Running head: DIABETES MANAGEMENT
Diabetes Management Through Information Technology
Kailey Hamrick
Auburn University/ Auburn University Montgomery
1
Running head: DIABETES MANAGEMENT
2
Abstract
Diabetes is a disease characterized by high glucose levels in the blood due to
defects in the body's ability to produce and/or use insulin. There are two types of
diabetes, Type 1, and Type 2. Type 1 diabetes is when the body does not produce
insulin. Type 2 diabetes mellitus (T2DM) is a disease that causes problems with insulin
production or utilization, which causes sugar levels in the blood to elevate which can lead
to permanent damage of the blood vessels and associated complications, such as heart
disease and stroke. T2DM comprises 90% of people with diabetes around the world. To
better manage their T2DM, patients must understand what it is and how and what
interventions are significant to controlling it. This paper seeks to answer the question of
in patients diagnosed with diabetes mellitus, does using information technology to deliver
education and management strategies compared to only face-to-face interactions, improve
patient glucose control, lifestyle choices, and knowledge? To begin an evidence-based
practice approach to answering this question, multiple articles will be analyzed and
recommendations will be drawn. Next, an implementation plan will be created and
potential facilitators and barriers to this plan, as well as expected short term and longterm outcomes will be discussed in detail. A small test of change will then be executed
of which results will be evaluated and an evidence-based conclusion drawn.
Keywords: Diabetes mellitus, Information Technology (IT), evidence-based,
GlucoseBuddy
Running head: DIABETES MANAGEMENT
3
Diabetes Management Through Information Technology
Evidence-based practice (EBP) is described by Melnyk and Fineout-Overholt
(2011) as a “problem-solving approach to clinical practice that integrates a systematic
search for as well as critical appraisal and synthesis of the most relevant and best research
to answer a burning clinical question, one’s own clinical expertise […], and patient
preferences and values (p. 4).” EBP allows for evidence to be translated into the best
clinical practice in order to obtain the best patient outcomes.
Introduction
Diabetes is a disease characterized by high glucose levels in the blood due to
defects in the body's ability to produce and/or use insulin. There are two types of
diabetes, Type 1, and Type 2. Type 1 diabetes is when the body does not produce
insulin. Type 2 diabetes mellitus (T2DM) is a disease that causes problems with insulin
production or utilization, which causes sugar levels in the blood to elevate which can lead
to permanent damage of the blood vessels and associated complications, such as heart
disease and stroke. T2DM comprises 90% of people with diabetes around the world.
Diabetes is a serious health problem that affects many people today. Diabetes lasts
throughout a patients’ life and can affect any age or race. It affects patients’ families,
wealth, lifestyle habits, potential comorbidities, and in turn life expectancy. Karakurt and
Kaşıkçı (2012) write the following:
In the next 25 years, it is predicted that diabetes will be one of the major fatal and
mutilating diseases in the world. According to the experts, the number of patients
with diabetes will be more than 300 million by the year 2025. […] Diabetes
incidence is expected to increase by 165% in the next 50 years. […] It is
Running head: DIABETES MANAGEMENT
4
estimated that there are 17 million people in the USA alone with diabetes. (p.
170).
These statistics show the importance of diabetes education and management.
Many people affected by diabetes do not know or understand the disease, its’
management, and its’ potential for severely debilitating and fatal comorbidities. For
patients to better manage their diabetes, patients must understand what it is and how and
what interventions are significant to controlling it. Successful treatment of diabetes is
directly associated with education of both patients and their families. Patient education is
one of the most vital responsibilities of nurses. Evidence-based practice should be used to
find the best ways to accomplish meaningful education that encompasses the needs and
goals of people with diabetes. The goal should be to empower patients with a better
understanding of their disease so they can take a more active role in self-management
(Tang et al., 2012).
PICO formatted questions are used in EBP in order to yield the most relevant and
best information (Melnyk & Fineout-Overholt, 2011). The PICO question used in this
paper is as follows; in patients diagnosed with diabetes mellitus (DM), does using
information technology to deliver education and management strategies compared to only
face-to-face interactions, improve patient glucose control, lifestyle choices, and
knowledge? The Population focus is patients who are over the age of 18 who have been
diagnosed with DM, and have not had diabetes education with the assistance of IT before.
The Intervention is providing necessary education, including but not limited to diet
changes, lifestyle modifications, medication guidelines, and signs of hypo and
Running head: DIABETES MANAGEMENT
5
hyperglycemia, with the assistance of IT, such as Glucose Buddy. The Comparison
intervention is only educating patients on the information stated above via face-to-face
interactions, or the standard currently used. The Outcome desired is more consistent
control of blood glucose levels observed on the trend tracker, which would be between 70
and 160, and a decrease in hemoglobin A1C level, preferably to a level less than 7. A
decrease in weight to bring the patients BMI closer to normal values, between 18.5-24.9,
and an increase in exercise is also desired outcomes because these factors are directly
related to blood glucose levels. Along with these knowledge/behavior outcomes, an
increase in the patients’ overall confidence in their diabetes management abilities is
anticipated.
Framework
The EBP model that will be used is the Rosswrum and Larrabee Model.
According to Thurston and King (2004), Rosswurm and Larrabees’ model is intended to
guide nurses through an evidence-based change process by following six steps: (1) assess
the need for change in practice, (2) link the problem with interventions and outcomes
using standardized classifications and language, (3) synthesize best evidence, (4) design
change(s) in practice, (5) implement and evaluate the change, and (6) integrate and
maintain the practice change. Facchiano, Snyder, and Núñez (2011), break these steps
down further: step 1 must include stakeholders, collect internal data about current
practice, compare internal data with external data, and identify the problem. For this
project the stakeholders are the not only the patients and doctors, but everyone involved
in healthcare as a whole, and the problem identified is poorly managed diabetes. Step 2
must use standardized classification systems and language, identify potential
Running head: DIABETES MANAGEMENT
6
interventions and activities, and select outcomes indicators. Once these are established,
step 3 can begin. Step 3 involves searching research literature related to major variables,
critiquing and weighing the evidence, synthesizing the best evidence, and assessing the
feasibility, benefits, and risks. Preforming extensive literature reviews on systematic
reviews, clinical practice guidelines, randomized controlled trials, and other pertinent
studies on diabetes education and management will do this. In step 4, one defines the
proposed change for diabetes education and management, identifies needed resources,
plans the implementation process, and defines the expected outcomes of the evidencebased practice project. Step 5 consists of implementing the diabetes project, evaluating
the process and outcome, and deciding to adapt, adopt, or reject the practice change. The
final step, step 6, is comprised of communicating the recommended change in diabetes
management and education to stakeholders, presenting a staff in service on change in
standards of practice, and monitoring the process and outcomes. This model will help
because it lays out the steps needed to critically think about potential evidence-based
changes in diabetes management by “utilizing change theory and a combination of
quantitative and qualitative data along with clinical expertise (Facchiano, Snyder, &
Núñez, 2011, p. 421).” In the past studies of outcomes related to diabetes selfmanagement education have shown mixed results. This illustrates that more evidencebased practice is needed to evaluate the effect of educational strategies on more longterm outcomes and the Rosswurm and Larrabees’ model can guide this.
