Development and Focus Group Testing of a Healthy Snack Pamphlet for People Living With Diabetes

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1 120 Development and Focus Group Testing of a Healthy Snack Pamphlet for People Living With Diabetes Sue Minicucci 1 BASc, Judy Paisley 1 PhD RD, Marilyn Mori 2 CDE RD, Janet Madill 2 MSc RD 1 School of Nutrition, Ryerson University,Toronto, Ontario, Canada 2 University Health Network,Toronto General Hospital,Toronto, Ontario, Canada OBJECTIVE This paper describes the development and testing of an educational pamphlet on snacks for people living with diabetes. METHODOLOGY A trained moderator conducted 3 focus group interviews (total participants=23) to test the clarity of key messages, and the usefulness and layout of the pamphlet. Data analysis involved summarization of participants responses to a semi-structured interview guide.the snack pamphlet was revised and re-tested based on participants and dietitians recommendations. RESULTS Participants recommended the clarification of key messages, changes to the food list and tips provided, and illustration of healthy snack choices and portion sizes using photographs. A B S T R A C T Healthy snack pamphlets should be simple and easy to read, and should contain macronutrient composition data and recommended portion sizes for a variety of snack foods in chart format.they should also feature photographs to pique users interest and add visual appeal. Address for correspondence: Judy Paisley School of Nutrition Ryerson University 350 Victoria Street Toronto, Ontario M5B 2K3 Canada Telephone: (416) , ext Fax: (416) OBJECTIF R É S U M É Ce compte rendu décrit l élaboration et l évaluation d un dépliant éducatif portant sur les collations pour les personnes atteintes de diabète. MÉTHODE Un animateur qualifié a mené trois entrevues de groupe semistructurées (nombre total de participants = 23) dans le but d évaluer la clarté des principaux messages ainsi que l utilité et la présentation du dépliant. L analyse des données a porté sur un résumé des réponses des participants recueillies au cours d une entrevue semi-structurée. Le dépliant a été révisé pour tenir compte des recommandations des participants et des diététistes. RÉSULTATS Les participants ont recommandé que les principaux messages soient rédigés plus clairement, que des changements soient apportés aux listes de collations et de conseils et que des photos soient ajoutées pour illustrer les choix et la taille des portions de collations saines. Un dépliant éducatif sur les collations saines doit être simple et facile à lire et doit contenir des renseignements sur les macro-éléments et la taille des portions d une variété de collations sous forme de tableau. Un tell dépliant doit aussi comprendre des illustrations pour éveiller l intérêt du lecteur et avoir un attrait visuel. CANADIAN JOURNAL OF DIABETES / 26:2 / pp

2 INTRODUCTION Healthcare professionals at a Diabetes Education Centre (DEC) recognized that a pamphlet providing information about healthy snack foods could be useful in supporting the dietary self-management of people living with diabetes.at this DEC, educators work with clients to develop individualized eating plans that include healthy snacks. During follow-up sessions, many clients request additional information about selecting healthy snacks. Currently, there is no educational pamphlet on snacking available for clients of this DEC. Orre-Pettersson et al found participants who ate a snack 2 hours after insulin injection maintained a more consistent blood glucose profile (1). Individuals who are on insulin therapy may need to eat snacks in order to avoid hypoglycemia (1,2). By providing a wide variety of educational and supportive materials, healthcare professionals support people in their dietary self-management of diabetes. Intended as a handy reference guide, the pamphlet should include macronutrient content of some common snack foods and tips about healthy snack choices. The readability of the text, layout and design are important issues to consider when creating new educational resources (3). Educational materials should be culturally sensitive and relevant (4). It is recommended that diabetes education materials, such as the snack pamphlet designed for this study, be pre-tested by a sample of potential users before they are disseminated (5). Therefore, the purpose of this study was to design and pre-test a pamphlet on healthy snacking that would be suitable for distribution to clients of a DEC. A qualitative focus group interview approach was chosen to answer the following research questions: 1) Would participants be able to identify the pamphlet s key messages? 2) From participants perspectives, how useful were each of the main components of the pamphlet (food list, nutrient breakdown, tips)? 3) What were participants responses to the format and layout of the pamphlet (readability, colour, use of food photographs, chart layout)? 4) Did participants find each of the foods depicted on the pamphlet to be appropriate and relevant snack choices? METHODOLOGY Pamphlet development An English-language snack food pamphlet was designed to provide information on healthy snack food choices, macronutrient composition, and tips on choosing healthier snacks for people living with diabetes.the original pamphlet was printed on 8 1 /2 by 11-inch heavyweight paper using landscape format and folded in 2 places to create 3 equal-sized flaps. The title was Common Snack Foods Nutritional Information.The front cover messages were Eating sensibly and exercising regularly minimizes the complications associated with diabetes. Eating throughout the day helps to stabilize your blood sugar levels. It is important to choose healthier snacks more often. focus group-testing of a healthy snack pamphlet Clip-art images of healthy foods were shown above the front cover message and below the title.through consultation with diabetes educators, a list of 26 common snack foods (apple, brownie, muffin, doughnut etc.) was developed for inclusion in the pamphlet.the inside of the pamphlet featured a chart providing the food name, recommended portion size, and energy (kcal), carbohydrate (g), protein (g) and fat (g) content for 26 snack foods, 13 of which were marked with asterisks as healthier choices. Thirteen of the foods had a corresponding photograph or clip-art image. Several dietitians and diabetes educators reviewed the draft pamphlet for content and accuracy. Revisions were made to the pamphlet based on this feedback.the revised pamphlet was tested during a series of 3 focus group interviews with clients of a DEC. Further revisions were made to the pamphlet based on this feedback and a final review by healthcare professionals. Moderator s guide and data collection The qualitative focus group interview approach was used to provide a comfortable atmosphere in which participants could share candid feedback concerning the pamphlet (6). Focus group interviews followed a semi-structured moderator s guide asking participants to respond to 6 questions regarding the message, usefulness and layout of the pamphlet (Table 1). The 6 questions were developed to provide responses to the research questions. The principal investigator moderated all focus group interviews. An experienced qualitative researcher provided the training for the focus group moderator. A university-affiliated hospital research ethics board approved the protocol for this study. The moderator s guide contained a standardized preamble to be read to the participants, 6 open-ended questions (Table 1) and a closing statement. Before commencing, participants were given an information sheet explaining the purpose of the study, how the interview was going to be conducted, the confidentiality and anonymity of their responses, the voluntary nature of their participation and duration of the focus group. The moderator s contact information was also included should the participants have any future questions. At the beginning of each focus group interview, participants were given time to read the snack pamphlet.the moderator s guide questions were written on flip chart paper and the moderator recorded the participants responses under each question. The questions were asked in sequence, using probes to obtain additional information or clarification when necessary.any discrepant responses were probed until differences in opinion were fully understood and had been recorded accurately. Revisions were made to the snack pamphlet after each focus group interview, according to the recommendations and feedback received from the participants.therefore, subsequent interview participants responded to questions on revised versions of the pamphlet. This serial interview technique was used to minimize redundancy, to verify that issues 121

