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Lawton J, Chadwick PM, de Zoysa N, Stanton-Fay S, Heller SR, Rankin D. Participants' experiences of attending a structured education course (DAFNEplus) informed by behavioural science. Diabet Med 2024; 41:e15309. [PMID: 38361333 DOI: 10.1111/dme.15309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/17/2024]
Abstract
AIMS As part of a broader process evaluation, we explored participants' experiences of, and engagement with, the DAFNEplus programme's group-based structured education course. This course, which was informed by behavioural science, provided participants with education and instruction to use flexible intensive insulin therapy (FIIT) together with techniques to identify and address unhelpful cognitive and emotional influences on their type 1 diabetes self-management. METHODS We interviewed n = 28 DAFNEplus participants. Data were analysed thematically and took account of previous work exploring individuals' experiences of standard DAFNE courses. RESULTS As well as benefitting from the DAFNEplus course's skills-based training and educational curriculum, participants' accounts suggested they had experienced cognitive and emotional changes that had positively influenced their confidence and motivation to adopt and sustain the use of FIIT. These benefits were most keenly felt by those who reported negative emotional states and mind-sets pre-course which had made their diabetes self-management challenging. Participants' cognitive and emotional changes were enabled through techniques used during the course to normalise setbacks and imperfect diabetes self-management, capitalise upon group synergies and encourage the use of social support, including from healthcare professionals. Participants also highlighted motivational gains arising from being reassured that diabetes complications are not common or inevitable if a FIIT regimen is followed. CONCLUSIONS Our findings suggest that offering training in FIIT, in conjunction with behaviour change techniques that target unhelpful mindsets and emotional resilience, may be more effective in promoting diabetes self-management than offering education and skills training alone.
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Affiliation(s)
- Julia Lawton
- Usher Institute, Medical School, University of Edinburgh, Edinburgh, UK
| | - Paul M Chadwick
- UCL Centre for Behaviour Change, University College London, London, UK
| | | | | | - Simon R Heller
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - David Rankin
- Usher Institute, Medical School, University of Edinburgh, Edinburgh, UK
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2
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McCall AL, Lieb DC, Gianchandani R, MacMaster H, Maynard GA, Murad MH, Seaquist E, Wolfsdorf JI, Wright RF, Wiercioch W. Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2023; 108:529-562. [PMID: 36477488 DOI: 10.1210/clinem/dgac596] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality. OBJECTIVE To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia. METHODS A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. RESULTS The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia. CONCLUSION The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.
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Affiliation(s)
- Anthony L McCall
- University of Virginia Medical School, Department of Medicine, Division of Endocrinology and Metabolism, Charlottesville, VA 22901, USA
| | - David C Lieb
- Eastern Virginia Medical School, Division of Endocrine and Metabolic Disorders, Department of Medicine, Norfolk, VA 23510, USA
| | | | | | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55905, USA
| | - Elizabeth Seaquist
- Diabetes Center and the Division of Endocrinology & Metabolism, Minneapolis, MN 55455, USA
| | - Joseph I Wolfsdorf
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Wojtek Wiercioch
- McMaster University GRADE Centre and Michael G. DeGroote Cochrane Canada Centre Department of Health Research Methods, Evidence, and Impact, Hamilton, ON, L8S 4L8, Canada
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3
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Cairns SR, Sjöström ES. Dietitians' perspectives on challenges and prospects for group-based education to adults with type 1 diabetes - a qualitative study. BMC Endocr Disord 2022; 22:249. [PMID: 36253850 PMCID: PMC9576129 DOI: 10.1186/s12902-022-01165-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/16/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Type 1 diabetes (T1DM) is an autoimmune disorder which can have short- and long-term adverse effects on health. Dietitians in diabetes offer specialist evidence-based advice to people with T1DM and provide education in either individual or group settings. The purpose of this study was to explore dietitians' perception of, and role in, group-based education as well as prospects for development. METHODS This was a qualitative descriptive study conducted in Sweden using a convenience sampling of dietitians working in adult diabetes care. Semi-structured interviews were conducted with participants and data were analysed using a content analysis approach. RESULTS Ten dietitians with a median experience of 14.5 years in diabetes care were interviewed. The informants were all appreciative of facilitating group-based education and perceived that it was beneficial for people with T1DM to be part of group processes, but the informants did also suggest that there were challenges for their professional role. The main challenges reported was to adjust the level of depth and complexity to the information provided and the lack of ability to individualize the education-sessions in a heterogenous group. None of the dietitians reported performing pre-assessment or follow-up audits on the group-based education. CONCLUSION There was a great engagement from the dietitians, but they identified a lack of framework that address challenges regarding group-based education. The dietitians experienced examples of person-centred care while facilitating group-based education, which may benefit people with T1DM. Based on the results, it would be valuable to explore the pedagogic training level of Swedish dietitians and potential barriers in their ability to facilitate group-based education. We suggest that a framework for group-based education should be explored together with patient representatives to optimize the care given to ensure cost-effectiveness, optimize clinical outcomes, quality of life and equally accessible care for people with T1DM.
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Rytter K, Schmidt S, Rasmussen LN, Pedersen-Bjergaard U, Nørgaard K. Education programmes for persons with type 1 diabetes using an insulin pump: A systematic review. Diabetes Metab Res Rev 2021; 37:e3412. [PMID: 33010190 DOI: 10.1002/dmrr.3412] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/10/2020] [Accepted: 09/05/2020] [Indexed: 01/26/2023]
Abstract
Education is essential in insulin pump therapy, but literature in the field is limited. We systematically reviewed insulin pump education programmes and their effects in two situations as follows: (1) basic education at the start of insulin pump therapy, providing the study design enabled us to separate the effects of insulin pump therapy itself from the effects of education and (2) re-education of experienced pump users. Population: individuals ≥16 years with type 1 diabetes using insulin pumps with or without continuous glucose monitoring. Systematic searches were run in MEDLINE, Embase, CINAHL and ERIC. Original studies reporting an effect of insulin pump education programmes were included if published in English between January 1999 and May 2019. Of 988 potentially relevant studies, 48 were assessed in full text. Nine studies fulfilled the inclusion criteria, including one randomised controlled trial. Educational approaches and settings were sparsely described in all studies, and the content was usually reported as teaching points. Two studies considered basic education, reporting evaluations of knowledge and application skills, and programme satisfaction. The remaining seven studies referred to re-education. Two studies measured severe hypoglycaemic events before and after a re-education intervention, both reporting a significant event reduction. HbA1c decreased significantly in three of four studies. Two studies reported increased knowledge and improved application skills. In conclusion, this review indicates benefits from basic education and from re-education. The strength of the conclusions is limited by the low number of studies and study designs. High-quality studies are needed comparing different approaches for insulin pump education.
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Affiliation(s)
- Karen Rytter
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | | | | | - Ulrik Pedersen-Bjergaard
- Nordsjaellands Hospital, Hillerød, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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5
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Willis C, Elliott C, Reid S, Nyquist A, Jahnsen R, Bölte S, Rosenberg M, Girdler S. "Capturing the magic": identifying the active ingredients of a physical activity participation intervention for children and youth with disabilities. Disabil Rehabil 2021; 44:1650-1659. [PMID: 33820452 DOI: 10.1080/09638288.2021.1907458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aimed to define the active ingredients of a participation-focused physical activity intervention for children and youth with disabilities. MATERIALS AND METHODS An ethnographic approach was employed, triangulating participant observation, interviews and focus groups. Participant recruitment occurred through purposive sampling of staff employed at Beitostolen Healthsports Centre (BHC), and paediatric service providers visiting the centre. Interviews were transcribed verbatim and coded together with observation data. Secondary coding linked data to corresponding categories of the International Classification of Functioning, Disability and Health: Child and Youth version. RESULTS Thirteen staff from BHC and 7 paediatric service providers participated in the study. Fourteen active ingredients were identified and were characterised at the level of the intervention (k = 8), the organisation (k = 4), and the individual (k = 2). Within the ingredients, 53 unique ICF-CY categories were identified. Twenty-six categories belonged to the ICF-CY component of "environment," and 26 categories to "activities and participation." No categories related to "body functions" or "body structures." CONCLUSIONS The role of the environment, and specifically support and relationships, may be an essential consideration for enabling physical activity participation. Outcomes may guide program design and implementation to promote and sustain physical activity behaviours for children and youth with disabilities.Implications for rehabilitationThe active ingredients identified in this study may guide the design and implementation of programs to promote and sustain physical activity behaviours of children and youth with disabilities.Leadership qualities and strength-based attitudes may be key characteristics of organisational practice that optimise outcomes for children and families.A "relationship-centred" approach, i.e., a network of children, families, health professionals, peers, mentors, and services in the community, may support children and young people with disabilities to achieve their physical activity participation goals.
