The Role Of Education

Knowledge is needed in order to self-manage diabetes. Many people with diabetes learn by trial and error. Information can come from other people with diabetes, lay sources (books, magazines and the Internet), or directly from medical experts, in which case it may be more consistent and accurate. A wide range of patient education programmes have been developed and evaluated over the last 20 years. Meta-analyses show that they increase patients' knowledge about diabetes and lead to improvement in some areas of self-management, but they do not appear to have a significant impact upon overall diabetes control24'25. In fact, some studies have found little relationship between level of knowledge and diabetic control26. The general conclusion is that patient education is a vital component of diabetes care, but is not sufficient in isolation27.

There is a difference between knowledge and skill acquisition. The latter needs attention to modelling, practice and feedback. It is unclear how well these are incorporated into diabetes education programmes, although authors now acknowledge that simple knowledge transfer is not enough 8. Attempts to use behavioural models from learning theory in education programmes have had some additional benefit29 and there are guidelines from adult education theory that may enhance the effectiveness of routine education. These include the use of different learning stages and styles30, and specific approaches for the acquisition of skills, rather than knowledge alone31.


Compliance is the extent to which a person's behaviour coincides with medical advice32. Early research showed that compliance correlated with the extent to which patients understood, remembered and were satisfied with the information provided17. As much as 16% of the variance in 'compliance' could be explained by these factors. However, there are still discrepancies between 'ideal' and 'real' informational care and improvements need to be made18. Simple strategies have been shown to improve recall and are summarized in Table 5.2. Other interesting examples of effective informational care include the use of the Internet33 and visual cards in ethnic populations34.

Individuals often value non-health aspects of their life more highly such as social relationships and occupational status. Collaborative consultations37 and joint decision making is needed to allow a patient to balance the desired health outcome with other aspects of his/her life. The health care professional needs to learn to facilitate behaviour change in a way that takes into account the person's overall choices and values and is not detrimental to his/her quality of life21,35. Consequently, a person's self-care, lack of symptoms, social functioning and emotional well-being need to be considered as separate, but relevant, domains. This is the essence of a patient-centred approach.

In health care, this is reflected in movement away from 'compliance', which implies an authoritarian 'do as I say' approach, to the use of the term 'adherence', with its evocation of greater self-determination and collaboration. In diabetes the term 'self-management', defined as the set of skilled

Table 5.2. Techniques to increase the understanding and memory of verbal communications. Based upon reference38


Improvement in recall (%)

Primacy: present the most important information first


Stressing importance: emphasize the most important



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