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Diabetes mellitus (DM) is a chronic disease that needs lifestyle modifications and

lifelong medical treatment. The greatest challenge in diabetes management is to


delay its progression so that acute and chronic complications can be avoided in
people with diabetes (Gillani, et al., 2012). Studies have shown that the onset of DM
can be postponed by modest weight loss, healthy eating practices and exercise
regularly (Bergman, 2013). However, improving patients adherence to medical
regime and life-style modifications are the most challenging tasks for healthcare
practitioners (HPCs). As HCPs we know that strict adherence to medication regime,
dietary intake, self-monitoring blood glucose and physical exercise could protect
patient from debility associated with diabetes-related complications but many do not.
Patient non-adherence problems in diabetes were well evident in the literatures
(Haynes, et al., 1979; Kurtz, 1990; Harris, 2001). When patients do not follow
the treatment advice recommended by the HCPs, HCPs often felt
frustrated and fed up with these noncompliant patients. From the
perspective of the HCPs, they have done their parts by putting in great
effort to advise and convince these patients to become compliant with the
treatment recommendations. If the patients are still stubborn and not
listening to their advice, it can be very discouraging and bewildering for
the HCPs. This unhappy scenario can be encountered everyday in the
outpatient clinic. However, the non-compliant patients were equally
frustrated with their inability to comply with the treatment
recommendations and frequently felt being blamed by their HCPs (Weiss,
2006).

As nurses, we play a pivotal role in diabetes self-management education and are


capable of making a difference in the life of people with diabetes by influencing their
self-care behaviours. It is important that people with diabetes are well-supported and
empowered to self-manage their conditions in the effort to achieve lifelong optimal
health. The ultimate goal in diabetes management is to motivate patients towards
achieving sustainable behavioural changes in lifestyle modification and proficiency in
self-care management. The aims of this assignment are to seek for evidence-based
approaches to 1) improve diabetic health education; 2) motivate patient adherence to
treatment recommendations; and 3) facilitate sustainable behavioural change and
self-care management in people with diabetes. In this write up, the author suggests a
potential useful evidence-based solution where a combination of an empowerment
based diabetes self-management education program with a counselling method
called motivational interviewing to improve the outcomes of people with T2DM in
Malaysia.

DM is a global epidemic which threatens both developed and developing countries in


the world (Yang, 2013). 90% of the diabetic population suffered from T2DM (Bagust,
2001). Globally, the disease trend has evolved from communicable diseases in
children to those of non-communicable or chronic diseases in adults especially
metabolic and dietary (Lim, et al., 2012). DM is the most prevalent metabolic
disorder in the world (Sharifa Ezat, et al., 2009) and it is a non-communicable
disease (NCD). In 2006, the United Nation passed a landmark resolution
acknowledging that diabetes is an expensive, debilitating and chronic condition
associated with serious complications, which can have negative impact on families,
communities and the whole world. It also threatened the progression towards the

Millennium Development Goals. This was the first time a non-infectious disease
presented a serious global health threat to all nations as infectious epidemics such
as AIDS (International Diabetes Federation IDF, 2006). T2DM is identified as a
product of globalization and collaborative effort across all nations is imperative to
curb the increasing prevalence (Venkat Narayan, et al., 2012). The Diabetes
Attitudes Wishes and Needs 2 study confirmed that the emotional, physical, and
financial burden of diabetes across countries and cultures were carried by the whole
family, not just by the individual with DM (Peyrot, et al., 2013). Due to its chronicity
and complications associated with multi-organ involvement, the cost to treat T2DM is
high. Therefore, DM is a burdensome disease, not only affecting individuals and
families, but also crippling the national healthcare system (Wan Norlida, et al., 2010).
This may lead to poverty as patients lose their ability to earn a living on top of having
to pay for the medical expenses associated with the treatment of diabetes. Zhang, et
al. (2010) estimated that by 2010, 12% of the health expenditure would be spent on
diabetes and the cost to treat one diabetic is USD 1330 globally. In 2010, Malaysia
allocated 16% of her national healthcare budget on diabetes-related expenditure,
ranking among the top 10 countries in the world in terms of percentage spent (Chan,
2013).

IDF estimated that diabetes would increase from 366 million in 2011 to 552 million in
2030 worldwide with the highest increased in Asia (Yang, 2013). Under the
globalization process of T2DM, IDF also reported that more than 60% of the worlds
population with diabetes would come from Asia (Yang, 2013) and the newly
industrialized countries like Malaysia and Singapore are anticipated to be highly
susceptible for developing diabetes (Rugayah, 2007). In Malaysia, T2DM is a major

global public health issue (Rugayah, 2007). Malaysias population is 28.3 million
(Malaysia. Department of Statistics Malaysia, 2010), of which there are nearly 2.6
million or 15.2% of the population are diabetes as reported by the Third Malaysian
National Health and Morbidity Survey (Kaur, et al., 2013). The prevalence is further
escalated by the recent rapid urbanization and industrialization in Malaysia (Rampal,
et al., 2010). With ongoing urbanization and industrialization, and adoption of
inactive lifestyles and unhealthy dietary habits, obesity is on the rise even among the
rural communities (Ismail, et al., 2002; Pon, et al., 2006), all of which have been
implicated as contributing factors in the development of T2DM.

