University of Louisville University of Louisville
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Doctor of Nursing Practice Papers School of Nursing
7-2021
Program evaluation: assessing the effectiveness of diabetes Program evaluation: assessing the effectiveness of diabetes
group education utilizing the diabetes knowledge test. group education utilizing the diabetes knowledge test.
Aminata Gueye
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Recommended Citation Recommended Citation
Gueye, Aminata, "Program evaluation: assessing the effectiveness of diabetes group education utilizing
the diabetes knowledge test." (2021).
Doctor of Nursing Practice Papers.
Paper 116.
Retrieved from https://ir.library.louisville.edu/dnp/116
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ASSESSING DIABETES GROUP EDUCATION 2
DEDICATION
I would like to dedicate this paper to my children Diarra, Abdoulaye, and Safiyah. You
all were my biggest motivation in completing this DNP program. I would also like to thank my
husband Mouhamdaou for constantly supporting me and encouraging me when I felt like giving
up. I would like to thank my siblings for helping me care for my children during this program.
Lastly, I would also like to thank all my friends for their support.
ASSESSING DIABETES GROUP EDUCATION 3
ACKNOWLEDGEMENTS
I would like to acknowledge my project committee chair Dr. Elisabeth Volpert and committee
member Dr. Cynethia Bethel- Jaiteh for their support and guidance through this process. I am so
blessed to have worked with such wonderful women. Thank you so much for patiently working
with me and constantly supporting and encouraging me.
ASSESSING DIABETES GROUP EDUCATION 4
ABSTRACT
Background: Diabetes Mellitus (DM) is the 7
th
leading cause of death in the United States (HHS
ODPHP, 2019). It is also the leading cause of chronic disease complications such as adult-onset
blindness, kidney failure, and lower-limb amputations (HHS ODPHP, 2019). It is recommended
that all people with diabetes should participate in diabetes self-management education (ADA,
2018).
Purpose: The purpose of this DNP project is to evaluate the effectiveness of diabetes group
education by assessing participants’ knowledge utilizing the diabetes knowledge test (DKT) at an
outpatient diabetes care center in Louisville KY. The evidence from the literature review
supports the importance of achieving knowledge for successful diabetes management and this
project's goal of evaluating a diabetes self-management education (DSME) program participants’
knowledge of diabetes by utilizing the DKT.
Methods: Participants were recruited by the DNP student at the start of the first session of the
diabetes education program. A pre/post-test design was used utilizing the DKT to evaluate the
change in knowledge of diabetes before and after DSME was provided. A paired t-test was used
to analyze the data.
Results: There was a total of 8 out of 10 participants that completed the DKT2. There was an
increase in DKT scores for both the general knowledge subscale and insulin use subscale from
pre and post intervention. This indicates that diabetes education is effective in increasing
patient’s knowledge, however the results were not statically significant.
Discussion: Although the results cannot be generalized due to a small sample size, the results
from this project still showed that diabetes group education increased knowledge about diabetes.
ASSESSING DIABETES GROUP EDUCATION 5
e Effective diabetes education is important for long term success of diabetes self- management
(Miller, 2017, Adam et al., 2018, Philips et al.,2018, Esden and Nichols., 2013., Flode et al.,
2017., Rygg et al.,).
ASSESSING DIABETES GROUP EDUCATION 6
KEYWORDS
Diabetes, knowledge, diabetes knowledge, knowledge test, diabetes knowledge test, diabetes
education, group education, diabetes management, diabetes group education program
ASSESSING DIABETES GROUP EDUCATION 7
Contents
Introduction……………………………………………………………………………………….7
Rationale…………………………………………………………………………………………11
Purpose ………………………………………………………………………………………….12
Environment (Setting)……………………………………………………………………………13
Ethics/Permissions……………………………………………………………………………….14
Conceptual Framework………………………………………………………………………….14
Intervention Description………………………………………………………………………....15
Literature Review & Synthesis………………………………………………………………….16
Procedures……………………………………………………………………………………….20
Measurements………………………………………………………………………....................21
Cleaning Data…………………………………………………………………………………….23
Data Analysis……………………………………………………………………………………24
Results……………………………………………………………………………………………24
Discussion………………………………………………………………………………………. 25
References……………………………………………………………………………………….28
Appendices……………………………………………………………………………………….31
ASSESSING DIABETES GROUP EDUCATION 8
Introduction
Background
Diabetes Mellitus (DM) is a chronic health condition in which the body is unable to
produce enough insulin (DM Type I) or unable to respond appropriately to insulin which results
in elevated glucose levels in the body (DM Type II). Based on the National Diabetes Statistics
Report by the Center for Disease Control and Prevention (CDC), DM Type I (DMT1) and Type
II (DMT2) affects roughly 34.2 million people of all ages in the United States and 34.1 million
of all adults ages 18 and older in the US (CDC, 2020). The statistics provided in this report do
not differentiate between DMT1 or DMT2, however DMT2 accounts for 90% to 95% of all
reported diabetes cases. (CDC, 2020) Additionally, 28% of Americans with diabetes are
undiagnosed (U.S. Department of Health and Human Services, Office of Disease Prevention and
Health Promotion [HHS ODPHP],2019). DM is the 7
th
leading cause of death in the United
States (HHS ODPHP, 2019). It is also the leading cause of chronic disease complications such as
adult-onset blindness, kidney failure, and lower-limb amputations (HHS ODPHP, 2019).