Review of Literature
With the prevalence of diabetes and other chronic illnesses increasing it is
imperative to use EBP to create new opportunities for improvement in healthcare delivery
Running head: DIABETES MANAGEMENT
7
for these patients; upon literature review, it was found that advances in Information
Technology (IT) are creating these opportunities. The literature reviewed for this project
was found by searching multiple databases and multiple keywords. The databases
searched were Academic Search Premier, CINAHL, PubMed, and Medline, and the
keywords searched were diabetes, diabetes management, diabetes education, diabetes
treatment, diabetes training, diabetes teaching, technology, and technology education.
The result achieved from this search yielded multiple articles imperative to this EBP
project, and will be discussed in detail below.
The AACE Diabetes Mellitus Clinical Practice Guidelines Task Force
(AACEDMCPGTF) provides clinicians with guidelines to care for patients with DM.
The guidelines demonstrate the effectiveness of lifestyle interventions in preventing the
progression of DM and state that rechecking patients’ understanding of basic self-care
concepts should be done routinely (AACEDMCPGTF, 2007). Information technology
can be used to recheck patients’ understanding of diabetes at regular intervals and can
help educate patients about lifestyle interventions, such as weight loss, and monitor such
interventions via online logs.
In their systemic review of 86 articles, H. Cooper, J. Cooper, and Milton (2009)
appraised 5 that found that Information and Communication Technology (ICT)-based
education has beneficial effects on knowledge and psychosocial wellbeing as well as
improvements in self-care behaviors. The review found that ICT allowed patients to
translate what they learned and that there was an increase in adherence of self-care as
evident by the numbers of transmitted blood glucose tests (with a decrease in frequency
of hyperglycemia and a maintenance of A1C levels of < 8%) (Cooper et al., 2009). The
Running head: DIABETES MANAGEMENT
8
article showed that a key issue is facilitating discussion in a way that enables patients to
talk about personal or sensitive information. ITC supports such discussion by providing a
forum for disclosure of personal or embarrassing questions that patients may feel unable
to ask in face-to-face sessions.
Adaji, Schattner, and Jones (2008) conducted a systematic review that also
highlighted how IT can improve patient self-management in diabetes and enhance the
way in which diabetes care is delivered. They reviewed 444 studies and following
appraisal included 29 trials that involved IT being used to provide clinicians with access
to data about individual patients, such as blood glucose and blood pressure readings that
were uploaded from the patients. The IT could also send reminders and alerts to patients
regarding their specific information. These web-based programs were also used to
provide diabetes education, physical activity programs tailored to the patient’s specific
needs, and access to online coaches and peer support groups. Their review supported that
with the use of IT, there was a significant improvement in HbA1c and lipids levels, and
the numbers of foot and eye check ups (Adaji et al., 2008).
Polisena et al. (2009) executed a systemic review and meta analysis on 26 home
telehealth studies and found that home telemonitoring (HTM) for patients with diabetes,
compared to usual care (UC), had a positive effect on glycemic control and that HTM
helped to reduce the number of patients hospitalized and bed days of care. In their
reviews, HTM was defined as remote care delivery or monitoring between the patients in
their place of residence and the health-care provider at a distant location. The HTM
could be IT that enabled individuals to communicate live through audio conferencing and
videoconferencing, or IT that involved storing data, which was forwarded to a healthcare
Running head: DIABETES MANAGEMENT
9
professionals via the Internet. The review showed that fewer patients were hospitalized
following the one-year post-enrolment period compared with the baseline (21.3% vs.
42.2%), and that the HbA1c levels in the HTM group were significantly lower than those
of patients in the UC group (Polisena et al., 2009).
A randomized control trial (RCT) of 104 diabetic patients done by McMahon et
al. (2005), assessed web-based care management for glucose and blood pressure control
in patients with poorly controlled diabetes. The trial consisted of randomly dividing the
participants into those who continued with their usual care or those who received webbased care management. The web-based group received a laptop, glucose and blood
pressure monitoring devices, and access to a website that provided educational modules,
accepted uploads from monitoring devices, and had a messaging system for patients to
communicate with the care manager. The outcomes found were that web-based care
management might be useful in the care of patients with poorly controlled diabetes as
evident by the improvements in A1C (McMahon et al., 2005).
A RCT of 379 patients done by Tang et al. (2012) evaluated an online disease
management system supporting patients with uncontrolled type 2 diabetes. The trial
consisted of randomly dividing the participants into those who continued with their usual
care or those who received web-based care management. The intervention group was
given a wirelessly uploading home glucometer that took readings with graphical
feedback, access to online comprehensive patient-specific diabetes summary status
reports on their nutrition and exercise logs, and insulin records, access to online
messaging with the patient's health team, and personalized text and video educational
‘nuggets’ dispensed electronically by the care team. The outcomes found were that
Running head: DIABETES MANAGEMENT
10
nurse-led, multidisciplinary health teams could manage a population of diabetic patients
primarily using online management and communication tools (Tang et al., 2012).
Smith et al. (2004) hypothesized that MyCareTeam (MCT), a web-based diabetes
management system, would provide frequent interactions between patients and providers
and thus result in improved glycemic control. They came to this hypothesis by
preforming a nonrandomized prospective feasibility study of 16 patients with poorly
controlled diabetes mellitus. Patients were asked to transfer their blood glucose data
electronically, maintain exercise logs, and communicate with their provider via MCT.
The provider gave interventions to optimize blood glucose control and education on
diabetes, nutrition, and exercise information via MCT. Findings showed a significant
reduction of over 2.22% points in hemoglobin A1C was seen for the total patient
population, as well as an improvement in systolic blood pressure, diastolic blood
pressure, total cholesterol, HDL, LDL, and triglycerides (Smith et al., 2004).
Turner, Larsen, Tarassenko, Neil, and Farmer (2009) reviewed experiences of 23
diabetic patients and the clinicians from 9 general practices who used IT monitoring.
