The need for prevention strategies is paramount to deal with the rising incidence of diabetes in the United States. The Centers for Disease Control and Prevention (CDC) estimated in 2019 that at least 88 million American adults have prediabetes (pre-DM), meaning they are at risk for type 2 diabetes (T2DM); eight out of 10 adults do not know they are at risk (CDC, 2019a). The Diabetes Prevention Program (DPP) is a national initiative that involves education to delay or prevent T2DM in individuals at high risk and to assist those diagnosed with T2DM to manage the disease and prevent complications by promoting lifestyle changes (National Diabetes Education Program, 2019).
The DPP was incorporated into an intervention led by faith community nurses (FCNs). A qualitative study design used the Delphi Survey technique to survey coaches about spiritual interventions utilized while leading a DPP course. This study asked the question, "What does the application of the Delphi Survey Technique reveal in terms of establishing the relative importance of spiritual interventions used by faith-based coaches leading DPP courses?"
LITERATURE REVIEW
The literature affirms a need to provide spiritual care to patients, to determine how healthcare providers should offer this dimension as part of their care, and how to educate nurses, medical staff, and students to complete spiritual assessments and care interventions (Pullen et al., 2015). However, few studies have surveyed nurses or healthcare providers about their spirituality and whether their beliefs may or may not impact their professional practices.
Coughlin et al. (2017) assessed spirituality in 406 maternal-child nurses, physicians and residents, and other healthcare workers at three hospitals in Philadelphia. Subjects who reported they were of Christian denomination and African American or Asian culture reported using more spiritual care practices. There was a positive correlation between those who were more spiritual and those who incorporated spiritual care and reflective practices into their work experience (Coughlin et al., 2017).
Another study by Hafizi et al. (2014) surveyed 720 Muslim nurses, medical students, and physicians from several hospitals in Tehran, Iran, about their spirituality, religious attitudes, and practices. Female physicians and nurses who were married reported higher levels of spirituality. Training level was inversely related to spirituality, with fewer years in practice or school reporting more spirituality (Hafizi et al., 2014). More schooling and time in practice decreased use of spiritual practices.
The findings of Coughlin et al. (2017) and Hafizi et al. (2014) showed that the more that providers are spiritually oriented, the more the providers tend to engage in spiritual behaviors in their role as healthcare providers. With 78% of Americans reporting that they believe in God and an additional 15% saying they believe in a higher power or universal spirit, linking the spirituality in providers with patients is an intervention that needs further exploration (Coughlin et al., 2017).
There is a need to identify spiritual interventions (SI) and measure the influence of spiritual/religious (S/R) activities in the support of diabetes self-care management. Spiritual interventions are therapeutic strategies that use a spiritual or religious dimension as a central component of the intervention (Hodge, 2011). Multiple disciplines (nursing, social work, psychology) have incorporated SIs in the treatment of anxiety, stress, substance abuse, depression (Goncalves et al., 2015), dementia (Ennis & Kazer, 2013), eating disorders (Richards et al., 2006), and cancer (Oh & Kim, 2014).
Spiritual interventions involve supporting clients' religious or spiritual beliefs (Koenig, 2013). People who are actively involved in religion or a church help each other such as offering emotional and spiritual support (Ellison & Hummer, 2010). The SIs listed in this research could fall into these categories, but are not mutually exclusive. Active listening, emotional support, touching/hugging, adding humor, and being present may fall under emotional support to generate feelings of belonging. Forgiveness facilitation, hope/inspiration, meditation facilitation, spiritual/sacramental rituals, and prayer may fall under spiritual support involving finding or sharing meaning between people (Ellis & Lloyd-Williams, 2012; Ellison & Hummer, 2010).
Research is needed that compares health outcomes in S/R environments with environments that do not (Koenig, 2011). Research is scarce in identifying and measuring the influence interventions provided by FCNs and other ministry workers on the outcome of health prevention programs, including diabetes prevention and management (Dyess et al., 2010; Unantenne et al., 2013). A few studies have reported outcomes in diabetes programs infused with SI such as religious rituals, prayer, meditation, and Scripture reading (Austin et al., 2013; Campbell et al., 2007; Kitzman et al., 2017; Ziebarth, 2014).