In 2017, the total estimated cost for diabetes in the U.S. was 327 billion dollars, whereas,
in 2012, the cost was 245 billion dollars (ADA, 2020). This represents a 26% increase in health
care costs over 5 years (ADA, 2020). Healthy People 2030 identified a need to reduce the burden
of DMT1 and DMT2 and improve quality of life for all persons with DM or those that are at risk
for developing DM. To accomplish this goal Healthy People 2030 created 15 objectives in
addressing the management of DM. The objectives include reducing the annual number of new
cases of diagnosed DM in the population, improving glycemic control among persons with
ASSESSING DIABETES GROUP EDUCATION 9
diabetes, and to increase daily self-glucose monitoring of adults with diabetes to at least once
daily (HHS ODPHP, 2020).
External Evidence of the Problem
According to the American Diabetes Association (ADA), there is a huge prevalence of
diabetes in the state of Kentucky. In the state of Kentucky, approximately 531,646 people, or
14.5% of the adult population have diabetes. Approximately 108,000 of these people who have
diabetes are unaware that they have diabetes. It is estimated that 27,000 people in Kentucky are
diagnosed with diabetes each year. It is also estimated that 1,168,000 people or 35.5% of the
adult population in KY have prediabetes. Prediabetes is a health condition where blood sugar
levels are more elevated than normal levels but not high enough to be diagnosed as DMT2
(ADA, 2018). The cost of diabetes and prediabetes in Kentucky yearly is estimated to be 4.8
billion. Medical expenses are also estimated to be 2.3 times higher in people with diabetes
compared to people who do not have diabetes in Kentucky due to the cost of antihyperglycemic
medications, supplies needed to treat diabetes, and office visits with physicians. (ADA, 2018).
The National Standards for Diabetes self-management education and support (DSMES)
define diabetes self-management education (DSME) as an ongoing process in the patient's
medical care (ADA, 2018). It is recommended that all people with diabetes should participate in
diabetes self-management education (ADA, 2018). This recommendation is to encourage and
support people with diabetes by teaching the knowledge, skills, and abilities that are required for
successful self-management of diabetes (ADA, 2018). The key goals and outcomes for diabetes
management involve improving clinical outcomes, health status, and quality of life. The
evidence has found that DSMES is highly attributable to improve diabetes knowledge, self-care
behaviors, lower A1c, improved quality of life, reduced mortality risk, and reduced healthcare
ASSESSING DIABETES GROUP EDUCATION 10
costs. DSMES has also been proven to increase the use of primary care services and preventative
care services and reduce the use of acute care and inpatient hospital services (ADA, 2018).
Significance
According to the World Health Organization (2019), diabetes complications can be
prevented by maintaining a healthy body weight, physical activity of at least 30 minutes daily,
eating a healthy diet by avoiding saturated fats and sugars, and avoiding tobacco use.
Approximately 1.6 million deaths in 2016 were directly related to diabetes complications. In
2012, 2.2 million deaths were related to elevated blood glucose. It was also noted that almost
half of the deaths related to high blood glucose occurred in patients less than 70 years of age
(World Health Organization ,2019)
The total percentage of patients diagnosed with diabetes and undiagnosed diabetes for
ages 45-64 in the US was 17.5%, and 26.8% for patients 65 years and older (CDC, 2020).
Among adults 18 and older in the US, the total percentage for diagnosed and undiagnosed
diabetes in non-Hispanic whites was 11.9% and 16.4% for non-Hispanic blacks (CDC, 2020).
According to the CDC, the incidence of diabetes increases with age (CDC, 2020). This increase
in DM with age is due to changes in a person’s body composition as aging occurs; there is an
increased risk for glucose intolerance and an increased risk of diabetes (CDC, 2020). According
to the American Diabetes Association (2018), older adults (65 years and older) typically have
more serious complications from diabetes including functional impairment, falls and fractures,
cognitive impairment, depression, and vision and hearing impairment (ADA, 2018). These
complications are often related to other comorbidities including renal disease, cardiovascular
disease, and dementia (Abdelhafiz & Sinclair, 2015).
ASSESSING DIABETES GROUP EDUCATION 11
Diabetes complications have been found to cause an increase in emergency room visits
and hospitalizations (CDC, 2020). According to the National Diabetes Statistic Reports (2020),
in 2016, a total of 16 million emergency department (ED) visits (among adults aged 18 years or
older) were reported in the U.S with a diagnosis of diabetes. Hyperglycemia crisis accounted for
224,000 of these visits, and 235,000 of these visits were related to hypoglycemia (CDC, 2020).
