Roles and competencies of the clinical psychologist in adult diabetes care-A consensus report

AIMS

Psychological care is recognised as an integral part of quality diabetes care. We set out to describe the roles and competencies of the clinical psychologist as a member of the multidisciplinary adult diabetes care team, focused on secondary care.

METHODS

The authors are clinically experienced psychologists involved in adult diabetes care, from Australia, Europe and North America, and active members of the international psychosocial aspects of diabetes study group. Consensus was reached as a group on the roles and competencies of the clinical psychologist working in adult diabetes secondary care, building both on expert opinion and a selective review and discussion of the literature on psychological care in diabetes, clinical guidelines and competency frameworks.

RESULTS

The clinical psychologist fulfils multiple roles: (1) as a clinician (psychological assessment and therapy), (2) as advisor to the healthcare team (training, consulting), (3) as a communicator and promotor of person-centred care initiatives and (4) as a researcher. Four competencies that are key to successfully fulfilling the above-mentioned roles in a diabetes setting are as follows: (a) specialised knowledge, (b) teamwork and advice, (c) assessment, (d) psychotherapy (referred to as STAP framework).

CONCLUSIONS

The roles and competencies of clinical psychologists working in diabetes extend beyond the requirements of most university and post-graduate curricula. There is a need for a comprehensive, accredited specialist post-graduate training for clinical psychologists working in diabetes care, building on the proposed STAP framework. This calls for a collaborative effort involving diabetes organisations, clinical psychology societies and diabetes psychology interest groups.

Integrating health geography and behavioral economic principles to strengthen context-specific behavior change interventions

The long-term economic viability of modern health care systems is uncertain, in part due to costs of health care at the end of life and increasing health care utilization associated with an increasing population prevalence of multiple chronic diseases. Control of health care spending and sustaining delivery of health care services will require strategic investments in prevention to reduce the risk of disease and its complications over an individual's life course. Behavior change interventions aimed at reducing a range of harmful and risky health-related behaviors including smoking, physical inactivity, excess alcohol consumption, and excess weight, are one approach that has proven effective at reducing risk and preventing chronic disease. However, large-scale efforts to reduce population-level chronic diseases are challenging and have not been very successful at reducing the burden of chronic diseases. A new approach is required to identify when, where, and how to intervene to disrupt patterns of behavior associated with high-risk factors using context-specific interventions that can be scaled. This paper introduces the need to integrate theoretical and methodological principles of health geography and behavioral economics as opportunities to strengthen behavior change interventions for the prevention of chronic diseases. We discuss how health geography and behavioral economics can be applied to expand existing behavior change frameworks and how behavior change interventions can be strengthened by characterizing contexts of time and activity space.

Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

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

Background

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

Methods

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

Results

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

Conclusion

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

Transforming the landscape of obesity education - The Canadian obesity education competencies

Background

With ongoing gaps in obesity education delivery for health professions in Canada and around the world, a transformative shift is needed to address and mitigate weight bias and stigma, and foster evidence-based approaches to obesity assessment and care in the clinical setting. Obesity Canada has created evidence-based obesity competencies for medical education that can guide curriculum development, assessment and evaluation and be applied to health professionals' education programs in Canada and across the world.

Methods

The Obesity Canada Education Action Team has seventeen members in health professions education and research along with students and patient experts. Through an iterative group consensus process using four guiding principles, key and enabling obesity competencies were created using the 2015 CanMEDS competency framework as its foundation. These principles included the representation of all CanMEDS Roles throughout the competencies, minimizing duplication with the original CanMEDS competencies, ensuring obesity focused content was informed by the 2020 Adult Obesity Clinical Practice Guidelines and the 2019 US Obesity Medication Education Collaborative Competencies, and emphasizing patient-focused language throughout.

Results

A total of thirteen key competencies and thirty-seven enabling competencies make up the Canadian Obesity Education Competencies (COECs).

Conclusion

The COECs embed evidence-based approaches to obesity care into one of the most widely used competency-based frameworks in the world, CanMEDS. Crucially, these competencies outline how to address and mitigate the damaging effects of weight bias and stigma in educational and clinical settings. Next steps include the creation of milestones and nested Entrustable Professional Activities, a national report card on obesity education for undergraduate medical education in Canada, and Free Open Access Medication Education content, including podcasts and infographics, for easier adoption into curriculum around the world and across the health professions spectrum.

Review of an international pilot project to adapt the Canadian Adult Obesity Clinical Practice Guideline

Background

The evidence-based Canadian Adult Obesity Clinical Practice Guideline (CPG) released in August 2020 were developed through a systematic literature review and patient-oriented research process. This CPG is considered a paradigm shift for obesity care as it introduced a new obesity definition that is based on health not body size, incorporates lived experiences of people affected by obesity, and addresses the pervasive weight bias and stigma that patients face in healthcare systems. The purpose of this pilot project was to assess the feasibility of adapting the Canadian CPG in Chile and Ireland.

Methods

An International Clinical Practice Guideline Adaptation Committee was established to oversee the project. The project was conducted through four interrelated phases: 1) planning and preparation; 2) pilot project application process; 3) adaptation; and 4) launch, dissemination, and implementation. Ireland used the GRADE-ADAPTE framework and Chile used the GRADE-ADOLOPMENT approach.

Results

Chile and Ireland developed their adapted guidelines in one third of the time it took to develop the Canadian guidelines. In Ireland, 18 chapters, which underpin the 80 key recommendations, were contextually adapted. Chile adopted 18 chapters and 76 recommendations, adapted one recommendation, and developed 12 new recommendations.
.

Conclusion

The pilot project demonstrated it is feasible to adapt the Canadian CPG for use in other countries with different healthcare systems, languages, and cultural contexts, while retaining the Canadian CPG's key principles and values such as the treatment of obesity as a chronic disease, adoption of new clinical assessment approaches that go beyond anthropometric measurements, elimination of weight bias and stigma, shifting obesity care outcomes to improved health and well-being rather than weight loss alone, and the use of patient-centred, collaborative and shared-decision clinical care approaches.

