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Health professionals have expressed unmet needs, including lacking the skills, confidence, training, and resources needed to properly attend to the psychological needs of people with diabetes.
Informed by needs assessments, this study aimed to develop practical, evidence-based resources to support health professionals to address the emotional needs of adults with type 1 or type 2 diabetes.
We developed a new
The literature review uncovered that psychological problems are common among adults with diabetes, but health professionals lack resources to provide related support. We planned and drafted resources to fill this unmet need, guided by stakeholder consultation and an Expert Reference Group (ERG). Before finalizing the resources, we implemented feedback received from stakeholders (ERG, health professionals, academics, and people with diabetes). The resulting resources were the practical, evidence-based
The new evidence-based resources are perceived by stakeholders as effective aids to assist health professionals in providing emotional support to adults with diabetes. The 7 A’s model may have clinical utility for routine monitoring of other psychological and health-related problems, as part of person-centered clinical care.
Diabetes is a serious chronic condition affecting more than 415 million people worldwide, and this number is rising [
Clinical guidelines recommend person-centered, holistic diabetes care, including routine monitoring for psychological problems [
Therefore, our aim was to address health professionals’ unmet needs, using a formative evaluation approach, by developing a practical, evidence-based resource:
To develop the
Summary of the formative evaluation of the Diabetes and Emotional Health handbook and toolkit.
To begin, we established a project team that included health and clinical psychologists and researchers with expertise in the psychological aspects of diabetes. We also established a multidisciplinary Expert Reference Group (ERG), representing various stakeholders (eg, general practitioner, endocrinologist, diabetes nurse educator, psychologist, key organizations, and people with diabetes). The project team worked collaboratively throughout the project, meeting regularly, holding workshops to discuss and progress ideas, and constructively reviewing each other’s work. We engaged the ERG at least quarterly to discuss plans and progress.
In 2013, we conducted a narrative literature review to investigate 7 research questions (see
The literature review confirmed the need for practical, user-friendly, and evidence-based resources; thus, we decided to develop a handbook to meet this need (See “Review the Problem and Previous Efforts to Address It: Literature Review” in the Results for further information).
From late 2013 to early 2014, JH and LB consulted with each ERG member individually to (1) gain a deeper understanding of their current practice related to diabetes-related psychological care and (2) ascertain their needs (individual and professional, content and design) for the
A review of each completed draft chapter and its corresponding summary and questionnaire cards was conducted to ensure that the content was consistent with best practice and recent evidence and met the needs of the intended audience. The factsheet (part of the
Owing to the significant time and work required to review the chapters (estimated minimum 3 hours), we offered remuneration to all reviewers. We provided the reviewers with background information (eg, aim, scope, content, and target population), instructions (eg, scope for the review), and a nontypeset copy of the chapter and summary (both annotated with guiding questions). JH prepared and provided guiding questions relevant to each reviewer’s background to ensure the reviews were within the scope of the individual’s expertise (eg, medical content was not the responsibility of mental health professionals or people with diabetes). The professionals provided written feedback, while the people with diabetes provided written or verbal feedback. JH met (face-to-face or telephone) with those who opted to provide verbal feedback, making comprehensive notes during and immediately after the conversation. Once all reviewers provided feedback, we consolidated the feedback for each chapter into a single document for team review and implementation.
The National Diabetes Services Scheme (NDSS; funding body) required its Medical, Education, and Scientific Advisory Council (MESAC) to review and approve the resources before publication. We submitted a standardized form with background information in addition to the nontypeset
As a final step, we undertook a qualitative study of the
We promoted the study via newsletter advertisements and direct emails to health professionals who had previously registered their interest. Participants were eligible if they worked in Australia as a general practitioner, endocrinologist, credentialed diabetes educator, nurse, or dietitian and consulted with at least 10 adults with diabetes weekly. About 2 weeks before the interview, we sent consenting participants a typeset copy of the
A researcher who did not develop the
The literature review demonstrated that psychological problems are common among Australian adults with type 1 and type 2 diabetes [
On the basis of the literature review findings (see
The literature review informed the
Overview of the Diabetes and Emotional Health handbook and toolkit.
Overview of the 7 A’s model.
