http://dx.doi.org/10.4093/jkd.2013.14.4.194 동남보건대학교간호학과김희숙 Role of Diabetes Educators and Effectiveness of Diabetes Education HeeSook Kim Department of Nursing, Dongnam Health College, Gyeonggi-do, Korea Abstract 194 Diabetes educators give patients with diabetes the knowledge, skills and tools they need to manage their diabetes. Also, they can help these patients avoid many of the complications associated with the disease. The diabetes education team is involved not only in coordinating the ongoing care of patients, but also in educating and counseling patients on medication and management of illness. This systematic review suggests the benefit of diabetes education on glycemic control and health outcome when compared with usual care. Additional studies are needed to delineate these findings further. (J Korean Diabetes 2013;14:194-198) Keywords: Diabetes mellitus, Education, Health educators, Role, Outcome assessment 서론 최근 2010 년국내의당뇨병유병률은 9.7% 로성인 10 명중 1 명이당뇨병을가지고있으며 [1], 2009 년당뇨병사망률의 O E C D 평균은인구 10 만명당 11.4 명이지만, 한국은 21 명으로 1990 년대이후계속해서 OECD 국가중가장높은수준을유지하고있다 [2]. 이는현재우리나라에서당뇨병의관리가효과적으로이루어지지않음을제시하고있다. 당뇨병치료의궁극적목표는지속적인자기관리를통해혈당조절상태를향상시켜당뇨병성합병증을예방함으로써건강한삶을유지하는것이다 [3]. 효과적인당뇨병관리를위해서는적절한약물투여와함께식이, 운동, 스트레스등의일상적인생활습관조절을위한철저한자기관리가필요하다 [4-6]. 당뇨병교육은효과적인자기관리에필요한지식과기술및능력등을습득하여자신의건강상태를유지, 개선하는데핵심역할을담당하고있다 [7]. 한편, 2007 년부터 2010 년까지의자료를통합한국민건강영양조사에의하면, 국내당뇨병전체유병률의 14.6% 만이당뇨병교육을받고있으며, 기존진단받은 대상자는 19.2% 만이당뇨병교육을받는다고보고하고있다 [1]. 당뇨병교육의중요성은아무리강조해도지나치지않지만국내당뇨병교육을받은사람은실제로부족한상황이다. 또한국내당뇨병환자수가해마다증가함에따라당뇨병치료에소요되는사회적비용도증가하고있지만이에대한국가적지원도체계성이부족한현실이고, 국내당뇨병교육효과와만족도에대해연구자료도미비한실정이다. 따라서본연구는당뇨병교육자의역할과당뇨병교육자에의해수행된당뇨병교육의효과를파악하여효과적인국내당뇨병관리에대한정책제안의기초자료로활용하고자한다. 본론 1. 당뇨병교육자의정의와역할 당뇨병교육자의정의를알아보면, 국내에서는대한당뇨병학회회원으로서일정기간이상당뇨병환자교육에종사하고, 학회가인정하는당뇨병교육자교육과정을이수하여당뇨병교육의전반적인지식과상담능력을갖추고당뇨병교육팀의팀원으로당뇨병환자교육을 교신저자 : 김희숙, 경기도수원시장안구천천로동남보건대학교간호학과, E-mail : kimhs02041@hotmail.com, khs0204@dongnam.ac.kr
