Goal-setting in diabetes self-management: A systematic review and meta-analysis

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Psychology & Health
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Goal-setting in diabetes self-management: A
systematic review and meta-analysis examining
content and effectiveness of goal-setting
interventions
Milou Fredrix, Jenny McSharry, Caragh Flannery, Sean Dinneen & Molly
Byrne
To cite this article: Milou Fredrix, Jenny McSharry, Caragh Flannery, Sean Dinneen & Molly
Byrne (2018) Goal-setting in diabetes self-management: A systematic review and meta-analysis
examining content and effectiveness of goal-setting interventions, Psychology & Health, 33:8,
955-977, DOI: 10.1080/08870446.2018.1432760
To link to this article: https://doi.org/10.1080/08870446.2018.1432760
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Goal-setting in diabetes self-management: A systematic review and
meta-analysis examining content and effectiveness of goal-setting
interventions
Milou Fredrixa
*, Jenny McSharrya
, Caragh Flannerya,‡, Sean Dinneenb and Molly Byrnea
a
School of Psychology, National University of Ireland, Galway, Ireland; b School of Medicine,
National University of Ireland, Galway, Ireland
(Received 12 June 2017; accepted 18 January 2018)
Background: Goal-setting is recommended and widely used within diabetes
self-management programmes. However, empirical evidence around its effec-
tiveness lacks clarity. This review aims to evaluate the effectiveness of goal-
setting interventions on diabetes outcomes and to determine which behaviour
change techniques (BCTs) are frequently used within these interventions.
Methods: A systematic search identified 14 studies, describing 12 interven-
tions targeting diabetic-control which incorporated goal-setting as the main
intervention strategy. Study characteristics, outcome measures and effect sizes
of the included studies were extracted and checked by two authors. The BCT
taxonomy v1 was used to identify intervention content. Meta-analyses were
conducted to assess intervention effects on the primary outcome of average
blood glucose levels (HbA1c) and on body-weight. Psycho-social and beha-
vioural outcomes were summarised in narrative syntheses.
Results: Significant post-intervention improvements in HbA1C were found
(−.22, 95% CI, −.40, −.04) across studies. No other main effects were identi-
fied. The BCT ‘goal-setting (behaviour)’ was most frequently implemented
and was identified in 84% of the interventions.
Conclusions: Goal-setting interventions appear to be associated with reduced
HbA1C levels. However, the low numbers of studies identified and the risk
biases across studies suggest more research is needed to further explore goal-
setting BCTs in diabetes self-management.
Keywords: diabetes; goal-setting; goal setting; interventions; behaviour
change techniques; systematic review; BCT
Background
Diabetes is rapidly becoming one of the most challenging public health issues across
the globe (Guariguata et al., 2014). If not treated properly, diabetes can cause health
complications such as cardiovascular diseases, foot ulcers and retina damage. To avoid
these complications, it is vital that people diagnosed with diabetes follow treatment
regimens to achieve overall healthy levels of blood glucose, also known as glycaemic
*Corresponding author. Email: [e-mail]
‡School of Public Health, University College Cork, Ireland’ as additional affiliation to Caragh
Flannery.
© 2018 Informa UK Limited, trading as Taylor & Francis Group
Psychology & Health, 2018
Vol. 33, No. 8, 955–977, https://doi.org/10.1080/08870446.2018.1432760

control. Diabetes treatment consists of ongoing medical care and continuous self-man-
agement by the patient (Ahola & Groop, 2013).
Diabetes self-management is a demanding and multifaceted task which includes a
variety of self-care activities and skill sets (American Diabetes Association, 2014). Self-
management behaviours, including continuous blood glucose monitoring, injecting insu-
lin and exercising, if executed properly, can significantly reduce the risk of diabetes-re-
lated complications (Funnell, Tang, & Anderson, 2007). However, despite the known
benefits of careful adherence to a treatment regimen, sub-optimal levels of glycaemic
control are commonly detected within people with diabetes (Ahola & Groop, 2013).
The complex nature of diabetes management makes developing effective self-man-
agement interventions a challenge. The various behaviours involved can make it diffi-
cult for clinicians, researchers, and intervention designers alike to know how best to
focus possible interventions and research projects (Grant et al., 2013).
A recent research prioritisation exercise, conducted with diabetes stakeholders, iden-
tified ‘goal-setting with patients’ as a priority research focus for behavioural research in
diabetes (McSharry, Fredrix, Hynes, & Byrne, 2016). Goal-setting techniques are fre-
quently implemented within diabetes self-management interventions and have been
identified as a core component present across structured diabetes educational pro-
grammes (Grant et al., 2013). Goal-setting techniques are often integrated within larger
multi-component programmes and interventions (Avery et al., 2015), but can also be
used as a primary intervention strategy (Miller & Bauman, 2014).
The practice of goal-setting is well defined within goal-setting theory (Locke &
Latham, 2002). Goal-setting theory has been used to explain and change behaviour across
several domains including health (Strecher et al., 1995). According to Locke and Latham
(2002), the process of goal-setting can facilitate behaviour change by guiding people’s
effort and attention. However, the effects of goal-setting on achieving outcomes are often
moderated by a number of variables. These can range from psychosocial factors such as
self-efficacy levels, to the nature of the goals and the implementation of accompanying
behaviour change strategies such as planning and feedback provision (Locke & Latham,
2002). For example, setting specific, more challenging goals in terms of behaviour tends
to lead to better performance, as compared to easily achievable goals, or goals focused on
vague outcomes. Furthermore, many of the behaviours we are trying to affect in beha-
vioural interventions such as diabetes self-management, are highly complex and will
require careful planning to develop appropriate goal-setting strategies. Therefore, tech-
niques such as action-planning and barrier-identification are essential parts of effective
goal-setting practices (Strecher et al., 1995). Additionally, incorporating feedback strate-
gies in goal-setting practices is believed to enhance goal attainment (Locke & Latham,
2002). Many of these behaviour change strategies assumed to moderate the effectiveness
of goal-setting practices, are represented in Michie et al. (2013) ‘Behavioural Change
Technique Taxonomy v1(BCTTv1)’.
The BCTTv1 provides us with a tool to describe the active content of complex
interventions in terms of behaviour change techniques (BCTs). BCTs can be described
as apparent, replicable and irreducible components of interventions that are designed to
change or redirect causal processes that regulate behaviour (Michie et al., 2013).
According to the BCTTv1, ‘goals and planning’ and ‘feedback and monitoring’ are two
of 16 broad clusters that contain a total of 16 specific BCTs between both clusters.
BCTs such as ‘goal-setting, behaviour’ and ‘goal-setting, outcomes’ represent different
956 M. Fredrix et al.

