Supporting self-management after attending a structured education programme: a qualitative longitudinal investigation of type 1 diabetes patients' experiences and views

From educator to facilitator: Healthcare professionals' experiences of, and views about, delivering a type 1 diabetes structured education programme (DAFNEplus ) informed by behavioural science

AIMS

The DAFNEplus programme incorporates behaviour change techniques into a modified educational intervention and was developed to help address the glycaemic drift observed amongst graduates of standard DAFNE programmes. As the programme's success will be contingent on staff buy-in, we explored healthcare professionals' experiences of, and views about, delivering DAFNEplus during a clinical trial to help inform decision making about rollout post-trial.

METHODS

We interviewed n = 18 nurses and dieticians who delivered DAFNEplus during the trial. Data were analysed thematically.

RESULTS

While many shared initial reservations, all described how their experiences of DAFNEplus programme delivery had had a positive, transformative impact upon their perceptions and working practices. This transformation was enabled by initial training and supervision sessions, the confidence gained from using scripts to support novel programme content delivery, and experiences of delivering the programme and observing DAFNEplus principles being well received by, and having a positive impact on, attendees. Due to these positive experiences, interviewees described a strongly felt ethical mandate to use some DAFNEplus techniques and curriculum content in routine clinical care. While being supportive of a national rollout, they anticipated a variety of attitudinal and logistical (e.g. workload) challenges.

CONCLUSIONS

This study provides a vital dimension to the evaluation of the DAFNEplus programme. Interviewees found the intervention to be acceptable and expressed high levels of buy-in. As well as offering potential endorsement for a national rollout, our findings offer insights which could help inform development and rollout of future behaviour change interventions to support diabetes self-management.

Participants' experiences of attending a structured education course (DAFNEplus) informed by behavioural science

AIMS

As part of a broader process evaluation, we explored participants' experiences of, and engagement with, the DAFNEplus programme's group-based structured education course. This course, which was informed by behavioural science, provided participants with education and instruction to use flexible intensive insulin therapy (FIIT) together with techniques to identify and address unhelpful cognitive and emotional influences on their type 1 diabetes self-management.

METHODS

We interviewed n = 28 DAFNEplus participants. Data were analysed thematically and took account of previous work exploring individuals' experiences of standard DAFNE courses.

RESULTS

As well as benefitting from the DAFNEplus course's skills-based training and educational curriculum, participants' accounts suggested they had experienced cognitive and emotional changes that had positively influenced their confidence and motivation to adopt and sustain the use of FIIT. These benefits were most keenly felt by those who reported negative emotional states and mind-sets pre-course which had made their diabetes self-management challenging. Participants' cognitive and emotional changes were enabled through techniques used during the course to normalise setbacks and imperfect diabetes self-management, capitalise upon group synergies and encourage the use of social support, including from healthcare professionals. Participants also highlighted motivational gains arising from being reassured that diabetes complications are not common or inevitable if a FIIT regimen is followed.

CONCLUSIONS

Our findings suggest that offering training in FIIT, in conjunction with behaviour change techniques that target unhelpful mindsets and emotional resilience, may be more effective in promoting diabetes self-management than offering education and skills training alone.

Sustaining the benefits of structured education: Participants' experiences of receiving structured individual support during a programme (DAFNEplus) informed by behavioural science

AIMS

The DAFNEplus programme seeks to promote sustained improvements in glycaemic management by incorporating techniques from behavioural science. It includes five sessions of structured individual support delivered over 12 months following group education. As part of a broader evaluation, and to inform decision-making about roll-out in routine care, we explored participants' experiences of, and engagement with, that individual support.

METHODS

We interviewed DAFNEplus participants (n = 28) about their experiences of receiving individual support and the impact they perceived it as having on their self management practices. We analysed data thematically.

RESULTS

Participants described several important ways individual support had helped strengthen their self management, including: consolidating and expanding their understandings of flexible intensive insulin therapy; promoting ongoing review and refinement of behaviour; encouraging continued and effective use of data; and facilitating access to help from healthcare professionals to pre-empt or resolve emergent difficulties. Participants characterised themselves as moving towards independence in self management over the time they received individual support, with their accounts suggesting three key stages in that journey: 'Working with healthcare professionals'; 'Growing sense of responsibility'; and, 'Taking control'. Whilst all portrayed themselves as changed, participants' progress through those stages varied; a few continued to depend heavily on DAFNEplus facilitators for advice and/or direction at 12 months.

CONCLUSIONS

While all participants benefited from individual support, our findings suggest that some may need, or gain further benefit from, longer-term, tailored support. This has important implications for decision-making about roll-out of DAFNEplus post-trial and for the development of future programmes seeking to bring about sustainable changes in self management practices.

Exploring Technology's Influence on Health Behaviours and Well-being in Type 1 Diabetes: a Review

PURPOSE OF REVIEW

Maintaining positive health behaviours promotes better health outcomes for people with type 1 diabetes (T1D). However, implementing these behaviours may also lead to additional management burdens and challenges. Diabetes technologies, including continuous glucose monitoring systems, automated insulin delivery systems, and digital platforms, are being rapidly developed and widely used to reduce these burdens. Our aim was to review recent evidence to explore the influence of these technologies on health behaviours and well-being among adults with T1D and discuss future directions.

RECENT FINDINGS

Current evidence, albeit limited, suggests that technologies applied in diabetes self-management education and support (DSME/S), nutrition, physical activity (PA), and psychosocial care areas improved glucose outcomes. They may also increase flexibility in insulin adjustment and eating behaviours, reduce carb counting burden, increase confidence in PA, and reduce mental burden. Technologies have the potential to promote health behaviours changes and well-being for people with T1D. More confirmative studies on their effectiveness and safety are needed to ensure optimal integration in standard care practices.

Prevalence and risk factors for diabetic foot complications among people living with diabetes in Harare, Zimbabwe: a cross-sectional study

BACKGROUND

Diabetic foot disease (DF) is a common diabetes-related complication; however, the prevalence and associated risk factors for DF are not well characterised among people living with diabetes (PLWD) in Zimbabwe. This may suggest the unavailability of adequate strategies to diagnose and treat DF in the country. This study aimed to determine the prevalence of DF and associated risk factors for PLWD in Harare, Zimbabwe.

METHODS

This was a cross-sectional study, employing a quantitative approach. In total, 352 PLWD were recruited from 16 primary care clinics in Harare. Sociodemographic and clinical data were collected via face-to-face interviews and clinical records reviews. The DF screening included an evaluation for peripheral neuropathy, ankle-brachial index (ABI), ulceration, and amputation. Self-administered questionnaires were used to assess knowledge, attitudes, and practices (KAPs), and KAP was scored using Bloom's cut-off. Chi-Square goodness-of-fit tests were performed, and regression analyses were used for association analysis. The threshold for significance was p < 0.05.

RESULTS

This group included 82 men and 279 women, with a combined mean age of 57.9 ± 14 years. Twenty one (~ 26%) men and 41 (15%) women had type 1 diabetes. The diabetes type distribution significantly differed by gender (p < 0.001). Oral hypoglycaemics (71%) were most commonly administered for management. DF was observed in 53% (95% CI = 50-56) of PLWD. Other DF symptoms observed were abnormal ABI (53%), peripheral neuropathy (53%), foot ulceration (17%) and amputation (3%). Peripheral neuropathy increased the risk of ulceration (OR = 1.7; 95% CI = 1.1-2.6; p = 0.019), while insulin use was protective against amputation (OR = 0.1; 95% CI = 0.1-0.9; p = 0.049). Most (87%) of the participants demonstrated good DF knowledge and the importance of adhering to medication to prevent DF. However, 96% did not know that smoking was a risk factor for DF. Nearly two-thirds (63%) demonstrated poor attitudes and practices. Poor attitudes and practices were not predictors of DF ulceration risk (p > 0.05).

CONCLUSION

This study showed that there was a high prevalence of DF (53%) in PLWD in Zimbabwe, and insulin use was protective against DF. There is an urgent need for policy revisions to include foot screening in routine primary care and increasing insulin use for PLWD to prevent complications such as DF as an integral part of primary care.

