He developed a strategy to teach critical consciousness to the impoverished people of Brazil. He stressed a relationship of equality and mutual respect between group members and facilitators who engaged the group in problem-posing dialogue designed to help them elucidate the root causes of problems they identified Wallerstein and Berstein, The empowerment model In recent years, there have been increasing calls for empowerment of both healthcare employees and the community members they serve Menon, The empowerment concept has therefore become very popular in the healthcare literature and setting Wallerstein and Berstein, Within healthcare, the empowerment philosophy of patient care is based on certain tenets Gibson, ; Feste, :.

Empowerment and the healthcare professional Although the healthcare provider should be involved in the decision-making process, the final determination of what is best for the patient is both the right and responsibility of the individual Gibson, ; Feste, Patient empowerment is therefore an outcome.

People with diabetes are empowered when they have the necessary knowledge, skills, attitudes and self-awareness to influence their behaviour and that of others in order to improve the quality of their lives.

The enabling act of empowerment, therefore, begins with information and education. This includes goal setting, which, according to Funnell and Anderson , is a five-step process:.

This approach to empowerment eliminates the notion of success or failure. Instead, all efforts represent opportunities to learn more about the true nature of the problem, related feelings and barriers, and to continually develop effective strategies to achieve the set goals with ongoing support of the care provider.

Education has long been recognised as the cornerstone of the diabetes management regimen Hurley and Shea, For example it has been reported that undertaking a self-care management regimen is more difficult than dealing with the diagnosis of diabetes Anderson, It is, therefore, important for the nurse to be aware of how complex the treatment regimen can be, particularly for individuals with type 1 diabetes mellitus.

Their lives revolve around a temporal regularity in which insulin doses must be calculated and administered at precise times. Meals, exercise, rest and monitoring of blood glucose parameters must be planned and performed to match those times when insulin levels are expected to drop or peak.

In the context of diabetes education, the concept of empowerment is thus based on several assumptions:. A helping hand In order for people with diabetes to become actively involved in their own care, it is important for the nurse to equip them with the information needed for effective self-management.

The person with diabetes also needs to understand the healthcare system and how to utilise it when necessary. This can only be achieved if the education programme contains all the relevant topics to improve knowledge. As shown in the extended list Table 1 , these topics should include knowledge about diabetes, dietary composition particularly with regard to reducing saturated fats , their impact on blood glucose levels, as well as the effect of other lifestyle issues such as exercise, smoking cessation, alcohol intake and illness.

How and why insulin needs to be adjusted to accommodate these factors also need to be explained. The importance of attending the diabetes clinic and eye appointments should be clearly emphasised.

It could be argued that those who are thus empowered benefit both psychologically and in terms of maintaining long-term metabolic control.

This approach to diabetes management, as Cavan argues, shifts from a purely traditional medical model to the provision of effective educational interventions to facilitate successful self-care, with immediate medical needs met at diagnosis and at intervals thereafter Figure 1.

However, not everyone with diabetes may be comfortable with taking responsibility for their lives. In such cases, the individual may prefer a more direct approach.

As Funnell et al assert:. The choice remains with the patient, even when the choice is to decline power. Patients who choose to remain the passive recipients of care are responsible for that choice and its consequences. The medical model In the medical model, treatment goals and plans often ignore the emotional, spiritual, social and cognitive aspects of living with a chronic disease such as diabetes Arnold et al, During a medical visit, there may be opportunities to see a nurse or dietitian.

Consequently, the medical model may well lead to conflict between healthcare professionals and people with diabetes. Furthermore, the medical model does not necessarily meet the psychological needs of the person with diabetes. For example, the diagnosis of diabetes is often a shock and frequently devastating to the individual.

Failure to effectively address this important aspect of psychological care may lead to poor self-esteem and low motivation to adopt self-care behaviour Jacobson et al, Moving towards empowerment A major goal of patient empowerment is to improve adherence to agreed self-care regimens.

People with diabetes are often unsure whether they can achieve the set goals. To become empowered, they need information, assurance, support and caring. The motivational interview model developed by Rollnick et al aims to assist healthcare professionals in helping patients manage their illness experience.

The adapted steps see below , extracted from the work of Rollnick et al , may be applied in full or in part, depending on where the individual is located in the process.

Many people with diabetes have misconceptions about their condition. They may associate diabetes with complications and fatalistic outcome. Such information enables the nurse to respond in an empathic manner. Exchanging information The amount of information given to a person with diabetes should be based on assessment and negotiation.

