Multifaceted Intervention to Improve Graft Outcome Disparities in African American Kidney Transplants (MITIGAAT Study): Protocol for a Randomized Controlled Trial

BACKGROUND

The outcome disparities for African American recipients of kidney transplant is a public health issue that has plagued the field of transplant since its inception. Based on national data, African American recipients have nearly twice the risk of graft loss at 5 years after transplant, when compared with White recipients. Evidence demonstrates that medication nonadherence and high tacrolimus variability substantially impact graft outcomes and racial disparities, most notably late (>2 years) after the transplant. Nonadherence is a leading cause of graft loss. Prospective multicenter data demonstrate that one-third of all graft loss are directly attributed to nonadherence. We have spent 10 years of focused research to develop a comprehensive model explaining the predominant risk factors leading to disparities in African American kidney recipients. However, there are still gaps in patient-level data that hinder the deeper understanding of the disparities. Lack of data from the patient often lead to provider biases, which will be addressed with this intervention. Culturally competent, pharmacist-led interventions in medication therapy management will also address therapeutic inertia. Pharmacist interventions will mitigate medication access barriers as well (cost and insurance denials). Thus, this multidimensional intervention addresses patient, provider, and structural factors that drive racial disparities in African American kidney recipients.

OBJECTIVE

This prospective, randomized controlled trial aimed to determine the impact of multimodal health services intervention on health outcomes disparities in African American recipients of kidney transplant. The aims of this study are to improve adherence and control of late clinical issues, which are predominant factors for racial disparities in kidney recipients, through a technology-enabled, telehealth-delivered, 4-level intervention.

METHODS

The Multifaceted Intervention to Improve Graft Outcome Disparities in African American Kidney Transplants (MITIGAAT) study is a 24-month, 2-arm, single-center (Medical University of South Carolina), 1:1 randomized controlled trial involving 190 participants (95 in each arm), measuring the impact on adherence and control of late clinical issues for racial disparities in kidney recipients, through a technology-enabled, telehealth-delivered, 4-level intervention. The key clinical issues for this study include tacrolimus variability, blood pressure, and glucose control (in those with diabetes mellitus). We will also assess the impact of the intervention on health care use (hospitalizations and emergency department visits) and conduct a cost-benefit analysis. Finally, we will assess the impact of the intervention on acute rejection and graft survival rates as compared with a large contemporary national cohort.

RESULTS

This study was funded in July 2023. Enrolled began in April 2024 and is expected to be complete in 2026. All patients will complete the study by the end of 2028.

CONCLUSIONS

In this protocol, we describe the study design, methods, aims, and outcome measures that will be used in the ongoing MITIGAAT clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06023615; https://www.clinicaltrials.gov/study/NCT06023615.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/57784.

Identification of Intervention Characteristics Within Diabetes Prevention Programs Using the Template for Intervention Description and Replication: A Scoping Review

OBJECTIVES

Diabetes prevention programs (DPPs) targeting dietary and physical activity behaviour change have been shown to decrease the incidence of type 2 diabetes; however, a more thorough reporting of intervention characteristics is needed to expedite the translation of such programs into different communities. In this scoping review, we aim to synthesize how DPPs are being reported and implemented.

METHODS

A scoping review using Arkey and O'Malley methods was conducted in accordance with the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis. MEDLINE, CINAHL, PsycINFO, EMBASE, and SPORTDiscus were searched for studies relating to diabetes prevention and diet/exercise interventions. Only studies delivering a diet/exercise intervention for adults identified as "at risk" for developing type 2 diabetes were included. The Template for Intervention Description and Replication (TIDieR) was used to guide data extraction, and each DPP was scored on a scale from 0 to 2 for how thoroughly it reported each of the items (0 = did not report, 2 = reported in full; total score out of 26).

RESULTS

Of the 25,110 publications screened, 351 (based on 220 programs) met the inclusion criteria and were included for data extraction. No studies comprehensively reported on all TIDieR domains (mean TIDieR score: 15.7 of 26; range 7 to 25). Reporting was particularly poor among domains related to "modifications," "tailoring," and "how well (planned/actual)." "How well (planned)" assesses the intended delivery of an intervention, detailing the initial strategies and components as per the original design, whereas "how well (actual)" evaluates the extent to which the intervention was executed as planned during the study, including any deviations or modifications made in practice.

