This study demonstrates that it is possible to work with a group of diverse stakeholders - people with diabetes, healthcare professionals and policy makers - in a consensus process to co-produce a prioritised list of behaviours to target for intervention research. Key stakeholders are more likely to drive forward the implementation of research findings for research topics important to them and over which they feel ownership. By engaging with key stakeholders from the outset, we have begun developing strategic alliances with health partners and service users which will be maintained throughout the programme of research.
Utilizing a nominal group process approach resulted in the identification of priorities at a broader level than could have been achieved with a more narrow focus on treatment uncertainties. Attendance and engagement with structured education, for example, would not have been identified as a priority if we had followed the guidance provided for James Lind Alliance Priority Setting Partnerships as evidence on the efficacy of structured education programmes is already available. Our approach allowed stakeholders to identify behaviours where regular performance of the behaviour, rather than treatment uncertainty, is the major problem.
The nominal group process findings indicated that in most cases, the most highly ranked behaviour was the same for Ranking 1 and Ranking 2, suggesting that the discussion and re-ranking process did not significantly change participants’ views. However, there were examples where behaviours featured in the top 6 at Ranking 2 but not at Ranking 1, presumably reflecting the impact of suggestions and arguments offered by participants during group discussions. Details of the discussions that might have led to these changes were not recorded, but would make an interesting and useful addition to future nominal group exercises. As expected in a consensus building study, consensus generally increased in relation to endorsement of the most highly ranked behaviours between the first and second rankings.
A number of striking findings emerged in relation to the most highly ranked priorities. For people with Type 1 DM there was general consensus that targeting ‘taking insulin as required’ is the most important behaviour for research. Indeed, the top three highest ranked behaviours were related to effectively monitoring and managing blood glucose, by administering insulin and counting carbohydrates. The skills required for people with Type 1 DM to maintain good glucose control are complex and demanding [21]. A number of studies report that glucose control remains unsatisfactory despite close monitoring and participation in educational programmes by many people with Type 1 DM [22], although there is some evidence that training in flexible, intensive insulin treatment can improve glycaemic control [23]. Future research should focus on developing and delivering effective interventions to promote the skills needed by people with Type 1 DM to achieve good glycaemic control.
For people with Type 2 DM, attending and engaging with structured education programmes was most highly ranked. Research into structured education programmes for people with Type 2 DM in Ireland has been lacking, but recent studies have demonstrated the efficacy of structured education in Ireland [24]. However, a significant proportion of people with Type 2 DM are either not offered or do not attend structured education programmes [25]. Future research should focus on ways to engage people with Type 2 DM in education programmes, as well as ensuring that such programmes are as patient-centred as possible to increase the benefits to participants.
Interestingly, behaviours related to collaborative goal setting and patient-centred care were highly ranked. ‘Engage in collaborative treatment goal setting with patients’ was the top ranked healthcare professional behaviour for the management of both Type 1 DM and Type 2 DM. Among people with diabetes, patients’ perceptions of collaborative care (including collaborative goal setting) have been shown to be associated with patients’ reported self-management [26], however, the relationship between collaborative goal setting and clinical control among remains poorly understood [27]. Future research should focus on interventions to promote the use of collaborative goal setting among healthcare professionals and people with diabetes, and measuring the associated impact on clinical outcomes.
In relation to preventing Type 2 DM, the most highly ranked behaviours were promotion of healthy exercise and diet, with priority given to engaging in healthy behaviours as a family. There is considerable evidence that increased levels of physical activity are related to better clinical outcomes in diabetes, and additional evidence that physical activity interventions are particularly effective when combined with dietary advice [28]. There was much discussion at the meeting around the need to advocate for policy change and attempt to promote environmental change to support healthy behaviour. There is evidence that environmental and policy approaches lead to increases in physical activity [29], and future research should focus on finding ways to maximise the role of behavioural science theory in development and implementation of public health interventions [30].
For healthcare professionals’ behaviours to prevent Type 2 DM, the highest ranked behaviour was ‘attend and engage with behaviour change training’. Recent trials of behaviour change counselling have found limited effects on behaviour change outcomes [31]. Future research should focus on finding more effective ways to train healthcare professionals to promote behaviour change among their patients.
The current study forms the first step in a behaviour change intervention development process. One behaviour relevant to people with diabetes, and one behaviour relevant to healthcare professionals, will be selected as targets for intervention development. As per recommended guidance [32], the selection of target behaviours will be informed by the comparison of the top behaviours identified in each key area under criteria of the likely impact of changing the behaviour, the likelihood of change, the potential positive or negative spillover to other behaviours and the ease of measurement of each behaviour.
Limitations
Post-meeting feedback indicated that participants would have liked more time for discussion, although whether this would be best achieved through a longer meeting or additional meetings was unclear. Addressing priorities for both Type 1 DM and Type 2 DM on the same day may have been overly ambitious and at times the research team agreed that the meeting felt rushed. Covering Type 1 DM and Type 2 DM at the meeting reflected an attempt to reduce time and travel burden for participants who had experience of both conditions. More time for discussion might have resulted in slightly different priorities. However, when asked how they found the length of the meeting, one third of participants indicated that the meeting was too long. Finding balance between adequate time for discussion and reducing burden on participants with busy schedules is a challenge and should be considered in future research prioritisation exercises.
The nominal group technique has been recommended for groups no larger than ten people [19]. However, to ensure we addressed a range of stakeholder experiences we included different types of healthcare professionals, as well as patients and policy makers. Including this range required a larger number of participants. This may also have added to the sense of the process being rushed as group feedback took longer than with a smaller number of participants. Future nominal group technique processes that require larger numbers could consider guidance from Cantrill et al. [19] to split the sample into two or more groups and to pool results.
Consensus refers to level of agreement among participants in a given round and stability refers to level of agreement between rounds. We did not decide on a priori levels of agreement and stability required for consensus but instead chose to work through two ranking rounds within a one day meeting. The degree to which true consensus was reached is not clear, although in general the endorsement of the most highly ranked behaviours increased between the first and second rankings.
Previous discussions on the use of nominal group technique have debated the merits of mixed versus homogenous groups of participants [19, 33]. As our intention was to achieve consensus on the most important target behaviours for research in diabetes in Ireland we included a mix of patients, providers and policy makers, as each of these stakeholders have a role in behaviour change in diabetes. Despite the best efforts of the experienced facilitator, it is possible that patients may have felt less confident in voicing their opinions given the potentially hierarchical nature of provider-patient relationships. However, the initial generation of lists of behaviours and the actual ranking of behaviours were conducted privately to reduce social pressure and to allow the opinion of each participant to be given equal weighting.
Our nominal group technique process also lacks the representativeness that might be achieved with a large random sample. The overall number of participants was relatively small and, although we purposively sampled for diversity of expertise and experience, the views cannot be claimed to be nationally representative. The views of the 24 stakeholders who took part may not be typical of such a widespread condition and could not be expected represent all possible priorities. In particular, we felt it would have been beneficial to include more people with diabetes, as experiences can vary widely between individuals. Previous studies using the nominal group technique have found participants’ views to be an adequate representation of the views of the wider community [34]. However, these studies used the nominal group technique with healthcare professionals; as our process included healthcare professionals, patient and policy makers we cannot claim the 24 included participants were representative of each of these groups. Finally, the current study describes research priorities identified within the Irish health system, and caution should be used when generalising as priorities vary according to health system context [35].
