The Canadian Experience in the Development of a Continuing Education Program for Diabetes Educators Based on the Transtheoretical Model of Behavior Change

Lynn Edwards, MHSA, RD, CDE, Helen Jones, MN, CDE,
and Anne Belton, RN, BA, CDE

Managing diabetes well is challenging. Diabetes mellitus is clearly a biological disease with a well-understood pathophysiology and improving, but still imperfect, biomedical interventions. Yet daily, ongoing management of diabetes rests primarily on the behavior of the individual.¹ The successful daily management of diabetes involves critical thinking and the application of a complex and demanding set of skills.

Individuals with diabetes experience two opposing forces. On the one hand, they know that the greater control they have over their blood glucose, the healthier they will be in both the short and long term. On the other hand, diabetes places staggering demands on individuals to alter their behavior. Problems in adherence to a complex, and often inadequate, treatment regimen greatly tax individuals and the health care system.

Most researchers and clinicians support the conclusions of the Diabetes Control and Complications Trial and the U.K. Prospective Diabetes Study and agree that any strategy that will improve or optimize blood glucose and hypertension control is of benefit to those with diabetes. Clinicians are currently being challenged to provide effective and efficient interventions to optimize diabetes control.^2,3

Until recently, the clinical care and educational strategies for diabetes have focused on action-oriented interventions (i.e., the behaviors that individuals with diabetes should perform in order to optimize blood glucose control). The development of diabetes education centers has greatly facilitated diabetes self-management by providing educational, supportive, and problem-solving interventions to encourage self-care in addition to clinical management. To date, when lack of self-care was identified, it has been dealt with by attempts to minimize barriers to adherence^4-6 as well as minimize the psychosocial burden of diabetes.^7-11

Recent research focusing on the process of behavior change has identified stages of readiness to change.^12-14 The implications of this model for diabetes management are significant and were the focus of the education programs developed in Canada. The central hypothesis of the Transtheoretical Model of Change (TTMC) is that not all individuals are prepared to take action to change their behavior at a given point in time. Contemporary diabetes management is based on an implicit assumption that all those attending a diabetes education program are prepared to change. In addition, many diabetes education/management programs have little to offer those individuals currently unwilling to attend diabetes education programs or to follow through on behavioral recommendations. TTMC offers these individuals a new approach to addressing behavior change in diabetes.

TTMC was postulated by Prochaska and DiClemente.^12-14 It contains a core set of constructs: stages of change, processes of change, self-efficacy, temptations, and pros and cons that have been integrated from numerous behavioral models. The model has recently been applied, in theory, to diabetes, but there is a need for research studies to evaluate its impact in a chronic disease requiring multiple behaviors, such as diabetes. Diabetes self-management involves multiple and complex behaviors and judgments, and there is a strong need to evaluate the efficacy of interventions intended to move a person from one stage of readiness to another. Existing data that support the model are derived from cross-sectional studies examining different individuals at different stages. To be maximally useful to the area of diabetes management, longitudinal studies examining stage-changing interventions are in process.

While concurrent research applying TTMC in diabetes proceeds in many countries, including Canada, programs have been designed in Canada to increase educators' and patients' understanding of the constructs of the model.

APPLICATION OF TTMC: A CANADIAN EXPERIENCE
In Canada, the Diabetes Educator Section (DES) membership of the Canadian Diabetes Association (CDA) proved a fertile ground for new ideas such as TTMC to take root and blossom. A small group of educators were motivated to pursue the development of this theory in their diabetes practice after attending a 1994 seminar introducing Dr. James Prochaska and the original TTMC work.

A development proposal was supported through an educational grant from Lifescan Educational Institute, and the Professional Development Advisory Council (PDAC) was formed in early 1997. Its mandate is to act as a steering and expert working committee to enable the application of TTMC in diabetes education practice. Concurrently, Dr. Prochaska's keynote address at DES 95 and the pre-conference workshop with Laurie Ruggerio in 1996 further increased awareness of and interest in TTMC in the Canadian diabetes educator community.

Needs Assessment
The first challenge was to understand/validate the educators' perceptions of what was needed to make this happen. Consequently, a needs assessment was mailed to all DES members in the spring of 1997. Questions were designed to evaluate how ready educators were to apply the model in practice, that is, "What stage of change were diabetes educators in?" The PDAC members established content validity for the questionnaire items.

