Effectiveness of Motivational Interviewing on Improving Care for Type 2 Diabetes Mellitus Patients in China
Condition: Diabete Type 2
MeSH terms: Diabetes Mellitus, Type 2
Study type: Interventional

Summary: 
      The International Diabetes Federation estimated that there were nearly 110 million diabetes
      mellitus (DM) patients in China, which was the highest number recorded in the world. In
      response to the rising patient numbers and costs, the Chinese government has invested heavily
      in primary healthcare, with the goal of improving chronic disease management in the primary
      care settings. A key part of the primary care improvement program prioritizes health
      education as a route to lifestyle modification. Although the content and modes of delivery
      vary enormously, most of the programs focused on providing information rather than
      facilitating patient change. The impacts of traditional patient education on lifestyle
      modification and changes in psychological status have been reported to be suboptimal. It is
      therefore necessary to rethink and explore a more structured, patient-centered approach to
      health education at improving the outcomes of DM control.

      Motivational interviewing (MI) is a collaborative, patient-centered counseling approach that
      aims to elicit behavior change.The focus of MI is to find and resolve the ambivalence,
      improve patients' perception of the importance of behavior change, and support them to make
      the change. MI provides a structural framework with guiding principles that can be easily
      followed by the primary care doctors. Some studies show that MI can contribute to improve
      healthy eating, weight control and increases in physical activity, but most research focused
      on intermediate outcome measures and did not evaluate the readiness to change. MI can be
      utilized by a variety of healthcare providers, which makes it adaptable for different culture
      and clinical settings. The effectiveness of MI in Chinese diabetic patients remains
      uncertain.Therefore, in this study, we adopted the group MI approach and developed a patient
      empowerment program (PEP) utilizing the techniques and framework of MI. We compared this to
      the most common form of DM education in China, a lecture on DM to patients and their carers
      in a hospital lecture theatre in a didactic manner. The study aimed to assess the
      effectiveness of the MI approach in terms of patient lifestyle modification and improving DM
      controls compared to the control group in a non-blinded randomized controlled trial (RCT)
      design.
    

Detailed description: 
      This RCT was implemented from May 2016 to April 2017 in Shenzhen, China. Shenzhen is the
      fourth-biggest city in China, with a rapidly expanding population of 12 million people and
      the highest GDP in the country. Most DM patients in China are managed at Endocrine Specialist
      hospital clinics, while the more stable patients are treated in the community. Therefore, we
      chose an endocrine specialist outpatient clinic and a family medicine clinic at the
      University of Hong Kong-Shenzhen Hospital (HKU-SZH), as well as three community health
      centers in the Luohu district as the sampling frame. DM patients were recruited by doctors at
      consultations. This is because health education lectures are one of the routine diabetes
      management strategies used by healthcare providers in China and patients are normally invited
      by their doctors to attend these lectures.

      Sample size estimation was calculated based on the previous published research conducted
      elsewhere in which the DM patients were given MI-guided behavior change counselling. The
      "Problem Areas in Diabetes" (PAID) score in that study was 29±22.64 in the intervention group
      vs. 29±24.32 in the control group. Therefore, 192 participants were needed to detect 10%
      effect size with an alpha of 0.05 and a power of 80.0%. With 15% of loss to follow-up
      anticipated, a total of 225 participants were targeted.

      Descriptive statistics were used to summarize characteristics of the participants. We
      analyzed the baseline data of the intervention and control groups to determine the
      consistency of the characteristics across the two groups of patients. The t-test was used for
      continuous variables such as waist circumference, body weight, and BMI, whereas chi-squared
      test was used for categorical variables in stages of change such as smoking, drinking, and
      exercise. Changes in PAID and PEI in post-intervention and follow-ups between the two groups
      were calculated and tested.

      When analyzing the two sets of variables in the intervention and control groups, we followed
      the principle of intent-to-treat analysis i.e. if the participant failed to participate in
      all four modules, the first questionnaire results would be assumed and analyzed as the final
      data, using the mixed design analysis of variance. In detecting the relationship between the
      continuity variable and categorical variable, we used bivariate correlation analyses. All
      analyses were performed in SPSS 20.0. We used p value<0.05 as the cut-off point of
      statistical significance.
    

Intervention name(s): Motivational interviewing (MI)-based patient empowerment program (PEP); Traditional lecture style health education
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Motivational interviewing (MI) is a collaborative, patient-centered counseling approach that aims to elicit behavior change. Counselors use empathy and other techniques to create an atmosphere to help patients to explore the discrepancies between the goals and their current behavior. The focus of MI is to find and resolve the ambivalence, improve patients' perception of the importance of behavior change, and support them to make the change. MI provides a structural framework with guiding principles that can be easily followed by the primary care doctors. Program content was further informed by the Hospital Authority Patient Empowerment Program in Hong Kong. The education program consisted of four modules, held once a week, that each lasted approximately 1½ to 2 hours. They were grouped under the following four broad headings: Knowing Diabetes, Diabetes Self-Care, Healthy Diet and Physical Exercise.; The control group received traditional lectures that consisted solely of conveying healthcare information to patients. In order to minimize intervention bias, the control group lectures were standardized and adapted into four modules, namely knowing diabetes, healthy diet, physical exercises, and how to use medication correctly, which were similar topic headings, durations and frequencies to those of the intervention group. Each lecture was 1 hour and was provided by one of four health professionals (a pharmacist, dietician, endocrinologist or nurse) who had never received any prior training in MI. We consciously avoided the inclusion of elements of self-reflection and motivation in these lectures.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Health Services Research
Keywords: Type 2 diabete; Motivational interviewing; Patient empowerment; Self-management; China