The effect of guided self-determination on self-management in persons with type 1 diabetes mellitus and HbA1c ≥64 mmol/mol: a group-based randomised controlled trial

A group-based intervention for diabetes-related emotional distress among emerging adults with type 1 diabetes: A pilot study

AIMS

To assess diabetes-related emotional distress (DD) in emerging adults with type 1 diabetes (T1D) and assess a group-based intervention's impact.

METHODS

To investigate DD we used data from the Problem Areas in Diabetes Questionnaire comprising 20 items (PAID-20). Furthermore, changes in the WHO Well-Being Index comprising five items (WHO-5) and glycated haemoglobin (HbA1c) were analysed. The intervention was evaluated using follow-up data from the emerging adults who participated.

RESULTS

From 2021 to 2023, we screened 180 emerging adults using PAID-20. DD (PAID-20≥30) was prevalent in 25.0 % (95 % CI 18.9; 32.0 %), and associated with the female sex, higher HbA1c and WHO-5 < 50. Continuous subcutaneous insulin infusion at baseline was associated with PAID-20<30. 21 individuals attended a group-based intervention. At one-week follow up PAID-20 was reduced (29.1 ± 15.4 vs. 41.3 ± 12.1 at baseline, p = 0.003), and at nine-twelve months' follow-up HbA1c was reduced (59.3 ± 15.3 mmol/mol vs. 68.0 ± 17.4 mmol/mol at baseline, p = 0.012).

CONCLUSIONS

This pilot study demonstrated that 25 % of the investigated emerging adults with T1D experienced DD (PAID-20≥30) associated with four clinical factors. We found a reduction in HbA1c and a short-term reduction in PAID-20 following the group-based intervention.

Determinants of diabetes self-care activities in patients with type 2 diabetes based on self-determination theory

AIMS

In type 2 diabetes control, self-management is an effective way to minimize the risk of developing complications and improve the quality of life. Self-determination theory (SDT) proposed a promising explanatory framework to predict self-regulated behavior which was particularly relevant for self-management. This study aimed to investigate whether SDT constructs can affect the self-management and controlling glycated hemoglobin A1c (HbA1c) levels in type 2 diabetic patients or not.

METHODS

This cross-sectional study was conducted from August to December 2022 at two diabetes clinics in Zahedan. The study included 300 patients with type 2 diabetes. Data collection was done using a researcher-administrated questionnaire that included demographic data, diabetes self-care activities, and self-determination constructs including autonomous support, autonomous motivation, and perceived competence.

RESULTS

The mean of the overall score of self-care activities was 34.62 ± 11.86 out of a maximum of 70. Patients in the fourth quarter (wealthiest) of the socioeconomic status had the highest mean self-care score (P = 0.003). There was a significant relationship between diet score with perceived competence (P = 0.009). Perceived competence (P<0.001) and controlled self-regulation (P<0.001) were the predictors of exercise score in diabetes patients. Independent self-regulation (P<0.001, r = 0.21) and overall self-regulation (P = 0.001, r = 0.19) were significantly related to blood-glucose testing score. There was a significant relationship between foot care score with perceived competence (P = 0.048, r = 0.11) and autonomous support (P = 0.013, r = 0.14). Multiple regression showed that exercise was the predictor of HbA1c (P = 0.014).

CONCLUSION

Exercise is crucial for achieving good individualized glycemic control and reducing the risk of diabetes complications. The findings provided valuable insights into the determinants of self-care activities in patients with type 2 diabetes and underscore the need for interventions that address socioeconomic disparities, enhance perceived competence, and provide autonomy support to improve diabetes self-care.

A Systematic Literature Review of Psychological Interventions for Adults with Type 1 Diabetes

INTRODUCTION

The psychological burden of type 1 diabetes mellitus (T1DM) is considerable. The condition affects the daily lives of adults living with T1DM (ALWT1DM) in many ways. International guidelines highlight the importance of providing psychological support to ALWT1DM to improve health outcomes and well-being.

METHODS

We conducted a systematic literature review of randomised controlled trials (RCTs) to identify the evidence on the impact of psychological interventions on glycaemic control and psychological outcomes in ALWT1DM. Literature searches of Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, and the grey literature were performed to identify relevant RCTs, published in English, from 2001 onward. Fourteen RCTs of ten psychological interventions in ALWT1DM were eligible and included in the qualitative synthesis. The studies varied considerably in terms of duration, target population, endpoints, and efficacy.