Moving beyond eat less, move more using willpower: Reframing obesity as a chronic disease impact of the 2020 Canadian obesity guidelines reframed narrative on perceptions of self and the patient-provider relationship

Obesity is becoming recognized as a complex, chronic medical condition. However, the dominant treatment narrative remains that goal weight can be achieved by eating less, moving more using willpower, placing responsibility for change on the person with obesity (PwO). This study evaluated the impact of revising this narrative, to viewing obesity as a treatable medical condition, on internalized weight bias and perceived patient-provider relationship. PwO were recruited into an online study in which two videos were presented; the first showing a traditional doctor endorsing the eat less, move more approach, and the second showing a doctor describing obesity as a treatable medical condition. After each video participants were asked to imagine that they were being treated by that doctor and completed the Weight Bias Internalization Scale (WBIS) and the Patient-Health Care Provider Communication Scale (PHCPCS). A total of 61 PwO (52% response rate) completed the protocol. Compared to the traditional narrative video, the revised narrative video resulted in significant reductions in WBIS scores and significant increases in the PHCPCS scores and was preferred by participants. Within the context of this small-scale study evidence supports that the revised narrative promoting obesity as a complex, chronic but treatable medical condition that is not the result of personal failure has a positive impact on the perceived patient-provider relationship and is associated with reductions in internalized weight bias. This evidence supports the need to help PwO reframe obesity from a personal failure to a legitimate medical condition worthy of care.

A scoping review of obesity education interventions for current and prospective medical professionals in Canada

Background

Obesity is a prevalent chronic disease in Canada. Individuals living with obesity frequently interact with medical professionals who must be prepared to provide evidence-based and person-centred care options. The purpose of this scoping review was to summarize existing educational interventions on obesity in Canada for current and prospective medical professionals and to identify key future directions for practice and research.

Methods

A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The search strategy was conducted using Medline (via PubMed), Embase, Eric, CBCA, Proquest Education, and Proquest Theses. The inclusion criteria included delivery of an educational intervention on obesity for current medical professionals, medical undergraduate trainees, or residents administered in Canada. Data were extracted from the included studies to thematically summarize the intervention content, and main outcomes assessed. Future directions for research and practice were identified.

Results

Eight studies met the inclusion criteria. The interventions ranged in terms of the mode of delivery, including interactive in-person workshops and seminars, online learning modules, webinars, and videos. The main outcomes assessed were attitudes towards patients living with obesity, self-efficacy for having sensitive obesity-related discussions, skills to assess obesity and provision of management options. All studies reported improvements in the outcomes. Future directions identified were the need to develop standardized obesity competencies for inclusion across medical education programs, further research on effective pedagogical approaches to integrating content into existing curricula and the need for broader awareness and assessment of the quality of obesity education resources.

Conclusion

Although there have been few obesity-specific educational interventions for current and prospective medical professionals in Canada, existing evidence shows positive learning outcomes. These findings advocate for continued investment in the development of obesity medical training and educational interventions.

Guardians For Health: A Practical Approach to Improving Quality of Life and Longevity in People with Type 2 Diabetes

Type 2 diabetes is one of the fastest-growing health emergencies of the twenty-first century, in part due to its association with cardiovascular and renal disease. Successful implementation of evidence-based guidelines for the management of patients with diabetes and pre-diabetes has been shown to improve patient outcomes by controlling risk factors for cardiovascular and renal disease. Recommendations include the early introduction of lifestyle adjustments, supported by pharmacological tools. Despite the availability of regularly updated, evidence-based guidelines, guideline implementation in clinical practice is low. As a result, people living with type 2 diabetes are not consistently receiving ideal clinical care. Improving guideline adherence has the potential to improve quality of life and longevity in patients with type 2 diabetes. This article introduces Guardians For Health, a global initiative that aims to improve guideline adherence by simplifying patient management and encouraging patient participation in the implementation of guidelines for type 2 diabetes. Guardians For Health is supported by a global community of implementers, with tools to support decision-making and quality assurance. Through achieving better guideline adherence, Guardians For Health hopes to achieve its vision to "stop early mortality by reducing cardiovascular and kidney complications in people with type 2 diabetes".

How Continuous Glucose Monitoring Can Motivate Self-Management: Can Motivation Follow Behaviour?

INTRODUCTION

Motivation to adhere to clinical recommendations requires engagement and urgency to act is one of many factors that contribute to achieving glycemic benefits in people with type 2 diabetes (PwT2D). Continuous glucose monitoring (CGM) devices are associated with improved glycemic benefits. We conducted a qualitative assessment of PwT2D who found using CGM extremely beneficial, examining the potential for CGM to elicit motivation to engage in self-management behaviours.

METHODS

Participants using CGM were recruited through social media, interviewed and transcripts analyzed (template analysis using thematic analysis) to generate coded responses and inductive themes by two raters.

RESULTS

Thirteen participants (84.6% women, T2D > 5 years and CGM usage > 6 months) were interviewed. Codes were organized around 3 themes: improved self-management; experience of glucose sensing technology vis-a-vis general positive or negative experience. Improved self-management was reflected in how the CGM technology provided personalized knowledge and ability to self-manage, particularly in contrast to finger pricking. Positive experience included motivation for behaviour changes, improved relationships with healthcare providers and in social situations. This translated into a sense of improved health and an avoidance of complications. Negative experience included costs, concern over location and comfort of the device.

CONCLUSIONS

CGM technology profoundly impacts multiple aspects of self-management and care for PwT2D. Developing a validated instrument to assess identified constructs could contribute to developing interventions leveraging benefits of this technology, particularly with regard to the motivational constructs of engagement and urgency.

Rethinking weight: Finding self-compassion for 'weight management'

Conventional weight management approaches emphasize engaging in health behaviours, such as healthy eating and physical activity, to control body weight and promote favourable health outcomes (e.g., lower blood pressure). However, weight management is a multi-faceted, complex process influenced by numerous factors that limit the impact of behaviour change on weight. Self-compassion, treating oneself kindly in times of increased distress or difficulty, may offer a way for individuals to cope with the challenges of managing weight. The objectives of this perspective paper are threefold: (1) to conceptualize weight management, (2) to describe the problem that arises when focusing solely on weight loss, and (3) to explore the theoretical rationale for integrating self-compassion into weight management interventions. To support individual health and well-being, there is a need to reframe measures of success and provide innovative ways to cope with the challenges of managing body weight. Continued research is needed to investigate whether self-compassion can support health outcomes for those with weight management goals. This manuscript provides a proposed research agenda and implications for future practice.

Behaviour Change to Promote Diabetes Outcomes: Getting More From What We Have Through Dissemination and Scalability

The potential benefits of advanced medical treatments (pharmacotherapies) and technologies (diagnostics, devices and apps) are unrealized due to lack of sustained behaviour change in individuals living with type 2 diabetes. The lack of scale-up of effective health behaviour change interventions limits health improvement. Identification of mediators of behaviour change (adherence, self-efficacy, intrinsic motivation) can address this limitation by shifting the focus of behaviour change from input (which behaviour change strategy to choose) to output (what can the person adhere to and sustain). Technology and accessing the workplace environment to promote change offer scalable opportunities for facilitating health behaviour change in populations.