Of these ED visits involving a hyperglycemia crisis, 8.1% were treated and released within 23
hours of arrival, and 85.6% were admitted to the hospital (CDC, 2020). For those admitted for
hypoglycemia, 71.0% were treated and released and 22.3% were admitted to the hospital (CDC,
2020).
In 2016, 7.8 million hospital discharges in the U.S reported diabetes as a diagnosis in
adults aged 18 years or older (CDC, 2020). Major cardiovascular disease accounted for 1.7
million of these discharges including 438,000 for ischemic heart disease and 313,000 for stroke
(CDC, 2020). Lower extremity amputations accounted for 130,000 discharges, 209,000 for
hyperglycemic crisis, and 57,000 for hypoglycemia (CDC, 2020). Based on crude estimates from
2013 - 2016, it was also found that 37% of adults aged 18 and older diagnosed with diabetes had
chronic kidney disease (CKD) stages 1-4 (CDC,2020). The CDC (2020) also illustrates that
52.5% of adults had moderate to severe CKD stages 3-4 (CDC, 2020). These complications
associated with diabetes can be prevented by lifestyle intervention, which is one of the major
components of DSME programs (ADA, 2012).
Target Population
The target population was a convenience sample of participants of an established diabetes
group education program in Louisville, KY. After a formal discussion with the manager of
thediabetes education program, and a review of a recent report of the diabetes group education
ASSESSING DIABETES GROUP EDUCATION 12
program’s participants' demographics, the average participant population who attended these
diabetes classes were 78% white, 10% black, 3% Hispanic, 2% Asian, 1% Middle Eastern, and
Other 1%. The report also revealed that 7% of the participants were between ages 19-44, 57%
of the participants were between ages 45-64, and 36% are 65 or older. In terms of health
insurance, 26% of the participants have Medicare, 3% Medicaid, 26% Anthem, 16% Humana,
and 29% other. Approximately 75% of the people participating in the program have other
comorbidities including hypertension and hyperlipidemia.
Based on the review, 56% of the participants have a diagnosis of DMT2, 3% of the
participants have a diagnosis of DMT1, and 41% of the participants have a diagnosis of
gestational diabetes and pre- DM. Participants with gestational diabetes and pre- DM are taught
in a separate class from those participants who have a diagnosis of DMT1 and DMT2. The
diabetes education class that will be evaluated in this DNP project is provided to participants
with DMT1 and DMT2 of any length of diagnosis. Newly diagnosed patients are not separated
from participants who have been previously diagnosed. Newly diagnosed participants are
considered participants that have been diagnosed with diabetes for less than 6 months.
Eligibility criteria for a person to participate in the DMSE program include the patient
must be 19 years and older and the patient must have a known diagnosis of DMT1 or DMT2.
Patients must also be referred to the program by their health care provider (HCP).
Environment
The DNP project was completed at a 519- bed hospital located in a Suburban area of
Louisville KY. Residents in this area benefit from the hospital’s emergency services, cancer
services, women’s health, orthopedics, neurosurgery, cardiovascular services, wound care,
behavioral health, occupational health, and in-home care. This agency also has a network of
ASSESSING DIABETES GROUP EDUCATION 13
primary care and specialty offices and urgent care centers. Educational services are provided on
the second floor of the hospital in the education center. Educational opportunities that are
provided include diabetes outpatient classes and education to deter diabetes (NEED), body
wellness, cancer resources, nutrition, exercise, maternity programs, safe sitter classes, and
weight-loss surgery seminars.
Rationale
Needs Assessment
This local agency utilizes the American Association of Diabetes Educators 7 Self- Care
Behaviors framework (AADE7) to deliver DSME to patients. This evidence-based framework
focuses on increasing patients’ knowledge about healthy eating, the importance of being more
physically active, how to monitor blood sugar, the importance of medication compliance,
problem-solving skills in situations of hypoglycemia and hyperglycemia, reducing risks.
Reducing risks is achieved by taking necessary precautions for health maintenance such as
getting routine physical exams, staying up to date on vaccinations, and healthy coping by
teaching patients to have a positive attitude about their condition and building positive
relationships with others (Association of Diabetes Care & Education Specialists [ADCES], n.d.).
DSME is provided at a diabetes outpatient care center. They consist of two hour-long in-
person classes in three sessions once a week. The classes are taught by one staff member, a
certified diabetes care education specialist (CDCES), or a registered dietician. A discussion with
the CDCES revealed that participants’ knowledge after completing the program has not been
evaluated. Currently, a retrospective chart review evaluating participants’ HbA1c is conducted
before the first-class meeting and again one year after the program concludes. The average A1c
at the start of the program is 8.2%. The average A1c one year after attending the program is
ASSESSING DIABETES GROUP EDUCATION 14
7.5%. In the first class, patients create three self-management goals. Immediately after the
completion of the 3-week program, the patients’ goals are reevaluated by the CDCES. The
CDCES asks the patients if they are meeting their goals. According to the CDCES, data of
patients’ ability or inability to achieve their goals has not been recorded.
