A tailored intervention to promote uptake of retinal screening among young adults with type 2 diabetes - an intervention mapping approach

Time and risk preferences and the perceived effectiveness of incentives to comply with diabetic retinopathy screening among older adults with type 2 diabetes

Behavioral economics has the potential to inform the design of incentives to improve disease screening programs by accounting for various behavioral biases. We investigate the association between multiple behavioral economics concepts and the perceived effectiveness of incentive strategies for behavioral change among older patients with a chronic disease. This association is examined by focusing on diabetic retinopathy screening, which is recommended but very variably followed by persons living with diabetes. Five time and risk preference concepts (i.e., utility curvature, probability weighting, loss aversion, discount rate, and present-bias) are estimated simultaneously in a structural econometric framework, based on a series of deliberately-designed economic experiments offering real money. We find that higher discount rates and loss aversion and lower probability weighting are significantly associated with lower perceived effectiveness of intervention strategies whereas present-bias and utility curvature have an insignificant association with it. Finally, we also observe strong urban vs. rural heterogeneity in the association between our behavioral economic concepts and the perceived effectiveness of intervention strategies.

Understanding tailoring to support the implementation of evidence-based interventions in healthcare: The CUSTOMISE research programme protocol

Although there are effective evidence-based interventions (EBIs) to prevent, treat and coordinate care for chronic conditions they may not be adopted widely and when adopted, implementation challenges can limit their impact.  Implementation strategies are "methods or techniques used to enhance the adoption, implementation, and sustainment of a clinical program or practice". There is some evidence to suggest that to be more effective,  strategies should be tailored; that is, selected and designed to address specific determinants which may influence implementation in a given context. Despite the growing popularity of tailoring the concept is ill-defined, and the way in which tailoring is applied can vary across studies or lack detail when reported. There has been less focus on the part of tailoring where stakeholders prioritise determinants and select strategies, and the way in which theory, evidence and stakeholders' perspectives should be combined to make decisions during the process. Typically, tailoring is evaluated based on the effectiveness of the tailored strategy, we do not have a clear sense of the mechanisms through which tailoring works, or how to measure the "success" of the tailoring process. We lack an understanding of how stakeholders can be involved effectively in tailoring and the influence of different approaches on the outcome of tailoring. Our research programme, CUSTOMISE (Comparing and Understanding Tailoring Methods for Implementation Strategies in healthcare) will address some of these outstanding questions and generate evidence on  the feasibility, acceptability, and efficiency of different tailoring approaches, and build capacity in implementation science in Ireland, developing and delivering training and supports for, and network of, researchers and implementation practitioners. The evidence generated across the studies conducted as part of CUSTOMISE will bring greater clarity, consistency, coherence, and transparency to tailoring, a key process in implementation science.

Conceptual tensions and practical trade-offs in tailoring implementation interventions

Tailored interventions have been shown to be effective and tailoring is a popular process with intuitive appeal for researchers and practitioners. However, the concept and process are ill-defined in implementation science. Descriptions of how tailoring has been applied in practice are often absent or insufficient in detail. This lack of transparency makes it difficult to synthesize and replicate efforts. It also hides the trade-offs for researchers and practitioners that are inherent in the process. In this article we juxtapose the growing prominence of tailoring with four key questions surrounding the process. Specifically, we ask: (1) what constitutes tailoring and when does it begin and end?; (2) how is it expected to work?; (3) who and what does the tailoring process involve?; and (4) how should tailoring be evaluated? We discuss these questions as a call to action for better reporting and further research to bring clarity, consistency, and coherence to tailoring, a key process in implementation science.

Characterising processes and outcomes of tailoring implementation strategies in healthcare: a protocol for a scoping review

Background: Tailoring strategies to target the salient barriers to and enablers of implementation is considered a critical step in supporting successful delivery of evidence based interventions in healthcare. Theory, evidence, and stakeholder engagement are considered key ingredients in the process however, these ingredients can be combined in different ways. There is no consensus on the definition of tailoring or on a single method for tailoring strategies to optimize impact, ensure transparency, and facilitate replication. Aim: The purpose of this scoping review is to describe how tailoring has been undertaken within healthcare to answer questions about how it has been conceptualised, described, and conducted in practice, and to identify research gaps. Methods: The review will be conducted in accordance with best practice guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR) will be used to guide the reporting. Searches will be conducted of MEDLINE, Embase, Web of Science, Scopus, from 2005 to present. Reference lists of included articles will be searched. Grey literature will be searched on Google Scholar. Screening and data extraction will be conducted by two or more members of the research team, with any discrepancies resolved by consensus discussion with a third reviewer. Initial analysis will be quantitative involving a descriptive numerical summary of the characteristics of the studies and the tailoring process. Qualitative content analysis aligned to the research questions will also be conducted, and data managed using NVivo where applicable. This scoping review is pre-registered with the Open Science Framework. Conclusions: The findings will serve as a resource for implementation researchers and practitioners to guide future research in this field and facilitate systematic, transparent, and replicable development of tailored implementation strategies.