Based on the disability adjusted life years (DALYs), among the top 10 total burden of
diseases in Malaysia, diabetes was ranked 6th for men and 5th for women (Faudzi,
et al., 2004). The significance of diabetes despite its lower ranking based on DALYs
is that it is a major contributing factor to cardiovascular diseases (Letchuman, et al.,
2010). Its significant morbidity associated with microvascular and macrovascular
complications reduces life expectancy and diminishes quality of life (Rampal, et al.,
2010). Annually, about 3 million deaths are ascribable to diabetes and more than
80% happen in developing countries (Wan Norlida, et al., 2010).

The current approach to diabetes management in Malaysia is based on the


traditional medical model where acute care model (ACM) is adopted as the main
paradigm in treating chronic illnesses (Yasin, et al., 2012). This traditional ACM is
effective in controlling communicable diseases and episodic short-term illnesses but
not effective in managing chronic diseases like T2DM (Yasin, et al., 2012). The
traditional ACM focusing on curative and compliance-oriented model of care is

unworkable in diabetes care (Hill-Briggs, 2003). In Malaysia, poor provider-patient


interaction is identified as one of the issues in diabetes health education (Rampal, et
al., 2010). Effort should be made to improve the communication and counselling
skills of the HCPs especially diabetes nurse educators (DNE). DNE should change
their health education approach from traditional didactic and expert-directed
approach to an empowerment-based chronic care approach where care is patientcentred and patient-practitioner partnership works collaboratively to manage T2DM
and improve patient adherence to diabetes self-care regimens (Rampal, et al.,
2010). In order to improve the provider-patient interaction, the author suggests that
motivational interviewing (MI) counselling method should be incorporated into
diabetes health education in Malaysia.

The empowerment-based chronic care model (CCM) emphasizes on improving


patients capacity and inherent potential to take charge of their diabetes
and their life (Hage and Lorensen, 2005). Diabetes self-management education
is the cornerstone for patients to manage diabetes effectively. It is the foundation for
the empowerment approach to chronic disease management (Funnell and Anderson,
2004). T2DM is a chronic disease that requires lifelong self-management focusing on
preventive care behaviours and ongoing self-care which are fundamental to maintain
optimal health (Tol, et al., 2013). The effectiveness of CCM in chronic illness care
has long been established (Wagner, et al., 2001). Empowerment is an enabling
process where HCPs facilitate the patients by increasing their capacity in making
autonomous and informed decisions for their diabetes self-care. The outcome is an
enhancement of patients confidence in diabetes self-management so that life-long
behavioural changes can be sustained (Anderson and Funnell, 2010).

In the subsequent section, the author explains why ACM is not suitable to treat
chronic diseases as opposed to an empowerment-based CCM. There are four main
differences between ACM and CCM (Alt and Schatell, 2008). These differences are
the duration of disease; goal of treatment; patients role; and practitioners role. The
duration of acute illnesses is short whereas in chronic illness it may last for life.
There is a cure in acute illness whereas people with chronic illnesses will never
recover. They have to adapt to the chronic condition and learn how to self-manage
their diseases in order for them to stay as healthy as possible. Therefore, a CCM
emphasizes on empowering, educating and supporting patients in diabetes selfmanagement is not only suitable but fundamental to patients long-term survival.

The traditional ACM trained and socialised HCPs to assume full responsibility in
patient care and outcomes (Anderson and Funnell, 2010). ACM does not embrace
the realities of dealing with chronic diseases where 98% of the diabetes care is
rendered by patients themselves where HCPs have no control over patients
diabetes self-management decisions and outcomes (Funnell and Anderson, 2004).
This ingrained perceived responsibility shapes the behaviour and attitude of the
HCPs in delivering chronic care. Health education is done through didactic approach
where information transfer and instruction is used to convince patients compliance to
the recommendations of HCPs. This model assumes that patients are obligated to
follow HCPs instructions and disregards the effects of those recommendations have
on patients daily life (Funnell and Anderson, 2004). This is because the care plan is
formulated to fit patients diabetes without taking into consideration the patients
psychological and lifestyles factors which are important determinants for lifelong

