CANADIAN JOURNAL OF DIABETES. 2010;34(3):218-226.
218 | CANADIAN JOURNAL OF DIABETES
ABSTRACTOBJECTIvE: The purpose of this study was to examine dia-betes educators perceptions of (a) their abilities, attitudes and difficulties/challenges related to physical activity and exercise counselling; and (b) their patients abilities and attitudes related to performing physical activity and exercise in managing their diabetes.
METhOD: Using a cross-sectional, observational design, diabetes educators (N=119) recruited from 3 provinces completed survey measures of counselling, referral and other efficacies; attitudes; perceived difficulty; barriers; and training practices related to physical activity and exercise.
RESULTS: Analyses revealed that diabetes educators lacked confidence in their own ability to counsel patients about, prescribe and make referrals for physical activity and exercise; they also lacked confidence in the ability of their patients to perform physical activity and exercise. While dia-betes educators had positive attitudes about physical activity and exercise, they perceived their typical patients attitudes to be much less positive. Diabetes educators perceived that including more in-depth physical activity and exercise coun-selling in their practice would be only somewhat difficult, but they indicated that they experienced multiple barriers in this area. Diabetes educators perceptions were also shown to be associated with their counselling practices related to physical activity and exercise.
CONCLUSION: These findings provide novel insight into dia-betes educators perceptions of their own abilities, as well as those of their patients, and further underscore the need to provide diabetes educators with greater training in physical activity and exercise counselling.
KEywORDS: counselling, diabetes, education, efficacy, exer-cise, patients, physical activity
RSUMOBJECTIF : Cette tude avait pour objet dexaminer comment les ducatrices/ducateurs spcialiss en diabte percevaient (a) leurs capacits et attitudes ainsi que les difficults lies au counselling sur lactivit physique et lexercice; et (b) les capacits des patients de faire de lactivit physique et de lexercice pour grer le diabte et les attitudes des patients en ce qui a trait lactivit physique et lexercice.
MThODE : Une enqute transversale observationnelle a t mene auprs dducatrices/ducateurs spcialiss en diabte (N = 119) de trois provinces, qui ont rempli un questionnaire sur le counselling, lorientation des patients et autres efficacits, les attitudes, la difficult perue, les obstacles et les pratiques de formation ayant trait lactivit physique et lexercice.
RSULTATS : Les analyses ont rvl que les ducatrices/ducateurs spcialiss en diabte manquaient de con-fiance dans leurs capacits de counselling, de prescription et dorientation des patients pour ce qui est de lactivit physique et de lexercice, ainsi que dans les capacits de leurs patients de faire de lactivit physique et de lexercice. Les ducatrices/ducateurs spcialiss en diabte avaient des attitudes favorables en ce qui concerne lactivit physique et lexercice, mais ils considraient que le patient typique avait des attitudes beaucoup moins favorables. Les duca-trices/ducateurs spcialiss en diabte considraient quil ne serait pas trs difficile dintensifier le counselling sur lactivit physique et lexercice, mais ont dit faire face de nombreux obstacles ce chapitre. L enqute a aussi rvl
Carrie J. Dillman BKinH, Christopher A. Shields1,2 PhD, Jonathon R. Fowles1,2 PhD, Arlene Perry BSc, Ren J.L. Murphy1,2 PhD, Peggy Dunbar3 MEd
1School of Recreation Management & Kinesiology, Acadia University, Wolfville, Nova Scotia, Canada2Centre of Lifestyle Studies, Acadia University, Wolfville, Nova Scotia, Canada3Diabetes Care Program of Nova Scotia, Halifax, Nova Scotia, Canada
Address for correspondence: Christopher A. Shields, Associate Professor, School of Recreation Management and Kinesiology
Acadia University, Wolfville, Nova Scotia, Canada B4P 2R6, E-mail: firstname.lastname@example.org
Including Physical Activity and Exercise in Diabetes Management: Diabetes Educators Perceptions of Their Own Abilities and the Abilities of Their Patients
CANADIAN JOURNAL OF DIABETES. 2010;34(3):218-226.
DIABETES EDUCATORS PERCEPTIONS OF PHYSICAL ACTIVITY COUNSELLING | 219
que les perceptions des ducatrices/ducateurs spcialiss en diabte taient associes leurs pratiques en matire de counselling sur lactivit physique et lexercice.