How is the NHS Low-Calorie Diet Programme expected to produce behavioural change to support diabetes remission: An examination of underpinning theory

Background

In 2020, the National Health Service Low-Calorie Diet Programme (NHS-LCD) was launched, piloting a total diet (TDR) replacement intervention with behaviour change support for people living with Type 2 Diabetes (T2D) and excess weight. Four independent service providers were commissioned to design and deliver theoretically grounded programmes in localities across England.

Aims

1) to develop a logic model detailing how the NHS-LCD programme is expected to produce changes in health behaviour, and (2) to analyse and evaluate the use of behaviour change theory in providers' NHS-LCD Programme designs.

Methods

A documentary review was conducted. Information was extracted from the NHS-LCD service specification documents on how the programme expected to produce outcomes. The Theory Coding Scheme (TCS) was used to analyse theory use in providers' programme design documents.

Results

The NHS-LCD logic model included techniques aimed at enhancing positive outcome expectations of programme participation and beliefs about social approval of behaviour change, to facilitate programme uptake and behaviour change intentions. This was followed by techniques aimed at shaping knowledge and enhancing the ability of participants to self-regulate their health behaviours, alongside a supportive social environment and person-centred approach.Application and type of behaviour change theory within service providers' programme designs varied. One provider explicitly linked theory to programme content; two providers linked 63% and 70% of intervention techniques to theory; and there was limited underpinning theory identified in the programme design documents for one of the providers.

Conclusion

The nature and extent of theory use underpinning the NHS-LCD varied greatly amongst service providers, with some but not all intervention techniques explicitly linked to theory. How this relates to outcomes across providers should be evaluated. It is recommended that explicit theory use in programme design and evidence of its implementation becomes a requirement of future NHS commissioning processes.

Characterising processes and outcomes of tailoring implementation strategies in healthcare: a protocol for a scoping review

Background: Tailoring strategies to target the salient barriers to and enablers of implementation is considered a critical step in supporting successful delivery of evidence based interventions in healthcare. Theory, evidence, and stakeholder engagement are considered key ingredients in the process however, these ingredients can be combined in different ways. There is no consensus on the definition of tailoring or single method for tailoring strategies to optimize impact, ensure transparency, and facilitate replication. Aim: The purpose of this scoping review is to describe how tailoring has been undertaken within healthcare to answer questions about how it has been conceptualised, described, and conducted in practice, and to identify research gaps. Methods: The review will be conducted in accordance with best practice guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR) will be used to guide the reporting. Searches will be conducted of MEDLINE, Embase, Web of Science, Scopus, from 2005 to present. Reference lists of included articles will be searched. Grey literature will be searched on Google Scholar. Screening and data extraction will be conducted by two or more members of the research team, with any discrepancies resolved by consensus discussion with a third reviewer. Initial analysis will be quantitative involving a descriptive numerical summary of the characteristics of the studies and the tailoring process. Qualitative content analysis aligned to the research questions will also be conducted, and data managed  using NVivo where applicable. This scoping review is pre-registered with the Open Science Framework. Conclusions: The findings will serve a resource for implementation researchers and practitioners to guide future research in this field and facilitate systematic, transparent, and replicable development of tailored implementation strategies.

Developing and Evaluating Behaviour Change Interventions for People with Younger-Onset Type 2 Diabetes: Lessons and Recommendations from Existing Programmes

