Reducing the Stress of Parents of Children with Type 1 Diabetes

by Katherine Blackburn, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of:   Whittemore R, Coleman J, Delvy R, et al. An eHealth Program for Parents of Adolescents With T1DM Improves Parenting Stress. The Diabetes Educator 2020;46(1):62-72.

Most parents' lives are full of stress with demands from multiple sources. Their work-life can demand one thing while their children's lives require something else. When do parents even find time to cook dinner? For parents of children living with a chronic illness, such as type 1 diabetes, their stress levels are much higher when compared to the average parent. However, it is vital that parents of children with type 1 diabetes learn how to manage their stress so that their stress does not adversely affect their child's life and care. A recently published study evaluated the benefits of a six-month educational program, called Type 1 Teamwork.¹ The investigators measured parental stress before and after using this innovative online program.

Type 1 Teamwork offers on-demand, online seminars and other activities focusing on the transfer of care responsibilities to the child, effective communication skills, and stress management. The study was a randomized control trial that recruited parents or guardians of a child between the ages of 11 and 16 with type 1 diabetes who were willing to commit to the six-month study and spoke fluent English. The eligible participants were randomly assigned to participate in the Type 1 Teamwork program or a control group. The participants in the Type 1 Teamwork group were immediately granted access to the online programming featuring diabetes information, tips for diabetes management, and skills for efficient communication between parents and children.  One of the goals of this program was to reduce parental stress. The program requested parents log into the portal once a week to review educational materials. The control group was given access to the Type 1 Teamwork program after completion of the study. To determine the primary outcomes of reducing parenting stress, the researchers utilized the Pediatric Inventory for Parents (PIP) and the Perceived Stress Scale. On both of these inventories, a higher score means a higher stress level. In addition to reducing parenting stress, researchers also analyzed parent anxiety, parent depressive symptoms, parent support for their child's autonomy, family conflict, and the child's A1C levels. To analyze the results, researchers used histograms and quantile-quantile plots to establish normality. For the primary outcome, they used an unadjusted, repeated measures regression model comparing parent's stress reported at baseline, three-months, and six-months in the two groups.¹

At baseline, 36% of parents participating in the study exhibited elevated depressive symptoms while 40% of parents exhibited elevated state anxiety symptoms. The average child’s baseline A1C was 7.9%. Parents reported that 75% of children used an insulin pump and 69% used a continuous glucose monitor to manage their diabetes. Researchers found that using Type 1 Teamwork deceased parent’s overall stress, improved communication between family members, and helped parents delegate responsibilities to their child to optimize their care. Parents also reported lower emotional distress and decreased struggles with parental roles and communication. However, because this was an online program focused on alleviating parenting stress, the program did not address ways to lower depression and anxiety symptoms other than encouraging parents to seek other treatment. While there were several benefits to participating in the Type 1 Teamwork program, the average A1C did not change over the six-month study.¹

One of the main strengths of this study was its broad eligibility criteria. These criteria allowed for people of all backgrounds, races, and geographic locations. However, most of the participants were married white women with a relatively high income. A potential weakness is the lack of objective verification – all results were self-reported by the parents.  Since the participants were not blinded, they may have been biased toward reporting positive results.¹ Though the study has weaknesses, I believe utilizing on-demand, online programs like Type 1 Teamwork can help reduce parental stress and can teach them new ways of communicating with their children.¹

In another study that examined parenting stress of fathers of children with type 1 diabetes, the investigators found that stress exhibited by the father can adversely impact both the mother and child’s stress response.² These fathers were also given the Pediatric Inventory for Parents to evaluate their overall stress levels; however, their results were much lower than the women in this study. In a third study completed in Germany, parents who attended weekly meetings with other families who also have children with Type 1 Diabetes exhibited lower psychological stress and improve parenting behaviors.³