CONCLUSION : Ces rsultats jettent un nouvel clairage sur les perceptions quont les ducatrices/ducateurs spcialiss en diabte de leurs capacits et de celles de leurs patients, et font encore une fois ressortir que les ducatrices/ducateurs spcialiss en diabte doivent recevoir davantage de forma-tion sur le counselling sur lactivit physique et lexercice.
MOTS CLS : counselling, diabte, ducation, efficacit, exer-cice, patients, activit physique
INTRODUCTION Physical activity and exercise are acknowledged as one of the primary modifiable risk factors in the prevention and treatment of type 2 diabetes (1-3) and are key components of diabetes self-management (4-6). Specifically, regular physical activity has been shown to prevent the develop-ment of complications resulting from diabetes (1,6,7), decrease the need for blood glucose-lowering medication (8) and reduce premature, all-cause mortality in individu-als with diabetes (9,10). Despite these benefits and a recent emphasis on physical activity counselling in quality diabetes management (11), it is estimated that between 60 and 76% of Canadians with diabetes are not active enough to achieve health benefits (12-15). Individuals with diabetes have traditionally reported receiving less support, education and encouragement for physical activity than for other lifestyle management issues (16), and progress in this area is limited (11). The promotion of physical activity for people with diabetes continues to be generally insufficient (17).
The role of diabetes educatorsDiabetes educators are often viewed as the primary source of information and assistance for people living with diabe-tes and, as such, are in a position to effectively encourage physical activity and exercise (18). The most recent clinical practice guidelines by the Canadian Diabetes Association (CDA) highlight the effectiveness of structured physical activity counselling by healthcare professionals in increas-ing physical activity levels and improving diabetes-specific outcomes (19). The guidelines provide general recommen-dations about the amount of exercise to be encouraged (e.g., 150 min of moderate-intensity aerobic exercise per week), but they lack specific details about prescribing intensity, modes of exercise (particularly resistance exercise) and tai-loring programs to account for individuals with complica-tions (19,20). As a result, although diabetes educators are attempting to address physical activity with their patients, the majority of diabetes educators do not feel confident
in doing so. Specifically, diabetes educators feel that they lack sufficient training, knowledge, skills and experience to effectively counsel patients about physical activity and exer-cise (11,21) and have reported anxiety about encouraging physical activity due to fears about increasing patient risk (11,22). Consequently, there is a lack of standardization in physical activity and exercise counselling delivery (23), with varied and inconsistent procedures for individualizing physical activity and exercise promotion (11,23).
It is important to recognize that diabetes educators per-ceptions regarding physical activity and exercise counselling may have behavioural implications in diabetes practice. Specifically, Social Cognitive Theory (24) highlights percep-tions of confidence in ones own abilities (known as self-efficacy) as a key determinant of personal behaviour (e.g. diabetes educators physical activity and exercise counselling practices). The health promotion literature appears to bear this out, showing that, in both general healthcare (25) and diabetes contexts (26), low levels of confidence in counselling to patients around lifestyle modification limits the provision of guidance in these areas. While diabetes educators lack of confidence with respect to physical activity and exercise counselling has been previously identified in small samples (11,24), the previous work does not recognize the social situ-ation in which much of diabetes self-management education occurs. This is not surprising given the theoretical focus and research emphasis on the role of self-efficacy (24).
However, Lent and Lopez (27) have offered some direc-tion in this regard, suggesting that in instructorpatient relationships, an understanding of an individuals beliefs about both parties in the relationship may be essential (27). While they recognize the importance of self-efficacy as a determinant of behaviour, they also underscore the impor-tance of an individuals beliefs about anothers capabilities, known as other efficacy. These other efficacy perceptions are theorized to affect the effort an individual expends in joint tasks with another person, the provision of assistance and satisfaction with the relationship (27). This may be particu-larly important in the context of diabetes management, as diabetes educators perceived confidence in their patients abilities to use physical activity and exercise to manage their diabetes may affect their interactions with patients and the feedback and support they provide. Nevertheless, despite the theoretical importance of these perceptions and pos-sible implications for counselling practices, there have been no examinations of diabetes educators confidence in their patients abilities in the diabetes/exercise literature.
