Motivational Interviewing to Improve Self-efficacy in Type 2 Diabetes Management


 Background: Self-efficacy predicts adherence to treatment in patients with diabetes. Motivational interviewing could be a promising intervention to increase the patients’ motivation to follow therapeutic recommendations. The present study aimed to assess the effects of motivational interviewing on self-efficacy in type 2 diabetes management. Methods: This quasi-experimental study with a pretest-posttest design was conducted on 60 patients with type 2 diabetes, who were members of the Bukan Diabetes Association in Iran. The patients were selected using a random number table and were randomly allocated into intervention (n=30) and control (n=30) groups. Five motivational interviewing sessions (30-45 minutes) were held for the intervention group (two sessions per week). Data were collected using a demographic questionnaire and the diabetes management self-efficacy scale (DMSES). Data were analyzed with SPSS software version 14.0 using descriptive and inferential statistics.Results: Sixty patients entered the analysis. A significant difference was observed in the mean score of diabetes management self-efficacy between the two groups before and after the intervention (P=0.014). The mean score of self-efficacy in diabetes management was increased significantly in the intervention group after MI (P=0.001).Conclusions: Motivational interviewing improved self-efficacy in diabetes management. Thus, this approach is recommended to be used in patients with type 2 diabetes in order to increase their self-efficacy.

Diabetes decreases patient's quality of life and disrupts their routine activities due to sickness, absenteeism, disability, loss of productivity, early retirement or even premature death. [4]. Disease management improves the quality of care and productivity of patients with chronic diseases [5].
Disease management could be defined as a comprehensive strategy to enhance the general health status and reduce the treatment costs [6]. A disease management program had significant positive clinical impacts on the levels of hemoglobin A1C in patients with diabetes [7]. Diabetes management requires proper commitment to health behaviors. Behavioral changes seem crucial in patients with diabetes, and special attention must be paid to the effective factors in empowering these patients.
Self-efficacy is one of the most important factors which play a key role in the proper management of diabetes [8]. In patients with diabetes, self-efficacy could predict adherence to blood glucose monitoring, diet, insulin injection, and physical exercise; therefore, higher self-efficacy was associated with better diabetes management in these patients [9]. Meybodi et al reported a significant correlation between self-efficacy and self-care behaviors of patients with diabetes and concluded that self-efficacy plays a pivotal role in successful diabetes management in these patients [10].
Motivational interviewing (MI) is a counseling approach used by healthcare providers to help patients adhere to treatment recommendations [11]. The main purpose of motivational interviewing is to reduce the patients' perception of their own disability in order to change successfully and eliminate barriers [12]. MI increases internal motivation of patients and helps them explore and resolve ambivalence [9]. In addition to increasing motivation, MI attracts the patients' attention to a specific topic, thereby allowing substantial changes in various behavioral patterns [13]. This counseling approach has been developed by Miller and Rollnick as a promising intervention to bring about positive health behavior in medicine, health, and psychiatry [9]. MI could be implemented individually and in groups owing to its flexibility and ability to be applied in different behavioral aspects [14]. MI approach of Miller and Rollnick aims to enhance self-efficacy and increase motivation in individuals through interactive and empathetic listening in order to change their behavior patterns [15]. Another study conducted by Chien et al showed that MI program significantly improved self-management, self-efficacy, and quality of life in patients with schizophrenia [16]. Moreover, the literature review revealed the superiority of the MI program over traditional intervention strategies in addressing a wide range of psychological and physical disorders [10][11][12]. Despite the rapid growth in the application of MI in different areas of health care worldwide, it is a novel approach and limited research was conducted about its effectiveness in Iran. Because of the prevalence of diabetes as a chronic, disabling, and lifestyle disease that is growing so rapidly, the present study was conducted to investigate the effect of MI on self-efficacy in type 2 diabetes management. Our hypothesis was that MI might have an impact on self-efficacy in type 2 diabetes management.

