Diabetes service provision: a qualitative study of newly diagnosed Type 2 diabetes patients' experiences and views

Achieving a useful and person-centred diabetes consultation is a shared responsibility between diabetologists and people with diabetes: a qualitative study of perspectives from people with type 1 diabetes

AIMS

To explore perceptions of useful routine consultations with diabetologists from the perspective of adults with type 1 diabetes, including preferences for discussing psychosocial issues.

METHODS

We conducted semi-structured interviews in 2018/2019 with 33 people with type 1 diabetes (age 22-75 years, 20 men and 13 women, median diabetes duration 25 years) recruited from two diabetes clinics in the capital region of Denmark. Interviews were audio recorded, transcribed verbatim and analysed using thematic text condensation.

RESULTS

Achieving a useful consultation was perceived as a shared responsibility between people with diabetes and diabetologists. Participants' perspectives of what constitutes a useful consultation and expectations for both consultation and diabetologist varied in relation to perceptions of (1) the interaction between the person with diabetes and diabetologist, including being prepared, being honest, experiencing good rapport and preferring a partnership with the diabetologist or 'keeping it clinical' and (2) the diabetologist's approach to diabetes care, including providing up-to-date knowledge and listening and showing understanding.

CONCLUSIONS

Both content and style of diabetes consultations need to be adapted to the individual person with type 1 diabetes. People with diabetes have an important role in expressing their needs and preferences related to both content and style. Diabetologists need to be aware of and attentive to the many individual needs and expectations among people with diabetes, including the desire and need to discuss psychosocial issues. Dialogue tools for preparation and in consultations may enable people with diabetes to voice their needs and expectations and diabetologists to juggle these diversities.

Reducing occupational sitting time in adults with type 2 diabetes: Qualitative experiences of an office-adapted mHealth intervention

AIM

Understanding barriers and facilitators for limiting occupational sitting and what impact it has on health on those with type 2 diabetes is essential for future trials and intervention development in primary healthcare settings. This study aimed to explore the feasibility and acceptability of an intervention using mobile health (mHealth) technology, together with counselling by a diabetes specialist nurse, to reduce occupational sitting in adults with type 2 diabetes.

METHODS

Individual semi-structured interviews were conducted in 15 participants with type 2 diabetes who completed a 3-month intervention including mHealth; activity tracker (Garmin Vivofit3) and SMS reminders, one initial face-to-face patient-centred counselling session and three telephone follow-up calls by a diabetes specialist nurse within the primary healthcare system in Sweden. The interviews were recorded, transcribed verbatim and analysed using qualitative content analysis.

RESULTS

Two themes were identified: (1) 'From baby steps to milestones' reflecting three categories; 'Small changes make it easier to reduce sitting', 'Encouraged by trustworthy coaching', 'Physical and mental rewards matter' and (2) 'Tailoring strategies that fit me and my workplace' reflecting four categories; 'It's up to me', 'Taking advantage of the support', 'Using creativity to find practical solutions for interrupting sitting' and 'Living up to expectations'.

CONCLUSION

The intervention was perceived as feasible and acceptable in different office workplaces, and led to increased awareness of sedentary behaviour in adults with type 2 diabetes. Stepwise goal setting together with personalization of the mHealth intervention should be emphasized in individual type 2 diabetes programmes aiming to reduce workplace sitting.

Patient and public perception and experience of community pharmacy services post-discharge in the UK: a rapid review and qualitative study

OBJECTIVES

To investigate the perception and experience of patients and the public (PP) about community pharmacy (CP) services and other primary care services after hospital discharge back home.

DESIGN AND SETTING

A rapid review and qualitative study exploring PP perceptions of primary care, focusing on CP services in the UK.

METHODS

A mixed-methods approach was adopted including a rapid review undertaken between 24 April and 8 May 2019 across four databases (MEDLINE, EMBASE, PsycINFO and CINAHL). Semistructured interviews were then conducted investigating for shifts in current PP perception, but also nuanced opinion pertaining to CP services. A convenience sampling technique was used through two online PP groups for recruitment. Thematic framework analysis was applied to interview transcripts.

PARTICIPANTS

Any consenting adults ≥18 years old were invited regardless of their medical condition, and whether they had used post-discharge services or not.

RESULTS

Twenty-five studies met the inclusion criteria. Patients were generally supportive and satisfied with primary care services. However, some barriers to the use of these services included: resource limitations; poor communication between healthcare providers or between patient and healthcare providers; and patients' lack of awareness of available services. From the 11 interviewees, there was a lack of awareness of CP post-discharge services. Nevertheless, there was general appreciation of the benefit of CP services to patients, professionals and wider healthcare system. Potential barriers to uptake and use included: accessibility, resource availability, lack of awareness, and privacy and confidentiality issues related to information-sharing. Several participants felt the uptake of such services should be improved.

CONCLUSION

There was alignment between the review and qualitative study about high patient acceptance, appreciation and satisfaction with primary care services post-discharge. Barriers to the use of CP post-discharge services identified from interviews resonated with the existing literature; this is despite developments in pharmacy practice in recent times towards clinical and public health services.

Modeling patients' choice between a primary care physician or a diabetes specialist for the management of type-2 diabetes using a bivariate probit analysis

AIMS

To determine the prevalence of type-2 diabetes patients that were initially and currently being treated by primary care physicians (PCPs) or diabetes specialists and assess predictors influencing their choice.

METHODS

This cross-sectional study was conducted in nine Greek primary healthcare units. Patients' choices were modeled using a bivariate probit analysis.

RESULTS

A total of 225 patients participated (84% response rate). Only 15.9% and 11.9% of the respondents acknowledged having chosen a diabetes specialist for their initial or current treatment, respectively. The family history of diabetes in siblings and the screening for diabetic retinopathy during the past year were significantly positively associated with choosing a diabetes specialist (initially p=0.033 or currently p=0.007), and resulted in a statistically significant reduction of the joint probabilities of choosing a PCP by 15.6% and 13.6%, respectively. Younger age (p=0.040), female sex (p=0.017), higher HbA1c (p=0.004), experience of hypoglycemia (p=0.029) and low cardiovascular morbidity index (p=0.016) emerged as important predictors for choosing a diabetes specialist for their treatment.

CONCLUSIONS

Our findings provide a better insight in diabetes patients' choices regarding the category of their treating physicians and their predictors. More studies are required to replicate them and identify patient subpopulations that may favor diabetes specialists' guidance.

Integrating care: the work of diabetes care technicians in an integrated care initiative

Background

As diabetes prevalence rises world-wide, the arrangement of clinics and care packages is increasingly debated by health care professionals (HCPs), health service researchers, patient groups and policy makers. ‘Integrated care’, while representing a range of approaches, has been positioned as a promising solution with potential to benefit patients and health systems. This is particularly the case in rural populations which are often removed from centres of specialist care. The social arrangements within diabetes integrated care initiatives are understudied but are of particular importance to those implementing such initiatives. In this paper we explore the ‘work’ of integration through an analysis of the role played by Health Care Assistants (HCAs) who were specially trained in aspects of diabetes care and given the title ‘Diabetes Care Technician’ (DCT).

Methods

Using thematic analysis of interview (n = 55) and observation data (n = 40), we look at: how the role of DCTs was understood by patients and other HCPs, as well as the DCTs; and explore what DCTs did within the integrated care initiative.

Results

Our findings suggested that the DCTs saw their role as part of a hierarchy, providing links between members of the integrated team, and explaining and validating clinical decisions. Patients characterised DCTs as friends and advisors who provided continuity. Other HCPs perceived the DCTs as supportive, providing long-term monitoring and doing a different job to conventional HCAs. We found that DCTs had to navigate local terrain (social, ethical and physical), engage in significant conversation and negotiate treatment plans created through integrated care. The analysis suggests that relationships between patients and the DCTs were strong, had the quality of friendship and mitigated loneliness.

