This study had two phases: 1) Training diabetes HPs to deliver LISTEN and 2) A pilot study investigating the feasibility and acceptability of LISTEN. All aspects (workshops, supervision, sessions) were conducted online (e.g. via Zoom video meetings), due to the coronavirus (COVID-19) pandemic, and the physical distancing restrictions in place throughout the project.
1) LISTEN training of diabetes health professionals
Recruitment and procedure
Three HPs volunteered to participate in the LISTEN training, including one who joined the study in case that one of the two HPs would become unavailable/withdrew). The HPs were employed at Diabetes Victoria (the Victorian Agent of the National Diabetes Services Scheme (NDSS), which is an initiative of the Australian Government, administered by Diabetes Australia). They were experienced in responding to NDSS Helpline calls for support and information for diabetes self-management. HPs were eligible to participate if they had: (1) qualifications as a Credentialled Diabetes Educator: Registered Nurse (RN or Division 1) or Accredited Practising Dietitian; (2) a minimum of 12 months experience in a diabetes setting; (3) previous training or experience in supporting people with emotional problems and/or motivation to upskill to do so; and (4) capacity to undertake the training and deliver LISTEN for the study duration. HPs consented to take part in the study and completed a brief online (pre-training) survey which included questions about their professional history and reasons for participating in, and expectations of, the training. HPs also completed an online post-training survey.
LISTEN training program
LISTEN training comprised: (1) participation in three half-day workshops, and (2) delivery under supervision to training cases.
The three-day workshop was adapted for diabetes HPs in Australia from an established training program,[21] which demonstrated high-level performance results among nurses.[32–34] A training manual and an example session narrative were provided. The online workshops comprised PST theory-informed learning modules and practical skills-training for facilitating LISTEN sessions, including one opportunity to role play a session. The training also focused on strategies to strengthen HPs’ skills in showing empathy (attentive listening, reflection, summarising),[35] and addressing common barriers to mental health support-seeking (e.g. from a general practitioner (GP) or mental health professional). The workshops were delivered by two experienced research fellows (SG and EH) with expertise and/or clinical experience in: a) psychological therapies, including PST; b) training health professionals in mental health and emotional support strategies; c) providing clinical supervision; and d) the psychosocial aspects of diabetes.
Following completion of the workshops, HPs were allocated a minimum of two, and a maximum of four, training cases. On average, HPs facilitated sessions with two training cases at a time. Training cases were adults with diabetes who met the inclusion criteria for the study (Additional file 1) and had volunteered to be a ‘training case’. With participants’ consent, all sessions were audio-recorded. Each session was reviewed, and structured feedback was provided to the HP during a weekly 1-hour supervision session with SG.
2) Pilot study
Study design
This was a single-group, pre-post pilot and feasibility study with online data collection at baseline, immediately post-intervention, and four-week follow-up (post-intervention).
Recruitment and eligibility
We aimed to recruit 20 adults with diabetes. Inclusion criteria were: currently residing in Victoria, Australia; aged 18 to 75 years; self-reported diagnosis of type 1 or type 2 diabetes; at least mild diabetes distress (score ≥ 25 on the Problem Areas in Diabetes (PAID) scale (or a score of ≥ 2 (moderate problem) on three or more PAID items). Exclusion criteria were: a score ≥ 3 on either the depression or anxiety subscales of the four-item Patient Health Questionnaire (PHQ-4), indicating moderate-to-severe depression and/or anxiety symptoms. A summary of the mental health inclusion criteria and referral pathways is presented in Additional file 1.
Prospective participants were recruited using convenience sampling through websites, e-newsletters and social media (Twitter, Facebook) via the researchers’ affiliated professional accounts. Diabetes Victoria staff were encouraged to promote the study through similar strategies, as well as via peer support and consumer groups.
Prospective participants were directed to an online survey hosted on the Qualtrics™ platform. Those who consented to take part in the study, completed questions to determine their eligibility and, if eligible, were directed to the baseline assessment. Those who were ineligible were informed immediately using an autogenerated message and based on their responses, were provided with links and resources to mental health support as well as an open text field for contact details if they consented to be followed up by the research team.