Purpose
The National Standards for Diabetes self-management education and support (DSMES)
define diabetes self-management education (DSME) as an ongoing process in the patients’
medical care (ADA, 2018). It is recommended that all people with diabetes should participate in
diabetes self-management education. This recommendation is to encourage and support people
with diabetes by teaching them the knowledge, skills, and abilities that are required for
successful self-management of diabetes (ADA, 2018). The key goals and outcomes for diabetes
management involve improving clinical outcomes, health status, and quality of life. The
evidence has found that DSMES is highly attributable to improve diabetes knowledge, self-care
behaviors, lower A1c, improved quality of life, reduced mortality risk, and reduced healthcare
costs. DSMES has also been proven to increase the use of primary care services and preventative
care services and reduce the use of acute care and inpatient hospital services (ADA, 2018).
The purpose of this DNP project is to evaluate the effectiveness of diabetes group
education by assessing participants’ knowledge utilizing the diabetes knowledge test (DKT). The
goal of the diabetes education program is that participants will have a 30% increase in DM
knowledge 3-weeks by the end of the 3 week-long program. The PICO question is, in adult
patients with type I and type II diabetes mellitus, do knowledge scores increase after a DSME
program compared to baseline knowledge scores.
Ethics and Permissions
ASSESSING DIABETES GROUP EDUCATION 15
Institutional Review Board (IRB) approval was obtained by the DNP student and her
faculty project members through the University of Louisville. The project was approved by the
manager of the diabetes education program. There was preliminary approval contingent on the
IRB approval from the research oversight team at the agency.
Conceptual Framework
The RE-AIM Framework is an evaluation framework. RE-AIM is the acronym for the
components included in this framework. The five components are Reach, Effectiveness,
Adoption, Implementation, and Maintenance. The reach component assessed the number of
individuals willing to participate in the program. The effectiveness of the program was
determined based on the outcomes of the intervention. The adoption looked at the individuals
willing to initiate the program. The implementation component looked at how the program is
delivered. The maintenance portion looked at the sustainability of a program (Gaglio et al.,
2013).
The goal of this DNP project is to assess the effectiveness of the group-based diabetes
education program, provided at a local outpatient diabetes education center, on patient
knowledge. The reach component was assessed by the population participating in this program
and their willingness to complete the DKT before the start of the program and at the end of the
program. The results of DKT assessed the effectiveness component of the RE-AIM framework
The adoption component evaluated how the educators participated to deliver the DKT to
patients. The implementation component assessed that resources were provided to participants to
be able to complete the DKT. The maintenance component will be assessed by the frequency of
use of this program evaluation method. This will assess whether the diabetes educators are
ASSESSING DIABETES GROUP EDUCATION 16
properly conducting patient evaluations utilizing the DKT after the completion of the DNP
project.
Intervention
Description
Based on the American Association of Diabetes Educators (AADE, 2009), there is a
sequence of outcomes to be measured with diabetes self-management education and training
(DSME/T). The immediate outcome involves patient knowledge (AADE, 2009). The AADE
recommends that learning, behavioral change, clinical improvement, and improved health status
be monitored frequently throughout a DSME program (AADE, 2009). The AADE recommends
that learning should be assessed by assessing basic DM skills, knowledge of diabetes, and
literacy (AADE, 2009). Knowledge attainment and skillsets such as blood glucose monitoring,
nutrition management, and insulin use are important components needed to successfully manage
diabetes (ADA, 2018).
This project assessed participants’ knowledge before the start of the DSME program and
at the end of the 3-week program as recommended by the AADE. The revised Michigan
Diabetes Knowledge Test (DKT2) instrument was utilized.
One of the standards identified by the National Standards for DSMES is Participant
Progress - Standard 9. This standard explains that the providers of DSMES services monitor and
communicate participants’ outcomes to evaluate the effectiveness of the educational programs
using appropriate measurement techniques (CDC, 2019). Within the patient progress standard
policy, one of the recommendations is that a clinical outcome is measured after DSMES services
and compared to a baseline value. Participant knowledge is one of the recommended measurable
clinical outcomes. (CDC, 2019). Utilizing the DKT2 will allow the agency to fulfill the National
ASSESSING DIABETES GROUP EDUCATION 17
Standards by evaluating their DSME program to ensure that participants are gaining knowledge
from the program.
Literature Review
Methods
A review of the literature was completed using CINAHL, Medline PubMed, and Medline
Ovid. The keywords used in this search included: “Diabetes self-management education” and
“patient knowledge”, “diabetes self-management education” and “diabetes knowledge”,
“diabetes self-management education” and “diabetes knowledge test”, “diabetes self-
management education” and “diabetes health literacy”
Eligibility
The search was limited to the English language, full-text articles from 2011- 2020, and
the adult population ages 19 and older. Studies were excluded if they did not pertain to the
impact of diabetes education on patient knowledge. The John Hopkins level of evidence model
and Equator- Network Guidelines were used to evaluate the quality of evidence of the studies.