Like the previously mentioned studies, this informal review involved patients
participation in a cohort study who received a mobile phone with a preloaded software
application that provided real-time data transmission and feedback through transmission
of blood glucose test results and real-time feedback of trends, an electronic patient diary
to record insulin doses, blood pressure results, and weight, and a blood glucose meter
linked to the phone via a BluetoothTM cradle. Unlike the other studies, this study
showed aspects of the IT valued from the clinicians standpoint: the ability to access upto-date information about patients’ blood glucose readings and insulin doses; the
Running head: DIABETES MANAGEMENT
11
potential to support patients in making their own adjustments to insulin regimens; and the
opportunity for patients with diabetes to enhance their personal control over the
management of their diabetes (J. Turner et al., 2009). This study correlated with the
previous studies in that there was a decrease in HbA1c seen after IT interventions. Six
weeks post-implementation, the participants HbA1C decreased by an average of 0.52%
and patients reported feeling more ‘in control’ and confident in their ability to selfmanage insulin titration (J. Turner et al., 2009).
Sevean, Dampier, Spadoni, Strickland, and Pilatzke, (2009) explored 10 patients’
and 4 family members’ experiences with video telehealth consultations as a method of
health care delivery in their qualitative study, and found that telehealth was valued for
three key reasons; it lessened the burden (cost of travel, accommodations, lost wages, lost
time and physical limitations), it increased supports (access to familiar home
environment, nurses and other care providers), and it allowed for tailoring specific ehealth systems to enhance patient and family needs. This study showed that video
telehealth is effective for delivering nursing and other health services to patients who
may not be able to physically go to healthcare facilities and therefore can impact
positively on the quality of health care for these patients (Sevean et al., 2009). This, as
well as the previously mentioned articles, demonstrates how IT has a positive effect on
DM management, as evident by multiple positive outcomes, and is therefore essential to
future healthcare delivery models.
The review of the literature shows that patients’ understanding of their disease
and the treatments for it is paramount to having improved health care outcomes. Patients
must not only make lifestyle modifications and keep logs to track their progress, but must
Running head: DIABETES MANAGEMENT
12
understand why they are doing so in order to truly achieve desired outcomes. Information
technology provides 24/7 access to education materials, support chat rooms, and
glucose/diet/exercise logs, and can help improve diabetes self-management behaviors in
those who utilize it.
Critical Appraisal of Evidence
There are seven levels for rating the hierarchy of evidence, the strongest being a
level I, and the weakest being a level VII. The AACE Diabetes Mellitus Clinical Practice
Guidelines Task Force is ranked level I. The objectives are clearly defined and results
considered extremely valid as multiple endocrinologists produced them, each of which
are experts and practitioners in diabetes, has published in the field of diabetes, and is
active in one or more of the main medical societies on diabetes care. The guidelines
speaks directly about the population of this project, stating T2DM is the most common
form of DM, making up more than 90% of DM cases.
Adaji, et al. (2008), Cooper et al. (2009), and Polisena et al. (2009) are all level I
articles because they are all systematic reviews and/or meta-analysis’s. Each of these
reviews are very consistent with each other; each population is patients with T2DM, each
intervention is a form of IT, each comparison is usual care, and each denotes outcomes of
reduced HbA1C levels. They are further appraised as follows:

Adaji et al. (2008) reviewed 25 articles and identified web-based programs as the
latest application of IT for chronic disease management. The findings are limited
by a few factors, one being that the scope was limited and did not, for example,
look at telemedical services. Also, there is considerable variability in the methods
used in the studies which have been identified and the majority of the studies were
Running head: DIABETES MANAGEMENT
13
implemented in the USA which could limit the generalization of the findings.
However this article is significant because it highlights how IT can improve
patient self-management in diabetes.

Cooper et al. (2009) reviewed 5 articles. The findings in this review are limited by
a few factors; the small number of viable studies, the heterogeneity of
interventions, short-term follow-up and diverse focal points. The reviews validity
is shown by way of the findings corresponding with those from other less targeted
reviews of ICT-based patient education, reinforcing the potential of ICT to
provide an impact on and a link between education and treatment concordance.

Polisena et al. (2009) reviewed 26 articles and only included articles whose
quality rated A-C on a scale from A (high quality and high degree of confidence
in study findings) to E (poor quality and unacceptable uncertainty for study
findings), these included RCTs and prospective cohort. A possible weakness this
review has is that some studies included did not report whether the patients
involved had type 1 or type 2 diabetes. Validity however, is shown by the fact that
the findings of this systemic review are generally consistent with several systemic
reviews on HTM or telecare for diabetes management. The significance lies in the
finding that home telehealth is clinically effective as evident by the positive
impact on the use of numerous health services and glycemic control.
McMahon et al. (2005) is a level II article as it is a randomized control trial
(RCT). The majority of participants were men in which >50% had college degrees. This
may reflect bias towards women and people who do not have higher education, however
the study states previous studies with a more balanced ratio of men and women show
Running head: DIABETES MANAGEMENT
14
similar outcomes (McMahon et al., 2005). Again this article focused on the population of
DM patients, used the intervention of IT, and had the outcome of decreased HbA1C.
Tang et al. (2012) is also a level II article because it is also a RCT. This study
had a large sample size of 379 patients even after its’ strict inclusion criteria, suggesting a
good sample of participants. It did however limit to English speaking patients and those
who have had diabetes for over a year. This is bias towards different ethnic groups and
leaves out other patients who could benefit and add to the article. The article shows that
using this technology decreases HgbA1C and LDL cholesterol levels, as well as leads to
patients recording their home glucose readings more frequently, talking with their
providers more, and having significantly lower treatment-distress scores and better
overall knowledge about diabetes and glucose testing. Patients who used the technology
also had greater overall treatment satisfaction and willingness to recommend the
technology to others (Tang et al., 2012).
Smith et al. (2004) is a level III article because it is a nonrandomized prospective
feasibility study. This feasibility study had a small population size and did not include a
control group, however, it did show significant trends in A1C reductions in patients who
used the intervention, IT, reflecting an outcome consistent with the previous articles.
J. Turner et al. (2009) is a level IV article because it is an informal review of a
cohort study. Twenty-three patients with uncontrolled T2DM from nine general practices
were used, creating diversity in population. However, only patients who commenced an
insulin regimen in the past 12 months were included, which would bias towards patients
who had been using insulin longer who still may need education. This study showed the
Running head: DIABETES MANAGEMENT
15
outcomes of decreased HbA1C levels as well as increased levels of overall confidence in
the participants’ diabetes management abilities.
