Original Research

Increasing Diabetes Educators Condence in Physical Activity and

Exercise Counselling: The Effectiveness of the Physical Activity and
Exercise Toolkit Training Intervention
Christopher A. Shields PhD
a, b,
*
, Jonathon R. Fowles PhD
a, b
, Peggy Dunbar MEd
c
, Brittany Barron BKinH
a
,
Stephanie McQuaid BKin
a
, Carrie J. Dillman BkinH
a
a
School of Recreation Management and Kinesiology, Acadia University, Wolfville, Nova Scotia, Canada
b
Centre of Lifestyle Studies, Acadia University, Wolfville, Nova Scotia, Canada
c
Diabetes Care Program of Nova Scotia, Halifax, Nova Scotia, Canada
a r t i c l e i n f o
Article history:
Received 10 June 2013
Received in revised form
15 August 2013
Accepted 19 August 2013
Keywords:
counselling
diabetes
education
efcacy
exercise
patients
physical activity
Mots cls :
counseling
diabte
enseignement
efcacit
exercice
patients
activit physique
a b s t r a c t
Objective: The objective of this action research was to examine the effectiveness of a comprehensive
intervention (the toolkit) in improving diabetes educators (DEs) perceptions of their abilities and their
patients abilities related to physical activity as part of regular diabetes self-management.
Methods: Two separate studies were conducted. Participants completed measures assessing condence,
attitudes and perceived difculty. In study 1, a quasi-experimental design was used to examine the
impact of the training intervention at 6 months. Cross-sectional sampling at baseline and 12 months then
was used to assess the longer-term impact of the intervention. In study 2, a pre-post design was used to
test the impact of the intervention at 12-months in a separate sample.
Results: The primary nding was a consistent increase in DEs condence in their ability to provide
physical activity and exercise counselling with increases of up to 20% after the training intervention.
Furthermore, DEs reported greater knowledge about physical activity (p<0.03) yet perceived physical
activity counselling to be more difcult after receiving the training (p<0.05). In study 2, the DEs reported
increases in perceived patient knowledge and condence in their patients (p<0.03) after the interven-
tion. Secondary analyses showed that frequently referring to the toolkit was associated with higher
counselling efcacy and lower perceived difculty (p<0.03).
Conclusions: These ndings suggest that the toolkit is an effective resource to improve DEs condence in
the area of physical activity counselling. As a result of this work, the toolkit has been adopted as standard
diabetes care across Nova Scotia and as a foundational resource for DEs across Canada.
2013 Canadian Diabetes Association
r s u m
Objectif : Lobjectif de cette recherche-action tait dexaminer lefcacit dune intervention globale
(le toolkit) dans lamlioration des perceptions des ducateurs spcialiss en diabte (SD) en ce qui
concerne leurs aptitudes et les aptitudes de leurs patients lies lactivit physique dans le cadre de la
prise en charge autonome du diabte.
Mthodes : Deux (2) tudes distinctes ont t menes. Les participants ont rpondu aux mesures valuant
la conance, les attitudes et les difcults perues. Dans ltude 1, un plan quasi exprimental a t utilis
pour examiner leffet de la formation 6 mois. Un chantillon transversal au dbut et 12 mois a ensuite
t utilis pour valuer leffet de lintervention long terme. Dans ltude 2, un plan avant et aprs a t
utilis pour vrier leffet de lintervention 12 mois dans un chantillon distinct.
Rsultats : Le principal rsultat a t une augmentation constante de la conance des SD en leur
aptitude offrir un counseling en matire dactivit physique et dexercice qui a montr des augmen-
tations allant jusqu 20 % aprs lintervention de formation. De plus, les SD ont rapport avoir une
meilleure connaissance de lactivit physique (p < 0,03) bien quils aient peru le counseling en matire
dactivit physique plus difcile aprs avoir reu la formation (p < 0,05). Dans ltude 2, les SD ont
* Address for correspondence: Christopher A. Shields, PhD, Associate Professor,
School of Recreation Management and Kinesiology, Acadia University, Wolfville,
Nova Scotia B4P 2R6, Canada.
