Empowerment
Self-management support in “real-world” settings: An empowerment-based intervention

https://doi.org/10.1016/j.pec.2009.09.029Get rights and content

Abstract

Objective

This study examined the impact of a 6-month, empowerment-based diabetes self-management support (DSMS) intervention on clinical outcomes, self-care behaviors, and quality of life (QOL) compared to a 6-month control period.

Methods

This control-intervention cohort study recruited 77 African-American adults with type 2 diabetes. Baseline, 6-month, and 12-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL. During the control period, participants received weekly educational newsletters. During the intervention period, participants attended weekly DSMS groups as frequently as they needed. Sessions were guided by participants’ self-management questions and concerns, and also emphasized experiential learning, coping, problem-solving, and goal-setting.

Results

The control period found significant improvements for diastolic BP (p < 0.05), serum cholesterol (p < 0.001), following a healthy diet (p < 0.01), and monitoring blood glucose (p < 0.01). The intervention period found significant additional improvements for A1C (p < 0.001), weight (p < 0.05), BMI (p < 0.05), and LDL (p < 0.001). Compared to the control period, participation in the intervention led to a significant reduction in A1C (p < 0.01).

Conclusion

Findings suggest that an empowerment-based, DSMS intervention is promising for improving and/or maintaining diabetes-related health, particularly A1C.

Practical implications

Incorporating empowerment principles in DSMS interventions may be useful for supporting patients’ self-management efforts in “real-world” settings.

Introduction

Patient empowerment has become widely recognized as a compelling paradigm for self-management education and behavior change in diabetes care [1], [2], [3]. As conceptualized by Anderson and Funnell [4], the empowerment approach encompasses three guiding principles: First, diabetes is a patient-managed disease. Patients, not providers, make the majority of daily decisions (e.g., dietary choices, physical activity, blood glucose monitoring) regarding their diabetes care. Second, diabetes care should emphasize a collaborative patient–provider relationship in which the provider functions as an educator and/or consultant to the patient who ultimately makes informed self-care decisions. Third, patients are in the best position to identify self-management priorities that have the greatest impact on their lives. When patients self-select behavior changes that are personally meaningful, they will be more motivated to initiate and sustain the behavior change.

As patient-centered care has become a central tenet of health care delivery, patient empowerment has received greater attention. In fact, a growing number of self-management interventions have been designed based on the empowerment approach or have incorporated empowerment principles [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Participation in these interventions has been associated with improvements in metabolic and cardiovascular outcomes, including A1C [7], [8], [9], [11], [12], [14], [16], [19], serum cholesterol [7], [8], [12], [18], [19], LDL [7], [12], [18], HDL [11], [18], systolic blood pressure (SBP) [7], and diastolic blood pressure (DBP) [7], [12]. These interventions have also led to reductions in weight [8], [16], [19], body mass index (BMI) [8], [18], and waist circumference [8]. Post-intervention data have also documented greater frequency of performing self-care practices, including making healthy nutritional choices [18], consuming fruits and vegetables [8], participating in physical activity [8], [18], monitoring blood glucose [18], and inspecting feet [8], [18]. Studies measuring psychological and emotional functioning have found positive changes in quality of life [14], [17], [18], self-empowerment [8], [11], [19], psychosocial functioning [17], perceived health status [9], and satisfaction with care [8], [12].

A hallmark of patient empowerment is the focus on patient-directed versus curriculum-directed interventions. For instance, Anderson et al. [19] developed an empowerment-based self-management education program driven entirely by patients’ diabetes-related questions, concerns, and priorities rather than a pre-determined curriculum with discrete self-management topics delivered in a fixed sequence. Given that patients live with diabetes in “real-world” settings that present unpredictable life challenges under ever-changing conditions, it would appear that a patient-driven self-management support program would be more suitable and responsive than a curriculum-driven program.

