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The Impact of Diabetes Self-Management Education on Glucose Management in Ethnic Armenians

The Impact of Diabetes Self-Management Education on Glucose Management in Ethnic Armenians. Zarmine Naccashian PhD, GNP, MN, RN , CDE Azusa Pacific University. Introduction. Diabetes: chronic and systemic disease Causes: not completely explicated

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The Impact of Diabetes Self-Management Education on Glucose Management in Ethnic Armenians

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  1. The Impact of Diabetes Self-Management Education on Glucose Management in Ethnic Armenians Zarmine Naccashian PhD, GNP, MN, RN, CDE Azusa Pacific University

  2. Introduction • Diabetes: chronic and systemic disease • Causes: not completely explicated • Prevalence: Epidemic proportions, serious complications • Self-care is needed for effective control • Involvement of individuals in their care • Knowledge, social and financial support

  3. Significance of the Study • Results of DCCT & UKPDS • 1%↓A1c, 35% reduction in complication • A1c as diabetes mgmt. index • DSME classes • Education thru empowerment • Engagement in self-care skills • Medicaid does not cover DSME • Ethnic minorities on Medicaid or no insurance

  4. Goal of Nursing • Promote health maintenance, • Prevent disease exacerbation, • Eliminate complications across all social ranks thru education, support, assurance (AADE, position statement, 2007)

  5. Orem’s Self-Care Conceptual Framework • Holistic view of the person • Individual: unitary being • Reciprocal interaction world view • Individual and environment • Persistence and change

  6. Self-Care • Self-directed, self-oriented, self-produced • Voluntary practice of action • Deliberate, learned over time, • Regulate one’s own functioning & development • Contin. action system to care for one’s self • Aimed @ maintaining life,health,well-being

  7. Caring • The most consistent theme in defining nursing (McCance et. Al, 1999) • People function and maintain life, health and well-being by caring for themselves • Most discussed and most used • Wide scope of application to any nursing practice situation

  8. Self-care deficit theory of nursing(SCDTN) • Theory of self-care • Theory of self-care deficit • Theory of Nursing Systems

  9. Theory of Self Care, Theory of Self Care Deficit andTheory of Nursing Systems (Adapted from Orem, 1995) Self-Care Self-care requisites Universal Developmental Health Deviation Therapeutic Self-Care Demands Self Care Agency < Self-Care Deficit Basic Conditioning Factors Age Gender Developmental state Sociocultural orientation Health state Family system factors Health care system factors Patterns of Living Environmental factors Resource availability and adequacy • Nursing Agency • Wholly compensatory • Partly compensatory • Supportive-educative

  10. Self-Care Deficit Theory of Nursing (SCDTN)Application to Nursing Research • Empirical studies suggest that personal and environmental factors affect one’s behaviors to achieve desirable health and well-being outcomes (Souza et al., 2005/06) • Orem’s SCDTN was selected for this research study to ensure a framework for a practice issue such as diabetes self-management to provide understanding of outcomes

  11. Self-Care Deficit Theory of Nursing (SCDTN)Application to Current Study

  12. Self Care Deficit Theory of Nursing Applied(Adapted from Orem, 1995) Self-care requisites Health Deviation: Diagnosis of diabetes Therapeutic Self-Care Demands Diet , Medications, Exercise, Blood Glucose Monitoring Self-Care Measured by A1c & DES < Self Care Agency Individual diagnosed with diabetes Self-Care Deficit • Nursing Agency • Supportive-educative - DSME Basic Conditioning Factors Age, Gender Developmental state Empowerment Socio-cultural orientationAcculturation Health state Years with Type 2 DM

  13. Literature Review • Purpose: Identify gaps in published research in relation to the impact of diabetes education classes on diabetes self-care practices in first generation immigrants of Armenian descent. • Will address: prevalence, types, burden of disease, minorities, Armenians, acculturation, empowerment.

  14. Literature Review (cont’d) • Prevalence : • Pandemic • 40% of diabetic patients more than 65 yo • 6th leading cause • 2050 to reach 48 million (1 in 3) • 5.2 million undiagnosed and untreated

  15. Literature Review (cont’d) • Financial Burden • $132 billion (CDC, 2007) annual • $3.8 billion hospitalization 2001 (AHCRQ) • 25% of total Medicare budget • 45.8 million Americans without insurance • Health disparities among racial & ethnic minority groups

  16. Literature Review (cont’d) • Minorities • Higher in ethnic minorities • ↑prevalence geriatric minority groups (Calif. Medi-Cal Study, 2004) • 40% patients age 64 ↑, limited evidence to guide their management (Chin et al., 2000) • Barriers: language, cultural beliefs, myths social support, attitudes, trust to HCP

  17. Literature Review (cont’d) • Armenians • In America 1618-1619 (Mirak,1983) • “Hidden minority” (Rollins, 1981) • Half million in LA • Maintain high levels of Armenian identity • American born Armenians: symbolic connotation • No studies on diab self-mgment in Armenians • Other studies: perception of identity, impact of cultural attitudes on comm. ed., culturally sensitive educ to increase awareness

  18. Literature Review (cont’d) • Acculturation • Process indiv adopts attitudes, beliefs, practices and behaviors congruent with dominant culture (Berry, 1980) • Acculturation: behavioral and psychological • Four modes: Assimilation, Integration, Separation, Marginalization • Three phase course:Contact, conflict, adaptation • Adaptation:psychological(int.)psychosocial(ext) • Evolution psychological adaptation varies in intra groups, variation reflects outcome of progress

  19. Empowerment • Gain mastery over their affairs (Rappaport, 1987) • Sense of control over their well-being (Nyatanga & Dunn, 2002) • Psychosocial phenomenon, measured (Menon, 2002) • Self-directed decision makers on their care, active & responsible member of the health care team (Anderson et al., 1991)

  20. Empowerment (cont’d) • Patient in charge of their health, high degree of psychosocial self-awareness to make educated decisions in abiding in a self-care plan, realistic and applicable to their living situation (Anderson, 1995).

