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Millennium Development Goals. This was the first time a non-infectious disease
presented a serious global health threat to all nations as infectious epidemics such
as AIDS (International Diabetes Federation IDF, 2006). T2DM is identified as a
product of globalization and collaborative effort across all nations is imperative to
curb the increasing prevalence (Venkat Narayan, et al., 2012). The Diabetes
Attitudes Wishes and Needs 2 study confirmed that the emotional, physical, and
financial burden of diabetes across countries and cultures were carried by the whole
family, not just by the individual with DM (Peyrot, et al., 2013). Due to its chronicity
and complications associated with multi-organ involvement, the cost to treat T2DM is
high. Therefore, DM is a burdensome disease, not only affecting individuals and
families, but also crippling the national healthcare system (Wan Norlida, et al., 2010).
This may lead to poverty as patients lose their ability to earn a living on top of having
to pay for the medical expenses associated with the treatment of diabetes. Zhang, et
al. (2010) estimated that by 2010, 12% of the health expenditure would be spent on
diabetes and the cost to treat one diabetic is USD 1330 globally. In 2010, Malaysia
allocated 16% of her national healthcare budget on diabetes-related expenditure,
ranking among the top 10 countries in the world in terms of percentage spent (Chan,
2013).
IDF estimated that diabetes would increase from 366 million in 2011 to 552 million in
2030 worldwide with the highest increased in Asia (Yang, 2013). Under the
globalization process of T2DM, IDF also reported that more than 60% of the worlds
population with diabetes would come from Asia (Yang, 2013) and the newly
industrialized countries like Malaysia and Singapore are anticipated to be highly
susceptible for developing diabetes (Rugayah, 2007). In Malaysia, T2DM is a major
global public health issue (Rugayah, 2007). Malaysias population is 28.3 million
(Malaysia. Department of Statistics Malaysia, 2010), of which there are nearly 2.6
million or 15.2% of the population are diabetes as reported by the Third Malaysian
National Health and Morbidity Survey (Kaur, et al., 2013). The prevalence is further
escalated by the recent rapid urbanization and industrialization in Malaysia (Rampal,
et al., 2010). With ongoing urbanization and industrialization, and adoption of
inactive lifestyles and unhealthy dietary habits, obesity is on the rise even among the
rural communities (Ismail, et al., 2002; Pon, et al., 2006), all of which have been
implicated as contributing factors in the development of T2DM.
Based on the disability adjusted life years (DALYs), among the top 10 total burden of
diseases in Malaysia, diabetes was ranked 6th for men and 5th for women (Faudzi,
et al., 2004). The significance of diabetes despite its lower ranking based on DALYs
is that it is a major contributing factor to cardiovascular diseases (Letchuman, et al.,
2010). Its significant morbidity associated with microvascular and macrovascular
complications reduces life expectancy and diminishes quality of life (Rampal, et al.,
2010). Annually, about 3 million deaths are ascribable to diabetes and more than
80% happen in developing countries (Wan Norlida, et al., 2010).
In the subsequent section, the author explains why ACM is not suitable to treat
chronic diseases as opposed to an empowerment-based CCM. There are four main
differences between ACM and CCM (Alt and Schatell, 2008). These differences are
the duration of disease; goal of treatment; patients role; and practitioners role. The
duration of acute illnesses is short whereas in chronic illness it may last for life.
There is a cure in acute illness whereas people with chronic illnesses will never
recover. They have to adapt to the chronic condition and learn how to self-manage
their diseases in order for them to stay as healthy as possible. Therefore, a CCM
emphasizes on empowering, educating and supporting patients in diabetes selfmanagement is not only suitable but fundamental to patients long-term survival.
The traditional ACM trained and socialised HCPs to assume full responsibility in
patient care and outcomes (Anderson and Funnell, 2010). ACM does not embrace
the realities of dealing with chronic diseases where 98% of the diabetes care is
rendered by patients themselves where HCPs have no control over patients
diabetes self-management decisions and outcomes (Funnell and Anderson, 2004).
