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Received: 21 April 2017 Revised: 31 July 2018 Accepted: 14 April 2019
DOI: 10.1111/ijn.12742
OR I G I N A L R E S E A R CH PA P E R
The effect of a transtheoretical model–based motivational
interview on self‐efficacy, metabolic control, and health
behaviour in adults with type 2 diabetes mellitus: A randomized
controlled trial
Alime Selçuk‐Tosun RN, PhD, Lecturer1 | Handan Zincir RN, PhD, Associate Professor2
1Faculty of Nursing, Selçuk University, Konya,
Turkey
2Faculty of Health Sciences, Erciyes
University, Kayseri, Turkey
Correspondence
Alime Selçuk‐Tosun, Faculty of Nursing, Selçuk
University, Alaaddin Keykubat Campus, Konya,
42250 Selçuklu, Turkey.
Email: alimeselcuk_32@hotmail.com
Funding information
Scientific Research Project Coordination
Department at Erciyes University, Grant/
Award Number: TDK‐2013‐4699
This study was an oral presentation at the International
Transtheoretic Model‐based Motivational Interview on Self
ference, Madrid Oral Presentation, October 6‐9, 2015, Mad
Int J Nurs Pract. 2019;25:e12742.
https://doi.org/10.1111/ijn.12742
Abstract
Aim: This study aimed to determine the effect of a transtheoretical model–based
motivational interview method on self‐efficacy, metabolic control, and health behav-
iour in adults with type 2 diabetes mellitus.
Methods: A randomized controlled study design was used. The study was con-
ducted with 50 individuals with type 2 diabetes mellitus, divided into an intervention
group and a control group. The researcher held motivational interviews with the
patients in the intervention group. Both groups were observed at the beginning of
the study and 6 months after the baseline interview. The study data were collected
between January 8 and November 18, 2014.
Results: Comparing the intervention and the control groups, the differences in the
level of self‐efficacy and participants' metabolic values were significant (P < .05). The
number of participants in the action stage of the intervention group for nutrition,
exercise, and medication use significantly increased compared with the control group
(P < .05).
Conclusion: The transtheoretical model–based motivational interview method
increased the self‐efficacy level of participants with type 2 diabetes mellitus, which
helped them improve their metabolic control and health behaviour stages over this
6‐month period.
KEYWORDS
metabolic control, motivational interview, nursing, self‐efficacy, type 2 diabetes mellitus
SUMMARY STATEMENT
What is already known about this topic?
• Type 2 diabetes mellitus is one of the top 10 potentially fatal dis-
eases that are increasing in prevalence worldwide.
Institute of Social and Economic Scie
‐Efficacy, Metabolic Control and Health
rid, Spain. pp. 92‐93.
wileyonlinelibrary.com/journa
• The level of self‐efficacy is directly associated with health‐
promotion behaviours such as proper diet and regular exercise.
The self‐belief or self‐efficacy level for a behaviour can increase
or decrease the motivation for taking action.
• The transtheoretical model facilitates the classification of stages a
person goes through before engaging in a behaviour.
nces 20th International Academic Conference. Selçuk‐Tosun A., Zincir H., The Effect of a
Behavior in Individuals with Type 2 Diabetes Mellitus, IISES 20th International Academic Con-
© 2019 John Wiley & Sons Australia, Ltdl/ijn 1 of 12
https://orcid.org/0000-0002-4851-0910
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https://doi.org/10.1111/ijn.12742
https://doi.org/10.1111/ijn.12742
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2 of 12 SELÇUK‐TOSUN AND ZINCIR
What this paper adds?
• The transtheoretical model–based motivational interview helps
people with type 2 diabetes mellitus control their blood glucose
levels; increase their level of self‐efficacy, which is important for
behavioural change; and make positive improvements in nutrition,
exercise, and medication use.
• The frequency of conducting transtheoretical model–based motiva-
tional interviews should be planned according to the characteristics
of individuals.
The implications of this paper:
• The transtheoretical model–based motivational interview method
for encouraging positive health behavioural change (nutrition, exer-
cise, and medication use) in adults with type 2 diabetes mellitus
who resist behavioural change may be beneficial in promoting
behavioural change.
• Health care providers can easily apply the transtheoretical model–
based motivational interview method.
1 | INTRODUCTION
The prevalence of type 2 diabetes mellitus (T2DM) has been growing
in most parts of the world in recent years. The increasing prevalence
of T2DM and the complications caused by its effect on individuals'
lifespan have very high costs. In disease management, the main prior-
ity of individuals and health professionals is to prevent acute compli-
cations and reduce the risk of chronic complications (ADA, 2017;
WHO, 2010). For example, early diagnosis and treatment reduces
complications in individuals withT2DM (ICN, 2010). With the purpose
of achieving these goals, patients are asked to maintain a sufficient
and balanced diet, do regular physical exercise, monitor their blood
glucose regularly, and administer their medication and insulin, if neces-
sary, at the right time and dose (ADA, 2017).
