A critical evaluation of a research report

The article Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care authored by Ricci-Cabello, I. et al. (2013) and published in the BMC Health Service Research had an objective of determining whether an intervention based on improving communication between patient and provider would help improve the quality outcomes for the patient. The second objective of the study was to determine whether telephone reinforcement enhance the effectiveness of such an intervention (Ricci-Cabello et al. 2013).

The study was conducted in a deprived neighbourhood in Granada, Spain. The participants for the study were 18 years and older people with low educational level. The participants were clustered in different groups and given different interventions intervention A, intervention B and control group. General practitioners (GPs) were randomized to the groups. The GPs allocated to intervention groups A and B were trained in communication skills. Those in intervention group B were given additional telephone reinforcement. Patients in the control group are receiving the usual care. The interventions are conducted during seven medical visits that are done over a three month period. The main measures are: HbA1c, blood pressure, lipidemia. Waist circumference and body mass index (BMI) are secondary measures (Ricci-Cabello et al. 2013).

The results of the study helped in developing better ways of managing diabetes especially for the vulnerable groups. This is through the development of low-cost intervention that can be incorporated across different healthcare settings to help reduce health inequalities for the vulnerable groups (Ricci-Cabello et al. 2013).


The aims of the study were adequately stated in the introduction. However, the aims should have been expanded to include determination of how cultural diversity influences provision of care for such vulnerable groups. It is important to note that Spain and other countries of the world are increasingly becoming more culturally and ethnically diverse. There is therefore need for healthcare professionals to respond to the diverse needs of the heterogeneous patients. By including the issue of cultural diversity as one of the aims, the report would provide insights on knowing how to provide services to different people from different backgrounds (Keyserling et al, 2002).

The sample size was scientifically determined. The population used for the study was a representative sample of the entire population. The researchers allowed for withdrawal of participants from the study. The withdrawal was done in an effective manner using different criteria including: whether the participants were likely to complete the study, whether the physical and emotional state of the participants would allow for follow-ups, whether the participants were participating in another study and if the participants did not follow the study requirements like attending the scheduled visits, refusal to complete questionnaires or provide the needed blood samples. The procedure of selecting the participants had some ethical-legal issues. This is because electronic health records were searched to determine eligible participants. This means that third parties had access to medical details of participants. This is an ethical-legal issue because such information should be kept with confidentiality and disclosed only under authority of the patient. However, the researchers allowed the participants to decide whether to participate in the project or not. If one wished to participate, then he completed a questionnaire that would allow the researchers to collect their socio-demographic characteristics (Keyserling et al, 2002).

The questions on self-care activities provided a good opportunity for the participants to discuss how they took care of themselves for the three month period. The participants were then given the results and allowed to discuss them with their relatives. However, there was need to integrate this method with another data collection method like performance management tests. This is because self-reports are always vulnerable to exaggerations and participants are likely to focus more on their strong points thereby not disclosing details about their weaknesses. Performance management tests are objective tests that the participants would be required to take. The advantages of these tests when integrated with the advantages of the self-reports would provide a broader and more objective view of the performance of the participants. In addition, the participants would feel more comfortable to share more information while dealing with the tests.

The fact that the nine general practitioners were well trained in cognitive, emotional and communication aspects made it easy for them to well understand the emotional, psychological and physical needs of the participants. This provided a great advantage to the study as there was emotional and psychological connection between the practitioners and the participants. However, this would have been better had the practitioners been trained in cultural and ethnic differences among the participants (Glazier, Bajcar, Kennie & Willson, 2006).

Intervention B that involved face-to-face intervention plus telephone reinforcement was conducted in a very good manner (Graziano & Gross, 2009). The practitioners were well trained in this intervention. During the study, an expert in T2DM self-management was involved. This made it easy for the practitioners to provide better advice to the students on the need for carrying out physical exercise and for the need of a balanced diet. The telephone conversations also allowed for feedback from the participants so that in case of any questions, the practitioners would answer the questions and concerns raised by the participants. The effectiveness of telephone conversation has been proven in previous studies (Eakin et al, 2008). This means that this method provided a good way of measuring and advising the patients on lifestyle changes in their lives. However, this would have been made much better had the study involved wellness and exercise experts who have a good understanding on wellness and exercise. In addition, the study needed to involve nutritionists who would provide the best advice on nutrition and diet that would help in reducing diabetes (Redondo-Sendino, Guallar-Castillón, Banegas & Rodríguez-Artalejo, 2006).