PROGRAM BACKGROUND
The basic format for the yearlong DPP includes a "core" segment and a "maintenance" segment. Weeks 1 through 26 comprise the core program and involve weekly group classes on dietary choices, physical activity, managing stress, and getting back on track after a slipup. Weeks 27 through 52 are the maintenance program: Six semimonthly or monthly classes cover topics about goal setting, staying motivated, and overcoming barriers (CDC, 2019b).
Diabetes programs offered in churches or community settings have reported positive outcomes such as weight loss and improved glucose control (Gutierrez et al., 2014; Sattin et al., 2016; Yeary et al., 2015). The DPP courses in this research study were offered in a Midwest state as a collaborative effort between a community health funding agency and a local hospital's Faith Community Nursing Department (FCND). The FCND provided coordination and recruitment of participants, recruitment and training of coaches, and implementation of the DPP courses.
Setting and participants
This qualitative study design used the Delphi Survey technique to survey coaches about SIs utilized while leading a DPP course. These coaches can be multidisciplinary, professional, paraprofessional, or lay persons. All coaches attend a standardized training program delivered by DPP trainers (CDC, 2018). For this study, coaches self-identified as a faith-based (FB) coach or a community-based (CB) coach.
Faith-based coaches. There are two types of FB coaches: FCNs or lay coaches. An FCN has specialized training and practices in a faith community and intentionally integrates faith in the promotion of holistic health to prevent and minimize illness (Dyess et al., 2010; Ziebarth, 2014). A lay coach may or may not be a healthcare professional (but not an RN) who is a member of a congregational health team or ministry.
Community-based coaches. A CB coach can be an RN, a healthcare professional, or a lay person. These coaches may work in the healthcare field not specifically related to diabetes education, such as social work, pharmacy, dietetics, and the like. They also may be members of the community-at-large and interested in wellness.
The DPP courses for this study were held from September 2015 through October 2017; all coaches were invited to participate. The FCND coordinated the courses and coach training. The coach names and DPP course locations were obtained by the researcher from the FCND program coordinator and web services specialist within the department.
METHODS
The purpose of this study was to identify SIs that FB coaches may use in their DPP classes, using a two-round Delphi Survey Technique. This study was approved by the Institutional Review Boards of the author's university and the hospital system.
The FCND coordinated the DPP courses that included recruiting and training the coaches. Fifteen coaches who had completed the core program (weeks 1-26) were invited to participate via an email letter and consent form that explained the research. After consenting to participate, the coaches completed a nine-question demographic survey. Eleven surveys were received from the coaches (six FB and five CB coaches).
At the demographic survey's end, an additional screening question was posed: "Have you been trained as a faith community nurse or are you part of a congregational (church/religious) health team participating as a DPP coach for your congregation?" If coaches responded "yes," they were asked to continue to the second part of the study that included the Delphi Survey. If the coaches clicked no, they exited the survey.
Design
The coaches who self-identified as FB moved on to answer the Delphi Survey. This technique is a method for achieving consensus from selected groups to assist in making decisions about real-world knowledge or to solve problems (Hsu & Sanford, 2007; McMillan et al., 2016). The procedure included using six FB coaches who were viewed as experts to develop consensus about SIs used while leading a DPP course. In the first round, the coach received a list of 10 SIs based on the FCND documentation system and a review of the literature. The coaches indicated which SI they used, if any, with an individual, the group, or both. The coaches could list other interventions used or describe how they used the SI.
The second round of the Delphi Survey was emailed after round one was analyzed. The most frequently indicated interventions (top 50%) plus any that were mentioned in the comment portion developed the second questionnaire. For the second round, the coaches indicated how important each SI was to support DPP participant success. The SI was rated using a Likert-type scale: 4) very important, 3) important, 2) somewhat important, or 1) not important.
