The effect of motivational interviewing on glycaemic control and perceived competence of diabetes self-management in patients with type 1 and type 2 diabetes mellitus after attending a group education programme: a randomised controlled trial

mHealth Intervention for Vietnamese Living With Diabetes: Protocol for a Stepped Wedge Pilot Study

BACKGROUND

Evidence indicates participation in a diabetes self-management education and support program improves self-care behaviors and hemoglobin A1c. Language and cultural differences may be barriers to program participation resulting in ineffective self-management, but these factors can be addressed with appropriate interventions. Given the high health care costs associated with diabetes complications, we developed a multicomponent, culturally tailored Self-Management Mobile Health Intervention for US Vietnamese With Diabetes (SMart-D).

OBJECTIVE

This study aims to evaluate the SMart-D intervention's feasibility, acceptability, and effectiveness with intentions to scale up the intervention in the future. This mixed methods study incorporates the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to evaluate the intervention.

METHODS

This stepped wedge randomized controlled pilot study will be conducted over 2 years in collaboration with primary care clinics. Eligible participants are patients with type 2 diabetes who are receiving health care from participating clinics. Clinics will be randomly assigned to an implementation date and will begin with patients enrolling in the control period while receiving standard care, then cross over to the intervention period where patients receive standard care plus the SMart-D intervention for over 12 weeks. Focus groups or interviews will be conducted with clinicians and patients after study completion. Qualitative data will be analyzed using NVivo. Outcomes on self-care behavior changes will be measured with the Summary of Diabetes Self-Care Activities scale and clinical changes will be measured using laboratory tests. A generalized linear mixed-effect model will be used to compute time effect, clustering effect, and the interaction of the control and intervention periods using SAS (version 9.4; SAS Institute).

RESULTS

We hypothesize that (1) at least 50% (n=5) of eligible clinics and 50% (n=40) of eligible patients who are invited will participate, and at least 70% (n=56) of patients will complete the program, and (2) patients who receive the intervention will have improved self-care behaviors and clinical test results with at least 75% (n=60) of the patients maintaining improved outcomes at follow-up visits compared with baseline, and participants will verbalize that the intervention is feasible and acceptable. As of August 2023, we enrolled 10 clinics and 60 patients. Baseline data results will be available by the end of 2023 and outcome data will be published in 2025.

CONCLUSIONS

This is the first Vietnamese diabetes self-management education and support intervention that leverages mobile health technology to address the barriers of language and culture differences through collaboration with primary care clinics. This study will provide a better understanding of the implementation process, demonstrate the potential effectiveness of the intervention, accelerate the pace of moving evidence-based interventions to practice among the US Vietnamese population, and potentially provide a replicable implementation model that can be culturally adapted to other non-English speaking ethnic minorities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48585.

Experiences of overweight and obese patients with diabetes and practice nurses during implementation of a brief weight management intervention in general practice settings serving Culturally and Linguistically Diverse disadvantaged populations

BACKGROUND

To explore the perspectives of overweight and obese patients with diabetes from culturally and linguistically diverse, and disadvantaged backgrounds, as well as practice nurses (PNs) during implementation of a brief PN-supported self-regulation nutrition strategy for weight management in general practice settings serving disadvantaged populations.

METHODS

During intervention implementation, semi-structured interviews were conducted with 12 patients and four nurses in two general practices located in metropolitan suburbs in Sydney, Australia.

RESULTS

Patients and PNs found challenges related to cultural expectations and the requirement of patients to set and adhere to dietary change goals and behaviours. Although patients expressed high levels of satisfaction with PNs, the suitability of the intervention to this group was questioned by PNs. Obstacles were also encountered in delivering the intervention in a busy general practice setting.

CONCLUSIONS

This pilot study provided initial evidence of the acceptability of a self-regulation nutrition intervention for weight management for overweight and obese patients with type 2 diabetes that was delivered by PNs. Cultural expectations of provider-patient roles, the type of intervention and flexibility in the workplace are important future considerations.

Effect of personality on blood glucose control in patients with type 1 diabetes

OBJECTIVE

The diagnosis of type 1 diabetes mellitus (DM1) has a major impact on young people and their families. Psychosocial factors, patient motivation, participation and acceptance of the disease are essential to achieve good blood glucose control. Our aims were to analyse personality traits and how they are related to blood glucose control in patients with DM1.

METHODS

Sixty-two patients with DM1 over 18 years of age, with at least one-year disease duration and absence of advanced chronic complications were studied. Clinical, biological and personality parameters were measured. The Millon Index of Personality Styles was administered for personality assessment.

RESULTS

Significant correlations between different personality variables and glycated haemoglobin (HbA1c) values were found. Individuals with poor blood glucose control had significantly higher scores on the Feeling-guided (53.6±25.7 vs 36.2±26.8, p=0.021), Innovation-seeking (36.7±24.1 vs 21.9±21.4, p=0.025), Dissenting (41.1±24.4 vs 15.6±16.6, p=0.001), Submissive (41.5±25.1 vs 28.3±14.7, p=0.038) and Dissatisfied (37.5±27.5 vs 19.5±20.2, p=0.015) scales. This psychological profile is characterised by greater focus on emotions and personal values (feeling-guided), the tendency to reject conventional ideas (innovation-seeking), an aversion to complying with norms and a preference for autonomy (unconventional/dissenting), labile self-confidence (submissive/yielding) and expressed disagreement with others (dissatisfied/complaining). Factor analysis based on the main components of the variance yielded four factors. Factor characterised as related to rebelliousness or independent judgement and action was correlated with poor blood glucose control (r=0.402, p<0.05).

CONCLUSION

The rebellious or non-conformist personality type is closely associated with poor blood glucose control in patients with DM1.

Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review

BACKGROUND

For people with diabetes mellitus to achieve optimal glycaemic control, motivation to perform self-management is important. The research team wanted to determine whether or not psychological interventions are clinically effective and cost-effective in increasing self-management and improving glycaemic control.

OBJECTIVES

The first objective was to determine the clinical effectiveness of psychological interventions for people with type 1 diabetes mellitus and people with type 2 diabetes mellitus so that they have improved (1) glycated haemoglobin levels, (2) diabetes self-management and (3) quality of life, and fewer depressive symptoms. The second objective was to determine the cost-effectiveness of psychological interventions.

DATA SOURCES

The following databases were accessed (searches took place between 2003 and 2016): MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsycINFO, EMBASE, Cochrane Controlled Trials Register, Web of Science, and Dissertation Abstracts International. Diabetes conference abstracts, reference lists of included studies and Clinicaltrials.gov trial registry were also searched.

REVIEW METHODS

Systematic review, aggregate meta-analysis, network meta-analysis, individual patient data meta-analysis and cost-effectiveness modelling were all used. Risk of bias of randomised and non-randomised controlled trials was assessed using the Cochrane Handbook (Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928).

DESIGN

Systematic review, meta-analysis, cost-effectiveness analysis and patient and public consultation were all used.

SETTING

Settings in primary or secondary care were included.

PARTICIPANTS

Adolescents and children with type 1 diabetes mellitus and adults with types 1 and 2 diabetes mellitus were included.