CONCLUSIONS

Although there is evidence to suggest that DPPs are efficacious, a more thorough reporting of program content and delivery is needed to improve the ability for effective programs to be implemented or translated into different communities.

Nutritional Profiles and Their Links to Insulin Resistance and Anthropometric Variables in a Female Cohort

This study investigates the relationship between dietary habits and metabolic health among women, emphasizing the role of anthropometric parameters as proxies for insulin resistance. We analyzed data from 443 women categorized into two groups based on the presence or absence of clinically diagnosed insulin resistance. Our assessments included dietary quality, socio-demographic characteristics, and a series of anthropometric measurements such as body weight, Body Mass Index (BMI), Waist-Hip Ratio (WHR), Abdominal Volume Index (AVI), and Body Adiposity Index (BAI). The results indicated significant disparities in these parameters, with the insulin-resistant group exhibiting higher average body weight (78.92 kg vs. 65.04 kg, p < 0.001), BMI (28.45 kg/m2 vs. 23.17 kg/m2, p < 0.001), and other related measures, suggesting a strong influence of dietary patterns on body composition and metabolic risk. The study underscores the importance of dietary management in addressing insulin resistance, advocating for personalized dietary strategies to improve metabolic health outcomes in women. This approach highlights the need for integrating dietary changes with lifestyle modifications and socio-demographic considerations to combat metabolic risks effectively.

Development of a Motivation Communication Training to Aid Diabetes-Specialist Podiatrists With Adherence Discussions

Diabetic foot ulcers (DFUs) impact a substantial proportion of patients with diabetes, with high recurrence rates, severe complications, and significant financial burden to health care systems. Adherence to treatment advice (e.g., limiting weight-bearing activity) is low with patients reporting dissatisfaction with the way in which advice is communicated. This study aimed to address this problem via the systematic development of a motivation communication training program. The program was designed to support diabetes-specialist podiatrists in empowering patients to actively engage with treatment. The development process followed an intervention mapping approach. Needs assessment involved observations of 24 patient-practitioner consultations within a diabetes-specialist foot clinic. This informed specification of a theory of change (self-determination theory) and relevant evidence-based communication strategies (drawing from motivational interviewing). The training program was developed iteratively with changes made following feedback from five diabetic foot health care professionals. The resulting training program, consisting of six one-hour face-to-face sessions over an 8-week period, was delivered to a further six diabetes specialist podiatrists, with five participating in postprogram telephone interviews to assess acceptability. Deductive thematic analysis of interview data revealed positive aspects of the training (e.g., valuable and relevant content), ideas for improvement (e.g., online resources and context-specific video examples), the acceptability of motivation strategies, and challenges putting the strategies into practice (such as time constraints and breaking old communication habits). This study contributes to our understanding of integrating motivation principles into routine consultations and holds potential for enhancing adherence to treatment recommendations in patients living with diabetic foot ulcers.

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.

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 self-determination theory in research and evaluation in primary care

BACKGROUND

Multimorbidity (the co-existence of two or more long-term conditions within an individual) is a complex management challenge, with a very limited evidence base. Theories can help in the design and operationalization of complex interventions.

OBJECTIVE

This article proposes self-determination theory (SDT) as a candidate theory for the development and evaluation of interventions in multimorbidity.

METHODS

We provide an overview of SDT, its use in research to date, and its potential utility in complex interventions for patients with multimorbidity based on the new MRC framework.

RESULTS

SDT-based interventions have mainly focused on health behaviour change in the primary prevention of disease, with limited use in primary care and chronic conditions management. However, SDT may be a useful candidate theory in informing complex intervention development and evaluation, both in randomized controlled trials and in evaluations of 'natural experiments'. We illustrate how it could be used multimorbidity interventions in primary care by drawing on the example of CARE Plus (a primary care-based complex intervention for patients with multimorbidity in deprived areas of Scotland).