success in chronic disease management (Jarvis, et al., 2010). This telling approach
is ineffective in effecting any desired behavioural changes and improved clinical
outcomes as supported by literatures (Brown, 1988; Brown, 1992; Malaysia. National
Institutes of Health and Ministry of Health, 2008). Evidences on its ineffectiveness
were manifested by patient non-compliance to treatment recommendations (Lutfey
and Wishner, 1999; Glasgow and Anderson, 1999).
Under the ACM, a parent-child relationship is applied in health education where
HCPs assume the expert role having the authority responsible for making all
decisions regarding treatment (Rollnick and Butler, 1999). Treatments are prescribed
and goals are predetermined by HCPs without engaging the patients (Funnell and
Anderson, 2004). The role of the patient in ACM is passive, obedient, accepting, and
dependent (Anderson, 1995). They only need to comply with treatment
recommendations without decision-making authority. This advice-giving approach
undermines patients autonomy and creates resistances (Rollnick and Butler, 1999)
because patients are treated like a child where the HCPs constantly order, direct,
control or blame patients when they fail to obey those instructions (Anderson, 1995).
Patient empowerment approach, on the other hand, acknowledges that patients are
the main decision-makers responsible for their daily diabetes self-care (Meetoo and
Gopaul, 2005). The role of HCPs is to help patients make informed choices to attain
their goals and tackle obstacles through support, expert recommendations,
appropriate care advices and education (Funnell and Anderson, 2004) rather than
dictating behaviour and compliance as in the traditional ACM. In CCM, HCPs
assume the role of facilitators, mentors and coaches (Alt and Schatell, 2008) who
provide autonomous and ongoing support in facilitating the abilities, skills and

knowledge necessary for diabetes self-management (Funnell, et al., 2011). It is a


collaborative care model where patients assume an active role working together with
HCPs in decision-making, goal-setting, care planning and problem-solving related to
diabetes self-care (Delamater, 2006). The relationship is an adult-to-adult
characterized by mutual respect and equal partnerships between patient and HCPs.
HCPs provides patient-centred care where education and interventions are tailored
to meet the specific needs and expectations of each individual patient (Strecher, et
al., 1994; Skinner, et al., 1994) while patients contribute their expert knowledge
about their personal life on the type of interventions work best for them (Anderson,
1995). The end product of this collaboration is a customized care plan which suits
the personal needs, priorities and lifestyles of the patient where patients adherence
to desired self-care regimens would be increased (Funnell and Anderson, 2004). In
this approach, the patients are activated by the proactive HCPs to make informed
choices on their daily diabetes self-care rather than being forced to comply with the
predetermined plan formulated by the HCPs.

Evidences have shown that diabetes self-management education (DSME) adopting


an empowerment model where behavioural and psychosocial interventions are
incorporated into education are more effective as compared to the traditional
information transfer approach as mentioned earlier. A UK diabetes education
program called DESMOND (Diabetes Education and Self-Management for Ongoing
and Newly Diagnosed) which based on psychological learning theories and patient
empowerment (Skinner, et al., 2006) has shown improvement in weight loss,
smoking cessation and beliefs in people with newly diagnosed diabetes (Davies, et
al., 2008). In USA, the DSME which based on an empowerment model and non8

didactic approach by incorporating behavioural goal-setting strategies is found to be


effective in supporting self-management behaviours and achieving optimal health
(Funnell, et al., 2011). A copy of the five-step goal setting process is contained in
appendix 1. The first two steps identify the issues and clarify patients attitudes and
emotions that may enhance or hamper patients efforts. The third helps patient to set
long-term goals by developing a plan. The forth gets patients commitment to
behaviour change in order to achieve their long-term goals. In the last step patient
evaluates and draws conclusion on what they have learnt from the experience.
Acquiring the necessary knowledge and skills are insufficient for people with
diabetes to self-manage successfully. DSME provides patients with the additional
skills on behavioural goal setting, risk reduction behavioural strategies and problemsolving in order for them to self-manage their diabetes effectively (Australian
Diabetes Educators Association, 2008; Funnell, et al., 2011).

MI is an evidence-based counselling technique emphasizing on a collaborative


therapeutic patient-practitioner partnership centred on eliciting behavioural change
through goal setting and self-management that can be used to improve patient
adherence to treatment regimes (McCarley, 2009; Rubak, et al., 2005; Tuah, et al.,
2012). Through collaborative interaction, MI could influence patients motivation and
readiness to change (Funnell and Anderson, 2004). MI derives from Prochaska and
DiClementes (1982) transtheoretical model of stages of change (TTM SOC)
explains that people move through the various SOC namely precontemplation,
contemplation, preparation, action, and maintenance which occur during behavioural
modification (Prochaska and DiClemente, 1986). Relapse is normalized and viewed
as an opportunity to learn about how to sustain life-long changes (Hall, et al., 2012).
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An individuals readiness to change is determined by the intentional behavioural


stage where he or she is at. Using MI techniques, HCPs can design motivational
strategies to match the specific level of SOC for their patients (Prochaska, et al.,
1992). These customized motivational strategies could foster a positive attitude
towards behaviour changes (Roumen, et al., 2009). A copy of the techniques used is
contained in appendix 2.

