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

Abstract

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 [HbA_1c, 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 (∆mean:23.4 ± 9.2) than the HE group (∆mean:12.4 ± 10.3), (P < 0.01). The moderate TBSE group showed significant improvements only in the HC group (P < 0.001).There was a significant reduction in HbA_1c 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 were explanatory variables for the reduction in HbA_1c among the HC patients in all the TBSE subgroups (P < 0.05). Among HE patients, improvement in CAL was an explanatory variable for change at HbA_1c in the low TBSE subgroup. Conclusions: The present findings show that HC is more effective in terms of reduced HbA_1c and CAL compared with HE. The data suggest that HC unlocks positive self-intrinsic motivation, anchoring the self-efficacy/competency beliefs for adjustment of healthy lifestyles. Thus, TBSE may be a practical starting point for empowerment and more effective outcomes.

INTRODUCTION

It becomes more and more important to identify and understand ways and tools to improve health behaviours and life-style related diseases. Type 2 diabetes (T2DM) and oral diseases (periodontal diseases), which are largely preventable chronic diseases¹, are described as globally pandemic because of their distribution and severe consequences. Periodontal disease and diabetes negatively affect each other². Periodontal inflammation in early old age has been shown to be associated with mortality in older age³. People with T2DM are more likely to have periodontal disease than those without T2DM⁴. Prevention and care of periodontitis involving consistent oral care at home is thus particularly important for diabetic patients⁵.

In recent years a larger and growing proportion of global health-care services expenditures are caused by life-style diseases, in particular diabetes and oral diseases6., 7.. This further increases the importance of management of these diseases.

Self-efficacy and knowledge are potentially modifiable risk factors for chronic disease-related outcomes (e.g. diabetes and oral health), and findings suggest that intervention on these factors could help foster positive healthy habits among families and individuals. De Silva-Sanigorski⁸ showed that greater parental self-efficacy was associated with more frequent toothbrushing (by parent and child) and more frequent visits to a dental professional. A number of studies have examined the influence of self-efficacy on self-care and glycaemic control. Self-efficacy has been shown to play an intermediary role in relation to quality of life, haemoglobin and stress in patients with T2DM⁹. Gao et al.¹⁰ concluded, in a study of adults with T2DM, that having greater self-efficacy was associated with better diabetes self-care behaviours and better glycaemic control.

Traditional or classic health education interventions targeted on improved knowledge has been examined and evaluated in numerous studies and numerous types of health behaviours¹¹. One of the main challenges related to health education is that even when an effect of interventions is found, it is usually mainly related to knowledge and only short lasting. Health education interventions have often been accused of not taking in factors that are out of control of the individual, and the term ‘victim blaming’ has been used to describe such studies. More recent so-called health promotion interventions do include other factors such as socioeconomics and availability of health services¹². However, a consistent and globally growing additional problem in relation to both health education – and health promotion efforts – is that large inequalities exist in most types of diseases and health-related behaviours. The inequalities in health seem to be strongly related to socioeconomic factors and educational level¹³. Neither health education nor health promotion seems to be able to reach those people with the least education and least finances or reduce inequalities. A recent study on inequality in oral health showed that the largest relative inequalities existed in countries with the best welfare regime¹⁴.

In attempts to improve lifestyle and health behaviours for all, including the ‘high-risk groups’, it may be important to examine and understand how behaviours change or which psychological and sociological factors are in play, and how. It is in this context that health coaching (HC) has developed. This is concerned with facilitating individuals in establishing and attaining health-promoting goals in order to change lifestyle-related behaviours, with the intention of reducing health risks, improving self-management of chronic conditions and increasing health-related quality of life¹⁵.

Cinar and Schou¹⁶ found that HC has a significantly greater impact on improvement of self-efficacy compared with health education among T2DM patients with low level of education and high proportion of unemployment. The present study aims to assess the role of self-efficacy in oral health and glycaemic control among these T2DM patients by comparing low self-efficacy with high self-efficacy groups in health education and health coaching.

METHODS

The present study is part of a prospective intervention study among patients with T2DM (n = 186), randomly selected from the outpatient clinics of two hospitals in Istanbul, Turkey. The power and sample size has been explained previously16., 17.. Eligibility criteria were: (1) confirmed T2DM, (2) 30- to 65-year-olds with at least four functional teeth and (3) no psychological treatment or hospitalisation.