Understanding strategies to improve medication adherence among persons with type 2 diabetes: A scoping review

AIMS

The objectives of this scoping review were to: (1) identify the target audience and contexts in which strategies to improve type 2 diabetes mellitus (T2DM) medication adherence have been used, (2) provide an overview of behaviour change techniques (BCTs) used, (3) describe the determinants of behaviour targeted by strategies and (4) to identify current gaps in strategies.

METHODS

A systemic search for articles related to T2DM, medication adherence and strategies was conducted in EMBASE, Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily using the OvidSP platform on 11 March 2021. All publications involving strategies to overcome medication non-adherence among adults with T2DM were included. Strategies were categorized according to the BCT taxonomy and the determinants of behaviour targeted by each strategy were classified by using the Theoretical Domains Framework (TDF).

RESULTS

The search identified 58 articles and 61 strategies. The BCT categories Antecedents and Natural consequences and BCTs Feedback on outcome(s) of behaviour, Adding objects to the environment and Information about health consequences were identified most frequently as components of strategies resulting in statistically significant improvement in medication adherence. Strategies targeting the TDF domains Reinforcement and Beliefs about Consequences most often resulted in statistically significant improvements in adherence measures.

CONCLUSIONS

The findings from this review identify BCTs and targeted behaviours with demonstrated success. Further exploration of the myriad of BCTs and the corresponding determinants of behaviour which were not accessed may be warranted for the development of future strategies to improve medication adherence in type 2 diabetes.

Adherence to Treatment Recommendations in Chronic Disease: What Is (Im)Possible? Expert Conclusions from the 30th ECOG Workshop 2021

Obesity is a chronic disease, in which treatment outcomes are highly dependent on patient and family adherence to behavioural recommendations. The role of healthy eating, physical activity, medication adherence as well as adherence to pre- and post-bariatric surgery protocols are of utmost importance for long-term treatment outcomes. Even the best interventions are not likely to reach their maximum benefit without significant levels of adherence on the part of the individual and family. Traditionally, the annual meeting of the European Childhood Obesity Group (ECOG) includes an expert workshop addressing one specific topic within the field of childhood obesity. During the 30th annual meeting, hosted by the University of Pécs, Hungary, as a virtual meeting, "adherence to treatment recommendations in obesity as a chronic disease" was addressed. The discussions that developed during the workshop are summarized in the following article.

Exploring weight bias internalization in pregnancy

Background

Recent research has shown that pregnant individuals experience weight stigma throughout gestation, including negative comments and judgement associated with gestational weight gain (GWG). Weight bias internalization (WBI) is often a result of exposure to weight stigma and is detrimental to biopsychological health outcomes. The purpose of this study was to explore WBI in pregnancy and compare scores based on maternal weight-related factors including pre-pregnancy body mass index (BMI), obesity diagnosis and excessive GWG.

Methods

Pregnant individuals in Canada and USA completed a modified version of the Adult Weight Bias Internalization Scale. Self-reported pre-pregnancy height and weight were collected to calculate and classify pre-pregnancy BMI. Current weight was also reported to calculate GWG, which was then classified as excessive or not based on Institute of Medicine (2009) guidelines. Participants indicated if they were diagnosed with obesity by a healthcare provider. Inferential analyses were performed comparing WBI scores according to pre-pregnancy BMI, excessive GWG, and obesity diagnosis. Significance was accepted as p < 0.05 and effect sizes accompanied all analyses.

Result

336 pregnant individuals completed the survey, with an average WBI score of 3.9 ± 1.2. WBI was higher among those who had a pre-pregnancy BMI of obese than normal weight (p = 0.04, η² = 0.03), diagnosed with obesity than not diagnosed (p < 0.001, Cohen’s d = 1.3), and gained excessively versus not (p < 0.001, Cohen’s d = 1.2).

Conclusions

Pregnant individuals who have a higher BMI, obesity and gain excessively may experience WBI. Given that weight stigma frequently occurs in pregnancy, effective person-oriented strategies are needed to mitigate stigma and prevent and care for WBI.

Assessing Physician's Motivational Communication Skills: 5-Step Mixed Methods Development Study of the Motivational Communication Competency Assessment Test

BACKGROUND

Training physicians to provide effective behavior change counseling using approaches such as motivational communication (MC) is an important aspect of noncommunicable chronic disease prevention and management. However, existing evaluation tools for MC skills are complex, invasive, time consuming, and impractical for use within the medical context.

OBJECTIVE

The objective of this study is to develop and validate a short web-based tool for evaluating health care provider (HCP) skills in MC-the Motivational Communication Competency Assessment Test (MC-CAT).

METHODS

Between 2016 and 2021, starting with a set of 11 previously identified core MC competencies and using a 5-step, mixed methods, integrated knowledge translation approach, the MC-CAT was created by developing a series of 4 base cases and a scoring scheme, validating the base cases and scoring scheme with international experts, creating 3 alternative versions of the 4 base cases (to create a bank of 16 cases, 4 of each type of base case) and translating the cases into French, integrating the cases into the web-based MC-CAT platform, and conducting initial internal validity assessments with university health students.

RESULTS

The MC-CAT assesses MC competency in 20 minutes by presenting HCPs with 4 out of a possible 16 cases (randomly selected and ordered) addressing various behavioral targets (eg, smoking, physical activity, diet, and medication adherence). Individual and global competency scores were calculated automatically for the 11 competency items across the 4 cases, providing automatic scores out of 100. From the factorial analysis of variance for the difference in competency and ranking scores, no significant differences were identified between the different case versions across individual and global competency (P=.26 to P=.97) and ranking scores (P=.24 to P=.89). The initial tests of internal consistency for rank order among the 24 student participants were in the acceptable range (α=.78).

CONCLUSIONS

The results suggest that MC-CAT is an internally valid tool to facilitate the evaluation of MC competencies among HCPs and is ready to undergo comprehensive psychometric property analyses with a national sample of health care providers. Once psychometric property assessments have been completed, this tool is expected to facilitate the assessment of MC skills among HCPs, skills that will better support patients in adopting healthier lifestyles, which will significantly reduce the personal, social, and economic burdens of noncommunicable chronic diseases.

