Maximising engagement, motivation and long term change in a Structured Intensive Education Programme in Diabetes for children, young people and their families: Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE)

Final-year medical students' awareness and knowledge about DKA: A cross-sectional study from a Saudi University

Background:

Final-year medical students are soon to be physicians who are expected to have sufficient knowledge about a life-threatening condition such as diabetic ketoacidosis (DKA); thus, the present study aimed to evaluate awareness and knowledge of medical students about DKA in a large Saudi University.

Methods:

An online survey was conducted using a convenience sample of 81 participants aged 18 years and above from Jazan region, Saudi Arabia. Awareness and knowledge about DKA were assessed using a prestructured questionnaire. Statistical analysis using the Statistical Package of Social Sciences (SPSS) included descriptive studies and Chi-square or Fisher's exact test, with the significance level set at P value < 0.05.

Results:

A total of 81 valid responses were analyzed (85.3% response rate), of which 51.9% were males. The mean age was 23.06 (Standard deviation 1.66 years). Regarding basic information about diabetes mellitus, most of the respondents correctly answered questions related to the system involved in diabetes, classic symptoms, glycemic control test, and the meaning of postprandial blood sugar. Also, students had a good knowledge regarding DKA definition and management. However, inadequate knowledge was found regarding electrolyte disturbance in DKA (59% of males vs. 30.8% of females P = 0.014) and fluid replacement in DKA patients (P < 0.05).

Conclusion:

The present study revealed that students had a good knowledge regarding basic information about diabetes and DKA definition and management. Students’ knowledge was deficient regarding electrolyte disturbance and fluid replacement in DKA. Interventions using study seminars and workshops are warranted to increase knowledge about DKA among final-year medical students.

Association of Demographic Variables with the Awareness of Type 2 Diabetes Mellitus Patients (T2DM) among the Northwest Population in Saudi Arabia

The chronic hyperglycemia in diabetes is associated with long-term damage, dysfunction, and failure of different organs. Lack of patient education and knowledge about these complications can worsen the quality of a patient's life. Hence, more efforts are needed to improve patient's education especially in rural areas. Aim. Our objective is to explore the association between demographic variables and the knowledge of self-care practices in type 2 diabetes mellitus. Methods. We used observational cross-sectional descriptive study using a validated self-administered questionnaire in both Arabic and English languages as well. A descriptive correlation design analyzed the questionnaire completed by a convenience sample meeting the inclusion criteria. Results. A total of 100 patients met the inclusion criteria for the analysis out of 3251 patients who completed the questionnaire. The study population has low moderate knowledge in diabetes, moderate knowledge in self-care practices, and good knowledge about complications of nephropathy and cardiovascular disease. No significant association between demographic variables. However, better knowledge observed in male (p = 0.028) and self-care practices with female (p = 0.020). Further, educational status is significantly influencing the knowledge of diabetic patients. Conclusion. The study emphasizing irrespective of demographic variable and the importance of patient education to achieve well glycemic control.

Managing with Learning Disability and Diabetes: OK-Diabetes - a case-finding study and feasibility randomised controlled trial

BACKGROUND

Obesity and type 2 diabetes are common in adults with a learning disability. It is not known if the principles of self-management can be applied in this population.

OBJECTIVES

To develop and evaluate a case-finding method and undertake an observational study of adults with a learning disability and type 2 diabetes, to develop a standardised supported self-management (SSM) intervention and measure of adherence and to undertake a feasibility randomised controlled trial (RCT) of SSM versus treatment as usual (TAU).

DESIGN

Observational study and an individually randomised feasibility RCT.

SETTING

Three cities in West Yorkshire, UK.

PARTICIPANTS

In the observational study: adults aged > 18 years with a mild or moderate learning disability, who have type 2 diabetes that is not being treated with insulin and who are living in the community. Participants had mental capacity to consent to research and to the intervention. In the RCT participants had glycated haemoglobin (HbA_1c) levels of > 6.5% (48 mmol/mol), a body mass index (BMI) of > 25 kg/m² or self-reported physical activity below national guideline levels.