E-mail address: chris.shields@acadiau.ca.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes
j ournal homepage:
www. canadi anj ournal of di abet es. com
1499-2671/$ e see front matter 2013 Canadian Diabetes Association
http://dx.doi.org/10.1016/j.jcjd.2013.08.265
Can J Diabetes 37 (2013) 381e387
rapport une augmentation de la connaissance et de la conance perues chez leurs patients (p < 0,03)
aprs lintervention. Les analyses secondaires ont montr que de manire frquente faire rfrence au
toolkit tait associ une efcacit de counseling plus leve et moins de difcults perues (p < 0,03).
Conclusions : Ces rsultats suggrent que le toolkit est une ressource efcace pour amliorer la conance
des SD dans le domaine du counseling en activit physique. En consquence de ces travaux, le toolkit a
t adopt comme norme en matire de soins du diabte dans toute la Nouvelle-cosse et comme une
ressource fondamentale pour les SD dans tout le Canada.
2013 Canadian Diabetes Association
Introduction
Currently, 1 in 4 Canadians has diabetes or prediabetes, and, if
unchecked, the prevalence is predicted to increase to 1 in 3 by the
year 2020 (1). The burden of type 2 diabetes weighs particularly
heavy in Nova Scotia, which has one of the highest prevalence rates
of diabetes in Canada (2), and is well above the national average (3).
Furthermore, evidence suggests the problem is growing because
there has been a 20% increase in the crude prevalence rate of dia-
betes in Nova Scotia between 2004 and 2009 (4). Reports by the
Canadian Diabetes Association (CDA) suggest that the prevalence of
diabetes in Nova Scotia is expected to continue to increase, and is
expected to more than double between 2000 and 2020, with a
commensurate 2.4-fold increase in associated medication and drug
costs (5). Risk factors, such as a rapidly aging population, a low
median family income and high rates of overweight and obesity, are
key contributors to the burden of diabetes felt in Nova Scotia (3).
Clearly, there is a need for effective approaches for addressing the
modiable risk factors in this population.
At the core of ongoing diabetes care is a focus on patient self-
management. To support patient self-management the provision
of effective self-management education and self-management
support (6) by diabetes care professionals is seen as a funda-
mental component of diabetes care (7). Nowhere is the need for
effective self-management education and support more apparent
than in the promotion of lifestyle modication. It is estimated that
more than 50% of cases of type 2 diabetes could be prevented or
delayed with lifestyle changes (8,9). In particular, physical activity
and exercise are recognized as primary interventions to prevent
and manage diabetes and are a recommended part of standard care
(7). Although the terms physical activity and exercise often are
used interchangeably, these terms represent different behaviours.
Physical activity is any bodily movement resulting in energy
expenditure (10) and often is unstructured and can include activ-
ities of daily living and active transportation. Alternatively, exercise
has been dened as a subset of physical activity, one that is plan-
ned, structured and repetitive and is of a sufcient intensity to lead
to improved physical tness or changes in body composition (10).
The CDA clinical practice guidelines highlight the importance of
being regularly physically active yet recommend that individuals
with diabetes also participate in a minimum of 150 minutes of
moderate to vigorous intensity aerobic exercise as well as resis-
tance exercise 3 times each week for optimal management of
their diabetes (7). Despite these recommendations, 60% to 76% of
Canadians with diabetes are inactive (11e13). In addition, recent
evidence has suggested that less than 5% of Atlantic Canadians
living with diabetes are meeting the CDA guidelines for weekly
exercise (14). These disappointing rates of inactivity highlight the
need for further promotion of physical activity and exercise in
diabetes care.
Diabetes educators (DEs) are key resources for those with type 2
diabetes (15) and are well positioned to provide physical activity
and exercise counselling (16). Despite this, promoting regular
voluntary physical activity and exercise remains a difcult chal-
lenge for DEs (17e19). DEs report that they are aware of the
importance of, and have positive attitudes toward, physical activity
and exercise for those with diabetes. However, a large majority
indicate that they are ill-trained and lack the skills, experience and
knowledge necessary to counsel their patients in these areas
(17,18,20). Further, studies have shown that DEs have low self-
efcacy (i.e. condence to manage specic situational demands to
achieve a desired goal) (21) to prescribe or counsel patients
regarding physical activity and exercise (17,18) and to appropriately
refer patients requiring additional clearance for physical activity
(17). Self-efcacy is a key determinant of behaviour (21) and such
low condence may inuence the likelihood that DEs will counsel
individuals with diabetes regarding lifestyle behaviours (22).
