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Teaching Diabetes Self-Management—in 4 Hours (or Less)
Linda S Gottfredson, PhDSchool of Education
University of Delaware
Kathy Stroh, MS, RD, CDEDiabetes Prevention and Control Program
Delaware Division of Public Health
1CEHD Colloquium, University of Delaware, February 28, 2013
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Juvenile Diabetes Maturity-onset Diabetes
Insulin dependent Non-insulin dependentDiabetes (IDD) Diabetes (NIDD)
Type I Diabetes Type II Diabetes
Type 1 Diabetes Type 2 Diabetes
Types of Diabetes
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Types of Diabetes (DM)
Type 1 -cell destruction; autoimmune disease; complete lack of insulin
5-10% of total patients
Type 2 -cell dysfunction and insulin resistance
Gestational -cell dysfunction and insulin resistance during pregnancy
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There is no such thing as Borderline Diabetes
or a “Touch of Diabetes.”
Pre-diabetes is a diagnosis.
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There is no such thing as Borderline Diabetes
or a “Touch of Diabetes.”5
Pre-diabetes
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DM defects
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Diabetes is a cardiovascular disease.
The Burden of Diabetes in Delaware, 2009. Diabetes Prevention and Control Program
People with diabetes are
twice as likely
to suffer a heart attack
or stroke
compared to people without diabetes.
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Natural history of Type 2 diabetes
Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.
Obesity Diabetes Uncontrolled Hyperglycemia
50100150
200250300350
50
100
150
200
250
Glu
cose
(mg/
dL)
Rel
ativ
eFu
nctio
n (%
)
-10 -5 0diagnosis
5 10 15 20 25 30Years of Diabetes
Post-meal Glucose
Fasting Glucose
Insulin Resistance
Insulin Level-cell Failure
Insulin ResistanceFamily History
Prediabetes
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Why teach self-management?
• Patients must control their blood glucose (BG) levels to avoid complications
• Controlling BG is a complex, 24/7, life-long task– Rx’s change, increase; may not insure optimal BG control– Changes in dietary intake & physical activity necessary– And more…
• So much to learn and do (or stop doing)
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PWD’s* everyday reality
* “Diabetic” is not a noun 10
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As teacher educators, how would you recommend
teaching diabetes self-management?
Here’s the challenge
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Private schools
0.4 mil teachers 5.4 mil pupils
$673 billion
15Federal
State
District
Federal
State
District
Regulations
Public schools
3 million 50 million
Diabetes education??
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$673 billion
16Federal
State
District
Federal
State
District
Regulations
Public schools
3 million 50 million
InstructionLearning tasks
Private schools
0.4 mil teachers 5.4 mil pupils
Diabetes education??
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Context: Exploding numbers
12012 Condition of Education, Table A-3-1. http://nces.ed.gov/pubs2012/2012045_5.pdf2 For 1970, All Ages is interpolated from 1968 and 1973. http://www.cdc.gov/diabetes/statistics/diabetes_slides.htm. 3For 1990 and 2010, All ages and 65+ derived from http://www.cdc.gov/diabetes/statistics/prev/national/tnumage.htm, and 18+ from http://www.cdc.gov/diabetes/statistics/prev/national/figadults.htm4 Boyle et al (2010), Projection of the year 2050 burden of diabetes in the US adult population. Population Health Metrics, 8(29).I averaged the results from their 4 models. Huang et al. (2009) estimated 34.2M for Type 2 alone: Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. 5CDC’s Diabetes Data & Trends. http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx,
Just 5 years!