types of goal-setting, with ‘goal-setting, behaviour’ described as ‘setting or agreeing on
a goal in terms of behaviour to be achieved’ and ‘goal-setting, outcome’ defined as ‘set-
ting a goal in terms of a positive outcome of wanted behaviour’. Furthermore, BCTs
such as ‘action-planning’ and ‘problem-solving’ represent strategies that accompany
goal-setting by outlining specific plans to reach goals. While there are other strategies
for describing intervention content within the field of behaviour change (Kok et al.,
2016), the BCTTv1 describes the different types of goal-setting most clearly, and is
well suited for coding intervention content retrospectively within cross disciplined inter-
vention research (Kok et al., 2016; McEwan et al., 2016; Michie et al., 2013).
While goal-setting is recognised as a core element of diabetes self-management educa-
tional programmes, there is limited evidence available for the effectiveness of goal-setting
as a primary intervention strategy to promote diabetes self-management. Avery, Flynn,
van Wersch, Sniehotta, and Trenell (2012) conducted a systematic review of interventions
aimed at increasing physical activity in adults with Type 2 diabetes. In a set of in-depth
analyses, they identified which BCTs were utilised within these interventions and which
BCTs may be associated with improvements in average blood glucose levels (measured in
glycated haemoglobin level; HbA1c; Avery et al., 2012). The analyses suggested that
‘goal-setting and planning BCTs’ such as ‘review of behavioural goals’ and ‘goal-setting,
behaviour’ were associated with improvements in HbA1c. However, these findings solely
applied to interventions using physical activity as a strategy for diabetes self-management.
While physical activity is a viable self-management option for people with Type 2 dia-
betes, it is not the only self-management option and other behaviours could be equally
essential (Ahola & Groop, 2013). Additionally, these BCTs were incorporated within mul-
ti-component complex interventions. It is therefore unclear how effective these goal-set-
ting techniques would be if they were implemented as the primary intervention strategy. A
previous systematic review by Miller and Bauman (2014) attempted to address this ques-
tion by giving an overview of interventions that had incorporated goal-setting as their pri-
mary strategy for improving a wider range of self-management behaviours and health
outcomes in people with T2DM. While this review provided some information on health
and behavioural outcomes following goal-setting-focused interventions, assessing inter-
vention effectiveness was not the primary focus of this review. Therefore, it was largely
descriptive and provided little information on the overall effectiveness of goal-setting-
focused interventions. Furthermore, this review provided no information on the actual
content of these ‘goal-setting’ interventions in terms of incorporated BCTs.
To our knowledge, no previous review has systemically assessed the effectiveness
of goal-setting as a primary intervention strategy to promote diabetes self-management.
In fact, Miller and Bauman (2014) highlighted that more systematic research is needed
to determine the effectiveness of goal-setting in this context, and the conditions and
behaviours for which goal-setting is most effective. Furthermore, no review has
attempted to specify the content of goal-setting-focused diabetes self-management inter-
ventions using the BCT taxonomy. Specifying intervention content in terms of BCTs
can help to clarify what ‘goals and planning’ techniques are mostly implemented and
under which conditions goal-setting is most effective. Furthermore, identifying if ‘feed-
back and monitoring’ BCTs have been incorporated, can help validate the assumed
effect of these BCTs on goal achievement. By specifying the presence or absence of
BCTs across studies, associations could be made between specific BCTs and higher
outcome effects. This could inform future intervention development.
Psychology & Health 957

