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Running head: GROUP BASED TRAINING IN TYPE II DIABETES
Group Based Training of Self Management Skills for Patients with Diabetes Type II
Lisa Sims
Auburn University/Auburn Montgomery
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Running head: GROUP BASED TRAINING IN TYPE II DIABETES
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Group Based Training of Self Management Skills for Patients with Diabetes Type II
Introduction
Diabetes is the seventh leading cause of death in the United States (Center of Disease
Control and Prevention, (CDC), 2011). Diabetes has been estimated to affect approximately 25.8
million Americans which are 8.3% of the United States population (CDC, 2011). There are 18.8
million people diagnosed and 7.0 million undiagnosed (CDC, 2011).
Diabetes is characterized by a lack of insulin secretion and/or an increased cellular
resistance to insulin which results in hyperglycemia and metabolic disturbances (American
Diabetes Association, (ADA), 2011). Diabetes is a very complex medical condition and can
cause neurological, cardiovascular, ocular, and renal complications (ADA, 2011). There are
different types of diabetes which include insulin-dependent diabetes mellitus (IDDM) or
Diabetes Type I and non-insulin-dependent (NIDDM) or Diabetes Type II. Diabetes Type II is
usually symptom free for years and then followed by a slow progression of symptoms. The
symptoms include excessive thirst and hunger, frequent urination, blurred vision, weight loss
and/or weight gain, recurrent infections (ADA, 2011). The risk factors for Diabetes Type II
include obesity, hypertension, hyperlipidemia, family history of diabetes and race to include
Hispanics, American Indian, and African American (ADA, 2011).
Diabetes is a costly disease. The medical costs for the treatment of diabetes are substantial.
The total direct cost for diagnosed diabetes in 2007 was $174 billion (ADA, 2011). For
successful management of diabetes, self management and patient education including intensive
treatment program is necessary. Treatment is aimed at lowering blood glucose levels through
modification of lifestyle behaviors and appropriate medical management. Comprehensive
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diabetes education programs can help to reduce the dire statistics and costs associated with
diabetes and improve outcomes for diabetes patients.
Proposal
This evidenced-based project PICO question is “Among adult patients with Type II
Diabetes, does group education focused on self management skills result in improved outcomes
(knowledge, glycemic control, self-management behavior) compared to standard diabetes
education?” The proposed project focuses on developing a group-based education program that
will assess the effects of self-management education in Type II Diabetes patients and if those
effects improve patient outcomes (knowledge, glycemic control, and self-management
behaviors). The National Diabetes Education Program (2009) reports that successful diabetes
education programs meet their objectives through education and life-style changes. The
objectives of this project are those of: 1) lifestyle change education, 2) health beliefs education
and 3) nutritional education. These objectives contribute to prevent and/or reduce the risk of
development of diabetes and also improve patient outcomes.
Target Population
The target population is adults with Type II Diabetes and glycated hemoglobin (A1C) >
7%. The target number for this evidenced-based project is 10-12 patients for the small test of
change. The location for the project will be a rural primary care clinic, Physician Care, in
Thomasville, AL. The area of focus is due to the patient’s perception and risk for increased
complications that may result because of poor glycemic control.
It is estimated that among United States residents who were 65 years of age and older,
26.9 % had diabetes in 2010 (CDC, 2011). A number of factors have been found to be associated
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with the development of Type II Diabetes. In the United States prevalence has been found to be
related to family income and ethnic groups, with the highest occurring in African American
populations (ADA, 2011). Patients who have hypertension, hyperlipidemia, obesity, family
history of diabetes and are of a specific race such as American Indian, Hispanic, or African
American are most likely to have or develop Type II Diabetes (ADA, 2011). There are
indications that not only do African Americans have a higher incidence of Type II diabetes than
other ethnic groups, they also are more likely to experience serious complications of the disease
(ADA, 2011). In Thomasville, AL, 46 % of the population is African American (IDcide, 2011).
Project Outcomes
According to the National Diabetes Education Program (2009) the most appropriate and
effective method for educating diabetic patients about their diet, nutrition, disease, and the kinds
of lifestyle changes needed to improve outcomes is through small group discussions. The
outcomes of this project are to: 1) increase knowledge of the disease, 2) increase glycemic
control through monitoring fasting glucose levels, and 3) improve self-management skills
through lifestyle changes.
