Dia-D Program: propositional essay of an educational intervention for self-management in type 2 diabetes

Brevidelli, Maria Meimei; Bergerot, Cristiane Decat; Domenico, Edvane Birelo Lopes De

doi:10.1590/2177-9465-EAN-2022-0291en

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REFLECTION • Esc. Anna. Nery 27 • 2023 • https://doi.org/10.1590/2177-9465-EAN-2022-0291en copy

Dia-D Program: propositional essay of an educational intervention for self-management in type 2 diabetes

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

to present the Diabetes em Dia (Dia-D) Program: an educational intervention for self-management in type 2 diabetes, focused on promoting healthy eating, being active, and taking medication, among adults with type 2 diabetes.

Method

a propositional essay of complex intervention based on two behavioral models: The ADCES7 Self-Care Behaviors™ (Association of Diabetes Care and Education Specialists); and the Behavior Change Wheel (BCW).

Results

BCW’s conceptual framework “Capability, Opportunity, Motivation-Behaviour (COM-B)” made it possible to define the determinants of target behaviors. Based on these, interventions were proposed, such as training, enablement, education, environmental restructuring, persuasion, service provision, guidelines, and communication. Behavior change techniques (demonstration and self-monitoring of behavior, information on health consequences, among others) underpinned the intervention content.

Final considerations and implications for practice

the theoretical models enabled the structuring of an educational intervention with an emphasis on proposing strategies for behavior modification, a central component in caring for people with diabetes. The relevance of adopting behavioral models in health education planning and the complex nature of the intervention design stand out.

Keywords:
Self-Management; Type 2 Diabetes; Chronic Disease; Patient Education as Topic; Health Education

Healthy eating: balanced carbohydrate consumption by controlling portions; encouraging low-glycemic carbohydrate consumption; replacement of saturated fats with monounsaturated fats
COM-B components	What needs to happen for the target behavior to be achieved?
*Physical capability* (physical ability)	· Willingness/spirit and ability to follow the proposed dietary pattern · Sufficient health staff and up to date on clinical guidelines
*Psychological capability* (knowledge, cognitive and interpersonal skills, memory, attention, decision processes, behavioral regulation)	· Knowledge about the proposed dietary pattern · Knowledge about the role of food in glycemic control · Capability to plan meals according to the proposed dietary pattern · Capability to maintain proposed dietary pattern in social events (e.g., meetings, parties, restaurants)
*Physical opportunity* (environmental context, material resources)	· Access to proposed dietary pattern at home and at work · Patient-centered healthcare staff approach
*Social opportunity* (culture, social influences)	· Family/friend support to follow the proposed dietary pattern
*Reflective motivation* (role and social identity, beliefs in one’s own capability, beliefs about risks/benefits associated with the behavior)	· Valuing the achievement of goals to control the disease · Personal self-efficacy to follow the proposed dietary pattern · Overcoming unhealthy food preferences (“fat is tasty”; “healthy foods don’t satisfy hunger”) · Perception of benefits of the proposed dietary pattern · Perception of risks associated with unhealthy eating · Overcoming male gender issues (e.g., “men consume alcohol in excess”; “healthy eating is not compatible with male work”) · Overcoming female gender issues (“taking care of others - children, husband, grandchildren - is a priority”)
*Automatic motivation* (emotions/drives arising from associative learning and/or innate dispositions, reinforcers)	· Ability to deal with food cravings or cravings · Feel comfortable trying new flavors/spices · Positive attitude towards diabetes
Physical activity (PA): doing 150 minutes a week (e.g., brisk walking) on a regular and progressive basis or increasing the daily number of steps (up to 10,000/day)
COM-B components	What needs to happen for the target behavior to be achieved?
*Physical capability* (physical ability)	· Willingness/spirit and ability to include regular PA in the daily routine · Sufficient health staff and up to date on clinical guidelines
*Psychological capability* (knowledge, cognitive and interpersonal skills, memory, attention, decision-making, and behavioral regulation)	· Knowledge about PA recommendations for people with diabetes · Knowledge about the role of PA in glycemic control · Ability to plan regular PA practice · Ability to perform PA safely (e.g., without hypoglycemia) · Ability to deal with everyday difficulties to perform PA (e.g., low mood, unforeseen events, extreme temperatures)
*Physical opportunity* (environmental context, resources, and equipment)	· Access to places to perform PA (e.g., streets, parks, gyms) · Time to perform PA · Patient-centered healthcare staff approach
*Social opportunity* (culture, social influences)	· Family/friend support to perform PA regularly
*Reflective motivation* (role and social identity, beliefs in one’s own capability, beliefs about risks/benefits associated with the behavior)	· Valuing the achievement of glycemic goals · Perception of PA benefits · Perception of risks associated with sedentary lifestyle · Personal self-efficacy for practicing PA regularly · Overcoming male gender issues (e.g., “men should prioritize work”) · Overcoming female gender issues (“taking care of others - children, husband, grandchildren - is a priority”)
*Automatic motivation* (emotions/drives arising from associative learning and/or innate dispositions, reinforcers)	· Positive attitude towards diabetes
Medications: strictly follow medication treatment (medication name, correct route, dose, time)
COM-B components	What needs to happen for the target behavior to be achieved?
*Physical capability* (physical skill)	· Willingness/spirit and ability to plan the taking medications · Sufficient health staff and up to date on clinical guidelines
*Psychological capability* (knowledge, cognitive and interpersonal skills, memory, attention, decision-making, and behavioral regulation)	· Knowledge about medications in use (name, dose, indication, action, conservation and side effects) · Knowledge about the relationship between compliance with treatment and glycemic control · Planning the daily routine according to the medications · Planning the taking medications in non-routine events (e.g., trips, outings, parties)
*Physical opportunity* (environmental context, resources, and equipment)	· Access to prescription drugs · Patient-centered healthcare staff approach
*Social opportunity* (culture, social influences)	· Family/friend support
*Reflective motivation* (role and social identity, beliefs in one’s own capability, beliefs about consequences - risks/benefits - associated with behavior)	· Valuing the achievement of glycemic goals · Perception of benefits of drug treatment · Perception of risks associated with failures in compliance with drug treatment · Personal self-efficacy to comply with drug treatment · Overcoming concerns about drug treatment · Overcoming fear of medication or injection side effects · Overcoming male gender issues (e.g., “men should be strong”)