INTERVENTIONS

The interventions used were psychological treatments, including and not restricted to cognitive-behavioural therapy, counselling, family therapy and psychotherapy.

MAIN OUTCOME MEASURES

Glycated haemoglobin levels, self-management behaviours, body mass index, blood pressure levels, depressive symptoms and quality of life were all used as outcome measures.

RESULTS

A total of 96 studies were included in the systematic review (n = 18,659 participants). In random-effects meta-analysis, data on glycated haemoglobin levels were available for seven studies conducted in adults with type 1 diabetes mellitus (n = 851 participants) that demonstrated a pooled mean difference of -0.13 (95% confidence interval -0.33 to 0.07), a non-significant decrease in favour of psychological treatment; 18 studies conducted in adolescents/children with type 1 diabetes mellitus (n = 2583 participants) that demonstrated a pooled mean difference of 0.00 (95% confidence interval -0.18 to 0.18), indicating no change; and 49 studies conducted in adults with type 2 diabetes mellitus (n = 12,009 participants) that demonstrated a pooled mean difference of -0.21 (95% confidence interval -0.31 to -0.10), equivalent to reduction in glycated haemoglobin levels of -0.33% or ≈3.5 mmol/mol. For type 2 diabetes mellitus, there was evidence that psychological interventions improved dietary behaviour and quality of life but not blood pressure, body mass index or depressive symptoms. The results of the network meta-analysis, which considers direct and indirect effects of multiple treatment comparisons, suggest that, for adults with type 1 diabetes mellitus (7 studies; 968 participants), attention control and cognitive-behavioural therapy are clinically effective and cognitive-behavioural therapy is cost-effective. For adults with type 2 diabetes mellitus (49 studies; 12,409 participants), cognitive-behavioural therapy and counselling are effective and cognitive-behavioural therapy is potentially cost-effective. The results of the individual patient data meta-analysis for adolescents/children with type 1 diabetes mellitus (9 studies; 1392 participants) suggest that there were main effects for age and diabetes duration. For adults with type 2 diabetes mellitus (19 studies; 3639 participants), baseline glycated haemoglobin levels moderated treatment outcome.

LIMITATIONS

Aggregate meta-analysis was limited to glycaemic control for type 1 diabetes mellitus. It was not possible to model cost-effectiveness for adolescents/children with type 1 diabetes mellitus and modelling for type 2 diabetes mellitus involved substantial uncertainty. The individual patient data meta-analysis included only 40-50% of studies.

CONCLUSIONS

This review suggests that psychological treatments offer minimal clinical benefit in improving glycated haemoglobin levels for adults with type 2 diabetes mellitus. However, there was no evidence of benefit compared with control interventions in improving glycated haemoglobin levels for people with type 1 diabetes mellitus.

FUTURE WORK

Future work should consider the competency of the interventionists delivering a therapy and psychological approaches that are matched to a person and their life course.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016033619.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 28. See the NIHR Journals Library website for further project information.

A systematic review of weight-related communication trainings for physicians

Obesity is a leading cause of preventable death in the USA. Given the high number of adults seeking routine health care services, physicians have an opportunity to address weight loss during routine clinical encounters. It's often reported that physicians lack the training to address weight. Training programs are implemented in medical settings to prepare physicians to have conversations with patients. Yet, the degree of consistency among training programs and factors associated with better outcomes is unclear. The purpose of this study is to systematically review literature in physician communication trainings related to weight-to compare the content, outcomes, and implementation of existing studies examining weight-related communication training programs for physicians and determine factors associated with physician and patient outcomes. Articles were extracted from PubMed, Proquest, and Embase. Search terms included: health communication, physician training, weight, and obesity. Studies implementing a training program addressing weight among physicians were included. Trainings using either motivational interviewing (MI) or 5 As (Ask, Advise, Assess, Assist, and Arrange) framework found improvements in physicians' communication skills. A small number of trainings including experiential components were also associated with improvements in positive physician outcomes. Findings suggest trainings based in MI or 5 As framework improve physicians' communication skills, but few programs affected patient outcomes. Gaps remain with trainings that can demonstrate weight loss in patients. While work is needed to enhance the effects of these trainings on patient outcomes, data suggest that trainings should be longer in duration and include an experiential component.

Training diabetes healthcare practitioners in motivational interviewing: a systematic review

Diabetes presents significant self-care challenges that require sustained motivation. Motivational Interviewing (MI) has substantial support in enhancing motivation for behavioural change, but its effective application in routine healthcare requires practitioners to acquire and use related skills. The aim of this systematic review was to investigate the impact of MI training on MI-related skills of practitioners who provide diabetes healthcare. PubMed, EMBASE and PsycINFO were searched using the terms motivational interviewing, motivation enhancement, and diabetes. Two assessors independently screened titles, abstracts and full texts for papers reporting the impact of MI training on diabetes healthcare practitioners' outcomes. Of 625 abstracts screened, 22 papers from 17 unique studies were included. All 17 studies reported some improvement in MI skills, with 14 finding improvements in more than 50% and three less than 35%. However, the risk of bias and outcome measures varied widely between studies. All studies showed diabetes healthcare practitioners acquired and applied MI skills post-training, to varying levels. Findings suggest training should include education, role play, and ongoing supervision to maintain skills.

Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials

BACKGROUND

Hospitals, clinics, and health organizations have provided psychosocial support interventions for medical patients to supplement curative care. Prior reviews of interventions augmenting psychosocial support in medical settings have reported mixed outcomes. This meta-analysis addresses the questions of how effective are psychosocial support interventions in improving patient survival and which potential moderating features are associated with greater effectiveness.

METHODS AND FINDINGS

We evaluated randomized controlled trials (RCTs) of psychosocial support interventions in inpatient and outpatient healthcare settings reporting survival data, including studies reporting disease-related or all-cause mortality. Literature searches included studies reported January 1980 through October 2020 accessed from Embase, Medline, Cochrane Library, CINAHL, Alt HealthWatch, PsycINFO, Social Work Abstracts, and Google Scholar databases. At least 2 reviewers screened studies, extracted data, and assessed study quality, with at least 2 independent reviewers also extracting data and assessing study quality. Odds ratio (OR) and hazard ratio (HR) data were analyzed separately using random effects weighted models. Of 42,054 studies searched, 106 RCTs including 40,280 patients met inclusion criteria. Patient average age was 57.2 years, with 52% females and 48% males; 42% had cardiovascular disease (CVD), 36% had cancer, and 22% had other conditions. Across 87 RCTs reporting data for discrete time periods, the average was OR = 1.20 (95% CI = 1.09 to 1.31, p < 0.001), indicating a 20% increased likelihood of survival among patients receiving psychosocial support compared to control groups receiving standard medical care. Among those studies, psychosocial interventions explicitly promoting health behaviors yielded improved likelihood of survival, whereas interventions without that primary focus did not. Across 22 RCTs reporting survival time, the average was HR = 1.29 (95% CI = 1.12 to 1.49, p < 0.001), indicating a 29% increased probability of survival over time among intervention recipients compared to controls. Among those studies, meta-regressions identified 3 moderating variables: control group type, patient disease severity, and risk of research bias. Studies in which control groups received health information/classes in addition to treatment as usual (TAU) averaged weaker effects than those in which control groups received only TAU. Studies with patients having relatively greater disease severity tended to yield smaller gains in survival time relative to control groups. In one of 3 analyses, studies with higher risk of research bias tended to report better outcomes. The main limitation of the data is that interventions very rarely blinded personnel and participants to study arm, such that expectations for improvement were not controlled.