Conclusions

DCTs played multidimensional roles in the integrated care initiative that required great social and emotional skill. Building friendships with patients was central to their work, which mitigated loneliness and facilitated the care they provided.

Exploring the provision of diabetes nutrition education by practice nurses in primary care settings

BACKGROUND

High-quality nutrition education is recommended as an essential component of diabetes care. In the UK, there has been a gradual shift of inter-professional boundaries with respect to providing nutritional care for people with type 2 diabetes. Only a minority now regularly receive advice from a dietitian. Instead, increased demands for nutrition education are being absorbed by practice nurses. The present study seeks to explore this situation through the views of practice nurses on the services that they provide and the issues they face.

METHODS

A qualitative approach using semi-structured interviews was employed. Practice nurses were recruited using purposive sampling, and nine were interviewed. Data were analysed using the Framework Method. The Theoretical Domains Framework from the COM-B ('capability', 'opportunity', 'motivation' and 'behaviour') model of behaviour change, as increasingly employed to explore the behaviour of healthcare professionals, was used to further frame the findings.

RESULTS

Practice nurses reported that ongoing diabetes nutrition education only took place at annual review appointments and was limited to 5-10 min. They described how they are expected to take on a more advanced role in diabetes nutrition education than they can provide and are becoming increasingly isolated in this role as a result of a lack of time, practical and informational support, and training standards and provision.

CONCLUSIONS

A range of service improvements led by dietitians, which focus on strengthening the working environment and enhancing professional support available for practice nurses who provide diabetes nutrition education, could improve quality of care and health outcomes in people with diabetes within current time restraints.

Experiences of South Asian patients in early inflammatory arthritis clinic: a qualitative interview study

Objective

The aim was to explore how UK South Asian patients living with RA interact with health care professionals and experience receiving health information in an early inflammatory arthritis clinic.

Methods

A semi-structured interview schedule, designed in conjunction with a patient partner, was used for face-to-face interviews. South Asian participants with RA were recruited from Central Manchester University Hospitals National Health Service Foundation Trust. Data were recorded and transcribed by an independent company. Data were analysed using inductive thematic analysis.

Results

Fifteen participants were interviewed. Three predominant themes emerged around participants’ experiences and interaction with health care professionals in early inflammatory arthritis clinic. First, ‘the personal experiences of RA and cultural link to early inflammatory arthritis clinic’, where participants described the impact of RA as individuals and their altered roles within their cultural setting. Second, ‘experiences of interacting and receiving information in the early inflammatory arthritis clinic’, where participants described their limited engagement with health care professionals and the quality of information discussed in the clinic. Third, ‘views on future content for early inflammatory arthritis clinics’, where participants highlighted new innovative ideas to build on current practice.

Conclusion

We believe this to be the first study to generate insight into the experiences of South Asian patients of interacting with health care professionals while attending an early inflammatory arthritis clinic. Policy directives aimed at improving access to services and delivery of information for ethnic minority groups in early inflammatory arthritis clinics should include consideration of the different roles of cultures. Professionals should be cognizant of the factors that drive health inequalities and focus on improving service delivery.

"I have got diabetes!" - interviews of patients newly diagnosed with type 2 diabetes

BACKGROUND

To be diagnosed with type 2 diabetes is a challenge for every patient. There are previous studies on patients' experience in general but not addressing the increased cardiovascular risk and multifactorial treatment. The aim of this study was to explore the thoughts, experiences and reactions of newly diagnosed patients with diabetes to this diagnosis and to the risk of developing complications.

METHODS

Ten adults (7 men/3 women, aged 50-79) diagnosed with type 2 diabetes within the last 12 months were interviewed at a primary health care center in Sweden. An interview guide was used in the semi-structured interviews that were transcribed verbatim. The analysis was qualitative and inspired by systematic text condensation (Malterud). The text was read several times and meaning units were identified. Related meaning units were sorted into codes and related codes into categories during several meetings between the authors. Finally, the categories were merged and formed themes.

RESULTS

We defined three main themes: Reaction to diagnosis, Life changes and Concerns about the future. Most patients reacted to the diagnosis without intensive feelings. Lifestyle changes were mainly accepted but hard to achieve. The patients' major concerns for the future were the consequences for daily life (being able to drive and read) and concerns for relatives rather than anxieties regarding medical issues such as laboratory tests. There were considerable differences in how much patients wanted to know about their future risks.

CONCLUSIONS

The results of this study might help to focus doctor-patient communication on issues highlighted by the patients and on the importance of individualizing information and recommendations for each patient.

Factors associated with patient-satisfaction in student-led physiotherapy clinics: A qualitative study

BACKGROUND AND PURPOSE

Student-led physiotherapy clinics are a valuable means for providing clinical education opportunities for student learning and providing cost-effective services to the public. Understanding patient satisfaction within the student-led physiotherapy clinic setting is important to inform organizational, educational, and clinical processes that aim to balance both student learning experiences and quality patient care.

DESIGN

A cross-sectional qualitative design using semi-structured interviews.

RESULTS

A total of 20 patients from three different university student-led physiotherapy clinics were interviewed. Five major themes were associated with patient satisfaction, style of supervision, student-supervisor relationship, quality of physiotherapy care, student qualities and cost, and location of the service.

CONCLUSION

The results emphasize the importance placed by patients on effective communication, as well as the relationship between the supervisor and student overseeing their care. The findings highlight the influence of both the student and supervisor on patient satisfaction and provide insight into the style of student supervision from the perspective of the patient.

Patients' views on interactions with practitioners for type 2 diabetes: a longitudinal qualitative study in primary care over 10 years

BACKGROUND

It has been suggested that interactions between patients and practitioners in primary care have the potential to delay progression of complications in type 2 diabetes. However, as primary care faces greater pressures, patient experiences of patient-practitioner interactions might be changing.

AIM

To explore the views of patients with type 2 diabetes on factors that are of significance to them in patient-practitioner interactions in primary care after diagnosis, and over the last 10 years of living with the disease.

DESIGN AND SETTING

A longitudinal qualitative analysis over 10 years in UK primary care.

METHOD

The study was part of a qualitative and quantitative examination of patient experience within the existing ADDITION-Cambridge and ADDITION-Plus trials from 2002 to 2016. The researchers conducted a qualitative descriptive analysis of free-text comments to an open-ended question within the CARE measure questionnaire at 1 and 10 years after diagnosis with diabetes. Data were analysed cross-sectionally at each time point, and at an individual level moving both backwards and forwards between time points to describe emergent topics.

RESULTS

At the 1-year follow-up, 311 out of 1106 (28%) participants had commented; 101 out of 380 (27%) participants commented at 10-year follow-up; and 46 participants commented at both times. Comments on preferences for face-to-face contact, more time with practitioners, and relational continuity of care were more common over time.

CONCLUSION

This study highlights issues related to the wider context of interactions between patients and practitioners in the healthcare system over the last 10 years since diagnosis. Paradoxically, these same aspects of care that are valued over time from diagnosis are also increasingly unprotected in UK primary care.