Ethical approval and written permission to conduct the study were granted by the Ministry of Health, in Istanbul, Turkey. The methodology of the study has been explained previously16., 17.. The research was conducted in full accordance with the World Medical Association 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 socioeconomic information about themselves and biomedical records were obtained from the hospitals, at baseline and after intervention. The drop-out rate was 7% (n = 10) of 186 participants, and the proportion of participants who did not regularly participate in all sessions was 13% (n = 24).

In order to ensure comparability with the original forms in English, two native speakers conducted back-translation to and from Turkish for the health behaviour questionnaires.

Procedure and randomisation

At the baseline visit, participants provided informed consent and filled in questionnaires (including demographic background, psychosocial and behavioural variables). Subsequently, all participants were invited for baseline oral examination, which was conducted by two calibrated examiners. Following the oral examination, participants were randomly allocated to either HC (intervention) (n = 77) or to formal oral health education (HE, control) (n = 109) group by a researcher who was blinded to outcome measures. The study included two phases (10-month initiation and maintenance, 6-month follow-up). During the 10-month intervention, all participants were invited for free periodontal cleaning and three seminars about oral health and diabetes management. At the end of the 6-month follow-up phase, the same outcome measures were obtained.

The content and the design of the HC and the HE have been described in detail previously16., 18.. The HC approach in the study originally stems from internationally accredited coaching, which uses specific psychological techniques16., 18. including neuro-linguistic programming19., 20. and self-efficacy²¹. Health coaching focuses on empowerment of patients for daily diabetes- and oral health-related practices (compliance with healthy diet, regular physical activity and daily toothbrushing), building up health-related capacity skills (self-efficacy, self-esteem) and taking responsibility for own health. The HC was provided by a dentist, who is also a professional coach (ABC), via a structured framework for coaching. The HE sessions were performed by a dentist (BEA) within a structured content addressing oral health and diabetes management (physical activity, diet).

The data (outcome measures) in the present study stem from the clinical measurements and self-assessed questionnaires that were collected initially and at the end of the intervention.

Outcome measures

Oral health management

At baseline, oral examinations were performed including number of teeth lost and clinical attachment loss (CAL), which is the distance from the cemento-enamel junction (CEJ) in an apical direction to the base of the pocket/sulcus. All examinations were carried out by two dentists using the Michigan-0 probe (Hu-Friedy Mfg. B.V., Rotterdam, the Netherlands). The examiners were experienced and calibrated at measurement of CAL. Intraclass and interclass κ value was 0.85 on average. The detailed clinical examination has been described previously¹⁷. High periodontal destruction is generally characterised by CAL more than 4 mm²². Thus the high-risk CAL group was defined as the patients having ‘attachment loss >4 mm’ at baseline. For further analysis, it was dichotomised, based on the total sum scores, so that everyone below mean (HC <2.2 ± 1.2 vs. HE <2.3 ± 1.2) was categorised as low risk, coded by ‘0’. The rest, those ≥mean, were classified as high risk, coded by ‘1’.

The toothbrushing self-efficacy (TBSE) scale23., 24., 25. was used to assess individual’s belief in his/her competency to brush his/her teeth daily across different challenging situations by the question ‘How sure are you that you can brush your teeth’. The TBSE scale consisted of eight items on a five-point Likert scale (0 = ‘not sure at all’ to 5 = ‘absolutely sure’). The design and validity–reliability measures of the scale have been described previously23., 24.. For further analysis, total sum scores (TSS) for the TBSE subgroups were categorised into three equal groups by taking the 33% percentiles as the cut-off points separately for the HC and the HE subgroups. Those who reported ‘≤33%’ of the 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 HbA_1c (glycated haemoglobin expressed as the percentage of haemoglobin that is exposed to glucose) levels were taken from the latest medical records at the hospital. Taking the target level (HbA_1c < 6.5%)²⁶ as the cut-point, respective variables, taken from the most recent health records, were recoded as ideal (HbA_1c < 6.5%), moderate risk (6.5% ≤ HbA_1c < 8%) and high risk (HbA_1c ≥ 8%)²⁶.

