Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Novel Patient�Centered Diabetes EducationProgram: A Study to Assess The Feasibility,
Design, Implementation, and Impact On Patients
Item Type text; Electronic Thesis
Authors Davis, Amy
Publisher The University of Arizona.
Rights Copyright © is held by the author. Digital access to this materialis made possible by the College of Medicine - Phoenix, Universityof Arizona. Further transmission, reproduction or presentation(such as public display or performance) of protected items isprohibited except with permission of the author.
Download date 14/02/2021 15:54:55
Link to Item http://hdl.handle.net/10150/623427
NOVEL PATIENT‐CENTERED DIABETES EDUCATION PROGRAM:
A STUDY TO ASSESS THE FEASIBILITY, DESIGN, IMPLEMENTATION, AND IMPACT ON PATIENTS
A thesis submitted to the University of Arizona College of Medicine‐ Phoenix
in partial fulfillment of the requirements for the Degree of Doctor of Medicine
Amy Davis
Class of 2017
Mentor: Shakaib Rehman, MD
ACKNOWLEDGEMENTS
I would like to thank my mentor, Dr. Shakaib Rehman, for his unwavering support and
guidance for the past four years. Shak: You are the paragon of a role model, and I appreciate
how you always have inspired me to achieve more. I would also like to thank Dewayne
Thurmond for his support and coordination of this study. Thank you to Dr. Khaleel Hussaini for
your tremendous help in the data analysis.
Also, thank you to my medical school, the University of Arizona College of Medicine‐
Phoenix, for focusing on student research and helping to shape lifelong learners. To the
director of the Scholarly Project, Dr. McEchron, thank you for your continual support and advice
for the past four years!
ABSTRACT
Type 2 diabetes (T2D) continues to be a growing public health concern and will be the
seventh leading cause of death by 2030. Education programs have shown to be moderately
effective in disease management, but there are little known about interactive patient‐centered
diabetes programs. This study implemented a single‐group pretest‐posttest quasi‐experimental
design including a three‐session novel patient‐centered diabetes education program at the
Phoenix Veterans Affairs Medical Center using the model originally developed by Esden and
Nichols. Measurements were obtained using validated and reliable instruments from Michigan
Diabetes Research Training Center (MDRTC), which included the Brief Diabetes Knowledge Test
(BDKT) and Diabetes Empowerment Scale (DES), and a participant satisfaction survey. Results
showed participants’ knowledge of diabetes was higher at three months follow up (M = 17; SD
= 4.64) than at baseline/pretest (M = 13.8; SD = 2.95) with a 23 percent change in knowledge
scores from baseline 95% CI [0.24,6.16], with corrected Cohen’s dunbiased = 0.66 (i.e., medium
effect). There was very good pre‐test reliability for the DES subscales: “managing the
psychosocial aspects of diabetes” (0.93), “assessing dissatisfaction and readiness to change
(0.83), “setting and achieving goals” (0.88). Despite moderate effects in these 3 subscales,
there were no statistically significant differences in posttest scores. In conclusion, Esden and
Nichol’s model was successfully replicated in the VA Heath Care setting, and future work with a
larger sample size and matched control is needed to further validate the results found in this
study.
