Development and pilot testing of a novel behavioral intervention for adults with type 2 diabetes using intervention mapping

Figures & data

Table 1. Intervention matrix of performance and change objectives for the Pathways Diabetes Intervention.

Personal Determinants
Performance objective (PO)	Risk perception	Knowledge	Outcome expectancies	Self-efficacy	Agency	Values	Intention	Action Control
PO 1. Identify current LGI foods consumed, PA behaviors and glucose patterns	State the relation among food and PA to health	Identify type and quantity of LGI foods commonly consumed; identify current PA behaviors	Expect food, PA and glucose self-monitoring will enable self-observation and awareness	Increase confidence in identifying LGI foods, portion sizes, and greater PA, and in monitoring behaviors	Realize change begins with awareness and acceptance of where you are and starting from that point	Clarify personal values related to health and well-being	Set intention to self-observe and self-monitor
PO 2. Compare current behavior to behavioral goals	Recognize excess HGI foods, inadequate level of PA, and out-of-range glucose values	State goals for LGI servings and minutes of PA; identify high-risk situations for over-eating and inactivity; identify food cues and sedentary behaviors			Express that hope is a learned way of thinking about goal pursuit		Agree that goal pathways develop strategies for goal pursuit	Appraise the situation as one that is relevant to personal goals
PO 3. Determine if discrepancies exist	Realize current behavior(s) increase risk and vulnerability for T2DM-related comorbidity		Acknowledge that discrepancies are normal	Use incremental tasks to narrow discrepancies; obtain verbal persuasion from facilitator			Set intention to reduce gap b/t current behaviors and recommended behaviors
PO 4. Create a plan to meet program goals		Demonstrate how to determine the GI value and portions of food, appropriate exercise routine, and stretching postures	Expect LGI food intake and increased PA will improve health	Increase confidence in initiating action plan (i.e. agency and action SE); imagine success	Commit to achieve goal; realize goal attainment occurs best through positive self-care and a healthy lifestyle	Internalize values for change; align goals with core values; become aware of in-the-moment decision-making consistent (or not) with values	Set SMART, ‘stretch’ goals consistent with core values; identify cues to action
PO 5. Self-monitor behaviors during goal pursuit		Explain how to properly use glucose monitoring device and self-monitoring logs	Expect monitoring to provide useful information and not be too time-consuming	Express confidence in using monitoring device and logs	Gain satisfaction in the journey; reinforce goal progress	Commit to self-regulation of behaviors; choose value-based decision-making		Perform monitoring with optimism; keep goal intentions salient
PO 6. Evaluate progress toward goal attainment		Identify reasonable progress outcomes	Expect to make gradual progress	Express confidence in persevering toward goals and prioritizing goals	Remind self that setbacks happen; recall when goals were attained despite obstacles; celebrate goal progress and success		Set intention to overcome obstacles and resolve goal conflicts	Agree that goal attainment requires deliberate effort
PO 7. Assess self-reaction regarding progress	Acknowledge lapses are common but increase vulnerability for relapse	Identify events which trigger a slip (e.g. when pursuing challenging goals); realize a lapse does not have to become a relapse; recognize that all information is helpful feedback	Feel positive about: lower glucose, more energy, achieving goals, praise from others	Visualize overcoming obstacles and resisting temptations; attribute failures externally and achievements internally (i.e. coping SE)	Experience satisfaction in goal attainment; maintain flexible thought to continue on the path to goal attainment	Acknowledge the information learned from slips; recognize that values serve as a compass in goal pursuit; commit to higher-order life values	Strengthen resolve to achieve goals	Focus on what is achieved rather than failure
PO 8. Modify diet and PA goals, as needed	Acknowledge sustained risk for T2DM-related comorbidity		Expect to be more successful in goal striving with information gained from self-evaluation	Express confidence in continued goal striving and recovery from setbacks (i.e. recovery SE); continue to exert effort and persevere	Realize setbacks do not have to result in goal abandonment; create alternate paths to goal attainment	Re-align goals with values, as needed	Set intention for a coping plan

Note: LGI: low glycemic index foods; PA: physical activity; HGI: high glycemic index; T2DM: type 2 diabetes mellitus.

Table 2. Intervention matrix and definition of behavior change methods and practical applications for each behavioral determinant in the Pathways Diabetes Intervention.