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Affiliation(s)
- Claire Willis
- Sport and Exercise Science, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia.,School of Human Sciences (Exercise Science), The University of Western Australia, Perth, Australia
| | - Catherine Elliott
- School of Occupational Therapy and Social Work, Curtin University, Perth, Australia
| | - Siobhan Reid
- School of Human Sciences (Exercise Science), The University of Western Australia, Perth, Australia
| | | | - Reidun Jahnsen
- Beitostolen Healthsports Centre, Beitostolen, Norway.,Research Centre for Habilitation and Rehabilitation Models and Services, University of Oslo, Oslo, Norway
| | - Sven Bölte
- Center of Neurodevelopmental Disorders (KIND), Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Child and Adolescent Psychiatry, Center for Psychiatry Research, Stockholm County Council, Stockholm, Sweden
| | - Michael Rosenberg
- School of Human Sciences (Exercise Science), The University of Western Australia, Perth, Australia
| | - Sonya Girdler
- School of Occupational Therapy and Social Work, Curtin University, Perth, Australia.,Center of Neurodevelopmental Disorders (KIND), Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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6
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Heller SR, Gianfrancesco C, Taylor C, Elliott J. What are the characteristics of the best type 1 diabetes patient education programmes (from diagnosis to long-term care), do they improve outcomes and what is required to make them more effective? Diabet Med 2020; 37:545-554. [PMID: 32034796 DOI: 10.1111/dme.14268] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2020] [Indexed: 12/17/2022]
Abstract
The last 20 years have witnessed a marked change in approaches to the management of type 1 diabetes in the UK. This is exemplified by National Institute of Health and Care Excellence (NICE) guidance which acknowledges that reaching and maintaining target glucose depends on people with type 1 diabetes effectively implementing flexible intensive insulin therapy. The guidance emphasizes that successful self-management requires the acquisition of complex skills and is best achieved by participation in high-quality structured education. Controlled trials and other research have shown that programmes teaching self-management can lower glucose levels while reducing hypoglycaemia, improve psychological outcomes and are highly cost-effective. An important principle of successful programmes is therapeutic education in which learning becomes a partnership between the professional and the person with diabetes who learns to fit diabetes into his/her everyday life. Other recommended elements of programmes include a written curriculum, group teaching by a professional multidisciplinary team and quality assurance. Yet many participants struggle post-course to implement and maintain skills, and overall HbA1c levels, particularly in the UK, remain far from target. Recent studies have identified the barriers to sustained effective self-management and concluded that even high-quality programmes generally lack critical components. These include incorporating evidence from behaviour change research, exploiting the promise of new technologies in reducing the burden of self-management, and providing structured professional support once people have completed the training. Studies are currently underway to evaluate structured training courses which have added these elements and examine whether they can lower glucose to levels closer to target without impairing quality of life.
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Affiliation(s)
- S R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - C Gianfrancesco
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - C Taylor
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - J Elliott
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
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7
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Fisher L, Polonsky W, Bowyer V, Hessler D. When patient-reported experience does not match change in clinical outcomes: A perplexing view from the inside of a diabetes distress intervention. J Diabetes Complications 2020; 34:107533. [PMID: 31955952 PMCID: PMC8713470 DOI: 10.1016/j.jdiacomp.2020.107533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/19/2019] [Accepted: 01/06/2020] [Indexed: 11/16/2022]
Abstract
AIMS To assess between-group differences in participant experiences in a two-arm diabetes distress (DD) reduction RCT and to determine their relationship to clinical outcomes (reductions in DD and HbA1C). METHODS For high DD adults with Type 1 diabetes and HbA1c ≥7.5% participating in T1-REDEEM, we evaluated post intervention 5-point ratings of overall program "helpfulness" and program component "helpfulness," along with open-ended feedback statements using 10 qualitative codes. We compared responses of those in OnTrack, a distressed-focused intervention, with KnowIt, an education/management intervention. RESULTS Those in OnTrack reported significantly higher levels of overall program helpfulness and greater helpfulness of each component of the program, greater group support, far fewer negative experiences, and more active and meaningful group engagement than those who participated in KnowIt. Ratings of helpfulness were unrelated to reductions in DD and HbA1C in both study arms. As previously reported, these findings occurred despite significant reductions in both DD and HbA1C in both arms with no between-group differences. CONCLUSIONS Findings highlight the importance of addressing the personal experience of diabetes interventions in clinical care as separate, distinct outcomes. Personal experience may not always be related to changes in traditional clinical indicators.
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Affiliation(s)
- Lawrence Fisher
- University of California, San Francisco, San Francisco, CA, USA.
| | - William Polonsky
- University of California, San Diego, San Diego, CA, USA; Behavioral Diabetes Institute, San Diego, CA, USA
| | - Vicky Bowyer
- University of California, San Francisco, San Francisco, CA, USA
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8
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Sanders T, Elliott J, Norman P, Johnson B, Heller S. Disruptive illness contexts and liminality in the accounts of young people with type 1 diabetes. SOCIOLOGY OF HEALTH & ILLNESS 2019; 41:1289-1304. [PMID: 30968432 DOI: 10.1111/1467-9566.12906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We utilise Bury's (1982) biographical disruption to examine young people's experiences of type 1 diabetes. Our findings show that young adults adopted various 'subject positions' across different illness contexts. The subject positions deployed are intended to produce a particular kind of normal embodied identity unaffected by diabetes. First, participants concealed their illness in public spaces and challenged cultural stereotypes of diabetes to maintain a normal illness biography. Disruption was ever present and required careful negotiation to avoid exposure of illness in public. Young adults upheld a 'normal public presentation'. Second, they resisted the medical system's pressure to adhere to glucose targets asserting and maintaining a subject position of 'independent and autonomous young adults'. Here, disruption was transient and temporary, present in the clinic but not always beyond. It remained in the background for much of the time until it was reinforced by parents or at meal times. Third, young adults acquired a 'pragmatic subject position' with diabetes viewed as complex but manageable, no longer a target for resistance. Frank's (1995) 'narrative restitution' is adopted to describe the transition to life with 'normal' illness. We argue that illness experience was 'liminal' and reflected the subject positions adopted by young adults.
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Affiliation(s)
- Tom Sanders
- Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Jackie Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Oncology & Metabolism, School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, UK
| | - Paul Norman
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Barbara Johnson
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Oncology & Metabolism, School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, UK
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9
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Fisher L, Polonsky WH, Hessler D. Addressing diabetes distress in clinical care: a practical guide. Diabet Med 2019; 36:803-812. [PMID: 30985025 DOI: 10.1111/dme.13967] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2019] [Indexed: 01/09/2023]
Abstract
Addressing the emotional side of diabetes and its management has received considerable attention in recent years. At the centre of most of these efforts is the concept of 'diabetes distress', a generic term that captures the primary sources and intensity of emotional distress associated with diabetes and its management over time. As interest in diabetes distress has grown, however, it has been difficult to integrate and translate the various strands of clinical research in a manner that can guide diabetes distress intervention efforts in the real world of clinical care. The aim of this paper is to fill this gap by outlining practical strategies for intervention in clinical settings and to assist diabetes healthcare professionals in thinking through how diabetes distress might be addressed practically in their clinics. To address these goals, this review is divided into five sections: a definition of diabetes distress, ways diabetes distress can be assessed and monitored, information about diabetes distress for use in intervention planning, topics to be considered for inclusion in diabetes distress interventions, and alternatives for where in the care process a diabetes distress intervention might be considered. We focus on diabetes distress experienced by adults with both Type 1 and Type 2 diabetes.
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Affiliation(s)
- L Fisher
- Department of Family & Community Medicine, University of California, San Francisco, Ca, USA
| | - W H Polonsky
- University of California, San Diego, Behavioral Diabetes Institute, San Diego, Ca, USA
| | - D Hessler
- Department of Family & Community Medicine, University of California, San Francisco, Ca, USA
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Papoutsi C, Colligan G, Hagell A, Hargreaves D, Marshall M, Vijayaraghavan S, Greenhalgh T, Finer S. Promises and Perils of Group Clinics for Young People Living With Diabetes: A Realist Review. Diabetes Care 2019; 42:705-712. [PMID: 31010940 DOI: 10.2337/dc18-2005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/22/2019] [Indexed: 02/03/2023]
Abstract
Group clinics are becoming popular as a new care model in diabetes care. This evidence synthesis, using realist review methodology, examined the role of group clinics in meeting the complex needs of young people living with diabetes. Following Realist And Meta-narrative Evidence Synthesis-Evolving Standards (RAMESES) quality standards, we conducted a systematic search across 10 databases. A total of 131 articles met inclusion criteria and were analyzed to develop theoretically informed explanations of how and why group clinics could work (or not) for young people with diabetes. Models of group-based care in the literature varied significantly and incorporated different degrees of clinical and educational content. Our analysis identified four overarching principles that can be applied in different contexts to drive sustained engagement of young people in group clinics: 1) emphasizing self-management as practical knowledge; 2) developing a sense of affinity between patients; 3) providing safe, developmentally appropriate care; and 4) balancing group and individual needs. Implementation of group clinics was not always straightforward; numerous adjustments to operational and clinical processes were required to establish and deliver high-quality care. Group clinics for young people with diabetes offer the potential to complement individualized care but are not a panacea and may generate as well as solve problems.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, U.K
| | - Grainne Colligan
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, U.K
| | - Ann Hagell
- Association for Young People's Health, London, U.K
| | - Dougal Hargreaves
- Department of Primary Care and Public Health, Imperial College London, London, U.K
| | - Martin Marshall
- Department of Primary Care and Population Health, University College London, London, U.K
| | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, U.K
| | - Sarah Finer
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, U.K. .,Barts Health NHS Trust, London, U.K
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11
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Dłużniak-Gołaska K, Panczyk M, Szypowska A, Sińska B, Szostak-Węgierek D. Interactive Nutrition Education Is More Effective in Terms of Improved Levels of Glycated Hemoglobin in Adolescent Patients with Poorly Controlled Type 1 Diabetes - A Randomized Study. Diabetes Metab Syndr Obes 2019; 12:2619-2631. [PMID: 31849506 PMCID: PMC6911330 DOI: 10.2147/dmso.s229246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/05/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Effectively conducted nutrition education is one of the key elements of the therapy of type 1 diabetes. The aim of the study was to compare the effectiveness of two methods of nutrition education. MATERIAL AND METHODS A noninvasive interventional randomized single-blind study included 151 patients (13.7±2.2 years old) with poorly controlled type 1 diabetes, treated with the use of insulin pumps. The participants were randomly divided into two groups: a control group (C) in which informative education methods were used (a lecture) and an experimental group (E) in which interactive methods (quiz and multimedia application) were additionally applied. The concentration of glycated hemoglobin (HbA1c) was the primary outcome. The secondary outcomes were: standard deviation score-body mass index (SDS-BMI), standard deviation score-systolic blood pressure (SDS-SBP), standard deviation score-diastolic blood pressure (SDS-DBP), scores of Nutrition Knowledge Survey (NKS) and indices of healthy and unhealthy diet. RESULTS A marked reduction in HbA1c concentrations was observed after 3 months in group E [-0.47% (-0.77; -0.17), P<0.01; P=0.038 for the intergroup difference]. The positive effect was no longer present after 6 months. No significant changes regarding HbA1c were noted in group C at any stage of the study. After 6 months, both groups obtained better results in one part of NKS ("Blood glucose response to food"): group C [0.41 (0.15; 0.66), P<0.01], group E [0.80 (0.52; 1.08), P<0.001; P=0.042 for the intergroup difference]. No statistically significant differences between groups were noted as regards the remaining parameters. CONCLUSION Interactive nutrition education is more effective in terms of improved levels of HbA1c in children and adolescents with poorly controlled diabetes. However, an intensification of training frequency is recommended due to the transient effect of education.