RESULTS

Overall, psychological interventions did not perform significantly better than control treatments in improving glycaemic control, although selected patient groups did report benefits from some psychological intervention types, such as cognitive behavioural therapy. Although most of the psychological interventions produced small, nonsignificant improvements in self-reported patient functioning, some treatments were effective in reducing diabetes distress and improving mental health, even if no impact on glycaemic control was observed.

DISCUSSION

Current guidelines for the treatment of T1DM recommend access to psychological services; however, there is a paucity of high-quality evidence from clinical trials on the effectiveness or preferred structure of psychological support. There is a clear need for more rigorous, large-scale, international research to address the efficacy of psychological interventions in ALWT1DM.

Patients' experiences with participating in a team-based person-centred intervention for patients at risk of or diagnosed with COPD in general practice

BACKGROUND

Symptoms and complications of chronic obstructive pulmonary disease (COPD) can affect daily activities and quality of life, and patients with COPD require long-term follow-up by their general practitioner. Providing patients with or at risk of COPD practical skills and motivation to improve their self-management is important. On this background, an interdisciplinary follow-up program was designed based on the Guided Self-Determination counselling method to facilitate problem-solving and mutual decision-making between healthcare professionals and patients. The aim of the study was to explore patients and healthcare professionals` experiences with the Guided Self-Determination-program to investigate feasibility issues.

METHODS

A qualitative design was used to get insights in the experiences of receiving the Guided Self-Determination counselling program. In total, 13 patients with COPD (mean age 71.7 ± 7.7 years) 4 were current smokers, and 7 at risk of COPD (mean age 54.1 ± 9.9 years) all current smokers, received the Guided Self-Determination program. The researchers performed individual semi-structured telephone interviews after the 12 months Guided Self-Determination program with two patients at risk of COPD, four patients with COPD, three nurses, and five general practitioners. The intervention consisted of structured consultations with the nurse and patient in collaboration with the general practitioner at baseline and after 3, 6, and 12 months. The Guided Self-Determination method comprised facilitation of a mutual reflection process between the patient and the nurse to enhance self-management skills. Each consultation lasted for 60 min. The interviews were analysed using thematic analyses.

RESULTS

Two themes were identified: (1) A structured follow-up is challenging but motivating. (2) A counselling method that opens for conversation, but it requires resources.

CONCLUSIONS

The findings indicated that patients with or at risk of COPD experienced enhanced self-management skills after participating in a structured and systematic team-based follow-up in general practice with use of the Guided Self-Determination method. The regularity of the follow-up seemed to be important to succeed to help the patients making lifestyle changes to increase health benefits. However, the Guided Self-Determination method was experienced as time consuming among the general practitioners and nurses, and there are currently no available financial rates for this type of treatment in Norway which may be a barrier to further implementation.

TRIAL REGISTRATION

The trial is registered in ClinicalTrials.gov (ID: NCT04076384).

Self-determination theory interventions versus usual care in people with diabetes: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Autonomy-supporting interventions, such as self-determination theory and guided self-determination interventions, may improve self-management and clinical and psychosocial outcomes in people with diabetes. Such interventions have never been systematically reviewed assessing both benefits and harms and concurrently controlling the risks of random errors using trial sequential analysis methodology. This systematic review investigates the benefits and harms of self-determination theory-based interventions compared to usual care in people with diabetes.

METHODS

We used the Cochrane methodology. Randomized clinical trials assessing interventions theoretically based on guided self-determination or self-determination theory in any setting were eligible. A comprehensive search (latest search April 2022) was undertaken in CENTRAL, MEDLINE, Embase, LILACS, PsycINFO, SCI-EXPANDED, CINAHL, SSCI, CPCI-S, and CPCI-SSH to identify relevant trials. Two authors independently screened, extracted data, and performed risk-of-bias assessment of included trials using the Cochrane risk-of-bias tool 1.0. Our primary outcomes were quality of life, all-cause mortality, and serious adverse events. Our secondary outcomes were diabetes distress, depressive symptoms, and nonserious adverse events not considered serious. Exploratory outcomes were glycated hemoglobin and motivation (autonomy, controlled, amotivation). Outcomes were assessed at the end of the intervention (primary time point) and at maximum follow-up. The analyses were conducted using Review Manager 5.4 and Trial Sequential Analysis 0.9.5.10. Certainty of the evidence was assessed by GRADE.

