title: Behaviour change maintenance in type 2 diabetes self management: Developing the evidence base for optimising education and support programmes
Creators: name: Carvalho, Márcia
Publisher: name: University of Galway
Year: 2025
Subjects: subject: Type 2 diabetes
subject: self-management
subject: self-management support interventions
subject: structured education
subject: behaviour maintenance
subject: sustained behaviour change
subject: Psychology
subject: FOS: Psychology
subject: Arts, Social Sciences and Celtic Studies

description: Background: Attendance at structured diabetes self-management education and support (DSMES) programmes is recommended to support type 2 diabetes (T2DM) management. Evidence indicates that DSMES programmes improve clinical and psychosocial outcomes in the short term, but difficulties maintaining behavioural changes post-programme appear to attenuate their long-term impact. Sustained changes in diabetes self-management, such as diet and physical activity, are critical to achieving and maintaining improvements in glycaemic levels (HbA1c) and minimising the risk of complications. However, little is known about the factors influencing the maintenance of behavioural changes post-programme and the support needs of people with T2DM after attending these programmes. Moreover, the components and ‘active ingredients’ of these programmes remain poorly understood, including whether included content is relevant to maintenance of behaviour change. Aim: This PhD thesis aimed to develop an evidence base on behaviour change maintenance after attendance at DSMES programmes for T2DM to facilitate the development and optimisation of programmes that better support behaviour change maintenance. Methods: A multimethod approach was adopted, informed by a modified four-step version of the Behaviour Change Wheel (BCW) approach for refining behavioural interventions. Three studies were conducted. First, a systematic review and qualitative evidence synthesis was conducted to identify and synthesise qualitative research on barriers and enablers to maintaining T2DM self-management behaviours after attending a self-management intervention. Barriers and enablers were synthesised using the best-fit framework synthesis approach guided by the themes and constructs identified by Kwasnicka et al. (2016) in their review of theoretical explanations for behaviour change maintenance. Second, a documentary analysis of the materials of two DSMES programmes delivered in the Republic of Ireland, the Community-Oriented Diabetes Education (CODE) and the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) programmes, was conducted to identify their behaviour change content and key features using multiple behavioural science tools, including the Behaviour Change Techniques (BCTs) Taxonomy v1, the Mode of Delivery Ontology v1 and the Intervention Source Ontology v1. Third, a longitudinal multi-methods qualitative study, comprising four semistructured interviews and optional experience sampling (written notes and photographs), was conducted to explore behaviour change maintenance experiences and post-programme support needs of adults with T2DM over 15 months following attendance at one of two DSMES programmes (CODE and DESMOND) offered in the Republic of Ireland. Data from this study were analysed following a two-stage process: 1) cross-sectional analysis of data from each interview time point using a combined deductive framework analysis, guided by the framework generated in the systematic review, and inductive thematic analysis, and 2) a longitudinal thematic analysis inspired by trajectory analysis principles. A patient and public involvement panel informed all three studies. Findings: In study one, the systematic review and qualitative evidence synthesis identified 28 barriers and enablers (13 barriers, five enablers, 10 barriers/enablers) to maintaining self-management behaviours following self-management interventions across 10 studies. Using the best-fit framework approach, an adapted framework was developed, combining constructs from the a priori framework with inductively developed constructs (N = 3) and sub-constructs (N =12). Social support, habit formation, lapse, relapse and coping with behavioural barriers, access to appropriate support and material resources, enjoyment of behaviour and satisfaction with outcomes, self-determination, knowledge, self-regulation skill, fear of negative health consequences, concurrent health problems, competing life demands, weather conditions and sociocultural norms were amongst the most frequently identified theoretical constructs. The review also identified the need for longitudinal studies with a duration of more than nine months and a better understanding of people’s preferences and needs regarding post-intervention support. In study two, findings from the documentary analysis revealed that the programmes include a relatively low number of BCTs (27-28) from a limited number of BCT groups, with some BCT groups rarely or never included. The BCTs included in the programmes were most frequently related to ‘goals and planning’, ‘feedback and monitoring’ and ‘natural consequences’. These were linked with several mechanisms of action, most frequently reflective motivation (‘beliefs about capabilities’ and ‘beliefs about consequences’) and psychological capability (‘knowledge’), and served different intervention functions, most commonly, ‘education’, ‘enablement’ and ‘persuasion’. In study three, twenty-one adults (67% female, aged 39–74) participated, seventeen of whom completed all four interviews. The cross-sectional analysis of the data resulted in an adapted framework, the Supporting Understanding and Strategies for Type 2 Diabetes Maintenance Self-Management (SUSTAIN) framework. Three themes, each comprising two to three sub-themes, were developed based on the longitudinal analysis of the data: (1) ‘Integrating the changes amidst the constant ebb and flow of life’; (2) ‘Consolidating the changes: Moving towards independent maintenance’; and (3) ‘Building bridges to self-maintenance: The role of support post-programme’. Theme one represents people’s struggles to maintain behavioural changes post-programme due to the challenges and tensions of integrating changes into their lives and maintaining them amidst the complexities of everyday life, and their strategies to deal with challenges and maintain these changes. Theme two represents two key pathways towards independent behaviour change maintenance: a) behavioural autonomy and intrinsic motivation, and b) behavioural automaticity. Theme three represents people’s experiences of, views about, and additional needs for post-programme support to better maintain behavioural changes. Conclusions: The findings of this research have advanced the evidence base regarding behaviour change maintenance following DSMES programmes for T2DM, laying the foundation for the development and refinement of programmes for better behaviour change maintenance support. Using multiple methods, including a unique 15-month multi-methods longitudinal qualitative study, this research has extended the international knowledge base in multiple ways. First, it has extended the current understanding of factors influencing behaviour change maintenance following this type of programme. Second, it advanced understanding of these programmes’ features and behaviour change content, thus facilitating the identification of missed opportunities to support behaviour change maintenance. Third, it identified participants’ needs and preferences for support post-programme. Fourth, it identified several research, practice and policy avenues to better understand and promote long term behaviour change maintenance in this context.