The ERG consultations facilitated greater understanding of the roles of different health professional disciplines and their needs. A summary of the key results is included in
Results and actions arising from stakeholder (Expert Reference Group) consultations
Topic | Results | Actions |
Assessment of psychological health in clinical practice settings | Each practicing health professional had a different preferred style, for example: Enquiring through conversation and open-ended questions, because they believe a structured questionnaire might divert the focus of the conversation from the agenda of the person with diabetes to the agenda of the health professional. Routine screening using short questionnaires, because they believed it is easy to miss problem areas in conversation, eg, the person with diabetes might not raise it themselves. They believed that asking people to complete the screening questionnaires in the waiting room (before the consultation) is appropriate. They agreed that introduction of the questionnaire to the person with diabetes is important (eg, to explain the purpose and that completion is optional). Annual assessment (eg, for diabetes distress using the PAIDa scale), because it forms part of an annual holistic approach to care and is acceptable to people with diabetes. |
As there is no evidence to support one approach over another, the |
Feedback about the |
Some thought the amount of detail (length) in the example chapter was appropriate and that there was a good balance of bullet points and sentences. They believed that some health professionals would want this level of detail, but that others may not have time to read it. So, it would be important to find a balance between detailed information and 1-page summaries. They offered various suggestions for presentation (eg, develop electronic and printed versions, use a PDF rather than CD for the electronic version). Of the 3 short formats provided, the 5 A’s model was preferred because it was a simple, step-by-step guide and would be familiar to many health professionals. They made minor suggestions for improvement (eg, reducing text and design elements). Summary cards would be useful to put on wall or in top drawer (for quick accesses). They suggested and agreed that factsheets for people with diabetes would be useful (to facilitate conversations to distribute in consultations and waiting rooms). |
The The 5 A’s model (later adapted to a 7 A’s model, see Electronic (PDF) and hardcopy versions of the |
Topic-specific feedback |
They offered suggestions regarding topics to include and exclude and questionnaires to include and exclude. |
We considered and included the suggestions as appropriate (eg, within scope of project and supporting evidence). |
Language considerations |
Use plain language in communications with and for people with diabetes. Define commonly used words and use terms consistently. Avoid referring to “patients.” |
We made efforts to ensure appropriate and consistent language use, and in accordance with published recommendations [ The The |
Ideas for future stakeholder consultation |
Include people with diabetes in the next phase of consultation. A suggestion was offered for implementing stakeholder consultation (based on a process which worked well for another organization when developing factsheets)—to prepare unformatted drafts and email it to stakeholders (eg, professional bodies and consumers), for written responses or tracked changes. Give a few guiding questions in the cover letter then leave it “open”. |
We adapted (to suit the project) and implemented the suggested consultation method. Health professionals, academic experts, and people with diabetes reviewed the |
Suggestions for dissemination and future work |
Consider attaining endorsement of the Consider developing training to complement the |
We did not pursue endorsements, owing to complexity of the process and because the We informed relevant professional bodies of the resources (enabling promotion to their members). We pursued funding opportunities to enable development of Web-based health professional training. |
aPAID: Problem Areas In Diabetes.
On the basis of the consultation results, we decided to develop both a
Drafting the
The reviewers (n=37) provided positive and constructive feedback. Many suggestions for improvement were minor and most was chapter specific (eg, add a reference, adapt a suggested strategy, or change a word). Several reviewer suggestions were outside the project scope (eg, include information about complex psychiatric conditions or for carers of people with diabetes) or included elsewhere in the
We held several whole-day team workshops to compare, discuss, and review the feedback. This included discussion of conflicting feedback and views. To overcome conflict, we discussed and collaboratively made pragmatic decisions (eg, could we add a text box or bullet point, or refer the reader to another page or chapter?). We sought clarification from reviewers as needed (eg, we wanted clarification or further information). Significant revisions were required for 2 chapters: “Communication” and “Facing life with diabetes.” Finally, the author who drafted the chapter implemented the agreed revisions.
Where relevant, we implemented feedback across multiple chapters of the
Structured case studies—we had developed 2 versions of the first 2 chapters reviewed (“Psychological barriers to insulin use” and “Depression”), one “structured” in accordance with the 7 A’s model and one “unstructured.” The reviewers indicated that the structured version was preferable, so we structured all other case studies in this manner.
Editing—we developed a style guide to ensure consistency across the handbook in reducing unnecessary wordiness, improving readability or understanding, and improving the language (to be more positive, empowering, inclusive, supportive, and consistent).
Quotes from people with diabetes—we added these to demonstrate examples of concepts in the handbook.
The MESAC viewed the
We implemented the requested changes as appropriate (eg, rewriting some sections to reduce wordiness), resulting in a
We interviewed 19 participants, of 25 health professionals who volunteered. The participants included 9 nurses and 6 dietitians (of whom 7 and 1 were credentialed diabetes educators, respectively), 2 general practitioners, and 2 endocrinologists. The participants worked in urban or metropolitan (9/19, 47%) and regional or rural (10/19, 53%) settings. Most (16/19, 84%) worked in a multidisciplinary health service that did not include a mental health professional in the team. They reported varying levels of confidence to talk about (median 3, range 2-5) and assist with (median 3, range 2-5) with diabetes-related emotional problems; 37% (7/19) had used a questionnaire in clinical care to assess emotional health. The 6 who did not participate could not be reached at the time of interview. They had similar confidence to talk about and assist with emotional problems, compared with the participants, but none had used questionnaires.