Framework
Research and implementation of the evidence collected needs to be guided by an Evidence
Practice Model (EBP). There are several different models that can be used to assist in the
research and implementation process. The Iowa Model of Evidenced-based Practice to Promote
Quality Care addresses both the individual practitioner and organizational perspective (Titler,
2006). This model uses patient population, intervention, comparison and outcomes (PICO) to
form the question related for the research (Kirton, 2006). Application of the Iowa Model of
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Evidenced-Based Practice to Promote Quality Care for research regarding Type II Diabetes and
self-management will assist in organizing the research in order to implement, monitor and
evaluate the outcomes of not only the patients but also the entire team. The framework for the
development and implementation of the project will be based on the Iowa Model of EvidencedBased Practice to Promote Quality Care. This model was chosen for the EBP framework because
it provides a clear understanding of the process for researching evidence-based practice. The
steps in this model include: 1) identification of a problem through problem focused triggers
and/or knowledge focused triggers 2) deciding if the problem is a priority for the organization 3)
forming a team 4) gathering research and literature 5) critique and synthesize the research for use
in practice 6) piloting the change 7) decide if the change is appropriate to adopt into practice and
8) monitor and analyze the process and outcomes (Ciliska et al. 2005). The problem identified
was through identification of a clinical problem which was self-management of Type II Diabetes.
It was determined that this was in fact a priority for the area/organization. The team has not yet
been developed but the process of relevant research and related literature has been initiated. The
process of critiquing and synthesizing the research has also been completed. The final steps will
be to pilot the change into a specific area of practice, monitor the outcomes and evaluate for
appropriateness to implement into practice. The problem focused trigger has been identified for
this project through identification of a clinical problem. Through the use of the PICO process, it
helps develop a question for research that is clear and concise. It is important to assess the
population and setting in which the evidence-based practice will be used and the Iowa Model
provide guidance in this process.
Theoretical Framework
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The theoretical framework serving as the conceptual foundation on which the diabetes
education program will be based is Orem’s Self-care Theory. This theory was developed by
Dorothea E. Orem in 1959 (Fawcett, 2005). The focus of Orem’s Self-Care Theory is the factors
that affect an individual’s ability to engage in self-care activities and how those self-care
demands will be met (Sousa & Zauszniewski, 2005). This model utilizes four major components:
1) self-care, 2) self-care agency, 3) therapeutic self-care demand and 4) self-care requisites.
When there is a deficit, the demands are larger than the individual’s ability to engage in self-care.
This theory provides a framework through the understanding of personal and environmental
factors that affect the self-management of diabetes.
Literature Review
The review of the literature was examined for evidence to support that group-based
education focused on self-management skills does improve outcomes in people with Type II
Diabetes. The keywords used with Type II Diabetes in the literature search were selfmaintenance, interventions, and patient education. The databases used were CINAHL, Medline,
PsycArticles and other online resources. There were 6 literature reviews examined that included
2 systematic reviews, 2 randomized control trials, 1 prospective trial and 1 clinical trial.
Review 1
In the systematic review conducted by Deakin, McShane, Cade & Williams (2005) to
assess the effects of group-based, patient-centered training on clinical, lifestyle and psychosocial
outcomes in people with Type II Diabetes, 14 publications describing 11 studies were included
involving 1532 participants. The following electronic databases were searched from the date on
which records began, up until January/February 2003: The Cochrane Library; MEDLINE;
CINAHL; ERIC; ASSIA; AMED; PsycINFO; EMBASE; LILACS; NHS Economic Evaluation
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Database (NHS EED); British Education Index (BEI); British Nursing Index (BNI); Wed of
Science (WOS); Index of Scientific & Technical Proceedings; National Research Register;
Digital Dissertation Abstracts. Conference proceeding and reference lists of articles were also
searched and contact was made with experts in the field. Two independent reviewers (TD, CM)
scanned the titles, abstract sections and keywords of every record retrieved. Wherever there was
any doubt regarding the existence of these criteria the complete article was retrieved for
clarification. Any differences in opinion were discussed and, if necessary, resolved by a third
party (JC). There were no instances where it was necessary to contact the authors for the review.
The results of the meta-analyses in favor of group-based diabetes education programs were
reduced A1C at four to six months, at 12-14 months and two years CI 0.5 to 1.4;; reduced fasting
blood glucose levels at 12 months; reduced body weight at 12-14 months Kg;; improved diabetes
knowledge at 12-14 months and reduced systolic blood pressure at four to six months. There was
also a reduced need for diabetes medication (Deakin, McShane, Cade, & Williams, 2005). This
review systematically reviewed 11 studies of group-based, patient-centered educational programs
for people with Type II Diabetes and found that these programs resulted in clinically and
statistically significant health outcomes.
