A web-based intervention to support self-management of patients with type 2 diabetes mellitus: effect on self-efficacy, self-care and diabetes distress

Background Management of diabetes mellitus is complex and involves controlling multiple risk factors that may lead to complications. Given that patients provide most of their own diabetes care, patient self-management training is an important strategy for improving quality of care. Web-based interventions have the potential to bridge gaps in diabetes self-care and self-management. The objective of this study was to determine the effect of a web-based patient self-management intervention on psychological (self-efficacy, quality of life, self-care) and clinical (blood pressure, cholesterol, glycemic control, weight) outcomes. Methods For this cohort study we used repeated-measures modelling and qualitative individual interviews. We invited patients with type 2 diabetes to use a self-management website and asked them to complete questionnaires assessing self-efficacy (primary outcome) every three weeks for nine months before and nine months after they received access to the website. We collected clinical outcomes at three-month intervals over the same period. We conducted in-depth interviews at study conclusion to explore acceptability, strengths and weaknesses, and mediators of use of the website. We analyzed the data using a qualitative descriptive approach and inductive thematic analysis. Results Eighty-one participants (mean age 57.2 years, standard deviation 12) were included in the analysis. The self-efficacy score did not improve significantly more than expected after nine months (absolute change 0.12; 95% confidence interval −0.028, 0.263; p = 0.11), nor did clinical outcomes. Website usage was limited (average 0.7 logins/month). Analysis of the interviews (n = 21) revealed four themes: 1) mediators of website use; 2) patterns of website use, including role of the blog in driving site traffic; 3) feedback on website; and 4) potential mechanisms for website effect. Conclusions A self-management website for patients with type 2 diabetes did not improve self-efficacy. Website use was limited. Although its perceived reliability, availability of a blog and emailed reminders drew people to the website, participants’ struggles with type 2 diabetes, competing priorities in their lives, and website accessibility were barriers to its use. Future interventions should aim to integrate the intervention seamlessly into the daily routine of end users such that it is not seen as yet another chore. Electronic supplementary material The online version of this article (doi:10.1186/s12911-014-0117-3) contains supplementary material, which is available to authorized users.

The scale contains 25 items that measure the intensity of self-efficacy for activities of the diabetes regimen. Subjects are asked to describe how much they believe they could or could not do what was stated. The responses on this 6-point scale range from "very sure I can't" to "very sure I can" do what was stated in each item. Higher scores indicate greater confidence in one"s ability to perform the designated treatment activities. The following statements are examples of the self-efficacy items: "Figure meals and snacks at home" and "Keep track of blood sugar levels". The modified self-efficacy scale has a moderate to high reliability (Cronbach"s alpha = 0.51 to 0.86). Self-care behaviour Summary of Diabetes Self-Care Activities Measure -Revised (3; 4) Items selected from this self-report instrument assess participants" frequency (over the past 7 days) of engaging in diabetes self-care behaviours, including following a healthy diet, spacing out carbohydrates evenly across the day, physical activity, self-monitoring of blood glucose testing, foot care, and medication and/or insulin taking. For each diabetes self-care behaviour, participants are asked to respond using the following prompt: "On how many of the last 7 days…" Responses, which are based on a 7-day week, range from 0 days to 7 days. Greater number of days indicated better self-management. Reliability and validity for this instrument have been found to be adequate, with a test-retest correlation of 0.40 and internal consistency of 0.47. Diabetesspecific quality of life Diabetes Distress Scale (5) The DDS is a 17 item instrument that assesses emotional distress and functioning specific to living with diabetes. Responses are scored on a 6-point Likert-type scale from 1 = "no problem" to 6 = "serious problem". Scores can range from 17-102 with higher scores indicating poorer diabetesrelated quality of life and lower scores indicating better diabetes-related quality of life. The DDS has been found to have high internal reliability with a Cronbach"s alpha of 0.93, good convergent validity with the Center for Epidemiological Studies Depression Scale (CESD) (r=0.56) and self-care behaviours including lower adherence to eating recommendations (r=0.30, p<0.001) and lower levels of physical activity (r=0.13, p<0.01) (5). In addition, diabetes distress has been demonstrated to be associated with HbA1c (r=0.17-0.31, P=.00-.001), diet (r=-0.38, P=.00), physical activity (r=-0.13, P=.01) and medication adherence (r=-0.16, P=.00)(6; 7)

Opening questions
As a participant in our study you were invited to visit and use the Diabetes Online Companion to assist you in self-managing your diabetes. We would like to talk to you about how you use the internet to gain knowledge about managing your diabetes. Interaction with the healthcare system  Did the Diabetes Online Companion help you with your interactions with your health care professionals? If so, how?  To clarify for them, can give example: "Some people might feel like it made no difference, that is was just a little extra perk on the side. Some people might have felt that it allowed them to learn more about diabetes on their own, which allowed them to ask their health care provider more specific questions about their own diabetes. Others might have felt that it made their interactions with health care providers less necessarybecause their answers were already answered. What do you think?  Did the website help you prepare for appointments with your doctor or other health care professionals? Tell me about that (which means that they can say it did or it didn"t but you can find out why or why not using this probe).  Did you ever use the website as a bridge to your next appointment  It"s a long time between appointments with your health care providers. If a health issue comes up in between what would you feel comfortable managing yourself? How would you deal with them?  What would you feel comfortable changing without speaking to your doctor?
 What types of issues would you go back to your family physician, endocrinologist ie diarrhea, cough?  Think of an example where you had a question between appts and you went to a website and you got information about your health, what would you do?  Did you get an opportunity to use the online tools to prepare for your appointments? Ie logs, blog about preparing for appointments?  Were these tools difficult to find?  How could we make it easier to find these tools? o Can you tell me why you didn"t "ask the expert" a question.
o What topics/things wouldn"t you feel comfortable asking in this blog format?

Strengths and Weaknesses of the Website
 We would like to know what you felt were the strengths/weaknesses of the Diabetes Online Companion:  What content was particularly helpful (or not helpful)? Refer to the general topics listed on the home page  We had general topics listed on the home page of the website ie blood pressure, blood sugar management. What other topics would you like to have seen?  Sometimes too much information can be overwhelming. What did you find with the Diabetes Online Companion? Was there too much information and you felt overwhelmed or freaked out? Or, was there enough information to be useful to you?  How do you think this balance of depth of information with not feeling overwhelmed can be best achieved?  Information on the website was presented in several different formats. Please, tell me how helpful and interesting you found the following formats: Videos, Logs, Blog, Text pages

Privacy/Sharing
We"re getting close to the end of the interview now, but I have just a few more questions for you. o What did you feel about the username and password system? Was it difficult to use?
o We had the website privacy protected because of privacy issues ie for logs where you were entering personal information, for instance "My blood glucose log". What solution could you suggest, beyond signing onto the site with a username and password, that would be reasonable and would still protect your privacy?

Sustainability of Use
You have used the Diabetes Online Companion for several months.
 What new content on the website will keep you coming back in the future?  What did you do when you received an email from the website about new content that was added to the site?  What would you tell other people with diabetes about the Diabetes Online Companion?
 That"s all of the questions I have for you. But is there anything else that you would like to add before we finish? Thank you for your time.