People with younger-onset type 2 diabetes (YOT2D, diagnosis before 40 years of age) are at higher risk of morbidity and premature mortality compared with their similar-age type 1 diabetes and later-onset type 2 diabetes peers. Despite recommendations for targeted, behavioural, and psychosocial approaches to optimising health outcomes, there are few such interventions for this group. Furthermore, evaluations of health behaviour change interventions targeting this priority population have proven challenging to complete. Despite this, there is little guidance for future behavioural programme developers. The aims of this paper are to synthesise lessons learned and recommendations from published evaluations of YOT2D-focused health behaviour change interventions, and illustrate challenges and solutions using case studies from our own experience. A rapid review of the literature identified 11 trials of behavioural interventions for YOT2D (5 randomised controlled trials, 6 pre/post studies). We sourced related needs assessment and development papers to describe the life course of each programme. We identified two development and two evaluation-related themes impacting successful trial execution. Development recommendations include ensuring appropriate adaptation of existing interventions to the unique challenges and characteristics of the target group, use of theory or theoretical frameworks throughout, and involvement of the priority population and key stakeholders from inception. Evaluation recommendations include planning for meaningful evaluation and development of age-appropriate Core Outcomes Sets. Future programme developers would benefit from closer attention to intervention development guidelines and a focus on supporting those with YOT2D to achieve behaviour change and diabetes self-management goals, ahead of change to biomedical outcomes.

Characteristics of repeat non-attenders at Diabetes Eye Screening Wales, a national community-based diabetes-related retinopathy screening service, during 2003-2018

AIMS

To understand factors associated with repeat non-attendance at screening for diabetes-related retinopathy.

METHODS

Retrospective observational study using anonymised data from Diabetic Eye Screening Wales for people with a full history of screening invitations and attendances was linked with primary and secondary care records held in the Secure Anonymised Information Linkage Databank. Repeat non-attendance was defined as no record of attendance during any 36-month period despite three cycles of annual screening invitations. The associations between repeat non-attendance and potential risk factors were examined using multivariable logistic regression analysis, stratified according to type 1 and type 2 diabetes.

RESULTS

A total of 18% with type 1 diabetes (1146/6513) and 8% with type 2 diabetes (12,475/156,525) were repeat non-attenders. Participants attending their very first appointment were least likely to become repeat non-attenders [odds ratio (95% confidence interval)]: type 1 diabetes: 0.12 (0.09, 0.17) and type 2 diabetes: 0.08 (0.07, 0.09). For both types of diabetes, those of a younger age, living in areas of higher deprivation and subject to multiple house moves were at greater risk of becoming repeat non-attenders.

CONCLUSION/INTERPRETATION

A more tailored approach is needed for the younger population, those living in areas of higher deprivation and/or undergoing multiple residential relocation and to ensure attendance at their initial appointment to minimise future repeat non-attendance.

Diabetic Retinopathy Screening: A Systematic Review of Qualitative Literature

OBJECTIVES

Diabetic retinopathy is a common microvascular complication that leads to vision loss. Despite national and international organizations developing guidelines for diabetic retinopathy screening, patients with diabetes remain unscreened. Our aim was to understand facilitators and barriers influencing diabetic retinopathy screening attendance and to examine factors that promote program success.

METHODS

MEDLINE, Embase, PsycINFO and CINAHL from inception until September 23, 2019 were used for data collection. Studies were included if they were original qualitative research articles, included adults >18 years of age and assessed diabetic retinopathy screening programs or retinopathy screening as a component of a general diabetes care program. A "best-fit" framework synthesis methodology was used for this analysis.

RESULTS

Twenty-nine articles involving 1,433 participants were identified. Six themes of barriers to, and facilitators of, diabetic retinopathy screening were identified, including access to screening, knowledge and information sharing, training and skills competency, service delivery, cultural competency and psychological factors. Cost and competing interests were common barriers to access; lack of knowledge about screening services was also a frequently reported barrier. Both patients and providers identified the need for improved service delivery, especially the referral and follow-up process. Providers recognized the need for additional training, patients enumerated several psychological barriers to screening uptake and cultural considerations were believed to be important, particularly among indigenous communities.

CONCLUSIONS

To improve screening uptake, the identified challenges must be addressed while also reinforcing the facilitators. Furthermore, program administrators could model new and unsuccessful screening programs after the successful ones while also considering local peculiarities.

Identifying gaps in patient access to diabetic screening eye examinations in Ontario: a provincially representative cross-sectional study

OBJECTIVE

Diabetes is the leading cause of acquired blindness in Canadians under the age of 50 years, and diabetic retinopathy affects an estimated 500 000 Canadians. Early identification of retinopathy with screening eye examinations allows for secondary prevention. To understand the need for resource allotment in diabetic screening, we undertook a cross-sectional study of key demographics and geographics of screened and unscreened patients in Ontario.

METHODS

Ontario Health Insurance Plan (OHIP) records were derived from physician and optometry billing, matched with patients aged >19 years with prevalent diabetes between 2011 and 2013. Data were cross-correlated with demographic covariates, including age, sex, income quintile, immigrant status, as well as geographic covariates such as rurality and patient Local Health Integration Network (LHIN).