Many studies have been conducted recently on healthy lifestyles.
The most commonly used health behaviour model is the
transtheoretical model (TTM) (Dray & Wade, 2012; Glanz, Rimer, &
Viswanath, 2008; Kirk, Mutrie, Macintyre, & Fisher, 2003;
Pichayapinyo, Lagampan, & Rueangsiriwat, 2015). TTM enables people
to use the targets and approaches of the behavioural change stage
rather than all or nothing; it deals dynamically with behavioural change
(Marshall & Biddle, 2001).
According to the TTM developed by Prochaska and DiClemente
(1982), people engage in behaviours by going through the stages of
precontemplation, contemplation, preparation, action, and mainte-
nance (Shinitzky & Kub, 2001). Only the stages of change were
assessed in this study. The model structure also involves the concept
of self‐efficacy (Prochaska & Velicer, 1997). For our purposes, self‐
efficacy is the belief that an individual can display positive health
behaviours. A person's self‐efficacy level directly affects their health‐
promotion behaviours (Stuifbergen, Seraphine, & Roberts, 2000).
Thus, as one of the four general principles of the motivational inter-
view, supporting self‐efficacy helps people change their behaviours
(Miller & Rollnick, 2009; Stuifbergen et al, 2000). A past study
reported that motivational interviews improved self‐efficacy. The
studies conducted with individuals that had T2DM also demonstrated
that self‐efficacy has a positive effect on health behaviours (Gao et al,
2013; Walker, Smalls, Hernandez‐Tejada, Campbell, & Egede, 2014).
The motivational interview is an evidence‐based counselling
method used by health care professionals to help people adopt the
targeted treatment recommendations (Chen, Creedy, Lin, & Wollin,
2012; Dellasega, Gabbay, Durdock, & Martinez‐King, 2010; Jones
et al, 2003; Welch, Zagarins, Feinberg, & Garb, 2011; West, Dilillo,
Bursac, Gore, & Greene, 2007). Studies on conducting motivational
interviews with patients withT2DM have shown that these interviews
improve HbA1C, weight loss, control of diet, and physical activity
(Chapman et al, 2015; Chen et al, 2012; Heinrich, Candel, Schaper, &
de Veries, 2010; Miller et al, 2014; Poursharif et al, 2010). On the
other hand, another study reported that motivational interviews had
no superiority compared with regular care (Rosenbek Minet, Wagner,
Lonving, Hjelmborg, & Henriksen, 2011).
TheTTM plays an integrative role in interventions utilizing a motiva-
tional approach. TheTTM‐based motivational interview is an appropri-
ate approach (Van Nes& Sawatzky, 2010) for nurses, who play an
important role in the protection and development of health in patients
withT2DM (ICN, 2010; Shinitzky & Kub, 2001). It is reported in litera-
ture that theTTM‐based motivational interview focuses more intensely
on the behavioural components of changes than do other educational
approaches (Jones et al, 2014). In planning a TTM‐based motivational
interview, customizing its duration and frequency can increase effec-
tiveness in managing T2DM (Jones et al, 2014; Minet, Moller, Vach,
Wagner, & Henriksen, 2010). In Turkey, no studies involveTTM‐based
motivational interviews for individuals withT2DM. Thus, this study will
act as a guide for nurses that work in protecting and treating health ser-
vices. These nurses will be able to help T2DM patients by increasing
their knowledge and experience in the TTM‐based motivational inter-
view technique using in‐service training programmes. This study aimed
to determine the effect of a TTM‐based motivational interview on the
self‐efficacy, metabolic control, and health behaviour changes in adults
withT2DM.
1.1 | Hypotheses of the study
H1. The self‐efficacy scores of participants in the
intervention and control groups will differ statistically
at follow‐up.
H2. The metabolic scores (weight, body mass index
[BMI], waist circumference, preprandial and postpran-
dial blood glucose levels, and HbA1c level) of partici-
pants in the intervention and control groups will
differ statistically at follow‐up.
H3. The exercise behaviour change stages of partici-
pants in the intervention and control groups will differ
statistically at follow‐up.
FIGURE
SELÇUK‐TOSUN AND ZINCIR 3 of 12
H4. The nutrition behaviour change stages of partici-
pants in the intervention and control groups will differ
statistically at follow‐up.
H5. The medication use behaviour change stages of
participants in the intervention and control groups will
differ statistically at follow‐up.