The selection and administration of intervention for the control group was also done in a proper manner. This is because the recruitment, baseline measurement, intervention and final measurement were carried out in routine every three months. This was done in a manner that minimised human and economic costs for both the study and the participants (Ruiz-Ramos et al, 2006). Due to this, the participants were less burdened about participating in the project thereby reducing their withdrawal rates from the study.  The low-cost nature of the study means that it can be easily designed and implemented in other population groups. The results of the study can therefore be used to help develop policies that can help reduce social inequalities of health in different care settings. This can be applied in countries like Spain that have a public national healthcare system. Through the interventions, the quality of life of the citizens in these countries will be improved.

The study had different measurements including HbA1c, blood pressure, lipidemia. Waist circumference and body mass index (BMI) are secondary measures. All the measures were accessed during the three month intervention period. Socio-demographic information of the participants was also collected after obtaining the informed consent of the participants. Some of the socio-demographic information collected included age, gender, ethnicity, social support and the number of children that the participant had. However, the study needed to collect more information like the proportionate increase in physical activities and the general activities that the participants engaged in for the three month period. This would provide a good basis for the practitioners to provide lifestyle and behavioural changes to the participants that would help reduce the prevalence of diabetes in Spain.

The researchers found it very necessary to measure social support using the Blake and McKay’s questionnaire. This questionnaire measured the number of friends or close relatives that the participant had. Through this measure, the researchers would be able to determine the amount of social support that the participants would obtain from their close friends and relatives (Blake & McKay, 1986). Questionnaires were used because of their ability to collect such data easily. However, the practitioners needed to use behavioural observation and focus groups to collect more data from participants. Behavioural observation would help in collecting information on how the participants had changed their lifestyles during the intervention Tang, Brown, Funnell & Anderson, 2008).

The sample A was composed mainly of female participants (54.3%). The mean age of the sample was 61.99 years. The patients had an average of 3.23 children and there were no significant between-group differences between the variables. Social support was very low for majority of the sample (74.9%). Group B had a high percentage of high social support. However, it should be noted that a high proportion of the patients in this study were women from minority ethnic groups. The participants did not have adequate health support. However, this study needed to have more men as patients or participants. This is because T2DM is more prevalent among men. The fact that more participants were women can be explained by the fact that more women attend medical appointments when compared to men. Most of the test results were moderate in the control group than in the intervention group.

The researchers in this study found a lot of difficulty in achieving the estimated sample size. The limitation of this is that this would limit the statistical ability of the study to detect differences between the different population groups. In addition, there was withdrawal of patients during the follow up period further reducing the statistical power of the study. Furthermore, the intervention was affected by bias in standardization of interventions. This problem was solved by training the practitioners to ensure that their interview styles were as close as possible. In addition, there were joint meetings to try and standardise the intervention methods. The standardisation of intervention helped in ensuring that the results would be easily translated across different platforms. To ensure that there was a high participation of the patients, the first interventions were carried out by healthcare professionals (Andersson et, al 2012).

The methodological vigour and viability of most components of the study were guarantee. This is because the study was designed by public health professionals who have a good understanding of designing such studies. In addition, the study was conducted by professionals who have a good understanding of the habits and characteristics of the population. The implication of this is that the data collected from the study is reliable and can be used as a reference for other studies (Gary et al, 2003).

To ensure that the participation rates are improved for such studies in future, it is important that the practitioners integrate their practice with such type of study. In addition, patients should be prepared early in advance for participating in such studies. This can go a long way in improving their participation rates (Ricci-Cabello et al. 2013).

The results were analysed using computer programs. The analysis was done after eliminating the errors that existed in the questionnaires. The statistical computer software was used because of their ability to easily generate reports. The choice of the programs was also motivated by the fact that they can analyse complex data.