Development of the Support self-guided, web application for adults living with type 1 diabetes in Canada by a multi-disciplinary team using a people-oriented approach based on the Behaviour Change Wheel

Background

Diabetes self-management education and support (DSME/S) are central in type 1 diabetes (T1D) where individuals are responsible for 95% of care. In-person DSME/S programs have been proven clinically effective (e.g. optimizing glycemic management, improving diabetes-related behaviors) but are limited by a lack of accessibility and long-term follow-up. Self-guided digital tools such as web applications (web apps) can be an alternative for delivering DSME/S.

Objective

This article describes the development of Support, a behavioral theory-based, self-guided, web application for adults living with T1D in the province of Quebec, Canada.

Methods

A multi-disciplinary team developed Support. Patient partners first proposed its focus, learning topics, and expressed barriers to using digital tools for DSME/S. These barriers were analyzed based on the Behaviour Change Wheel. A group of healthcare professionals (HCPs) drafted the evidence-based learning content which was reviewed by external HCPs and by patient partners.

Results

Support is a bilingual (English and French) web app accessible at any time via the Internet. It has four learning paths focusing on hypoglycemia and based on the user's method of diabetes treatment. Learning modules are divided into six categories with a maximum of three learning levels. It contains features such as a discussion forum, videos, and quizzes to ensure interactivity, provide social support, and maintain the motivation and long-term engagement of users.

Conclusions

To the best of the authors' knowledge, Support is the first self-guided evidence-based web app for adults living with T1D. It is currently under study to evaluate its feasibility and clinical impacts.

Factors Affecting the Reception of Self-Management Health Education: A Cross-Sectional Survey Assessing Perspectives of Lower-Income Seniors with Cardiovascular Conditions

INTRODUCTION

Self-management education and support (SMES) programs can prevent adverse chronic disease outcomes, but factors modifying their reception remain relatively unexplored. We examined how perceptions of an SMES program were influenced by the mode of delivery, and co-receipt of a paired financial benefit.

METHODS AND PATIENTS

Using a cross-sectional survey, we evaluated the perceived helpfulness of a SMES program among 446 low-income seniors at high risk for cardiovascular events in Alberta, Canada. Secondary outcomes included frequency of use, changes in perspectives on health, satisfaction with the program, and comprehensibility of the material. Participants received surveys after engaging with the program for at least 6 months. We used modified Poisson regression to calculate relative risks. Open-ended questions were analyzed inductively.

RESULTS

The majority of participants reported that the SMES program was helpful (>80%). Those who also received the financial benefit (elimination of medication copayments) were more likely to report that the SMES program was helpful (RR 1.24, 95% CI 1.11-1.39). Those who received the program electronically were more likely to use the program weekly (RR 1.51, 1.25-1.84). Both those who received the intervention electronically (RR 1.18, 1.06-1.33), and those who also received copayment elimination (RR 1.17, 1.05-1.31) were more likely to state that the program helped change their perspectives on health.

CONCLUSION

When designing SMES programs, providing the option for electronic delivery appears to promote greater use for seniors. The inclusion of online-delivery and co-receipt of tangible benefits when designing an SMES program for seniors results in favorable reception and could facilitate sustained adherence to health behavior recommendations. Participants also specifically expressed that what they enjoyed most was that the SMES program was informative, helpful, engaging, and supportive.

Perspectives of patients with chronic pain about a pain science education video

Purpose: Patients have responded in variable ways to pain science education about the psychosocial correlates of pain. To improve the effectiveness of pain education approaches, this study qualitatively explored participants' perceptions of and responses to pain science education.Methods: We conducted a qualitative content analysis of interviews with fifteen, adult patients (73.3% female) who had recently attended a first visit to a chronic pain clinic and watched a pain science educational video.Results: Participants thought it was important to improve their and healthcare providers' understanding of their pain. They viewed the video favorably, learned information from it, and thought it could feasibly facilitate communication with their healthcare providers, but, for many participants, the video either did not answer their questions and/or raised more questions. Participants' responses to the video included negative and positive emotions and were influenced by their need for confirmation that their pain was real and personal relevance of the pain science content.Conclusion: Study results support the feasibility and value of delivering pain science education via video and increase our understanding of patients' perceptions of and responses to pain science education. The video's triggering of emotional responses warrants additional research.

The DAFNEplus programme for sustained type 1 diabetes self management: Intervention development using the Behaviour Change Wheel

AIMS

Self-management programmes for type 1 diabetes, such as the UK's Dose Adjustment for Normal Eating (DAFNE), improve short-term clinical outcomes but difficulties maintaining behavioural changes attenuate long-term impact. This study used the Behaviour Change Wheel (BCW) framework to revise the DAFNE intervention to support sustained behaviour change.

METHODS

A four-step method was based on the BCW intervention development approach: (1) Identifying self-management behaviours and barriers/enablers to maintain them via stakeholder consultation and evidence synthesis, and mapping barriers/enablers to the Capability, Opportunity, Motivation-Behaviour (COM-B) model. (2) Specifying behaviour change techniques (BCTs) in the existing DAFNE intervention using the Behaviour Change Techniques Taxonomy (BCTTv1). (3) Identifying additional BCTs to target the barriers/enablers using the BCW and BCTTv1. (4) Parallel stakeholder consultation to generate recommendations for intervention revision. Revised materials were co-designed by stakeholders (diabetologists, psychologists, specialist nurses and dieticians).

RESULTS

In all, 34 barriers and 5 enablers to sustaining self-management post-DAFNE were identified. The existing DAFNE intervention contained 24 BCTs, which partially addressed the enablers. In all, 27 BCTs were added, including 'Habit formation', 'Credible source' and 'Conserving mental resources'. In total, 15 stakeholder-agreed recommendations for content and delivery were incorporated into the final DAFNEplus intervention, comprising three co-designed components: (1) face-to-face group learning course, (2) individual structured follow-up sessions and (3) technological support, including blood glucose data management.

CONCLUSIONS

This method provided a systematic approach to specifying and revising a behaviour change intervention incorporating stakeholder input. The revised DAFNEplus intervention aims to support the maintenance of behavioural changes by targeting barriers and enablers to sustaining self-management behaviours.

Protocol for a cluster randomised controlled trial of the DAFNEplus (Dose Adjustment For Normal Eating) intervention compared with 5x1 DAFNE: a lifelong approach to promote effective self-management in adults with type 1 diabetes

INTRODUCTION

The successful treatment of type 1 diabetes (T1D) requires those affected to employ insulin therapy to maintain their blood glucose levels as close to normal to avoid complications in the long-term. The Dose Adjustment For Normal Eating (DAFNE) intervention is a group education course designed to help adults with T1D develop and sustain the complex self-management skills needed to adjust insulin in everyday life. It leads to improved glucose levels in the short term (manifest by falls in glycated haemoglobin, HbA1c), reduced rates of hypoglycaemia and sustained improvements in quality of life but overall glucose levels remain well above national targets. The DAFNEplus intervention is a development of DAFNE designed to incorporate behavioural change techniques, technology and longer-term structured support from healthcare professionals (HCPs).

METHODS AND ANALYSIS

A pragmatic cluster randomised controlled trial in adults with T1D, delivered in diabetes centres in National Health Service secondary care hospitals in the UK. Centres will be randomised on a 1:1 basis to standard DAFNE or DAFNEplus. Primary clinical outcome is the change in HbA1c and the primary endpoint is HbA1c at 12 months, in those entering the trial with HbA1c >7.5% (58 mmol/mol), and HbA1c at 6 months is the secondary endpoint. Sample size is 662 participants (approximately 47 per centre); 92% power to detect a 0.5% difference in the primary outcome of HbA1c between treatment groups. The trial also measures rates of hypoglycaemia, psychological outcomes, an economic evaluation and process evaluation.

ETHICS AND DISSEMINATION

Ethics approval was granted by South West-Exeter Research Ethics Committee (REC ref: 18/SW/0100) on 14 May 2018. The results of the trial will be published in a National Institute for Health Research monograph and relevant high-impact journals.

TRIAL REGISTRATION NUMBER

ISRCTN42908016.