Of the approximately 1,500 people contacted by mail, 247 educators responded to the survey, a very acceptable rate of return, with 3 surveys not usable (Table 1). While the concept of stages was familiar to most, responses indicated a very superficial understanding of the model. With the exception of Consciousness-raising, (44.4% somewhat or very comfortable), educators did not feel well prepared to apply the various processes of the model in their practice.

We concluded that most educators were in the Contemplation or early Preparation stages, somewhat aware, willing to learn, trying out some small steps but not yet ready to put the model into practice. Overall, the results indicated a general awareness of the model's concepts, but supported PDAC's perception that educators were generally not ready to take action to fully integrate the model into practice.

A more complex analysis was required for the qualitative responses to the pros and cons question ("Please list what you see as the pros and cons of the model."). According to TTMC, the pros must be equal to or greater than the cons before people will take action. We attempted to assess these factors in order to address them in our program development. All comments were transcribed and independently reviewed for themes by three reviewers. Results indicated a remarkable consistency in the themes of the responders, which are detailed in Table 2.

Without applying rigorous scientific methodology, the pros and cons appeared fairly equal in both number and weight, which is congruent with being in the Contemplation stage with respect to applying the model. Our challenge was to design learning experiences associated with change processes that would maximize the pros and minimize the cons of using TTMC in diabetes education.

The Canadian Program

"Essential Skills in the Application of the Staged Model of Change": Basic program

Development
An Essential Skills workshop, complete with facilitator and participants' manuals, was developed by PDAC members, all active diabetes educators who saw this opportunity as part of a personal quest to learn, more fully understand, and implement TTMC into their daily practice. The Essential Skills Program learner objectives are:

1.  Diabetes educators will articulate an understanding of the basic concepts/constructs of the Staged Model of Change [TMC].

2.  Educators will be willing to apply the Staged Model of Change in practice.

Figure 1.  Transtheoretical Model of Change

The workshop and manual is sequenced to highlight the learners' passage through learning, or change in their ability to carry out the above behaviors. PDAC linked the concepts of TTMC together through the graphic depiction of a rainbow--an effort to clarify and simplify the model (Figure 1) We helped to make the model come alive through personal examples, case applications taken from practice, and simplification of the model name. We refer to TTMC as the Staged Model of Change, but we are careful not to focus on stages at the expense of the other constructs.

The Essential Skills program was piloted in November 1997 at the Diabetes Educator Section, CDA Leadership Forum of about 45 educators from across Canada. The results of the pilot were positive and identified areas in which the program required tailoring. The education manual and the pace of the workshop required revision. We identified both the need for and the opportunities within the program to incorporate more participative educational strategies. Overall, people were interested in the topic, felt it was relevant to their practice, and said they wanted or needed more information to be able to integrate the model into their practices. Following the pilot, the manual was translated into French.

The program has been developed in a train-the-trainer fashion. However, facilitators to date have been limited to the members of the PDAC.

Implementation
The first Essential Skills workshop was held in March 1998, and a total of 11 workshops have been completed to date. Workshop group size has ranged in number from 15 to 52. The length of the program is approximately 4 hours, allowing organizers some flexibility to fit with schedules of interested communities. Programs have been delivered in the morning/afternoon and afternoon/ evening, during the week and on Saturday. Facilitators prefer morning/afternoon combinations since the Essential Skills program is comprehensive and requires concentrated attention that is difficult after working a full day.

Two diabetes educators from PDAC have usually facilitated the program. Although it did not make a difference on program evaluations, a team approach is the preferred method of delivery for the facilitators. Due to travel costs, upcoming programs will be delivered by one trained PDAC facilitator, who may choose to enlist help from someone knowledgeable at the local level if needed.

As the program has evolved, we have been able to incorporate more opportunities for participation and personalization. We have found success in asking people to apply the model to a change they are personally trying to make before trying to come up with an example from their practice. We have started bringing in typical teaching tools, and at the end of the program we ask the participants to state where and how that tool might be used in the model (processes of change). This last exercise brings the theory into reality and allows the participants to think through application of the model to practice.

Evaluation
A three-step evaluation of the program has been developed to include a pre-program questionnaire completed before the workshop, a post-program questionnaire mailed 6 months after the program, and a participant satisfaction survey.

The pre- and post-program questionnaires are designed to measure participants' level of knowledge of the constructs of the model using a 5-point Likert scale and the stage of change of the educator in using the model in practice by answering 5 temporal staging questions.¹⁴ The response rate for the pre-program questionnaires is 100%. Of the 95 post-program questionnaires sent to date, 24 have been returned, a response rate of 25%.