Review 2
In a systematic review by Norris, Engelgau, & Narayan (2001), there were 72 studies
identified for this review. The Medline database was used to search for the evidence. The process
measures that were identified were knowledge, lifestyle behaviors, psychological and quality-oflife outcomes, glycemic control, cardiovascular disease risk factors and economic measures and
health service utilization (Norris, Engelgau, & Narayan, 2001). The results showed that
education improved diabetes knowledge. Lifestyle behaviors which included dietary changes
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showed improvements in carbohydrate and fat intake and decrease in caloric intake (Norris,
Engelgau, & Narayan, 2001). There was no evidence that supported self-management strategies
related to neither cardiovascular risk factors nor improvement in economic and health-care
utilization outcomes.
Review 3
In the study by Polonsky et al. (2003), a Diabetes Outpatient Intensive Treatment (DOIT)
program was evaluated for effectiveness of glycemic control and self care behaviors over a short
period of time. Other factors included the frequency of case management contacts and whether
or not insulin was started during the program. This was a randomized control study which
included patients with type 1 and type 2 diabetes with an A1C >8.5 (Polonsky et al., 2003). They
were assigned to the (DOIT) and also EDUPOST which is quarterly educational mailings. There
were 167 patients selected of which 78 were assigned to EDUPOST and 89 to DOIT. They all
completed baseline measures which included A1c and self-care behaviors (following meal plan,
attention to carbohydrate and fat contents (ACFC), days of exercise, blood glucose monitoring
and use of blood glucose monitoring to adjust regimen) and a questionnaire accessing diabetes
self-care behaviors. After 6 months, 117 patients (52 EDUPOST and 65 DOIT) returned for
follow up on A1C and self-care questionnaire. The results showed that the follow up with the
DOIT program reported significant drop in A1C than EDUPOST. DOIT also reported
significantly more frequent blood glucose monitoring. The frequency of the case manager follow
up contact was linked to better A1C outcomes. Diabetes self-care behaviors and glycemia
appears to be better with the DOIT program.
Review 4
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The purpose of this study was to compare two self-management supports strategies
(automated telephone self-management support (ATSM) and group medical visits (GMV) as
adjuncts to care and compared them to usual care (Schillinger, Handley, Wang, & Hammer,
2009). This is a practical clinical trial that was conducted in a safety net health system. There
were 339 outpatients of which had poorly controlled diabetes in county-run clinics. Half of the
participants spoke limited English, were uninsured, and had less than a high school education. Of
the 339 participants, 112 were assigned to ATSM, 113 were assigned to GMV, and 114 were
assigned to usual care. ATSM participants received automated telephone calls over 39 weeks.
Each call takes between six-ten minutes. GMV participants attended 90 minute monthly sessions
over nine months. There were six-ten participants per group and a primary care physician and
health educator. The outcome measured was one year change in self-management behavior. The
study found that providing SMS resulted in improvements in patient’s experiences, self-efficacy,
and self-management behaviors.
Review 5
A study conducted by Kulzer, Hermanns, Reinecker & Haak (2007), was to determine the
efficacy of three types of education programs. The three programs were a didactic-oriented
training program (treatment A), self-management-oriented program (treatment B) and
individualized training (treatment C) (Kulzer, Hermanns, Reinecker, & Haak, 2007). There were
181 participants with an age range from 50-70. There was improvement in A1C in treatment B
after 3 months. There were not any benefits of the treatment C compared to treatment B. The
self-management training was more effective than the didactic training. Group training was more
effective than individual training (Kulzer, Hermanns, Reinecker, & Haak, 2007).
Review 6
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This literature review was a report on the recommendations of the Task force on
Community Preventive Services (TFCPS), 2001. This report reviewed evidence regarding
strategies that could be implemented by community and health-care systems for people with
Type II Diabetes (Task Force on Community Preventative Services, 2001). There were seven
interventions that were reviewed of which two were focused on disease and case management
and five of which were focused on delivery of self-management education in community settings
(community gathering place, home, work, school and recreational camps) (TFCPS, 2001). There
were 105 studies reviewed, 35 were excluded due to limitations and 70 were included for the
recommendations of the review. Based on the results of the review, the Task Force
recommended only four out of the seven interventions. They include disease management, case
management, diabetes self-management education in the home and diabetes self-care
management education in community gathering places (TFCPS, 2001). Disease management
improved provider monitoring of A1C and also when case management was involved. Glycemic
control improved in self-management education provided in community gathering place and at
home (TFCPS, 2001).
