the role of self-efficacy in health coaching and health education for patients with type 2 diabetes

ORIG INAL ART ICLE

The role of self-efficacy in health coaching and healtheducation for patients with type 2 diabetes

A. Basak Cinar1 and Lone Schou2

1Oral Public Health Department, Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen,Denmark; 2Oral Health Promotion Department, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.

Purpose: To assess the role of toothbrushing self-efficacy (TBSE) in diabetes management by comparing health education(HE) and health coaching (HC) in type 2 diabetes. Methods: The data [HbA1c, Clinical Attachment Loss (CAL), TBSE]were collected initially and after intervention. Participants were allocated randomly to HC (n = 77) and HE (n = 109)groups. Results: The low TBSE subgroup showed greater improvement in TBSE in the HC group (Δmean:23.4 � 9.2)than the HE group (Δmean:12.4 � 10.3), (P < 0.01). The moderate TBSE group showed significant improvements onlyin the HC group (P < 0.001).There was a significant reduction in HbA1c and CAL in all the TBSE subgroups in HC(P < 0.05), which was significantly higher than in the HE groups (P < 0.05). Improvements in TBSE and CAL wereexplanatory variables for the reduction in HbA1c among the HC patients in all the TBSE subgroups (P < 0.05). AmongHE patients, improvement in CAL was an explanatory variable for change at HbA1c in the low TBSE subgroup. Conclu-sions: The present findings show that HC is more effective in terms of reduced HbA1c and CAL compared with HE. Thedata suggest that HC unlocks positive self-intrinsic motivation, anchoring the self-efficacy/competency beliefs for adjust-ment of healthy lifestyles. Thus, TBSE may be a practical starting point for empowerment and more effective outcomes.

Key words: Diabetes Type II, health coaching, health education, self-efficacy, clinical attachment loss

INTRODUCTION

It becomes more and more important to identify andunderstand ways and tools to improve health behav-iours and life-style related diseases. Type 2 diabetes(T2DM) and oral diseases (periodontal diseases),which are largely preventable chronic diseases1, aredescribed as globally pandemic because of their distri-bution and severe consequences. Periodontal diseaseand diabetes negatively affect each other2. Periodontalinflammation in early old age has been shown to beassociated with mortality in older age3. People withT2DM are more likely to have periodontal diseasethan those without T2DM4. Prevention and care ofperiodontitis involving consistent oral care at home isthus particularly important for diabetic patients5.In recent years a larger and growing proportion of

global health-care services expenditures are caused bylife-style diseases, in particular diabetes and oral dis-eases6,7. This further increases the importance of man-agement of these diseases.Self-efficacy and knowledge are potentially modifi-

able risk factors for chronic disease-related outcomes

(e.g. diabetes and oral health), and findings suggestthat intervention on these factors could help fosterpositive healthy habits among families and individu-als. De Silva-Sanigorski8 showed that greater parentalself-efficacy was associated with more frequent tooth-brushing (by parent and child) and more frequent vis-its to a dental professional. A number of studies haveexamined the influence of self-efficacy on self-care andglycaemic control. Self-efficacy has been shown toplay an intermediary role in relation to quality of life,haemoglobin and stress in patients with T2DM9. Gaoet al.10 concluded, in a study of adults with T2DM,that having greater self-efficacy was associated withbetter diabetes self-care behaviours and better glycae-mic control.Traditional or classic health education interventions

targeted on improved knowledge has been examinedand evaluated in numerous studies and numeroustypes of health behaviours11. One of the main chal-lenges related to health education is that even whenan effect of interventions is found, it is usually mainlyrelated to knowledge and only short lasting. Healtheducation interventions have often been accused of

© 2014 FDI World Dental Federation 1

International Dental Journal

doi: 10.1111/idj.12093

not taking in factors that are out of control of theindividual, and the term ‘victim blaming’ has beenused to describe such studies. More recent so-calledhealth promotion interventions do include otherfactors such as socioeconomics and availability ofhealth services12. However, a consistent and globallygrowing additional problem in relation to both healtheducation – and health promotion efforts – is thatlarge inequalities exist in most types of diseases andhealth-related behaviours. The inequalities in healthseem to be strongly related to socioeconomic factorsand educational level13. Neither health education norhealth promotion seems to be able to reach those peo-ple with the least education and least finances orreduce inequalities. A recent study on inequality inoral health showed that the largest relative inequali-ties existed in countries with the best welfareregime14.In attempts to improve lifestyle and health behav-

iours for all, including the ‘high-risk groups’, it maybe important to examine and understand how behav-iours change or which psychological and sociologicalfactors are in play, and how. It is in this context thathealth coaching (HC) has developed. This is con-cerned with facilitating individuals in establishing andattaining health-promoting goals in order to changelifestyle-related behaviours, with the intention ofreducing health risks, improving self-management ofchronic conditions and increasing health-related qual-ity of life15.Cinar and Schou16 found that HC has a signifi-

cantly greater impact on improvement of self-efficacycompared with health education among T2DMpatients with low level of education and high propor-tion of unemployment. The present study aims toassess the role of self-efficacy in oral health and gly-caemic control among these T2DM patients by com-paring low self-efficacy with high self-efficacy groupsin health education and health coaching.