CONCLUSIONS

SDT may have utility in both the design and evaluation of complex interventions for multimorbidity. Further research is required to establish its usefulness, and limitations, compared with other candidate theories.

PATIENT OR PUBLIC CONTRIBUTION

Our funded research programme, of which this paper is an early output, has a newly embedded patient and public involvement group of four members with lived experience of long-term conditions and/or of being informal carers. They read and commented on the draft manuscript and made useful suggestions on the text. They will be fully involved at all stages in the rest of the programme of research.

Effects of Leisure-Time Physical Activity on Cognitive Reserve Biomarkers and Leisure Motivation in the Pre-Diabetes Elderly

The purpose of this study was to investigate the change in cognitive reserve biomarkers of the pre-diabetic individual according to the types of leisure-time physical activity (aerobic or resistance physical activity). The research subjects (n = 184) who participated in the survey were pre-diabetic and diabetic patients who were visiting university hospitals and welfare centers. The intervention subjects (n = 36) who were elderly females with pre-diabetes volunteered to participate in the study by performing regular physical exercise (aerobic or resistance exercise). The study participants were 65 years of age or older with pre-diabetes defined by a glycated hemoglobin (HbA1c) level of (5.7−6.4)%. All research subjects performed motivation and stress questionnaire survey. All intervention subjects participated in leisure-time physical activity (LTPA) for 12 weeks. Body composition, HbA1c, and cognitive reserve biomarkers were measured at baseline, and at 6 and 12 weeks. LTPA motivation confirmed that the LTPA participants had a high level of motivation. Stress confirmed that the stress level of LTPA participants was low. Two-way within-factor ANOVA revealed significant group × time interaction for weight (p < 0.05), BMI (p < 0.01), % fat (p < 0.001), SBP (p < 0.05), HbA1c (p < 0.001), BDNF (p < 0.001), and Beta-Amyloid 1−42 (p < 0.001). In both physical activity groups, HbA1c (p < 0.001), NGF (p < 0.05), BDNF (p < 0.05), and Cathepsin B (p < 0.05) improved significantly at 12 weeks, compared to baseline and 6 weeks. In the resistance physical activity group, Beta-Amyloid 1−42 (p < 0.01) and Homocysteine (p < 0.05) significantly decreased at 12 weeks, compared to baseline and at 6 weeks. The LTPA showed high levels of integrated and identified regulation among leisure motive types, and the level of stress was found to be low. The LTPA is effective in reducing the HbA1c levels of the pre-diabetes elderly. In addition, the pre-diabetes elderly were found to have increased NGF, BDNF, and cathepsin B, and decreased Beta-Amyloid 1−42 and homocysteine. Regular leisure-time physical activity has a positive effect on cognitive reserve biomarkers through improving glycemic control by reducing weight and % fat in the pre-diabetes elderly.

Facilitators and Barriers to Uptake of Community-Based Diabetes Prevention Program Among Multi-Ethnic Asian Patients With Prediabetes

OBJECTIVE

This study aimed to identify facilitators and barriers to the uptake of a community-based diabetes prevention program (DPP) from the perspectives of decliners with prediabetes in a multi-ethnic Asian community.

METHODS

Semi-structured interviews were conducted with 29 individuals with prediabetes who declined participation in a large community-based diabetes prevention program in Singapore. Thematic analysis was undertaken to identify themes, which were subsequently mapped onto the Capacity-Opportunity-Motivation and Behavior model (COM-B).

RESULTS

We identified 16 key themes under three COM-B domains. Health status at the time of invitation, perceived ability of self-management, understanding of prediabetes condition and/or the program intention (Capability) were important determinants. Family commitment had the strong potential to enable or hinder physical and social Opportunity related to participation. Many participants desired involvement of physician as part of program invitation and component. Fear of exacerbation coupled with an automatic aversion for suffering influenced Motivation for participation.

