The Association of Patient Activation with Type 2 Diabetes Mellitus Self-Management and Clinical Outcomes in Saudi Arabian Primary Care Settings

Abstract

Background: Type 2 diabetes mellitus (T2DM) is a major public health challenge. The primary tool to manage T2DM is self-management (i.e., diet, physical activity, blood glucose self-monitoring, foot care and adherence to medication). Patient activation, ‘an individual’s knowledge, skill and confidence for managing their health and health care,’ is associated with better self-management and clinical outcomes. Despite the increasing number of studies exploring the association between patient activation and T2DM self-management behavioural and clinical outcomes, no study has been conducted in Saudi Arabian primary care settings. This study attempted to fill this gap by conducting a two-phase study. Phase I aimed to map any association between patient activation and T2DM self-management and clinical outcomes. Phase II aimed to assess the impact of a patient activation-focused self-management intervention on T2DM self-management among people diagnosed with T2DM in Saudi Arabian primary care settings. Methods: Phase I was a cross-sectional study, while phase II was a pre- and post-intervention study. Patients attending the primary care centres who were aged ≥18 years old and diagnosed with T2DM were recruited to participate in the survey and interventional studies. A survey consisting of questions about demographics, clinical outcomes and patient activation measure (PAM) was administered. The survey also contained the summary of diabetes self-care activities (SDSCA) test, the diabetes knowledge test (DKT), the problem area in diabetes test and the diabetes quality of life test. Patients who agreed to participate in the phase II study received tailored patient activation intervention consisting of monthly face-to-face 15–30 minute sessions for 3 months, followed by a telephone call per month for the next 3 months. The intervention was designed and tailored based on the participants’ patient activation level, which was collected at baseline. The main objectives of the intervention were to improve diabetes knowledge, problem-solving and goal-setting skills, self-management and stress management skills among the participants. The participants were actively involved in the program through shared decision-making. Results: A total of 398 patients (male, 54.9%) with a mean age of 53.2 years old (SD = 10.7 years) participated in the survey study (phase I). The mean haemoglobin A1C (HbA1c) was 8.4% (SD = 1.7%), and 74.5% of patients had uncontrolled blood glucose. The mean patient activation measure (PAM) score was 55.9 (SD = 13.); 24.4% of patients were at level 1, 26.7% were at level 2, 37.4% were at level 3 and 11.5% were at level 4. Most patients had low self-management behaviours, moderate to low diabetes-related knowledge, moderate diabetes-related distress and average quality of life. A high PAM level was significantly associated with better glycaemic control, a higher SDSCA overall score and higher scores on the subscales (including diet, physical activity, blood glucose self-testing, foot care and smoking) (p < .05) but not with adherence to medication. We also found that a high activation level was significantly associated with better diabetes-related knowledge and quality of life (p < .05). In the interventional study (phase II), 100 participants from phase I were recruited, out of which 82 completed the intervention. The majority of the participants were female (61%), with a mean age of 51.3 years old (SD = 9.9 years). After 6 months of intervention, there was a significant increase in PAM score from 54.74 to 61.58 (p < .001), a significant decrease in HbA1c from 8.38 to 7.55 (p < .001) and in body mass index from 30.90 to 29.16 (p < .001), a significant increase in SDSCA scores (diet from 3.12 to 3.67, exercise from 2.54 to 3.49, blood glucose self-testing from 2.37 to 3.24; p < .001) and in DKT from 6.29 to 7.22 (p = .01). The results suggest that the intervention effectively enhanced the participants' ability to self-manage their diabetes, leading to positive clinical outcomes such as improved HbA1c and BMI. Conclusions: The findings from this study concluded that a high activation level was significantly associated with better T2DM self-management and better glycaemic control. These findings indicated that tailoring intervention based on the patient’s activation level can improve T2DM clinical outcomes and self-management behaviours. These findings provide valuable information for clinical practice to deliver interventions that meet patient needs based on each patient’s activation level.