Help with Hurdling: Getting over the Barriers to Self Management

A recent review article in the journal 'Diabetic Medicine' described in detail the kind of barriers that get in the way of people with diabetes from being able to successfully self manage their condition, that is, taking the actions that are likely to promote and maintain health, such as measuring blood glucose, taking and adjusting medication, looking after feet, eating healthily being physically active and taking steps to prevent or deal promptly with hypoglycaemia and high blood glucose levels.

While a review article doesn’t aim to make recommendations for changes in practice, in describing the evidence for each of the barriers, it does reveal what is effective or less effective. This is helpful because, ideally, it gives the chance for diabetes services and health professionals to use the evidence base to implement effective strategies for promoting and supporting self management and ‘lose’ the less effective ones.

Unfortunately this is not always what happens. Translating knowledge into action in relation to living with diabetes is in fact cited as one of the barriers. For example, the knowledge that persistent high blood glucose levels can lead to long term complications does not lead most people to keep their blood glucose levels within recommended ranges all the time. And it is exactly the same with health professionals – the knowledge that telling people what to do, advice giving and ‘warnings’ about complications is not effective in helping people manage their diabetes, does not stop them doing it regularly. There are other factors involved in effectively taking action and some of these are illuminated in this review article.

In keeping with previous blogs, I would like to suggest that in the evidence for effectiveness cited for each of the factors, there are as many messages for people working with diabetes as there are for those living with it, and reflecting and taking action on these could potentially help us all to feel more successful and satisfied in our efforts.

So, to make it easier than reading the whole paper in a lofty journal – who has time for that?! - here’s an SD 'key points' guide for both health professionals AND people with diabetes, along with some of the strategies that really work to promote and prize self management of diabetes, based on the evidence in this review. Think of it as your ‘hurdling guide’ - ideas for getting over the barriers when they arise!

‘Your SD Hurdling Guide’

Knowledge is important in self management. Unless someone knows what to do, why and when, they are unlikely to take useful action. However, Knowledge delivered once, or in a didactic or authoritarian way is not effective. Knowledge given in the context of an opportunity to use it, for example as part of an activity or as a result of someone's questions is much more helpful and likely to be remembered. Also, information given at diagnosis, is particularly likely to be forgotten, so must be revisited and checked. So, health professionals need to provide education and ask if it has been received, and for people learning about diabetes, they need to generate questions they need the answers to, and also check from time to time, to ensure their knowledge is accurate.

Motivation to take care of diabetes is influenced by how severe someone thinks their condition is, and how likely they believe themselves to be at risk of problems from it. Also, taking a particular action, for example starting insulin or taking up a new activity, will have benefits and barriers which will also determine whether it happens. So, health professionals need to explore with people what their perceptions are of severity, personal risk and benefits and barriers, rather than just dictate what actions they should take. For people with diabetes, being aware of the pros and cons for them of taking a particular action, and being prepared to discuss these in a consultation is very useful.

A higher level of confidence in self management makes it more likely that someone will do this effectively. Confidence can be measured on a simple 0-10 (high) scale, with discussion of the number given and working out what the barriers are if confidence is low. Discussions about confidence are vital, to shed light on what a person feels more or less able to achieve. For health professionals, this means giving people an opportunity to consider and assess their confidence and discuss it with them. For people with diabetes, it means being able to work out what they feel less confident about and why and what might improve their score in these areas.

Day to day problem solving is associated with better self management. Problem solving involves first acknowledging a problem, then working out what would improve the situation (a goal) and what action needs to be taken to achieve this. For health professionals, this means that consultations need to be based around what problems the person with diabetes is currently troubled by, then working together to set a goal and action plan. For the person with diabetes, reflection on their key problems and their preferred ways to solve them, and actively practising problem solving is helpful, to make it become an everyday habit.

Finally, social support, that is the availability of help from others, is an important factor in self managing diabetes. Support refers not only to practical, but emotional and informational help as well. People with more support seem to be more successful at taking care of their diabetes. This means that health professionals need to explore with people what kind of support they have and ways they could access more if they need it. For people with diabetes, the implication of this is to consider who and how they receive support and affirmation in managing their condition, and where there are gaps. Also, to recognise that they may need to ask for, or set up support rather than feeling like they have to 'soldier on' alone or ignore their condition for fear of what others may think.


