Department of State Hospitals-Patton

Barriers to Diabetes Education within the Psychiatric Long-Term Care System

1/03/19

Jonathan Tellier, Dietetic Intern

Introduction/Literature review.
Diabetes mellitus, is a chronic illness that places a large load on the public health sector. There

are three different types of diabetes mellitus, type one, type two, and gestational diabetes.

Diabetes mellitus type one develops from a cell-mediated autoimmune response causing a

gradual loss of B cells within genetically susceptible people (Nelms et al. 2015). For example

40-50% of people carrying a specific gene on the HLA region of chromosome 6, develop type 1

diabetes mellitus. Diabetes mellitus type two is considered to be polygenic and is a progressive

disease that develops due to inadequate insulin production, or decreased insulin sensitivity, or

both. Environmental factors influencing development of diabetes type 2 include obesity, poor

nutrition, and physical inactivity. Gestational diabetes mellitus develops from an alteration in

insulin secretion and alterations in glucose, lipid, and amino acid metabolism. These alterations

occur during the second or third trimester of pregnancy in order to meet maternal and fetal

demands. CDC (2018) estimates 39.8% of the U.S. population to have obesity. Obesity is found

amongst 50% of patients that have a diagnosis of schizophrenia and are currently being treated

with antipsychotic medications (Annamali et al. 2017). The rate of obesity in patients with a

diagnosis of schizophrenia is 10.2% higher than in the general public. Olanzapine is a common

antipsychotic prescribed, which has a high probability of causing diabetes. Throughout this paper

diabetes mellitus will be referred to as diabetes and will encompass all types.

Patients that develop diabetes are at increased risk of developing kidney disease and

cardiovascular disease. Diabetes affects 9.4% of the U.S. population and in 2015 diabetes was

the 7th leading cause of death (American Diabetes Association). Patients with schizophrenia

have a decreased life span of up to 20-25 years due mostly to physical illness, instead of factors

directly associated with psychiatric conditions, however, one study was unable to find a

significant prevalence of diabetes amongst those taking psychiatric medications (Abitbol et al.
2017). Although diabetes is not more common amongst patients with schizophrenia taking

antipsychotic medications, obesity is. Thus, clinicians should be proactive about screening,

monitoring, and implementing education for diabetics.

Literature Review

Abitbol et al. (2017) evaluated outpatient geriatric patients exposed to antipsychotic medications

and their risk of developing diabetes compared with psychiatric and non-psychiatric controls of

similar age. This study evaluated a total of 325 patients with a psychiatric condition, sixty-four

of which were atypical antipsychotic-unexposed, 61 atypical antipsychotic-exposed, and a group

of 200 controls that were psychotropic-naive. The results were shown to be insignificant,

however, increases in fasting glucose were independently associated with antidepressants,

cholinesterase inhibitor, or valproate use. Although the significance of these findings have not

been investigated. Treatment of diabetes has been a challenge in many institutions, and some

non-traditional barriers exist when trying to educate patients with a diagnosis of schizophrenia

(Abitbol et al. 2017). Some of the barriers include low motivation, apathy, and cognitive deficits,

which are the symptoms of schizophrenia.

The foundation of diabetes care is education, nutritional therapy, and physical exercise.

Diabetes education can improve self-care and knowledge, which in turn improves HbA1c,

triglycerides, and body weight. Lopez et al. (2017) found using multimedia educational tools in

combination with nutritional therapy is an effective method to improve HbA1c, triglycerides, and

weight. Very few patients with diabetes (25%-30%) can control their HbA1c to optimal levels

less than or equal to 6.5% on their own or with treatment. Adequate metabolic control can help

prevent micro and macrovascular complications. This study found that HbA1c, glucose, total

cholesterol, LDL-C, HDL-C, triglycerides, and atherogenic index all improved to a greater
degree in the subject group receiving nutrition therapy and multimedia education. Although this

study was able to show improvements in HbA1c, triglyceride, and body weight, similar studies

showed that only knowledge and perception of risk is influenced by multimedia education.