CONCLUSION

Identifying facilitators and barriers embedded in the COM-B will assist systematic program modifications to increase participation of individuals with prediabetes. How information about modifiable risk factors is communicated by physicians at the point of diagnosis and program introduction is key to participation. Co-locating programs with family activity, development of mHealth, readiness assessment, and tailored explanation of program purpose may increase participation. These findings will be used to guide future national interventions in the community to ensure successful implementation.

Factors Related to Diabetes Self-Management Among Patients with Type 2 Diabetes: A Chinese Cross-Sectional Survey Based on Self-Determination Theory and Social Support Theory

PURPOSE

Self-management behavior (SMB) plays a significant role in glycemic control. This study aimed to explore the factors related to SMB among patients with type 2 diabetes and how these factors interacted with each other.

PATIENTS AND METHODS

Patients diagnosed with type 2 diabetes were recruited from 18 community healthcare stations (CHSs) from six community healthcare centers (CHCs) in Beijing, China from April to May in 2017. Motivation, competence, autonomy support, social support, self-management skills, adherence to self-monitoring of blood glucose (SMBG) and haemoglobin A1c (HbA1c) measurement were tested by questionnaire. Correlation analysis and path analysis were performed so as to identify the factors associated with patients' SMB.

RESULTS

A total of 532 participants completed this study. Participants who have good compliance to SMBG got higher scores in social support (F = 7.68, p = 0.01), competence (F = 10.47, p = 0.01), and skills (F = 12.34, p < 0.01). Higher competence (β = 0.03, P < 0.001), higher social support (β = 0.01, P < 0.001), better skills(β = 0.01, P < 0.001) directly led to better adherence to SMBG. Social support had a positive effect on autonomy support (β = 0.69, P < 0.001), motivation (β = 0.45, P < 0.001), competence (β = 0.28, P < 0.001), skills (β = 0.14, P < 0.001), which was also indirectly linked to better adherence to SMBG. Better self-management skills directly led to better adherence to HbA1c measurement (β = 0.03, P < 0.001). Social support had a positive effect on autonomy support (β = 0.69, P < 0.001), motivation (β = 0.45, P < 0.001), competence (β = 0.28, P < 0.001), skills (β = 0.14, P < 0.001), which was also indirectly linked to better adherence to HbA1c measurement.

CONCLUSION

Self-determination theory and social support theory were practical in explaining SMB in Chinese population. Competence, motivation and social support played an important role in diabetic self-management. Paying attention to the promotion of individual's intrinsic motivation and self-efficacy may be able to help patients maintain self-management behavior in the long-term routine.

Psychedelics and health behaviour change

Healthful behaviours such as maintaining a balanced diet, being physically active and refraining from smoking have major impacts on the risk of developing cancer, diabetes, cardiovascular diseases and other serious conditions. The burden of the so-called 'lifestyle diseases'-in personal suffering, premature mortality and public health costs-is considerable. Consequently, interventions designed to promote healthy behaviours are increasingly being studied, e.g., using psychobiological models of behavioural regulation and change. In this article, we explore the notion that psychedelic substances such as psilocybin could be used to assist in promoting positive lifestyle change conducive to good overall health. Psilocybin has a low toxicity, is non-addictive and has been shown to predict favourable changes in patients with depression, anxiety and other conditions marked by rigid behavioural patterns, including substance (mis)use. While it is still early days for modern psychedelic science, research is advancing fast and results are promising. Here we describe psychedelics' proposed mechanisms of action and research findings pertinent to health behaviour change science, hoping to generate discussion and new research hypotheses linking the two areas. Therapeutic models including psychedelic experiences and common behaviour change methods (e.g., Cognitive Behaviour Therapy, Motivational Interviewing) are already being tested for addiction and eating disorders. We believe this research may soon be extended to help promote improved diet, exercise, nature exposure and also mindfulness or stress reduction practices, all of which can contribute to physical and psychological health and well-being.

Striving for autonomy in everyday diabetes self-management-qualitative exploration via grounded theory approach

OBJECTIVES

The rapid worldwide increase in the incidence of diabetes significantly influences the lives of individuals, families and communities. Diabetes self-management requires personal autonomy and the presence of a supportive social environment. These attributes can considerably ameliorate the outcomes of the chronic condition. However, little is known about individual variations in overcoming the illness-related challenges and in the achievement of autonomy in daily activities. This paper seeks to bridge this knowledge gap.