Procedure
Eligible respondents were paired with an available HP by the project coordinator (SG). The HP supported each participant over a maximum of four weekly 45–60-minute sessions, via phone or video call. The number of sessions was determined by the participant, based on their needs and acquisition of problem-solving skills. Sessions were offered weekly to allow participants to implement their action plan (homework tasks) between sessions. During each session, the HPs kept a ‘tracking sheet’ of the participant’s problem, goal, solution and action plan and emailed a simplified version to the participant. The HPs audio-recorded at least 25% of their sessions, which were reviewed (by SG and EH) to inform feedback provided during fortnightly (and ad hoc) individual and monthly group supervision sessions. A combination of different sessions (e.g. first, second) was selected for review.
Following their final session, participants completed online post-intervention and four-week (post-intervention) assessments.
Intervention
LISTEN sessions were centred on a seven-step model of PST: (1) defining the problem; (2) setting an achievable goal; (3) brainstorming solutions; (4) assessing pros and cons of solutions; (5) choosing a solution; (6) creating an action plan; and (7) evaluating outcomes. During sessions, participants received support from the HP in identifying and addressing a problem that may be contributing to diabetes distress. Participants could focus on different problems in subsequent sessions. Participants were encouraged to reframe problems that lacked a behavioural component or that were beyond their control. If participants disclosed significant distress, they were encouraged to seek further mental health support. At the end of each session, participants were prompted to create an action plan that included meaningful and enjoyable activities during the week.
Measures and outcomes
(1) LISTEN training of diabetes HPs
Feasibility
Recorded training-case sessions were reviewed against the Problem Solving Treatment Adherence and Competence Scale (PST-PAC)[36] by SG and EH independently. The PST-PAC examines fidelity to technical skills, adherence to the problem-solving steps, process tasks, communication and interpersonal effectiveness (15-items), and global competence (1-item). Competency is rated from 0 (not completed) to 5 (well above standard). SG and EH discussed the PST-PAC scores until consensus was reached. Completion of a minimum of two and maximum of four training cases, including a PST-PAC rating of at least 3 (satisfactory) for three consecutively rated sessions, was required for HPs to progress to delivery of LISTEN. These cut-offs were selected based an established PST training program.[21]
Acceptability
HPs’ satisfaction with the LISTEN training (and weekly supervision) were explored using study-specific rating scales and open-ended questions via a post-training online survey.
2) Pilot study
Feasibility
determined by participation rates, time taken to recruit N = 20 eligible participants (within a 4-month recruitment period) and the number of LISTEN sessions completed by participants.
Acceptability
participants’ satisfaction with the intervention, and suggestions for improvement, were explored using study-specific rating scales and open-ended survey questions. Open-ended questions were adapted from previously developed items designed to explore acceptability with brief PST.[29]
Potential psychological benefits of LISTEN
The emotional and mental health of people with diabetes was assessed at baseline, post-intervention and at 4-week follow-up. Diabetes distress was assessed using the 20-item PAID scale.[5] Respondents rate the extent to which each issue is a problem for them on a 5-point scale (0, “not a problem,” to 4, “serious problem”). A PAID total score is calculated as the standardized sum of item scores (range 0–100) with higher scores indicating greater diabetes-specific distress. General emotional well-being was assessed with the WHO-5 Index.
Demographic and self-reported clinical data (e.g., type and duration of diabetes, treatment type) were collected at baseline only.
Statistical analysis
Descriptive statistics were used to summarise the demographic characteristics of HPs and participants; and to explore feasibility outcomes and intervention acceptability ratings. To explore potential changes (from baseline to post-intervention and 4-week follow-up) in diabetes distress (PAID) and emotional wellbeing (WHO-5), mean change scores and confidence intervals were computed, with post-hoc comparisons between groups explored using Bonferroni correction. Normality of data was tested using a Shapiro-Wilk test. All tests were 2-sided, with p < 0.05 considered statistically significant. Analyses were performed using SPSS v26. Qualitative data generated from free-text responses to open-ended questions about the intervention were subjected to inductive template analysis.