CONTEXT PURPOSE QUALITATIVE METHODS

Social support, self-efficacy and motivation in the journey through HEALD Ana B Mladenovic, MPH1, Lisa Wozniak, MA1, Ronald C Plotnikoff, PhD2, Jeffrey A Johnson, PhD1,3, Steven T Johnson, PhD1,4 1

Alliance for Canadian Health Outcomes Research in Diabetes (ACHORD), University of Alberta, 2 Priority Research Center for Physical Activity and Nutrition, University of Newcastle, 3 School of Public Health, University of Alberta, 4 Faculty of Health Disciplines, Athabasca University

CONTEXT The Healthy Eating and Active Living for Diabetes in Primary Care Networks (HEALD) was a:  24-week, group-based walking program led by exercise specialists (ES) for adults with type 2 diabetes (T2D);  Piloted in 4 Primary Care Networks in Alberta, Canada;  Focused primarily on improving participants’ physical activity and dietary behaviors;  Guided by Social Cognitive Theory (SCT) HEALD consisted of two phases: 1. Participants were instructed to increase their daily steps 2. Participants were asked to increase the intensity of their walking and to exchange foods higher in glycemic index with foods lower in glycemic index In each phase, participants attended two group meetings at community recreation centers. Group meetings involved educational classes and supervised group walking sessions.

FINDINGS Before HEALD: Participants described reasons for joining HEALD, including a lack of social support for diabetes from their usual healthcare providers , an interest in self-managing their condition better, and feeling afraid or desperate:

“I felt a little bit flying solo… The doctor kind of said, "Oh and by the way, you're diabetic". This is life changing for me, and he just kind of throws it at me” (F4-WB). “The exercise specialist asked me to join, and this kind of thing is of interest to me, especially if there’s some learning for me” (F4- WD).

“I wanted to take part because diabetes runs in my family… You kind of get desperate… it is a scary topic, and more and more Canadians are developing it” (F1- WB).

 To describe the roles of social support, self-efficacy and motivation in participants’ experiences of the journey through HEALD (i.e., before, during and after HEALD)

QUALITATIVE METHODS  Program “completers “were identified through purposeful sampling  Completers were invited to partake in semi-structured telephone interviews (n=13) six months after completing HEALD  Interview guide focused on participants’ satisfaction with HEALD and the maintenance of learned behaviors six months after HEALD ended  Interviews were transcribed verbatim and managed in Nvivo 10  Content analysis was used to derive codes and themes

PARTICIPANT CHARACTERISTICS  Seven male, 6 female program completers; mean age 57.8 years, A1C 7.1%, BMI 3.5. kg/m2  Representing all 4 PCNs and recruitment waves  Diverse in terms of employment status, income, diabetes duration, as well as baseline physical activity (walking)

During HEALD: Participants reported feeling confident (i.e., self-efficacious) and motivated towards self-managing their diabetes and performing physical activity, as well as strong sense of social support during HEALD:

“Oh yeah, HEALD helped me manage [my diabetes] undoubtedly” (M3- WC).

"I know if I do what [the ES] said that I wouldn’t have to take medication. It's just being able to do it. And I thought I was disciplined enough to do it- and I can't” (F2- WB).

"After being involved in [HEALD] I found that I had a tendency to go and exercise more. But after being left on my own, it just tapers off and gradually you get back to the old routine” (M3- WC).

Recommendations: Participants recommended longer-term support from the exercise specialists and more opportunities for sharing and discussion with peers, to facilitate the maintenance of behaviors learned through HEALD:

HEALD was part of the Alberta’s Caring for Diabetes (ABCD) Project.

PURPOSE

After HEALD: Participants reported not feeling confident or motivated to maintain physical activity when social support no longer available:

"What I liked about it is you'd check in and so it kept you more motivated, because you had your book and they were looking at it and- I felt like I had to do the walking” (F4- WA).

““It’s a great idea, except it’s not enough time to change a behavior. At least a year to monitor the records and keep the walking up–we’re all adults but we still need to be held accountable” (F2- WB).

"I think if a bunch of people just got together and talked about their experiences, how they're coping with being diabetic, exercise they're doing, what they're eating- that would be a good thing too“ (M3- WD).

Conclusions and Implications for Practice “[She] was able to steer me in the right direction. And she provided resources- if people had questions outside the book, she provided extra resources” (F4-WD).

“I just really enjoyed going to these meetings because it really does give you a little family to talk to, someone who's in the same boat as you” (F1- WB).

 HEALD “completers” felt confident and motivated to perform PA while taking part in the HEALD program; this was tied to having moderate levels of social support during the intervention.  Participants desired ongoing social support from peers and exercise specialists six months after HEALD because they struggled with selfefficacy, motivation and maintenance of PA.  Following an intervention like HEALD, periodic check-ins with a healthcare provider, such as an exercise specialist, and creative modes of offering peer support are needed to promote sustainable health behavior adoption.

We are grateful to the PCN Boards, staff, and participants who agreed to participate in the ABCD Project, including the HEALD program. The ABCD Project is funded in part through a grant from Alberta Health and a CIHR Emerging Team grant for ACHORD. Additional funding for HEALD was provided by the Lawson Foundation.