High levels of parental stress can not only impact the parent’s mental health but also affect the care their child receives. Online programs, such as Type 1 Teamwork, offer support for parents and their children from the comfort of their home and at a time that is convenient, thereby reducing barriers to participation.¹ Educators should be aware of programs available for parents of children with Type 1 Diabetes to provide support materials they can review and choose from, such as the Diabetes Empowerment Foundation, which offers material for the person with diabetes, parents, and partners.⁴ Educators need to consider the circumstances each parent faces as well. Do they have a support system present? Are they the main caregiver for their child? Does the parent have time to incorporate meetings into their schedule? Are they financially stable? It is important to consider all factors of the patients when making recommendations because if educators overwhelm them with too much information, it can cause their stress levels to increase even more.

References

1. Whittemore R, Coleman J, Delvy R, et al. An eHealth Program for Parents of Adolescents With T1DM Improves Parenting Stress. The Diabetes Educator 2020;46(1):62-72.

2. Mitchell SJ, Hilliard ME, Mednick L, et al. Stress among Fathers of Young Children with Type 1 Diabetes. Fam Syst Health 2009; 27(4):314-324.

3. Sabmann H, de Hair M, Danne T, Lange K. Reducing stress and supporting positive relations in families of young children with type 1 diabetes: A randomized controlled study for evaluating the effects of the DELFIN parenting program. BMC Pediatrics 2012;12:152.

4. Diabetes Empowerment Health, Support & Wellbeing [Internet]. 2019 [cited 2020 Oct 9]. Available from: http://www.diabetesempowerment.org

Preparing Students to be Self-directed Learners

by Spencer Roper, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Learner-centered teaching, problem-based learning, self-directed learning, active learning; these terms are all used to express a concept that has become more and more common, especially in higher education. Broadly described, learner-centered teaching transitions the primary basis of learning from passive listening of teacher-led lectures to active self-directed learning activities and multi-sided discussions. This transition in higher education has been prompted by research showing active learning strategies might be better when compared to traditional methods, especially when it comes to exam scores and long-term retention of information.¹ Despite these benefits, it can be challenging for students and many resist the transition from being "spoon-fed" information to being required to actively seek out answers.

While previous research seems to have addressed many of the barriers to the implementation of active learning strategies, there has been less focus on the mitigation of student reluctance to trust this method of instruction. Weimer discusses some common reasons for resistance that instructors may encounter including increased workload, fear of failure, sense of loss, and not being intellectually ready for certain activities requiring self-sufficiency.²  As students transition to this new form of instruction, no longer are they given polished PowerPoint notes that require no more than reading and memorizing what the instructor deems important. Rather, students have to determine what information is most important, must decide when to take a deeper dive into available literature, and must develop original ideas in response to case-based questions. This can produce anxiety because students who are unaccustomed to this way of learning are often unsure of their conclusions and wonder if the information sources they’ve used have led them down the wrong road, to the wrong insights, to the wrong answers.

With this knowledge of what causes students to be resistant to change, how do we as instructors address their anxiety? There honestly is no easy, single-solution answer. Instead, new and experienced instructors alike should use a multi-faceted approach when introducing self-directed learning to students. At first, it is important to promote student awareness about the (long-term) utility of independent thinking. A 2012 study evaluating problem-based learning implemented in a chemical engineering course suggested that contextualization helps to motivate students toward becoming self-sufficient learners.³ The writers explain that providing real-world problems that parallel the sort of work students would be doing in the future is critically important. By providing real-world problems, the instructor stimulates student motivation because learning the material falls in line with students’ goals – learning how to solve similar problems throughout their careers.

Once students understand the value of self-directed learning, instructors must find ways to keep students motivated/engaged during a time where they've had more independence than ever. One educator wanted to reduce student resistance to practice-based learning by identifying and implementing potential solutions.  He classified these solutions as either explanative or facilitative. ⁴ Explanation strategies served the purpose of helping students meaningfully participate in active-learning activities by showing how participation would help meet their personal goals as well as the goals of the course. Facilitation strategies can be used before and during instructional activities to reduce resistance by making tasks seem less daunting, by providing encouragement, and by ensuring students can make mistakes without consequences. Using these strategies was met with increased student involvement, less perceived distractions, and an increase in positive evaluations. Table 1 lists the specific strategies that any instructor can use when implementing active-learning methods.

