This study describes results from a randomized effectiveness trial comparing two approaches to diabetes education. The purpose of this study was to evaluate participants’ understanding of the clinical relevance of the diabetes ABCs and their recall of personal ABC values. Participants in the empowerment intervention arm were significantly more likely to accurately recall the clinical meaning of the diabetes ABCs compared with participants in the traditional education arm. Similarly, participants in the empowerment intervention arm were much more likely to accurately recall their personal ABC values and a clinically reasonable target level for their ABC values compared to those in the traditional education arm.
The empowerment approach seems to have a profound rather than a subtle effect on our measure of the understanding of the ABCs and recall of personal and goals values. In the traditional education arm, very few participants could report an accurate understanding of the clinical meaning of any of the ABCs or recall any of their personal or goal ABC values. In contrast, nearly all the participants in the empowerment intervention arm accurately reported an understanding of the ABCs, and most could recall their personal or goal ABC values. These differences account for a ten-fold difference in the overall scores of participants in the two groups on the ABCs questionnaire. The knowledge difference between traditional and patient empowerment approaches in this study mirrors the differences found between these two approaches in a broad array of tests of diabetes self-management training [6
]. The empowerment approach to self-management training is considered “a cornerstone of chronic disease care” [10
] and is widely considered to be the conceptual basis for self-management support within the chronic care model [3
The results of our study support the need for adaptations of the empowerment approach to other facets of patient education embedded within health services programs. In essence, this study found that an empowerment approach to teaching the diabetes ABCs leads to a patient who may be ready to apply these new concepts to her personal diabetes care and daily routine (i.e., an informed, activated patient). Patient education programs grounded in this approach are important drivers of effective chronic care, because an activated patient in partnership with a prepared provider team forms a foundation for optimal chronic illness management [3
]. Two key principles found within our intervention are worth underscoring. First, we translated the basic knowledge element of our education intervention using a conceptual metaphor [19
]. This metaphor, “predicting the weather”, is especially effective in this setting because it uses low-literacy pictorial icons that have similar meaning across many populations, and because weather prediction is a widely understood concept for risk prediction (with the added benefit of conveying an understood sense of error and uncertainty in weather prediction). Participants in the current study appeared to comprehend and work very quickly with the information presented in and moved towards linking the ABCs to their daily activities.
The second principle underlies the pedagogical process used in the intervention. We used a team-based, active learning approach that is consistent with the contemporary literature on adult learning theory [24
]. The team-based learning approach empowered patients by fostering discussion among all participants about the relevance of the information, drawing on their prior and present experiences. In the team-based discussions, participants could “practice” using their understanding of the ABC concepts through case examples and working with others to resolve conflict and make decisions that simulated the topics and environments that they would face in their daily experiences with diabetes. In contrast, traditional diabetes education, at least with respect to the ABCs, relies on passive modes of learning in which participants are simply recipients of facts, often with little personal context. Such lecture-based modes of learning do not foster recall of facts let alone understanding of how to adapt new knowledge to novel problems and daily experiences with chronic care [26
Improving patients’ diabetes-related understanding and their ability to critically resolve many of the daily challenges of diabetes self-care are key process measures of the empowerment approach to diabetes [6
]. In addition, Anderson and Funnell [18
] have described increased self-efficacy as an important outcome measure of the empowerment approach. Improved self-efficacy, especially when measured as the confidence to perform specific diabetes self-management tasks, is instrumental to achieving clinically important diabetes outcomes, such as metabolic control [10
]. We have recently demonstrated [27
] that participants enrolled in our four-session, group clinic intervention had significantly greater improvements in glycosylated hemoglobin levels post-intervention (0.67% ± 1.3%, P=.03) compared with those who attended traditional diabetes education and nutrition groups. These differences in metabolic improvements persisted (0.59% ±1.4%, P=.05) at one-year follow-up. Longitudinal data analyses demonstrated that self-efficacy for diabetes self-management was a mediator of the observed metabolic changes [27
]. An empowerment approach to diabetes education and self-management support, therefore, may improve metabolic outcomes of diabetes care through enhancements in diabetes self-efficacy. Additional studies are needed to adequately test this relationship.
The current study has some limitations. First, the primary results rely on a novel measurement tool developed for this study. Our standardized, blinded, consensus-building process used to score participants’ responses has not been used in prior work or validated in other populations. Second, the wording of the ABC questionnaire during the follow-up data collection was more suited to the empowerment intervention process and may reflect participants’ familiarity with the process and materials rather than improvements in recall. Consistent with the conceptual model of the intervention [3
], an activated patient may not need to rely on rote memory to facilitate adaptation of diabetes knowledge into improvements in self-management and clinical outcomes. The study did utilize a randomized, comparative effectiveness design underscoring its internal validity and practical clinical impact [28
]. However, study participants were largely male Veterans from a single regional health center; which may limit the external validity of these findings. Further research using broader patient populations, settings, and clinical circumstances are needed to validate this adaptation of patient empowerment to patient education in chronic care.