Facilitators of Diabetes Self-Management Among

Rural Individuals The prevalence of Type 2 diabetes mellitus has increased dramatically with a higher rate in rural populations. Diabetes self-management behaviors such as medication administration, blood glucose testing, and appropriate diet and exercise regimens must be implemented daily to increase chances of achieving therapeutic patient outcomes. Home healthcare clinicians are pivotal in assisting these individuals to be more self-confident and independent in managing their diabetes, achieving therapeutic goals, and addressing diabetes-related complications. This article will discuss facilitators of diabetes selfmanagement in rural populations and implications for home healthcare clinicians.

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iabetes mellitus is a chronic disease that affects more than 25 million people in the United States, with Type 2 diabetes mellitus (T2DM) accounting for at least 90% of all cases (U.S. Department of Health and Human Services [USDHHS], 2011). The prevalence of T2DM is higher in rural areas than in urban settings (Barker et al., 2010; Logan et al., 2013; Utz, 2008). Nearly 25% of the U.S. population reside in rural areas and approximately 65% of the nation’s counties are considered rural (Johnson, 2012). Effective management of diabetes mellitus is significantly influenced by diabetes selfmanagement behaviors (Handley et al., 2010). However, with limited monetary resources, healthcare provider shortages, and inadequate healthy resources, these skills are particularly difficult for those living in rural areas (O’Brien & Denham, 2008; Schoenberg et al., 2011). In fact, patients often report that carrying out the daily diabetes self-management regimen is more difficult than dealing with their diagnosis of diabetes (Mishali et al., 2011). Facilitators influence diabetes self-management behaviors and assist individuals living with diabetes to set and attain realistic self-management goals. Therefore, the purpose of this paper is to identify facilitators of diabetes self-management behaviors in rural individuals living with T2DM and to discuss implications for home healthcare clinicians.

Caralise W. Hunt, PhD, RN, Joan S. Grant, PhD, RN, Jennifer J. Palmer, MSN, RN, and Laura Steadman, EdD, CRNP, RN

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Ozier Muhammad/The New York Times/ Redux

Facilitators of Diabetes Self-Care Management Behaviors The American Association of Diabetes Educators (AADE) identifies seven standard self-management behaviors (Haas et al., 2013). These behaviors are (a) eating healthy, (b) being active, (c) monitoring blood glucose, (d) taking medications, (e) problem solving for diabetes self-care issues, (f) coping in a healthy manner, and (g) reducing risks of acute and chronic complications. Empirical evidence suggests facilitators of diabetes self-management behaviors include diabetes self-management education, social support, problem-solving skills, and self-efficacy (Fisher et al., 2012; Glasgow et al., 2007; Hill-Briggs, 2003; King et al., 2010; Raffle et al., 2012; Skelly et al., 2005). Healthcare provider communication also is associated with performing diabetes self-management behaviors and these behaviors are directly linked to improvements in glycemic control (Gao et al., 2013; Nagelkerk et al., 2006).

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Diabetes Self-Management Education

The National Standards for Diabetes SelfManagement Education state that diabetes selfmanagement education (DSME) is necessary for all individuals living with diabetes and can prevent or delay complications of diabetes. Selfmanagement education should be individualized, patient-centered, and ongoing. Education should focus on the seven essential diabetes self-management behaviors of eating healthy, being active, monitoring blood glucose, taking medications, problem solving, coping, and reducing risks of complications (Haas et al., 2013). Individuals who receive DSME are more likely to participate in self-management behaviors (Gumbs, 2012). Although the importance of DSME has been established, only half of individuals living with diabetes receive formal selfmanagement education (Davis et al., 2012). Individuals who live in rural communities are less likely to receive diabetes education than their

