The use of dialogue tools to promote dialogue-based and person-centred patient education for people with type 2 diabetes

An evidence-based nurse-led intervention to reduce diabetes distress among adults with type 1 diabetes and diabetes distress (REDUCE): Development of a complex intervention informed by the Medical Research Council framework

BACKGROUND

Diabetes distress refers to the negative emotional reaction to living with the demands of diabetes and is occurring in more than 40 % of adults with type 1 diabetes. However, no interventions to reduce diabetes distress are specifically designed to be an integral part of diabetes care.

OBJECTIVE

To modify and adapt existing, evidence-based methods into a nurse-led group intervention to reduce diabetes distress among adults with type 1 diabetes and moderate to severe diabetes distress.

METHODS

The overall framework of this study was informed by the initial phase of the Medical Research Council complex intervention framework undertaking intervention identification and development to guide the adaptation of the intervention. This study took place at two specialised diabetes centres in Denmark from November 2019 to June 2021. A total of 36 adults with type 1 diabetes participated in 10 parallel workshops. Twelve diabetes-specialised nurses were interviewed and participated in one co-creation workshop and 12 multidisciplinary specialists (psychologists, educational specialists, and researchers) participated in four co-creation workshops and 14 feedback meetings. Data were analysed by applying a deductive analytical approach.

RESULTS

The intervention included five bi-weekly 2½-hour small group sessions with adults with type 1 diabetes and diabetes distress delivered by two trained diabetes specialist nurses guided by a detailed step-by-step manual. The intervention material includes visual conversation tools, covering seven diabetes-specific sources derived from the 28-item diabetes distress scale for measuring diabetes distress: 1) powerlessness, 2) self-management, 3) fear of hypoglycaemia, 4) food and eating, 5) friends and family, 6) negative social perception, and 7) physician distress. The tools are designed to kick-start awareness and sharing of diabetes-specific challenges and strengths, individual reflections as well as plenary- and peer-to-peer discussions about strategies to manage diabetes distress, providing new perspectives on diabetes worries, and strategies to overcome negative emotions. Diabetes specialist nurses expressed a need for a manual with descriptions of methods and detailed guidelines for using the tools. To deliver the intervention nurses needed increased knowledge about diabetes distress, how to support diabetes distress reduction, and training and supervision to improve skills.

CONCLUSIONS

This co-design study has described the adaption of a complex intervention with a strong evidence base including detailed reporting of the theoretical underpinnings and core mechanisms.

CLINICALTRIAL

Helping providers address psychological aspects of obesity in routine care: Development of the obesity adjustment dialogue tool (OADT)

Background

This study developed and validated a dialogue tool (Obesity Adjustment Dialogue Tool) to efficiently assess QoL and drive to eat for use in routine clinical care.

Methods

A 13-question interview was created, assessing the impact of living with obesity on quality of life and drive to eat. In a counter-balanced order, PwO were interviewed and completed the Obesity Adjustment Survey (OAS), the Impact of Obesity on Quality of Life-Lite scale (IWQoL), the Three Factor Eating Questionnaire (TREQ), and the Control of Eating Questionnaire (COEQ). Questionnaire results were used to validate the interview using correlational and concordance measures.

Results

101 PwO consented and 98 completed all measures (mean BMI = 37.8; 30.7% Class III obesity). Correlations between the QoL dialogue tool and validated instruments (OAS, IWQOL) were moderate to high. Correlations between cravings questions and validated measures (TFEQ, COEQ) were high except for attempts to control eating. Correspondence based on categorizing both the dialogue tool and scales into high/low impact was high except for attempts to control eating (which was dropped from the final tool).

Conclusion

The Obesity Adjustment Dialogue Tool is a brief clinician-led structured interview which closely matches information derived from validated scales. This tool offers an efficient approach to incorporating QoL factors into obesity management.

