Self-Rescue Program™ (SRP)
A Pilot Study of the Effectiveness and Acceptability of the Self-Rescue Program™ (SRP) in Maori & Pacific Islander Adults diagnosed with Type 2 diabetes mellitus
By Ephraim Cooper
The purpose of this pilot study is to determine the effectiveness and acceptability of the Self-Rescue Program™ (referred to as SRP in this document) in Maori & Pacific Islander adult Men and Women of the age of 35 years and over diagnosed with type 2 diabetes mellitus. The aim of SRP is to help people who are facing diabetes to increase their abilities in self-management of the disease by embedding change within their behaviours and within their social environments which can stick over time.
Burden of Diabetes
Diabetes in New Zealand is targeted because its economic and social costs are increasing exponentially. There are 257,776 adults diagnosed with diabetes in New Zealand, as at December 2014, which is growing at an average compound annual rate of 7.2% which equates to more than 50 people newly diagnosed with diabetes every single day1. Furthermore, one in four adults (25%) in New Zealand2 are pre-diabetic3 which are at a high risk of developing diabetes. Most people who have type 2 diabetes are largely preventable and can be slowed by lifestyle interventions involving weight loss, improved diet and increased physical activity4. The total annual cost of diabetes in New Zealand in 2014 is about NZ$2.3 bn (US$1.5bn) based on the annual cost of NZ$5,944 (US$3,883) per person with diabetes5.
Maori & Pacific Islanders
Maori & Pacific Islander peoples are chosen for this pilot study because they are at the highest risk of developing diabetes in New Zealand than any other single ethnic group. For instance, Maori make up 14.4% and Pacific Islanders make up 11.8% of the total people diagnosed with diabetes respectively6.
However, whilst this pilot study will test SRP’s effectiveness and acceptability in Maori & Pacific Islanders, it is not intended to test or provide a comparison of results between Maori & Pacific Islanders, and Non-Maori & Non-Pacific Islanders respectively.
A Social Holistic Intervention rather than Standard Clinical Medicine
SRP intervention is achieved by educational and social holistic means as opposed to traditional clinical medical means. In other words, SRP intervention provides a consolidated structure for learning that targets changing behaviours in the person and within their social environments; as such, it is both curative and preventative in nature rather than intervention by traditionally providing clinical medicine or instruments which seem to be curative only.
At its core, SRP is designed based on the integration of three key evidenced-based frameworks which are each world-renowned in their own right for achieving behavioural change successfully; however, they have never been combined in this way before for the purpose of managing diabetes. The first framework is based on a participant going through a process of ‘Unfreezing-Changing-Refreezing’7 if changes are to stick. The second framework is based on a participant going through 8-steps of transformation8 in order for change to occur successfully. And the third framework is based on changing the participant and their social environments if behavioural changes are to be long lasting9.
The SRP framework integrates all three models for changing behaviour in a unique and simple way. It focuses on helping those struggling most with diabetes by influencing them to change from their ineffective habits to effective habits for the long run, thus empowering the individuals to self-manage their disease more effectively (See Figure 1 SRP Framework). A full detailed explanation is included within the Self-Rescue Program™ Instruction Manual, which a copy can be provided upon request.
SRP’s philosophy is based on creating a Mentorship relationship between Program Instructors and Program Participants, which are referred to as Program Mentors and Guests respectively.
SRP is designed to be run by two Program Mentors at the same time with a maximum group size of thirty Guests in a course at any one time. The course content is delivered in the form of powerpoint presentations, visual aids, discussions, specific measurable achievable relevant and time based goals (SMART Goals), written and verbal reflections, written and verbal pathways, field trips, day activities, competitions, an overnight camp and a Facebook social media environment. Activities are held in various types of physical settings which include: the classroom, a kitchen and dining hall, at home, the workplace, at church or place of religion, at a local community gathering place, a medical clinic, the local park, the local nursery, the local supermarket and at an outdoor camping ground.
SRP is about changing the Guest and their social environments; therefore, the Guest’s family and/or friends are involved throughout the program. They are however, especially invited to attend two strategic activities – the Chef Cooking Competition Activity and the Gardening Competition Activity.
SRP Program Stages
The full SRP program is delivered in 3 stages over 5 years which includes (See Figure 1 SRP Framework):
Stage 1 is the Champions course (included in this pilot study). It consists of 55 hours total over 8 weeks for each guest as follows:
- A total of 35 hours dealing with changing the Guest’s behaviour:
- 15 hours – One 3 hour workshop held on week’s 1-3, 6 and 8 within a classroom setting. 20 hours – One Overnight Camp Activity held on week 7 at an outdoor camping ground.
- A total of 20 hours dealing with changing the Guest’s Social Environment:
- 5 hours – Five 1 hour individual modules scheduled throughout the 8 week course held separately within each of the Guest’s home, workplace, place of religion, and other social environments unique to the individual Guest.