3 122 Table 1. Moderator s questions for focus group interviews 1. For you, what are the main messages of the snack pamphlet? 2. Do you feel the information provided would be useful for you? What is most useful? What is least useful? Would this information help you make better snack food choices? 3. I would like you to look at the layout of the pamphlet. What do you like about the way the material is presented? What do you dislike about the way the material is presented? What would you like to see changed about the way the material is presented on the pamphlet? 4. I would like you to look at the foods shown on the pamphlet. Are the foods shown on the pamphlet foods that you eat or are likely to eat? What foods would you change? What other foods not shown here would you like to see on the snack pamphlet? Do you find the photographs helpful or useful? 5. This pamphlet will be used to give information on snacking. Do you think it will be useful to people? 6. Is there anything else you would like to say or add? identified by previous participants had been resolved by the changes made to the pamphlet, and to confirm that such changes did not create new issues. By exposing the data to scrutiny by other study participants, serial interviewing can be used to verify the credibility of qualitative data (6). This technique actively involves best informants, or those who have relevant experience in the area of study, in data analysis and reduces the likelihood of researcher bias influencing study findings (6,7). Data analysis The data set arising from each interview consisted of a list of 6 questions with corresponding responses. The analysis of highly specific and straightforward data such as these involves the accurate summarization of participants responses to each question (6). Data were analyzed independently by 2 coders and discussed until consensus was reached. The summary results of data analysis for the 3 focus group interviews are presented in this paper. Participants and recruitment Based on general recommendations for focus group sample size and from previous studies, 8 to 12 participants were sought for each focus group interview (7-11). Participants in the focus group interviews were English-speaking clients who attended a 3-day educational program or a follow-up educational program at the DEC. There were no gender- or health-related exclusion criteria. All participants were over age 18. Healthcare professionals recruited study participants by asking clients attending educational programs if they were interested in volunteering to take part in a 20-minute focus group interview during their scheduled lunch break. Demographic information was not collected from the study participants. RESULTS Participants Three focus groups, totalling 23 participants, were held at the DEC.A summary of the results of data analysis follows. Key messages Participants recommended that the title and key messages of the pamphlet be worded more simply and directly.they correctly identified the key messages of the snack pamphlet as how to snack sensibly; the quantities of energy, protein, fat, and carbohydrate in common snack foods; and appropriate portion sizes for snacks. Usefulness of the pamphlet The participants indicated that the snack pamphlet was very useful for people living with diabetes and that they would like to see it distributed at the DEC to support their dietary selfmanagement. Participants commented that the most useful information included energy, fat, protein and carbohydrate composition information, snack food tips, food photographs, and the message that eating sensibly can reduce the risk of complications of diabetes. They reported that many of the snack tips were common sense. Layout All participants liked the layout of the pamphlet and found the inclusion of food photographs particularly appealing. Some participants commented that the snack pamphlet was easy to follow and colourful and offered an easy way to obtain macronutrient information. One participant suggested revising the pamphlet into a smaller version that could fit into a pocket or purse; other participants felt that an expanded version of the pamphlet showing nutrition composition data for a wider variety of snack foods would be helpful.