CONCLUSIONS

In this meta-analysis, OR data indicated that psychosocial behavioral support interventions promoting patient motivation/coping to engage in health behaviors improved patient survival, but interventions focusing primarily on patients' social or emotional outcomes did not prolong life. HR data indicated that psychosocial interventions, predominantly focused on social or emotional outcomes, improved survival but yielded similar effects to health information/classes and were less effective among patients with apparently greater disease severity. Risk of research bias remains a plausible threat to data interpretation.

Motivational Interviewing and Self-Care in Type 1 Diabetes: A Randomized Controlled Clinical Trial Study Protocol

Background

Type 1 diabetes is a disease with complex therapeutic recommendations that require day-to-day lifestyle changes. Motivational Interviewing is a communication tool that has proved effective in changing behaviors in people with addictions, obesity and type 2 diabetes. Our objective is to evaluate the effects of a Motivational Interviewing intervention in people with type 1 diabetes.

Methods

Sixty-six patients with type 1 diabetes and hemoglobin A1c >= 8% have been included and randomly assigned (computer-generated sequence, sealed envelopes, ratio 1:1) either to the intervention or to the control group. In the intervention group, appointments every 4 months with the endocrinologist include Motivational Interviewing; in the control group, the appointments proceed as usual. Patients will be followed for 16 months. The primary outcome will be self-care behaviors, assessed by a validated questionnaire, the Diabetes Self-Care Inventory-Revised Version. Secondary outcomes include: HbA1c, motivation for self-care, self-efficacy, health-related quality of life, satisfaction with professional-patient relationship, and fulfillment of patients' own objectives. The practitioners receive training in Motivational Interviewing in order to help them promote adherence to self-care, encourage patient motivation and improve the doctor-patient relationship. The Motivational Interviewing intervention will be evaluated by two psychologists, blinded to the assigned treatment, through video recordings of the sessions and the administration of a purpose-built questionnaire, the EVEM 2.0 scale.

Discussion

There is evidence that MI can improve self-care in type 2 diabetes. In this study, we aim to evaluate the effect of MI on self-care and HbA1c in people with type 1 diabetes.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT03906786, identifier NCT03906786.

The MIPAM trial: a 12-week intervention with motivational interviewing and physical activity monitoring to enhance the daily amount of physical activity in community-dwelling older adults - a study protocol for a randomized controlled trial

BACKGROUND

Physical Activity Monitors (PAMs) have been shown to effectively enhance level of physical activity (PA) in older adults. Motivational interviewing is a person-centred model where participants are guided using self-reflection and counselling, and addresses the behavioural and psychological aspects of why people initiate health behaviour change by prompting increases in motivation and self-efficacy. The addition of motivational interviewing to PA interventions may increase the effectiveness of PAMs for older adults.

METHODS

This motivational interviewing and PA monitoring trial is designed as an investigator-blinded, two arm parallel group, randomized controlled superiority trial with primary endpoint after 12 weeks of intervention. The intervention group will receive a PAM-based intervention and motivational interviewing and the control group will only receive the PAM-based intervention. The primary outcome is PA, objectively measured as the average daily number of steps throughout the intervention period. Secondary outcome measures include self-reported PA health-related quality of life, loneliness, self-efficacy for exercise, outcome expectancy for exercise, and social relations. The outcomes will be analysed with a linear regression model investigating between-group differences, adjusted for baseline scores. Following the intention to treat principle, multiple imputation will be performed to handle missing values.

DISCUSSION

A moderate effect of daily PA measured using PAMs is expected in this superiority RCT investigating the effect of adding motivational interviewing to a PAM intervention. According to the World Health Organization, walking and cycling are key activities in regular PA and should be promoted. To increase the general public health and lower the burden of inactivity in older adults, cost-beneficial solutions should be investigated further. If this RCT shows that motivational interviewing can enhance the effect of PAM-based interventions, it might be included as an add-on intervention when appropriate. No matter what the results of this study will be, the conclusions will be relevant for clinicians as the dependence on technology is increasing, especially in relation to public health promotion.

TRIAL REGISTRATION

NCT03906162 , April 1, 2019.

Effectiveness of motivational interviewing on improving Care for Patients with type 2 diabetes in China: A randomized controlled trial

Background

To assess the effects of a motivational interviewing (MI)-based patient empowerment program (PEP) on type 2 diabetes mellitus (DM) patient self-management compared to traditional diabetes health education.

Methods

Two hundred and twenty-five patients, recruited from community health centers (CHCs) and the family medicine clinic in the University of Hong Kong-Shenzhen Hospital in Shenzhen, were randomly assigned to the intervention or control groups. Patients in the intervention group (n = 117) received a four-session PEP in small groups over 1 month by trained nurses and doctors. The control group (n = 108) received the traditional lecture-style health education on DM. All the patients were followed up for 3 months. Outcomes included problem areas in diabetes (PAID) that measures diabetes-related emotional distress, patient enablement index (PEI), mental health, patient satisfaction respectively as well as lifestyle behaviors were assessed at baseline, post-activity and 3 months.

Results

At post-intervention and the 3-month follow-up, the PAID score improved significantly in the intervention group (12.7 ± 13.6, 5.8 ± 7.6) compared to the control group (22.7 ± 22.8, 11.7 ± 14.6). No difference was found between groups for changes to exercise, diet, and medication adherence. The PEI score improved significantly at the 3-month follow-up in the MI group (7.27 ± 2.45 vs 5.81 ± 2.97).

Conclusion

The PEP has a significant effect on improving diabetes-related distress, but MI was not significantly different from the traditional health education programs when it comes to the readiness to change.

Trial registration

NCT04120844, ClinicalTrials.Gov. Date of registration: October 9th 2019 (Retrospectively registered).

Multidisciplinary work promotes preventive medicine and health education in primary care: a cross-sectional survey

Background

Preventive medicine and health education are among the strategies used in coping with chronic diseases. However, it is yet to be determined what effect do personal and organizational aspects have on its’ implementation in primary care.

Methods

A cross-sectional survey was conducted in order to assess and compare preventive medicine and health education activities in three types of primary care models: solo working independent physicians, nurse-physician collaborations and teamwork (nurses, dietitians and social workers working alongside a physician). Questionnaires were emailed to 1203 health professionals between September and November 2015, working at Maccabi Healthcare Services, the second largest Israeli healthcare organization.

Self-reported rates of health education groups conducted, proactive appointments scheduling and self-empowerment techniques use during routine appointments, were compared among the three models. Independent variables included clinic size as well as health professionals’ occupation, health behaviors and training.