DESIGN

This qualitative study used the grounded theory approach. Semi-structured interviews were conducted, and the data collection and data analysis probed participant experiences of autonomy through the self-management of their daily socio-physical environments.

SETTING

Participants were recruited from the outpatient ward of a university clinic in Hungary.

PARTICIPANTS

The study was conducted with 26 adult patients with type 2 diabetes mellitus (15 females and 11 males aged between 26 and 80 years; M=62.6 years; SD=13.1). The inclusion criteria were: T2D diagnosis at least 1 year before the beginning of the study; prescribed insulin injection therapy; aged over 18 years; native Hungarian speaker and not diagnosed with dementia or any form of cognitive impairment.

RESULTS

The study established three principal aspects of the active construction of personal autonomy in diabetes self-management: coping strategies vis-à-vis threats posed by the symptoms and the treatment of the disease; autonomous ways of creating protective space and time and relationship processes that support everyday experiences of self-directedness.

CONCLUSIONS

The results of this study confirm the validity of the self-determination theory in diabetes self-management. They also imply that pathways towards constructing everyday experiences of self-directedness in participants lead through self-acceptance, supporting family relationships and a doctor-patient relationship characterised by partnership. The tentative empirical model of pathways towards patients' experience of self-directedness can serve as a framework for future research, patient-centred clinical practice, and education.

Fitness Facility Staff Can Be Trained to Deliver a Motivational Interviewing-Informed Diabetes Prevention Program

Background: Training programs must be evaluated to understand whether the training was successful at enabling staff to implement a program with fidelity. This is especially important when the training has been translated to a new context. The aim of this community case study was to evaluate the effectiveness of the in-person Small Steps for Big Changes training for fitness facility staff using the 4-level Kirkpatrick training evaluation model. Methods: Eight staff were trained to deliver the motivational interviewing-informed Small Steps for Big Changes program for individuals at risk of developing type 2 diabetes. Between August 2019 and March 2020, 32 clients enrolled in the program and were allocated to one of the eight staff. The Kirkpatrick 4-level training evaluation model was used to guide this research. Level one assessed staff satisfaction to the training on a 5-point scale. Level two assessed staff program knowledge and motivational interviewing knowledge/skills. Level three assessed staff behaviors by examining their use of motivational interviewing with each client. Level four assessed training outcomes using clients' perceived satisfaction with their staff and basic psychological needs support both on 7-point scales. Results: Staff were satisfied with the training (M = 4.43; SD = 0.45; range = 3.86-4.71). All learning measures demonstrated high post-training scores that were retained at implementation follow-up. Staff used motivational interviewing skills in practice and delivered the program at a client-centered level (≥6; M = 6.34; SD = 0.83; range = 3.75-7.80). Overall, clients perceived staff supported their basic psychological needs (M = 6.55; SD = 0.64; range = 6.17-6.72) and reported high staff satisfaction scores (M = 6.88; SD = 0.33; range = 6-7). Conclusion: The Small Steps for Big Changes training was successful and fitness facility staff delivered a motivational interviewing-informed program. While not all staff operated at a client-centered level, clients perceived their basic psychological needs to be supported. Findings support the training for future scale-up sites. Community fitness staff represent a feasible resource through which to run evidence-based counseling programs.

'Is Insulin Right for Me?' Development of a theory-informed, web-based resource for reducing psychological barriers to insulin therapy in type 2 diabetes

OBJECTIVE

To develop a theory and evidence-based web intervention to reduce psychological barriers towards insulin therapy among adults with non-insulin-treated type 2 diabetes (T2D).

METHODS

Salient psychological barriers towards insulin were identified from the literature and classified using the Theoretical Domains Framework (TDF). Relevant TDF domains were mapped to evidence-based behaviour change techniques (BCTs), which informed the content for each barrier. Acceptability was explored using cognitive debriefing interviews (n=6 adults with T2D).