When the person is ready for more information, it should be provided in an unbiased, non-judgmental manner. Where diabetes medications are concerned, their action, any possible side-effects, and storage should be explained in a style that is readily understood by the person with diabetes.

The present and the future This strategy allows people with diabetes to discuss their expected outcomes as a result of undertaking the prescribed self-care activities. Expected outcomes may include weight loss, normal blood glucose level, and prevention of complications.

Any concerns for the future should be addressed in a compassionate and non-judgmental manner. Although the approach to asking the questions is neutral and non-judgmental, they do not necessarily produce a desired outcome. Conclusion The empowerment philosophy clearly represents a shift in attitude for both patients and healthcare professionals.

In the context of diabetes, there is perhaps an understandable apprehension that allowing people with this condition to learn about the care and education they should receive may give rise to an increasingly demanding population of patients.

It cannot be denied that healthcare professionals who routinely practice empowerment have seen the emergence of well-informed people with diabetes, who are aware of their rights. Frank and honest information about the lack of resources and other factors that impede the delivery of appropriate care will result in a better-informed population who have a significant effect on our healthcare providers and political figures.

Consequently, people with diabetes are our best allies in our fight to deliver the optimum level of care. Facilitating empowerment to people with diabetes and their families is therefore well worth the time and energy required to achieve it.

Anderson RM Is the problem of non-compliance all in our heads? The Diabetes Educator 11 1 : 31—34 Arnold M, Butler P, Anderson RM et al Guidelines for facilitating a patient empowerment program. The Diabetes Educator 21 4 : —12 Cavan D Giving power to the patients. Modern Diabetes Management 2 4 : 15—16 Department of Health National Service Framework for Diabetes: Standards.

DoH, London Department of Health The National Service Framework for Diabetes: Delivery Strategy. DoH, London Falk-Rafael AR Advocacy and empowerment: dichotomous or syncronomous concepts? Advances in Nursing Science 19 2 : 25—32 Feste C A practical look at patient empowerment.

Diabetes Care 15 7 : —25 Freire P Pedagogy of the Oppressed. Continuum Publishing, New York Funnell MM, Anderson RM, Arnold MS et al Empowerment: an idea whose time has come in diabetes education.

The Diabetes Educator 17 1 : 37—41 Funnell MM, Anderson RM Empowerment and self-management of diabetes. Clinical Diabetes 22 : —27 Gibson CH A concept analysis of empowerment. Journal of Advanced Nursing 16 : —61 Hurley CC, Shea CA Self-efficacy: strategy for enhancing diabetes self-care.

The Diabetes Educator 18 2 : —50 Jacobson AM, Hauser ST, Willett, JB et al Psychological adjustment to IDDM: year follow-up of an onset cohort of child and adolescent patients. This product requires a minimum order of 1.

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Education has long been recognised as the cornerstone of the diabetes management regimen Hurley and Shea, For example it has been reported that undertaking a self-care management regimen is more difficult than dealing with the diagnosis of diabetes Anderson, It is, therefore, important for the nurse to be aware of how complex the treatment regimen can be, particularly for individuals with type 1 diabetes mellitus.

Their lives revolve around a temporal regularity in which insulin doses must be calculated and administered at precise times. Meals, exercise, rest and monitoring of blood glucose parameters must be planned and performed to match those times when insulin levels are expected to drop or peak.

In the context of diabetes education, the concept of empowerment is thus based on several assumptions:. A helping hand In order for people with diabetes to become actively involved in their own care, it is important for the nurse to equip them with the information needed for effective self-management.

The person with diabetes also needs to understand the healthcare system and how to utilise it when necessary. This can only be achieved if the education programme contains all the relevant topics to improve knowledge.

As shown in the extended list Table 1 , these topics should include knowledge about diabetes, dietary composition particularly with regard to reducing saturated fats , their impact on blood glucose levels, as well as the effect of other lifestyle issues such as exercise, smoking cessation, alcohol intake and illness.

How and why insulin needs to be adjusted to accommodate these factors also need to be explained. The importance of attending the diabetes clinic and eye appointments should be clearly emphasised.

It could be argued that those who are thus empowered benefit both psychologically and in terms of maintaining long-term metabolic control. This approach to diabetes management, as Cavan argues, shifts from a purely traditional medical model to the provision of effective educational interventions to facilitate successful self-care, with immediate medical needs met at diagnosis and at intervals thereafter Figure 1.