RESULTS

Our search identified 5578 potentially eligible studies of which 11 randomized trials (6059 participants) were included. All trials were assessed at overall high risk of bias. We found no effect of self-determination theory-based interventions compared with usual care on quality of life (mean difference 0.00 points, 95% CI -4.85, 4.86, I2 = 0%; 225 participants, 3 trials, TSA-adjusted CI -11.83, 11.83), all-cause mortality, serious adverse events, diabetes distress, depressive symptoms, adverse events, glycated hemoglobulin A1c, or motivation (controlled). The certainty of the evidence was low to very low for all outcomes. We found beneficial effect on motivation (autonomous and amotivation; low certainty evidence).

CONCLUSIONS

We found no effect of self-determination-based interventions on our primary or secondary outcomes. The evidence was of very low certainty.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020181144.

Using Patient Profiles for Sustained Diabetes Management Among People With Type 2 Diabetes

INTRODUCTION

Our objective was to evaluate the association between patient profiles and sustained diabetes management (SDM) among patients with type 2 diabetes.

METHODS

We collected HbA_1c values recorded from 2014 through 2020 for 570 patients in a hospital in Taipei, Taiwan, and calculated a standard level based on an HbA_1c level less than 7.0% to determine SDM. We used patients' self-reported data on diabetes self-care behaviors to construct profiles. We used 8 survey items to perform a latent profile analysis with 3 groups (poor management, medication adherence, and good management). After adjusting for other determining factors, we used multiple regression analysis to explore the relationship between patient profiles and SDM.

RESULTS

The good management group demonstrated better SDM than the poor management group (β = 0.183; P = .003). Using the most recent HbA_1c value and the 7-year average of HbA_1c values as the outcome, we found lower HbA_1c values in the good management group than in the poor management group (β = -0.216 [P = .01] and -0.217 [P = .008], respectively).

CONCLUSION

By using patient profiles, we confirmed a positive relationship between optimal patient behavior in self-care management and SDM. Patients with type 2 diabetes exhibited effective self-care management behavior and engaged in more health care activities, which may have led to better SDM. In promoting patient-centered care, using patient profiles and customized health education materials could improve diabetes care.

Impact of the person-centred intervention guided self-determination across healthcare settings-An integrated review

AIM

To review the evidence of the existing literature on the impact of guided self-determination across methodologies in different healthcare settings.

METHODS

An integrated five-stage review.

RESULTS

Forty-five eligible papers were included. Guided self-determination was applied in full- or small-scale, or combined with another intervention or approach in different healthcare settings handling, for example diabetes, stroke survivorship, schizophrenia, attention-deficit hyperactivity disorder and medical disorder, gynaecological and breast cancer, endometriosis, persons with chronic pain, persons in haemodialysis and intensive care survivors. The included studies covered 12 randomised trials, 26 qualitative and seven papers of different methodology. A statistically significant effect was found in three trials. Six main themes describe the qualitative findings across papers on patients: (1) Guided self-determination reduces disease-related loneliness, (2) Insight enables integration of life and disease, (3) Reflection sheets-appreciated but challenging tool to prompt insights and person-specific knowledge, (4) New person-specific knowledge enables person-centred support, (5) Feeling seen and believed in a new and trusted relationship and (6) Exchange of knowledge enables the development of life skills. Four themes describe the healthcare professionals' experience: (1) Change of usual practice-a decision from above, (2) A new role-unlearning previous behaviour and need for support, (3) Reflection sheets as facilitators and barriers and (4) Discovering the benefits of changing to a person-centred approach.

CONCLUSION

Overall, guided self-determination proved to have a great impact on patient important outcomes and was useful and well-accepted by the majority of patients and healthcare professionals. Albeit guided self-determination is not a 'one size fits all' method. Continuous training and supervision of professionals are a necessary mean when implementing guided self-determination to enhance adoption and sustainability in clinical practice.

Self-Determination Theory and Quality of Life of Adults with Diabetes: A Scoping Review

Background

Diabetes is one of the leading causes of sickness, death, and decreased quality of life globally. The prevalence of diabetes keeps rising globally due to lifestyle changes and urbanization. Therefore, improved quality of life (QoL) and appropriate diabetes self-management practices, including treatment adherence, are crucial to improving and sustaining the health of diabetic patients. Some studies have adopted the self-determination theory (SDT) to study diabetes interventions, but less is known about its effectiveness in improving QoL, treatment adherence, and diabetes self-management. Aim/Objective. This review assessed the effectiveness of SDT in improving self-management practices, treatment adherence, and QoL among adult diabetic patients.

