Effect evaluation of a Motivational Interviewing based counselling strategy in diabetes care

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Abstract

Aim

The present study assessed the effects of a Motivational Interviewing (MI) based counselling training for nurses on clinical, behavioural and process outcomes among diabetes type 2 patients.

Methods

The study is an RCT with follow-up measurements after 12 and 24 months. Thirty-three nurses and 584 patients participated. Nurses in the experimental condition received the training; control group nurses were trained after the study. The training consisted of two training sessions, two follow-up meetings, written feedback and three direct feedback sessions. Basic MI-principles and techniques and an MI-based counselling protocol were addressed.

Results

Results indicated disadvantageous effects on fat intake and HDL and advantageous effects on chance locus of control and knowledge. No effects were found on vegetable or fruit intake, physical activity, HbA1c, weight, blood pressure, total cholesterol, LDL, triglycerides, health care climate, quality of life or on self-efficacy.

Conclusions

As in other MI studies, mixed results were found. It would be premature to recommend dissemination of MI in diabetes care. More studies are needed in real-world settings with health care professionals of the field instead of intensively trained MI interventionists. Knowledge should be gained about adequate training and factors contributing to the implementation of MI in daily practice.

Introduction

The incidence of diabetes type 2 (DM2) worldwide increases rapidly due to changing lifestyles and increased longevity [1], [2]. In addition to physical and psychological burden to the patient, the increase in diabetes causes a financial burden to society [3]. Besides pharmacological treatment, lifestyle modification (such as adjustment of diet and physical activity) is a crucial element in treatment to prevent or delay the onset of complications [4], [5], [6]. Because of their daily responsibility for a large number of behavioural choices and activities, patients play a central role in their own treatment. Patients experience difficulties with self-management during daily life, contributing to frequent suboptimal control of risk factors [7], [8], [9], [10]. To limit the consequences of the increase of patients with DM2, effective ways of patient counselling are urgently needed.

A promising counselling strategy in the treatment of lifestyle problems and disease is ‘Motivational Interviewing’ (MI). MI is defined as ‘a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence’ (p. 25) [11]. In contrast to traditional, more paternalistic, counselling styles, MI gives the patients’ knowledge and experiences a central role in finding the best behaviour change strategies. The motivation to change should originate from the patient instead of being imposed by the health care professional.

MI was originally developed in the addiction field, but this relatively new counselling style is increasingly being advocated in other health areas such as diet, exercise, and diabetes [12], [13], [14]. Nevertheless, consistent evidence for the effectiveness of MI in these areas is still limited and additional research is indicated [14], [15], [16]. MI in chronic disease care may require a different approach than in addictive behaviours and the health care providers are different [14]. However, as summarized by Martins and colleagues [17], MI shows potential for diabetes care. In some of the nine studies reviewed by Martins and colleagues [17], beneficial effects on glucose levels, physical activity, weight and engagement in dietary changes were found. In all studies the intervention consisted of separate (additional) MI-sessions aimed at behaviour change instead of MI embedded in usual care.

In conclusion, MI seems promising for diabetes care but its effectiveness when incorporated in daily practice and not as a separate intervention in addition to usual care is still unclear. Therefore, the present study determined the effects of an MI-based counselling training to nurses on clinical, behavioural and process outcomes in DM2 patients. Nurses were supposed to use the counselling style during usual care.

Section snippets

Study design and procedures

In The Netherlands, diabetes care is provided mainly in primary care. In most practices patients are seen annually by their general practitioner and quarterly by a “practice” nurse, whose main tasks are monitoring the disease, providing education and lifestyle counselling. These nurses specialize in the care in chronic diseases such as diabetes and COPD, and are supervised by the general practitioner.

General practices were recruited in the southern parts of The Netherlands. In total 33 nurses

Descriptives

From a total of 36 general practices, 584 patients started in our study of which 537 (92%) filled out the baseline questionnaire, 447 (77%) filled out the questionnaire at twelve months follow up and finally 423 (72%) filled out the questionnaire at 24 months. Of all patients, 389 (67%) filled out all three questionnaires and 32 (5%) filled out none.

Concerning clinical parameters, 570 (98%) patients had at least one valid value at baseline, 498 (85%) at 12 months follow up and 462 (79%) at 24

Discussion

The present study was an evaluation of an MI-based counselling strategy embedded in usual diabetes care. Results indicate no major intervention effects on outcome measures, although minor differences between groups were found at follow-up measurements for fat intake, HDL-cholesterol, chance health locus of control and knowledge.

Concerning fat intake and HDL-cholesterol an adverse effect was found. At baseline, the control group had a higher fat intake compared to the experimental group and a

Conflict of interest

There are no conflicts of interest.

Acknowledgement

The study was supported by a grant from the Dr. Paul Janssen Foundation.

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