Appraisal of Evidence
The literature that was reviewed for this project supported the evidence that group-based
education focused on self-management skills improves patient outcomes. The knowledge sources
were from systematic reviews and randomized control trials. There was one literature review that
was a report from an expert committee but the report included evidence from systematic reviews
to support the recommendations. The validity and reliability of the evidence was clear to support
best practices and offered specific actions and recommendations if additional research was
needed. It is with high certainty that group-based education focused on self-management skills
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improve patient outcomes (see Appendix A). The sources provided randomized designs and
validated outcome measures. The level of quality, quantity, and consistency of the literature and
rating the level of hierarchy of the source was used to determine the strength of the evidence (see
Appendix A). The level of evidence or strength of the evidence was as follows: 1 = strong
evidence, 2 = intermediate evidence, 3 = weak evidence, 4 = no evidence. The knowledge
sources were appraised for internal and external evidence. The validity of the sources was
evaluated to include bias. The reliability of the sources was evaluated based on the significance
of the intervention and treatment. The measurement of the confidence interval for interventions
or treatments was evaluated if provided. The applicability of the sources and evidence was
appraised to determine if the results of the evidence would provide support for recommendations
of the proposed project of determining if group-based education focused on self-management of
Type II Diabetes improves patient outcomes.
Results of the reviews are reported based on the quality of evidence. The grades are as
follows: A = high- further research is unlikely, B = moderate- further research is likely to have
an impact on the evidence, C = low – further research is very likely to have an impact on the
evidence, and D = very low – the evidence is uncertain. Recommendations for the proposed
project based on the evidence include group-based education for Type II Diabetes. The evidence
supports that group education is more effective than the individualized approach. The grade of
evidence for this recommendation is A. Education that focuses on self-management skills and
lifestyle modification are other recommendations that are supported by the evidence. Selfmanagement skills prove to be effective in lowering glycated hemoglobin and fasting glucose
levels. The grade of evidence for this recommendation is A. Lifestyle modifications to include
physical activity and decrease in caloric intake prove to be effective in glycemic control. The
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grad of evidence for this recommendation is A. In the literature reviewed, there were not any
studies that provided evidence on the patient’s preferences as to the type of education programs
preferred. Further research is needed to determine the degree of patient satisfaction in regards to
group education programs.
Needs Assessment
Diabetes Type II is an increasing national health concern. According to the County Health
Ranking (2010), the population of Clarke County Alabama is 9,455 and the number of diabetic
Medicare patients that were screened by testing A1C level was 67%. The overall average for the
state of Alabama is 78% and the target is 84% (County Health Ranking, 2010). In Thomasville,
AL, 46 % of the population is African American (IDcide, 2011).
Physicians Care Clinic of Thomasville is rural primary care clinic located in Clarke County
Alabama and provides one additional outreach clinic within the county. The primary patient
service area for the clinic extends into two additional counties of Marengo (63% HbA1c
screening rate) and Wilcox (67% A1C screening rate) (County Health Ranking, 2010).
Physicians Care currently has a patient base of approximately 11,000. Physicians Care averages
13,000 annual visits per year with approximately 2,000 of the visits being related to Diabetes.
This accounts for only 15% of the volume. One of the ongoing concerns has been the fact that a
number of patients seen in the clinic that have Type II Diabetes are unable to verbalize self
management skills, obtain glycemic control and verbalize understanding of the disease. There is
a need for focus towards diabetes management because of the patient’s perception and risk for
increase complications that may result because of poor glycemic control and follow up. The
facility where the group education meetings will be conducted is Physician’s Care of
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Thomasville. There is a conference room in the facility that is available for the meetings and
another location has been identified as back-up if there are problems with space.
The clinic has implemented an electronic medical records system that assist in efforts to increase
screening of A1C and compliance with the standards of competent diabetes care.
The stakeholders that can benefit from the project include the physician, nurse
practitioners, staff, patients and community. Being able to provide evidence that Diabetes
education is effective in improving self management of diabetes and decreasing other associated
risks, is one way the clinic can assist in improving overall quality of care and provide them with
a comprehensive care plan.
Implementation Plans
The Type II Diabetes Group Education Program will be implemented at Physicians Care, a
rural primary care clinic in Thomasville, AL The National Diabetes Education Program (2009)
reports that successful diabetes education programs meet their objectives through education and
lifestyle changes. The area of focus is due to the patient’s perception and risk for increased
complications that may result because of poor glycemic control. All information and materials
that will be used in the program will be developed from current sources and will be reviewed by
the physician prior to implementation.
Participants will be patients who use Physicians Care of Thomasville for their medical
care. The criteria for selecting 15 -20 patients will be based on a diagnosis of Type II Diabetes
and A1C > 7%. If any of the selected patients wish not to participate, the investigator (student)
will continue to select alternatives within the time frame prior to the group meetings. Consent
forms will be completed for all participants with a very through explanation of the project.
Confidentiality and how the information will be kept and stored will also be discussed during the
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interview process. The participants will receive information regarding the dates, times and
location of the group meetings and what to expect from the meetings. The information will
include the topic of discussion for each individual meeting. A pre questionnaire will be given to
the participant that includes current lifestyle behaviors and current knowledge of Type II
Diabetes. A daily glucose log sheet will be given to the participant with instructions regarding
daily recording of blood glucose sticks. Verification of home glucose monitor will be done also.
