Rodney A. Lorenz

Changing Behavior: Practical lessons from the Diabetes Control and Complications Trial

The recently completed Diabetes Control and Complications Trial (DCCT) has elicited renewed interest in behavior change strategies, because intensive therapy of 1DDM in the DCCT was a comprehensive behavioral change program with unequivocal health benefits (1,2). Intensive therapy lowered blood glucose levels and slowed the appearance and progression of microvascular and neuropathic complications because participants changed many behaviors, including testing blood glucose and administering insulin more frequently, quantifying and regulating dietary intake, and modifying diet, insulin, and physical activity to balance their effects on blood glucose levels. It is natural to ask what can be learned from the DCCT about changing behavior that is pertinent to diabetes management in clinical practice. The DCCT compared two treatment programs that differed in many ways. Among the differences between the two treatments was the more frequent use of behavioral change strategies in the intensive therapy group. Use of specific behavior change strategies depended on the needs of individual patients. In addition, while the framework of intensive therapy was dictated by the study protocol, the detailed application of behavioral change strategies is presumed to have varied with the skills and preferences of each Clinical Center staff, as was also true of other elements of treatment such as insulin management and the choice of pump or multiple injection therapy. Consequently, there were uncontrolled differences across clinics and individuals in the use of behavioral interventions. Therefore, the DCCT Study Group has not attempted to draw systematic conclusions about the effectiveness of specific behavioral change strategies or other elements of the intensive therapy program. Nevertheless, it is possible to offer opinions on the behavioral strategies that seemed most helpful. To generate a broad synthesis of practical lessons from the DCCT, the first author recruited collaborators from several DCCT Clinics and disciplines, including nursing, nutrition, clinical psychology, psychiatry, and social work. The practical lessons we offer here were not discovered or used for the first time in the DCCT, but are well grounded in a large body of literature, examples of which we cite. A short list of additional reading is also included. The point emphasized here is that the DCCT has demonstrated that these strategies are truly effective in achieving longterm behavioral changes and health benefits in subjects with IDDM. Before discussing specific behavioral change strategies, we wish to articulate a general principle suggested by the DCCT: ordinary people can adopt and maintain substantial behavioral changes. Because of the extraordinary adherence of the DCCT volunteers to the protocol, it has been implied that they were so well

Translation of the diabetes nutrition recommendations for health care institutions.

The Nutrition Recommendations and Principles for People With Diabetes Mellitus (1,2) reflect current scientific nutrition and diabetes knowledge and consensus. The recommendations apply primarily to individuals receiving diabetes medical nutrition therapy on an outpatient basis and living in a home setting and not to hospitalized patients or residents of long-term care facilities with diabetes. This population takes on added importance when one considers that adults with diabetes are hospitalized three times more often than adults without diabetes and tend to have longer hospital stays. In addition, ~18% of all long-term care residents have diabetes (3). To provide guidance on implementation of the nutrition recommendations in acute and long-term health care facilities (e.g., hospitals, nursing homes), a task force was formed by the American Diabetes Association. The task force began by gathering data on how, and if, health care facilities were implementing the nutrition recommendations as well as on other nutrition issues related to the recommendations that should be addressed. This technical review summarizes the survey; reviews the role of diabetes medical nutrition therapy in acute and long-term health care settings; summarizes the advantages and disadvantages of meal planning systems used; reviews the role of patient selfmanagement education in acute-care settings; examines nutrition issues such as liquid and surgical diets, catabolic illness, and nutrition support; and suggests areas for future research. The technical review summarizes published research and recommendations, as well as traditional and usual acute and long-term nutrition care and food service. However, for many of the issues, few studies were available. This area requires additional research to determine if current nutrition therapy practices for diabetes lead to desired nutrition, medical, and clinical outcomes.

