Hospitalization for type 2 diabetes: the effects of the suspension of reality on patients' subsequent management of their condition

Strengthening Health Literacy Through Structured Sessions for Non-Communicable Diseases in Low-Resource Settings: The Learning Nest Model

Health literate self-management education is at stake for the prevention and management of non-communicable diseases in low resources settings and countries. Here we describe the Learning Nest in Ordinary Context (NA-CO in French, Nids d'Apprentissage en Contexte Ordinaire) aiming at the structuring of health education programs at the micro- (education sessions) and the meso-levels (adapted to context). The Learning Nest model was designed based on a combination on health literacy principles and on studies conducted with vulnerable people with non-communicable diseases. Observation of NA-CO active-learning sessions found them to be operational and relevant as they center on access, understanding, and use of health information while integrating the ordinary context of learners. The Learning Nest packages (including several adapted thematic sessions, training of trainers and development in context) were shown to be feasible and realistic in diverse locations (Reunion, Mali, Mayotte, Mauritius, Burundi). Qualitative and intervention studies have documented the potential usefulness of the Learning Nest model for context- and setting-specific health literacy interventions.

Knowledge of type 2 diabetic patients followed for less than 5 years in primary care in the western region of Reunion Island: a cross-sectional pilot study

Background

The learning needs of newly diagnosed diabetic patients followed up in medical offices in Reunion Island are unknown, although necessary for the improvement of education programmes and disease control.

Aim

To assess the knowledge of type 2 diabetic patients in primary care followed for less than 5 years.

Method

A cross-sectional study was carried out, using a self-questionnaire to assess patients' knowledge of diabetes, complications, follow-up, diet and physical activity. Patients were recruited from medical offices in the western region of Reunion Island.

Results

From 23^rd April to 31^st July 2021, 89 patients were included. The knowledge level of the total sample was moderate (mean correct answers 65 % ± 17). The best knowledge levels were in the areas "generalities on diabetes" and "complications", while the lowest levels were in the categories "follow-up" and "diet and physical activity". Glycated haemoglobin, libido disorders, frequency of urinalysis and dental consultation, and the recommended diet for patients with diabetes which is the same as for the general population, were the least known concepts.

Conclusion

This study revealed gaps in patients' knowledge that could be used to improve education programmes which in turn could reduce or prevent diabetes complications.

Health literacy in context: struggling to self-manage diabetes - a longitudinal qualitative study

OBJECTIVES

Considering health literacy needs is a key component of health services responsiveness to diabetes self-management among vulnerable individuals. The purpose of this qualitative study was to provide a detailed analysis of the health literacy of people with type 2 diabetes in relation to their daily self-care practices.

DESIGN

Nested qualitative study in the ERMIES randomised controlled trial testing a 2-year structured care in type 2 diabetes. First round of semidirected interviews at the beginning of the trial with thematic analysis of content. Second round at the completion with directed interviews guided by the first round's themes together with Health Literacy Questionnaire.

SETTINGS

Interviews conducted at home.

PARTICIPANTS

Forty-four (31 females/13 males, 30-79 years, glycated haemoglobin (HbA1c)≥7.5%) consecutive participants out of 100 recruited in the ERMIES trial from 4 diabetology outpatient settings (Reunion Island). Forty-two respondents to the second round interviews.

RESULTS

Three poles structured into eight themes characterised practices in context: health knowledge, disease management, expertise and social support. The relationships of participants in each of the eight themes were differentiated, ranging from functional to interactive and critical. Treatment and follow-up were essentially functional, while diet and exercise remained more interactive. Social support and relationship to health professionals were important determinants of disease management.

CONCLUSIONS

Treatment management and disease monitoring remain primarily the job of health professionals, as opposed to diet, physical activity and social support being part of ordinary practice. Decision-making, as a shared social task, as well as resources for participation in health services, should be considered for relevant interventions in type 2 diabetes.

TRIAL REGISTRATION NUMBER

NCT01425866.