Connectivity, contest and the ties of self-management support for type 2 diabetes: a meta-synthesis of qualitative literature

This paper presents a meta-synthesis of the literature on community-based self-management to support experiences of people diagnosed with type 2 diabetes. The aim was to synthesise findings on both formal and informal self-management support with particular reference to the relevance and influence of the social context operating at different levels. The review forms part of EU-WISE, a project financed through EU's 7th Framework Programme. The review was performed by systematically searching MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO and Web of Science for English language publications between 2005 and 2014 presenting research conducted in Europe on the experiences and perspectives of self-management concerns of patients diagnosed with type 2 diabetes. The search yielded 587 abstracts, which were reduced through search strategy refinement and eligibility and quality criteria to 29 papers that were included in the review. This review highlights the relevance of contextual factors operating at micro- and macro-levels. The synthesis yielded six second-order thematic constructs relating to self-management: sense of agency and identity, the significance and meaning of social networks, minimal disruption of everyday life, economic hardship, the problem of assigning patients' responsibility and structural influences of primary care. Using a line of argument synthesis, these themes were revisited, and a third-order construct, connectivity emerged which refers to how links in daily life are interwoven with peoples' social networks, local communities, economic and ideological conditions in society in a way which support self-management activities. This meta-synthesis indicates a need to heed the notion of connectivity as a means of mobilising and supporting the self-management strategies of people with type 2 diabetes in everyday life.

A Positive Psychology Intervention for Patients with an Acute Coronary Syndrome: Treatment Development and Proof-of-Concept Trial

Positive psychological constructs are associated with superior outcomes in cardiac patients, but there has been minimal study of positive psychology (PP) interventions in this population. Our objective was to describe the intervention development and pilot testing of an 8-week phone-based PP intervention for patients following an acute coronary syndrome (ACS). Initial intervention development and single-arm proof-of-concept trial, plus comparison of the PP intervention to a subsequently-recruited treatment as usual (TAU) cohort. PP development utilized existing literature, expert input, and qualitative interview data in ACS patients. In the proof-of-concept trial, the primary outcomes were feasibility and acceptability, measured by rates of exercise completion and participant ratings of exercise ease/utility. Secondary outcomes were pre-post changes in psychological outcomes and TAU comparisons, measured using effect sizes (Cohen's d). The PP intervention and treatment manual were successfully created. In the proof-of-concept trial, 17/23 PP participants (74 %) completed at least 5 of 8 exercises. Participants rated the ease (M = 7.4/10; SD = 2.1) and utility (M = 8.1/10, SD = 1.6) of PP exercises highly. There were moderate pre-post improvements (ds = .46-.69) in positive affect, anxiety, and depression, but minimal effects on dispositional optimism (d = .08). Compared to TAU participants (n = 22), PP participants demonstrated greater improvements in positive affect, anxiety, and depression (ds = . 47-.71), but not optimism. A PP intervention was feasible, well-accepted, and associated with improvements in most psychological measures among cardiac patients. These results provide support for a larger trial focusing on behavioral outcomes.

Understanding adherence-related beliefs about medicine amongst patients of South Asian origin with diabetes and cardiovascular disease patients: a qualitative synthesis

BACKGROUND

Prevalence of diabetes and cardiovascular (CVD) disease amongst UK South Asians is higher than in the general population. Non-adherence to medicines may lead to poor clinical outcomes for South Asian patients with diabetes and CVD. To understand the decision making processes associated with taking medicines, a qualitative systematic meta-synthesis exploring medicine taking behaviours, and beliefs was undertaken.

METHODS

Four databases (Medline, Embase, Science Citation Index and CINAHL) were searched to identify qualitative studies of South Asian patients taking diabetic medicines. Data were thematic coded and synthesised.

RESULTS

The following themes were identified: [1] beliefs about the need for and efficacy of medicines; [2] toxicity of medicines and polypharmacy; [3] the necessity of traditional remedies versus "western medicines"; [4] stigma and social support; and [5] communication.

CONCLUSIONS

South Asians described cultural social stigma associated with diabetes and reported fears about drug toxicity as barriers to taking medicines. Cultural beliefs about traditional remedies and interactions with healthcare professionals also appeared to play a role in the way people made decisions about medicines. Advice should be tailored provided to South Asian patients highlighting the long term consequences of diabetes and CVD.

Making sense of change: patients' views of diabetes and GP-led integrated diabetes care

BACKGROUND

Health system reform is directed towards better management of diabetes. However, change can be difficult, and patients' perspectives are a key aspect of implementing change.

OBJECTIVE

This study investigated patients' perceptions and experiences of type 2 diabetes (T2DM), self-care and engagement with GP-led integrated diabetes care.

DESIGN

Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care. Normalization process theory was used to orientate the thematic analysis, to explain the work of implementing change.

SETTING

Two specialist GP-based complex diabetes services in primary care in Brisbane, Australia.

PARTICIPANTS

Intervention group patients (n = 30) in a randomized controlled trial to evaluate a model of GP-led integrated care for complex T2DM.

MAIN OUTCOME MEASURES

Participants' experiences and perceptions of diabetes management and a GP-led model of care.

RESULTS

Three themes were identified: sensibility of change, 'diabetic life' and diabetes care alliance. The imperative of change made sense, but some participants experienced dissonance between this rational view and their lived reality. Diabetes invaded life, revealing incongruities between participants' values and living with diabetes. They appreciated a flexible and personalized approach to care.

DISCUSSION

Participants responded to advice in ways that seemed rational within the complexities of their life context. Their diabetes partnerships with health professionals coupled providers' biomedical expertise with patients' contextual expertise.

CONCLUSIONS

Learning to manage relationships with various health professionals adds to patients' diabetes-related work. Providers need to adopt a flexible, interactive approach and foster trust, to enable better diabetes care.

Development and Evaluation of a Computer-Based, Self-Management Tool for People Recently Diagnosed with Type 2 Diabetes

Aim. The purpose of this study was to develop and evaluate a computer-based, dietary, and physical activity self-management program for people recently diagnosed with type 2 diabetes. Methods. The computer-based program was developed in conjunction with the target group and evaluated in a 12-week randomised controlled trial (RCT). Participants were randomised to the intervention (computer-program) or control group (usual care). Primary outcomes were diabetes knowledge and goal setting (ADKnowl questionnaire, Diabetes Obstacles Questionnaire (DOQ)) measured at baseline and week 12. User feedback on the program was obtained via a questionnaire and focus groups. Results. Seventy participants completed the 12-week RCT (32 intervention, 38 control, mean age 59 (SD) years). After completion there was a significant between-group difference in the "knowledge and beliefs scale" of the DOQ. Two-thirds of the intervention group rated the program as either good or very good, 92% would recommend the program to others, and 96% agreed that the information within the program was clear and easy to understand. Conclusions. The computer-program resulted in a small but statistically significant improvement in diet-related knowledge and user satisfaction was high. With some further development, this computer-based educational tool may be a useful adjunct to diabetes self-management. This trial is registered with clinicaltrials.gov NCT number NCT00877851.

The impact of using musculoskeletal ultrasound imaging and other influencing factors on medication adherence in patients with rheumatoid arthritis: a qualitative study

BACKGROUND

Medication can ease symptoms and limit disease progression in rheumatoid arthritis (RA). Despite this, nonadherence to medication is common in RA. We explored the determinants of high and low adherence to disease-modifying antirheumatic drugs (DMARDs) in patients with RA and provide suggestions on approaches to improving adherence to DMARDs.

METHODS

Patients with RA were identified from those who had previously participated in a questionnaire measuring levels of medication adherence. Twenty patients participated (ten high and ten low adherers, as determined by responses to the Medication Adherence Report Scale). In-depth individual semistructured interviews were undertaken until data saturation was reached. Interviews were transcribed and analyzed using a constant comparative method.

RESULTS

Four main themes related to adherence were identified: 1) symptom severity; 2) illness perception; 3) perceived benefits and risks of DMARDs; and 4) the quality and quantity of information about RA and DMARDs. In addition, patients' suggestions about strategies to optimize adherence to DMARDs were captured and they fell within the following themes: 1) musculoskeletal ultrasound to explain the disease process and to provide objective feedback about the extent to which their disease activity is being effectively controlled; 2) better explanations of the consequences of poorly controlled RA; and 3) a good relationship with the health professional.

