Helle Terkildsen Maindal

Translation, adaptation and validation of the American short form Patient Activation Measure (PAM13) in a Danish version

BackgroundThe Patient Activation Measure (PAM) is a measure that assesses patient knowledge, skill, and confidence for self-management. This study validates the Danish translation of the 13-item Patient Activation Measure (PAM13) in a Danish population with dysglycaemia.Methods358 people with screen-detected dysglycaemia participating in a primary care health education study responded to PAM13. The PAM13 was translated into Danish by a standardised forward-backward translation. Data quality was assessed by mean, median, item response, missing values, floor and ceiling effects, internal consistency (Cronbachs alpha and average inter-item correlation) and item-rest correlations. Scale properties were assessed by Rasch Rating Scale models.ResultsThe item response was high with a small number of missing values (0.8–4.2%). Floor effect was small (range 0.6–3.6%), but the ceiling effect was above 15% for all items (range 18.6–62.7%). The α-coefficient was 0.89 and the average inter-item correlation 0.38. The Danish version formed a unidimensional, probabilistic Guttman-like scale explaining 43.2% of the variance. We did however, find a different item sequence compared to the original scale.ConclusionA Danish version of PAM13 with acceptable validity and reliability is now available. Further development should focus on single items, response categories in relation to ceiling effects and further validation of reproducibility and responsiveness.

Gaps in understanding health and engagement with healthcare providers across common long-term conditions: a population survey of health literacy in 29 473 Danish citizens

Objectives To (1) quantify levels of subjective health literacy in people with long-term health conditions (diabetes, cardiovascular disease, chronic obstructive pulmonary disease, musculoskeletal disorders, cancer and mental disorders) and compare these to levels in the general population and (2) examine the association between health literacy, socioeconomic characteristics and comorbidity in each long-term condition group. Design Population-based survey in the Central Denmark Region (n=29 473). Main outcome measures Health literacy was measured using two scales from the Health Literacy Questionnaire (HLQ): (1) Ability to understand health information and (2) Ability to actively engage with healthcare providers. Results People with long-term conditions reported more difficulties than the general population in understanding health information and actively engaging with healthcare providers. Wide variation was found between disease groups, with people with cancer having fewer difficulties and people with mental health disorders having more difficulties in actively engaging with healthcare providers than other long-term condition groups. Having more than one long-term condition was associated with more difficulty in engaging with healthcare providers and understanding health information. People with low levels of education had lower health literacy than people with high levels of education. Conclusions Compared with the general population, people with long-term conditions report more difficulties in understanding health information and engaging with healthcare providers. These two dimensions are critical to the provision of patient-centred healthcare and for optimising health outcomes. More effort should be made to respond to the health literacy needs among individuals with long-term conditions, multiple comorbidities and low education levels, to improve health outcomes and to reduce social inequality in health.

Adaptation, data quality and confirmatory factor analysis of the Danish version of the PACIC questionnaire

BACKGROUND The Patient Assessment of Chronic Illness Care (PACIC) 20-item questionnaire measures how chronic care patients perceive their involvement in care. We aimed to adapt the measure into Danish and to assess data quality, internal consistency and the proposed factorial structure. METHODS The PACIC was translated by a standardised forward-backward procedure, and filled in by 560 patients receiving type 2 diabetes care. Data quality was assessed by mean, median, item response, missing values, floor and ceiling effects, internal consistency (Cronbachs α and average inter-item correlation), item-rest correlations and factorial structure was assessed by confirmatory factor analysis (CFA). RESULTS The item response was high (missing answers: 0.5-2.9%). Floor effect was 2.7-69.2%, above 15% for 17 items. Ceiling effect was 4.0-40.4%, above 15% for 12 items. The subscales had average inter-item correlations over 0.30 and CFA showed high factor loadings (range 0.67-0.77). All had α over 0.7 and included items with both high and low loadings. The CFA model fit was good for two indices out of six (TLI and SRMR). CONCLUSIONS Danish PACIC is now available and validated in primary care in a type 2 diabetes population. The psychometric properties were satisfactory apart from ceiling and floor effects. We endorse the proposed five scale structure. All the subscales showed good model fit, and may be used for separate sum scores.

Quality of type 2 diabetes management in general practice is associated with involvement of general practice nurses

AIMS To assess whether involvement of general practice nurses in type 2 diabetes care in Danish general practice is associated with improved adherence to national guidelines on regular type 2 diabetes monitoring, and with lower HbA1c and cholesterol levels in the type 2 diabetes population. METHODS The study was an observational study soliciting questionnaire data from 193 Danish general practices and register data on 12,960 patients with type 2 diabetes (age range 40-80 years) from a diabetes database and a laboratory database. Clustering was addressed in the analyses. RESULT Practices with well-implemented nurse-led type 2 diabetes consultations and practices with no nurse(s) employed differed according to the mean proportions of patients whose HbA1c was measured (6.4%-points: 95% CI: 1.5 to 11.4), and the mean proportions of patients whose HbA1c was ≥ 8% (-3.7%-points: 95% CI: -6.7 to -0.6). Small non-significant differences were found in the cholesterol analyses. CONCLUSION Compared with practices with no nurse(s) employed, the quality of diabetes management was generally higher in terms of that HbA1c was measured according to the guidelines in a larger proportion of the diabetes population and the proportion of patients with an HbA1c level ≥ 8% was lower in practices with well-implemented nurse-led type 2 diabetes consultations.