Adaptive web-based stress management programs among adults with a cardiovascular disease: A pilot Sequential Multiple Assignment Randomized Trial (SMART)

OBJECTIVE

To assess the feasibility and acceptability of using a Sequential Multiple Assignment Randomized Trial (SMART) to optimize the delivery of a web-based, stress management intervention for patients with a cardiovascular disease (CVD).

METHODS

59 patients with a CVD and moderate stress were randomized to a self-directed web-based stress management program (n = 30) or the same intervention plus lay telephone coaching (n = 29). After 6 weeks, non-responders were re-randomized to continue with their initial intervention or switched to motivational interviewing (MI). Feasibility, acceptability, and clinical significance were assessed.

RESULTS

SMART procedures were feasible. Attrition rates were almost twice as high in the web-only group than the lay coach group. This might be because of the low satisfaction (47%) in the web-only group. On average, 1.7/5 modules were completed. Effect sizes for stress and quality of life generally exceeded 0.2 (clinical benchmark), except for the group that initially received lay coaching and then switched to MI.

CONCLUSIONS

Results suggest that a larger trial would be feasible. Issues pertaining to attrition and satisfaction for non-responders need to be addressed.

PRACTICE IMPLICATIONS

Findings contribute to the evidence on how best to develop and deliver e-Health interventions to maximize their efficacy while remaining cost-effective.

User-driven open-source artificial pancreas systems and patient-reported outcomes: A missed opportunity?

AIM

This paper aims to highlight the attributes of engagement and urgency to act to control diabetes demonstrated by open-source artificial pancreas system users with the view that increased user involvement in research and practice can capitalize on these self-management traits; and to outline the challenges of researching outcomes in the context of unlicensed therapies.

METHODS

A group of technically minded people with type 1 diabetes have reverse-engineered commercially available diabetes devices to help them achieve the diabetes outcomes they desire. Although studies have reported improved biomedical outcomes with these artificial pancreas systems, there are only a few studies examining patient-reported outcomes.

RESULTS

The investigation of patient-reported outcomes for open-source artificial pancreas system users has been hampered by the rapid advances in the technology, the lack of randomized controlled trials and the ethical challenges of researching unregulated technologies. There is an on-going debate about the most appropriate types of measures to evaluate patient-related outcomes.

CONCLUSIONS

The early adopters of open-source artificial pancreas systems exhibit many of the characteristics that predict optimal diabetes outcomes through engagement and urgency regarding self-management. These qualities should be harnessed to improve research in this and other areas of diabetes management.

Understanding national trends in COVID-19 vaccine hesitancy in Canada: results from five sequential cross-sectional representative surveys spanning April 2020-March 2021

OBJECTIVE

To examine rates of vaccine hesitancy and their correlates among Canadian adults between April 2020 and March 2021.

DESIGN

Five sequential cross-sectional age, sex and province-weighted population-based samples who completed online surveys.

SETTING

Canada.

PARTICIPANTS

A total of 15 019 Canadians aged 18 years and over were recruited through a recognised polling firm (Leger Opinion). Respondents were 51.5% female with a mean age of 48.1 (SD 17.2) years (range 18-95 years) and predominantly white (80.8%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates of vaccine hesitancy over the five surveys (time points) and their sociodemographic, clinical and psychological correlates.

RESULTS

A total of 42.2% of respondents reported some degree of vaccine hesitancy, which was lowest during surveys 1 (April 2020) and 5 (March 2021) and highest during survey 3 (November 2020). Fully adjusted multivariate logistic regression analyses revealed that women, those aged 50 and younger, non-white, those with high school education or less, and those with annual household incomes below the poverty line in Canada were significantly more likely to report vaccine hesitancy, as were essential and healthcare workers, parents of children under the age of 18 and those who do not get regular influenza vaccines. Endorsing prevention behaviours as important for reducing virus transmission and high COVID-19 health concerns were associated with 77% and 54% reduction in vaccine hesitancy, respectively. Having high personal financial concerns was associated with 1.33 times increased odds of vaccine hesitancy.

CONCLUSIONS

Results highlight the importance of targeting vaccine efforts to specific groups by emphasising the outsized health benefits compared with risks of vaccination. Future research should monitor changes in vaccine intentions and behaviour to better understand underlying factors.

A26 DECONSTRUCTING DISTRESS: STAKEHOLDER ENGAGEMENT FOR EVIDENCE-BASED, PATIENT-CENTERED INTERVENTIONS FOR THE MANAGEMENT OF IBD-ASSOCIATED PSYCHOLOGICAL DISTRESS

Background

The growing prevalence of Inflammatory Bowel Disease (IBD) along with increasing complexity of providing high-quality, patient-centered care within a resource-constrained healthcare environment presents a major challenge. IBD-related psychological distress (IBD-PD) is the emotional impact of IBD and is associated with mental health disorders, increased disease severity, and premature mortality. With estimates of nearly 90% of IBD patients experiencing PD, the inability to provide high-quality, person-centered care for IBD-PD that is proportionate to clinical need is a significant care gap in the Canadian healthcare system.

Aims

To generate stakeholder-derived data to inform the design and development of stepped-intensity, cognitive behavioral therapy-based interventions for IBD-PD using evidence-based, patient–centered interventions and implementation strategies.

Methods

Virtual semi-structured interviews were conducted from September to October 2021. The interview guide was developed iteratively by researchers, IBD care providers, and patient research partners and guided by the COM-B Model of Behaviour and the Theoretical Domains Framework. Questions assessed perceptions, experiences, barriers, and facilitators to accessing IBD-PD care. Adults diagnosed with IBD were recruited from academic centers across Canada. Interviews were co-facilitated by a researcher and patient research partner, audio recorded, and transcribed. Using thematic analysis, codes were generated to identify themes using an inductive approach.

Results

As of October 2021, six interviews have been completed, with data collection ongoing. The mean participant age was 34.3 years (range 21–55 years) with 100% of respondents being female. The majority of participants worked full time (4/6, 67%) and all had completed at least high school. Diagnoses of Crohn’s Disease (3/6, 50%) and ulcerative colitis (3/6, 50%) were evenly distributed. Thematic analyses identified five major themes: 1) Lack of holistic care and acknowledgement of IBD-PD; 2) System-level and financial barriers to psychological support; 3) Lack of psychological support from providers with an understanding of IBD; 4) Preference for individualized virtual-based support; 5) Heavy reliance on informal support structures (caregivers) due to lack of access to formal psychological support.

Conclusions

As part of human-centered design, stakeholder engagement is key to understanding behavioral, social, attitudinal, and environmental barriers and facilitators for accessing IBD-PD care. Interviews are ongoing and specific intervention functions will be defined and incorporated into patient-centered implementation strategies.