A series of multivariate linear regressions were performed in order to identify predictors of preventive medicine and health education implementation.

Computerized health records (CHR) validated our self-report data through data regarding patients’ health behaviours and outcomes, including health education group registration, adherence to occult blood tests and influenza vaccinations as well as blood lipid levels.

Results

Responders included physicians, nurses, dietitians and social workers working at 921 clinics (n = 516, response rate = 31%).

Higher rates of proactive appointments scheduling and health education groups were found in the Teamwork and Collaboration models, compared to the Independent Physician Model. Occupation (nurses and dietitians), group facilitation training and personal screening adherence were identified as preventive medicine and health education implementation predictors.

Group registration, occult blood tests, healthy population’s well-controlled blood lipids as well as influenza vaccinations among chronically ill patients were all significantly higher in the Teamwork and Collaboration models, compared to the Independent Physician Model.

Conclusions

The Teamwork and Collaboration models presented higher rates of preventive medicine and health education implementation as well as higher rates of patients’ positive health behaviours documented in these models.

This suggests multidisciplinary primary care models may contribute to population’s health by enhancing preventive medicine and health education implementation alongside health professionals’ characteristics.

Factorial Structure and Psychometric Analysis of the Persian Version of Perceived Competence Scale for Diabetes (PCSD-P)

As a basic psychological need, the level of perceived competence could expedite the achievement of diabetes self-management goals. Because of a lack of a specific data collection tool to measure the level of self-competence among Persian-speaking patients with diabetes, this study was conducted for (1) cross-cultural adaptation and (2) psychometric assessment of the Persian version of the Perceived Competence Scale for Diabetes (PCSD-P). Standard translation/back-translation procedure was carried out to prepare a preliminary draft of the PCSD-P. Content and face validities of the early draft were checked by an expert panel including 15 scholars in the field of health education and promotion as well as nursing education with experience of working and research on diabetes. The final drafted questionnaire was completed by 177 randomly selected patients with type 2 diabetes. On the basis of the collected data, the structural validity of the contrived version was appraised using exploratory and confirmatory factor analysis (EFA, CFA). Cronbach’s alpha and intraclass correlation (ICC) coefficients were used to check the scale’s reliability and internal consistency. The estimated measures of content validity index (CVI = 0.95) and content validity ratio (CVR = 0.8) were within the acceptable recommended range. The EFA analysis results demonstrated a single factor solution according to the items’ loadings for the corresponding component. The model fit indices, that is, root mean square error approximation (RMSEA = 0.000), comparative fit index (CFI = 1), Tucker–Lewis index (TLI = 1), incremental fit index (IFI = 1), normed fit index (NFI = 0.999), and relative fit index (RFI = 0.995), confirmed the consistency of the hypothesized one-factor solution. The values of the internal consistency and reliability coefficients were also in the vicinity of an acceptable range (α = 0.892, ICC = 0.886, P = 0.001). The study findings revealed good internal validity and applicability of the PCSD-P to measure the degree of self-competence among Persian-speaking type 2 diabetes patients to manage the chronic disease. Owing to unrepresentativeness of the study sample, future cross-cultural tests of PCSD-P are recommended on diverse and broader Persian-speaking populations.

Skin Problems Due to Treatment with Technology Are Associated with Increased Disease Burden Among Adults with Type 1 Diabetes

BACKGROUND

In a 4-month follow-up survey, we examined whether treatment with continuous subcutaneous insulin infusion (CSII) and/or continuous glucose monitoring (CGM) in adults with type 1 diabetes was associated with sustained skin problems and whether skin problems were associated with diabetes-related emotional distress.

RESEARCH DESIGN AND METHODS

A total of 111 adult patients completed a follow-up questionnaire concerning skin problems as a result of CSII and/or CGM use. The questionnaire included a patient-reported outcome measure, the Problem Areas in Diabetes (PAID) scale.

RESULTS

Current visible skin problems caused by CSII or CGM use were reported by 51 (46.0%) participants, in 34 (66.7%) of whom skin problems had been reported more than 4 months earlier. Seventy-two (64.9%) participants reported skin problems as a result of CSII use, whereas 38 (74.5%) reported skin problems owing to CGM use at some time. Itching was the most prevalent complaint. CSII-related itching was associated with a mean PAID score >20 (P = 0.01), and patients with more than one skin problem had an increased PAID score compared with those with one or no skin problems (P = 0.006).

CONCLUSIONS

More than half patients treated with CSII, CGM, or both had experienced skin problems during 4 months of follow-up that were associated with increased diabetes burden. Skin problems represent a persistent health issue affecting diabetes-specific emotional distress.

The Effect on Health Outcomes of Post-Intervention Transtheoretical Model-Based Motivational Interview in Adults with Type 2 Diabetes Mellitus: Follow up a Cross-Sectional Study

Introduction: The individuals with type 2 diabetes mellitus were supported with the individual motivational interview in the previous randomized controlled trial. The aim of this study was to assess whether the effect of motivational interview persists relative to the self-efficacy, metabolic control, and health-behavioral change of them. Methods: This study was contacted a cross-sectional design. This study was the follow-up to the previous randomized controlled trial. Total of 32 participants, including 18 from the intervention group and 14 from the control group, were contacted. No new intervention was performed to previous groups (control and intervention). The participants in the intervention and control groups were contacted by phone in the 18th month, and their self-efficacy, metabolic control and health behaviors were assessed. Results: The intergroup comparisons showed that the difference between the sixth month and 18th month was statistically significant except for medical treatment self-efficacy subscale score, postprandial blood glucose and waist circumference. The groups were similar in terms of their use of medicine, nutrition and physical activity behavior stages according to the 18th-month follow-up. Conclusion: This study found that the self-efficacy scores of the intervention group decreased negatively, and their metabolic values increased negatively in the 18th months, compared with the sixth month. In this respect, it is recommended that motivational interviews should be carried out at certain intervals assessing the characteristics of participants without discontinuing them after the intervention.

Effect of a Health Coach Intervention for the Management of Individuals With Type 2 Diabetes Mellitus in China: A Pragmatic Cluster Randomized Controlled Trial

Aim: To determine the effect of a health coach intervention for the management of glycemic control, as well as physiological, psychological and self-care outcomes of patients with type 2 diabetes mellitus (T2DM), compared with usual care. Methods: This pragmatic cluster RCT was conducted in the Fengtai district of Beijing from August 2011 to December 2013. Forty-one community health stations (CHSs) were cluster randomized (stratified geographically, 1:1 ratio) and eligible, randomly selected T2DM patients were sequentially contacted by CHSs. Control participants received usual care according to the Chinese Guideline for Diabetes Prevention and Management. Intervention participants received 18-months of health coaching based on principles of Motivational Interviewing (MI) plus usual care. Medical and pathology fees were waived for both groups. Outcome assessment was performed at baseline, 6, 12, and 18-months. The primary outcome was glycated hemoglobin (HbA1c); secondary outcomes encompassed a suite of physiological, psychological and self-care measures. Results: No differential treatment effect was found at 18-months for HbA1c (adj. difference -0.07, 95% CI -0.53 to 0.39, p = 0.769) or any specified secondary outcomes. Interestingly, both groups displayed a statistically and clinically significant within-group improvement of the same magnitude at 18-months for HbA1c (intervention: mean change -3.65, 95% CI -3.92 to -3.37; control: mean change -3.38, 95% CI -3.67 to -3.08). Conclusions: The lack of differential treatment effects observed indicate that it may be premature to recommend the routine delivery of health coach interventions based on MI principles for the management of T2DM in China. However, the large, comparable within-group improvement in mean HbA1c promotes the establishment of free, regular clinical health assessments for individuals with T2DM in China.

