Assessment of a National Diabetes Education Program diabetes management booklet: The GRADE experience

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Type 2 diabetes is a serious disease that has reached epidemic proportions among Americans in the past decade (Centers for Disease Control and Prevention, 2014). Type 2 diabetes is primarily a chronic condition that relies on patient behavior and certain skills to reduce complications. Diabetes management knowledge and self‐efficacy are important factors in patient behaviors; however, primary care providers are increasingly pressed for time during patient visits, and “supplementary” counseling around management of chronic diseases such as diabetes may not be the priority during the time available (Østbye et al., 2005). At the same time, current literature explores the impact of nurse practitioners and registered nurses on clinical and nonclinical outcomes for diabetes patients. For example, Richardson, Derouin, Vorderstrasse, Hipkens, and Thompson (2014) found that integrating nurse practitioners into primary care teams had a significant impact on clinical measures, such as A1C and blood pressure, but also showed increases in patient self‐efficacy. Further, one study found that primary care registered nurses can effectively expand their role beyond clinical assessment to include relevant education and self‐management support as part of a collaborative care delivery system (Boyle, Saunders, & Drury, 2016).
Diabetes education requires a variety of interventions and tools, and diabetes education programs should continue to produce accessible, evidence‐based information for patients, providers, and partners to help prevent and manage diabetes. An array of self‐management tools and programs have been developed to help patients learn to manage their type 2 diabetes to maximize their health and help prevent and/or delay complications in the future. This includes tools to educate and empower patients to engage healthcare providers, cope with their disease, eat well, be active, and engage in everyday behaviors such as medication adherence, foot care, and oral care.
There are a number of patient education resources available to support diabetes management counseling. The National Diabetes Education Program (NDEP) created the 4 Steps to Manage Your Diabetes for Life (4 Steps) booklet (catalog no. NDEP‐067) to provide key steps to help people with diabetes understand, monitor, and manage their disease. The NDEP is a federally funded program sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention and includes over 200 partners at the federal, state, and local levels, working together to improve the treatment and outcomes for people with diabetes, promote early diagnosis, and prevent or delay the onset of type 2 diabetes. While many of the NDEP's resources are developed based on formative research and are pretested among members of the target audience, few efficacy studies have been conducted on how resources, including 4 Steps, impact patient outcomes.
The 4 Steps resource is one of the NDEP's most popular diabetes management publications. The 16‐page booklet incorporates plain language principles, is available for free in print and digital, and designates clear calls to action for patients with check marks throughout the booklet. 4 Steps helps patients learn (a) about diabetes, (b) the diabetes ABCs (A1C test, blood pressure, cholesterol, and smoking cessation), (c) how to live well with diabetes, and (d) routine care needed to stay healthy. The resource, which includes colorful images and graphics to enhance appeal and comprehension, also includes a summary of important points from the booklet, a diabetes care record to keep track of important test results, and links to additional resources.
The NDEP revised the 4 Steps publication in 2012, incorporating health literacy and plain language principles. Having low health literacy skills is a serious problem for individuals with chronic diseases, such as diabetes.
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