Table 1: Strategies to reduce resistance⁴

Explanation Strategies	Facilitation Strategies
Explain the purpose of the activity	Walk around the room
Explain course expectations	Approach non-participating students
Explain activity expectations	Have an encouraging demeanor
	Invite questions from students
	Promote feedback from students
	Develop a routine
	Make participation grades
	Design activities that require active participation
	Break down tasks into incremental steps

While the table above lays out potential strategies one may use to keep students engaged, it's important to be adaptive in your approach. Each student reacts to challenges differently, and some students require more attention than others. That is why it is so important to be present physically and mentally during these active learning activities so that one can evaluate which students may be struggling and require more encouragement. Today classrooms are more likely to be the virtual variety, so may require rotating through break-out rooms and facilitating discussion among students.  If a student seems to be less engaged, it is appropriate to ask their opinion on the current problem or asking if they require help. Approaching these situations should always be done in an encouraging manner rather than a confrontational one so that the classroom is seen as a safe space for learning rather than a place to be punished for mistakes or lack of knowledge.

Keeping students engaged during class is important, however, it is also important to help students develop self-directed learning skills. Dr. Maryellen Weimer provides some great ideas for building student’s self-directed learning skills.⁵ For instance, letting students summarize the material allows each person to evaluate their own habits. By quizzing students with a few questions relevant to the day’s discussion and having them read verbatim from their notes, an instructor can promote the students’ critique of their note taking skills. It is also imperative to allow students to defend what they have taught themselves by permitting the acceptance of additional multiple-choice answers as correct if they can provide written evidence either from their notes or the text that supports the alternative answer(s).

As educators, it's important to realize that students' fear of a new learning style is warranted. Being uncomfortable with change is something that everyone experiences. While it is a common experience, combatting the reluctance to change requires the application of few different strategies. By being aware of how students may respond to active learning methods, instructors should implement a few strategies to ease the students’ transition from passive to active learning and then facilitate their growth into self-directed learners.

 

References:

1. Freeman S, Eddy SL, McDonough M, et al. Active learning increases student performance in science, engineering, and mathematics. Proceedings of the National Academy of Sciences 2014; 111(23): 8410–8415.
2. Weimer M. Learner-centered teaching: Five key changes to practice. John Wiley & Sons; 2002. 237 p.
3. Harun NF, Mohd-Yusof K, Jamaludin M, et al. Motivation in Problem-based Learning Implementation. Procedia - Social and Behavioral Sciences 2012; 56: 233-242.
4. Tharayil S, Borrego M, Prince M, et al. Strategies to mitigate student resistance to active learning. IJ STEM Ed 2018; 5:7.
5. Weimer M. Learner-Centered Teaching: 10 Ideas for Getting Started. Faculty Focus; 2019.

Teaching to Learn

by William Gust, PharmD, PGY-1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery V.A. Medical Center

Former French inspector general and poet Joseph Joubert once wrote that “To teach is to learn twice over.”¹ Joubert’s maxim is rooted in the idea that while the learner is only responsible for his or her own understanding, the teacher’s added responsibility to accurately communicate a concept to others incentivizes more active engagement of both the subject itself and one’s own deficiencies with it. Furthermore, teaching often necessitates the creation of educational materials, which requires the highest level of cognition.² Thus, promoting the sort of active engagement that teaching requires can be a powerful tool in expediting the learning process. By creating and presenting educational materials to teach others, students enhance their knowledge, comprehension, and confidence related to the subject far more than they would through traditional instructor-led methods.