CONCLUSION

Patients' beliefs about medicines, perceptions about RA, and level of satisfaction with information about DMARDs influenced their adherence to DMARDs. The use of musculoskeletal ultrasound to image the inflamed joint may help to improve patient adherence to DMARDs.

Determinants of adherence to disease modifying anti-rheumatic drugs in White British and South Asian patients with rheumatoid arthritis: a cross sectional study

Background

Rheumatoid arthritis (RA) is a common chronic inflammatory disease causing joint damage, disability, and reduced life expectancy. Highly effective drugs are now available for the treatment of RA. However, poor adherence to drug regimens remains a significant barrier to improving clinical outcomes in RA. Poor adherence has been shown to be linked to patients’ beliefs about medicines with a potential impact on adherence. These beliefs are reported to be different between ethnic groups. The purpose of this study was to identify potential determinants of adherence to disease modifying anti-rheumatic drugs (DMARDs) including an assessment of the influence of beliefs about medicines and satisfaction with information provided about DMARDs and compare determinants of adherence between RA patients of White British and South Asian.

Methods

RA patients of either White British (n = 91) or South Asian (n = 89) origin were recruited from secondary care. Data were collected via questionnaires on patients’: (1) self-reported adherence (Medication Adherence Report Scale-MARS); (2) beliefs about medicines (Beliefs about Medicines Questionnaire-BMQ); (3) illness perceptions (Illness Perceptions Questionnaire-IPQ) and (4) satisfaction with information about DMARDs (Satisfaction with Information about Medicines questionnaire-SIMS). In addition, clinical and demographic data were collected.

Results

The results revealed that socio-demographic factors only explained a small amount of variance in adherence whereas illness representations and treatment beliefs were more substantial in explaining non-adherence to DMARDs. Patients’ self-reported adherence was higher in White British than South Asian patients (median 28 (interquartile range 26–30) vs median 26 (interquartile range 23–30) respectively; P = 0.013, Mann–Whitney test). Patients who reported lower adherence were more dissatisfied with the information they had received about their DMARDs (P < 0.001, Spearman correlation, SIMS action and usage subscale; P < 0.001, Spearman correlation, SIMS potential problems subscale) and had more negative beliefs about their DMARDs and were related to ethnicity with South Asian patients having more negative views about medicines.

Conclusions

Socio-demographic factors were found to explain a small amount of variance in adherence. Illness representations and treatment beliefs were more important in explaining non-adherence to DMARDs. Clinicians managing South Asian patients with RA need to be aware that low adherence may be linked to negative beliefs about medicines and illness representations of RA.

How social inequalities impact the course of treatment and care for patients with type 2 diabetes mellitus: study protocol for a qualitative cross-sectional study from the patient's perspective

INTRODUCTION

Studies from various scientific disciplines have demonstrated that socioeconomic inequalities in type 2 diabetes mellitus negatively affect groups with a low socioeconomic status. Furthermore, socioeconomic inequalities also exist in terms of access to, and utilisation and perceived quality of, diabetological care. The aim of this qualitative study, which focuses on the patient's perspective, is to provide insights into the ways socioeconomic inequalities impact the course of treatment and care of patients with type 2 diabetes mellitus. The study aims to develop an understanding of how socioeconomic inequalities in care arise.

METHODS AND ANALYSIS

A cross-sectional qualitative study will be conducted using a sample of about 20 patients with type 2 diabetes mellitus aged 18 and older. Patients will be recruited successively from the University Hospital in Halle/Saale, Germany, a general practitioner's office, and in a specialised diabetological practice. The patients will be interviewed personally once, using semistructured qualitative interviews. All interviews will be recorded, transcribed, and analysed based on Grounded Theory.

ETHICS AND DISSEMINATION

All interviewees will receive comprehensive written information about the study and sign a declaration of consent prior to the interview. The study will comply rigorously with data protection legislation. The research team has obtained the approval of the Ethical Review Committee at the MLU Halle-Wittenberg, Germany. The results of the study will be published in high-quality, peer-reviewed international journals, presented at several congresses and used for developing follow-up research projects.

TRIAL REGISTRATION NUMBER

This study has been registered with the German Clinical Trials Register and assigned DRKS00007847.

Positive Psychological Interventions for Patients with Type 2 Diabetes: Rationale, Theoretical Model, and Intervention Development

Most patients with type 2 diabetes (T2D) have suboptimal adherence to recommended diet, physical activity, and/or medication. Current approaches to improve health behaviors in T2D have been variably effective, and successful interventions are often complex and intensive. It is therefore vital to develop interventions that are simple, well-accepted, and applicable to a wide range of patients who suffer from T2D. One approach may be to boost positive psychological states, such as positive affect or optimism, as these constructs have been prospectively and independently linked to improvements in health behaviors. Positive psychology (PP) interventions, which utilize systematic exercises to increase optimism, well-being, and positive affect, consistently increase positive states and are easily delivered to patients with chronic illnesses. However, to our knowledge, PP interventions have not been formally tested in T2D. In this paper, we review a theoretical model for the use of PP interventions to target health behaviors in T2D, describe the structure and content of a PP intervention for T2D patients, and describe baseline data from a single-arm proof-of-concept (N = 15) intervention study in T2D patients with or without depression. We also discuss how PP interventions could be combined with motivational interviewing (MI) interventions to provide a blended psychological-behavioral approach.

A qualitative synthesis of diabetes self-management strategies for long term medical outcomes and quality of life in the UK

Background

Qualitative research on self-management for people with Type 2 Diabetes Mellitus (T2DM) has typically reported one-off retrospective accounts of individuals’ strategies. The aim of this research was to identify the ways in which self-management strategies are perceived by people with T2DM as being either supportive or unsupportive over time, by using qualitative findings from both longitudinal intervention studies and usual care.

Methods

A systematic review of qualitative literature, published between 2000 and 2013, was conducted using a range of searching techniques. 1374 prospective qualitative papers describing patients’ experiences of self-management strategies for T2DM were identified and screened. Of the 98 papers describing qualitative research conducted in the UK, we identified 4 longitudinal studies (3 intervention studies, 1 study of usual care). Key concepts and themes were extracted, reviewed and synthesised using meta-ethnography techniques.

Results

Aspects of self-management strategies in clinical trials (e.g. supported exercise regimens) can be perceived as enabling the control of biomarkers and facilitative of quality of life. In contrast, aspects of self-management strategies outwith trial conditions (e.g. self-monitoring) can be perceived of as negative influences on quality of life. For self-management strategies to be sustainable in the long term, patients require a sense of having a stake in their management that is appropriate for their beliefs and perceptions, timely information and support, and an overall sense of empowerment in managing their diabetes in relation to other aspects of their life. This enables participants to develop flexible diabetes management strategies that facilitate quality of life and long term medical outcomes.

Conclusions

This synthesis has explored how patients give meaning to the experiences of interventions for T2DM and subsequent attempts to balance biomarkers with quality of life in the long term. People with T2DM both construct and draw upon causal accounts as a resource, and a means to counter their inability to balance medical outcomes and quality of life. These accounts can be mediated by the provision of timely and tailored information and support over time, which can allow people to develop a flexible regimen that can facilitate both quality of life and medical outcomes.

Quality improvements in diabetes care, how holistic have they been? A case-study from the United Kingdom

Aims

As quality in diabetes care includes patient centred support for self-management, investigating patients’ experiences upon diagnosis can help improve access to this element of care among diverse populations. This research explored this care in the context of recent national quality improvement initiatives which support self-management.

Methods

South Asian and White European patients over 16 years with a recent (< 1 year) diagnosis of diabetes were recruited from 18 General Practitioner (GP) practices in three UK locations - Luton, West London and Leicester. A semi-structured qualitative interview was conducted with 47 patients.