TABLE OF CONTENTS
Introduction and Significance ......................................................................................................... 1
Research Methods and Materials ................................................................................................... 3
Results ............................................................................................................................................. 8
Discussion and Future Directions ................................................................................................. 12
Conclusions ................................................................................................................................... 14
References .................................................................................................................................... 15
Appendix A .................................................................................................................................... 17
Appendix B .................................................................................................................................... 18
LIST OF FIGURES AND TABLES
Table 1: MDRTC Assessment Tools ................................................................................................. 4
Table 2: Demographic Data of Participants at Session 1 ................................................................ 9
Table 3: MDRTC’s Assessment Tool Outcome Variables .............................................................. 10
Figure 1: Post‐Intervention Participant Satisfaction Survey ......................................................... 11
1
INTRODUCTION AND SIGNIFICANCE
Type 2 diabetes (T2D) is a growing public health concern for Americans due to the
increasing prevalence of the disease. Today, approximately eight percent of the American
adult population is diagnosed with T2D, and an estimated five percent are undiagnosed.1 T2D
is known to be associated with many long‐term complications such as nephropathy,
neuropathy, retinopathy, and cardiovascular disease.2 Due to the rise in prevalence of this
disease and its association with serious medical complications that span various organ
systems, it is not surprising that diabetes mellitus was the eighth leading cause of death in
2011 according the World Health Organization.3
It has been well established that T2D requires a combination of continuous medical
care, patient self‐management, disease education, and medication adherence to reduce the
risk of long‐term complications.2 Self‐management is a tasking dilemma for both physicians
and patients to balance. Peyrot and colleagues suggest that the daily diabetic management
(i.e.‐ diet, exercise, medication adherence) is stressful to patients, while Polonsky et. al
describes living with diabetes as a “complex, demanding, and often confusing set of self‐care
directives, [and] patients may become frustrated, angry, overwhelmed, and/or
discouraged.”4,5 Numerous studies over the years have shown that diabetes education can
effectively improve patients’ metabolic and psychosocial outcomes.6 A wide variety of
strategies, from family‐based group visits to more modern technological driven self‐
management interventions, have been implemented as potential methodologies for diabetes
education. Previous work by Siwik and colleagues demonstrated that group office visits can
be a possible new and sustainable model for diabetes prevention, especially for primary care
physicians.7 Alternative approaches have utilized technological advancements, like the work
of Lyles and colleagues. Their work incorporated diabetes care through mobile phones and a
game console web browser.8 Although these models seem to be initially beneficial, the long‐
term effects of these interventions are still in question, as there is still a worldwide concern of
T2D prevalence and uncontrolled disease management.
This major concern was the significance and rationale behind this project; although
there have been countless diabetes programs established to improve patient outcomes, T2D
2
continues to be a burden on physicians and their patients. “Patient‐centered” education is a
novel concept that incorporates the patients’ lifestyles with an interactive, continuous
program. This innovative approach to diabetes education can foster significant lifestyle
changes in patients to improve their health outcomes. This study adopted the intervention of
Esden and Nichols to base the framework of a patient‐centered group diabetes education
program at the Phoenix Veteran’s Affairs (VA) Medical Center.6 The ideal program would
encompass an inclusive look at the patients as a whole and tap into their lifestyle struggles to
facilitate long‐term changes. Therefore, this project focused on assessing lifestyle barriers and
how to overcome them by simple education and interactive sessions. Through these sessions,
the ultimate goal was to empower the participants to become their own health advocates.
This novel empowerment philosophy necessitates a paradigm shift from provider‐centered
care to a patient‐centered approach. Empowerment was defined by Funnell et. al as “the
discovery and development of one’s inherent capacity to be responsible for one’s own life.”9
This study examined the effectiveness of a patient‐centered education program by designing a
program, implementing it into a clinical setting, and assessing the parameters of disease
knowledge, psychosocial aspects to diabetes management, and overall patient satisfaction.
3
RESEARCH METHODS AND MATERIALS
Study Population and Design
This study was a single‐group pretest‐posttest quasi‐experimental design that was
implemented at the Phoenix VA Medical Center to assess the efficacy of a novel patient‐
centered approach to diabetes education. The methodological intervention was mainly
adopted from the work conducted by Esden and Nichols. Participants were recruited for the
study through randomization of patients in the VA electronic medical records who met the
inclusion criteria. Inclusion criteria were broad and only included the ages between 18 and 85
with a known T2D diagnosis. We initially recruited 12 veterans of whom 8 (N=8) attended the
first session, and 5 (N=5) veterans completed the entire program (3 sessions) and post‐
intervention measurements. Informed consent was given by each participant, and they were
allocated an identification number to ensure subject privacy. The intervention administered
followed the protocol:
Diabetes knowledge and patient perceived self‐efficacy prior to and after the program
were assessed using the same materials of Esden and Nichols‐ the Michigan Diabetes
Research and Training Center’s (MDRTC) Brief Diabetes Knowledge Test (BDKT) and Diabetes
Empowerment Scale (DES), respectively. Subjects also completed a participant satisfaction
survey created by the program designer at the final session to evaluate their experience and
confidence in their future management of T2D.
Three group sessions of approximately 2‐3 hours in duration were held monthly from
May 23, 2015 to July 18, 2015. Each session focused on different topics related to educating
participants about the disease and how to properly manage their T2D according to their
lifestyle. A medical student at the University of Arizona College of Medicine‐ Phoenix taught
each session with supervision from the student’s research mentor, an internist at the Phoenix
VA Medical Center. To create a patient‐centered and cohesive environment, patients
participated in a number of reflective and interactive group activities to get to know other
individuals in the program.