2 | METHODS
2.1 | Study design
This study was planned as a randomized controlled study with the aim
of assessing the effectiveness of a TTM‐based motivational interview
technique. This study was conducted by the researcher in the endocri-
nology and metabolism polyclinic of a university hospital with study
data collected between January 8 and November 18, 2014.
2.2 | Sample size
The study group consisted of people who met the study's inclusion
criteria. On the basis of the total self‐efficacy mean score of the
1 CONSORT flow diagram
pre–follow‐up in a study conducted by Kartal and Özsoy (2014), the
sample group size was determined to be 70, with an impact size of
0.34, 90% power, and a 5% margin of error. The individuals in the
study sample were assigned to groups by an independent statistician
in the computer environment. Computer program randomization
placed 35 participants in the intervention group and 35 participants
in the control group. In the present study, nine interviews and two
interviews were conducted on average with the intervention and con-
trol groups, respectively. In addition, the researcher was both the
practitioner and responsible for the assessment. Therefore, the criteria
for blinding could not be met. During the course of the study, 10 par-
ticipants from the intervention group and 10 participants from the
control group left or were excluded, and the study was completed
with 50 participants (Figure 1).
2.3 | Study participants
The inclusion criteria for this study were that participants had T2DM
and hypertension or dyslipidemia; were aged between 20 and
65 years; were primary school graduates; had a BMI of 25 kg/m2 or
more (overweight or obese); had a glycated haemoglobin (HbA1c) level
of 7% or more; had been diagnosed with T2DM for 6 months or
4 of 12 SELÇUK‐TOSUN AND ZINCIR
longer; and were using oral diabetic medication, insulin, or both. The
exclusion criteria were having medical problems that hindered
exercise; having serious peripheral or autonomic neuropathy; having
severe retinopathy; and having a psychiatric disorder. The termination
criteria were being unwilling to continue participating in the study;
developing other diabetic complications that hindered continued par-
ticipation in the study; and not keeping records on a regular basis.
2.4 | Study instruments, primary and secondary
outcome measures
The researcher created the personal information form. The form has
five questions about gender, age, education level, and the duration
of T2DM.
The primary outcome was the self‐efficacy mean score measured
at baseline and the sixth‐month follow‐up. This outcome was assessed
with the Self‐efficacy (Competence) Scale for Patients with Type 2
Diabetes, the validity and reliability of which has been assessed (Kara,
van der Bijl, Shortridge‐Bagget, Astı, & Erguney, 2006; Van der Bijl,
Van Poelgeest‐Eeltink, & Shortridge‐Baggett, 1999).
The cross‐cultural adaptation of the scale was conducted by Kara
et al (2006) in Erzurum, Turkey; the Cronbach alpha value of the
scale was .89, test‐retest reliability was 0.91, and its construct valid-
ity was 0.80.
The secondary outcomes were metabolic values (weight, BMI,
waist circumference, preprandial and postprandial blood glucose
levels, and HbA1c level); the number of steps taken; and the health
behaviour change stage measured at baseline and the sixth‐month
follow‐up.
2.4.1 | Height was measured in order to calculate
BMI
Height of individuals was measured as the length from the top of the
head to the soles when they had their feet bare and adjacent and were
standing in a Frankfort plane (back of the skull, shoulders, pelvis, and
heels touching the same horizontal plane and the individual standing
at attention) (Pekcan, 2011).
2.4.2 | Weight
The weights of the individuals were measured by the researcher using
an electronic scale, and it was ensured that the individuals were bare-
foot and wearing light clothes (Pekcan, 2011). The weights of the indi-
viduals were measured using a TESS electronic scale that had a
capacity of weighing a maximum 200 kg and a minimum sensitivity
of 50 g.
2.4.3 | Body mass index
The researcher calculated the BMI values of all individuals using their
height and weight measurement [(weight (kg)/height2 (m2)] (Saglik
Bakanligi, 2011; Pekcan, 2011).
2.4.4 | Waist circumference
The researcher measured the waist circumferences of the individuals
over their underwear after a mild expiration between the edge of
the lower costal margin and iliac crest using a tape measure while
the individuals were standing (Pekcan, 2011). A 1.5‐m‐long tape mea-
sure was used to measure the waist circumference of the individuals.
The measurement of waist circumference is also used individually
and may be descriptive for the risk of chronic diseases (Saglik
Bakanligi, 2011; Pekcan, 2011).