Encouraging students to develop learning materials for themselves or fellow students bolsters their comprehension. Uskokovic demonstrated this during his employment of a co-creational classroom, in which students developed not only lectures and presentations but also the curriculum itself.³ In this model, the instructor assigns students a broad topic and encourages them to break it down into a series of questions that will be answered by their learning materials. Once questions are assessed for appropriateness of scope by the instructor, students are free to develop learning materials however they see fit. Following the creation of their learning materials, students present to the class for discussion who then ask questions and suggest revisions. In this study, the investigator compared exam performance using this co-creational model compared to the students' exam performance using a traditional didactic instructional model and a flipped classroom model, in which students read the material before class in preparation for elaborating on that material during class meetings. Although the sample size was small (n=8), students performed significantly better on exams when the co-creational model was used when compared to exams where the material was delivered via traditional didactic or flip methods.³

Student teaching also improves knowledge retention. In a crossover-study evaluating the benefit of peer-teaching on learning, Peets et al. randomly assigned medical students to serve as peer educators in small groups at different periods during a Gastroenterology/Hematology course.⁴ Peer educators were not given outside resources by the investigators but were responsible for coordinating and leading their assigned small group discussions. At the end of the course, the investigators administered a 94-item multiple-choice examination broken down by the various clinical cases covered during the course. After comparing student performance stratified by clinical case, students who served as peer educators for a given clinical case performed significantly better on questions than their group members who were only responsible for their own learning (Mean Score 80.7% vs 77.6%, Cohen’s d = 0.33; p < 0.01).

Taken together, these studies support the idea that student-teaching with student-created learning materials enhances student knowledge and comprehension. The results of Uskokovic make a particularly compelling case for the student involvement in the teaching process given the improvement in exam performance with the co-creational method when compared to the flipped classroom method. Had the results in both groups been similar, the better exam performance could have been explained by the presence of active learning, which is central to constructivist theory. The results of Uskokovic, however, suggest that student construction of the content to be covered as well as the learning materials promotes enhanced engagement that cannot be replicated by other active learning methods. Students who serve as peer teachers spend more time engaged with the material.  Peets et al. showed that student peer educators spent significantly more time engaging with the learning material (99 +/- 60 minutes vs 36 +/- 33 minutes, Cohen’s d = 1.3, p < 0.001) when compared to the other group members.

By encouraging (or perhaps requiring) students to create their own learning materials, teachers can improve student knowledge, confidence, and long-term retention. While the studies above focus on the creation of learning materials as a tool to teach other students in traditional classroom settings, this teaching strategy can be adapted to an array of settings, including patient education during practice-based experiences. It is important to note, however, that allowing students to teach with their own learning materials does not eliminate the need for a teacher. Critically, instructors that choose to employ student-generated materials as a teaching method must reduce cognitive load by choosing the right topics to cover and the right questions to ask. In this way, teachers can foster maximal learning in the students’ zone of proximal development while minimizing the chances the students will feel overwhelmed or bored. Overall, student-created learning materials offer a powerful way to enhance knowledge and retention by making the student an active participant.

References:

1. Joubert, J. Joubert: A Selection from His Thoughts [Internet]. New York: Dodd, Mead & Co.; 1899. Accessed 2020 Nov 23.
2. Armstrong, P. Bloom’s Taxonomy [Internet]. Nashville (TN): Vanderbilt University, Center for Teaching. Accessed 2020 Nov 1.
3. Uskoković V. Flipping the flipped: the co-creational classroom. Res Pract Technol Enhanc Learn 2018; 13(1):11.
4. Peets AD, Coderre S, Wright B, et al. Involvement in teaching improves learning in medical students: a randomized cross-over study. BMC Med Educ 2009; 9:55.

Simulation Activities Improve Students’ Perceptions and Confidence

by Erica Claire Loden, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Ledbetter E, Lau S, Enterline A, Sibbitt B, and Chen AMH. A simulation activity to assess student pharmacists’ knowledge and perceptions of oncology pharmacy. Am J Pharm Educ 2019; 84: Article 7474.