4
Table 1: MDRTC Assessment Tools
Toola Description
Brief Diabetes Knowledge Test (BDKT) 23 questions encompassing a test of general diabetes knowledge.
Diabetes Empowerment Scale (DES) 28‐item questionnaire using Likert‐type scale designed to assess the psychosocial self‐efficacy of patients with diabetes; contain 3 subscales: managing the psychosocial aspects of diabetes, assessing dissatisfaction and readiness to change, and setting and achieving goals.
aSource: Michigan Diabetes Research Center. Survey Instruments. http://diabetesresearch.med.umich.edu
5
Session 1:
Pathophysiology of diabetes
Diet recommendations
Overcoming barriers to a healthy diet
Session 2:
Medication education
Monitoring blood glucose
Overcoming barriers to medication adherence
Session 3:
Preventative care
Exercise education and importance
Risk factor reduction
During Session 1, the participants initially completed the pre‐intervention assessment
tools, which were taken under no time restrictions. The program facilitator (medical student)
was available to answer any questions. To get to know one another, participants were paired
together and introduced each other to the group. Group education included basic
pathophysiology of diabetes, and participants were interactive in this discussion to ensure
complete understanding of this disease. A registered dietician at the Phoenix VA then visited
for the remainder of the session to discuss nutrition goals for a diabetic patient. She brought
in fresh herbs to emphasize how to cook with fresh ingredients and displayed a presentation
on ideal foods to eat for the participants. There was an interactive game that included
identifying foods as a carbohydrate, fat, or protein. To conclude the first session, the
participants spent time writing and vocalizing their personal goals to work on for the next
session.
Session 2 began with another interactive game where each participant commented
about something they excelled at over the last month or something they felt was a challenge
to them. This facilitated a good discussion with the group on how several participants were
facing similar barriers and challenges. The main educational topic of this session revolved
6
around medication adherence. The participants split into pairs and discussed their medication
regimen for managing T2D. Each pair of participants was given a poster to write down their
medications and what specific barriers prevented them from complying with their regimen.
The group then came together to have one discussion and set goals for the next session. The
group also discussed self‐monitoring blood glucose levels and proper management for
hyperglycemia and hypoglycemia states.
At the final session, we started the discussion with each participant discussing one
thing they did well over the past month and one challenging task they faced regarding
medication adherence. We then focused on lab results and what they signified to the
participants before delving into what they mean from a physician standpoint. Next, an
interactive discussion was given on exercise. Each participant wrote down one activity that
he/she enjoyed for exercise and shared it with the group. We discussed realistic goal setting
and how to overcome barriers to maintaining a proper exercise regimen. To end the session,
an interactive Jeopardy game was played to reinforce many of the topics covered over the
past three sessions. Then, the participants completed the post‐intervention MDRTC
assessment tools and participant satisfaction survey.
Data and Statistical Analysis
Quantitative and qualitative data were obtained and analyzed in this study.
Demographic data, such as age, gender, ethnicity, martial status, education level,
employment, etc. were assessed. Results from the standardized tests assessed the effects of
the intervention on diabetes knowledge, patient perceived self‐efficacy, and barriers to self‐
care. A large focus was placed on the overall experience by the patients through the analysis
of participant satisfaction surveys at the end of the final session.
Pre‐ and post‐program data, including results of BDKT and DES and lab values, were
entered into Microsoft Excel and then univariate and bivariate statistical procedures were
conducted using SAS v9.4 (SAS Institute, Cary, NC). Univariate analyses included examining the
distribution and bivariate analyses included parametric and non‐parametric tests to assess
differences in difference scores (i.e., pretest and posttest scores). Effect sizes were estimated
using correction factors and confidence intervals were estimated.10,11,12
7
Institutional Review
The research protocol for this study was approved by the Subcommittee on Human
Studies and the Phoenix Veteran’s Affairs Health Care System Institutional Review Board with
deferred approval by the University of Arizona Institutional Review Board prior to the start of
the study. All individuals involved in the research study were trained in biomedical research,
informed consent, Health Insurance Portability and Accountability Act (HIPAA) compliance,
and heath information privacy and security through the Collaborative Institutional Training
Initiative (CITI).
8
RESULTS
Initially 12 veterans (11 male, 1 female) were recruited, 8 veterans participated in the
pre‐intervention assessment, and 5 veterans completed the post‐intervention assessment (4
male, 1 female). Demographic data were collected at the start of the study (Table 1). The
average years with diagnosis of T2D was 5.82 years with the range of 0.06 years to 10 years.