METHODS

The present study is part of a prospective interventionstudy among patients with T2DM (n = 186), ran-domly selected from the outpatient clinics of two hos-pitals in Istanbul, Turkey. The power and sample sizehas been explained previously16,17. Eligibility criteriawere: (1) confirmed T2DM, (2) 30- to 65-year-oldswith at least four functional teeth and (3) no psycho-logical treatment or hospitalisation.Ethical approval and written permission to conduct

the study were granted by the Ministry of Health, inIstanbul, Turkey. The methodology of the study hasbeen explained previously16,17. The research was con-ducted in full accordance with the World MedicalAssociation Declaration of Helsinki.

Of the patients participating (n = 186), 96%attended the clinical examinations (baseline visit,n = 179; final visit, n = 176) and more than 90%filled in the questionnaires (baseline visit, n = 179;final visit, n = 168). All patients provided basic socio-economic information about themselves and biomedi-cal records were obtained from the hospitals, atbaseline and after intervention. The drop-out rate was7% (n = 10) of 186 participants, and the proportionof participants who did not regularly participate in allsessions was 13% (n = 24).In order to ensure comparability with the original

forms in English, two native speakers conductedback-translation to and from Turkish for the healthbehaviour questionnaires.

Procedure and randomisation

At the baseline visit, participants provided informedconsent and filled in questionnaires (including demo-graphic background, psychosocial and behaviouralvariables). Subsequently, all participants were invitedfor baseline oral examination, which was conductedby two calibrated examiners. Following the oralexamination, participants were randomly allocated toeither HC (intervention) (n = 77) or to formal oralhealth education (HE, control) (n = 109) group by aresearcher who was blinded to outcome measures.The study included two phases (10-month initiationand maintenance, 6-month follow-up). During the 10-month intervention, all participants were invited forfree periodontal cleaning and three seminars aboutoral health and diabetes management. At the end ofthe 6-month follow-up phase, the same outcome mea-sures were obtained.The content and the design of the HC and the HE

have been described in detail previously16,18. The HCapproach in the study originally stems from interna-tionally accredited coaching, which uses specific psy-chological techniques16,18 including neuro-linguisticprogramming19,20 and self-efficacy21. Health coachingfocuses on empowerment of patients for daily diabe-tes- and oral health-related practices (compliance withhealthy diet, regular physical activity and daily tooth-brushing), building up health-related capacity skills(self-efficacy, self-esteem) and taking responsibility forown health. The HC was provided by a dentist, whois also a professional coach (ABC), via a structuredframework for coaching. The HE sessions were per-formed by a dentist (BEA) within a structured contentaddressing oral health and diabetes management(physical activity, diet).The data (outcome measures) in the present study

stem from the clinical measurements and self-assessedquestionnaires that were collected initially and at theend of the intervention.

2 © 2014 FDI World Dental Federation

Cinar and Schou

Outcome measures

Oral health management. At baseline, oral exami-nations were performed including number of teethlost and clinical attachment loss (CAL), which is thedistance from the cemento-enamel junction (CEJ) inan apical direction to the base of the pocket/sulcus.All examinations were carried out by two dentistsusing the Michigan-0 probe (Hu-Friedy Mfg. B.V.,Rotterdam, the Netherlands). The examiners wereexperienced and calibrated at measurement of CAL.Intraclass and interclass j value was 0.85 on average.The detailed clinical examination has been describedpreviously17. High periodontal destruction is generallycharacterised by CAL more than 4 mm22. Thus thehigh-risk CAL group was defined as the patientshaving ‘attachment loss >4 mm’ at baseline. Forfurther analysis, it was dichotomised, based on thetotal sum scores, so that everyone below mean (HC<2.2 � 1.2 vs. HE <2.3 � 1.2) was categorised aslow risk, coded by ‘0’. The rest, those ≥mean, wereclassified as high risk, coded by ‘1’.The toothbrushing self-efficacy (TBSE) scale23–25

was used to assess individual’s belief in his/her compe-tency to brush his/her teeth daily across different chal-lenging situations by the question ‘How sure are youthat you can brush your teeth’. The TBSE scale con-sisted of eight items on a five-point Likert scale(0 = ‘not sure at all’ to 5 = ‘absolutely sure’). Thedesign and validity–reliability measures of the scalehave been described previously23,24. For further analy-sis, total sum scores (TSS) for the TBSE subgroups werecategorised into three equal groups by taking the 33%percentiles as the cut-off points separately for the HCand the HE subgroups. Those who reported ‘≤33%’ ofthe total sum score (HC TSS ≤ 12.4 vs. HE TSS ≤10.3)were defined as the high-risk subgroups for TBSE.

