Effectiveness of individual and group interventions for people with type 2 diabetes1

OBJECTIVE: to compare the effectiveness of two educational interventions used by a healthcare provider in the monitoring of individuals with type 2 diabetes mellitus (T2DM), regarding knowledge of the disease, impact on quality of life and adoption of self-care actions. METHODS: comparative, longitudinal, prospective study performed with 150 subjects with type 2 diabetes, analyzed according to the type of participation in the program (individual and/or group). Participants of the individual intervention (II) received nursing consultations every six months and those of the group intervention (GI) took part in weekly meetings for three months. Data were collected through four questionnaires: Identification questionnaire, Problem Areas in Diabetes Questionnaire (PAID), Summary of Diabetes Self-Care Activities Questionnaire (SDSCA) and the Diabetes Knowledge Scale (DKN-A). Data were analyzed using the Friedman and Mann Whitney tests, considering a statistical significance of p ≤ 0.05. RESULTS: there was an increase in knowledge about the disease in the II (p<0.003) and GI (p<0.007), with reduction of the impact on the quality of life in the II (p<0.007) and improvement in self-care actions in the GI (p<0.001). CONCLUSION: in both intervention models improvements were observed in the indicators, over the six month monitoring period.


Introduction
The high rates of morbidity and mortality from type 2 diabetes mellitus (T2DM) determine the need for proposals for the reorientation of a healthcare model that prioritizes the practices that promote health and the integrality of the care (1) , in both the public and private sectors. Accordingly, the Ministry of Health, through the National Health Agency (ANS), stimulated changes in private healthcare providers, and the Normative Resolution (RN) No. 94, of 2005, established the criteria for the development of health promotion programs (2) . This is due to health promotion being a community empowerment process in the practice of improving the quality of life and health, including greater participation in the control of this process, and contributing to the development of integral healthcare (3) .
In this context, health education is the theoretical and methodological basis for health promotion actions, as it can support both diseases prevention and rehabilitation and promote citizenship, personal and social responsibility related to health and contribute in the training of multipliers and caregivers (4) . Thus, health promotion and health education are strictly linked, considering that for effective health promotion it is necessary to articulate technical and popular knowledge, and mobilize institutional and community, public and private resources. Thus, health education constitutes a tool to improve individual and collective health conditions, reinforcing the maintenance of positive health habits through a multi-dimensional approach toward the health-disease process (5) .
Health education is now considered a social process, which is defined as any influence experienced by individuals, capable of modifying their behavior. It is related to the implementation of problem-solving activities by health professionals, which valorize the everyday experience of individuals and social groups, and encourage the active participation of the learner in the educational process. It involves the adoption of approaches systematically planned and implemented in a non-coercive manner (5) . Thus, health education differs from the traditional model of knowledge transmission.
Accordingly, educational activities, in which a key element is health education, are experiences materialized in organized and systematized activities, inherent to the healthcare project at all levels of care. They permit the appropriation of knowledge, improvement of the quality of life of the population, reduction of problems and damage originating from the diseases and a critical reflection regarding the actions necessary to resolve such problems, involving system users and health professionals, especially nurses (6) .
Therefore, for educative actions to generate learning, it is necessary for them to be based on an accessible and emancipatory type of health education, that is, the dialogic model of health education that is primed by problematization, the construction of knowledge and skills, and based on dialogue, prolonged changes in behavior and greater autonomy for the individual (7) .
In this sense, the national and international literature on health education and T2DM, produced between 1997 and 2007, shows that the majority of studies were experimental and employed the following strategies: interactive education, community educational intervention, operative groups, seminars, monitoring of clinical and biochemical parameters, home visits, educational conferences, activities regarding nutrition and physical exercise, ophthalmological exams, case reports and educational colonies (8) .
It should be noted that studies on educational activities based on dialogic health education and developed in the private sector with individuals with T2DM are still incipient. Despite this gap in the literature, a study that aimed to analyze health promotion actions in diabetes education, developed in groups of a private healthcare provider, reports that the activities were dynamic and driven by the needs cited by the participants. In the same study, the authors consider the importance of studies that aim to evaluate the effectiveness of the educational programs, aiming to support the redirection of new strategies also within the private health context (9) . Therefore, among the relevant factors to be considered in the evaluation of such programs, the literature highlights knowledge about the disease, the impact of diabetes on the quality of life and the adoption of self-care actions, which may predict disease control in the daily life of the individual (10)(11)(12) .
In accordance with the above, in a study that evaluated the effectiveness of individual and group intervention offered by the outpatient clinic of a public hospital in Belo Horizonte, the authors found that the results of both strategies were similar regarding attitudes, changes of behavior and quality of life, however, with greater effectiveness in the group intervention, with regards to laboratory exams (9) .  was considered when ≤ 160 mg/dl and uncontrolled glycemia when > 160 mg/dl, good glycemic control of glycated hemoglobin was considered when ≤ 7%, and inadequate glycemic control when > 7% mg/dl (13) .
-Problem Areas in Diabetes Questionnaire (PAID), validated in Brazil (14) , consisting of 20 questions, distributed over four dimensions: emotional, foodrelated, social support and treatment problems. The total score ranges from 0-100 points, with higher scores indicating high levels of emotional distress (14) .
-Summary of Diabetes Self-Care Activities Questionnaire (SDSCA), validated in Brazil (15) , consisting of 17 items, distributed over six dimensions, which enables the evaluation of adherence to self-care activities, taking as reference the frequency with which certain activities were carried out in the previous seven days. In the analysis of the adherence, the questionnaire items were parameterized in number of days of the week, from zero to seven, zero being the worst possible situation and seven the more favorable. In the items that assess the consumption of foods high in fat and sugar, the values are reversed (15) .  (16) . The responses are presented in a multiple choice scale and the total score ranges from zero to 15 points, with scores lower than seven indicating unsatisfactory knowledge, and scores equal to or greater than eight indicating satisfactory knowledge (10) .

