Tri-Service General Hospital, Department of Internal Medicine
Phase: NA
Conditions: Diabetes Mellitus, Type 2
Sponsor: Tri-Service General Hospital

 
Effectiveness of App-based Positive Psychological Intervention on Patients Newly Diagnosed with Type 2 
Diabetes  
2021. OCT. 20 
 
 

 
Effectiveness of App-based Positive Psychological Intervention on Patients Newly Diagnosed with Type 2 
Diabetes  
 
Positive psychological constructs (PPCs), such as optimism, gratitude, self-efficacy, and resilience 
have been considered to positively impact adherence and self-care behaviour of patients with type 2 diabetes 
(T2DM) (Celano et al., 2013). Moreover, diabetes self-care behaviours would be consistently improved as 
the PPCs have strengthened (Huffman et al., 2015). Based on systematic reviews, the positive psychological 
intervention has significantly improved positive emotions, quality of life, self-efficacy, depression, 
optimism, gratitude, and well-being of patients with T2DM (Huffman et al., 2019; Steinhardt et al., 2015; 
Miller et al., 2014, Cohn et al., 2014; DuBois et al., 2016; Moskowitz et al., 2017). The strengthen of PPCs 
could be regarded as a strategy for improving type 2 diabetes self-management. 
 
Positive psychology intervention (PPI) emphasises enhancing PPCs via consciousness raising and 
enhancing personal strengths. With the systemic practice of PPI, it develops individual positive cognition 
and emotions. A previous Internet-based intervention study found that people have been taught positive 
emotional skills shown a significantly lower depression level than those having the daily emotional diary 
(Chon et al., 2014). Additionally, a one-group pre–post test study found that both optimism and gratitude 
have significantly increased after a 12-week phone-based PPI in patients with T2DM(Huffman et al., 2015). 
Another one-group pretest–posttest study demonstrated that optimism and well-being had significantly 
increased after a 12-week PPI. Furthermore, optimism, gratitude, frustrated, depressive, and distress, 
diabetes self-care and health behaviours adherence have obvious improved (DuBois et al., 2016). In recent 
study, Celano et al. (2019) demonstrated that self-care behaviour and diet behaviour had significantly 
improved after a 16-week phone-based psychological-motivational interviewing intervention among the 
patients with Type 2 diabetes (T2DM) with 8 years duration of diabetes.  
 
Although previous studies have demonstrated the effectiveness of PPI on PPCs, only few studies 
investigate the impact on patients newly diagnosed with T2DM. The aim of this study is to explore the 
effectiveness of app-based PPI on patients newly diagnosed with T2DM. 
Method 
Design 
This study will be conducted by experimental research design from 1st Oct 2021 to 31st July 2023. To 
prevent intervention contamination, patients newly diagnosed with T2DM of an endocrinology clinic in a 
medical center in northern Taiwan are assigned to the experimental group (n=57), while patients at an 
endocrinology clinic in southern Taiwan are assigned to the control group (n=113). Both groups have the 
pre-test at the baseline. Afterwards, experimental group will have a 3-month App-based intervention which 
include PPI and diabetes-related health education, physical records, and online consultation. The control 

 
group only received a diabetes-related health education by certificated diabetes educators. The post-test will 
be conducted at the end of intervention, 3 months, and 9 months post- intervention.  
Sampling 
The inclusion criteria of eligible participants are: (1) newly diagnosed with T2DM less than 6 months; (2) 
aged 20 to 64; (3) without any mental illness; (4) controlling diabetes through oral medication or insulin 
injection; (5) able to use Android phone. Exclusion criteria were unable to communicate with language or 
having mental illness. Based on the previous literature, an a priori G*power was conducted to determine a 
sufficient sample size using an alpha value of 0.05, a power of 0.80, and medium effect size of 0.5 by t-test 
(DuBois et al., 2016; Miller et al., 2014; Steinhardt et al., 2015). Ratio of numbers of participant in control 
group and experimental group will be 2:1. Moreover, an attrition rate of 20% was expected. Thus, the 
desired minimum sample size of 130 participants (experimental group= 57, control group= 113) are required 
for the study.   
Outcome Measures 
Outcome variables will be collected by self-reported questionnaires including followings. 
1.Demographic and disease characteristics Form 
Demographic and disease characteristics form is used to collect participants’ gender, age, education level, 
marital status, occupation status, comorbidities (e.g., hyperlipidaemia, hypertension, and coronary artery 
disease), duration of diabetes, and treatment methods. Additionally, body mass index and HbA1c levels will 
be obtained from medical records of each participants.  
2.Diabetes Distress Scale 
Diabetes Distress Scale will assess the burden causing by diabetes self-management, which measured by a 
short form of Problem Areas in Diabetes scale in Chinese version (Hsu et al. 2013). It consists of 8 items, 
rated on a 4-point Likert scale, ranging from 0 (not a problem) to 4 (very serious problem). Total score 
ranges from 0 to 32, with high score indicating a greater level of diabetes distress. 
3.Optimism 
Optimism will be measured using the Life Orientation Test-Revised (LOT-R) developed by (Scheier et al., 
1994). It consists of 6 items, rating from 0 as strongly disagree to 4 as strongly agree. The overall score of 
LOT-R is 42 points, with higher scores indicating higher dispositional level of optimism. 
4.Gratitude 
 A Gratitude Questionnaire (GQ) is frequently used to assess in gratitude (McCullough et al., 2002). It 
consists of 6 items, rating from 1 (strongly disagree) to 7 (strongly agree). The overall score of GQ is 42 
points, with higher scores indicating higher gratitude disposition. 
5.Self-efficacy 

