Group self-management education to address fear of hypoglycaemia as a barrier to physical activity: The role of behaviour change theories.
Despite established physical activity (PA) guidelines and international consensus,1 many people living with type 1 diabetes (T1D) are not currently meeting minimum PA requirements. Internationally, studies report between 65% to 82% of T1D study participants were not sufficiently active,2-5 suggesting people with T1D may not be as active as their general population counterparts.3, 4, 6, 7 This disparity suggests there may be a difference in how people with T1D experience and approach PA. Blood glucose responses to PA in people with T1D can be extremely variable between and within individuals. The rate and direction of glucose excursions will depend on the intensity, type, duration, and timing of activity in relation to how much circulating insulin the individual has onboard.1 These variables, as well as current blood glucose trends, will dictate how the individual adjusts their carbohydrate intake and/or insulin.1, 8 The complex interplay between these variables makes T1D management very challenging before, during and up to 24 hours after PA, during which time hyper or hypoglycaemia can ensue. Indeed, our recent systematic scoping review found hypoglycaemia/fear of hypoglycaemia (FoH) were the most frequently described barriers to PA among adults living with T1D.9 Despite the prevalence of hypoglycaemia/FoH as a barrier, there is a paucity of literature in how to address it.9
Current whole population PA campaigns are not equipped to address these unique challenges faced by the T1D population.9 Without the knowledge, confidence, or specific self-management skills, it is conceivable that people living with T1D may choose to avoid PA to avoid the unpleasant and often unsafe extremes of hyper and hypoglycaemia. However, knowledge and skill alone are not suffice to change PA behaviour.10 To encourage behaviour change, client education needs to be grounded in behaviour change theories that encourage psychosocial concepts such as self-efficacy and self-determined motivation.10, 11 Although theory-driven interventions have been shown to improve efficacy and are encouraged in key frameworks for developing behaviour change interventions,12-14 our review found very few have trialled theory-driven PA diabetes education using robust study designs.9
In response, Type 1 TACTICS for Exercise©, a theory-driven, group self-management education program, was developed to address diabetes-specific barriers to PA, specifically FoH. We hypothesised that by addressing diabetes-specific barriers, people with T1D may be better equipped to participate in wider community PA initiatives alongside their counterparts living without T1D. We began investigating the practicality and need for this program in 2017 with a small explorative study. Early indications suggest the program may have some effect on FoH as a barrier to PA in a small group of adults with T1D and warranted further investigation following a number of program iterations.15 In 2018, a larger and more robust investigation using a mixed methods RCT design was planned and piloted, the results of which have been published elsewhere.16, 17 The aim of this paper is to describe the intervention, Type 1 TACTICS for Exercise© and its underpinning theories, with reference to recently published participant outcomes.16, 17
Type 1 TACTICS for Exercise©
Type 1 TACTICS for Exercise© was developed by Diabetes WA in 2017 in an effort to address a gap in services for adults living with T1D who experience diabetes-specific barriers to PA. The program consisted of an initial three-hour session, a one-hour booster session (four weeks following the initial session), and an optional private peer-led Facebook™ group. The program content detailed the endocrine and metabolic response to PA in T1D; how intensity, type, timing, frequency, and duration of activity effects blood glucose response; contemporary evidence-informed strategies to manage blood glucose levels for PA (as per Riddell et al.1 consensus statement); and encouraged participants to problem solve their own exercise scenarios as a group. Two validated and widely used psychological learning theories, Dual Process Theory18 and Social Cognitive Theory19, underpinned the program and guided its delivery.
The role of Dual Process Theory
Dual Process Theory, or more specifically, the heuristic-systematic model of information processing distinguishes between heuristic and systematic processing.18 Heuristic processing is a passive form of persuasion by which a participant relies on simple rules or cognitive heuristics and is likely to agree with messages delivered by ‘experts’ without meaningfully scrutinising its content.20 This form of information processing can result in superficial understanding and opinion change, prone to subsequent change by other influential figures within family, social circles, or the media.21 This can create confusion and frustration for the person living with diabetes.