Satisfaction and experiences of patients taking fingolimod and involved in a pharmacy-based patient support program in Switzerland - a qualitative study

BACKGROUND

Fingolimod is an oral multiple sclerosis drug that is considered a specialty drug due to its high cost and safety issues. The Fingolimod Patient Support Program (F-PSP) is a specialty pharmacy service developed to ensure the responsible use of fingolimod by promoting patient safety and medication adherence. This study aims to explore the satisfaction, experiences and perceptions regarding the F-PSP among patients currently involved in this program or recently withdrawn.

METHODS

A qualitative study was conducted via individual, face-to-face semistructured interviews with patients involved in the F-PSP. The interviews were audio-recorded, transcribed verbatim, coded and analyzed via thematic content analysis.

RESULTS

The main themes identified from the interviews (n = 17) were overall perception of the F-PSP, perception of the pharmacist-led consultations, perception of the tools (electronic monitor and drug intake graph), reasons to participate or potentially withdraw, and suggestions for improvements. Participants perceived the F-PSP as a reassuring support that complemented their medical care, providing a more human, personalized and person-centered approach than usual pharmacy care. Pharmacist-led consultations were valued for the medication-related and holistic support they provided. The importance of the pharmacist's attitude was emphasized. The electronic monitor was valued for promoting daily medication adherence and allowing the involvement of relatives, which reassured participants and their relatives. The participants appreciated the drug intake graph because it provided an objective overview of medication adherence, thereby reassuring, rewarding, and motivating them. The main reason to join the program was to be supported, especially with respect to medication adherence.

CONCLUSIONS

Participants were satisfied with the F-PSP, each for different reasons. Their feedback enabled the identification of measures for the optimization of the F-PSP and should facilitate its dissemination and transfer to other drugs/diseases/populations. Essential elements of generic pharmacist-led patient support programs considered valuable from the patients' perspective were identified.

Diabetes of the Exocrine Pancreas Related to Hereditary Pancreatitis, an Update

PURPOSE OF REVIEW

The aim was to review evidence about diabetes secondary to hereditary pancreatitis, seeking novel diagnostic and treatment features.

RECENT FINDINGS

Hereditary pancreatitis (HP) is an autosomal dominant condition, characterized by recurrent episodes of acute pancreatitis, progression to fibrosis, and chronic pancreatitis. Clinical presentation includes diabetes of the exocrine pancreas (DEP). HP prevalence ranges from 0.3 to 0.57 per 100,000 people, with up to 80% of these develop DEP. This condition often requires specific interventions: with regard to metabolic control, metformin is the first choice for those with mild DEP, and for those in advanced disease, insulin is considered the first-line therapy. Insulin analogues and insulin pump therapy are preferred due to the brittle glycemic pattern and risk of hypoglycemia. In case of exocrine insufficiency, pancreatic enzyme replacement therapy is recommended. Pancreatic polypeptide administration is a promising novel treatment feature. DEP due to HP appears to be a misdiagnosed condition. The requirement of specific management demonstrates the importance of this matter; therefore, appropriate recognition and classification are important.

PoDFEd: Podiatrists and Diabetes Footcare Education Survey - How do Australian podiatrists provide diabetes education?

BACKGROUND

Podiatrists provide care and education to people with diabetes. This often includes the use of education relating to complications of the disease and how to prevent them. It is currently unknown how Australian podiatrists provide this education. This study aimed to describe the foot related diabetes education being delivered to people with diabetes within the Australian podiatry setting.

METHODS

This cross-sectional cohort study contacted Australian podiatrists to complete an online survey regarding their provision of diabetes education. The Qualtrics online survey application was advertised to Australian podiatrists via social media, at state conferences and through the Australian Podiatry Association and other similar association group emails. A multivariate stepwise progression was utilised to collate and decipher data. A chi-squared test was used to determine significant links between podiatrist's method of education, demographic variables and topics of education.

RESULTS

Findings linked the use of visual, written, generic handout and individualised handouts to various components of education and demographic information of Australian podiatrists. Verbal education had no significant links to demographic and topics of education relating to diabetes.

CONCLUSIONS

This paper discovered a range of topics covered and methods used by Australian podiatrists during consultations with patients with diabetes.

Experiences of Attending Group Education to Support Insulin Initiation in Type 2 Diabetes: A Qualitative Study

INTRODUCTION

Type 2 diabetes is a progressive condition and many people require insulin therapy 5-10 years post diagnosis. Considering the global increase in type 2 diabetes, group education programmes to initiate insulin are beneficial as they are cost-effective and provide peer support. However, group education to initiate insulin has not been widely evaluated and there is a need to elicit the views and experience of people with type 2 diabetes who start insulin in groups. The aim of this study was to explore the perspectives of people with type 2 diabetes who receive nurse-led group-based insulin education.

METHODS

Qualitative, semi-structured interviews of people with type 2 diabetes in south London, UK, who had attended group education sessions to start insulin. Inductive thematic analysis identified themes within the data.

RESULTS

Fifteen people with type 2 diabetes were interviewed. Three main themes were identified: creating a supportive environment; facilitator skills; and effectiveness of group. Factors which created a supportive environment included peer support, providing reassurance and printed materials. Facilitator skills associated with positive experiences included addressing negative insulin beliefs and managing group dynamics. The effectiveness of the group was determined by ongoing self-management success, need for more peer support, and insulin concerns post insulin education group.

CONCLUSION

Positive experiences of insulin group education for people with type 2 diabetes were associated with sharing experiences with other people starting insulin, reassurance from healthcare professionals, appropriate supportive materials, and skill of the facilitator to address insulin concerns and manage group dynamics. People with type 2 diabetes may benefit more from education if healthcare professionals are skilled in psychological techniques to facilitate group education aimed at addressing concerns around insulin therapy. Further research needs to assess the effectiveness of structured insulin group education for people with type 2 diabetes.

Working with Insulin, Carbohydrates, Ketones and Exercise to Manage Diabetes (WICKED): evaluation of a self-management course for young people with Type 1 diabetes

AIMS

To evaluate a 5-day self-management education course for young people with Type 1 diabetes and assess its effects on knowledge, self-efficacy, beliefs, distress, self-management behaviours and HbA_1c .

METHODS

This is an evaluation of a structured education course. Young people (aged 16-24 years) with Type 1 diabetes were recruited from three diabetes centres. In the first centre, participants completed self-report measures of knowledge, self-efficacy, positive and negative outcome expectancies, and hypoglycaemic worries at baseline (n=47) and the end of the course (n=42). In two additional centres, participants completed these and other measures assessing self-management behaviours, cognitive adaptation to diabetes and diabetes distress at baseline (n=32), the end of the course (n=27) and 3-month follow-up (n = 27). HbA_1c levels were recorded at baseline (n=79), 6 months (n=77) and 12 months (n=65).

RESULTS

There were statistically significant increases in self-report knowledge, self-efficacy, positive outcome expectancies and self-management behaviours, and a statistically significant decrease in negative outcome expectances, between baseline and the end of the course. There were also statistically significant increases in self-report knowledge, self-efficacy, self-management behaviours and cognitive adaptation to diabetes between baseline and 3-month follow-up. Compared with baseline, HbA_1c levels decreased by a mean (sd) of 5.44 (19.93) mmol/mol (0.48%) at 6 months (P=0.019), and by 5.98 (23.32) mmol/mol (0.54%) at 12 months (P =0.043).

DISCUSSION

The results indicate the potential benefits of a self-management course designed to address the developmental needs and challenges faced by young people with Type 1 diabetes. Further studies with larger numbers and appropriate controls are required to confirm these initial findings.

Socioeconomic disparities in access to intensive insulin regimens for adults with type 1 diabetes: a qualitative study of patient and healthcare professional perspectives

BACKGROUND

Type 1 diabetes is a complex chronic condition which requires lifelong treatment with insulin. Health outcomes are dependent on ability to self-manage the condition. Socioeconomic inequalities have been demonstrated in access to treatment and health outcomes for adults with type 1 diabetes; however, there is a paucity of research exploring how these disparities occur. This study explores the influence of socioeconomic factors in gaining access to intensive insulin regimens for adults with type 1 diabetes.