Method

We followed the six-stage framework by Arksey and O'Malley in conducting the review. PubMed, JSTOR, Central, and ScienceDirect databases were searched for published articles from January 2011 to October 2021 using keywords and Boolean logic. Furthermore, we screened a reference list of related articles. Also, Google Scholar, Z-library, and web-based searches were carried out to retrieve other relevant evidence that applied SDT in improving QoL, diabetes self-management, and treatment adherence. Findings. Fifteen studies met the inclusion criteria, from which data were extracted as findings. SDT effectively improved QoL, diabetes treatment adherence, and diabetes self-management among diabetic patients. Of these studies, 11 provided data on SDT and diabetes self-management and affirmed the effectiveness of the theory in improving appropriate diabetes self-management practices. Two studies confirmed the effectiveness of SDT in improving treatment adherence. SDT and QoL were assessed in 4 of the studies, which demonstrated the effectiveness of SDT in enhancing the QoL of diabetic patients.

Conclusion

SDT effectively improved QoL, diabetes treatment adherence, and diabetes self-management. The application of SDT in diabetes management will improve the health and QoL of diabetic patients. Hence, diabetes management interventions could adopt SDT to guide treatment.

Guided self-determination intervention versus attention control for people with type 2 diabetes in outpatient clinics: a protocol for a randomised clinical trial

INTRODUCTION

In the management of type 2 diabetes, autonomy-supporting interventions may be a prerequisite to achieving more long-term improvement. Preliminary evidence has shown that the guided self-determination (GSD) method might have an effect on haemoglobin A1c and diabetes distress in people with type 1 diabetes. Previous trials were at risk of uncertainty. Thus, the objective is to investigate the benefits and harms of a GSD intervention versus an attention control group intervention in adults with type 2 diabetes.

METHODS AND ANALYSIS

This trial protocol is guided by the The Standard Protocol Items: Recommendations for International Trials Statement. We describe the protocol for a pragmatic randomised, dual-centre, parallel-group, superiority clinical trial testing a GSD intervention versus an attention control for people with type 2 diabetes in outpatient clinics. The participants (n=224) will be recruited from two diverse regions of Denmark. The experimental stepped-care intervention will consist of three to five GSD sessions lasting up to 1 hour with a trained GSD facilitator. The sessions will be conducted face to face, by video conference or over the telephone. The attention controls will receive three to five sessions lasting up to an hour with a communication-trained healthcare professional provided face to-face, by video conference, or over the telephone. Participants will be included if they have type 2 diabetes,>18 years old, are not pregnant. Participants will be assessed before randomisation, at 5-month, and 12-month follow-up, the latter being the primary. The primary outcome is diabetes distress. Secondary outcomes are quality of life, depressive symptoms and non-serious adverse events. Exploratory outcomes are haemoglobin A1c, motivation and serious adverse events. Data will be collected using REDCap and analysed using Stata V.16.

ETHICS AND DISSEMINATION

The trial will be conducted in compliance with the protocol, the Helsinki Declaration in its latest form, International Harmonisation of Good Clinical Practice guidelines and the applicable regulatory requirement(s). The trial has been approved by the Danish Data Protection Agency (P-2020-864). The Ethics Committee of the Capital Region of Denmark reviewed the trial protocol, but exempted the trial protocol from full review (H-20003638). The results of the trial will be presented at the outpatient clinics treating people with type 2 diabetes, at national and international conferences as well as to associations for people with diabetes and their relatives.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT04601311.

Nurses' and physicians' experiences with diabetes consultations and the use of dialogue tools in the DiaPROM pilot trial: A qualitative study

AIM

To explore nurses' and physicians' experiences with diabetes consultations in general and the use of dialogue tools in the Diabetes Patient-Related Outcome Measures (DiaPROM) pilot trial.

METHODS

We used a qualitative explorative design by conducting semi-structured in-depth interviews with five nurses and nine physicians engaged in the DiaPROM pilot trial. The pilot trial aimed to test an intervention utilizing the patient-reported Problem Areas In Diabetes (PAID) scale and person-centred communication skills as dialogue tools in clinical consultations with adults with type 1 diabetes. We used thematic analysis to analyse the data.

RESULTS

We generated three themes (each including two subthemes) from the analysis of participants' experiences: (1) 'Conflicting demands and priorities' (subthemes: 'Balancing guideline recommendations with patients' main concerns' and 'Experiencing that patients need more support to disclose their emotional concerns'); (2) 'Insights about using dialogue tools' (subthemes: 'The benefits and challenges of using the PAID as a dialogue tool' and 'Communication techniques are helpful'); and (3) 'Facilitating new interventions is challenging' (subthemes: 'Unclear roles and responsibilities in the multidisciplinary teamwork' and 'The capacity sets the limit, not the willingness').