To encourage meaningful information processing, we delivered education relating to the endocrine and metabolic response to PA using systematic processing. Systematic processing requires participants to actively engage in the learning process by scrutinising and piecing together information. Unlike heuristic processing, the facilitator guides participants’ knowledge discovery, giving as little information as possible.18, 21 Visual aids (Feltman®22), analogies, and careful questioning by the facilitator helped participants to understand how intensity, type, timing, frequency, and duration of activity effects blood glucose response. For example, the concept of muscle contraction-mediated glucose uptake (insulin-independent pathway) was explained using the analogy of ‘magic doors’ (that is, doors on a muscle cell that are wide open without relying on insulin to open the door) appearing on the muscle cell with muscle contraction. Once participants understood fundamental principles of how their body responds to activity, they were able to deduce which management strategies and tactics to employ to minimise variation in blood glucose levels. They were able to take new information away to explore and test it in their day-to-day T1D management. Systematic processing allows participants to be more confident in their acquired knowledge, so they are equipped to scrutinise new information from external sources.21 Similar to the experiences of others using systematic processing in diabetes education, we found participants’ recall of this information was excellent up to six months after the intervention.17, 21
The role of Social Cognitive Theory
Social Cognitive Theory explains that individuals learn by observing others and this experience will be influenced by personal factors, environmental factors and behaviour.19 The reproduction of observed behaviour is reliant on a person’s belief in their ability to complete the behaviour – self-efficacy.19 Self-efficacy is a key determinant of health behaviours, both directly and indirectly.23 Bandura19 outlines four key sources of self-efficacy: mastery experience, role modelling, verbal persuasion, and physiological and affective states.24 Type 1 TACTICS for Exercise© was delivered in a group environment by an experienced and skilled facilitator who exposed participants to these key sources of self-efficacy in an effort to reduce barriers to PA.
The most influential source of self-efficacy is mastery experience and was a key focus of the intervention.25 Type 1 TACTICS for Exercise© created opportunities for participants to gain self-efficacy belief from their own experiences both during and after the intervention. Participants were encouraged to plan out personal PA scenarios using the ‘timeline activity’ and problem solve anticipated or experienced problems with the new skills and tactics they had learnt. Participants had the opportunity to trial these plans with the support of a peer-led Facebook™ group over four weeks and returned to the booster session to discuss their experiences and learnings.
Role modelling was a dominant feature of the intervention. Participants were encouraged to gain self-efficacy belief from the success of others by observing their blood glucose management with PA then applying these learnt strategies. Role modelling was also fostered by the Facebook™ group, where participants were encouraged to share their experiences and ask questions of their peers. The T1D-specific group setting cultivated this source of self-efficacy as individuals are more likely to model behaviours from people with whom they identify.25
Although less powerful than mastery experience and role modelling, positive verbal persuasion was used by both the facilitator and participants as another means of improving self-efficacy.19 Positive behaviours and efforts were encouraged by the group during face-to-face encounters and Facebook™ group interactions. For example, when a participant shared their successes or challenges with the group, they were met with encouragement, support, and ideas of how to move forward.
Physiological and affective states were also explored with participants. These states are important as some individuals may interpret negative emotions or bodily symptoms as a sign of incapability.26 For example, an individuals’ experience of FoH as a barrier to PA may be attributed to being personally incapable of managing hypoglycaemia, rather than to a changeable physiological state. Exploration of this barrier from a physiological and affective state helped participants to correctly attribute negative emotions and bodily symptoms. This may help reduce fear by allowing participants to focus on active strategies to manage blood glucose for PA.
