Supporting professionals to talk about remission with people with type 2 diabetes: Using multi-methods to develop a communication guidance resource

Abstract

Objective

People living with type two diabetes can achieve remission through weight loss, and services are available to support this. Our aim was to develop an evidence-informed resource supporting professionals to communicate about remission with diverse people with type 2 diabetes.

Methods

We followed a multi-method, four phase approach: (1) evidence review, identifying empirically based communication practices (2) patient and professional interviews, understanding priorities that could facilitate positive conversations about remission (3) triangulation and resource creation, and (4) resource review, including testing with our multidisciplinary team and remission coaches, and final iteration. People with lived experience were involved throughout and we included participants from diverse backgrounds to support relevance and acceptability.

Results

The evidence review found framing advice positively and delicately, maximising patient involvement, methods motivating referral uptake were effective. Interviews found staff and patients valued: asking rather than telling, gently introducing remission, understanding an individual's perceptions of success. Triangulating patient and professional responses revealed results were largely complementary, foregrounding what and how discussions about remission could transpire. The multidisciplinary team provided additional information for inclusion. Training was delivered in 2023–2024 to diabetes remission service providers and was integrated into Diabetes UK resources.

Conclusions

Grounded in communication evidence, this resource supports professionals to discuss remission with diverse people with type 2 diabetes. As diabetes remission services expand, this resource needs testing to determine its impact on patient engagement in remission services.

Innovation

A multi-method approach informed the development of a communication resource to support effective, inclusive conversations about diabetes remission.

1. Introduction

Type 2 diabetes (T2D) is a growing global health concern. An estimated 462 million individuals currently live with this condition, and this is projected to rise to 782 per 100,000 people by 2040 [1]. Whilst previously considered a lifelong condition, research has shown that achieving remission from T2D is possible1 [2], [3]. The Diabetes Remission Clinical Trial (DiRECT) demonstrated that intensive weight management, in the form of total diet replacement (TDR), combined with structured support was associated with 46% of patients achieving remission at 12 months [4]. Achieving remission through weight loss can improve the quality of life of people living with type 2 diabetes, reduce healthcare costs, and accumulating evidence suggests it may also reduce the risk of long-term diabetes-related clinical events [5], [6].

In 2019 the NHS in England began offering ‘Path to Remission’ (PtR), a TDR programme for patients living with T2D and overweight or obesity. PtR is effective, low-cost, and low-risk relative to bariatric surgery which is the most effective method for achieving significant weight loss [7]. However, evaluations of PtR have found that only a small fraction of eligible people with T2D actually take up PtR, and consequent completion rates for individuals from deprived areas are lower [8], and people of Asian and Black ethnicities had lower mean weight loss [9]. While PtR is situated within the NHS, similar remission-focused interventions are being implemented internationally [10], [11], [12], and challenges in uptake are likely to be relevant across healthcare systems. It is thus important to determine whether there could be a more effective way to deliver remission interventions.

In PtR, patients are provided with meal replacement products and receive frequent contact with a health professional to provide participants with the help and advice they need throughout every stage of the programme. This support is delivered through interactions – communication – between patients and professionals [13]. Communication about remission can be challenging because people with T2D vary in their understanding of remission, their priorities, and what they consider a successful outcome [14]. Discussions also take place in the context of diabetes and weight-related stigma which can affect patient experiences of care [15]. Effective communication is therefore important for supporting patient autonomy and ensuring that information about remission and available services is responsive to individual needs and priorities. Extant research has demonstrated clear relationships between how professionals communicate and improved patient experiences [16], and clinical outcomes. For example, a 2023 cohort study demonstrated that small differences in how weight loss treatment was communicated, such as asserting the benefits of weight loss and minimising the activity burden on patients resulted in significant increase in treatment uptake, and greater weight loss one year later. However, to our knowledge, no research has integrated empirical evidence about communication practices with experiential evidence to inform communication about diabetes remission [17].