Public schools Diabetes casesNumber needing instruction
Millions enrolled1 Millions diagnosed with diabetes Type 1 or 2(non-institutionalized civilians)
Fall ofTotal
Elementary (preK-8) HS (9-12)
197045.532.513.0
1990 41.229.911.3
201049.534.614.9
202052.737.315.4
All agesAdults (18+)Older (65+)
19702
3.619903
6.66.62.8
20103
20.920.7 7.8
20204
33.5
2004 % diagnosed adults > 20 years 5 2009
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Average $/person2 4,310 7,925 10,694 (2008)
11,093 6,745 1,834 466
Context: Exploding costs
12011 Digest of Education Statistics, Table 28, http://nces.ed.gov/programs/digest/d11/tables/dt11_028.asp. Table reports costs in current dollars, so inflation calculator used to bring up to 2010 values.22011 Digest of Education Statistics, Table 194, http://nces.ed.gov/programs/digest/d11/tables/dt11_194.asp3 Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. Used inflation calculator to translate dollars from 2007 to 2010. http://www.usinflationcalculator.com4Huang et al. (2009) Using clinical information to project federal health care spending. Health Affairs, 28(5), w978-990. Includes Type 2 only. Type 1 would be <5% of cases but higher per capita cost. Inflation calculator used to change costs from 2007 to 2010 dollars. 5 No 2020-2030 projections available for school expenditures, so just repeated % GDP from the prior 2 decades. Used Huang et al.’s total diabetes medical costs for 2007, together with 2007 GDP, to calculate costs as % GDP in that year (1.1%). Then used their Exhibit 3 (projected real growth as multiple of GDP) to estimate % GDP in 2010, 2020, and 2030. No data prior to 2007, so just took line toward asymtope .
Students in public schools , K-12 Diabetes cases, diagnosed and undiagnosedTotal expenditures
(2010 dollars)Medical costs only
(2010 dollars)
1970 1990 2010 20073 20204
Total $ (billions)1 270 415 673Type 1
11 Type 2
111 Undiag
12 Pre-diab
27Total160
Type 2237
1970 1980 1990 2000 2010 2020 20300.0
5.0
10.0
15.0Costs as % of GDP1,5
Diabetes
Schools
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Total medical costs, by age & diabetes type, 2007$ (billions)
25.3
105.7
11.0
10.5
Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars. 19
%(prevalence)
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18–34 35–44 45–54 55–59 60–64 65+0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
3,567
4,775
6,387
8,198
11,722
3,837 3,7144,561
5,077 5,359
9,061
5,425
1,3742,327 2,063
4,763
579210 305 391 488 537 716
Type 1Type 2UndiagnosedPre-diabetes
II
Ages:
Average
35,365
Average cost ($)
Average medical costs per person by age & diabetes type, 2007
Dall et al.(2010). The economic burden of diabetes. Health Affairs, 29(2), exhibit 4. 2007 current dollars.20
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Context: Institutional resources
Public schools Diabetes self-management educationDedicated space Permanent buildings Varies; hospitals, medical offices, community sites
Guaranteed funding 100% tax-supported1
(local, state, federal)Varies by health plan; free community classes provided by DPH/DPCP.
Mandatory attendance 10-14 years None, all voluntary. ~ 24% of Medicare patients attended DSMT class.
Teaching force:
Trained in content areaCertified to teach
Classroom teachers
All (N=3.1 million) 1
99%1
Many staff do DSME: medical (e.g., MD, RN, RD, NP, PA, RPh); non-medical (e.g., CHW, CHES, peer educators).DSMP classes given by lay trainers.Trained in disease management: MD, RN, RPh, RD, NP, CDE. Trained to educate: Only CDEs (N=8710), national credential; possible state licensure too.
Curriculum content &
Teacher lesson plans
State national standards (CCSS2) Always. Vary by teacher common planning
Curriculum content: ADA and AADE certify Recognized Programs. DSMP has evidence-based curriculum.Lesson plans: vary with ADA & AADE programs. Fidelity agreement for DSMP.
12012 Condition of Education, Tables A-19-1 (2008-2009), A-17-1 & A-17-2 (2007-2008) 2 http://www.corestandards.org/
= trend towards
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More variable for DSME
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5 levels of diabetes educators*o Level 1, non-healthcare professional,o Level 2, healthcare professional non-diabetes educator,o Level 3, non-credentialed diabetes educator,
Level 4, credentialed diabetes educator, and Level 5, advanced level diabetes educator/clinical manager.