Although it is common to see key frameworks encourage theory-driven behaviour change interventions, few have been trialled in the area of PA for T1D.12-14 We trialled the use of Dual Process Theory18 and Social Cognitive Theory19 to facilitate a group self-management education program with the aim to address FoH as a barrier to PA in adults living with T1D in Perth, Western Australia. In order to evaluate the feasibility, acceptability, and preliminary efficacy of this theory-driven group education program, we conducted a single blind RCT and focus group interviews with adults living with T1D in Perth, Western Australia. Preliminary efficacy, supported by qualitative findings suggest learning using systematic processing, mastery experience, role modelling, verbal persuasion, and exploring physiological and affective states may lead to improved self-efficacy to manage blood glucose levels with PA and a reduction in barriers to PA, (including FoH).16 A full discussion of our study results has been published and reported elsewhere.16, 17 A future definitive trial is justified to replicate preliminary efficacy and to determine the utility of Type 1 TACTICS for Exercise© in improving PA participation. Local dissemination of Type 1 TACTICS for Exercise© will occur in parallel with this trial in an effort to pilot new program iterations, resources, and facilitator training models.
Providing education on blood glucose management for PA to adults living with T1D is challenging owing to complex diabetes-specific barriers to PA. In order to assist those experiencing these barriers, diabetes health professionals need to consider theory-driven approaches to behaviour change. Facilitating an opportunity for group education and/or interactions for those living with T1D appears to be an important feature in addressing diabetes-specific barriers to PA. Behaviour change theories that encourage systematic learning and self-efficacy through mastery experience and role modelling from relatable peers are key to PA behaviour change in this population. Where group interactions are not possible, diabetes health professionals should focus on improving self-efficacy through mastery experience – learning from their own experiences and guided trial and error.
MB has been awarded a research fellowship from the Australian Diabetes Educator Association – Diabetes Research Foundation and a Research Stipend Scholarship from the Curtin School of Nursing, which have provided a researcher stipend to support Doctor of Philosophy studies. We would like to thank our research participants and steering group members for volunteering their time and meaningful contributions to the project. We would also like to thank Diabetes Western Australia for providing in-kind support to the project.
Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, et al. Exercise management in type 1 diabetes: A consensus statement. The Lancet Diabetes & Endocrinology. 2017;5(5):377-390. doi:10.1016/S2213-8587(17)30014-1
Bohn B, Herbst A, Pfeifer M, Krakow D, Zimny S, Kopp F, et al. Impact of physical activity on glycemic control and prevalence of cardiovascular risk factors in adults with type 1 diabetes: A cross-sectional multicenter study of 18,028 patients. Diabetes Care. 2015;38(8):1536-1543. doi:10.2337/dc15-0030
McCarthy M, Whittemore R, Grey M. Physical activity in adults with type 1 diabetes. Diabetes Educ [Article]. 2016;42(1):108-115. doi:10.1177/0145721715620021
Plotnikoff R, Taylor L, Wilson P, Courneya K, Sigal R, Birkett N, et al. Factors associated with physical activity in Canadian adults with diabetes. Med Sci Sports Exerc. 2006;38(8):1526-1534. doi:10.1249/01.mss.0000228937.86539.95
Speight J, Browne JL, Holmes-Truscott E, Hendrieckx C, Pouwer F, Diabetes MILES â Australia reference group (2011). Diabetes MILES â Australia 2011 Survey Report. Melbourne, Victoria: Diabetes Australia; 2011. Available from: https://www.ndss.com.au/wp-content/uploads/resources/report-miles-youth-2011.pdf6.
Clarke TC, Norris T, Schiller JS. Early release of selected estimates based on data from 2016 National Health Interview Survey 2017.
World Health Organisation. Germany. Physical activity factsheet [Internet]. 2016 [cited 23.04.2018]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0010/288109/GERMANY-Physical-Activity-Factsheet.pdf?ua=18.
Moser O, Riddell MC, Eckstein ML, Adolfsson P, Rabasa-Lhoret R, van den Boom L, et al. Glucose management for exercise using continuous glucose monitoring (CGM) and intermittently scanned CGM (isCGM) systems in type 1 diabetes: position statement of the European Association for the Study of Diabetes (EASD) and of the International Society for Pediatric and Adolescent Diabetes (ISPAD) endorsed by JDRF and supported by the American Diabetes Association (ADA). Diabetologia. 2020;63(12):2501-2520. doi:10.1007/s00125-020-05263-99.