Integrating Self-Management Education and Support in Routine Care of People With Type 2 Diabetes Mellitus: A Conceptional Model Based on Critical Interpretive Synthesis and A Consensus-Building Participatory Consultation

The integration of self-management education and support into the routine diabetes care is essential in preventing complications. Currently, however, there is no consensus on how to conceptualise integration in relation to self-management education and support. Therefore, this synthesis presents a framework conceptualising integration and self-management.

Methods

Seven electronic databases (Medline, HMIC, PsycINFO, CINAHL, ERIC, Scopus and Web of Science) were searched. Twenty-one articles met the inclusion criteria. Data were synthesised using principles of critical interpretive synthesis to build the conceptual framework. The framework was presented to 49 diabetes specialist nurses working at different levels of care during a multilingual workshop.

Results

A conceptual framework is proposed in which integration is influenced by five interacting components: the programme ethos of the diabetes self-management education and support intervention (content and delivery), care system organisation (the framework in which such interventions are delivered), adapting to context (the aspects of the people receiving and delivering the interventions), interpersonal relationship (the interactions between the deliverer and receiver of the intervention), and shared learning (what deliverer and receiver gain from the interactions). The critical inputs from the workshop participants related to the different priorities given to the components according to their sociolinguistic and educational experiences, Overall, they agreed with the conceptualisation of the components and their content specific to diabetes self-management education and support.

Discussion

Integration was conceptualised in terms of the relational, ethical, learning, contextual adapting, and systemic organisational aspects of the intervention. It remains uncertain which prioritised interactions of components and to what extent these may moderate the integration of self-management education and support into routine care; in turn, the level of integration observed in each of the components may moderate the impact of these interventions, which may also apply to the impact of the professional training.

Conclusion

This synthesis provides a theoretical framework that conceptualises integration in the context of diabetes self-management education and support in routine care. More research is required to evaluate how the components identified in the framework can be addressed in clinical practice to assess whether improvements in self-management education and support can be effectively realised in this population.

Physical activity containing behavioural interventions for adults living with modifiable chronic non-communicable diseases in Africa: a systematic mixed-studies review

Background

Physical activity improves physiological, cognitive and psychosocial functioning in chronic non-communicable diseases (NCDs). This study reviewed papers on the effects and patients' experiences of physical activity interventions for chronic NCDs in Africa.

Methods

We conducted a systematic review of clinical and qualitative studies by searching eight bibliographic databases and grey literature until 19 April 2017. The mixed-methods appraisal and Cochrane Collaboration's tools were used for quality and risk of bias assessments. Three-stage sequential explanatory syntheses were done.

Results

One randomized controlled trial (RCT), two non-controlled before and after studies and two qualitative studies of diabetic South African and Reunion patients were included. Exercise and sports unrelated to home and occupational activities were increased in the long term (1 year, moderate quality evidence) and short term immediately after a 4-week intervention (low quality evidence). There was conflicting evidence of intervention effects on home and occupational physical activities. Behaviour-change techniques improving chronic disease knowledge, addressing environmental barriers and stimulating/supporting physical activity were important to patients. Procedure-related components-health professional training and adequate health facilities-were important to patients, but were not addressed.

Conclusion

High quality RCTs are needed to confirm the intervention components for improving physical activity for chronic NCD management in Africa.

Characterisation of health literacy strengths and weaknesses among people at metabolic and cardiovascular risk: Validity testing of the Health Literacy Questionnaire

Objectives:

Health literacy refers to the ability of individuals to gain access to, use, and understand health information and services in order to maintain a good health. The assessment of health literacy profiles in a population is potentially crucial to respond to health needs. The Health Literacy Questionnaire explores nine dimensions of health literacy and has been shown to display robust psychometric properties. The aim was to test the validity of the multidimensional Health Literacy Questionnaire and to describe the health literacy profiles in a French population at risk of cardiovascular disease.

Methods:

Data were collected using self-administered questionnaires from 175 participants attending health education and support programmes in local associations of patients in Paris. Analysis included scale reliability, confirmatory factor analysis, and health literacy profiles via descriptive statistics.