INTERVENTIONS

Standardised SSM. TAU supported by an easy-read booklet.

MAIN OUTCOME MEASURES

(1) The number of eligible participants identified and sources of referral; (2) current living and support arrangements; (3) current health state, including level of HbA_1c, BMI and waist circumference, blood pressure and lipids; (4) mood, preferences for change; (5) recruitment and retention in RCT; (6) implementation and adherence to the intervention; (7) completeness of data collection and values for candidate primary outcomes; and (8) qualitative data on participant experience of the research process and intervention.

RESULTS

In the observational study we identified 147 eligible consenting participants. The mean age was 54.4 years. In total, 130 out of 147 (88%) named a key supporter, with 113 supporters (77%) being involved in diabetes management. The mean HbA_1c level was 54.5 mmol/mol [standard deviation (SD) 14.8 mmol/mol; 7.1%, SD 1.4%]. The BMI of 65% of participants was > 30 kg/m² and of 21% was > 40 kg/m². Many participants reported low mood, dissatisfaction with lifestyle and diabetes management and an interest in change. Non-response rates were high (45/147, 31%) for medical data requested from the primary care team. In the RCT, 82 participants were randomised. The mean baseline HbA_1c level was 56 mmol/mol (SD 16.5 mmol/mol; 7.3%, SD 1.5%) and the mean BMI was 34 kg/m² (SD 7.6 kg/m²). All SSM sessions were completed by 35 out of 41 participants. The adherence measure was obtained in 37 out of 41 participants. The follow-up HbA_1c level and BMI was obtained for 75 out of 82 (91%) and 77 out of 82 (94%) participants, respectively. Most participants reported a positive experience of the intervention. A low response rate and difficulty understanding the EuroQol-5 Dimensions were challenges in obtaining data for an economic analysis.

LIMITATIONS

We recruited from only 60% of eligible general practices, and 90% of participants were on a general practice learning disability register, which meant that we did not recruit many participants from the wider population with milder learning disability.

CONCLUSIONS

A definitive RCT is feasible and would need to recruit 194 participants per arm. The main barrier is the resource-intensive nature of recruitment. Future research is needed into the effectiveness of obesity treatments in this population, particularly estimating the longer-term outcomes that are important for health benefit. Research is also needed into improving ways of assessing quality of life in adults with a learning disability.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41897033.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 26. See the NIHR Journals Library website for further project information.

Knowledge and awareness of diabetes mellitus and its risk factors in Saudi Arabia

OBJECTIVES

To summarize available peer-reviewed publications about public knowledge and awareness of diabetes mellitus (DM) among the population of Saudi Arabia.

METHODS

We followed the standard reporting guidelines outlined in the PRISMA statement for the preparation of this systematic review. In February 2018 we conducted literature searches of PubMed, Scopus, BIOSIS Citation Index, and Web of Science using the following keywords: "Knowledge" OR "Awareness" AND "Diabetes Mellitus" AND "Saudi Arabia." Records were screened, and relevant studies were selected and synthesized narratively.

RESULTS

Nineteen articles are included in our systematic review. These studies included the following populations: DM patients (n=13), healthcare workers (n=3), medical students (n=1), secondary school students (n=1), and general population (n=1). Most studies found a lack of public awareness of the risk factors and complications of DM. Among medical students and healthcare workers, knowledge about the epidemiology of the disease and angle of insulin injection was deficient.

CONCLUSION

This review highlights the need for increased knowledge and awareness of DM among the Saudi population. The means of improving knowledge and awareness of DM needs to be integrated into existing healthcare systems and processes to better inform patients, families and communities about this chronic disease.

Development of a supported self-management intervention for adults with type 2 diabetes and a learning disability

BACKGROUND

Although supported self-management is a well-recognised part of chronic disease management, it has not been routinely used as part of healthcare for adults with a learning disability. We developed an intervention for adults with a mild or moderate learning disability and type 2 diabetes, building on the principles of supported self-management with reasonable adjustments made for the target population.