Data analysis

Statistical analyses were performed using SPSS v.17 (SPSS, Chicago, IL, USA)²⁷. For assessment of correlation and baseline similarities/differences between the HC and the HE groups, respectively, Spearman rank correlation and Independent sample t test were used. Original sample sizes were weighted by three to have the adequate statistical sample for paired samples t-test (n = 54), which was calculated by G*power at the 0.05 significance level. Paired-sample t-tests were used for normally distributed data to assess change over time for each group alone. Changes (∆) at the variables from baseline to post-intervention were assessed by subtracting baseline scores from scores after intervention. Multiple linear regression analysis, adjusted for change at CAL from baseline to post-intervention, was performed to explain the reduction in HbA_1c levels in each TBSE subgroup among the HC and the HE patients. Statistical significance was set at a P-value of <0.05 for each test.

RESULTS

Patients in the HC group had 13.1 ± 21.8 years of clinically diagnosed diabetes and this was 10.8 ± 12.2 for the HE group (P > 0.05). There was no statistical difference between the HC and the HE groups for any of the clinical or socioeconomic parameters (P > 0.05). No statistical difference was observed between the TBSE subgroups within the HC and the HE groups (Table 1). At baseline most of the patients in both the HC and the HE groups were retired/unemployed and had HbA_1c levels higher than the target level (HbA_1c < 6.5%) for each TBSE subgroup.

Table 1.

Clinical and socio-economic parameters of the toothbrushing self-efficacy (TBSE) subgroups among the health 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 parameters
HbA1c
Ideal	77	29	22	31	ns	102	19	26	35	ns
Moderate risk		33	48	50			39	42	34
High risk		38	30	19			42	32	31
CAL
Low risk (<mean)	74	71	65	56	ns	86	53	58	63	ns
High risk (≥mean)		29	35	44			47	42	37
Socioeconomic parameters
Age (years)
30–49	76	40	29	22	ns	66	28	34	27	ns
50–59		48	54	59			44	47	49
≥60		12	17	19			28	19	24
Gender
Female	76	56	46	74	ns	97	59	62	67	ns
Male		44	54	26			61	37	33
Occupation
Retired/unemployed	75	76	67	81	ns	87	73	82	76	ns
Working		24	33	19			27	18	24
Education
≤Primary school	77	52	52	59	ns	89	74	52	52	ns
High 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 paired matches.

ns, Non-significant.

At baseline, the independent samples t-test showed no statistical significant differences in the mean for low TBSE subgroups (those reporting <33% percentile) between the HC group (4.6 ± 3.6) and the HE group (4.5 ± 4.1) (P > 0.05).

There was a significant difference between means of each TBSE subgroup in both the HC and the HE groups at baseline (P < 0.01), and after intervention in the HE group but not in the HC group between the low and the moderate TBSE subgroups (P > 0.05). From baseline to post-intervention, there was a significant difference between the means of the low and the moderate TBSE subgroups in the HC (Table 2). In the low TBSE subgroups, the improvement in TBSE from baseline to post-intervention was significantly higher in the HC group (∆mean 23.4 ± 9.2) than in the HE group (∆mean 12.4 ± 10.3), (P < 0.01). Compared with the HE group, the HC group showed significantly greater improvement in TBSE in the moderate TBSE subgroup (∆mean 9.7 ± 8.2, P = 0.001), whereas there was no significant change in the high TBSE subgroup in either the HC or HE groups (P > 0.05).

Table 2.

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

TBSE	Health coaching subgroups			P	Health education subgroups			P	Difference between subgroups
	n	Baseline	Post-intervention		n	Baseline	Post-intervention		Baseline	Post-intervention
		Mean ± 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	0.001
Moderate (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.

After intervention, there was a significant reduction in HbA_1c in all the TBSE subgroups from the HC group (Table 3). Only in the low TBSE subgroup did neither the moderate nor the high TBSE subgroup from the HE group show a significant reduction in HbA_1c. All the TBSE subgroups in both the HC and the HE groups showed a statistically significant reduction in CAL (P < 0.01). All the TBSE subgroups in the HC group had significantly greater reduction in HbA_1c levels and CAL than those in the HE subgroups (P < 0.05).