Aim
The aim of this review was to assess the effectiveness of goal-setting behavioural
change interventions on clinical, health, psychosocial or behavioural outcomes in people
with diabetes. An additional aim was to identify which ‘Goals and planning’ and
‘Feedback and monitoring’ BCTs are most frequently used in these interventions and
which are most effective in improving outcomes.
Method
A systematic review of intervention studies was conducted. This systematic review and
meta-analysis were conducted and reported in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher,
Liberati, Tetzlaff, & Altman, 2009; for completed PRISMA checklist see Supplementary
Material in Appendix 2). The review protocol was pre-registered with the International
Prospective Register of Systematic Reviews (PROSPERO) database (doi: 10.15124/
CRD42015027561).
Eligibility criteria
Types of studies
Eligible study designs included randomised controlled trials (RCTs), non-randomised
controlled trials, quasi experimental studies or studies with a pre–post design. Based on
a recent review by McEwan et al. (2016), eligible studies were intervention studies util-
ising goal-setting techniques as the primary intervention strategy to improve health and
behavioural outcomes in people with diabetes. The primary focus of the interventions
therefore needed to involve setting diabetes self-management goals. Studies were
excluded if an intervention’s primary focus was unrelated to goal-setting, or if the
intervention included goal-setting techniques as secondary components of a larger
intervention (i.e. stated that goal-setting was used but did not articulate how or how
often). Furthermore, for inclusion, the practice of goal-setting within the intervention
had to be patient driven or executed collaboratively with the patient and had to be
individually focused and measured (group interventions were included only if they also
involved individual goal-setting). Interventions that sought to elicit behaviour change in
combination with a pharmacological or surgical treatment were excluded from this
review. Studies including a control group had to compare the intervention to usual care
to be included. Studies were included regardless of treatment intensity, duration and
mode of delivery of the intervention. Only studies published in English were included.
Types of participants
Adults diagnosed with T1DM or T2DM.
Types of outcome measures
Studies were included that reported any of the following primary outcome measures:
average blood glucose levels/ glycaemic control as measured by glycated haemoglobin
level (HbA1c) or average number of hyperglycaemic/ hypoglycaemic episodes. Studies
958 M. Fredrix et al.

were also included if they reported any of the following secondary outcomes measures:
body mass index (BMI)/ body weight, physical activity or self-care behaviours as
identified by Grant et al. (2013) (carbohydrate counting and awareness, insulin dose
adjustment, self-monitoring of blood glucose, managing hypoglycaemia, managing
equipment and injection sites or accessing health care).
Information sources
Ovid MEDLINE (1946–January 2016), PsycINFO (1887–January 2016), EBSCO
CINAHL (1961–January 2016), EMBASE (1947–January 2016) and PubMed (1946–
January 2016) electronic database searches were conducted. The search strategy for
each database can be seen in Appendix 1 of Supplementary Material. We checked
articles cited in a previous review (Miller & Bauman, 2014) and conducted backward
and forward citation searches of included studies.
Study selection
One author (MF) imported citations into a reference management software package
(EndNote) and removed duplicates. In the first screening stage, all titles of the search
results were examined and clearly irrelevant titles were removed. In the second screen-
ing stage, 720 titles and abstracts were screened. Ten per cent of titles and abstracts
were double screened by a second reviewer (JMS or MB) using the Covidence online
systematic review management system (www.covidence.org/). Any discrepancies were
resolved by discussion between authors until consensus was reached. Cohen’s Kappa
(κ) was calculated to determine the extent of inter-rater agreement and a substantial
agreement was reached of κ = .78 (Landis & Koch, 1977). In the third stage of the
screening process, relevant review articles were obtained in full, and assessed against
the inclusion criteria. Full text screening was conducted by MF, with 20% double
screened by a second reviewer (JMS or MB); discrepancies were resolved by discussion
until consensus was reached. Initial full text double screening showed a moderate inter-
rater agreement of κ = .41 (Landis & Koch, 1977) due to disagreement on study design
inclusion. After agreement on study design inclusion was reached, a high inter-rater
agreement of κ = .79 was established. The numbers of articles at each stage can be seen
in the PRISMA flow chart (Figure 1)
Data extraction
A data extraction form was developed based on the Workgroup for Intervention Devel-
opment and Evaluation Research (WIDER) recommendations for reporting intervention
components (Albrecht, Archibald, Arseneau, & Scott, 2013). Data were extracted by
one reviewer (MF) and independently checked by another (JMS or MB). In the case of
discrepancies, consensus was reached through discussion. Extracted data included:
detailed description of the interventions in published papers (participant information,
setting, mode of delivery, intensity, duration, adherence/fidelity, description of the inter-
vention content), a description of the control condition if applicable, and outcome data.
The BCT taxonomy v1 (BCTTv1; Michie et al., 2013) was used to code ‘goals and
planning’ and the ‘feedback and monitoring’ BCTs included in the interventions.
Psychology & Health 959