Is diabetes self-management education still the Cinderella of diabetes care?

A qualitative evidence synthesis of users' experience of mobile health applications in the self-management of type 2 diabetes

AIM

The aim of this qualitative evidence synthesis was to identify and synthesise qualitative research relating to experiences of using mobile health (mHealth) applications to aid self-management of Type 2 Diabetes.

METHODS

Using a systematic search strategy, 11 databases were searched (Medline, CINAHL, PsychInfo, PubMed, Web of Science, Embase, Cochrane Library, Scopus, ProQuest A&1, ProQuest UK & Ireland, Mednar). "Best fit" framework synthesis was used guided by the Health Information Technology Acceptance Model (HITAM). Assessment of methodological limitations was conducted using Critical Appraisal Skills Programme (CASP) and confidence in the review findings were guided by GRADE-CERQual.

RESULTS

Fourteen eligible studies were included in the synthesis (7 qualitative and 5 mixed methods). Key themes identified under the health, information and technology zones of the HITAM revealed the benefits of mHealth apps, barriers to their use, their perceived usefulness and ease of use.

DISCUSSION

Most people used the apps for feedback on their self-management and found them helpful in their communication with health care providers. Some embraced the technology and found it easy to use while others found mHealth apps to be counterintuitive.

Perspectives of deprived patients on diabetes self-management programmes delivered by the local primary care team: a qualitative study on facilitators and barriers for participation, in France

Background

Diabetes self-management education (DSME) is an effective intervention for patients with type 2 diabetes mellitus (T2DM); nevertheless, patient participation in this type of programme is low. Implementation of DSME programmes in primary care practices by the local multi-professional team is a potential strategy to improve access to DSME for T2DM patients. The aim of this study was to identify perceived facilitators and barriers by patients to participation in local DSME delivered by primary care professionals in France.

Method

T2DM patients, informed and recruited during consulting with their usual care provider, who had attended a structured and validated DSME programme delivered by 13 primary care providers within a multi-professional primary care practice in a deprived area of 20,000 inhabitants, were invited to participate in this study. A qualitative study with semi-structured, in-depth interviews was conducted with study participants, between July 2017 and February 2018. A reflexive thematic analysis of the interviews was carried out. Coding schemes were developed to generate thematic trends in patient descriptions of facilitators and barriers to DSME participation.

Results

Nineteen interviews (mean length 31 min; [20–44 min]) were completed with T2DM patients. Four themes on facilitators for programme participation emerged from the data: geographical proximity of a DSME programme held in the local multi-professional primary care practice; effective promotion of the DSME programme by the local multi-professional team; pre-existing relationship between patients and their healthcare providers; and potential to establish new social interactions within the neighbourhood by participating in the programme. Three themes on barriers to attendance emerged: integrating the DSME programme into their own schedules; difficulties in expressing themselves in front of a group; and keeping the motivation for self-managing their T2DM.

Conclusions

From the patient perspective, the programme geographical proximity and the pre-existing patient-healthcare provider relationship were important factors that contributed to participation. Healthcare providers should consider these factors to improve access to DSME programmes and diabetes self-management in deprived populations. Longitudinal studies should be performed to measure the impact of these programmes.

Wellness project implementation within Houston's Faith and Diabetes initiative: a mixed methods study

Background

Faith-based health promotion has shown promise for supporting healthy lifestyles, but has limited evidence of reaching scale or sustainability. In one recent such effort, volunteers from a diverse range of faith organizations were trained as peer educators to implement diabetes self-management education (DSME) classes within their communities. The purpose of this study was to identify factors associated with provision of these classes within six months of peer-educator training.

Methods

This study used the Consolidated Framework for Implementation Research (CFIR) to identify patterns from interviews, observations, attendance records, and organizational background information. Two research team members thematically coded interview transcripts and observation memos to identify patterns distinguishing faith organizations that did, versus did not, conduct DSME classes within six months of peer-educator training. Bivariate statistics were also used to identify faith organizational characteristics associated with DSME class completion within this time frame.

Results

Volunteers from 24 faith organizations received peer-educator training. Of these, 15 led a DSME class within six months, graduating a total of 132 participants. Thematic analyses yielded two challenges experienced disproportionately by organizations unable to complete DSME within six months: [1] Their peer educators experienced DSME as complex, despite substantial planning efforts at simplification, and [2] the process of engaging peer educators and leadership within their organizations was often more difficult than anticipated, despite initial communication by Faith and Diabetes organizers intended to secure informed commitments by both groups. Many peer educators were overwhelmed by training content, the responsibility required to start and sustain DSME classes, and other time commitments. Other priorities competed for time in participants’ lives and on organizational calendars, and scheduling processes could be slow. In an apparent dynamic of “crowding out,” coordination was particularly difficult in larger organizations, which were less likely than smaller organizations to complete DSME classes despite their more substantial resources.

Conclusions

Initial commitment from faith organizations’ leadership and volunteers may not suffice to implement even relatively short and low cost health promotion programs. Faith organizations might benefit from realistic previews about just how challenging it is to make these programs a sufficiently high organizational and individual priority.

