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Assessing Psychosocial VariablesA Tool for Diabetes EducatorsFrom the University of Massachusetts Lowell. Correspondence to Kelly L. Fisher, PhD, RN, 14 Innisfree Drive, Haverhill, MA 01832.
The purpose of this article is to share an educational strategy or tool that is relevant for use in patient and professional diabetes education. The tool offers an opportunity for diabetes educators to screen for psychosocial variables such as depression or emotional distress. A systematic review of the literature was conducted to identify psychological variables that have an impact on individuals living with diabetes and their ability to self-manage their disease. The literature revealed that both depression and emotional distress related to diabetes was experienced by individuals with diabetes along with those individuals who were unable to self-management their disease. The Accu-Check Interview is a computer software program that may assist diabetes educators to provide diabetes education. Use of the Accu-Check Interview software program has been implemented at various sites including the Joslin Clinic (Boston, Mass), Baystate Medical Center (Springfield, Mass), and Emerson Hospital (Concord, Mass). The Diabetes Self Care Profile is a Web-based version of the Accu-Check Interview and can be accessed as a demonstration in English and Spanish. These tools allow diabetes educators to screen for psychosocial variables and address issues with individuals while using a motivational interviewing approach.
In the face of unending and often burdensome regimen care requirements, many individuals with type 2 diabetes become overwhelmed by the frustrations of the regimens, constant reminders, and daily disease-related necessary adjustments.1 The diagnosis of diabetes, symptoms, and the strict treatment regimens can each be a source of much psychological distress (eg, anxiety and depression) for the patient.2 Researchers have found that regardless of gender and ethnic background, both men and women reported that stress negatively affected their ability to adhere to their diabetes regimen. While a number of researchers have suggested a link between psychosocial factors and the onset of diabetes mellitus,3,4 studies of naturally occurring life stress have repeatedly indicated a positive association between major life stressors and poor diabetic functioning.5 Most of the attention regarding life stressors has been given to the potential influence of major stressful life events (eg, divorce, death of significant family member) and has not included emotional distress, daily life stressors, and psychological problems.6 In a study conducted of 184 individuals with type 2 diabetes, approximately 25% of the variance in self-care behaviors can be explained by psychosocial variables (eg, knowledge, stress, depression, anxiety, health beliefs, and social support) and demographic variables.7 Preliminary research has linked a potential relationship between the onset of secondary complications of diabetes and psychological distress, self-blame, and depression.8
Depression and Diabetes
Diabetes Educators' Role
Accu-Check Interview as a Tool The first step to initiate the program into a diabetes counseling session is for the patient to complete the Accu-Check Interview questionnaire by either using a computer or answering verbally as the questions are read by the educator and documented into the Accu-Check computer software program at the beginning of the session. The questionnaire provides 7 self-care options in the assessment phase of the visit, including blood glucose monitoring, diet and food, hypoglycemia, exercise, tobacco use, a topic of the patient's choice, or "opt-out." This process takes about 10 minutes to complete; a 1-page assessment report is then printed and used for self-management discussion with the diabetes educator. The report is organized in a simple 1-page layout that identifies key issues using 2 brief summaries and 4 traffic light icons that highlight the action areas. The traffic lights are color coded green (no problem present), yellow (moderate problem present), and red (severe problem present). The traffic lights provide summaries for these 4 areas by indicating a brightness in the green, yellow, or red color: overall diabetes-related emotional distress, presence of depression, presence of hypoglycemia, and nicotine dependence. Below the 4 traffic light icons are 3 summary panels giving details on the patient's identified barriers to diabetes self-care management, level of emotional distress related to diabetes, and specific symptoms of depression experienced by the individual. In the first section, the panel provides a rating of low to high confidence level in making a health behavior change for a selected topic (eg, food and eating) that can later be addressed in a counseling session. The Diabetes Emotional Distress section is the rating of the individual's overall experience in adjusting to diabetes and includes an action section for the educator to see what specific areas to address where the most emotional distress is felt. Last, the depression screen will identify whether the patient is experiencing no depression, probable subclinical depression, or probable depression. The action section will state 1 of the depression options such as to make a suggestion for referral for treatment. The top section of the patient report includes demographic information, self-reported blood glucose monitoring, diabetes treatment, frequency of hypoglycemia, and whether or not the patient is a smoker. The accompanying manual provided for the Accu-Check Interview can assist the educator in interpreting the patient's report and in offering suggestions on how to counsel the individual in response to their identified concerns. For example, a barrier associated with food and eating states, "Eat just because food is there." Suggestions to incorporate might include "help patient gain an increase in awareness and control the cues to unwanted eating," "suggest a diary to keep track of all eating for a few days," "place food out of sight," or "explore alternative activities to divert attention from eating."22 Another barrier is the patient identifying, "I feel hopeless because I have tried and failed so many times." Suggestions to incorporate might include the following: use open-ended questions to encourage the patient to talk, identify past occasions when the patient was successful, and reinforce that all people have setbacks while making changes.22 Accu-Check Interview is just a start to exploring patient perceptions of self-care options and helping them find out what is workable or of interest to them by using a motivational interviewing style that differs from the traditional "advice-giving" counseling approach to behavior change. This program can be used for both initial comprehensive visits and follow-up education counseling sessions with patients. Overall, the Accu-Check Interview is a useful tool for diabetes educators to detect emotional distress or depression that can seriously undermine the individual's ability to manage his or her diabetes.
Motivational Interviewing: Patient-Centered Counseling Approach The Accu-Check Interview has a Web-based version named the Diabetes Self Care Profile (DSCP) that can be accessed as a demonstration in both English and Spanish. The DSCP includes a patient assessment of current diabetes self-care behaviors (diet, exercise, diabetes mediations, blood glucose monitoring) with a brief set of 10 questions. This Web site includes the identification of one self-care topic to work on and specific barriers the patient faces in the area of self-care (eg, for exercise, "bad weather or outside conditions"). Similar to the Accu-Check Interview CD-ROM, the program assesses 6 known psychosocial problem areas that can hinder diabetes self-care (ie, major depression, alcohol use, binge eating, low social support, hypoglycemia, high levels of diabetes-specific emotional distress [PAID], or burnout). Last, most recent hemoglobin A1C is presented using a thermometer-style graphic with red, yellow, or green coding used to identify the level of significant danger of blood glucose. This lab addition to the DSCP Web version helps the patient to reflect on this important lab result and tie it to self-care goals.24
The Accu-Check Interview and the DSCP are of enormous value in that the patient is engaged and involved from the very beginning in developing a behavior change treatment plan. The Accu-Check Interview and DSCP provide strategies to assess psychological factors and implement interventions to assist individuals attempting to manage their diabetes.
I would like to acknowledge Garry Welch, PhD, director of behavioral medicine research at Baystate Medical Center, for his generosity in sharing the Accu-Check Interview, the PAID questionnaire, and the Diabetes Self Care Profile, in addition to Sue Kutenplon, RN, MEd, CDE, at Emerson Hospital for her expertise and support.
The Diabetes Educator, Vol. 32, No. 1,
51-58 (2006)
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