We aimed to develop an evidence-informed resource to support professionals to communicate about remission and the services available to help patients achieve this with the diverse population recently diagnosed with T2D. We undertook interviews with patients and professionals and reviewed the existing empirical communication literature, triangulating these to create an evidence-informed resource. We outline our development process, how we trained professionals, and the potential implications.

2. Methods

We took a multi-methods approach to resource development [18]. We followed NIHR's INCLUDE [19] guidance, aiming to democratise the process and to ensure inclusion and diversity were a priority [20]. A diverse patient and public involvement panel of people with type 2 diabetes provided input throughout. They were recruited via the Deep End Research Alliance (DERA) [21], and the University of Oxford Health Behaviours Team Weight Management Patient Advisory Group. In addition, a lived-experience co-researcher (CN) was part of the core research team, providing detailed input at all stages. We undertook the following methods to develop resource format, and content:

2.1. Resource format

We aimed to develop a resource that could be used by healthcare professionals when delivering remission services. We took a pragmatic approach to deciding on resource format, informed by findings from the patient and professional interviews alongside existing literature. Findings from this work informed our multidisciplinary team discussions about the degree of structure and flexibility the resource required. The team comprised communication specialists (JJ, CA), general practitioners (PA, EM), and dietitians (NG, SJ) - all of whom are researchers, including with detailed expertise in the field; and a lived experience co-researcher with type 2 diabetes (CN).

2.2. Resource content

As ‘effective’ communication can be counterintuitive [17], and differ from prevalent practice [22] we drew on a range of evidence to develop resource content, rather than our multi-disciplinary experience alone. The development of the resource content proceeded through four distinct phases: (1) evidence review, (2) patient and professional interviews, (3) triangulation of findings and resource creation, and (4) resource review and iteration:

2.2.1. Evidence review

To identify relevant evidence on how to enhance communication between professionals and patients we narratively reviewed existing studies that were conducted using empirical approaches to analyse social interaction (e.g. Conversation Analysis [23]). We prioritised literature which analysed real interaction to identify evidence of specific ways of communicating about: motivating change; making referrals; managing interactional ‘troubles’ [24]; facilitating patient engagement; and handling interactional resistance [25]. We also reviewed existing communication guidance such as ‘Language Matters: Diabetes’ [26], resources on remission from Diabetes UK [27], and extant training available for professionals delivering remission services (health coaches). We extracted specific communication practices relating to the design and content of specific communication approaches, including their grammatical format; prosodic and embodied elements; and word choice.

2.2.2. Patient and professional interviews

We conducted in-depth interviews to understand the experiences of people living with T2D, and with healthcare professionals to understand their experiences of delivering T2D prevention and remission programmes.

A qualitative researcher (JJ) and lived-experience researcher (CN) conducted narrative interviews [28] with people living with type 2 diabetes between October 2022 – June 2023. Sampling was iterative and we prioritised diversity, including: age, gender, ethnicity, diabetes duration, occupation, living arrangements, dietary limitation, disabilities, and socioeconomic status. We specifically sought to sample people from populations who are currently underserved by PtR, with a focus on people from South Asian communities, and people with learning disabilities. To ensure maximum variation and diversity of sample we undertook a range of recruitment activities, including: leafleting/speaking at community events and community and religious centres, via word-of-mouth, through newsletters and email lists, on social media and radio interviews (see Table 2 for full characteristics). Narrative interviews included a single question (co-designed with lived-experience researcher CN and reviewed by out PPI group [29]): ‘Can you tell me about the effect of type two diabetes on your life, starting from when you were first diagnosed?’, and were followed by prompts to further elucidate support received, and knowledge and perspectives about remission.

Table 2.

Participant characteristics.