Sevean et al. (2009) is a level V article because it is a qualitative study. The
articles’ sample size was 10 patients and four family members in nine communities. The
small and geographically focused nature makes transferability of the findings difficult,
however, this article showed how IT could benefit those who may not seek treatment due
to their lack of access to care by allowing practitioners to monitor and educate these
patients via the Internet. Refer to Appendix 1 for a more detailed analysis of the
evidence.
Recommendations
After a thorough review of the literature, the following recommendations have
been established and are listed with their grade equivalent.
1. Routinely rechecking patients’ understanding of basic self-care concepts and
evaluating the effectiveness of the patients’ lifestyle interventions in preventing
the progression of T2DM. (Grade A). (AACEDMCPGTF, 2007).
2. Self-care at home is an immense component of diabetes management, and
telehealth has shown to be clinically effective as a home care tool. (Grade A).
(Polisena et al., 2009).
3. Using IT for forums where patients can discuss personal information they may
feel is embarrassing to ask in face-to-face sessions, which allows for patients to
better comprehend their T2DM and in turn be more likely to adhere to correct
self-care management. (Grade A). (Adaji, et al., 2008; Cooper et al., 2009).
4. Use IT to record/store logs of patients' blood glucose, insulin, diet, and exercise,
Running head: DIABETES MANAGEMENT
16
so they can be shared with the patients’ practitioner who can then evaluate and
manage their patients DM. It is recommended that IT should be used because it
allows access to educational modules, coaches, and peer support groups that
facilitate the comprehension process and in turn increase each patients
confidence. (Grade A). (Adaji, et al., 2008; J. Turner et al., 2009; McMahon et al.,
2005; Polisena et al., 2009; Smith et al., 2004;).
5. Empowering patients with a better understanding of their disease processes and
encouraging them to take a more active role in self-management leads to better
control of their disease and can be done through technology. (Grade A). (Tang et
al., 2012).
6. Using video telehealth consultations as a method of health care delivery. (Grade
D). (Sevean et al., 2009).
Clinical Setting Assessment
The Baptist Health Center for Diabetes and Nutrition Education has been
recognized for excellence by the American Diabetes Associates since 1995. At this
organization there are two registered dieticians and two registered nurses, three out of the
four of these employees are certified diabetes educators. The center is next to Baptist East
Hospital and has multiple rooms set up for different lesson plans.
The primary patient population at this center is adults over the age of 20, referred
to the diabetes center by their primary care physician. In 2012, 857 patients were seen at
this center. 748 were diagnosed with Type II Diabetes. The patient demographics for
2012 consisted of 462 Caucasians, 382 African Americans, 7 who were Hispanic, Indian,
Running head: DIABETES MANAGEMENT
17
or another race, and 6 Asians. 546 of the patients were females and 311 were males. The
approximate volume of patients seen per week at the center is around 25.
Education sessions at the center are done on Mondays, Wednesdays, and
Thursdays. Currently the patients are taught one-on-one and in small groups about
diabetes management; blood glucose testing, medication, diet and exercise. The center
utilizes food models, handouts, and food and exercise diaries. They provide new
diabetics with 30 minutes of one-on-one teaching followed by six hours of group
teaching, three with the registered nurse and three with the dietician, and then another 30minute one-on-one session for review and questions. The patients are encouraged to
follow up and are called by the center six months after their visit. An educator at the
center said there is a lot of lost patient follow-ups and continuing of monitoring and
educating after that initial visit. She stated that almost none of their patients return or call
for follow up appointments, and that therefore they do not have data showing the
effectiveness of their education. The educator suggests that these patients do not follow
up because insurance only covers a short amount of hours for education and any further
meetings at the center would be an out-of-pocket expense.
The primary educator at the center was informed of the evidence-based project
(EBP) and PICO question of in patients diagnosed with diabetes mellitus, does using
information technology to deliver education and management strategies compared to only
face-to-face interactions, improve patient glucose control, lifestyle choices, and
knowledge? The educator seemed very reluctant to consider change in terms of new
models of education or follow-up modalities. She voiced multiple times that she feels
nothing is better than the face-to-face interaction for educating patients. She did however
Running head: DIABETES MANAGEMENT
18
state that she saw how technology could help improve follow-ups with patients and
increase the patients’ educational participation after the initial teaching. She said she is
willing to try anything that could help increase education and improve outcomes for her
patients. The educator also stated she saw the importance of technology in the future and
how online programs and smart phone apps could offer a place for questions to be
answered 24/7 and could provide better follow up and tracking than what currently takes
place at the center.
“One of the most significant barriers to diabetes self-management is the burden of
tracking and collating all of the important elements to manage the disease (Tang et al.,
2012, p. 3).” The lack of log keeping, communication, and follow up by patients as seen
at the center is evidence of a need for change in diabetes education and management.
Patients with diabetes have a potentially life-long disease that can lead to serious and lifethreatening comorbidities. For this reason follow-ups are necessary to ensure the patients
understand the education taught and that they are capable of managing their diabetes. IT
can help monitor whether the patient understands and follows these education and
management skills by keeping a log of the patients’ blood glucose, diet, exercise, weight,
and more.
These online programs/applications also have support and question forums from
which patients can benefit 24/7. For example, J. Tran, R. Tran, & White (2012) share
that the app Glucose Buddy allows patients to record and monitor glucose, medications,
carbohydrate intake, and A1C and enables data to be easily synchronized online where it
can be shared with healthcare providers. The app also gives reminders to check blood
glucose and take medication at specific time intervals. There is also an online forum
Running head: DIABETES MANAGEMENT
19
enabling users to share their experiences and have questions answered from others (p.
176). Patients are more likely to use these applications for monitoring because they do
not actually have to leave their homes, they can simply e-mail their results to their
educator or physician, and some of the applications are free to download and install.
Implementation Plan
With the population expanding and healthcare changing, there is an increased
demand on physicians’ to obtain first-rate patient outcomes while managing more
patients with less time. For this reason new methods for healthcare professionals to
partner in managing patients diabetes are needed (Tang et al., 2012). The center for
Diabetes/Nutrition Education is a good place to implement a new method of diabetes
management. Implementation of this project would require multiple steps. The first step
would include determining which web-based diabetes-learning program to implement at
the Center for Diabetes/Nutrition Education, whether it be computer or smart phone
based. Resources used for this include the Auburn University online library databases as
well as the Internet. Next, a flyer will be created that will be given to participants
explaining the online learning program, especially how to upload glucose readings,
record their diet and exercise logs, and use the interactive forums for questions/support.
