Group visits to encourage insulin initiation: targeting patient barriers

A remotely accessible plant-based culinary intervention for Latina/o/x adults at risk for diabetes: lessons learned

Introduction

Little research has examined how community-engaged and -participatory dietary interventions adapted to remotely-accessible settings during the COVID-19 pandemic.

Objectives

To identify lessons learned in design, implementation, and evaluation of a remotely-accessible, community-based, nurse-led approach of a culturally-tailored whole food plant-based culinary intervention for Latina/o/x adults to reduce type 2 diabetes risk, delivered during a pandemic.

Methods

A mixed methods quasi-experimental design consisting of a pre-post evaluation comprised of questionnaires, culinary classes, biometrics, and focus groups.

Lessons learned

Community partnerships are essential for successful recruitment/retention. To optimally deliver a remotely-accessible intervention, community leadership and study volunteers should be included in every decision (e.g., timeframes, goals). Recommendations include managing recruitment and supply chain disruption of intervention supplies.

Conclusion

Future research should focus on increasing accessibility and engagement in minoritized and/or underserved communities, supply chain including quality assurance and delivery of services/goods, study design for sustainable, remotely-accessible interventions, and health promotion.

The Barriers to Insulin Therapy Initiation in Type 2 Diabetes Patients: A Study of General Practitioner Perceptions in Huinan Community in South Shanghai

Background

Despite the demonstrated benefits of insulin therapy, many general practitioners (GPs) are hesitant to administer it due to challenges such as a lack of knowledge, time constraints, and patient reluctance. The barriers that prevent a GP from initiating insulin therapy may vary in comparison to those encountered by a diabetic patient; this aspect of clinical research in the South Shanghai metropolitan area has received limited attention so far.

Objective

This is a 6-months of interventional analytic cohort study. The prime aim is to investigate the barriers general practitioners (GPs) face when initiating insulin therapy for patients with type 2 diabetes (T2D).

Materials and Methods

As part of a training program, all 189 registered GPs in Nanhui Health Service Center in Shanghai were given a structured online-multi-choice questionnaire before and after a six-month interval, during which the GPs received sessions of training on insulin therapy either on theoretic classes or clinical practices.

Results

Before and after training, via the methods of multiple-response analyses, the results showed that social, GP's, and patient barriers to initiating insulin therapy were comparable. However, through the crosstabs chi-square test, we found significant changes in the basal insulin initiation following the prescription of the senior endocrinologists, the titration of insulin, and the need for training (p<0.05). The Spearman analyses discovered significant changes associated with the cause of initial insulin refusal and the factors influencing insulin administration. Finally, the binary logistic regression analysis revealed that distinct causes such as social factors, insurance, GP experience, insulin dosage calculation, follow-up, and patients' feelings are related to insulin treatment application before and after training.

Conclusion

According to this study, training increased general practitioners' confidence in initiating insulin administration, especially basal insulin. General practitioners require additional education on insulin therapy, with a potential need for increased face-to-face training for insulin initiation.

'Is insulin right for me?': Feasibility of a pilot randomised controlled trial and acceptability of a web-based intervention to reduce psychological barriers to insulin therapy among adults with type 2 diabetes

AIMS

Acceptable and accessible interventions are needed to address 'psychological insulin resistance', which is a common barrier to insulin uptake among adults with type 2 diabetes (T2D). Our aim was to test the feasibility of a randomised controlled trial (RCT) study design and acceptability of a theoretically grounded, psycho-educational, web-based resource to reduce negative insulin appraisals among adults with T2D.

METHODS

A double-blinded, parallel group, two-arm pilot RCT (1:1), comparing intervention with active control (existing online information about insulin). Eligible participants were Australian adults with T2D, taking oral diabetes medications.

EXCLUSION CRITERIA

prior use of injectable medicines; being 'very willing' to commence insulin. Primary outcomes: study feasibility (recruitment ease, protocol fulfilment, attrition, data completeness); secondary outcomes: intervention acceptability (intervention engagement, user feedback) and likely efficacy (negative Insulin Treatment Appraisal Scale [ITAS] scores at follow-up). Online surveys completed at baseline and 2 weeks.