RESULTS

'Is Insulin Right for Me' addresses eight barriers, phrased as common questions: Does insulin mean my diabetes is more serious? Do insulin injections cause complications? Is it my fault I need to inject insulin? Will I gain weight? Will injecting hurt? What about hypos? Will injecting insulin be a burden? What will others think of me? BCTs, including persuasive communication and modelling/demonstration, were delivered using appropriate methods (eg, demonstration of the injection process). Participant suggestions for improvement included clear and direct messages, normalising insulin and avoiding confronting images.

CONCLUSIONS

'Is Insulin Right for Me' is the first theory and evidence-based, web intervention designed to reduce psychological barriers towards insulin therapy for adults with T2D. Evaluation is needed to determine its impact on negative appraisals and receptiveness towards insulin.

Dissonance in the discourse of the duration of diabetes: A mixed methods study of patient perceptions and clinical practice

Background

Remission of diabetes can be rewarding for patients and physicians, but there is limited study of how patients perceive the timeline of a disease along the continuum of glycaemic control.

Objective

To explore how patients perceive the timeline of diabetes along the continuum of glycaemic control and their goals of care and to identify whether family physicians communicate the principles of regression and remission of diabetes.

Design

Mixed methods approach of qualitative semi‐structured interviews with purposive sampling followed by cross‐sectional survey of physicians.

Participants

Thirty‐three patients living with prediabetes (preDM) or type 2 diabetes mellitus (T2DM) at medical centres in Georgia and Nevada; and 387 family physicians providing primary care within the same health system.

Results

Patients described two timelines of diabetes: as a lifelong condition or as a condition that can be cured. Patients who perceived a lifelong condition described five treatment goals: reducing glucose‐related laboratory values, losing weight, reducing medication, preventing treatment intensification and avoiding complications. For patients who perceived diabetes as a disease with an end, the goal of care was to achieve normoglycaemia. In response to patient vignettes that described potential cases of remission and regression, 38.2% of physician respondents would still communicate that a patient has preDM and 94.6% would tell the patient that he still had diabetes.

Conclusions

Most physicians here exhibited reluctance to communicate remission or regression in patient care. Yet, patients describe two different potential timelines, including a subset who expect their diabetes can be ‘cured’. Physicians should incorporate shared decision making to create a shared mental model of diabetes and its potential outcomes with patients.

Patient or Public Contribution

In this mixed methods study, as patients participated in the qualitative phase of this study, we asked patients to tell us what additional questions we should ask in subsequent interviews. Data from this qualitative phase informed the design and interpretation of the quantitative phase with physician participants.

Integrating Self-determination Theory and Upper Limb Factors to Predict Physical Activity in Patients With Breast Cancer During Chemotherapy

BACKGROUND

Some empirical investigations try to describe the factors that affect the physical activity of breast cancer survivors, but these investigations rarely focus on the basic psychological needs or motivation regulation of breast cancer survivors in physical activity.

OBJECTIVE

The aim of this study was to construct structural equation modeling of the self-determination theory and upper limb factors to predict the physical activity of breast cancer patients during chemotherapy.

METHODS

A total of 236 breast cancer survivors completed measures of basic psychological needs, behavioral regulation in exercise, symptoms and dysfunction of upper limb factors, and physical activity. Path analyses structured the direct and indirect effects (via motivational orientations) of basic psychological needs and upper limb factors on physical activity.

RESULTS

A total of 216 (91.5%) participants met the standard physical activity metabolic equivalent recommended. The final model has a good degree of fit (χ2 = 809.363, df = 391, χ2/df ≤ 2.07 [1-3]; root-mean-square error of approximation, 0.067 [<0.008]). The competence (0.309) of basic psychological needs and amotivation (-0.38) of motivation regulations have the greatest effect on physical activity.

CONCLUSIONS

Competence is the most important basic psychological need of breast cancer patients during chemotherapy, and amotivation is the most important motivation regulation.

IMPLICATIONS FOR PRACTICE

Nurses need to pay more attention to the basic psychological needs and the motivation regulation in breast cancer patients during chemotherapy. Randomized controlled trials of breast cancer survivor interventions based on the self-determination theory are needed.