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urban counterparts (Davis et al., 2012; Strom et al., 2011). A telephone survey by Raffle et al. (2012) of 3,841 people living in the Appalachian region emphasized the value of diabetes education. In this study, having attended a diabetes education class was the most significant predictor of successful diabetes self-management. A sample of rural African American individuals living with diabetes also emphasized the importance of education as a facilitator for diabetes management. Participants stated they received diabetes education from healthcare providers, Internet groups, and peers. Study participants described the need for increased availability and accessibility of diabetes education in their communities (Utz et al., 2006). With scarce healthcare resources, including healthcare providers in rural communities, this study emphasizes the importance of identifying other types of resources to assist in providing DSME. To be effective, diabetes education must address the needs of individuals living with diabetes. To illustrate, a study conducted in a rural area of the southern United States held focus groups to develop an educational intervention for diabetes self-management. The intervention incorporated American Diabetes Association (ADA) recommendations into topics identified as pertinent by participants. Participants participated in problem-solving activities and received support from healthcare providers and peers living with diabetes. Compared with a control group of participants who received typical DSME, intervention group participants had significant improvements in diabetes selfmanagement activities following the intervention (New, 2010). Another intervention included teaching and counseling modules based on common symptoms experienced by individuals living with diabetes. The modules were individualized to allow participants to choose the priority order of the modules and which self-management strategies to use. Modules included symptoms of hyperglycemia and hypoglycemia, numbness and tingling in the feet, and prevention of cardiovascular symptoms. Following the intervention, improvements were noted for diet, medication, and foot care self-management practices (Skelly et al., 2009). Therefore, diabetes education must focus on identifying specific needs of individuals with T2DM and addressing those needs over time.

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Social Support

Daily self-management can be overwhelming for individuals living with diabetes (Chlebowy et al., 2010). Self-management of diabetes can be increased with social support (Sousa et al., 2004). Social support is an exchange of resources between at least two persons that is aimed at increasing the well-being of the receiver (Kadirvelu et al., 2012). Higher levels of social support are linked with improved health and well-being (Westaway et al., 2005). Sources of social support include family members, peers, friends, medical professionals, community health advisors, social programs, and informal networks such as churches and Internet resources (Andreae et al., 2012; Coffman, 2008; Kadirvelu et al., 2012). The importance of social support in diabetes self-management is reflected in empirical literature. In a descriptive study of 200 rural African American individuals living with diabetes, increased levels of support for diabetes selfmanagement were associated with a higher frequency of glucose testing (Brody et al., 2008). Individuals living with diabetes require teaching regarding the skill of blood glucose monitoring and how to interpret results and problem solve to adjust behaviors based on their results (AADE, 2010). Social interaction is important to individuals living with diabetes and should be included in DSME sessions. Social interaction allows for assimilation of information, provides a sense of belonging, and offers an opportunity to build a support system (New, 2010). Being with others who have similar concerns and issues can promote diabetes self-management (Ho et al., 2010). People living with diabetes report that experiences of others living with diabetes are valued sources of education and information (MajeedAriss et al., 2013). One study found that rural older adults with higher levels of social engagement and a stronger social network were more likely to adhere to diabetes management behaviors such as monitoring glucose, checking feet, maintaining a heart-healthy diet, and participating in formal exercise (Skelly et al., 2005). Emphasizing social interaction appears to be important for incorporating diabetes self-management activities into the lives of people living with T2DM. A review of diabetes care and education in rural regions also noted the importance of including family and community in diabetes management. Studies reviewed reported family and

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C A S E S T U D Y. A H o m e H e a l t h c a r e C l i n i c i a n F a c i l i t a t i n g D i a b e t e s Self-Management Skills of a Rural Individual Living W i t h Ty p e 2 D i a b e t e s M e l l i t u s