Instructions and the importance of how the daily glucose log will be used in evaluation of the
project will be explained. A post questionnaire will be given at the end of the meetings to assess
any changes in lifestyle behaviors and knowledge that may have changed since the group
education meetings.
The facilitators will include the physician, nurse practitioners and the student. The program
will be discussed with the physician, nurse practitioners and staff to include the purpose, goals,
support and educational content of the program. Barriers will be assessed to include negative
attitudes and participation from patients and potential re-location of sessions due to space. The
plans for managing these barriers include very through explanation of the purpose of the sessions
with the participants/patients in the initial interview.
The resources needed for this project will be educational content, which will be provided
from evidenced-based resources that may be made available through representative of drug
companies, information, ideas, and statistics about diabetes from the American Diabetes
Association and material obtained from the local hospital. The costs associated with running the
lab test will also be a financial consideration. The lab company for the clinic will be approached
regarding assisting in possible discounts or even waiving the fees for the purpose of the program.
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A small test of change for this project will be piloted. The component that will be
evaluated will be the assessment of the pre-questionnaire and post-questionnaire. Assessment
will be made at the beginning and end of the program to determine any changes regarding the
general knowledge of the disease and A1C, nutrition, diet, exercise and self-management skills.
The project timeline for the small test of change is eight weeks. This includes two weeks
for patient interviews and scheduling sessions, four weeks for educational sessions on lifestyle
changes, health beliefs, and nutrition and two weeks for outcome measurement and evaluation.
Each session will be approximately one hour each thus providing four hours of information and
education related to Type II Diabetes. The financial costs associated with the project are
estimated to be no more than $50. That includes copying questionnaires and providing snacks for
the participants.
Evaluation Plans
The outcomes for the project are both patient-focused and include both behavioral and
clinical. The level of measurement will be ratio because the data obtained from the measures will
be meaningful and can be compared using the pre, post and daily glucose log information. The
measures include a pre-questionnaire that includes current lifestyle behaviors and a postquestionnaire that includes lifestyle changes that have occurred since group education meetings.
Another measure will include daily glycemic monitoring log that is to be kept by each patient at
the beginning to the end of the project. The student will be responsible for providing the prequestionnaire and post-questionnaires and will monitor the compliance of each patient
maintaining a daily glycemic log at each session. All data will be evaluated and compiled at the
end of the project.
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The outcomes include increase knowledge of the disease, increase glycemic control, and
improve self-management skills through lifestyle changes. The participants will be evaluated on
the pre and post questionnaire scores based on the improvement in their regular exercise, diet,
self-management skills and of knowledge regarding the disease. This will allow for pre and post
comparisons of each participant. The daily glucose log will also be daily by each participant and
reviewed at each education session. This will allow the participants to see how any changes that
they may make in their diet, exercise and self-management skills improve their glucose levels.
The most effective way to evaluate the program will be to monitor the A1C at 3 month intervals
and compare to baseline measurements.
The results of the project will be disseminated to the stakeholders due to their relationship
with the patients and their efforts to continue to improve their lifestyle habits. Satisfaction of the
stakeholders will be assessed for development of close relationship with the participants and
support from their caregivers to participate in the program.
The measure that will be monitored within the evaluation plan for the small test of change
is the pre-questionnaire and post-questionnaire. The education sessions will also allow for
discussion of the participants progress and hopefully gain additional support from other group
participants.
Actual Evaluation
The timeline for the small test of change included obtaining IRB approval from Auburn
University, meeting with key stakeholders to review the EBP project, launching the EBP project,
meeting with key stakeholders to review progress with the project, review any issues and success
of the project, address concerns or questions of the stakeholders, complete final data collection
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for the project evaluation and review recommendations for future research and/or practice
changes with the key stakeholders.
There were 42 patients that met the criteria for the project. Eight of the 42 (19%) agreed to
participate and scheduled initial interviews. Six of the eight (75%) actually showed up for the
initial interview. All of the six that participated in the initial interview completed the prequestionnaire.
During the implementation phase of the project, the timeline was adjusted to meet the
requirements of the EBP project. Limitations and barriers that were a results of the participants’
included lack of transportation, conflicting schedule, unable to contact due to patient’s
disconnected phone, decision to withdraw, failure to follow up with initial interview
appointment, and lack of interest (admission of non-compliance). Despite multiple efforts, follow
up data were unable to be collected and used to evaluate the outcomes of group-based education
in diabetes.