TRIAL REGISTRATION

ISRCTN registry - ISRCTN01010526 (https://doi.org/10.1186/ISRCTN01010526).

Telephone-Based Intervention to Improve Rehabilitation Engagement After Spinal Stenosis Surgery: A Prospective Lagged Controlled Trial

BACKGROUND

Spine surgery outcomes are variable. Patients who participate in and take responsibility for their recovery have improved health outcomes. Interventions to increase patient involvement in their care may improve health outcomes after a surgical procedure. We conducted a prospective interventional trial to compare the effectiveness of health behavior change counseling with usual care to improve health outcomes after lumbar spine surgical procedures.

METHODS

In this study, 122 patients with lumbar spinal stenosis undergoing a decompression surgical procedure from December 2009 through August 2012 were enrolled. Participants were assigned, according to enrollment date, to health behavior change counseling or usual care. Health behavior change counseling is a brief, telephone-based intervention intended to increase rehabilitation engagement through motivational interviewing strategies that elicit and strengthen motivation for change. Health behavior change counseling was designed to identify patients with low patient activation, to maximize postoperative rehabilitation engagement, to decrease pain and disability, and to improve functional recovery. Participants were assessed before the surgical procedure and for 3 years after the surgical procedure for pain intensity (Brief Pain Inventory), disability (Oswestry Disability Index), and physical health (12-Item Short-Form Health Survey, version 2). Differences in changes in health outcomes after the surgical procedure were compared between the health behavior change counseling group and the usual care group.

RESULTS

By 12 months, health behavior change counseling participants reported significantly greater reductions in pain intensity (p = 0.008) and disability (p = 0.028) and significantly greater improvement in physical health compared with usual care participants (p = 0.025). These differences were attenuated by 24 and 36 months after the surgical procedure. Early improvements in health outcomes were mediated by improvements in physical therapist-rated engagement and self-reported attendance at physical therapy sessions in the health behavior change counseling group.

CONCLUSIONS

Health behavior change counseling improved health outcomes during the first 12 months after the surgical procedure through changes in rehabilitation engagement. Wider use of health behavior change counseling may lead to improved outcomes not only after lumbar spine surgery but also in other conditions for which rehabilitation is key to recovery.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Psychological interventions for diabetes-related distress in adults with type 2 diabetes mellitus

BACKGROUND

Many adults with type 2 diabetes mellitus (T2DM) experience a psychosocial burden and mental health problems associated with the disease. Diabetes-related distress (DRD) has distinct effects on self-care behaviours and disease control. Improving DRD in adults with T2DM could enhance psychological well-being, health-related quality of life, self-care abilities and disease control, also reducing depressive symptoms.

OBJECTIVES

To assess the effects of psychological interventions for diabetes-related distress in adults with T2DM.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, BASE, WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was December 2014 for BASE and 21 September 2016 for all other databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on the effects of psychological interventions for DRD in adults (18 years and older) with T2DM. We included trials if they compared different psychological interventions or compared a psychological intervention with usual care. Primary outcomes were DRD, health-related quality of life (HRQoL) and adverse events. Secondary outcomes were self-efficacy, glycosylated haemoglobin A1c (HbA1c), blood pressure, diabetes-related complications, all-cause mortality and socioeconomic effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified publications for inclusion and extracted data. We classified interventions according to their focus on emotion, cognition or emotion-cognition. We performed random-effects meta-analyses to compute overall estimates.

MAIN RESULTS

We identified 30 RCTs with 9177 participants. Sixteen trials were parallel two-arm RCTs, and seven were three-arm parallel trials. There were also seven cluster-randomised trials: two had four arms, and the remaining five had two arms. The median duration of the intervention was six months (range 1 week to 24 months), and the median follow-up period was 12 months (range 0 to 12 months). The trials included a wide spectrum of interventions and were both individual- and group-based.A meta-analysis of all psychological interventions combined versus usual care showed no firm effect on DRD (standardised mean difference (SMD) -0.07; 95% CI -0.16 to 0.03; P = 0.17; 3315 participants; 12 trials; low-quality evidence), HRQoL (SMD 0.01; 95% CI -0.09 to 0.11; P = 0.87; 1932 participants; 5 trials; low-quality evidence), all-cause mortality (11 per 1000 versus 11 per 1000; risk ratio (RR) 1.01; 95% CI 0.17 to 6.03; P = 0.99; 1376 participants; 3 trials; low-quality evidence) or adverse events (17 per 1000 versus 41 per 1000; RR 2.40; 95% CI 0.78 to 7.39; P = 0.13; 438 participants; 3 trials; low-quality evidence). We saw small beneficial effects on self-efficacy and HbA1c at medium-term follow-up (6 to 12 months): on self-efficacy the SMD was 0.15 (95% CI 0.00 to 0.30; P = 0.05; 2675 participants; 6 trials; low-quality evidence) in favour of psychological interventions; on HbA1c there was a mean difference (MD) of -0.14% (95% CI -0.27 to 0.00; P = 0.05; 3165 participants; 11 trials; low-quality evidence) in favour of psychological interventions. Our included trials did not report diabetes-related complications or socioeconomic effects.Many trials were small and were at high risk of bias for incomplete outcome data as well as possible performance and detection biases in the subjective questionnaire-based outcomes assessment, and some appeared to be at risk of selective reporting. There are four trials awaiting further classification. These are parallel RCTs with cognition-focused and emotion-cognition focused interventions. There are another 18 ongoing trials, likely focusing on emotion-cognition or cognition, assessing interventions such as diabetes self-management support, telephone-based cognitive behavioural therapy, stress management and a web application for problem solving in diabetes management. Most of these trials have a community setting and are based in the USA.

AUTHORS' CONCLUSIONS

Low-quality evidence showed that none of the psychological interventions would improve DRD more than usual care. Low-quality evidence is available for improved self-efficacy and HbA1c after psychological interventions. This means that we are uncertain about the effects of psychological interventions on these outcomes. However, psychological interventions probably have no substantial adverse events compared to usual care. More high-quality research with emotion-focused programmes, in non-US and non-European settings and in low- and middle-income countries, is needed.

Motivational interviewing by general practitioners for Type 2 diabetes patients: a systematic review

BACKGROUND

Motivational interviewing (MI) is an effective tool to help clinicians with facilitating behavioural changes in many diseases and conditions. However, different forms of MI are required in different health care settings and for different clinicians. Although general practitioners (GPs) play a major role in Type 2 diabetes management, the effects of MI delivered by GPs intended to change the behaviours of their Type 2 diabetes patients and GP outcomes, defined as GP knowledge, satisfaction and practice behaviours, have not been systematically reviewed.

