Participant Explanations for Non-Completion of a Diabetes Self-Management Education Program

Research Article

Ann Nurs Res Pract. 2017; 2(1): 1012.

Participant Explanations for Non-Completion of a Diabetes Self-Management Education Program

Hunt CW¹*, Kavookjian J² and Ekong G²

¹School of Nursing, Auburn University, USA

²Health Outcomes Research & Policy, Auburn University, USA

*Corresponding author: Caralise W Hunt, School of Nursing, Auburn University, 219 Miller Hall, Auburn, AL 36849, USA

Received: December 06, 2016; Accepted: January 03, 2017; Published: January 05, 2017


The purpose of this study was to identify reasons for non-completion of an accredited diabetes self-management education program offered at a hospitalbased diabetes and nutrition center in a Southeastern state. A cross-sectional study design was used to implement an anonymous survey which was mailed to patients with diabetes who started, but did not complete diabetes selfmanagement education classes during a one year time period. The survey was designed to gain information regarding participants’ rationale for not completing classes, things that would have influenced participants to continue classes, and what they liked about the classes that they did complete. Data were analyzed for the final sample size of 98 participants. The most commonly reported reason participants gave for why they stopped coming to classes was they thought they had completed. Other reasons included not being able to afford the cost, logistical issues, and competing obligations. Participants’ responses to the survey question about what would have caused them to continue attending were categorized as personal, economic, logistical, and other reasons. Participants gave many open-ended answers to the survey question about what they liked about the classes that included the class content, instructors, and peer support. Identifying patient barriers and facilitators to participation in diabetes self-management education classes can assist educators to address these issues and promote patient involvement. In this study, a need was identified to emphasize the importance of diabetes self-management education follow-up visits.

Keywords: Health behavior; Diabetes; Self-management education; Chronic disease management


T2DM: Type 2 Diabetes Mellitus


The upward trend in diabetes prevalence continues to be a concern in the United States. A recent study reported the prevalence of diabetes as 12% to 14% with the highest rates among African, Asian, and Hispanic Americans. Significant increases in diabetes have occurred across age, gender, race, educational level, and income categories [1]. Initial and ongoing diabetes self-management education is essential for these people who face daily and evolving health issues related to diabetes [2]. The American Diabetes Association recognizes diabetes self-management education as one of the cornerstones of diabetes care and recommends that all people with diabetes participate in diabetes self-management education to develop the knowledge, skills, and abilities needed to manage diabetes [3]. Multiple research studies have concluded that diabetes self-management education leads to improvements in outcomes including diabetes knowledge and glycemic control [4-7]. However, a joint position statement from the American Diabetes Association, American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics, reported that only 6.8% of people with newly diagnosed diabetes who had private health insurance and 4% of Medicare patients participated in diabetes self-management education within 12 months of diagnosis [2].

Literature Review

Literature indicates people do not receive or complete diabetes education programs due to a number of factors. People living with diabetes may not understand the necessity and effectiveness of diabetes self-management education or healthcare providers may fail to discuss the importance of self-management education with patients leading them to believe that it is not important or that what they are currently doing is sufficient for self-management [8]. Providers may have confusion regarding when people should be referred for diabetes self-management education, how the process works, or reimbursement [8-9]. Schafer and colleagues reported that physicians significantly influence patients’ decisions to participate in diabetes education [9]. Access to diabetes self-management education may be limited due to financial barriers and lack of or poor insurance reimbursement for diabetes education [2,8,10-11]. Expense of travel to and from classes was also discussed as a financial barrier [12].

Many personal issues for non-attendance of diabetes education classes exist. These include lack of transportation or access to classes, long travel times to classes, competing family commitments or work schedules, and disabilities or comorbidities that make attendance difficult [2,9,12]. In a previous study, participants reported that diabetes had low priority in their lives because they were too busy or not in the mood for classes and other things were more important [9]. Finally, diabetes education classes are often offered in group settings and some participants do not feel comfortable in the group format [12].

Perhaps some of the most difficult reasons to address for nonattendance are attitudes regarding diabetes and diabetes education. In one qualitative study, participants stated that they did not realize the importance of diabetes self-management skills and if they are not doing well, they did not want to go to classes where they may be reprimanded for not managing properly [8]. Another qualitative study reported that participants avoided diabetes education classes because they did not want to hear other people’s struggles, learn about the bad things that could happen to them, or they lacked the desire to make behavior changes to manage diabetes. A commonly reported reason for non-attendance was feeling that their current knowledge and self-management practices were sufficient [9]. In the study by Schafer and colleagues more than half of the participants stated they did not need to attend classes because their knowledge of diabetes was sufficient [12]. Finally, people living with diabetes may have negative attitudes about diabetes education classes. Participants reported they thought there was too much discussion about issues that were not relevant to their self-management [9]. Other reasons participants chose not to participate in diabetes education included negative feelings regarding the classes, feared excessive demands to self-manage diabetes, and thought the content of the classes would be too difficult [12].

A recently published systematic review identified two main themes from published studies on non-attendance of diabetes education courses. The themes were classified as those who could not go and those who would not go. Those who could not go identified logistical barriers, competing commitments, and medical or financial reasons. Those who would not go did not perceive any benefit, felt they had enough information on self-management care, had negative feelings or were in denial about their condition, and experienced language, literacy, or cultural issues [13]. Similarly, a recent qualitative study identified two main categories for non-attendance at diabetes education classes. Schwennesen and colleagues categorized reasons for non-attendance into individual and organizational explanations. Individual explanations included illness, lack of perceived benefit, and timing of invitation to join classes. Organizational explanations included program scheduling issues such as interference with work or family life [14].

