Additional Evidence From Diabetes Research

In addition to the work described here, there are two lines of research in the diabetes literature to suggest that an evidence base for this approach is emerging in the peer-reviewed literature, the descriptive research, followed by the intervention research.

Kyngas and Hentinen37 interviewed a number of adolescents about their perceptions of their health care professionals, specifically their physicians and nurses. The adolescents' descriptions of their carers' behaviour were put into three or four categories. Two of these categories were common to both nurses and physicians; 'motivating'—asks, listens and takes notice of adolescent's opinion, decisions concerning care are made together, action of professionals is influenced by adolescents; and 'routine'—professionals act according to their goals, ask the same questions every visit, and answers are ignored. For physicians, the other two categories were 'authoritarian' and 'negligent'. For nurses, the other category was 'behaving according to physician's instruction'. What is important to note is that those adolescents whose health care professionals were described as motivating (which is closely related to the description of empowerment), were substantially more likely to have been rated as having 'good compliance', which in turn was related to better control of diabetes.

Along similar lines, Street and colleagues19 studied the consultations of nurses with patients with type 2 diabetes attending a 31 day diabetes education course. The recorded consultations were coded by assistants blind to the purpose of the research. After controlling for baseline HbA1, follow-up HbA1, taken 2-3 months after the consultations, was predicted by features of the nurse-patient interactions. Specifically, after interacting with nurses who were more controlling and directive in their communication, patients experienced poorer metabolic control.

Another important descriptive study was recently published by Williams and colleagues38. They conducted a prospective study of 128 adults with diabetes. Their data indicated that when the health care climate was experienced as being rich with provision of choice, information about the problem, acknowledgement of the patient's emotions and minimal pressure to behave in particular ways, patients display improved physiological outcomes, in this case glycosylated haemoglobin. Furthermore, Williams demonstrated the process by which an empowering consultation may lead to improved patient outcomes. Their prospective data indicated that patients who experienced a more autonomy-supportive health care climate reported more autonomous motivation (experienced a sense of volition, self-initiation and personal endorsement of the behaviour), rather than controlled motivation (people felt pressured to behave by some interpersonal or intrapsychic pressure). This sense of autonomous motivation mediated the association between an autonomous health care climate and blood glucose regulation.

In a review of research on the role of patient participation in a visit to a doctor, Golin and colleagues39 concluded that patient participation was associated with self-care. They hypothesized that increased patient participation in the consultation would influence subsequent self-care, through improving the fit between the treatment regimen and patients' lifestyle. This would clearly make it more likely that the individual would enact the treatment recommendations. In addition, by permitting patients to communicate their concerns and priorities to the provider they are more likely to receive more of the information they want and need, rather than what the health care professional thinks they want, the result of which may be greater relevance of information and subsequent improved use of knowledge and skills. Therefore, it is not surprising that prospective studies have found a direct link between patient participation and expression of their views and subsequent self-care.

Furthermore, a couple of studies have shown that increased information giving, meeting of patients' expectations, and expression of empathy effect patients' satisfaction with their medical care more than do the costs of care or the technical competence of the physician40'41 Individuals were more satisfied with interactions in which they expressed their own opinions, and also reported feeling less motivated to adhere when they were scolded by a provider. Therefore, it would seem that there is a sound theoretical rationale and increasing descriptive data to support the argument for a more empowering approach to consultations. This descriptive data cannot demonstrate a causal relationship, which can only be demonstrated through intervention studies. However, there are at least two published intervention studies that provide further support for the principles of empowerment.

Greenfield and colleagues42 conducted a randomized controlled trial of an intervention designed to improve patients' participation in their diabetes care. In a 20 minute session just before the regular clinic visit, the participants reviewed their medical records with a clinical assistant, guided by a diabetes algorithm. Using systematic prompts, the assistant encouraged participants to use the information gained to negotiate medical decisions with the doctor. In the control group, the participants just reviewed standardized educational material. The intervention was successful in terms of changing the nature of the consultation. The experimental group were more active, asking more questions, speaking more, and obtaining more information. At follow-up the participants in the intervention group showed significant improvements in glycosylated haemoglobin and fewer functional limitations. Furthermore, there was a significant correlation between more effective information seeking and follow-up glycosylated haemoglobin. It should also be noted that the increase in patient participation did not result in a lengthening of the clinic visit time.

Building on this work, Kinmonth and colleagues43 conducted a randomized controlled trial of training primary care professionals in more 'patient-centred' care. This was operationalized by encouraging professional carers to review the evidence for patient-centred care, and provide them with relevant skills training, such as active listening and negotiation of behaviour change. In addition, patients in the intervention group received a booklet encouraging them to ask more questions. All newly diagnosed patients with type 2 diabetes at the 41 participating practices were then followed for a year. The intervention participants subsequently reported better communication with health care professionals, greater treatment satisfaction and better emotional well-being. These benefits were achieved without adversely affecting glycae-mic control. The authors concluded that the 'study shows the power of the consultation to affect patients' health and well-being'.

Neither of these interventions was overtly based on the empowerment model, and only focused on certain aspects of the model as described above. However, in conjunction with the work previously described in this chapter, the data indicates that giving patients more choice, actively listening to them and answering their questions—in effect empowering them to take care of their diabetes—will result in improved physical and emotional health. However, it must be noted that to date, the authors are not aware of any study that has fully tested the empowerment model. Studies report changes in health care professionals' attitudes towards patients having more autonomy, choice and involvement in their diabetes care, as a result of attending 'empowerment training workshops'. There is, as yet, no published data to indicate that this results in changes in health care professionals' behaviour in clinical practice, and that this will result in improvements in patients' health. Bearing this in mind, we feel that the literature briefly reviewed here suggests that patients' physical and emotional health will be enhanced if an empowerment model is adopted. Thus, there is the beginning of an evidence base for this model of diabetes care, but a full test of the model is needed.

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