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

Barriers and enablers to maintaining self-management behaviours after attending a self-management support intervention for type 2 diabetes: a systematic review and qualitative evidence synthesis

Attendance at type 2 diabetes self-management interventions is associated with improved outcomes. However, difficulties maintaining self-management behaviours attenuate long-term impact. This review aimed to identify and synthesise qualitative research on barriers and enablers to maintaining type 2 diabetes self-management behaviours after attending a self-management intervention. Eight electronic databases were searched to identify relevant peer-reviewed and grey literature studies. Data were synthesised using the best-fit framework synthesis approach guided by the themes and constructs identified by Kwasnicka et al. (2016) on their review of theoretical explanations for behaviour change maintenance. Study methodological limitations and confidence in findings were assessed using an adapted version of the Critical Appraisal Skills Programme (CASP) tool and the GRADE-CERQual approach respectively. Eleven articles reporting on 10 studies were included. Twenty-eight barriers and enablers were coded to the a priori themes. Barriers were commonly coded to the themes self-regulation, resources, and environmental and social influences. Enablers were commonly coded to the themes habits and maintenance motives. Methodological limitations of included studies varied, leading to moderate or low confidence in most findings. Interventions may improve behavioural maintenance by providing post-intervention support, promoting positive behaviour change motives, self-regulation, habit formation, and facilitating access to resources and support.

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.

Blood Glucose Level Time Series Forecasting: Nested Deep Ensemble Learning Lag Fusion

Blood glucose level prediction is a critical aspect of diabetes management. It enables individuals to make informed decisions about their insulin dosing, diet, and physical activity. This, in turn, improves their quality of life and reduces the risk of chronic and acute complications. One conundrum in developing time-series forecasting models for blood glucose level prediction is to determine an appropriate length for look-back windows. On the one hand, studying short histories foists the risk of information incompletion. On the other hand, analysing long histories might induce information redundancy due to the data shift phenomenon. Additionally, optimal lag lengths are inconsistent across individuals because of the domain shift occurrence. Therefore, in bespoke analysis, either optimal lag values should be found for each individual separately or a globally suboptimal lag value should be used for all. The former approach degenerates the analysis's congruency and imposes extra perplexity. With the latter, the fine-tunned lag is not necessarily the optimum option for all individuals. To cope with this challenge, this work suggests an interconnected lag fusion framework based on nested meta-learning analysis that improves the accuracy and precision of predictions for personalised blood glucose level forecasting. The proposed framework is leveraged to generate blood glucose prediction models for patients with type 1 diabetes by scrutinising two well-established publicly available Ohio type 1 diabetes datasets. The models developed undergo vigorous evaluation and statistical analysis from mathematical and clinical perspectives. The results achieved underpin the efficacy of the proposed method in blood glucose level time-series prediction analysis.

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.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Quantitative and qualitative analysis of the quality of life of Type 1 diabetes patients using insulin pumps and of those receiving multiple daily insulin injections

Introduction

Insulin pump therapy represents an alternative to multiple daily injections and can improve glycemic control and quality of life (QoL) in Type 1 diabetes mellitus (T1DM) patients. We aimed to explore the differences and factors related to the T1DM-specific QoL of such patients in Latvia.

Design and methods

A mixed-method cross-sectional study on 87 adult T1DM patients included 20 pump users and 67 users of injections who participated in the quantitative part of the study; 8 pump users and 13 injection users participated in the qualitative part. Patients were invited to participate using a dedicated digital platform. Their QoL and self-management habits were assessed using specially developed questionnaires adapted to Latvian conditions. Multiple logistic regression models were built to investigate the association between social and self-management factors and patients’ QoL. In addition, qualitative analysis of answers was performed.

