Table of Contents  

Ali, Platat, Baynouna, and El Baki: Community-based diabetes nutrition education programme for Emirati adults with type 2 diabetes mellitus – barriers to participation

Introduction

According to the International Diabetes Federation, the prevalence of type 2 diabetes mellitus in the United Arab Emirates (UAE) is 18.98%.1 For the Al Ain, UAE, population, the prevalence rates of diagnosed type 2 diabetes mellitus, undiagnosed type 2 diabetes mellitus and pre-type 2 diabetes mellitus were 10.5%, 6.6% and 20.2%, respectively.2 In this context, there is an urgent need for culturally adapted nutrition education strategies for Emirati adults with type 2 diabetes mellitus, as well as those at risk for developing the disease.

Diabetes self-management education (DSME) is a critical element of care for all people with type 2 diabetes mellitus and those at risk of developing the disease. DSME has elements related to lifestyle changes, including diet and physical activity.3 However, implementing these behavioural changes, particularly in the long term, is challenging. Therefore, in order to improve outcomes of DSME, overcoming barriers is crucial so that the individuals with type 2 diabetes mellitus can develop and maintain behaviours that prevent or delay the complications of disease.

A systematic review to summarize the existing knowledge related to the various barriers of type 2 diabetes mellitus management found they are related to both patient and clinician factors.4 Patient factors include attitude to type 2 diabetes mellitus self-management. Patients with a positive attitude towards the management of their disease are more likely to adhere to the treatment for type 2 diabetes mellitus than those with a negative attitude.5,6 Health care barriers to patient education are belief, attitude, knowledge, communication skills and the health care system. For example, the health care professionals’ lack of knowledge about recent evidence-based guidelines may affect the outcome of care for type 2 diabetes mellitus.7 Two of the most common reasons given for defaulting from type 2 diabetes mellitus education services were being unable to take time off from work or being unable to afford time off work.810 Lower levels of participation in type 2 diabetes mellitus education services among individuals who are employed compared with those who are unemployed have been reported.11,12 Past literature also found transportation issues,9 distance to facilities12,13 and moving out of the area10 to negatively influence attendance of type 2 diabetes mellitus education programmes.

Thus, identifying barriers to type 2 diabetes mellitus education services to ensure adherence to standards of care is a crucial step in improving DSME outcomes and intervention effectiveness. The ‘Skills for Change’ Diabetes Nutrition Education Program was a randomized intervention trial conducted in seven Ambulatory Healthcare Services (AHS) health centres in Al Ain between 2011 and 2013. The educational intervention focused on improving nutrition knowledge, physical activity levels and other outcomes among Emirati adults with type 2 diabetes mellitus. The purpose of this study was to describe factors affecting regular participation in the ‘Skills for Change’ programme to improve participation and retention strategies of future type 2 diabetes mellitus education programmes in the UAE.

Materials and methods

Study design

This was a cross-sectional descriptive study investigating factors affecting participation in a community-based type 2 diabetes mellitus nutrition education programme among Emirati patients with type 2 diabetes mellitus.

Subjects

Participants of this present study were selected from Emirati adults with type 2 diabetes mellitus who participated in the ‘Skills for Change’ Diabetes Nutrition Education Program. This programme was conducted in the AHS health centres between November 2011 and March 2013. It included three intervention health centres in Al Ain where the ‘Skills for Change’ programme was implemented and four control health centres where no specific educational programme was implemented during the period of the intervention. These four control health centres were excluded for selection of the participants for the current study. The educational programme of the ‘Skills for Change’ programme consisted of individual nutrition counselling, group nutrition education and supervised group physical activity sessions.