2.4.5 | Preprandial and postprandial blood glucose
levels and HbA1c level
Preprandial blood glucose is the glucose level of blood that is mea-
sured after at least an 8 hours fast at night. Postprandial blood glucose
is the value of blood glucose measured 2 hours after a meal. The
HbA1c level shows the mean glycaemic value over the last 3 months
(Saglik Bakanligi, 2011; International Diabetes Federation, 2012). Pre-
prandial and postprandial blood glucose levels and HbA1c level were
evaluated following a venous blood draw in the hospital biochemistry
laboratory. These values were requested by the physician when the
individuals went to physician consultations were taken from the
patient file and recorded by the researcher. The researcher also gave
glucose metres to individuals in the experimental group to enable
them to monitor their blood sugar levels at home.
2.4.6 | Activity levels
Participants in the intervention group received pedometers (Omron
HJ‐321‐E) to monitor their daily activities. The individuals were asked
to record on a tracking chart the dates they walked, the times of
starting and finishingthe walk, and the number of steps taken, with
the purpose of ensuring that they regularly followed the exercise pro-
gramme. The numbers of steps in the first‐ and sixth‐month assess-
ments were calculated as the 30‐day means of step number in their
records.
The pedometers were used as a motivational tool to increase
walking (Baker, Mutrie, & Lowry, 2008).
2.4.7 | The stage of change in health behaviour
This was assessed using the Diagnosis Form for Behavioral Change
Stage in Patients with Type 2 Diabetes Mellitus, which was prepared
by the researcher based on information in the literature (Burbank,
Reibe, Padula, & Nigg, 2002; Gillespie & Lenz, 2011; Prochaska,
DiClemente, & Norcross, 1992; Salehi, Mohammad, & Montazeri,
2011; Shinitzky & Kub, 2001; Velicer et al, 2000) and on the TTM.
The researcher consulted six experts (four public health nursing
experts, one internal diseases nursing expert, and one statistics
expert). The form consisted of three sections: physical exercise, nutri-
tion, and medication use (Table 1). It included five multiple‐choice
questions presenting the change stages through which a participant
TABLE 1 Diagnosis Form for Behavioral Change Stage in Patients with Type 2 Diabetes Mellitus
Medication use: Are you taking your medications regularly (at the same every day)?
Nutrition: Are you eating adequately and properly (eg, are you eating three main meals and three snacks on a regular basis?)
Physical exercise: Are you exercising at a moderate level three times a week (a total of at least 150 min) or more on a regular basis (eg, brisk walking)?
Please mark the most appropriate choice.
Question Medication use Nutrition Physical exercise
1. No, and I do not intend to begin using medications/eating adequately and properly/doing
physical exercise on a regular basis within the next 6 months. “Precontemplation” stage
2. No, but I intend to begin using medications/eating adequately and properly/doing physical
exercise on a regular basis within the next 6 months. “Contemplation” stage
3. No, but I intend to begin using medications/eating adequately and properly/doing physical
exercise on a regular basis within the next 30 days. “Preparation” stage
4. Yes, I am, but I have been using my medications/eating adequately and properly/doing
physical exercise for less than 6 months. “Action” stage
5. Yes, I have been using my medications/eating adequately and properly/doing physical
exercise for more than 6 months. “Maintenance” stage
SELÇUK‐TOSUN AND ZINCIR 5 of 12
could pass. This form was used in both the intervention and control
groups to determine the participants' change stage regarding their
physical exercise, nutrition, and medication use. The assessment was
based on self‐reporting.
The researcher performed measurements of primary and second-
ary outcomes (except preprandial and postprandial blood glucose
levels and HbA1c level) using a face‐to‐face interview technique with
the participants in a private room in the endocrine and metabolism
outpatient clinic designated for the study.
2.5 | Interventions
2.5.1 | Intervention group
TTM‐based motivational interview guide
The TTM‐based motivational interview method for this study was
developed by the researcher using motivational interview strategies
consistent with theTTM's targets and approaches to behaviour stages,
with the aim of producing a guide for patients with T2DM and health
professionals. The physical exercise, adequate and proper nutrition,
and medication use targeted for behavioural change were considered
according to the change stages of the model. The literature was used
while setting targets and approaches with regard to each change stage
(Burbank et al, 2002; Gillespie & Lenz, 2011; Koyun & Eroglu, 2013;
Miller & Rollnick, 2009; Prochaska et al, 1992; Prochaska & Velicer,
1997; Salehi et al, 2011; Shinitzky & Kub, 2001; Velicer et al, 2000;
Yildiz, 2008). An interview protocol was prepared to ensure consis-
tency among the participants in the intervention group during
interviews.
The researcher (specialized in public health nursing) took a two‐
stage motivational interview technique course, each stage taking
9 hours. The researcher collected the data at the beginning and imme-
diately after completion of the intervention (in the sixth month after
the baseline interview) and held personal motivational interviews.
