Silke KuskeI; Andrea IcksI,*; Jelka ZaletelII; Ulrike RotheIII; Jaana LindströmIV; Monica SørensenV; Marina MagginiVI; on behalf of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)
IHeinrich Heine University, German Diabetes Center, Düsseldorf, Germany
IINational Institute of Public Health, Ljubljana, Slovenia
IIIDresden University of Technology, Dresden, Germany
IVNational Institute for Health and Welfare, Helsinki, Finland
VNorwegian Directorate of Health, Oslo, Norway
VICentro Nazionale di Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy
OBJECTIVE. To contribute to the development of a set of quality criteria for patient education and health professionals training that could be applied in European countries.
METHODS. Literature review quality criteria, pre-selection based on a comparison of the criteria, peer group and expert based selection of the criteria.
RESULTS. 14 quality criteria were selected: goals, rationale, target group, setting, scheduling of the education/training sessions, environmental requirements, qualification of the trainers/educators, core components of the educator/trainer's role, curriculum, education methods, education didactics, monitoring of the effectiveness and quality of the program, implementation level and source of funding.
DISCUSSION. A set of preliminary quality criteria for patient education and health professionals training was developed, which could be applied in European countries.
Key words: quality criteria, patient education, training, diabetes, review
Diabetes education is an essential component of diabetes treatment. It is intended to prevent or delay the complications of diabetes . In the context of patient education, an education program is an international accepted and vital intervention with a targeted structure of education for people with diabetes with an evident effect on therapy and prognosis of diabetes. Usually, in education program the core contents, goals, methods and didactics are described in a curriculum and materials or tools for the educators and participants are provided. Patient education is described as a complex intervention with special requirements on evidence and transparency regarding its rationale, methodology, performance and outcome representation [2, 3].
Systematic reviews on the effect of education of people with diabetes do exist. Several outcome measures were considered, e.g, on metabolic control, diabetes knowledge and measures regarding quality of live and empowerment to evaluate the programs . A Cochrane Review identified 11 studies of group based patient-centred education for people with type 2 diabetes. The included studies were published between 1988 and 2002, mainly in US, UK, Austria, Italy, Argentina, Germany and Spain . Another Cochrane Review reported 9 studies of individual patient education for people with type 2 diabetes compared with usual care ("receiving the standard care such as regular follow up with the health provider"). The included studies were published between 1996 and 2007 . These studies were conducted mainly in US, UK, Australia, Netherlands, Spain, Japan and China.
Training of the professionals "(...) is required to enable health professionals to be effective diabetes educators. Within these areas, training programs and curricula are necessary to prepare people for the role of diabetes educator. Diabetes education is a specialty and requires knowledge and competence at an advanced level if it is to be delivered effectively" . Since 2002, the International Diabetes Federation (IDF) has facilitated the development of curriculum, standards, diabetes education modules, didactic materials by diabetes experts that could be used by all members of IDF . The American Association of Diabetes Educators (AADE) developed in 2009 a guideline and a standard to provide diabetes educators tools, training to empower people with diabetes . Furthermore, trainings of health professionals were developed in UK in the line of the "The Quality Framework for the delivery of Education and Learning to the Health sector" from the National Skills Academy .
In the United States and in several states of the EU patient education and health professionals training programs, and quality criteria for their evaluation do exist. However, different numbers of quality criteria and particularly different definitions were used. Therefore, aim of this paper was to contribute to the development of a preliminary set of quality criteria for patient education and health professionals training that could be applied in European countries.
Identification of quality criteria
A literature review of evaluation criteria of education and training programs was conducted searching the Cochrane library, Medline and Google scholar. Literature from 2000 to May 2014 was selected to identify the latest state of art.
The following search terms in English and German were used, using the Boolean operators: diabetes, curricula, educat*, trainer*, training, evaluation, quality criteria, indicator*, measures, quality, standard*, guideline*, and review*. MeSH terms were: standards, diabetes mellitus, quality indicators, guideline, education, and teaching.
Inclusion and exclusion criteria
Publications that provide criteria overviews as systematic reviews, curricula, standards and guidelines were included. Literature recommendations of the experts, if meeting the inclusion criteria, were considered.
The publications had to provide descripted quality criteria for patient education and health professionals training programs and they had to be described in German or English language.
Pre-selection and selection of the quality criteria
One reviewer (SK) reviewed all relevant literature in full-text. First, criteria resulting from the identified standards and recommendations were extracted, categorized and compared by using an extraction matrix. Because of a high variety in the presentation of quality requirements in the publications deriving from the organizations, the criteria were abstracted with the aim of a consistent description.
The quality criteria from different publications were then compared with each other separately for patient education programs and health professionals' training programs. Common aspects were summarized. It was aimed to provide a short list of criteria on high abstract level that is applicable for both types of programs (education and training). The criteria were reviewed and discussed by the author group until the core quality criteria were selected. The list of the quality criteria was sent to each expert (author) separately for commenting the selected criteria. After reviewing the comments, all experts discussed the criteria to consent the set of quality criteria.
In total, 10 publications [1, 2, 4, 6, 9-14] that met the inclusion criteria were identified out of a number of 46 full-texts. Six dealt with education programs and four with professionals training (Table 1).
Quality criteria for patient education (Table 2) were selected from four publications being standards, guidance and guidelines of four organizations: the American Diabetes Association (ADA) , the American Association of Diabetes Educators (AADE) , The National Collaborating Centre for Chronic Conditions (NCCCC, UK)  and the Bundesärztekammer (BÄK, Germany) and its other collaborating partners . The publications from the USA were summarized because they focussed on the same quality criteria [1, 9]. Two further publications were a Systematic Cochrane Review  and a RCT .