Intervie wer	Participant	Duration (min)
JBJ	ND1_01, British Pakistani woman, 76 years old, 5–10 years since diagnosis	22
JBJ	ND1_02, British Pakistani man, 70 years old, 10+ years since diagnosis	24
JBJ	ND1_03, White British man, 68 years old, 10+ years since diagnosis	27
JBJ	ND1_04, White British woman, 63 years old, 2–5 years since diagnosis	15
JBJ, CN	ND1_05, British Pakistani woman, 30 years old, 0–2 years since diagnosis	19
JBJ	ND1_06, British Pakistani woman, 52 years old, 10+ years since diagnosis	20
JBJ	ND1_07, South Asian man, 61 years old, 5–10 years since diagnosis	31
JBJ, CN	ND1_08, White British woman, 72 years old, 0–2 years since diagnosis	20
JBJ	ND1_09, South Asian woman, 38 years old, 0–2 years since diagnosis	30
JBJ, CN	ND1_10, White British man, 72 years old, 5–10 years since diagnosis	22
JBJ, CN	ND1_11, British Pakistani woman, 55 years old, 10+ years since diagnosis	31
JBJ	ND1_12, African Caribbean woman, 68 years old, 10+ years since diagnosis	36
JBJ	ND1_13, White British man, 69 years old, 10+ years since diagnosis	20
JBJ	ND1_14, African Caribbean man, 71 years old, 5–10 years since diagnosis	28
JBJ, CN	ND1_15, White British man, 62 years old, 2–5 years since diagnosis	22
JBJ, CN	ND1_16, White British man, 80 years old, 10+ years since diagnosis	32
JBJ, CN	ND1_17, White British man, 61 years old, 10+ years since diagnosis	15
JBJ	ND1_18, British Pakistani woman, 35 years old, 0–2 years since diagnosis	17
JBJ	ND1_19, Sikh Indian woman, 53 years old, 10+ years since diagnosis	22
JBJ	ND1_20, British Pakistani woman, 36 years old, 0–2 years since diagnosis	20
JBJ	ND1_21, South Asian woman, 24 years old, 5–10 years since diagnosis	25
JBJ	ND1_22, South Asian man, 28 years old, 2–5 years since diagnosis	29
JBJ	ND1_23, White British woman, 58 years old, 0–2 years since diagnosis	17
JBJ	ND1_24, White British woman, 63 years old, 10+ years since diagnosis	20
JBJ	ND1_25, White British woman, 57 years old, 2–5 years since diagnosis	22
JBJ	ND1_26, African Caribbean woman, 73 years old, 5–10 years since diagnosis	19
JBJ	ND1_27, Sikh Indian man, 65 years old, 5–10 years since diagnosis	30
JBJ	ND1_28, White British man, 63 years old, 10+ years since diagnosis	18
JBJ	ND1_29, White British woman, 54 years old 10+ years since diagnosis	21
JBJ	ND1_30, White British woman, 63 years old, 2–5 years since diagnosis	20
JBJ	ND1_31, White British man, 69 years old, 2–5 years since diagnosis	15
JBJ	ND1_32, British Pakistani woman, 55 years old, 10+ years since diagnosis	27
JBJ	ND1_33, Sikh Indian woman, 48 years old, 0–2 years since diagnosis	22
JBJ	ND1_34, White British woman, 49 years old, 5–10 years since diagnosis	26
JBJ	ND1_35, British Pakistani man, 53 years old, 0–2 years since diagnosis	31
JBJ	ND1_36, Sikh Indian man, 44 years old, 0–2 years since diagnosis	24
JBJ	ND1_37, South Asian man, 46 years old, 0–2 years since diagnosis	29
JBJ	HC1_01, Diabetes health coach	28
JBJ	HC1_02, Diabetes health coach	20
JBJ	HC1_03, Diabetes health coach	19
JBJ	HC1_04, Diabetes health coach	31
JBJ	HC1_05, Diabetes health coach	31
JBJ	HC1_06, Diabetes health coach	22
JBJ	HC1_07, Diabetes health coach	32
JBJ	HC1_08, Diabetes health coach	23
JBJ	HC1_09, Diabetes health coach	16
JBJ	HC1_10, Diabetes health coach	30
JBJ	HC1_11, Diabetes health coach	22
JBJ	HC1_12, Diabetes health coach	26
JBJ	HC1_13, Diabetes health coach	19
JBJ	HC1_14, Diabetes health coach	17
JBJ	HC1_15, Diabetes health coach	25
JBJ	HC1_16, Diabetes health coach	27