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Affiliation(s)
- Karolina Dłużniak-Gołaska
- Department of Clinical Dietetics, Faculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland
| | - Mariusz Panczyk
- Department of Education and Research in Health Sciences, Faculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland
- Correspondence: Mariusz Panczyk Department of Education and Research in Health Sciences, Faculty of Health Sciences, Medical University of Warsaw, Zwirki i Wigury 61, Warsaw02-091, PolandTel +48 22 572 0490Fax +48 22 572 0491 Email
| | - Agnieszka Szypowska
- Department of Pediatrics, The First Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Beata Sińska
- Department of Human Nutrition, Faculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Szostak-Węgierek
- Department of Clinical Dietetics, Faculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland
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12
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Campbell F, Lawton J, Rankin D, Clowes M, Coates E, Heller S, de Zoysa N, Elliott J, Breckenridge JP. Follow-Up Support for Effective type 1 Diabetes self-management (The FUSED Model): A systematic review and meta-ethnography of the barriers, facilitators and recommendations for sustaining self-management skills after attending a structured education programme. BMC Health Serv Res 2018; 18:898. [PMID: 30482202 PMCID: PMC6258400 DOI: 10.1186/s12913-018-3655-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 10/26/2018] [Indexed: 11/23/2022] Open
Abstract
Background People with type 1 diabetes who attend structured education training in self-management using flexible intensive therapy achieve improved blood glucose control and experience fewer episodes of severe hypoglycaemia. However, many struggle to sustain these improvements over time. To inform the design of more effective follow-up support we undertook a review of qualitative studies which have identified factors that influence and inform participants’ self-management behaviours after attending structured education and their need for support to sustain improvements in glycaemic control. Methods We undertook a meta-ethnography of relevant qualitative studies, identified using systematic search methods. Studies were included which focused on participants’ experiences of self-managing type 1 diabetes after attending structured education which incorporated training in flexible intensive insulin therapy. A line of argument approach was used to synthesise the findings. Results The search identified 18 papers from six studies. The studies included were judged to be of high methodological quality. The line of argument synthesis developed the Follow-Up Support for Effective type 1 Diabetes self-management (FUSED) model. This model outlines the challenges participants encounter in maintaining diabetes self-management practices after attending structured education, and describes how participants try to address these barriers by adapting, simplifying or personalising the self-management approaches they have learned. To help participants maintain the skills taught during courses, the FUSED model presents ten recommendations abstracted from the included papers to provide a logic model for a programme of individualised and responsive follow-up support. Conclusions This meta-ethnography highlights how providing skills training using structured education to people with type 1 diabetes does not necessarily result in participants adopting and sustaining recommended changes in behaviour. To help people sustain diabetes self-management skills after attending structured education, it is recommended that support be provided over the longer-term by appropriately trained healthcare professionals which is responsive to individuals’ needs. Although developed to inform support for people with type 1 diabetes, the FUSED model provides a framework that could also be applied to support individuals with other long term conditions which require complex self-management skills to be learned and sustained over time. Trial registration PROSPERO registration: CRD42017067961. Electronic supplementary material The online version of this article (10.1186/s12913-018-3655-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fiona Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, S1 4DA, Sheffield, England.
| | - Julia Lawton
- The Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, Scotland
| | - David Rankin
- The Usher Institute of Population Health Sciences and Informatics, Edinburgh Medical School of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, Scotland
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, S1 4DA, Sheffield, England
| | - Elizabeth Coates
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, S1 4DA, Sheffield, England
| | - Simon Heller
- Sheffield University School of Medicine, Academic Unit of Diabetes, Endocrinology, and Metabolism, School of Medicine and Biomedical Sciences, Sheffield, UK
| | - Nicole de Zoysa
- Diabetes Centre, King's College Hospital, Denmark Hill, London, SE5 9RS, England
| | - Jackie Elliott
- Sheffield University School of Medicine, Academic Unit of Diabetes, Endocrinology, and Metabolism, School of Medicine and Biomedical Sciences, Sheffield, UK
| | - Jenna P Breckenridge
- School of Nursing and Health Sciences, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, Scotland
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13
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Sanders T, Elliott J, Norman P, Johnson B, Heller S. Experiences of self-management among young adults with Type 1 diabetes in the context of a structured education programme: a qualitative study. Diabet Med 2018; 35:1531-1537. [PMID: 30030858 DOI: 10.1111/dme.13784] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 12/11/2022]
Abstract
AIMS To explore the experiences of young adults with regard to self-management of Type 1 diabetes in the context of a structured education programme. METHODS Qualitative interviews and focus groups were conducted with young adults attending a structured education course promoting a flexible and self-directed format. Participants attending the structured education courses were recruited using purposive sampling to acquire a broad mix of participants based on age and equal numbers of young men and women. Fifteen interviews were conducted 12 weeks after each course, whilst seven focus groups and observations of the course delivery were conducted at two course sites and were led by nurse/dietitian educators representing two different diabetes centres (paediatric and adult). The interview and focus group data were audio recorded and transcribed, coded, and analysed thematically to identify similarities and differences. RESULTS The analysis revealed three themes, 'we're in it together', 'tacit benefits' and 'transitions beyond the structured education programme'. The findings show that structured education programmes can facilitate reflective critical thinking and greater engagement with diabetes self-management if they: a) foster maximal learning from fellow participants to decrease feelings of isolation, b) maximize engagement during the course by delivering the content in a flexible manner, and c) recognize the social and emotional needs of young adults. CONCLUSION Structured education courses can result in improved critical thinking and engagement with diabetes self-management by empowering young adults through a flexible and self-directed learning style that encourages peer group discussion.
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Affiliation(s)
- T Sanders
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - J Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | - P Norman
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - B Johnson
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - S Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
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14
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Coates V, Horigan G, Carey M, Davies M. Using qualitative data to enhance our understanding of the reasons young people decline Structured Diabetes Education programmes. J Clin Nurs 2018; 27:3139-3147. [PMID: 29752855 DOI: 10.1111/jocn.14508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Vivien Coates
- Western Health and Social Care Trust, Ulster University, Coleraine, UK
| | | | - Marian Carey
- Diabetes Research Centre, University of Leicester, Leicester.,Kairos Communications & Research Ltd
| | - Mark Davies
- Belfast Health and Social Care Trust, Belfast, UK
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15
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Coates V, Slevin M, Carey M, Slater P, Davies M. Declining structured diabetes education in those with type 2 diabetes: A plethora of individual and organisational reasons. PATIENT EDUCATION AND COUNSELING 2018; 101:696-702. [PMID: 29103881 DOI: 10.1016/j.pec.2017.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/18/2017] [Accepted: 10/20/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE to identify the expressed reasons adults with type 2 diabetes decline structured diabetes education (SDE). METHODS cross sectional survey of 335 adults with type 2 diabetes who had declined SDE within the past two years, from across Northern Ireland and England. Standardised instruments comprising The Diabetes Attitude Scale, Diabetes Empowerment Scale (Short Form), and Diabetes Knowledge Test plus a questionnaire to elicit the reasons for declining SDE were used. RESULTS Mean age 57.6 years (±21.1) 50.7% males, predominantly of White ethnicity (85.7%). They were most frequently invited to attend by a diabetes specialist nurse (36%), general practitioner (27%) or practice nurse (19%). Although a diversity of reasons for declining SDE were cited the most common were; 'The course was too long' (47.2%), 'I have other health problems' (41.2%) and they had other priorities (33.4%). Hierarchical cluster analysis revealed that expressed reasons for declining SDE were highly individualised. CONCLUSION The wide range of reasons that impeded attendance suggests there is no simple solution that will improve attendance rates. PRACTICE IMPLICATIONS In the same way that medical treatment for diabetes is becoming increasingly individualised, educational provision should be encouraged to move away from a one size fits all model.
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Affiliation(s)
- Vivien Coates
- Institute of Nursing and Health Research, Ulster University, Magee campus, Londonderry BT48 7JL, United Kingdom; Western Health and Social Care Trust, Altnagelvin Hospital,Glenshane Road, Londonderry BT47 6SB, United Kingdom.
| | - Mary Slevin
- Institute of Nursing and Health Research, Ulster University, Cromore Road, Coleraine BT52 1SA, United Kingdom
| | - Marian Carey
- Leicester Diabetes Centre (Air Wing), Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, United Kingdom
| | - Paul Slater
- Institute of Nursing and Health Research, Ulster University, Shore Road, Newtownabbey, Co Antrim BT37 0QB, United Kingdom
| | - Mark Davies
- Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, United Kingdom
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16
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Willis CE, Reid S, Elliott C, Rosenberg M, Nyquist A, Jahnsen R, Girdler S. A realist evaluation of a physical activity participation intervention for children and youth with disabilities: what works, for whom, in what circumstances, and how? BMC Pediatr 2018; 18:113. [PMID: 29544462 PMCID: PMC5856004 DOI: 10.1186/s12887-018-1089-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 03/07/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The need to identify strategies that facilitate involvement in physical activity for children and youth with disabilities is recognised as an urgent priority. This study aimed to describe the association between context, mechanisms and outcome(s) of a participation-focused physical activity intervention to understand what works, in what conditions, and how. METHODS This study was designed as a realist evaluation. Participant recruitment occurred through purposive and theoretical sampling of children and parents participating in the Local Environment Model intervention at Beitostolen Healthsports Centre in Norway. Ethnographic methods comprising participant observation, interviews, and focus groups were employed over 15 weeks in the field. Data analysis was completed using the context-mechanism-outcome framework of realist evaluation. Context-mechanism-outcome connections were generated empirically from the data to create a model to indicate how the program activated mechanisms within the program context, to enable participation in physical activity. RESULTS Thirty one children with a range of disabilities (mean age 12y 6 m (SD 2y 2 m); 18 males) and their parents (n = 44; 26 mothers and 18 fathers) participated in the study. Following data synthesis, a refined program theory comprising four context themes, five mechanisms, and six outcomes, were identified. The mechanisms (choice, fun, friends, specialised health professionals, and time) were activated in a context that was safe, social, learning-based and family-centred, to elicit outcomes across all levels of the International Classification of Functioning, Disability and Health. CONCLUSIONS The interaction of mechanisms and context as a whole facilitated meaningful outcomes for children and youth with disabilities, and their parents. Whilst optimising participation in physical activity is a primary outcome of the Local Environment Model, the refined program theory suggests the participation-focused approach may act as a catalyst to promote a range of outcomes. Findings from this study may inform future interventions attempting to enable participation in physical activity for children and youth with disabilities.