Brennan MC, Brown JA, Ntoumanis N, Leslie GD. Barriers and facilitators of physical activity participation in adults living with type 1 diabetes: A systematic scoping review. Applied Physiology, Nutrition, and Metabolism. 2021;46(2):95-107. doi:10.1139/apnm-2020-0461
Knight KM, Dornan T, Bundy C. The diabetes educator: Trying hard, but must concentrate more on behaviour. Diabet Med. 2006;23(5):485-501. doi:10.1111/j.1464-5491.2005.01802.x
Ntoumanis N, Ng JYY, Prestwich A, Quested E, Hancox JE, ThÃ¸gersen-Ntoumani C, et al. A meta-analysis of self-determination theory-informed intervention studies in the health domain: Effects on motivation, health behavior, physical, and psychological health. Health Psychol Rev. 2020:1-31. doi:10.1080/17437199.2020.1718529
Dombrowski SU, Sniehotta FF, Avenell A, MacLennon G, Arau`jo-Soares V. Identifying active ingredients in complex behavioural interventions for obese adults with obesity-related co-morbidities or additional risk factors for co-morbidities: A systematic review. Health Psychol Rev. 2012;6:7-32. doi:https://doi.org/10.1080/17437199.2010.51329813.
Taylor N, Conner M, Lawton R. The impact of theory on the effectiveness of worksite physical activity interventions: A meta-analysis and meta-regression. Health Psychol Rev. 2012;6:33-73. doi:https://doi.org/10.1080/17437199.2010.533441
Craig P, Dieppe PA, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: The new Medical Research Council guidance. Br Med J. 2008;337:979-983. doi:https://doi.org/10.1136/bmj.a165515.
Brennan MC, Brown JA. Fear of hypoglycaemia as a barrier to physical activity: A report of a group education session. Diabetes & Primary Care Australia. 2019;3(1):169-175.16.
Brennan MC, Albrecht MA, Brown JA, Leslie GD, Ntoumanis N. Self-management group education to reduce fear of hypoglycaemia as a barrier to physical activity in people living with type 1 diabetes: A pilot randomised controlled trial. Canadian Journal of Diabetes. 2021, in pressÂ doi:https://doi.org/10.1016/j.jcjd.2021.01.00117.
Brennan MC, Brown JB, Leslie GD, Ntoumanis N. The acceptability of self-management group education to reduce fear of hypoglycaemia as a barrier to physical activity in people living with type 1 diabetes: A mixed methods approach. Canadian Journal of Diabetes. 2021; Under review18.
Chaiken S, Wood W, Eagly A. Principles of persuasion. In: Higgih ET, Kruglanski AW, editors. Social psychology: Handbook of basic principles. New York: Guildford press; 1996.19.
Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215. doi:10.1037/0033-295X.84.2.19120.
Chaiken S. Heuristic versus systematic information processing and the use of source versus message cues in persuasion. J Pers Soc Psychol. 1980;39(5):752-766. doi:10.1037/0022-35184.108.40.2062
Skinner TC, Cradock S, Arundel F, Graham W. Four theories and a philosophy: Self-management education for individuals newly diagnosed with type 2 diabetes. Diabetes Spectr. 2003;16(2):75-80. doi:10.2337/diaspect.16.2.75
Victorian Aboriginal Community Controlled Health Organisation, Diabetes Victoria. Feltman [Internet]. [cited 6 January 2020]. Available from: https://www.diabetesvic.org.au/resources-aboriginal-torres-strait-islander
Bandura A. Health Promotion by Social Cognitive Means. Health Educ Behav. 2004;31(2):143-164. doi:10.1177/1090198104263660
Zinken KM, Cradock S, Skinner TC. Analysis System for Self-Efficacy Training (ASSET). Assessing treatment fidelity of self-management interventions. Patient Educ Couns. 2008;72(2):186-93. doi:10.1016/j.pec.2008.04.00625.
Bandura A. Principles of behaviour modification. London: Holt, Reihart and Winston; 1971.26.
Bandura A. Self-efficacy: The exercise of control / Albert Bandura. New York: W.H. Freeman; 1997.