Again, Auburn University’s’ online library databases will be used for resources on the
programs, as well as the websites/apps themselves, and the Internet will be used for flyer
examples. A print lab is also needed to form and print the high volume of flyers, which
will require financial resources. The subsequent step involves educating the center staff
about how to present the IT flyer to patients and how to instruct the patients to utilize the
website/application. Resources such as peer-reviewed articles on how other facilities
Running head: DIABETES MANAGEMENT
20
implemented web-based learning will be used to educate the staff. The optimal form of
educating involves showing the patient first hand how to use the website/application.
Next, the patients will be selected based on inclusion criteria. The patient information is
available at the center to be used as a resource prior to the patient arrival so the decision
on whether the patient fits criteria or not is made before the patient walks through the
door. Once the patient meets inclusion criteria, baseline information/labs will be
obtained, staff will give them a flyer, provide a detailed explanation on the IT program,
and provide them with glucometers and computers/smart phones if the patients do not
already have such resources, or help them set up the program for those who do. This will
require staff to assist participants with becoming familiar with the IT program before they
leave the center. The participants will then leave and start their IT education and diabetes
management. Finally, data on patient outcomes with web based intervention will be
collected via mailed or over-the-phone questionnaires and laboratory data. Money for
stamps, envelopes, and printed questionnaires will be needed, as well as time from the
personnel to contact each patient and check follow up labs. All desired outcomes will be
measured and recorded using the statistics program at pre-implementation, six weeks
post-implementation, six months post-implementation, and a year post-implementation.
The methods for measuring these outcomes will be discussed further in the evaluation
section.
Potential Facilitators and Barriers
The center for Diabetes/Nutrition Education already has the name of web
resources printed on the back of their booklet, however I would seek to maximize this IT
resource by providing a more detailed flyer description of how the websites/applications
Running head: DIABETES MANAGEMENT
21
can help/be used. The manager said she would pass out anything to her patients that may
help their diabetes management, and evidence-based flyer on IT programs for diabetes
management would fit this criterion. There are six employees at the center, therefore it
would be relatively easy to meet with all of the employees and educate them on the IT
program being implemented. Staff at the center talk with each patient individually and
can assess whether the patient meets criteria and if they should be given the flyer and
detailed explanation on the IT program. At this time the staff could obtain a baseline
glucose and HgbA1C from their records, weight, and BMI from patient. The biggest
facilitator to this project is that the educators having a strong passion for the wellness of
their patients, and therefore the willingness to try implementing the parts of the EBP
project capable.
Potential barriers to this EBP project are the small volume of patients, the older
age of the patients, the lack of access or lack of knowledge of computers or smart phones
of the patients, the budgetary requirements needed to provide patients with computers
and online access, or smart phones, and the cultural barriers of the center employees. The
educator stated most patients are older adults and that it was her feeling that most do not
use computer resources or smart phones for their diabetes education possibly due to lack
of access, which they do not supply, or lack of knowledge about maneuvering websites
and applications. There are many computer websites and smart phone apps that are free
or of low cost, however getting patients who do not have a computer/smart phone these
devices could be a huge financial requirement as well as a large requirement in time and
money from the human resources standpoint for the staff needed to train the patients on
Running head: DIABETES MANAGEMENT
22
using the computers and websites. Exploring grants and insurance options could be an
option to possibly minimize this burden.
On the opposite barrier spectrum, is that of the culture of the centers’ employees.
Some of the educators at the center seem hesitant about the use of IT for diabetes
education and management, doubting its’ validity and fearing a change from the norm.
This barrier will attempt to be minimized by showing them the positive research found on
IT education and diabetes control. Another barrier involving center staff is that the
project director would not be at the site at all times to ensure the correct patients were
included or that the flyer was actually handed out and explained. To minimize faulty
patient selection and lack of handing out flyers, the criteria for selection will be stressed
with the staff at the center as well as the importance of handing out the flyer.
A barrier to the outcome measurement portion of this project is that center
employees will not be paid extra for calling participants and therefore may not desire to
do so, leaving it on the project leader. Patients may not return calls or e-mailed or mailed
questionnaires. The barrier of lack of patient response could be minimized by frequent
calls or e-mails to the participants explaining the importance of their response.
Evaluation Plan
Population data important to collect for this EBP project includes gender, age,
ethnicity, and coinciding diagnoses. These are important because significant variances in
any of these can skew results, for example, a 76 year old female with arthritis may not be
able to lose weight or use a computer the way a 26 year old male with no comorbidities
can. This population data will be collected by the initial nurse/dietician via a
questionnaire prior to the EBP project being implemented, as well as an initial blood
Running head: DIABETES MANAGEMENT
23
glucose, HgbA1C level, weight/BMI, amount of exercise per week, and the patients’
overall confidence in their diabetes management abilities and knowledge/behavior about
what foods to eat and which to avoid, signs and symptoms of hyper/hypoglycemia,
potential complications to look for, and how to properly use insulin, measured via a
visual analogue scale (VAS). This same data will be measured six weeks postimplementation, six months post-implementation, and a year post-implementation by a
staff nurse. All of the data from this one pilot at the center will be transferred to the
statistical software program Statistical Package for the Social Sciences (SPSS) in order to
better track and visualize results.
Expected Outcomes
Expected short-term outcomes for six weeks post-implementation of this specific
EBP project include a decrease in blood glucose levels of patients to under 170 observed
on the trend tracker/glucose log, a HgbA1C less than 8, a decrease in BMI (for those
patients needing a reduction in BMI), and an increase in behavioral change, such as an
increase in knowledge/confidence on diabetes management, as evident on the VAS.
Long-term outcomes for one year post-implementation include better health outcomes
such as more consistent control of blood glucose levels, between 70 and 160, a decrease
in HgbA1C level, preferably to a level less than 7, a BMI preferably under 25, but
specific for each patient.
The process of measuring knowledge/behavior outcomes, as well as the patients
overall confidence in their diabetes management abilities, will be a VAS. Foley (2008)
writes that visual analogue scales are a form of graphic rating scale in which the rater
Running head: DIABETES MANAGEMENT
24
places a mark along a100 mm long line with no marks between the ends where one end
of the line represents 0 and the other end represents 100. Raters place a mark at a point
along the line to indicate their rating. The scale is scored using a ruler, measuring in
millimeters, the score being reflected by how many mms from 0 the rater has placed a
mark. Visual analogue scales have been compared with other kinds of scales to
determine whether two scales produce similar results and it was found that the VAS was
similar in both reproducibility and sensitivity (Foley, 2008). VAS has been used for
several years and has consistently produced evidence of reliability and validity. Foley
(2008) states that, “given the flexibility of this kind of scale, it has the potential to
enhance many areas of measurement in nursing education” (p. 210). This scale will be
particularly valuable in measuring the patients’ confidence in diabetes management
because as stated by Turner, Draaisma, Oosterveld, and ten Cate (2008), the VAS offers a
quick and simple measure of self-efficacy, which can be defined “as a persons’ belief in
his or her capability to organize and execute the course of action required to produce
particular outcomes”(p. 503). A strong sense of self-efficacy is believed to influence an
individuals’ behavior by influencing choices, thought patterns, and emotional reactions
and determining effort (N. Turner et al., 2008). The VAS is shorter than other
questionnaires, and therefore may improve compliance. Measurement of the more
specific outcomes, such as blood glucose levels, HgbA1C levels, and weight/BMI, will
be checked via logs, blood tests, and a calibrated physician scale, which along with
height, allows for interpretation of the patients’ BMI.