The PubMed search yielded 459 citations and 6 studies met the inclusion criteria. There
were 20 citations from CINAHL, this included 3 duplicates from PubMed. Three articles from
CINAHL were selected to be included in this review. Ovid yielded 7 citations, and 3 articles that
met the inclusion criteria were selected to be included in this review. Twelve articles were
originally selected for this review, however, upon further evaluation, an additional 6 articles
were excluded due to not meeting the inclusion criteria. A total of 6 articles were utilized in this
review.
Results
ASSESSING DIABETES GROUP EDUCATION 18
The primary investigator identified five studies in the literature review that utilized the
DKT instrument to evaluate patients’ knowledge after a DSME program (Miller, 2017, Adam et
al., 2018, Philips et al.,2018, Esden and Nichols., 2013., Flode et al., 2017).
Evidence has shown that people who participate in DSME have an increase in DM
knowledge of DMT2 disease complications, diet, physical activity, and improving metabolic
control (Rygg et al., 2012). Rygg et al. (2012) evaluated the effectiveness of group-based DSME
by utilizing a 12- item questionnaire; developed by the studies investigators for this study.
Results from the questionnaire revealed that the intervention group, who participated in DSME,
improved their knowledge as evident by the intervention group achieving higher knowledge
scores at 6 months (6.3 vs 7.9, p=0.000), and 12 months (6.3 vs 8.0, p= 0.0000) after the
intervention (Rygg et al., 2012).
The literature has shown that there are different ways to conduct DSME (Adam et al.,
2018). Adam et al. (2018) evaluated the impact of DSME on patients' knowledge in their
randomized control study that utilized traditional group education (TE) or conversation maps
(CM) providing education on diagnostic criteria for diabetes, types of diabetes, nutrition
management, exercise, and self-monitoring. Participants' knowledge was evaluated by the
participants completing an adapted version of the revised Michigan diabetes knowledge test. The
participants who received DM education via conversation had a significant increase in
knowledge scores from baseline to 2 weeks and 3 months after the program, (15.20±3.43 vs
18.10±1.60 vs, 17.90±1.79 (p<0.005). Those who participated in traditional group education had
an increase in knowledge, but the knowledge test results were not significant from baseline to 2
weeks and 3 months after the program (14.73±2.41 vs 16.18±1.40 vs 15.82±1.60) (Adam et al.,
2018).
ASSESSING DIABETES GROUP EDUCATION 19
A facility can successfully provide DSME with the AADE7 (Miller, 2017). Miller’s
(2017) convenience sampling-based study used the AADE7 self-care behaviors framework to
conduct group medical visits for 65 patients with DMT2 with an A1C greater than 7.5. DKT2
was utilized to assess knowledge before the start of the 6-week program and at the end of the
program. The baseline mean for DKT at the start of the program was 12.52. Upon completion of
the program, the mean was 18.10. This signifies a statistically significant improvement in the
participants' knowledge. Esden and Nichols (2013) also showed the effectiveness of using DKT
to evaluate the participants’ knowledge. Esden and Nichols (2013) noted improved DKT scores
as evidence by the pre-intervention mean knowledge score of 52% and the post-intervention
mean knowledge score of 71.7 % (Esden and Nichols, 2013).
In a study by Flode et al. (2017), a group-based DSME program was provided to 115
primary care patients with DMT2, the DKT was also used to assess participants' DM knowledge.
Mean DKT scores improved significantly immediately after the program ended versus the scores
of the participants before the program (69 vs 78, p <0.0001). Flode et al. (2017) also showed that
participants’ knowledge gained persisted three months after the program as evidenced by the
knowledge scores 3 months after the program ended being improved (82) compared to the scores
immediately after the completion of the program (80, p= 0.141) (Flode et al., 2017).
The evidence shows a lack of diabetes education and knowledge among patients with
diabetes who do not attend DSME (Phillips et al., 2018). Phillips et al. (2018) conducted a
qualitative study that evaluated the relationship between diabetes knowledge, glycemic control,
and associated health conditions between DM participants who attend a previous program and
participants who had never participated in DSME. The participants that never received formal
education scored 15.3% lower than those who had previously attended a DSME program
ASSESSING DIABETES GROUP EDUCATION 20
(Phillips et al., 2018). Another randomized control study that showed that people with DM who
did not attend a DSME had lower knowledge tests scores were completed by Jiang et al. (2019).
He concluded that participants who received general care education had a lower Chinese
Diabetes-Related Knowledge Questionnaire (C-DKQ) score compared to those who received
education through a structured DM program (p < 0.001) (Jiang, 2019).