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Affiliation(s)
- C. E. Willis
- School of Sport Science, Exercise and Health, The University of Western Australia, M408 35 Stirling Hwy, Perth, WA 6008 Australia
| | - S. Reid
- School of Sport Science, Exercise and Health, The University of Western Australia, M408 35 Stirling Hwy, Perth, WA 6008 Australia
| | - C. Elliott
- Department of Paediatric Rehabilitation, Child and Adolescent Health Service, 37-39 Hay St, Perth, WA 6008 Australia
- School of Occupational Therapy and Social Work, Curtin University, Kent St, Perth, WA 6102 Australia
| | - M. Rosenberg
- School of Sport Science, Exercise and Health, The University of Western Australia, M408 35 Stirling Hwy, Perth, WA 6008 Australia
| | - A. Nyquist
- Beitostolen Healthsports Centre, Sentervegen 4, 2953 Beitostolen, Oppland Norway
| | - R. Jahnsen
- Beitostolen Healthsports Centre, Sentervegen 4, 2953 Beitostolen, Oppland Norway
- Department of Clinical Neurosciences for Children, Oslo University Hospital, Kirkeveien 166, 0450 Oslo, Norway
| | - S. Girdler
- School of Occupational Therapy and Social Work, Curtin University, Kent St, Perth, WA 6102 Australia
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17
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Stefanowicz A, Mysliwiec M, Adamkiewicz-Drozynska E. Parental knowledge and metabolic control of children and young adults with type 1 diabetes. Arch Med Sci 2018; 14:52-59. [PMID: 29379532 PMCID: PMC5778408 DOI: 10.5114/aoms.2015.53832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 07/20/2015] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The authors aimed to answer the following questions: 1) What level of knowledge of type 1 diabetes do the parents of children and young adults with this disease have? 2) Will this level of knowledge increase after 1 year of observation? 3) Does improving the knowledge of young adults and their parents result in better metabolic control of the patients? MATERIAL AND METHODS This study included 227 patients between the ages of 5 and 20 years with type 1 diabetes. The research was conducted from March 2009 to June 2011. The following two time points were examined: the beginning of the study (test 1a) and one year later (test 1b). The knowledge levels of the patients and parents were obtained using a survey and a knowledge test. RESULTS Comparison of the results from the two study time points showed that the respondents had a significantly higher level of knowledge after 1 year (p = 0.001). The comparison of glycated hemoglobin levels between the two time points in patients with type 1 diabetes revealed that the levels were significantly higher at test 1b compared to test 1a (p = 0.0005). CONCLUSIONS The parents of children and young adults with type 1 diabetes demonstrate a satisfactory level of theoretical knowledge of therapeutic conduct and self-monitoring principles. The test 1b results demonstrated a higher level of theoretical knowledge in all respondents and poorer metabolic control. Poorer metabolic control in some patients suggests that metabolic control in type 1 diabetes depends on factors other than education. Further research is necessary to determine these additional factors.
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Affiliation(s)
- Anna Stefanowicz
- Advanced Registered Nurse Practitioner, Department of General Nursing, Chair of Nursing, Faculty of Health Sciences with Subfaculty of Nursing and Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Gdansk, Poland
- Chair and Clinics of Pediatrics, Diabetology and Endocrinology, Medical University of Gdansk, Gdansk, Poland
| | - Malgorzata Mysliwiec
- Chair and Clinics of Pediatrics, Diabetology and Endocrinology, Medical University of Gdansk, Gdansk, Poland
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18
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Vyas C, Dalal L, Talaviya P, Saboo B. Multiple educational programs improves glycemic control, quality of life with diminishing the impact of diabetes in poorly controlled type 1 diabetics. Diabetes Metab Syndr 2017; 11 Suppl 2:S601-S606. [PMID: 28927968 DOI: 10.1016/j.dsx.2017.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
AIMS The aim of present study was to assess the outcomes of multiple educational programs on glycemic control, quality of life and impact of diabetes in poorly controlled Type 1 Diabetic patients. PARTICIPANTS AND METHODS A 12 months diabetes education programs were conducted every week for first one month then followed by every 3 months with follow up on improvement of HbA1c and QOL in T1D patients (n=54). Clinical characteristics were recorded at baseline visit. The QOL was evaluated by 15 set DQOL questionnaires in 40 consecutive patients at baseline, 3, 6 and 12 months after education programs. The HbA1c level (%) was evaluated at same time point. Decrease in DQOL score was reported as improvement in QOL. RESULTS The rate of patients response to educational programs was noted 74.07% (n=40) at end of the study (12 months). The prevalence of T1D was reported higher in men than in women. The overall DQOL score and HbA1c% level was significantly (P<0.05) decreased at 3, 6 and 12 months after educational programs. Patients exhibited greater satisfaction and diminished impact of diabetes after educational programs was observed after 3 months and it was continue up to end of study. The frequencies of self-monitoring of blood glucose were increased. Numbers of hypoglycemic and DKA events were decreased after educational programs when compared to baseline. CONCLUSION Results of study revealed that the appropriate education and counseling diminish impact of diabetes, improve QOL and help to achieve desired glycemic (HbA1c) level in poorly control T1D patients.
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Affiliation(s)
- Chintan Vyas
- Saarathi Institute of Diabetes Sciences, Anand, Gujarat, 388 345, India.
| | - Lopa Dalal
- Saarathi Institute of Diabetes Sciences, Anand, Gujarat, 388 345, India
| | - Praful Talaviya
- Saarathi Institute of Diabetes Sciences, Anand, Gujarat, 388 345, India; DiaCare - An Advance Diabetes Care Center, Ahmedabad, Gujarat, 380 015, India
| | - Banshi Saboo
- DiaCare - An Advance Diabetes Care Center, Ahmedabad, Gujarat, 380 015, India
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19
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Kahkoska AR, Mayer-Davis EJ, Hood KK, Maahs DM, Burger KS. Behavioural implications of traditional treatment and closed-loop automated insulin delivery systems in Type 1 diabetes: applying a cognitive restraint theory framework. Diabet Med 2017; 34. [PMID: 28626906 PMCID: PMC5647213 DOI: 10.1111/dme.13407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
As the prevalence of obesity in Type 1 diabetes rises, the effects of emerging therapy options should be considered in the context of both weight and glycaemic control outcomes. Artificial pancreas device systems will 'close the loop' between blood glucose monitoring and automated insulin delivery and may transform day-to-day dietary management for people with Type 1 diabetes in multiple ways. In the present review, we draw directly from cognitive restraint theory to consider unintended impacts that closed-loop systems may have on ingestive behaviour and food intake. We provide a brief overview of dietary restraint theory and its relation to weight status in the general population, discuss the role of restraint in traditional Type 1 diabetes treatment, and lastly, use this restraint framework to discuss the possible behavioural implications and opportunities of closed-loop systems in the treatment of Type 1 diabetes. We hypothesize that adopting closed-loop systems will lift the diligence and restriction that characterizes Type 1 diabetes today, thus requiring a transition from a restrained eating behaviour to a non-restrained eating behaviour. Furthermore, we suggest this transition be leveraged as an opportunity to teach people lifelong eating behaviour to promote healthy weight status by incorporating education and cognitive reappraisal. Our aim was to use a transdisciplinary approach to highlight critical aspects of the emerging closed-loop technologies relating to eating behaviour and weight effects and to promote discussion of strategies to optimize long-term health in Type 1 diabetes via two key outcomes: glycaemic control and weight management.
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Affiliation(s)
- A R Kahkoska
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - E J Mayer-Davis
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - K K Hood
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - D M Maahs
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - K S Burger
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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20
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Quinn S, Bond R, Nugent C. A two-staged approach to developing and evaluating an ontology for delivering personalized education to diabetic patients. Inform Health Soc Care 2017; 43:264-279. [PMID: 29035605 DOI: 10.1080/17538157.2017.1364246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Ontologies are often used in biomedical and health domains to provide a concise and consistent means of attributing meaning to medical terminology. While they are novices in terms of ontology engineering, the evaluation of an ontology by domain specialists provides an opportunity to enhance its objectivity, accuracy, and coverage of the domain itself. This paper provides an evaluation of the viability of using ontology engineering novices to evaluate and enrich an ontology that can be used for personalized diabetic patient education. We describe a methodology for engaging healthcare and information technology specialists with a range of ontology engineering tasks. We used 87.8% of the data collected to validate the accuracy of our ontological model. The contributions also enabled a 16% increase in the class size and an 18% increase in object properties. Furthermore, we propose that ontology engineering novices can make valuable contributions to ontology development. Application-specific evaluation of the ontology using a semantic-web-based architecture is also discussed.