The chapters selected by participants were fear of hypoglycemia (n=7), diabetes distress (n=5), eating problems (n=4), psychological barriers to insulin use (n=1), depression (n=1), and anxiety disorders (n=1). Most also read other chapters of the
Participant quotes are included in
The participants reported how the
The participants commented how the
The participants identified some possible
Given the positive feedback and lack of major concerns, CH, JH, and JS finalized the content and typesetting. Electronic and hardcopy versions of the
Qualitative study evaluation of the handbook and toolkit by health professionals.
Topic | Example quotes |
Perceived highlights |
“Most useful section was the ASK section as it gave practical tips on asking questions that will bring up any issues.” (Dietitian, male, eating problems) “I really liked the quotes from practice nurses and quotes from health professionals and quotes from consumers. I thought that was a nice value add. And, I liked the ‘ABCs of effective communication.’” (Dietitian, female, diabetes distress) “Loved the summary cards and felt that this was the “Irena [case study]…that would be a very common scenario…I thought it was a great example, and it's brief, it's not too lengthy. And then it sets out the 7 A’s framework in each section of what you can do…. so it's easy for the practitioner to work with that.” (Registered nurse-diabetes educator, female, fear of hypoglycemia) “I’m quite visual in my learning, so, when I’m trying to think about structures in my head, I think visually and I like colors… I like the approach of it.” (Registered nurse, female, diabetes distress) “The structure is well laid out and it certainly follows the 7 A’s model very well. All the chapters have done that, which is exactly what you want. You want consistency so that the reading is streamlined and everyone who reads it can access what they want very quickly.” (GP, male, fear of hypoglycemia) |
Role of health professionals |
“I think that the one thing that the “For me, this book has really normalized that our role is working with a whole person, their emotional health and their physical health… sometimes in the rush of everything, and especially in a tertiary setting, you can get quite focused on the physical aspect of somebody who’s acutely unwell… I found it a really useful tool to just ensure that we all keep in mind that we’re working with a person.” (Registered nurse, female, diabetes distress) “I think the point that kept coming through… most people actually do want to go to a member of their diabetes team to talk about this. So, if my question was, you know, is this my role? Well, yeah, it is. They’re seeing it as my role.” (Dietitian, female, diabetes distress) |
Encourage self-reflection |
“I think it's a really good way to actually reflect back on… your own thoughts and about how you actually engage in asking about diabetes distress.” (Nurse practitioner-credentialed diabetes educator, female, diabetes distress) “I used the Diabetes Distress chapter more for like, a concrete reflection on my practice.” (Registered nurse, female, diabetes distress) “I discussed it with a Type 1 client and we've made an arrangement that next time that she has an appointment that we will discuss her views on this, because it's something that I feel that I could do better on it as a clinician.” (Credentialed diabetes educator-registered nurse, female, fear of hypoglycemia) |
Build self-confidence |
“And, the other comment that’s interesting is that diabetes distress is best managed within the context of diabetes care… [it] improves my confidence and I think ‘yeah – that’s what I do with people’ and just talking through their feelings and what’s an issue for them – that I’m doing the right thing… Which is such a feeling of relief really.” (Dietitian, female, diabetes distress) “That 7A’s thing, it really worked. I was nicely surprised. Yeah. And, it felt like I didn’t do anything different to what I normally do, but, I had a language for it. So, that I could work it through for myself.” (Registered nurse, female, diabetes distress) |
Influence clinical practice |
“I was reading the “The 7A’s tool itself, in working with this client – it let me look at structuring how to work both with … the physical aspects and the emotional responses together. It was really useful.” (Registered nurse, female, diabetes distress) “I really think that part of my practice I need to do more of regularly is start to use the PAID scale and particularly for everyone, not just picking some people but just doing it on everyone, not all the time, but doing it. But, I really think it will actually bring out a lot of things that both sides of the party didn’t realize or think about.” (Nurse practitioner-credentialed diabetes educator, female, diabetes distress) “I can think of a number of people I see where I've recognized fear of hypoglycemia and there's information within that chapter which may help me work through that fear with them.” (Endocrinologist, male, fear of hypoglycemia) |
Spread the word |
“I actually showed one of my neighbors who is a pharmacist and I was discussing with him, on chapter 5, how good I thought it was to do decisional balancing with someone who is reluctant to start insulin.” (Credentialed diabetes educator-registered nurse, female, fear of hypoglycemia) “I’ll be actively promoting it as a resource and I’ll be wanting our GPs to have it available to them and I’ll be promoting it heavily.” (Credentialed diabetes educator-registered nurse, female, eating problems) “I’ve talked to my boss and I wouldn’t mind doing a bit of an information session to other dietitians and coaches about it… summarize the importance of dealing with the emotional aspect of diabetes and then point to some of these summary cards and… the |