Glycaemic control. Information regarding HbA1c

(glycated haemoglobin expressed as the percentage ofhaemoglobin that is exposed to glucose) levels weretaken from the latest medical records at the hospital.Taking the target level (HbA1c < 6.5%)26 as the cut-point, respective variables, taken from the most recenthealth records, were recoded as ideal (HbA1c < 6.5%),moderate risk (6.5% ≤ HbA1c < 8%) and high risk(HbA1c ≥ 8%)26.

Data analysis

Statistical analyses were performed using SPSS v.17(SPSS, Chicago, IL, USA)27. For assessment of correla-tion and baseline similarities/differences between theHC and the HE groups, respectively, Spearman rankcorrelation and Independent sample t test were used.

Original sample sizes were weighted by three to havethe adequate statistical sample for paired samples t-test (n = 54), which was calculated by G*power atthe 0.05 significance level. Paired-sample t-tests wereused for normally distributed data to assess changeover time for each group alone. Changes (Δ) at thevariables from baseline to post-intervention wereassessed by subtracting baseline scores from scoresafter intervention. Multiple linear regression analysis,adjusted for change at CAL from baseline to post-intervention, was performed to explain the reductionin HbA1c levels in each TBSE subgroup among theHC and the HE patients. Statistical significance wasset at a P-value of <0.05 for each test.

RESULTS

Patients in the HC group had 13.1 � 21.8 years ofclinically diagnosed diabetes and this was 10.8 � 12.2for the HE group (P > 0.05). There was no statisticaldifference between the HC and the HE groups for anyof the clinical or socioeconomic parameters (P > 0.05).No statistical difference was observed between theTBSE subgroups within the HC and the HE groups(Table 1). At baseline most of the patients in both theHC and the HE groups were retired/unemployed andhad HbA1c levels higher than the target level(HbA1c < 6.5%) for each TBSE subgroup.At baseline, the independent samples t-test showed

no statistical significant differences in the mean forlow TBSE subgroups (those reporting <33% percen-tile) between the HC group (4.6 � 3.6) and the HEgroup (4.5 � 4.1) (P > 0.05).There was a significant difference between means of

each TBSE subgroup in both the HC and the HEgroups at baseline (P < 0.01), and after interventionin the HE group but not in the HC group between thelow and the moderate TBSE subgroups (P > 0.05).From baseline to post-intervention, there was a signifi-cant difference between the means of the low and themoderate TBSE subgroups in the HC (Table 2). In thelow TBSE subgroups, the improvement in TBSE frombaseline to post-intervention was significantly higherin the HC group (Δmean 23.4 � 9.2) than in the HEgroup (Δmean 12.4 � 10.3), (P < 0.01). Comparedwith the HE group, the HC group showed signifi-cantly greater improvement in TBSE in the moderateTBSE subgroup (Δmean 9.7 � 8.2, P = 0.001),whereas there was no significant change in the highTBSE subgroup in either the HC or HE groups(P > 0.05).After intervention, there was a significant reduction

in HbA1c in all the TBSE subgroups from the HCgroup (Table 3). Only in the low TBSE subgroup didneither the moderate nor the high TBSE subgroupfrom the HE group show a significant reduction in


Self-efficacy in diabetes management

HbA1c. All the TBSE subgroups in both the HC andthe HE groups showed a statistically significant reduc-tion in CAL (P < 0.01). All the TBSE subgroups inthe HC group had significantly greater reduction inHbA1c levels and CAL than those in the HE sub-groups (P < 0.05).Linear regression analysis revealed that improve-

ment in TBSE and reduction in CAL were explanatoryvariables for reduction in HbA1c levels among the HCpatients from the low TBSE subgroup (adjustedR2 = 0.51, ΔTBSE b = �0.31, P = 0.001; CALb = �0.67, P = 0.001), the moderate TBSE subgroup(adjusted R2 = 0.37, ΔTBSE b = �0.59, P = 0.001;

and ΔCAL b = �0.25, P = 0.010) and the high TBSEsubgroup (adjusted R2 = 0.37, ΔTBSE b = �0.48,P = 0.001; ΔCAL b = �0.31, P = 0.002) groups. Inthe HE low TBSE subgroup, the change in CAL wasthe explanatory variable for the change in HbA1c

(adjusted R2 = 0.15, b = �0.41, P = 0.007).