METHODS

An electronic search was conducted through Cochrane Library, Scopus, ProQuest, Wiley Online Library, Ovid MEDLINE, PubMed, CINAHL, MEDLINE Complete and Google Scholar from the earliest date of each database to 2017. Reference lists from each article obtained were reviewed. Measured changes in GP satisfaction, knowledge, and practice behaviours, and patient outcomes were recorded.

RESULTS

Eight out of 1882 studies met the criteria for inclusion. Six studies examined the effects of MI on Type 2 diabetes patient outcomes, only one of which examined its effects on GP outcomes. Two-thirds of the studies (4/6) found a significant improvement in at least one of the following patient outcomes: total cholesterol, low-density lipoproteins, fasting blood glucose, HbA1c, body mass index, blood pressure, waist circumference and physical activity. The effects of MI on GP outcomes yielded mixed results.

CONCLUSIONS

Few studies have examined evidence for the effectiveness of MI delivered by GPs to Type 2 diabetes patients. Evidence to support the effectiveness of MI on GP and patient outcomes is weak. Further quality studies are needed to examine the effects of MI on GP and patient outcomes.

The effect of text message support on diabetes self-management in developing countries - A randomised trial

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Report of a randomised trial on an mHealth intervention in 3 low income countries.

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There was no additional effect of the text message self-management support.

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Coverage, routine care and disease progression interfere with the potential impact.

Objective

mHealth interventions have the potential to facilitate self-management. This TEXT4DSM study implemented a mobile phone intervention in existing diabetes programmes in three low- and middle-income countries (Democratic Republic of Congo, Cambodia, and the Philippines).

Research design and methods

Sub-studies with a similar randomised controlled trial design were conducted in three different countries. Each sub-study included 480 adults with diabetes. Subjects were randomised to receive either routine care or routine care plus text message self-management support. The primary outcome was the difference in the proportion of subjects with well-controlled diabetes after 2 years.

Results

Baseline and 2-year HbA1c measurements were available for 781 individuals. After 2 years, the proportion of subjects with controlled HbA1c was 2.8% higher in the intervention group than in the control group (difference not statistically significant). In the logistic regression model, the odds ratio for having controlled diabetes after the intervention was 1.1, after adjusting for baseline HbA1c level, sex, receiving insulin treatment, and participating in the routine programme. The HbA1c dynamics over time differed between programmes; the number of people with controlled diabetes tended to increase in DR Congo and decrease in Cambodia.

Conclusion

This study was the first to test the same mHealth intervention in different countries. The finding that text messages did not show an additional effect on diabetes control implied that expectations about mHealth should be cautious. The degree of coverage, the quality of the routine programme, and the progression of disease can interfere with the expected impact.

Trial registration: ISRCTN registry (86247213).

Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control

OBJECTIVE

Assess effect of diabetes self-management education and support methods, providers, duration, and contact time on glycemic control in adults with type 2 diabetes.

METHOD

We searched MEDLINE, CINAHL, EMBASE, ERIC, and PsycINFO to December 2013 for interventions which included elements to improve participants' knowledge, skills, and ability to perform self-management activities as well as informed decision-making around goal setting.

RESULTS

This review included 118 unique interventions, with 61.9% reporting significant changes in A1C. Overall mean reduction in A1C was 0.74 and 0.17 for intervention and control groups; an average absolute reduction in A1C of 0.57. A combination of group and individual engagement results in the largest decreases in A1C (0.88). Contact hours ≥10 were associated with a greater proportion of interventions with significant reduction in A1C (70.3%). In patients with persistently elevated glycemic values (A1C>9), a greater proportion of studies reported statistically significant reduction in A1C (83.9%).

CONCLUSIONS

This systematic review found robust data demonstrating that engagement in diabetes self-management education results in a statistically significant decrease in A1C levels.

PRACTICE IMPLICATIONS

The data suggest mode of delivery, hours of engagement, and baseline A1C can affect the likelihood of achieving statistically significant and clinically meaningful improvement in A1C.

Management of type 2 diabetes in China: the Happy Life Club, a pragmatic cluster randomised controlled trial using health coaches

OBJECTIVE

To assess the effectiveness of a coach-led motivational interviewing (MI) intervention in improving glycaemic control, as well as clinical, psychosocial and self-care outcomes of individuals with type 2 diabetes mellitus (T2DM) compared with usual care.

DESIGN

Pragmatic cluster randomised controlled trial (RCT).

SETTING

Community Health Stations (CHSs) in Fengtai district, Beijing, China.

PARTICIPANTS

Of the 41 randomised CHSs (21 intervention and 20 control), 21 intervention CHSs (372 participants) and 18 control CHSs (296 participants) started participation.

INTERVENTION

Intervention participants received telephone and face-to-face MI health coaching in addition to usual care from their CHS. Control participants received usual care only. Medical fees were waived for both groups.

OUTCOME MEASURES

Outcomes were assessed at baseline, 6 and 12 months. Primary outcome measure was glycated haemoglobin (HbA1c). Secondary outcomes included a suite of anthropometric, blood pressure (BP), fasting blood, psychosocial and self-care measures.

RESULTS

At 12 months, no differential treatment effect was found for HbA1c (adjusted difference 0.02, 95% CI -0.40 to 0.44, p=0.929), with both treatment and control groups showing significant improvements. However, two secondary outcomes: psychological distress (adjusted difference -2.38, 95% CI -4.64 to -0.12, p=0.039) and systolic BP (adjusted difference -3.57, 95% CI -6.08 to -1.05, p=0.005) were robust outcomes consistent with significant differential treatment effects, as supported in sensitivity analyses. Interestingly, in addition to HbA1c, both groups displayed significant improvements in triglycerides, LDL cholesterol and HDL cholesterol.

CONCLUSIONS

In line with the current Chinese primary healthcare reform, this study is the first large-scale cluster RCT to be implemented within real-world CHSs in China, specifically addressing T2DM. Although a differential treatment effect was not observed for HbA1c, numerous outcomes (including HbA1c) improved in both groups, supporting the establishment of regular, free clinical health checks for people with T2DM in China.

TRIAL REGISTRATION NUMBER

ISRCTN01010526; Pre-results.

The detection and management of diabetes distress in people with type 1 diabetes

Diabetes distress (DD) represents a significant clinical burden in which levels of DD are related to both glycated haemoglobin (HbA1c) and some self-management behaviours. DD is related to, but different from, depression. Differences in DD experienced in people with type 1 and type 2 diabetes have been observed. Commonly measured using the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS), rates of elevated DD in research study participants range from 20 to 30 %. Risk factors for elevated DD in type 1 diabetes are longer duration of diabetes, severe hypoglycaemia, younger age and being female. A systematic review of intervention studies assessing DD identified eight randomised controlled trials (RCTs) and nine pre-post design studies. Only three studies targeted DD with the intervention. Intervention types were diabetes self-management education (DSME), psychologically informed self-management and devices. DSME pre-post studies, namely the Dose Adjustment For Normal Eating (DAFNE) programme, produced more consistent improvements in DD and HbA1c at follow-up. Psychologically informed self-management was more heterogeneous, but several RCTs were effective in reducing DD. Group interventions offered the greatest benefits across intervention designs.

