Identifying and overcoming barriers to effective selfcare

Patients who have been diagnosed with diabetes are immediately faced with a multitude of challenges, all related to maintaining the quality of their daily life. Research has well demonstrated the galaxy of complications that can follow the onset of diabetes, in the absence of good diabetes management. Yet, good diabetes management requires acquiring numerous skills, making countless lifestyle changes and adjustments, and investing significant amounts of time and effort into a lengthy, complicated education process. Seven specific self-care behaviors have been identified as inherent in good self-care in diabetes (see Figure 7.4).

Unfortunately, many patients encounter barriers that prevent them from accomplishing effective self-care (see Figure 7.5). Barriers encountered by the healthcare provider that should also be considered are: • Treatment goals and regimens: consider the patient's overall health and the patient's goals for diabetes treatment once the patient has been educated about diabetes and potential complications. Adjust therapies based on those findings.

Figure 7.4 Seven self-care behaviors

1 Healthy eating

2 Being active

3 Taking medication

4 Monitoring blood glucose

5 Problem-solving

6 Healthy coping

7 Reducing risks

Figure 7.5 Patient-perceived barriers to effective self-care

1 Frequent lack of symptoms with elevated blood glucose, blood pressure and cholesterol levels - failure to incentivise patients

2 Lack of knowledge and understanding of meal plans

3 Requirements for multiple, daily interventions

4 Lack of individualized, coordinated care

5 Occasions of hypoglycemia that may occur as the appropriate treatment plan is developed and implemented

6 Limited resources

7 Problems related to glucose testing.

8 Inconvenient, expensive group diabetes education programs

9 Inability to cope with appropriate medication treatment regimen as a result of poor information or understanding.

10 Inability or unwillingness to participate in exercise activities

11 Perceived loss of control

12 Psychological impact of chronic disease and related issues

• Management of hypoglycemia: determine that the patient has been educated on both the management of hypoglycemia and the prevention of hypoglycemia. Make incremental changes to therapies frequently until goals have been achieved.

• Clinical inertia: make incremental changes to patient therapies, based on treatment goals. Consider using staff nurse phone visits to receive patient reports of blood glucose logs and to make protocol-driven treatment changes for insulin-treated patients.

• Use of insulin as a treatment option: provide patient with information regarding this option at diagnosis or new patient "first" visit. Current treatment options include various injection devices as well as inhaled insulin therapy.

Healthcare providers can anticipate many of those barriers mentioned in Figure 7.5 and above, and prepare patients to more effectively manage obstacles as they are encountered.

We have acknowledged that patients must be "team leaders" of their diabetes team because of their "expertise" on their own knowledge, beliefs, support system, attitudes, resources, culture, likes and dislikes, habits, etc. Those same factors play a role not only in management of diabetes but in the education process as well. Education that promotes adherence is patient-focused, includes collaboration between healthcare providers and patients, and empowers patients to make positive behavior changes.

Studies indicate that people with diabetes are 1.5 to 2 times more inclined to be clinically depressed than people who do not have diabetes. Further, this depression in the population of people with diabetes increases their risk of mortality by 30%. Depression can be linked to poor self-care, poor diabetes control and higher risks of complications [18, 19].

In a recent study on self-care behaviors in diabetes, it was determined that only 6% of patients performed the four self-care behaviors under study at recommended levels. These included: physical activity, fruits and vegetable consumption, home blood glucose testing and home foot examination. Interestingly, performance of all self-care behaviors was higher in the insulin-requiring patients. Nearly 90% of all patients in the study engaged in at least one self-care behavior but the percentage dropped dramatically as the number of self-care behaviors being observed increased [20]. Another recent study determined that a consistent relationship exists between self-efficacy and self-management in diabetes, identifying self-efficacy as a viable target for educational interventions designed to improve self-care [21]. Diabetes education promotes self-care by providing knowledge; however, knowledge alone will not produce successful self-care. Self-efficacy is an integral

Figure 7.6 Effective strategies for successful diabetes self-management

1 Collaborative relationship with healthcare providers

2 Clearly define "good glycemic control"

3 Positive patient and provider attitudes

4 Ensure adequate monitoring of blood glucose levels

5 Formal/informal support groups

6 Address co-morbidities that are involved in secondary complications

7 Ample resources exist for good self-management

8 Appropriate medication management, including combinations of agents

9 Working with diabetes team in both formal and informal education processes to empower patients for good self-management

10 Healthcare team phone follow-ups

part of good self-care in diabetes. If people believe they will be successful, they will be motivated to succeed [22]. This is in keeping with the patient empowerment philosophy, as applied in patient-centered practices, involving interactions between healthcare providers and patients that are positive and well-informed [23] (see Figure 7.6). These interactions are based on the chronic care model discussed in Chapter 4 [26].

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