Respondents have returned the questionnaires anonymously, so the post-workshop questionnaires cannot be matched to the same person's pre-workshop questionnaire. Thus, although the data are actually dependent (i.e., repeated measures), the analysis has treated the data as independent. Statistically, this means that a larger observed difference needs to occur in order for significance to be achieved (i.e., treating the data as independent observations is a more conservative approach). We conducted t-tests to compare the pre-workshop and post-workshop data. To control for the problem of compounding error rates with multiple statistical tests, we set our error rate at 0.006 (i.e., 0.05/8 = 0.006). In this way, the collective error rate for these comparisons is 0.05.

The data on the proportion of respondents in each stage pre- and post-workshop was analyzed using the chi-square statistic, with the error rate set at 0.05.

Table 3 outlines the results. Following the workshop, we found significant increases in the following:

• Comfort in describing the stages
• Use of informal questioning to determine an individual's stage
• Confidence in explaining the change processes
• Making changes to the education program to include change processes

The analysis failed to show changes on the following items:

• Interest in learning about the staged model
• Finding the staged model useful
• Using a self-developed assessment tool to identify a person's stage

The lack of change on the interest and usefulness items can be explained by a ceiling effect. That is, before the workshop, the scores on these items were so high that it is not possible to statistically find an increase. No increase in the development of an assessment tool may reflect that educators feel they have more to learn about the model.

Finally, one item (planning to review one's program in relation to TTMC) showed a significant decrease from pre- to post-workshop. Given the results on the respondents' stage (see below) this is likely due to the fact that changes had already been made at post-workshop assessment. Therefore the review had already taken place.

Data collected on the respondents showed the following:

Precontemplation. There were very few precontemplators before the workshop and none after. Given these small numbers, lack of significant changes is not surprising (a floor effect).

Contemplation. The proportion of precontemplators decreased significantly from pre- to post-workshop.

Preparation. The proportion of those in the preparation stage decreased significantly from pre- to post-workshop.

Action. The proportion of those in the action stage increased significantly from pre- to post-workshop.

Maintenance. The proportion of those in the maintenance stage approached a significant increase from pre- to post-workshop (P = 0.08).

Clearly, there was a huge shift in the respondents' use of TTMC in their practice. Before the workshop, the majority of respondents were in pre-action stages (89%). After the workshop, 62.4% moved into the action stages.

At each workshop, participants were also given a satisfaction survey. 252 evaluations have been returned out of a possible 322. Average results (see Table 4) have been calculated over the 11 programs on a 5-point Likert scale. The satisfaction surveys have been reviewed after each program to allow for an iterative process for program refinement.

The results of both the pre- and post-program questionnaire and the satisfaction survey show that educators felt they learned something new and have started to implement the model into their practice. Comments such as "Need more practical applications," "Follow up workshop with sharing re: utilization would be beneficial," and "More case studies/examples would be useful" have reinforced the original plan for the development of an advanced program.

Advanced program--application of theory using TTMC
Currently a workshop is being designed to offer activities that enable experienced diabetes educators to:

Describe the current state of application of the model in diabetes care.

• Critically examine staging tools.
• Describe examples of change processes used in diabetes education programs, with particular emphasis on identifying those appropriate for use in pre-contemplation and contemplation stages.
• Analyze their individual program(s) in terms of the model.
• Create ideas for improving their program/service(s).

A condensed half-day version of this program was conducted as part of the 1997 DES conference activities. A full-day workshop will be offered in 1999.

Consumer Programs
These two programs were designed to help educators teach their clients about TTMC. The consumer programs take two approaches: a long lesson plan (for a 1-hour group discussion) and a short version (for a 15-minute introductory session). These programs were developed as a first step in addressing a major con consistently identified by diabetes educators in their ability to apply TTMC in their practice: lack of teaching tools. The consumer programs are teaching tools available for diabetes educators to add to their tool chest.

CONCLUSION
The results of the needs assessment supported the PDAC's original impression of the need for both a basic and an advanced program. The vast majority (96.3%) of educators believed that TTMC offered great potential value to their practice. Ninety-eight percent (241) expressed their strong interest in attending a practical workshop, with 77% feeling prepared for a basic course and 22% (53) feeling prepared for a more advanced program. Over the past 2 years, these programs have been developed and have been extremely well received. Both subjective evaluations and objective measures of practice change support the efficacy of this education intervention.