Using the standard body mass index classification, 5 participants were classified as
‘overweight’ (BMI 25‐29.9), 1 participant identified under ‘class I obesity’ (BMI 30‐34.9), 1
participant fell under ‘class II obesity’ (BMI 35‐39.9), and 1 participant classified in the
‘normal’ range (BMI 18.5‐24.9).
Table 2 illustrates the results of the MDRTC measurements, including the BDKT and
DES assessment tools. Only 5 participants completed both pre‐ and post‐intervention tests
which were utilized in the analysis of data. For the BDKT, which included 23 questions, the
pretest mean was 13.8 ± 2.95 and the posttest mean was 17 ± 4.64. There was a 23 percent
increase in average BDKT scores from pretest, with a moderate effect. (0.66; 95% CI: 0.24‐
6/16; p = 0.04). The DES measured three subscales: managing the psychosocial aspects of
diabetes (MPAD), assessing dissatisfaction and readiness to change (ADRC), and setting and
achieving goals (GS), and all subscales demonstrated moderate effects sizes of 0.74, 0.75, and
0.75, respectively. This assessment tool reflect patient perceived self‐efficacy, however, the
results were not statistically significant due to a small sample size.
Results of the participant satisfaction survey (Figure 1) delineated the participants’
overall experience of the program. Sixty percent of participants reported “strongly agree” to
the statements “I will change the way I manage my diabetes” and “the sessions increased my
confidence in managing my diabetes.”
9
Table 2: Demographic Data of Participants at Session 1
Demographics Pre‐intervention (N = 8)
Age in years (SD) 67.5 (+7.62)
Sex (%)
Male 7 (87.5%)
Females 1 (12.5%)
Race/Ethnicity (%)
African American/Black 2 (25%)
White ‐ Hispanic 3 (37.5%)
White ‐ Non‐Hispanic 3 (37.5%)
Marital Status (%)
Divorced 3 (37.5%)
Married 3 (37.5%)
Separated 1 (12.5%)
Single 1 (12.5%)
Occupation (%)
Carpet Cleaner 1 (12.5%)
Electrician 1 (12.5%)
Federal Worker 1 (12.5%)
Housekeeper 1 (12.5%)
Produce Stocker 1 (12.5%)
Retired 1 (12.5%)
Warehouse 1 (12.5%)
Unknown 1 (12.5%)
Height in inches (SD) 68.5 (+ 2.2)
Weight in US pounds (SD) 192.75 (+ 31.78)
Years with diabetes (SD) 5.82 (+ 4.65)
Body Mass Index Classification (%)
Overweight 5 (62.5%)
Class I Obesity 1 (12.5%)
Class II Obesity 1 (12.5%)
Normal Weight 1 (12.5%)
10
Table 3: MDRTC’s Assessment Tool Outcome Variables
MDRTC Brief Diabetes Knowledge Test 5 13.8 2.95 5 17 4.64 3.2 23.19 0.66 0.24, 6.16 0.04
Managing the psychosocial aspects of
diabetes (MPAD)†
5 4.02 0.97 5 4.69 0.31 0.67 16.67 0.74 -0.3,1.64 0.129
Assessing dissatisfaction and readiness to
change (ADRC)†
5 3.64 0.83 5 4.33 0.62 0.69 18.96 0.75 -0.32,1.7 0.13
Setting and achieving goals (GS)† 5 4.04 0.78 5 4.64 0.45 0.6 14.85 0.75 0, 1.2 0.053
Note: M = Mean; SD = Standard Deviation ***p < 0.001 **p < 0.01 *p < 0.05† Pretest reliabilities for MPAD (α = 0.93); ADRC (α = 0.83); GS (α = 0.88).‡ Cohen's d = Posttest Mean - Pretest Mean where Sav =
Sav
95% CIEffect
Size‡
P-valueOutcome variables Pretest Mean
Pretest SD
Posttest Scores
Posttest SD
% Change
Pretest (N)
Posttest (N)
Difference In Means
1 ∗
11
Figure 1: Post‐Intervention Participant Satisfaction Survey Using Likert Scale.