METHODS

We undertook a qualitative descriptive study informed by a phenomenological perspective. In-depth face-to-face interviews were conducted with 28 patients and 6 healthcare professionals involved in their care. The interviews were analysed using a thematic approach. The Candidacy theory for access to healthcare for vulnerable groups framed the analysis.

RESULTS

Access to intensive insulin regimens was through hospital-based specialist services in this sample. Patients from lower socioeconomic groups had difficulty accessing hospital-based services if they were in low paid work and because they lacked the ability to navigate the healthcare system. Once these patients were in the specialist system, access to intensive insulin regimens was limited by non-alignment with healthcare professional goals, poor health literacy, psychosocial problems and poor quality communication. These factors could also affect access to structured diabetes education which itself improved access to intensive insulin regimens. Contact with diabetes specialist nurses and attendance at structured diabetes education courses could ameliorate these barriers.

CONCLUSIONS

Access to intensive insulin regimens was hindered for people in lower socioeconomic groups by a complex mix of factors relating to the permeability of specialist services, ability to navigate the healthcare system and patient interactions with healthcare providers. Improving access to diabetes specialist nurses and structured diabetes education for vulnerable patients could lessen socioeconomic disparities in both access to services and health outcomes.

Experiences of people with type 1 diabetes fasting Ramadan following structured education: A qualitative study

BACKGROUND AND AIMS

Although people with type 1 diabetes are exempt from fasting the month of Ramadan due to the risk to their health, many wish to fast nonetheless. Little is known about the impact of structured education on the fasting experiences of people with type 1 diabetes. This study aimed to explore how the Dose Adjustment for Normal Eating (DAFNE) course affected people with type 1 diabetes' fasting experiences to provide insight into the benefits of structured education for people wishing to fast while managing their diabetes.

METHODS

Semi-structured interviews were conducted with 40 DAFNE graduates who fasted Ramadan. The purposive sample was selected from the DAFNE registry at Dasman Diabetes Institute in Kuwait. The interviews were transcribed verbatim and analysed thematically in an iterative process. Topics discussed included fasting experiences prior to attending the DAFNE course, fasting experiences this year, and how DAFNE affected their fasting.

RESULTS

Five themes emerged; (1) Reduction in fluctuations and complications, (2) Improvement in confidence and self-reliance, (3) Tailored support for dose and pump programming adjustments, (4) Positive effect on wellbeing, and (5) Encouraging informed-decision making about fasting.

CONCLUSIONS

The findings have provided insight into the impact of DAFNE structured education on the fasting experiences of people with type 1 diabetes and has shown how overall, DAFNE had enhanced the quality of fasting. In addition, by assisting them in fulfilling their fasting wishes, DAFNE has had a positive effect on their wellbeing.

Promises and Perils of Group Clinics for Young People Living With Diabetes: A Realist Review

Group clinics are becoming popular as a new care model in diabetes care. This evidence synthesis, using realist review methodology, examined the role of group clinics in meeting the complex needs of young people living with diabetes. Following Realist And Meta-narrative Evidence Synthesis-Evolving Standards (RAMESES) quality standards, we conducted a systematic search across 10 databases. A total of 131 articles met inclusion criteria and were analyzed to develop theoretically informed explanations of how and why group clinics could work (or not) for young people with diabetes. Models of group-based care in the literature varied significantly and incorporated different degrees of clinical and educational content. Our analysis identified four overarching principles that can be applied in different contexts to drive sustained engagement of young people in group clinics: 1) emphasizing self-management as practical knowledge; 2) developing a sense of affinity between patients; 3) providing safe, developmentally appropriate care; and 4) balancing group and individual needs. Implementation of group clinics was not always straightforward; numerous adjustments to operational and clinical processes were required to establish and deliver high-quality care. Group clinics for young people with diabetes offer the potential to complement individualized care but are not a panacea and may generate as well as solve problems.

Broadening the Debate About Post-trial Access to Medical Interventions: A Qualitative Study of Participant Experiences at the End of a Trial Investigating a Medical Device to Support Type 1 Diabetes Self-Management

Increasing ethical attention and debate is focusing on whether individuals who take part in clinical trials should be given access to post-trial care. However, the main focus of this debate has been upon drug trials undertaken in low-income settings. To broaden this debate, we report findings from interviews with individuals (n = 24) who participated in a clinical trial of a closed-loop system, which is a medical device under development for people with type 1 diabetes that automatically adjusts blood glucose to help keep it within clinically recommended ranges. Individuals were recruited from UK sites and interviewed following trial close-out, at which point the closed-loop had been withdrawn. While individuals were stoical and accepting of the requirement to return the closed-loop, they also conveyed varying degrees of distress. Many described having relaxed diabetes management practices while using the closed-loop and having become deskilled as a consequence, which made reverting back to pre-trial regimens challenging. Participants also described unanticipated consequences arising from using a closed-loop. As well as deskilling, these included experiencing psychological and emotional benefits that could not be sustained after the closed-loop had been withdrawn and participants reevaluating their pre- and post-trial life in light of having used a closed-loop and now perceiving this life much more negatively. Participants also voiced frustrations about experiencing better blood glucose control using a closed-loop and then having to revert to using what they now saw as antiquated and imprecise self-management tools. We use these findings to argue that ethical debates about post-trial provisioning need to be broadened to consider potential psychological and emotional harms, and not just clinical harms, that may result from withdrawal of investigated treatments. We also suggest that individuals may benefit from information about potential nonclinical harms to help make informed decisions about trial participation.

Participants' Experiences of, and Views About, Daytime Use of a Day-and-Night Hybrid Closed-Loop System in Real Life Settings: Longitudinal Qualitative Study

OBJECTIVE

To explore individuals' experiences of daytime use of a day-and-night hybrid closed-loop system, their information and support needs, and their views about how future systems could be improved.

RESEARCH DESIGN AND METHODS

Twenty-four adults, adolescents, and parents were interviewed before using a hybrid day-and-night closed-loop system and 3 months later, data were analyzed thematically.

RESULTS

Participants praised the closed loop's ability to respond to high and low blood glucose in ways which extended beyond their own capabilities and to act as a safety net and mop up errors, such as when a mealtime bolus was forgotten or unplanned activity was undertaken. Participants also described feeling less burdened by diabetes as a consequence and more able to lead flexible, spontaneous lives. Contrary to their initial expectations, and after trust in the system had been established, most individuals wanted opportunities to collaborate with the closed loop to optimize its effectiveness. Such individuals expressed a need to communicate information, such as when routines changed or to indicate different intensities of physical activity. While individuals valued frequent contact with staff in the initial month of use, most felt that their long-term support needs would be no greater than when using an insulin pump.

CONCLUSIONS

While participants reported substantial benefits to using the closed loop during the day, they also identified ways in which the technology could be refined and education and training tailored to optimize effective use. Our findings suggest that mainstreaming this technology will not necessarily lead to increased demands on clinical staff.

Follow-Up Support for Effective type 1 Diabetes self-management (The FUSED Model): A systematic review and meta-ethnography of the barriers, facilitators and recommendations for sustaining self-management skills after attending a structured education programme

Background

People with type 1 diabetes who attend structured education training in self-management using flexible intensive therapy achieve improved blood glucose control and experience fewer episodes of severe hypoglycaemia. However, many struggle to sustain these improvements over time. To inform the design of more effective follow-up support we undertook a review of qualitative studies which have identified factors that influence and inform participants’ self-management behaviours after attending structured education and their need for support to sustain improvements in glycaemic control.

Methods

We undertook a meta-ethnography of relevant qualitative studies, identified using systematic search methods. Studies were included which focused on participants’ experiences of self-managing type 1 diabetes after attending structured education which incorporated training in flexible intensive insulin therapy. A line of argument approach was used to synthesise the findings.