Data analysis
Data analysis of the demographic data from the two groups of coaches included using Chi-Square and Fisher's Exact Test for categorical variables to determine statistical differences. Data analysis for the Delphi Survey involved evaluating responses to this multistage questionnaire including individual feedback. Round one results helped to develop the next round. The number of rounds initiated is dependent on the level of dissension expected on the topic and can be modified depending on the results from the previous round (Holey et al., 2007). In most studies, two rounds are used.
RESULTS
Fifteen DPP coaches were invited to participate in this study. Eleven (N = 11) completed the demographic survey. Six self-identified as FB coaches either as an FCN (n = 3) or as a member of a congregational health team/ministry (n = 3). The five remaining coaches identified as CB nurses (n = 4) and one dietitian. All coaches were female. Most coaches were age 51 to 65, with 64% white as compared with 36% African American. Nearly 50% of the coaches were employed full time and all had college degrees (Table 1). Most of the classes were held in community settings (82%) as compared with FB settings (18%). All coaches indicated they were active members of their church or religious organization, with 82% being Christian.
To determine if a significant difference existed between the FB coaches and CB coaches based on the demographic information, Chi-Square crosstabs were computed. The Fisher's Exact test was used for statistical analysis due to the small sample size of 15 (Fields, 2009). No statistically significant differences were noted between the two groups of coaches based on age, education, race, employment, religious denomination, or site of the DPP course (Table 1).
Six FB coaches completed a two-round Delphi Survey (Table 2) about SI used while leading a DPP course. The six coaches served as "experts" to develop a list of the type and frequency of SI used. In the first round, the Delphi Survey included a list of 10 SIs. The results showed that 8 of the 10 interventions were used by all the FB coaches. Two of the interventions-meditation facilitation and presence-were not used by 50% of the coaches (Table 2). Reasons may include the classroom style and time constraints. These interventions were eliminated for round two.
Comments from the coaches about SI used in round one of the Delphi Survey include, "Sometimes I have used prayer along with encouragement for participants" and "We always start a session with prayer." Another coach commented about hope and inspiration: "I frequently point out how Jesus never criticized anyone who came to him for help. I point out how he always encourages us to start over when we mess up. I mention this throughout the program, but especially in Session 11."
The second round invited the coaches to rate the eight remaining SIs on the importance of using them in a DPP group setting. The FB coaches rated each SI based on this statement: "Please indicate how important the intervention is to help a participant be successful in the DPP program" (Table 3). The responses ranged from two to four for all six coaches, which indicate all the SIs are at least somewhat important.
Five of the six coaches commented about SIs. One coach indicated she used Bible verses. Four coaches described using prayer, and one encouraged participants to lead the prayer. Results from this survey showed that active listening, emotional support, and prayer are the SIs that all FB coaches reported as very important to support participants. One coach wrote: "I use a prayer to start the meeting, and frequently end the meeting with prayer. I point out how similarly difficult it is to change our habits, whether our sinful habits or our eating/physical activity habits."
Another coach commented: "The group shared personal successes and setbacks and we emailed and shared prayer requests. This helped keep the group connected."
Giving hope and use of humor (83.3% each) were rated very important by five of the six coaches. Two coaches noted, "I write a different inspirational/humorous quote on the whiteboard at each meeting. I reinforce how important it is to stay positive and to encourage oneself and look for even the smallest changes of behavior." This coach added, "I like to add humor to keep the participants relaxed and not uptight. I find that being happy helps, also."
Use of spiritual/sacramental activities was rated important by 83% of the coaches. An interesting finding is that the "touch/hug" intervention was rated as somewhat important (16.7%) and important (33.3%). The coaches seemed to be respecting the need for personal space when using this SI in group settings.
In summary, the results of this Delphi Survey showed that all the FB coaches reported using prayer, active listening, and emotional support in leading their DPP course. Furthermore, giving hope, incorporating humor, and using spiritual/sacramental activities were rated as important or very important by the majority of coaches.