Discussion
The literature shows that most of the studies utilized some form of a reliable knowledge
test or questionnaire to assess knowledge (Miller, 2017, Adam et al., 2018, Philips et al.,2018,
Esden and Nichols., 2013., Flode et al., 2017). Only one of the studies in this search utilized a
self-developed questionnaire for their program (Rygg et al., 2012). These studies provide
evidence indicating that diabetes education regardless of the format is effective in improving
diabetes knowledge (Miller, 2017, Adam et al., 2018, Philips et al.,2018, Esden and Nichols.,
2013., Flode et al., 2017., Rygg et al., 2012).There are a limited number of studies that took
place in the U.S. However, the studies included in the review included are very strong in quality
as evidence by most of the studies being randomized control trials. Some of the studies had small
sample sizes (Esden and Nichols, 2013) Overall, the studies in this review recommended a need
to provide effective education to improve patient knowledge which will lead to better diabetes
self-management (Miller, 2017, Adam et al., 2018, Philips et al.,2018, Esden and Nichols.,
2013., Flode et al., 2017., Rygg et al., 2012).
Procedures
Intervention Team/Stakeholders
The intervention team for the project included the DNP student, diabetes educators, and
registered dieticians. The education was provided by the diabetes educator and the dietician. The
ASSESSING DIABETES GROUP EDUCATION 21
key stakeholders are the administration and the research oversight council member who are
responsible for approving projects that are conducted at the organization. The other stakeholders
include the manager of the diabetes management education program, diabetes educators, and
registered dieticians because they help conduct the program.
Informed Consent
Participants received a consent form to be signed at the start of the program by the DNP
student. The project purpose and description were included. Information including risks,
benefits, and confidentiality were also included. There are minimal risks for this project.
Minimal risks may include being self-conscious during the process of the project due to wanting
to achieve goals and feeling distressed if goals are not achieved.
Data collection
Informed consent was obtained from all participants before the start of collecting any
data. An identification number was then assigned to each participant and then demographic data
was collected. The demographic data collected included age in years, years with known diabetes,
sex, marital status, race, living arrangements, education, employment status, attendance of a
previous DSME program, and insurance status. Lastly, the DKT was administered by the DNP
student before the start of any education at the first class. The DKT was administered again by
the DNP student at the end of the last class..
Data Maintenance and Security
All patient information collected was stored in the office of the DNP student at the
University of Louisville, School of Nursing in a locked file. Participants received an
identification number and sensitive information was de-identified. Data entry was completed on
ASSESSING DIABETES GROUP EDUCATION 22
an excel spreadsheet using de-identified data. Once data was entered into the excel spreadsheet,
all original documents with participants' names were shredded.
Measurements
Project Design
This evidence-based DNP project utilized a pre/post-test design to evaluate the change in
knowledge of diabetes before and after DSME is provided. Participants were recruited by the
DNP student at the start of the first in-person group DSME class.
Description of the Instrument Properties
The Revised Michigan Diabetes Knowledge test (DKT2) instrument is an updated
version of the original Diabetes Knowledge Test (DKT) instrument. The Diabetes Knowledge
Test was originally developed and published in 1998 (Fitzgerald et.al, 1998). It was created by a
group of nationally recognized experts in diabetes education and care who created the content
and test items. This test was then used worldwide to test the knowledge among type 1 and type 2
diabetes patients. The test includes a 14-item general test, and a 9- item insulin use subscale
(Fitzgerald et.al, 2016). With the fact that the DKT was still in high demand, Fitzgerald et. al
conducted a literature search and reviewed the 1998 version of the DKT. It was determined that
the content included in the test was outdated and needed revision (Fitzgerald et.al, 2016).
The instrument needed to be updated to reflect current diabetes care and education
guidelines. Fitzgerald et.al (2016) and their team of diabetes behavioral researchers reviewed
each item on the DKT and updated it when required. They also ensured that it was consistent
with current diabetes self-management education standards and current practices. Once the
revision was complete, it was reviewed by a team of diabetes care providers and patients. This
included a physician, a Certified Diabetes Educator nurse, and a Certified Diabetes Educator
ASSESSING DIABETES GROUP EDUCATION 23
dietitian. The DKT2 provides a low-cost method to assess the overall diabetes knowledge of
patients or a population (Fitzgerald et.al, 2016).
Scoring and Score interpretation
DKT2 still includes 23 items just like the original test. There were no items added or
excluded but there were 13-items that were modified. There were 2- items changed to improve
grammar, 7- items changed to clarify questions or responses, and 4-items were changed to match
current national standards. There are two components of the DKT2 including the general
knowledge section which has 14-items and the 9-items for insulin use subscale. These items are
given in multiple-choice format. Each of these sections is scored separately. One point is given
for each item answered correctly. The general knowledge section is appropriate for adults with
both type 1 and type 2 diabetes. The insulin use subscale is appropriate for adults with type 1
diabetes and adults with type 2 diabetes who need to use insulin (Fitzgerald et.al, 2016)
Reliability and Validity Data
The reliability and validity of the DKT2 were assessed using two separate patient
samples. An online survey called Qualtrics, LCC was used to recruit the first sample. The second
sample was recruited from the University of Michigan’s Division of Metabolism, Endocrinology
& Diabetes (MEND) Diabetes Registry. The revised Diabetes Knowledge Test 2 was completed
by one hundred and ninety participants. Majority of the sampling came from the Qualtrics
sample (101 participants) while 89 participants were from the MEND sample (Fitzgerald et.al,
2016).