We conducted semi-structed interviews with health coaches delivering existing diabetes prevention and remission programmes between October – December 2022. Coaches were recruited opportunistically through snowballing, and with support from a senior coach. We explored perspectives on the difficulties their patients experience, common communication challenges in existing service delivery, and their strategies for overcoming these.

Interview data were analysed using reflexive thematic analysis [30]. Full methodological detail is available in the interview results paper [14] and study protocol [31]).

2.2.3. Triangulation of findings and resource creation

To ensure resource content included empirical communication approaches relevant to discussing remission, and also incorporated experiential insights from patients and professionals, we undertook a process of data triangulation [32]. This process brought together the results from the interviews and literature review to develop a comprehensive understanding of how the communication practices and perspectives we had identified were contradictory or complementary/supplementary in order to inform resource content [33]. Triangulation of the evidence proceeded iteratively via 4 stages: (1) Analysis: evidence from each data source (e.g. evidence review and interviews) were analysed independently, as described in previous phases, (2) Evaluation: evidence was brought together in NVivo to facilitate comparison across sources and evaluate whether and how insights converged or diverged, (3) Integration: findings were tabulated and discussed with the multidisciplinary team to consider how they could inform the resource. A pragmatic approach informed by MoSCoW prioritisation (‘must’, ‘should’, ‘could’ and ‘would not’ include) was used as a discussion aid to determine what could usefully and feasibly be incorporated; and (4) Reflexivity: findings were reviewed by our lived experience panel and our multi-disciplinary team, who supported with interpretation. Results were used to create the draft training resource, led by JJ. Consistent with our interpretivist approach to the qualitative analysis, researcher perspectives were treated as part of the interpretive process.

2.2.4. Resource review and iteration

We engaged in detailed testing with our multidisciplinary team. We undertook role-plays using the resource (with team members acting as coach and patient, and others observing), and engaged in discussion to understand what aspects may require refinement, addition, or removal. We undertook this process twice, iterating after each discussion. We created training on how to use the resource and explaining the underpinning principles. We delivered training to health coaches and iterated both the training and communication resource following their feedback.

3. Results

3.1. Resource format

The format of the resource was informed by the interview findings as well as multidisciplinary discussion. Interviews highlighted a mismatch between the diversity of patient experience and the relative rigidity of existing services reported by diabetes coaches [14]. Coaches recognised the need for individualised support and described using their own communication skills to tailor delivery and be responsive to individual patient circumstances [14]. The interviews also indicated variation in coaches' familiarity with behaviour-change approaches, with professionals bringing different existing skills and expertise to their practice. Together these findings suggested a one-size-fits-all approach may be inappropriate for both the diversity of patient conversations, and the professionals experience delivering them. We therefore sought a format that provided sufficient structure and evidence-informed guidance to support professionals while remaining flexible enough to integrate with, and not constrain, their existing communication skills. We considered creating a ‘script’ for professionals to use, however given the interview findings and mixed evidence of effectiveness on scripts for clinical communication training [34], we instead developed an ‘aide memoir’ which could be accessed during conversations, and which would contain details of key information, and suggested communication techniques or approaches to particular scenarios professionals may encounter, but would not be completely prescriptive. We felt this would enable professionals to use this resource to supplement and build on (rather than replace) their existing skills. Given time pressures experienced by healthcare professionals [35], we aimed to keep resources as brief and specific as possible.

