“Ready to Act“ - a health education programme

16th Nordic Congress of General PracticeCopenhagen, May 14, 2009

Helle Terkildsen Maindal, RN, MPH, PhD Department of General Practice, Aarhus University, Denmark

Anglo-Danish-Dutch study of intensive treatment in people with screen detected diabetes in primary careReach, process evaluation and effects

of the “Ready to Act” intervention

Aims of this presentation

• To illustrate the challenges of the implementation and

evaluation of a health-promoting intervention for

people screen-detected in general practice with type 2

diabetes, impaired glucose tolerance or impaired

fasting glucose

Today’s presentation

• Target group

• Brief introduction to the intervention

• Attendance

• Initial outcomes

• Intermediary outcomes

• Long-term outcomes

What kind of intervention was needed?

• People with prediabetes and T2 diabetes diagnosed by screening in

general practice, recruited from the ADDITION-study *

• After the screening-procedure followed early multi-factorial

intervention, behavioural and pharmacological

• This intervention is one of the patient adressed behavioural

interventions aiming at health promotion

*The Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-

Detected Diabetes in Primary Care

Study population and design

509 randomised at the individual level (2:1)

322 Intervention 187 Control

Conventional treatment

ADDITION-study, general practice, Denmark

Intensive treatment

People with screen-detected dysglycaemia

”Right at the beginning you

need somebody’s arms around you”

(Peel, 2004)

”Right at the beginning you

need somebody’s arms around you”

(Peel, 2004)

”No symptoms, no

problem?” (Adriaanse,

2003, Lawton, 2005)

”No symptoms, no

problem?” (Adriaanse,

2003, Lawton, 2005)

”I feel I lack knowledge and

confidence” (Lawton, 2005)

”I feel I lack knowledge and

confidence” (Lawton, 2005)

”My GP focuses on the blood

sugars -I focus on my

cooking”(Woodcock,2001)

”My GP focuses on the blood

sugars -I focus on my

cooking”(Woodcock,2001)

”It is a mild disease”

(Adriaanse, 2002)

”It is a mild disease”

(Adriaanse, 2002)

Action Competence

Individualinterview

IndividualinterviewGroup meetings

Health beliefs

Readiness to change

Outcome expectan-cies

Action plan

Feed back

Looking ahead

Social support

Informed decision-making

Motivation Informed decision-making

Action experience

1

Cardio-vascular risk and dys-glycaemia:

Symptoms, signs, physiology, causes and treatment. Action planning.

2

Preventive actions:

Health behaviour and medical treatment.

The collabo-rative approach.

3

Actions related to diet:

Blood glucose, lipids, weight and well-being.

Change strategies.

Action planning.

4

Actions related to physical activity:

Physical exercise and blood glucose.

Change strategies.

Resources and barriers.

5

Actions related to diet:

Health beliefs.

Foods composi-tion and purchase.

6

Actions related to diet:

Skill training.

Eating patterns.

Everyday and occasional food.

7Actions related to physical activity:

Skill training.

Effects on risk, weight and blood glucose.

8

Attitude to risk and diagnose:

Variations in feelings.

Action planning.

Support and local resources.

Nurse and GPNurse NurseNurse Dietician Dietician

Physio-therapist

Physio-therapistDietician Nurse

Social involvement

Outcomes

• Initial outcomes (3 months)

• Autonomy support

• Perceived outcome

• Recommend the intervention to others

• Intermediary outcomes (1 year)

• Treatment motivation

• Perceived competence

• Long-term outcomes (1 year)

• Activation

• Dietary quality

• Physical activity

• Long-term outcomes (3 year)• HbA1c

• Lipids• Body Mass Index• Cardiovascular risk score

Baseline characteristics

Randomisation groups

  All n Intervention n Control n

Age, year mean (SD) 61.8 (7.2) 509 62.2 (6.9) 322 61.2 (7.6) 187

Sex, % female 46,8 509 47,2 322 46 187

Diagnosis, % prediabetes

47,5 509 46 322 50,3 187

Diagnosis duration, year mean (SD)

1.7 (1.8) 509 1.8 (1.8) 322 1.6 (1.8) 187

Body mass index (kg/m2)

30.0 (5.3) 501 29.9 (5.1) 315 30.2 (5.8) 186

Glycated haemoglobin (%)

6.0 (0.9) 509 6.0 (0.8) 322 6.1 (0.9) 187

Intervention reach in the randomised controlled trial

Intervention group (N=322)

38% (n=123)Accepted the programme and completed

6% (n=19)Accepted, but did not complete

34% (n=109) Declined the invitation

22% (n=71) No response

Control group (N=187)

Effect evaluation

• Moderate effects on psychological outcomes

• No effects on diet, physical activity or activation

• No evidence of clinical outcomes (yet)

Process evaluation

• Reach 38%• Perceived autonomy support

median 6,2 (max. 7)• 90% would recommend the

intervention to others• 80% perceived positive or

very positive outcomes

Results of 1-year follow-up (short form!)

Are these conflicting results? Not necessarily …

Discussion

• Did the intervention work?

• Did we choose the right outcomes?

• Do we have sufficient evidence for further

implementation?

• If further implementation...

• Do we need further evidence?

• Are there critical areas to be adjusted?

Conclusion and perspectives

• Transparent and systematic intervention development

• 44% accepted the intervention, 38% completed

• Positive process evaluation

• Moderate effects – clinical relevance?

• Intervention linked to health promotion activities after early detection of T2

diabetes and prediabetes remains a future challenge….

”Absence of evidence is not evidence of absence”

(Bland & Altman 1995)

Financial support: University College of Jutland, Danish Council of Nursing, The Danish Diabetes Association, Novo Nordic Foundation DK