To calculate scale interim reliability, Cronbach’s coefficient alpha was used. The samples
were assessed separately and then together. The reliability was conducted for the general test
component and the insulin use subscale. The Cronbach’s alpha for the general test for the
ASSESSING DIABETES GROUP EDUCATION 24
Qualtrics sample was a=.70 and a=.28 for the MEND sample. For both samples combined, the
Cronbach alpha was a=.77. For the insulin use subscale, the results for the general test
component was a= .74 for the Qualtrics sample. The result of the MEND sample was a=.45. For
both samples combined, the Cronbach’s alpha was a= .84. Overall, the DKT2 has been proven to
be a reliable and valid instrument that can be utilized by researchers, clinicians, and diabetes
educators (Fitzgerald et.al, 2016).
Cleaning Data
A codebook for data entry was created utilizing an excel spreadsheet. Column 1 of the
excel spreadsheet included participant ID number, age in years, years with known diabetes’s,
marital status, race, living arrangements, education, employment status, attendance of a previous
DSME program, and insurance status. The DKT results were also entered into the spreadsheet.
All data were analyzed in SPSS using a codebook. Data entry errors were assessed by the DNP
student in SPSS to identify any duplicates or extra spaces. Information in SPSS was confirmed
with the data collected using an excel spreadsheet with participant data.
Data analysis
SPSS version 27 was used for data analysis. Descriptive statistics were used to analyze
demographic data. A paired-samples t-test was used to analyze data collected from the pre-
intervention DKT scores and post-intervention DKT scores for each participant. Both the DM
general knowledge subscale and insulin use subscale were analyzed separately. A combined
analysis of the total DKT scores was also conducted.
Results
Participant demographics
ASSESSING DIABETES GROUP EDUCATION 25
There were 10 participants (Table 1). The majority of the participants were female
(60%). All of the participants were white. Most of the participants were between the ages 45-54
years (50%). Most of the participants were married and resided at home with their spouses and
children. All of the participants had a high school diploma or higher. Majority (70%) of the
participants work a full-time job at least 40 hours per week. Most (80%) of the participants had
private insurance and the other 20% had both private insurance and Medicare.
Diabetes characteristics
All of the participants were Type 2 diabetics and most of them have only been diagnosed
with diabetes less than a year (90%) (Table 2). The majority of the participants were non-insulin
users (90%). None of the participants had previously attended a diabetes education class.
DKT
A paired - samples t-test was conducted to evaluate the difference in DKT scores pre and
-post-intervention. The DKT2 was completed by 10 participants at the before the DSME
program while 8 participants completed the DKT2 before and after the DSME program. .
Twoof the participants were lost to follow up. There was an increase in general knowledge
scores from pretest to post-test, but the results were not statistically significant (M= -5.36, SD=
16.97, t (-.89), p= .402 (two-tailed). The average scores for the insulin use subscale increased
from 58.3% to 62.5% but were not statistically significant (M= - 4.17, SD= 20.52, t (-.57) =, p=
.584 (two-tailed). The average total DKT pretest scores was 70.7%. The average total DKT
posttest score was 75.5%. These results were also not statistically significant (M= -4.89, SD=
16.17, t (-.86) =, p= .421 (two-tailed).
Discussion
ASSESSING DIABETES GROUP EDUCATION 26
The purpose of this project was to determine the effectiveness of diabetes group
education by evaluating the results of diabetes knowledge scores . The results from this project
showed that diabetes knowledge does increase with diabetes group education, however, the
results were not statistically significant. There was a greater increase in scores of the general
knowledge use subscale compared to the insulin use subscale. This could be attributed to the fact
that the majority of the participants were non-insulin users. One plan for the project was to
evaluate whether people who were insulin users did better on the insulin use subscale, but this
was not able to be analyzed because there was only one participant who was not an insulin user.
The RE-AIM framework was a great conceptual framework to use for this project. In
terms of the reach component of the framework, the DNP student was able to get all of the
patients that attended the group sessions to be able to participate in the intervention. In terms of
adopting the DKT as an evaluation tool, the diabetes educators felt that the DKT took too long
and took time away from their teaching time.
Limitations
One limitation of this project was that the sample size was small. The original goal of the
project was to be able to have 40 to 50 participants complete the intervention by collecting data
from at least four different groups. However, due to the COVID- 19 pandemic, the agency had to
decrease class sizes to be able to follow social distancing protocols. Typically, the diabetes group
education class consists of at least 10 patients per group session. The group sessions for this
project consisted of 3-4 patients per group session. Due to the small sample size and the fact that
the intervention was also completed at one particular agency, these results cannot be generalized
to the general population. Another limitation of the project was that 2 participants were lost to
ASSESSING DIABETES GROUP EDUCATION 27
follow up. because they did not attend the last session of the education program. There were
only 3 group sessions evaluated becauseclasses were canceled as a result of low interest .