Participants were interviewed in a randomized order. At the begin-
ning of the study, the participants filled out the personal information,
Self‐efficacy (Competence) Scale for Patients with Type 2 Diabetes,
the Diagnosis Form for Behavioral Change Stage in Patients withType
2 Diabetes Mellitus, and the Metabolic Control Follow‐up Form. The
researcher also set the dates for the next interview.
TTM‐based motivational interview procedures
The researcher printed out TTM‐based motivational interview guides
for each individual. TTM‐based motivational interviews were per-
formed to assess targets and approaches to the nutrition, exercise,
and medication use behaviour stages of the participants in the inter-
vention group according to the Diagnosis Form for Behavioral
Change Stage in Patients with Type 2 Diabetes Mellitus. Motiva-
tional interview methods such as expressing empathy, developing
discrepancy, rolling with resistance, supporting self‐efficacy, avoiding
giving advice, providing simple decisional balance, using an
importance‐confidence scale, using open‐ended questions, reflecting,
and summarizing were used. Participants were given a medication
use follow‐up table, a walking follow‐up table, and a food consump-
tion registration form to fill out monthly. They were asked to bring
their monthly follow‐up tables with them to the motivational inter-
views. During the motivational interviews, these forms were used
to help the individuals see the positive or negative changes in their
behaviours related to their nutrition, exercise, and medication use
and to encourage them make positive changes in themselves. In
addition, any individual adaptations following the motivational inter-
views were evaluated at the end of the sixth‐month period consider-
ing self‐efficacy, metabolic values, number of steps, and behaviour
change stage of nutrition, exercise, and medication use. The nutri-
tion, exercise, and medication use guide for T2DM, prepared based
on expert opinions, was given to the participants in the intervention
group after the first TTM‐based motivational interview. Interviews
were conducted every 15 days or monthly, at the participants' con-
venience. Each interview was scheduled to take 30 to 45 minutes.
These interviews ended in the sixth month after the baseline inter-
view of the individual, and 9.12 (1.20) (mean [SD]) interviews were
conducted with each participant.
6 of 12 SELÇUK‐TOSUN AND ZINCIR
In the monthly interviews, the researcher assessed each individual
with the Diagnosis Form for Behavioral Change Stage in Patients with
Type 2 Diabetes Mellitus. If the participant was in the action stage or
came to the action stage, the motivational interviews continued to
maintain their behaviour and prevent them from regressing into previ-
ous behaviours. If the participant had slipped back to previous behav-
iours (in other words, they returned from the action stage to the
preparation stage), the interview continued in accordance with the tar-
get and approaches of the preparation stage.
The forms that had been filled out at the beginning were filled out
again, except for the personal information form, and the study was
terminated.
2.5.2 | Control group
The researcher collected the data from the control group at the begin-
ning and in the sixth month of the study. The participants also filled
out the Self‐efficacy (Competence) Scale for Patients withType 2 Dia-
betes, the Diagnosis Form for Behavioral Change Stage in Patients
with Type 2 Diabetes Mellitus, and the Metabolic Control DiagnosisForm.
The participants in the control group received noTTM‐based moti-
vational interviews. Instead, they continued to receive the usual care
in the polyclinic, including diagnosis tests and medication treatment.
Participants who maintained their blood glucose levels were recom-
mended to come for check‐up every 3 months; if their blood glucose
levels were not regulated, they were recommended to come for
check‐up every 10 days. This check‐up only reviewed medication. If
the participant used insulin, the diabetes education nurse or insulin
educator in the polyclinic provided education regarding the features
and use of insulin. Participants who sought care at the polyclinic were
also provided with diabetes mellitus education between 9 and 10 AM
once a week. This education was provided to groups of approximately
10 individuals using a narration method and slide presentation in a sin-
gle session. Since the DM training was provided once a week, not all
the individuals in the study received this training.
The study was terminated in the sixth month, and afterwards, the
researcher provided training to the participants about nutrition, exer-
cise, and medication use.
2.6 | Data analysis
Data were analysed using SPSS Statistics version 22.0 (IBM Corp.,
Armonk, New York, USA). The number of units (n), percentage (%),
mean (standard deviation [SD]), and 25th and 75th percentile values
of the median (median [25%‐75%]) were determined as the summary
statistics. Whether the number of samples was adequate in each
group was assessed with power analysis. The normal distribution of
data was assessed with a Shapiro‐Wilk test and Q‐Q plot. The inde-
pendent samples t test was used for the normally distributed vari-
ables; a Mann‐Whitney U test and Wilcoxon test were used for
the nonnormally distributed variables. For the comparison of cate-
gorical variables, the exact method of chi‐square test was used and
P < .05 was regarded as statistically significant. The researcher per-
formed intention‐to‐treat analysis for the lost data. An initial analysis
was conducted within the study. The individuals that did not com-
plete the intervention and the sixth‐month monitoring was also
included in the analysis. For this procedure, the researcher assigned
the missing values using the expectation‐maximization method with
missing value analysis.