However, not everyone with diabetes may be comfortable with taking responsibility for their lives. In such cases, the individual may prefer a more direct approach. As Funnell et al assert:. The choice remains with the patient, even when the choice is to decline power.

Patients who choose to remain the passive recipients of care are responsible for that choice and its consequences. The medical model In the medical model, treatment goals and plans often ignore the emotional, spiritual, social and cognitive aspects of living with a chronic disease such as diabetes Arnold et al, During a medical visit, there may be opportunities to see a nurse or dietitian.

Consequently, the medical model may well lead to conflict between healthcare professionals and people with diabetes.

Furthermore, the medical model does not necessarily meet the psychological needs of the person with diabetes. For example, the diagnosis of diabetes is often a shock and frequently devastating to the individual.

Failure to effectively address this important aspect of psychological care may lead to poor self-esteem and low motivation to adopt self-care behaviour Jacobson et al, Moving towards empowerment A major goal of patient empowerment is to improve adherence to agreed self-care regimens.

People with diabetes are often unsure whether they can achieve the set goals. To become empowered, they need information, assurance, support and caring.

The motivational interview model developed by Rollnick et al aims to assist healthcare professionals in helping patients manage their illness experience. The adapted steps see below , extracted from the work of Rollnick et al , may be applied in full or in part, depending on where the individual is located in the process.

Many people with diabetes have misconceptions about their condition. They may associate diabetes with complications and fatalistic outcome. Such information enables the nurse to respond in an empathic manner. Exchanging information The amount of information given to a person with diabetes should be based on assessment and negotiation.

When the person is ready for more information, it should be provided in an unbiased, non-judgmental manner. Where diabetes medications are concerned, their action, any possible side-effects, and storage should be explained in a style that is readily understood by the person with diabetes.

The present and the future This strategy allows people with diabetes to discuss their expected outcomes as a result of undertaking the prescribed self-care activities. Expected outcomes may include weight loss, normal blood glucose level, and prevention of complications.

Any concerns for the future should be addressed in a compassionate and non-judgmental manner. Although the approach to asking the questions is neutral and non-judgmental, they do not necessarily produce a desired outcome.

Conclusion The empowerment philosophy clearly represents a shift in attitude for both patients and healthcare professionals.

In the context of diabetes, there is perhaps an understandable apprehension that allowing people with this condition to learn about the care and education they should receive may give rise to an increasingly demanding population of patients.

It cannot be denied that healthcare professionals who routinely practice empowerment have seen the emergence of well-informed people with diabetes, who are aware of their rights. Frank and honest information about the lack of resources and other factors that impede the delivery of appropriate care will result in a better-informed population who have a significant effect on our healthcare providers and political figures.

Consequently, people with diabetes are our best allies in our fight to deliver the optimum level of care. Facilitating empowerment to people with diabetes and their families is therefore well worth the time and energy required to achieve it.

Anderson RM Is the problem of non-compliance all in our heads? Four-year long-term follow-up of diabetes patients after implementation of the chronic care model in primary care: a cross-sectional study.

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Use of the patient assessment of chronic illness care PACIC with diabetic patients: relationship to patient characteristics, receipt of care, and self-management. Simonsen N, Koponen AM, Suominen S. Patients' assessment of chronic illness care: a validation study among patients with type 2 diabetes in Finland.

Toljamo M, Hentinen M. Adherence to self-care and social support. J Clin Nurs. Brandt PA, Weinert C. The PRQ — a social support measure. Nurs Res. McCormack LA, Williams-Piehota PA, Bann CM, Burton J, Kamerow DB, Squire C, et al.

Development and validation of an instrument to measure resources and support for chronic illness self-management: a model using diabetes.

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Res Rep. Hays RD, Sherbourne CD, Mazel RM. The RAND item health survey 1. Health Econ. Donald M, Dower J, Ware R, Mukandi B, Parekh S, Bain C. Living with diabetes: rationale, study design and baseline characteristics for an Australian prospective cohort study.

BMC Public Health. Aujoulat I, d'Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Aujoulat I, Luminet O, Deccache A. The perspective of patients on their experience of powerlessness. Qual Health Res. Browne JL, Nefs G, Pouwer F, Speight J.

Depression, anxiety and self-care behaviours of young adults with type 2 diabetes: results from the international diabetes management and impact for long-term empowerment and success MILES study. Piatt GA, Anderson RM, Brooks MM, Songer T, Siminerio LM, Korytkowski MM, et al.

