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Psychological Family Intervention for Poorly Controlled Type 2 Diabetes
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Psychological Family Intervention for Poorly Controlled Type 2 Diabetes

Karen M. Keogh, PhD; Susan M. Smith, MD; Patricia White, PhD; Sinead McGilloway, PhD; Alan Kelly, PhD; James Gibney, MD; and Tom O'Dowd, MD
A family-based intervention targeting negative and/or inaccurate illness perceptions in patients with poorly controlled type 2 diabetes was effective in improving glycemic control.
However, both groups continue to have unacceptably high A1C levels at follow-up, with neither group achieving optimal glycemic control targets. Nonetheless, the 0.4% decrease in A1C in this study is comparable to improvements associated with other psychosocial interventions for patients with diabetes,23,24 and a decrease in A1C of 0.5% is increasingly recognized as clinically significant. Although the numbers were small, patients in the most vulnerable subgroup of this population with poor control (baseline A1C >9.5%) showed the greatest improvement in A1C, with a 1.2% decrease. That is comparable to improvements seen after the introduction of new oral hypoglycemic medications.25 Arguably, the intervention was most effective in those with the poorest control because they had the greatest scope for improvement at a psychological and biologic level. As patients in this group are often the most challenging to manage, the approach adopted in this trial may be of value to clinicians and patients alike. A recent pharmacist-managed collaborative care intervention for poorly controlled diabetes also found that some patients benefited more than others.26 When evaluating complex interventions, future research might address the question of what best works for whom, and under what circumstances, so that clinicians and service planners can target such interventions more cost-effectively.

The intervention group also reported significant improvements in most illness perception dimensions (except consequences and timeline), indicating that patients had a more accurate and positive view of diabetes. Our results are consistent with results of the small number of interventions in other illness populations that have had similar success in changing illness perceptions.27 Baseline scores on the timeline dimension indicated that participants had an accurate view of diabetes as a chronic condition; thus, there was little scope for improvement. With regard to consequences, there was a significant improvement in the intervention group when nonparticipants were excluded from the analysis.

There was little scope for changes in blood pressure, as both groups had acceptable control at baseline. The lack of any change in body mass index is in keeping with other family intervention studies23 and highlights the difficult task faced by patients in controlling their weight. The lack of improvements in specific self-management behaviors may have arisen as participants were given the opportunity to select the behaviors targeted for change. This raises questions about interventions that emphasize patients’ own goals for  change, as specific self-management behaviors (eg, foot care) may be undervalued and not addressed.

Strengths and Limitations

The key strengths of this study include its firm theoretical base, its mixed-methods approach, its multidisciplinary team input, and its adherence to the high-quality practices recommended for randomized controlled trials.28 These factors, as well as the pattern of improvements across primary and secondary outcomes, suggest that internal validity was  high. However, given the high “did not attend” rates at recruitment clinics, and the consistent association between infrequent clinic attendance and adverse clinical outcomes,29 it is  likely that the most vulnerable of those with poor glycemic control (ie, those who default from care) were not recruited. However, it was not possible to analyze this group, as we had no consent to access their records. Additionally, in terms of controlling for medication change, only a change from oral hypoglycemic agents to insulin was included in the analysis. It was not possible to collect data on other types of medication changes, although this is an important factor that future studies may want to consider. Also, the current study would ideally have included a longer follow-up (eg, 12 months) to investigate whether observed improvements were maintained.

We were unable to identify from the literature any other home-based interventions for patients with poorly controlled type 2 diabetes. However, home-based interventions for other groups30 have been found to be acceptable and convenient to patients, and may help to educate family members and encourage family involvement in disease management. Such interventions may also be more effective at accessing vulnerable populations, including the elderly, ethnic minorities, patients from socially deprived areas, patients with multimorbidity, and those who fail to attend regular clinic-based care. The increased costs associated with home-based interventions, however, ought to be balanced against their overall effectiveness. Future studies may consider implementing this kind of intervention in a clinic setting, alongside a full cost-effectiveness analysis, to determine whether it has similar positive effects. While this intervention was delivered by a psychologist, other health professionals could be trained to deliver it in other contexts. This is an important consideration in terms of the effective future implementation of such psychological interventions into routine care.

Without a patient-only intervention arm, it was not possible to conclusively elucidate the effects of including a family member. However, the robust theoretical framework underlying the intervention, coupled with appropriate process and outcome measures, suggests that the family member was a key active ingredient. The majority of the sample (75%) nominated their spouses, and the remaining proportion proposed their children. The study was not powered to detect whether there were any differences in outcomes depending on the family relationship, and this factor may be an area for future research. Eight patients did not receive the intervention because their family member declined to participate. It is possible that mobilizing family support is most important in this group. However, it also may be possible to deliver the intervention to these patients individually. Although additional arms increase trial complexities and costs, it may be worthwhile to conduct future studies comparing a family intervention with a patient-only intervention.

Finally, it must be noted that the delivery of this intervention was challenging and time consuming, due in part to the difficulties in accessing participants despite repeated efforts. Clinicians and service planners will recognize the existence of a hard-to-reach group of high-risk patients who frequently require unplanned care with repeated hospital admissions  to deal with the complications of poor control. Continued persistence and flexibility may be the solution to accessing these vulnerable populations in both research and clinical  settings, although these interventions initially may be more costly and time consuming. In the long term, such interventions may improve illness outcomes for patients, thereby reducing costs and improving quality of life for patients and families.

CONCLUSIONS

This study indicates that targeting inaccurate and/or negative beliefs about poorly controlled type 2 diabetes, in the home setting and in the presence of a family member, can change illness perceptions and improve poor glycemic con trol, self-management, psychological well-being, and familysupport. Given the resource-intensive nature of this  intervention and the modest improvement in glycemic control, future studies are needed to assess the effectiveness of the delivery of this type of intervention delivered in alternative settings, and by other health professionals. Tailoring these kinds of interventions to those with the poorest of control may deliver the most benefit, at least in the short term.

Acknowledgments

The authors would like to thank all participating patients and their families; staff at the diabetes clinics; and Professor Steward Mercer, MD, University of Glasgow, and Michael Donnelly, PhD, Queen's University Belfast, who provided valuable feedback on the study.

 

Author Affiliations: From the Department of Public Health and Primary Care (KMK, SMS, PW, AK, TO), Trinity College Dublin, Ireland; Department of Psychology (SM), National University of Ireland, Maynooth, Ireland; and Department of Endocrinology (JG), Trinity College Dublin, Ireland.
 

Funding Source: This study was funded by the Irish Health Research Board, project grant RP/2005/178.
 

Author Disclosures: The authors (KMK, SMS, PW, SM, AK, JG, TO) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
 

Authorship Information: Concept and design (SMS, PW, AK, JG, TO); acquisition of data (KMK, PW); analysis and interpretation of data (KMK, SMS, PW, SM, AK); drafting of the manuscript (KMK, SMS, PW, SM, AK, TO); critical revision of the manuscript for important intellectual content (KMK, SMS, PW, SM, AK, JG, TO); statistical analysis (KMK, SMS, PW, SM, AK); provision of study materials or patients (KMK, SMS, JG); obtaining funding (SMS, PW, AK, TO); administrative, technical, or logistic support (KMK, SMS, PW, AK); and supervision (SMS, PW, SM, TO).
 

Address correspondence to: Karen M. Keogh, PhD, Department of Public Health and Primary Care, Trinity College Dublin, Trinity College Centre for Health Sciences, AMNCH, Tallaght, Dublin 24, Ireland. E-mail: keoghkm@tcd.ie.

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