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r. Jones is an obese 60-year-old who lives with his wife in a rural area. He has hypertension, hyperlipidemia, mild cataracts, and an extensive foot ulcer that refuses to heal, despite treatment. Mr. Jones’s physician orders a glycosylated hemoglobin level, which was 12.5%, resulting in Mr. Jones being newly diagnosed with Type 2 diabetes. His physician prescribes metformin 500 mg twice daily and 10 units of insulin glargine (Lantus) at bedtime. Diabetes Education A home healthcare clinician discusses healthy meal planning, weight loss, medication management, and blood glucose testing with Mr. Jones and his wife. Foot care and normal saline dressing changes to the foot ulcer are reviewed, in addition to physical activity adaptations that will lessen putting weight on his foot ulcer while it is healing. Stress management strategies also are discussed as Mr. Jones learns to cope with this new diagnosis and important selfmanagement skills regarding his T2DM. The home healthcare clinician gives them written materials on these subjects. Mr. Jones is scheduled to see his physician again in 3 months or sooner if his foot ulcer refuses to heal. In addition to his foot ulcer healing, Mr. Jones’ goals are to eat a healthier diet, lose 10 lb, and become comfortable checking his blood glucoses, self-administering his insulin, and changing his foot ulcer dressing. Social Support Mr. Jones is comfortable using his cell phone and Mr. Jones’s wife has access to a computer at work. In working with them, Mr. Jones records his daily glucose readings and his wife faxes them weekly, so his healthcare provider can adjust his medication. As support, the home healthcare clinician discusses with Mr. Jones and his wife organizations and online sources that provide information about T2DM. Mr. Smith also is encouraged to write down

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self-management questions, so that he can ask the home healthcare clinician during weekly scheduled phone calls. Problem-Solving Skills In assessing Mr. Jones’s problemsolving approach, Mr. Jones admits that although he is comfortable solving problems, he often tends to delay solving them. Mr. Jones admits that his wife is very supportive of his decisions and provides positive encouragement. Mr. Jones is encouraged to identify weekly challenges regarding his diabetes, goals and dates for achieving short-term goals, and people who are most important in addressing these problems: himself, his wife, friends, family, and home healthcare clinician. He also is encouraged to develop at least two solutions for each problem, using these relevant people and their potential roles. The home healthcare clinician explores with Mr. Jones the usefulness of the Smart Health Tracker and Diabetes Tracker to log his self-management behaviors. Self-Efficacy Mr. Jones is very motivated, wanting to avoid his mother’s health problems that he thinks are partially related to her avoiding learning to manage her T2DM successfully. In assessing his selfefficacy, Mr. Jones rates his confidence in changing his normal saline foot dressings as 6 out of 10. The home healthcare clinician works with Mr. Jones to increase his feelings of self-efficacy by providing oral and written information regarding his normal saline dressings, using both the postal service and email. Additionally, the home healthcare clinician demonstrates the dressing change and allows return demonstration at the next visit. In establishing nutritional plans regarding eating a healthier diet and losing weight, the home healthcare clinician works with Mr. Jones and his wife to initially keep a record of his glucose values, food intake, and facilitators and barriers to following his goal of eating a healthy diet. The nurse also

encourages Mr. Jones and his wife to link their successes to specific diabetes outcomes (e.g., glycosylated hemoglobin level every 3 months). Healthcare Provider Communication In working with Mr. Jones and his wife, the home healthcare clinician provides encouragement and a caring attitude as they learn important self-management skills. Mr. Jones tells the home healthcare clinician that his wife is testing his glucose twice a day before breakfast and lunch, but his morning glucose is always high. He is not fond of his current glucose meter provided by his physician because the test strips are very expensive and his cataracts make it difficult for him to read and record his glucose values. In encouraging self-management, the home healthcare clinician works with Mr. Jones and his wife to check his glucose at random before meals and at bedtime to ascertain his glucose patterns, especially at bedtime to determine possible causes of his high morning glucose values. The healthcare clinician also gives him the names of some cheaper, larger meters that will make it easier for him to visualize his glucose numbers. Mr. Jones is referred to his pharmacist who can train him to use the new meter once it is purchased. The healthcare clinician also discusses the option of voice glucose meters if his cataracts worsen. On learning from Mr. Jones that his wife gives him his insulin because of his vision, the home healthcare clinician confers with Mr. Jones’ healthcare provider, who changes his insulin to glargine (Lantus SoloSTAR). The home healthcare clinician instructs both Mr. Jones and his wife about insulin injections via an insulin pen. Mr. Jones is taught to both count clicks on his insulin pen and to use a magnifier in assuring the correct insulin dosage. Further, Mr. Jones’ wife double checks the accuracy of his insulin dosage before he administers it at bedtime.