METHODS

In five steps, we:Clarified the principles of supported self-management as reported in the published literatureIdentified the barriers to effective self-management of type 2 diabetes in adults with a learning disabilityReviewed existing materials that aim to support self-management of diabetes for people with a learning disabilitySynthesised the outputs from the first three phases and identified elements of supported self-management that were (a) most relevant to the needs of our target population and (b) most likely to be acceptable and useful to themImplemented and field tested the intervention.

RESULTS

The final intervention had four standardised components: (1) establishing the participant's daily routines and lifestyle, (2) identifying supporters and their roles, (3) using this information to inform setting realistic goals and providing materials to the patient and supporter to help them be achieved and (4) monitoring progress against goals.Of 41 people randomised in a feasibility RCT, thirty five (85%) completed the intervention sessions, with over three quarters of all participants (78%) attending at least three sessions.Twenty-three out of 40 (58%) participants were deemed to be very engaged with the sessions and 12/40 (30%) with the materials; 30 (73%) participants had another person present with them during at least one of their sessions; 15/41 (37%) were reported to have a very engaged main supporter, and 18/41 (44%) had a different person who was not their main supporter but who was engaged in the intervention implementation.

CONCLUSIONS

The intervention was feasible to deliver and, as judged by participation and engagement, acceptable to participants and those who supported them.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41897033 (registered 21/01/2013).

Development of an acceptable and feasible self-management group for children, young people and families living with Type 1 diabetes

AIMS

This study developed an acceptable and feasible self-management intervention that addresses the self-identified needs of children and young people with Type 1 diabetes and their parents.

METHODS

Phase 1 reviewed previous interventions and interviewed the clinical team, young people and families. Phase 2 ran three age-matched focus groups with 11 families of children aged 8-16 years. Feedback was used to modify the workshop. Phase 3 evaluated feasibility of delivery, as well as the effects on metabolic control, quality of life and fear of hypoglycaemia, measured at baseline and 1-3 months post intervention.

RESULTS

Eighty-nine families were invited to take part. Twenty-two (25%) participated in seven pilot groups (median age of young people 10 years, 36% girls). The intervention comprised a developmentally appropriate workshop for young people and parents addressing: (1) blood glucose control, (2) the potential impact of long-term high HbA_1c , (3) the effects of 'hypos' and 'hypers', (4) self-management techniques and (5) talking confidently to people about diabetes. Participants were enthusiastic and positive about the workshop and would recommend it to others. Young people liked sharing ideas and meeting others with diabetes, while parents enjoyed listening to their children talk about their diabetes knowledge.

CONCLUSIONS

Families living with Type 1 diabetes participated in developing a self-management group intervention. Although we demonstrated acceptability and feasibility, the pilot study results do not support the development of a randomized control trial to evaluate the effectiveness in improving HbA_1c .

Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy?

There is extensive health and public health literature on the ‘evidence-policy gap’, exploring the frustrating experiences of scientists trying to secure a response to the problems and solutions they raise and identifying the need for better evidence to reduce policymaker uncertainty. We offer a new perspective by using policy theory to propose research with greater impact, identifying the need to use persuasion to reduce ambiguity, and to adapt to multi-level policymaking systems.

We identify insights from secondary data, namely systematic reviews, critical analysis and policy theories relevant to evidence-based policymaking. The studies are drawn primarily from countries such as the United States, United Kingdom, Canada, Australia and New Zealand. We combine empirical and normative elements to identify the ways in which scientists can, do and could influence policy.

We identify two important dilemmas, for scientists and researchers, that arise from our initial advice. First, effective actors combine evidence with manipulative emotional appeals to influence the policy agenda – should scientists do the same, or would the reputational costs outweigh the policy benefits? Second, when adapting to multi-level policymaking, should scientists prioritise ‘evidence-based’ policymaking above other factors? The latter includes governance principles such the ‘co-production’ of policy between local public bodies, interest groups and service users. This process may be based primarily on values and involve actors with no commitment to a hierarchy of evidence.