Quality criteria for professionals trainings (Table 3) were selected from four core publications of three organizations: the International Diabetes Federation (IDF) [6, 12], the American Diabetes Association (ADA)  and the Department of Health (DH) . The IDF publications [6, 12] were summarized because the publication of 2003 contained the standards which were the starting point of the developed curriculum in 2008.
Quality criteria for patient education
The publication of the American Association of Diabetes Educators  including Haas et al.  was based on a Task Force review. The Task Force was convened by AADE and ADA and included experts, e.g., from the areas of public health, individuals with diabetes, diabetes researchers, certified diabetes educators, registered nurses, registered dietitians, physicians, pharmacists, and a psychologist. They reviewed the current National Standards for Diabetes Self-Management Education for their appropriateness, relevance, and scientific basis and updated them using available evidence based on expert consensus [1, 9]. The selected criteria from the national guideline of the Bundesärztekammer et al.  were based on a 3 step approach. First, there was a selection of source-guidelines based on a systematic guideline search using the following inclusion criteria: topic relevance, aim of the guideline, applicability and transferability, evidence, consensus and other augmented reasons. Second, a full text evaluation was performed based on the following criteria: methodological quality, accepted institutions, and medical relevance. Third, an evaluation of the methodological quality of final guidelines was conducted using the DELBI-Instrument .
The National clinical guideline of the National Collaborating Centre for Chronic Conditions was developed based on clinical evidence-based questions, a systematic search for evidence, and a critical appraisal of the evidence including incorporating health economic evidence, an extraction and synthesis of data, development of recommendations and grading, consenting the recommendations. At the end of the development process literature was updated . The study of Kulzer et al. aimed to investigate a didactic-oriented training program compared with a self-management-oriented program delivered in group sessions, or in a more individualized approach. It was based on a RCT including 181 diabetes type 2 patients, measuring efficacy 3 month after baseline, including a follow up after 15 months after baseline . The Systematic Review of Deakin et al. aimed to assess the effects of group-based training on clinical, lifestyle and psychosocial outcomes. RCTs and CTs that measured group-based education programs compared with routine treatment, waiting list control or no intervention were included .
Quality criteria for professionals training
Recommendations were described predominantly in the context of a framework, including, e.g., guiding principles and a glossary. Some documents were also based on standards and a framework containing quality criteria for education as well as training programs. Additionally, the report of the Department of Health contained a theoretical model to consider the need in patient education [11, 13].
The standards of the IDF [6, 12] were developed since 1997. They were revised by performing a consensus process using focus groups. These standards, when possible evidence based, derived from the American Diabetes Association 1995, the Australian Diabetes Educators Association, the Canadian Diabetes Association 2000, the Declaration of the Americas, Finland 2000-2010, Hong Kong 2001 and the United Kingdom 2001.
The ADA  provided general standards for diabetes care that were developed based on literature review. The standards considered all types of diabetes and focussed on several aspects of diabetes care. The recommendations considered also standards and evidence regarding education and support with the aim to assist diabetes educators in education and self-management support.
Finally, the DH  provided a reference point, framework for developing and evaluating local programs by describing criteria on learning needs assessment, health professional training, assuring quality, accreditation and research and development. It also showed gaps in education provision. The criteria resulted from an agreement process by the Patient Education Working Group.
Selected quality criteria
After the comparison and evaluation of the 55 individual criteria of the 10 publications (Table 2 and 3), a set of 14 quality criteria (Table 4) was developed. Predominantly, criteria were chosen that were mentioned in most of the publications. There were two exceptions, the "source of funding" and "implementation level". The source of funding was deducted from the ADA recommendations, and the implementation level from the IDF. The set contained only criteria on structure level to provide a basic set on a consistent measurement level.
By performing a literature review a set of 14 core quality criteria was developed by a peer-group based approach. These quality criteria for patient education and health professionals' training could be applied in European countries.
The evidence of the identified literature for selecting the criteria varied. However, the final selected criteria were based on consensus processes [1, 2, 10-12] with the result of agreed quality requirements mostly based on standards. The task force approaches included experts on diabetes from the field of public health, politics or health services. Organisations developed research questions, defined core terms and conducted a literature searches [1, 2, 10, 11, 15]. Some of them evaluated the identified guidelines by using a critical appraisal instrument . All publications confirmed the importance of consented quality requirements in diabetes education and health professionals' trainings with the aim to increase diabetes education, e.g., on self-management.
In our approach one researcher conducted the literature search, the abstraction of the structure criteria, and their comparison. Therefore, a selection bias is presumable. However, the process was reviewed by an expert peer group.
In conclusion a set of preliminary quality criteria for patient education and health professionals' training was developed, which could be applied in European countries.
This publication arises from the Joint Action CHRODIS, which has received funding from the European Union, in the framework of the Health Programme (2008-2013). Sole responsibility lies with the authors and the Consumers, Health, Agriculture and Food Executive Agency is not responsible for any use that may be made of the information contained therein.
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Address for correspondence:
Public Health Unit, Faculty of Medicine, Heinrich-Heine University
40225 Düsseldorf, Germany.
Submitted on invitation.
Accepted on 9 June 2015.
Conflict of interest statement:There is no conflict of interest.
*Joint first authorship