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Evaluating the effect of an education programme on quality of life

Lou Bean
, Claire Buckingham
, Jean Constable

Many studies have shown the effectiveness of providing diabetes education programmes for people with diabetes, although not all used quality of life (QoL) as an outcome. An audit was carried out to evaluate the effectiveness of one recently-developed programme. QoL measurements were used since they have been shown to be important in this patient group. Results showed improved QoL as measured by the disease-specific tool. The authors recommend the development of patient-focused QoL measurement tools.

Research has shown that diabetes patient education improves patient outcomes (Brown, 1990; Tan et al, 1997). However, research in this field has been limited because such studies have often focused on patient knowledge retention and metabolic control as outcome measures. Glasgow and Osteen (1992), in a review of the research in this field, highlighted the need for studies to focus on the use of quality of life (QoL) measures in order to present a more realistic measure of patient outcome.

The importance of measuring QoL as an outcome indicator for diabetes has also been promoted by the National Centre for Health Outcome Development (Home et al, 1999). A recently published Effective Health Care Bulletin also made a similar recommendation with regard to future research into diabetes self-management (NHS Centre for Reviews and Dissemination, 2000). 

Taking these views into account, it was decided that in order to evaluate a new diabetes education service in Thanet, the methodology would need to measure the QoL of patients.

Programme development
The Thanet Diabetes Education Programme emerged from a need exposed during local practice nurse training. It was highlighted that there was a growing requirement for the provision of diabetes patient education for people newly diagnosed with type 2 diabetes. Practice nurses have an important role in educating people with diabetes; however, the time that they have to perform this role is limited. The programme was initiated through joint collaboration between the Diabetes Co-ordinator and Health Promotion Specialist. 

A literature search was undertaken to identify any existing initiatives that were providing an education referral programme for people with type 2 diabetes. The Royal Bournemouth Hospital was found to have designed and implemented an effective education programme for people with newly diagnosed type 2 diabetes (Everett and Kerr, 1998) and provided the template for the Thanet Diabetes Education Programme.

A local steering group comprising diabetes specialist nurses (DSNs), chiropodists, a community diabetes specialist dietitian, health promotion specialists and the chairman of the local Diabetes UK branch was formed to study the feasibility of implementing a similar programme in Thanet.

Programme contents and process
The programme contents are shown in Table 1. The steering group agreed that each programme should be delivered over a six-week period and that the programme as a whole should be available over an initial six-month period. After review, this period was extended to one year. Each patient referred to the programme received an education pack that was related to the topics presented.

The project started in March 1998 and patients were referred into the programme via DSNs. Three months after the project started, GPs and practice nurses were also invited to refer patients to the programme.

Evaluation of the programme
In order to measure the effectiveness of the project an outcome audit was designed to ascertain the effect of diabetes education on the QoL for patients participating in the programme.

The objective of the audit was to evaluate each patient’s disease-specific and general QoL at the time they started the programme (time one) and then six months after they had completed the programme (time two). This was in order to record whether there had been any change in each patient’s health status, with regard to their quality of life, after they had received diabetes education.

The disease-specific QoL tool used was a modified Diabetes Impact Measurement Scales (DIMS) questionnaire (with only 17 items rather than the original 44). This had been designed by Hammond and Aoki (1992) from the Rand Health Insurance study and Arthritis Impact Measurement Scales. The questionnaire has been designed to reflect the presence of important symptoms, functional capacity of impairment and general wellbeing.

The general health QoL tool used was the Short Form-36 (SF-36) general health profile questionnaire which was also developed from the Rand Insurance Study (Ware, 1993) The instrument consists of nine dimensions, as follows: 

  • Physical functioning
  • Social functioning
  • Role limitation due to physical problems
  • Role limitation due to emotional problems
  • Mental health
  • Energy/vitality
  • Body pain
  • General health perception
  • Health changes over the last past 12 months. 

A higher score indicates health improvement in all but the health transition dimension.

These two instruments were selected because they were developed from the same study and have both been tested for validity and reliability. The data produced by the questionnaires were analysed using the  Statistical Package for Social Sciences (SPSS) version 9 (SPSS (UK) Ltd, Woking).

The evaluation was considered to be an outcome clinical audit and therefore did not require ethical approval. Patients were informed about the objectives of the project and were also given the opportunity not to take part in the evaluation if they wished.