Reference

Ahola, AJ., Groop, P-H. (2013). Barriers to self management of diabetes. Diabetic Medicine, 30, 413-420

Let's Hear it for Listening

Yesterday the Department of Health announced a new rating for GP surgeries – marks out of 10 for ‘patient experience’. The rating is designed to enable people to make comparisons between surgeries when deciding which surgery to register with. A score of 10 is high and it is based on information given in the patient’s survey, a questionnaire given to a random selection of people visiting their GP after their consultation. You can see the ratings on the NHS Choices website.

A key new factor included in the rating is ‘whether doctors and nurses are good at explaining things and listening to people’ – part of the job description of a health professional, you might think, and certainly this factor is welcomed by the Patient’s Association who say they hear increasingly from people who are not listened to effectively. However, this seemingly straightforward aspect of a consultation being rated has raised some strong feelings among healthcare staff. A comment from a practice manager in the health professional online magazine ‘Pulse’ yesterday was that maybe patients should be rated on their ability to listen as many problems arose because of people ‘failing to remember the basic information they have been told’. This comment drew a number of ‘well said’s from other contributors, among them a GP who felt that ‘It’s about time patients' responsibilities were highlighted as well as doctor’s’.

It sounds from all this, as though both patients and doctors feel frustrated – patients because they don’t get enough time to take in information properly, and doctors and other health professionals because their attempts to give the best care are hijacked by government pressure and targets, for example having to deal with a number of medical issues in only a 10 minute consultation. When stressed like this, it’s not surprising that both parties are tempted to blame the other.

But could there be another suspect entirely that is to blame for the mismatch between expectations and reality? namely the system in which care is delivered. For example, we have often heard from health professionals who have been given extended consultation time alongside undertaking a course, to help people manage their diabetes more effectively (‘Insulin for Life’: Chaplin, Widdowson and Reeve, 2012). They report that they found the benefits of conversing with people in a more relaxed way about their lives, challenges and hopes and dreams was incredibly useful, not to mention satisfying. Even more importantly, this approach improved outcomes for both patient and health professional.

This would seem to suggest that, in long term conditions at least, that systems need to change to accommodate the needs. In the above example, many GP surgeries also began dedicated clinics for diabetes as a result of their experiences, and have found it a really effective way of meeting the needs of people with diabetes. This suggests that there needs to be a practical and meaningful stimulus to make change happen.

By coincidence, an editorial in recent edition of Diabetic Medicine (Cradock and Cranston, 2012), addresses just this point. The authors suggest that much more ‘emotional mastery’ - support for people with diabetes to deal with the stress caused by taking care of their diabetes - is needed alongside ‘insulin mastery’ (dealing with the practical aspects). This suggestion is based on research showing that at least some diabetes-related stress may actually come from the diabetes consultation itself. This is because traditionally, the consultation places medically-based expectations on the person with diabetes, causing feelings of anxiety and guilt and thus contributing to raised HbA1c levels. Creating a system of care which places much less emphasis on insulin and much more on reducing the emotional effects of diabetes may well be an important factor in reducing HbA1c – the ‘holy grail’ of most current diabetes services.

Perhaps the findings of such a model could be shared with health services as a whole and adapted so that both health professionals and people using their services can feel less pressured, less blamed and become more healthy as a result? After all, as Einstein himself said: ‘doing the same experiment over and over, and expecting different outcomes… is the definition of insanity’. Perhaps given its benefits, healthcare professionals may not be so defensive about changing the experiment to include more listening?

References

Chaplin, S, Widdowson, J., Reeve, B. (2012). The Insulin for Life programme: nine years on. Practical Diabetes, 29, 2 (supplement)

Cradock, S., Cranston, I. (2012).  Type 1 diabetes education and care: time for a rethink? Diabetic Medicine, 29, 2, 159-160

Department of Health (2012). Government opens up data to benefit patients and GPs online

http://mediacentre.dh.gov.uk/2012/06/07/goverment-opens-up-data-to-benefit-patients-and-gps/