Study design and participants
This quasi-experimental study with pre-test and post-test design was conducted in 2017. Participants were selected among patients with type 2 diabetes who were members of Bukan Diabetes Association in a city in west Azerbaijan located in the northwest of Iran. In total, 60 patients were selected using a random number table. The participants were allocated into the control (n = 30) and intervention (n = 30) groups by drawing "A" and "B" cards. The sample size was determined based on the study by Navidian et al with 95% confidence interval and 80% test power using the GPower 3.1 [17]. The inclusion criteria were as follows: 1) willingness to participate in the study; 2) no history of psychiatric diseases based on medical record; 3) no participation in similar MI programs; 4) no communication problems (e.g., blindness/deafness) and 5) no history of cognitive disorders. Unwillingness to participate in the study and hospitalization was considered as the exclusion criteria.

Measures
Data were collected using a demographic questionnaire including the age, gender, occupational status, education level, marital status, duration of diabetes, and type of medications. Moreover, the diabetes management self-efficacy scale (DMSES) was applied to evaluate self-efficacy in diabetes management. DMSES is theoretically based on Bandura's self-efficacy construct and it was developed by Naderimagham et al in 2013 [18]. This instrument consists of 17 items covering five domains: a specific diet, physical exercise, blood glucose monitoring, foot care, and smoking habits. The items in DMSES are scored based on a five-point Likert scale (Completely Disagree-Completely Agree) within the score range of 17-85. In the present study, we calculated the mean score in this questionnaire.
The qualitative content and construct validity of DMSES was confirmed by Noroozi et al and the internal consistency of the instrument was also confirmed by Cronbach's alpha coefficients (α = 0.92) [19].

Intervention
We obtained permission from the Ethics Committee of Urmia University of Medical Sciences in Iran (IR.UMSU.RCC.1395.132). We explained the purpose of the research to the participants, and assured their privacy and the confidentiality of their personal information. In addition, the participants signed an informed consent form, and they were notified of the voluntary nature of enrollment in the study.
After all patients completed the questionnaire, we randomly allocated the patients to the intervention and control groups. Then, the intervention group was divided into three subgroups of 10. The lead researcher performed MI sessions based on the research contents. He had previous experience regarding MI and attended in a training class in this regard. The research content was about the specific diet, physical exercise, blood glucose monitoring, foot care, and smoking habits ( Table 1). The structure of the MI sessions was based on Miller and Rollnick (2012) book [9], and the intervention was implemented in five sessions (two sessions of 30-45 minutes per week). The lead researcher who was trained about the MI approach, presented in each session to guide the group.

Data analysis
Analysis was performed on 60 patients who completed the baseline and 4-weeks follow-up assessments ( Fig. 1). Shapiro-Wilk test was used to determine the normal distribution of the data.
Data analysis was performed using SPSS software version 14 (SPSS, Inc., Chicago, IL, USA). The descriptive (mean, standard deviation, number and percentage) and inferential (independent t-test, paired t-test, Mann-Whitney U test, and Chi-square) statistics were used to analyze data. P-value of less than 0.05 was considered significant.

Results
There was no significant difference between the intervention and control groups in terms of demographic characteristics (P > 0.05). As such, it could be claimed that the research groups were homogeneous in regards to the demographic characteristics (Table 2). There was a significant difference between the intervention and control groups regarding the mean nutrition score before and after the intervention (P = 0.006). In addition, the results indicated a significant difference between two groups in terms of the mean score of physical exercise before and after the intervention (P = 0.004). After the MI sessions, a significant difference was observed between the two groups in terms of the self-assessment score (P = 0.0001). The independent t-test showed a significant difference regarding the mean score of foot care between two groups after the intervention (P = 0.0001). In contrast, no significant difference was observed in the mean score of smoking habits between the groups after the MI sessions (P = 0.091). Moreover, independent t-test demonstrated a significant difference in the mean score of diabetes management self-efficacy between the two groups after the intervention (P = 0.014) ( Table 3). There was a significant difference in the mean score of nutrition, physical exercise, self-assessment, and foot care before and after the intervention in the intervention group (P = 0.0001). However, no significant difference was observed in the intervention group in terms of the mean score of smoking habits before and after the intervention (P = 0.433). The results of paired t-test also demonstrated no significant difference in the mean score of diabetes management self-efficacy in the control group before and after the intervention (P = 0.744). Nevertheless, a significant difference was observed in the intervention group regarding the mean score of diabetes management self-efficacy before and after the intervention (P = 0.001) (Table 4).