CONCLUSIONS

Our findings indicate that the physicians and nurses experienced substantial challenges related to time and resources in the use of dialogue tools to support people's emotional concerns in clinical diabetes consultations. Thus, there is a need for healthcare organizations to adjust priorities to focus on the emotional burden of diabetes if the multidisciplinary diabetes teams are to successfully integrate psychosocial support into routine diabetes care.

The patient's agenda: nurses' experience of learning and using guided self-determination

OBJECTIVES

Health care has seen a shift towards person-centred care to encompass the entirety of a person's needs and preferences, but research is sparse on healthcare professionals learning and using person-centred care.

AIM

To investigate nurses' experiences of learning and using the person-centred method guided self-determination (GSD) in three different gynaecological settings and to determine whether, and potentially, how new tasks introduced by the GSD method influence their professional identity.

DESIGN

A qualitative interview study conducted between January 2019 and January 2020.

METHOD

We conducted 16 semi-structured interviews with nurses educated in using GSD. Applying inductive and deductive reasoning, we analysed the interviews using thematic analysis. The study was registered with the Danish Data Protection Agency (file no.: VD-2018-445, I-Suite no.: 6700).

RESULTS

The analysis generated three main themes with two subthemes each: (a) prerequisites and barriers to learning and using GSD in terms of personal factors and organisational and method-related factors; (b) new knowledge and understanding of illness with the subthemes expanded understanding of illness and a different relationship; and (c) nursing undergoing change with the subthemes, a new role and a professional self shaped through interaction with other professions.

CONCLUSIONS

Although other professionals may have either supported or challenged the use of GSD, most nurses indicated that it supplemented their professional role and identity as they gained new knowledge about person-centred challenges and felt more confident. When introducing GSD in nursing, the organisation must not only consider individual characteristics, multidisciplinary collaboration and communication but also plan individual education and supervision. This is necessary because all these factors affect how a new professional role is constructed and adopted, not to mention how it influences the nurses' perception of their professional identity and use of GSD. Establishing a helpful person-centred environment must also be considered.

Self-determination theory interventions versus usual care in people with diabetes: a protocol for a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Existing self-management and behavioural interventions for diabetes vary widely in their content, and their sustained long-term effectiveness is uncertain. Autonomy supporting interventions may be a prerequisite to achieve 'real life' patient engagement and more long-term improvement through shared decision-making and collaborative goal setting. Autonomy supportive interventions aim to promote that the person with diabetes' motivation is autonomous meaning that the person strives for goals they themselves truly believe in and value. This is the goal of self-determination theory and guided self-determination interventions. Self-determination theory has been reviewed but without assessing both benefits and harms and accounting for the risk of random errors using trial sequential analysis. The guided self-determination has not yet been systematically reviewed. The aim of this protocol is to investigate the benefits and harms of self-determination theory-based interventions versus usual care in adults with diabetes.

METHODS/DESIGN

We will conduct the systematic review following The Cochrane Collaboration guidelines. This protocol is reported according to the PRISMA checklist. A comprehensive search will be undertaken in the CENTRAL, MEDLINE, EMBASE, LILACS, PsycINFO, SCI-EXPANDED, CINAHL, SSCI, CPCI-S and CPCI-SSH to identify relevant trials. We will include randomised clinical trials assessing interventions theoretically based on guided self-determination or self-determination theory provided face-to-face or digitally by any healthcare professional in any setting. The primary outcomes will be quality of life, mortality, and serious adverse events. The secondary will be diabetes distress, depressive symptoms and adverse events not considered serious. Exploratory outcomes will be glycated haemoglobin and motivation. Outcomes will be assessed at the end of the intervention and at maximum follow-up. The analyses will be performed using Stata version 16 and trial sequential analysis. Two authors will independently screen, extract data from and perform risk of bias assessment of included studies using the Cochrane risk of bias tool. Certainty of the evidence will be assessed by GRADE.

DISCUSSION

Self-determination theory interventions aim to promote a more autonomous patient engagement and are commonly used. It is therefore needed to evaluate the benefit and harms according to existing trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020181144.