RESULTS

During 4-week recruitment, 76 people expressed interest: 51 eligible and 35 enrolled (intervention = 17, control = 18; median[interquartile range] age = 62[53, 69] years; 17 women). Protocol fulfilment achieved by 26 (74%) participants (n = 13 per arm), with low participant attrition (n = 6, 17%). Intervention acceptability was high (>80% endorsement, except format preference = 60%). ITAS negative scores differed between-groups at follow-up (M diff = -6.5, 95% confidence interval: -10.7 to -2.4), favouring the intervention.

CONCLUSIONS

This novel web-based resource ("Is insulin right for me?") is acceptable and associated with a likely reduction in negative insulin appraisals, relative to existing resources. This pilot shows the study design is feasible and supports conduct of a fully powered RCT.

Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes: study protocol for a two-armed randomised controlled trial of 'Is insulin right for me?'

INTRODUCTION

Psychological barriers to insulin therapy are associated with the delay of clinically indicated treatment intensification for people with type 2 diabetes (T2D), yet few evidence-based interventions exist to address these barriers. We describe the protocol for a randomised controlled trial (RCT) examining the efficacy of a novel, theoretically grounded, psychoeducational, web-based resource designed to reduce psychological barriers to insulin among adults with non-insulin treated T2D: 'Is insulin right for me?'.

METHODS AND ANALYSIS

Double-blind, parallel group RCT. A target sample of N=392 participants (n=196/arm) will be randomised (1:1) to 'Is insulin right for me?' (intervention) or widely available online resources (control). Eligible participants include adults (18-75 years), residing in Australia, currently taking oral hypoglycaemic agents to manage T2D. They will be primarily recruited via invitations and reminders from the national diabetes registry (from a purposefully selected sample of N≥12 000).

EXCLUSION CRITERIA

experience of self-administered injectable; previously enrolled in pilot RCT; 'very willing' to start insulin as baseline. Outcomes will be assessed via online survey at 2 weeks and 6 months. Primary outcome between-group: difference in mean negative Insulin Treatment Appraisal Scores (ITAS negative) at 2-week and 6-month follow-up.

SECONDARY OUTCOMES

between-group differences in mean positive insulin appraisals (ITAS positive) and percentage difference in intention to commence insulin at follow-up time points. All data analyses will be conducted according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

Deakin University Human Research Ethics Committee (2020-073). Dissemination via peer-reviewed journals, conferences and a plain-language summary.

TRIAL REGISTRATION NUMBER

ACTRN12621000191897; Australian and New Zealand Clinical Trials Registry.

The role of psychological insulin resistance in diabetes self-care management

Aims

The purpose of this study was to identify the role of psychological insulin resistance in the relationship between diabetes self-efficacy and diabetes self-care management in people with diabetes over 65 years of age.

Design

A descriptive, cross-sectional design was used.

Methods

Participants included 326 patients with type 2 diabetes who were over 65 years of age. Structural equation modelling was performed to estimate the direct and indirect effects of diabetes self-efficacy on diabetes self-care management when psychological insulin resistance was entered as a mediator. Data were collected from May 2015 to January 2017.

Results

Diabetes self-efficacy (r = .53, p < .001) and psychological insulin resistance (r = .33, p < .001) were significantly associated with diabetes self-care management, whereas a negative association was found between diabetes self-efficacy and psychological insulin resistance (r = -.16, p < .001). When psychological insulin resistance was entered as a mediator, the association between diabetes self-efficacy and diabetes self-care management was attenuated. Therefore, psychological insulin resistance served as a mediator of diabetes self-care management.

A Narrative Review of Diabetes Group Visits in Low-Income and Underserved Settings

BACKGROUND

Prior studies have supported the efficacy of diabetes group visits. However, the benefit of diabetes group visits for low-income and underserved individuals is not clear. The purpose of this study was to conduct a narrative review in order to clarify the efficacy of diabetes group visits in low-income and underserved settings.

