Sharing stories: complex intervention for diabetes education in minority ethnic groups who do not speak EnglishBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7492.628 (Published 17 March 2005) Cite this as: BMJ 2005;330:628
(Posted as supplied by the author)
Reproduced with permission from the ‘Sharing stories’ training manual16
By the end of the course the learner will be expected to
The learner has demonstrated the ability to
Key assessment criteria
Key assessment evidence
- Function effectively as a member of a professional learning group
- Set and apply ground rules
- Agree group objectives for each session
- Communicate information and feelings to the group
- Respond appropriately and sensitively to information and feelings conveyed by other group members
- Use a range of communication methods appropriately in group work
- Evaluate each session in terms of both content and process
Tutor observation of group process
Tutor report on performance in group
- Understand and apply storytelling techniques in the context of group learning of health care professionals
- Select and share stories about the illness experience and health care encounters of clients in a protected group setting
- Reflect on the perspectives and needs of clients as illustrated by stories shared in this professional setting
- Show understanding of the role of emotions and life narrative in determining health behaviour
- Develop strategies to take account of these when supporting particular clients
Tutor observation of group process
Written accounts of clients' illness and life narratives showing relevance to topic area, sensitivity to client's perspective, and suggestions for modification of professional input
Tutor report on performance in group
Written account of clients' illness and life narratives following template or otherwise
- Identify and address their own professional learning needs through storytelling in a professional group
- Identify own professional learning needs based on clients' stories of illness and health care encounters
- Access and select information and resources to meet particular needs
Written account of clients' illness and life narratives showing awareness of learning needs arising from these accounts
Written account of clients' illness and life narratives
- Use external sources to meet identified learning needs
- Access and select information and resources to meet particular needs
Tutor assessment of relevance, accuracy and validity of information and resources collected by learner
Annotated list of resources used and materials collected by learner
- Apply the information gained from storytelling to the development of health promotion materials
- Develop health promotion materials based on the needs identified through clients' illness and life narratives and the information collected to meet those needs
Assessment of relevance, accuracy and validity of health promotion materials produced or co-produced by learner
Health promotion materials (written or otherwise) produced or co-produced by learner
- Review own practice and record and report appropriately
- Produce written accounts of clients' illness and life narratives that include sensitivity to the client's perspective, a reflective interpretation and specific learning points
- Set appropriate and measurable goals for own learning and development based on these accounts
Tutor assessment of relevance, scope, quality and reflective interpretation of clients' illness and life narratives
Student self audit of learning goals based on the above
Personal action plan
Aim of review
To determine the impact of self management training on diabetes related outcomes
72 RCTs. Overall, significant improvement in self management skills and diabetes knowledge and small but significant reduction in HbA1c. However, impact was highly heterogeneous across studies and many showed no effect
To establish clinical effectiveness and cost effectiveness of diabetes education
16 trials in type 2 diabetes. No clear benefit from diabetes education. Trials of lowest methodological quality suggested greatest benefit and vice versa
To identify critical success factors in trials of diabetes education; specifically, to explore the link between promotion of self efficacy and effective diabetes self management
45 trials described in narrative review. Trials that produced the best outcomes seemed to be characterised by involving people in their own care, exploring their feelings about having diabetes, teaching key skills, and active learning. Statistical meta-analysis was not done
To determine the efficacy of interventions to promote self care in older African-American or Latino adults with diabetes
8 RCTs. Mixed findings. Greater impact of the programme was associated with poor glycaemic control at baseline (HbA1c>11%), cultural tailoring or age tailoring the intervention, use of group counselling or support, and involvement of spouses and adult children
To determine the effectiveness of education, self management and psychological interventions on psychosocial outcomes in diabetes
36 RCTs, heterogeneous in both design and findings. Counselling tended to improve depression; self management training tended to improve quality of life
Van Dam, 2003w29
To determine the relative importance of interventions to change professional behaviour and empower patients in achieving better diabetes outcomes
8 RCTs, highly heterogeneous. Interventions to make diabetes doctors "more patient centred" had weak impact, but those that directly focused on patients’ behaviour (such as promoting assertiveness) improved outcome (including glycaemic control); the latter included group based empowerment interventions
To compare diabetes outcomes with psychological interventions (counselling, cognitive-behaviour, or psychodynamic) to those in patients given usual care
25 RCTs. Highly significant improvement in HbA1c and reduction in psychological distress in intervention group
RCT=randomised controlled trial.