Data collection

A survey questionnaire was developed by the research team from the existing literature on barriers to type 2 diabetes mellitus education.9,10,12,13 The questionnaire was pre-tested with 10 patients with type 2 diabetes mellitus and modified accordingly before use for the current survey. Questions were related to barriers to regular participation in the ‘Skills for Change’ programme, barriers to adhering to the recommended dietary changes and barriers to attending the group physical activity sessions. The patients were also encouraged to provide their own reasons for lack of regular attendance in the programme. Questions about barriers to attending the programme had three possible responses: agree, neither agree nor disagree and disagree. This three-point Likert scale was used instead of the traditional five-point Likert scale because of the low education level of the majority of the ‘Skills for Change’ programme participants. In addition, the respondents were asked about type 2 diabetes mellitus education services that they considered important to be available in the AHS health centres. Demographic data of the participants were retrieved from data collected during the baseline data collection period for the ‘Skills for Change’ programme. Research assistants, who were not involved in the implementation of the educational intervention, made up to three telephone calls to reach each survey participant (usually at different times of the day) and were able to contact 109 out of 219 (50.7%) of the original sample recruited from the three intervention health centres within the 3-week period of the survey.

Ethical approval

This project was approved by the Al Ain Medical District Human Research Ethics Committee and the Research Ethics Committee of the AHS.

Statistical analysis

Data were analysed using the Statistical Package for Social Sciences (SPSS), v. 20.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistical tests – mean, standard deviation and percentage – were used.

Results

Table 1 presents the demographic characteristics of the survey participants. The mean age was 53.7 ± 8.76 years and 67.6% were older than 50 years of age. Nearly half of the participants had no formal education and less than a quarter of them (23.4%) had at least a high-school education. More than 50% (58.3%) of the survey participants were unemployed or housewives and less than a quarter (22.2%) were employed, including those working in their own business. The mean duration of type 2 diabetes mellitus was 8.0 ± 6.35 years (median: 5.5 years). Forty per cent of participants had type 2 diabetes mellitus for less than 5 years, and the majority of the participants were managed with oral hypoglycaemic agents. Only 6.4% of them were managed with diet and physical activity only. A relatively small number of the survey respondents (7.2%) did not visit a dietitian during the 6 months preceding the interview and 14.7% did not attend any of the group education sessions that were offered as part of the ‘Skills for Change’ programme.

TABLE 1

Demographic characteristics of the survey participants

Characteristic n %
Age (years) (n = 108)
≤ 50 35 32.4
> 50 73 67.6
Gender (n = 109)
Male 31 28.4
Female 78 71.6
Educational level (n = 107)
Illiterate 53 49.5
Primary school 21 19.6
Intermediate school 8 7.5
High school or equivalent 17 15.9
College/university or equivalent 8 7.5
Occupation (n = 108)
Working at a job outside home 15 13.9
Working at own business 9 8.3
Raising a family or running a household 63 58.3
Retired 19 17.6
Other 2 1.9
Diabetes duration (years) (n = 102)
< 5 41 40.2
5–10 32 31.4
> 10 29 28.4
Type 2 diabetes mellitus treatment (n = 109)
No medication 7 6.4
Oral medication 91 83.5
Insulin and oral medication 11 10.1

Table 2 shows the main barriers the survey participants cited as interfering with regular participation in the ‘Skills for Change’ educational intervention. Time constraints because of other commitments, transportation issues and moving out of the area of the health centre were the three main reasons mentioned by the survey participants. Approximately one-quarter of participants (26.2%) felt that the times of the educational sessions were not suitable for them. On the other hand, the majority of the respondents (87.5%) disagreed that the dietitian was not available (Table 2).

TABLE 2

Barriers to regular participation in the ‘Skills for Change’ programme (n = 109)

Characteristic %
Time constraints because of other commitments (work, childcare or housework)
Agree 40
Neutral 6.7
Disagree 53.3
Lack of transportation
Agree 36.2
Neutral 5.7
Disagree 58.1
Moving out of the area of the health centre
Agree 32.4
Neutral 3.8
Disagree 63.8
Forgetting the time or date of the appointment
Agree 19.2
Neutral 10.6
Disagree 70.2
Dietitian was not available
Agree 9.6
Neutral 2.9
Disagree 87.5
Time of day when sessions were held was not convenient for me
Agree 26.2
Neutral 5.8
Disagree 68.0

As shown in Table 3, the main barriers for the participants making dietary changes recommended by their health professionals were: (1) not being responsible for cooking food at home, (2) not easy to change diet because of family preferences and (3) not easy to change diet because of social gatherings (59.6%, 50.5% and 42.9%, respectively). On the other hand, only 10.5% of the respondents felt that the health care team did not spend enough time explaining the recommendations.