2.7 | Ethical considerations
Approval was obtained from the Ethics Committee of University Clin-
ical Studies (EUCS), EUCS No: 2013/14, 08.01.2013. Study partici-
pants were informed according to an informed volunteer consent
form, and their written consent was obtained. This study was funded
by the Scientific Research Project Coordination Department at Erciyes
University (project No.: TDK‐2013‐4699). International Standard
Randomised Controlled Trial Number Register (ISRCTN): 15662612.
3 | RESULTS
3.1 | Descriptive characteristics
The study had 70 participants. Table 2 shows the distribution of
descriptive characteristics of the participants. The groups were similar
in terms of descriptive characteristics (age, sex, educational level, and
disease duration) (P > .05).
3.2 | Self‐efficacy
The self‐efficacy scores in both groups increased, but the increase was
higher in the intervention group. The intragroup and intergroup differ-
ences (apart from the physical exercise subscale score of self‐efficacy)
were statistically significant in both groups (P < .05) (Table 3).
3.3 | Metabolic values
The difference between the baseline and sixth‐month follow‐ups in
the intervention group for metabolic values was significant (P < .05).
In the between‐group comparison, the metabolic values were statisti-
cally significant, and the decrease in metabolic values in the interven-
tion group was significant (P < .05) (Table 3). At the sixth month of
intervention and control groups, the Cohen's effect size of the HbA1c
value was 1.0. The Cohen's effect size of the HbA1c value of the inter-
vention group was 0.7 with regard to the change between baseline
and sixth months within that group (Table 3).
3.4 | Number of steps
Most participants in the intervention group (76.0%) did not have reg-
ular exercise habits at baseline. The mean (SD) number of steps mea-
sured using the pedometer was 4338.12 (2326.96) 1 month after the
first TTM‐based motivational interview (first follow‐up), and 5271.04
TABLE 2 Distribution of descriptive characteristics of participants
Descriptive Characteristic
Intervention Group (n = 35) Control Group (n = 35)
P
Mean (SD)d
Median (25%‐75%)
Mean (SD)d
Median (25%‐75%)
Age, y 49.34 (6.96) 51.71 (7.65) .180a
HbA1c, % 8.20 (7.50‐9.20) 8.20 (7.40‐9.50) .576b
BMI, kg/m2 37.88 (30.93‐43.30) 34.81 (29.83‐38.27) .036b
Self‐efficacy scale (total score) 59.31 (7.00) 61.68 (5.56) .121a
Sex n % n %
Female 25 71.4 21 60.0 .450c
Male 10 28.6 14 40.0
Educational level
Elementary school or less 24 68.6 28 80.0 .413c
High school or more 11 31.4 7 20.0
Disease duration
≤5 y 9 25.7 15 42.9 .208c
>5 y 26 74.3 20 57.1
Abbreviation: BMI, body mass index.
at test.
bMann‐Whitney U test.
cχ2 test.
dMean (SD): mean (standard deviation).
SELÇUK‐TOSUN AND ZINCIR 7 of 12
(2162.30) at the sixth‐month follow‐up. The difference in number of
steps between the follow‐ups in the intervention group was statisti-
cally significant (P < .05). According to intragroup comparisons, the dif-
ference between the first follow‐up and the sixth‐month follow‐up
was statistically significant (P < .05), and the number of steps
increased at the sixth‐month follow‐up compared with the first
follow‐up.
3.5 | Behaviour change stage of nutrition, exercise,
and medication use
The groups were similar in terms of nutrition, exercise, and medication
use behaviour stages at baseline (P > .05). At the sixth‐month follow‐
up in the intervention group, 96.0% of participants were in the action
stage for nutrition, 92.0% for exercise, and 96.0% for medication use.
At the sixth‐month follow‐up in the control group, 16.0% of partici-
pants were in the action stage for nutrition, 8.0% for exercise, and
60.0% for medication use. The groups were different in terms of nutri-
tion, exercise, and medication use behaviour stages at the sixth‐month
follow‐up (P < .05).
4 | DISCUSSION
In this study, the use of aTTM‐based motivational interview technique
for improving self‐efficacy, maintaining metabolic control, and devel-
oping positive health behaviours in people with T2DM was assessed.
An important aspect of this study is the use of nutrition, exercise,
and medication approaches together. For comparison of results, the
literature was consulted for studies assessing the effect of motiva-
tional interviews on the health results of people with T2DM and
education‐based research because of the limited number of studies
related to the model.
