Integrating behaviour change counselling into chronic disease management: a square peg in a round hole? A system-level exploration in primary health care.

OBJECTIVES: The objective of this study is to evaluate the uptake of competency-based behaviour change counselling training within a primary healthcare setting. Specific questions concerning provider readiness for training, perceived importance of training in the context of service demands and perceptions of competence after training were addressed. STUDY DESIGN: A process-focused study which adopted a complex systems approach to implementation. Each step was evaluated before the next step was developed. The design was guided by the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. METHODS: Four specific primary care services were identified and behaviour change counselling training tailored to each service was provided, based on a model of training built around competencies in establishing change-based relationships, assessing and promoting readiness to change, using evidence-based behaviour modification skills when ready and addressing psychosocial determinants of behaviour within scope of practice. Before training, a manager's readiness to facilitate training and identification of peer leaders to support ongoing practice of skills were completed. RESULTS: Two programs negotiated 8 h of formal training, one program received 10 h and one program received 12 h. All programs engaged in peer support activities. Despite willingness to support training, 90% of managers were ambivalent about training activities, relative to one half of healthcare providers (HCPs). Few HCPs and no managers self-identified as ready without ambivalence. Furthermore, HCPs were reluctant to be evaluated by an expert and preferred self-evaluation methods. In contrast, HCPs uniformly endorsed the relevance, value and professional commitment to all component skills of the behaviour change counselling model. At the end of the training, over 75% of staff reported receiving formal training (reach). Almost 80% of staff reported using change-based relationship skills daily, with less frequent use of skills associated with addressing psychosocial issues. The degree of corrective feedback was generally low, however. An index of competency based on formal training, frequent use and receiving corrective feedback indicated that most HCPs did not meet these criteria. CONCLUSION: Training in behaviour change counselling competencies was successfully implemented in this project. The vast majority of HCPs received training, despite ambivalence. Furthermore, HCPs strongly valued these skills and used them frequently. However, they were reluctant to accept corrective feedback. Future research is needed to evaluate innovative strategies to overcome obstacles to receiving corrective feedback in the use of behaviour change counselling skills.

Equipping providers with principles, knowledge and skills to successfully integrate behaviour change counselling into practice: a primary healthcare framework.

OBJECTIVES: There is an urgent need for healthcare providers and healthcare systems to support productive interactions with patients that promote sustained health behaviour change in order to improve patient and population health outcomes. Behaviour change theories and interventions have been developed and evaluated in experimental contexts; however, most healthcare providers have little training, and therefore low confidence in, behaviour change counselling. Particularly important is how to integrate theory and method to support healthcare providers to engage in behaviour change counselling competently. In this article, we describe a general training model developed from theory, evidence, experience and stakeholder engagement. This model will set the stage for future evaluation research on training needed to achieve competency, sustainability of competency, as well as effectiveness/cost-effectiveness of training in supporting behaviour change. DESIGN AND METHODS: A framework to support competency based training in behaviour change counselling is described in this article. This framework is designed to be integrative, sustainable, scalable and capable of being evaluated in follow-up studies. RESULTS AND DISCUSSION: Effective training in behaviour change counselling is critical to meet the current and future healthcare needs of patients living with, or at risk of, chronic diseases. Increasing competency in establishing change-based relationships, assessing and promoting readiness to change, implementing behaviour modification and addressing psychosocial issues will be value added to the healthcare system.

Emerging adulthood and Type 1 diabetes: insights from the DAWN2 Study.

AIMS: To compare clinical, psychological, education and social variables in emerging adults (aged 18-30 years) with Type 1 diabetes with their adult counterparts aged >30 years. METHODS: A single assessment multinational sample was surveyed as part of the larger second Diabetes Attitudes, Wishes and Needs (DAWN2) study. Participants completed a series of surveys incorporating demographic as well as clinical questions (comorbidities, hypoglycaemia) and validated self-report scales concerning psychosocial (health impact, quality of life, beliefs and attitudes, self-management behaviours, healthcare experience and family support) and diabetes education factors. RESULTS: Emerging adults differed from adults aged >30 years with regard to a number of psychosocial variables. Emerging adults reported better overall quality of life, social support and support from their healthcare team compared with adults aged >30 years of age; however, emerging adults experienced greater diabetes-specific distress and were less engaged in self-management. Diabetes education was related to a number of indicators, while experience of discrimination was harmful, but these impacts did not differ between emerging adults and adults aged >30 years. An analysis of geographical regions suggested that emerging adults in North America and Europe had better well-being than older adults, while the opposite was observed in Asia. CONCLUSIONS: Emerging adults, particularly those in the later phase (ages 25-30 years) are especially at risk in terms of diabetes-specific distress. There is a need for novel interventions to meet the needs of these vulnerable emerging adults more effectively.