Co-creating active communities: processes and outcomes of linking public rehabilitation programs with civic engagement for active living in a Danish municipality

BACKGROUND

Increased levels of physical activity are associated with beneficial health effects for people with type 2 diabetes, cardiovascular disease and/or severe obesity; however, transforming knowledge about these effects into action is challenging. The aim of this paper is to explore lessons learnt from a co-creation process in a partnership project involving local stakeholders, including citizens, and researchers. The purpose of the process was to link a public health care institution with civil society organisations in the local community to make it possible for citizens to continue to be physically active after ending their public rehabilitation. Secondarily, this paper aims to develop a conceptual model of the above process.

METHODS

The study constitutes the first part of Project Active Communities and was based on a partnership between three research institutions and a Danish rural municipality, involving municipal and civil society stakeholders and citizens with type 2 diabetes, cardiovascular disease and/or severe obesity in co-creation of concrete interventions for implementation. The co-creation process was divided into two tracks, one involving citizens (two workshops) and one involving municipal and civil society stakeholders (two workshops). The two tracks were concluded with a final workshop involving all stakeholders, including local politicians. Data sources are focus groups and bilateral meetings, workshop observations, and questionnaires.

RESULTS

Lessons learnt include the importance of having a flexible timeframe for the co-creation process; giving room for disagreements and matching of mutual expectations between stakeholders; the value of a coordinator in the municipality to achieve acceptance of the project; and the significance of engaging local politicians in the co-creation process to accommodate internal political agendas. We have developed a conceptual model for a co-creation process, where we outline and explain three distinct phases: stakeholder identification and description, co-creation, and prototyping. The model can be adapted and applied to other sectors and settings.

CONCLUSIONS

This study documents lessons learnt in a co-creation process aiming to link a public health care institution with civil society organisations in the local community. Further, this study has specified productive co-creative processes and documented the various phases in a conceptual model.

An Evaluation of a Virtual Food Safety Program for Low-Income Families: Applying the Theory of Planned Behavior

Low-income families are reported to have a limited knowledge of food safety and resources to follow food safety practices compared with the rest of the population. This paper evaluated a virtual food safety educational program targeting food handlers in low-income families. Trained native speakers of English and Spanish delivered course materials in both languages. A total of 60 individuals participated in the program, with 30 participants in each language group. Most were female, and most had fewer than three children. After the program, participants’ food safety knowledge and self-reported safe food practice behavior scores increased significantly from 5.32 to 7.43 (out of 8.00) and from 24.78 to 29.30 (out of 35.00), respectively. The theory of planned behavior (TPB) was used to understand individuals’ behavior change intention of food safety practices. All the TPB constructs’ scores, including attitudes toward the behavior, perceived behavioral control, subjective norms, and behavior change intentions, were improved significantly; however, only the subjective norms and perceived behavioral control were significantly correlated with the behavior change intentions. This virtual educational program improved low-income individuals’ food safety knowledge and changed their food safety attitudes and behaviors, giving a path to develop and evaluate more virtual food safety educational programs in the future.

Achieving a useful and person-centred diabetes consultation is a shared responsibility between diabetologists and people with diabetes: a qualitative study of perspectives from people with type 1 diabetes

AIMS

To explore perceptions of useful routine consultations with diabetologists from the perspective of adults with type 1 diabetes, including preferences for discussing psychosocial issues.

METHODS

We conducted semi-structured interviews in 2018/2019 with 33 people with type 1 diabetes (age 22-75 years, 20 men and 13 women, median diabetes duration 25 years) recruited from two diabetes clinics in the capital region of Denmark. Interviews were audio recorded, transcribed verbatim and analysed using thematic text condensation.

RESULTS

Achieving a useful consultation was perceived as a shared responsibility between people with diabetes and diabetologists. Participants' perspectives of what constitutes a useful consultation and expectations for both consultation and diabetologist varied in relation to perceptions of (1) the interaction between the person with diabetes and diabetologist, including being prepared, being honest, experiencing good rapport and preferring a partnership with the diabetologist or 'keeping it clinical' and (2) the diabetologist's approach to diabetes care, including providing up-to-date knowledge and listening and showing understanding.