Jonesa et al. (2013) recognized for a patient to be willing to participate in group education it is a

question of their self efficacy to read or write.

Self-efficacy is important when considering how motivated a person is to learn (Jonesa et

al. 2013). Self-efficacy is an individual's innate belief in their ability to achieve goals. Bandura’s

four sources of efficacy is referenced in this literature. Bandura’s four sources include mastery

experiences, emotional/physiological states, social/verbal persuasions, and vicarious experiences,

this theory tries to explain where self-efficacy originates. “Mastery experiences” are the mastery

of a certain skill no matter what it is and how this can influence one’s efficacy belief in the long-

term. “Emotional state” depends on what a person is feeling or their mood. Emotional factors can

decrease the ability to problem solve, remember, learn, and think. “Physiological state” can be

how well nourished a person is or how well a person sleeps the night before. Influential people in

someone's life such as a teacher or parent can influence and strengthen a person's belief in their

ability to succeed, this is “verbal persuasion.” “Vicarious experiences” is the observation of

others success. This study defined sources of self-efficacy and attempted to evaluate self-efficacy

to read and write to determine if these are barriers to participation in prison education. Jonesa et

al. (2013) found that prison education is seen as ordinary school by inmates serving a shorter

sentence and prison education is not adapted to the needs of the inmate with a short sentence. No

findings indicated reading skills to be a predictor of participation in education, but writing skills

are. A populations living circumstances and past personal history is important in considering

self-efficacy. Patients may also need multiple modalities to facilitate learning.

 This study evaluated heart disease but the mode of education could be used for diabetes

education as implied. Mensing et al. (2003) evaluated what is more effective, group education or

individual education interventions. There are benefits to both modalities. Group education

practitioners are able to save time by delivering the education to multiple people at a time,

whereas one on one counseling is time consuming. Groups are also economically efficient and if

patient centered can improve self-efficacy. After implementing groups where patients were able

to share past experiences and rehearse communication skills patients had increased self-efficacy

and feeling of control over their medical condition.

Purpose Statement

Department of State Hospitals-Patton (DSH-P) has been trying to implement a diabetes clinic or

educational group that patients can attend once per month for continued education and improved

diabetes outcomes. DSH-P is a psychiatric facility housing approximately 1,500 patients, all of

which have a form of mental illness and are taking antipsychotic medications. Most

antipsychotic medications increase appetite and promote weight gain in patients (Annamali et al.

2017). This often leads to a downward spiral of obesity and the eventual development of

diabetes. The objective of this study is to determine barriers to implementing diabetes groups by

evaluating if self-efficacy, age, length of stay, perceived ability to read and write, and group

participation are barriers.

Methods

Participants in this study were chosen based on their medication prescription and unit

assignment. The N building potentially had a total of 400 patient participants who took the

questionnaire, of which an estimated 133 participants have an open problem for diabetes. Out of

133 patients with an open problem for diabetes only 18 patients participated. The questionnaire
was dispersed at lunch time in the cafeteria due to convenience of all patients gathering in one

location. The shift leads of each unit recommended lunch would be the best time to disperse this

questionnaire. When dispersed the patients were told “that a questionnaire from nutrition

services is on the table and if they would please fill out the questionnaire that would be

appreciated.” A dietetic intern was available to answer questions. If the patients took the

questionnaire back to the unit they were directed to fill it out and give the form to the nursing

station, where the lead was directed to leave the questionnaires in a folder provided for the

dietetic intern to collect. This method of disbursement was done for units 20, 21, 24, and 25. For

units 22, 23, 26, and 27 the dietetic intern asked each individual at lunch if they have diabetes

and if so would they fill out a questionnaire. The developed questionnaire assessed patient

willingness to participate in a diabetes education group by evaluating barriers mentioned in the

referenced literature. Questions included a modified general self-efficacy scale as well as length

of time spent at DSH-P, age, participation in groups, and

perceived ability to read and write. If a patient denied

having diabetes or did not answer the questionnaire, they

were excluded from this study. Registered dietitians

(RDs) were asked similar questions about self-efficacy of

patients, perceived reading and writing ability of the

patients, and given a free text option for other potential

barriers. The survey for RDs was delivered through

SurveyMonkey, an online platform that helps produce

and deliver surveys.