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The American Association of Diabetes Educators identifies seven standard self-management behaviors. These behaviors are (a) eating healthy, (b) being active, (c) monitoring blood glucose, (d) taking medications, (e) problem solving for diabetes self-care issues, (f) coping in a healthy manner, and (g) reducing risks of acute and chronic complications. community members are sources of support that provide assistance, advice, and information for diabetes management (Andreae et al., 2012; O’Brien & Denham, 2008). For example, a qualitative study identified factors that promoted or inhibited ability to self-manage diabetes. African Americans from three rural communities were recruited for the study with a total of 73 attending one group session. Group-centered analysis of data revealed social support to be an important facilitator for self-management. Participants described the importance of social support from peers successfully managing diabetes, churchsponsored programs, healthcare professionals, relatives, and friends (Utz et al., 2006). Another qualitative study described the lived experience of being a person with multiple morbidities, including diabetes, and living in a rural, underresourced area. Participants stated support from free clinics and health departments that included information, medication and equipment samples, and support services were important in managing their conditions. Participants in this same study also described the invaluable support they receive from immediate family members (Schoenberg et al., 2011). In a study of peer support for individuals with diabetes, Fisher et al. (2012) described the attributes of effective peer support as including assistance in daily management, social and emotional support, linkage to clinical care, and ongoing availability of support. These results included the idea that peer support interventions may be more feasible in some situations, such as for economically

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challenged rural individuals, because patients’ health behavior, metabolic control, and perceived quality of life improved with peer support. Andreae et al. (2012) also emphasized the value of using peer support regarding diabetes mellitus to a rural, medically underserved population, focusing on community assessment and fostering collaborations with community stakeholders and program planning. In rural settings, the combination of peer advisors and telephone-based support may decrease transportation, money, and time restraint barriers (Massey et al., 2010). Hunt and Grant (2012) emphasized the potential value of community health advisors (CHAs) as a source of support for people with diabetes mellitus. CHAs are trained members of a target community and are either volunteers or paid staff of state, county, local, or community-based organizations (Goodwin & Tobler, 2008). Commonly, they work in health departments, communitybased centers, churches, and other settings (Faridi et al., 2010; Goodwin & Tobler, 2008; Thompson et al., 2007; Viswanathan et al., 2009). CHAs help individuals with diabetes mellitus improve self-management behaviors such as exercising, glucose monitoring, healthy eating, and checking feet for complications as well as healthcare outcomes, such as glycemic control, cholesterol and triglyceride levels, and blood pressure (Castillo et al., 2010; Gary et al., 2003; Joshu et al., 2007; Keyserling et al., 2002; USDHHS, 2011). Problem Solving

People who live with T2DM are faced daily with situations that require adjustments in their selfmanagement plan. Problem solving is an important skill for managing these situations. Problem solving can assist patients to translate recommended self-management techniques into actual behaviors that facilitate individual self-management. The AADE recommends assisting people living with T2DM to develop problem-solving strategies for self-management situations that affect their daily plan (Haas et al., 2013). The AADE defines problemsolving as learned behaviors that include generation of potential strategies for problem resolution, selecting and applying an appropriate strategy, and evaluating effectiveness of the selected strategy (Mulcahy et al., 2003). Using the problemsolving approach, patients can make adjustments to their treatment plan in conjunction with healthcare providers. Problem solving requires that

