Evaluation of a Diabetes Education Program's Non-Attendees: The Program Response

Diabetes self-management education programs: Results from a nationwide population-based study on characteristics of participants, rating of programs and reasons for non-participation

OBJECTIVE

Population-based studies of reasons for not participating in diabetes self-management education (DSME) are scarce. Therefore, we investigated what sociodemographic and disease-related factors are associated with participation in DSME, the reasons for not participating in DSME and how participants evaluate DSME.

RESEARCH DESIGN AND METHODS

We used data from the nationwide survey "Disease knowledge and information needs-Diabetes mellitus 2017", which included a total of 1396 participants diagnosed with diabetes mellitus (diabetes; n = 394 DSME-participants, n = 1002 DSME-never-participants). Analyses used weighted logistic or multinominal regression analyses with bivariate and multivariable approaches.

RESULTS

Participants were more likely to attend DSME if they had a medium (OR 1.82 [95%CI 1.21-2.73]),or high (OR 2.04 [95%CI 1.30-3.21]) level of education, had type 1 diabetes (OR 2.46 [1.24-4.90]) and insulin treatment (OR 1.96 [95%CI 1.33-2.90]). Participants were less likely to attend DSME if they lived in East Germany (OR 0.57 [95%CI 0.39-0.83]), had diabetes for >2 to 5 years (OR 0.52 [95%CI 0.31-0.88] compared to >5 years), did not agree that diabetes is a lifelong disease (OR 0.30 [95%CI 0.15-0.62], had never been encouraged by their physician to attend DSME (OR 0.19 [95%CI 0.13-0.27]) and were not familiar with disease management programs (OR 0.67 [95%CI 0.47-0.96]). The main reasons for non-participation were participant's personal perception that DSME was not necessary (26.6%), followed by lack of recommendation from treating physician (25.7%) and lack of information on DSME (20.7%). DSME-participants found DSME more helpful if they had a medium educational level (OR 2.06 [95%CI 1.10-3.89] ref: low level of education) and less helpful if they were never encouraged by their treatment team (OR 0.46 [95%CI 0.26-0.82]).

DISCUSSION

Professionals treating persons with diabetes should encourage their patients to attend DSME and underline that diabetes is a lifelong disease. Overall, the majority of DSME participants rated DSME as helpful.

Participants' and Health Care Providers' Insights Regarding a Web-Based and Mobile-Delivered Healthy Eating Program for Disadvantaged People With Type 2 Diabetes: Descriptive Qualitative Study

BACKGROUND

Healthy eating is a key element of type 2 diabetes (T2D) self-management. Digital interventions offer new avenues to reach broad audiences to promote healthy eating behaviors. However, acceptance of these interventions by socioeconomically disadvantaged people (eg, those with lower levels of education and income or from ethnic minority groups) has not yet been fully evaluated.

OBJECTIVE

This study aimed to investigate the acceptability and usability of EatSmart, a 12-week web-based and mobile-delivered healthy eating behavior change support program, from the perspective of intervention participants living with T2D and health care providers (HCPs) involved in diabetes care.

METHODS

This study used a qualitative descriptive design. Overall, 60 disadvantaged adults with T2D, as determined by receipt of either a HealthCare Card or a pension or benefit as the main source of income, were recruited. Data from participants regarding their experiences with and perceptions of the program and longer-term maintenance of any behavior or attitudinal changes were collected through a web-based self-report survey with open-ended questions administered 12 weeks after baseline (54/60, 90%) and semistructured telephone interviews administered 36 weeks after baseline (16/60, 27%). Supplementary semistructured interviews with 6 HCPs involved in diabetes care (endocrinologists, accredited practicing dietitians, and diabetes nurse educators) were also conducted 36 weeks after baseline. These interviews aimed to understand HCPs' views on successful and unsuccessful elements of EatSmart as a technology-delivered intervention; any concerns or barriers regarding the use of these types of interventions; and feedback from their interactions with patients on the intervention's content, impact, or observed benefits. All data from the surveys and interviews were pooled and thematically analyzed.