Results

The search identified 18 papers from six studies. The studies included were judged to be of high methodological quality. The line of argument synthesis developed the Follow-Up Support for Effective type 1 Diabetes self-management (FUSED) model. This model outlines the challenges participants encounter in maintaining diabetes self-management practices after attending structured education, and describes how participants try to address these barriers by adapting, simplifying or personalising the self-management approaches they have learned. To help participants maintain the skills taught during courses, the FUSED model presents ten recommendations abstracted from the included papers to provide a logic model for a programme of individualised and responsive follow-up support.

Conclusions

This meta-ethnography highlights how providing skills training using structured education to people with type 1 diabetes does not necessarily result in participants adopting and sustaining recommended changes in behaviour. To help people sustain diabetes self-management skills after attending structured education, it is recommended that support be provided over the longer-term by appropriately trained healthcare professionals which is responsive to individuals’ needs. Although developed to inform support for people with type 1 diabetes, the FUSED model provides a framework that could also be applied to support individuals with other long term conditions which require complex self-management skills to be learned and sustained over time.

Trial registration

PROSPERO registration: CRD42017067961.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3655-z) contains supplementary material, which is available to authorized users.

Autoimmunity and intestinal colonization by Candida albicans in patients with type 1 diabetes at the time of the diagnosis

PURPOSE

Type 1 diabetes mellitus (T1DM) is a chronic and immune-mediated disease, which is characterized by the progressive destruction of pancreatic beta cells. T1DM precipitates in genetically susceptible individuals through environmental factors. In this study, we aimed to evaluate the impact of autoimmunity and intestinal colonization of Candida albicans on the development of T1DM.

METHODS

Forty-two patients newly diagnosed with T1DM and 42 healthy subjects were included in this monocentric study. The basic and clinical characteristics of the patients were recorded. T1DM-, thyroid-, and celiac-associated antibodies were evaluated. Stool cultures for C. albicans were performed to assess whether or not gut integrity was impaired in patients with T1DM.

RESULTS

The evaluation of T1DM- and thyroid-associated antibodies showed that the prevalences of islet cell antibodies and antithyroperoxidase positivity were higher in the study patients than in the patients in the control group. Furthermore, the direct examination and culture of fresh stool samples revealed that 50% of the patients with T1DM and 23.8% of the control subjects had fungi (C. albicans).

CONCLUSION

Through this study, we suggest that the presence of intestinal C. albicans colonization at the time of the diagnosis of T1DM may indicate impairment of normal intestinal microbiota. We also suggest that there may be a tendency of T1DM in patients with a high prevalence of intestinal C. albicans.

A cluster randomised trial, cost-effectiveness analysis and psychosocial evaluation of insulin pump therapy compared with multiple injections during flexible intensive insulin therapy for type 1 diabetes: the REPOSE Trial

BACKGROUND

Insulin is generally administered to people with type 1 diabetes mellitus (T1DM) using multiple daily injections (MDIs), but can also be delivered using infusion pumps. In the UK, pumps are recommended for patients with the greatest need and adult use is less than in comparable countries. Previous trials have been small, of short duration and have failed to control for training in insulin adjustment.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of pump therapy compared with MDI for adults with T1DM, with both groups receiving equivalent structured training in flexible insulin therapy.

DESIGN

Pragmatic, multicentre, open-label, parallel-group cluster randomised controlled trial, including economic and psychosocial evaluations. After participants were assigned a group training course, courses were randomly allocated in pairs to either pump or MDI.

SETTING

Eight secondary care diabetes centres in the UK.

PARTICIPANTS

Adults with T1DM for > 12 months, willing to undertake intensive insulin therapy, with no preference for pump or MDI, or a clinical indication for pumps.

INTERVENTIONS

Pump or MDI structured training in flexible insulin therapy, followed up for 2 years. MDI participants used insulin analogues. Pump participants used a Medtronic Paradigm^® Veo^TM (Medtronic, Watford, UK) with insulin aspart (NovoRapid, Novo Nordisk, Gatwick, UK).

MAIN OUTCOME MEASURES

Primary outcome - change in glycated haemoglobin (HbA_1c) at 2 years in participants whose baseline HbA_1c was ≥ 7.5% (58 mmol/mol). Key secondary outcome - proportion of participants with HbA_1c ≤ 7.5% at 2 years. Other outcomes at 6, 12 and 24 months - moderate and severe hypoglycaemia; insulin dose; body weight; proteinuria; diabetic ketoacidosis; quality of life (QoL); fear of hypoglycaemia; treatment satisfaction; emotional well-being; qualitative interviews with participants and staff (2 weeks), and participants (6 months); and ICERs in trial and modelled estimates of cost-effectiveness.

RESULTS

We randomised 46 courses comprising 317 participants: 267 attended a Dose Adjustment For Normal Eating course (132 pump; 135 MDI); 260 were included in the intention-to-treat analysis, of which 235 (119 pump; 116 MDI) had baseline HbA_1c of ≥ 7.5%. HbA_1c and severe hypoglycaemia improved in both groups. The drop in HbA_1c% at 2 years was 0.85 on pump and 0.42 on MDI. The mean difference (MD) in HbA_1c change at 2 years, at which the baseline HbA_1c was ≥ 7.5%, was -0.24% [95% confidence interval (CI) -0.53% to 0.05%] in favour of the pump (p = 0.098). The per-protocol analysis showed a MD in change of -0.36% (95% CI -0.64% to -0.07%) favouring pumps (p = 0.015). Pumps were not cost-effective in the base case and all of the sensitivity analyses. The pump group had greater improvement in diabetes-specific QoL diet restrictions, daily hassle plus treatment satisfaction, statistically significant at 12 and 24 months and supported by qualitative interviews.

LIMITATION

Blinding of pump therapy was not possible, although an objective primary outcome was used.

CONCLUSION

Adding pump therapy to structured training in flexible insulin therapy did not significantly enhance glycaemic control or psychosocial outcomes in adults with T1DM.

RESEARCH PRIORITY

To understand why few patients achieve a HbA_1c of < 7.5%, particularly as glycaemic control is worse in the UK than in other European countries.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN61215213.

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. 21, No. 20. See the NIHR Journals Library website for further project information.

On the pathogenesis of insulin-dependent diabetes mellitus: the role of microbiota

Type 1 diabetes (T1D) is an autoimmune disorder characterized by the selective destruction of insulin-producing β cells as result of a complex interplay between genetic, stochastic and environmental factors in genetically susceptible individuals. An increasing amount of experimental data from animal models and humans has supported the role played by imbalanced gut microbiome in T1D pathogenesis. The commensal intestinal microbiota is fundamental for several physiologic mechanisms, including the establishment of immune homeostasis. Alterations in its composition have been correlated to changes in the gut immune system, including defective tolerance to food antigens, intestinal inflammation and enhanced gut permeability. Early findings reported differences in the intestinal microbiome of subjects affected by prediabetes or overt disease compared to healthy individuals. The present review focuses on microbiota-host homeostasis, its alterations, factors that influence microbiome composition and discusses their putative correlation with T1D development. Further studies are necessary to clarify the role played by microbiota modifications in the processes that cause enhanced permeability and the autoimmune mechanisms responsible for T1D onset.

A physical activity intervention for children with type 1 diabetes- steps to active kids with diabetes (STAK-D): a feasibility study

Background

This study describes the development and feasibility evaluation of a physical activity intervention for children with type 1 diabetes called ‘Steps to Active Kids with Diabetes’ (STAK-D). It aims to explore the feasibility and acceptability of the intervention and study design.

Methods

Thirteen children aged 9–11 years and their parents were recruited from one paediatric diabetes clinic. A process evaluation was conducted alongside a two-arm randomised feasibility trial, including assessment of rate of recruitment, adherence, retention, data completion and burden, implementation fidelity and adverse events. Qualitative interviews with children (n = 9), parents (n = 8), healthcare professionals (n = 3) and STAK-D volunteers (n = 8) explored intervention acceptability. Interviews were analysed thematically.

Results

Rate of recruitment was 25%, with 77% retention at 3-month follow-up. Study burden was low, data completion was high and the intervention was delivered as per protocol. No serious adverse event was reported. Engagement with intervention materials was generally good, but attendance at group activity sessions was low due to logistical barriers. Interview analysis identified preferred methods of recruitment, motivations for recruitment, barriers and facilitators to adherence, the experience of data collection, experience of the STAK-D programme and its perceived benefits.