Behavior change techniques	Description
Encouraging willingness and skills (physical and psychological capability)
Behavior demonstration	Provide an observable sample of how to perform the behavior directly or indirectly, via video or pictures, so that people can be inspired or imitated.
Behavior self-monitoring	Establish a method for the person to monitor or record performance of the behavior.
Shaping knowledge/educating (psychological capability)
Instructions on how to perform the behavior	Advise or agree on how to perform the behavior; includes skills training.
Information about health consequences	Provide information about the health consequences associated with carrying out the behavior, not only for oneself, but also for others.
Information about emotional consequences	Provide information about emotional consequences of performing the behavior.
Prompts/cues	Introduce an environmental or social stimulus for the purpose of promoting or warning the behavior.
Promoting training (automatic and reflective motivation; social opportunity)
Goal setting	Establish or agree to defined goals in terms of desired behavior.
Action planning	Develop a detailed plan for how to perform the behavior, including context, frequency, duration, and intensity. Context can be environmental (physical or social) or internal (physical, emotional or cognitive).
Commitment	Ask a person to affirm and reaffirm their commitment to behavior change.
Graded tasks	Determine tasks that are easy to perform, gradually increasing the difficulty.
Problem solving	Encourage the analysis of the factors that influence the achievement of desired behavior and generate/propose strategies to overcome barriers and/or make it feasible.
Feedback on behavior	Monitor information and provide feedback on performance of behavior.
Feedback on outcome(s) of behavior	Monitor and provide feedback on the outcome associated with performing the behavior.
Pros and cons	Advise the person to identify and compare advantages and disadvantages in performing the behavior.
Comparative imagining of future outcomes	Promote comparison of future results between performing or not changing behavior
Social support (practical and emotional)	Advise/provide practical and emotional help from family/friends/health care staff to perform the behavior.
Reduction of negative emotions	Advise on ways to lessen demands on mental resources to facilitate behavior change.
Persuading (automatic and reflexive motivation)
Salience of consequences	Use specific methods to emphasize consequences of carrying out the behavior, with the purpose of making them unforgettable, going beyond informing (e.g., using shocking images about harmful consequences associated with smoking).
Framing/Reframing	Suggest adopting a new perspective on the behavior and its purpose, with the intention of changing associated reasoning or emotions.
Verbal persuasion about capability	Assertively communicate that the person has the capability to perform desired behavior, dispelling their doubts and emphasizing the potential for success.
Environmental restructuring (physical opportunity)
Restructuring the physical environment	Change or advise to change the physical environment in order to facilitate the performance of desired behavior or to create difficulties for the unwanted behavior.
Behavior substitution	Promote unwanted behavior replacement with desired one.