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Affiliation(s)
- Susan Quinn
- a Computer Science Research Institute, School of Computing & Maths , University of Ulster , Newtownabbey , County Antrim , UK
| | - Raymond Bond
- a Computer Science Research Institute, School of Computing & Maths , University of Ulster , Newtownabbey , County Antrim , UK
| | - Chris Nugent
- a Computer Science Research Institute, School of Computing & Maths , University of Ulster , Newtownabbey , County Antrim , UK
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21
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Vanstone M, Rewegan A, Brundisini F, Giacomini M, Kandasamy S, DeJean D. Diet modification challenges faced by marginalized and nonmarginalized adults with type 2 diabetes: A systematic review and qualitative meta-synthesis. Chronic Illn 2017; 13:217-235. [PMID: 27884930 DOI: 10.1177/1742395316675024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Diet modification is an important part of the prevention and treatment of type 2 diabetes, but sustained dietary change remains elusive for many individuals. This paper describes and interprets the barriers to diet modification from the perspective of people with type 2 diabetes, paying particular attention to the experiences of people who experience social marginalization. Methods A systematic review of primary, empirical qualitative research was performed, capturing 120 relevant studies published between 2002 and 2015. Qualitative meta-synthesis was used to provide an integrative analysis of this knowledge. Results Due to the central role of food in social life, dietary change affects all aspects of a person's life, and barriers related to self-discipline, emotions, family and social support, social significance of food, and knowledge were identified. These barriers are inter-linked and overlapping. Social marginalization magnifies barriers; people who face social marginalization are trying to make the same changes as other people with diabetes with fewer socio-material resources in the face of greater challenges. Discussion A social-ecological model of behavior supports our findings of challenges at all levels, and highlights the need for interventions and counseling strategies that address the social and environmental factors that shape and sustain dietary change.
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Affiliation(s)
- Meredith Vanstone
- 1 Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,2 Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Alex Rewegan
- 3 MA Program in Social Anthropology, York University, Hamilton, ON, Canada
| | - Francesca Brundisini
- 2 Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.,4 Health Policy PhD Program, McMaster University, Hamilton, ON, Canada
| | - Mita Giacomini
- 2 Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.,5 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Sujane Kandasamy
- 5 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Deirdre DeJean
- 2 Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.,5 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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22
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Knight BA, Hickman IJ, Gibbons K, Taylor J, McIntyre HD. Psychosocial outcomes in adults with type 1 diabetes following a novel ‘short course’ structured flexible MDI therapy self-management programme. PRACTICAL DIABETES 2017. [DOI: 10.1002/pdi.2126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Brigid A Knight
- Queensland Diabetes Centre; Mater Health Services; South Brisbane Australia
- Lady Cilento Children's Hospital; South Brisbane Australia
- TIPS for Diabetes; Brisbane Australia
| | - Ingrid J Hickman
- Department of Nutrition & Dietetics; Princess Alexandra Hospital; Woolloongabba Australia
- Mater Research Institute; University of Queensland; South Brisbane Australia
- Mater Clinical School; University of Queensland; South Brisbane Australia
| | - Kristen Gibbons
- Mater Research Institute; University of Queensland; South Brisbane Australia
| | - Janet Taylor
- Queensland Diabetes Centre; Mater Health Services; South Brisbane Australia
- TIPS for Diabetes; Brisbane Australia
| | - Harold D McIntyre
- Queensland Diabetes Centre; Mater Health Services; South Brisbane Australia
- Mater Research Institute; University of Queensland; South Brisbane Australia
- Mater Clinical School; University of Queensland; South Brisbane Australia
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23
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Coates VE, Horigan G, Davies M, Davies MT. Exploring why young people with Type 1 diabetes decline structured education with a view to overcoming barriers. Diabet Med 2017; 34:1092-1099. [PMID: 28430377 DOI: 10.1111/dme.13368] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2017] [Indexed: 12/13/2022]
Abstract
AIMS To identify factors that influence lack of engagement of young adults with Type 1 diabetes (aged 13-21 years) with structured diabetes education (SDE) to inform and broaden the reach of future SDE. METHODS A quantitative, cross-sectional survey was undertaken of 227 young people with Type 1 diabetes drawn from 11 health trusts across Northern Ireland and England, deemed to be representative of the wider population. Participants were asked to complete a questionnaire exploring non-attendance, along with the Diabetes Care Profile, the Diabetes Empowerment Scale (Short Form), the Diabetes Knowledge Test and the 12-item General Health Questionnaire. Demographic, health and diabetes-specific variables including HbA1c were also collected. RESULTS The five most commonly cited reasons for non-attendance were 'Had other things to do' (68.3%), 'No time' (62.2%), 'Could not get time off school/college or work' (60.8%), 'Learnt about diabetes from other sources' (55.5%) and 'Feel able to cope on own' (52.9%). CONCLUSIONS Greater emphasis is required on communication with young people about the benefits of SDE. In addition, efforts need to be directed to making diabetes education more accessible without losing the quality of structured programmes.
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Affiliation(s)
- V E Coates
- School of Nursing, Ulster University, and Western Health and Social Care Trust, Londonderry
| | - G Horigan
- School of Nursing, Ulster University, and Western Health and Social Care Trust, Londonderry
| | - M Davies
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester
| | - M T Davies
- Clinical Psychology Department, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
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Trento M, Merlo S, Durando O, Rapetti S, Cavallo F, Porta M. Self-management education and psychological support improve self-esteem in people with type 1 diabetes. Acta Diabetol 2017; 54:415-416. [PMID: 27796657 DOI: 10.1007/s00592-016-0935-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/15/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Marina Trento
- Laboratory of Clinical Pedagogy, Department of Medical Sciences, University of Turin, Corso AM. Dogliotti 14, 10126, Turin, Italy.
| | - Stefano Merlo
- Laboratory of Clinical Pedagogy, Department of Medical Sciences, University of Turin, Corso AM. Dogliotti 14, 10126, Turin, Italy
| | - Olga Durando
- Laboratory of Clinical Pedagogy, Department of Medical Sciences, University of Turin, Corso AM. Dogliotti 14, 10126, Turin, Italy
| | - Serena Rapetti
- Laboratory of Clinical Pedagogy, Department of Medical Sciences, University of Turin, Corso AM. Dogliotti 14, 10126, Turin, Italy
| | - Franco Cavallo
- Department of Public Health and Paediatrics, University of Turin, Turin, Italy
| | - Massimo Porta
- Laboratory of Clinical Pedagogy, Department of Medical Sciences, University of Turin, Corso AM. Dogliotti 14, 10126, Turin, Italy
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Rogers H. It's education, Jim, but not as we know it. PRACTICAL DIABETES 2016. [DOI: 10.1002/pdi.2039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Helen Rogers
- King's College Hospital NHS Foundation Trust; London UK
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Modeling predictors of changes in glycemic control and diabetes-specific quality of life amongst adults with type 1 diabetes 1 year after structured education in flexible, intensive insulin therapy. J Behav Med 2015; 38:817-29. [PMID: 26072044 DOI: 10.1007/s10865-015-9649-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/02/2015] [Indexed: 12/15/2022]
Abstract
Few studies have identified determinants of glycemic control (HbA1c) and diabetes-specific quality of life (DSQoL) in adults with type 1 diabetes. To identify factors predicting outcomes following structured diabetes education. 262 participants completed biomedical and questionnaire assessments before, and throughout 1 year of follow-up. The proportion of variance explained ranged from 28 to 62 % (DSQoLS) and 14-20 % (HbA1c). When change in psychosocial variables were examined, reduced hypoglycemia fear, lower 'perceived diabetes seriousness', greater self-efficacy and well-being predicted QoL improvements from baseline to 3-months. Increased frequency of blood glucose testing predicted improvements in HbA1c from baseline to 6-months. Greater benefits may be achieved if programs focus explicitly on psychosocial factors. Self-care behaviours did not predict HbA1c suggesting existing assessment tools need refinement. Evaluation of treatment mechanisms in self-management programs is recommended.
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Elliott J, Rankin D, Jacques RM, Lawton J, Emery CJ, Campbell MJ, Dixon S, Heller SR. A cluster randomized controlled non-inferiority trial of 5-day Dose Adjustment for Normal Eating (DAFNE) training delivered over 1 week versus 5-day DAFNE training delivered over 5 weeks: the DAFNE 5 × 1-day trial. Diabet Med 2015; 32:391-8. [PMID: 25363466 DOI: 10.1111/dme.12621] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/04/2014] [Accepted: 10/28/2014] [Indexed: 12/24/2022]
Abstract
AIMS To compare, in a randomized controlled non-inferiority trial, the outcomes of the traditional format for Dose Adjustment for Normal Eating structured education courses; that is, one delivered over 5 consecutive days (1-week course) with a variant of this format delivered 1 day a week for 5 consecutive weeks (5-week course). METHODS Adults with Type 1 diabetes, from seven UK Dose Adjustment For Normal Eating training centres, were individually randomized, stratified by centre, to receive either a 1-week or 5-week course. A qualitative study was embedded within the trial to explore patients' experiences. RESULTS In total, 213 patients were randomized and 160 completed the study procedures. In the per-protocol analysis, the difference in HbA1c levels (95% CI) between the arms at 6 months was 0.4 mmol/mol (-2.4, 3.1) or 0.03% (-0.22, 0.28) and -0.9 mmol/mol (-3.9, 2.2) or -0.08% (-0.36, 0.20) at 12 months. All confidence limits were within the non-inferiority margin of ± 5.5 mmol/mol (0.5%) for HbA1c %. For those patients with a baseline HbA1c of ≥ 58 mmol/mol (≥ 7.5%) the mean change (95% CI) in HbA1c was -2.2 mmol/mol (-4.0, -0.4) or -0.20% (-0.37, -0.04) at 6 months (P = 0.016), and -2.0 mmol/mol (-4.1, 0.04) or -0.18% (-0.37 to 0.004) at 12 months (P = 0.055). Episodes of severe hypoglycaemia were decreased by 82% [relative risk 0.18 (95% CI 0.03-0.936); P = 0.042], psychosocial outcomes improved significantly, and the difference between arms was not significant. Qualitative interviews showed that patients overwhelmingly favoured the format of course that they attended. CONCLUSIONS In summary, 5-week and 1-week Dose Adjustment for Normal Eating courses are equivalent in terms of biomedical and psychosocial outcomes, and we were persuaded that both course formats should be made available in routine care.