Results
Bar graphs were used to analyze responses from the RDs. Nineteen RDs received the survey,

only 10 responded. The results of the survey indicate 40% of RDs identify lack of motivation as

a barrier, 50% of RDs identified inadequate staffing or schedule conflicts as a barrier, 20% of

RDs identified intellectual problems as a barrier, 20% of RDs identified poor support systems at

the hospital as a barrier, 10% of RDs identified other barriers, including mental state related to

side effects of medications, and health being a low priority. Multiple choice questions were

analyzed using bar graphs; 100% of RDs identify self-efficacy as a barrier to education, 40% of

RDs identify writing skills as a barrier to education, and 80% of RDs identify reading skills as a

barrier to education.

The questionnaire delivered to patients in N building found the average length of stay to

be 12.7 years and average age of participants to be 49.4 years, 50% recognized they have

reading/spelling difficulty, and 78% currently participate in health-related groups. The average

for all participants for the self-efficacy portion of this questionnaire was 16. To find the general

self-efficacy, 16 is multiplied by two to get 32 on the general self-efficacy scale.

Discussion

We found that patients present with an average self-efficacy score of 32, low motivation, and

apathy. Furthermore, RDs and level of care staff identify inadequate staffing, poor support

systems, and low self-efficacy to read and write as barriers. However, length of sentence is not a

barrier.

The questionnaire delivered to the dietitians found self-efficacy to be a barrier to

education. This is congruent with literature, however, the patients that participated in the

questionnaire scored within the average range of the general self-efficacy scale. The average

range indicated the participants showed the same amount of confidence to successfully handle
situations; generally believed in their ability to problem-solve in most situations; and are not any

more vulnerable to developing anxiety or depression than others. The reason why self-efficacy

was high amongst participants may be due to voluntary questionnaire and participants likely

being higher functioning patients that take their medical conditions seriously. The general self-

efficacy scale can accurately assess self-efficacy and is used worldwide (Jonesa et al. 2003). The

scale used in this research was modified in length for the given patient population. Therefore, the

validity of this questionnaire is in question. However the only alteration to the general self-

efficacy questionnaire is the length; wording and intent of the questionnaire remained the same.

Jonesa et al. (2013) found that low self-efficacy to write can help predict the amount of

participation from a group of individuals. Forty percent of dietitians believed that ability to write

was a barrier to education and 80% find reading to be a barrier to education. This is congruent

with the findings from the patient questionnaire where 50% of participants acknowledge that

they have reading or writing difficulties. Some participants displayed lack of reading and writing

skills. This was evident by the participants need for assistance while filling out the questionnaire.

Those not able to read or write may find it hard to attend groups because group flyers may go

unread. Those that have difficulty writing may find it hard to take notes during classes. Staff on

the unit were asked what they believe barriers to education are. This was a verbal question and

could not be quantified, however, staff and patients acknowledged that difficulty reading and

writing can affect participation.

Length of stay at DSH-P was evaluated, those that participated had an average length of

stay of 12.7 years. Jonesa et al. (2013) considers a short sentence shorter than 6 months, and a

sentence of 5 years or more a long sentence. Prison education may be seen as ordinary school

and is not well adapted for those serving a shorter sentence. Also, patients serving a short
sentence may not see education as a realistic opportunity and staff may not be motivated to start

education. Patients with a long sentence may identify they have enough time to possibly plan an

education and utilize it upon their release. However, that said if a patient has a very long

sentence this can be de-motivating because patients do not see opportunities for using the

education (Jonesa et al. 2013). The shortest length of stay was three months and skewed the

results downward, if taken out the results shift upward by one year. All other participants are

considered to be long term.