하고있는자를의미한다 [8]. 국내당뇨병교육은의사, 간호사, 영양사가기본적으로교육팀을이루고기관에따라사회복지사, 운동처방사, 약사등이교육팀의일원으로참여하고있다 [8-10]. 미국당뇨병교육자협회 (American Association of Diabetes Educators: AADE) 에서제시한당뇨병교육자는간호사, 약사, 영양사와훈련된전문가등이해당된다. 대부분전문적인당뇨병교육자는 AADE 의회원이며, 일부당뇨병교육자는 Certified Diabetes Educators (CDE) 나 Board Certified Advanced Diabetes Managers (BC-ADM) 가있다. 미국당뇨병교육자협회는당뇨병자가관리행위를 7 가지영역 (AADE7 Self-Care Behaviors) 으로새롭게규명하였는데, 구체적으로건강한식이 (Healthy eating), 신체활동 (Being active), 혈당감시 (Monitoring), 투약 (Taking medication), 혈당조절과관련된문제해결 (Problem solving), 건강한대처 (Healthy coping), 당뇨병합병증에대한위험요인의감소 (Reducing risks) 이고, 이러한영역들이건강상태의증진과삶의질의향상에필수적인요소라고제시하였다 [11]. 당뇨병교육은환자에게당뇨병관리에대한지식과기술을제공하여생활습관을변화하여당뇨병을조절할뿐만아니라당뇨병의위기에대처하며당뇨병을성공적으로조절하는데도움을주는과정을의미한다 [11,12]. 당뇨병자기관리훈련 (diabetes selfmanagement training: DSMT) 이나당뇨병자기관리교육 (diabetes self management education: DSME) 으로알려진당뇨병교육은당뇨병을가졌거나당뇨병의위험을가진사람이질병을성공적으로관리하기위해필요한지식과기술을얻도록돕는연합적인과정으로정의한다 [11]. 최근우리나라보건복지부고시안에의하면, 당뇨병교육자는교육의내용, 횟수, 간격등에대한계획을하고해당요양기관임상과또는관련학회등의자문을받은자료를이용하여미리계획된교육프로그램으로당뇨병의치료및합병증예방, 당뇨병자가관리등포괄적인내용을교육하도록되어있다 [7,9,13]. 당뇨병교육자는당뇨병관리의임상적, 교육적, 심리학적접근이결합된복합적인역할과기능을수행한다. 당뇨병교육자는당뇨병환자의행동변화를촉진하여대상자의자가관리행동변화의결과로임상적결과가향상되도록교육자, 상담가, 코디네이터, 촉진자의역할을한다 [7,14]. 특히당뇨병교육간호사는실제적인당뇨병교육프로그램을적용하고유지하는데필수교육자이면서상담가, 건강행위촉진자및코디네이터역할을하고있다 [14]. 결과적으로당뇨병교육자 는당뇨병환자가질환을관리하기위한기술을가르치는것을넘어서효과적으로자기관리를할수있도록돕는것이다 [7,14]. 2. 당뇨병교육자의당뇨병교육효과 당뇨병치료와관리를위해대상자에게자가관리를잘하도록지지하고강화하는것은중요한부분이며, 실제단순한약물치료보다는환자가질환을이해하고혈당을조절하도록대상자를교육하는것이효과적이라는것은알려져있다 [5]. 따라서당뇨병교육자에의해실시된당뇨병교육과당뇨병관리프로그램의효과에대해교육성과, 교육형태에따른교육효과및교육지속효과를세부적으로살펴보고자한다. 1) 당뇨병교육의성과 (outcomes) 당뇨병교육을통한건강결과를보면, 당뇨병교육을받은대상자는혈당조절이잘되지만, 교육을제대로받지못한대상자는당화혈색소가지속적으로상승하고당뇨병의합병증이증가한다는보고가있다 [15-17]. 구체적으로 Norris 등은제 2 형당뇨병대상자의자가관리프로그램의효과에대한 72 개의 RCT 연구설계로진행된연구의체계적문헌고찰에서자가관리프로그램이대상자의지식, 자가혈당측정의빈도와정확성, 자기보고된식이습관, 혈당조절에서 6 개월이하의단기추후관리에서긍정적인효과를제시하였다 [18]. 하지만, 지질, 신체활동, 체중및혈압에대한중재효과는다양한결과가있으며, 장기추후관리를통한정규적인강화는혈당조절의긍정적인효과를보고하고있다. 또한당뇨병교육은대상자의당뇨병관련지식과자기관리행동이향상되고 [18,19], 공복혈당, 식후혈당, 당화혈색소를포함한임상적생리지표가개선되고 [19-21], 당뇨병으로인한만성합병증의발생률이감소하고 [19], 환자만족도, 재원기간, 진료비및하지절단율감소등의연구결과를통해효과가검증되고있다 [22-26]. 한편, 여러연구에서당뇨병교육은비용이발생하지만결과적으로는비용 - 효과적인것으로제시되고있다 [20,27,28]. 김지현과장상아는당뇨병교육은중재군에서당뇨병에대한지식증가, 혈당과지질수치향상되었으나당뇨병의자기관리및자기효능감에미치는효과는미비하다고보고하였다 [29]. 위와같은다양한연구에서당뇨병교육이당뇨병대상자에게혈당조절을포함해서건강결과에이로운효과를나타내는것으로사료된다. 성인당뇨병교육의효과를수많은연구에서입증해 195