RESULTS

In total, 5 key themes emerged from the data: program impact on food-related behaviors and routines, satisfaction with the program, reasons for low engagement and suggestions for future programs, benefits and challenges of digital interventions, and cultural considerations. Results showed that EatSmart was acceptable to participants and contributed positively to improving food-related behaviors. Most participants (27/43, 63%) mentioned that they enjoyed their experience with EatSmart and expressed high satisfaction with its content and delivery. The educational and motivational content was considered the most useful part of the program. Benefits discussed by intervention participants included gaining health knowledge and skills, positive changes in their food purchasing and cooking, and eating greater quantities and varieties of fruits and vegetables. HCPs also described the intervention as beneficial and persuasive for the target audience and had specific suggestions for future tailoring of such programs.

CONCLUSIONS

The findings suggested that this digitally delivered intervention with supportive educational modules and SMS text messages was generally appealing for both participants and HCPs. This intervention medium shows promise and could feasibly be rolled out on a broader scale to augment usual diabetes care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19488.

Type 2 diabetes peer support interventions as a complement to primary care settings in high-income nations: A scoping review

OBJECTIVES

Inadequate social support make way for peer support initiatives to complement the health system delivery of diabetes self-management education programs for type 2 diabetes (T2D). This review synthesizes knowledge about T2D peer support in terms of their various models and impact, endorsement, and contextual information in high-income nations.

METHODS

A scoping review was conducted on published and grey literature in four electronic bibliographic databases between January 2007 to December 2021.

RESULTS

76 records were included. Face-to-face self-management programs and telephone-based peer support seem the most promising modalities given the largest scientific coverage on T2D outcomes. Face-to-face self-management programs were the most preferred by ethnic minority groups. Unlike peer supporters, healthcare professionals had mixed views about T2D peer support interventions. Managers of peer support programs perceived cultural competency as a cornerstone for peer support implementation. Care must be taken in recruiting, training and retaining peer supporters for sustainable practice.

CONCLUSIONS

Various T2D peer support models lie at the interface between primary care and community-based settings.

PRACTICE IMPLICATIONS

Fostering the role of peer support beyond healthcare organizations should be encouraged to engage the hardly reached, and to leverage community support to complement the health system.

Reasons for non-participation in a self-care training program for diabetic patients: a qualitative study

Introduction

Self-care behaviors in diabetic patients is considered an important factor for controlling the diabetes. Therefore, diabetic patients need training the self-care behaviors to control this disease. This study aims to investigate the reasons for diabetic patients’ non-participation in a self-care training program.

Method

This qualitative study was carried out between 1 April to 1 July 2019. We used in-depth semi-structured interviews with 30 diabetic patients who did not participate in the self-care training program. Data analysis was conducted using content analysis with MAXQDA software.

Findings

The results of this study showed that there are 5 themes and 14 sub-themes for patients’ non-participation in self-care training program. Themes included access; individual, familial and social factors; attitude and awareness; motivator factors and need Factors. Also sub-themes were physical access, time access, physical abilities, social-familial responsibilities, attitude to disease, attitude to education, attitude to health, awareness, incentive, communication, teaching methods, perceived risk, access to other educational resources and self-efficacy.

Conclusion

According to the results of this study, simple physical and time access, offering high-quality education, providing virtual and distant training, organizing and designing modern training methods can lead to increase participation in self-care training programs.

Understanding adherence of hypertensive patients in Mexico to an exercise-referral scheme for increasing physical activity

Among the strategies developed thus far for promoting physical activity (PA), exercise-referral schemes (ERs) have gained in popularity as an effective means of preventing secondary health conditions such as hypertension. However, information on the factors affecting adherence to these programs is limited. Using a mixed-methods approach, we undertook the present study to determine the factors associated with adherence to a specific ER aimed at increasing PA among the hypertensive patients in a Social Security institution in Mexico. Data were obtained through semi-structured questionnaires and interviews as well as from the clinical records of participants. For the quantitative component, multinomial regression analysis estimated the factors behind the varying levels of adherence. For the qualitative component, we performed a content analysis based on the health belief model. According to our findings, 80% of participants who began the ER exhibited high levels of adherence. Older age and being female were the key demographic characteristics of those showing increased adherence. Meanwhile, financial issues, the investment of time required, low perception of the benefits of PA, lack of confidence in being able to achieve changes in lifestyle, and a reluctance to acknowledge the seriousness of their health condition were the principal factors among those who did not join the program or exhibited low levels of adherence. Our findings can serve as a basis for designing PA interventions that take into account individual, cultural and administrative elements in their efforts to improve adherence to PA programs for those suffering from chronic conditions such as hypertension.