We conclude that successful engagement in ‘evidence-based policymaking’ requires pragmatism, combining scientific evidence with governance principles, and persuasion to translate complex evidence into simple stories. To maximise the use of scientific evidence in health and public health policy, researchers should recognise the tendency of policymakers to base judgements on their beliefs, and shortcuts based on their emotions and familiarity with information; learn ‘where the action is’, and be prepared to engage in long-term strategies to be able to influence policy; and, in both cases, decide how far you are willing to go to persuade policymakers to act and secure a hierarchy of evidence underpinning policy. These are value-driven and political, not just ‘evidence-based’, choices.

Effectiveness of a structured educational intervention using psychological delivery methods in children and adolescents with poorly controlled type 1 diabetes: a cluster-randomized controlled trial of the CASCADE intervention

INTRODUCTION

Type 1 diabetes (T1D) in children and adolescents is increasing worldwide with a particular increase in children <5 years. Fewer than 1 in 6 children and adolescents achieve recommended glycated hemoglobin (HbA1c) values.

METHODS

A pragmatic, cluster-randomized controlled trial assessed the efficacy of a clinic-based structured educational group incorporating psychological approaches to improve long-term glycemic control, quality of life and psychosocial functioning in children and adolescents with T1D. 28 pediatric diabetes services were randomized to deliver the intervention or standard care. 362 children (8-16 years) with HbA1c≥8.5% were recruited. Outcomes were HbA1c at 12 and 24 months, hypoglycemia, admissions, self-management skills, intervention compliance, emotional and behavioral adjustment, and quality of life. A process evaluation collected data from key stakeholder groups in order to evaluate the feasibility of delivering the intervention.

RESULTS

298/362 patients (82.3%) provided HbA1c at 12 months and 284/362 (78.5%) at 24 months. The intervention did not improve HbA1c at 12 months (intervention effect 0.11, 95% CI -0.28 to 0.50, p=0.584), or 24 months (intervention effect 0.03, 95% CI -0.36 to 0.41, p=0.891). There were no significant changes in remaining outcomes. 96/180 (53%) families in the intervention arm attended at least 1 module. The number of modules attended did not affect outcome. Reasons for low uptake included difficulties organizing groups and work and school commitments. Those with highest HbA1cs were less likely to attend. Mean cost of the intervention was £683 per child.

CONCLUSIONS

Significant challenges in the delivery of a structured education intervention using psychological techniques to enhance engagement and behavior change delivered by diabetes nurses and dietitians in routine clinical practice were found. The intervention did not improve HbA1c in children and adolescents with poor control.

TRIAL REGISTRATION NUMBER

ISRCTN52537669, results.

Effectiveness of diabetes education and awareness of diabetes mellitus in combating diabetes in the United Kigdom; a literature review

Diabetes mellitus is a metabolic disorder that is characterized by high blood glucose level, and body cannot produce enough insulin, or does not respond to the produced insulin. In spite of the diabetes education campaigns and programmes, a large number of people in the United Kingdom are living with diabetes. The main objective of the study is to evaluate the role of knowledge and awareness of diabetes in fighting against diabetes and to interpret to which extent is diabetes education successful. The systematic review to be carried out will include literature from 2001 to 2011 in the United Kingdom regarding awareness of diabetes among UK population and effectiveness of diabetes education. Literature will be accessed using search database, British medical journals, and library. Good quality papers will be used for the systematic review. Previous studies about diabetes education will consulted and assessed. This study is going to summarize the efficacy of diabetes education campaigns and programmes which are promising to enhance the awareness The outcome of the review will be the guideline for the government, education centres, researchers, and campaigns to implement more diabetic education programmes and easily accessible diabetes services and education interventions to increase the awareness of risk factors and complications of diabetes to overcome the increasing epidemic of diabetes in the United Kingdom.