Impact of the Guided Self-Determination Intervention among Adolescents with Co-Existing ADHD and Medical Disorder: A Mixed Methods Study

Adolescents with ADHD are at increased risk of having a co-existing medical disorder. Research shows that having co-existing ADHD and a medical disorder interferes with the adolescents' daily life, creating a dual task that cannot be managed as two independent disorders. Interventions to support adolescents in managing the dual task of living with co-existing ADHD and medical disorder are needed. The Guided-Self-Determination intervention might be suitable for this population, as it is an empowerment-based intervention facilitating patient involvement and self-management of a disease. The purpose of this study was to evaluate how the Guided Self-Determination intervention impacted 10 adolescents with ADHD and a co-existing medical disorder. The study used a convergent mixed methods design. Quantitative data measuring support from nurses, support from parents, and self-management were collected though self-reported questionnaires at baseline, 3 months, and 6 months and were analyzed with descriptive statistics. Qualitative data capturing the adolescents' experiences of the intervention and the intervention's impact on support from nurses, parents, and self-management were collected through semi-structured interviews and analyzed thematically. Results of the quantitative and qualitative analyses were integrated in a mixed methods analysis. The integrated results suggest that this intervention may improve adolescents' management of the difficulties of living with co-existing ADHD and a medical disorder, and that self-insight and nurse support are prerequisites for developing self-management strategies. However, the results showed that the intervention did not impact parental support. Further research is needed to evaluate the impact of the intervention on a larger scale.

Experiences of self-management support in patients with diabetes and multimorbidity: a qualitative study in Norwegian general practice

Aim:

The purpose of this study was to explore how patients with diabetes and multimorbidity experience self-management support by general practitioners (GPs), nurses and medical secretaries in Norwegian general practice.

Background:

Self-management support is recognised as an important strategy to improve the autonomy and well-being of patients with long-term conditions. Collaborating healthcare professionals (cHCPs), such as nurses and medical secretaries, may have an important role in the provision of self-management support. No previous study has explored how patients with diabetes and multimorbidity experience self-management support provided by cHCPs in general practice in Norway.

Methods:

Semi-structured interviews with 11 patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) with one or more additional long-term condition were performed during February–May 2017.

Findings:

Patients experienced cHCPs as particularly attentive towards the psychological and emotional aspects of living with diabetes. Compared to GPs, whose appointments were experienced as stressful, patients found cHCPs more approachable and more likely to address patients’ questions and worries. In this sense, cHCPs complemented GP-led diabetes care. However, neither cHCPs nor GPs were perceived to involve patients’ in clinical decisions or goal setting during consultations.

The Self-Management Experiences of Adolescents with Type 1 Diabetes: A Descriptive Phenomenology Study

Many adolescents with type 1 diabetes experience challenges in achieving good glycemic control and have insufficient understanding in executing interventions for glycemic control. This study aimed to understand self-management experiences of adolescents with type 1 diabetes in Taiwan. In this descriptive phenomenological study, we conducted in-depth interviews with 18 adolescents with type 1 diabetes from the pediatric outpatient clinic of a medical center. Data were analyzed using the Colaizzi's method. Four themes were identified: (1) misconception regarding self-management of blood glucose; (2) conflict between depending on and breaking away from parental assistance for glycemic control; (3) encounter with disruptions in glycemic control regimen due to the presence of schedule changes; and (4) lack of motivation to achieve good glycemic control. The findings indicated that the misconceptions of adolescents with type 1 diabetes about managing glycemic levels resulted from an insufficient understanding of self-management of diabetes. In Taiwan, the heavy emphasis of academic achievement and changes of schedules during breaks tended to disrupt the regimen for glycemic control. Healthcare professionals are encouraged to provide individualized education focusing on the adolescents' misconceptions regarding self-management of diabetes.

Measuring the Effects of Sharing Mobile Health Data During Diabetes Consultations: Protocol for a Mixed Method Study

BACKGROUND

There is rising demand for health care's limited resources. Mobile health (mHealth) could be a solution, especially for those with chronic illnesses such as diabetes. mHealth can increases patients' options to self-manage their health, improving their health knowledge, engagement, and capacity to contribute to their own care decisions. However, there are few solutions for sharing and presenting patients' mHealth data with health care providers (HCPs) in a mutually understandable way, which limits the potential of shared decision making.

OBJECTIVE

Through a six-month mixed method feasibility study in Norway, we aim to explore the impacts that a system for sharing patient-gathered data from mHealth devices has on patients and HCPs during diabetes consultations.

