Motivational interviewing delivered by diabetes educators: Does it improve blood glucose control among poorly controlled type 2 diabetes patients?☆,☆☆
Introduction
Diabetes self management education (DSME) is critical in type 2 diabetes (T2DM) treatment planning. DSME focuses on diabetes knowledge and skills training and fosters behavior change for targeted self management behaviors. These include following an appropriate diet, consistent use of (often multiple) medications, regular monitoring of blood glucose levels to inform decision making, regular physical activity, practical problem solving and communication skills, and psychosocial adaptation skills [1].
Diabetes specialists, including 30,000 diabetes educators of whom approximately half are certified diabetes educators (CDEs), are working on the front line of diabetes care and are well positioned to help behavioral researchers translate innovative educational and behavioral strategies into workable and sustainable patient programs [2]. Current control rates for blood glucose are suboptimal and innovative new treatment approaches are needed to help reduce the devastating effects of diabetes complications on patients and the healthcare system [3]. While appropriate evidence-based medical care is critical to good diabetes control, effective DSME and patient support are also key factors in T2DM treatment. One recent theoretical advance in the delivery of DSME has been an emphasis on patient-centered or collaborative approaches to care and education [4], [5], [6], although these have not been well studied in terms of clinical outcomes and theoretical mechanisms [7].
Motivational interviewing (MI), a patient-centered behavior change strategy, has proven valuable in the treatment of addictions and other chronic medical conditions [8]. MI aims to identify and reduce patient ambivalence regarding health behavior change and to improve patient perceptions of the importance of behavior change and confidence (self-efficacy). MI is traditionally delivered by mental health counselors such as clinical psychologists or social workers. These counselors are typically not trained in diabetes treatment or integrated into primary care settings, where 80–95% of diabetes care is delivered [9]. By contrast, CDEs have specialized knowledge in diabetes pathophysiology and treatment approaches and are trained in patient-centered behavior change strategies [2]. Therefore, it may be beneficial to adopt scaleable MI strategies into DSME, utilizing the expertise of CDEs.
No study to date has reported on the use of MI in the context of DSME provided by diabetes educators. The goal of this study was to create a brief DSME intervention that blended an MI counseling approach with the practical teaching of diabetes knowledge and skills training (e.g., help patients identify barriers, facilitate problem solving, and develop coping skills to effectively manage their diabetes) [1]. We compared the clinical benefit of a six month MI-based DSME intervention with standard DSME. Our primary clinical outcome was blood glucose control (HbA1c). To advance our theoretical knowledge in this area, we also examined a range of salient psychosocial and behavioral mediators expected to influence blood glucose control outcome over the course of the MI-based DSME intervention.
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Subjects, materials and methods
Patients were recruited from the adult T2DM patient population of a large hospital medical center following chart review and physician approval for patient participation (Fig. 1). Patients were recruited from a variety of sources within the hospital network, including the diabetes clinic and hospital laboratory database. Study patients were aged 30–70 years, had poorly controlled blood glucose (HbA1c ≥ 7.5%), and were able to speak and write in English. Exclusion criteria included the presence of
Results
Two hundred and thirty four patients were randomized to the four study conditions, with n = 118 receiving MI and n = 116 not receiving MI. Mean ± SD age in the study population was 55.7 ± 10.2 years, and 59% of participants were women. The majority (84%) of participants were white, 12% were black, 1% were Asian, and 3% were another race or mixed race; 12% of participants self-identified as Hispanic. Sixty four percent of participants reported at least some college education. Duration of diabetes was 8.2
Discussion
We compared a four-session, six-month MI-based DSME intervention to traditional patient-centered DSME with blood glucose control as the primary outcome. Despite successful MI training findings and the high professional satisfaction associated with using MI reported informally by our study CDEs receiving MI training, the MI intervention itself was not found to be associated with improvement in blood glucose control when compared to the non-MI condition. In fact, mean HbA1c change for the non-MI
Conflict of interest
There are no conflicts of interest.
Acknowledgments
We would like to thank CDEs Barbara Bellucci, RN, Maria Consedine, RN, Maryann Hayes, RD, and Karen Zapka, RN as well as Denise Ernst, PhD and Gary Rose, PhD for their MI training expertise provided during the study.
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Effect of diabetes self-management education (DSME) on glycated hemoglobin (HbA1c) level among patients with T2DM: Systematic review and meta-analysis of randomized controlled trials
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2020, Patient Education and CounselingCitation Excerpt :The interventions included different strategies/components. The most frequently used component was educational information such as evidence about diabetes and lifestyle advice [18,28,30–47], followed by activation strategies such as decision support, goal setting, and action plans [18,28,30,28–33,35,36,38,40,41,43,31–47], behavioral interventions such as motivational interviewing (MI) [18,30,36,37,41–45] and other types of psychological intervention [18,27,29,31,36,40,43,46,47], then finally social support [32,36,37,40,42,47]. Interventions were provided by a variety of professionals, including nurses, physicians, psychologists, dieticians, diabetes educators, and paraprofessionals.
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Data in this manuscript will be presented at the meeting of the American Diabetes Association in Orlando, Florida, June 25–29, 2010.
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This research was supported by National Institutes of Health grant #1R01DK060076.