3.2. Resource content

3.2.1. Evidence review

Our review of existing studies conducted using empirical approaches to analyse social interaction identified several interactional practices relevant to be incorporated into training. We grouped these into nine communication approaches (Table 1).

Table 1.

Communication approaches identified through evidence review.

Topic	Example
Ground advice in the priorities of participants [39], [52], [53], [54]	“you mentioned wanting to come off medication”
Maximise the degree of participant involvement [39], [52]	“tell me how you found the programme”
Minimise the activity burden on the participant [36], [52]	“…let's focus on the small steps…”
Use higher-entitled request formats [37], [55], [56]	“Let's give this programme a go”
Give advice delicately [41], [57]	“…even a little bit of weight loss…”
Positively frame conversations [36], [38], [58], [59], [60]	“The great news is that there is a free programme…”
Keep recommendations and advice brief and specific [38], [55], [61]	“Evidence shows this is the most effective programme”
Pay attention to the sequential order of the talk as well as its composition [40], [62]	Follow the resource structure of the conversation so the information about the remission programme and about the weight loss programme(s) do not get mixed together.
Recognise resistance enables overcoming or acquiescing to it [25], [63], [64]	If a patient displays resistance (e.g. hesitancy, negative or very minimal responses), then it could be better to ask them for their views so that any challenges can be dealt with, and/or offer something else rather than pursue a referral unlikely to be accepted.

These insights highlighted the importance of positively delivered advice [36] coupled with language choices that assume the patient will take up the advice/recommendation (known as ‘high-entitled’ requests) [37], [38] e.g. “It's really convenient for you, so let's give this programme a go”. Results also emphasised maximising the degree of participant involvement by grounding advice in an individual's priorities [39] (e.g. “you mentioned coming off medication—remission could help with that”), and the importance of paying attention to the order (sequence) of conversation [40] as well as the design (composition). We found advice which was delivered gently and minimised the burden to patients (e.g. “just starting to think about weight loss is the first step”) supported a positive conversation [41].

3.2.2. Interviews

We interviewed 37 diverse patient-participants and 16 health coaches who deliver diabetes prevention and remission services. Analysis highlighted that approaches to remission support are currently system-centred that are not responsive to an individual's needs and do not provide choice; and this contrasted with a desire for a person-centred approach affording more choice and control [14]. Overall, interviews showed that it is perceived as helpful and useful for professionals to communicate in a way which supports patients to become experts in their own condition. Full details on participant demographics and detailed themes are available in our results paper [14]. Analysis highlighted seven communication approaches that could be incorporated into resource development:

• (a)“Ask” don't “tell”

There was great variety in experience and knowledge of T2D. Talking about remission could start from a place of asking about current knowledge, listening, and understanding (so that information could be tailored for individuals) rather than ‘telling’ and instructing.

• (b)Gentle introductions

Many participants reported that the time following diagnosis was confusing and emotional. Communication could involve specific information about what remission means with signposting to support networks (e.g. charities such as Diabetes UK), coupled with ongoing support that recognises the potential emotional tumult.

• (c)The prospect of remission

Interviews showed that people had varied understandings of ‘remission’. It could be advantageous to check understandings and explain remission if necessary.

• (d)Cultivate support

Participants reported that having additional support from friends and family strongly influenced their experience. Remission conversations could help people to identify a personal ‘champion’ to celebrate their successes.

• (e)Balancing honesty with activity burden

Participants valued honesty from professionals but focusing too much on the effort required for remission could be demotivating. Being honest about the opportunity and challenges remission while emphasising the ‘small steps/successes’ could be advantageous.

• (f)Becoming an expert

Participants with T2D valued being recognised as an expert in their own life and how management of their diabetes fit with their day-to-day activities. Remission conversations could emphasise the role the person with diabetes has at the centre of their care—acknowledging that success may not be solely defined by clinical remission, but also by personally meaningful goals. Supporting individuals to define what success looks like for them could reinforce expertise.