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patients have knowledge and support to make appropriate decisions (Baghbanian & Tol, 2012). A diabetes self-management educational intervention that included problem-solving strategies was implemented with rural African Americans living with T2DM. Participants in this study improved participation in self-management behaviors and glycemic control following the intervention (Utz et al., 2008). In a systematic review of diabetes education for women, a situational problem-solving intervention was linked to improvements in diet, anthropometric measurements, and physical activity (Gucciardi et al., 2013). Additionally, a community-based, peer-led diabetes self-management program for adults with T2DM was assessed for its effect on dietary management, physical activity, and glucose monitoring. This program offered self-management behavior instruction and group communication on problem solving. Improvements were noted for the intervention group compared to the control group for glucose monitoring, healthy eating, and reading food labels at 6 months follow-up (Lorig et al., 2009). A systematic review of problemsolving in diabetes management literature found associations between problem solving and specific self-management behaviors including eating healthy, exercising, and monitoring blood glucose (Hill-Briggs & Gemmell, 2007). Using telephone and mobile applications also shows promise in providing diabetes education and assisting with problem solving for self-management (Årsand et al., 2012; Davis et al., 2012; Dennis et al., 2013; Naik et al., 2012). For example, significant improvements were noted for Hemoglobin A1C (HA1C) and diabetes-related distress in rural older adults with diabetes and depression when participants received telephone behavioral coaching. The focus of the coaching was to help patients establish diabetes self-care goals and action plans, focusing on collaborative problem solving to lessen perceived barriers to self-care (Naik et al., 2012). Self-Efficacy

Self-efficacy is defined as belief in the ability to perform actions that affect outcomes in a person’s life. Self-efficacy is a determining factor in how people think, act, and feel (Bandura, 1994). The ability to perform diabetes self-management activities is affected by individuals’ belief in their ability to perform these tasks (Bandura, 1986). Higher levels of self-efficacy are associated with increased

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participation in diabetes self-management behaviors (Lanting et al., 2008; O’Hea et al., 2009). In a systematic review of empirical evidence regarding the relationship between self-efficacy and diabetes self-management, Krichbaum et al. (2003) emphasized the importance of increasing self-efficacy by involving people living with diabetes in their own care, guiding them in actively learning about their disease, exploring their feelings about having the disease, and teaching them skills necessary to adjust behaviors to generate positive health outcomes. A descriptive correlational study of people living with diabetes in rural areas found significant positive correlations between self-efficacy and diabetes self-management behaviors; specifically diet, exercise, and foot care (Hunt et al., 2012). In another study of rural participants, those with higher levels of self-efficacy experienced greater reductions in HA1C values over the course of the study. Participants in this study received videophone calls from a nurse practitioner who promoted and reinforced self-efficacy for diabetes self-management behaviors (Hawkins, 2010). Similarly, another study found a strong association between self-efficacy and HA1C. Based on these findings, researchers recommend screening patients for self-efficacy and implementing self-efficacy enhancing interventions (O’Hea et al., 2009). Although self-efficacy appears to be important in improving diabetes self-management, there are few studies using rural populations. Healthcare Provider Communication

The value of healthcare provider communication must be recognized. An open approach to communication is designed to provide meaningful skills and resources that are necessary to establish and implement self-management goals, thereby promoting patients’ ability to use critical-thinking skills and make autonomous, informed decisions (Baghbanian & Tol, 2012). A meta-synthesis of nine qualitative studies indicated that empathy and a caring attitude from healthcare professionals can promote effective self-management of diabetes (Ho et al., 2010). In fact, a recommendation by healthcare providers to test is a significant predictor of patients performing self-monitoring of blood glucose (Skelly et al., 2005). In a sample of adults living with diabetes across the United States, participants who received medical advice about specific selfmanagement behaviors were more likely to perform those behaviors (Vaccaro et al., 2012).