Table 3.

Change at clinical parameters among the toothbrushing self-efficacy (TBSE) subgroups of the health coaching and the health education patients from baseline to post-intervention

	Health coaching group									Health education group
	TBSE									TBSE
	Low (<33%)			Moderate (33% ≤ x < 66%)			High (≥66%)			Low (<33%)			Moderate (33% ≤ x < 66%)			High (≥66%)
	Baseline (n = 66)*	Post-intervention (n = 66)*	P	Baseline (n = 72)*	Post-intervention (n = 72)*	P	Baseline (n = 69)*	Post-intervention (n = 69)*	P	Baseline (n = 102)*	Post-intervention (n = 102)*	P	Baseline (n = 72)*	Post-intervention (n = 72)*	P	Baseline (n = 81)*	Post-intervention (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
Improvement, %		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
Improvement, %		51.7			57.1			47.8			16			39.1			14.2

^*Original sample sizes were weighted by three to have the adequate statistical sample for paired samples t-test, which was calculated by G*power (n = 54) at 0.05 significance level.

CAL, clinical attachment loss; HbA_1c, glycated haemoglobin; ns, non-significant.

Statistically significant results are in bold.

Linear regression analysis revealed that improvement in TBSE and reduction in CAL were explanatory variables for reduction in HbA_1c levels among the HC patients from the low TBSE subgroup (adjusted R² = 0.51, ∆TBSE β = −0.31, P = 0.001; CAL β = −0.67, P = 0.001), the moderate TBSE subgroup (adjusted R² = 0.37, ∆TBSE β = −0.59, P = 0.001; and ∆CAL β = −0.25, P = 0.010) and the high TBSE subgroup (adjusted R² = 0.37, ∆TBSE β = −0.48, P = 0.001; ∆CAL β = −0.31, P = 0.002) groups. In the HE low TBSE subgroup, the change in CAL was the explanatory variable for the change in HbA_1c (adjusted R² = 0.15, β = −0.41, P = 0.007).

DISCUSSION

The present study showed that both HC and HE can influence and improve diabetes management in T2DM patients, as measured by clinical data and questionnaires. It further showed that TBSE played an important and modifiable role. All improvements from baseline to post-intervention were significantly higher in all the HC TBSE subgroups than in the HE TBSE subgroups. The low TBSE subgroup in both the HC and the HE groups showed the greatest improvements in HbA_1c and in the moderate and high TBSE HE subgroups there were no significant improvements. This is in line with an earlier publication by Cinar and Schou16., 17. and Wolever et al.²⁸. It thus appears that HC has a greater effect than HE in terms of improving diabetes management. It also seems that TBSE plays an important and explanatory role in these improvements. Improvements in self-efficacy seem easier to achieve in low and moderate self-efficacy subgroups compared with subgroups with high self-efficacy. This latter finding is interesting because those in greatest need for behavioural changes are those most likely to have low self-efficacy. Whether the role of self-efficacy in changing health-related behaviour is a causal effect or spuriously associated has recently been discussed²⁹. Given the limitations of the literature, Williams and French²⁹ concluded that there is an absence of compelling evidence for self-efficacy being a cause of physical activity rather than the consistent association resulting from self-efficacy being an effect. The same question could be asked of TBSE.