4.1 | Self‐efficacy
The self‐efficacy level is an important indicator for health behaviour
change, and self‐efficacy increases or decreases a person's motiva-
tion for engaging in action (Redding, Rossi, Rossi, Velicer, &
Prochaska, 2000). In the present study, the TTM‐based motivational
interview seemed to be an effective method for developing self‐
efficacy, appeared to help the study participants increase control
over their health, and encouraged them to change their nutrition,
exercise, and medication use behaviours in a positive way. The
results supported the H1 hypothesis (Table 3). Similar to the results
of this study, in other studies, it was reported that the motivational
interview caused self‐efficacy scores to increase (Chen et al, 2012;
Meybodi, Pourshrifi, Dastbaravarde, Rostami, & Saeedii, 2011). How-
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self‐efficacy perceptions(Atak, Gurkan, & Kose, 2009; Olgun &
Akdoğan Altun, 2012; Jalilian, Motlagh, Solhi, & Gharibnavaz, 2014).
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8 of 12 SELÇUK‐TOSUN AND ZINCIR
SELÇUK‐TOSUN AND ZINCIR 9 of 12
with motivational interviews, the participants' cognitive, psychologi-
cal, and behavioural aspects were assessed together. This multiface-
ted assessment might have provided additional benefit for
participants in maintaining their terminal behaviours and helping
them to maintain their motivation. The results support the H3 to
H5 hypotheses.
4.2 | Number of steps
Nutrition, physical exercise, and medication constitute three essential
bases for DM treatment (Kara & Çinar, 2011; ADA, 2017). In this
respect, exercise has an extremely important place in the treatment
of DM, and pedometers can be used as a motivational tool to increase
daily physical activity (Baker et al, 2008). In the present study, the
number of steps in the intervention group increased at the sixth‐
month follow‐up compared with the first follow‐up; the mean number
of steps at the sixth‐month follow‐up was 5271, so the targeted num-
ber of steps (3500‐5500) was achieved (Tudor‐Locke, Washington, &
Hart, 2009). Results related to the effect of motivational interviews
on physical activity and education‐based studies on physical activity
vary across studies (Atak et al, 2009; Heinrich et al, 2010; Jansink
et al, 2013; Kirk et al, 2003; Olgun & Akdoğan Altun, 2012).
Although the effects of both behavioural and education‐based
studies on physical exercise behaviour varied, the motivation‐based
intervention may be effective in maintaining behaviour. The pedome-
ters used as a motivational tool to encourage the participants in this
study might promote more physical activity, and physical activity is
associated with glycaemic control (Poskiparta, Kasila, & Kiuru, 2006;
Umpierre et al, 2011).
4.3 | Metabolic control
As in the present study, conducting motivational interviews that focus
on the behavioural components of change in ensuring glycaemic control
can be more effective than the methods used in education‐based stud-
ies (Jones et al, 2014). In the present study, the HbA1c level decreased
1.22% at the sixth‐month follow‐up. The participants in the interven-
tion group were closer to the targets for HbA1c level (less than 7.0%),
preprandial blood glucose level (70‐130mg/dL), and postprandial blood
glucose level (less than 180 mg/dL) suggested by the ADA (2016)
(Table 3), and these results support the H2 hypothesis. Discussing
behavioural components (nutrition, exercise, and medication) together
within the conceptual framework of TTM had a strong effect on ensur-
ing glycaemic control. Studies report that the change in HbA1c level is
0.41% to 1.20% (Kartal & Özsoy, 2014; Kitiş & Emiroğlu, 2006;
Shibayama, Kobayashi, Takano, Kadowaki, & Kazuma, 2007; Welch
et al, 2011; West et al, 2007). Planned education programmes caused
mild improvements in glycaemic control in the short term (Minet et al,
2010; Norris, Lau, Smith, Schmid, & Engelgau, 2002). However,
education‐based studies cannot ensure the necessary behavioural
changes required for healthy DM management in the short term
(McGloin, Timmins, Coates, & Boore, 2015). Indeed, the behavioural
intervention regarding nutrition, physical exercise, and medication use
is more effective in ensuring permanent development of glycaemic
control.