  21. Diabetes Self-Management Education Programs (DSME) • ↑self-efficacy, predictor to self care (meta analysis, Glasgow et al., 2001) • Can be achieved: motivational interview, role play, behavior modification (Peyrot et al., 2007) • Research indicates: DSME improves self-mgmt

  22. Methodology • Research design: • Quasi-experimental • Before and after single group • Impact of education on A1c & empowerment

  23. STUDY DESIGNPre-experimental one group pretest-posttest design Sample selection criteria listed, assessment of HgbA1c within past six months of enrollment date obtained from PCP IV - DSME Mediator – Age, gender, acculturation and years with diabetes DV – Diabetes Self-Management measured by empowerment and HbA1c

  24. Research Questions Q 1: Patients diagnosed with Type 2 diabetes of Armenian descent have higher scores on DES after completing the DSME classes compared to pre-class enrollment DES scores. Q 2: Patients of Armenian descent living in Los Angeles, diagnosed with Type 2 diabetes will have improved A1c levels after enrolling in DSME classes taught in Armenian compared to their A1c levels prior to the class enrollment

  25. Research Questions Q 3: Is there a relationship between the characteristics of the sample age, gender, acculturation, number of years with diabetes and empowerment? Q 4: Is there a relationship between the characteristics of the sample age, gender, acculturation, type of diabetes, number of years with diabetes and A1c levels The psychometric properties of the DES and AEOQ-R was examined.

  26. Statistical model with DSME classes as IVage, gender, acculturation, yrs with DM as mediator and A1c and empowerment scores as DV Mediating variable IV Age Gender Acculturation Yrs with DM DSME classes DV Diabetes management Measured by Empowerment scores and A1c levels

  27. Setting • Daylight Adult Health Daycare centers

  28. Target Population • L A California: residence of immigrants of diverse ethnic backgrounds • Glendale, California: residence of largest Armenian community outside Armenia • Total city population: 200,000 • Armenians in Glendale: 85,000

  29. Target Population (cont’d) • Quota sampling • Inclusion criteria: • Medicare referral guidelines • DM type 2

  30. Sample Size N= (SD¹ + SD²)(Z1-α + Z2-β)² = Δ² (mean1-mean2)² (1.7² +1.5²)(0.84+1.64) =5.14+6.15 = 7.3-7.6 0.3² • 35/group (Neutens & Robinson, 2002)

  31. Data Collection Procedure • Flyers • Posters • Study will be explained • 9 hrs, 6 sessions (1 & ½ hours/session) • A1c will be retrieved from PCP office at the time of study and 3 months after the study completion

  32. Tools • Demographics: gender, age, # yrs DM • HbA1c • Diabetes Empowerment Scale (DES) • Armenian Ethnic Orientation Questionnaire-Revised (AEOQ-R)

  33. Robert Anderson Ed.D

  34. Data Analysis • Paired t-test, differences in scores empowerment and A1c (Q 1 & Q 2) • Two sets of multiple regression: age, gender, acculturation, DM # of yrs on empowerment (Q 3) & on A1c (Q 4) • Psychometric properties of DES & AEOQ (factor analysis, alpha)

  35. Results:Demographic Data: gender

  36. Results:Demographic Data: age, yrs DM

  37. Results: paired t-testPre and post DES score

  38. Results: paired t-testPre and post A1c

  39. Results: Inter-correlation of age, gender, acculturation, # yrspre and post DES

  40. Results: Inter-correlation of age, gender, acculturation, # yrspre and post A1c

  41. Discussion • Reliability of tools used: DES • DES-SF alpha 0.85 (original) • DES-Chinese alpha 0.86 • DES-Swedish alpha 0.68-0.91 • Current study alpha 0.78 (pilot alpha 0.77) • Correlation reliability Swedish 0.33-0.72 • Current study correlation reliability 0.07-0.58

  42. Discussion • Reliability of tools used: AEOQ-R • 15 item revised version alpha 0.71 • Other study alpha 0.85 (Shirikian, 2006) • This study 0.40 • Possible explanation: age group

  43. The Impact of DSME on Empowerment • DES score increased from 4.05 to 4.36 • Increase was 0.31 (sig. 0.01) • Empowerment viewed by participants: • Conversation and contemplation • Nurse-patient dialogue, current status, backup plan in times of sickness • Spent time with the participants • Education by visual method (food plate)

  44. The Impact of DSME on A1c • A1c reduced from 7.8% to 6.5% (sig 0.00) • Community specific interventions • Family • Language

  45. Implications to Practice • Nurses have fundamental role in educating patients • Identify health behavior practices in particular ethnic group • Be aware of similarities and differences with other cultures • Food preparation, food classification, portion sizing of existent ethnic dishes, family members’ understanding of food choices

  46. Conclusion • Better understanding of the self-care practices of ethnic Armenians • Appreciation towards education • Trust in HCP • Adherence to health care instructions

  47. The End Thank you all for attending Znaccashian@apu.edu 626-815-6000

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