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Affiliation(s)
- J Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, UK
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28
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Heller S, Lawton J, Amiel S, Cooke D, Mansell P, Brennan A, Elliott J, Boote J, Emery C, Baird W, Basarir H, Beveridge S, Bond R, Campbell M, Chater T, Choudhary P, Clark M, de Zoysa N, Dixon S, Gianfrancesco C, Hopkins D, Jacques R, Kruger J, Moore S, Oliver L, Peasgood T, Rankin D, Roberts S, Rogers H, Taylor C, Thokala P, Thompson G, Ward C. Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes. PROGRAMME GRANTS FOR APPLIED RESEARCH 2014. [DOI: 10.3310/pgfar02050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BackgroundMany adults with type 1 diabetes cannot self-manage their diabetes effectively and die prematurely with diabetic complications as a result of poor glucose control. Following the positive results obtained from a randomised controlled trial (RCT) by the Dose Adjustment For Normal Eating (DAFNE) group, published in 2002, structured training is recommended for all adults with type 1 diabetes in the UK.AimWith evidence that blood glucose control is not always improved or sustained, we sought to determine factors explaining why some patients benefit from training more than other patients, identifying barriers to successful self-management, while developing other models to make skills training more accessible and effective.FindingsWe confirmed that glycaemic outcomes are not always improved or sustained when the DAFNE programme is delivered routinely, although improvements in psychosocial outcomes are maintained. DAFNE courses and follow-up support is needed to help participants instil and habituate key self-management practices such as regular diary/record keeping. DAFNE graduates need structured professional support following training. This is currently either unavailable or provided ad hoc without a supporting evidence base. Demographic and psychosocial characteristics had minimal explanatory power in predicting glycaemic control but good explanatory power in predicting diabetes-specific quality of life over the following year. We developed a DAFNE course delivered for 1 day per week over 5 weeks. There were no major differences in outcomes between this and a standard 1-week DAFNE course; in both arms of a RCT, glycaemic control improved by less than in the original DAFNE trial. We piloted a course delivering both the DAFNE programme and pump training. The pilot demonstrated the feasibility of a full multicentre RCT and resulted in us obtaining subsequent Health Technology Assessment programme funding. In collaboration with the National Institute for Health Research (NIHR) Diabetes Research Programme at King’s College Hospital (RG-PG-0606-1142), London, an intervention for patients with hypoglycaemic problems, DAFNE HART (Dose Adjustment for Normal Eating Hypoglycaemia Awareness Restoration Training), improved impaired hypoglycaemia awareness and is worthy of a formal trial. The health economic work developed a new type 1 diabetes model and confirmed that the DAFNE programme is cost-effective compared with no structured education; indeed, it is cost-saving in the majority of our analyses despite limited glycated haemoglobin benefit. Users made important contributions but this could have been maximised by involving them with grant writing, delaying training until the group was established and funding users’ time off work to maximise attendance. Collecting routine clinical data to conduct continuing evaluated roll-out is possible but to do this effectively requires additional administrator support and/or routine electronic data capture.ConclusionsWe propose that, in future work, we should modify the current DAFNE curricula to incorporate emerging understanding of behaviour change principles to instil and habituate key self-management behaviours that include key DAFNE competencies. An assessment of numeracy, critical for insulin dose adjustment, may help to determine whether or not additional input/support is required both before and after training. Models of structured support involving professionals should be developed and evaluated, incorporating technological interventions to help overcome the barriers identified above and enable participants to build effective self-management behaviours into their everyday lives.Trial registrationClinicalTrials.gov NCT01069393.FundingThe NIHR Programme Grants for Applied Research programme.
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Affiliation(s)
- Simon Heller
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Debbie Cooke
- Division of Psychology, University College London, London, UK
| | - Peter Mansell
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan Brennan
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jackie Elliott
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jonathan Boote
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- Centre for Research into Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Celia Emery
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Wendy Baird
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hasan Basarir
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Beveridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rod Bond
- School of Psychology, University of Sussex, Brighton, UK
| | - Mike Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Timothy Chater
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Marie Clark
- Division of Psychology, University College London, London, UK
| | | | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | - Richard Jacques
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jen Kruger
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Moore
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Lindsay Oliver
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Tessa Peasgood
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Sue Roberts
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | | | - Carolin Taylor
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Gill Thompson
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Candice Ward
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Kousoulis AA, Patelarou E, Shea S, Foss C, Ruud Knutsen IA, Todorova E, Roukova P, Portillo MC, Pumar-Méndez MJ, Mujika A, Rogers A, Vassilev I, Serrano-Gil M, Lionis C. Diabetes self-management arrangements in Europe: a realist review to facilitate a project implemented in six countries. BMC Health Serv Res 2014; 14:453. [PMID: 25278037 PMCID: PMC4283086 DOI: 10.1186/1472-6963-14-453] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 09/11/2014] [Indexed: 01/01/2023] Open
Abstract
Background Self-management of long term conditions can promote quality of life whilst delivering benefits to the financing of health care systems. However, rarely are the meso-level influences, likely to be of direct relevance to these desired outcomes, systematically explored. No specific international guidelines exist suggesting the features of the most appropriate structure and organisation of health care systems within which to situate self-management approaches and practices. This review aimed to identify the quantitative literature with regard to diabetes self-management arrangements currently in place within the health care systems of six countries (The United Kingdom, The Netherlands, Norway, Spain, Bulgaria, and Greece) and explore how these are integrated into the broader health care and welfare systems in each country. Methods The methodology for a realist review was followed. Publications of interest dating from 2000 to 2013 were identified through appropriate MeSH terms by a systematic search in six bibliographic databases. A search diary was maintained and the studies were assessed for their quality and risk of bias. Results Following the multi-step search strategy, 56 studies were included in the final review (the majority from the UK) reporting design methods and findings on 21 interventions and programmes for diabetes and chronic disease self-management. Most (11/21, 52%) of the interventions were designed to fit within the context of primary care. The majority (11/21, 52%) highlighted behavioural change as an important goal. Finally, some (5/21, 24%) referred explicitly to Internet-based tools. Conclusions This review is based on results which are derived from a total of at least 5,500 individuals residing in the six participating countries. It indicates a policy shift towards patient-centred self-management of diabetes in a primary care context. The professional role of diabetes specialist nurses, the need for multidisciplinary approaches and a focus on patient education emerge as fundamental principles in the design of relevant programmes. Socio-economic circumstances are relevant to the capacity to self-manage and suggest that any gains and progress will be hard to maintain during economic austerity. This realist review should be interpreted within the wider context of a whole systems approach regarding self-care support and chronic illness management. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-453) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Voutes, P,O, Box 2208, Heraklion 71003, Greece.
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Snow R, Sandall J, Humphrey C. Use of clinical targets in diabetes patient education: qualitative analysis of the expectations and impact of a structured self-management programme in Type 1 diabetes. Diabet Med 2014; 31:733-8. [PMID: 24495236 DOI: 10.1111/dme.12401] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/15/2013] [Accepted: 01/28/2014] [Indexed: 01/12/2023]
Abstract
AIMS To explore the impact of education and target-setting on the life stories of patients with diabetes up to 10 years after they had participated in the Dose Adjustment for Normal Eating programme (DAFNE). METHODS Qualitative, semi-structured interviews were conducted before and after DAFNE courses to elicit narrative accounts from participants at three UK education centres. Observations of courses also took place. Data were gathered from 21 participants over 32 interviews and 146 h of observations, and analysed using a narrative approach. RESULTS Findings suggest that patient education can create positive transformations in the lives of people with diabetes in ways that are not fully captured by simple quality-of-life scores. However, a review of evidence from other studies shows that DAFNE-recommended blood glucose results are in fact out of reach of even these most motivated and well-informed patients. This information was not shared with DAFNE attendees, who were expected to aim for near-normal HbA1c levels. After the course, participants sometimes perceived themselves as failing in their efforts, even when they had better than average blood glucose results. CONCLUSIONS Specific and measurable low HbA1c targets may be desirable for reducing the risk of complications in diabetes, but they are not attainable or realistic even for most DAFNE graduates. It is suggested that setting goals without information about how achievable they really are could be counterproductive in terms of supporting and maintaining patient self-efficacy long-term.
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Affiliation(s)
- R Snow
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
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Snow R, Humphrey C, Sandall J. What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study. BMJ Open 2013; 3:e003583. [PMID: 24231459 PMCID: PMC3831109 DOI: 10.1136/bmjopen-2013-003583] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To explore the impact of patient education on the lives of people with diabetes, including the effect on interactions with doctors and other healthcare professionals. DESIGN Qualitative user-led study using longitudinal interviews and 146 h of participant observation. Data were analysed using a narrative approach. PARTICIPANTS 21 patients with type 1 diabetes, those either about to attend a patient education course or those who had completed the course in the previous 10 years. SETTING Established patient education centres in three UK teaching hospitals teaching the Dose Adjustment for Normal Eating (DAFNE) course. RESULTS Both postcourse and several years later, most participants spoke of the experience of taking part in education as life-changingly positive. It helped them understand how to gain control over a very complex disease and freed them from dependence on medical advice and restrictive regimes. However, interactions within the health system following patient education could be fraught. Participants emerged from the course with greater condition-specific knowledge than many of the healthcare professionals they encountered. When these professionals did not understand what their patients were trying to do and were uncomfortable trusting their expertise, there could be serious consequences for these patients' ability to continue effective self-management. CONCLUSIONS Patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions, and expertise taught to patients in one branch of medicine can be considered non-compliant by those who are not specialists in that field. Although patient education can give people confidence in their own self-management skills, it cannot solve the power imbalance that remains when a generalist healthcare professional, however well meaning, blocks access to medication and supplies needed to manage chronic diseases successfully. There is a role for those involved in primary and hospital care, including those supporting and training healthcare professionals, to recognise these problems and find ways to acknowledge and respect chronic patients' biomedical and practical expertise.