Review of research grant allocation to psychosocial studies in diabetes research.

AIMS: To estimate and discuss the allocation of diabetes research funds to studies with a psychosocial focus. METHODS: Annual reports and funded-research databases from approximately the last 5 years (if available) were reviewed from the following representative funding organizations, the American Diabetes Association, the Canadian Diabetes Association, Diabetes Australia, Diabetes UK, the Dutch Diabetes Research Foundation and the European Foundation for the Study of Diabetes, in order to estimate the overall proportion of studies allocated research funding that had a psychosocial focus. RESULTS: An estimated mean of 8% of funded studies from our sample were found to have a psychosocial focus. CONCLUSIONS: The proportion of funded studies with a psychosocial focus was small, with an estimated mean ratio of 17:1 observed between funded biomedical and psychosocial studies in diabetes research. While several factors may account for this finding, the observation that 90% of funded studies are biomedical may be partly attributable to the methodological orthodoxy of applying biomedical reductionism to understand and treat disease. A more comprehensive and systemic whole-person approach in diabetes research that resembles more closely the complexity of human beings is needed and may lead to improved care for individuals living with diabetes or at risk of diabetes.

Correlates of psychological outcomes among family members of people with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study.

AIMS: To conduct a second Diabetes Attitudes, Wishes and Needs (DAWN2(™) ) study, examining the experiences of family members caring for adults with diabetes in order to identify correlates of family member psychological outcomes (generic psychological well-being, perceived quality of life, and diabetes-related burden, impact and distress). METHODS: A total of 2057 family members living with a person with diabetes and involved in their care participated in an online, telephone or in-person survey. Samples of 120 respondents were recruited in each of 17 countries. Significant (P < 0.05) correlates of psychological outcomes were identified by multi-level multiple regression. RESULTS: Outcomes were worse for family members not working because of diabetes or those who had other competing obligations. Outcomes were worse if the person with diabetes was not a partner or parent, used injected diabetes medication, or had more frequent hypoglycaemia. Outcomes were worse for family members who believed that diabetes was more severe, were more involved in diabetes care, had more conflict over diabetes care or were frustrated about not knowing how to help the person with diabetes. Outcomes were better for those who had greater support from others and felt they found good ways to help the person with diabetes. There were significant differences in outcomes among countries before and after adjustment for individual characteristics, and correlates of outcomes varied by country. CONCLUSIONS: Several modifiable risk and protective factors for family member psychological outcomes were identified in this study. Diabetes education and social support were associated with improved outcomes, especially if they were helpful in supporting people with diabetes.

Quality of life and psychological well-being in obesity management: improving the odds of success by managing distress.

BACKGROUND: Obesity is increasing in prevalence and placing an ever-greater burden on individuals and healthcare resources alike. Obesity management is complex and, for many, elusive. AIMS AND METHODS: This paper reviews the major factors that influence psychological well-being in individuals with obesity and describes the means by which their impact on distress and other aspects of quality of life (QoL) can be quantified. The goal is to enable healthcare providers to set reasonable, achievable, maintainable weight loss targets that will improve the psychological well-being and QoL of individuals living with obesity. PubMed and Web of Science searches were conducted to identify literature that addresses the key question: How can distress over obesity be measured and taken into account when tailoring weight loss interventions for a particular patient? DISCUSSION AND CONCLUSIONS: 'Distress over obesity' is a key parameter that illustrates the psychological consequences of excess weight. Healthcare providers can draw on a range of obesity-specific and non-specific assessment tools to quantify distress as well as the other contributions of obesity to QoL and mental/emotional health. When physicians consider the psychological/QoL aspects of obesity and how these change with successful weight loss, it becomes possible to set achievable, realistic weight loss goals and develop a manageable plan to achieve them. Any future developments that make it easier to achieve these goals should be made widely available to all patients in need, in order to help them turn a vicious cycle of failure into a virtuous cycle of success.

If it does not significantly change HbA1c levels why should we waste time on it? A plea for the prioritization of psychological well-being in people with diabetes.

Despite improvements in pharmacological treatments and methods of care and care delivery, the burden of living with diabetes remains an ongoing challenge, as many people with diabetes are at increased risk of mental health disorders, psychological disturbances and functional problems associated with living with diabetes. Person-centred collaborative care that also meets the psychological needs of the individual is not available to many people with diabetes. The present article examines the role of psychological factors in the onset of diabetes and in relation to living with diabetes. It is argued that the pursuit of psychological well-being is worthy of individual attention in the care of people with diabetes and should not be contingent upon attainment of somatic indices of health. The barriers to attaining this goal are examined, including the costs of treating (or not treating) psychological problems in people with diabetes. Recommendations on how to improve diabetes care are offered, including psychological interventions that are both evidence-based and cost-effective.

Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Obesity counselling in primary care is positively associated with self-reported behaviour change in patients with obesity. Obesity counselling is rare, and when it does occur, it is often of low quality because of poor training and/or competency of providers' obesity management, lack of time and economical disincentives, and negative attitude towards obesity and obesity management. 5As frameworks are routinely used for behaviour-change counselling and addiction management (e.g. smoking cessation), but few studies have examined its efficacy for weight management. WHAT THIS STUDY ADDS: This study presents pilot data from the implementation and evaluation of an obesity management tool (5As of Obesity Management developed by the Canadian Obesity Network) in a primary care setting. Results show that the tool facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care. Obesity remains poorly managed in primary care. The 5As of Obesity Management is a theory-driven, evidence-based minimal intervention designed to facilitate obesity counselling and management by primary care practitioners. This project tested the impact of implementing this tool in primary care clinics. Electronic self-administered surveys were completed by pre-screened obese subjects at the end of their appointments in four primary care clinics (over 25 healthcare providers [HCPs]). These measurements were performed before (baseline, n = 51) and 1 month after implementing the 5As of Obesity Management (post-intervention, n = 51). Intervention consisted of one online training session (90 min) and distribution of the 5As toolkit to HCPs of participating clinics. Subjects completing the survey before and after the intervention were comparable in terms of age, sex, body mass index, comorbidities, satisfaction and self-reported health status (P > 0.2). Implementing the 5As of Obesity Management resulted in a twofold increase in the initiation of obesity management (19 vs. 39%, P = 0.03), and caused a statistically significant increase in the perceived follow-up/coordination efforts (self-reported Patient Assessment of Chronic Illness Care components, 45 ± 22 vs. 67 ± 12 points, P = 0.002), as well as two components of the 5As framework: Assess (50 ± 29 vs. 66 ± 15 points, P = 0.03) and Assist (54 ± 26 vs. 72 ± 13 points, P = 0.01). Our results suggest that using the 5As of Obesity Management facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care.

Diabetes Attitudes, Wishes and Needs second study (DAWN2™): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes.

AIMS: The second Diabetes Attitudes, Wishes and Needs (DAWN2) study aimed to assess psychosocial outcomes in people with diabetes across countries for benchmarking. METHODS: Surveys included new and adapted questions from validated questionnaires that assess health-related quality of life, self-management, attitudes/beliefs, social support and priorities for improving diabetes care. Questionnaires were conducted online, by telephone or in person. RESULTS: Participants were 8596 adults with diabetes across 17 countries. There were significant between-country differences for all benchmarking indicators; no one country's outcomes were consistently better or worse than others. The proportion with likely depression [WHO-5 Well-Being Index (WHO-5) score ≤ 28] was 13.8% (country range 6.5-24.1%). Diabetes-related distress [Problem Areas in Diabetes Scale 5 (PAID-5) score ≥ 40] was reported by 44.6% of participants (17.2-67.6%). Overall quality of life was rated 'poor' or 'very poor' by 12.2% of participants (7.6-26.1%). Diabetes had a negative impact on all aspects investigated, ranging from 20.5% on relationship with family/friends to 62.2% on physical health. Approximately 40% of participants (18.6-64.9%) reported that their medication interfered with their ability to live a normal life. The availability of person-centred chronic illness care and support for active involvement was rated as low. Following self-care advice for medication and diet was most common, and least common for glucose monitoring and foot examination, with marked country variation. Only 48.8% of respondents had participated in diabetes educational programmes/activities to help manage their diabetes. CONCLUSIONS: Cross-national benchmarking using psychometrically validated indicators can help identify areas for improvement and best practices to drive changes that improve outcomes for people with diabetes.

Radiation induced angiosarcomas of the nasopharynx.

Angiosarcoma is a malignant tumour of the vascular endothelial cell that rarely occurs in the head and neck. We present two cases arising in the nasopharynx after radiotherapy. The role of radiotherapy in carcinogenesis is considered with reference to the delay between treatment of a primary head and neck tumour and presentation with the second primary.

Radiation therapy of squamous carcinoma of the tonsil: an analysis of prognostic factors and of treatment failures.

A retrospective analysis of the results of treatment by primary irradiation of 87 cases of squamous-cell carcinoma of the tonsil at one institution over a 20-year period is presented. Survival at 5 years for all patients was 20%. The major determinants of survival were tumour size (T) and nodal status (N) at presentation. Degree of histological differentiation had no prognostic significance. Initial failure occurred in the primary tonsil site or in cervical lymph nodes in almost all cases. It is clear that treatments that increase loco-regional control are needed if the prognosis for the more advanced tumours is to be improved and it is suggested that a combined-modality approach (surgery plus irradiation) needs to be explored. For early lesions, primary radiation therapy remains the treatment of choice.