In the present study, participants' weight, BMI, and waist circumfer-
ence values were examined as indicators of nutrition behaviour. Having
these values at normal levels ensures glycaemic control. In the present
study, the weight change in the sixth month was 3.30 kg, whereas the
change was 4.70 kg in the study of West et al (2007) examining the
effect of motivational interviews on weight loss. The difference in the
weight change may be because the participants in the intervention
group in West et al (2007) received a group‐based behavioural weight
control programme as well as the motivational interview, and this pro-
grammemight have provided additional benefit for weight loss. In other
studies, which differ in working time, there was no difference between
groups for VKI (Meybodi et al, 2011; Rubak, Sandbæk,Lauritzen, Borch‐
Johnsen, & Christensen, 2011), weight, and waist circumference
(Rosenbek Minet et al, 2011). The results of the that studies show that
it takes more time for people to make the desired behaviour change at
the cognitive level before the effectiveness of the motivational inter-
view than after it (Rubak, Sandback, Lauritzen, & Christensen, 2005).
In a study based on nutrition education for peoplewithT2DM, no differ-
ence was found between the groups in terms of weight and BMI values
according to the assessment conducted 1 month after the intervention
(Sharifirad, Entezari, Kamran, & Azadbakht, 2009). As distinct from the
methods used in the present study, addressing only nutrition and the
short duration of the assessment may have had an effect on obtaining
these different results.
4.4 | Behaviour change stage of nutrition, exercise,
and medication use
A randomized controlled study to assess the effect of nutrition, phys-
ical activity, and medication use on behaviour change reported that
the HbA1c level increased in both intervention and control groups,
that the increase was higher in the control group, and that the diet
and exercise change stages of the intervention group showed more
positive improvement; however, the activity in the change stages of
medication use was lower (Partapsingh, Maharaj, & Rawlins, 2011).
The result of the present study differs from that of the study con-
ducted by Partapsingh et al (2011) because the change in the HbA1c
level and the nutrition, exercise, and medication use behaviour change
stages were at higher levels. The intervention group showed greater
improvement in terms of this positive behaviour change and in the
metabolic values than did the control group. Another reason why the
intervention group showed better improvement in terms of metabolic
values may be their regular medication use.
4.5 | Limitations
This study sample was limited because the study was conducted in
patients who applied to a health care centre. The study results cannot
be generalized because of the experimental design used in the study,
10 of 12 SELÇUK‐TOSUN AND ZINCIR
but they can contribute to the generalization. The potential bias of the
evaluators and the nonblind nature of the study were limitations of
the study. Additionally, the small sample size and self‐reported mea-
surement can be as potential sources of bias. The researcher had con-
versations by observing the motivational conversation guide, which
they developed themselves, throughout the study, they were strictly
loyal to the principles of motivational conversation, which contributed
to the limitation of the study. One of the limitations of the study is that
only the participants in the intervention group were provided with
pedometers and glucosemetres. Future research designs can be created
considering this limitation and the effect of motivational interviews of
behavioural change can be determined more clearly by providing the
control group with the same tools (pedometer and glucose metre).
Monthly interviews are not cost‐effective because they require intense
effort. However, the motivational interviews can be more cost‐
effective, and the same results can be obtained after the number of
interview sessions are planned according to individuals. The individuals
who left the study also limit the study results. However, their group
distributions at the beginning were examined and found to be similar.
Although the interviews were conducted with participants in the inter-
vention and control groups by appointment during the follow‐ups, there
may have been short‐term interactions between the two groups.
5 | CONCLUSION
The present study showed that using the TTM‐based motivational
interview in patients with T2DM increased the level of their self‐
efficacy and positively affected their metabolic control and health
behaviour change.
The TTM‐based motivational interview method for encouraging
positive health behavioural (nutrition, exercise, and medication use)
changes in adults withT2DM who resist behavioural change is needed
to achieve successful management of T2DM. Health care providers
can easily apply theTTM‐basedmotivational interviewmethod. In addi-
tion, health professionals' knowledge and experience can be improved
by including the motivational interview method in the undergraduate
curricula of nursing as well as in‐service training programmes. Further
studies should be based on behavioural approaches and examine the
long‐term effects of the motivational interview, taking into consider-
ation the frequency of the motivational interviews, the duration of
use, and having the TTM‐based motivational interviews conducted by
nurses specializing in the area being studied. Moreover, further studies
are needed for the comparison of the effect durations of the education‐
based studies and the motivational interview on positive behaviour
change. A retrospective study assessing the long‐term effect of the
intervention in the present study is ongoing.
ACKNOWLEDGEMENT
We would like to thank Ferhan Elmalı (Department of Biostatistics and
Medical Informatics, İzmir Katip Çelebi University, PhD Associate Pro-
fessor Departmental Director) for his contribution to the evaluation of
the statistical findings.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interests.
AUTHORSHIP STATEMENT
AST and HZ designed the study. AST collected the data. AST and HZ
analysed the data and prepared the manuscript. All authors approved
the final version for submission.
ORCID
Alime Selçuk‐Tosun https://orcid.org/0000-0002-4851-0910
Handan Zincir https://orcid.org/0000-0002-1722-4647
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