METHODS

The authors performed a narrative review, categorizing studies into nonrandomized and randomized.

RESULTS

A total of 14 studies were identified. Hemoglobin A1c was the most commonly measured outcome, which improved for the majority of group visit participants. Preventive care showed consistent improvement for intervention arms. There were several other study outcomes including metabolic (i.e., blood pressure), behavioral (i.e., exercise), functional (i.e., quality of life), and system-based (i.e., cost).

CONCLUSION

Diabetes group visits for low-income and underserved individuals resulted in superior preventive care but the impact on glycemic control remains unclear.

Peer Education Group Intervention to Reduce Psychological Insulin Resistance: A Pilot Mixed-Method Study in a Chinese Population

INTRODUCTION

Psychological insulin resistance (PIR) is common among type II diabetes (DM) patients. Although interventions to reduce PIR have been suggested, there is no standardized intervention to reduce PIR. This trial aimed to assess the preliminary effectiveness of a well-structured interventional patient group (for sample size calculation for larger trials), as well as the acceptability and feasibility of this intervention group.

METHODS

This study used a quasi-experimental, mixed-method approach. Fifty-three patients with DM were recruited to an interventional group that included a general education of DM and insulin, an insulin pen demonstration, and an insulin-using peer sharing session. Each group consisted of around 15 participants and lasted for 2 h each. The validated Chinese version of the insulin treatment appraisal scale (C-ITAS) was administered before, immediately after, and 1 month after the intervention to measure any changes in the participants' PIR. Patients were interviewed to assess the acceptability of the intervention until data saturation.

RESULTS

Repeated measures ANOVA showed that the post-intervention C-ITAS scores (immediately post group and at 1 month) were lower than the pre-intervention C-ITAS scores (p < 0.001). Changes in multiple attitudes toward insulin were detected before and after the group intervention. Ten patient interviews were conducted and found that the intervention was welcomed by all interviewees; no discomfort or adverse reactions were reported.

CONCLUSION

Preliminary results showed that patient intervention groups with general education, insulin pen demonstration, and peer sharing appeared to be safe, acceptable, and effective in reducing PIR. Larger multicenter trials are needed to generalize these findings.

Integrating CHWs as Part of the Team Leading Diabetes Group Visits: A Randomized Controlled Feasibility Study

Purpose The purpose of the study was to evaluate the feasibility of integrating Community Health Workers (CHWs) as part of the team leading diabetes group visits. Methods This was a randomized controlled study that integrated CHWs as part of the team leading diabetes group visits for low-income Hispanic adults (n = 50). Group visits met for 3 hours each month for a 6-month duration. Main measures included baseline and 6-month clinical outcomes (ie, A1C, lipids), concordance with 8 standard of care guidelines (ie, screens for cervical, breast, and colon cancer) from the US Preventive Task Force and American Diabetes Association, and participant acceptability. Results Compared to control participants, the intervention group resulted in significantly better clinical outcomes or guideline concordance for the following areas: target A1C levels, retinal eye exams, diabetes foot exams, mammograms, and urine microalbumin. Significantly more individuals in the control group gained weight, whereas a greater number of participants in the intervention group lost weight. Intervention participants found the group visits highly acceptable. Conclusions Integrating CHWs as part a comprehensive diabetes group visit program is a feasible and effective system-level intervention to improve glycemic control and achieve guideline concordance.

Forum for Injection Technique and Therapy Expert Recommendations, India: The Indian Recommendations for Best Practice in Insulin Injection Technique, 2017

Health-care professionals in India frequently manage injection or infusion therapies in persons with diabetes (PWD). Patients taking insulin should know the importance of proper needle size, correct injection process, complication avoidance, and all other aspects of injection technique from the first visit onward. To assist health-care practitioners in their clinical practice, Forum for Injection Technique and Therapy Expert Recommendations, India, has updated the practical advice and made it more comprehensive evidence-based best practice information. Adherence to these updated recommendations, learning, and translating them into clinical practice should lead to effective therapies, improved outcomes, and lower costs for PWD.