Results

Insulin pump users were younger, had higher incomes, and reported higher T1DM expenses than users of multiple daily injections. There were no differences in self-management between the groups; Total QoL differed at the 0.1 significance level. In fully adjusted multiple logistic regression models, the most important factor that increased Total QoL was lower T1DM-related expenses (odds ratio, OR 7.02 [95% confidence interval 1.29; 38.0]). Men and those with more years of living with T1DM had better QoL (OR 9.62 [2.20; 42.1] and OR 1.16 [1.05; 1.29], respectively), but the method of administration was not significantly associated with QoL (OR 7.38 [0.87; 62.9]). Qualitative data supported the results of quantitative analysis.

Conclusions

QoL was the main reason to use an insulin pump, while the expense was the main reason to avoid the use of it or to stop using it. Reimbursement policies thus should be considered to enable patients to choose the more convenient method for themselves.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02029-2.

Barriers and facilitators related to self-management of shoulder pain: a systematic review and qualitative synthesis

OBJECTIVE

The objective of this review was to identify barriers and facilitators related to self-management from the perspectives of people with shoulder pain and clinicians involved in their care.

DATA SOURCES

CINAHL, MEDLINE, PsycINFO, SPORTDiscus, Embase, ProQuest Health, Web of Science, and Scopus were searched from inception to March 2022.

REVIEW METHODS

A meta-aggregative approach to the synthesis of qualitative evidence was used. Two independent reviewers identified eligible articles, extracted the data, and conducted a critical appraisal. Two reviewers independently identified and developed categories, with validation by two further researchers. Categories were discussed among the wider research team and a comprehensive set of synthesized findings was derived.

RESULTS

Twenty studies were included. From the perspective of patients, three synthesized findings were identified that influenced self-management: (1) support for self-management, including subthemes related to patient-centred support, knowledge, time, access to equipment, and patient digital literacy; (2) personal factors, including patient beliefs, patient expectations, patient motivation, pain, and therapeutic response; and (3) external factors, including influence of the clinician and therapeutic approach. From the perspective of clinicians, two synthesized findings were identified that influenced self-management: (1) support for self-management, including education, patient-centred support, patient empowerment, time, and clinician digital literacy; and (2) preferred management approach, including clinician beliefs, expectations, motivation, therapeutic approach, and therapeutic response.

CONCLUSION

The key barriers and facilitators were patient-centred support, patient beliefs, clinician beliefs, pain, and therapeutic response. Most of the included studies focused on exercise-based rehabilitation, and therefore might not fully represent barriers and facilitators to broader self-management.

Barriers and enablers to sustaining self-management behaviours after attending a self-management support intervention for type 2 diabetes: a protocol for a systematic review and qualitative evidence synthesis

Background: Attendance at self-management support interventions is associated with improved outcomes for people with type 2 diabetes. However, initial improvements are often not sustained beyond one year, which may be a result of difficulties in sustaining positive changes made to self-management behaviours. The aim of this systematic review is to synthesise qualitative research on the barriers and enablers to sustaining self-management behaviours following attendance at a self-management support intervention for type 2 diabetes.

Methods: The review will use the “best fit” framework synthesis method to develop a new conceptual model of sustained behaviour change in type 2 diabetes. MEDLINE (Ovid), EMBASE (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), SCOPUS, ProQuest Dissertations and Theses, WorldCat and Open Grey will be searched to identify primary qualitative studies. A parallel search will be conducted in Google Scholar to identify relevant theories for the development of an a priori framework to synthesise findings across studies. Methodological limitations of included studies will be assessed using an adapted version of the Critical Appraisal Skills Programme tool for Qualitative Studies. A sensitivity analysis will be conducted to examine the impact of studies with methodological limitations on synthesis findings. Confidence in the synthesis findings will be assessed using the GRADE-CERQual tool. Screening, data extraction, methodological limitation assessment, synthesis and GRADE-CERQual assessment will be conducted by one author with a second author independently verifying a randomly selected 20% sample.

Discussion: This review will develop a new model of sustained behaviour change in type 2 diabetes self-management. The findings can be used to inform the development of new interventions or revision of existing interventions to better support sustained engagement in type 2 diabetes self-management behaviours.