Funding Agencies

None

Weight gain, weight management and medical care for individuals living with overweight and obesity during the COVID‐19 pandemic (EPOCH Study)

Objective

Medical care and weight related experiences have been challenged by the coronavirus disease 2019 (COVID‐19) pandemic for those living with obesity. The magnitude of this impact requires further attention in order to optimize patient care and outcomes. The aim of this study was to assess the impact of the COVID‐19 pandemic and lockdown on access to, and experience of, medical care, weight gain and management strategies, as well as predictors of weight gain.

Methods

An online survey (June–October 2020) was conducted with two samples; one representative of Canadians living with overweight and obesity (n = 1089) and a second of individuals recruited through obesity clinical services or patient organizations (n = 980).

Results

Less than half of the total respondents thought that their providers were available for their medical care and most preferred in‐person appointments over telemedicine. Only one quarter were satisfied with their obesity care. Sixty percent of the respondents reported weight gain (on average 5.65 kilograms [kg] gained), with 39.0% gaining more than 5% of their body weight (10.2% gained more than 10%). Over half of the respondents experienced decreased motivation for healthy eating or exercise. One third experienced more frequent and greater food consumption. Although worsening sleep occurred in approximately 20%, there was no significant increase in smoking, alcohol, or cannabis use. Predictors of weight gain were younger patients, higher weight categories, those who struggled with obtaining medical care during the pandemic, as well as those who struggled with eating.

Conclusion

These results suggest that the COVID‐19 pandemic negatively impacted patient care for those living with overweight and obesity and was associated with weight gain and interfered with weight management strategies. Greater attention to personalized weight management and interventions that focus on the predictors of weight gain should be undertaken.

How well do covariates perform when adjusting for sampling bias in online COVID-19 research? Insights from multiverse analyses

COVID-19 research has relied heavily on convenience-based samples, which-though often necessary-are susceptible to important sampling biases. We begin with a theoretical overview and introduction to the dynamics that underlie sampling bias. We then empirically examine sampling bias in online COVID-19 surveys and evaluate the degree to which common statistical adjustments for demographic covariates successfully attenuate such bias. This registered study analysed responses to identical questions from three convenience and three largely representative samples (total N = 13,731) collected online in Canada within the International COVID-19 Awareness and Responses Evaluation Study ( www.icarestudy.com ). We compared samples on 11 behavioural and psychological outcomes (e.g., adherence to COVID-19 prevention measures, vaccine intentions) across three time points and employed multiverse-style analyses to examine how 512 combinations of demographic covariates (e.g., sex, age, education, income, ethnicity) impacted sampling discrepancies on these outcomes. Significant discrepancies emerged between samples on 73% of outcomes. Participants in the convenience samples held more positive thoughts towards and engaged in more COVID-19 prevention behaviours. Covariates attenuated sampling differences in only 55% of cases and increased differences in 45%. No covariate performed reliably well. Our results suggest that online convenience samples may display more positive dispositions towards COVID-19 prevention behaviours being studied than would samples drawn using more representative means. Adjusting results for demographic covariates frequently increased rather than decreased bias, suggesting that researchers should be cautious when interpreting adjusted findings. Using multiverse-style analyses as extended sensitivity analyses is recommended.

Alleviating carbohydrate counting with a FiASP-plus-pramlintide closed-loop delivery system (artificial pancreas): Feasibility and pilot studies

AIM

To assess whether a FiASP-and-pramlintide closed-loop system has the potential to replace carbohydrate counting with a simple meal announcement (SMA) strategy (meal priming bolus without carbohydrate counting) without degrading glycaemic control compared with a FiASP closed-loop system.

MATERIALS AND METHODS

We conducted a 24-hour feasibility study comparing a FiASP system with full carbohydrate counting (FCC) with a FiASP-and-pramlintide system with SMA. We conducted a subsequent 12-day outpatient pilot study comparing a FiASP-and-placebo system with FCC, a FiASP-and-pramlintide system with SMA, and a FiASP-and-placebo system with SMA. Basal-bolus FiASP-and-pramlintide were delivered at a fixed ratio (1 U:10 μg). Glycaemic outcomes were measured, surveys evaluated gastrointestinal symptoms and diabetes distress, and participant interviews helped establish a preliminary coding framework to assess user experience.

RESULTS

Seven participants were included in the feasibility analysis. Time spent in 3.9-10 mmol/L was similar between both interventions (81%-84%). Four participants were included in the pilot analysis. Time spent in 3.9-10 mmol/L was similar between the FiASP-and-placebo with FCC and FiASP-and-pramlintide with SMA interventions (70%), but was lower in the FiASP-and-placebo with SMA intervention (60%). Time less than 3.9 mmol/L and gastrointestinal symptoms were similar across all interventions. Emotional distress was moderate at baseline, after the FiASP-and-placebo with FCC and SMA interventions, and fell after the FiASP-and-pramlintide with SMA intervention. SMA reportedly afforded participants flexibility and reduced mealtime concerns.

CONCLUSIONS

The FiASP-and-pramlintide system has the potential to substitute carbohydrate counting with SMA without degrading glucose control.

Protecting individuals living with overweight and obesity: Attitudes and concerns toward COVID-19 vaccination in Canada

OBJECTIVE

The aim of this study was to assess attitudes toward coronavirus disease 2019 (COVID-19) vaccination and the degree of fear of COVID-19 among those living with obesity.

METHODS

Two samples were recruited for an online survey: one sample was a representative sample of Canadians living with overweight and obesity (n = 1,089), and the second was a convenience sample of individuals recruited from obesity clinical services or patient organizations (n = 980). Respondents completed ratings of their comfort receiving a COVID-19 vaccination along with the Vaccine Hesitancy Scale and the Fear of COVID-19 Scale.

RESULTS

Approximately one-third of respondents, regardless of sample or weight category, were not comfortable receiving a vaccination, and one-half expressed moderate or greater perceived risks of vaccination. Confidence in vaccinations was extremely low, especially for those in the clinical sample. Fear of COVID-19 was substantial and predicted attitudes toward vaccination. Females were less comfortable receiving the vaccine and perceived more risks than males.

CONCLUSIONS

These results suggest those living with obesity are highly ambivalent about COVID-19 vaccination. Despite their being at high risk, their confidence in vaccines is very low. Results suggest the need for patient-centered counseling, with a focus on shared decision-making to strengthen confidence and reduce perceived risk.