This ingrained perceived responsibility shapes the behaviour and attitude of the
HCPs in delivering chronic care. Health education is done through didactic approach
where information transfer and instruction is used to convince patients compliance to
the recommendations of HCPs. This model assumes that patients are obligated to
follow HCPs instructions and disregards the effects of those recommendations have
on patients daily life (Funnell and Anderson, 2004). This is because the care plan is
formulated to fit patients diabetes without taking into consideration the patients
psychological and lifestyles factors which are important determinants for lifelong
success in chronic disease management (Jarvis, et al., 2010). This telling approach
is ineffective in effecting any desired behavioural changes and improved clinical
outcomes as supported by literatures (Brown, 1988; Brown, 1992; Malaysia. National
Institutes of Health and Ministry of Health, 2008). Evidences on its ineffectiveness
were manifested by patient non-compliance to treatment recommendations (Lutfey
and Wishner, 1999; Glasgow and Anderson, 1999).
Under the ACM, a parent-child relationship is applied in health education where
HCPs assume the expert role having the authority responsible for making all
decisions regarding treatment (Rollnick and Butler, 1999). Treatments are prescribed
and goals are predetermined by HCPs without engaging the patients (Funnell and
Anderson, 2004). The role of the patient in ACM is passive, obedient, accepting, and
dependent (Anderson, 1995). They only need to comply with treatment
recommendations without decision-making authority. This advice-giving approach
undermines patients autonomy and creates resistances (Rollnick and Butler, 1999)
because patients are treated like a child where the HCPs constantly order, direct,
control or blame patients when they fail to obey those instructions (Anderson, 1995).
Patient empowerment approach, on the other hand, acknowledges that patients are
the main decision-makers responsible for their daily diabetes self-care (Meetoo and
Gopaul, 2005). The role of HCPs is to help patients make informed choices to attain
their goals and tackle obstacles through support, expert recommendations,
appropriate care advices and education (Funnell and Anderson, 2004) rather than
dictating behaviour and compliance as in the traditional ACM. In CCM, HCPs
assume the role of facilitators, mentors and coaches (Alt and Schatell, 2008) who
provide autonomous and ongoing support in facilitating the abilities, skills and
MI has many benefits. One of the valuable benefits is that MI is feasible for even a
10-to-15 minute patient visit (Resnicow, et al., 2002; Rollnick, et al., 2002). This
addresses the misconception that offering emotional and psychosocial care is time
consuming (Levinson, et al., 2000; King, et al., 2002). MI empowers patients to
become well-informed, active collaborators and decision-makers through providing
support, assurance, caring and knowledge in diabetes self-care (Meetoo and
Gopaul, 2005). HCPs embrace the three spirits of MI: autonomy, evocation and
collaboration to promote behavioural change as opposed to the authoritativepaternalistic approach so that patients stay motivated to sustain their behavioural
changes (Miller and Rollnick, 2002). In MI, patients autonomy, right and
responsibility in diabetes self-management are acknowledged and HCPs recognize
that it is entirely up to the patient whether or not to change. In the authoritativepaternalistic approach, the HCPs tend to use their authority to order patient to make
changes. When dealing with patients resistance to change, HCPs applying MI do
not impose solutions (Levensky, et al., 2007) or direct patient on what to do (Miller
and Rollnick, 2002) as what is being practiced in the authoritative-paternalistic
approach rather they activate patients motivation for change by eliciting and
connecting reasons for change to things that patient values and cares about (Hall, et
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al., 2012) while encouraging patient to generate ideas on how to achieve behavioural
change (McCarley, 2009). Additionally, equal collaborative partnership between
HCPs and patients is established in which HCPs provide empathy and support while
helping patient to formulate a change plan and set realistic behavioural goal to
achieve desired change rather than coercing the patient to change as what is being
practiced in the authoritative-paternalistic approach (Miller and Rollnick, 2002). In
this way, MI promotes behavioural change by internalizing patients own reasons for
change and helping them to set personal goals. Patient who participates actively in
collaborative decision-making and goal-setting process is internally motivated and
more likely to achieve the desired outcomes identified as important by them (Heisler,
et al., 2003). In addition, this collaborative relationship can act as a powerful
motivator when HCPs support self-efficacy by instilling a belief in the possibility of
change (Hall, et al., 2012). Promoting hope that change is possible enhances
patients self-efficacy in executing their plans and achieving self-identified goals
(Levensky, et al., 2007).
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include expressing empathy for the challenges faced by patients; using reflective
listening; asking open-ended questions; using the ask-provide-ask approach to
provide information; affirming patients opinions and progress; and summarizing main
points and goals (McCarley, 2009).
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