Recent work by Dillman et al (17) supports this relationship
because DEs who included physical activity and exercise in less
than 25% of their sessions with patients reported lower efcacy for
physical activity and exercise counselling than those who coun-
selled more often on the topic.
In addition to low levels of condence in their own abilities to
counsel on physical activity and exercise, DEs also have been found
to report very lowcondence in their patients abilities (M(mean)
38%/100%) to manage physical activity and exercise (17). Further-
more, Dillman et al (17) found that DEs perceived that patients did
not view incorporating physical activity and exercise into diabetes
self-care as highly important (M2.8/5). From the perspective of
providing effective self-management education, these ndings are
worth noting because it has been suggested that these other related
beliefs may create self-fullling prophecies. Practitioners uncon-
sciously may conrm their expectations regarding a patients
capability by the approach they use or the tasks they choose for the
patient (23,24). These beliefs also may be passed on to patients,
impacting patients self-efcacy and subsequent behaviour, thus
potentially reinforcing practitioners expectations (23,25). For
instance, a lack of condence in a patients ability to actually
manage physical activity may lead to an avoidance of the topic by
practitioners, and consequently less directed education being
provided to foster patients condence to engage in physical
activity.
Although correlational in nature, ndings by Dillman et al (17)
support this because DEs who included physical activity and exer-
cise counselling less frequently also reported lower levels of con-
dence in their patients abilities to manage physical activity and
exercise. Without sufcient counselling on physical activity and
exercise, patients are likely less able to gain the self-management
skills necessary to engage in the behaviour. This possibility may
be particularly problematic in the context of diabetes education
because patients have been shown to already have low levels of
condence in their abilities to be physically active (13).
It is recognized that improving patients condence and
engagement in the management of their diabetes is the overall goal
of self-management education and support (6). However, it is
difcult to foresee long-term change in physical activity and exer-
cise participation among those with diabetes if diabetes care pro-
fessionals are unprepared to provide effective self-management
education and support in this area and lack condence in their
patients ability to change. As a consequence, it is essential that
interventions aimed at improving physical activity and exercise
counselling in diabetes education not only target DEs perceptions
C.A. Shields et al. / Can J Diabetes 37 (2013) 381e387 382
of their own abilities but also their perceptions of their patients
abilities as well.
In light of the following: (1) increasing prevalence rates of type 2
diabetes in Nova Scotia, (2) the importance of physical activity and
exercise in diabetes self-management, and (3) DEs lack of training
in this area, the Diabetes Care Program of Nova Scotia (DCPNS)
engaged in participatory action research with local researchers to
develop and distribute resources and associated training work-
shops to improve the physical activity promotion among DEs in the
province. The DCPNS is the provincial body that works to establish
guidelines and addresses the standards of care delivered in the
province of Nova Scotia. The purpose of the present study was to
evaluate the effectiveness of this evidence-based, theoretically
driven training intervention to improve DEs self-efcacy, attitudes,
and perceived difculty with engaging in physical activity and
exercise counselling, as well as DEs perceptions of their patients
abilities and attitudes relating to physical activity and exercise in
diabetes self-management.
Methods
To address the overall research objective, 2 separate action
research studies were conducted. Action research is a collaborative
process, often led by organizations or those working in the eld,
and is designed to improve the way a specic issue or problem is
addressed while conducting research around this change in prac-
tice (26). To assess the immediate and longer-term impact of the
resources and training, 3 separate analytic approaches were used.
Specically, in study 1, a 2 (intervention vs. standard practice) by 2
(baseline vs. 6 months postintervention) quasi-experimental
design was used to examine the immediate impact of the training
intervention in Nova Scotia. The longer-term impact then was
examined across the intervention and standard practice groups
using cross-sectional sampling at baseline and 12 months after the
roll-out in Nova Scotia. In study 2, a pre-post designwas used to test
the impact of the intervention 12 months after its introduction in
the remaining Atlantic provinces.