4 focus group-testing of a healthy snack pamphlet 123 Table 2. Modifications made to the snack pamphlet Message The front cover message was changed from: Eating sensibly and exercising regularly minimizes the complications associated with diabetes. Eating throughout the day helps to stabilize your blood sugar levels. It is important to choose healthier snacks more often. to Eating sensibly can reduce the risk of complications associated with diabetes. Layout The title of the pamphlet was changed from Common Snack Foods Nutritional Information to Healthy Snacking. Two distinct snack food categories were created: Choose More Often and Choose Less Often. The title of the tips section was changed from Tips for Healthier Snack Eating to Tips for Healthy Snacking. In the tips section, the cartoon-like picture of a teacher was removed and changed to a design incorporating fruit. Photographs of snack foods were used instead of clip-art images. Where possible, portion sizes were changed into common household measures. Food choices Foods removed: Chips Ahoy! cookie, brownie, corn dog, Dad s oatmeal cookie, nutrigrain bar, plain muffin, Quaker Granola Bar, Snickers chocolate bar, confectionery doughnut. Foods added: celery, cheddar cheese, bran muffin, potato chips, milk chocolate (Hershey s Kiss), plain doughnut. Relevance of the foods listed Several participants wanted to add food choices to the pamphlet that may not be considered typical snack foods, such as fish and eggs. Other suggestions included changing the Snickers chocolate bar to a plain milk chocolate bar and changing the confectionary doughnut to a plain doughnut. Participants felt that by making some of the information less specific they could then use the information to estimate the nutrient content of similar, unlisted foods. They proposed that the recommended portion size for celery be changed from cups to number of stalks. Participants recommended adding other snacks, such as potato chips and cheese, to the pamphlet. Not all recommendations or suggestions were incorporated into the revision of the pamphlet, as some suggestions were inconsistent with the purpose of the snack pamphlet. Based on the feedback from the dietitians and the focus group participants, several changes were made to the snack pamphlet (Table 2). The simplification of the pamphlet title and key messages made the pamphlet easier to read and understand. The inclusion of more generic versions of some food items may be important, particularly when a limited number of food choices can be shown on an educational resource.the importance of selecting portion size recommendations that best suit specific foods was also demonstrated in this study. Healthy snack pamphlets should be simple and easy to read, contain macronutrient composition data (in chart format) and recommended portion sizes for a variety of culturally appropriate snack foods, and feature photographs to pique users interest and add visual appeal. Many participants commented that they valued the opportunity to contribute to the development of this resource. Participants who indicated an interest received a copy of the final pamphlet by mail.the serial nature of data collection used in this study provided an effective means of verifying that changes suggested by participants did indeed improve the pamphlet. Future educational material for the DEC could incorporate participants recommendations that a booklet be created providing details of more snack food choices. Further projects will involve the development and testing of culturally competent healthy snacking pamphlets in Portuguese, Chinese, Italian,Tamil and Spanish. REFERENCES 1. Orre-Pettersson AC, Lindstrom T, Bergmark V, Arnquist HJ. The snack is critical for the blood glucose profile during treatment with regular insulin preprandially. J Intern Med. 1999;245: Kong N, Ryder RE. What is the role of between meal snacks with intensive basal bolus regimens using preprandial lispro? Diabetes Med. 1999;16: Farrell-Miller P, Gentry P. How effective are your patient education materials? Guidelines for developing and evaluating written educational materials. Diabetes Educ. 1989;15: Wilson E, Wardle EV, Chandel P, Walford S. Diabetes education: An Asian perspective. Diabetes Med. 1993;10: Anderson LA, Satterfield D, German R, Anderson RM. Using quantitative and qualitative methods to pretest the publication. Take Charge of Your Diabetes: a Guide for Care. Diabetes Educ. 1996;22: Paisley JA. Words! Words! Words! Qualitative data collection and analysis. In: Paisley JA, Keller H, Ledermann B, eds. Research Works: An Introductory Manual for Practice-based Research. Toronto: Canadian Diabetes Association; 2000: Morse JM. Introduction. In: Morse JM, ed. Qualitative Health Research.Thousand Oaks, CA: Sage Publications Inc; 1992:xi. 8. Shepherd SK, Sims LS, Cronin FJ, et al. Use of focus groups to explore consumers preferences for content and graphic design of nutrition publications. J Am Diet Assoc. 1989;89:

5 Watts PR, Brockschmidt BA, Sisk RJ, et al. Use of focus groups to determine the need for health promotion and wellness education services in rural communities. J Health Educ. 1997;28: Crockett SJ, Heller KE, Merkel JM, Peterson JM. Assessing beliefs of older rural Americans about nutrition education: use of focus group approach. J Am Diet Assoc. 1990;90: Jackson W. Methods: Doing Social Research. 2nd ed. Scarborough, ON: Prentice-Hall Canada Inc; 1999:134.

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