Establishing a System for Health Professional Training and Certification in Diabetes Self-Management Education in the Caribbean Free

When we returned to Jamaica after training and practicing in North America, we recognized that diabetes educators were the missing members of the Caribbean diabetes management team. Clinicians took an ad hoc approach to DSME, with no member of the health team specifically designated to fill this role. Although efforts at DSME were being made, these were not widely available or tailored to meet individual patients' needs. Patients were not receiving standard messages about diabetes care from their health care team, and often received conflicting information about the timing of oral medications, insulin administration, treatment of hypoglycemia, and sick day management. Awareness and use of devices such as glucose meters and insulin pens were low. There were few efforts to document the teaching and learning process or evaluate the effectiveness of DSME.

We initially explored opportunities for training HCPs from the American Association of Diabetes Educators (AADE), the International Diabetes Federation (IDF), and the Education Committee of the Declaration of the Americas (DOTA). AADE had limited resources for training outside the United States, and their certification program would only be open to HCPs who were licensed to practice in the United States. IDF did not have funding available, although training resources (e.g., manuals) could be obtained through their headquarters or website. There was uncertainty about active funding from DOTA at the time of application. Clearly, developing our program was going to require the creative use of locally available resources to provide a culturally relevant and acceptable training experience for Caribbean HCPs.

In 2004, a 2-day diabetes education conference was held in Jamaica. Experts in diabetes in Jamaica (endocrinologists, nutritionists/dietitians, obstetricians, pharmacists, and one trained diabetes educator) were brought together to present aspects of diabetes care relevant to their discipline. The hardworking team of volunteers, sponsorship from pharmaceutical companies and attendee registration fees made this inaugural meeting possible. The 39 attendees with backgrounds in pharmacy, nutrition, and nursing expressed their satisfaction with the event and were interested in having additional meetings of this nature to improve their DSME skills.

The next year, a second conference was organized, this time with two simultaneous meetings. One was a repeat of the basic diabetes training module on the fundamentals of DSME. The other, intended for those who had completed the basic training, addressed specific topics in diabetes, including renal disease, cardiovascular disease, foot and eye complications, and therapeutics. Attendees from other Caribbean islands invited the Jamaican group to delivery similar programs in their home countries.

It soon became clear that there was a need for DSME training on an ongoing basis in different geographical settings. This would have to be done without the benefit of funding for faculty, travel, or meeting venues and with limited regional expertise in diabetes management.

We reviewed IDF¹²  and AADE¹³  curriculums, used feedback from participants and our experience offering CME programs in the Caribbean to develop an evidence-based, culturally relevant, 2-day training program. The program was redesigned to be delivered by a single diabetes educator (AH), with participation by other HCPs depending on the expertise available in the location in which the program was offered. The training was specifically tailored for registered HCPs, offering practical information that could be used in everyday patient management.

The University of the West Indies Department of Community Health and Psychiatry was approached to provide a venue and certification of the program. The department had a longstanding history of HCP training and proved to be an ideal setting for delivering the basic DSME training program.

The 2-day training program now includes didactic lectures, hands-on exercises, group work, and participant presentations covering core concepts of DSME as described by the ADA, IDF, and AADE.^12–14  Topics include diabetes pathophysiology, pharmacology of diabetes medications, promoting behavior change, making healthier food choices, medication adherence, and preventing diabetes complications. Special emphasis is placed on assessment of the educational needs of child and adult learners, the use of assessment forms, goal-setting for patients with diabetes, and documentation and evaluation of DSME. The program is offered twice a year through the Department of Community Health and Psychiatry and can be delivered on request.

After completing the basic program, participants receive e-mail support from the trainers. In some settings, an additional day has been included during which participants are taken into a primary care clinic and shown how to conduct group education and use available patient education materials such as flip charts, carbohydrate exchange lists, and educational charts.

The Caribbean initiative recognize the need to provide recognition for HCPs who had completed the basic training and were actively involved in DSME. The partnership with the University of the West Indies Department of Community Health and Psychiatry was especially helpful in that regard. The University of the West Indies is a regional university with campuses in most of the English-speaking Caribbean territories. This allows participants to receive a university-approved certification and to sit for the certification examination in their home territories. Criteria for certification are based on those of the National Certification Board for Diabetes Educators,¹⁵  taking into consideration the regional practice environment. Participants are expected to complete the basic 2-day program, followed by a minimum of 250 hours providing DSME for people with diabetes in their own communities. After documented completion of these hours, registered HCPs are eligible to take the Caribbean certified diabetes educator (CCDE) examination. Certification is for a 3-year period and can be renewed either by taking another examination or by showing evidence of 30 hours of diabetes continuing education and the payment of a renewal fee.