Type 1 Diabetes Patient Experiences Before and After Transfer from a Paediatric to an Adult Hospital

INTRODUCTION

The management of type 1 diabetes (T1D) is especially complex during adolescence when youths are transferred to adult care centres. The objectives of this qualitative study were to: a) determine the expectations of young T1D patients prior to transfer, b) evaluate the transfer process between the 2 centres, and c) evaluate the therapeutic education and care programme (TECP) in the adult centre from their point of view.

MATERIAL AND METHODS

Opinion sampling of adolescents from 2018-2019 was performed: Phase 1: adolescents with T1D prior to transfer to the adult hospital; Phase 2: adolescents with T1D one or two years after transfer and having undergone TECP. A focus group (1.5h) and semi-structured interviews (45 min) were performed and taped, transcribed, and sent to the participants for confirmation. Date analysis was performed of the transcriptions of the focus group and interviews. Fragments were selected and meta-categories created.

RESULTS

Eleven youths accepted to participate: 7 in Phase 1, 4 repeated in Phase 2 and 4 more transferred 2 years previously were added. The meta-categories obtained were: 1) perception of the quality of care and therapeutic education in the paediatric hospital. 2) transfer to the adult hospital. 3) experience of the youths 1-2 years after transfer and having undergone TECP. The data are presented in narrative form and are supported with text fragments of the participants' discussions.

DISCUSSION AND CONCLUSIONS

Analysis of patients' experience complemented by clinical-educational evaluation of TECP provides understanding of the perspectives of youths on the complexity of living with a chronic disease since childhood. It also provides information regarding the factors favouring quality care and therapeutic education, the complexity of transfer from paediatric to adult care, determination of the strong and weak points and the establishment of strategies to improve the programme.

Barriers and enablers to sustaining self-management behaviours after completing a self-management support intervention for type 2 diabetes: a protocol for a systematic review and qualitative evidence synthesis

Background: Attendance at self-management support interventions is associated with improved outcomes for people with type 2 diabetes. However, initial improvements are often not sustained beyond one year, which may be a result of difficulties in sustaining positive changes made to self-management behaviours. The aim of this systematic review is to synthesise qualitative research on the barriers and enablers to sustaining self-management behaviours following completion of a self-management support intervention for type 2 diabetes. Methods: The review will use the “best fit” framework synthesis method to develop a new conceptual model of sustained behaviour change in type 2 diabetes. MEDLINE (Ovid), EMBASE (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), SCOPUS, ProQuest Dissertations and Theses, WorldCat and Open Grey will be searched to identify primary qualitative studies. A parallel search will be conducted in Google Scholar to identify relevant theories for the development of an a priori framework to synthesise findings across studies. Methodological limitations of included studies will be assessed using an adapted version of the Critical Appraisal Skills Programme tool for Qualitative Studies. A sensitivity analysis will be conducted to examine the impact of studies with methodological limitations on synthesis findings. Confidence in the synthesis findings will be assessed using the GRADE-CERQual tool. Screening, data extraction, methodological limitation assessment, synthesis and GRADE-CERQual assessment will be conducted by one author with a second author independently verifying a randomly selected 20% sample. Discussion: This review will develop a new model of sustained behaviour change in type 2 diabetes self-management. The findings can be used to inform the development of new interventions or revision of existing interventions to better support sustained engagement in type 2 diabetes self-management behaviours.

Empowered by Intertwined Theory and Practice – Experiences From a Diabetes Sports Camp for Physically Active Adults With Type 1 Diabetes

Aims

To describe the experiences of individuals with diabetes type 1 (T1D) participating in diabetes sports camps and how acquired knowledge could be used in daily self-management.

Methods

Semi-structured telephone interviews were conducted with 15 adults with T1D. A strategic sample procedure was chosen. The interviews were analyzed using qualitative content analysis.