Conclusions

STAK-D was feasible and acceptable to children, their parents and healthcare professionals, but group sessions may present logistical issues. Recruitment and retention may be improved with a clinic-wide approach to recruitment.

Trial registration

This trial was registered on ClinicalTrials.gov: NCT02144337 (16/01/2014).

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1036-8) contains supplementary material, which is available to authorized users.

Initial versus ongoing education: Perspectives of people with type 1 diabetes in 13 countries

PURPOSE

To understand the perspectives of people with type 1 diabetes with regards to the diabetes education they receive within the health system.

METHODS

Grounded Theory was used for the collection and analysis of data from interviews with 101 people with type 1 diabetes from 13 countries.

RESULTS

There are two aspects to education, namely initial education received when diagnosed and the ongoing education people continue to receive. Within these two categories content and process of diabetes education are important as are factors linked to the healthcare worker and setting.

CONCLUSIONS

Tangible elements are the "what" that is delivered and are the different skills and information needed for people to manage their diabetes. Process elements are the "how" this is delivered. Finally intangible elements are those, which were found to be specific to certain contexts and health professionals. These could be the hardest to replicate, but possibly the most important.

PRACTICE IMPLICATIONS

Health systems can provide the tangible elements and organize themselves to have processes in place to deliver education. The challenge is how can the intangible elements be seen as important and developed and delivered to improve management, but also meet the needs of people with diabetes.

What is important for you? A qualitative interview study of living with diabetes and experiences of diabetes care to establish a basis for a tailored Patient-Reported Outcome Measure for the Swedish National Diabetes Register

OBJECTIVES

There is a growing emphasis on the perspective of individuals living with diabetes and the need for a more person-centred diabetes care. At present, the Swedish National Diabetes Register (NDR) lacks patient-reported outcome measures (PROMs) based on the perspective of the patient. As a basis for a new PROM, the aim of this study was to describe important aspects in life for adult individuals with diabetes.

DESIGN

Semistructured qualitative interviews analysed using content analysis.

SETTING

Hospital-based outpatient clinics and primary healthcare clinics in Sweden.

PARTICIPANTS

29 adults with type 1 diabetes mellitus (DM) (n=15) and type 2 DM (n=14).

INCLUSION CRITERIA

Swedish adults (≥ 18 years) living with type 1 DM or type 2 DM (duration ≥ 5 years) able to describe their situation in Swedish. Purposive sampling generated heterogeneous characteristics.

RESULTS

To live a good life with diabetes is demanding for the individual, but experienced barriers can be eased by support from others in the personal sphere, and by professional support from diabetes care. Diabetes care was a crucial resource to nurture the individual's ability and knowledge to manage diabetes, and to facilitate life with diabetes by supplying support, guidance, medical treatment and technical devices tailored to individual needs. The analysis resulted in the overarching theme 'To live a good life with diabetes' constituting the two main categories 'How I feel and how things are going with my diabetes' and 'Support from diabetes care in managing diabetes' including five different categories.

CONCLUSIONS

Common aspects were identified including the experience of living with diabetes and support from diabetes care. These will be used to establish a basis for a tailored PROM for the NDR.

[Peer training for patients with diabetes mellitus 2. A quantitative and qualitative evaluation in the Basque Country and Andalusia]

Objetivo

Evaluar la estrategia formativa entre iguales para pacientes con diabetes mellitus tipo 2 de los programas «Paciente Activo» (País Vasco) y «Escuela de Pacientes» (Andalucía).

Diseño

Diseño mixto cuantitativo/cualitativo de evaluación pre/post de los programas de formación llevado a cabo entre 2012 y 2014.

Emplazamiento

País Vasco y Andalucía.

Participantes

Un total de 409 pacientes y pacientes-formadores, participantes en la formación entre iguales. Muestreo intencional de 44 pacientes para el estudio cualitativo.

Método

Análisis estadístico bivariante y ganancias netas de las variables comunes de cuestionarios pre/post del País Vasco y Andalucía: salud autopercibida, actividades diarias, ejercicio físico, uso de servicios sanitarios y autocuidados. Análisis de contenido de 8 grupos focales con pacientes y pacientes-formadores, incluyendo: codificación, árbol de categorías y triangulación de resultados.

Resultados

La formación entre iguales incide positivamente en la realización de ejercicio físico, uso de recursos sanitarios y autoeficacia en los cuidados, con diferencias por género en algunas dimensiones. La formación se valora positivamente en cuanto que: favorece la relación de los/las pacientes con el personal sanitario, genera apoyo grupal y autoconfianza y facilita la gestión emocional. Las áreas de mejora identificadas son: acceso y continuidad de la formación, y aceptación y apoyo por parte del personal y las instituciones sanitarias.

Conclusiones

Los beneficios en salud y calidad de vida promovidos a través de la formación entre iguales requiere la colaboración de las instituciones y personal sanitario, que deben facilitar el acceso, la continuidad y la adecuación de los contenidos a las necesidades y expectativas de los/las pacientes.

Structured type 1 diabetes education delivered in routine care in Australia reduces diabetes-related emergencies and severe diabetes-related distress: The OzDAFNE program

AIMS

To evaluate structured type 1 diabetes education delivered in routine practice throughout Australia.

METHODS

Participants attended a five-day training program in insulin dose adjustment and carbohydrate counting between April 2007 and February 2012. Using an uncontrolled before-and-after study design, we investigated: HbA1c (% and mmol/mol); severe hypoglycaemia; diabetes ketoacidosis (DKA) requiring hospitalisation, and diabetes-related distress (Problem Areas in Diabetes scale; PAID), weight (kg); body mass index. Data were collected pre-training and 6-18 months post-training. Change in outcome scores were examined overall as well as between groups stratified by baseline HbA1c quartiles. Data are mean ± SD or % (n).

RESULTS

506 participants had data eligible for analysis. From baseline to follow-up, significant reductions were observed in the proportion of participants reporting at least one severe hypoglycaemic event (24.7% (n=123) vs 12.1% (n=59), p<0.001); and severe diabetes-related distress (29.3% (n=145) vs 12.6% (n=60), p<0.001). DKA requiring hospitalisation in the past year reduced from 4.1% (n=20) to 1.2% (n=6). For those with above target baseline HbA1c there was a small, statistically significant improvement (n=418, 8.4 ± 1.1% (69 ± 12 mmol/mol) to 8.2 ± 1.1% (66 ± 12 mmol/mol). HbA1c improvement was clinically significant among those in the highest baseline quartile (n=122, 9.7 ± 1.1% (82 ± 11 mmol/mol) to 9.0 ± 1.2% (75 ± 13 mmol/mol), p<0.001).

CONCLUSIONS

The proportion of participants reporting severe hypoglycaemia, DKA and severe diabetes-related distress was at least halved, and HbA1c reduced by 0.7% (7 mmol/mol) among those with highest baseline levels. Structured type 1 diabetes education delivered in routine practice offers clinically important benefits for those with greatest clinical need.

Empowerment in the Treatment of Diabetes and Obesity

As the available therapies for diabetes and obesity are not effective enough, diabetologists and educators search for new methods to collaborate with patients in order to support their health behaviors. The aim of this review is to discuss perspectives for the development of new empowerment-type therapies in the treatment of diabetes/obesity. Empowerment is a process whereby patients gain the necessary knowledge to influence their own behavior to improve the quality of their lives. It is carried out in five stages: (1) identify the problem, (2) explain the feelings and meanings, (3) build a plan, (4) act, and (5) experience and assess the execution. Although many years have passed since the advent and popularization of the concept of empowerment, the area remains controversial, mainly with regard to the methodology of therapy. Some previous studies have confirmed the positive effect of empowerment on body weight, metabolic control, and quality of life of patients with type 2 diabetes; however, few studies have been conducted in patients with type 1 diabetes. There is still a need to confirm the effectiveness of empowerment in accordance with Evidence Based Medicine by performing long-term observational studies in a large group of patients. In future, empowerment may become part of the standard of care for patients with diabetes and/or obesity.