The examination is overseen by a body consisting of a diabetes educator and endocrinologist. Examinations are marked through the Department of Community Health and Psychiatry using the university protocol of second markers. A grade of at least 70% is required for successful certification.

The Diabetes Educators of the Caribbean (DEC), a nonprofit organization, was established to support people who are trained or have an interest in diabetes education. This was particularly important for trainees who worked in regions or islands with no access to an endocrinologist or diabetes specialist. The DEC 1) provides educational opportunities for the professional growth and development of diabetes educators, 2) promotes and aids the growth and development of quality diabetes education for people with diabetes, and 3) fosters communication and cooperation among individuals and organizations involved in diabetes education.

The basic diabetes education program has now become a standard offering on the region's continuing education calendar. It continues to attract new participants each year, and increasingly more physicians have been taking the course to receive updates on diabetes management and to better understand the role of diabetes educators. In addition to Jamaica, the program has been offered in other territories, including the Bahamas, Guyana, Trinidad and Tobago, and the Cayman Islands. To date, 748 people have completed the basic training. Most of these trainees have been nurses (60%), followed by pharmacists/pharmacy technicians (16%), nutritionists/dietitians (8%), and medical doctors (7%).

Short, half-day modules have been developed to help participants meet the needs of specific populations, the most recent focusing on pediatric diabetes. The modules have been delivered face-to-face in a classroom setting.

The certification program has had 24 candidates (from Jamaica, the Cayman Islands, Trinidad, and the Bahamas) successfully complete the examination and obtain the CCDE designation. The examination has also been offered to people who have completed other diabetes education training courses such as the Johns Hopkins Diabetes Outreach Program in Trinidad and the IDF training program (after review of the curriculum of those programs).

Funding remains a challenge. Although we obtain funding from registration fees and pharmaceutical company sponsors, this is insufficient to maintain an independent secretariat for the training and certification process or for travel to support trainees in other islands.

There is also a crucial need for the health care system (administrators and providers) to recognize and designate an HCP to provide DSME. Diabetes educator positions do not exist in most government-funded institutions, and HCPs who complete the training often provide DSME outside of regular working hours and in addition to their other responsibilities. This does not encourage providers to develop the skills needed to provide effective DSME or obtain the CCDE designation.

Until designated diabetes educators are appointed, we are advocating that HCPs who have completed the basic training be assigned responsibility for DSME as part of their routine activities. For hospital-based nurses, this may involve having specific times to provide DSME to inpatients, whereas clinic-based nurses may use time at the beginning of the day to organize a group class or for case management.

The effect that DSME can have on health outcomes for patients with diabetes is often underestimated by health administrators (as well as by many HCPs), who fail to recognize that educated patients can reduce the costs of health care through the more rational use of available resources. Additionally, many of the skills developed through DSME training are crucial to combating the chronic disease epidemic. These include a patient-centred approach to care, goal-setting, and the use of effective behavior-change techniques. Other practices encouraged through this program, including continuing education, use of standard operating procedures, and evidence-based practice guidelines, are also needed for chronic disease management. We advocate that special attention be paid to patient education and that DSME be integrated into chronic disease strategic plans within the region.

Research on the education process, including evaluating the work that is currently being performed, developing more locally prepared materials, evaluating other modalities for diabetes education and case management, and gaining an understanding of the learning process for Caribbean populations is vital. Our aim is to encourage greater access to educational materials and resources produced by pharmaceutical companies, as are available in the United States and the United Kingdom. Our partnership with the University of the West Indies Department of Community Health and Psychiatry will assist with this process.

Sustainability of the program is of great concern. Having more certified educators would be one way of increasing funding because costs for educational activities could be offset through registration fees and contributions for continuing education activities. We plan to investigate the use of distance learning facilities available through the University of the West Indies to improve support and educational opportunities for candidates. Identification of the next generation of trainers is important for continuity. We plan to lobby local and regional governments and international agencies for funding to train HCPs in this area and to identify new funding sources that will support these educational efforts.

Developing a diabetes education program for this region has been a challenging yet rewarding experience. Working with existing templates, local resources, and health care systems and relying on health professionals who are dedicated to improving diabetes care has helped us make tremendous strides in a short period of time. We have learned many valuable lessons that we would willingly share with other HCPs facing similar challenges.

The authors thank the team of hardworking volunteers who have donated their time, energy, and other resources to this cause. They also thank Patrick Vassel, Annazika Watkins, and the staff of the Department of Community Health and Psychiatry, University of the West Indies (Mona), for their support of this program.