Patient and paramedic experiences with a direct electronic referral programme for focused hypoglycaemia education following paramedic service assist-requiring hypoglycaemia in London and Middlesex County, Ontario, Canada

AIMS

Hypoglycaemia is a common treatment consequence in diabetes mellitus. Prior studies have shown that a large proportion of people with paramedic assist-requiring hypoglycaemia prefer not to be transported to hospital. Thus, these episodes are "invisible" to their usual diabetes care providers. A direct electronic referral programme where paramedics sent referrals focused hypoglycaemia education at the time of paramedic assessment was implemented in our region for 18 months; however, referral programme uptake was low. In this study, we examined patient and paramedic experiences with a direct electronic referral programme for hypoglycaemia education postparamedic assist-requiring hypoglycaemia, including barriers to programme referral and education attendance.

METHODS

We surveyed paramedics and conducted semistructured telephone interviews of patients with paramedic-assisted hypoglycaemia who consented to the referral programme and were scheduled for an education session in London and Middlesex County, Canada.

RESULTS

Paramedics and patient participants felt that the direct referral programme was beneficial. A third of paramedics who responded to our survey used the referral programme for each encounter where they treated patients for hypoglycaemia. Patients felt very positive about the referral programme and their paramedic encounter; however, they described embarrassment, guilt and prior negative experience as key barriers to attending education.

CONCLUSIONS

Paramedics and patients felt that direct referral for focused hypoglycaemia education postparamedic assist-requiring hypoglycaemia was an excellent strategy. Despite this, referral programme participation was low and thus there remain ongoing barriers to implementation and attendance. Future iterations should consider how best to meet patient needs through innovative delivery methods.

"What's the Point?": Understanding Why People With Type 2 Diabetes Decline Structured Education

Structured diabetes education (SDE) is an evidence-based intervention that supports self-management in people with type 2 diabetes. In the United Kingdom, health care providers working in primary care settings are responsible for referring people with type 2 diabetes to SDE programs. However, national audits record a high percentage of nonattenders. We explored the personal experience of living with type 2 diabetes that led to individuals declining invitations to attend SDE programs. The themes suggested that emotional, cognitive, and social issues related to diagnosis and living with diabetes may be responsible for declining to attend SDE and that these factors may be masked by explanations of practical barriers. A person-centered approach to understanding the personal meaning of being diagnosed and living with type 2 diabetes may help to identify individuals' psychosocial barriers to attending SDE.

Health care professionals' views towards self-management and self-management education for people with type 2 diabetes

OBJECTIVES

Significant problems with patients engaging with diabetes self-management education (DSME) exist. The role of healthcare professionals (HCPs) has been highlighted, with a lack of enthusiasm, inadequate information provision and poor promotion of available programmes all cited as affecting patients' decisions to attend. However, little is known about HCPs' views towards DSME. This study investigates the views of HCPs towards self-management generally and self-management in the context of DSME more specifically.

DESIGN

A qualitative study using semi-structured interviews to investigate HCPs views of type 2 diabetes self-management and DSME. Data were analysed thematically and emergent themes were mapped on to the constructs of Normalisation Process Theory (NPT).

SETTING

Two boroughs in London, UK.

PARTICIPANTS

Sampling was purposive to recruit a diverse range of professional roles including GPs, practice nurses, diabetes specialist nurses, healthcare assistants (HCAs), receptionists and commissioners of care.

RESULTS

Interviews were conducted with 22 participants. The NPT analysis demonstrated that while a self-management approach to diabetes care was viewed by HCPs as necessary and, in principle, valuable, the reality is much more complex. HCPs expressed ambivalence about pushing certain patients into self-managing, preferring to retain responsibility. There was a lack of awareness among HCPs about the content of DSME and benefits to patients. Commitment to and engagement with DSME was tempered by concerns about suitability for some patients. There was little evidence of communication between providers of group-based DSME and HCPs or of HCPs engaging in work to follow-up non-attenders.

CONCLUSIONS

HCPs have concerns about the appropriateness of DSME for all patients and discussed challenges to engaging with and performing the tasks required to embed the approach within practice. DSME, as a means of supporting self-management, was considered important in theory, but there was little evidence of HCPs seeing their role as extending beyond providing referrals.

Reasons why patients referred to diabetes education programmes choose not to attend: a systematic review

AIMS

To identify the reasons why those offered a place on diabetes education programmes declined the opportunity.

