194 Diabetes Mellitus
and self-care instructions. Despite decades of effort, gaps
remain in the number of diabetes patients who have access
to or take advantage of education (Coonrod, Betschart, &
Harris, 1994), the amount of knowledge achieved (McCaul,
Glasgow, & Schafer, 1987), and the diabetes-related informa-
tion disseminated or acquired by patients (Dunn, Beeney,
Hoskins, & Turtle, 1990). Early diabetes education pro-
grams demonstrated increases in knowledge that did not
translate into improvements in glycemic control or other
health outcomes (Watts, 1980), although good measures of
glycemic control, for example GHb, were not available then.
More recent studies have also failed to “nd a link between
knowledge and glycemic control (Peyrot & Rubin, 1994), but
some have found improvements that were maintained up to
12 months (Rubin, Peyrot, & Saudek, 1991).
A number of researchers have recognized that education
through information transfer alone, without attention to other
aspects of diabetes care, has limited impact on BG control
(Dunn et al., 1990; Rubin, Peyrot, & Saudek, 1989). Patient
education has been in”uenced by the growing awareness that
psychosocial factors such as motivation, health beliefs, cop-
ing strategies, and self-ef“cacy contribute signi“cantly to be-
havior and health outcomes and are amenable to change
(Beeney et al., 1994). Thus, more recent educational efforts
have gone beyond didactic presentation of facts and have
adopted a more pragmatic approach by teaching self-care
skills and strategies to facilitate lifestyle change, with posi-
tive (Clement, 1995), and sometimes long-term, (Rubin et al.,
1991) results.
Other studies have sought to disaggregate the components
of diabetes education in an attempt to understand the mecha-
nisms by which the programs achieve their outcomes. Some
have proposed that it may be important to distinguish between
self-regulation behaviors (e.g., SMBG, insulin adjustments)
and self-care activities (e.g., diet, exercise). Self-care activi-
ties have been shown to be more resistant to improvement
(Rubin et al., 1991), possibly because they are more rooted in
a person•s lifestyle and take more time to accomplish. Another
study demonstrated the additive effect of three aspects of dia-
betes behaviors: insulin administration, self-monitoring, and
exercise (Peyrot & Rubin, 1994). Additionally, physician fac-
tors have been shown to play a role in the success of diabetes
patient education. A study that incorporated education and
training for both the patient (e.g., target behaviors) and resi-
dent physician (e.g., attitudes, beliefs) accomplished greater
improvements in health outcomes than the education of either
participant alone (Vinicor et al., 1987). Finally, because of
the demands of the regimen for newly diagnosed insulin-
requiring diabetes patients, Jacobson (1996) suggested that an
incremental approach to education be undertaken, starting
with information and skill building, with the immediate goal
of stabilizing metabolism, followed by more in-depth educa-
tion once the patient and family have made an •emotional
adjustmentŽ to the disease. Other recommendations for com-
ponents of a diabetes education program include use of the
patient•s primary language (Martinez, 1993); accommodation
of the patient•s literacy level, a model that involves two-way
communication between patient and provider (Glasgow,
Fisher, et al., 1999); and recognition of the dynamic nature of
the diabetic regimen (Glasgow & Anderson, 1999).
A goal of Healthy People 2000 (U.S. Department of
Health and Human Services, 1991) is to have 75% of people
with diabetes receive education. Toward that end and toward
the goal of continuing to improve the effectiveness of dia-
betes education, a number of recent models for diabetes pa-
tient education have been proposed (e.g., Glasgow, 1995) and
guidelines established (Funnell & Haas, 1995). Common
themes include the consideration of individual patient char-
acteristics (e.g., attitudes & beliefs, cultural in”uences, psy-
chological status, literacy, age), process skills (e.g., coping,
self-ef“cacy, problem solving), attitudes and beliefs, patient-
provider outcomes, behavioral orientation, ongoing support
and evaluation, improved access, and examination of cost
effectiveness.SummaryDiabetes education has had positive effects on a number of
aspects of diabetes management. Despite attempts to broaden
the access and scope of diabetes education, many diabetic
individuals have never had the opportunity to participate in
and bene“t from diabetes education. This remains especially
problematic for subgroups of diabetic patients, such as those
of lower socioeconomic status, those who do not speak
English, those who do not require insulin, and/or those with a
high prevalence of the disease. Diabetes management is com-
plex and involves multiple behaviors and components, and
effective diabetes education is likely to be similarly complex
and multifactorial. We already know that optimal programs
will include multiple options to accommodate individualized
modes of learning, knowledgeable and trained instructors,
integration with clinical services, a behavioral/interactive
approach, culturally relevant and linguistically appropriate
content and process, ongoing support, and program evalua-
tion. Future studies will further enhance our understanding of
the process by continuing to test models for diabetes educa-
tion and examining what components of a program are re-
sponsible for the positive effects.