Procedure
Before recruitment, each study received institutional ethical
approval; all participants were required to provide informed
consent. Convenience sampling was used with diabetes care pro-
viders recruited at provincial annual meetings for DEs as well as
through Diabetes Educator Section Chapter Chairs. At annual
meetings, participants were provided the option of completing
and returning the baseline questionnaires on-site or returning
them by mail using a self-addressed stamped envelope. DEs
recruited through a Chapter Chair were asked to complete a
secure, online version of the same questionnaire. At follow-up
evaluation (6 or 12 months), all participants were directed to a
secure website containing the online follow-up questionnaires.
The intervention was funded, in part, by the DCPNS. As a result, in
study 1, those participants recruited from Nova Scotia received the
intervention material whereas DEs recruited from New Brunswick,
Newfoundland and Labrador formed the standard care group. DEs
from these provinces were targeted for recruitment as standard
care participants as a result of geographic proximity and similar-
ities in the context of care and access to resources (e.g. primarily
rural provinces). In study 2, the intervention then was delivered
and tested in New Brunswick, Newfoundland, Labrador and Prince
Edward Island.
Intervention
The training intervention used both Self-Efcacy Theory (27)
and the Transtheoretical Model (TTM) (28) as guiding
frameworks and included 3 components. The rst component of
the intervention was a resource manual referred to as the physical
activity and exercise toolkit. The toolkit was developed in part-
nership with, and including input from, the DCPNS and multiple
experienced diabetes care professionals (e.g. DEs, dietitians,
physiotherapists and physicians) working in the eld. The toolkit
includes 3 sections: (1) an extensive review of the literature on
physical activity and exercise for individuals with type 2 diabetes
including guidelines for risk stratication, assessing readiness for
exercise and a referral process for patients who are at increased
risk; (2) resources such as a decision tree to guide DEs through the
process of assessment and prescription of physical activity and
exercise; and (3) resources to be provided to patients including
sample exercise programs, goal setting worksheets, decisional
balance sheets and informational brochures. The toolkit uses te-
nets of the TTM to provide guidelines for DEs to counsel in-
dividuals on physical activity and exercise based on categorizing
clients into 1 of 3 groups: group 1: inactive, not ready for physical
activity; group 2: inactive, ready or preparing for physical activity;
and group 3: active, already engaged in physical activity or exer-
cise. The recommendations made in the toolkit follow current CDA
guidelines, and are in keeping with the scope of practise of DEs (7).
The second component of the intervention was a 3-hour intro-
ductory workshop on how to use the toolkit effectively. Half of the
workshop was dedicated to presenting each component of the
toolkit as well as key steps in physical activity and exercise pro-
motion for individuals with diabetes. Participants were given
instructions on, and time to practice, counselling, including
motivational interviewing as well as training on how to perform
and instruct patients on the resistance exercises identied in the
toolkit. In the third component of the intervention, participants
were provided with a 3-hour regional workshop aimed at
enhancing their ability to use the toolkit resources and incorporate
them within the context of their specic scope of practice. These
small, interactive workshops were conducted on-site at diabetes
centres and were devoted to problem solving around potential
issues in incorporating the toolkit material within the context of
their specic practice. To facilitate the promotion of physical ac-
tivity and exercise, DEs discussed a range of options from the
toolkit (i.e. providing brochures through motivational interview-
ing) and were encouraged to begin by engaging in the level of
physical activity promotion that best t their expertise and context
of care.
In designing the intervention, attention was paid to the impor-
tance of providing mastery experiences, modelling and positive
feedback because all are key antecedents of self-efcacy (27).
Overall, the intervention aimed to highlight the benets and
importance of physical activity and exercise, and provide strategies
for physical activity and exercise counselling. Furthermore, given
the structural constraints of DEs practice (e.g. limited time and
space and managing patients multiple comorbidities), and the
importance of patients ongoing engagement in physical activity,
the training and associated materials were designed specically
to facilitate improved self-management education and self-
management support related to the promotion of physical activity
and exercise within the current context of practice.
Standard Care
The standard care group was instructed to refer to the CDAs
clinical practice guidelines for physical activity (7) and to provide
Canadas physical activity guide, as per standard type 2 diabetes
outpatient counselling recommendations at the time. This 1-page
resource presents both the benets of regular physical activity
and exercise as well as the health risks of being inactive and pro-
vides suggestions and dose guidelines for a variety of physical
activities.