Implementing a structured education program for children with diabetes: lessons learnt from an integrated process evaluation

BACKGROUND

There is recognition of an urgent need for clinic-based interventions for young people with type 1 diabetes mellitus that improve glycemic control and quality of life. The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) is a structured educational group program, using psychological techniques, delivered primarily by diabetes nurses. Composed of four modules, it is designed for children with poor diabetic control and their parents. A mixed methods process evaluation, embedded within a cluster randomized control trial, aimed to assess the feasibility, acceptability, fidelity, and perceived impact of CASCADE.

METHODS

28 pediatric diabetes clinics across England participated and 362 children aged 8-16 years, with type 1 diabetes and a mean glycosylated hemoglobin (HbA1c) of 8.5 or above, took part. The process evaluation used a wide range of research methods.

RESULTS

Of the 180 families in the intervention group, only 55 (30%) received the full program with 53% attending at least one module. Only 68% of possible groups were run. Staff found organizing the groups burdensome in terms of arranging suitable dates/times and satisfactory group composition. Some staff also reported difficulties in mastering the psychological techniques. Uptake, by families, was influenced by the number of groups run and by school, work and other commitments. Attendees described improved: family relationships; knowledge and understanding; confidence; motivation to manage the disease. The results of the trial showed that the intervention did not significantly improve HbA1c at 12 or 24 months.

CONCLUSIONS

Clinic-based structured group education delivered by staff using psychological techniques had perceived benefits for parents and young people. Staff and families considered it a valuable intervention, yet uptake was poor and the burden on staff was high. Recommendations are made to inform issues related to organization, design, and delivery in order to potentially enhance the impact of CASCADE and future programs.

CURRENT CONTROLLED TRIALS

ISRCTN52537669.

An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings

BACKGROUND

Type 1 diabetes occurs more frequently in younger children who are often pre-school age and enter the education system with diabetes-related support needs that evolve over time. It is important that children are supported to optimally manage their diet, exercise, blood glucose monitoring and insulin regime at school. Young people self-manage at college/university.

METHOD

Theory-informed mixed-method systematic review to determine intervention effectiveness and synthesise child/parent/professional views of barriers and facilitators to achieving optimal diabetes self-care and management for children and young people age 3-25 years in educational settings.

RESULTS

Eleven intervention and 55 views studies were included. Meta-analysis was not possible. Study foci broadly matched school diabetes guidance. Intervention studies were limited to specific contexts with mostly high risk of bias. Views studies were mostly moderate quality with common transferrable findings.Health plans, and school nurse support (various types) were effective. Telemedicine in school was effective for individual case management. Most educational interventions to increase knowledge and confidence of children or school staff had significant short-term effects but longer follow-up is required. Children, parents and staff said they struggled with many common structural, organisational, educational and attitudinal school barriers. Aspects of school guidance had not been generally implemented (e.g. individual health plans). Children recognized and appreciated school staff who were trained and confident in supporting diabetes management.Research with college/university students was lacking. Campus-based college/university student support significantly improved knowledge, attitudes and diabetes self-care. Self-management was easier for students who juggled diabetes-management with student lifestyle, such as adopting strategies to manage alcohol consumption.

CONCLUSION

This novel mixed-method systematic review is the first to integrate intervention effectiveness with views of children/parents/professionals mapped against school diabetes guidelines. Diabetes management could be generally improved by fully implementing and auditing guideline impact. Evidence is limited by quality and there are gaps in knowledge of what works. Telemedicine between healthcare providers and schools, and school nurse support for children is effective in specific contexts, but not all education systems employ onsite nurses. More innovative and sustainable solutions and robust evaluations are required. Comprehensive lifestyle approaches for college/university students warrant further development and evaluation.

Developing and evaluating a child-centred intervention for diabetes medicine management using mixed methods and a multicentre randomised controlled trial

Aim

To develop and evaluate an individually tailored age-appropriate diabetes diary and information pack for children and young people aged 6–18 years with type 1 diabetes to support decision-making and self-care with a specific focus on insulin management and blood glucose monitoring, compared with available resources in routine clinical practice.