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Affiliation(s)
- Rosamund Snow
- Department of Health Care Evaluation, King's College London, London, UK
| | - Charlotte Humphrey
- Patient Safety and Service Quality Research Centre, King's College London, London, UK
| | - Jane Sandall
- Department of Social Science and Women's Health, King's College London, London, UK
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Lawton J, Rankin D, Elliott J. Is consulting patients about their health service preferences a useful exercise? QUALITATIVE HEALTH RESEARCH 2013; 23:876-886. [PMID: 23618684 DOI: 10.1177/1049732313485161] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
As part of the shift toward patient-centered care, patients are increasingly being consulted about their preferences for health services and interventions, including those explored during randomized controlled trials (RCTs), to ensure that service recommendations are aligned to their own circumstances and needs. Hence, we interviewed patients (N = 40) who participated in a randomized control trial comparing diabetes education courses delivered using two different formats to establish whether, and why, they preferred one format to the other, to inform recommendations for future course delivery. Not only did patients report changing their preferences, and the reasons underlying these preferences, over time, but all patients also claimed to prefer the particular course they had attended. We use our findings and experiences to problematize the notion of a patient preference and to raise questions about what we can really learn from consulting patients about the care they receive within the context of an RCT.
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Affiliation(s)
- Julia Lawton
- University of Edinburgh, Edinburgh, United Kingdom.
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Lawton J, Rankin D, Cooke DD, Elliott J, Amiel S, Heller S. Self-treating hypoglycaemia: a longitudinal qualitative investigation of the experiences and views of people with Type 1 diabetes. Diabet Med 2013; 30:209-15. [PMID: 22946549 DOI: 10.1111/dme.12007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS Despite improvements in insulin therapy, hypoglycaemia remains an inevitable part of life for many people with Type 1 diabetes. Little attention has been paid to how individuals self-treat hypoglycaemia and their likes and dislikes of clinically recommended treatments. We explored participants' experiences of self-treating hypoglycaemia after attending a structured education programme for people with Type 1 diabetes. Our aims were: to identify treatments that are acceptable to people with Type 1 diabetes; and to provide recommendations for promoting self-treatment in line with clinical guidelines. METHODS Thirty adults with Type 1 diabetes were recruited from the Dose Adjustment for Normal Eating (DAFNE) programme in the UK. Study participants were interviewed post-course and 6 and 12 months later, enabling their experiences to be explored over time. RESULTS Study participants described a poor knowledge of how to self-treat hypoglycaemia correctly pre-course. Post-course, individuals often struggled to adhere to clinically recommended guidelines because of: panic, disorientation, hunger sensations and consequent difficulties ingesting fixed quantities of fast-acting carbohydrate; use of sweets to manage hypoglycaemia; reversion to habituated practices when cognitive impairment as a result of hypoglycaemia supervened; difficulties ingesting dextrose tablets; and other people's anxieties about under-treatment. CONCLUSIONS Historical experiences of hypoglycaemia and habituated practices can influence present self-treatment approaches. Professionals need to be aware of the range of difficulties individuals may experience restricting themselves to fixed quantities of fast-acting carbohydrate to manage hypoglycaemia. There may be merit in developing a more acceptable range of treatments tailored to people's own preferences, circumstances and needs.
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Affiliation(s)
- J Lawton
- Centre for Population Health Sciences, University of Edinburgh, UK.
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Elliott J, Lawton J, Rankin D, Emery C, Campbell M, Dixon S, Heller S. The 5x1 DAFNE study protocol: a cluster randomised trial comparing a standard 5 day DAFNE course delivered over 1 week against DAFNE training delivered over 1 day a week for 5 consecutive weeks. BMC Endocr Disord 2012; 12:28. [PMID: 23136929 PMCID: PMC3515469 DOI: 10.1186/1472-6823-12-28] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 10/29/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Structured education programmes are now established as an essential component to assist effective self-management of diabetes. In the case of Type 1 diabetes, the Dose Adjustment For Normal Eating (DAFNE) programme improves both glycaemic control and quality of life. Traditionally delivered over five consecutive days, this format has been cited as a barrier to participation by some patients, such as those who work full-time. Some centres in the UK have organised structured education programmes to be delivered one day a week over several consecutive weeks. This type of format may add benefit by allowing more time in which to practice skills between sessions, but may suffer as a result of weaker peer support being generated compared to that formed over five consecutive days. METHODS/DESIGN We aim to compare DAFNE delivered over five consecutive days (1 week course) with DAFNE delivered one day a week over five weeks (5 week course) in a randomised controlled trial. A total of 213 patients were randomised to attend either a 1 week or a 5 week course delivered in seven participating centres. Study outcomes (measured at baseline, 6 and 12 months post-course) include HbA1c, weight, self-reported rates of severe hypoglycaemia, psychosocial measures of quality of life, and cost-effectiveness. Generalisability was optimised by recruiting patients from DAFNE waiting lists at each centre, and by mailing eligible patients from hospital clinic lists. The inclusion and exclusion criteria were identical to those used to recruit to a standard DAFNE course (e.g., HbA1c <12%, with no lower limit). Qualitative interviews were undertaken with a sub-sample of n=30 patients and their course educators (n=11) to help understand and interpret differences and similarities in outcomes between the two arms, and to identify logistical problems and unanticipated issues arising from the adaptation and delivery of a 5 week course. DISCUSSION This trial has been designed to test the hypothesis that the benefits of delivering a structured education programme over 5 weeks are comparable to those observed after a 1 week course. The results of the trial and the qualitative sub-study will both inform the design and delivery of future DAFNE courses, and the development of structured education programmes in other fields of medicine. TRIAL REGISTRATION Clinicaltrials.gov NCT01069393.
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Affiliation(s)
- Jackie Elliott
- Academic Unit of Diabetes, Endocrinology & Metabolism, Department of Human Metabolism, The University of Sheffield, The Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Julia Lawton
- Centre for Population Health Sciences, The University of Edinburgh, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - David Rankin
- Centre for Population Health Sciences, The University of Edinburgh, Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Celia Emery
- DAFNE NIHR Project Office, 11 Broomfield Rd, Sheffield, S10 2SE, UK
| | - Mike Campbell
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Simon Dixon
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Simon Heller
- Academic Unit of Diabetes, Endocrinology & Metabolism, Department of Human Metabolism, The University of Sheffield, The Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
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Lawton J, Rankin D, Cooke D, Elliott J, Amiel S, Heller S. Patients' experiences of adjusting insulin doses when implementing flexible intensive insulin therapy: a longitudinal, qualitative investigation. Diabetes Res Clin Pract 2012; 98:236-42. [PMID: 23084281 DOI: 10.1016/j.diabres.2012.09.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 06/19/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
Abstract
AIM To explore patients' experiences of using flexible intensive insulin therapy, a regimen requiring them to determine and adjust quick-acting and background/basal insulin doses and mealtime ratios. METHODS Repeat, in-depth interviews with 30 type 1 diabetes patients converted to flexible intensive insulin therapy recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. RESULTS While patients found determination of quick acting insulin doses relatively straightforward, many struggled, over time, to determine the correct mealtime ratios and adjust basal insulin doses independently. Reasons included: lack of confidence and poor analytical skills; deferential attitudes to health professionals; worries about hypoglycaemia; and, lack of record/diary keeping resulting in fixation on current readings and failure to spot patterns and problems. When health professional support was not sought and/or record keeping neglected, patients gradually developed over-reliance on corrective doses to attain blood glucose readings within target ranges. CONCLUSION While patients are motivated to use flexible intensive insulin therapy, they expressed a need for on-going health professional input, particularly to support adjustment of background insulin doses and mealtime ratios. The need to sustain diary/record keeping should be emphasised to patients and provision of a dedicated glycaemic support service is recommended.
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Affiliation(s)
- J Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
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Rankin D, Cooke DD, Elliott J, Heller SR, Lawton J. Supporting self-management after attending a structured education programme: a qualitative longitudinal investigation of type 1 diabetes patients' experiences and views. BMC Public Health 2012; 12:652. [PMID: 22891794 PMCID: PMC3490905 DOI: 10.1186/1471-2458-12-652] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 08/03/2012] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Structured education programmes for patients with diabetes and other chronic conditions are being widely adopted. However, follow-up studies suggest that course graduates may struggle to sustain the self-care practices taught on their courses over time. This study explored the support needs of patients with type 1 diabetes after attending a structured education programme promoting an empowerment approach and training in use of flexible intensive insulin therapy, a regimen now widely advocated and used to manage this condition. The objective was to inform future support offered to course graduates. METHODS Repeat, in-depth interviews with 30 type 1 diabetes patients after attending Dose Adjustment for Normal Eating (DAFNE) courses in the UK, and six and 12 months later. Data were analysed using an inductive, thematic approach. RESULTS While the flexible intensive insulin treatment approach taught on DAFNE courses was seen as a logical and effective way of managing one's diabetes, it was also considered more technically complex than other insulin regimens. To sustain effective disease self-management using flexible intensive insulin treatment over time, patients often expected, and needed, on-going input and support from health care professionals trained in the approach. This included: help determining insulin dose adjustments; reassurance; and, opportunities to trouble-shoot issues of concern. While some benefits were identified to receiving follow-up support in a group setting, most patients stated a preference or need for tailored and individualised support from appropriately-trained clinicians, accessible on an 'as and when needed' basis. CONCLUSIONS Our findings highlight potential limitations to group-based forms of follow-up support for sustaining diabetes self-management. To maintain the clinical benefits of structured education for patients with type 1 diabetes over time, course graduates may benefit from and prefer ongoing, one-to-one support from health care professionals trained in the programme's practices and principles. This support should be tailored and personalised to reflect patients' specific and unique experiences of applying their education and training in the context of their everyday lives, and could be the subject of future research.