MI has many benefits. One of the valuable benefits is that MI is feasible for even a
10-to-15 minute patient visit (Resnicow, et al., 2002; Rollnick, et al., 2002). This
addresses the misconception that offering emotional and psychosocial care is time
consuming (Levinson, et al., 2000; King, et al., 2002). MI empowers patients to
become well-informed, active collaborators and decision-makers through providing
support, assurance, caring and knowledge in diabetes self-care (Meetoo and
Gopaul, 2005). HCPs embrace the three spirits of MI: autonomy, evocation and
collaboration to promote behavioural change as opposed to the authoritativepaternalistic approach so that patients stay motivated to sustain their behavioural
changes (Miller and Rollnick, 2002). In MI, patients autonomy, right and
responsibility in diabetes self-management are acknowledged and HCPs recognize
that it is entirely up to the patient whether or not to change. In the authoritativepaternalistic approach, the HCPs tend to use their authority to order patient to make
changes. When dealing with patients resistance to change, HCPs applying MI do
not impose solutions (Levensky, et al., 2007) or direct patient on what to do (Miller
and Rollnick, 2002) as what is being practiced in the authoritative-paternalistic
approach rather they activate patients motivation for change by eliciting and
connecting reasons for change to things that patient values and cares about (Hall, et

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al., 2012) while encouraging patient to generate ideas on how to achieve behavioural
change (McCarley, 2009). Additionally, equal collaborative partnership between
HCPs and patients is established in which HCPs provide empathy and support while
helping patient to formulate a change plan and set realistic behavioural goal to
achieve desired change rather than coercing the patient to change as what is being
practiced in the authoritative-paternalistic approach (Miller and Rollnick, 2002). In
this way, MI promotes behavioural change by internalizing patients own reasons for
change and helping them to set personal goals. Patient who participates actively in
collaborative decision-making and goal-setting process is internally motivated and
more likely to achieve the desired outcomes identified as important by them (Heisler,
et al., 2003). In addition, this collaborative relationship can act as a powerful
motivator when HCPs support self-efficacy by instilling a belief in the possibility of
change (Hall, et al., 2012). Promoting hope that change is possible enhances
patients self-efficacy in executing their plans and achieving self-identified goals
(Levensky, et al., 2007).

In order to strengthen patients commitment to change, MI provide these guiding


principles: resist the righting reflex by avoiding the tendency to force solutions to
patients problem; develop a discrepancy between patients goal and behaviour to
promote patients awareness on the importance to change; roll with resistance where
HCPs approach resistance with a non-judgemental stance; and support self-efficacy
by increasing patients confidence to change (Hall, et al., 2012).

In terms of improving provider-patient interaction, MI provides HCPs with a range of


MI therapeutic skills where HCPs can apply during diabetes health education. These

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include expressing empathy for the challenges faced by patients; using reflective
listening; asking open-ended questions; using the ask-provide-ask approach to
provide information; affirming patients opinions and progress; and summarizing main
points and goals (McCarley, 2009).

Although diabetes health education is widely promoted in Malaysia, its effectiveness


in achieving the desired effect on improvement of self-care for people living with
diabetes remains doubtful. HCPs especially DNE who have direct involvement in
diabetes health education should make a paradigm shift from the traditional didactic
approach to a non-didactic approach where HCPs truly embrace the philosophy of
patient empowerment (Anderson and Funnell, 2010) while incorporating behavioural
strategy like goal-setting and psychological strategy like MI into diabetes health
education. These approaches address the fundamental factors that lead to
behavioural changes such as patients readiness, willingness and ability to change,
patients sense of importance on behaviour change and confidence in achieving
change (Delamater, 2006). These interventions have shown to be effective in
improving the metabolic and psychosocial outcomes of people with T2DM (Funnell
and Anderson, 2004). One of the greatest challenges faced by Malaysia is constraint
in human capacity where trained personnel qualified in managing diabetes are
scarce (Yasin, et al., 2012). Human capacity building for the existing nurses can be
done through continuous professional development programs where the concept of
CCM and MI are taught to the nurses and other HCPs. In order to equip our future
nurses with the essential chronic care skills, counselling skills based on behavioural
and psychological theories such as MI; chronic care model; patient empowerment;
and evidence-based practices in chronic care should be incorporated into the

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nursing curriculum. In addition, innovative strategies should be explored to increase


the human resources required to encourage and support diabetes self-management
education such as using lay leaders and family members may be particularly
beneficial (Yasin, et al., 2012).

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