-standard-classification-of-education-isced-2011-en.
pdf. [Last accessed on 2020 Oct 14].
45. Kueh YC, Morris T, Ismail AA. The effect of diabetes knowledge
and attitudes on self-management and quality of life among
people with type 2 diabetes. Psychol Health Med 2017;22:138-44.
46. Choudhry NK, Denberg TD, Qaseem A, Clinical Guidelines
Committee of American College of Physicians. Improving
adherence to therapy and clinical outcomes while containing
costs: Opportunities from the greater use of generic medications:
Best practice advice from the clinical guidelines committee
of the American College of Physicians. Ann Intern Med
2016;164:41-9.
47. Karimy M, Koohestani HR, Araban M. The association between
attitude, self-efficacy, and social support and adherence to
diabetes self-care behavior. Diabetol Metab Syndrome 2018;10:86.
48. Burke SD, Sherr D, Lipman RD. Partnering with diabetes
educators to improve patient outcomes. Diabetes, metabolic
syndrome and obesity: Targets and therapy. Diabetes
Metab Syndr Obes 2014;7:45-53.
49. Abazari P, Vanaki Z, Mohammadi E, Amini MM. Barriers to
effective diabetes self-management education. Iran J Med Educ
2013;13:221-32.
50. Bordonaro K. Adult learning theories and autoethnography:
Informing the practice of information literacy. IFLA J 2019;46:163-71.
51. Vandenbosch J, van den Broucke S, Schinckus L, Schwarz P,
Doyle G, Pelikan J, et al. The impact of health literacy on diabetes
self-management education. Health Educ J 2018;18:62-349.
52. Lee YH. Sociodemographic factors associated with participation
in diabetes education among community-dwelling adults with
diabetes. Yonsei Med J 2020;61:169-78.
53. American Association of Diabetes Educators. Competencies
for Diabetes Educators and Diabetes Paraprofessionals; 2016.
Available from: https://www.diabeteseducator.org/docs/
default-source/practice/practice-resources/comp003.pdf. [Last
accessed on 2020 Jul 09].
54. Alharbi T, Thomacos N, McLelland G. Core competencies for
diabetes educators: A scoping review. Diab Metab Syndrome
2019;13:2671-82.
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