Results

Twenty one out of 47 (45%) reported unmet support and information needs at diagnosis. Although there was a small proportion of participants (8 out of 47, 17% of all respondents) who felt they did not require any help or support with managing their diabetes because their GP had provided comprehensive and efficient care, there was an equal number who voiced a negative view of the care they had received to date. This concerned information giving, support and communication, suggesting that recently implemented national quality improvement interventions may not have been successful in improving all aspects of diabetes care, particularly those encouraging self-management. The emerging analysis led to consideration of concordance as an important concept through which to understand inequalities and improve access to quality diabetes care. In order to encourage self-management from the start, care providers need to be cognisant that patients are not homogeneous and be responsive to their different information needs and emotional responses to diagnosis.

Conclusions

In order to support self-management and deliver patient centred care in diverse populations, care providers will need to be adaptable to individual needs around diagnosis.

Diet and physical activity in the self-management of type 2 diabetes: barriers and facilitators identified by patients and health professionals

Aim To explore the views of individuals recently diagnosed with type 2 diabetes in relation to self-management of dietary intake and physical activity, and to compare these with the views of health professionals (HPs).

BACKGROUND

Diabetes education has become a priority area in primary and secondary care, and many education programmes are now embedded within a patient's care package. There are few contemporaneous explorations of patients' views about lifestyle self-management. Such research is vital in order to identify areas that require further support, refinement or enhancement in terms of patient education.

METHODS

Focus groups were held with patients recently diagnosed with type 2 diabetes (n = 16, 38% female, aged 45-73 years). In-depth semi-structured interviews were conducted with HPs (n = 7). Discussions focussed on self-management specifically in relation to making dietary and physical activity changes. All discussions were tape recorded, transcribed and analysed by emergent themes analysis using NVivo to manage the coded data. Findings Barriers were divided into six main categories: difficulty changing well-established habits, negative perception of the 'new' or recommended regimen, barriers relating to social circumstances, lack of knowledge and understanding, lack of motivation and barriers relating to the practicalities of making lifestyle changes. HPs generally echoed the views of patients. In conclusion, even against a background of diabetes education, recently diagnosed patients with type 2 diabetes discussed a wide range of barriers to self-management of diet and physical activity. The findings could help to provide HPs with a deeper understanding of the needs of recently diagnosed patients and may help refine current diabetes education activities and inform the development of educational resources.

Type 1 diabetes patients' experiences of, and need for, social support after attending a structured education programme: a qualitative longitudinal investigation

AIMS AND OBJECTIVES

To explore patients' experiences of, views about and need for, social support after attending a structured education programme for type 1 diabetes.

BACKGROUND

Patients who attend structured education programmes attain short-term improvements in biomedical and quality-of-life measures but require support to sustain self-management principles over the longer term. Social support can influence patients' self-management practices; however, little is known about how programme graduates use other people's help.

DESIGN

This study was informed by the principles of grounded theory and involved concurrent data collection and analysis. Data were analysed using an inductive, thematic approach.

METHODS

In-depth interviews were undertaken postcourse, six and 12 months later, with 30 adult patients with type 1 diabetes recruited from Dose Adjustment for Normal Eating courses in the United Kingdom.

RESULTS

Patients' preferences for social support from other people ranged from wanting minimal involvement, to benefiting from auxiliary forms of assistance, to regular monitoring and policing. New self-management skills learnt on their courses prompted and facilitated patients to seek and obtain more social support. Support received/expected from parents varied according to when patients were diagnosed, but parents' use of outdated knowledge could act as a barrier to effective support. Support sought from others, including friends/colleagues, was informed by patients' domestic/employment circumstances.

CONCLUSION

This study responds to calls for deeper understanding of the social context in which chronic illness self-management occurs. It highlights how patients can solicit and receive more social support from family members and friends after implementing self-care practices taught on education programmes.

RELEVANCE TO CLINICAL PRACTICE

Health professionals including diabetes specialist nurses and dietitians should explore: patients' access to and preferences for social support; how patients might be encouraged to capitalise on social support postcourse; and new ways to inform/educate people within patients' social networks.

A patient-centred approach to health service delivery: improving health outcomes for people with chronic illness

BACKGROUND

The Wagner Model provides a framework that can help to facilitate health system transition towards a chronic care oriented model. Drawing on elements of this framework as well as health policy related to patient centred care, we describe the health needs of patients with chronic illness and compare these with services which should ideally be provided by a patient-centred health system. This paper aims to increase understanding of the challenges faced by chronically ill patients and family carers in relation to their experiences with the health care system and health service providers.

METHOD

We interviewed patients, carers and health care professionals (HCPs) about the challenges faced by people living with complicated diabetes, chronic heart failure or chronic obstructive pulmonary disease.

RESULTS

Patients indicated that they had a range of concerns related to the quality of health care encounters with health care professionals (HCPs), with these concerns being expressed as needs or wants. These included: 1) the need for improved communication and information delivery on the part of HCPs; 2) well organised health services and reduced waiting times to see HCPs; 3) help with self care; 4) greater recognition among professionals of the need for holistic and continuing care; and 5) inclusion of patients and carers in the decision making processes.

CONCLUSIONS

In order to address the challenges faced by people with chronic illness, health policy must be more closely aligned with the identified needs and wants of people affected by chronic illness than is currently the case.

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

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.

Patients' expectations of the health advice conversation with the diabetes nurse practitioner

Type 2-diabetes usually makes its first appearance in adult age. In order for patients to feel in control of the disease, they need support and information that can easily be understood and which is relevant for the individual. By educating and supporting them, patients can conduct self-care and take control. The aim of this study was to highlight the expectations that patients with type 2-diabetes have of the health advice conversation with the nurse practitioner. A qualitative method using interviews was conducted and the data material was analysed according to manifest and latent content analysis. Three categories emerged in the results. Firstly, providing good accessibility to the diabetes nurse practitioner is of importance. Secondly, there is a demand for group activities in which patients have the opportunity to talk with other individuals who have diabetes. Finally, knowledge about self-care means that the patients themselves are able to change the intake of medication, their eating habits, and exercise according to need, as this leads to increased independence and self-management. The latent content demonstrates that the patient is striving towards competence and self-confidence in order to achieve a balance between lifestyle and the normalisation of blood sugar levels, which means empowerment. In addition, the informants expressed a demand for group activities where they can discuss the disease with others in the same situation. A combination of knowledge about the disease, receiving individual advice, and participation in groups can be beneficial in order to motivate the informants about lifestyle changes and to gain the ability to manage the disease.

Opinions of patients with type 2 diabetes about responsibility, setting targets and willingness to take medication. A cross-sectional survey

OBJECTIVE

To assess opinions and their determinants of patients with type 2 diabetes about responsibility for managing their diabetes, setting treatment targets and willingness taking medication.

METHODS

Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands.

OUTCOMES

opinions about responsibility, targets and medication. Multinomial logistic regression analysis.

RESULTS

Data of 994 consecutive persons were analysed (mean age 65 years; 54% males). Of these 62% agreed to take responsibility for their diabetes. In the opinion of 89% the setting of targets should be by or in cooperation with their physician or nurse and 40% were willing to take tablets until all targets were attained. Patients who perceived dysfunction by barriers to activity did not agree to take responsibility (OR 3.68; 1.65-8.19). Patients with complications preferred to set targets in cooperation with their physician or nurse (OR 1.98; 1.03-3.80). Males were more willing to take tablets until all targets were attained (OR 1.62; 1.17-2.25).

CONCLUSION

Not all patients want to take responsibility for their diabetes or taking all necessary tablets, especially those with barriers to activity or complications.

PRACTICE IMPLICATIONS

Doctors and nurses should ask for patients' opinions about responsibility and treatment goals before starting education.