A significant number of participants demonstrated movement in their personal stage of readiness to use TTMC in practice. PDAC members are emboldened by this initial success and plan to continue evaluating both the model and educator expertise practice patterns. We hope to develop effective interventions for educators at all stages and to present solid evidence of their impact.

The Diabetes Stages of Change (DiSC) study is currently in process at two Canadian sites (Mt. Sinai Hospital, Toronto, and QEII Health Sciences Center in Halifax). Working with the research team at the University of Rhode Island, we are conducting the first randomized, prospective clinical trial of the staged-based intervention for diabetes self-care behaviors. This continues the search for effective self-management strategies to enhance the practice of health professionals who work with people who have diabetes and, ultimately, to improve the lives of people affected by diabetes.

References

¹Jacobson AM: Depression and diabetes. Diabetes Care 16:1621-23, 1993.

²The DCCT Research Group: Implementation of treatment protocols in the Diabetes Control and Complications Trial. Diabetes Care 18:361-76, 1995.

³The DCCT Research Group: Influence of intensive diabetes treatment on quality-of-life outcomes in the Diabetes Control and Complications Trial. Diabetes Care 19:195-203, 1996.

⁴Jones PM, Remley C, Engberg R: Development and testing of the Barriers to Self-monitoring Blood Glucose scale. Diabetes Educ 22:609-16, 1996.

⁵Woolridge KL, Wallston KA, Graber AL, Brown AW, Davidson P: The relationship between health beliefs, adherence, and metabolic control of diabetes. Diabetes Educ 18:495-500, 1992.

⁶Mollem ED, Snoek FJ, Heine RJ: Assessment of perceived barriers in self-care of insulin-requiring diabetic patients. Patient Educ Couns 29:277-81, 1996.

⁷Araki A, Izumo Y, Inoue J, Hattori A, Nakamura T, Takahashi R, Takanashi K, Teshima T, Yatomi N, Shimizu Y: Burden of dietary therapy on elderly patients with diabetes mellitus. Nippon Ronen Igakkai Zasshi 32:804-809, 1995.

⁸Jensen SB: Emotional aspects in diabetes mellitus: a study of somatopsychological reactions in 51 couples in which one partner has insulin-treated diabetes. J Psychosom Res 29:353-59, 1985.

⁹Surwit RS, Schneider MS: Role of stress in the etiology and treatment of diabetes mellitus. Psychosom Med 55:380-93, 1993.

¹⁰Surwit RS, Schneider MS, Feinglos MN: Stress and diabetes mellitus. Diabetes Care 15:1413-22, 1992.

¹¹Rubin RR, Peyrot MP: Psychosocial problems and interventions in diabetes: a review of the literature. Diabetes Care 15:1640-57, 1992.

¹²Glanz K, Patterson RE, Kristal AR, DiClemente CC, Heimendinger J, Linnan L, McLerran DF: Stages of change in adopting healthy diets: fat, fiber, and correlates of nutrient intake. Health Educ Q, 21:499-519, 1994. (Published erratum appears in Health Educ Q 22:261, 1995.)

¹³Greene GW, Rossi SR, Reed GR, Willey C, Prochaska JO: Stages of change for reducing dietary fat to 30% of energy or less. J Am Dietetic Assoc 94:1105-10, 1994.

¹⁴Ruggiero L, Prochaska JO (Eds.): Readiness for change: application of the transtheoretical model to diabetes. Diabetes Spectrum 6:22-60, 1993.

Acknowledgments

This program was supported by an educational grant from Lifescan Educational Institute, Lifescan Canada, and Novo Nordisk Canada. Statistical analysis was completed by Dr. Michael Vallis, Diabetes Management Centre, Queen Elizabeth II Health Sciences Centre. Thank you to Barb Ledermann, a co-author of the original essential skills and consumer programs. A special thank you also to Brenda Chaddock for her support in moving this program forward.

Lynn Edwards, MHSA, RD, CDE, is conducting research at the Diabetes Management Centre, Queen Elizabeth II Health Sciences Centre, in Halifax, Nova Scotia, and is the Primary Care Demonstration Project Coordinator for the Nova Scotia Department of Health. Helen Jones, MN, CDE, is a clinical nurse specialist in the Diabetes Clinical Research Unit at Mount Sinai Hospital in Toronto. Anne Belton, RN, BA, CDE, is manager of the Diabetes Education Centre, NWGTA Brampton Memorial Hospital Campus, in Brampton, Ontario.

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