Group discussions are a popular research method for exploring the experience of diabetes and perceived barriers to optimum care in minority communities.w1-w4 Group approaches to diabetes education are often used in busy clinics,w5 and several studies (notably the large DAFNE trial in the United Kingdomw6) have shown dramatic and sustained improvements in type 1 diabetes with intensive group education.
Many studies of education (or psychological support) in type 2 diabetes have been done; these have been the subject of several recent systematic reviews, which are summarised in table B). Relatively few of the hundreds of primary studies cited in these reviews compared group sessions with individual sessions.
In type 2 diabetes, a high quality randomised trial in Italy with a follow up of five years showed significantly better diabetes knowledge, problem solving ability, quality of life, glycated haemoglobin, body mass index, and cholesterol in hospital outpatients randomised to intensive group education compared with those randomised to an optimised package of ongoing individual education.w7 Another randomised trial from Spain showed no difference in clinical or psychometric outcome measures between group and individual education,w8 and a third study from the United States showed no difference in outcomes but greater cost effectiveness of group education.w9 A small study in the United States randomised patients with type 2 diabetes to group A (an educational programme followed by 18 months of "support group sessions"), group B (educational programme alone), or group C (neither). Group A showed significantly greater improvements in both knowledge and psychosocial functioning than did either group B or group C.w10 A large multicentre randomised trial of group education in type 2 diabetes (DESMOND) is under way in the United Kingdom, and a Cochrane review on the topic is in progress.w11
The recent spate of well designed clinical trials of group education and support in type 2 diabetes is welcome, and these studies have included people from many different ethnic groups. However, they were not designed to investigate the specific cultural or linguistic needs of particular "hard to reach" ethnic minorities nor to evaluate the impact of the group itself (as opposed to the educational package delivered to the group). Indeed, a major limitation of all the published studies is lack of process information on what actually went on in the groups.
Another small American study randomised Mexican-Americans with type 2 diabetes to an eight week programme of group education plus group support from a Spanish speaking community worker or usual care; significant differences were obtained in diabetes knowledge and glycated haemoglobin.w12 Again, little detail was given on the nature of the intervention or the role of the community worker, and we could find no other randomised trials of group work across a language barrier in diabetes. The role of bilingual health advocates in group based health education more generally is virtually unexplored. Yet a MORI survey in 1994 showed that nearly three quarters of users of advocacy services had not had any kind of group based health education with the advocate. Of the quarter who had, 80% had found it "very useful" and another 14% found it "fairly useful."w13
The mechanism by which diabetes education has an impact on self management behaviour is not known, although the self efficacy model of Lorig and Holman is currently popular.w14 This does not explain the significantly greater impact of group education over individual education shown in the largest and highest quality randomised controlled trials to date.w6 w7 On the basis of our observations of the group process in our own study, we suggest that individual change that results from group interaction may not be mediated through a simple self efficacy model but by a more complex process involving several (perhaps all) of the following:
, in which the questions and responses of other group members prompt reflection and consolidation of individual adult learningw15 w16
- Critical discourse
through the social construction of a shared perspective on a problem and the collective negotiation of the meaning of individual experiences relating to itw17 w18
- Sense making
of individual identities, aspirations, and motivation against the norm set by the groupw19 w20
—that is, mutual understanding, support, and commitment to help and support others, leading to the development of social ties and support outside the groupw21 w22
—that is, the physical enactment of stories within the group.w23
- Narrative drama
In the next phase of this research, we hope to use detailed process evaluation alongside a randomised controlled trial to explore these different mechanisms further and follow through their impact on individual lifestyle choices.
w1 Greenhalgh T, Helman C, Chowdhury AM. Health beliefs and folk models of diabetes in British Bangladeshis: a qualitative study. BMJ 1998;316:978-83.
w2 Anderson RM, Barr PA, Edwards GJ, Funnell MM, Fitzgerald JT, Wisdom K. Using focus groups to identify psychosocial issues of urban black individuals with diabetes. Diabetes Educ 1996;22:28-33.