RESULTS

Of almost 1 146 000 patients included in the analysis, approximately 406 000 were unscreened. Of note, this included 234 000 adults aged 40-64 years. Approximately 818 000 patients with diabetes lived in large cities, and 301 000 (37%) were unscreened. When the City of Toronto was analyzed as an urban area with the highest density of unscreened prevalence, autocorrelation between the percentage of eye examinations among patients with diabetes aged >40 years and low-income revealed that large areas of Toronto Central correlated for low examination rates and low income. The majority (13/22) of Community Health Centres are present in these areas.

CONCLUSIONS

Large cross-sectional population statistics for diabetes prevalence and ophthalmic examinations provides a geographic and socioeconomic profile for populations of middle-aged adults in large urban areas at risk for developing diabetic retinopathy and who might benefit from interventions to improve the rates of screening eye examinations.

A Review of Advancements and Evidence Gaps in Diabetic Retinopathy Screening Models

Diabetic retinopathy (DR) is a microvascular complication of diabetes with a prevalence of ~35%, and is one of the leading causes of visual impairment in people of working age in most developed countries. The earliest stage of DR, non-proliferative DR (NPDR), may progress to sight-threatening DR (STDR). Thus, early detection of DR and active regular screening of patients with diabetes are necessary for earlier intervention to prevent sight loss. While some countries offer systematic DR screening, most nations are reliant on opportunistic screening or do not offer any screening owing to limited healthcare resources and infrastructure. Currently, retinal imaging approaches for DR screening include those with and without mydriasis, imaging in single or multiple fields, and the use of conventional or ultra-wide-field imaging. Advances in telescreening and automated detection facilitate screening in previously hard-to-reach communities. Despite the heterogeneity in approaches to fit local needs, an evidence base must be created for each model to inform practice. In this review, we appraise different aspects of DR screening, including technological advances, identify evidence gaps, and propose several studies to improve DR screening globally, with a view to identifying patients with moderate-to-severe NPDR who would benefit if a convenient treatment option to delay progression to STDR became available.

Effect of a tailored leaflet to promote diabetic retinopathy screening among young adults with type 2 diabetes: a randomised controlled trial

Background

Young adults with type 2 diabetes (aged 18–39 years) are at risk of early onset and rapid progression of diabetic retinopathy, the leading cause of blindness and vision loss in working age adults. Early detection via retinal screening can prevent most vision loss, yet screening rates are consistently lower among this priority population than the general diabetes population. We aimed to test the effect of a tailored, evidence-based brief health behaviour change intervention (leaflet) on self-reported screening uptake, and previously identified social cognitive determinants of retinal screening.

Methods

A pragmatic, two-arm randomised controlled trial was conducted from September 2014 to April 2015. Participants were stratified by prior screening uptake (Yes/No) and randomly allocated to intervention (leaflet) or ‘usual care’ control (no leaflet). Primary outcome was self-reported screening uptake four weeks post-intervention for ‘No’ participants who had not previously screened for diabetic retinopathy. Secondary outcome variables were changes in knowledge, attitudes, normative beliefs, intention and behavioural skills for all participants, irrespective of prior screening behaviour. To assess intervention effects on secondary outcome variables, we conducted independent samples t-tests (two-tailed) on pre-post change scores.

Results

129 young adults (26% no prior retinal screen) completed baseline; 101 completed post-intervention. Power to determine effect on the primary outcome was curtailed by low recruitment of individuals with no prior retinal screen and loss to follow-up. Attrition was associated significantly with country of birth, language spoken at home, and marital status. Significant intervention effect was observed for one secondary outcome variable: knowledge of diabetic retinopathy (p = .03) with moderate effect (partial eta squared η² = .05); no adverse effects were reported. Control group participants received the leaflet at study completion.

Conclusions

This study confirms that a well-designed eye health and retinal screening promotion leaflet can increase knowledge of diabetic retinopathy, an important screening predictor. The study highlights the challenges of conducting ‘real-world’ health behaviour change research with this priority population, providing insights for clinicians and researchers. Strategies to recruit, engage and retain hard-to-reach populations are discussed including nonconventional alternatives to randomised controlled trial designs. Trial registration: ACTRN12614001110673, UTN No.: U1111–1161-9803. Registered 20 October 2014 - retrospectively registered https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367127.