This study shows that both self-efficacy itself and clinical parameters can be improved, particularly in low TBSE subgroups, by using HC for diabetes patients. A recent meta-analysis by Williams and French²⁹ showed that intervention studies that included ‘action planning’ (specific detailed planning of when, where and how the specific behaviour is going to be performed) produced significant improvements in self-efficacy and physical activity behaviour scores. Cox et al.³⁰ found that global cardiovascular risk, a precursor of T2DM, can be effectively decreased via lifestyle changes informed using (1) readiness to change assessment, (2) individualised counselling and (3) targeting specific behaviours. The study was based on the principles of motivational interviewing (MI)³¹ and self-empowerment by self-efficacy. An evidence-based analysis of behavioural interventions for T2DM has shown that behavioural interventions, which focused mainly on problem solving, goal setting and encouraging participants to engage in activities that protect and promote health (e.g. modifying behaviour, change in diet and increase physical activity) produce a moderate reduction in HbA_1c levels in patients with T2DM compared with usual care³². In the present study, the HC approach uses specific techniques to guide patients to set 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 the patient at a very deep level and challenging him/her to determine what is most important for his/her agenda³³. This enables the patients to develop their resources to maintain and adopt the new health behaviour, and thereby the health coach supports anchoring of positive health behaviours by self-empowerment techniques, namely self-efficacy. Self-empowerment is based on the patient’s own motivational factors. In the present study, the health coach assisted the patients in finding out what they want for their health by forward action and deepening the learning through discovery, awareness and the patient’s own choice. Information was given on oral health and diabetes where the patient asked for this. This HC process deals with patients’ discovering and using their own resources to achieve a specific goal; this results in an increased and enhanced experience of mastery, which is one of the major resources of self-efficacy, as proposed by Bandura²¹. This may explain why the HC subgroups had greater improvement at TBSE and thereby HbA_1c compared with the HE subgroups. Health coaching may help/encourage patients’ awareness of self-capacity and action that they were unable to perceive before; this may be a totally new experience for those in the low TBSE subgroup in the HC group, such that they were then able to unlock the potential ‘flow’ of self-capacity to adopt healthy lifestyles.

Social persuasion is another resource for self-efficacy²¹ and it is defined as encouragements/discouragements that affect an individual’s self-efficacy³⁴. Nundy et al.³⁴ found that positive feedback by the interviewers increased the self-efficacy of diabetes patients. It has also been found that self-efficacy is correlated with professional support and social support, and thereby self-efficacy has a positive impact on HbA_1c levels10., 35.. In the present study, professional support by a health coach guided patients to seek social support and resources for better management of T2DM. In addition, the health coach gave positive feedback and encouragement, when the patient achieved a goal or took a positive action. When the patient had challenges to performance, the health coach provided constructive feedback and encouraged the patient to move forward. All this may explain why self-efficacy was significantly improved by HC, in particular in the low and moderate TBSE subgroups (i.e. this was a result of professional support, encouragement and indirect enhancement of social support). It is possible that the high TBSE subgroups already had sufficient professional support, encouragement and indirect enhancement of social support. This was not specifically examined in this study but could be addressed in a future study.

Physiological responses, another source for self-efficacy, are defined as individual’s perceptions of physiological responses³⁴, whereby they can be motivational determinants for health actions³⁵. von Wagner et al.³⁵ developed a framework which proposes that health actions (e.g. oral health and diabetes self-management) determine health outcomes (e.g. HbA_1c level) through motivational determinants (perceptions and beliefs) and volitional determinants (e.g. self-efficacy). These determinants are affected by external factors such as professional support and doctor–patient communication. In the present study, patient’s perceptions on improvement of his/her oral health (reduced CAL, less bleeding, decreased malodour, feeling freshness in your mouth) were used as enablers or anchors for beliefs to adopt or empower the new health behaviours; by the questions such as: ‘What has success at brushing twice a day brought to you’, ‘What can success at having reduced CAL bring to you in terms of eating healthy or losing weight?’ and ‘How do you feel when you see your gums are better?’. All this may lead the patient to be more aware of the physiological outcomes of his or her new health behaviour, and observation of positive outcomes may increase the self-efficacy. Thus positive physiological responses and TBSE, namely motivational and volitional determinants, may work symbiotically and be positively affected by the health coach’s support and empowerment approach. This may explain why both TBSE and CAL were explanatory factors for HbA_1c in all TBSE subgroups in the HC group. In the low TBSE HE subgroup, CAL was an explanatory factor for HbA_1c. However the reduction in HbA_1c was not as high compared with the HC subgroup. Furthermore, despite the greater improvement in periodontal health, namely increased physiological responses, these did not seem sufficient to make any significant changes in HbA_1c levels in moderate TBSE subgroup in the HE group. This may be because HE lacks the approach of HC where the patient sets up specific goals and performs specific actions by self-empowerment for positive self-perceptions and self-efficacy under the guidance of the coach. Goal setting is one of the corner stones of achieving diabetes-related outcomes36., 37.. In their study, DeWalt et al.³⁶ underlined that goal setting process should be reinforced by coaching approach for better diabetes 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 possible to increase the number of participants. However, the original sample size is within the range of sample sizes of the studies in the field that measure the impact of behavioural interventions on HbA_1c38., 39., 40., 41. and periodontal health⁴². Another limitation is that the sample mostly consists of patients with low socioeconomic status even though the main research initially did not target this group of patients. Therefore, the results may not be able to be generalised to other populations. However, the aim of the present study was to evaluate how low/high TBSE affects glycaemic control by comparing the subgroups within and between HC and HE among T2DM patients. Even though the sample is small and is not representative of the general population of T2DM patients in Turkey, the study could be a model for further studies. The study is, to our knowledge the first of its kind which analyses the impact of different levels of self-efficacy specific for oral health (TBSE) on diabetes intervention by comparing HC and HE approaches. The strengths of the study are that it has a comparison group (HC vs. HE), it has a relatively long period of intervention (16 months, including a follow-up), it is structured and uses internationally accredited content of HC, and uses a validity–reliability tested self-efficacy measurement instrument. Furthermore, all HbA_1c measures were taken from the records of the hospitals, so there was no possible bias from self-reports. Finally, involvement of a professional health coach with an international coaching training background and an experienced periodontologist for HE were among the other strengths of the study. These have been underlined as important criteria for assessing and evaluating the interventions for T2DM in meta-analysis review.