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The importance of effective healthcare provider communication is described by people living with diabetes. For example, identification of strategies to enhance diabetes self-management was the focus of a qualitative study of adults with T2DM (Nagelkerk et al., 2006). Participants were recruited from a rural primary care facility to participate in one 2-hour focus group session. Content analysis of the sessions revealed various strategies for enhancing self-management, such as having a collaborative relationship with a healthcare provider who gave positive coaching, expected accountability, and assisted them in making adjustments to their plan of care. They also needed healthcare providers’ assistance in accessing and negotiating the healthcare system to obtain needed supplies, medications, and consultations.

Implications for Home Healthcare Clinicians Knowledge of diabetes self-management facilitators can assist clinicians to select the most appropriate interventions for their patients living with T2DM. Facilitators include self-management education, social support, problem-solving skills, selfefficacy, and healthcare provider communication. Table 1 identifies these facilitators and examples

of interventions relevant for clinicians. For the purpose of this paper, clinician refers to the home healthcare provider. Providing Diabetes Self-Management Education

Clinicians can provide valuable education for individuals in rural areas (Luger & Chabanuk, 2009). Patients’ baseline knowledge should be assessed to determine primary educational needs. Clinicians should individualize education and, when possible, support people should be included in self-management education (Anderson & Funnell, 2010). Positive attitudes that prompt proactive learning and education that encourages questions and discussions should be applied (Nagelkerk et al., 2006). The emotional aspects of living with diabetes should be discussed and patients should be encouraged to incorporate life experiences into self-management plans (Anderson & Funnell, 2010; New, 2010). The ADA recommends that all individuals diagnosed with diabetes participate in DSME (Hale et al., 2010). Table 2 offers suggestions for areas of teaching for individuals living with diabetes. Specifically, clinicians can discuss the importance of blood glucose control, yearly eye exams, daily foot

Table 1. Facilitators and Clinician Interventions Facilitators

Clinician Interventions

Diabetes self-management education

• Assess patient’s knowledge base • Include patient’s support system in education • Provide information regarding diabetes self-management behaviors (eating healthy, monitoring glucose, taking medications, monitoring for complications, exercising)

Social support

• Assess sources, availability, and quality of support • Identify community, church, and online resources • Use telephone calls, mobile applications, and Internet resources to offer support

Problem-solving skills

• Identify patient’s problem-solving approach • Encourage positive problem-solving behaviors • Assist patient to apply past experiences to current problems • Ensure patient has adequate knowledge base to solve problems

Self-efficacy

• Assess patient’s level of self-efficacy • Use collaborative goal setting and decision making with patient • Track diabetes self-management behaviors and link to diabetes outcomes

Healthcare provider communication

• Use letters, phone calls, e-mails, and text messages to contact patients • Coordinate multidisciplinary communication to develop and modify patient’s plan of care

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exams, a heart-healthy diet, and consistent physical exercise. Self-monitoring is important for regulation of blood glucose control. Clinicians should assess availability of testing supplies and work with patients to establish a testing plan that works with the patient’s resources. Patients should be instructed to follow the recommended blood glucose testing plan. Further, education about checking feet daily and contacting the healthcare provider promptly about treatment of blisters, ingrown toenails, ulcers, and wounds is essential. Incorporating basic information about signs and symptoms of peripheral neuropathy and safety measures, such as wearing properly fitting, comfortable shoes, avoiding walking barefoot, and having someone check the temperature of bath water if neuropathy is present, is also valuable. Clinicians should discuss nutrition with patients at each visit. Clinicians can encourage patients to keep a log of foods eaten and blood glucose values to assess for correlations. This correlation is the basis for patient-assisted problem solving in modifying the self-management plan. Consistent exercise should be encouraged. Clinicians can recommend appropriate exercise based on individual patients’ resources and abilities. Individuals living with T2DM should be educated about the importance of taking diabetes medications at the same time each day to prevent blood glucose changes that occur when medication is taken randomly (Hale et al., 2010; Jacobs & Fetzer, 2013). These individuals also should be reminded to refill prescriptions before they are depleted. Offering Social Support

