The aim of the study to improve glycaemic control by the end of the 48-week period was not realized. Interestingly however, the hypothesis test indicated there was a statistically significant difference between the change in glycaemic control measured for the intervention and control groups. The results from mean HbA1c indicated that all patients had poorer control of their diabetes at the end of the study compared to baseline. The hypothesis test indicated patients who received the intervention had a significantly smaller increase in HbA1c levels by the end of the study than those who received the control. The statistical significance of this result adds another dimension to the overall negative result as follows: although both the intervention and control groups had poorer glycaemic control reflected by higher HbA1c levels compared to baseline, the increase in HbA1c measured at the end of the 48-week period was 0.57% less with the intervention compared to the control (p = 0.025).
Implications of the study
The negative result obtained highlight two important considerations: first, there is some value to applying the SOC model to type 2 diabetes care as evidenced by the 0.57% less rise in HbA1c relative to the control group, and second, there is possibly a tendency for glycaemic control to worsen over time among patients at SMHC.
What do we know about this topic so far?
A large RCT supports the findings of this paper which suggests that patients can be moved from one stage of change to another and that this can be beneficial . The longitudinal comparisons of the stage of change shifts from Figures 2, 3 and 4 illustrated these patterns which add support to the intervention model and its theory. A crossover pattern  was observed wherein the number of patients in the precontemplation, contemplation and preparation stages (collectively) decreased while there was a simultaneous increase in the number of patients in the action and maintenance stages (collectively) at the end of the study.
In that publication application of a stage of change model based intervention resulted in a greater reduction of HbA1c than standard care, but this did not reach statistical significance . So this paper adds to the literature by illustrating that a statistically significant difference between intervention and controls can be achieved (even though there are limits to our results as we saw above).
What other factors may have caused this bilateral worsening of glycemic control in both intervention and control groups?
After dialogue with patients we postulate that severe economic stress and social hardship facing the patients who utilized the SMHC during the time of the study and contributed to the unusual results. This economic hardship occurred because of the closure of the sugar factory, Caroni (1975) Limited  which was the major employer in the Ste. Madeline area. This closure meant that study participants would not have had the financial wherewithal to fully carry out the planned behaviour change, since this would involve more expensive diets and time spent exercising. This study started in February 2006, 3 years after the closure of the sugar industry, and at a time where many of the planned social buffers had not yet been put in place.
Limitations of the Stages of Change model to Type 2 diabetes care at SMHC
The Stages of Change model was devised based on observations of people giving up smoking - an addictive behaviour requiring complete cessation . Smoking can be considered to have one common set of behaviour patterns as it is a single behaviour. Managing type 2 diabetes by diet, exercise and medication use needs to consider the interaction of three different behaviours, each having differing sets of patterns, and each impacting on glycaemic control.
It is possible that patients engaging in exercise and dietary behaviours can be viewed as proceeding through a continuous directional flow through steps beginning with initiating the behaviour, followed by continuing it, while constantly adapting it during the diabetes-disease trajectory. Each of these steps, in turn, can be considered to have their unique set of SOC, including the possibility of new stages, and have their unique aims. The intervention model did not incorporate such a complex view of these behaviours and therefore it is possible that this could have contributed to the results observed.
As we noted above there is a need for economic considerations in whether the model succeeds or not.
Limitation of the study
Complete blinding at any level (single, double, triple) was not achieved in this study since the PI provided care to all patients- both the intervention and control group. The PI was aware of the limits placed on the study by his involvement in these steps and placed due care on extraction of information from notes and in care of patients to ensure his personal biases did not interfere with the conduct of the study. Ideally additional personnel should be involved but the structure of the health services clinic did not allow for this. We acknowledge that this is a serious, but not fatal, shortcoming of the study.
Planning for the future
The overall results suggest the possibility of a tendency for glycaemic control to be naturally worsened over time at SMHC. This directs attention to other factors, additional to the nature or style of the patient-physician consultation, that are instrumental to the success of achieving improved glycaemic control among type 2 diabetes at SMHC. These factors can include external physical factors, external psychological factors and internal psychological factors .