Design

Four-stage study following the Medical Research Council framework for designing and evaluating complex interventions. Stage 1: context – brief review of reviews and mixed-method systematic review; updating of database of children’s diabetes information; children’s diabetes information quality assessment and diabetes guideline analysis; and critical discourse analysis. Stage 2: intervention development – working with expert clinical advisory group; contextual qualitative interviews and focus groups with children and young people to ascertain their information preferences and self-care practices; ongoing consultation with children; development of intervention programme theory. Stage 3: randomised controlled trial (RCT) to evaluate the diabetes diaries and information packs in routine practice. Stage 4: process evaluation.

Findings

The RCT achieved 100% recruitment, was adequately powered and showed that the Evidence into Practice Information Counts (EPIC) packs and diabetes diaries were no more effective than receiving diabetes information in an ad hoc way. The cost per unit of producing the EPIC packs and diabetes diaries was low. Compared with treatment as usual information, the EPIC packs fulfilled all NHS policy imperatives that children and young people should receive high-quality, accurate and age-appropriate information about their condition, self-management and wider lifestyle and well-being issues. Diabetes guidelines recommend the use of a daily diabetes diary and EPIC diaries fill a gap in current provision. Irrespective of allocation, children and young people had a range of recorded glycated haemoglobin (HbA1c) levels, which showed that as a group their diabetes self-management would generally need to improve to achieve the HbA1clevels recommended in National Institute for Health and Care Excellence guidance. The process evaluation showed that promotion of the EPIC packs and diaries by diabetes professionals at randomisation did not happen as intended; the dominant ‘normalisation’ theory underpinning children’s diabetes information may be counterproductive; risk and long-term complications did not feature highly in children’s diabetes information; and children and young people engaged in risky behaviour and appeared not to care, and most did not use a diabetes diary or did not use the information to titrate their insulin as intended.

Limitations

Recruitment of ‘hard to reach’ children and young people living away from their families was not successful. The findings are therefore more relevant to diabetes management within a family context.

Conclusions

The findings indicate a need to rethink context and the hierarchical relationships between children, young people, parents and diabetes professionals with regard to ‘partnership and participation’ in diabetes decision-making, self-care and self-management. Additional research, implementation strategies and service redesign are needed to translate available information into optimal self-management knowledge and subsequent optimal diabetes self-management action, including to better understand the disconnection between children’s diabetes texts and context; develop age-appropriate Apps/e-records for recording blood glucose measurements and insulin management; develop interventions to reduce risk-taking behaviour by children and young people in relation to their diabetes management; reconsider what could work to optimise children’s self-management of diabetes; understand how best to reorganise current diabetes services for children to optimise child-centred delivery of children’s diabetes information.

Study registration

Current Controlled Trials ISRCTN17551624.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The lived experiences of young people (13-16 years) with Type 1 diabetes mellitus and their parents--a qualitative phenomenological study

AIMS

Within a programme of research aiming to develop a technology-based educational intervention for young people with Type 1 diabetes, this study aimed to explore adolescents' and parents' experiences of living with Type 1 diabetes from an interpretive phenomenological perspective.

METHODS

In-depth interviews were conducted with 20 adolescents with Type 1 diabetes from a diabetes clinic in North West England, and 27 of their parents.

RESULTS

Living with Type 1 diabetes in adolescence was characterized by three distinct stages: (1) adapting to the diagnosis; (2) learning to live with Type 1 diabetes; (3) becoming independent. Experiential learning was key to adolescents developing self-management skills and independence. Parents and health professionals were instrumental in facilitating environments that gave adolescents the freedom to learn through trial and error. They also provided the support, feedback and discussion necessary to facilitate such learning.

CONCLUSIONS

For adolescents to become independent in Type 1 diabetes self-management, they must develop capability through experiential learning. It is important that parents and health professionals understand the important role they play in this process and have the skills to support adolescents in this way. Data from this study have been used to develop an online interactive 'Adolescent Diabetes Needs Assessment Tool', which assesses individual learning and support needs to aid the process of feedback and discussion.