Zain AZ. The external realities of people with type 2 diabetes-Understanding disease perspective and self-management behaviour via Grounded Theory Approach

BACKGROUND

Qualitative strategies can uncover the relationship between the external realities of people living with type 2 diabetes (T2D) and the barriers that are associated with disease self-management. Information from in-depth interviews (IDI) and focus group discussions (FGD) can be used to devise psychological models that could potentially facilitate behaviour changes in people with T2D. We aim to identify salient factors that govern the external realities of people with T2D in relation to disease management.

METHODS

A qualitative study was conducted at a regional primary care clinic in Malaysia using a Grounded Theory Approach. People with T2D were recruited through purposeful sampling to determine their living experiences with the disease. A total of 34 IDIs with 24 people with T2D and 10 health care professionals, followed by two FGDs with people with T2D, were conducted.

RESULTS

Three major processes that arbitrate self-management practices include- 1) external reality, 2) internal reality, 3) mediators of behaviour. Within the context of external reality, three important sub-themes were identified-intrinsic background status, personal experience, and worldview. Lifestyle habits of persons with T2D play a central role in their disease management. Another common recurring concern is the issue of a low-quality food environment in the country. More importantly, individuals with T2D have a high degree of expectations for a more person-centered approach to their illness.

CONCLUSIONS

We identified modifiable and non-modifiable behavioural factors that influence the daily living environment of people with T2D. This information can be used to customize the management of T2D through targeted behavioural interventions.

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.

Motivational Counseling to Reduce Sedentary Behaviors and Depressive Symptoms and Improve Health-Related Quality of Life Among Women With Metabolic Syndrome

Background

Motivational interviewing, as a counseling approach, could promote not only behavioral changes but also individuals' psychological adaptation. Previous studies provide evidence that motivational interviewing focused on increasing physical activity decreases the risk of metabolic syndrome in women. Its effects on sedentary behaviors, depressive symptoms, and health-related quality of life (HRQL) remain unknown.

Objectives

The aim of this study was to evaluate whether a 12-week motivational counseling program reduces sedentary behaviors and depressive symptoms and improves HRQL in Taiwanese women.

Methods

A randomized controlled study was conducted. Participants (n = 115) were randomly assigned into 3 groups: experimental group (received a brochure on lifestyle modification combined with 12 weeks of motivational counseling), comparison group (received a lifestyle modification brochure), and usual care group (UCG). Outcome variables were measured at baseline and at 12 weeks post intervention by the International Physical Activity Questionnaire, Beck Depression Inventory, and Medical Outcomes Short Form-36 Health Survey. Generalized estimating equations were applied to analyze the intervention effects of groups by interaction of group and time.

Results

Women in the experimental group not only reduced (P < .001) weekly sitting time by 374 minutes but also decreased (P < .05) depressive symptoms, as well as had greater overall HRQL including 8 subscales as compared with the UCG. As compared with the UCG, the women in the comparison group had no change in sedentary behaviors, but they had reduced depressive symptoms and improvement on some HRQL subscales.

Conclusions

Motivational counseling that incorporates behavioral change principles is effective in reducing sedentary behaviors and depressive symptoms and improving HRQL for women with metabolic syndrome.

The Use of Behavior Change Theories in Dietetics Practice in Primary Health Care: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Behavior change theories frameworks provide the theoretical underpinning for effective health care. The extent to which they are applied in contemporary dietetics interventions has not been explored.

OBJECTIVE

To systematically review the evidence of behavior change theory-based interventions delivered by credentialed nutrition and dietetics practitioners in primary health care settings.

METHODS

Medline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Embase, and Cochrane databases were searched for English language, randomized controlled trials before August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. Eligible interventions included adults (aged ≥18 years) receiving face-to-face dietetics care underpinned by behavior change theories in primary health care settings with outcome measures targeting changes in health behaviors or health outcomes. Screening was conducted independently in duplicate and data were extracted using predefined categories. The quality of each study was assessed using the Cochrane Risk of Bias tool. The body of evidence was assessed using the Academy of Nutrition and Dietetics Evidence Analysis Manual Conclusion Grading Table.