Behaviour change in diabetes: behavioural science advancements to support the use of theory

Behaviour is central to the management of diabetes, both for people living with diabetes and for healthcare professionals delivering evidence-based care. This review outlines the evolution of behavioural science and the application of theoretical models in diabetes care over the past 25 years. There has been a particular advancement in the development of tools and techniques to support researchers, healthcare professionals and policymakers in taking a theory-based approach, and to enhance the development, reporting and replication of successful interventions. Systematic guidance, theoretical frameworks and lists of behavioural techniques provide the tools to specify target behaviours, identify why ideal behaviours are not implemented, systematically develop theory-based interventions, describe intervention content using shared terminology, and evaluate their effects. Several examples from a range of diabetes-related behaviours (clinic attendance, self-monitoring of blood glucose, retinal screening, setting collaborative goals in diabetes) and populations (people with type 1 and type 2 diabetes, healthcare professionals) illustrate the potential for these approaches to be widely translated into diabetes care. The behavioural science approaches outlined in this review give healthcare professionals, researchers and policymakers the tools to deliver care and design interventions with an evidence-based understanding of behaviour. The challenge for the next 25 years is to refine the tools to increase their use and advocate for the role of theoretical models and behavioural science in the commissioning, funding and delivery of diabetes care.

Exploring organizational support for the provision of structured self-management education for people with Type 2 diabetes: findings from a qualitative study

AIM

To explore the organizational context in which Type 2 diabetes structured group education is provided.

METHODS

Four Clinical Commissioning Groups in England providing Type 2 diabetes structured self-management education participated in a qualitative study exploring the context for provision of that education. Using UK National Diabetes Audit returns, two Clinical Commissioning Groups were selected that had non-attendance rates of ≤25%, and two that had non-attendance rates of ≥50%. Between May 2016 and August 2017, 20 interviews were conducted with Clinical Commissioning Group staff including: commissioners, healthcare professionals, managers, general practitioners and diabetes educators. Data gathering was prolonged as it proved challenging to engage with healthcare staff as a result of frequent local restructuring and service disruption.

RESULTS

Local audits revealed discrepancies in basic data such as referral and attendance numbers compared with national audit data. There was a commonality in the themes identified from interviews: diabetes education was rarely embedded in service structure; where education uptake was poor, a lack of central support to delivery teams was noticeable; and where education uptake was positive, delivery teams were actively engaged, sometimes relying on enthusiastic individuals. Both situations put the local sustainability of diabetes education at risk.

CONCLUSIONS

There appears to be a link between attendance rates and organizational issues, therefore, when considering how to increase attendance rates, the state of the diabetes education infrastructure should be reviewed. Good uptake of diabetes education can be too reliant on the enthusiastic commitment of small teams or individuals delivering the education.

Barriers and facilitators to attendance at Type 2 diabetes structured education programmes: a qualitative study of educators and attendees

AIMS

Attendance at structured diabetes education has been recommended internationally for all people with Type 2 diabetes. However, attendance rates are consistently low. This qualitative study aimed to explore experiences of attending and delivering Type 2 diabetes structured education programmes in Ireland and barriers and facilitators to attendance.

METHODS

People with Type 2 diabetes who had attended one of the three programmes delivered in Ireland and educators from the three programmes took part in semi-structured telephone interviews. Interviews were audio-taped, transcribed and analysed using inductive thematic analysis.

RESULTS

Twelve attendees and 14 educators were interviewed. Two themes were identified in relation to experiences of programme attendance and delivery: 'Structured education: addressing an unmet need' and 'The problem of non-attendance'. The third theme 'Barriers to attendance: can't go, won't go, don't know and poor system flow' outlined how practicalities of attending, lack of knowledge of the existence and benefits, and limited resources and support for education within the diabetes care pathway impacts on attendance. The final theme 'Supporting attendance: healthcare professionals and the diabetes care pathway' describes facilitators to participants' attendance and the strategies educators perceived to be important in increasing attendance.

CONCLUSIONS

Healthcare professionals have an important role in improving attendance at structured diabetes education programmes. Improving attendance may require promotion by healthcare professionals and for education to be better embedded and supported within the diabetes care pathway.

Using qualitative data to enhance our understanding of the reasons young people decline Structured Diabetes Education programmes

AIM

To explore the reasons young people with type 1 diabetes decline Structured Diabetes Education from the perspectives of the young people themselves, their parents and diabetes educators.

BACKGROUND

Structured Diabetes Education programmes that are evidence based and quality assured are a key component to empowering people with diabetes to self-manage effectively. However, research reveals that uptake of structured education programmes is disappointingly low.

DESIGN

Qualitative cross-sectional study involving participants from Northern Ireland and England.

METHODS

Twenty young people with type 1 diabetes (13-22 years) who had declined Structured Diabetes Education within the past 2 years, 17 parents of a young person with type 1 diabetes and 16 diabetes educators participated in semistructured interviews and focus groups.

RESULTS

Three main themes emerged from across all three groups: timing, access and communication issues. In addition, a lack of understanding by the referrer was cited by some young people and their parents. Diabetes educators were sympathetic and understood many of the reasons why Structured Diabetes Education was declined. Solutions were proposed to overcome expressed barriers.

CONCLUSIONS

Although the expressed reasons for declining might suggest that the young people simply did not prioritise education, this study adds a more nuanced scenario to the debate. The interviews revealed the tensions that exist between people's daily commitments and their need to self-manage their diabetes. The young people and their parents must be given a much stronger sense of the importance of Structured Diabetes Education and ways to accommodate attendance must be sought. Diabetes educators must be able to better promote the importance of Structured Diabetes Education.

RELEVANCE TO CLINICAL PRACTICE

As optimal glycaemic control is so vital for long-term health, there is an urgent need to understand how to respond more fully to the needs of young people who have type 1 diabetes.