Conclusion
Although the results cannot be generalized due to small sample size, the study still
showed that diabetes group education increased patient’s knowledge about diabetes. All of the
studies in the literature review showed a statistically significant increase in diabetes knowledge
after a diabetes group education program. However, most of these studies had larger sample sizes
and the intervention lasted longer. Overall, the DKT is a reliable cost-effective way to evaluate a
diabetes education program. This intervention can be used for future practice, however larger
sample sizes and longer intervention times maybe needed to demonstrate statistical significance.
.
ASSESSING DIABETES GROUP EDUCATION 28
References
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ASSESSING DIABETES GROUP EDUCATION 29
https://www.cdc.gov/learnmorefeelbetter/programs/diabetes.htm#:~:text=Participatingin
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toolkit/standards/standard9.html
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ASSESSING DIABETES GROUP EDUCATION 30
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room/fact-sheets/detail/diabetes
ASSESSING DIABETES GROUP EDUCATION 31
Appendices
Table 1. Participant Demographics
Note. N= 10
ASSESSING DIABETES GROUP EDUCATION 32
Table 2. Participants Diabetes Characteristics
Variable____________________________________n______________%_______________________
Gender
Female 6 60.0
Male 4 40.0
Age Range
25-34 1 10.0
35
‐
44
1 10.0
45
‐
54
5 50.0
55-64 1 10.0
65 and older 2 20.0
Race
White 10 100.0
Marital Status
Single 1 10.0
Married/ Domestic Partnership 8 80.0
Divorced 1 10.0
Education level
High school degree or equivalent 3 30.0
Associates degree 1 10.0
Bachelor’s degree 3 30.0
Master’s degree 2 20.0
Doctorate 1 10.0
Employment status
Employed full- time (40+ hours a week) 7 70.0
Employed part- time (less than 40 hours a week) 1 10.0
Retired 2 20.0
Household
Alone 2 20.0
Spouse/Partner 2 20.0
Spouse/partner and children 5 50.0
Family and non-relatives 1 10.0
Insurance Status
Private 8 80.0
Private and Medicare 2 20.0
ASSESSING DIABETES GROUP EDUCATION 33
Variable n %
Type of Diabetes
Type 2 10 100.0
Years diagnosed with diabetes
Less than a year 9 90.0
3-5 years 1 10.0
Insulin use
Yes 1 10.0
No 9 90.0
Previous diabetes education
No 10 10.0
Note. N = 10
Table 3. DKT Scores Paired Samples Statistics
Mean
N
Std.
Std. Error Mean
ASSESSING DIABETES GROUP EDUCATION 34
Deviation
Pair 1-General Knowledge pretest scores
General Knowledge posttest scores
78.5714
83.9286
8
8
9.35220
18.21068
3.30650
6.43848
Pair 2- Insulin use pretest scores
Insulin use posttest scores
58.3333
62.5000
8
8
9.84895
18.72242
3.48213
6.61938
Pair 3- Total pretest scores
Total posttest scores
70.6522
75.5435
8
8
6.87452
16.09073
2.43051
5.68893
Table 4. DKT Scores Paired Samples Correlations
N
Correlation
Sig.
ASSESSING DIABETES GROUP EDUCATION 35
Pair 1- General Knowledge
pretest scores &
General Knowledge
posttest scores
8
.385
.346
Pair 2- Insulin use pretest
scores & Insulin use posttest
scores
8
.072
.866
Pair 3- Total pretest scores &
Total posttest scores
8
.201
.632
Table 5. DKT Scores Paired Samples Test
ASSESSING DIABETES GROUP EDUCATION 36
Mean
Std.
Deviation
Std.
Error
Mean
95% Confidence Interval
of the Difference
Lower Upper
t
d
f
Sig. (2 tailed)
Pair 1-General
Knowledge pretest
scores
General
Knowledge posttest
scores
-5.35714
16.96764
5.99897
-19.54245 8.82816
-.893
7
.402
Pair 2- Insulin use
pretest scores
Insulin use
posttest scores
-4.16667
20.52013
7.25496
-21.32193 12.98859
-.574
7
.584
Pair 3- Total pretest
scores
Total
posttest scores
-4.89130
16.17443
5.71852
-18.41347 8.63086
-.855
7
.421
Table 6. DKT Scores Paired Sample Effect Sizes
ASSESSING DIABETES GROUP EDUCATION 37
Standardizer
Point
Estimate
95% Confidence Interval
of the Difference
Lower Upper
Pair 1-General Knowledge pretest
scores
General Knowledge posttest
scores
Cohen’s d
Hedges
Correction
16.96764
17.94971
-.316
-.298
-1.017 .406
-.961 .384
Pair 2- Insulin use pretest scores
Insulin use posttest scores
Cohen’s d
Hedges
Correction
20.52013
21.70782
-.203
-.192
-.897 .505
-.848 .477
Pair 3- Total pretest scores
Total posttest scores
Cohen’s d
Hedges
Correction
16.17443
17.11059
-.302
-.286
-1.003 .418
-.948 .395