Comparing a Clinician Assisted and App-Supported Positive Psychiatry Behavioral Activation Intervention

Positive psychiatry offers a unique approach to promote brain health and well-being in aging populations. Health interventions are increasingly becoming available using self-guided apps, however, little is known about the effectiveness of app technology or the difference between in-person versus self-guided app methodology for behavioural activation. The objective of this study was to investigate the difference in users and outcomes between two formats of a positive psychiatry intervention to promote brain health and well-being in later-life: (1) clinician-assisted, and (2) independent app use for self-management. As part of a larger national knowledge translation intervention two methods of a behavioural activation intervention (Clinician-assisted vs. Independent app use) were retrospectively compared. Main outcomes were patient characteristics (age, sex, and completion rate), psychological outcomes (health and resilience, and well-being), and behavioural outcomes (goal attainment, and items of goal SMART-ness). Clinician-assisted patients (n=254) were more likely to be male, older, and had lower health and resilience scores at baseline than Independent app users (n=333). Clinician-assisted patients had notably higher completion rates (99.2% vs. 10.8%). Psychological outcomes were similar regardless of intervention method for those who completed the intervention. Clinician-assisted patients had higher rates of goal attainment and goal SMART-ness. A preliminary goal setting methodology for effective behavioural activation, to promote brain health and wellness, is given. Clinician-patient relationships were found to be an important factor for intervention completion, caution is given for app use referral. Results indicate a need for further exploration to determine best practices for health app use in clinical practice.

The LISA randomized trial of a weight loss intervention in postmenopausal breast cancer

Obesity has been associated with poor breast cancer (BC) outcomes. We investigated whether a standardized, telephone-based weight loss lifestyle intervention in the adjuvant setting would impact BC outcomes. We conducted a multicenter trial randomizing women 1:1 to mail-based educational material alone (control) or combined with a standardized, telephone-based lifestyle intervention that focused on diet, physical activity, and behavior and involved 19 calls over 2 years to achieve up to 10% weight loss. In all, 338 (of 2150 planned) T1-3, N0-3, M0 hormone receptor positive BC patients with body mass index (BMI) ≥24 kg/m2 receiving adjuvant letrozole were randomized (enrolment ended due to funding loss). The primary outcome was disease-free survival (DFS); secondary outcome was Overall Survival (OS). At 8 years' median follow-up, in a planned analysis, DFS and OS were compared using the Kaplan-Meier method. Baseline BMI and other characteristics were similar between study arms. In all, 22 of 171 (12.9%) in the lifestyle intervention arm versus 30 of 167 (18.0%) in the education had DFS events; the hazard ratio (HR) was 0.71 (95% confidence interval [CI]: 0.41-1.24, p = 0.23). Although loss of funding reduced sample size, we view these hypothesis generating results as compatible with our hypothesis of a potential beneficial effect of a lifestyle intervention on DFS. They provide support for completion of ongoing randomized controlled trials of the effect of lifestyle interventions in BC outcomes.

Perceptions of barriers to effective obesity management in Canada: Results from the ACTION study

Obesity is a chronic disease with a significant and growing impact on Canadians. The "Awareness, Care and Treatment In Obesity MaNagement" (ACTION) Study investigated perceptions, attitudes and perceived barriers to obesity management among Canadian people with obesity (PwO), healthcare providers (HCPs) and employers. In this study adult PwO (body mass index ≥30 kg/m² , based on self-reported height/weight), HCPs (physicians and allied HCPs managing PwO) and employers (≥20 employees; offering health insurance), completed online surveys between 3 August and 11 October 2017 in a cross-sectional design. Survey respondents (N = 2545) included 2000 PwO, 395 HCPs and 150 employers. Obesity was viewed as a "chronic medical condition" by most PwO (60%), HCPs (94%) and employers (71%) and deemed to have a large impact on overall health (74%, 78%, 81%, respectively). Many PwO (74%) believed weight management was their own responsibility. While PwO (55%) reportedly knew how to manage their weight, only 10% reported maintaining ≥10% weight reduction for >1 year. Despite low success rates, the most commonly reported effective long-term weight loss methods tried and/or recommended were "improvements in eating habits" (PwO 38%; HCP 63%) and "being more active" (PwO 39%; HCP 54%). PwO and HCPs reported very different perceptions of the quality and content of their interaction during obesity management discussions. These findings highlight the communication gaps and misunderstanding between PwO, HCPs and employers. This underscores the importance of, and need for, evidence-based management of obesity and a collaborative approach and understanding of the complex nature of this chronic disease.

Integrating behaviour change counselling into chronic disease management: a square peg in a round hole? A system-level exploration in primary health care

OBJECTIVES

The objective of this study is to evaluate the uptake of competency-based behaviour change counselling training within a primary healthcare setting. Specific questions concerning provider readiness for training, perceived importance of training in the context of service demands and perceptions of competence after training were addressed.

STUDY DESIGN

A process-focused study which adopted a complex systems approach to implementation. Each step was evaluated before the next step was developed. The design was guided by the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.

METHODS

Four specific primary care services were identified and behaviour change counselling training tailored to each service was provided, based on a model of training built around competencies in establishing change-based relationships, assessing and promoting readiness to change, using evidence-based behaviour modification skills when ready and addressing psychosocial determinants of behaviour within scope of practice. Before training, a manager's readiness to facilitate training and identification of peer leaders to support ongoing practice of skills were completed.

RESULTS

Two programs negotiated 8 h of formal training, one program received 10 h and one program received 12 h. All programs engaged in peer support activities. Despite willingness to support training, 90% of managers were ambivalent about training activities, relative to one half of healthcare providers (HCPs). Few HCPs and no managers self-identified as ready without ambivalence. Furthermore, HCPs were reluctant to be evaluated by an expert and preferred self-evaluation methods. In contrast, HCPs uniformly endorsed the relevance, value and professional commitment to all component skills of the behaviour change counselling model. At the end of the training, over 75% of staff reported receiving formal training (reach). Almost 80% of staff reported using change-based relationship skills daily, with less frequent use of skills associated with addressing psychosocial issues. The degree of corrective feedback was generally low, however. An index of competency based on formal training, frequent use and receiving corrective feedback indicated that most HCPs did not meet these criteria.

CONCLUSION

Training in behaviour change counselling competencies was successfully implemented in this project. The vast majority of HCPs received training, despite ambivalence. Furthermore, HCPs strongly valued these skills and used them frequently. However, they were reluctant to accept corrective feedback. Future research is needed to evaluate innovative strategies to overcome obstacles to receiving corrective feedback in the use of behaviour change counselling skills.