The value of family, friends, and community as a means of social support for individuals living with T2DM must be recognized. Assessment of patients living with T2DM should include availability, sources, and quality of social support provided. Once effective sources of social support have been identified, strategies for receiving positive support should be discussed with patients and included as part of the self-management plan. Family and friends who offer support to patients living with T2DM should be included in education and care as often as possible. Clinicians can connect patients with community resources, including educational and peer support group meetings in the community, churches, and online. Individuals living with T2DM should receive information

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regarding clinics that provide medications, glucose strips, insulin, and glucometers (Bellamy et al., 2011). For patients living in rural resourcepoor communities, support can be offered through telephone calls. Clinicians can use calls to establish and monitor behavioral goals related to self-management (Davis et al., 2012). Additionally, mobile applications can be used to provide support. Various mobile applications can transfer blood glucose data, encourage reflection and discussion among patients and healthcare providers (i.e., using a mobile phone diary), motivate patients and facilitate physical activity (i.e., using a step counter with automatic data transfer), and provide information about food (Årsand et al., 2012). Clinicians should assess availability of these applications and teach patients to use them when available. Many mobile applications are available for free on devices that patients already use. Promoting Problem Solving

Clinicians are in an ideal position to facilitate collaborative goal setting and problem solving for self-management. A four-step model proposed by Hill-Briggs (2003) promotes problem solving for diabetes self-management. Using this model, clinicians can identify patients’ usual approach to problem solving, encourage a positive orientation toward problem solving, assist with application of past experiences and learning to solve current problems, and ensure patients have the knowledge base related to self-management to adequately solve problems (Hill-Briggs, 2003). Shortterm and realistic goals with potential solutions for problems are discussed at each home visit and/or telephone contact. Discussing goals and the effectiveness of solutions to problems encourages patients to be active participants in their care and creates a sense of ownership and responsibility for diabetes management (Langford et al., 2007). Effective problem-solving skills require continuing education on subjects such as nutrition, glucose monitoring, medication administration, exercise, and diabetes complications (Rodriguez, 2013). Mobile applications can assist patients with problem solving. These applications provide visual feedback about glucose control and diabetes self-management. Clinicians and patients also can collaboratively problem solve and make adjustments to the plan of care based on this feedback.

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Enhancing Self-Efficacy

Self-efficacy is important for effective diabetes self-management. Rural patients with high selfefficacy are more likely to take part in detailed diabetes self-management. Quality education, care, and support are important components for building and strengthening self-efficacy for diabetes self-management (Rodriguez, 2013). Promotion of self-efficacy involves education and support from healthcare providers as well as inclusion of patients’ expertise about their own goals, priorities, traditions, culture, values, and available resources (Anderson & Funnell, 2010). Clinicians should establish the patient’s current level of self-efficacy for managing diabetes and use this to determine individualized goals and strategies (Al-Khawaldeha et al., 2012). Assessment of self-efficacy can be done by asking patients to rate on a 1-10 scale how confident they feel performing a particular self-management behavior. Collaborative goal-setting is important for the rural individual who may be performing diabetes self-management with sparse support from healthcare professionals (Vaccaro et al., 2012). Clinicians can promote self-efficacy for diabetes self-management by encouraging participation in decision-making about their care, educating them about their condition, motivating them to adopt healthy behaviors, exploring their feelings about having the disease, teaching them skills necessary to adjust behaviors to generate positive health outcomes, and advising them about when to seek help from healthcare providers. Identification of past successes can build selfconfidence and increase self-management skills (Rodriguez, 2013). Facilitating small, achievable goals can increase self-efficacy for managing diabetes and build confidence for achievement of

larger, more complex goals (O’Hea et al., 2009). Patients can keep track of self-management behaviors and how it affects their well-being. If patients see the link between self-management and positive diabetes outcomes, self-efficacy for performing these behaviors may increase (Al-Khawaldeha et al., 2012). Clinicians can encourage patients to keep a log of self-management behaviors performed and blood glucose values. Online educational tools and free phone applications, such as Smart Health Tracker, My Exercise Pal, and Diabetes Tracker, may be used to log self-management behaviors (Lorig et al., 2010; Tani et al., 2010). Clinicians can review these documented behaviors with patients and discuss how to interpret blood glucose data and use it to make dietary, exercise, and medication adjustments as needed (Al-Khawaldeha et al., 2012) Facilitating Healthcare Provider Communication