Findings/Discussion
The findings suggest that there is a need for education for Type II Diabetes. The initial
interview data for the six participants showed that the average compliance rate was 56% with
self-management skills in Type II Diabetes (see figure 1) and 76% with knowledge related to
A1C (see figure 2). During the initial interview, it was discovered that many of the participants
were at different stages of change. There were difficulties with self-management behaviors that
were discovered in the initial interview process. Some of the difficulties were based on education
needs and some were due to the fact that the participant did not even have a home blood glucose
monitor. During patient clinic visits, assessment for the individual needs of the patient need to be
addressed and then determine what type of educational learning is best for that individual.
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Recommendations for Future Research and/or Practice Change
While research supports group-based education in Type II Diabetes, primary care clinics
in rural areas pose additional challenges due to background variables, motivation and support.
The literature and research supports evidence that can improve patient care through improvement
in self-management behaviors but the patient’s willingness and openness to make those changes
are one of the biggest challenges. Research shows that the use of theoretical framework such as
the model of behavior change is being used in primary care clinics by nurse practitioners. Due to
the fact that group based education may not be effective if everyone is in a different stage of
change, this must be assessed in the interview process and consideration of the readiness stage of
change in each patient. One thing to consider for rural settings is individual educational sessions
one on one rather than group based.
Conclusion
The issues that were presented during the EBP project revealed how difficult it can be to
change patient behaviors. Learning to adapt and individualize patient care is becoming more
apparent. Although this project was not able to be completed as planned, it provided valuable
information that will be beneficial in future projects. The learning experience during this EBP
project validates the unique role that an advanced practice nurse contributes in improving patient
care.
Running head: GROUP BASED TRAINING IN TYPE II DIABETES
100%
80%
60%
40%
20%
0%
19
% Compliance with Self-management skills
88%
63%
59%
69%
41%
14%
#1#2#3#4#5#6HgA1C- HgA1C- HgA1C- HgA1C- HgA1C- HgA1C11.1
11.6
8.2
9.1
8.5
9.3
Figure 1. Pre-questionnaire - Percentage compliance of each participate with self-management
skills prior to education meetings.
120%
100%
80%
60%
40%
20%
0%
Score for HgA1c Knowledge Test
90%
70%
100%
100%
60%
40%
#1#2#3#4#5#6HgA1C- HgA1C- HgA1C- HgA1C- HgA1C- HgA1C11.1
11.6
8.2
9.1
8.5
9.3
Figure 2. Pre-questionnaire – Percentage of current knowledge regarding A1C prior to education
meetings.
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Kulzer, B., Hermanns, N., Reinecker, H., & Haak, T. (2007). Effects of self-management
training in Type 2 diabetes: a randomized, prospective trial. Diabetic Medicine: A
Journal Of The British Diabetic Association, 24(4), 415-423. Retrieved from
EBSCOhost.
National Diabetes Education Program, 2009. Guiding principles for diabetes care. Retrieved
from http://www.ndep.nih.gov/media/GuidPrin_HC_Eng.pdf
Norris, S. L, Engelgau, M. M., & Narayan, K. M. (2001). Effectiveness of self-management
training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes
Care, 24(3), 561-587. Retrieved from EBSCOhost.
Polonsky, W. H., Earles, J., Smith, S., Pease, D. J., Macmillan, M., Christensen, R., … Jackson,
R. A. (2003). Integrating medical management with diabetes self-management training.
Diabetes Care, 26(11), 3048-3053. doi:10.2337/diacare.26.11.3048
Schillinger, D., Handley, M., Wang, F., & Hammer, H. (2009). Effects of self-management
support on structure, process, and outcomes among vulnerable patients with diabetes.
Diabetes Care, 32(4), 559-566.doi:10.2337/dc08-0787
Running head: GROUP BASED TRAINING IN TYPE II DIABETES
22
Sousa, V., & Zauszniewski, J. (2005). Toward a theory of diabetes self-care management.
Journal of Theory Construction & Testing, 9(2), 61-67. Retrieved from
http://web.ebscohost.com.spot.lib.auburn.edu/ehost/pdfviewer/pdfviewer?sid=a7a51be8b41d-46a2-9f89-501e91fbab36%40sessionmgr10&vid=6&hid=8
Task Force on Community Preventive Services (TFCPS). (2001). Strategies for reducing
morbidity and mortality from diabetes through health-care system interventions and
diabetes self-management education in community settings. Retrieved from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5016a1.htm
Titler, M. G. (2006). Developing an Evidenced-Based Practice. In G. LoBiondo-Wood, & J.
Haber, Nursing Research: Methods and Critical Appraisal for Evidenced-Based Practice
(pp. 439-475). St. Louis: Mosby Elsevier.