Average age was also evaluated to see if the older or younger population were more

likely to participate in diabetes education. The average age of participants was 49.4 years. This

age is congruent with research that identifies participation in education decreases with age

(Jonesa et al. 2013). Of those that participated in the questionnaire, 78% participate in

educational groups already. Those that participate in groups are likely to have a higher perceived

self-efficacy when compared to those that do not participate in group education (Mensing et al.

2003). The findings of this study for group participation were congruent with findings from

literature reviewed.

Dietitians identified other barriers to education. Staffing was the most recognized barrier

to education, which is not just a problem for the nutrition services department. LOC staff

verbally indicated that staffing is a problem for group education and the lack of transporting staff

was the largest barrier. Four dietitians (40%) found lack of motivation as a barrier and one

dietitian (10%) indicated lack of concern for health as a barrier. This is congruent with research

that widespread apathy exists among patients with schizophrenia (Abitbol et al. 2017). Dietitians

indicated intellectual problems to be a barrier and literature reviewed supported this. Dietitians
indicated poor support systems as a barrier, however, LOC staff did not. Research does identify

social support as a determinant of self-efficacy under the category of emotional factors.

Other findings that may help with future studies include disbursement of questionnaire,

length of questionnaire, and degree of difficulty of questionnaire. The modality of disbursing the

questionnaire was recommended by shift leads in N building. However, patient’s participation in

completing the questionnaire was less than expected. Of the possible 133 patients that have

diabetes in N building only 18 participated in the study. That is only 13% of the given population

and may not be a significant representation of the diabetes groups. That said, those who were not

willing to participate in the questionnaire could be seen as those not willing to participate in a

diabetes group education.

Some limitations of this study should be addressed. This test population should not be

generalized for other educational groups because those with different diseases may perceive their

condition to be more or less sever. Size of participating group is small compared to the group of

patients that have a diagnosis for diabetes. The 18 patient participants were those willing to take

the questionnaire and are likely to be those that participate in other activities and educational

groups. Alteration to the length of the self-efficacy test may have caused the participating

population to score higher or lower. This modification limits the findings of this research and we

are not able to say if self-efficacy is a significant predictor of participation. One possible source

of error is the loss of questionnaires by staff or patient. Because discriminating against a

diagnosis was a perceived problem this questionnaire was delivered to all 400 patients in N

building. Making collection of questionnaires difficult to keep track of.

Conclusion
Patients being treated for mental health conditions are more prone to developing obesity and

diabetes (Nelms et al. 2015). Because these patients are more susceptible to developing diabetes

than the general population multiple modalities of education are important. Mental health

patients because of this increased susceptibility to chronic diseases have a shorter lifespan when

compared to the public. Physical illness caused by macro and micro vascular injuries are most

responsible for causing this premature death.

Research found several barriers to education including apathy, low motivation, cognitive

deficits, poor self-efficacy, length of stay, and age. When assessed poor self-efficacy was not

found amongst the participating group, however, should be assessed in future research. Longer

length of stay was found to be congruent with previous research that found patients with a longer

sentence are more willing to participate in education (Jonesa et al 2013). More research should

be done to target the most receptive age group for education. Reading and writing problems were

found in 50% of the participating group and could be a barrier according to staff. Further

research should be done to find out how to minimize this barrier. Dietitians and staff identified

apathy, low motivation, cognitive deficits, and poor self-efficacy as barriers. Dietitians and LOC

staff recognized staffing as a large barrier to education. Given the amount of diabetics at DSH-P

implementing an education group where all diabetics attend would take a large amount of

staffing which is not available. Although education is needed for diabetics, patients at DSH-P are

not receptive to education and many barriers such as low motivation, apathy, cognitive deficits,

inadequate staffing, poor support systems, and poor self-efficacy to read and write exist, which

makes education difficult. Multimedia education is used for other groups at DSH-P and should

be looked into as an alternative to group education. Assessments by the dietitian should be done

minimum every six months to provide continuous reinforcement of education learned. One study
supports that dietitians should see patients every three months for the first 3-4 sessions after

diagnosis of diabetes and every six months after (Gordon 2018). That said diabetic patients

should be given a medical nutrition risk score of moderate or high risk, ensuring they are seen by

a dietitian within six months.

