M. Teresa Volpone, PharmD, CDE, BC-ADM is back with a new article “What Is In It For Me?”. This year’s AADE educator of the year focuses on how we can get our patients to actually change behavior.
“What Is In It For Me?”
M. Teresa Volpone, Pharm D, CDE, Rph-BC-ADM
Recently while sorting through my “reading” pile two recent articles got my attention.. The first was a study by Larkin et al. in the May/June The Diabetes Educator. This study explored the attitudes that contributed to psychological insulin resistance (PIR) in type 2 patients. One-hundred insulin-naive adults completed self-report surveys to determine the prevalence of PIR. Interestingly almost all patients’ perceived insulin as preventing complications, improving health, maintaining good control and improving energy. On the other hand, the participants perceived taking insulin as an indication that their disease was more severe represented personal failure and that the use of insulin restricted lifestyle and presented increased risk of hypoglycemia. One-third of the participants found the perceived negatives to outweigh the positives and stated they would be unwilling to use insulin.
Early patient education programs focused on knowledge. If people only KNEW more about how diabetes affected their bodies they would take steps to stave off its effects by exercising, eating well and taking their medications. The outcome would be a resultant improvement in their health and well-being. Post program assessments did show an increase in knowledge outcomes did not.change. There was a disconnect between increased knowledge and personal action. Perhaps there was not much “in it” for the attendees in terms of changing their behavior and health status.
Programs evolved to incorporate educational principals. We acknowledged that each person has a different set of needs, skills and learning style. We learned that each person is somewhere on the continuum of adapting to their diabetes. We became adept at assessing these issues and using this assessment to guide instruction. Knowledge deficits were addressed but now the information was incorporated into problem solving techniques. Attendees were encouraged to select self-care goals. Still measurable outcomes were limited.
More recently, educators are employing the technique of motivational interviewing. The goal is to have individuals become more aware of the impact of their own behaviors on their health, weigh the costs and benefits of their options and then become motivated to change. Our focus is to guide the client and deliver “usable” skills and techniques to achieve their goals.
The second article is by Robert Anderson and Martha Funnell. They state that for 20 years behavioral scientists have developed evidence-based behavioral approaches to diabetes education. Successful education, however, requires more – something termed “The Therapeutic Alliance”. To quote from the article “Relationships between health professionals and their patients based on trust, empathy, respect, and compassion are fundamental to the provision of effective patient care.”
All of us have, at one time of another, been involved with a person who continues to return for visits but makes no change behavior changes. You try to employ motivational interviewing but as you leave the appointment you may feel that you have failed as their “guide” to better health. Yet, despite all this, they continue to come to appointments routinely and consider the interaction valuable. One day, to your happy surprise, the person returns and has started to test their blood sugars or limit snacking or started walking. This seems to be a result of motivational approaches combined with continued, non-judgmental support.
In the case of the patients in the Larkin study would use of motivational interviewing help the 33% of participants who stated they would not use insulin? Could you assist the patient to overcome barriers and to visualize the positives? Could you do it without being empathetic?
My concern is that we do not even have a chance to try.
A decade ago, AADE held a leadership meeting that focused on the marketing of Diabetes Educations programs. According to the marketing group conducting the meeting how we answered this question would be a pivotal influence in our success to attract consumers to our services. “They” being both those with diabetes and the big organizations that would support the program. The concept is simple. Getting “something” is always good, is it not? We see evidence of this at large community focused diabetes related meetings – who hasn’t’ seen folks leaden with bags struggling back to their car. They can easily identify the very tangible “what’s” in that situation.
Despite the evolution of programs and technique, the struggle continues to engage those with diabetes in behavior change. For that matter, the struggle continues to have those with diabetes to access and have access to self-care services. We need to sell what they get both to institutions, to persons with diabetes to society. . We need to continue to collect “evidence” of the impact of education and training. We need to be able to state “what they get” clearly
Our teaching objectives should translate into measurable learning outcomes just as we ask attendees to have measurable goals. We should be able to tell those who sign up “what they will get” and state it in our program descriptions. We need to sell what the attendee will be able to do when they leave the program..
We need to apply motivational skills, provide non-judgmental support. We always need to think, “What’s in it for them?” But we also need to sell, sell, sell.
What and how to sell seems to be the biggest challenge facing us today. We have the compassion and behavioral techniques but this does not mean “they will come”. Not until we can find the universal answer to the question of what is in it for them will be able to reach those most in need.
This is a huge challenge but I am hopeful.
Anderson RM, Funnell MM, The art of diabetes education. Practical Diabetology:2008, June: 37-39
Larkin ME, Capasso VA, Chen C et al. Measuring psychological insulin resistance: barriers to insulin use. The Diabetes Educator. 2008 34 (3);511-517