Background: 
Compared to the general population, people with mental illness are at higher risk of developing overweight and type 2 diabetes, due to medication, sedentary lifestyle and unhealthy diet. In people with mental illness, support from educators is crucial to engage in sustainable health behaviour change. It is known from the literature that educators’ attitudes and expectations related to behaviour change play an important role. However, educators are often socialised into a biomedical approach and trained to be experts, which has been shown to have limited or negative effects on behaviour change in their target groups. Studies point to collaborative approaches such as consensus building or shared decision-making to be beneficial and preferable in health promoting activities targeting people with mental illness. However, the literature is sparse concerning concrete methods to facilitate a collaborative approach that addresses health behaviour change.  

Aims:
The aim of this study was to explore the feasibility of a collaborative approach in health promotion targeting people with mental illness and (risk of) type 2 diabetes. 

Methods:
The research based approach was based on two empirically grounded health education models, a guide and seven dialogue tools developed in co-creation with people with mental illness and (risk of) type 2 diabetes. Three dialogue tools comprised images and statements addressing psychosocial and physical health, social relations and perspectives and thoughts about healthy life. The four remaining tools focused on balancing expectations about the content and setting of the health promotion activity, dialogue about daily life and strategies to explore motivation for behaviour change. 54 educators, mainly nurses, physiotherapists and social workers, received training in the new approach on a three-day course. The courses consisted of a theoretical introduction, practical training with the tools, communication training through role plays, and experience sharing with other educators and people with mental illness who participated in the course as discussion partners. Communication training included concrete techniques such as using open-ended questions, active listening and summarising shared decisions. As part of the course, educators tested the approach (communication techniques and at least one tool) in their own practice and discussed experiences with their target groups. Health promotion activities included health checks, health education, exercise and cooking classes. Data were collected through observations of educators testing the approach integrated in health promoting activities (n=15), written stories from educators about the testing with focus on target group reactions (n=15), observations of three courses and responses to questionnaires for educators (n=49). Data were analysed using systematic text condensation and frequencies.  

Results:
We observed that the collaborative approach facilitated a high level of dialogue and active involvement of the target group. Educators successfully integrated tools in their practice whether it was group-based or individual activities, and whether communication was based on a particular topic such as fatigue or exercise or health promotion in general. In observations, people with mental illness and (risk of) type 2 diabetes reported that the tools articulated their resources and facilitated dialogue about concrete options related to health behaviour change. Furthermore, people with mental illness expressed that tools with images and statements stimulated their ability to concentrate and stay focused throughout the activity. Observations revealed that concrete techniques such as active listening and open-ended questions were difficult to integrate in the communication for some educators. Educators reported that the new approach to a moderate/high degree had improved their collaborative skills (89.3%) and was well-suited for their practice (93.5%). However, some educators responded that they lacked support from their manager to implement the new approach. Only 28% of educators had discussed implementation of the tools with their manager. 

Discussion:
A collaborative approach based on dialogue tools and new communication techniques fostered collaboration between educators and people with mental illness and (risk of) type 2 diabetes. The collaborative approach promoted dialogue, active involvement and addressed resources, perspectives and options of the target groups regarding health behaviour change. The study highlights the importance of including the target group in the development and implementation of an intervention approach. However, the study showed that implementation of the approach requires a substantial focus on training of educators in communication techniques and more dialogue with the managers of the educators. Next step is a pilot test of effect on behaviour change.

Dialogue about health behaviour change in people with mental illness and diabetes: Is a collaborative approach feasible?