I am a student pharmacist and very interested in pursuing a career as an oncology pharmacy specialist. This study grabbed my attention because many of my classmates are unaware that knowledge regarding oncological diseases and treatments is essential in all practice settings. The study analyzed students’ perceptions of the importance of pharmacists in the treatment of cancer and measured their confidence in answering oncology-related questions. This study is necessary because improving confidence and perceptions of oncology therapeutics may help fill the gaps in patient care needs across practice settings.

The instructional activity was implemented by faculty at Cedarville University College of Pharmacy.  The intervention was a two-hour class session during week 4 of a required 5-week oncology module. There were two cohorts of students: third-year pharmacy students in 2016 and 2017. The same activity was implemented in both years. The instructional activity involved four interactive stations involving simulations in a managed care, community pharmacy, a hospital that does not have a clinical pharmacy oncology specialist, and a hospital that does have a clinical pharmacy oncology specialist. Students were placed in pre-assigned groups and given 75 minutes to complete all four stations and a 30 minute debrief followed. At the first station, students used information from a cost-minimization research abstract to examine the cost and efficacy of an oncology medication to be considered for the formulary. At the second station, students made non-pharmacological recommendations to help a patient presenting with chemotherapy-related adverse effects. At the third station, students determined when to discontinue medications and when to restart them for a patient enrolled in an oncology clinical drug trial who presented for cancer-related surgery. Students also developed a communication plan for the surgical team for this patient. At the fourth station, students utilized compounding and calculation skills to verify four prescriptions. The same faculty member facilitated the activity each year for both cohorts and led the debrief sessions. A pre-activity and post-activity survey assessed perceptions and knowledge of oncology-related topics. The same 17 item survey instrument was administered on day 1 of the oncology module (pre-activity survey) and again after students completed the activity in week 4 (post-activity survey). The survey rated items on a seven-point Likert-type scale. The survey measured two concepts: the first nine items assessed students’ confidence in answering oncology-related questions. The remaining eight items evaluated the student’s perceptions based on their level of agreement with pharmacists’ involvement in oncology patient care.

The results show that students in both cohorts had significantly greater confidence answering all nine oncology-related questions following the instructional activity than they did at baseline (p<0.001). Student pharmacists’ perceptions of pharmacists’ roles improved post-activity for all questions except one regarding hospital pharmacists’ ability to answer oncology-related questions at institutions with a clinical oncology pharmacist. Increases in knowledge between the pre-survey and post-survey were similar in both cohorts.

Overall, this educational activity adheres to some of the best practices in instructional design. The pre- and post-activity assessments were created carefully by the module coordinator and by a faculty member with experience developing surveys. Additionally, the instructional activities were kept constant between both cohorts. The study found no difference in responses based on differences in ages, ethnicity, past oncology experience, or gender. However, there are several weaknesses and limitations to this study. The instructional design was incomplete. Learning objectives were unclear and difficult to measure. Students were all from the same school; therefore, the results are less likely to be generalizable to other institutions. There are also other variables that researchers failed to consider. The increase in confidence and perceptions could be due to students completing the other instructional activities during the course before taking the post-survey, rather than the two-hour activity. Future studies could give the survey immediately before and after the instructional activity to alleviate this attribution problem. This study only addressed perceptions and not knowledge or outcomes. Responder bias is a concern because students may have given favorable ratings based on a belief that favorable survey responses could have positively influenced grades. Future studies could include administering knowledge assessments before the activity and administering longitudinal assessments to determine the long-term impact on students’ knowledge and perceptions following the course.