Group-based, person-centered diabetes self-management education: healthcare professionals' implementation of new approaches

Background

Healthcare professionals’ person-centered communication skills are pivotal for delivering successful diabetes education. Many healthcare professionals favor person-centeredness as a concept, but implementation in practice remains challenging. Today, programs have often a fixed curriculum dominated by biomedical issues. Most person-centered methods are developed targeting individual consultations, although group-based programs are a widespread and efficient method of support. Person-centeredness in group-based programs requires a change in practice towards addressing biopsychosocial issues and facilitating group processes. The objective of this study was to explore how healthcare professionals implement new approaches to facilitate group-based, person-centered diabetes education targeting people with type 2 diabetes.

Methods

The study was guided by action research and divided into three studies: investigation, development, and pilot using a variety of qualitative methods. In the first study; observations across five settings were conducted. Forty-nine group participants and 13 professionals took part; the focus was to investigate approaches that supported or hindered person-centeredness in groups. Observations were supplemented by interviews (n = 12) and two focus groups (n = 16) with group participants, as well as interviews (n = 5) with professionals. In the second study; 14 professionals collaborated in two workshops to develop new approaches. In the third study, new approaches were pilot-tested using observations in three settings. Twenty-five group participants and five professionals took part. The analysis of the pilot test led to the final workshop where six professionals took part.

Results

Implementation was characterized by three categories. Some professionals chose not to implement the methods because they conflicted with their practice relying on the biomedical model. Other incorporated some approaches but was unable to structure the process, leaving participants uncertain about the aim. Finally, one setting succeeded with implementation, tailoring content and processes to group participants’ needs.

Conclusion

The use of action research created context-sensitive approaches and increased professionals’ readiness to implement. More attention should be paid to systematic training of professionals. Training should be structured stepwise incorporating techniques directed towards existing skills including ample time to train and reiterate skills.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4183-1) contains supplementary material, which is available to authorized users.

Sustained behaviour change in healthy eating to improve obesity outcomes: It is time to abandon willpower to appreciate wanting

The purpose of this study was to report on a nationally representative survey of the experience of Canadian adults regarding food cravings and the impact of these cravings on behaviour and quality of life. A total of 1532 respondents (16% of members of an online panel emailed an invitation and link) completed a nationally distributed survey. Almost two-thirds of the sample reported experiencing cravings, with women being more likely to report cravings than men. Of those with cravings, 83.1% reported moderate or strong cravings. Cravings impacted eating behaviours and quality of life, especially for those with strong cravings. Cravings were associated with being bored, emotional or watching TV. Those who identified themselves as overweight or as trying to lose weight were more likely to have cravings. Of those reporting to be overweight and trying to lose weight few experienced distress because of lack of access to help and rates of interest in being guided by healthcare professionals were low, except in those with strong cravings. These results reinforce the notion that eating behaviour may differ from other behaviours in that there is a strong drive to eat that is difficult to control for many individuals. Behavioural interventions targeting healthy eating should be developed to address this construct of drive to eat, that is, food cravings.

Abstract PD6-04: Lifestyle intervention study (LISA) in early breast cancer (BC): An RCT of the effects of a telephone-based weight loss intervention (with educational materials) vs educational materials alone on disease-free survival (DFS)

Background: Obesity has been associated with poor BC outcomes. We investigated whether a standardized, telephone-based weight loss lifestyle intervention in recently diagnosed BC patients would lower recurrence and death rates.

Methods: We conducted a multicenter RCT comparing mail-based educational material alone (control arm) or combined with a standardized, telephone-based lifestyle intervention (19 calls over 2 years, (intervention arm) that focused on diet (500-100 kcal/day deficit), physical activity (150-200 minutes of moderate-intensity activity per week) and behavior (compliance, relapse prevention) to achieve up to 10% weight loss. 338 (of 2150 planned) T1-3, N0-3, M0 ER/PgR+ BC patients with body mass index (BMI) ≥ 24 kg/m2 receiving adjuvant letrozole were randomized Aug 2007 to Jan 2010 (enrolment ended due to funding loss). Primary outcome was DFS; secondary outcome OS. Weight loss (5.3 vs 0.7% at 6 months and 3.6 vs 0.4% at 24 months in the intervention vs control arms, respectively) has been reported (JCO 2014;32:2331). At 8 years median follow-up (May 2018), DFS and OS were compared using Cox proportional hazards regression.

Results: Mean age was 61.6 vs 60.4 years, mean BMI 31.4 vs 31.0 kg/m2 and adjuvant chemotherapy was received by 56.1 vs 57.5% in intervention vs controls arms respectively. T1/T2/T3 66.7/27.5/5.9% vs 61.7/33.5/3.6% and N0/1/2+ 62.6/28.7/8.8 vs 63.5/32.3/4.2% in intervention vs controls arms respectively. HER2+ in 8.8 vs 15.0% (intervention vs control). 20 of 171 (11.7%) in the lifestyle intervention arm vs 30 of 167 (18.0%) in the mail-based arm had DFS events, HR 0.71, 95%CI 0.41-1.24, p=0.23). DFS curves separated at 2 yrs; beyond 3-3.5 yrs separation approximated 5%. In a landmark DFS analysis of women alive at 24 months, DFS HR=0.68 (0.34-1.37, p=0.28).

Conclusions: We identified fewer DFS events in the lifestyle intervention arm. Although loss of funding reduced sample size and lowered power, these results are consistent with a potential beneficial effect of a lifestyle intervention on DFS in postmenopausal ER/PgR+ BC patients. They provide strong support for completion of ongoing RCTs (e.g. BWEL) that will provide definitive evidence regarding the effect of lifestyle based weight loss on BC outcomes.

Funded by Novartis Pharmaceuticals Inc.; Sponsored by the Ontario Clinical Oncology Group

Citation Format: Goodwin PJ, Segal R, Vallis M, Ligibel JA, Pond GR, Robidoux A, Findlay BP, Gralow JR, Mukherjee SD, Levine MN, Pritchard KI. Lifestyle intervention study (LISA) in early breast cancer (BC): An RCT of the effects of a telephone-based weight loss intervention (with educational materials) vs educational materials alone on disease-free survival (DFS) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-04.