Positive Psychological Interventions for Patients with Type 2 Diabetes: Rationale, Theoretical Model, and Intervention Development

Most patients with type 2 diabetes (T2D) have suboptimal adherence to recommended diet, physical activity, and/or medication. Current approaches to improve health behaviors in T2D have been variably effective, and successful interventions are often complex and intensive. It is therefore vital to develop interventions that are simple, well-accepted, and applicable to a wide range of patients who suffer from T2D. One approach may be to boost positive psychological states, such as positive affect or optimism, as these constructs have been prospectively and independently linked to improvements in health behaviors. Positive psychology (PP) interventions, which utilize systematic exercises to increase optimism, well-being, and positive affect, consistently increase positive states and are easily delivered to patients with chronic illnesses. However, to our knowledge, PP interventions have not been formally tested in T2D. In this paper, we review a theoretical model for the use of PP interventions to target health behaviors in T2D, describe the structure and content of a PP intervention for T2D patients, and describe baseline data from a single-arm proof-of-concept (N = 15) intervention study in T2D patients with or without depression. We also discuss how PP interventions could be combined with motivational interviewing (MI) interventions to provide a blended psychological-behavioral approach.

A randomized controlled trial to provide adherence information and motivational interviewing to improve diabetes and lipid control

PURPOSE

The purpose of this study was to assess whether providing medication adherence information with or without motivational interviewing improves diabetes and lipid control.

METHODS

Study participants were adult members of a health system in southeast Michigan, were using both oral diabetes and lipid-lowering medications, and had glycated hemoglobin (A1C) or low-density lipoprotein cholesterol (LDL-C) levels not at goal. Participants were randomly assigned to receive usual care (UC), n = 567; have medication adherence information (AI) provided to their physician, n = 569; or have AI and receive motivational interviewing (MI) though trained staff (AI + MI), n = 556. Primary outcomes were A1C and LDL-C levels at 18 months post randomization.

RESULTS

Primary outcomes were not significantly different between patients in the AI or AI + MI study arms when compared with UC. Similarly, neither oral diabetes nor lipid-lowering medication adherence was significantly different between groups. Patient participation in the AI + MI arm was low and limit the interpretation of the study results, but post hoc analysis of the AI + MI study arm showed that the number of MI sessions received was positively associated with only oral diabetes medication adherence.

CONCLUSION

Neither AI nor MI significantly improved diabetes and lipid control when compared with UC. Moreover, patient participation appeared to be a particular barrier for MI.

Time to do more: addressing clinical inertia in the management of type 2 diabetes mellitus

AIMS

Clinical inertia, the tendency to maintain current treatment strategies despite results demanding escalation, is thought to substantially contribute to the disconnect between clinical aspirations for patients with diabetes and targets achieved. We wished to explore potential causes of clinical inertia among physicians and people with diabetes.

METHODS

A 20-min online survey of 652 adults with diabetes and 337 treating physicians in six countries explored opinions relating to clinical inertia from both perspectives, in order to correlate perceptions and expectations relating to diagnosis, treatment, diabetes complications and therapeutic escalation.

RESULTS

Physicians had low expectations for their patients, despite the belief that the importance of good glycaemic control through lifestyle and pharmacological interventions had been adequately conveyed. Conversely, people with diabetes had, at best, a rudimentary understanding of the risks of complications and the importance of good control; indeed, only a small proportion believed lifestyle changes were important and the majority did not intend to comply.

CONCLUSIONS

The principal findings of this survey suggest that impairments in communication are at the heart of clinical inertia. This manuscript lays out four key principles that we believe are achievable in all environments and can improve the lives of people with diabetes.

Motivational interventions in the management of HbA1c levels: a systematic review and meta-analysis

AIMS

To review the diabetes literature in order to examine the effect of motivational interventions on treatment outcome as measured by changes in glycated haemoglobin.

METHODS

Relevant databases were systematically searched for randomised controlled trials in which motivational interventions were examined in relation to treatment outcome in people with type 1 and type 2 diabetes mellitus.

RESULTS

The 13 studies identified for review included 1223 participants diagnosed with type 1 diabetes and 1895 participants diagnosed with type 2 diabetes. The analysis showed a 0.17% (95% CI: -0.09, 0.43%) improvement in glycemic control in people who received a motivational intervention compared to a control group, however, the effect was not statistically significant.

CONCLUSIONS

The impact of motivational interventions in the management of blood glucose levels appears to be limited. However, due to the small number of studies and issues of heterogeneity caution in interpreting the present findings is advised. Moreover, the unique contribution of motivational interventions may be better assessed by outcomes such as behaviour change and other intermediate outcomes. Further research examining the delivery and focus of motivational interventions in helping people manage their diabetes is recommended. The clinical implications of the present findings are therefore uncertain pending further research.

State of the science: diabetes self-management interventions led by nurse principal investigators

Over the past decade, diabetes self-management (DSM) interventions have become increasingly heterogeneous to address the needs of diverse populations. The purpose of this integrative review is to summarize the state of the science regarding DSM interventions led by nurse principal investigators. The Preferred Reporting Items of Systematic Reviews and Meta-Analyses framework informed identification, selection, and appraisal of the literature. A total of 44 national and international studies (RCTs [randomized controlled trial] and quasi-experimental studies) were identified for inclusion. Across national studies, diverse ethnic groups (Latinos, African Americans, Asians, and Native Americans) were most frequently sampled (67%). Review findings identified (a) DSM intervention typologies (primary DSM intervention, DSM reinforcement intervention, and primary DSM intervention plus reinforcement intervention) and selection of blended or bundled intervention components; (b) DSM intervention translation to community-based, electronic, and home settings; and (c) DSM intervention delivery (interventionists, dosages, and fidelity).

Effectiveness of a training course for general practice nurses in motivation support in type 2 diabetes care: a cluster-randomised trial

Background

Type 2 diabetes is a common metabolic disease with the potential for prevention of complications. The prevention requires a high level of lasting actions from the patients, which may be burdensome. The aim of this trial was to evaluate the effectiveness of a training course for general practice nurses in motivation support at 18 months follow-up in the affiliated type 2 diabetes population.

Methods

Forty general practices with nurse-led diabetes consultations from the area of Aarhus, Denmark were randomised 1∶1 to either intervention or usual practice. Intervention practices were offered a 16-hour Self-determination theory - based course including communication training for general practice nurses delivered over 10 months. The affiliated diabetes populations (aged 40–74 years) were identified from registers (intervention n = 2,005; usual n = 2,029). Primary outcomes were register-based glycated haemoglobin (HbA_1c) -, total cholesterol levels, and well-being measured by the Problem Areas In Diabetes scale (PAID) and the mental component summary score, SF12 (SF12, mcs). Intention-to-treat analyses were performed. Predefined subgroups analyses were performed.