CONCLUSIONS

Both content and style of diabetes consultations need to be adapted to the individual person with type 1 diabetes. People with diabetes have an important role in expressing their needs and preferences related to both content and style. Diabetologists need to be aware of and attentive to the many individual needs and expectations among people with diabetes, including the desire and need to discuss psychosocial issues. Dialogue tools for preparation and in consultations may enable people with diabetes to voice their needs and expectations and diabetologists to juggle these diversities.

Testing an analogue game to promote peer support and person-centredness in education for people with diabetes: A realist evaluation

Aim

To explore the outcomes of testing an analogue game to incorporate person‐centredness and peer dialogues in group‐based diabetes education targeting people with diabetes.

Design

Realist evaluation using quantitative and qualitative methods to explore context, mechanisms and outcomes of the intervention.

Methods

In March–July 2019, the game was tested among 76 people with type 2 diabetes and 17 professionals in 19 settings across nine Danish municipalities. Data consisted of game tests, interviews and questionnaires. Data were analysed using systematic text condensation and descriptive statistics.

Results

Outcomes of using the game were as follows: (a) a playful atmosphere; (b) active engagement; c) reflections on diabetes‐specific experiences; (d) focused dialogues; (e) professionals gaining insight into the needs of participants; and (f) professionals experiencing peer dialogue as important to incorporate into education. Questionnaire responses showed that 92% people with diabetes and 94% professionals found that the game incorporated person‐centredness and peer dialogues into education.

Coconstruction d’une intervention infirmière centrée sur la personne pour soutenir l’autogestion des individus vivant avec le diabète de type 2

Introduction : People living with type 2 diabetes are brought to make demanding behavioral changes that can lead to self-management difficulties.Background : The guidelines recommend that healthcare professionals follow a person-centered approach (PCA) when caring. However, this approach seems difficult to adopt in practice.Objective : Coconstruct an intervention inspired by the concept map (CM) to promote the adoption of PCA by nurses during self-management support encounters.Method : This study is based on a model for developing evidence-based nursing interventions. Five experts (2 patients, 2 nurses, 1 educational specialist) collaborated in the coconstruction of the intervention.Results : The Person-Centered Approach Diabetes Self-Management Support (PCA-DSMS) intervention has been developed in accordance with the foundations of a PCA and the CM. It includes four steps : 1) Introduce the intervention ; 2) Develop the Needs Map ; 3) Intervene according to priority needs ; 4) Conclude and plan a follow-up.Discussion : More studies are needed to explore whether the intervention is acceptable and feasible as well as its ability to lead nurses to adopt PCA.Conclusion : The PCA-DSMS could bring nurses to adopt a PCA.

Dimensions, application, and outcomes of person-centered self-management interventions for those living with type 2 diabetes: A scoping review

OBJECTIVES

To explore which dimensions of the person-centered approach (PCA) are adopted in self-management interventions, how they are applied, and its outcomes.

METHODS

A review team carried out a scoping review using the methodology of Arksey and O'Malley on diabetes mellitus type 2, person-centered care, and self-management.

RESULTS

Of the 364 titles identified, 22 articles were included in this review. No study contained all five dimensions described by the person-centered framework. Some dimensions seemed difficult to assess, mainly having a sympathetic presence and engagement. The application of the five PCA dimensions are presented. Although the authors claimed their intervention to be person-centered, none used a specific tool to measure person-centered care in a holistic way.

CONCLUSION

Although the guidelines recommend a PCA to professionals, there is a gap with practice, professionals having difficulty adopting and measuring this approach.

PRACTICE IMPLICATIONS

Some strategies to facilitate the adoption of a PCA with people living with type 2 diabetes are proposed. These can help researchers and clinicians develop a PCA, by identifying the care delivery processes necessary to provide it. It seems important for researchers to measure whether their intervention is truly person-centered, using holistic tools and combining different methods (observation, questionnaire, interview).

Effect of a participatory patient education programme (NExt EDucation) in group-based patient education among Danes with type 2 diabetes

OBJECTIVE

To assess the effect of a participatory group-based education programme for individuals with type 2 diabetes, Next Education.