BACKGROUND

It is well established that diabetes education is critical to optimum diabetes care; it improves metabolic control, prevents complications, improves quality of life and empowers people to make informed choices to manage their condition. Despite the significant clinical and personal rewards offered by diabetes education, programmes are underused, with a significant proportion of patients choosing not to attend.

METHODS

A systematic search of the following databases was conducted for the period from 2005-2015: Medline; EMBASE; Scopus; CINAHL; and PsycINFO. Studies that met the inclusion criteria focusing on patient-reported reasons for non-attendance at structured diabetes education were selected.

RESULTS

A total of 12 studies spanning quantitative and qualitative methodologies were included. The selected studies were published in Europe, USA, Pakistan, Canada and India, with a total sample size of 2260 people. Two broad categories of non-attender were identified: 1) those who could not attend for logistical, medical or financial reasons (e.g. timing, costs or existing comorbidities) and 2) those who would not attend because they perceived no benefit from doing so, felt they had sufficient knowledge already or had emotional and cultural reasons (e.g. no perceived problem, denial or negative feelings towards education). Diabetes education was declined for many reasons, and the range of expressed reasons was more diverse and complex than anticipated.

CONCLUSION

New and innovative methods of delivering diabetes education are required which address the needs of people with diabetes whilst maintaining quality and efficiency.

Health coaching in primary care: a feasibility model for diabetes care

BACKGROUND

Health coaching is a new intervention offering a one-on-one focused self-management support program. This study implemented a health coaching pilot in primary care clinics in Eastern Ontario, Canada to evaluate the feasibility and acceptability of integrating health coaching into primary care for patients who were either at risk for or diagnosed with diabetes.

METHODS

We implemented health coaching in three primary care practices. Patients with diabetes were offered six months of support from their health coach, including an initial face-to-face meeting and follow-up by email, telephone, or face-to-face according to patient preference. Feasibility was assessed through provider focus groups and qualitative data analysis methods.

RESULTS

All three sites were able to implement the program. A number of themes emerged from the focus groups, including the importance of physician buy-in, wide variation in understanding and implementing of the health coach role, the significant impact of different systems of team communication, and the significant effect of organizational structure and patient readiness on Health coaches' capacity to perform their role.

CONCLUSIONS

It is feasible to implement health coaching as an integrated program within small primary care clinics in Canada without adding additional resources into the daily practice. Practices should review their organizational and communication processes to ensure optimal support for health coaches if considering implementing this intervention.

Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial

Background

Previous research suggests that lifestyle intervention for the prevention of diabetes and cardiovascular disease (CVD) are effective, however little is known about factors affecting participation in such programs. This study aims to explore factors influencing levels of participation in a lifestyle modification program conducted as part of a cluster randomized controlled trial of CVD prevention in primary care.

Methods

This concurrent mixed methods study used data from the intervention arm of a cluster RCT which recruited 30 practices through two rural and three urban primary care organizations. Practices were randomly allocated to intervention (n = 16) and control (n = 14) groups. In each practice up to 160 eligible patients aged between 40 and 64 years old, were invited to participate. Intervention practice staff were trained in lifestyle assessment and counseling and referred high risk patients to a lifestyle modification program (LMP) consisting of two individual and six group sessions over a nine month period. Data included a patient survey, clinical audit, practice survey on capacity for preventive care, referral and attendance records at the LMP and qualitative interviews with Intervention Officers facilitating the LMP. Multi-level logistic regression modelling was used to examine independent predictors of attendance at the LMP, supplemented with qualitative data from interviews with Intervention Officers facilitating the program.

Results

A total of 197 individuals were referred to the LMP (63% of those eligible). Over a third of patients (36.5%) referred to the LMP did not attend any sessions, with 59.4% attending at least half of the planned sessions. The only independent predictors of attendance at the program were employment status - not working (OR: 2.39 95% CI 1.15-4.94) and having high psychological distress (OR: 2.17 95% CI: 1.10-4.30). Qualitative data revealed that physical access to the program was a barrier, while GP/practice endorsement of the program and flexibility in program delivery facilitated attendance.

Conclusion

Barriers to attendance at a LMP for CVD prevention related mainly to external factors including work commitments and poor physical access to the programs rather than an individuals’ health risk profile or readiness to change. Improving physical access and offering flexibility in program delivery may enhance future attendance. Finally, associations between psychological distress and attendance rates warrant further investigation.

Trial registration

ACTRN12607000423415