Implementation of the Small Test of Change
Running head: DIABETES MANAGEMENT
25
A small test of change (STOC) pilot was executed at the Baptist Health Center for
Diabetes and Nutrition Education. It involved creating a pamphlet on the application
GlucoseBuddy, recruiting participants, educating participants on the app and installing
the app on their phones if available or instructing them how to download it on their
computer. Data was collected pre-pilot and four weeks after the participants used
GlucoseBuddy. Expenditures for this project included the cost of supplies such as paper
and ink used for the consent and flyers given to participants, as well as the gas and
mileage used driving to and from the center recruiting participants. No financial burdens
were presented to any participants or to the clinical setting employees or stakeholders.
The STOC pilot commenced January 14th, 2014. The first few weeks were spent
gathering and organizing all evidence-based articles and supplies for the project, gaining
approval for the project from Baptist and Auburns’ institutional review boards (IRB), and
creating a timeline for the project implementation. The project was put on hold for a few
days because Auburn’s IRB required additional information. After receiving IRB
approval, the Baptist Health Center for Diabetes and Nutrition Education staff were
educated about the project, including participant requirements, the IT program
GlucoseBuddy, and the flyer (Appendix 2) and consent forms to be given to the
participants. Dates for recruiting participants were then discussed and decided upon
based on whether the date had patients who could be potential participants. Participants
had to be adults over the age of 18 diagnosed with T2DM and referred to the diabetes
center by their primary care physician. These patients had to have a smart phone or
access to a computer in order to be able to use the IT and be involved in this pilot
Running head: DIABETES MANAGEMENT
26
The project commenced at the center January 31st, 2014. The goal was to have
10 participants by February 14th, 2014, however this had to be pushed back to February
28th, 2014 because it was rather difficult obtaining willing and capable participants.
Multiple factors contributed to this including the center not having a high volume of new
diabetic patients and many of the prospective patients not showing up. Another issue was
that many of the patients were elderly and did not want to participate due to not having a
smartphone or not having much knowledge of computers. By February 28th however,
five participants were enrolled in the pilot. The participants were given a flyer on the
project as well as a detailed explanation on the GlucoseBuddy application. After giving
consent, baseline information was obtained from the participants. This information
included their age, gender, ethnicity, years since diagnosis of diabetes, diet, oral diabetic
medications, insulin type, weight, Body Mass Index (BMI), average blood glucose,
HgbA1C, participant’s current weekly exercise amount, and confidence score based on
the VAS questionnaire they filled out (Appendix 3). Next, the IT application was either
downloaded to the participants’ smartphone or they were sent home with instructions on
how to get it on their phone/computer later. The participants then went on to use the
application to help manage their diabetes.
Participants were called after initiation of the project to follow up on any
questions or concerns about the application/project they might have had. On March 28th,
2014, post-implementation data was collected from all five participants for analysis on
the projects’ efficacy. This data included their weight, exercise routine, blood sugar, and
confidence score based on the VAS questionnaire. The data was compiled into an excel
spreadsheet as well as SPSS software for appraisal.
Running head: DIABETES MANAGEMENT
27
Data Management
The variables, gender, and ethnicity were entered into an excel spreadsheet as 1male and 2-female, and 1- Caucasian, 2- Latino, 3- African American, and 4- other. The
participant’s age and years since diabetes diagnosis were entered as current age and
amount of time in years. The current diet variables were entered as: 1- regular, 2- low
carb (diabetic), 3- low fat, 4- low salt, and 5- other/combination. The current oral
diabetes medications used were labeled as: 1-Metformin, 2- Glipizide/DiaBeta, 3Avandia/Actos, 4- Januvia, 5- other/combination, and 6- none. The variables of use of
insulin types were labeled as: 1- Humalog/Novalog, 2- Humulin R/Novolin R, 3Humulin N/Novolin N, 4- Levemir/ Lantus, 5- other/combination, and 6- none. Weight
was entered in pounds, and current weekly exercise amount was entered as: 1- never, 21-3 times week, 3- 3-5 times week, and 4- daily. The average initial glucose and HgA1c
levels were obtained based on the patients record and BMIs were obtained based on the
patients weight and height given. The VAS scores were entered as answered on the
participants’ questionnaire sheets.
Analysis Report
The data was entered into the statistical software program Statistical Package for
the Social Sciences (SPSS) and descriptive and inferential statistical analyses were
conducted. The groups’ data was analyzed for improvement using t-Tests. The variables
compared were their initial BMI, weight, blood glucose, exercise, and VAS score with
the post-implementation BMI, weight, blood glucose, exercise, and VAS score. The
level of significance was set at alpha = .01 due to the small sample size.
28
Running head: DIABETES MANAGEMENT
Description of sample. The group (n=5) was 60% male, 60% Caucasian, and
40% African American. The mean age of the participants was 56.8 (14.2 SD) years. Of
the participants, 20% reported eating a low carb diet, 40% a regular diet, and 40% a
combination or other diet. Initial exercise of the participants consisted of 80% never
exercising and 20% exercising 1-3 times a week. The mean for the initial VAS score was
64.4 (25.6 SD).
Tests for improvement. Paired samples statistics were computed for variables of
pre and post participation BMI, weight, blood glucose, exercise, and VAS score. After
implementation, the groups’ mean weight dropped from 233.6 (41.5 SD) to 229.2 (38.3
SD). The result was significant with a t score of 2.4 with a p-value of 0.07. The initial
mean BMI for the group was 33.6 (5.5 SD), and post-implementation the mean was 32.98
(5.1 SD). This showed significant improvement with a t score of 2.5 and a p-value of
0.07. The initial blood glucose readings for the group was 197 (54.3 SD), dropping to
119.2 (36.1 SD) post participation. This has a t score of 2.5 and a p-value of 0.07. These
results are illustrated in Figure 1.