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Affiliation(s)
- David Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK.
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Rankin D, Cooke DD, Heller S, Elliott J, Amiel S, Lawton J. Experiences of using blood glucose targets when following an intensive insulin regimen: a qualitative longitudinal investigation involving patients with Type 1 diabetes. Diabet Med 2012; 29:1079-84. [PMID: 22486156 DOI: 10.1111/j.1464-5491.2012.03670.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS Use of blood glucose targets is considered essential to help patients with Type 1 diabetes achieve tight glycaemic control following structured education. To foster effective use of blood glucose targets, we explored patients' experiences and views of implementing clinically recommended blood glucose targets after attending a structured education programme promoting intensive insulin treatment. METHODS Repeat, in-depth interviews with 30 patients with Type 1 diabetes recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. Data were analysed using an inductive, thematic approach. RESULTS Patients found use of blood glucose targets motivational. Targets enabled patients to identify problems with blood glucose control and prompted them to make insulin dose adjustments independently, or with assistance. However, patients tended to adapt or simplify targets over time to: make them more attainable and easy to remember; reduce risk of hypoglycaemia; and, mitigate feelings of failure when attempts to attain clinically defined targets were unsuccessful. Some patients were advised to use elevated targets to counter hypoglycaemia unawareness and required help from health professionals to determine when/if these should be reduced. CONCLUSIONS Although blood glucose targets are an important component of diabetes self-management, patients may adapt and personalize them over time, sometimes inadvertently, with a potentially detrimental impact on long-term glycaemic control. Blood glucose targets should be regularly revisited during clinical reviews and revised/new targets agreed to accommodate patients' concerns and difficulties. Other interventions may need to be considered to promote effective use of blood glucose targets.
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Affiliation(s)
- D Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
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Wilmot EG, Davies MJ, Edwardson CL, Gorely T, Khunti K, Nimmo M, Yates T, Biddle SJH. Rationale and study design for a randomised controlled trial to reduce sedentary time in adults at risk of type 2 diabetes mellitus: project stand (Sedentary Time ANd diabetes). BMC Public Health 2011; 11:908. [PMID: 22151909 PMCID: PMC3262766 DOI: 10.1186/1471-2458-11-908] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 12/08/2011] [Indexed: 02/02/2023] Open
Abstract
Background The rising prevalence of Type 2 Diabetes Mellitus (T2DM) is a major public health problem. There is an urgent need for effective lifestyle interventions to prevent the development of T2DM. Sedentary behaviour (sitting time) has recently been identified as a risk factor for diabetes, often independent of the time spent in moderate-to-vigorous physical activity. Project STAND (Sedentary Time ANd Diabetes) is a study which aims to reduce sedentary behaviour in younger adults at high risk of T2DM. Methods/Design A reduction in sedentary time is targeted using theory driven group structured education. The STAND programme is subject to piloting and process evaluation in line with the MRC framework for complex interventions. Participants are encouraged to self-monitor and self-regulate their behaviour. The intervention is being assessed in a randomised controlled trial with 12 month follow up. Inclusion criteria are a) aged 18-40 years with a BMI in the obese range; b) 18-40 years with a BMI in the overweight range plus an additional risk factor for T2DM. Participants are randomised to the intervention (n = 89) or control (n = 89) arm. The primary outcome is a reduction in sedentary behaviour at 12 months as measured by an accelerometer (count < 100/min). Secondary outcomes include physical activity, sitting/lying time using the ActivPAL posture monitor, fasting and 2 h oral glucose tolerance test, lipids, inflammatory biomarkers, body weight, waist circumference, blood pressure, illness perceptions, and efficacy beliefs for behaviour change. Conclusions This is the first UK trial to address sedentary behaviour change in a population of younger adults at risk of T2DM. The results will provide a platform for the development of a range of future multidisciplinary interventions in this rapidly expanding high-risk population. Trial registration Current controlled trials ISRCTN08434554, MRC project 91409.
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Affiliation(s)
- Emma G Wilmot
- Diabetes Research, Department of Cardiovascular Sciences, University of Leicester, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester LE1 5WW, UK
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Casey D, Murphy K, Lawton J, White FF, Dineen S. A longitudinal qualitative study examining the factors impacting on the ability of persons with T1DM to assimilate the Dose Adjustment for Normal Eating (DAFNE) principles into daily living and how these factors change over time. BMC Public Health 2011; 11:672. [PMID: 21878104 PMCID: PMC3175192 DOI: 10.1186/1471-2458-11-672] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 08/30/2011] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The literature reveals that structured education programmes, such as DAFNE, result in many positive outcomes for people with Type 1 diabetes including a decrease in HbA1c levels and reductions in hypoglycaemia. While there is evidence that some of these outcomes are maintained we do not know at present what factors are most important over time. The study aim was to identify the key factors impacting on persons with Type 1 diabetes ability to assimilate the Dose Adjustment For Normal Eating (DAFNE) DAFNE principles into their daily lives and how these factors change over time. METHODS This is a longitudinal descriptive qualitative study. Interviews were undertaken with 40 participants who had attended DAFNE in one of 5 study sites across the Island of Ireland, at 6 weeks, 6 and 12 months after completion of the programme. The interviews lasted from 30 to 60 minutes and were transcribed verbatim. Data were analysed in three ways, a within time analysis, a cross sectional analysis for each participant and a thematic analysis which focused on examining changes over time RESULTS Four themes that influenced participants' ability to assimilate DAFNE into their daily lives over time were identified. These were: embedded knowledge, continued responsive support, enduring motivation and being empowered. Support at the 6 month period was found to be crucial to continued motivation. CONCLUSIONS Understanding the factors that influence people's ability to assimilate DAFNE principles over time into their daily lives can help health professionals give focused responsive support that helps people with diabetes become more empowered. Understanding that continued support matters, particularly around 6 months, is important as health professionals can influence good management by providing appropriate support and enhancing motivation. TRIAL REGISTRATION ISRCTN79759174.
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Affiliation(s)
- Dympna Casey
- School of Nursing & Midwifery, National University of Ireland, Galway, Ireland.
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Rankin D, Cooke DD, Clark M, Heller S, Elliott J, Lawton J. How and why do patients with Type 1 diabetes sustain their use of flexible intensive insulin therapy? A qualitative longitudinal investigation of patients' self-management practices following attendance at a Dose Adjustment for Normal Eating (DAFNE) course. Diabet Med 2011; 28:532-8. [PMID: 21244477 DOI: 10.1111/j.1464-5491.2011.03243.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Conventional insulin therapy requires patients with Type 1 diabetes to adhere to rigid dietary and insulin injection practices. Recent trends towards flexible intensive insulin therapy enable patients to match insulin to dietary intake and lifestyle; however, little work has examined patients' experiences of incorporating these practices into real-life contexts. This qualitative longitudinal study explored patients' experiences of using flexible intensive insulin therapy to help inform the development of effective long-term support. METHODS Semi-structured interviews were conducted with 30 adult patients with Type 1 diabetes following participation in a structured education programme on using flexible intensive insulin therapy, and 6 and 12 months post-course. Longitudinal data analysis used an inductive, thematic approach. RESULTS Patients consistently reported feeling committed to and wanting to sustain flexible intensive insulin therapy. This regimen was seen as a logical and effective method of self-management, as patients experienced improved blood glucose readings and/or reported feeling better. Implementing and sustaining flexible intensive insulin therapy was enhanced when patients had stable routines, with more challenges reported by those working irregular hours and during weekends/holidays. Some patients re-crafted their lives to make this approach work for them; for instance, by creating dietary routines or adjusting dietary choices. CONCLUSIONS Clinical data have shown that flexible intensive insulin therapy can lead to improvement in glycaemic control. This study, drawing on patients' perspectives, provides further endorsement for flexible intensive insulin therapy by demonstrating patients' liking of, and their motivation to sustain, this approach over time. To help patients implement and sustain flexible intensive insulin therapy, follow-up support should encourage them to identify routines to better integrate this regimen into their lives.
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Affiliation(s)
- D Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
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Lawton J, Rankin D, Cooke DD, Clark M, Elliot J, Heller S. Dose Adjustment for Normal Eating: a qualitative longitudinal exploration of the food and eating practices of type 1 diabetes patients converted to flexible intensive insulin therapy in the UK. Diabetes Res Clin Pract 2011; 91:87-93. [PMID: 21129802 DOI: 10.1016/j.diabres.2010.11.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 11/02/2010] [Accepted: 11/04/2010] [Indexed: 11/21/2022]
Abstract
AIM To explore whether, and why, patients change their food and eating practices following conversion to flexible intensive insulin therapy (FIIT), a regimen which requires quick acting insulin doses to be matched to the carbohydrate content of meals/snacks consumed. METHODS repeat, in-depth interviews with 30 type 1 diabetes patients converted to FIIT recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. Data were analysed using an inductive, thematic approach. RESULTS despite the potential of FIIT to enable greater dietary flexibility and freedom, most patients reported food and eating practices which were remarkably resistant to change. In some cases, FIIT adoption resulted in greater dietary rigidity over time. The opportunities FIIT presented for greater dietary freedom were counterbalanced by new challenges and burdens (e.g. having to simplify food choices to make carbohydrate estimation easier). Due to the emphasis FIIT places on carbohydrate counting, and patients' fears of hypos, low/no carbohydrate foodstuffs sometimes came to be seen as the healthiest or safest options. CONCLUSION concerns that FIIT may result in more excessive or unhealthy eating appear largely unfounded; however, consideration needs to be paid to the ways in which patients' conceptualisations of, and relationship with, food may change following FIIT conversion.
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Affiliation(s)
- J Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
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