Abstract
We studied the patient experience of a telephone booster intervention, i.e. weekly reinforcement of the clinic advice regarding lifestyle modification advice to support weight loss. Forty six adults with Type 2 diabetes and a body mass index >28 kg/m2 were randomised into either intervention (n = 25) or control (n = 21) groups. Semi-structured interviews were conducted with the intervention group participants to explore their views and experiences. The patients were satisfied or very satisfied with the telephone calls and most would recommend the intervention to others in a similar situation. The content of the telephone follow-up met their need for on-going support. The benefits arising from the telephone calls included: being reminded to comply with their regimen; prompting and motivating adherence to diabetes self-care behaviours; improved self-esteem; and feeling ‘worthy of interest’. The convenience and low cost of telephone support has much potential in chronic disease management.
Introduction
Obesity is one of the global public health challenges of the 21st century with increasing obesity being noted in both the developed and developing countries. 1,2 Current approaches to the problem assume that giving information on diet and exercise will lead to lifestyle changes, but this has not proved effective 3 because ongoing support from health-care professionals is required. 4 Modifying lifestyle to achieve weight loss is complex and may be influenced by multiple factors including: relationship to food; comprehension and recall of educational interventions; willingness to change; perceptions of diabetes; and psychological co-morbidities such as depression and anxiety. 5
There is evidence that telephone follow-up interventions can improve glycaemic control. 6–10 However, in many of these studies the interventions had multiple components. The potential of a telephone booster intervention in its simplest form (i.e. weekly reinforcement of the clinic advice regarding lifestyle modification advice to support weight loss) has not been investigated in detail. We have conducted a small study to explore the patients' experience of a telephone booster intervention (acceptability) and their concordance with advice.
Methods
The study was approved by the appropriate ethics committee. Potential participants (n = 262) were screened in an NHS diabetes care centre in England. A total of 61 patients met the inclusion criteria (at least 18 years old, confirmed diagnosis of Type 2 diabetes, body mass index (BMI) > 28 kg/m2, English speaking with telephone access). Forty six patients were randomised into either the intervention (n = 25) or control (n = 21) groups, and 15 patients refused to participate due to lack of time (Table 1).
Demographic characteristics of patients
Weekly telephone calls which repeated the key messages given in the clinic were delivered to the intervention group over 12 weeks. All intervention group participants were offered a semi-structured exit interview focussing on satisfaction with the telephone follow-up, the lifestyle change during the intervention, their experiences of the intervention and how they felt about being telephoned every week. All interviews were tape-recorded and transcribed verbatim.
A thematic framework approach was adopted 11 involving the systematic sifting, charting and categorising of data according to key themes and issues. All coding was checked by an independent coder and any disagreements between coders discussed with subsequent recoding of data where necessary. Connections between the themes and their sub-categories were then developed.
Results
General impressions and feelings about the intervention
Only two out of the 21 participants referred to the timeliness of the telephone calls and both identified how the intervention occurred at an appropriate time in terms of their disease trajectory. Five participants referred to the convenience of the telephone calls that they had received at home or at work. Fifteen participants referred to the convenience of the timing of telephone calls. Two mentioned the inconvenience of telephone calls when they were driving with seven preferring scheduled calls. In contrast, two participants reported that they preferred to have unscheduled telephone calls. Another participant reported that it was difficult to schedule the telephone calls, while three participants reported that they were happy with telephone calls at any time. The majority of participants were happy that the telephone calls were initiated by the researcher. However, one participant reported that she would have preferred an option to contact the researcher.
Participants' experiences with the telephone calls
Twenty participants (95%) referred to the frequency of the telephone calls with most (n = 16) reporting that they were happy with the weekly telephone call. One participant reported that a reduction in frequency would not have been useful. Two participants reported that they would have liked the telephone calls more frequently. Four participants referred to the length of each telephone call. A telephone call lasting 5–10 min was preferred.
Only two participants commented on the duration of the intervention. One participant thought that the duration of the intervention should have lasted more than 12 weeks, while another participant thought that the intervention should have been shorter.