Behavior change techniques	intervention content
Encouraging willingness and skills
Behavior demonstration	Food: composition of a healthy dish through interaction games with participants; demonstration of simple recipes to increase vegetable consumption and reduce carbohydrate and saturated fat consumption (video). Physical activity: demonstration of a personalized program of physical activity at no cost (video on how to walk, strength exercises and stretches).
Behavior self-monitoring	Participants will receive a Diário Diabetes em Dia, to monitor and record the follow-up of the action plan, and will be guided to use applications for cell phones to count steps, when possible.
Shaping knowledge/educating
Instructions on how to perform the behavior	Participants will receive detailed guidance on how to: (i) plan meals according to the proposed dietary pattern; (ii) carry out the proposed physical activity program; (iii) taking medications correctly and planning daily activities according to medication schedules.
Information on health/emotional consequences	Participants will be instructed on: (i) the role of diet, physical activity and medications in glycemic control; (ii) health benefits of complying with the proposed behaviors and risks of not complying with.
Prompts/cues	Participants struggling to remember medication times will receive personalized information on how to create reminders and prompts.
Promoting training
Goal setting/action planning	Participants will be individually encouraged and guided to set lifestyle change goals in relation to target behaviors. Guidelines will be personalized and adjusted to the socioeconomic and clinical profile of the participants and the type of medication being used.
Commitment	Participants will be encouraged to commit to the proposed planning and goals, by completing the Diário Diabetes em Dia and the booklet Diabetes Dia a Dia: Descobrindo Soluções, which will present situations involving problems and request the search for solutions.
Graded tasks	Composition of food/physical activity goals will be done gradually to facilitate compliance with the plan.
Problem solving	Difficulties to change behavior will be discussed in the group, in order to encourage the exchange of experiences and the search for solutions. Strategies for overcoming barriers will be discussed based on the entries in the booklet Diabetes Dia a Dia: Descobrindo Soluções.
Feedback on behavior	Compliance with the action plan will be monitored by the health staff and participants will receive feedback.
Feedback on outcome(s) of behavior	Participants’ clinical data will be monitored before and after the intervention and participants will receive feedback.
Pros and cons/ Comparative imagining of future outcomes	During the health staff’s interactions with the participants, they will be encouraged to: (i) consider the pros and cons of following the proposed action plan, with the aim of weighing the benefits and risks; (ii) reflect on one’s perspective of health in the future, in relation to how it is in the present.
Social support (practical and emotional)	Family members will be invited to participate in the group sessions to discuss how they can engage and help comply with the action plan.
Reduction of negative emotions	Participants will be guided on simple relaxation/meditation techniques to reduce the emotional burden of diabetes.
Persuading
Salience of consequences	Information about the health risks of not complying with desired behaviors will be emphasized with the use of aversive images about the chronic complications of diabetes.
Framing/Reframing	During interactions with the health staff, participants will be encouraged to reflect on beliefs that make it difficult to comply with desired behaviors (e.g., "fat is tasty"; "healthy food does not satisfy hunger"; "men need to consume alcohol in excess"; " healthy lifestyle is not compatible with male work”; “for women, taking care of children, husband or grandchildren is a priority”; “men must be strong”).
Verbal persuasion about capability	During individual interactions, participants will be encouraged to follow through with the action plan, emphasizing successes and new skills acquired.
Environmental restructuring
Restructuring the physical environment	Participants will be advised to organize the environment to fulfill the plan, through: (i) purchase of food; (ii) resources needed to perform physical activity (appropriate location and clothing); (iii) adequate supply and resources to organize medication doses and schedules.
Behavior substitution	In individual interactions, if participants report a lack of time for physical activity, they will be advised to review their daily life routine in order to learn how to manage time and replace “sedentary” time with “active”.

Universidade Federal do Rio de Janeiro Rua Afonso Cavalcanti, 275, Cidade Nova, 20211-110 - Rio de Janeiro - RJ - Brasil, Tel: +55 21 3398-0952 e 3398-0941 - Rio de Janeiro - RJ - Brazil
E-mail: annaneryrevista@gmail.com

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[1] Corresponding author:
Maria Meimei Brevidelli. E-mail: maria.brevidelli@docente.unip.br