DISCUSSION

The present study showed that both HC and HE caninfluence and improve diabetes management in T2DMpatients, as measured by clinical data and questionnaires.It further showed that TBSE played an important and

Table 1 Clinical and socio-economic parameters of the toothbrushing self-efficacy (TBSE) subgroups among thehealth coaching and the health education patients at baseline

TBSE n* Health coaching, % P n* Health education, % P

Low Moderate High Low Moderate High<33% 33% ≥ x < 66% ≥66% <33% 33% ≥ x < 66% ≥66%

Clinical parametersHbA1c

Ideal 77 29 22 31 ns 102 19 26 35 nsModerate risk 33 48 50 39 42 34High risk 38 30 19 42 32 31

CALLow risk (<mean) 74 71 65 56 ns 86 53 58 63 nsHigh risk (≥mean) 29 35 44 47 42 37

Socioeconomic parametersAge (years)

30–49 76 40 29 22 ns 66 28 34 27 ns50–59 48 54 59 44 47 49≥60 12 17 19 28 19 24

GenderFemale 76 56 46 74 ns 97 59 62 67 nsMale 44 54 26 61 37 33

OccupationRetired/unemployed 75 76 67 81 ns 87 73 82 76 nsWorking 24 33 19 27 18 24

Education≤Primary school 77 52 52 59 ns 89 74 52 52 nsHigh school 30 35 26 23 24 24≥University 18 13 15 3 24 24

History of diagnosed diabetes (years)<Mean 64 68 70 76 ns 74 48 58 59 ns≥Mean 32 30 24 52 24 41

*The total number for each variable differs because the same participants did not answer all the questions; n for each variable represents pairedmatches.ns, Non-significant.

Table 2 Differences in the toothbrushing self-efficacy (TBSE) subgroups of the health coaching and the healtheducation patients before and after intervention

TBSE Health coachingsubgroups

P Health educationsubgroups

P Difference betweensubgroups

n Baseline Post-intervention n Baseline Post-intervention Baseline Post-interventionMean � SD Mean � SD Mean � SD Mean � SD P P

Low (<33%) 24 4.4 � 3.8 26.7 � 11.6 0.001 32 4.2 � 4.3 16.4 � 9.8 0.001 ns 0.001Moderate(33% ≤ x < 66%)

21 18.4 � 2.7 28.1 � 7.2 0.001 31 18.6 � 2.9 22.4 � 9.8 ns ns 0.04

High (≥66%) 27 31.5 � 3.7 32.6 � 4.7 ns 21 30.9 � 3.9 28.9 � 6.5 ns ns 0.04

ns, Non-significant.


Cinar and Schou

modifiable role. All improvements from baseline topost-intervention were significantly higher in all the HCTBSE subgroups than in the HE TBSE subgroups. Thelow TBSE subgroup in both the HC and the HE groupsshowed the greatest improvements in HbA1c and in themoderate and high TBSE HE subgroups there were nosignificant improvements. This is in line with an earlierpublication by Cinar and Schou16,17 and Woleveret al.28. It thus appears that HC has a greater effectthan HE in terms of improving diabetes management.It also seems that TBSE plays an important andexplanatory role in these improvements. Improvementsin self-efficacy seem easier to achieve in low and mod-erate self-efficacy subgroups compared with subgroupswith high self-efficacy. This latter finding is interestingbecause those in greatest need for behavioural changesare those most likely to have low self-efficacy. Whetherthe role of self-efficacy in changing health-relatedbehaviour is a causal effect or spuriously associatedhas recently been discussed29. Given the limitations ofthe literature, Williams and French29 concluded thatthere is an absence of compelling evidence for self-effi-cacy being a cause of physical activity rather than theconsistent association resulting from self-efficacy beingan effect. The same question could be asked of TBSE.This study shows that both self-efficacy itself and

clinical parameters can be improved, particularly inlow TBSE subgroups, by using HC for diabetespatients. A recent meta-analysis by Williams andFrench29 showed that intervention studies that included‘action planning’ (specific detailed planning of when,where and how the specific behaviour is going to beperformed) produced significant improvements in self-efficacy and physical activity behaviour scores. Coxet al.30 found that global cardiovascular risk, a precur-sor of T2DM, can be effectively decreased via lifestylechanges informed using (1) readiness to change assess-ment, (2) individualised counselling and (3) targetingspecific behaviours. The study was based on the princi-ples of motivational interviewing (MI)31 and self-empowerment by self-efficacy. An evidence-basedanalysis of behavioural interventions for T2DM hasshown that behavioural interventions, which focusedmainly on problem solving, goal setting and encourag-ing participants to engage in activities that protect andpromote health (e.g. modifying behaviour, change indiet and increase physical activity) produce a moderatereduction in HbA1c levels in patients with T2DM com-pared with usual care32. In the present study, the HCapproach uses specific techniques to guide patients toset up goals and action plans to improve their lifestyles.This type of HC stems from MI and focuses on self-empowerment by increasing self-efficacy. In contrast,HC differs from MI in that it involves listening to thepatient at a very deep level and challenging him/her todetermine what is most important for his/her agenda33.T

able

3Changeatclinicalparametersamongthetoothbrushingself-efficacy

(TBSE)subgroupsofthehealthcoachingandthehealtheducationpatients

from

baselineto

post-intervention

Healthcoachinggroup

Healtheducationgroup

TBSE

TBSE

Low

(<33%)