 
A Diabetes Self-efficacy scale (DSES) is used to determine an individual’s confidence on executing diabetes 
self-care behaviour (Lee et al., 2016). It consists of 14 items with a five-point Likert scale, rating from 0 as 
“Extremely unconfident” to 4 as “80% to 100% confident”. 
6.Diabetic Positive Characteristics Scale  
A Diabetic Positive Characteristic Scale (DPCS) is used to determine individual positive characteristics of 
diabetic patients. It consists of 20 items with a five-point Likert scale, rating from 1 as “strongly disagree” to 
5 as “strongly agree”. The overall score of DPCS is 100 points, with higher scores indicating greater 
likelihood of positive characteristics disposition. 
7..Self-care behaviour 
A Diabetes Self-care Behaviour Scale-Chinese version is used to measure the level of self-care behaviour in 
diabetes patients (Lee et al., 2016).  It consists of 17 items with five-point Likert scale, including exercise (3 
items), dietary management (3 items), medical adherence (3 items), blood sugar monitoring (4 items), and 
adversity prevention (4 items). It rates from 0 (never) to 4 (always), ranging from 0 to 68 points. The higher 
scores indicate a greater execution in self-care behaviours. 
8..Quality of life 
A Quality of Life Scale (QoLS) is used to identify the impact of diabetes treatment in daily life (Hsu et al., 
2018). It is a 15-item instrument with three sub-domains of Quality of life: psychosocial functioning, 
treatment regimen adherence, and diabetes-related influences in daily life. It consists of 15 items with five-
point Likert scale (0= ‘Never’, 4= ‘Always’), with higher scores indicating a higher quality of life.   
App-based Intervention 
 
The intervention will be conducted on the app, including PPI, diabetes-related health education, 
physical records, and online consultation. The PPI has included a 12-week PPI lessons (Table 1). Each 
lesson has separated into 3 parts:  introduction, activity, and feedback. In term of Diabetes-related health 
education will include the basic knowledge of diabetes, diet, and exercise related videos. Physical records 
include their daily blood sugar, blood pressure, HbA1c, dietary record, and exercise record. In terms of 
dietary records, the amount of carbohydrates of each food will be calculate automatically after documented.  
Exercise records documents the burn of calories of each exercise (per 30 minutes). Both unit of dietary and 
exercise are based on Health Promotion Administration’s criteria. Moreover, participants are available to 
have one-on-one instant online consultation with their diabetes educators via App.  
Data Analysis 
 
The statistical software IBM SPSS ver.25 will be used for data analysis. A x2 tests is used to compare 
the differences in demographic and disease characteristic between control group and experimental group. An 
independent t-test is used to compare the differences at baseline, week at the end of intervention, 3 months, 
and 9 months post-intervention for each outcome variable between control group and experimental group; 
and a paired t-test is used to compare the differences within both groups. A Generalized Estimation Equation 

 
(GEE) is used to compare the changing amount of outcome variables from baseline to week at the end of 
intervention, to 3 months, and to 9 months post-intervention between a control group and experimental 
group. A p-value <.05 is considered statistically significant. 

 
Table 1 Positive Psychological Interventions Outline 
Week 
Topic 
Goal 
Week1 
Introduction of positive psychology 
Understanding positive psychology 
Week 1-1 
Luxuries of Life 
Intangible assets  
Week 2 
Plating the Seed of Hope 
Promote motivation for change 
Week 3 
Learn to be Grateful 
Enhance gratitude and optimism 
Week 4 
A little progress each day adds up a BIG result 
Enhance confidence and keep motivation 
Week 5 
Exploring beauty 
Enhance gratitude 
Week 6 
Show your talent 
Reduce implementation difficulties and 
obstacles 
Week 7 
Encouragement: A Driving force for advancing  
Enhance self-efficacy and resilience 
Week 8 
Thankful 
Review the concepts of Gratitude 
Week 9 
Be Responsible to yourself 
Enhance self-efficacy and resilience 
Week 10 
Be a better person 
Enhance self-efficacy and resilience 
Week 11 
Have you found your beauty yet? 
Review the concepts of beauty 
Week 12 
Do you have positive perspective of your life? 
Evaluation and feedback 
 

 
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