All of the reviewed literature addressed reasons for nonparticipation in diabetes education classes, but there is scant information about those who begin, yet do not complete classes. The purpose of this mixed method, descriptive study was to identify reasons for non-completion of a diabetes self-management education program with a high attrition rate. The diabetes education center staff approached the researchers about conducting a survey to determine reasons for non-completion in order to implement measures to decrease the non-completion rate.


Study aims

The aims of this study were to explore the reasons why an attrition level of greater than 80% has been observed in an outpatient diabetes education center associated with a regional hospital in the Southeastern United States (US). Aim 1 intended to examine prevalence of rationale for not completing the classes. Aim 2 intended to explore and report open-ended response for: a) reasons that would have caused participants to continue the classes and b) what they did like about the education/classes they completed. Aim 3 intended to examine associations between demographic and medical history variables to see if participants’ characteristics could explain or predict the most prevalent reasons for not completing.

A cross-sectional, descriptive study design was used to implement a brief, anonymous survey which was mailed to patients with diabetes who started, but did not complete diabetes self-management education classes in 2014. Approval for the study was granted by the Institutional Review Boards of the hospital and university.

Participants and recruitment

Adults with either type 1, type 2, or prediabetes who enrolled and attended at least one class or session during the year 2014, but did not complete the entire set, were invited to participate in the study. Women with gestational diabetes were excluded. The setting for the study was an American Diabetes Association accredited outpatient diabetes and nutrition center associated with a 350-bed regional hospital in the Southeastern US. The hospital and diabetes and nutrition center draw from rural and underserved areas with minority populations at greater risk and higher diabetes prevalence than the national and state rates. The diabetes self-management education program includes three group classes and culminates with a one-on-one meeting with a registered dietician for personal goalsetting and planning. Patients attend one class per week for three consecutive weeks then meet with a registered dietician for a followup visit two to four weeks later. Patients are followed monthly for a year after completing the classes. The Center provided approximately 715 initial education visits in 2014; with approximately 500 of those enrolling in the diabetes self-management education program, but 420 did not complete the full program.

Questionnaire development and measures

Content for the survey questions was derived from a review of the literature on diabetes education attrition/non-participation and openended, unstructured interviews with four diabetes educators. The onepage, anonymous questionnaire included sections for demographic and medical history variables; reasons they stopped coming to the classes; open-ended comments on what would have caused them to continue; and open-ended comments on what things they liked most about the classes they did attend. The questionnaire reading level was edited to a 7th grade reading level and was pre-tested among center diabetes educators and a few diabetes patients for face and content validity. A one-time mail out was sent to all 420 non-completers from the 2014 diabetes self-management education classes. A cover letter from the center director, the IRB study information letter, and a postage-paid envelope addressed to the center was included with the survey. The survey packet was prepared by study personnel, but staff from the diabetes education center addressed and mailed the letters to protect patient identity.

Data analyses

Using IBM SPSS Statistics Software Version 21, descriptive statistics (means and frequencies) were generated to report participant demographic and medical history variables; correlations were generated to describe associations among variables. Aim 1 was addressed with frequencies for each of the 13 provided reasons they indicated for why they stopped coming to the classes (participants could check multiple options as their most important reasons they stopped). These were then individually coded into a yes/no dichotomy for item analysis purposes.

For Aim 2, qualitative research methods were applied to comments participants gave in the open-ended questions regarding what would have caused them to continue and what they liked about the classes they did attend. Two researchers independently examined each comment and proposed a set of themes from among the responses to each of the two open-ended questions; they subsequently met and came to consensus on a common set of themes per question. Next, they independently examined each response and assigned it to the agreed themes, and then discussed their assigned themes and came to consensus on where each response would fit among the themes. After theme-coding per item, each theme was quantified in that frequencies were calculated to identify prevalence of each of the items regarding what would have caused them to continue and what they liked about the classes they did attend.

Aim 3 was addressed through generation of correlations among demographic and medical history variables and the items for reasons they stopped attending, as well as the coded responses to the questions regarding what would have caused them to continue and what they liked most about the classes they did attend. Pearson correlations were used among continuous variables; Spearman correlations were used among categorical variables. T tests were also used to explore differences in means for continuous variables across the dichotomous yes/no for the variables noted in Aim 1.


A total of 420 surveys were mailed to patients who enrolled in, but did not complete the diabetes education course. Of those surveys, 12 were returned undeliverable. Fifty-two surveys were completed and returned. Due to the low response rate (12%), IRB approval was granted to conduct follow-up telephone calls to the target population to gain additional responses via structured interview. An intern at the Diabetes and Nutrition Center randomly selected 102 patients from the list of 420 non-completers and asked them to answer questions over the telephone. Participants were assured that no names would be included on the survey and study personnel did not have access to the list of non-completers; only the intern saw the list. All noncompleters were not contacted due to lack of time and resources. Of the 102 participants contacted by phone, 50 additional participants responded for a response rate of 24%. Fifty-two indicated they already mailed in the survey, didn’t answer the phone after three attempts, or were unwilling to respond.

Participant characteristics

Data from 102 surveys were collected. Four participants did not meet inclusion criteria so the final sample size was 98. Participants ranged in age from 18 to 79 and the majority were female (n=60) and of either Black/African American (n=39; 40%) or Caucasian (n=54; 55%) race. See Table 1 for descriptive characteristics of the sample.