In order to protect patient confidentiality, as few details as possible were recorded. All participants were sent information on the outcome of the project.

A total of 63 patients were allocated to one of the six diabetes education programmes that took place over one year. The response rate for time one was 95% (n=60) and 81% (n=51) for time two. Therefore, only the results of 51 patients were compared at both time one and time two.

Scores from the DIMS questionnaire demonstrated that QoL improved significantly between times one and two (P=0.001, 95% CI=1.2–5.0, paired t-test) (Table 2). A total of 37 patients (72%) had a higher DIMS score at time two than at time one. 

No significant differences were found between times one and two with regard to SF-36 scores. However, scores in the health transition dimension indicated a slight health improvement (Table 2). Sixteen patients (25%) had other medical conditions that affected their SF-36 scores at both time one and time two. 

Across all of the SF-36 dimensions, 50–60% of patients had time two scores that were either the same or better then their time one scores (Table 3).

The evaluation provides evidence that the diabetes education programme has had a positive impact on how patients perceive their QoL with regard to their diabetes. However the scores from the SF-36 questionnaires indicate that the impact of diabetes education on how patients perceive their general health QoL was more difficult to measure. A number of patients had other medical conditions, which may have influenced their perceptions of their general health. The age of patients was also not taken into account, and may have been a factor that influenced responses to the SF-36 questions.

It should be noted that the patient population of this evaluation was small and the diabetes education programme provided was a local initiative so it is not possible to conclude if the results can be generalised to the whole population.

The evaluation did not try to measure the exact impact of what patients were taught but just focused on the impact of the total six-week programme on each patient’s QoL.

Issues concerning the measurement of QoL are complex. This is because there is no consensus on the concept itself, due to its nebulous nature (Watkinson, 1999). 

The many personal and social influences acting on individuals, together with the variation in their perspectives and expectations regarding their own health, make it important to attempt to develop a more individualised quality of life measurement process. One such process is the the Patient-Generated Index of QoL tool (Ruta et al, 1999). With this tool, patients select the five most important aspects of their lives affected by their condition. Each area is then rated by the patients according to the severity of impact. Patients are given 60 points to indicate which of the five areas they would like to see improved (Jenkinson and McGee, 1998). Repeated over time, this process gives a more individualised measurement of a patient’s QoL.

In this study, evaluation of a diabetes education programme for people with newly-diagnosed type 2 diabetes using established measurement tools showed that it is possible, to some degree, to measure the impact of diabetes education on patients’ QoL. However, such tools are limited because of the individualised nature of the concept of QoL. The production of more specific patient-focused QoL measurement processes should assist in monitoring the content, delivery and impact of diabetes education, hence improving the lives of patients.


Brown S (1990) Studies of education interventions and outcomes in diabetic adults: a meta-analysis revisited. Patient Education and Counselling 16: 189–215
Everett J. Kerr D (1998) Nurse-led management of newly diagnosed type 2 diabetes. Journal of Diabetes Nursing 2(1): 12–14, 19–21
Glasgow RE, Osteen VL (1992) Evaluating diabetes education: are we measuring the most important outcomes? Diabetes Care 15: 1423–31
Hammond GS, Aoki TT (1992) Measurement of health status in diabetic patients. Diabetes Care 15: 469–75
NHS Centre for Reviews and Dissemination (2000) Effective Health Care: Complications of Diabetes, Renal Disease and Promotion of Self Management. Royal Society of Medicine Press, York
Home P, Coles J, Goldacre M, et al (eds) (1999)  Health Outcome Indicators: Diabetes. Report of a working group to the Department of Health. National Centre for Health Outcomes Development, Oxford
Jenkinson C, McGee H (1998) Health Status Measurement. Radcliffe Medical Press, Oxford
Ruta DA, Garratt AM, Russell IT (1999) Patient centred assessment of quality of life for patients with four common conditions. Quality in Health Care 8: 22–9
Tan ASL, Yong LS, Wan S (1997) Patient education in the management of diabetes mellitus. Singapore Medical Journal 38(4): 156–60
Watkinson M (1999) Are blood glucose control and quality of life related? Journal of Diabetes Nursing 3(5): 154–58
Ware JE (1993) SF-36 Health Survey: Manual and Interpretation Guide. The Health Institute, New England Medical Center, Boston

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