C.A. Shields et al. / Can J Diabetes 37 (2013) 381e387 383
Measures
Because there is little to no research examining many of the
constructs of interest within the context of diabetes education, all
measures were developed by the researchers for use in the current
work. All measures used in both studies were vetted for appro-
priateness for use in patients with diabetes by an experienced
professional in the diabetes care community with notable experi-
ence in the eld.
Efcacy beliefs
Three efcacy beliefs were measured in each study. Counselling
efcacy was measured using 13 items assessing DEs condence in
their ability to perform specic aspects of physical activity and
exercise counselling with their patients over the next month (e.g.
design a physical activity or exercise program that accommodates
patients individual needs). Referral efcacy was measured by
3 items that captured DEs condence in their ability to refer pa-
tients who require additional clearance or information before
beginning an exercise program that may be outside the scope of
DEs expertise (e.g. referral to physical therapists for those patients
who showmusculoskeletal or orthopedic problems). Other efcacy
concerned DEs condence in their typical patients ability to
perform physical activity and exercise behaviours over the next
month (e.g. set and work toward realistic goals and perform exer-
cise appropriate for their tness level and condition) and was
measured across 3 items. In line with recommendations regarding
the measurement of efcacy constructs, all items were assessed
using a 0% (not at all condent) to 100% (completely condent)
scale (29). Items then were summed and averaged to provide an
overall indication of condence out of 100 for each respective
measure.
Perceived difculty
Perceived difculty was measured using a 4-item questionnaire
that assessed how difcult DEs perceived it would be to incorpo-
rate various approaches of recommending physical activity and
exercise into sessions with their patients (e.g. providing informa-
tion and instruction). Items were assessed on a 1 (not at all difcult)
to 5 (very difcult) scale and were averaged to provide an overall
perceived difculty score out of 5.
Attitudes
Both DEs attitudes and DEs perceptions of their patients
attitudes around physical activity and exercise were measured using
a series of separate items, each rated on a 1 (not at all) to 5
(extremely) scale. Items assessed perceived importance of physical
activity and exercise in diabetes management, how receptive DEs/
their patients would be to an increased focus on physical activity
and exercise counselling in their diabetes care, and how knowl-
edgeable DEs/their patients felt about physical activity and exercise.
Of note, internal consistencies of all multi-item questionnaires
in which composite scores were calculated were acceptable at both
baseline and follow-up evaluation (Cronbach alpha>.80) (30).
Results
Impact at 6 Months
A total of 119 participants provided informed consent and
baseline data. Complete baseline and follow-up data were obtained
from a total of 43 DEs (Mage43.4 years) recruited from
Nova Scotia (intervention), and New Brunswick, Newfoundland
and Labrador (standard care). Multivariate analysis of variance
(MANOVA) and chi-square analyses showed no signicant differ-
ences between those who provided data at both baseline and
6 months and those who did not. The majority of the nal sample
was female (97.6%), and self-reported their ethnicity as Caucasian
(95.2%). In terms of practice, 40.5% of the sample had worked in the
eld for fewer than 5 years and another 40.5% had worked as a DE
for more than 10 years. The majority of the sample saw fewer than
10 patients per day (67.5%), and spent between 20 and 40 minutes
with each client (51.2%). More than 60% of participants had
received/been exposed to instruction on physical activity and
exercise counselling, predominantly in the form of attending a
professional development workshop or related conference pre-
sentation. However, on average, participants reported receiving
only one form of instruction or training in this area.
Before conducting the main time-by-group analyses on DE
perceptions, potential between-group differences at baseline were
examined using MANOVA and chi-square procedures. No signi-
cant differences were found between the intervention and control
groups for any of the main outcome variables at baseline.
To examine the immediate effectiveness of the intervention,
3 separate 2 (group) by 2 (time) repeated-measures MANOVAs
were conducted to assess potential differences on the following: (1)
DEs efcacy in their own abilities in physical activity and exercise
counselling and appropriate referral, (2) DEs attitudes and
perceived difculty regarding physical activity and exercise
counselling and (3) DEs perceptions of their patients beliefs and
abilities regarding physical activity and exercise.
