Diabetes conversation map in Nigeria: A new socioeducational tool in diabetes care.

The importance of diabetes education in the management of patients is very crucial. One-on-one education, didactic group lectures are traditional methods employed in Diabetes Education. In our environment, group interaction using the Diabetes Conversation Map tools may prove to be effective especially during regular meetings of the Diabetes Association.

INTRODUCTION

The increase in prevalence of diabetes worldwide is currently a source of concern. The recent figures released by the International Diabetes Federation (IDF) indicate that as at the year 2011, 366 million people were living with diabetes worldwide and this figure is expected to rise to 520 million by 2030.[1] Most of this increase will be in low and middle income countries that are expected to experience an increased prevalence of about 90%.[1]

The importance of good glycaemic control in the prevention of diabetes complications has been shown in some landmark studies.[23] In addition, diabetes is considered to be an independent risk factor for cardiovascular disease and a coronary event.[4] This has led to recommendations that hypertension and dyslipidaemia be handled aggressively in patients with diabetes to reduce their risk of dying from cardiovascular disease. This is more so as cardiovascular disease is a common cause of diabetes mortality.[5]

Diabetes education is a very crucial aspect of management of a patient with diabetes. Lifestyle modification which includes diet management, weight reduction and regular exercise is the initial step in management of any newly diagnosed patient.[6] This continues even when drugs are introduced for better glycaemic control. The adoption and maintenance of proper lifestyle measures by a patient with diabetes can only be successful if there is proper education of the patient about the disease to enhance treatment. Diabetes education has been shown to improve patients’ knowledge and attitude to the disease, and also glycaemic control.[7] It is recommended that initial and on-going education on self-management should be made available to all patients with diabetes.[8]

Tools for diabetes education

The basic method for diabetes self-management education is the one-on-one interaction between a patient and his health care provider. This could be a primary health care physician, a specialist or a nurse. Formal diabetes educators are an integral part of most clinics that attend to persons with diabetes.

Lack of supportive health care systems has been a key obstacle in the implementation of effective diabetes management strategies. The adoption of chronic care models by some institutions has been shown to be beneficial.[8] The elements of a chronic care model include decision support, clinical information systems, self-management education, and delivery system redesign.[8] The American Diabetes Association recommends that variety of strategies and techniques should be used to provide adequate education and development of problem-solving skills in the various aspects of diabetes management.[9]

The conversation map

Diabetes conversation maps are new tools designed to engage patients in making behaviour changes needed for better health. They are visual tools designed for use by small interactive groups of usually 3 to 10 persons. The participants learn about the key topics in diabetes which include; basic facts about diabetes, living with diabetes, healthy eating, staying active, self-monitoring of blood glucose, diabetes complications and gestational diabetes.

The earliest development of the conversation map was in Canada in 2004 after observing how the forms were used in business organizations and felt it could be adapted for use in health education.[10] A team of educators selected by the Canadian Diabetes Association worked with the company Healthy Interactions Inc. to develop the first maps. After a pilot study, the maps were introduced in 2005 to Canadian diabetes educators. It was observed that the educators needed to be trained in the use of the maps. This was because the role of the educators as facilitators required a different set of skills.[10] In a survey conducted on the earliest educators to use the maps, one of them reported that it was not very easy to act as a facilitator rather than the educator she was used to being. She said that she found it hard to just listen as the participants worked their way through the map stations and had to restrain herself from giving out the right answers immediately. A few of the educators reported negative experiences with the maps. These constraints included lack of space, reluctance to open up to discussion by some of the participants and occasional personality clashes among the participants.

A US based conversation map was produced by Merck® in partnership with the American Diabetes Association (ADA) in 2006. The US conversation maps consist of five maps. Map 1 provides an overview of diabetes, Map 2 discusses healthy eating, Map 3 highlights the importance of monitoring glucose and map 4 describes the natural course of diabetes and the long-term complications while Map 5 focuses on gestational diabetes. The IDEA study (Interactive Dialogue to Educate and Activate) aimed to investigate the usefulness of the US conversation map as a tool for diabetes education in comparison with individual education or usual care.[11] The study also showed the importance of training educators as facilitators prior to the use of the maps for patient education. Further analysis however suggested that though mean HbA1c decreased in all groups, patients who underwent individual education had better glucose control outcomes than those who had group education with the conversation map.[12]

Eli Lilly® launched the Diabetes Conversation map in 2008, in collaboration with Healthy Interactions, a global leader in health education and the European region of the IDF. The conversation map consists of a 3 feet by 5 feet table top visual which serves as a focal point for the discussion. There are also question and discussion cards with which prior knowledge and attitudes about diabetes are explored. There is a facilitator who guides the participants in the discussion. The facilitator is a trained diabetes educator who reads out the cards to stimulate participant discussion. These cards are presented as “myth” versus “fact” in which myths about diabetes are read aloud, they are discussed and then the fact is presented in a clear and concise manner. Within the first year of its launch, the maps had been distributed in 68 countries in 31 different languages.

By 2010, the Eli Lilly maps were introduced in Sub-Saharan Africa. A training of experts on the use of the conversation maps took place in Abuja, Nigeria, in August 2010. Following this, maps were distributed to participants from all the zones of the country and are gradually being introduced into diabetes education programs. Follow-up studies on their use in our environment are anticipated. The level of acceptance among Nigerian diabetics is high. The Northern Muslims who traditionally use mats during prayers prefer laying the maps on the floor and they sit around it during educational sessions.

The use of conversation maps in Nigeria

Common methods of diabetes education across the country include one-on-one interactions with various members of the diabetes care team and the use of didactic lectures during clinic visits or meetings of the Diabetes Association of Nigeria. In the typical crowded clinics commonly encountered in most centres in Nigeria, these methods may not be very effective. The use of these maps in smaller groups may greatly improve patient outcomes. This is more so considering the fact that a lot of myths and superstitious practices are common among our patients.

CONCLUSION

The importance of diabetes education in the management of patients cannot be over-emphasised. One-on-one education, didactic group lectures are traditional methods employed in the education of patients. The introduction of new tools such as the conversation maps will likely improve patient outcomes. In our environment, group interactions are likely to be effective especially during regular meetings of the Diabetes Association of Nigeria.