Results with Significant Change
300
200
PRE
100
POST
0
WEIGHT
BMI
BLOOD GLUCOSE
Figure 1. Results with Significant Change. Weight: t= 2.4 p= .07, BMI: t= 2.5 p= .07, and blood
glucose: t= 2.5 p= .07
29
Running head: DIABETES MANAGEMENT
The VAS questionnaire used to collect confidence data had a pre-implementation
mean of 64.4 (25. 6 SD), and a post- implementation mean of 86 (8 SD), showing
significance with a t score of -2.6 and a p-value of 0.06. Of the 10 questions on the
questionnaire, 5 were significantly improved and are illustrated in Figure 2.
Specific Confidence Questions with Significant Change
Post
Pre
How confident do you feel about your knowledge
on your diabetes medications? t= -2.9 p= .05
How confident do you feel that you know what to
do when your blood sugar level goes higher or
lower than it should be? t= -3 p= .04
How confident do you feel about recognizing
signs of high and low blood sugar? t= -2.3 p= .09
How confident do you feel that you understand
what diabetes is? t= -3.7 p=.02
8.8
3.6
6.4
6.4
8.6
8.6
7.8
9.8
Figure 2: Specific Confidence Questions with Significant Change
Application to Overall Project
This small test of change helped highlight issues that would need to be addressed
before implementing the larger project. First, more participants would need to be
included to get a better judge of efficacy. There was difficulty recruiting participants
because there was a low amount of newly diagnosed diabetics at the center on days the
project leader was present and most of the patients were elderly and not interested in or
unfamiliar with smartphones and computers. Perhaps another clinical setting would be
more conducive for the project in terms of having a higher number of younger to middle
aged adults who are more familiar with smartphones or computers and in turn would be
more willing to participate in a project with these devices. With more funding, the staff
Running head: DIABETES MANAGEMENT
30
where the pilot would be executed could be educated on how to conduct an evidencebased pilot and how to maneuver the specific app GlucoseBuddy. This would allow the
staff to be able to recruit participants for the pilot, leading to the possibility of gaining
more participants than possible with just the project leader recruiting.
Some potential participants could not take part in the pilot because they did not
have a smartphone or access to a computer. It would greatly benefit the larger project to
be able to provide the participants with a form of one of these devices, either an iPhone or
iPad for example. Not only would providing devices allow for more participants, it
would also allow the project leader to track how often and how much the participants
used the GlucoseBuddy application.
More frequent check-ins with the participants would help trouble shoot questions
about the application as well as remind the participants to use the IT. These check-ins
could be done monthly via phone calls or more ideally clinic or home visits where the
device being used could be checked by the project leader. Also the implementation
would need to be set over a longer time frame, such as a year, in order to more adequately
evaluate the long-term effectiveness of the intervention. The STOC did show decreases
in blood glucose, however the time frame was to short to be able to monitor the more
precise judge of blood glucose control, HgbAlC.
Conclusions
Diabetes Mellitus is a tangible and prevalent problem that left unmanaged can
lead to severe complications. Control of diabetes leads to a better quality of life for
patients and a decreased risk of developing comorbidities. Advanced practice nurses
have a tremendous responsibility towards their patients in relation to educating them on
Running head: DIABETES MANAGEMENT
31
how to control and manage their diabetes. With the prediction of diabetes incidence
rising drastically in the next 50 years, healthcare must attempt to get ahead of the
problem by finding programs with the best evidence-based reports of improvement for
managing the intricate disease of diabetes and preventing its’ complications. By
implementing an evidence-based project and choosing a research framework to guide
explorations, it is possible to ascertain the best evidence for managing diabetes. Clinical
practice is based off of this evidence, therefore, in advanced practice nursing it is
imperative to find the strongest evidence available and develop recommendations based
upon said recommendations. Advanced practice nurses must be able to provide patients
with the best tools available for increasing their understanding of diabetes and their
ability to manage it.
The small test of change did result in noteworthy changes in blood glucose,
weight, BMI, and confidence in diabetes management over the 4 weeks of
implementation. The significance of this report supports the incorporation and utilization
of Information Technology programs, such as GlucoseBuddy, in this setting to help
educate about and manage diabetes.
Running head: DIABETES MANAGEMENT
32
References
AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. (2007). American
association of clinical endocrinologists medical guidelines for clinical practice for
the management of diabetes mellitus. Endocrine Practice, 13(1). Retrieved from
http://bestwebdecisions.com/diabetesed.net/resources/ClinicalPracticeGuidelines12
0.pdf
Adaji, A., Schattner, P., & Jones, K. (2008). The use of information technology to
enhance diabetes management in primary care: A literature review. Informatics In
Primary Care, 16(3), 229-237.
Cooper, H., Cooper, J., & Milton, B. (2009). Technology-based approaches to patient
education for young people living with diabetes: A systematic literature review.
Pediatric Diabetes, 10(7), 474-483. doi:10.1111/j.1399-5448.2009.00509.x
Facchiano, L., Snyder, C., & Núñez, D. E. (2011). A literature review on breathing
retraining as a self-management strategy operationalized through Rosswurm and
Larrabee's evidence-based practice model. Journal Of The American Academy Of
Nurse Practitioners, 23(8), 421-426. doi:10.1111/j.1745-7599.2011.00623.x
Foley, D. (2008). Development of a visual analogue scale to measure curriculum
outcomes. Journal Of Nursing Education, 47(5), 209-213. doi:10.3928/0148483420080501-04
Karakurt, P., & Kaşıkçı, M. (2012). The effect of education given to patients with type 2
diabetes mellitus on self-care. International Journal Of Nursing Practice, 18(2),
Running head: DIABETES MANAGEMENT
33
170-179. doi:10.1111/j.1440-172X.2012.02013.x
McMahon, G. T., Gomes, H. E., Hohne, S.H., Hu, T. M., Levine, B. A., & Conlin, P. R.
(2005). Web-based care management in patients with poorly controlled diabetes.
Diabetes Care 28(7). Retrieved from
http://www.mycareteam.com/documents/boston_va_randomized_clinical_trial.pd
f
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing &
healthcare (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Polisena, J. J., Tran, K. K., Cimon, K. K., Hutton, B. B., McGill, S. S., & Palmer, K. K.
(2009). Home telehealth for diabetes management: A systematic review and metaanalysis. Diabetes, Obesity & Metabolism, 11(10), 913-930. doi:10.1111/j.14631326.2009.01057.x
Sevean, P., Dampier, S., Spadoni, M., Strickland, S., & Pilatzke, S. (2009). Patients and
families experiences with video telehealth in rural/remote communities in
Northern Canada. Journal Of Clinical Nursing, 18(18), 2573-2579.
doi:10.1111/j.1365-2702.2008.02427.x
Smith, K. E., Levine, B. A., Clement, S. C., Hu, M., Alaoui, A., & Mun, S. K. (2004).