When a description of the empowerment-based program was presented to African-Americans and Latinos with type 2 diabetes in a focus group setting, an overwhelming majority expressed great interest in participating [20]. In addition, they strongly agreed that this type of program would help patients improve emotional coping, develop effective self-management strategies, and enhance self-care practices. However, transportation and competing life demands were the most frequently cited barriers to participation. Therefore, in addition to patient-directed discussion, the intervention, itself, needs to be flexible and accommodating to “real-world” deterrents.

Considering these findings, Tang et al. [18] piloted the feasibility and acceptability of a weekly, empowerment-based, self-management support intervention for African-Americans with type 2 diabetes. Conducted in a central location in the community, patients were encouraged to attend sessions as frequently as they needed based on their individual support needs. The study successfully recruited the target number of participants and met the pre-established weekly attendance criteria. Moreover, significant improvements were found for BMI, lipids, self-care practices, quality of life, and other measures of psychosocial functioning. However, a significant limitation to the pilot study was the lack of a control group.

This study addresses this limitation by utilizing an attention-control condition. The purpose of an attention-control condition is to determine if any significant changes observed in the experimental condition are a result of the intervention itself rather than the additional attention participants would receive by simply enrolling into a research study [21]. Unlike a “usual care” control condition that receives no treatment during the course of a research study, an “attention” control condition receives a placebo treatment that provides the same time and attention as the experimental treatment condition.

In this study, we elected to use a mailed intervention as our attention-control condition. Specifically, we provided clinical feedback to participants and their physicians immediately following baseline assessment, and also mailed participants weekly educational newsletters. We considered this mailed intervention as an appropriate attention-control condition because it emulates the “usual care” any patient with diabetes should receive (clinical feedback to patient and their provider and patient education material). In addition, this control condition provides the same time and attention (weekly educational newsletter) as the experimental treatment (weekly DSMS groups). It should be noted that we define same time and attention as the same number of encounters with the study whether these encounters are face-to-face or mailings.

The objectives of this study are two-fold:

  • 1.

    To examine the impact of a 6-month empowerment-based self-management intervention (Lifelong Management) on metabolic and cardiovascular outcomes, self-care practices, and diabetes-specific quality of life compared to a 6-month attention-control period.

  • 2.

    To determine the acceptability of an ongoing empowerment-based program using attendance rate and patterns.

Section snippets

Participants and recruitment

This study was approved by the University of Michigan Institutional Review Board. In contrast to Tang et al's [18] pilot study which did not have a control group, the present study follows a control-intervention time-series design with subjects serving as their own controls. This study design allows us to compare the intervention condition with a control condition. In the first 6 months of the study (months 0–6), subjects participate in the “attention-control” period (see Fig. 1). In the second

Characteristics of the sample

Table 1 presents the demographics of the sample. At post-LM intervention, 12 participants had dropped out of the study yielding an attrition rate of 13% (below the expected rate of 20% per year). Participants were between the ages of 40 and 84 years with a mean of 61 years (SD = 10.4). Thirty-one percent (n = 24) were men; 69% (n = 53) were women. Forty-three percent were currently married (n = 33). Thirty-one percent (n = 24) had a high school degree or less; 18% (n = 14) were currently employed; 56% had

Discussion

The Lifelong Management (LM) intervention was designed to support patients’ efforts in achieving and sustaining self-management goals in a “real-world” setting. Specifically, the LM intervention followed an empowerment-based approach that was patient-driven and flexible to individual needs, priorities, and life circumstances. This study examined the diabetes-related health impact of the first 6 months of the LM intervention on clinical, self-care, and psychosocial outcomes compared to a 6-month

Acknowledgments

This study was supported by a K23 patient-oriented career development award from National Institutes of Health, K23 DK068375, National Institutes of Diabetes and Digestive and Kidney Diseases, and by a grant NIH P60 DK20572 from the National Institute of Diabetes and Digestive and Kidney Diseases.

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