METHOD

In a quasi-experimental study, individuals with type 2 diabetes were recruited from 14 Danish municipalities with a patient education programme. Eight municipalities using Next Education were intervention sites; six control sites used usual group-based education programmes. Data were collected through questionnaires at baseline and at 3 and 12 months after programmes ended. Changes in quality of life (EQ-5D-5L), diabetes-related emotional distress (PAID-5), physical activity, diet, foot care and sense of coherence (SOC-13) were assessed in generalised linear mixed models.

RESULTS

At baseline, 310 participants (52.6% females, mean age 62.5 years [SD = 10.7] and a mean duration of type 2 diabetes of 6.9 years [SD = 8.4]) participated in Next Education (n = 234) or group-based education (n = 76) at control sites. Compared with participants at control sites, participants at intervention sites had significantly larger sense of coherence scores at 3 (9.4%, p = 0.03) and 12 (9.8%, p = 0.02) months of follow-up. Other measures did not differ significantly between groups.

DISCUSSION

It is likely that person-centeredness and high degrees of user participation at the intervention sites improved sense of coherence among Danes with type 2 diabetes.

Impact of patient-centred diabetes self-management education targeting people with type 2 diabetes: an integrative review

AIMS

To synthesize primary research into the impact of person-centred diabetes self-management education, and support that targets people with type 2 diabetes, on behavioural, psychosocial and cardiometabolic outcomes and to identify effective mechanisms underlying positive outcomes of person-centred diabetes self-management education and support.

METHODS

Using Whittemore and Knafl's integrative review method, we conducted a systematic search of peer-reviewed literature published between January 2008 and June 2019 using PubMed, Scopus and CINAHL. After article selection according to established criteria, study quality was assessed using Critical Appraisal Skills Programme checklists for cohort studies, randomized controlled trials and qualitative research.

RESULTS

From 1901 identified records, 22 (19 quantitative, two qualitative, and one mixed methods) were considered eligible for inclusion. Interventions were categorized by content, medium of delivery, and outcomes. Qualitative studies, quantitative cohort studies and randomized controlled trials demonstrated positive outcomes, with no differences in success rates across study design. Interventions were largely successful in improving HbA_1c and patient-reported outcomes such as quality of life but had limited success in lowering cholesterol and weight, or initiating long-term improvements in lifestyle behaviours. Primary objectives were achieved more often than secondary objectives, and studies with fewer outcomes appeared more successful in achieving specific outcomes.

CONCLUSIONS

Person-centred diabetes self-management education and support has demonstrated a considerable impact on desired diabetes-related outcomes in people with type 2 diabetes. To advance the field further, new studies should take advantage of systematic and transparent approaches to person-centred diabetes self-management education.

Qualitative exploration of the experiences of renal dietitians and how they help patients with end stage kidney disease to understand the renal diet

AIM

Dietary modification is integral to the management of end stage kidney disease. However, adherence to the renal diet is poor. Few studies have explored the perspectives of renal dietitians and how they work with patients to facilitate dietary change. The objectives of this study were to explore the experiences of renal dietitians about educating patients with end stage kidney disease; and to describe the strategies perceived to help patients understand the renal diet.

METHODS

Semi-structured interviews based on Sensemaking theory were conducted with renal dietitians (n = 27) working in Australia and New Zealand from a range of metropolitan, regional and remote areas.

RESULTS

Five major themes across two categories were derived from the data. The renal dietitians in this study experienced feelings of frustration, frequently worked in practice environments with limited or inadequate resources and perceived that establishing trust and demonstrating empathy were important to sense making. Renal dietitians helped patients make sense of and understand the diet by clarifying ambiguities and conflicting information; and simplifying complexity by using simple explanations, individualised advice and practical support. These strategies were considered critical to the renal diet sense making process.