Impact of MyCareTeam for poorly controlled diabetes mellitus. Diabetes
Technology & Therapeutics 6(6), 828-835. Retrieved from
http://www.mycareteam.com/documents/SmithDiabetesTech_TherArticle.pdf
Running head: DIABETES MANAGEMENT
34
Tang, P. C., Overhage, J. M., Chan, A. S., Brown, N. L., Aghighi,B., Entwistle, M. P,
Hui, S. L., Hyde, S. M., Klieman, L. H., Mitchell, C. J., Perkins, A. J., Qureshi, L.
S., Waltimyer, T. A., Winter, L. J., & Young, C. Y. (2012). Online disease
management of diabetes: Engaging and motivating patients online with enhanced
resources-diabetes (EMPOWER-D), a randomized controlled trial. Journal of the
American Medical Informatics Association,0, 1-9. doi:10.1136/amiajnl-2012001263
Thurston, N. E., & King, K. M. (2004). Implementing evidence-based practice: Walking
the talk. Applied Nursing Research, 17(4), 239-247.
Tran, J., Tran, R., & White, J. R. (2012). Smartphone-based glucose monitors and
applications in the management of diabetes: An overview of 10 salient “apps” and
a novel smartphone-connected blood glucose monitor. Clinical Diabetes, 30(4),
173-178. Retrieved from
http://clinical.diabetesjournals.org/content/30/4/173.full.pdf
Turner, J., Larsen, M., Tarassenko, L., Neil, A., & Farmer, A. (2009). Implementation of
telehealth support for patients with type 2 diabetes using insulin treatment: An
exploratory study. Informatics In Primary Care, 17(1), 47-53.
Turner, N., AJ, Draaisma, J., Oosterveld, P., & ten Cate, O. (2008). Validity of the visual
analogue scale as an instrument to measure self-efficacy in resuscitation skills.
Medical Education, 42(5), 503-511.
Running head: DIABETES MANAGEMENT
Zyskind, A., Jones, K., Pomerantz, K. & Barker, A. (2009). Exploring the use of
computer based patient education resources to enable diabetic patients from
underserved populations to self-manage their disease. Information Services &
Use, 29(1), 29-43. doi: 10.3233/ISU-2009-0592
35
Running head: DIABETES MANAGEMENT
36
Appendix 2
Diabetes Control Study
Be part of an important diabetes research study
Are you older than 19 years of age?
Do you want to be able to better understand and control your diabetes?
Do you have access to a smartphone or computer?
If you answered YES to these questions, you may be eligible to participate in
research study on diabetes and information technology (IT).
The purpose of this research study is to determine if in patients with diabetes
mellitus, using information technology to deliver education and management
strategies compared to only face-to-face interactions, improves patient glucose
control, lifestyle choices, and knowledge. Benefits include having access to a log that
can be used to record and monitor blood sugar, medications, food intake, HgbA1C,
weight, and exercise, as well as access to an online forum where you can share
experiences and questions with others. The app also gives reminders to check blood
glucose and take medication at specific time intervals. No medications will be given.
It is theorized that using technology will help decrease your blood sugar levels,
HgbA1C, and BMI (weight), and can help increase your knowledge and confidence
on your diabetes management.
This study is being conducted by the Baptist Health Center for Diabetes and
Nutrition Education.
Please discuss with the center staff for more information or Kailey Hamrick, RN at
kmh0051@auburn.edu.
37
Running head: DIABETES MANAGEMENT
Appendix 3
Diabetes Management Through Information Technology Initial
Questionnaire
Personal Information:
1. Name:
Date:
2. Phone number:
3. Email:
4. Address:
5. What is your age:
6. What is your gender:
Male
7. What is your ethnicity:
Other
Caucasian
8. What type of diabetes do you have:
Female
Latino
African American
Type 1
Type 2
9. How many years have you been diagnosed with diabetes:
10. What type of diet do you follow:
Low fat
Low salt
Regular
Low carb (diabetic)
Other/ combo
11. What oral diabetes medications are you currently taking:
Glipizide/ DiaBeta
Avandia/ Actos
Other/ combo
None
Metformin
Januvia
12. What type of insulin are you currently on: Humalog/ Novalog
Humulin R/Novolin R
Humulin N/Novolin N
Lantus
Other/ combo
13. How much do you weigh:
14. How tall are you:
15. Current average blood sugar:
16. Current HgbA1C:
Levemir/
None
38
Running head: DIABETES MANAGEMENT
17. How often do you exercise: Never
Daily
Visual Analogue Scale Survey:
1-3 Xs week
3=5 Xs week
1. How confident do you feel that you understand what diabetes is?
Not at all
Confident
1
2
3
4
5
6
7
8
9
10
Completely
Confident
2. How confident do you feel about recognizing signs of high and low blood sugar?
Not at all
Confident
1
2
3
4
5
6
7
8
9
10
Completely
Confident
3. How confident do you feel that you know what to do when your blood sugar level goes
higher or lower than it should be?
Not at all
Confident
Completely
1
2
3
4
5
6
7
8
9
10 Confident
4. How confident do you feel about checking your blood sugar?
Not at all
Confident
1
2
3
4
5
6
7
8
9
10
Completely
Confident
5. How confident do you feel that you can choose the appropriate foods to eat when you
are hungry and which to avoid (for example, snacks)?
Not at all
Confident
Completely
1
2
3
4
5
6
7
8
9
10 Confident
6. How confident do you feel about your knowledge on your diabetes medications? Skip
if not applicable.
Not at all
Confident
1
2
3
4
5
6
7
8
9
10
Completely
Confident
7. How confident do you feel that you can judge when the changes in your illness mean
you should visit the doctor?
Not at all
Confident
Completely
1
2
3
4
5
6
7
8
9
10 Confident
8. How confident do you feel about understanding potential complications of diabetes?
39
Running head: DIABETES MANAGEMENT
Not at all
Confident
Completely
1
2
3
4
5
6
7
8
9
10 Confident
9. How confident do you feel that you can control your diabetes so that it does not
interfere with the things you want to do?
Not at all
Confident
Completely
1
2
3
4
5
6
7
8
9
10 Confident
10. How confident are you that information technology (smart phone or computer
applications) will help you manage and learn about your diabetes?
Not at all
Confident
Completely
1
2
3
4
5
6
7
8
9
10 Confident