TABLE 3

Barriers to making dietary changes (n = 109)

Characteristic %
It is not easy for me to change my diet because of family preferences
Agree 50.5
Neutral 15.2
Disagree 34.3
I am not responsible for cooking food at home
Agree 59.6
Neutral 6.1
Disagree 34.3
It is not easy for me to change my diet because of social gatherings
Agree 42.9
Neutral 13.3
Disagree 43.9
I do not want to change what I currently eat
Agree 27.8
Neutral 21.2
Disagree 51.5
Health care team did not spend enough time explaining the recommendations
Agree 10.5
Neutral 5.3
Disagree 84.2

With respect to regular attendance of the group physical activity sessions, the main reason survey participants cited for lack of participation was changing to another health centre (42.1%). Other barriers, which more than one-third of the survey respondents cited, were time constraints, not willing to exercise with other patients, transportation issues and lack of suitable exercise facilities in the health centre (Table 4). On the other hand, relatively small numbers of the respondents agreed that the physical activity sessions were difficult to perform or that the trainer was not supportive (13.3% and 12.5%, respectively).

TABLE 4

Barriers to participation in group physical activity sessions (n = 109)

Characteristic %
Time constraints
Agree 37.8
Neutral 8.2
Disagree 54.1
I do not want to do exercise with other patients
Agree 35.1
Neutral 6.2
Disagree 58.8
Transportation issues
Agree 38.8
Neutral 3.1
Disagree 58.2
I changed to another health centre
Agree 42.1
Disagree 57.9
Lack of suitable exercise facilities in the health centre
Agree 35.3
Neutral 5.9
Disagree 58.8
Distance difficulties (too far)
Agree 32.0
Neutral 13.4
Disagree 54.6
I am not motivated
Agree 18.4
Neutral 8.2
Disagree 73.5
Exercise programme was too difficult
Agree 13.3
Neutral 20.0
Disagree 66.7
The trainer was not supportive
Agree 12.5
Neutral 12.5
Disagree 75

Figure 1 shows the percentage of respondents who considered the availability of certain health education services in the AHS health centres as important or very important. The majority of respondents (88.6%) considered dietitian availability in the health centre to be very important or important. Similarly, a large proportion of the survey respondents (81.0%) considered the availability of exercise facilities in the health centre to be very important or important.

FIGURE 1

Suggested services in the health centres.

8-2-3-fig1.png

Discussion

Type 2 diabetes mellitus self-management educational programmes have been shown to improve patient outcomes. DSME is a critical element of care for all people with type 2 diabetes mellitus and those at risk of developing the disease.3 Given the high prevalence of diabetes in the UAE, it is imperative to investigate barriers to type 2 diabetes mellitus education services. This study explored factors influencing regular participation in the ‘Skills for Change’ programme and desired nutrition-related services in the AHS health centres from the perspective of the programme participant. The ‘Skills for Change’ programme was implemented in the AHS health centres to facilitate improved management of type 2 diabetes mellitus through dietary changes and increased physical activity levels.

Barriers to attendance identified in this study were most likely related to a lack of time and interference with work schedules. Time constraints can be a factor in type 2 diabetes mellitus education participation. Previous research has reported that the levels of participation in type 2 diabetes mellitus education services among individuals who are employed are lower than those who are unemployed.11 In this study, although less than one-quarter of survey participants were employed, they still reported a number barriers to regular participation in the educational programme. This might be related to taking care of children, since more than 50% of them reported they are housewives or raising a family. Moreover, transportation issues played an important role in programme participation as more than one-third of participants cited transportation difficulties as a barrier to regular participation in the programme or attending the group physical activity sessions. In fact, lack of time and transportation issues are common barriers documented by previous type 2 diabetes mellitus education programmes.9,14,15 Therefore, future intervention programmes should consider issues related to transportation to the health centres and the time of day when educational sessions are held to facilitate regular attendance of the programme.