CONCLUSIONS

The experience of providing renal diet advice to adults with end stage kidney disease was emotionally and professionally challenging. Alternative approaches to patient education may help dietitians to empower patients to better understand the renal diet. Further research exploring the experiences of learning about the renal diet from the patient and carer perspective would also help to inform future alternative approaches.

Development and testing of a mobile application to support diabetes self-management for people with newly diagnosed type 2 diabetes: a design thinking case study

BACKGROUND

Numerous mobile applications have been developed to support diabetes-self-management. However, the majority of these applications lack a theoretical foundation and the involvement of people with diabetes during development. The aim of this study was to develop and test a mobile application (app) supporting diabetes self-management among people with newly diagnosed type 2 diabetes using design thinking.

METHODS

The app was developed and tested in 2015 using a design-based research approach involving target users (individuals newly diagnosed with type 2 diabetes), research scientists, healthcare professionals, designers, and app developers. The research approach comprised three major phases: inspiration, ideation, and implementation. The first phase included observations of diabetes education and 12 in-depth interviews with users regarding challenges and needs related to living with diabetes. The ideation phrase consisted of four interactive workshops with users focusing on app needs, in which ideas were developed and prioritized. Finally, 14 users tested the app over 4 weeks; they were interviewed about usability and perceptions about the app as a support tool.

RESULTS

A multifunctional app was useful for people with newly diagnosed type 2 diabetes. The final app comprised five major functions: overview of diabetes activities after diagnosis, recording of health data, reflection games and goal setting, knowledge games and recording of psychological data such as sleep, fatigue, and well-being. Users found the app to be a valuable tool for support, particularly for raising their awareness about their psychological health and for informing and guiding them through the healthcare system after diagnosis.

CONCLUSIONS

The design thinking processes used in the development and implementation of the mobile health app were crucial to creating value for users. More attention should be paid to the training of professionals who introduce health apps.

TRIAL REGISTRATION

Danish Data Protection Agency: 2012-58-0004. Registered 6 February 2016.

Principled Promotion of Health: Implementing Five Guiding Health Promotion Principles for Research-Based Prevention and Management of Diabetes

Background: Based on widespread critique of the moralizing paradigm that has long characterized much of the work conducted within the field of health promotion, Steno Health Promotion Research has developed a comprehensive health promotion approach consisting of five principles that constitute the framework for a new intervention paradigm. The five principles are: (1) A broad and positive health concept; (2) Participation and involvement; (3) Action and action competence; (4) A settings perspective and (5) Equity in health. Objectives: To describe a comprehensive health promotion approach consisting of five principles; to present research and development projects based on this set of principles; and to discuss experiences and results from implementing the health promotion principles in healthcare practices. Results and conclusion: The principle approach enables consolidation of hitherto disparate approaches into a single comprehensive approach. The principles have turned out to be productive and effective “management tools” that have led to new discoveries, but also helped to identify limitations.

Barriers to and motivators for physical activity among people with Type 2 diabetes: patients' perspectives

AIM

To explore barriers to and motivators for physical activity in a group of overweight and obese individuals with dysregulated Type 2 diabetes.

METHODS

Data were collected from the Steno Diabetes Center's outpatient clinic in Denmark. Four focus groups were conducted including 28 individuals with Type 2 diabetes aged 39-71 years. The facilitators used open-ended questions and probes such as images, statements and quotations about physical activity to foster active participation and interaction among participants. Focus groups were recorded on video and the discussions were transcribed and analysed thematically.

RESULTS

We identified four main themes: 1) the body as a barrier to physical activity because of functional limitations; 2) logistical challenges, including lack of time and awareness of where to exercise in the local area; 3) being physically active with others, providing a sense of mutual commitment and enjoyment; and 4) goal-setting and self-tracking, which was seen as an opportunity to track physical improvement over time.

CONCLUSIONS

The findings suggest that, once people are active, a high level of social interaction may help maintain their activity levels. Further research is needed to investigate the effect of combining individually tailored exercise plans with the establishment of customized and locally based exercise communities that offer enjoyment and support. Additionally, it is relevant to explore experiences of using self-tracking technologies to review short- and long-term goals.