RESULTS

Thirty articles reporting on 19 randomized controlled trials met the eligibility criteria, representing 5,172 adults. Thirteen studies (68%) showed significant improvements for the primary outcome measured. Social cognitive theory was the behavior change theory most commonly applied in interventions (n=15) with 11 finding significant intervention effects. Goal setting, problem solving, social support, and self-monitoring were the most commonly reported techniques (n=15, n=14, n=11, and n=11, respectively). Most studies had a high (n=11) or unclear (n=8) risk of bias. There was fair evidence (Grade II) supporting the use of behavior change theories to inform development of dietetics interventions.

CONCLUSIONS

Interventions delivered by credentialed nutrition and dietetics practitioners that were underpinned by behavior change theories and utilizing various behavior change techniques were found to have potential to be more effective at improving patient health outcomes than dietary interventions without theoretical underpinnings. Findings from this review should inform future primary health care research in the area of dietary behavior change. In addition, findings from this review highlight the need for stronger documentation of use of behavior change theory and techniques that map on to the theory within dietetics practice.

Lifestyle and Psychosocial Patterns and Diabetes Incidence Among Women with and Without Obesity: a Prospective Latent Class Analysis

We conducted latent class analyses to identify women with homogeneous combinations of lifestyle and behavioral variables and tested whether latent classes were prospectively associated with diabetes incidence for women with or without baseline obesity. A total of 64,710 postmenopausal women aged 50-79 years without prevalent diabetes at baseline (years 1993-1998) were followed until 2018 with a mean follow-up of 14.6 years (sd = 6.4). Lifestyle variables included smoking, diet quality, physical activity, and sleep quality. Psychosocial variables included social support, depression, and optimism. Multivariable Cox proportional hazards regression models tested associations between latent classes and diabetes incidence controlling for age, race/ethnicity, and education. During follow-up, 8076 (12.4%) women developed diabetes. For women without baseline obesity, five latent classes were identified. Compared with a lower risk referent, diabetes incidence was higher in classes characterized by high probability of multiple lifestyle and psychosocial risks (HR = 1.45; 95% CI 1.28, 1.64), poor diet and exercise (HR = 1.23; 95% CI 1.13, 1.33), and psychosocial risks alone (HR = 1.20; 95% CI 1.12, 1.29). For women with baseline obesity, four latent classes were identified. Compared with a lower risk referent, diabetes incidence was higher for women with obesity in classes characterized by high probability of multiple lifestyle and psychosocial risks (HR = 1.48; 95% CI 1.32, 1.66), poor diet and exercise (HR = 1.32; 95% CI 1.19, 1.47), and intermediate probabilities of multiple risks (HR = 1.17; 95% CI 1.05, 1.30). Diabetes prevention efforts that focus on diet and exercise may benefit from attention to how lifestyle behaviors interact with psychosocial variables to increase diabetes risks, and conversely, how psychological or social resources may be leveraged with lifestyle changes to reduce the risk for women with and without obesity.

New Possibilities in Life with Type 2 Diabetes: Experiences from Participating in a Guided Self-Determination Programme in General Practice

Research suggests that guided self-determination programmes can support self-management of diabetes by empowering self-determined goal setting and competence building. As most research in this area has focused on people with type 1 diabetes, knowledge is lacking on how adults with type 2 diabetes mellitus experience participation in such programmes. This study reports the modelling phase of a complex intervention design that explored the experiences of adults with type 2 diabetes who participated in a nurse-led guided self-determination programme in general practice and examines how the programme affected patients' motivation to self-manage diabetes. The qualitative design with semistructured interviews included 9 adults with type 2 diabetes who participated in the programme. Qualitative content analysis was used to analyse the data. The findings indicate that the participants experienced new life possibilities after participating in the programme, which seemed to have a positive influence on their motivation for self-management. Through reflections about how to live with diabetes, the participants reinterpreted their life with diabetes by gradually developing a closer relationship with the disease, moving towards acceptance. The fact that dialogue with the nurses was seen to be on an equal footing helped support the participants to become more self-determined.