In a similar study which surveyed students from five pharmacy schools in Florida, the investigators found that the majority of the pharmacy students surveyed (75%) were only moderately or not at all comfortable with the field of oncology¹. They concluded maximizing experiential opportunities for students could potentially close knowledge gaps and improve confidence levels. In both studies, researchers found a desire from students to increase experiential learning opportunities related to oncology pharmacy practice. A separate study conducted at the University of South Florida showed participation in an ovarian-cancer simulation improved students' oncology-related knowledge and their perceived understanding of the roles of oncology pharmacists.² This study used a similar study design in that it utilized pre-assessment and post-assessment surveys to assess students’ perceptions.

I believe further studies are needed to produce higher quality, generalizable results. I am unsure if this educational intervention would increase students’ desire to become an oncology pharmacist. The study did show that instruction about oncology pharmacotherapy increases students’ confidence in oncology but it’s not surprising that perceptions about pharmacists' roles in oncology practice would increase after these learning activities. Insights from the science of learning indicate that the brain is malleable and that learning is an experience-dependent process.³ In that way, the 4-stations were well-designed and offered students a range of simulated experiences that illustrate what pharmacists can do across several practice settings. Another study showed experiential learning is capable of improving students’ confidence and perceptions and that students desire more experiential learning opportunities.⁴  The implications are that the best instructional activities immerse students in rich, engaging tasks that can help them achieve a conceptual understanding. Therefore, it is my recommendation that educators balance lectures with a number of simulation and experiential activities to facilitate comprehension and skills development. These activities would be more successful if done multiple times during a module. Providing oncology pharmacy experiences across all pharmacy schools and developing awareness on the importance of knowledge and training in oncology practice will better prepare students to deliver high-quality patient care.

References

1. May P, Ladd J. Florida Pharmacy Students’ Perspectives on Careers in Oncology. J Hema Onc Pharm 2017; 7 (2): 69-75.
2. Serag-Bolos ES, Chudow M, Perkins J, Patel RV. Enhancing Student Knowledge Through a Comprehensive Oncology Simulation. Am J Pharm Educ. 2018; 82(3): Article 6245.
3. Cantor P, Osher D, Berg J, Steyer L, Rose T. Malleability, plasticity, and individuality: How children learn and develop in context. App Developmental Sci. 2018; 23 (4): 307-337
4. Darling-Hammond L, Flook L, Cook-Harvey C, Barron B, Osher D.Implications for educational practice of the science of learning and development. Appl Development Sci 2019; 24 (2): 97-140.

Group-based Education for Self-Management of Type 2 Diabetes Mellitus

by Olivia Husband, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Rygg LØ, Rise MB, Grønning K, Steinsbekk A. Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial. Patient Education and Counseling. 2012 Jan;86(1):98–105.

Type 2 Diabetes Mellitus (T2DM) is one of the most prevalent disease states worldwide, and it is projected that the number of people diagnosed with T2DM will continue to increase over the next decade.¹ As a student pharmacist, T2DM is something I am interested in, not only because of its high prevalence but the impact a pharmacist can have on the management of people with T2DM. An integral component of T2DM treatment is patient self-care and management, including self-monitoring blood glucose and self-administering insulin injections. Patient education is crucial in ensuring that patients are getting the greatest benefit out of their diabetes treatment regimen. The authors of this study state there was very little evidence regarding the efficacy of local, group-based T2DM education.¹