To best implement education, rehab therapists (RT) suggest building based education.

Transport for patients is much easier when patients do not have to leave the building. They

suggest posting flyers and sign up sheets on each unit ahead of time and verbally telling patients

to sign up. For N building the RT suggests using room C103 for building based education. This

may fit 10-15 people at a time. RTs also believe multimedia education to be effective.
 References

Abitbol, R., Rej, S., Segal, M., Looper, K. (2017). Diabetes mellitus onset in geriatric patients:

does long-term atypical antipsychotic exposure increase risk? Psychogeriatrics, 15: 43-

50. doi: 10.1111/psyg.12081

Annamlai, A., Kosir, U., Tek, C. (2017). Prevalence of obesity and diabetes in patients with

schizophrenia. World Journal of Diabetes. 8(8) 390-396. doi: 10.4239/wjd.v8.i8.390

Jonesa, L.., Mangerb, T., Eikland, O., Asbjomsen, A. (2013). Participation in Prison Education: Is it a

Question of Reading and Writing Self-Efficacy Rather than Actual Skills? The Journal of

Correctional Education, 64(2). Retrieved from

http://web.b.ebscohost.comC.portal.lib.fit.edu/ehost/pdfviewer/pdfviewer?vid=13&sid=986419

33-d66c-4539-8c54-5d6b070ba91e%40pdc-v-sessmgr01
Lopez, V, L., Torres, A., Bravo, P., Gil, J., Klunder, M., Pena, J., (2017). Multimedia education program and

nutrition therapy improving HbA1c, weight, and lipid profile of patients with type 2 diabetes: a

randomized clinical trial. Endocrine, 58:236-245. doi: 10.1007ls12020-017-1416-0

Mensing, C., Norris, S. (2003). Group Education in Diabetes: Effectiveness and Implementation. Diabetes

journal, 16(2). Retrieved from http://spectrum.diabetesjournals.org/content/16/2/96

Gordon, B. (2018). How an RDN can help with Diabetes. https://www.eatright.org/health/diseases-and-

conditions/diabetes/how-an-rdn-can-help-with-diabetes

Nelms, M., Sucher K. P., Lacery, K. (2015). Nutrition Therapy and Pathophysiology. Boston,

MA: Cengage Learning

American Diabetes Association (2018, March 22). Statistics About Diabetes.

http://www.diabetes.org/diabetes-basics/statistics/

Nguyen, Q, M., Xu, J, H., Chen, W., Srinivasan, S, R., Berenson, G, S. (2012). Correlates of Age

Onset of Type 2 Diabetes Among Relatively Young Black and White Adults in a

Community. American Diabetes Association, 35(6) 1341-1346. doi: 10.2337/dc11-1818

Centers for Disease Control and Prevention (2018, August 13). Obesity Facts.

https://www.cdc.gov/obesity/data/adult.html
Hypothesis of First Study

Jonesa et al. (2013) examined participation in prison education by evaluating the inmate’s
perceived ability or self-efficacy to read and write.
Location-Norway
N=600
Level of education or efficacy beliefs in writing did have a significant relation to prisoners
participation in education where reading did not.
Average education level 10.2 years
Hypothesis of Second Study

Lopez et al. (2017) using multimedia educational tools and nutritional therapy evaluated the
effect of diabetes education on metabolic control goals.
A randomized clinical trial was conducted in 351 patients randomly assigned to either an
experimental group receiving a multimedia diabetes education program (MDE) and nutrition
therapy (NT) (NT + MDE: n = 173), or to a control group who received nutrition therapy only
(NT: n = 178).
At baseline, 7, 14, and 21 months, the glycated hemoglobin (HbA1c), glucose,
cholesterol, triglycerides, LDL-cholesterol, and HDL-cholesterol were measured.
Weight, body mass index (BMI), waist circumference (WC), fat percentage, fat
and lean mass, systolic blood pressure (SBP), and diastolic (DBP) were also
recorded.\
Conclusion- Nutrition therapy and a multimedia diabetes education program
have a favorable impact on achieving metabolic control goals in type 2 diabetes.
Hypothesis of Third Study

Mensing et al. (2003) evaluated what is more effective, group education or individual education
interventions.
The effectiveness of group education
Comparing group and individual education
literature in diabetes education is divided, although effects may be more positive for group delivery of lifestyle
programs (interventions focusing on diet and physical activity) than for individual programs.