- 5 hours – A Gardening Competition Activity held in week 4 which goes for the full day at each Guest’s home with a visit to the local nursery.
- 5 hours – A Chef/Cooking Competition Activity held in week 5 which goes for the full day within a cooking/dining hall setting and a visit to the local supermarket.
Stage 2 is the True Champions course (partially included in this pilot study). It consists of 24 hours total over 2 years for each guest. It includes a 1 hour ‘Return & Report’ session, either online or in-person, each month for the next 2 years immediately following the completion of the Champions Course.
Stage 3 is the Ultimate Champions course (not included in this pilot study). It consists of 12-18 hours total over 3 years for each guest. It includes a 1 hour ‘Return & Report’ session, either online or inperson, every 2-3 months for the next 3 years immediately following the completion of the True Champions Course.
Figure 1 SRP Framework
The SRP program has been fully detailed within the Self-Rescue Program™ Instruction Manual and the Self-Rescue Program™ Workbook which is coordinated and must be used together. The Instruction Manual is written specifically for Program Mentors which outlines in detail exactly how the SRP program should be delivered. The Workbook is specifically prepared for the Guests which should be used as a personal tool to record SMART goals, reflections, pathways, measures and personal progress – a vital record of personal progress and a visual reminder to the Guest of their personal vision of what they are striving to accomplish in the program. Copies of the Instruction Manual and the Workbook can be provided upon request.
PILOT STUDY DESIGN
Pilot Study Period
This pilot study will go for a period of 6 months only which is intended to test the Champions course (only) of the full SRP program.
The pilot study design of SRP is based on ensuring that fair testing10 has been undertaken. It is based on principles of comparing ‘like with like’11 in every aspect deemed reasonable and practically possible.
The pilot will comprise of sixty Maori and/or Pacific Islander adults diagnosed with type-2 diabetes living in the Counties Manukau District, which one group of thirty shall receiving SRP and the other group of thirty shall not receive SRP. Adults will consist of men and women aged 35 years12 and over.
All candidates will initially be identified by their GP and referred for SRP subject to meeting all the prequalification criteria and expressing their willingness to participate in the pilot study. Following the receipt of all GP referrals, all potential candidates will be contacted directly with a personal invitation to attend the briefing meeting where an outline of the pilot study will be given, the SRP Initial Assessment Questionnaire will be completed by each candidate and their solid commitment to participate in the pilot study will be obtained.
Final candidate selection for the two distinct groups, one which will receive SRP and the other which will not, shall be made based on achieving true Blinding13. Candidates for both groups shall be selected at random and without any biases. To ensure validity, thirty female candidate names and thirty male candidate names will be placed into separately concealed envelopes labelled ‘Female’ and ‘Male’ respectively. Then fifteen candidate names will be hand picked out of each concealed envelope. The first fifteen female names and the first fifteen male names drawn out of the envelopes shall constitute Group-1 which will receive SRP. The remaining fifteen female names and fifteen male names shall constitute Group-2 which will not receive SRP. However, both groups will be tested and recorded in the exact same way during the full pilot study.
The baseline will be the test results of Group-1 before receiving SRP and Group-2’s ongoing tests results over the full duration of the pilot study. Effectiveness is determined by the performance above baseline.
All candidates will be eligible to participate in the pilot study if they meet the following requirements:
Inclusions: GP Referral; Diagnosed type-2 diabetes with a haemoglobin A1c and/or a fasting plasma glucose level above the normal target range14 which shall be greater than 53 mmol/mol (or HbA1c 7.0%) respectively; Basic literacy in reading, writing and arithmetic; Physically capable of participating, time availability and commitment to participating in the full pilot study; Signs informed consent.
Exclusions: Medical comorbidity or medication that could affect behaviour patterns, weight or glucose metabolism; Current or planed pregnancy during the pilot study period.
Objective and Measures
The objective of these measures is to determine how effective SRP will be in Maori & Pacific Islander Adults in self-managing their diabetes. To determine this, quantitative tests will be measured and trends will be observed in comparison with the baseline, and between Group-1 and Group-2 results. Tests in the following categories will be undertaken and statistically analysed and reported:
- Haemoglobin A1c levels. (4) Diet: Type, Portions, Number (6) Weight Loss: Kg and BMI.
- Blood Glucose Levels. of Meals, Healthy Cooking. (7) Taking Diabetic Medications.
- Blood Pressure Levels. (5) Physical Activity. (8) Developed Complications.
Objective and Measures
The objective of these measures is to determine how acceptable SRP is by Maori & Pacific Islander Adults. To determine this, a qualitative test will be carried out via a questionnaire, which will ask questions and make statements, which each Guest will be asked to indicate their level of agreement. Answers will be statically analysed and observed in the following categories:
- Cultural Acceptance. (4) Attendance will be recorded (5) Graduation rates will be
- Gender Acceptance. and attrition determined. Its recorded and analysed in total, results will be analysed in total, per gender and per age group.