12
DISCUSSION AND FUTURE DIRECTIONS
From a broad perspective, the ultimate goal of this study was to help reinvent the
manner in which disease management education is delivered to patients. Traditional
individual education does not result in long‐term improvement of T2D management, and
research has demonstrated that diabetes education needs to be ongoing to maintain positive
outcomes.6 This study was the first that we know of to successfully replicate a novel patient‐
centered diabetes education program originally developed by Esden and Nichols and
implement it in the VA setting. We achieved similar results to Esden and Nichols, with
increased diabetes knowledge (~23 percent increase) at three months following the BDKT
pretest. The results also showed a moderate effect of the DES subscale items (MPAD, ADRC,
and GS). The effect sizes are not as large as the original study because we corrected for our
small sample size in our analysis, as suggested by Cumming, to account for a major limitation
to our study.11,12
In addition, according to the post‐intervention participant satisfaction survey, the
majority of participants agreed that they gained greater confidence in managing their disease
and learned new information at the sessions. Participant comments from the survey included:
“overall great class,” “excellent resource,” “[I enjoyed] the interchange between members,”
and “[I enjoyed] learning new things about diabetes that I was not aware of or exposed to.”
The high satisfaction of participants was a main objective for this program, as it can promote
long‐term success in T2D management.
Organizational realities often limit research studies, such as to this single‐group
pretest‐posttest design. Limitations of this study included a small sample size, lack of a
control group, and inconsistent participant attendance. Therefore, future work needs to be
done to address these limitations to further validate this novel education program. With a
larger sample size, ideally 30 to 40 participants, and a matched control group, these variables
would provide validity to this current and original studies and be more representative of the
T2D population. While a large sample size provides power to detect a statistically significant
effect, it also poses its own inherent challenges of managing a cohort of participants, tracking
and ensuring attendance to all sessions, as well as ensuring fidelity of the program. Future
13
work should also assess physiologic measures associated with T2D, including hemoglobin A1C,
blood pressure, and lipid panel. The literature has shown that group education can have
positive outcomes in terms of metabolic control of T2D patients, but additional studies are
needed with this novel patient‐centered program.13,14
14
CONCLUSIONS
The paucity of research regarding patient‐centered education for diabetes
management is concerning, and our study was the first replication study of this novel patient‐
centered group education model. While our results were promising and showed similar
conclusions to the original study, future work is encouraged to further validate this model of
disease management. This study, despite a small sample size, successfully replicated the
effectiveness of a patient‐centric group intervention diabetes education program. In the
future, this paradigm of disease education can be utilized for other prevalent chronic
conditions inflicting our society, such as hypertension and hyperlipidemia. Patient
empowerment should continue to be the philosophy that drives educators to inspire, inform,
support, and facilitate patients to attain their own goals.9 This idea is vital to promote self‐
confidence in managing a chronic disease like T2D.
15
REFERENCES
1. W Seidel R, Pardo KA, A Estabrooks P, et al. Beginning a patient‐centered approach in the design of a diabetes prevention program. Int J Environ Res Public Health. 2014;11(2):2003‐2013.
2. Al Hayek AA, Robert AA, Al Dawish MA, Zamzami MM, Sam AE, Alzaid AA. Impact of an
education program on patient anxiety, depression, glycemic control, and adherence to self‐care and medication in type 2 diabetes. J Family Community Med. 2013;20(2):77‐82.
3. World Health Organization. The top 10 causes of death.
http://www.who.int/mediacentre/factsheets/fs310/en/.
4. Peyrot M, Rubin RR, Lauritzen T, Snoek FJ, Matthews DR, Skovlund SE. Psychosocial problems and barriers to improved diabetes management: Results of the cross‐national diabetes attitudes, wishes and needs (DAWN) study. Diabet Med. 2005;22(10):1379‐1385.
5. Polonsky WH, Fisher L, Earles J, et al. Assessing psychosocial distress in diabetes:
Development of the diabetes distress scale. Diabetes Care. 2005;28(3):626‐631.
6. Esden JL, Nichols MR. Patient‐centered group diabetes care: A practice innovation. Nurse Pract. 2013;38(4):42‐48.
7. Perez Siwik V, Kutob RM, Ritenbaugh C, Aickin M, Gordon JS. Families United/Familias
unidas: Development and implementation of a family‐based group office visit model for the primary prevention of type 2 diabetes. Diabetes Educ. 2012;38(6):811‐821.
8. Lyles CR, Harris LT, Le T, et al. Qualitative evaluation of a mobile phone and web‐based
collaborative care intervention for patients with type 2 diabetes. Diabetes Technol Ther. 2011;13(5):563‐569.
9. Funnell MM, Anderson RM. Patient Empowerment: A look back, a look ahead.
Diabetes Educ. 2003;29(3):454‐464.