• (g)Perceptions of a ‘successful’ end goal

There was great variety in how individuals perceived success, often this was linked with biomedical measures but not always. When it came to a successful end goal, ‘Returning to normal’ was a common desire. ‘Normal’ was understood as not needing to think about food choices and, to a lesser extent, coming off medication. When talking about remission professionals should understand patients own perceptions of a ‘successful’ end goal and incorporate this into discussion.

3.2.3. Triangulation of findings and resource development

Triangulation showed that the results were largely complementary; results identified through interview analyses related to the structure, tone, and content of conversations. Interactional practices identified through the evidence review complemented this, providing specific mechanisms through which to achieve an appropriate and effective tone and content. Triangulation did identify some tensions in the evidence. For example, coaches described actively seeking to create ‘lightbulb moments’ and, in some cases, pushing patients toward change, whereas patients described meaningful realisations as highly individual and often recognisable only retrospectively; repeated efforts by coaches to change could also be described by patients as ‘punishment’ [14]. Interviews also showed that ‘remission’ was ambiguous to many participants and rarely described as a marker of success; while becoming an expert in their diabetes, improving their wider health and achieving other personally meaningful changes were valued [14]. This highlighted a potential tension between service-defined outcomes of remission with patient's own definitions of success. Rather than resolving these tensions in favour of either professional or patient, the resource emphasised an ‘ask, don't tell’ approach with prompts for professionals to establish what success means to the individual allowing professionals to create opportunities for reflection and change while also allowing patients to identify their own priorities, solutions and goals alongside remission. Results from triangulation were used to create the draft communication resource. This resource comprised guidance for an initial discussion about remission and then follow up. For the initial discussion, this included six sections structuring the conversation (1) introductions, (2) explanation of the remission programme, (3) assessing knowledge of remission, (4) establish goals and motivations, (5) introduce the programme, (6) explain next steps. It also included a page of general communication principles, which applied throughout conversations. Each section included a series of scenarios that coaches may encounter, comprising key issues that people living with diabetes may raise, and highlighted communication approaches to use in each scenario. Scenarios were composited from interviewee reports, PPI feedback and professional experience of potential responses. The full resource is available in [supplementary file 1].

3.2.4. Resource review and iteration

Role-plays using the resource with our multidisciplinary team, and subsequent discussions, resulted in additional scenarios being identified which participants may experience. Questions participants could ask were also considered and their answers consequently tested in the role-play, and the resource iterated.

We created training in how to use the resource and its underpinning principles. The training focused on two key parts: a brief discussion of the science behind remission to address any misconceptions, followed by an explanation of the overall logic and structure of the communication resource, its general aim of keeping the participant with us and to support them, and how the resource should be used—as a supportive tool to enhance existing expertise and skills. Training incorporated opportunities for coaches to question, reflect, and practice the content from the communication guidance resource. Using a role-play approach offered a safe space for coaches to get things wrong and try again.

We delivered training in using the guide to a small group of health coaches and senior coaches in a 3-h online session in October 2023 (5 coaches) and a revised 2-h online training session in July 2024 (4 coaches). Coaches were varied in experience, background and expertise with many having little or no knowledge of T2D. Coaches positively reflected that the training built on and complemented their existing skillset and training. There was some uncertainty about safety of TDR (which PtR uses) for potentially encouraging unhealthy behaviours. As a result, the training to support the use of the resource was iterated to address uncertainty about PtR by highlighting that the resource is specific to remission, and that TDR with its associated rapid weight loss is safe and effective in this context. Verbal feedback was positive with coaches commenting on how the resource did not contradict other training but built on what they knew. Some coaches also delivered other programmes for people with T2D and reported that they envisaged using this in those other programmes with their patients.