Running head: GROUP BASED TRAINING IN TYPE II DIABETES
23
Appendix A
Evidence Grid
Evidence Grid: Evidence-Based Practice Proposal Project
Article citation in APA format
Purpose of study/research
questions
Evidence Level - 3
Centers for Disease Control and
Prevention, Task Force on
Community Preventive Services.
(2001). Strategies for reducing
morbidity and mortality from
diabetes through health-care
system interventions and diabetes
self-management education in
community settings. Retrieved
from:
www.cdc.gov/mmwr/preview/mm
rhtml/rr5016a1.htm
Evidence Level - 1
Deakin, T. A, McShane, C.E.,
Design type and
methods (sampling
method/sample size,
description of
interventions (if any),
and outcomes
measured
Major
Critique of
findings/finding validity, bias and
s relevant to
significance
project
The purpose of this review is to 
focus on population-oriented
strategies that can be
implemented by communities

and health-care systems to
improve the care of persons
with diabetes.
This was a report 
that reviewed 105
studies.
The interventions
were disease and
case management,
and selfmanagement of
education in
community
gathering places,
home, school, work
and recreational
camps.
The results
recommended
4 of the 7
interventions
which were
disease and
case
management,
selfmanagement
of education in
the community
setting and
home.
The strength of
the
recommendation
is based on the
strength of
evidence of
effectiveness.
Self-management
education
interventions are
effective in
improving health
outcomes.

This was a

systematic review.
11 studies
included in
The adoption of
self-management
The purpose of this study was
to assess the effects of group-
Running head: GROUP BASED TRAINING IN TYPE II DIABETES
Cade, J. E., Williams R. Group
based training for selfmanagement strategies in people
with type 2 diabetes mellitus.
Cochrane Database of Systematic
Reviews 2005, Issue 2. Art. No.:
CD003417. doi:
10.1002/14651858.CD003417.pub
2
based, patient-centered training 
on clinical, lifestyle and
psychosocial outcomes in
people with type 2 diabetes.


Evidence Level - 2
Kulzer, B., Hermanns, N.,
Reinecher, H., & Haak, T. (2007).
Effects of self-management
training in type 2 diabetes: a
randomized, prospective trial.
Diabetic Medicine, 24, 415-423.
doi: 10.1111/j.1464-
The purpose was to measure
the efficacy of three
educational programs for Type
II Diabetes patients



24
14 publications
describing 11
studies were
included involving
1532 participants.
The types of
interventions were
group-based
educational
programs
The outcomes
measured were
glycated
hemoglobin, fasting
blood glucose,
diabetes knowledge,
quality of life,
empowerment/self
efficacy,
This was a
randomized trial.
181 patients took
part in this trial.
Efficacy was
assessed at 3
months, baseline

this review
skills by the
provided
person with
evidence that
diabetes is
group-based
necessary in order
diabetes
to manage their
education
diabetes. The
programs for
method of selfadults with
management
type 2 diabetes education is
result in
effective for
clinically
people with type 2
important
diabetes.
improvements
in health
outcomes for
glycated
hemoglobin,
fasting blood
glucose levels
and diabetes
knowledge at
four to six
months and 12
month follow
up.
This trial showed
There was no
support that a selfchange in the
managementA1c
throughout the oriented group
intervention is
study in
significantly more
treatment
effective than a
group A.
traditional
There was
Running head: GROUP BASED TRAINING IN TYPE II DIABETES
5491.2007.02089.x
25
and at follow-up to
15 months.
Evidence Level - 1
Norris, S. L., Engelgau, M. M., &
Narayan, K. M. (2001).
Effectivenss of self-management
training in type 2 diabetes: a
systemactic review of randomized
controlled trials. Diabetes Care,
24(3), 561-587. Retrieved from
EBSCOhost.
The purpose of this study was
to review the effectiveness of
self-management training in
type II diabetes.
Evidence Level - 2
The purpose of this study was




significant
improvement
is HA1c of
0.7% in
treatment
group B at 3
months which
was sustained
at follow-up to
15 months.
The evidence
supports the
effectiveness
of selfmanagement
training in
type II
diabetes.
This was a

systematic review.
A total of 72 studies
described in 84
articles were
identified for this
review.
The outcomes
measured were
knowledge, selfcare, lifestyle
behaviors,
psychological and
quality-of-life
outcomes, glycemic
control,
cardiovascular
disease risk factors
and economic
measures and health
service utilization.
This was a

Diabetes self
diabetes education
program.
Performance,
selection, attrition,
and detection bias
wee common in
studies reviewed,
and external
generalizability
was often limited.