Results
Of the 150 individuals included in the study, 120 (80%) participated in the second assessment, and 114 (76%) in the third. Considering the mode of intervention, the loss of 31 subjects (28.9%) was verified from the individual intervention and five (11.63%) from the group intervention. Among the reasons for leaving, 28 cases were due to termination of the health plan, six due to change of city and two due to serious complications in the health status.
Regarding the initial assessment, it was found that the 150 individuals participating in the study had a mean age of 60 years (± 12.49 years), a mean individual of income of 5.5 minimum wages (± 9.85), more than half (56%) were female, and the majority were white ( 80%), lived with a partner (74%), and had more than eight years of education (64%). It was also found that the majority of the participants had satisfactory knowledge about the disease (71.3%), perceived a high impact on their quality of life (76%) and presented good adherence to self-care practices. Table 1 shows that there was a significant increase level of knowledge about the disease from M1 to M3, in the two types of intervention. Regarding the impact of the disease on the quality of life, there was a significant reduction of the scores from M1 to M2 and from M1 to M3 only among the individual intervention participants.
Finally, there was a significant increase in the self-care median scores from M1 to M2 and from M1 to M3, only among the group intervention participants.
It can be observed in Table 2, when comparing the two groups, at the different moments, that no statistically significant differences were found for any of the variables under study. Table 1  ||The median values were rounded up.

Discussion
The data from this study show improvements in the Thus, these findings corroborate the results of an experimental study (9) conducted with T2DM subjects, which also identified the effectiveness of both types of intervention, individual and group, at different moments and referred to the same aspects evaluated.
However, in the present study, the group intervention constituted an extra activity in relation to the individual intervention, in that its participants took part in both approaches. Educational activities implemented by health professionals together with individuals, families and community, are essential for controlling this disease, as the complications of diabetes are directly related to knowledge about the disease, considering that this supports the performance of daily self-care and the adoption of a healthier lifestyle (17) . Individual or group interventions comprise the educational strategies most commonly used in the health promotion and monitoring of patients with diabetes (18) . However, it is important to consider that certain educational strategies can encourage the active participation of the individual in controlling the disease and preventing its complications or, on the contrary, simply strengthen the curative character focused on the disease and on the transmission of information (19) . The number of individuals who, at the beginning of the program, already presented satisfactory knowledge regarding the disease was high, a fact that differs from a similar study conducted in a primary health unit, in which the level of knowledge was considered unsatisfactory for the majority of the individuals, which was shown to be associated with the low educational level of the study participants (12) . In addition, in the present study, an increase of values related to knowledge of the disease was observed over six months, both among participants of the individual intervention as well as among those who participated in the group intervention. Strategies aimed at health education should be employed, aiming for the development of self-care (13) . In health education, one of the indicators most used for assessment in diabetic patients has been the level of knowledge about the disease, as this variable is related to the efficacy of the program (20) .
Regarding quality of life (21) , therefore the presence of the diagnosis of diabetes influences the self-perception of physical and psychological well-being (22) .
A study conducted in Denmark, with 143 T2DM individuals, found no significant difference between individual and group interventions with regard to improving the quality of life, except for the improvement of clinical data in the individual intervention, which may have contributed to these individuals evidencing a lower impact of the disease (23) . Therefore, in line with the results of the present study, it has been concluded that individual monitoring by the nurse, directed toward selfmanagement and disease control, helps to reduce the impact on the quality of life of individuals (24) . However, it should be emphasized that statistically professionals (24) . The multidisciplinary team, therefore, tends to favor the reduction of the stress associated with the disease, receptivity to the treatment, self-esteem, sense of self-efficacy and a more positive perception regarding the health (10) .  (25) . The results also showed that in the two types of intervention significant changes occurred from M1 to M2 or M3, but not from M2 to M3. This means, on one hand, that the acquired knowledge and behavior have permanence in time, as they did not decrease from M1 to M3; while on the other hand, apart from the influence of personal motivation, usually observed at the beginning of the interventions, it was found that people have a limit for the acquisition of knowledge and behavioral skills.
These particularities indicate that health professionals who treat patients with chronic diseases, such as T2DM, must consider the need for adjustments in the educational program, aiming to ensure the maintenance of the benefits achieved, regardless of the type of educational intervention used.
Thus, the performance of studies to assess the effects of the interventions 12 months after their completion is proposed, in order to identify whether the benefits remain over the long term, which would characterize the residual effect of interventions previously performed. Therefore, it is appropriate to propose the continuation of studies of this nature, through qualitative methodologies that enable the identification of the elements that contribute to changes, the comprehension of how these elements work in these changes, and the clarification of the boundaries between individual and group interventions in the modulation of self-care, considering that the educational process constitutes something dynamic and therefore subject to continuous and multidimensional assessment.