In the current study, in spite of the special efforts made to coordinate the timing of the educational sessions with the patients’ medical care appointment during the implementation of the ‘Skills for Change’ programme, slightly more than one-quarter of respondents agreed that the programme educational session times were not convenient for them. On the other hand, the majority of respondents agreed that dietitian availability was not a barrier. Although none of the three health centres where the intervention was conducted had a full-time dietitian, the management of the AHS supported the implementation of the programme by assigning the dietitian to cover extra days in the three intervention health centres during the implementation of the intervention. Other barriers reported in previous studies include not remembering the appointment or difficulty in getting an appointment.16 However, this not was the case in this study, probably because telephone call reminders were made to participants and times of educational sessions were flexible and offered in coordination with the patient’s appointment for routine medical care. Previous studies suggested phone call reminders as the preferred method to remind patients of their next scheduled appointments.17,18

The role of social support for type 2 diabetes mellitus management from family members, peers, health professionals and other people in the social network of persons with type 2 diabetes mellitus is well established.1921 Thus, it is not surprising that the three main barriers related to adhering to the dietary advice from health care professionals (family preferences, social eating and not being responsible for cooking at home) are related to the social network of the participants. This is consistent with past literature, suggesting the important role that family and the social environment play in dietary change and type 2 diabetes mellitus management.2124 Although the patients were encouraged to invite their family members, only a few of them brought a family member to these sessions. One possible reason was that the sessions were often held during the patient’s clinic appointment for medical care to facilitate attendance and such timings might not have been convenient for other family members to attend the educational sessions. On the other hand, a greater participation of family members was observed during the group physical activities that involved walking in the parks. Future interventions should investigate strategies for enhanced inclusion of family members in the educational sessions that are held in the health centres.

One of the factors that can affect participation in lifestyle interventions is the patient changing health centres. In fact, a major barrier to regular participation in the ‘Skills for Change’ programme, as well as the attendance of the physical activity group sessions, was changing to another health centre. The main reason that led many patients to change health centres was an opening of a new clinic specializing in type 2 diabetes mellitus management in Al Ain during the time the intervention programme was being implemented.

Lack of facilities for cooking demonstrations was one of the barriers the programme faced during the implementation of the intervention. Future interventions should consider use of mobile kitchens to conduct cooking demonstrations when such facilities are not available in the health centre. Moreover, there was a lack of suitable exercise facilities in the health centres. Only one of the three intervention health centres had facilities to conduct group physical activity sessions. In order to overcome this barrier, some of the group exercise sessions were held in schools. However, some of the participants had transportation difficulties when school facilities were used.

Based on the findings of this study, we suggest that physical activity sessions should be integrated into the routine medical visit by offering patients an exercise session in addition to medical and dietitian consultations. In addition, alternative educational strategies, including providing patients with a list of community-based resources where physical activity can be performed, such as parks and pathways for walking, should be considered. Furthermore, since the majority of the respondents in the survey considered the availability of dietitians and exercise facilities in the health centres to be important, these services should be made available.

Finally, although survey participants perceived the existence of a number of barriers for regular participation in the ‘Skills for Change’ programme, their perceptions about the programme were positive, especially with respect to the staff involved in the educational programme. In addition, the majority of them felt that the physical activity programme was not difficult. Thus, it seems that the physical activity programme was culturally adapted to the target population.

Conclusion

Participants of the ‘Skills for Change’ programme identified a number of barriers that affected their regular participation in a community-based type 2 diabetes mellitus education programme. They also made suggestions for desired type 2 diabetes mellitus education services in the health services. The findings of this study highlight important issues that can influence patient participation in community-based type 2 diabetes mellitus education services, and thus should be taken into consideration when planning future educational interventions.

Acknowledgements

We are grateful to the Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences for providing the financial support for the ‘Skills for Change’ Diabetes Nutrition Education Program (MRG 04-09/10) and the management of Ambulatory Health Care Services (AHS), Abu Dhabi Health Services (SEHA), for facilitating the implementation of the project in the AHS health care centres.

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