DISCUSSION
Among this group of professional and paraprofessional coaches, 81% indicated they practice a religious faith. The coaches in this study were not randomly assigned to teach a DPP course at a specific site. As the coaches were trained and sites became available, coaches were offered a site for classes. Thus, introducing a spiritual aspect at a CB site was up to the coach and the participants. Including religious/SIs is considered a modification to the DPP without changing the curriculum. Research focusing on participant outcomes and enlisting FB coaches who are allowed to use SIs needs to continue. It cannot be assumed that all nurses or all DPP coaches are spiritual or religious. Research needs to continue to survey the coaches and the participants about their spirituality.
Three of the six FB coaches in this study were FCNs. Six service areas typically provided by the FCNs are health education, personal counseling, health screening, referral, spiritual support, and health advocacy (Schroepfer, 2016). In the current study, the FCNs worked with groups of DPP participants who provided five of the six identified service areas. The activities of the FB coaches (nurse and nonnurse coaches) leading a DPP included physical care (blood pressure and weight screened at every class), emotional care (active listening, giving emotional support, providing hope, and use of humor), group discussion, health screening (the initial DPP screening form), spiritual care (praying with the class and using spiritual/sacramental activities), and being a health advocate. The FCNs provided spiritual care as a main component of nursing care, which is valued and expected in faith communities (Schroepfer, 2016).
A secondary data analysis by Hixson (2019) reviewed the health education (group and individual activities) and SIs used by FCNs. Data were collected from 13,715 participants from five faith community networks in four states. In reviewing documentation for SIs, the top five were active listening, prayer, presence, promoting understanding, and touch/hug. Like this research, prayer, active listening, and emotional support were most commonly used by the FB coaches leading their DPP course. In contrast, hug/touch was used less frequently by DPP coaches.
Three of the FB coaches in this study were members of their congregational health ministry team. The diabetes literature promotes the use of lay community members to provide selected health services. The American Association of Diabetes Educators (2009) published a position statement about using community health workers in diabetes management and prevention. Most community health workers are employed by healthcare systems or health departments because they share the culture, language, and life experience of the people they serve (Crespo et al., 2015).
Finally, when a person is diagnosed with diabetes or discovers that he or she is at risk for diabetes, education about lifestyle changes and social support are both needed. Social support includes family, friends, work colleagues, school personnel, and religious gatherings. A new diagnosis of diabetes may disrupt some of these relationships (Koenig, 2013). Changing lifestyle behaviors to promote health and prevent illness are more than biological/physical manifestations. The impact includes psychological, behavioral, and spiritual dimensions that embrace the whole person, their family, and their support systems.
LIMITATIONS
Study limitations included the small sample size. Also, this research was done at the beginning stages of the supporting hospital's development of the DPP and further credentialing of the program through the CDC. Additionally, coaches were not randomized to the classes that they led. Another limitation is that outcomes were not measured for the participants, which is the reason behind offering DPPs. Outcomes based on FB or CB coaching are currently being evaluated utilizing this hospital program that will be reported at a future time.
CONCLUSION
This research surveyed a group of DPP coaches providing courses both in FB and CB settings. The coaches incorporated SIs as they felt appropriate to support individual goals. Spiritual interventions and using FB coaches are a DPP modification provided to support diabetes health education in a community. Further study is needed with a larger sample size to fully explore the impact of FB coaches and SIs in providing DPP courses.
Web Resources
* American College of Preventative Medicine: Diabetes Prevention-https://www.acpm.org/initiatives/diabetes-prevention/
* American Medical Association-https://amapreventdiabetes.org/tools-resources
* Centers for Disease Control and Prevention: National Diabetes Prevention Program-https://www.cdc.gov/diabetes/prevention/index.html
* Faith Leaders Toolkit: Diabetes Prevention and Management-http://peersforprogress.org/wp-content/uploads/2016/06/160627-faithleaders_toolk
* Rural Health Information Hub: Faith-Based Model-https://www.ruralhealthinfo.org/toolkits/diabetes/2/faith-based
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