In conclusion, the study on Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care authored by Ricci-Cabello, I. et al. achieved its objectives. This is because through the study, the practitioners determined that improving communication between patient and provider would help improve the quality outcomes for the patient. The second objective that was achieved was that the results of the study showed that telephone reinforcement helped in achieving the objectives of the study. The study was well designed as the participants were carefully selected for the study. However, there are some aspects of the study that needed to be changed. The study needed to collect more socio-demographic data from the participants. This would allow the practitioners to provide better interventions for the diabetic patients. While selecting participants, the researchers needed to focus also on male participants because diabetes is more prevalent among male patients (Scholle, Chang, Harman & McNeil, 2002). If such a study is to be conducted in future, then the researchers should ensure that the patients are not overburdened. Furthermore, the researchers should carefully design the study to ensure that the sample chosen is a good representation of the entire population. The future studies also need to have more ways of collecting data. All in all, the research was well conducted ensuring that the objectives were achieved.


Andersson C, Van Gaal L, Caterson ID, Weeke P, James WP, Couthino W, Finer N, Sharma

AM, Maggioni AP, Torp-Pedersen C. (2012). Relationship between HbA(1c) levels and risk of cardiovascular adverse outcomes and all-cause mortality in overweight and obese cardiovascular high-risk women and men with type 2 diabetes. Diabetologia 55(9):2345–2355. May 26.

Blake RL, McKay DA. (1986). A single-item measure of social supports as a predictor of

morbidity. J Fam Pract 22(1):82–84.

Eakin EG, Reeves MM, Lawler SP, Oldenburg B, Del Mar C, Wilkie K, Spencer A, Battistutta

D, Graves N. (2008). The Logan Healthy Living Program: A cluster randomized trial of a telephone-delivered physical activity Ricci-Cabello et al. BMC Health Services Research 2013, 13:433 Page 8 of 9 http://www.biomedcentral.com/1472-6963/13/433and dietary behavior intervention for primary care patients with type 2 diabetes or hypertension from a socially disadvantaged community- Rationale, design and recruitment. Contemp Clin Trials 29:439–445

Gary TL, Bone LR, Hill MN, Levine DM, McGuire M, Saudek C, Brancati FL. (2003).

Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetesrelated complications in urban African Americans. Prev Med, 37:23–32.

Glazier RH, Bajcar J, Kennie NR, Willson K. (2006). A systematic review of interventions to

improve diabetes care in socially disadvantaged populations. Diabetes Care, 29:1675–1688.

Graziano JA, Gross CR (2009). A randomized controlled trial of an automated telephone

intervention to improve glycemic control in type 2 diabetes. Adv Nurs Sci 2009, 32:E42–E57.

Keyserling TC, Samuel-Hodge CD, Ammerman AS, Ainsworth BE, HenríquezRoldán

CF, Elasy TA, Skelly AH, Johnston LF, Bangdiwala SI (2002). A randomized trial of an intervention to improve self-care behaviors of African-American women with type 2 diabetes impact on physical activity. Diabetes Care  25:1576–1583.

Redondo-Sendino A, Guallar-Castillón P, Banegas JR, Rodríguez-Artalejo (2006). Gender

differences in the utilization of health-care services among the older adult population of Spain. BMC Public Health  16(6):155.

Ricci-Cabello, I. et al. (2013). Effectiveness of two interventions based on improving patient-

practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care. BMC Health Service Research, 13, 433-441.

Ruiz-Ramos M, Escolar-Pujolar A, Mayoral-Sanchez E, Corral-San Laureano F, Fernandez-

Fernandez I (2006). Diabetes mellitus in Spain: death rates, prevalence, impact, costs and inequalities. Gac Sanit 20(Suppl 1):15–24

Scholle SH, Chang JC, Harman J, McNeil M, (2002). Trends in women’s health services by type

of physician seen: data from the 1985 and 1997–98 NAMCS. WHI 2(4):165–177.

Tang TS, Brown MB, Funnell MM, Anderson RM. (2008). Social support, quality of life, and

self-care behaviors among African Americans with type 2 diabetes. Diabetes Educ 2008, 34:266–276.