Results:

In confirmatory factor analysis, the nine-factor structure was close to the original Health Literacy Questionnaire. A nine-factor confirmatory factor analysis model was fitted to the 44 items with no cross-loadings or correlated residuals allowed. Given the restricted nature of the model, the fit was satisfactory: χ²_WLSMV(866 df) = 1383.81, p = 0.0000, comparative fit index = 0.925, Tucker–Lewis index = 0.918, root mean square error of approximation = 0.058, weighted root mean square residual = 1.175. Composite reliability ranged from 0.77 to 0.91. Among the 9 scales of the Health Literacy Questionnaire, the highest scores were found for scale 1 ‘Feeling understood and supported by healthcare professionals’ and scale 9 ‘Understand health information enough to know what to do’ and the lowest for scale 2 ‘Having sufficient information to manage my health’ and scale 7 ‘Navigating the healthcare system’.

Conclusion:

The French version of the Health Literacy Questionnaire was shown to be psychometrically robust with good reliability. In the context of France, the 9 scales of Health Literacy Questionnaire allow a thorough assessment of health literacy strengths and weaknesses to respond to health literacy needs and improve the accessibility of health information and services.

Structured peer-led diabetes self-management and support in a low-income country: The ST2EP randomised controlled trial in Mali

Objectives

Our objective was to evaluate the effectiveness of peer-led self-management education in improving glycaemic control in patients with type 2 diabetes in a low-income country (Mali).

Methods

We conducted an open-label randomised controlled trial. A total of 151 adults (76% women, mean age 52.5) with type 2 diabetes (HbA1c≥8%), treated in the diabetes consultation units of two secondary health centres in Bamako, were allocated to peer-led structured patient education (n = 76) or conventional care alone (n = 75). The intervention group received 1 year of culturally tailored structured patient education (3 courses of 4 sessions) delivered in the community by five trained peer educators. Both groups underwent conventional diabetes monitoring and follow-up. Primary outcome was the mean absolute change in HbA1c from baseline to 12 months.

Results

177 education sessions were delivered to the intervention group. Patient attrition was 8%. From baseline to 12 months, the decrease in HbA1c levels was 1.05% (SD = 2.0; CI95%: 1.54;-0.56) in the intervention group compared with 0.15% (SD = 1.7; CI95%: -0.56; 0.26) in the control group, p = 0.006. Mean BMI change was -1.65 kg/m2 (SD = 2.5; CI95%: -2.25; -1.06) in the intervention group and +0.05 kg/m2 (SD = 3.2; CI95%: -0.71; 0.81) in the control group, p = 0.0005. Mean waist circumference decreased by 3.34 cm (SD = 9.3; CI95%: -5.56;-1.13) in the intervention group and increased by 2.65 cm (SD = 10.3; CI95%: 0.20; 5.09) in the control group, p = 0.0003.

Conclusions

Peer-led structured patient education delivered over 1 year to patients with poorly controlled type 2 diabetes in Mali yielded substantial improvements in glycaemic control and anthropometric parameters. This is of importance for the scaling up of efficient interventions in low-resource settings in the future.

Trial registration

ClinicalTrials.gov NCT01485913

CHOICE: Choosing Health Options In Chronic Care Emergencies

Background

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives

The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design

A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting

Primary care. Manchester and London.

Participants

People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results

Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations

The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions

Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work

The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

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.

Interdisciplinary Diabetes Care: A New Model for Inpatient Diabetes Education

A patient-centered interdisciplinary diabetes care model was implemented at Vidant Medical Center in Greenville, N.C., a 909-bed tertiary care teaching hospital, for the purpose of providing all patients with diabetes clear and concise instructions on diabetes survival skills. Survival skills education during hospitalization is needed for safe transition to community resources for continued and expanded diabetes self-management education. This article describes the process used to develop, implement, and evaluate the model. This initiative achieved substantial cost savings, with no significant changes in length of stay (LOS) or diabetes readmission rates. This patient-centered model demonstrates how a team of interdisciplinary health care professionals can integrate services in providing care for a large population of patients with chronic disease.