This randomized controlled trial was conducted from May 2006 to November 2008 in central Norway. Participants were patients age 18 or older with a physician confirmed diagnosis of type 2 diabetes mellitus who had at least one general practitioner consultation within the previous three years.¹ There was no specific A1C requirement to enter the trial; however, patients who previously attended a diabetes education program in the past 12 months were excluded from the study.¹ Twenty general practitioners in the local area were asked to evaluate their patients to identify those who met the inclusion criteria for T2DM group education and then to mail out an invitation to participate in the diabetes management course.  Patients who accepted the invitation were then interviewed and randomized into one of two groups: the intervention group, which consisted of two cohorts, hospital 1 and hospital 2, and a control group.¹ The intervention group cohorts attended 15 hours of T2DM education delivered over three class sessions. The members of the control group were told they would be placed on a waiting list and would be offered the education program after one year.  Control group patients were instructed to continue their self-management practices.¹ The intervention received education about T2DM as well as nutrition taught by a diabetes nurse educator who had several years of experience. The education methods used included lectures, interactive skills training with activities, including blood glucose monitoring and problem-solving activities, and group discussion.¹ The primary outcomes of the study were changes in A1C (a measure of long-term blood glucose control) as well as patient response to a questionnaire that assessed their knowledge.  The outcomes were measured at baseline, at 6 months after the education program, and again at 1-year post-program.¹ The results were analyzed using both per protocol and intention to treat analysis.¹

There were no statistically significant differences between the intervention and control groups in regards to primary outcomes at 6 months.¹ But, after 1 year, the control group had a worsening of their A1C level from baseline of 0.3% while the intervention group maintained their baseline A1C (p=0.032).¹ All groups improved their diabetes knowledge after 12 months, but the patients in the intervention group significantly greater improvements in diabetes knowledge when compared to the control group.¹ The intervention group also had a higher level of treatment satisfaction at 6 months, but not at 12 months.¹ There was also a significant increase in the number of participants who avoided fatty foods and regularly self-monitored their blood glucose (p=0.027) among members of the intervention group.¹ Although the intervention group improved their knowledge of self-management of T2DM, their quality of life decreased from baseline over the course of 12 months (p=0.005).¹ This was not the case for the control group, as their quality of life scores remained unchanged when compared to baseline.¹ I think the decline in quality of life in the intervention group might be due to the more intensive monitoring and, ironically, with greater knowledge, more anxiety about the negative effects of diabetes.

Many of the participants in the study had a baseline A1C that was below the recommended treatment goal, and this is a major limitation of this study. To offset this limitation, a sub-group was performed for the subset of patients with an A1C greater than 7.7% at baseline.¹ These participants had poorer glycemic control at baseline, so they reaped the most benefit from the T2DM education program. One way the investigators could have prevented this limitation is to have a baseline A1C requirement for participants to enter the study. I think it is important to note the general decline in patient quality of life within the year following the education program perhaps due to more stress and anxiety related to the management of their T2DM. The program consisted of 15 hours of education across 3 sessions which are very long sessions and it’s hard to absorb that much information. This could have been avoided if the 15 hours was separated into more sessions. The sessions themselves seemed to use an effective combination of lectures, activities, and discussions, with breaks provided for participants.¹ I think overall, the methods of this study were appropriate because the investigators measured both glycemic control as well as patient knowledge after attending the classes.  However, I think they should have scheduled shorter sessions and perhaps included sessions about stress reduction strategies.

Several studies have analyzed the benefits of providing group-based type 2 diabetes management education and most have produced positive results. Participants saw an improvement in their glycemic control.  In one analysis patients were more likely to see improvement when the program was taught by a pharmacist rather than a different healthcare professional.² In most other studies, participants also saw an improvement in their overall quality of life, which was not seen in this study.^1-3 

This study shows that patient education about type 2 diabetes mellitus and self-care is an essential element of its management. This study reinforces the importance of patient education while providing insight on how to structure it. Learning how to manage a disease can be overwhelming, so it is important to address the stress and anxiety that can occur.

References

1. Rygg LØ, Rise MB, Grønning K, Steinsbekk A. Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial. Patient Education and Counseling. 2012;86:98–105.
2. Mikhael EM, Hassali MA, Hussain SA. Effectiveness of diabetes self-management education programs for type 2 diabetes mellitus patients In middle east countries: A systematic review. Diabetes Metab Syndr Obes. 2020;13:117-138.
3. Kumah E, Sciolli G, Toraldo ML, Murante AM. The diabetes self-management education programs and their integration in the usual care: A systematic literature review. Health Policy 2018;122:866–77.