w3 El-Kebbi IM, Bacha GA, Ziemer DC, Musey VC, Gallina DL, Dunbar V, et al. Diabetes in urban African Americans. V. Use of discussion groups to identify barriers to dietary therapy among low-income individuals with non-insulin-dependent diabetes mellitus. Diabetes Educ 1996;22:488-92.
w4 Maillet NA, D’Eramo MG, Spollett G. Using focus groups to characterize the health beliefs and practices of black women with non-insulin-dependent diabetes. Diabetes Educ 1996;22:39-46.
w5 Audit Commission. Testing times: a review of diabetes services in England and Wales. London: The Audit Commission, 2000.
w6 Koev DJ, Tankova TI, Kozlovski PG. Effect of structured group education on glycemic control and hypoglycemia in insulin-treated patients. Diabetes Care 2003;26:251.
w7 Trento M, Passera P, Borgo E, Tomalino M, Bajardi M, Cavallo F,et al. A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care 2004;27:670-5.
w8 Dalmau Llorca MR, Garcia BG, Aguilar MC, Palau GA. [Group versus individual education for type-2 diabetes patients.] Aten Primaria 2003;32:36-41.
w9 Rickheim PL, Weaver TW, Flader JL, Kendall DM. Assessment of group versus individual diabetes education: a randomized study. Diabetes Care 2002;25:269-74.
w10 Gilden JL, Hendryx MS, Clar S, Casia C, Singh SP. Diabetes support groups improve health care of older diabetic patients. J Am Geriatr Soc 1992;40:147-50.
w11 Deakin TA, Cade J, Williams DRW. Group based self-management strategies in people with type 2 diabetes mellitus [protocol]. Cochrane Database Syst Rev 2002;(1):CD003417.
w12 Brown SA, Hanis CL. A community-based, culturally sensitive education and group-support intervention for Mexican Americans with NIDDM: a pilot study of efficacy. Diabetes Educ 1995;21:203-10.
w13 MORI. Evaluation of bilingual health care schemes in East London. London: East London Consortium, 1994.
w14 Lorig KR, Holman H. Self-management education: history, definition, outcomes and mechanisms. Ann Behav Med 2003;26:1-7.
w15 Hawe P, Shiell A, Riley T. Complex interventions: how "out of control" can a randomised controlled trial be? BMJ 2004;328:1561-3.
w16 Kolb DA. The process of experiential learning. In: Thorpe M, Edwards R, Hanson A, eds. Culture and processes of adult learning. London: Routledge, 1993:138-56.
w17 Bruner J. Acts of meaning. Cambridge, MA: Harvard University Press, 1990.
w18 Wenger E. Communities of practice: learning, meaning and identity. Cambridge: Cambridge University Press, 1996.
w19 Elwyn G, Greenhalgh T, Macfarlane F. Groups—a hands-on guide to small group work in education, management and research. Oxford: Radcliffe, 2000.
w20 Goffman E. The presentation of self in everyday life. New York: Penguin, 1969.
w21 Bion W. Experiences in groups and other papers. London: William Heinemann, 1961.
w22 Frank A. Just listening: narrative and deep illness. Fam Syst Health 1998;16:197-216.
w23 Mattingly C. Healing dramas and clinical plots: the narrative structure of experience. New York: Cambridge University Press, 1998.
w24 Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:561-87.
w25 Loveman E, Cave C, Green C, Royle P, Dunn N, Waugh N. The clinical and cost-effectiveness of patient education models for diabetes: a systematic review and economic evaluation. Health Technol Assess 2003;7(22):iii, 1-190.
w26 Krichbaum K, Aarestad V, Buethe M. Exploring the connection between self-efficacy and effective diabetes self-management. Diabetes Educ 2003;29:653-62.
w27 Sarkisian CA, Brown AF, Norris KC, Wintz RL, Mangione CM. A systematic review of diabetes self-care interventions for older, African American, or Latino adults. Diabetes Educ 2003;29:467-79.
w28 Steed L, Cooke D, Newman S. A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus. Patient Educ Couns 2003;51:5-15.
w29 Van Dam HA, van der HF, van den BB, Ryckman R, Crebolder H. Provider-patient interaction in diabetes care: effects on patient self-care and outcomes: a systematic review. Patient Educ Couns 2003;51:17-28.
w30 Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet 2004;363:1589-97.
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