Chronotope disruption as a sensitizing concept for understanding chronic illness narratives

Objectives: This article aims to elaborate chronotope disruption —a changed relation to time and space— as a sensitizing concept for understanding chronic illness narratives. Methods: Sixteen men and 16 women with Type 2 diabetes were purposefully sampled. Each was interviewed about his or her experience of diabetes self-management using the biographical-narrative interview method. Transcripts were inspected for key moments defined as emotionally laden stories relevant to the purpose of the research. We present dialogically inflected discursive analysis of exemplar extracts. Results: The analysis demonstrates how the concept of chronotope disruption helps identify, and understand, important aspects of patients’ chronic illness narratives. First, we investigate how medical advice can conflict with embodied experience and how progressive bodily deterioration can provoke a reevaluation of past illness (self-mis)management. Second, the increasing temporal and spatial intrusion of chronic illness into participants’ lives is examined. Finally, we focus on the masquerade of health as an attempt to manage, hide, or deny that one is physically challenged. Conclusions: Chronotope disruption offers a useful sensitizing concept for approaching chronic illness narratives and around which to organize analytical insights and to develop practice. Chronotope analysis fills an important gap in the science through compensating current health sciences’ focus on rationality, cognition, and prospective time (prediction) with a patient-oriented focus on emotionality, embodiment, and retrospective time (nostalgia). Chronotope disruption could be used to develop practice by gaining empathic understanding of patients’ life-worlds and provides a tool to examine how new technologies change the way in which the chronically ill have “being” in the world.

Prevalence, correlates and management of type 2 diabetes mellitus in Lebanon: findings from a national population-based study

AIMS

This study aims to examine the prevalence, associated risk factors and complications of diabetes, as well management and preventive care in Lebanon, a small, middle-income country of the Mediterranean region.

METHODS

Using a comprehensive multi-dimensional questionnaire, a cross-sectional national survey of 2195 Lebanese adults aged ≥25 years was conducted based on the WHO STEPwise guidelines. The outcome variable, diabetes, was self-reported. Measures for diabetes management included frequency of blood glucose testing and regular eye and foot exams. Macrovascular and microvascular complications were also recorded.

RESULTS

The prevalence of type 2 diabetes was 8.5% (95%CI=7.3-9.7). Factors associated with an increased risk of having diabetes were: being divorced or widowed (OR=2.56; 95%CI=1.07-5.42) compared to single, being obese (OR=1.50, 95%CI=1.00-2.57), and having a family history of diabetes (OR=3.40;95%CI=2.48-5.19). Vigorous physical activity significantly decreased the odds of diabetes (OR=0.42; 95%CI=0.24-0.72). Diabetes management and self-care goals were as follows: 82% were not measuring their blood sugar via dextro on a daily basis, 64.2% did not have a foot exam within the past year, and 52.4% did not obtain the recommended yearly eye exam. The most common complications included heart disease (27.8%) and retinopathy (16.6%).

CONCLUSIONS

Prevalence of diabetes in Lebanon was comparable to that found in the West, yet remained lower than estimates in other resource-rich neighboring countries. Adherence to management and self-care measures was sub-optimal resulting in high complication rates. Contextual factors play a role in increasing diabetes risk. Population-based interventions to enhance and promote self-management behaviors are essential to improve complication rates.