*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf
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Context: Instructional resourcesop0 Public schools Diabetes self-management education
Hours of instruction in content area (average per year)
State/district-mandated minimum hours:1
G1-4: 418 read/write 194 math 292 science
Varies greatly by health plan & site - Classes: 10-15 hrs - Individual DSME: varies
Instructional strategies Systematic use of pedagogical principles
For individual patients: CDE’s assessment of patient’s needs. For groups: scripts for some non-medical educators (e.g., DSMP)Pace, sequencing, Bloom level not always considered.
Special needs studentsEstablished protocols? Yes, legal obligation (IDEA) Currently, no DSME materials or curricula specifically for elderly or
persons with disabilities.
Age- and ability-differentiated instruction & materials
Age grouping, preK-12 Elem: reading/math groups within or between classrooms, all with different lessonsHS: Tracks
None.Growing concern over low “health literacy” & age-related cognitive decline with PWDs, but -Diabetes education materials vary widely; content, but not complexity, matched to PWD’s learning needs. - PWDs are given pre-determined meters and supplies, regardless of their abilities.
1Data for 2003-2004. Source: “Changes in Instructional Hours in Four Subjects by Public School Teachers of Grades 1 Through 4,“ May 2007, NCES report 2007-305 http://www.eric.ed.gov/PDFS/ED497041.pdf/2http://www.cdc.gov/diabetes/statistics/preventive/tNewDEduAgeTot.htmwww.eric.ed.gov/PDFS/ED497041.pdf
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Little differentiation
Limited time
Materials too complex
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Example of required task for all PWDs:
Glucose metersand
lancet devices
Demonstration !!
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Our efforts
1. Describe job of self-care from patient’s perspective.
– Collaboration with CDS: AUCD Conference
– AADE Conference: “Cognitive Demands of DSME”
– NACDD Teleconference: “Cognitive Demands of DSME”
– AADE Conference 2013: “Psychometrics of DSME in the Elderly”
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
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AADE’s description of DSM*Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that:
• Requires making and acting on choices, on a regular and recurring basis, that affect one’s health
• Includes learning the body of knowledge relevant to the disease state, defining personal goals, weighing the benefits and risks of various treatment options, making informed choices about treatment, developing skills (both physical and behavioral) to support those choices, evaluating the efficacy of the plan toward reaching self-defined goals.
*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf
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AADE’s description of DSM*Living well with diabetes requires active, diligent, effective self-management of the disease. It is a process that:
• Requires making and acting on choices, on a regular and recurring basis, that affect one’s health
• Includes learning the body of knowledge relevant to the disease state, defining personal goals, weighing the benefits and risks of various treatment options, making informed choices about treatment, developing skills (both physical and behavioral) to support those choices, evaluating the efficacy of the plan toward reaching self-defined goals.
*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, pp. 1-2. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf
What Bloom level would you assign to each?• Remember• Understand• Apply• Analyze• Evaluate• Create 27
AADE7TM curriculum content
1. Healthy eating2. Being active3. Monitoring4. Taking medication5. Problem solving6. Reducing risks7. Healthy coping
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Objective: Maintain blood glucose within healthy limits to avoid complications• Learn about diabetes in general (At “entry’)
– Physiological process– Interdependence of diet, exercise, meds– Symptoms & corrective action– Consequences of poor control
• Apply knowledge to own case (Daily, Hourly)– Implement appropriate regimen – Continuously monitor physical signs – Diagnose problems in timely manner– Adjust food, exercise, meds in timely and appropriate manner
• Coordinate with relevant parties (Frequently)– Negotiate changes in activities with family, friends, job – Enlist/capitalize on social support– Communicate status and needs to practitioners
• Update knowledge & adjust regimen (Occasionally)– When other chronic conditions or disabilities develop– When new treatments are ordered– When life circumstances change
• Conditions of work—24/7, no days off, no retirement
Our more patient-centered job description
Self-
management
Training
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Objective: Maintain blood glucose within healthy limits to avoid complications• Learn about diabetes in general (At “entry’)
– Physiological process– Interdependence of diet, exercise, meds– Symptoms & corrective action– Consequences of poor control
• Apply knowledge to own case (Daily, Hourly)– Implement appropriate regimen – Continuously monitor physical signs – Diagnose problems in timely manner– Adjust food, exercise, meds in timely and appropriate manner
• Coordinate with relevant parties (Frequently)– Negotiate changes in activities with family, friends, job – Enlist/capitalize on social support– Communicate status and needs to practitioners
• Update knowledge & adjust regimen (Occasionally)– When other chronic conditions or disabilities develop– When new treatments are ordered– When life circumstances change
• Conditions of work—24/7, no days off, no retirement
Our more patient-centered job description
Self-
management
Training
29
It is NOT just following a plan.