Weakness:
Running head: GROUP BASED TRAINING IN TYPE II DIABETES
Polonsky, W. H., Earles, J.,
Smith, S., Pease, D. J.,
Macmillan, M., Christensen, R.,
… Jackson, R. A. (2003).
Integrating Medical Management
With Diabetes Self-Management
Training. Diabetes Care, 26(11),
3048-3053. doi:
10.2337/diacare.26.11.3048
to evaluate how the Diabetes
Outpatient Intensive Treatment
(DOIT) program affected
glycemic control and self-care
behaviors over a short term.
Other factors included
frequency of case management 
contacts and whether or not
insulin was started during the
program.



26
randomized control
study which
included patients
with type 1 and type
2 diabetes with an
A1c >8.5.

They were assigned
to the (DOIT) and
also EDUPOST
which is quarterly
educational
mailings. There
were 167 patients 
selected of which 78
were assigned to
EDUPOST and 89
to DOIT.
They all completed
baseline measures to
include A1c and self
care behaviors and a
questionnaire
accessing diabetes
self-care behaviors.
After 6 months, 117
patients (52
EDUPOST and 65
DOIT) returned for
follow up on A1c
and self care
questionnaire.
The follow up with
care behaviors
and glycemia
appears to be
better with the
DOIT program.
The follow up
with the DOIT
Program
reported
significant drop
in A1c than
EDUPOST.
DOIT also
reported
significantly
more frequent
blood glucose
monitoring.
The frequency
of the case
manager follow
up contact was
linked to better
A1c outcomes..
There were some
limitations which
included 15% of
the patients were
eliminated from
all data analysis
because their
baseline data were
incomplete and
these patients
were
disproportionately
represented in the
EDUPOST
condition. The
ethnic breakdown
of the population
does not reflect
the typical
American
population. The
education level
was high on the
patients in the
control study.
Changes in
medication
dosages were not
available for this
study.
The study sample
was the Hawaiian
population.
Running head: GROUP BASED TRAINING IN TYPE II DIABETES

Evidence Level - 2
Schillinger, D., Handley, M.,
Wang, F., & Hammer, H. (2009).
Effects of self-management
support on structure, process, and
outcomes among vulnerable
patients with diabetes. Diabetes
Care, 32(4), 559-
The purpose of this study was
to compare two self
management supports strategies
(automated telephone selfmanagement support (ATSM)
and group medical visits
(GMV) as adjuncts to care and
compared them to usual care.
27
the DOIT program
reported significant
drop in A1c than
EDUPOST.
DOIT also reported
significantly more
frequent blood
glucose monitoring.
 The frequency
of the case manager
follow up contact
was linked to better
A1c outcomes.
 This is a practical
clinical trial that
was conducted in a
safety net health
system.
 There were 339
outpatients of
which had poorly
Strengths:
Changes in self
care behaviors
contribute to
better diabetes
care.
The ongoing self
care behaviors are
essential for long
term control.
Significance for
project:
The need for
awareness of
outpatient training
and self care skills
for diabetes
patients.
How case
management can
also prove
effective in
diabetes self
management.
The study found
that providing
SMS resulted in
improvements in
patient’s
experiences,
self-efficacy,
and self-
Strengths:
Randomized
design.
Population based
recruitment.
A safety net
setting.
A multilingual
Running head: GROUP BASED TRAINING IN TYPE II DIABETES
566.doi:10.2337/dc08-0787



28
controlled diabetes
in county-run
clinics. Half of the
participants spoke
limited English,
were uninsured,
and had less than a
high school
education.
Of the 339
participants, 112
were assigned to
ATSM, 113 were
assigned to GMV,
and 114 were
assigned to usual
care.
ATSM participants
received automated
telephone calls
over 39 weeks.
Each call takes
between 6-10
minutes.
GMV participants
attended 90 minute
monthly sessions
over 9 months.
There were 6-10
participants per
group and a
primary care
management
behaviors.
population with a
range of literacy
skills.
High rate of
participant follow
up.
Use of validated
outcome
measures.
Weaknesses:
The study took
place in only one
safety net setting.
Systematic
inaccuracies in
patient-reported
outcomes may
have occurred due
to recall bias or
social desirability.
Can’t determine
whether
differences
between ATSM
and GMV models
resulted from their
different
structures,
program logic,
periodicity or
levels of intensity.
The study was not
adequately
Running head: GROUP BASED TRAINING IN TYPE II DIABETES

29
physician and
health educator.
The outcome
measured was 1
year change in selfmanagement
behavior.
powered to
provide definitive
answers regarding
relative impacts
across subgroups.
Significance for
project:
There is not
enough research
conducted for
SMS interventions
to adequately
measure outcomes
in safety net
settings,
uninsured
population and
those with
communication
barriers.