Determinant	Method	Method definition^a	Practical application
General	Participation	Assure high level engagement of participants	Group-based intervention; participants divide into small groups or pairs for ‘hands on’ activities and goal-setting activities
	Belief selection	Use messages designed to strengthen positive beliefs, weaken negative beliefs, and introduce new beliefs	Explain benefits of LGI foods compared to higher GI foods; review benefits of PA and ill effects of sedentary behaviors
	Active learning	Encourage learning from goal-driven and activity-based experience	Include goal-based activities
	Individualization	Provide opportunities for learners to have questions answered or instructions paced according to their individual progress	Questions addressed during group sessions; individual feedback provided on self-monitoring records; facilitator contact information provided for questions/help needed between group sessions
	Feedback	Give information regarding the extent to which individuals are accomplishing learning or performance, or the extent to which performance is having an impact	Group facilitator provides feedback on self-monitoring records and weekly self-set goal selection; identifies patterns in glucose responses pre- and post-prandially in self-monitoring records
Risk Perception	Consciousness raising	Provide information, feedback, or confrontation about the causes, consequences, and alternatives for a problem or a problem behavior	Discuss glucose targets before and after eating; compare individual values from self-monitoring to target values; help identify relations between food intake, PA and glucose response
	Personalize risk	Provide information about personal costs or risk of action or inaction with respect to the target behavior	Explain relation between A1c values and diabetes comorbidities; self-monitor blood glucose pre- and post-prandially and compare values to targets
	Self-affirmation	Increase self-image by having people elaborate on their relevant values or desirable characteristics	Elaborate core values, especially health values
Knowledge	Chunking	Use stimulus patterns that may be made up of parts but that one perceives as a whole	Organize new information into sub-units to minimize ‘information overload’; include concept maps regarding carbohydrates and GI; summarize key concepts via text boxes in participant manual
	Advance organizers	Present an overview of the material that enables a learner to activate relevant schemas so that new material can be associated	Include weekly session objectives and outline of topics in participant manual
	Discussion	Encourage consideration of a topic in open informal debate	Include weekly group review and discussion of topics and activities
	Elaboration	Stimulate the learner to add meaning to the information that is processed	Include ‘hands on’ activities to apply principles discussed; integrate new concepts with prior concepts; highlight recommended behaviors via text boxes in participant manual
Outcome expectancies	Self-reevaluation	Encourage combining both cognitive and affective assessments of one’s self-image with and without an unhealthy behavior	Review self-monitoring records to assess goal progress
	Direct experience	Encourage knowledge through the interpretation of experience	Monitor and record pre- and post-prandial glucose values; identify glucose patterns in relation to food and PA; measure food portions during food label session; select LGI foods at supermarket; include group walk during PA session
Self-efficacy	Verbal persuasion	Use messages to suggest possession of certain capabilities	Group facilitator encourages goal initiation and striving each week
	Modeling	Provide an appropriate model being reinforced for the desired action	Supermarket session to demonstrate shopping for LGI foods; include walking and demonstrate stretching during PA session; participants share ‘lessons learned’ during goal striving
	Guided practice	Prompt rehearsal and repetition of behavior, discuss experience, and provide feedback	Provide LGI substitutions for high GI foods; provide ideas for: grocery shopping lists, household pantry, snacks and meals; demonstrate recipe modification; provide LGI recipes; identify LGI foods when dining out
	Enactive mastery experience	Provide increasingly challenging tasks	Encourage incremental goal setting each week
Agency	Reattribution training	Help people reinterpret previous failures in terms of unstable attributions and previous successes in terms of stable attributions	Recognize that slips happen; learn from prior slips
	Improve physical and emotional states	Prompt interpretation of enhancement or reduction of physiological and affective states to judge own capabilities	Develop strategies for preventing hypoglycemia and positive self-talk
Values	Self-reevaluation	Encourage combining both cognitive and affective assessments of one’s self-image with and without an unhealthy behavior	Elaborate core values; align goals and actions with values
Intention	Goal setting	Prompt planning regarding what to do to achieve target behavior	Establish weekly SMART, stretch goals via goal maps
	Action planning	Specify when, where, what, and how to achieve the goal	Plan what, when, where, how, and how often for each goal behavior; place monitoring tools in appropriate location(s) as cues to monitor; identify preparatory behaviors
	Coping planning	Prompt list of potential barriers and ways to overcome them	Plan how to overcome obstacles to goals via goal maps
Action control	Self-monitoring of behavior(s)	Prompt record keeping of specified behavior(s)	Plan day, time and location to monitor glucose; plan day, time and location to record glucose values, food intake, and PA in logs

Note: LGI: low glycemic index; GI: glycemic index; PA: physical activity.