Moderate

(33%

≤x<66%)

High(≥66%)

Low

(<33%)

Moderate

(33%

≤x<66%)

High(≥66%)

Baseline

(n=66)*

Post-

inter-

vention

(n=66)*

PBaseline

(n=72)*

Post-

inter-

vention

(n=72)*

PBaseline

(n=69)*

Post-

inter-

vention

(n=69)*

PBaseline

(n=102)*

Post-

inter-

vention

(n=102)*

PBaseline

(n=72)*

Post-

inter-

vention

(n=72)*

PBaseline

(n=81)*

Post-

inter-

vention

(n=81)

P

HbA1c

7.7

(�1.8)

7.1

(�1.5)

0.011

7.4

(�1.5)

7.0

(�1.3)

0.001

7.3

(�1.2)

6.8

(�1.0)

0.001

7.9

(�1.5)

7.7

(�1.4)

0.02

7.7

(�1.6)

7.8

(�1.5)

ns

7.6

(�1.7)

7.6

(�1.8)

ns

Improvem

ent,

%7.8

5.4

6.8

2.5

--

CAL

2.07(�

1.3)

1.0

(�0.8)

0.001

2.1

(�1.3)

0.9

(�0.7)

0.001

2.3

(�1.0)

1.2

(�0.8)

0.001

2.5

(�1.5)

2.1

(�1.7)

0.002

2.3

(�1.3)

1.4

(�1.5)

0.001

2.1

(�1.0)

1.8

(�1.3)

0.004

Improvem

ent,

%51.7

57.1

47.8

16

39.1

14.2

*Original

sample

sizeswereweightedbythreeto

have

theadequate

statisticalsample

forpaired

samplest-test,whichwascalculatedbyG*p

ower

(n=54)at0.05significance

level.

CAL,clinicalattachmentloss;HbA1c,glycatedhaem

oglobin;ns,non-significant.

Statisticallysignificantresultsare

inbold.



This enables the patients to develop their resources tomaintain and adopt the new health behaviour, andthereby the health coach supports anchoring of positivehealth behaviours by self-empowerment techniques,namely self-efficacy. Self-empowerment is based on thepatient’s own motivational factors. In the presentstudy, the health coach assisted the patients in findingout what they want for their health by forward actionand deepening the learning through discovery, aware-ness and the patient’s own choice. Information wasgiven on oral health and diabetes where the patientasked for this. This HC process deals with patients’ dis-covering and using their own resources to achieve a spe-cific goal; this results in an increased and enhancedexperience of mastery, which is one of the majorresources of self-efficacy, as proposed by Bandura21.This may explain why the HC subgroups had greaterimprovement at TBSE and thereby HbA1c comparedwith the HE subgroups. Health coaching may help/encourage patients’ awareness of self-capacity andaction that they were unable to perceive before; thismay be a totally new experience for those in the lowTBSE subgroup in the HC group, such that they werethen able to unlock the potential ‘flow’ of self-capacityto adopt healthy lifestyles.Social persuasion is another resource for self-

efficacy21 and it is defined as encouragements/discour-agements that affect an individual’s self-efficacy34.Nundy et al.34 found that positive feedback by theinterviewers increased the self-efficacy of diabetespatients. It has also been found that self-efficacy is cor-related with professional support and social support,and thereby self-efficacy has a positive impact on HbA1c

levels10,35. In the present study, professional support bya health coach guided patients to seek social supportand resources for better management of T2DM. Inaddition, the health coach gave positive feedback andencouragement, when the patient achieved a goal ortook a positive action. When the patient had challengesto performance, the health coach provided constructivefeedback and encouraged the patient to move forward.All this may explain why self-efficacy was significantlyimproved by HC, in particular in the low and moderateTBSE subgroups (i.e. this was a result of professionalsupport, encouragement and indirect enhancement ofsocial support). It is possible that the high TBSE sub-groups already had sufficient professional support,encouragement and indirect enhancement of social sup-port. This was not specifically examined in this studybut could be addressed in a future study.Physiological responses, another source for self-

efficacy, are defined as individual’s perceptions of phys-iological responses34, whereby they can be motivationaldeterminants for health actions35. von Wagner et al.35

developed a framework which proposes that healthactions (e.g. oral health and diabetes self-management)

