Goal setting in diabetes self-management: Taking the baby steps to success

Abstract

Objective

To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals.

Methods

We conducted a quasi-experimental study using a one group pretest posttest design to assess the effectiveness of a goal setting intervention along with a self-management guide. English- and Spanish-speaking patients with diabetes had one in-person session and two telephone follow-up calls with a non-clinical provider over a 12–16-week period. At each call and at the end of the study, we assessed success in achieving behavioral goals and problem solving toward those goals. Satisfaction with the self-management guide was assessed at the end of the study.

Results

We enrolled 250 patients across three sites and 229 patients completed the study. Most patients chose to set goals in diet and exercise domains. 93% of patients achieved at least one behavioral goal during the study and 73% achieved at least two behavioral goals. Many patients exhibited problem solving behavior to achieve their goals. We found no significant differences in reported achievement of behavior goals by literacy or language. Patients were very satisfied with the guide.

Conclusions

A brief goal setting intervention along with a diabetes self-management guide helped patients set and achieve healthy behavioral goals.

Practice implications

Non-clinical providers can successfully help a diverse range of patients with diabetes set and achieve behavioral goals.

Introduction

Patient directed and clinician facilitated goal setting is an increasingly popular method of behavioral counseling in primary care settings. This method has been used in chronic disease self-management training [1], [2] and is central in many newly developed diabetes education programs [3], [4]. These programs have incorporated goal setting to help patients improve their self-efficacy in diabetes management, change their behavior, and improve their health outcomes [1], [2]. Quality improvement programs in primary care now emphasize the role of goal setting when implementing the self-management support part of the chronic care model [5]. In fact, diabetes quality improvement programs often track whether a patient has a self-management goal documented in the chart as a performance measure [6].

Previous work on goal setting in primary care encounters demonstrated that primary care physicians can be trained to help patients set goals and that it can lead to behavior change [7]. However, the same study reported problems with the feasibility of physicians performing this service in the context of the primary care visit [8]. Although some advocates argue that the goal setting framework should not add appreciable time to the visit [2], time limitations and competing demands make additional tasks difficult for the primary care physician. Models of care that can delegate aspects of patient care to other team members may be a more feasible alternative [9].

In many primary care clinical settings, goal setting is not a routine part of clinical care. Three factors may contribute to the lack of regular goal setting in clinical settings. First, patient education materials are usually not designed to facilitate goal setting. Most educational materials provide information but do not facilitate discussion or patient-directed behavioral goals. As such, clinicians and their patients frequently adhere to an interaction model focused on information transfer rather than motivation and problem solving for achievable behavioral change. Second, many clinicians are not trained to help patients create achievable, short-term behavioral goals. For example, clinicians may believe they need to set the goals for the patient and may lack knowledge and skills in facilitating patient-directed small goals or action plans. Third, physicians lack time and the practice is not designed to have someone else help the patient set goals [8], [10].

With this in mind, we developed a diabetes self-management guide in English and Spanish and a brief counseling intervention to help facilitate goal setting and to improve self-efficacy in diabetes management. We designed the guide and counseling intervention for use by any practice staff member and for patients of all literacy levels [11]. In a separate paper, we reported that patients who received this intervention had improved activation, self-efficacy, diabetes knowledge, and self-care, and less diabetes distress [12]. The objective of this study was to evaluate the usefulness of the guide and brief counseling intervention in helping patients set and achieve their behavioral goals from the patient's perspective. We also assessed how often patients used problem solving skills during the process of goal attainment, and measured their satisfaction with the guide.