Additionally, while providing information and guid-ance on physical activity and exercise directly to patients is the most studied aspect of physical activity promotion by diabetes educators, providing effective physical activity and exercise counselling for those with diabetes can require
220 | CANADIAN JOURNAL OF DIABETES
resources and expertise beyond those typically available to diabetes educators. For example, prior to engaging in regular exercise, it may be important for patients with signs of coronary artery disease or musculoskeletal problems to be referred to a specialist. As a result, recognizing when to make appropriate referrals to other healthcare profession-als (e.g. cardiologists, internists, physiotherapists, qualified exercise professionals) for further screening or advice is a key yet understudied aspect of the counselling process when working with people with diabetes.
Given the fundamental role of physical activity and exer-cise in the management of diabetes, the important position diabetes educators hold in assisting patients with managing their condition, and the potential impact of diabetes educa-tors perceptions on their counselling behaviour there is a need to examine diabetes educators beliefs about their patients abilities and their own abilities in a large sample. This study had 3 purposes. The first was to examine diabetes educators perceptions of their abilities, attitudes and difficulties related to physical activity and exercise counselling. The second was to examine diabetes educators perceptions of their patients abilities and attitudes related to physical activity and exercise
in managing their diabetes. The third was to examine the self-reported barriers diabetes educators face with respect to physical activity and exercise counselling. Also of interest was the training and experience diabetes educators have with regard to physical activity and exercise counselling.
METhODSDesign and participantsThis study used a cross-sectional, survey-based design. Diabetes educators (N=119) were recruited across 3 Atlantic provinces: Nova Scotia (n=69), New Brunswick (n=34) and Newfoundland (n=16). The mean age of the sample was 44 years, almost all were female (97%) and most self-reported their ethnicity as Caucasian (90%). The majority of the sample (92%) held at least a bachelors degree, with the pri-mary educational backgrounds being in nutrition (59%) and nursing (16%). In terms of employment, 42% of diabetes educators reported having worked at a diabetes education centre for more than 10 years, while 15% had worked at a centre for less than 2 years. The majority of participants saw fewer than 10 patients per day (57%), with another 30% seeing 10 to 15 patients per day. In their practice, most participants (59%) reported that sessions with patients were typically between 20 and 40 minutes in length. Full partici-pant demographics are presented in Table 1.
MeasuresGiven that little to no research has examined many of the constructs of interest and that this represents the first such work in the context of diabetes education, all measures were developed by the researchers for use in the current study.
Counselling efficacyThis 13-item measure was used to assess participating diabe-tes educators confidence in their ability to perform specific aspects of physical activity and exercise counselling with their patients over the next month. For example, one item asks about diabetes educators confidence in design[ing] a physical activity or exercise program that accommodates clients indi-vidual needs or limitations. In line with recommendations regarding the measurement of efficacy-related constructs, all items were assessed using a 0% (not at all confident) to 100% (completely confident) scale (28). Items were averaged to pro-vide an overall indication of diabetes educators confidence to perform physical activity and exercise counselling. Cronbachs alpha was calculated as a measure of internal consistency and was found to be acceptable (alpha=0.96) (29).
Referral efficacyThis efficacy measure assessed diabetes educators confi-dence in their ability to refer patients who required addition-al clearance or information prior to beginning an exercise
Table 1. Participant demographics (N=119)
Parameter % (n)
Educational backgroundGraduate schoolBachelorsDiploma
8 (10)83 (98)
59 (26)16 (7)14 (6)5 (2)5 (2)2 (1)
Time working at a DEC10 years
15 (18)8 (9)
13 (15)13 (15)10 (12)41 (49)
Patients per day20
14 (17)43 (51)29 (35)10 (12)3 (3)
Time spent with patients50 min
1 (1)16 (19)24 (28)34 (41)
9 (11)16 (19)
DEC = diabetes education centre*N providing name of specific diploma/degree held = 44
CANADIAN JOURNAL OF DIABETES. 2010;34(3):218-226.
DIABETES EDUCATORS PERCEPTIONS OF PHYSICAL ACTIVITY COUNSELLING | 221
respect to physical activity and exercise. Specifically, single items were used to measure diabetes educators perceptions of (a) how important their patients felt physical activity and exercise was in diabetes management; (b) how receptive they felt t...