The rst MANOVA showed both signicant main and interaction
effects. There was a signicant main effect for time (Wilks.83,
p0.027) with univariate follow-up tests indicating that, overall,
DEs condence in providing physical activity and exercise counsel-
ling increased signicantly (p0.008) from baseline (M51.06) to
6 months (M58.31). However, this main effect was superseded by a
signicant time-by-group interaction (Wilks.82, p0.019) with
subsequent univariate F tests showing that the interaction
was signicant for counselling efcacy (p0.01). Post hoc Bonferroni
corrected tests showed that the counselling efcacy of those in the
intervention group was signicantly higher at 6 months (MIN-
T6mo68.34) as compared with the levels of the intervention group
at baseline (MINTbase54.02), as well as compared with the coun-
selling efcacy levels of the standard care group at baseline and
6 months (MSCbase48.01, p0.001, MSC6mo48.27, all p<0.001).
The second MANOVA showed a signicant main effect for time
(Wilks.58, p<0.001). Follow-up univariate tests indicated a sig-
nicant overall increase in DEs perceived difculty (p0.001) with
physical activity and exercise counselling from baseline (M2.66)
to 6 months (M3.71). No other signicant effects were found.
The nal repeated-measures MANOVA showed a signicant
main effect for time (Wilks.54, p0.001). Follow-up univariate
tests indicated that this main effect was signicant for both
perceived patient receptiveness (p0.003) and DEs condence in
their patients (p<0.001). Overall, DEs perceived their patients to be
more receptive to an increased focus on physical activity and
exercise in their education sessions with their DE at 6 months
(M3.46) compared with baseline (M3.13). Furthermore, DEs
condence in their patients abilities to manage physical activity
and exercise increased from baseline (M40.18) to 6 months
(M50.17). No other statistically signicant effects were found.
Results of study 1 at 12 months
Separate cross-sectional samples were drawn at baseline
(N121, Mage44 years, 57% toolkit) and 12 months after the
introduction of the toolkit intervention in Nova Scotia (N124,
Mage44 years, 66% toolkit). Between-group analyses were
conducted at baseline and then again using the samples obtained
at 12 months. Before distribution of the toolkit, MANOVAs and
chi-square tests showed no signicant between-group differences
C.A. Shields et al. / Can J Diabetes 37 (2013) 381e387 384
on DE perceptions or practices. However, 12 months after the
intervention, separate MANOVAs showed signicant effects for DE
efcacies (p0.021) and DE attitudes and perceived difculty
(p<0.001), with those who received the toolkit intervention
reporting higher counselling efcacy (MINT58.0, MSC50.4,
p0.03), and greater knowledge around physical activity in dia-
betes management (MINT3.44, MSC3.07, p0.02) yet greater
perceived difculty in including physical activity and exercise
within their counselling sessions with their patients (MINT2.98,
MSC2.37, p0.001) compared with those offering standard care.
No other signicant between-group differences were found.
Effect of toolkit implementation at 12 months: secondary analysis
Although these results indicated that DEs who received the
toolkit had higher condence in their abilities to counsel, and
believed they were more knowledgeable about physical activity
and exercise counselling after having the toolkit for several months,
the magnitude of these ndings are moderate at best. As a result, a
secondary analysis was performed to examine the implementation
level of the toolkit resources by DEs in practice, and to explore the
impact the implementation level had on the perceptions of DEs
receiving the intervention. By examining the responses of DEs
providing data 12 months after the toolkit was introduced (N78)
it was found that the majority (58.2%) of DEs referred to or made
use of the toolkit in less than 25% of their sessions with patients.
Two separate MANOVAs then were conducted to examine
whether DEs personal perceptions and perceptions of their clients
at 12 months differed across those who used or referred to the
toolkit in more than 50% of their sessions with patients (n17)
compared with those who used the resource in less than 50% of
their regular sessions with patients (n61). An overall effect for
implementation level was found for DEs personal perceptions
(Wilks.83, p0.031). Specically, compared with those who used
the toolkit resources in less than 50% of their sessions with patients,
DEs who referred to the toolkit in the majority of their sessions
with patients had higher counselling efcacy (M>50%68.09,
M<50%56.22, p0.004) and lower perceived difculty (M>50%
2.56, M<50%3.11, p0.026). There were no signicant differences
in the perceptions of clients held by DEs across the 2 levels of
toolkit implementation.