Is adherence a relevant issue in the self-management education of diabetes? A mixed narrative review

While therapeutic patient education is now recognized as essential for optimizing the control of chronic diseases and patient well-being, adherence to treatment and medical recommendations is still a matter of debate. In type 2 diabetes, the nonadherence to therapy, estimated at more than 40%, is perceived as a barrier for improving the prognosis despite recent therapeutic advances. Interventional studies have barely begun to demonstrate the effectiveness of technical and behavioral actions. The aim of this review is to question the concept of adherence in terms of therapeutic education based on quantitative and qualitative data. The research on therapeutic education has shown the effectiveness of structured actions in type 2 diabetes, but adherence is rarely an end point in randomized trials. A positive but inconsistent or moderate effect of education actions on adherence has been shown in heterogeneous studies of varying quality. Program types, outlines, theoretical bases, and curricula to set up for action effectiveness are still being discussed. Qualitative studies, including sociological studies, provide a useful and constructive focus on this perspective. Adherence is a soft and flexible tool available to the patient in his/her singular chronic disease trajectory, and as such, integrates into individual therapeutic strategies, including socio-cultural interactions, beyond the medical explanation of the disease and the patient. Four key elements for the development of structured therapeutic education are discussed: 1) the access to health literacy, 2) the contextualization of education activities, 3) the long-term chronic dimension of self-management, and 4) the organizational aspects of health and care. Rather than focusing the objective on behavioral changes, structured therapeutic education actions should attempt to provide tools and resources aimed at helping individuals to manage their disease in their own context on a long-term basis, by developing health literacy and relational and organizational aspects of the health professionals and system.

Why do patients with long-term conditions use unscheduled care? A qualitative literature review

Unscheduled care (UC) refers to non-routine face-to-face care, such as accident and emergency care, out-of-hours care, or walk-in centres. Current health service policy aims to reduce its use. Unscheduled care is common in people with long-term conditions such as diabetes, asthma, chronic obstructive pulmonary disease and coronary heart disease. By reviewing qualitative research literature, we aimed to understand the breadth of psychosocial and other influences on UC use in people with long-term conditions. Few qualitative papers specifically address UC in patients in these disease groups. Therefore, our literature search also included qualitative research that explored factors potentially relevant to UC use, including attitudes to healthcare use in general. By searching Medline, Embase, Psycinfo and Cinahl from inception to 2011, we identified 42 papers, published since 1984, describing relevant original research and took a meta-ethnographic approach in reviewing them. The review was conducted between Spring 2009 and April 2011, with a further search in December 2011. Most papers reported on asthma (n = 13) or on multiple or unspecified conditions (n = 12). The most common methods reported were interviews (n = 33) and focus groups (n = 13), and analyses were generally descriptive. Theoretical and ethical background was rarely explicit, but the implicit starting point was generally the 'problem' of UC, and health-care, use in general, decontextualised from the lives of the patients using it. Patients' use of UC emerged as understandable, rational responses to pressing clinical need in situations in which patients thought it the only option. This belief reflected the value that they had learned to attach to UC versus routine care through previous experiences. For socially or economically marginalised patients, UC offered access to clinical or social care that was otherwise unavailable to them.

Making and maintaining lifestyle changes after participating in group based type 2 diabetes self-management educations: a qualitative study

BACKGROUND

Disease management is crucial in type 2 diabetes. Diabetes self-management education aims to provide the knowledge necessary to make and maintain lifestyle changes. However, few studies have investigated the processes after such courses. The aim of this study was to investigate how participants make and maintain lifestyle changes after participating in group-based type 2 diabetes self-management education.

METHODS

Data was collected through qualitative semi-structured interviews with 23 patients who attended educational group programs in Central Norway. The participants were asked how they had used the advice given and what they had changed after the course.

RESULTS

Knowledge was essential for making lifestyle changes following education. Three factors affected whether lifestyle changes were implemented: obtaining new knowledge, taking responsibility, and receiving confirmation of an already healthy lifestyle. Four factors motivated individuals to maintain changes: support from others, experiencing an effect, fear of complications, and the formation of new habits.

CONCLUSION

Knowledge was used to make and maintain changes in diet, medication and physical activity. Knowledge also acted as confirmation of an already adequate lifestyle. Knowledge led to no changes if diabetes appeared "not that scary" or if changes appeared too time consuming. Those involved in diabetes education need to be aware of the challenges in convincing asymptomatic patients about the benefits of adherence to self-management behaviour.