Results

The differences between the intervention- and the control practices’ mean HbA_1c and total cholesterol at follow-up adjusted for baseline values and clustering were respectively: −0.02%-points (95% CI: −0.11 to 0.07; p: 0.67); 0.08 mmol/l (95% CI: 0.01 to 0.15; p: 0.02). Differences in median scores adjusted for clustering were for PAID: 1.25; p = 0.31 and SF12, mcs: 0.99; p = 0.15. Women in intervention practices differed from women in usual practices on mean HbA_1c: −0.12%-points (−0.23 to −0.02; p = 0.02) and SF12, mcs: 2.6; p = 0.01.

Conclusions

Offering a training course for general practice nurses in applying the Self-determination theory in current type 2 diabetes care had no effect compared with usual practice measured by HbA_1c and total cholesterol levels and the well-being at 18 months of follow-up in a comprehensive register-based diabetes population. Subgroup analyses suggested a possible effect in women, which deserves further attention.

Trial Registration

ClinicalTrials.gov (Identifier NCT01187069).

The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations: a clinical review

Having good intentions to engage in healthy behaviours, to change our lives in a positive direction and make substantial, lasting changes may not always translate into actions or behaviour that is maintained. Motivational Interviewing is a directive person-centred approach designed to explore ambivalence and activate motivation for change [Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behaviour. London: Guilford Press, 1991]. A key component of a motivational interviewing conversation is to acknowledge that clients have every right to make no change. It uses a guiding communication style which invites people to consider their own situation and find their own solutions to situations that they identify as problematic that are preventing change. Motivational Interviewing was first introduced in adult health addiction services in the early 1980s. It has developed in the physical health specialties, and in the last 20 years or so attention has turned to the potential of Motivational Interviewing in the paediatric setting and the challenges of using it in families with children at differing ages and developmental stages. This article summarizes studies published from 2006 to 2011 of Motivational Interviewing in individuals across the lifespan with type 1 and type 2 diabetes and obesity.

Patients' responses to the communication of vascular risk in primary care: a qualitative study

AIM

To examine the perspectives of patients identified as being at 'high risk' of cardiovascular events, with particular reference to the potential responses to risk messages.

BACKGROUND

Systematic population screening for cardiovascular disease (CVD) aims to identify those at high risk and provide medication and lifestyle support. In the United Kingdom, this takes the form of the National Health Service Health Check.

METHODS

We conducted a qualitative interview study. In 2011 we interviewed 37 patients, from seven UK primary care practices, who were at high risk of developing CVD.

FINDINGS

Risk messages were delivered via face-to-face consultations or by letter and were relayed in either a 'downplaying' or 'serious warning' style. Patients' accounts of receiving information about risk revealed two broad response styles: 'committed' (active resistance; commitment to change) and 'non-committed' (procrastination; downplaying and fatalism). Responses to risk messages are usually assumed to be due to individual characteristics but they may be explained by an interaction between the way risk is communicated and the patient's response style.

Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Motivational Interviewing (MI) is a method for encouraging people to make behavioral changes to improve health outcomes. We used systematic review and meta-analysis to investigate MI's efficacy in medical care settings.

METHODS

Database searches located randomized clinical trials that compared MI to comparison conditions and isolated the unique effect of MI within medical care settings.

RESULTS

Forty-eight studies (9618 participants) were included. The overall effect showed a statistically significant, modest advantage for MI: Odd ratio=1.55 (CI: 1.40-1.71), z=8.67, p<.001. MI showed particular promise in areas such as HIV viral load, dental outcomes, death rate, body weight, alcohol and tobacco use, sedentary behavior, self-monitoring, confidence in change, and approach to treatment. MI was not particularly effective with eating disorder or self-care behaviors or some medical outcomes such as heart rate.

CONCLUSION

MI was robust across moderators such as delivery location and patient characteristics, and appears efficacious when delivered in brief consultations.

PRACTICE IMPLICATIONS

The emerging evidence for MI in medical care settings suggests it provides a moderate advantage over comparison interventions and could be used for a wide range of behavioral issues in health care.

Diabetes nurse case management and motivational interviewing for change (DYNAMIC): results of a 2-year randomized controlled pragmatic trial

BACKGROUND

The aim of the present study was to determine whether the addition of nurse case managers (NCMs) trained in motivational interviewing (MI) to usual care would result in improved outcomes in high-risk type 2 diabetes patients.

METHODS

A 2-year randomized controlled pragmatic trial randomized 545 patients to usual care control (n=313) or those who received the intervention (n=232) with additional practice-embedded NCM care, including MI-guided behavior change counseling. The NCMs received intensive MI training with ongoing fidelity assessment.

RESULTS

Systolic blood pressure (SBP) was better in the intervention than usual care group (131 ± 15 vs. 135 ± 18 mmHg, respectively; P<0.05). Improvements were seen in both the control and intervention groups in terms of HbA1c (from 9.1% to 8.0% and from 8.8% to 7.8%, respectively), low-density lipoprotein (LDL; from 127 to 100 mg/dL and from 128 to 102 mg/dL, respectively), and diastolic blood pressure (from 78 to 74 mmHg and from 80 to 74 mmHg, respectively). Depression symptom scores were better in the intervention group. The reduction in diabetes-related distress approached statistical significance.

CONCLUSIONS

The NCMs and MI improved SBP and complications screening. The large decrease in HbA1C and LDL in the control group may have obscured any further intervention effect. Although nurses prompted providers for medication titration, strategies to reduce provider clinical inertia may also be needed.

No identifiable Hb1Ac or lifestyle change after a comprehensive diabetes programme including motivational interviewing: a cluster randomised trial

OBJECTIVE

To study the effectiveness of a comprehensive diabetes programme in general practice that integrates patient-centred lifestyle counselling into structured diabetes care. Design and setting. Cluster randomised trial in general practices.

INTERVENTION

Nurse-led structured diabetes care with a protocol, record keeping, reminders, and feedback, plus training in motivational interviewing and agenda setting.

SUBJECTS

Primary care nurses in 58 general practices and their 940 type 2 diabetes patients with an HbA1c concentration above 7%, and a body mass index (BMI) above 25 kg/m². Main outcome measures. HbA1c, diet, and physical activity (medical records and patient questionnaires).

RESULTS

Multilevel linear and logistic regression analyses adjusted for baseline outcomes showed that despite active nurse participation in the intervention, the comprehensive programme was no more effective than usual care after 14 months, as shown by HbA1c levels (difference between groups = 0.13; CI 20.8-0.35) and diet (fat (difference between groups = 0.19; CI 20.82-1.21); vegetables (difference between groups = 0.10; CI-0.21-0.41); fruit (difference between groups = 20.02; CI 20.26-0.22)), and physical activity (difference between groups = 21.15; CI 212.26-9.97), or any of the other measures of clinical parameters, patient's readiness to change, or quality of life.

CONCLUSION

A comprehensive programme that integrated lifestyle counselling based on motivational interviewing principles integrated into structured diabetes care did not alter HbA1c or the lifestyle related to diet and physical activity. We thus question the impact of motivational interviewing in terms of its ability to improve routine diabetes care in general practice.