It is also thinking and acting to minimize problems.
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Our efforts
1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
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UD survey: Criticality
rankings
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Our efforts
1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
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Bloom’s Taxonomy of Learning ObjectivesLatest (2001) revision
Bloom levels = continuum of cognitive complexityNot just readability!!
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*Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching,
and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.
To be or not to be, that is the question.
To be or not to be, that is the question.
To be or not to be, that is the question.
To be or not to be, that is the question.
To be or not to be, that is the question.
To be or not to be, that is the question.
“To be or not to be”Bloom’s taxonomy of educational objectives (cognitive domain)*
Simplest tasks1. Remember
recognize, recall,Identify, retrieve
2. Understand paraphrase, summarize,
compare, predict, infer
3. Apply execute familiar task,,
apply procedure to unfamiliar task
4. Analyze distinguish, focus, select,
integrate, coordinate
5. Evaluate check, monitor, detect
inconsistencies, judge effectiveness
6. Create hypothesize, plan, invent,
devise, design
Most complex tasks34
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*Revised 2001: Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching,
and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.
Anticipate effect of exercise & foods on blood glucose.
Coordinate meds, diet, and exercise.
Manage sick days.
Determine when & why blood glucose is out of
control
Monitor symptoms; assess whether action needed;
evaluate effectiveness of actions
Create daily and contingency plans that control blood
glucose
Recall effects of exercise on glucose.
Remember to take BGs & Rx.
Bloom’s taxonomy of educational objectives (cognitive domain)*
Simplest tasks1. Remember
recognize, recall,Identify, retrieve
2. Understand paraphrase, summarize,
compare, predict, infer
3. Apply execute familiar task,,
apply procedure to unfamiliar task
4. Analyze distinguish, focus, select,
integrate, coordinate
5. Evaluate check, monitor, detect
inconsistencies, judge effectiveness
6. Create hypothesize, plan, invent,
devise, design
Most complex tasks
Remember to measure foods, drinks & read labels.
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What about reading nutrition labels?
• How important?
• How complex?
Essential
Extremely
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Information is better because it’s inchart form
Amount per serving
But, it contains aconfusing technical symbol.
Can you spot it?
“Amount/serving”
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What’s the problem here?
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And here?
Organic
HealthyNo sugar
added40
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Pros: • Fewer items• Single vertical
list • Major headings
stand out
Cons: • Lots of irrelevant
info
• Seemingly inconsistent info
Better, but…
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Food Label revision…counting carbohydrates
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Bloom’s taxonomy of educational objectives (cognitive domain)
Simplest tasks1. Remember
recognize, recall,Identify, retrieve
2. Understand paraphrase, summarize,
compare, predict, infer,
3. Apply execute familiar task,,
apply procedure to unfamiliar task
4. Analyze distinguish, focus, select,
integrate, coordinate
5. Evaluate check, monitor, detect
inconsistencies, judge effectiveness
6. Create hypothesize, plan, invent,
devise, design
Most complex tasks
Distractors:CHOs vs Fiber vs Fat
Carb vs non-carb ??Sequence of labelTotal CHOs important, “Sugars” notGrams as volume vs wt
Part of meal vs snack OK?CHOs in intended serving? CHOs vs Fat/Chol vs Na
Location of relevant CHO (carb) gms
How many CHO gms in 1 serving?Subtract fiber gms from CHO gms
Plan a meal or snack
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Our efforts
1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
How different in ability can adults be?