Curbing excess gestational weight gain in primary care: using a point-of-care tool based on behavior change theory

Introduction

Excess gestational weight gain (GWG) is a risk factor for several adverse outcomes for mothers and their offspring. In Nova Scotia, Canada, approximately 60% of women experience excess GWG. Outside the pregnancy arena, a patient-centered approach has been shown to promote increased patient adherence to clinician recommendations, and increased intentions for, and attempts at, behavior change. The 5As of Healthy Pregnancy Weight Gain is a tool that assists clinicians to have patient-centered discussions about GWG. This feasibility trial examined the association between training in the use of this tool and women’s self-efficacy to manage GWG, readiness to adhere to GWG guidelines, perception of their clinicians’ patient-centeredness when discussing GWG, and guideline concordance of total GWG.

Method

Participants were 11 family physicians who provide prenatal care and 24 of their patients who were pregnant. Physicians were randomly assigned to a single 60-minute training session in the use of the tool or usual care. Consenting patients completed measures of social support, stress, patient-perceived patient-centeredness, self-efficacy, and motivation. At the end of each woman’s pregnancy, data pertaining to guideline concordance of GWG were collected.

Results

Comparison of patient participants with prenatal care providers in the trained and untrained groups showed no significant difference in patient-perceived physician patient-centeredness when discussing GWG, self-efficacy to manage GWG, readiness to adhere to GWG guidelines, or GWG congruence with the guidelines.

Conclusion

This feasibility study required very little time commitment and entailed minimal disruption to clinicians’ practices. Nonetheless, it was very difficult to recruit clinicians for the study. Although recent theory-driven work showed that prenatal care providers have, overall, high perceived self-efficacy in discussing GWG with their patients, most studies have demonstrated that these providers do not often discuss GWG with their patients; so, there is clearly a mismatch in their perceived self-efficacy and what actually transpires.

Diabetes-Related Behavior Change Knowledge Transfer to Primary Care Practitioners and Patients: Implementation and Evaluation of a Digital Health Platform

BACKGROUND

Behavioral science is now being integrated into diabetes self-management interventions. However, the challenge that presents itself is how to translate these knowledge resources during care so that primary care practitioners can use them to offer evidence-informed behavior change support and diabetes management recommendations to patients with diabetes.

OBJECTIVE

The aim of this study was to develop and evaluate a computerized decision support platform called "Diabetes Web-Centric Information and Support Environment" (DWISE) that assists primary care practitioners in applying standardized behavior change strategies and clinical practice guidelines-based recommendations to an individual patient and empower the patient with the skills and knowledge required to self-manage their diabetes through planned, personalized, and pervasive behavior change strategies.

METHODS

A health care knowledge management approach is used to implement DWISE so that it features the following functionalities: (1) assessment of primary care practitioners' readiness to administer validated behavior change interventions to patients with diabetes; (2) educational support for primary care practitioners to help them offer behavior change interventions to patients; (3) access to evidence-based material, such as the Canadian Diabetes Association's (CDA) clinical practice guidelines, to primary care practitioners; (4) development of personalized patient self-management programs to help patients with diabetes achieve healthy behaviors to meet CDA targets for managing type 2 diabetes; (5) educational support for patients to help them achieve behavior change; and (6) monitoring of the patients' progress to assess their adherence to the behavior change program and motivating them to ensure compliance with their program. DWISE offers these functionalities through an interactive Web-based interface to primary care practitioners, whereas the patient's self-management program and associated behavior interventions are delivered through a mobile patient diary via mobile phones and tablets. DWISE has been tested for its usability, functionality, usefulness, and acceptance through a series of qualitative studies.

RESULTS

For the primary care practitioner tool, most usability problems were associated with the navigation of the tool and the presentation, formatting, understandability, and suitability of the content. For the patient tool, most issues were related to the tool's screen layout, design features, understandability of the content, clarity of the labels used, and navigation across the tool. Facilitators and barriers to DWISE use in a shared decision-making environment have also been identified.

CONCLUSIONS

This work has provided a unique electronic health solution to translate complex health care knowledge in terms of easy-to-use, evidence-informed, point-of-care decision aids for primary care practitioners. Patients' feedback is now being used to make necessary modification to DWISE.

Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes

It is currently estimated that 11 million Canadians are living with diabetes or prediabetes. Although hyperglycemia is associated with serious complications, it is well established that improved glycemic control reduces the risk of microvascular complications and can also reduce cardiovascular (CV) complications over the long term. The UKPDS and ADVANCE landmark trials have resulted in diabetes guidelines recommending an A1C target of ≤ 7.0% for most patients or a target of ≤ 6.5% to further reduce the risk of nephropathy and retinopathy in those with type 2 diabetes (T2D), if it can be achieved safely. However, half of the people with T2D in Canada are not achieving these glycemic targets, despite advances in diabetes pharmacological management. There are many contributing factors to account for this poor outcome; however, one of the major factors is the delay in treatment advancement, particularly a resistance to insulin initiation and intensification. To simplify the process of initiating and titrating insulin in T2D patients, a group of Canadian experts reviewed the evidence and best clinical practices with the goal of providing guidance and practical recommendations to the diabetes healthcare community at large. This expert panel included general practitioners (GPs), nurses, nurse practitioners, endocrinologists, dieticians, pharmacists, and a psychologist. This article summarizes the panel recommendations.

Emerging adulthood and Type 1 diabetes: insights from the DAWN2 Study

AIMS

To compare clinical, psychological, education and social variables in emerging adults (aged 18-30 years) with Type 1 diabetes with their adult counterparts aged >30 years.

METHODS

A single assessment multinational sample was surveyed as part of the larger second Diabetes Attitudes, Wishes and Needs (DAWN2) study. Participants completed a series of surveys incorporating demographic as well as clinical questions (comorbidities, hypoglycaemia) and validated self-report scales concerning psychosocial (health impact, quality of life, beliefs and attitudes, self-management behaviours, healthcare experience and family support) and diabetes education factors.

RESULTS

Emerging adults differed from adults aged >30 years with regard to a number of psychosocial variables. Emerging adults reported better overall quality of life, social support and support from their healthcare team compared with adults aged >30 years of age; however, emerging adults experienced greater diabetes-specific distress and were less engaged in self-management. Diabetes education was related to a number of indicators, while experience of discrimination was harmful, but these impacts did not differ between emerging adults and adults aged >30 years. An analysis of geographical regions suggested that emerging adults in North America and Europe had better well-being than older adults, while the opposite was observed in Asia.

CONCLUSIONS

Emerging adults, particularly those in the later phase (ages 25-30 years) are especially at risk in terms of diabetes-specific distress. There is a need for novel interventions to meet the needs of these vulnerable emerging adults more effectively.