Insights from our multidisciplinary team and patient and public involvement group at this final stage highlighted that the general ‘communication principles’ included in the full communication resource applied beyond delivering diabetes remission services to also support communication during referral into these remission services. In response we additionally created an infographic to summarise and disseminate these general ‘communication principles’ to professionals working across a range of settings (Fig. 1, infographic).

Fig. 1.

Joyce, JB, Newbert, C, Guess, N, Fryer, K, Mitchell, C, Bespala, L, Morris, E, Aveyard, P, Jebb, SA, Albury, C. Communicating diabetes remission and referral [infographic]. Nuffield Department of Primary Care Health Sciences, Oxford UK. 2025. Available from: http://dx.doi.org/10.13140/RG.2.2.26394.35527/1

4. Discussion

We took a multi-methods approach to develop an evidence-informed resource to support professionals to communicate about remission with people with newly diagnosed type 2 diabetes, focussing on high-risk and underserved groups to ensure our findings are representative of the diverse patient population. The evidence review highlighted specific interactional approaches that are used in similar contexts, such as taking a positive approach to advice delivery [36] coupled with ‘higher-entitled requests’ [37], and grounding advice in an individual's priorities to ensure participants are involved and advice is personalised for them [39].

The NHS PtR programme has demonstrated the real-world effectiveness of remission services [8]. Increasing evidence suggests that remission may also be associated with avoidance of long-term clinical events underlining the importance of remission programmes globally [6]. However, uptake of NHS PtR is much lower than it might be. While adherence of those who engage is high overall, some groups are underserved by its implementation, including Asian and Black ethnicities and people experiencing socio-economic deprivation [9], [42]. To ensure the communication resource was relevant for those who are currently underserved, and did not reinforce existing inequity, we included a wide range of participants in our interview study (see Table 2). While the resource was also developed for those early after diagnosis to mirror NHS PtR, our wide range of participants included those with a range of diabetes durations to capture how remission is understood and experienced [14]. Our evidence informed resource may help practitioners to better support individuals less likely to take part in, or more likely to drop out from weight loss interventions like PtR, for example by aiming to understand an individual's own unique priorities.

The available data suggests most people offering PtR turn it down [4] and our own interviews highlighted how a “rigid system” does not cater to the need for choice and experimentation amongst individuals with different needs. Broader structural and social factors can also influence engagement with remission pathways, for example, removing personal and social stigmatisation, lowering premiums on mortgages and insurance coverage, and remission can remove some occupational restrictions [43]. A strength of our resource is that is can be used to support a patient on any weight loss or behavioural programme seeking remission, as the findings (high-entitled requests, cultivating support, balancing honesty with activity burden) are potentially transferable for wider dietary behaviour change.

Interview results showed communication content that was important for both patients and professionals. This included that: communication should support patients to become experts in their own condition, and professionals should recognise that expertise; and people who access remission services have varying existing knowledge and understanding of remission, and it is important assess this current knowledge. These findings are consistent with literature on diabetes and on other long-term conditions such as cancer, where recognition of expertise and patient empowerment have been shown to be crucial for effective care [44], [45], [46]. Interviews also foregrounded common scenarios that were encountered during conversations about remission. Triangulation across methods identified what should be communicated (key information, and principles to incorporate, generated from interviews) and how this could be achieved (including words choice and grammatical structure, generated from reviewing relevant literature). Lived experience expertise throughout ensured the resource was acceptable to diverse patients and incorporated their priories. Professionals who deliver remission services responded positively to this resource during testing.