A metasynthesis of the self-management of type 2 diabetes

Type 2 diabetes is a metabolic disorder characterized by chronically elevated blood glucose and high risk of comorbidities. In this article we report a metasynthesis of the 21st-Century qualitative research concerning the self-management of type 2 diabetes. We identified 38 relevant articles (sample size range 6 to 175), which were synthesized through a process of iterative reading and theory development. In this literature, authors argued and assumed that diabetes management is influenced by multiple, complex, competing factors, including interpersonal relations, gender, and sociocultural context. Conversely, self-management was sometimes construed as a facet of individual agency and was accepted uncritically, placing accountability for health with patients themselves. We conclude that a satisfactory account of diabetes care would pay attention to the "inner" world, while acknowledging the social and political conditions in which diabetes-related experiences unfold.

Type 2 diabetes and dog walking: patients' longitudinal perspectives about implementing and sustaining physical activity

BACKGROUND

Physical activity is particularly important for people with type 2 diabetes, as evidence suggests that any reduction in sedentary time is good for metabolic health.

AIM

To explore type 2 diabetes patients' talk about implementing and sustaining physical activity.

DESIGN OF STUDY

Longitudinal, qualitative study using repeat in-depth interviews with 20 patients over 4 years following clinical diagnosis.

SETTING

Patients were recruited from 16 general practices and three hospitals across Lothian, Scotland.

RESULTS

Discussion, and salience, of physical activity was marginal in patient accounts of their diabetes management. Patients claimed to have only received vague and non-specific guidance about physical activity from health professionals, and emphasised a perceived lack of interest and encouragement. Aside from walking, physical activities which were adopted tended to attenuate over time. Patients' accounts revealed how walking a dog assisted this kind of activity maintenance over time. Three main themes are highlighted in the analysis: 1) incidental walking; 2) incremental physical activity gains; and 3) augmenting physical activity maintenance. The problems arising from walking without a dog (for example, lack of motivation) are also examined.

CONCLUSION

Asking patients about pet preferences might seem tangential to medical interactions. However, encouraging dog walking or identifying another interest that promotes a regular commitment to undertake physical activity may yield long-term health benefits.

Integrating preconception care for women with diabetes into primary care: a qualitative study

BACKGROUND

National guidelines emphasise the need to deliver preconception care to women of childbearing age. However, uptake of the services among women with diabetes in the UK is low. Questions arising include how best to deliver preconception care and what the respective roles of primary versus secondary caregivers might be.

AIM

To explore the perspective of GPs and secondary care health professionals on the role of GPs in delivering preconception care to women with diabetes.

DESIGN OF STUDY

Qualitative, cross-sectional study.

SETTING

A London teaching hospital and GP practices in the hospital catchment area.

METHOD

Semi-structured interviews with GPs and members of the preconception care team in secondary care. Thematic analysis using the framework approach.

RESULTS

GPs and secondary care professionals differ in their perception of the number of women with diabetes requiring preconception care and the extent to which preconception care should be integrated into GPs' roles. Health professionals agreed that GPs have a significant role to play and that delivery of preconception care is best shared between primary and secondary care. However, the lack of clear guidelines and shared protocols detailing the GP's role presents a challenge to implementing 'shared' preconception care.

CONCLUSION

GPs should be more effectively involved in providing preconception care to women with diabetes. Organisational and policy developments are required to support GPs in playing a role in preconception care. This study's findings stress the importance of providing an integrated approach to ensure continuity of care and optimal pregnancy preparation for women with diabetes.

Reasons for participation in group-based type 2 diabetes self-management education. A qualitative study

AIMS

To investigate reasons for participating in group-based diabetes self-management education (DSME) for patients with type 2 diabetes.

METHODS

A qualitative study using focus groups and individual semi-structured interviews was conducted with 22 patients attending seven different groups in Central Norway.

RESULTS

Patients with diabetes described two main reasons for attending DSME; experiencing practical problems and feeling insecure. These reasons differed by affecting the patients in two ways - practically or emotionally. Practical problems and feeling insecure both originated from lack of or contradictory information and from lack of contact with other patients with diabetes. This affected the patients' everyday lives in important areas such as diet, medication, social settings and lifestyle changes.

CONCLUSIONS

The underlying reason for participating in a DSME was the participants' experience of having insufficient information about their diabetes, which led to practical problems and emotional insecurity. Being aware of the patients' reasons for participating can help professionals keep a focus which is more consistent with patients' needs.

Expectations about and experiences with insulin therapy contribute to diabetes treatment satisfaction in insulin-naïve patients with type 2 diabetes

AIM

The aim of this study was to investigate how patients' expectations about and experiences with insulin therapy contribute to diabetes treatment satisfaction.

METHODS

The Expectations about Insulin Therapy (EAITQ) and the Experience with Insulin Therapy Questionnaires (EWITQ) were administered at baseline and end-point, respectively to insulin-naïve patients with type 2 diabetes in a randomised trial comparing treatment algorithms for inhaled insulin. Pearson correlation coefficients were calculated between EAITQ and EWITQ scores, patient characteristics and patient-reported outcomes measures. Wilcoxon Signed Rank test compared EAITQ and EWITQ item score distributions. Differences between EAITQ and EWITQ scores were calculated to categorize patients according to the extent to which their expectations were met by experiences (i.e. unmet, met, exceeded).

RESULTS

EAITQ and EWITQ data were available for 240 patients (61% male, mean age 58 years, mean diabetes duration 10 years, mean baseline HbA(1c) 8.4%). Increasingly positive expectations were significantly associated with greater self-efficacy; greater levels of positive experiences were significantly associated with greater positive expectations, shorter diabetes duration, less symptom distress, greater well-being, self-efficacy and diabetes treatment satisfaction. Overall, patients' experiences with inhaled insulin therapy were significantly more positive than their expectations: 58% patients' experiences exceeded expectations, 29% patients' experiences met expectations and 13% patients' experiences did not meet expectations. Post hoc tests indicated that treatment satisfaction scores differed among these groups (all p < 0.01).

CONCLUSION

Expectations may not independently impact treatment satisfaction, but the relationship with experiences significantly contributes to it. The EAITQ and EWITQ may be useful tools for clinicians to better understand patients' expectations about and experiences with insulin therapy.

Lifting the lid of the "black intervention box" - the systematic development of an action competence programme for people with screen-detected dysglycaemia

Background

The evidence gained from effective self-management interventions is often criticised for the ambiguity of its active components, and consequently the obstruction of their implementation into daily practice.

Our aim is to report how an intervention development model aids the careful selection of active components in an intervention for people with dysglycaemia.

Methods

The first three phases of the UK Medical Research Council's model for developing complex interventions in primary care were used to develop a self-management intervention targeting people with screen-detected dysglycaemia. In the preclinical phase, the expected needs of the target group were assessed by review of empirical literature and theories. In phase I, a preliminary intervention was modelled and in phase II, the preliminary intervention was pilot tested.

Results

In the preclinical phase the achievement of health-related action competence was defined as the overall intervention goal and four learning objectives were identified: motivation, informed decision-making, action experience and social involvement. In Phase I, the educational activities were defined and the pedagogical tools tested. In phase II, the intervention was tested in two different primary healthcare settings and adjusted accordingly. The 18-hour intervention "Ready to Act" ran for 3 months and consisted of two motivational one-to-one sessions conducted by nurses and eight group meetings conducted by multidisciplinary teams.

Conclusions

An intervention aimed at health-related action competence was successfully developed for people with screen-detected dysglycaemia. The systematic and transparent developmental process is expected to facilitate future clinical research. The MRC model provides the necessary steps to inform intervention development but should be prioritised according to existing evidence in order to save time.