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Can Fam Physician. PubMed PubMed Central Google Scholar. Download references. The work was supported by the Social Insurance Institution of Finland, Samfundet Folkhälsan i Svenska Finland and the Finnish Cultural Foundation, Varsinais-Suomi Regional Fund.

Folkhälsan Research Center, Public Health Research Program, P. Box , , Helsinki, Finland. Department of Public Health, University of Helsinki, Helsinki, Finland. Department of Public Health, University of Turku, Turku University Hospital, Lemminkäisenkatu 1, Turun yliopisto, , Turku, Finland.

School of Health and Education, University of Skövde, Skövde, Sweden. You can also search for this author in PubMed Google Scholar. NS had the main responsibility for conception and design of the study as well as for data analysis, interpretation of data and drafting the manuscript.

AMK and SS contributed to study design, interpretation of data and revising the manuscript. All authors NS, AMK, SS contributed to the collection of study data. All authors NS, AMK, SS read and approved the final version of the manuscript. Correspondence to Nina Simonsen. The study was approved by the Ethical Committee of the Hjelt Institute, University of Helsinki.

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Skip to main content. Search all BMC articles Search. Download PDF. Research article Open access Published: 01 May Empowerment among adult patients with type 2 diabetes: age differentials in relation to person-centred primary care, community resources, social support and other life-contextual circumstances Nina Simonsen ORCID: orcid.

Abstract Background Rising prevalence of type 2 diabetes T2D , also among younger adults, constitutes a growing public health challenge. Results Respondents in the youngest age-group were more likely to have low empowerment scores, less continuity of care, and lower wellbeing than the other age-groups, and to perceive less social support, but a higher level of person-centred care than the oldest group.

Conclusion Person-centred care and community support, including possibilities to influence community health issues, supports empowerment among adults with T2D. Introduction The rising prevalence of type 2 diabetes T2D has been described as a pandemic, and thus a growing public health challenge worldwide [ 1 ].

Measures Outcome variable We used the short form of the Diabetes-Empowerment Scale DES-SF as the outcome variable. Main independent variables We measured person-centred care with the Patient Assessment of Chronic Illness Care, i.

Statistical analyses In descriptive analyses, to test for age-related differences in background, dependent, main independent and additional independent variables, Chi-square-test, one-way analysis of variance ANOVA and Kruskal-Wallis test were applied, as appropriate.

Age differentials in study variables: descriptive findings Table 1 provides background data on the study sample across age groups. Table 3 Bivariate correlations between study variables Full size table.

Discussion In a large register-based sample of adults with T2D, we found age differentials in empowerment and in all variables proposed as possible correlates of empowerment. Strengths and limitations The most important limitation of this study is its cross-sectional design, which implies that the observed associations can at least partially represent bi-directional influence.

Conclusions This study, among adult patients with T2D, and with a special focus on patient age, found that community support and possibilities to influence community health issues was consistently and independently associated with higher empowerment in all age groups, as was person-centred primary healthcare in the two older age groups, thus supporting assumptions of the CCM and empowerment literature.

Availability of data and materials A license for collecting the data through SII was granted for the present study. Abbreviations CCM: Chronic Care Model PACIC: Patient Assessment of Chronic Illness Care T2D: Type 2 Diabetes. References Zheng Y, Ley SH, Hu FB.

Article PubMed Google Scholar International Diabetes Federation. Google Scholar Kela Social Insurance Institution of Finland. Article Google Scholar Bo A, Pouwer F, Juul L, Nicolaisen SK, Maindal HT.

Article CAS PubMed Google Scholar Hessler DM, Fisher L, Mullan JT, Glasgow RE, Masharani U. Article PubMed Google Scholar American Diabetes Association.

Type 2 diabetes mellitus is primarily a lifestyle condition. Diabetes is influenced by lifestyle and in turn affects the quality of life. Modifiable lifestyle risk factors are important in diabetes care as they are independently associated with diabetes [ 1 ].

Thus, a holistic approach to diabetes care is needed in which patients are empowered to make lifestyle changes. By itself, pharmacologic management does not ensure improvement in long-term patient-oriented outcomes such as the quality of life or all-cause mortality.

Additional nonpharmacologic interventions are needed to empower individuals to improve their quality of life [ 2 ]. Yet, a majority of these individuals remain nonadherent to lifestyle guidelines [ 3 ]. The Diabetes Score questionnaire is a behavior change tool designed to improve lifestyle factors such as diet and exercise in individuals with diabetes online suppl.