Effect on motivation, perceived competence, and activation after participation in the ‘‘Ready to Act’’ programme for people with screen-detected dysglycaemia: A 1-year randomised controlled trial, Addition-DK

Aim: To investigate the reach of the ‘‘Ready to Act’’ programme and the 1-year effects on psychological determinants of healthy behaviour: motivation, perceived competence, and activation level. Methods: A total of 509 adults with dysglycaemia were recruited from general practioners (GPs) in the intensive arm of the Danish Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care (ADDITION) study, a type 2 diabetes screening programme. The participants were randomised to the ‘‘Ready to Act’’ programme added on top of GP care (n = 322) or to GP care (n = 187). The core components of the programme were motivation, action experience, informed decision-making, and social involvement conducted in two one-to-one sessions and eight group-meetings (18 hours). The reach of the programme was measured by the proportion of people who signed up. Outcomes were changes in treatment motivation (Treatment Self-Regulation Questionnaire, TSRQ), perceived competence (Perceived Competence Scale, PCS), and activation in chronic care (Patient Activation Measure, PAM). Effect size was the difference between 1-year changes in the randomisation groups analysed by intention-to-treat. Results: A total of 142 (44%) of 322 signed up and 123 (87%) of these completed. At 1 year, the difference in autonomous motivation for behavioural treatment (TSRQ) between the randomisation groups was 1.0 (95% CI 0.1 to 2.0), and the difference in perceived competence changes in healthy diet (PCS-d) was 1.5 (95% CI 0.2 to 2.7). No differences were observed for activation (PAM) between the groups. Subgroup analysis revealed men to benefit more from the intervention than women. Conclusions: The programme is a promising health-promoting component in prevention and care for people with screen-detected dysglycaemia, as it attracted four of 10 people and had effects on motivation and perceived competence.

Health literacy mediates the relationship between educational attainment and health behavior: A Danish population-based study

Individuals with a lower education level frequently have unhealthier behaviors than individuals with a higher education level, but the pathway is not fully understood. The aim of this study was to investigate whether health literacy mediates the association between educational attainment and health behavior (smoking, physical inactivity, poor diet) and obesity. The study included respondents ages 25 years or older drawn from a large population-based survey conducted in 2013 (N = 29,473). Two scales from the Health Literacy Questionnaire were used: (a) Understanding health information well enough to know what to do and (b) Ability to actively engage with health care providers. Multiple mediation analyses were conducted using the Karlson-Holm-Breen method. The study showed that health literacy in general and the ability to understand health information in particular mediated the relationship between educational attainment and health behavior, especially in relation to being physically inactive (accounting for 20% of the variance), having a poor diet (accounting for 13% of the variance), and being obese (accounting for 16% of the variance). These findings suggest that strategies for improving health behavior and reducing health inequalities may benefit from adopting a stronger focus on health literacy within prevention, patient education, and other public health interventions.

A cluster randomised pragmatic trial applying Self-determination theory to type 2 diabetes care in general practice

BackgroundTreatment recommendations for prevention of type 2 diabetes complications often require radical and life-long health behaviour changes. Observational studies based on Self-determination theory (SDT) propose substantial factors for the maintenance of behaviour changes and concomitant well-being, but experimental research is needed to develop and evaluate SDT-based interventions. The aims of this paper were to describe1) the design of a trial assessing the effectiveness of a training course for practice-nurses in autonomy support on patient-perceived motivation, HbA1, cholesterol, and well-being among a diabetes population,2) the actual intervention to a level of detail that allows its replication, and3) the connection between SDT recommendations for health care-provider behaviour and the content of the training course.Methods/DesignThe study is a cluster-randomised pragmatic trial including 40 Danish general practices with nurse-led diabetes consultations, and the associated diabetes population. The diabetes population was identified by registers (n = 4034).The intervention was a 16-hour course with interactive training for practice nurses. The course was delivered over 4 afternoons at Aarhus University and one 1/2 hour visit to the practice by one of the course-teachers over a period of 10 months (0, 2, 5, 10 mths.). The intervention is depicted by a PaT Plot showing the timeline and the characteristics of the intervention components.Effectiveness of the intervention will be assessed on the diabetes populations with regard to well-being (PAID, SF-12), HbA1c- and cholesterol-levels, perceived autonomy support (HCCQ), type of motivation (TSRQ), and perceived competence for diabetes care (PCD) 15-21 months after the core course; the completion of the second course afternoon. Data will be retrieved from registers and by questionnaires.DiscussionChallenges and advantages of the pragmatic design are discussed. In a real-world setting, this study will determine the impact on motivation, HbA1c, cholesterol, and well-being for people with diabetes by offering a training course in autonomy support to practice-nurses from general practices with nurse-led consultations.Trial registrationClinicalTrials.gov: NCT01187069