10. Coe R. It’s the effect size, stupid. What effect size is and why it is important. http://www.leeds.ac.uk/educol/documents/00002182.htm.
11. Cumming, G. Understanding the New Statistics: Effect Sizes, Confidence Intervals, and
Meta‐Analysis. New York, NY: Routledge; 2012.
16
12. Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t‐tests and ANOVAs. Front Psychol. 2013;4:863. doi: 10.3389/fpsyg.2013.00863.
13. Trento M, Passera P, Tomalino M, et al. Group visits improve metabolic control in type
2 diabetes: a 2‐year follow‐up. Diabetes Care. 2001;24(6):995‐1000.
14. Trento M, Passera P, Borgo E, 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(3):670‐675.
17
APPENDIX A
18
APPENDIX B
Date: _______________
University of Michigan Diabetes Research and Training Center
DIABETES ATTITUDE QUESTIONNAIRE
PLEASE ANSWER THE FOLLOWING QUESTIONS
19
Attitudes Toward Diabetes – DES
Strongly Agree Neutral Disagree Strongly Agree Disagree In general, I believe that I:
1. ...know what part(s) of taking care of my diabetes that I am satisfied with. ( ) ( ) ( ) ( ) ( )
2. ...know what part(s) of taking care of my diabetes that I am dissatisfied with. ( ) ( ) ( ) ( ) ( ) 3. ...know what part(s) of taking care of my diabetes that I am ready to change. ( ) ( ) ( ) ( ) ( ) 4. ...know what part(s) of taking care of my diabetes that I am not ready to change. ( ) ( ) ( ) ( ) ( ) 5. ...can choose realistic diabetes goals. ( ) ( ) ( ) ( ) ( ) 6. ...know which of my diabetes goals are most important to me. ( ) ( ) ( ) ( ) ( ) 7. ...know the things about myself that either help or prevent me from reaching my diabetes goals. ( ) ( ) ( ) ( ) ( ) 8. ...can come up with good ideas to help me reach my goals. ( ) ( ) ( ) ( ) ( )
9. ...am able to turn my diabetes goals into a workable plan. ( ) ( ) ( ) ( ) ( )
20
Strongly Agree Neutral Disagree Strongly Agree Disagree In general, I believe that I:
10. ...can reach my diabetes goals once I make up my mind. ( ) ( ) ( ) ( ) ( ) 11. ...know which barriers make reaching my diabetes goals more difficult. ( ) ( ) ( ) ( ) ( )
12. ...can think of different ways to overcome barriers to my diabetes goals ( ) ( ) ( ) ( ) ( )
13. ...can try out different ways of overcoming barriers to my diabetes goals. ( ) ( ) ( ) ( ) ( )
14. ...am able to decide which way of overcoming barriers to my diabetes goals works best for me. ( ) ( ) ( ) ( ) ( ) 15. ...can tell how I’m feeling about having diabetes. ( ) ( ) ( ) ( ) ( ) 16. ...can tell how I’m feeling about caring for my diabetes ( ) ( ) ( ) ( ) ( ) 17. ...know the ways that having diabetes causes stress in my life. ( ) ( ) ( ) ( ) ( ) 18. ...know the positive ways I cope with diabetes-related stress. ( ) ( ) ( ) ( ) ( ) 19. ...know the negative ways I cope with diabetes-related stress. ( ) ( ) ( ) ( ) ( )
21
Strongly Agree Neutral Disagree Strongly Agree Disagree In general, I believe that I:
20. ...can cope well with diabetes- related stress. ( ) ( ) ( ) ( ) ( ) 21. ...know where I can get support for having and caring for my diabetes. ( ) ( ) ( ) ( ) ( )
22. ...can ask for support for having and caring for my diabetes when I need it. ( ) ( ) ( ) ( ) ( ) 23. ...can support myself in dealing with my diabetes. ( ) ( ) ( ) ( ) ( )
24. ...know what helps me stay motivated to care for my diabetes. ( ) ( ) ( ) ( ) ( ) 25. ..can motivate myself to care for my diabetes. ( ) ( ) ( ) ( ) ( ) 26. ...know enough about diabetes to make self-care choices that are right for me. ( ) ( ) ( ) ( ) ( ) 27. ...know enough about my- self as a person to make diabetes care choices that are right for me. ( ) ( ) ( ) ( ) ( ) 28. ...am able to figure out if it is worth my while to change how I take care of my diabetes. ( ) ( ) ( ) ( ) ( )
Thank you very much for completing this questionnaire.