METHODS

Patients with diabetes will be recruited through their HCPs. Participants will use the Diabetes Diary mobile phone app to register and review diabetes self-management data and share these data during diabetes consultations using the FullFlow data-sharing system. The primary outcome is the feasibility of the system, which includes HCP impressions and expectations (prestudy survey), usability (System Usability Scale), functionalities used and data shared during consultations, and study-end focus group meetings. Secondary outcomes include a change in the therapeutic relationship, patient empowerment and wellness, health parameters (HbA1c and blood pressure), and the patients' own app-registered health measures (blood glucose, medication, physical activity, diet, and weight). We will compare measures taken at baseline and at six months, as well as data continuously gathered from the app. Analysis will aim to explain which measures have changed and how and why they have changed during the intervention.

RESULTS

The Full Flow project is funded for 2016 to 2020 by the Research Council of Norway (number 247974/O70). We approached 14 general practitioner clinics (expecting to recruit 1-2 general practitioners per clinic) and two hospitals (expecting to recruit 2-3 nurses per hospital). By recruiting through the HCPs, we expect to recruit 74 patients with type 2 and 33 patients with type 1 diabetes. Between November 2018 and July 2019, we recruited eight patients and 15 HCPs. During 2020, we aim to analyze and publish the results of the collected data from our patient and HCP participants.

CONCLUSIONS

We expect to better understand what is needed to be able to share data. This includes potential benefits that sharing patient-gathered data during consultations will have on patients and HCPs, both individually and together. By measuring these impacts, we will be able to present the possibilities and challenges related to a system for sharing mHealth data for future interventions and practice. Results will also demonstrate what needs to be done to make this collaboration between HCPs and patients successful and subsequently further improve patients' health and engagement in their care.

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.

Psychometric properties of the Persian Health Care Climate Questionnaire (HCCQ-P): assessment of type 2 diabetes care supportiveness in Iran

Background: Health-care systems play a key role in responding to the growing problems of patients with type 2 diabetes by supporting their autonomy in providing routine care. The Health Care Climate Questionnaire (HCCQ) was designed to assess patients' perceived degree of autonomy support within the care practice settings. The main purpose of this study was to translate and evaluate psychometric properties of the Persian version of the HCCQ (HCCQ-P) to be applied among Iranian and other Persian-speaking patients with type 2 diabetes. Method: Translation/back-translation procedures were carried out to prepare a preliminary draft of the HCCQ-P that was subsequently sent for face and content validity appraisal by a group of 15 health education/promotion and nursing specialists. Minor revisions were performed based on the feedback, and the content validity ratio (=0.91) and content validity index (=0.95) were within the acceptable range. The structural validity of the scale was assessed by exploratory and confirmatory factor analysis. Results: The exploratory and confirmatory factor analysis outputs (root mean square error of approximation=0.079, comparative fit index=0.976, Tucker Lewis index=0.967, standardized root mean square residual=0.022) demonstrated the proper performance and fitness statistics of the translated HCCQ in a one-dimensional model similar to the original scale. The internal consistency and reliability scores endorsed the validity of the translated measure (α=0.945, intraclass correlation coefficient=0.999, P=0.000). Conclusion: In this study, the translated HCCQ-P scale showed robust internal validity for its application in the assessment of health-care settings' supportiveness in care provision to Persian-speaking patients with type 2 diabetes. Future cross-cultural and multidisciplinary studies are recommended to investigate the applicability of the scale in different patients/cultural groups and health-care settings.

Analysing mHealth usage logs in RCTs: Explaining participants' interactions with type 2 diabetes self-management tools

Background

The Introduction of mobile health (mHealth) devices to health intervention studies challenges us as researchers to adapt how we analyse the impact of these technologies. For interventions involving chronic illness self-management, we must consider changes in behaviour in addition to changes in health. Fortunately, these mHealth technologies can record participants’ interactions via usage-logs during research interventions.

Objective

The objective of this paper is to demonstrate the potential of analysing mHealth usage-logs by presenting an in-depth analysis as a preliminary study for using behavioural theories to contextualize the user-recorded results of mHealth intervention studies. We use the logs collected by persons with type 2 diabetes during a randomized controlled trial (RCT) as a use-case.

Methods

The Few Touch Application was tested in a year-long intervention, which allowed participants to register and review their blood glucose, diet and physical activity, goals, and access general disease information. Usage-logs, i.e. logged interactions with the mHealth devices, were collected from participants (n = 101) in the intervention groups. HbA1c was collected (baseline, 4- and 12-months). Usage logs were categorized into registrations or navigations.