determine health outcomes (e.g. HbA1c level) throughmotivational determinants (perceptions and beliefs)and volitional determinants (e.g. self-efficacy). Thesedeterminants are affected by external factors such asprofessional support and doctor–patient communica-tion. In the present study, patient’s perceptions onimprovement of his/her oral health (reduced CAL, lessbleeding, decreased malodour, feeling freshness in yourmouth) were used as enablers or anchors for beliefs toadopt or empower the new health behaviours; by thequestions such as: ‘What has success at brushing twicea day brought to you’, ‘What can success at havingreduced CAL bring to you in terms of eating healthy orlosing weight?’ and ‘How do you feel when you seeyour gums are better?’. All this may lead the patient tobe more aware of the physiological outcomes of his orher new health behaviour, and observation of positiveoutcomes may increase the self-efficacy. Thus positivephysiological responses and TBSE, namely motivationaland volitional determinants, may work symbioticallyand be positively affected by the health coach’s supportand empowerment approach. This may explain whyboth TBSE and CAL were explanatory factors forHbA1c in all TBSE subgroups in the HC group. In thelow TBSE HE subgroup, CAL was an explanatory fac-tor for HbA1c. However the reduction in HbA1c wasnot as high compared with the HC subgroup. Further-more, despite the greater improvement in periodontalhealth, namely increased physiological responses, thesedid not seem sufficient to make any significant changesin HbA1c levels in moderate TBSE subgroup in the HEgroup. This may be because HE lacks the approach ofHC where the patient sets up specific goals and per-forms specific actions by self-empowerment for positiveself-perceptions and self-efficacy under the guidance ofthe coach. Goal setting is one of the corner stones ofachieving diabetes-related outcomes36,37. In their study,DeWalt et al.36 underlined that goal setting processshould be reinforced by coaching approach for betterdiabetes management.A limitation of the present study is the small sample

size. Owing to a number of organisational challenges,personnel, training, funding, time, etc., it was not possi-ble to increase the number of participants. However,the original sample size is within the range of samplesizes of the studies in the field that measure the impactof behavioural interventions on HbA1c

38–41 and peri-odontal health42. Another limitation is that the samplemostly consists of patients with low socioeconomicstatus even though the main research initially did nottarget this group of patients. Therefore, the resultsmay not be able to be generalised to other populations.However, the aim of the present study was to evaluatehow low/high TBSE affects glycaemic control bycomparing the subgroups within and between HC andHE among T2DM patients. Even though the sample


Cinar and Schou

is small and is not representative of the generalpopulation of T2DM patients in Turkey, the studycould be a model for further studies. The study is, to ourknowledge the first of its kind which analyses the impactof different levels of self-efficacy specific for oral health(TBSE) on diabetes intervention by comparing HC andHE approaches. The strengths of the study are that ithas a comparison group (HC vs. HE), it has a relativelylong period of intervention (16 months, including a fol-low-up), it is structured and uses internationally accred-ited content of HC, and uses a validity–reliability testedself-efficacy measurement instrument. Furthermore, allHbA1c measures were taken from the records of the hos-pitals, so there was no possible bias from self-reports.Finally, involvement of a professional health coach withan international coaching training background and anexperienced periodontologist for HE were among theother strengths of the study. These have been underlinedas important criteria for assessing and evaluating theinterventions for T2DM in meta-analysis review.

Conclusion

Whether self-efficacy is a cause or an effect in relationto better glycaemic control of patients with T2DMrequires further analysis. However, the present findingsshow that HC is more effective in diabetes manage-ment, in terms of reduced HbA1c and CAL, comparedwith HE. Healthy diabetes requires successful dailyhealth practices; the data in this study suggest that HCunlocks positive intrinsic self-motivation, anchoringthe self-efficacy/competency beliefs for adoption ofhealthy lifestyles. Toothbrushing self-efficacy may be apractical start point for empowerment in diabetes man-agement; further studies may therefore bring newinsights and more effective outcomes from health pro-motion for diabetes patients.

Practice implications

Health coaching interventions, including brief goalsetting, action plans and empowerment through self-efficacy can help patients to adopt healthier behav-iours more effectively compared to HE.This study underlines the need to assess the empow-

erment needs of patients in terms self-efficacy levels;patients with low self-efficacy may need specificbehavioural interventions in terms of intensity, con-tent and close monitoring.It is noteworthy that the low TBSE subgroup in the

HC group had improvements in TBSE so that there wereno significant differences in the TBSE subgroups afterthe intervention. Almost the same trend was observedfor HbA1c and CAL. This may suggest that HC focus-ing on empowerment by self-efficacy in particular,

helps the ‘high-need’ group (those with low self-efficacyto begin with) to improve their diabetes management.Doctor–patient communication, even simple medical

consultations or educational sessions, can be more effec-tive by integration of self-efficacy focused messages.Non-clinical personnel can learn and facilitate HC,

which may ease the burden on the physician.The success of this intervention at reduction of

HbA1c models a strategy through which clinicians canreach beyond ‘traditional approach formal education’by including self-empowerment and visioning of thewhole picture of diabetes management, including oralhealth outcomes, as shorter and more observable out-come measures.