Incorporating Psychological Predictors of Treatment Response into Health Economic Simulation Models: A Case Study in Type 1 Diabetes

BACKGROUND

. Health economic modeling has paid limited attention to the effects that patients' psychological characteristics have on the effectiveness of treatments. This case study tests 1) the feasibility of incorporating psychological prediction models of treatment response within an economic model of type 1 diabetes, 2) the potential value of providing treatment to a subgroup of patients, and 3) the cost-effectiveness of providing treatment to a subgroup of responders defined using 5 different algorithms.

METHODS

. Multiple linear regressions were used to investigate relationships between patients' psychological characteristics and treatment effectiveness. Two psychological prediction models were integrated with a patient-level simulation model of type 1 diabetes. Expected value of individualized care analysis was undertaken. Five different algorithms were used to provide treatment to a subgroup of predicted responders. A cost-effectiveness analysis compared using the algorithms to providing treatment to all patients.

RESULTS

. The psychological prediction models had low predictive power for treatment effectiveness. Expected value of individualized care results suggested that targeting education at responders could be of value. The cost-effectiveness analysis suggested, for all 5 algorithms, that providing structured education to a subgroup of predicted responders would not be cost-effective.

LIMITATIONS

. The psychological prediction models tested did not have sufficient predictive power to make targeting treatment cost-effective. The psychological prediction models are simple linear models of psychological behavior. Collection of data on additional covariates could potentially increase statistical power.

CONCLUSIONS

. By collecting data on psychological variables before an intervention, we can construct predictive models of treatment response to interventions. These predictive models can be incorporated into health economic models to investigate more complex service delivery and reimbursement strategies.

Out-of-office hours nurse-driven acute telephone counselling service in a large diabetes outpatient clinic: A mixed methods evaluation

OBJECTIVE

To map the usage of out-of-office hours acute telephone counselling (ATC) provided by diabetes specialist nurses (n=18) for diabetes patients to explore potentials for improvement.

METHODS

A mixed methods study involved mapping of ATC-usage during 6 months and a retrospective audit of frequent users.

RESULTS

Altogether, 3197 calls were registered that were related to 592 individual patients, corresponding to 10% of the population. Proportionally more users suffered from type 1 diabetes (p<0.001). ATC-users' mean HbA1c was 8.8% (73 mmol/mol) compared to 8.1% (65 mmol/mol) for all patients attending the clinic (p<0.001). Hyperglycaemia was the most frequent reason for calling. The use of ATC likely prevented 15 admissions. More than half of the calls came from general nurses based in the community (n=619) and general nurses and nursing assistants based in care homes (n=1018). The majority (75%) of patients called less than five times. However, 8% called 16 times or more accounting for 52% of all calls. A retrospective audit identified them as physically and/or psychologically fragile patients.

CONCLUSION

Hyperglycaemia was the most frequent reason for calling, and insulin dose adjustment the most frequent advice given.

PRACTICE IMPLICATIONS

Frequent users identified need additional support.

Supporting patients to self-monitor their oral anticoagulation therapy: recommendations based on a qualitative study of patients' experiences

BACKGROUND

Clinical trials suggest that oral anticoagulation therapy (OAT) self-monitoring is safe and effective, however little is known about the patient experience of this process. There is a lack of understanding about how best to train and support patients embarking on OAT self-monitoring.

AIM

To collect in-depth information about patients' experiences of OAT self-monitoring outside of clinical trial conditions and to produce a set of recommendations on how best to support such patients.

DESIGN AND SETTING

Semi-structured qualitative interviews with patients who self-monitor and live in England.

METHOD

In total, 26 of the 267 (9.7%) who participated in the Cohort study of Anticoagulation Self-Monitoring (CASM) and were still self-monitoring after 12 months' follow-up were interviewed. Topics discussed included experiences of OAT self-monitoring, healthcare support, training, and decision making. Framework analysis was used.

RESULTS

Following initial problems using the monitoring device, interviewees described a mostly positive experience. Although less effort was expended attending monitoring appointments with health professionals, effort was required to conduct self-monitoring tests and to interpret and act on the results. Desire to self-manage was variable, especially when dosing advice systems worked promptly and reliably. Interviewees overcame patchy healthcare system knowledge and support of self-monitoring by educating themselves. Family and friends provided support with learning to use the monitor and managing OAT dosage adjustments.

CONCLUSION

Better, more-consistent training and health-service support would have alleviated a number of problems encountered by these patients who were self-monitoring. This training and support will become even more important if self-monitoring becomes more accessible to the general population of people on OAT.

Modeling predictors of changes in glycemic control and diabetes-specific quality of life amongst adults with type 1 diabetes 1 year after structured education in flexible, intensive insulin therapy

Few studies have identified determinants of glycemic control (HbA1c) and diabetes-specific quality of life (DSQoL) in adults with type 1 diabetes. To identify factors predicting outcomes following structured diabetes education. 262 participants completed biomedical and questionnaire assessments before, and throughout 1 year of follow-up. The proportion of variance explained ranged from 28 to 62 % (DSQoLS) and 14-20 % (HbA1c). When change in psychosocial variables were examined, reduced hypoglycemia fear, lower 'perceived diabetes seriousness', greater self-efficacy and well-being predicted QoL improvements from baseline to 3-months. Increased frequency of blood glucose testing predicted improvements in HbA1c from baseline to 6-months. Greater benefits may be achieved if programs focus explicitly on psychosocial factors. Self-care behaviours did not predict HbA1c suggesting existing assessment tools need refinement. Evaluation of treatment mechanisms in self-management programs is recommended.

Adopting the sensemaking perspective for chronic disease self-management

BACKGROUND

Self-monitoring is an integral component of many chronic diseases; however few theoretical frameworks address how individuals understand self-monitoring data and use it to guide self-management.

PURPOSE

To articulate a theoretical framework of sensemaking in diabetes self-management that integrates existing scholarship with empirical data.

METHODS

The proposed framework is grounded in theories of sensemaking adopted from organizational behavior, education, and human-computer interaction. To empirically validate the framework the researchers reviewed and analyzed reports on qualitative studies of diabetes self-management practices published in peer-reviewed journals from 2000 to 2015.

RESULTS

The proposed framework distinguishes between sensemaking and habitual modes of self-management and identifies three essential sensemaking activities: perception of new information related to health and wellness, development of inferences that inform selection of actions, and carrying out daily activities in response to new information. The analysis of qualitative findings from 50 published reports provided ample empirical evidence for the proposed framework; however, it also identified a number of barriers to engaging in sensemaking in diabetes self-management.

CONCLUSIONS

The proposed framework suggests new directions for research in diabetes self-management and for design of new informatics interventions for data-driven self-management.

Perceptions and experiences of using automated bolus advisors amongst people with type 1 diabetes: a longitudinal qualitative investigation

AIMS

We explored people's reasons for, and experiences of, using bolus advisors to determine insulin doses; and, their likes/dislikes of this technology.

SUBJECTS AND METHODS

42 people with type 1 diabetes who had received instruction in use of bolus advisors during a structured education course were interviewed post-course and 6 months later. Data were analysed thematically.

RESULTS

Participants who considered themselves to have poor mathematical skills highlighted a gratitude for, and heavy reliance on, advisors. Others liked and chose to use advisors because they saved time and effort calculating doses and/or had a data storage facility. Follow-up interviews highlighted that, by virtue of no longer calculating their doses, participants could become deskilled and increasingly dependent on advisors. Some forgot what their mealtime ratios were; others reported a misperception that, because they were pre-programmed during courses, these parameters never needed changing. Use of data storage facilities could hinder effective review of blood glucose data and some participants reported an adverse impact on glycaemic control.

DISCUSSION

While participants liked and perceived benefits to using advisors, there may be unintended consequences to giving people access to this technology. To promote effective use, on-going input and education from trained health professionals may be necessary.

Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes

Background

Many adults with type 1 diabetes cannot self-manage their diabetes effectively and die prematurely with diabetic complications as a result of poor glucose control. Following the positive results obtained from a randomised controlled trial (RCT) by the Dose Adjustment For Normal Eating (DAFNE) group, published in 2002, structured training is recommended for all adults with type 1 diabetes in the UK.