Study 2: retesting the toolkit impact
Once the toolkit intervention had been fully rolled out in Nova
Scotia, a second, separate action research study was conducted to
deliver the toolkit and evaluate its effectiveness among DEs from
the remaining Atlantic provinces. From an original sample of
144 DEs, complete matched data were obtained from 34 DEs
(Mage44.4 y) drawn from New Brunswick, Newfoundland,
Labrador and Prince Edward Island at baseline and 12 months after
the toolkit intervention was introduced in these provinces. The
majority of the nal sample was female (94.1%), self-reported their
ethnicity as Caucasian (91.2%) and had worked in the eld for more
than 8 years (53.1%). To examine the effectiveness of the inter-
vention, 3 separate pre-post, repeated-measures MANOVAs were
performed. Before conducting the main analyses, MANOVA showed
that there were no differences across those who provided complete
data and those who did not on any of the primary variables of in-
terest (Wilks.90, p0.15).
The rst MANOVA showed a signicant change in DEs self-
efcacies (Wilks.46, p<0.001) with univariate follow-up tests
indicating that DEs condence in providing physical activity and
exercise counselling increased signicantly (Mbase39.05,
M12mo59.72, p<0.001). The second MANOVA showed signicant
changes in DEs attitudes and perceived difculty (Wilks.55,
p0.001). Follow-up univariate tests indicated signicant increases
in DEs knowledge about physical activity (Mbase3.03,
M12mo3.54, p0.005), as well as perceived difculty in including
physical activity counselling in their sessions with patients
(Mbase2.20, M12mo2.61, p0.049). The nal MANOVA showed
signicant changes in DEs perceptions of their patients beliefs and
abilities (Wilks.65, p0.010) such that signicant increases were
seen in both DEs perceived patient knowledge (p0.026,
Mbase2.29, M12mo2.65) and DEs condence in their patients
(Mbase33.78, M12mo46.77, p0.002).
Discussion
The purpose of this action research was to conduct an initial
evaluation of the effectiveness of the physical activity and exercise
toolkit intervention in improving DEs self-efcacy, attitudes and
perceived difculty regarding physical activity and exercise coun-
selling, as well as DEs perceptions of their patients abilities and
attitudes regarding physical activity and exercise. The toolkit
training was shown to be effective in improving DEs condence in
their ability to provide physical activity and exercise counselling
with evidence of increases of up to 20% at 6 and 12 months after the
introduction of the resources. Further, the DEs reported having
greater knowledge about physical activity as part of diabetes care as
a result of receiving the toolkit training. These ndings are in line
with previous work that highlights the importance of supplemen-
tary training around lifestyle modication to increase the con-
dence of diabetes care providers in delivering advice in this area
(18,19,31,32). The current ndings also build on existing research
by providing insight into the impact of physical activity and exer-
cise training on the other efcacy perceptions DEs hold of their
patients. Specically, there was evidence that DEs condence in
their patients abilities to manage physical activity and exercise as
part of diabetes self-management increased after the intervention.
This represents an extension of previous work because both self-
and other efcacy beliefs are theorized to play an important role in
the practitioner-patient relationship. Training that can enhance
both efcacy beliefs has the potential to lead to more effective
self-management education.
Although the present ndings provide an encouraging demon-
stration of the effectiveness of the intervention on the efcacy
beliefs of DEs, a number of unexpected results are also worth
noting. First, increases in perceived difculty in physical activity
and exercise counselling were seen over time, particularly after
receiving the toolkit training. This may be owing, in part, to DEs
involvement in a study focused on the inclusion of physical activity
and exercise counselling in diabetes care leading to a heightened
awareness of the regular inclusion of this topic in practice (standard
care group) and the complexities of doing so (intervention group).