Utility of a Brief Self-Efficacy Scale in Clinical Training Program Evaluation

Self-efficacy is often studied as a predictor of professional practice behaviors or as an outcome of clinical training, using brief scales with little validation. This study examines the utility of a brief self-efficacy scale in the evaluation of a clinical training program. Subjects were 119 registered dietitians who participated in diabetes training. Hypothesized relationships between self-efficacy ratings and indices of skill mastery, participation in training, and subsequent practice change were examined. Self-efficacy ratings after training correlated significantly with relevant prior experience (r = .4 and .29, p < .01) but not total experience and with knowledge post-test score (r = .21, p < .02). Self-efficacy for all 12 program objectives increased significantly after training. Post-training self-efficacy for two program objectives correlated significantly with self-reported successful practice changes related to those objectives (r = .4, p < .04 and r = .51, p < .01). The data suggest that brief self-efficacy assessments can contribute meaningfully to clinical training program evaluation.

Evaluation of a training program for improving adherence promotion skills

A workshop for improving the adherence counseling skills of health professionals was developed and evaluated. Target audiences have included medical students, nursing students, dietetic interns, and practising nurses and dietitians. Four categories of skills are taught: relationship building, interviewing, problem diagnosis, and behavioral intervention. Teaching methods include faculty demonstration, participant rehearsal, and group and individual feedback. The Adherence Promotion Training (APT) workshop has been offered as a 3- to 5-day intensive course and as a semester-long elective. A reliable coding system was developed to assess these skills from videotaped provider-patient interactions. A standardized patient task was given to 60 subjects before and after participation in the adherence counseling skills workshop. Videotapes were coded by trained raters, who were masked to whether the tape came from before or after the workshop. Significant short-term improvements were observed in all four core skills. This uncontrolled evaluation suggests that the Adherence Promotion Training program is a promising way to enhance the ability of health professionals to care for nonadherent patients.

Diabetes Training for Dietitians: Needs Assessment, Program Description, and Effects on Knowledge and Problem Solving

Recent changes in management and medical nutrition therapy for diabetes mellitus have produced a need to retrain many practicing dietitians. To meet this need, a multidisciplinary group experienced in medical nutrition therapy and educational methods used a formal needs-assessment process to design a new training program. Sugar is Not a Poison (SNAP): The Dietitians New Role in Diabetes Management is a 2 1/2-day program that uses written text, didactic presentation, and exercises that simulate patient encounters to accomplish 12 learning objectives. Program evaluations show high levels of participant satisfaction. Mean (+/- standard deviation) scores on pre- and postests of knowledge and problem solving were 69 +/- 13% and 86 +/- 9%, respectively (P < 0.01). The SNAP program needs assessment, training methods, and knowledge problem-solving test are relevant to all types of education programs in clinical dietetics.

Evaluation of a home study continuing education program on patient teaching skills

&NA; We developed a home study version of an established and successful workshop program called Effective Patient Teaching (EPT), making use of suggested guidelines for developing home study courses. The self‐study modules we produced consisted of workbook materials, videotaped illustrations, and practice exercises, all of which focused on patient teaching and counseling skills. During a period of 2 years and 3 months, 28 participants enrolled in the home study course. Only one participant completed the entire course. Another participant completed the portion purchased. The barrier most commonly cited as preventing completion of the home study course was other work‐related deadlines. We suspect that our requirement for a feedback procedure (either an audio‐ or n videotape of an instruction interview) may also have prevented submission of a completed course. The low, completion rate made quantitative evaluations impossible. Although the literature includes reported successes in the use of self‐learning courses, few formal evaluations have been conducted and reported. The efficacy of home study courses, particularly when enhanced skill is the desired outcome rather than knowledge gain, is yet to be e published, and merits close examination and rigorous evaluations.

Adherence‐related questioning by fourth‐year medical students interviewing ambulatory diabetic patients

Patient adherence is one determinant of the success of medical therapy, but little is known about the extent to which health professionals routinely assess adherence. This study evaluated the extent of patient adherence assessment by senior medical students in an outpatient diabetes clinic. The number of adherence questions students asked was low in all areas of the patients’ diabetes regimen. The number of questions asked did not relate to patients’ clinical status or their self‐reported regimen adherence. Findings suggest a need for systematic attention to adherence issues in physician education.