Material; for online suppl. material, see www. This instrument consists of 10 questions pertaining to physical activity, nutrition, and self-care. Each question is rated by patients on a scale from 0 to 10 points based on the level of adherence.

A total score ranging from 0 to is obtained by adding the points from the 10 individual questions. The questionnaire has been carefully designed for clinical use. All items are actionable and behaviorally oriented. Thus, items that cannot be changed directly by patients themselves, such as blood glucose levels or BMI, are excluded.

This is in contrast to the traditional biomedical approach to self-management, which has failed to yield meaningful results [ 4 ]. All regions of the world are experiencing an epidemic of obesity and type 2 diabetes [ 7 ]. Diabetes tends to be underdiagnosed and undertreated [ 8 ]. Glycemic levels are suboptimally controlled despite advances in diabetes therapy [ 10 ].

There is an urgent need for a practical, low-cost patient decision aid for diabetes self-management. We aimed to evaluate the Diabetes Score questionnaire in a clinical context. In particular, we sought to assess whether Diabetes Score correlates with better glycemic control among adult patients with diabetes.

A cross-sectional questionnaire survey was conducted at a primary care clinic in the city of Al Ain, United Arab Emirates, in Researcher-administered structured brief interviews were conducted with otherwise healthy, community-dwelling, adult individuals with type 2 diabetes in an ambulatory setting.

Inclusion criteria for recruitment of subjects in the study were age 18 years or greater and an established diagnosis of type 2 diabetes mellitus. Exclusion criteria included any mental or hearing deficits and other severe medical conditions such as mobility restrictions that would impede participation in the study.

A minimum sample size of 47 subjects was deemed sufficient to detect a correlation of 0. A trained researcher H. conducted all the interviews to ensure consistency and reliability. Patients in the clinic waiting area were offered information about the study, and voluntary informed consent was requested.

Preprinted questionnaire forms were used to collect data in a structured format. Demographic age, gender, occupation, and education and clinical weight, recent blood glucose, and HbA1C data were recorded. Statistical data analysis was conducted using the current version of SPSS Statistics version 26; IBM SPSS Inc.

In addition to descriptive measures, statistical tests for bivariate correlation, t test, and multivariate regression were performed. Reliability analysis was assessed using the alpha Cronbach model.

Factor analysis was used to evaluate principal components subscales for diet, exercise, and self-care. An alpha level of 0. A total of 60 adult patients with type 2 diabetes mellitus participated in the study.

The sample was representative of a wide range of diabetic patients Table 1. The ages ranged from 43 to 70 years mean 56; standard deviation [SD], 5. A broad range of occupations electricians and engineers to farmers and carpenters and educational backgrounds mean years of formal education, 13; SD, 2.

The mean Diabetes Score was Patients were more adherent to dietary items than to exercise or physical activity Fig. There was no significant difference between male and female patients in terms of glycemic control A1C 6.

Comparison of these 2 groups showed that better Diabetes Scores were associated with significantly lower BMI and improved glycemic control Table 2. The questionnaire data were analyzed for reliability and acceptability. Reliability analysis for internal consistency yielded a Cronbach alpha of 0.

Diabetes Score was associated with better glycemic control among adult patients with type 2 diabetes. The questionnaire showed fair evidence of construct validity, internal consistency, reliability, and patient satisfaction.

We found that patients were more likely to comply with dietary guidelines than with exercise. This is consistent with previous research showing the impact of diabetes on the ability to exercise [ 14 ].

Foot care was often neglected, indicating an area for self-improvement. Self-reported adherence to diabetes medications was high in our survey indicating awareness of its importance.

Knowledge of diabetes self-management has tended to remain low despite counseling by dieticians and diabetes educators [ 9 ]. In resource-limited settings such as developing countries, where the largest numbers of diabetes patients reside, frequent blood tests and physician visits may not be feasible.

Innovative approaches are needed to focus on low-cost, nonpharmacological interventions such as lifestyle change [ 16 ]. Previous diabetes questionnaires have tended to be lengthy and complicated, making them unsuitable for use in clinical settings [ 11, 13 ]. Many questionnaires were designed for gathering data for research purposes, rather than for improving patient care.

Thus, a questionnaire is needed that can be used not only for measuring adherence to diet and exercise but also for discussing targets and monitoring progress.