Discussion
The results of this study indicated no significant differences in demographic characteristics between the two groups. In other words, the study groups were homogenous in terms of demographic characteristics, and any significant difference in the dependent variable was attributed to the MI sessions at the end of the study.
Our findings also demonstrated that the MI approach positively influenced the nutritional self-efficacy in patients with diabetes. In addition, the MI method could effectively enhance the sense of self-efficacy in the face of negative emotions, social pressure, and physical discomfort situations, leading the patients toward performing positive and enjoyable activities. In fact, the MI approach could create sustainable and relatively long-lasting changes in all of the previously mentioned parameters. These findings confirmed the hypothesis that MI is a more effective method than routine education approach in increasing the sense of self-efficacy of eating behavior as a predictor of success in weight loss programs. Baer believes that low self-confidence in the control of eating behavior, especially when experiencing negative emotions, is associated with symptoms of eating disorders [20]. Our results showed that physical exercise self-efficacy could improve in patients with diabetes after MI sessions.
It might be due to enhancing optimism and positive emotions and reinforcing the self-care and selfmanagement motivation of these patients after MI sessions. Nowadays, experts consider physical exercise along with diet and medication as the third major pillar of diabetes treatment [21].
Our results showed the MI approach positively influenced the self-monitoring of blood glucose ( when it comes to change rather than resistance/poor will power. Diabetes control requires the understanding of the information and required treatment procedures, and inadequate knowledge regarding the disease control process may decrease the patients' self-confidence in this process.
After MI sessions in our study, the mean score of diabetes management self-efficacy increased in the intervention groups. Thus, it confirmed that the implementation of the MI approach could positively influence the management self-efficacy of these patients. MI has a positive impact on the self-efficacy of individuals by affecting the perceptions and increasing the mental involvement of patients to realize their conditions and learn to manage their problems independently.

Study Limitations
One of the limitations of our study was the small sample size, which might have an impact on the effect size of the study. Conducting the study in a small region, which had a specific cultural background was another limitation of the study. The cultural tendencies of individuals affect their learning abilities and implementation of the teachings. Therefore, it is suggested that further investigations be conducted in this regard with larger sample sizes and in larger areas with various cultures, so that the effects of MI on diabetes management self-efficacy could be confirmed, and the results could be generalized with greater confidence.

Conclusions
Self-efficacy plays a key role in the prediction of self-care activities in patients' with diabetes, and diabetes management self-efficacy could be improved through implementing the MI approach and increasing the motivation of the patients. Our findings could be used in various fields, such as nursing management, nursing research, and nursing services, as well as in the diabetes associations and educational centers in order to improve the quality of nursing care and ultimately to promote health and quality of life in patients with diabetes.

Ethics approval and consent to participate
This study is approved by the ethics committee of Urmia University of Medical Sciences (Approval code: IR.UMSU.RCC.1395.132). The participants were fully informed about the purpose of the study.
Each participant provided written consent prior to participation. They were given explanation regarding their voluntary nature of participation and that they can stop cooperation at any given time. Participants were also assured about the privacy and confidentiality of their information.

Consent for publication
Not applicable.

Figure 1
Design methodology flow chart / Analysis was performed on 60 patients who completed the baseline and 4-weeks follow-up assessments (Figure 1).