Effective healthcare provider information is essential for diabetes self-management. Healthcare provider communication creates a rapport with individuals living with T2DM to motivate positive behaviors (Radhakrishnan, 2012). Individuals living with T2DM need healthcare professionals to listen to them and allow time for expressing concerns and asking questions. They also need clear and relevant information expressed without medical jargon that acknowledges their ability to manage their own diabetes (Escudero-Carretero et al., 2007). Further, individuals living with T2DM desire open communication with healthcare providers about problems and challenges related to diabetes management. They also desire information about diabetes education classes, dietary expectations, physical activity regimens, medications,

Table 2. Home Healthcare Clinician Teaching Topics for Individuals Living With Diabetes Home Healthcare Clinicians Should Teach Individuals Living With Type 2 Diabetes Mellitus to: Integrate appropriate nutritional skills into the social routine. Use medications safely and for maximum therapeutic effectiveness. Monitor blood glucose and other boundaries and translate and use the results for critical self-management decisions. Prevent, detect, and treat acute and chronic complications. Develop personal strategies to address psychosocial issues and concerns. Implement personal strategies to promote health and behavior change.

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and blood glucose monitoring (Nagelkerk et al., 2006; Venkatesh & Weatherspoon, 2013). Clinician contact with patients through letter reminders, e-mails, text messages, or phone calls can promote positive relationships (Labhardt et al., 2011). Consults and phone participation from other health team members, such as registered dieticians, physicians, nurse practitioners, occupational therapists, and physical therapists, can increase participation in self-management behaviors and facilitate patient involvement in diabetes care (Nam et al., 2011). Clinicians can coordinate these multidisciplinary communications and ensure that patient goals and preferences are included in the plan of care. Clinicians reinforce healthcare providers whose expertise empowers people with T2DM to live healthy lives and reduce their chances of developing complications. A composite case study based on the authors’ experience is presented in the case study to illustrate how clinicians facilitate self-management skills of rural individuals living with T2DM.

Conclusion Diabetes self-management skills are challenging for those who live in rural areas because of limited monetary resources, healthcare provider shortages, and inadequate healthy resources. Empirical literature suggests that DSME, social support, problem-solving skills, self-efficacy, and healthcare provider communication are important factors in diabetes self-management for rural individuals. Home healthcare clinicians and patients should work together to individualize treatment guidelines to achieve desired outcomes. Routine telephone calls, mobile applications, and Internet resources are but a few examples of creative strategies that may be used to assist in the development of diabetes selfmanagement skills by individuals with T2DM and their families. Caralise W. Hunt, PhD, RN, is an Assistant Professor, Auburn University School of Nursing, Auburn, Alabama. Joan S. Grant, PhD, RN, is a Professor, University of Alabama at Birmingham School of Nursing, Birmingham, Alabama. Jennifer J. Palmer, MSN, RN, is a PhD Student, University of Alabama at Birmingham School of Nursing, Birmingham, Alabama.

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Laura Steadman, EdD, CRNP, RN, is an Assistant Professor, University of Alabama at Birmingham School of Nursing, Birmingham, Alabama. The authors declare no conflicts of interest. Address for correspondence: Caralise W. Hunt, PhD, RN, Auburn University School of Nursing, 219 Miller Hall, Auburn, AL 36849 ([email protected]). DOI:10.1097/NHH.0000000000000027 REFERENCES

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Facilitators of diabetes self-management among rural individuals.

The prevalence of Type 2 diabetes mellitus has increased dramatically with a higher rate in rural populations. Diabetes self-management behaviors such...
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