Although counterintuitive, perceptions reecting a realization of
how difcult behaviour change can be is not uncommon in the
exercise literature (33). Second, no signicant changes were seen in
DE referral efcacy as a result of the intervention. The lack of
change in referral efcacy as a function of training may reect a
continued lack of access to the appropriate professionals. Despite
receiving training on referral practices, no changes in the avail-
ability to other health professionals were made as part of the
intervention. These ndings are supported by previous work in
which DEs identied lack of resources as a key barrier to effective
physical activity and exercise counselling (17). Finally, although
signicant improvements in condence were seen after exposure
to the training, a secondary analysis showed that the imple-
mentation of the resources overall was lower than hoped. The
results suggest that increased use of the resources is associated
with improvements in condence regarding physical activity
counselling, and future work aimed at improving the level at which
C.A. Shields et al. / Can J Diabetes 37 (2013) 381e387 385
DEs implement the resources may further enhance the impact of
the training in practice.
Limitations
The present action research study was designed to develop,
deliver and evaluate physical activity and exercise training using an
evidence-based, theory-driven resource designed to t within the
current context of diabetes care in Nova Scotia. The initial ndings
illustrate the effectiveness of the toolkit training in signicantly
improving DEs condence to counsel patients on physical activity
and exercise. It is recognized that the effects detected were modest
and that there were limitations to this study. Because of the rolling
delivery of regional workshops, some DEs had a relatively short
amount of time to read, become familiar with and use the toolkit
resources within their practice. Despite nding signicant effects
and signicant interactions, the matched 2 2 and pre-post ana-
lyses used small samples, thus limiting the statistical power of this
work. Although it is acknowledged that the variability present in
the data may be a true reection of the variability in perceptions
held by DEs with varying levels of experience (34), further exami-
nation of the toolkit training should use larger samples. Further-
more, although participants providing matched data over time
were shown not to differ from the larger baseline samples, the loss
of participants over time was a limitation. Likewise, although the
ndings provided by the cross-sectional analysis used to explore
differences at 12 months provided insights into the effect of the
intervention over the longer term, stronger evidence may have
been obtained if matched data over time had been obtained.
However, it should be noted that the objectives of this action
research project were 2-fold: to develop and distribute a much-
needed resource to DEs to address the gap that exists in physical
activity and exercise counselling in diabetes care and to evaluate
this resource within the current context of care. As such, the
challenges in obtaining matched follow-up data from larger sam-
ples may have, in part, been a reection of the demanding nature of
diabetes care. Future work will need to recognize the importance of
integrating data collection on effectiveness with, and not in addi-
tion to, current practices and professional demands. Finally,
although the examination of DEs perceptions is essential to un-
derstand the impact of training interventions, future work exam-
ining the impact of training on perceived barriers, counselling
behavior and client outcomes is needed.
Taking the next step: practice implications
The current standard of diabetes care emphasizes patient self-
management, and by extension the importance for diabetes care
professionals to provide effective self-management education (7). It
is important for diabetes care professionals to develop condence
in their physical activity and exercise counselling as well as in their
patients abilities to perform this mode of self-management. Based
on the current ndings, the toolkit intervention has the potential to
improve self-management by leveraging the knowledge and beliefs
of DEs in providing self-management education in this area.
As a result of this research project, the toolkit was adopted as
standard care in diabetes centres across Nova Scotia. Further, since
the development of this resource, the CDA has made physical ac-
tivity and exercise counselling a pillar in the training and delivery of
diabetes education. The toolkit has now been adopted as a foun-
dational resource for diabetes care across Canada.
Acknowledgements
The toolkit was developed using seed funding fromthe Diabetes
Care Program of Nova Scotia. The research evaluation component
was funded by a grant from the Lawson Foundation. TheraBand
Academy donated resistance bands to be included in all of the
toolkits used in the intervention.
Author Contributions
Christopher Shields and Jonathon Fowles were co-authors of the
toolkit resource and worked in collaboration with Peggy Dunbar in
the design and delivery of the intervention workshops; Christopher
Shields and Jonathon Fowles were co-investigators on the project
and were involved in all aspects of the research process including
conceptualization, design, delivery, data collection and analysis and
manuscript preparation; Peggy Dunbar contributed to the design
and delivery of the workshops and also was integral in the
conceptualization of this action research, in facilitating data
collection and in preparing the manuscript; Brittany Barron,
Stephanie McQuaid and Carrie Dillman were all project
coordinators and were involved in the coordination and delivery
of the intervention, made signicant contributions in workshop
delivery and all made substantive contributions to data collection
and analysis. The submitted manuscript was approved by all
contributing authors.
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