Acknowledgements

We express our deepest thanks to Prof. Nazif Bagriac-ik (Head, Turkish Diabetes Association), AssociateProf. Mehmet Sargin and Head Diabetes Nurse SengulIsik (Diabetes Unit, S. B. Kartal Research and Educa-tion Hospital) for all their support and help during theresearch. We thank Prof. Aytekin Oguz for his help onthe preparation of the documents for the ethical per-mission. We also thank Prof. I Oktay and periodontol-ogist Dr A. Beklen for clinical oral examinations. Wealso express our thanks to Duygu Ilhan for trainingand her support for clinical examinations and to BilgeErtoglu Akmenek for her provision of oral health edu-cation to the patients. We also thank ZENDIUM fororal health care kits, SPLENDA (TR) for the promo-tional tools, ChiBall World Pty Ltd for exercising chi-balls and to IVOCLAR Vivadent, Plandent, Denmarkfor provision of CRT kits. Many thanks also to ourpatients for their participation and cooperation, andthe staff at Diabetes Unit, S. B. Kartal Research andEducation Hospital for their kind help and support.We also thank to Christian Dinesen (Master Trainerfor Coaching, Danish Coaching Institute, Denmark),for the professional training of AB Cinar and also hissuppport for the research. The research is part of aninternational project that has two phases: the Turkishphase, which is presented here and is supported byFDI, and the International Research Fund of Univer-sity of Copenhagen.

Conflict of interest

None declared.

REFERENCES

1. WHO. Global Strategy on Diet, Physical Activity and Health:Facts related to chronic diseases. 2010. Available from: http://www.who.int/dietphysicalactivity/publications/facts/chronic/en/index.html. Accessed 2 October 2013.



2. Nishimura F, Kono T, Fujimoto C et al. Negative effects ofchronic inflammatory periodontal disease on diabetes mellitus.J Int Acad Periodontol 2000 2: 49–55.

3. Avlund K, Schultz-Larsen K, Krustrup U et al. Effect of inflam-mation in the periodontium in early old age on mortality at21-year follow-up. J Am Geriatr Soc 2009 57: 1206–1212.

4. Sandberg GE, Sundberg HE, Fjellstrom CA et al. Type 2 diabe-tes and oral health: a comparison between diabetic and non-diabetic subjects. Diabetes Res Clin Pract 2000 50: 27–34.

5. Syrj€al€a AM, Kneckt MC, Knuuttila ML. Dental self-efficacy asa determinant to oral health behavior, oral hygiene and HbA1clevel among diabetic patients. J Clin Periodontol 1999 26: 616–621.

6. Marcenes W, Kassebaum NJ, Bernab�e E et al. Global burden oforal conditions in 1990–2010: a systematic analysis. J Dent Res2013 92: 592–559.

7. IDF. Latest diabetes figures paint grim global picture. 2013.Available from: https://www.idf.org/latest-diabetes-figures-paint-grim-global-picture. Accessed 2 October 2013.

8. de Silva-Sanigorski A, Ashbolt R, Green J et al. Parental self-efficacy and oral health-related knowledge are associated withparent and child oral health behaviors and self-reported oralhealth status. Community Dent Oral Epidemiol 2013 41: 345–352.

9. Alipour A, Zare H, Poursharifiet H et al. The intermediary roleof self-efficacy in relation with stress, glycosylated haemoglobinand health-related quality of life in patients with type 2 diabe-tes. Iranian J Publ Health 2012 41: 76–80.

10. Gao J, Wang J, Zheng P et al. Effects of self-care, self-efficacy,social support on glycemic control in adults with type 2 diabe-tes. BMC Fam Pract 2013 14: 66.

11. Kay EJ, Locker D. Is dental health education effective? A sys-tematic review of current evidence. Community Dent Oral Epi-demiol 1996 24: 231–235.

12. Locker D, Wexler E, Schou L. Principles of oral health promo-tion. In: Pine C, Harris R, editors. Community Oral Health.London, UK: Quintessence Publishing Co. Ltd; 2007. p. 1–16.

13. Marmot M. Social determinants of health inequalities. Lancet2005 365: 1099–1104.

14. Guarnizo-Herre~no CC, Watt RG, Pikhart H et al. Socioeco-nomic inequalities in oral health in different European welfarestate regimes. J Epidemiol Community Health 2013 67: 728–735.

15. Butterworth SW, Linden A, McClay W. Health coaching as anintervention in health management programs. Dis ManageHealth Outcomes 2007 15: 299–307.

16. Cinar AB, Schou L. Health promotion for patients with diabe-tes: health coaching or formal health education? Accepted forpublication Int Dent J 2014 64: 20–28.

17. Cinar AB, Oktay I, Schou L. “Smile healthy to your diabetes”:health coaching based intervention for oral health and diabetesmanagement. Clin Oral Invest 2013. [Accepted forpublication].

18. Cinar AB. One for AllTM: How to Tackle with Diabetes, Obes-ity and Periodontal Diseases. In: Manakil J, editor. PeriodontalDiseases: A Clinician’s Guide InTECH; 2012. Available from:http://www.intechopen.com/books/show/title/periodontal-diseases-a-clinician-s-guide. Accessed 29 April 2013. [online book].[Accessed October 2 2013].