Results

There were n = 29 non-mHealth users, n = 11 short-term users and n = 61 long-term users. Non-mHealth users increased (+0.33%) while Long-term users reduced their HbA1c (-0.86%), which was significantly different (P = .021). Long-term users significantly decreased their usage over the year (P < .001). K-means clustering revealed two clusters: one dominated by diet/exercise interactions (n = 16), and one dominated by BG interactions and navigations in general (n = 40). The only significant difference between these two clusters was that the first cluster spent more time on the goals functionalities than the second (P < .001).

Conclusion

By comparing participants based upon their usage-logs, we were able to discern differences in HbA1c as well as usage patterns. This approach demonstrates the potential of analysing usage-logs to better understand how participants engage during mHealth intervention studies.

Factors explaining variation in self-esteem among persons with type 1 diabetes and elevated HbA1c

OBJECTIVES

To investigate associations between perceived autonomy support from health-care professionals, autonomy-driven motivation, diabetes self-perceived competence and self-esteem in adults (age 18-55 yrs) with suboptimally regulated type 1 diabetes mellitus (T1DM) with at least one HbA1c≥8.0% (≥64 mmol/mol) during the past year, and whether these factors could predict decrease in self-esteem over time.

METHODS

A cross-sectional population-based survey was performed, and 9 months follow-up data were collected. Data collection comprised clinical and socio-demographic variables, blood sampling (HbA1c) and self-report questionnaires; the Health Care Climate Questionnaire (HCCQ), Treatment Self-Regulation Questionnaire (TSRQ), the Perceived Competence in Diabetes Scale (PCDS), and the Rosenberg Self-esteem Scale (RSES). We fitted block-wise linear regression models to assess associations between RSES and variables of interest (HCCQ, TSRQ, PCDS, HbA1c, clinical and socio-demographic variables) and linear regression models to assess predictors of change over time.

FINDINGS

In this study sample, aged 36.7 (±10.7) mean HbA1c 9.3% (±1.1), 31.5% had long-term complications and 42.7% had experienced severe hypoglycemia within the previous 12 months. In the final regression model the association between PCDS and RSES was strongly significant (B = 1.99, p<0.001) and the associations between HCCQ, TSRQ and RSES were reduced to non-significance. All predictor variables combined explained 42% of the variability of RSES (adjusted R2 = 0.423) with PCDS contributing 18% to explained variance (R-square change = 0.184, p<0.001). The strongest predictors of change in RSES over time were long-term complications (B = 2.76, p<0.001), specifically foot-related problems, and being female (B = -2.16, p = 0.002).

CONCLUSIONS

Perceived autonomy support, autonomy-driven motivation and diabetes self-perceived competence play a significant role in explaining self-esteem among adults with suboptimally regulated T1DM. Healthcare professionals should acknowledge self-esteem as a valuable factor in understanding the multifaceted health choices people with T1DM make.

TRIAL REGISTRATION

Clinical Trials.gov with identification number NCT 01317459.

Written reflection in an eHealth intervention for adults with type 2 diabetes mellitus: a qualitative study

BACKGROUND

Individuals with type 2 diabetes mellitus (T2DM) are responsible for the daily decisions and actions necessary to manage their disease, which makes self-management the cornerstone of diabetes care. Many patients do not reach recommended treatment goals, and thus it is important to develop and evaluate innovative interventions that facilitate optimal motivation for adequate self-management of T2DM.

OBJECTIVE

The aim of the current study was to explore how adults with T2DM experience using reflection sheets to stimulate written reflection in the context of the Guided Self-Determination (GSD) eHealth intervention and how written reflection might affect their motivation for self-management of T2DM.

METHODS

We used a qualitative design in which data were collected through individual interviews. The sample consisted of 10 patients who completed the GSD eHealth intervention, and data were analyzed using qualitative content analysis.

RESULTS

The qualitative content analysis yielded 2 main themes. We labeled the first theme as "Written reflection affects awareness and commitment in diabetes self-management", which reflects 2 subthemes, namely, "Writing creates space and time for autonomous reflection" and "Writing influences individuals' focus in diabetes self-management". We labeled the second theme as "Written reflection is perceived as inapplicable in diabetes self-management", which reflects 2 subthemes, namely, "Responding in writing is difficult" and "The timing of the writing is inappropriate".

CONCLUSION

Our findings indicate that written reflection in the context of the GSD eHealth intervention may be conducive to motivation for diabetes self-management for some patients. However, it seems that in-person consultation with the diabetes nurse may be necessary to achieve the full potential benefit of the GSD as an eHealth intervention. We advocate further development and examination of the GSD as a "blended" approach, especially for those who consider written reflection to be difficult or unfamiliar.