^aKok et al. (2016).

Table 3. Content topics presented during weekly intervention sessions.

Week	Topics discussed
1	Program overview and program goals; impact of GI on health; guidelines for effective self-monitoring
2	Reading food labels and portion control; impact of GI and glycemic load on post-prandial glucose; self-monitoring goals reviewed
3	How food processing and preparation affect GI values; SMART goals defined and illustrated
4	Using the GI in menu planning and grocery shopping; goal mapping introduced
5	Impact of physical and mental energy on motivation; agentic thinking and positive self-talk
6	PA for effective diabetes self-management with a brief walk
7	Supermarket tour and recipe modification
8	Selecting low GI foods when dining out; overcoming obstacles to lifestyle change and goal mapping
9	Value identification and recovering from setbacks
10	Program review of key points; goal mapping for maintaining lifestyle change

Table 4. Baseline scores and change scores for the behavioral determinants of change in the Pathways Diabetes Intervention.

Low GI food items^a	Baseline value	Change score	Cohen’s d^b
	Mean (±SE)
Outcome expectancies (7 items)	4.2 (±0.1)	0.1 (±0.2)	0.15
Behavioral intention (8 items)	4.1 (±0.2)	0.3 (±0.2)	0.51
Action SE (9 items)^c	6.5 (±0.6)	2.4 (±0.7)	1.45
Coping SE (4 items)	3.5 (±0.3)	0.7 (±0.4)	0.78
Recovery SE (4 items)	3.5 (±0.3)	0.9 (±0.4)	0.97
Action control (9 items)	3.5 (±0.3)	0.1 (±0.3)	0.09
Action planning (5 items)	3.3 (±0.3)	1.0 (±0.3)	1.40
Coping planning (5 items)	2.5 (±0.3)	1.4 (±0.3)	1.94
PA items^a
Outcome expectancies (16 items)	4.1 (±0.1)	0.2 (±0.1)	0.46
Behavioral intention (1 item)^d	6.8 (±0.8)	1.5 (±1.0)	0.69
Action SE (13 items)	3.1 (±0.1)	0.1 (±0.1)	0.21
Coping SE (4 items)	3.7 (±0.2)	0.2 (±0.3)	0.27
Recovery SE (4 items)	3.8 (±0.2)	0.3 (±0.3)	0.46
Action control (5 items)	3.1 (±0.2)	0.4 (±0.2)	0.58
Action planning (4 items)	4.2 (±0.3)	1.4 (±0.3)	0.65
Coping planning (3 items)	2.9 (±0.3)	0.9 (±0.4)	0.87
Disease risk and self-regulation items
Composite risk perception of diabetes and its complications (26 items)^e	12.0 (±0.4)	-0.1 (±0.5)	-0.10
Hope State Scale: total score^f	5.8 (±0.3)	0.8 (±0.2)	0.90
Pathways subscore (3 items)	6.4 (±0.3)	0.4 (±0.2)	0.46
Agency subscore (3 items)	5.2 (±0.5)	1.3 (±0.3)	1.04
Brief Self-Control Scale (10 items)^g	3.5 (±0.2)	0.1 (±0.2)	0.14

^aResponse options ranged from 1 = ‘strongly disagree’ to 5 = ‘strongly agree,’ except where indicated, with higher scores being more favorable.

^bBased on Cohen’s d for effect size estimation.

^cResponse options ranged from 0 = ‘strongly disagree’ to 10 = ‘strongly agree.’

^dResponse options ranged from 0 = ‘0%, not at all confident or likely’ to 10 = ‘100%, extremely confident or likely.’

^eComposite score across five subscales measuring personal control, worry, optimistic bias, personal disease risk, and comparative environmental risk with a 4-point response format; higher score indicates greater comparative perceived risk.

^fResponse options ranged from 1 = ‘definitely false’ to 8 ‘definitely true.’

^gResponse options ranged from 1 ‘very much like me’ to 5 = ‘not at all like me.’

Kok, G., Gottlieb, N. H., Peters, G. J. Y., Mullen, P. D., Parcel, G. S., Ruiter, R. A. C., … Bartholomew, L. K. (2016). A taxonomy of behavior change methods. An intervention mapping approach. Health Psychology Review, 10, 297–312. doi: 10.1080/17437199.2015.1077155

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