19. O’Connor J, Lages A. Coaching With NLP: How to be a Mas-ter Coach. London: Element; 2004.

20. Tosey P, Mathison J. Introducing Neuro-Linguistic Program-ming. Surrey. UK: Centre for Management Learning and Devel-opment, School of Management, University of Surrey; 2006.Available from: http://www.som.surrey.ac.uk/NLP/Resources/IntroducingNLP.pdf. Accessed 29 April 2013

21. Bandura A. Self-Efficacy: The Exercise of Control. New York:W.H. Freeman and Company; 1997. p. 604.

22. Parameter on chronic periodontitis with slight to moderate lossof periodontal support. J Periodontol 2000 71(Suppl 5): 853–855.

23. Cinar AB, Kosku N, Sandalli N et al. Self-efficacy perspectiveon oral health among Turkish preadolescents. Oral Health PrevDent 2005 4: 209–215.

24. Cinar AB, Oktay I, Schou L. Self-efficacy perspective on oralhealth behavior and diabetes management. Oral Health PrevDent 2012 10: 379–387.

25. Cinar AB. Preadolescents and Their Mothers as Oral Health-Promoting Actors: Non-Biologic Determinants of Oral HealthAmong Turkish and Finnish Preadolescents, Doctorate Thesis.Helsinki: University of Helsinki; 2008.

26. International Diabetes Federation. Clinical Guidelines TaskForce Global Guideline for Type 2 Diabetes; Chapter 6: Glu-cose control levels and Chapter 12: Cardiovascular risk protec-tion. 2005.

27. SPSS Inc. SPSS Statistics for Windows, Version 17.0. Chicago:SPSS Inc; 2008.

28. Wolever RQ, Dreusicke M, Fikkan J et al. Integrative healthcoaching for patients with type 2 diabetes: a randomized clini-cal trial. Diabetes Educ 2010 36: 629–639.

29. Williams SL, French DP. What are the most effective interven-tion techniques for changing physical activity self-efficacy andphysical activity behavior – and are they the same? HealthEduc Res 2011 26: 308–322.

30. Cox JL, Vallis TM, Pfammatter A et al. A novel approach tocardiovascular health by optimizing risk management(ANCHOR): behavioral modification in primary care effec-tively reduces global risk. Can J Cardiol 2013 29: 1400–1407.

31. Miller R, Rollnick S. Motivational Interviewing – PreparingPeople for Change. New York: The Guilford Press; 2002.p. 428.

32. Health Quality Ontario. Behavioral interventions for type 2diabetes: an evidence-based analysis. Ont Health TechnolAssess Ser 2009 9: 1–45.

33. Newnham-Kanas C, Morrow D, Irwin JD. Motivationalcoaching: a functional juxtaposition of three methods forhealth behavior change: motivational interviewing, coaching,and skilled helping. Int J Evid Based Coach Mentor 2010 8:27–48.

34. Nundy S, Dick JJ, Solomon MC et al. Developing a behavioralmodel for mobile phone-based diabetes interventions. PatientEduc Couns 2013 90: 125–132.

35. Von Wagner C, Steptoe A, Wolf MS et al. Health literacy andhealth actions: a review and a framework from health psychol-ogy. Health Educ Behav 2009 36: 860–877.

36. DeWalt DA, Davis TC, Wallace AS et al. Goal setting in diabe-tes self-management: taking the baby steps to success. PatientEduc Couns 2009 77: 218–223.

37. Estabrooks PA, Nelson CC, Xu S et al. The frequency andbehavioral outcomes of goal choices in the self-management ofdiabetes. Diabetes Educ 2005 31: 391–400.

38. Gary TL, Genkinger JM, Guallar E et al. Meta-analysis ofrandomized educational and behavioral interventions in type 2diabetes. Diabetes Educ 2003 29: 488–501.

39. Chen SM, Creedy D, Lin HS et al. Effects of motivational inter-viewing intervention on self-management, psychological andglycemic outcomes in type 2 diabetes: a randomized controlledtrial. Int J Nurs Stud 2012 49: 637–644.

40. West DS, DiLillo V, Bursac Z et al. Motivational interviewingimproves weight loss in women with type 2 diabetes. DiabetesCare 2007 30: 1081–1087.


Cinar and Schou

41. Welch G, Zagarins SE, Feinberg RG et al. Motivational inter-viewing delivered by diabetes educators: does it improve bloodglucose control among poorly controlled type 2 diabetespatients? Diabetes Res Clin Pract 2011 91: 54–60.

42. Renz A, Newton T, Robinson PG et al. Psychological interven-tions to improve adherence to oral hygiene instructions inadults with periodontal diseases. Cochrane Database Syst Rev2007 2: CD005097.

Correspondence to:Ayse B. Cinar,

The Department of Odontology,University of Copenhagen,

Norre Alle 20, DK–2200 Copenhagen,Denmark.

Email: [email protected]



the role of self-efficacy in health coaching and health education for patients with type 2 diabetes

Documents