Structured self-management education maintained over two years in insufficiently controlled type 2 diabetes patients: the ERMIES randomised trial in Reunion Island

Background

Self-management education programs can reduce the complications and mortality in type 2 diabetes. The need to structure these programs for outpatient and community care with a vision for long-term maintenance has been recognised. In Reunion Island, an area affected by epidemiological and nutritional transition, diabetes affects 18% of the adult population over 30 years, with major social disparities, poor glycaemic control and frequent cardiovascular complications.

Methods/Design

ERMIES is a randomised controlled trial designed to test the efficacy of a long-term (2 years) structured group self management educational intervention in improving blood glucose in non-recent, insufficiently controlled diabetes. After an initial structured educational cycle carried out blind for the intervention arm, patients will be randomised in two parallel group arms of 120 subjects: structured on-going group with educational intervention maintained over two years, versus only initial education. Education sessions are organised through a regional diabetes management network, and performed by trained registered nurses at close quarters. The educational approach is theoretically based (socio-constructivism, social contextualisation, empowerment, action planning) and reproducible, thanks to curricula and handouts for educators and learners. The subjects will be recruited from five hospital outpatient settings all over Reunion Island. The main eligibility criteria include: age ≥18 years, type 2 diabetes treated for more than one year, HbA1c ≥ 7.5% for ≥3 months, without any severe evolving complication (ischaemic or proliferative retinopathy, severe renal insufficiency, coronaropathy or evolving foot lesion), and absence of any major physical or cognitive handicap. The primary outcome measure is HbA1c evolution between inclusion and 2 years. The secondary outcome measures include anthropometric indicators, blood pressure, lipids, antidiabetic medications, level of physical activity, food ingestion, quality of life, social support, anxiety, depression levels and self-efficacy. An associated nested qualitative study will be conducted with 30 to 40 subjects in order to analyse the learning and adaptation processes during the education cycles, and throughout the study.

Conclusions

This research will help to address the necessary but difficult issue of structuring therapeutic education in type 2 diabetes based on: efficacy and potential interest of organising on-going empowerment group–sessions, at close quarters, over the long term, in a heterogeneous socioeconomic environment.

Trial registration

ID_RCB number: 2011-A00046-35

Clinicaltrials.gov number: NCT01425866

Hypoglycemia education needs

Because more than half of those participating in a community-based diabetes session expressed experience with hypoglycemia, we sought additional information by conducting focus groups before developing programs or materials for educational support. The objectives of these focus groups were to determine how and to what extent hypoglycemia affected people, and what, if any, methods were used to prevent or treat the condition, to better target education in the future. Four focus groups were held using a tiered discussion script with a moderator and comoderator. Discussions were audiotaped, transcribed, and analyzed by content by independent researchers. Five themes emerged from the discussions: friends, family, and neighbors need hypoglycemia education as well as individuals themselves; leaving home is a concern if you experience hypoglycemia; overeating occurs when treating hypoglycemia; routine is important; and hypoglycemia is a limitation. We found that hypoglycemia had a significant impact on the participants' quality of life.

The experience of living with diabetes following a self-management program based on motivational interviewing

Self-management is an important part of diabetes treatment, but the promotion of self-care activities is still a challenge. In this study, we explored how living with diabetes in everyday life was experienced following a self-management intervention program based on motivational interviewing. We conducted seven focus group interviews, each comprising 3 to 5 participants diagnosed with type 1 or type 2 diabetes. Data analysis based on a phenomenological method revealed three main themes concerning diabetes self-management: becoming a self-regulating practitioner, managing the rules of self-management, and creating a supportive social network. Narrative analysis revealed a divergence in patients' self-perceived competence in handling diabetes. The study findings indicate that people with diabetes have specific needs for support in the daily responsibility of managing diet, exercise, medication, and blood glucose monitoring. A meaningful treatment from the patient's perspective would appear to be one aimed at overcoming problems the patient experiences in self-management of diabetes.

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.