Conclusion

Whether self-efficacy is a cause or an effect in relation to better glycaemic control of patients with T2DM requires further analysis. However, the present findings show that HC is more effective in diabetes management, in terms of reduced HbA_1c and CAL, compared with HE. Healthy diabetes requires successful daily health practices; the data in this study suggest that HC unlocks positive intrinsic self-motivation, anchoring the self-efficacy/competency beliefs for adoption of healthy lifestyles. Toothbrushing self-efficacy may be a practical start point for empowerment in diabetes management; further studies may therefore bring new insights and more effective outcomes from health promotion for diabetes patients.

Practice implications

Health coaching interventions, including brief goal setting, action plans and empowerment through self-efficacy can help patients to adopt healthier behaviours more effectively compared to HE.

This study underlines the need to assess the empowerment needs of patients in terms self-efficacy levels; patients with low self-efficacy may need specific behavioural interventions in terms of intensity, content and close monitoring.

It is noteworthy that the low TBSE subgroup in the HC group had improvements in TBSE so that there were no significant differences in the TBSE subgroups after the intervention. Almost the same trend was observed for HbA_1c and CAL. This may suggest that HC focusing on empowerment by self-efficacy in particular, helps the ‘high-need’ group (those with low self-efficacy to begin with) to improve their diabetes management.

Doctor–patient communication, even simple medical consultations or educational sessions, can be more effective 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 HbA_1c models a strategy through which clinicians can reach beyond ‘traditional approach formal education’ by including self-empowerment and visioning of the whole picture of diabetes management, including oral health outcomes, as shorter and more observable outcome measures.

Acknowledgements

We express our deepest thanks to Prof. Nazif Bagriacik (Head, Turkish Diabetes Association), Associate Prof. Mehmet Sargin and Head Diabetes Nurse Sengul Isik (Diabetes Unit, S. B. Kartal Research and Education Hospital) for all their support and help during the research. We thank Prof. Aytekin Oguz for his help on the preparation of the documents for the ethical permission. We also thank Prof. I Oktay and periodontologist Dr A. Beklen for clinical oral examinations. We also express our thanks to Duygu Ilhan for training and her support for clinical examinations and to Bilge Ertoglu Akmenek for her provision of oral health education to the patients. We also thank ZENDIUM for oral health care kits, SPLENDA (TR) for the promotional tools, ChiBall World Pty Ltd for exercising chi-balls and to IVOCLAR Vivadent, Plandent, Denmark for provision of CRT kits. Many thanks also to our patients for their participation and cooperation, and the staff at Diabetes Unit, S. B. Kartal Research and Education Hospital for their kind help and support. We also thank to Christian Dinesen (Master Trainer for Coaching, Danish Coaching Institute, Denmark), for the professional training of AB Cinar and also his suppport for the research. The research is part of an international project that has two phases: the Turkish phase, which is presented here and is supported by FDI, and the International Research Fund of University of Copenhagen.

Conflict of interest

None declared.