Aim

With evidence that blood glucose control is not always improved or sustained, we sought to determine factors explaining why some patients benefit from training more than other patients, identifying barriers to successful self-management, while developing other models to make skills training more accessible and effective.

Findings

We confirmed that glycaemic outcomes are not always improved or sustained when the DAFNE programme is delivered routinely, although improvements in psychosocial outcomes are maintained. DAFNE courses and follow-up support is needed to help participants instil and habituate key self-management practices such as regular diary/record keeping. DAFNE graduates need structured professional support following training. This is currently either unavailable or provided ad hoc without a supporting evidence base. Demographic and psychosocial characteristics had minimal explanatory power in predicting glycaemic control but good explanatory power in predicting diabetes-specific quality of life over the following year. We developed a DAFNE course delivered for 1 day per week over 5 weeks. There were no major differences in outcomes between this and a standard 1-week DAFNE course; in both arms of a RCT, glycaemic control improved by less than in the original DAFNE trial. We piloted a course delivering both the DAFNE programme and pump training. The pilot demonstrated the feasibility of a full multicentre RCT and resulted in us obtaining subsequent Health Technology Assessment programme funding. In collaboration with the National Institute for Health Research (NIHR) Diabetes Research Programme at King’s College Hospital (RG-PG-0606-1142), London, an intervention for patients with hypoglycaemic problems, DAFNE HART (Dose Adjustment for Normal Eating Hypoglycaemia Awareness Restoration Training), improved impaired hypoglycaemia awareness and is worthy of a formal trial. The health economic work developed a new type 1 diabetes model and confirmed that the DAFNE programme is cost-effective compared with no structured education; indeed, it is cost-saving in the majority of our analyses despite limited glycated haemoglobin benefit. Users made important contributions but this could have been maximised by involving them with grant writing, delaying training until the group was established and funding users’ time off work to maximise attendance. Collecting routine clinical data to conduct continuing evaluated roll-out is possible but to do this effectively requires additional administrator support and/or routine electronic data capture.

Conclusions

We propose that, in future work, we should modify the current DAFNE curricula to incorporate emerging understanding of behaviour change principles to instil and habituate key self-management behaviours that include key DAFNE competencies. An assessment of numeracy, critical for insulin dose adjustment, may help to determine whether or not additional input/support is required both before and after training. Models of structured support involving professionals should be developed and evaluated, incorporating technological interventions to help overcome the barriers identified above and enable participants to build effective self-management behaviours into their everyday lives.

Trial registration

ClinicalTrials.gov NCT01069393.

Funding

The NIHR Programme Grants for Applied Research programme.

Diabetes education: the experiences of young adults with type 1 diabetes

INTRODUCTION

Clinician-led diabetes education is a fundamental component of care to assist people with Type 1 diabetes (T1D) self-manage their disease. Recent initiatives to incorporate a more patient-centered approach to diabetes education have included recommendations to make such education more individualized. Yet there is a dearth of research that identifies patients' perceptions of clinician-led diabetes education. We aimed to describe the experience of diabetes education from the perspective of young adults with T1D.

METHODS

We designed a self-reported survey for Australian adults, aged 18-35 years, with T1D. Participants (n = 150) were recruited by advertisements through diabetes consumer-organizations. Respondents were asked to rate aspects of clinician-led diabetes education and identify sources of self-education. To expand on the results of the survey we interviewed 33 respondents in focus groups.

RESULTS

SURVEY

The majority of respondents (56.0%) were satisfied with the amount of continuing clinician-led diabetes education; 96.7% sought further self-education; 73.3% sourced more diabetes education themselves than that provided by their clinicians; 80.7% referred to diabetes organization websites for further education; and 30.0% used online chat-rooms and blogs for education. Focus groups: The three key themes that emerged from the interview data were deficiencies related to the pedagogy of diabetes education; knowledge deficiencies arising from the gap between theoretical diabetes education and practical reality; and the need for and problems associated with autonomous and peer-led diabetes education.

CONCLUSION

Our findings indicate that there are opportunities to improve clinician led-diabetes education to improve patient outcomes by enhancing autonomous health-literacy skills and to incorporate peer-led diabetes education and support with clinician-led education. The results provide evidence for the potential value of patient engagement in quality improvement and health-service redesign.

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.

What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study

OBJECTIVE

To explore the impact of patient education on the lives of people with diabetes, including the effect on interactions with doctors and other healthcare professionals.

DESIGN

Qualitative user-led study using longitudinal interviews and 146 h of participant observation. Data were analysed using a narrative approach.

PARTICIPANTS

21 patients with type 1 diabetes, those either about to attend a patient education course or those who had completed the course in the previous 10 years.

SETTING

Established patient education centres in three UK teaching hospitals teaching the Dose Adjustment for Normal Eating (DAFNE) course.

RESULTS

Both postcourse and several years later, most participants spoke of the experience of taking part in education as life-changingly positive. It helped them understand how to gain control over a very complex disease and freed them from dependence on medical advice and restrictive regimes. However, interactions within the health system following patient education could be fraught. Participants emerged from the course with greater condition-specific knowledge than many of the healthcare professionals they encountered. When these professionals did not understand what their patients were trying to do and were uncomfortable trusting their expertise, there could be serious consequences for these patients' ability to continue effective self-management.

CONCLUSIONS

Patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions, and expertise taught to patients in one branch of medicine can be considered non-compliant by those who are not specialists in that field. Although patient education can give people confidence in their own self-management skills, it cannot solve the power imbalance that remains when a generalist healthcare professional, however well meaning, blocks access to medication and supplies needed to manage chronic diseases successfully. There is a role for those involved in primary and hospital care, including those supporting and training healthcare professionals, to recognise these problems and find ways to acknowledge and respect chronic patients' biomedical and practical expertise.

Risk factors and primary prevention trials for type 1 diabetes

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disease resulting in the designated immune destruction of insulin producing β-cells, usually diagnosed in youth, and associated with important psychological, familial, and social disorders. Once diagnosed, patients need lifelong insulin treatment and will experience multiple disease-associated complications. There is no cure for T1DM currently. The last decade has witnessed great progress in elucidating the causes and treatment of the disease based on numerous researches both in rodent models of spontaneous diabetes and in humans. This article summarises our current understanding of the pathogenesis of T1DM, the roles of the immune system, genes, environment and other factors in the continuing and rapid increase in T1DM incidence at younger ages in humans. In addition, we discuss the strategies for primary and secondary prevention trials of T1DM. The purpose of this review is to provide an overview of this disorder's pathogenesis, risk factors that cause the disease, as well as to bring forward an ideal approach to prevent and cure the disorder.

Type 1 diabetes structured education: What are the core self-management behaviours?

AIMS

Study aims were to (1) describe and compare the way diabetes structured education courses have evolved in the UK, (2) identify and agree components of course curricula perceived as core across courses and (3) identify and classify self-care behaviours in order to develop a questionnaire assessment tool.

METHODS

Structured education courses were selected through the Type 1 diabetes education network. Curricula from five courses were examined and nine educators from those courses were interviewed. Transcripts were analysed using framework analysis. Fourteen key stakeholders attended a consensus meeting, to identify and classify Type 1 diabetes self-care behaviours.

RESULTS

Eighty-three courses were identified. Components of course curricula perceived as core by all diabetes educators were: carbohydrate counting and insulin dose adjustment, hypoglycaemia management, group work, goal setting and empowerment, confidence and control. The broad areas of self-management behaviour identified at the consensus meeting were carbohydrate counting and awareness, insulin dose adjustment, self-monitoring of blood glucose, managing hypoglycaemia, managing equipment and injection sites; and accessing health care. Specific self-care behaviours within each area were identified.

CONCLUSIONS

Planned future work will develop an updated questionnaire tool to access self-care behaviours. This will enable assessment of the effectiveness of existing structured education programmes at producing desired changes in behaviour. It will also help people with diabetes and their healthcare team identify areas where additional support is needed to initiate or maintain changes in behaviour. Provision of such support may improve glycaemia and reduce diabetes-related complications and severe hypoglycaemia.