Preferences and opinions of patients with Type 2 diabetes on education and self-care: a cross-sectional survey

OBJECTIVE

To assess the preferences of patients with Type 2 diabetes regarding self-care activities and diabetes education.

RESEARCH DESIGN AND METHODS

Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands.

OUTCOMES

preferred setting for education, preferred educator, and preferred and most burdensome self-care activity. Multinomial logistic regression analysis assessed associations between outcomes and patient characteristics, preferences and opinions.

RESULTS

Data of 994 consecutive individuals were analysed (mean 65 years; 54% male; 97% Caucasian; 21% low education level; 80% primary care). Of these, 19% thought they had poor to average glycaemic control, 61% thought they were over-weight and 32% thought they took too little exercise. Eighty per cent of respondents preferred diabetes education during regular diabetes check-ups. Patients taking insulin preferred education to be given by nurses [odds ratio (OR) 2.45; 95% confidence interval (CI) 1.21-4.96]. Individuals who thought their health to be poor/average preferred education to be given by doctors (OR 1.65; 95% CI 1.08-2.53). Physical exercise was the preferred self-care activity of those who thought they took too little exercise (OR 1.97; 95% CI 1.32-2.93) but was preferred less by patients with mobility problems (OR 0.65; 95% CI 0.43-0.97). Patients with eating disinhibition reported keeping to a healthy diet (OR 4.63; 3.00-7.16) and taking medication (OR 1.66; 95% CI 1.09-2.52) as the most burdensome self-care activities. Age was not an independent determinant of any preference.

CONCLUSIONS

When providing education for patients with newly diagnosed Type 2 diabetes, healthcare providers should consider making a tailored education plan, irrespective of the patient's age.

Mobile digital fundus screening of type 2 diabetes patients in the Finnish county of South-Ostrobothnia

In 1999 we introduced a digital, mobile eye fundus camera for screening type 2 diabetes mellitus patients (adult onset diabetes) in the Finnish county of South-Ostrobothnia. Prior to this, eye fundus examinations were only available in the regional central hospital, and no systematic screening of type 2 (adult onset) diabetes patients was possible. The total number of screenings carried out with the mobile equipment from 1999 to 2006 was 17,471 cases. There were significant benefits, most important from improved coverage of type 2 diabetes patients. Because the mobile system made eye fundus examinations available to patients in their nearest health centre, approximately 85% of all patients with diabetes in the region are now screened. On average this means that each patient is screened once every 2.5 years, which is in line with national recommendations. As a result, more of the earlier stage retinopathy cases have been diagnosed. There have also been changes in the frequency and type of procedures at the eye department of the regional central hospital. The number of cases referred to the eye department for follow-up studies has decreased from 49 in 2000 to 19 in 2005. The screening system adopted in South-Ostrobothnia has had beneficial effects for both patients and health-care providers.

Patients' perceptions and experiences of transitions in diabetes care: a longitudinal qualitative study

OBJECTIVE

To examine patients' perceptions and experiences over time of the devolvement of diabetes care/reviews from secondary to primary health-care settings.

DESIGN

Repeat in-depth interviews with 20 patients over 4 years.

PARTICIPANTS AND SETTING

Twenty type 2 diabetes patients recruited from primary- and secondary-care settings across Lothian, Scotland.

RESULTS

Patients' views about their current diabetes care were informed by their previous service contact. The devolvement of diabetes care/reviews to general practice was presented as a 'mixed blessing'. Patients gained reassurance from their perception that receiving practice-based care/reviews signified that their diabetes was well-controlled. However, they also expressed resentment that, by achieving good control, they received what they saw as inferior care and/or less-frequent reviews to others with poorer control. While patients tended to regard GPs as having adequate expertise to conduct their practice-based reviews, they were more ambivalent about nurses taking on this role. Opportunities to receive holistic care in general practice were not always realized due to patients seeing health-care professionals for diabetes management to whom they would not normally present for other health issues.

CONCLUSIONS

It is important to educate patients about their care pathways, and to reassure them that frequency of reviews depends more on clinical need than location of care and that similar care guidelines are followed in hospital clinics and general practice. A patients' history of service contact may need to be taken into account in future studies of service satisfaction.

Patients with Type 2 Diabetes experiences of making multiple lifestyle changes: a qualitative study

OBJECTIVES

To explore patients newly diagnosed with Type 2 Diabetes Mellitus (T2DM) experiences of making single (diet) or multiple (diet and physical activity) changes in order to (1) assess whether patients experienced increases in physical activity as supporting or hindering dietary changes and vice versa, and (2) whether patients found making multiple lifestyle changes counterproductive or beneficial.

METHODS

In-depth interviews with 30 individuals taking part in a randomised controlled trial that aimed to determine the effect of diet and physical activity on T2DM. Interviewees had been randomised to receive usual care, intensive dietary advice, or intensive dietary advice plus information on physical activity. Respondents were interviewed 6 and 9 months post-randomisation. They were asked about their experiences of making lifestyle changes. Data were analysed thematically.

RESULTS

Findings suggest providing diet and physical activity information together encourages patients to use physical activity in strategic ways to aid disease management and that most patients find undertaking multiple lifestyle changes helpful.

CONCLUSION

Increasing physical activity can act as a gateway behaviour, i.e. behaviour that produces positive effects in other behaviours.

PRACTICE IMPLICATIONS

Practitioners should provide diet and physical activity information together to encourage patients to use physical activity strategically to maintain dietary changes.

Patients' perceptions and experiences of taking oral glucose-lowering agents: a longitudinal qualitative study

AIMS

The aims of this study were to examine Type 2 diabetic patients' expectations, perceptions and experiences of oral glucose-lowering agents (OGLAs), including their reasons for taking/not taking these drugs as prescribed and to provide recommendations for developing interventions to improve OGLA adherence.

METHODS

Longitudinal, qualitative study using repeat in-depth interviews with patients (n = 20) over 4 years following clinical diagnosis. Respondents were recruited from primary and secondary care settings across Lothian, Scotland, UK.

RESULTS

Despite experiences of side-effects, dislikes and concerns about taking multiple drugs and a belief that OGLAs could themselves cause one's diabetes to progress, most respondents appeared motivated to take these drugs as prescribed. This motivation seemed to arise from respondents' experiences of taking OGLAs and observing them to 'work'. Some respondents described feeling better after taking OGLAs, others, typically those who were asymptomatic, used blood glucose self-monitoring and/or glycated haemoglobin results to observe and evidence the effects of their OGLAs. Most respondents demonstrated a 'passive' expectation that health professionals should be responsible for decisions about medications. Hence, non-adherence typically resulted from forgetfulness rather than ambivalence about either medication or consultation style. Respondent concern about OGLA's largely centred upon lack of knowledge about the medication and what to do when doses were missed.

CONCLUSION

The findings call for multifaceted strategies to promote adherence. These could include education to address misconceptions and advise patients how to respond to missed doses; reminders to help patients remember to take their drugs; and structured feedback on the impact of OGLAs on glycaemic control.

A qualitative study in the United Kingdom of factors influencing attendance by patients with diabetes at ophthalmic outpatient clinics

INTRODUCTION

Many diabetics do not have regular eye examinations, although it is known that early diagnosis and treatment of sight-threatening retinopathy reduces the risk of blindness. The barriers that prevent diabetics from attending eye clinics are poorly understood.

PURPOSE

To determine what factors may influence diabetic patients' attendance at eye clinics.

METHODS

A qualitative survey of both patients and eye care providers was undertaken in a rural district general hospital and in an urban tertiary teaching hospital. Methods employed included semi-structured interviews, focus groups and non-participatory observations. All interviews and discussions were recorded and transcribed. The transcripts were then analyzed to detect emerging themes. Data collection continued until no new themes emerged.