Evidence shows that effective communication has potential to support improved patient outcomes, adherence, satisfaction, and trust in their provider [16], [17]. However, evidence from empirical studies of what constitutes ‘effective communication’ in practice can misalign with prevalent practice, post-hoc assumptions, and can be counterintuitive [17], [22]. Empirical evidence also shows that ‘effective’ communication is highly context dependent, rather than universally applicable. This is underscored by research demonstrating how public health messaging which is not tailored to its context can lead to confusion [47]. A range of approaches grounded in empirical evidence of effective communication have been used to develop training to enhance healthcare professionals' communication skills. This includes The Conversation Analytic Role Play method (CARM) and RealTalk which show professionals animated audio and video recordings of real-time conversations [48], [49]; and the Conversation Analysis Based Simulation approach (CABS) where professionals undertake simulated interactions based on learning from analysis of real healthcare interactions. These extant methods rely on access to recordings of real interactions. Whilst this ensures training is grounded in empirical evidence of best practice, in some instances where there is a timely need for communication resources it may not be possible to secure such evidence in the first instance. Here we trial an alternative approach to developing communication guidance that is grounded in review of empirical evidence of communication in related settings, triangulated with interview data, and embedding lived experience throughout.

4.1. Strengths and limitations

A strength was drawing on multiple evidence sources to create the communication resource. Moreover, the highly varied sample of participants and the involvement of a person with lived experience of T2D as a co-researcher contributed to fuller, more relevant and impactful findings for more people with T2D especially those underserved and unrepresented in diabetes remission research.

A limitation was that we were unable to undertake detailed assessment and evaluation of the resources we developed. We acknowledge that incorporating empirical evidence from recorded interaction would have strengthened the resource and allowed us to use methods like CARM and CABS to train our professionals, but we did not have access to these data. Subsequent research could address this. Whilst people with learning disabilities were well represented in our sample, we feel further support and guidance is needed for people who support people with learning disabilities [50], [51], and this should be an avenue for future research.

4.2. Innovation

This study applies a multi-methods pragmatic approach to combining empirical communication literature, qualitative interviews, and lived-experience input to develop an evidence-based communication resource focused on type 2 diabetes remission. Previous qualitative work, including our own, has identified a mismatch between patient experiences and the relative rigidity of existing services, highlighting the important of individualisation, and patient-defined success [14], [44]. However, identifying these priorities does not in itself establish how professionals can enact them in interaction. Our approach bridges these evidence bases by integrating what should be communicated (derived from patient and professional perspectives) and how it should be communicated (derived from empirical interaction research), addressing a gap in existing training which often focuses on one or the other. The explicit focus on underserved populations and inclusion of lived-experience co-researcher throughout the development process enhances the relevance and acceptability of the resulting resource.

5. Conclusion

A multimethod approach, integrating evidence from a range of sources, was used to create an evidence-informed resource to support professionals to communicate about remission with diverse people with type 2 diabetes. This resource is acceptable to professionals and people with lived experience. The ways that professionals communicate can support improved patient satisfaction and outcomes, and the effects of this resource should be subsequently tested. As diabetes remission services expand commissioners and providers of services should consider the key role communication can play in supporting successful implementation.

CRediT authorship contribution statement

Jack B. Joyce: Writing – review & editing, Writing – original draft, Visualization, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Carolyn Newbert: Writing – review & editing, Methodology, Investigation, Formal analysis, Conceptualization. Nicola Guess: Writing – review & editing, Writing – original draft, Investigation, Conceptualization. Kate Fryer: Writing – review & editing, Funding acquisition. Caroline A. Mitchell: Writing – review & editing, Funding acquisition. Elizabeth Morris: Writing – review & editing, Funding acquisition. Paul Aveyard, Susan A. Jebb: Writing – review & editing, Funding acquisition. Charlotte Albury: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Susan Jebb holds research grants from the National Institute for Health Research (NIHR). Oviva and Second Nature have provided weight-loss interventions as part of research studies. Paul Aveyard is an NIHR senior investigator and is supported by Oxford and Thames Valley Applied Research Collaboration, NIH Oxford Biomedical Research Centre, and NIHR Oxford Health Biomedical Research Centre. Charlotte Albury has worked as an independent consultant for the Behavioural Insights team, Wildfowl Wetlands Trust, Adelphi Real World, Oxford Health BRC, and Linney Create for which she was paid personally. She was an academic advisor for NESTA, and did not receive personal payment.