Hypothesis of Fourth Study

Annamali et al. (2017) evaluated the prevalence of obesity in patients taking antipsychotic
medications and the effect of antipsychotic exposure on diabetes prevalence.
population- The study sample included 326 patients with schizophrenia and 1899 subjects in the
population control group.
Demographic data showed control group was on average 7.6 years older (P = 0.000), more Caucasians
(78.7% vs 38.3%, P = 0.000), and lower percentage of males (40.7% vs 58.3%, P = 0.000). Patients with
schizophrenia had a higher average BMI than the subjects in the population control (32.11, SD = 7.72 vs
27.62, SD = 5.93, P = 0.000). Patients with schizophrenia had a significantly higher percentage of obesity
(58.5% vs 27%, P = 0.000) than the population group. The patients with schizophrenia also had a much
higher rate of diabetes compared to population control (23.9% vs 12.2%, P = 0.000). After controlling for
age sex, and race, having schizophrenia was still associated with increased risk for both obesity (OR =
3.25, P = 0.000) and diabetes (OR = 2.42, P = 0.000). The increased risk for diabetes remained even
after controlling for obesity (OR = 1.82, P = 0.001). There was no difference in the distribution of
antipsychotic dosage, second generation antipsychotic use or multiple antipsychotic use within different
BMI categories or with diabetes status in the schizophrenia group.

Hypothesis of Fifth Study

Abitbol et al. (2017) evaluated outpatient geriatric patients exposed to antipsychotic medications
and if they have a higher risk of developing diabetes compared to psychiatric and non-psychiatric
controls of similar age.
In this retrospective longitudinal study, 61 atypical AP-exposed and 64 atypical AP-unexposed geriatric
psychiatric patients were compared to a group of 200 psychotropic-naïve controls. Our main composite
outcome was diabetes incidence over a 4-year period, defined by fasting blood glucose ≥ 7.0 mmol/L or a
new-onset oral hypoglycaemic or insulin prescription during the 4-year period.
The 4-year incidence of DM did not differ significantly between groups: 12.3%, 6.7%, and 11.9% in the
atypical AP-exposed, atypical AP-unexposed, and control groups, respectively (χ(2) = 1.40, P = 0.50).
Depression and antidepressant, cholinesterase inhibitor, and valproate use were independently
associated with increases in fasting glucose. However, hyperglycaemia and hypoglycaemic prescriptions
were not more common in geriatric psychiatric patients

Similarities
First Similarity
Mensing, Norris (2003) used audiovisual and other modalities to deliver diabetes
education. Lopez et al. (2017) used a multimedia program developed by a multidisciplinary
group composed of physicians, psychologists, epidemiologist, web designers, and certified
nutritionists.
Second Similarity
Jonesa et al. (2013) used a general self-efficacy test to evaluate inmates. Mensing et al.
(2003) used group-format program meetings to improve problem solving and self-management.
The results of these groups after 12 months were patients had an improved feeling of self-
efficacy.
Differences
First Difference
Abitibol et al. (2017) & Annamali et al. (2017) evaluated if patients prescribed
antipsychotic medications were at increased risk of developing type 2-diabetes and if patients
who were diagnosed with schizophrenia were predisposed to developing type 2-diabetes. All
other studies evaluated the barriers and benefits to providing group education.
Second Difference
Jonesa et al. (2013) conducted research on a prison population and their perceived-
efficacy. All other studies were conducted on non-incarcerated individuals.
Discussion
Studies found that there is a need for diabetes education, and that the barriers are most reliant on
the perceived ability of the patient to accomplish a goal. Mensing et al. (2003)