- Age Acceptance: 35-44 yrs, 45- per gender and per age group.
54 yrs, 55-64 yrs, and 65 yrs plus.
The same questionnaire will be asked of each guest in Group-1 (only) at each test, which responses will show a trend for progression and/or regression as they would have progressed through SRP. All responses will be analysed in comparison per gender and age group. Possible answers include: 1=strongly disagree, 2=disagree, 3=not sure, 4=agree, 5=strongly agree.
Acceptability questions/statements will include the following:
(1) I am happy with the program.
(2) I understand the content clearly.
(3) The pace and length of the program was good.
(4) I understand clearly why I need to self-manage my diabetes better.
(5) I understand clearly how I can self-manage my diabetes better.
(6) I have been able to selfmanage my diabetes better.
(7) I have been able to change my bad habits to good habits.
(8) My family, friends and colleagues were happy to be involved and to support me.
(9) The program was culturally sensitive, appropriate and relevant.
(10) Having all the guests from a similar cultural background in the same group was good for me.
(11) I want to become an Ultimate Champion.
(12) I feel I can become an Ultimate Champion with the help of my family, friends and the Self-Rescue Program™.
(13) The Program Mentors were a great help to me in making the needed changes.
(14) I would recommend this program to anyone who needs help in self-managing their diabetes.
(15) To improve the program, I would make the following comments:
The schedule for testing all sixty Guests will be as follows:
- Test 1 will be undertaken during the week before SRP begins, which will become the baseline.
- Test 2 will be taken at the completion of SRP 8-Week Course, which will be 2 months from baseline.
- Test 3 will be taken at 2 months after the completion of SRP 8-Week Course, which will be 4 months from baseline.
- Test 4 will be taken at 6 months from baseline.
All data and responses for the Effectiveness Measures and the Acceptability Measures will be tested and collected on the same date as per the tests schedule. Data for the Effectiveness Measures will be tested and collated by reputable diabetes specialist GP’s and/or Nurses. The responses to the Questionnaire for the Acceptability Measures will be given out and collected by the Program Mentors.
- Ministry of Health, 2014. A Brief Overview of the 2014 VDR Results. Retrieved on 17 July 2015 from http://www.health.govt.nz/our–work/diseases–and–conditions/diabetes/about–diabetes/virtual–diabetesregister–vdr/2014–virtual–diabetes–register–results
- Ministry of Health, 2014. Annual Report for the year ended 30 June 2014: Including the Director-General of Health’s Annual Report on the State of Public Health and the Minister of Health’s Report on Implementing the New Zealand Health Strategy. Pg 214. Wellington: Ministry of Health.
- Coppell KJ, Mann JI, Williams SM, et al. 2013. Prevalence of diagnosed and undiagnosed diabetes and prediabetes in New Zealand: findings from the 2008/09 Adult Nutrition Survey. New Zealand Medical Journal 126: 23-42.
- Yudkin JS. 2014. The epidemic of pre-diabetes: the medicine and the politics. BMJ 349: g4485.
- International Diabetes Federation, 2014. New Zealand, Diabetes in New Zealand, 2014. Retrieved on 17 July 2015 from http://www.idf.org/membership/wp/new–zealand
- Ministry of Health, 2014. Annual Report for the year ended 30 June 2014:
- Lewin, Kurt. Field Theory and Social Change. (New York: Harper and Brothers, 1951).
Lewin, Kurt. Group Decision and Social Change. (New York: Holt, Rinehart and Winston, Eds. , 1958), 197-211.
- Kotter, John P. Choosing Strategies for Change. (Harvard Business Review, July-August 2008), 130-139.
Kotter, John P. Leading Change: Why Transformation Efforts Fail. (Harvard Business Review, January 2007), 96-103.
- Carlopio, James. Changing Gears: The Strategic Implementation of Technology. (Palgrave Macmillan, January 2003), 4-6.
- Evans, Imogen, Hazel Thornton, Iain Chalmers, and Paul Glasziou. Testing Treatments: Better Research for Better Healthcare. 2nd ed. (London: Pinter & Martin Ltd, 2011), 64-84.
- Evans, et al., 69.
- 35 years of age is chosen as the minimum adult age in this pilot study because the prevalence of diabetes in New Zealand begins to rise more noticeably between the ages of 35-39 years which peaks at the ages of 7579 years.
Reference: Ministry of Health, 2014. Annual Report for the year ended 30 June 2014: Pg 213, Fig 3.26.
- Evans, et al., 79-80.
- NDSS: Diabetes Australia Website, Blood Glucose Monitoring, What HbA1c do I aim for?
Retrieved 15 June 2015 from http://www.ndss.com.au/en/About-Diabetes/Information-Sheets/AboutDiabetes/Blood-Glucose-Monitoring1/#Targets for glycaemic control