Effectiveness of a Training Course for General Practice Nurses in Motivation Support in Type 2 Diabetes Care: A Cluster-Randomised Trial

Background Type 2 diabetes is a common metabolic disease with the potential for prevention of complications. The prevention requires a high level of lasting actions from the patients, which may be burdensome. The aim of this trial was to evaluate the effectiveness of a training course for general practice nurses in motivation support at 18 months follow-up in the affiliated type 2 diabetes population. Methods Forty general practices with nurse-led diabetes consultations from the area of Aarhus, Denmark were randomised 1∶1 to either intervention or usual practice. Intervention practices were offered a 16-hour Self-determination theory - based course including communication training for general practice nurses delivered over 10 months. The affiliated diabetes populations (aged 40–74 years) were identified from registers (intervention n = 2,005; usual n = 2,029). Primary outcomes were register-based glycated haemoglobin (HbA1c) -, total cholesterol levels, and well-being measured by the Problem Areas In Diabetes scale (PAID) and the mental component summary score, SF12 (SF12, mcs). Intention-to-treat analyses were performed. Predefined subgroups analyses were performed. Results The differences between the intervention- and the control practices’ mean HbA1c and total cholesterol at follow-up adjusted for baseline values and clustering were respectively: −0.02%-points (95% CI: −0.11 to 0.07; p: 0.67); 0.08 mmol/l (95% CI: 0.01 to 0.15; p: 0.02). Differences in median scores adjusted for clustering were for PAID: 1.25; p = 0.31 and SF12, mcs: 0.99; p = 0.15. Women in intervention practices differed from women in usual practices on mean HbA1c: −0.12%-points (−0.23 to −0.02; p = 0.02) and SF12, mcs: 2.6; p = 0.01. Conclusions Offering a training course for general practice nurses in applying the Self-determination theory in current type 2 diabetes care had no effect compared with usual practice measured by HbA1c and total cholesterol levels and the well-being at 18 months of follow-up in a comprehensive register-based diabetes population. Subgroup analyses suggested a possible effect in women, which deserves further attention. Trial Registration ClinicalTrials.gov (Identifier NCT01187069).

How to prevent type 2 diabetes in women with previous gestational diabetes? A systematic review of behavioural interventions

OBJECTIVES Women with previous gestational diabetes (GDM) have a seven times higher risk of developing type 2 diabetes (T2DM) than women without. We aimed to review the evidence of effective behavioural interventions seeking to prevent T2DM in this high-risk group. METHODS A systematic review of RCTs in several databases in March 2016. RESULTS No specific intervention or intervention components were found superior. The pooled effect on diabetes incidence (four trials) was estimated to: -5.02 per 100 (95% CI: -9.24; -0.80). CONCLUSIONS This study indicates that intervention is superior to no intervention in prevention of T2DM among women with previous GDM.

Effectiveness of a brief theory-based health promotion intervention among adults at high risk of type 2 diabetes: One-year results from a randomised trial in a community setting.

AIM To examine the effect of a brief theory-based health promotion intervention delivered in the community on health behaviour and diabetes-related risk factors among Danish adults at high risk of diabetes. METHODS A randomised trial was conducted among 127 individuals aged 28 to 70 with fasting plasma glucose: 6.1-6.9 mmol/l and/or HbA1c: 6.0-<6.5% (42-<48 mmol/mol) recruited from general practice in Holstebro, Denmark. Participants were randomised to a control group or to receive the intervention delivered over four 2h group sessions during five weeks, and two further sessions after one and six months. Questionnaire data and clinical measures were collected at baseline, three months and one year after intervention. Primary outcomes; total-fat intake <30% of energy intake; saturated-fat intake <10% of energy intake; fibre-intake ≥15 g/1000 kcal; weight reduction >5%; changes in physical activity. RESULTS 85% attended one-year follow-up. After adjusting for gender, age and education, Odds ratio (OR) (95% CI) intervention vs control: total-fat intake <30% energy intake: 0.52 (0.22;1.20), saturated-fat intake <10% energy intake: 1.22 (0.52;2.87), fibre intake ≥ 15 g/1000 kcal: 1.18 (0.48;2.92), weight reduction >5%: 2.47 (0.95; 6.39). β (95% CI) between intervention vs control in changes from baseline: IPAQ, MET min/week: -236 (-2760; 2288), waist circumference,cm: -2.5 (-4.5; -0.5); systolic blood pressure, mmHg: -4.6 (-8.8; -0.3). CONCLUSION A brief theory-based health promotion intervention delivered in the community indicated effect on weight, waist circumference and systolic blood pressure at one year among Danish adults at high risk of diabetes. No effect was shown on diets or physical activity.