Behaviour change in diabetes: behavioural science advancements to support the use of theory

Behaviour is central to the management of diabetes, both for people living with diabetes and for healthcare professionals delivering evidence-based care. This review outlines the evolution of behavioural science and the application of theoretical models in diabetes care over the past 25 years. There has been a particular advancement in the development of tools and techniques to support researchers, healthcare professionals and policymakers in taking a theory-based approach, and to enhance the development, reporting and replication of successful interventions. Systematic guidance, theoretical frameworks and lists of behavioural techniques provide the tools to specify target behaviours, identify why ideal behaviours are not implemented, systematically develop theory-based interventions, describe intervention content using shared terminology, and evaluate their effects. Several examples from a range of diabetes-related behaviours (clinic attendance, self-monitoring of blood glucose, retinal screening, setting collaborative goals in diabetes) and populations (people with type 1 and type 2 diabetes, healthcare professionals) illustrate the potential for these approaches to be widely translated into diabetes care. The behavioural science approaches outlined in this review give healthcare professionals, researchers and policymakers the tools to deliver care and design interventions with an evidence-based understanding of behaviour. The challenge for the next 25 years is to refine the tools to increase their use and advocate for the role of theoretical models and behavioural science in the commissioning, funding and delivery of diabetes care.

Understanding the uptake of a national retinopathy screening programme: An audit of people with diabetes in two large primary care centres

Background: Diabetic retinopathy (DR) is estimated to affect 25–26% of the Irish population with diabetes and is one of the leading causes of blindness among working-age adults. Regular diabetic retinopathy screening (DRS) can reduce the risk of sight loss. In 2013, the new national screening programme (RetinaScreen) was introduced in Ireland. Maximising DRS uptake (consent to participate in the programme and attendance once invited) is a priority, therefore it is important to identify characteristics which determine DRS uptake among those with diabetes in Ireland. We report uptake in an Irish primary care population during the initial phase of implementation of RetinaScreen and investigate factors which predict consenting to participate in the programme. Methods: In two primary care practices, data were extracted from records of people with diabetes (type 1 and type 2) aged ≥18 years who were eligible to participate in RetinaScreen between November 2013 and August 2015. Records were checked for a RetinaScreen letter. RetinaScreen were contacted to establish the status of those without a letter on file. Multivariable Poisson regression was used to examine associations between socio-demographic variables and consenting. Adjusted incident rate ratios (IRR) with 95% CI were generated as a measure of association. Results: Of 722 people with diabetes, one fifth (n=141) were not registered with RetinaScreen. Of 582 who were registered, 63% (n=365) had participated in screening. Most people who consented subsequently attended (n=365/382, 96%). People who had attended another retinopathy screening service were less likely to consent (IRR 0.65 [95%CI 0.5-0.8]; p<0.001). Other predictors were not significantly associated with consent. Conclusions: Over one third of eligible participants in RetinaScreen had not consented. Research is needed to understand barriers and enablers of DRS uptake in the Irish context. Implementing strategies to improve DRS uptake, barriers to consent in particular, should be a priority.

Understanding the uptake of a national retinopathy screening programme: An audit of patients with diabetes in two large primary care centres

Background: Diabetic retinopathy (DR) affects 8.2% of the Irish population with type 2 diabetes over 50 years and is one of the leading causes of blindness among working-age adults. Regular diabetic retinopathy screening (DRS) can reduce the risk of sight loss. In 2013, the new national screening programme (RetinaScreen) was introduced in Ireland. Maximising DRS uptake (consent to participate in the programme and attendance once invited) is a priority, therefore it is important to identify characteristics which determine DRS uptake among those with diabetes in Ireland. We report uptake in an Irish primary care population during the initial phase of implementation of RetinaScreen and investigate factors which predict consenting to participate in the programme. Methods:  In two primary care practices, data were extracted from records of people with diabetes (type 1 and type 2) aged ≥18 years who were eligible to participate in RetinaScreen between November 2013 and August 2015. Records were checked for a RetinaScreen letter. RetinaScreen were contacted to establish the status of those without a letter on file. Multivariable Poisson regression was used to examine associations between socio-demographic variables and consenting. Adjusted incident rate ratios (IRR) with 95% CI were generated as a measure of association. Results: Of 722 people with diabetes, one fifth (n=141) were not registered with RetinaScreen. Of 582 who were registered, 63% (n=365) had participated in screening. Most people who consented subsequently attended (n=365/382, 96%). People who had attended another retinopathy screening service were less likely to consent (IRR 0.65 [95%CI 0.5-0.8]; p<0.001). Other predictors were not significantly associated with consent. Conclusions: Over one third of people eligible to participate in RetinaScreen had not consented. Research is needed to understand barriers and enablers of DRS uptake in the Irish context. Implementing strategies to improve DRS uptake (consent and attendance) should be a priority.