196 왔으나임신성당뇨병여성을위한중재효과연구는약물효과연구를제외하고소수에불과한상태이다 [30-33]. 임신성당뇨병관리프로그램을수행연구결과를보면, 자가관리를증가시켜서혈당수치의감소와모성정체성을향상시키고, 임신성당뇨병여성의교육만족도를증가시켰다는연구 [30,31] 와자기효능감, 우울및불안이감소되었다고보고하고있다 [32]. 임신성당뇨병에대한교육효과는앞으로계속적인연구와추적관찰이필요한것으로사료된다. 2) 교육형태에따른당뇨병교육의효과당뇨병교육의형태는개별교육, 집단교육, 교육입원, 당뇨캠프, 자조모임, 조식회, 중식회등다양하게이뤄지고, 교육내용으로는당뇨병개요, 자가혈당검사, 식이요법, 운동요법, 생활습관변화, 약물요법, 인슐린주사법, 당뇨합병증, 발관리, 저혈당관리, 아픈날의관리, 일상생활관리, 심리적적응과스트레스관리, 가족의역할등으로구성된다 [7,10]. 2007 AADE National Practice Survey 에서당뇨병교육은 51% 의일대일개별교육과집단교육, 31% 의개별적교육, 13% 의그룹교육및 2% 의화상진료 (Telemedicine) 로이뤄지는것으로조사되었다 [34]. Duke 등은제 2 형당뇨병대상자의개별환자교육효과에대한체계적문헌고찰결과를통한혈당조절, 당뇨병지식및정신사회적결과에미치는효과를제시하였다 [35]. 중재군인개별적면대면교육과대조군인일반적통상관리 (usual care) 를비교한결과에서 12~18 개월기간동안시행한개별교육이혈당조절을향상시키지않았다. 그러나평균 glycosylated haemoglobin (HbA1c) 8% 이상인대상자에게수행한개별당뇨병교육이혈당조절에효과가있는것으로나타났다. 또한식이자기관리, 당뇨병지식, 정신사회적결과, 흡연습관과관련된개별교육의효과를메타분석하기에는연구가너무적었고, 당뇨병합병증, 건강서비스이용도, 비용분석에대한자료는없었다고제시하고있다 [35]. Norris 등의제 2 형당뇨병대상자의자가관리프로그램의효과에대한 72 개연구의체계적문헌고찰에의하면, 교육방법에서환자와협력을수반한교육적중재가지시적식이요법중재보다혈당, 체중, 지질수치의향상에더효과적이라고제시하고있다 [18]. 따라서혈당조절이안된대상자는개별교육이필요함을알수있으며, 대상자의협력적인교육이혈당조절을포함한긍정적인효과를나타내는것으로사료된다. 3) 당뇨병교육의지속기간당뇨병교육의지속효과를당뇨병의종류에따라알아보고재교육의시점을알아보고자한다. 제 1 형당뇨병교육지속효과연구를보면, 당뇨병교육과상담후에 6 개월후에당화혈색소가호전되었다가효과가없어진다고보고가있으며 [36], 교육전후와교육후 3 개월에당화혈색소는감소되었으나교육 9 개월이후에다시당화혈색소가증가하는경향을제시하여교육후 9 개월이후에는당뇨병관리에대한동기부여와재교육이필요하다고밝히고있다 [37]. 제 2 형당뇨병교육지속효과연구를보면, 대상자에게 1~2 회이상의당뇨병교육실시후대상자의자가관리행동은 1 년 6 개월후에절반수준으로감소한다고제시하였다 [15]. 송민선등의체계적당뇨병교육이제 2 형당뇨병대상자에게미치는 4 년간추적조사연구에서중재군이자가관리행동이향상되었으나시간이지남에따라점차감소됨을제시하고있다 [5]. 중재군에서당뇨병교육 1 년후에혈당조절이크게향상되었고, 당화혈색소의감소 (HbA1c, 중재군 7.9 vs. 대조군, 8.9%, P =.009), 고밀도지단백콜레스테롤 ( 중재군 1.1 vs. 대조군, 1.0 mmol/l, P =.006) 의향상에효과가있다고제시하고있다. 또한홍명희등의당뇨병환자의자기조절프로그램의효과와지속에관한연구에서제 2 형당뇨병환자로 6 개월이상인슐린치료를받고있는당화혈색소 7.5% 이상대상자에게 4 주간의자기조절프로그램을실시한결과교육직후, 2 개월, 6 개월조사후자기효능감과자기간호행위는증가시켰지만, 혈당조절에는유의한차이가없다고제시하고있다 [38]. 당뇨병교육의지속효과에대해서는다양한결과를보이지만, 결과적으로당뇨병교육후에도추후관리와재교육이필요함을알수있다. 결론 당뇨병교육자의역할과당뇨병교육자에의해수행된당뇨교육프로그램의효과로교육성과, 교육형태에따른교육효과, 교육효과지속시간등을세부적으로고찰하였다. 당뇨병교육은만성질환인당뇨병의치료와성공적인자가관리를위해필수적이며, 대상자의당뇨병관련지식과자기관리행동의향상, 혈당조절을포함한임상적생리지표의개선, 만성합병증발생률의감소, 환자만족도증가등다양한영역에서효과적임을알수있었다. 하지만당뇨병교육후에도추후관리와재교육이필요하고, 당뇨병교육을통한자가관리훈련이심혈관질환관련사건과사망률, 비용효과, 건강관리체계이용도에미치는효과에대한자료는없으므로추후
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