RESULTS

Lack of awareness was seen as the greatest barrier by both patients and providers. Patients were aware that diabetes could affect the eye, but not that it could lead to blindness, nor that severe retinopathy could be asymptomatic. Patients reported that fundus images used for screening were a valuable educational resource. Fear, particularly of laser treatment, and guilt, about poor control causing retinopathy, deterred patients from attending. Both patients and providers recognized that regular attendance was inconvenient; however, providers underestimated the difficulties patients faced in obtaining time off work to attend clinics.

CONCLUSION

Providing more complete information about diabetic retinopathy, and making eye clinic attendance more convenient for patients, may increase the number of diabetics who have regular eye examinations.

Expectations held by type 1 and 2 diabetes mellitus patients and their relatives: the importance of facilitating the health-care process

AIM

To understand the expectations held by type 1 and 2 diabetes mellitus (DM 1 & 2) patients and their relatives regarding the health-care provided to them.

DESIGN

qualitative. Focus groups.

SETTING AND PARTICIPANTS

Andalusia. A theoretical sample that includes the most characteristic profiles. Thirty-one subjects with DM. segmentation characteristics receiving health-care for DM in Primary or Specialized care, living in urban and rural areas, men and women, age, varying diagnosis times, DM course and consequences. Subjects were recruited by health-care professionals at reference care centres.

RESULTS

Patients expect their health-care professionals to be understanding, to treat them with kindness and respect, to have good communication skills, to provide information in a non-authoritarian manner while fully acknowledging patients' know-how. Regarding the health-care system, their expectations focus on the system's ability to respond when required to do so, through a relevant professional, along with readily available equipment for treatment. The expectations of people affected by DM1 focus on leading a normal life and not having their educational, labour, social and family opportunities limited by the disease. Expectations in people with DM2 tend towards avoiding what they know has happened to other patients.

CONCLUSIONS

'Facilitating', is a key word. Both the health-care system and its professionals must pay keener attention to the emotional aspects of the disease and its process, adopting a comprehensive approach to care. It is vital that health-care professionals take an active interest in the course of their patient's disease, promoting accessibility and an atmosphere of trust and flexibility.

Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients' perspectives

OBJECTIVE

To explore views of patients with type 2 diabetes about self monitoring of blood glucose over time.

DESIGN

Longitudinal, qualitative study.

SETTING

Primary and secondary care settings across Lothian, Scotland.

PARTICIPANTS

18 patients with type 2 diabetes.

MAIN OUTCOME MEASURES

Results from repeat in-depth interviews with patients over four years after clinical diagnosis.

RESULTS

Analysis revealed three main themes-the role of health professionals, interpreting readings and managing high values, and the ongoing role of blood glucose self monitoring. Self monitoring decreased over time, and health professionals' behaviour seemed crucial in this: participants interpreted doctors' focus on levels of haemoglobin A(1c), and lack of perceived interest in meter readings, as indicating that self monitoring was not worth continuing. Some participants saw readings as a proxy measure of good and bad behaviour-with women especially, chastising themselves when readings were high. Some participants continued to find readings difficult to interpret, with uncertainty about how to respond to high readings. Reassurance and habit were key reasons for continuing. There was little indication that participants were using self monitoring to effect and maintain behaviour change.

CONCLUSIONS

Clinical uncertainty about the efficacy and role of blood glucose self monitoring in patients with type 2 diabetes is mirrored in patients' own accounts. Patients tended not to act on their self monitoring results, in part because of a lack of education about the appropriate response to readings. Health professionals should be explicit about whether and when such patients should self monitor and how they should interpret and act upon the results, especially high readings.

Contextualising accounts of illness: notions of responsibility and blame in white and South Asian respondents' accounts of diabetes causation

We undertook a secondary analysis of in-depth interviews with white (n = 32) and Pakistani and Indian (n = 32) respondents who had type 2 diabetes, which explored their perceptions and understandings of disease causation. We observed subtle, but important, differences in the ways in which these respondent groups attributed responsibility and blame for developing the disease. Whereas Pakistani and Indian respondents tended to externalise responsibility, highlighting their life circumstances in general and/or their experiences of migrating to Britain in accounting for their diabetes (or the behaviours they saw as giving rise to it), white respondents, by contrast, tended to emphasise the role of their own lifestyle 'choices' and 'personal failings'. In seeking to understand these differences, we argue for a conceptual and analytical approach which embraces both micro- (i.e. everyday) and macro- (i.e. cultural) contextual factors and experiences. In so doing, we provide a critique of social scientific studies of lay accounts/understandings of health and illness. We suggest that greater attention needs to be paid to the research encounter (that is, to who is looking at whom and in what circumstances) to understand the different kinds of contexts researchers have highlighted in presenting and interpreting their data.

"It's no skin off my nose": why people take part in qualitative research

In this article, the authors analyze participants' accounts of why they took part in a repeat-interview study exploring newly diagnosed patients' perceptions of diabetes service provision in Lothian, Scotland. The study involved three semistructured in-depth interviews with each patient (N = 40), which spanned a year. The authors provide a thematic discursive analysis of responses to the question, Can I ask you what made you decide to part in the study and why you've stayed involved over the past year? The main themes are (a) recruitment within health contexts ("the nurse said it would help"), (b) altruism ("if it can help somebody"), (c) qualitative research being seen as inherently innocuous ("nothing to lose"), and (d) therapeutic aspects of interviewing ("getting it off my chest"). The analysis contributes both to the qualitative literature about generic research participation and to a germinal literature exploring qualitative health research participation.

Presenting risk information to people with diabetes: evaluating effects and preferences for different formats by a web-based randomised controlled trial

OBJECTIVE

Web-based patient information is widespread and information on the benefits and risks of treatments is often difficult to understand. We therefore evaluated different risk presentation formats - numerical, graphical and others - addressing the pros and cons of tight control versus usual treatment approaches for diabetes.

METHOD

DESIGN

Randomised controlled trial.

SETTING

Online. Publicity disseminated via Diabetes UK.

PARTICIPANTS

People with diabetes or their carers.

INTERVENTIONS

Control group information based on British Medical Journal 'Best Treatments'. Four intervention groups received enhanced information resources: (1) detailed numerical information (absolute/relative risk, numbers-needed-to-treat); (2) 'anchoring' to familiar risks or descriptions; (3) graphical (bar charts, thermometer scales, crowd figure formats); (4) combination of 1-3.

OUTCOMES

Decision conflict scale (DCS, a measure of uncertainty); satisfaction with information; further free text responses for qualitative content analysis.

RESULTS

Seven hundred and ten people visited the website and were randomised. Five hundred and eight completed the questionnaire for quantitative data. Mean DCS scores ranged from 2.12 to 2.24 for the five randomisation groups, indicating neither clear delay or vacillation about decisions (usually DCS>2.5) nor tending to make decisions (usually DCS<2.0). There were no statistically significant effects of the interventions on DCS, or satisfaction with information. Two hundred and fifty-six participants provided responses for qualitative analysis: most found graphical representations helpful, specifically bar chart formats; many found other graphic formats (thermometer style, crowd figures/smiley faces) and 'anchoring' information unhelpful, and indicated information overload. Many negative experiences with healthcare indicate a challenging context for effective information provision and decision support.

CONCLUSION

Online evaluation of different risk representation formats was feasible. There was a lack of intervention effects on quantitative outcomes, perhaps reflecting already well-informed participants from the Diabetes UK patient organisation. The large qualitative dataset included many comments about what participants found helpful as formats for communicating risk information.

PRACTICE IMPLICATIONS

These findings assist the design of online decision aids and the representation of risk information. The challenge is to provide more information, in appropriate and clear formats, but without risking information overload. Interactive web designs hold much promise to achieve this.