Twenty participants (95%) referred to the content of the telephone calls. Eight reported that the content of the telephone calls addressed their needs. One participant would have liked to have had goal setting as part of the telephone conversation. Eleven participants reported that the telephone calls either encouraged them or offered support to their weight management and adherence to their regimen. Three participants reported that the telephone calls were informative and helpful. Two made comments on the content of telephone calls. One recommended more probing questions. Another felt that the general questions were repetitive and did not progress each week.
Satisfaction with the telephone calls
Twenty participants (95%) referred to their satisfaction with the introducing agent (either the dietician or the Desmond group educator). The majority of the participants (n = 14) reported that they were very satisfied with the dietician or group educator, and the remainder were mostly satisfied. Twenty participants (95%) referred to their satisfaction with the telephone calls. All the participants reported that they were happy with the telephone calls with more than half (n = 11) reporting that they were very satisfied with the telephone call while the remainder were satisfied.
Regarding the role of the caller, four participants reported that they liked to have support and help from someone outside the family. One participant reported that she liked the caller having an association with the diabetes clinic. One participant mentioned that he would have preferred the telephone calls from the dietician.
Almost half of the participants (n = 10) commented on the characteristics of the caller. The dominant themes were: rapport building, being encouraging and understanding, being able and knowledgeable, and prompting. Nineteen participants (90%) referred to recommending the telephone calls to others with the majority (n = 17) reporting that they would have liked to recommend the telephone calls to a friend who was in a similar situation. One participant was not sure about making a recommendation.
Three participants referred to other approaches such as text messaging or email, which they thought could be additional but not an alternative.
Perceived effects of the telephone follow-up calls
One participant reported that the telephone calls provided a starting point for her health behaviour change. Ten participants referred to the motivation that they received from the telephone calls or an incentive for their health behaviour change. Nearly half the participants (n = 10) mentioned that the telephone calls had prompted their health behaviour change and reminded them to comply with the healthy diet and continue exercise. Eight participants reported that the telephone calls monitored their health-care behaviours. Ten participants reported that they liked the telephone contacts which made them feel they were worthy of interest. Five participants reported that the telephone calls helped to build up their self-esteem.
Four participants reported that the telephone calls helped them with behaviour change such as cutting down the portion size or increasing the amount of exercise. One participant mentioned that she was happy to see the improvement of her body image as a result of the telephone follow-up calls. Four participants reported that they felt guilty when they thought that they had not done enough exercise or had not complied with their diet regimen.
Perceived cost or burden of the telephone follow-up calls
Five participants referred to the cost of the telephone calls that they had received in terms of the time required for the conversation. Other participants acknowledged that there was no negative effect on their personal life. Twelve participants referred to the effect of the telephone calls on their family members. None reported that the telephone calls interfered with their family life or had any negative effects on the people with whom they lived. Six participants reported that their spouse/partner supported the telephone calls.
Discussion
In the present study, the sample size was small and the subjects were mainly White British people who were in their mid-late life and had been recruited from a single treatment centre. Thus the findings must be viewed with caution. Nonetheless the telephone booster was well accepted by both newly diagnosed patients and those with a long history of Type 2 diabetes, echoing Long et al.'s findings. 12 Those in receipt of the telephone booster had better attendance at their follow-up appointments compared to the control group. The dietician suggested that the telephone contact might have improved continuity of care between clinic appointments, thereby enhancing future clinic attendance. Furthermore, those who achieved the clinical weight loss target reported the highest level of satisfaction with the telephone calls, suggesting that patient preference and satisfaction may be important. 13
The telephone booster appeared to be acceptable and to meet a number of psychological needs of the patients, particularly in terms of improving self-esteem. There is increasing evidence of the negative psychological consequences of having diabetes. 14 Indeed, the opportunity to talk to someone revealed the complex psycho-emotional feelings of some patients as they struggled with recommended behaviour changes. It is likely that patients will benefit from psychological support, although this may need to be tailored to individual patients.
The convenience and low cost of telephone support has much potential in chronic disease management. However, more research is needed to refine the use of telephone support in weight management among people with Type 2 diabetes.