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Typical literacy items, by difficulty levelNational Adult Literacy Survey (NALS), 1993
NALS difficulty level (& scores)
% US adults (age 65+) peaking at this level
Simulated everyday tasks
5(375-500)
3% ~0%
Use calculator to determine cost of carpet for a room Use table of information to compare 2 credit cards
4(325-375)
15%4%
Use eligibility pamphlet to calculate SSI benefits Explain difference between 2 types of employee benefits
3(275-325)
31%16%
Calculate miles per gallon from mileage record chart Write brief letter explaining error on credit card bill
2(225-275)
28%33%
Determine difference in price between 2 show tickets Locate intersection on street map
1(0-225)
23%47%
Total bank deposit entry Locate expiration date on driver’s license
Daily self-maintenance in modern literate societies
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NALS difficulty level (& scores)
% US adults (age 65+) peaking at this level
Simulated everyday tasksNational Adult Literacy Survey (NALS), 1993)
5(375-500)
3% ~0%
Use calculator to determine cost of carpet for a room Use table of information to compare 2 credit cards
4(325-375)
15%4%
Use eligibility pamphlet to calculate SSI benefits Explain difference between 2 types of employee benefits
3(275-325)
31%16%
Calculate miles per gallon from mileage record chart Write brief letter explaining error on credit card bill
2(225-275)
28%33%
Determine difference in price between 2 show tickets Locate intersection on street map
1(0-225)
23%47%
Total bank deposit entry Locate expiration date on driver’s license
level of inference (“connecting the dots”) abstractness of info
distracting information
number of features to match
Not reading per se, but “problem solving”
Typical literacy items, by difficulty levelNational Adult Literacy Survey (NALS), 1993
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Complexity & aging
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g - Basic information processing(GF)
Basiccultural Knowledge(GC)
Age-related cognitive decline
Learning & reasoning abilityAge 8
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Age 80
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Our efforts
1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
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“Rx for Physical Activity” for a Rural Community Health Center
Linda S. Gottfredson, PhDSchool of EducationUniversity of Delaware
Kathy Stroh, MS, RD, CDEDiabetes Prevention & Control ProgramDelaware Division of Public Health
Presented at the 2009 Diabetes Translation Conference of the Centers for Disease Control & Prevention (CDC). Long Beach, CA, April 24, 2009
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Basic pedometer—just counts steps
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Graduated RxBasic Rx
increases
speed
http://www.udel.edu/educ/gottfredson/Rx54
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Teaching the teacher: Script for CDE when prescribing “Rx for Walking”
Provides the CDE with:
Educationally sound teaching strategy
• Key ideas • Content, sequence, and pace of
instruction, etc.
Implicit training • Be concrete, personalize,
use meaningful metaphors, etc.
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Lesson plan: Don’t assume they know what’s obvious to you
Can’t assume:
That patient will know: • What a pedometer is• How to wear it • The exact regimen of the Rx
• i.e., extra steps
That the educator will know specific learning steps for:
• Aim of script (e.g., extra steps)• How to adjust regimen
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Our efforts
1. Describe job of self-care from patients’ perspective
2. Identify the job’s most critical tasks
3. Trace (and limit) cognitive complexity of learning tasks
4. Differentiate instruction by ability (“literacy”) level
5. Provide scripts for providers that minimize complexity
6. Provide patient handout that reinforces learning
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Thank you.
Questions?Advice?
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5 levels of diabetes educators*o Level 1, non-healthcare professional,o Level 2, healthcare professional non-diabetes educator,o Level 3, non-credentialed diabetes educator,
Level 4, credentialed diabetes educator, and Level 5, advanced level diabetes educator/clinical manager.
*American Association of Diabetes Educators (AADE) (2011). Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators, p. 4. http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/ScopeStandards_Final2_1_11.pdf
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