Barriers to implementation |
“I think the problem with the psychology referral is that… people with a specific interest in diabetes are few and far between… But, it would be really nice to know which psychologists for instance, in our area, are interested in dealing with patients with diabetes and the same with psychiatrists. I think that’s where I struggle clinically.” (Endocrinologist, male, fear of hypoglycemia) “You know, unless you are lucky enough to have a psychologist that works and is employed within a practice and they don't charge a gap, people can’t afford that.” (Nurse practitioner-credentialed diabetes educator, female, diabetes distress) “Regarding diabetes distress, it's [ “We have 20 minute appointments and have to deal with the medical side of diabetes and then to deal with psychological side too, we probably can designate maybe five minutes – ten minutes, if we’re lucky… we need the numbers and the resources and things at our fingertips… I think it’s fantastic and it definitely is needed but we need to have that information right there or in a website form where we can just go click.” (Endocrinologist, female, fear of hypoglycemia) |
Suggestions for promotion |
“Getting it out there, is the key… a good advertising campaign, and that's probably best orchestrated through presentation of some of the work in the book at the various diabetes-related clinical meetings that occur around the countryside...” (Endocrinologist, female, fear of hypoglycemia) “I think it needs to go into the Graduate Certificate for Diabetes Education. I think it needs to go to medical students and…pharmacy students as well…” (Credentialed diabetes educator-registered nurse, female, fear of hypoglycemia) |
Training needs and ideas |
“… actually getting people to physically do the questionnaire themselves or give them a case study scenario so that they’re doing it from the perspective of their person… it’s really important to be familiar with the tool. But, also scoring. So, it’s one thing to give people a questionnaire to fill out but to then be able to score it on the spot and give them some feedback.” (Dietitian, female, diabetes distress) “…as part of the training something along the lines of a mentoring or relationship...you might, as part of the training process, bring along how you do things, case studies, that part of it is meeting and talking with a peer.” (Nurse practitioner-credentialed diabetes educator, female, diabetes distress) “...I think they [chapters] could all be incorporated into one workshop, covering how to ask questions and what to do with the information once you've got it and how to build trust, all that sort of thing.” (Nurse-diabetes educator, female, eating problems) “…practical case studies based. The other thing that works well for medical practitioners is webinars and well, something where people can be at home listening to or do it in their own time or, perhaps type questions in.” (Endocrinologist, female, fear of hypoglycemia) “We need to make the assessment of emotional health a compulsory part of guidelines… because they all tick off these other things on their list. We have to test their cholesterol levels twice a year. We're going to do their HbA1c twice a year… but no one actually asks them about how they are.” (Dietitian, female, eating problems) |
While guidelines recommending psychological care in diabetes have existed for 25 years [
Formative evaluation is an essential first step for developing high quality and effective interventions that are acceptable to the target population [
These resources are important stepping stones toward more consistent implementation of clinical practice guidelines and better integration of psychological health into routine diabetes consultations. As described by 1 qualitative study participant, the
We acknowledge that there is more work to do. For example, a limitation of this study was the exclusive focus on adults with type 1 and type 2 diabetes. We selected these 2 groups as they represent the largest populations in need of psychological support, and our previous research had focused largely on adults [
Diabetes and Emotional Health is a practical, evidence-based, clinically informed handbook and toolkit developed in consultation with end-users and other stakeholders. The findings of our formative evaluation suggest that the resources are comprehensive yet user friendly, addressing the previously unmet needs of multidisciplinary health professionals, enabling professional development and supporting real-world implementation of clinical practice guidelines related to the psychological care of people with diabetes.
Diabetes and Emotional Health provides health professionals with practical information and tools required to implement clinical practice guidelines related to the psychological aspects of diabetes. More than 1000 hardcopies have been distributed to Australian health professionals and more than 1400 electronic copies have been downloaded. The resources remain freely available on the Web. [
Literature review questions, results, lessons, and actions.
Expert Reference Group
Medical, Education, and Scientific Advisory Council
National Diabetes Services Scheme
The authors would like to thank the people with diabetes, health professionals, academics, and organizations who contributed to the development or review of the
None declared.