Results

The overarching theme ”Empowered by intertwined theory and practice”, included three main categories: Learning in a motivation-enhancing environment, incorporation of new habits and perceptions of glycemic control and health-related outcomes. The participants considered the camp to be an excellent opportunity to share feelings, ideas, and knowledge. They felt empowered by the camp atmosphere as well as supportive environment. After the camp, the general well-being was improved by incorporating new habits and improvements in glucose control.

Conclusions

A diabetes sports camp constitutes an excellent, but resource-intensive, complimentary support in diabetes care and provides opportunities for T1D individuals to become more independent and autonomous. The findings indicate the need for more directed learning activities for individuals with type 1 diabetes and health care providers to increase their competence in the area of T1D and exercise in order to adequately manage counseling in various types of sports.

Formative research to develop diabetes self-management education and support (DSMES) program for adults with Type 1 Diabetes

BACKGROUND AND AIM

There is a lack of data on effectiveness of diabetes self-management education and support (DSMES) programs for South Asian adults with type 1 diabetes mellitus (T1DM). This formative research was conducted to explore existing practices on the said subject and gather information for planning an intervention program.

METHODS AND MATERIALS

We conducted in-depth semi-structured interviews with endocrinologists, dieticians, diabetes educators and adults with T1DM. The participants were selected from a mix of public and private health facilities. Thematic analysis using inductive and deductive approach was undertaken. The intervention was developed and refined using the principles of FUSED and COM-B models.

RESULTS

In total, 28 in-depth interviews were conducted, 18 with health care professionals and 10 with adult individuals with T1DM. The results demonstrated deficiencies in the implementation of a structured self-management program for diabetes owing to several patient and healthcare system-related factors. A detailed nutritional counseling was provided at all sites by a qualified dietitian, however, carbohydrate counting was not routinely practiced. The interviews of this formative research revolved around: (a) evaluation of the existing usual care and gaps in implementation of a structured DSMES program, and (b) development of themes that will help in formulation of an intervention package and its effective delivery to the participants.

CONCLUSION

This research study comprehensively investigated the existing practices among diabetes-health care professionals caring for persons living with T1DM and rendered insights towards development of a scientific DSMES program.

Parents' experiences on the combined use of continuous subcutaneous insulin infusion and real-time continuous glucose monitoring to manage Type 1 diabetes in their children: A systematic review and meta-synthesis of qualitative studies

AIM

To explore the experiences and perspectives of the combined use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) on parents of children with TIDM on their daily life.

DESIGN

A systematic review and meta-synthesis of qualitative studies.

METHODS

A systematic literature search of English studies published in seven databases between 2006-2021: CINAHL, MEDLINE, EMBASE, PubMed, PsycINFO, Cochrane Library and Scopus. All included studies underwent the process of thematic interpretive integration by the author team.

RESULTS

Nine studies met the inclusion criteria. Six derived themes were generated which contained interacting with devices, interacting with glycaemic information, improving quality of life for parents of children with T1DM, burden of living with CSII therapy and CGM, impact on the parent-child relationship, requirement and expectation to advanced diabetes technology. Advanced diabetes technologies affect physical, emotional and relationship between the daily life of parents and their children with T1DM.

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.

Sustained type 1 diabetes self-management: Specifying the behaviours involved and their influences

AIMS

Sustained engagement in type 1 diabetes self-management behaviours is a critical element in achieving improvements in glycated haemoglobin (HbA1c) and minimising risk of complications. Evaluations of self-management programmes, such as Dose Adjustment for Normal Eating (DAFNE), typically find that initial improvements are rarely sustained beyond 12 months. This study identified behaviours involved in sustained type 1 diabetes self-management, their influences and relationships to each other.

METHODS

A mixed-methods study was conducted following the first two steps of the Behaviour Change Wheel framework. First, an expert stakeholder consultation identified behaviours involved in self-management of type 1 diabetes. Second, three evidence sources (systematic review, healthcare provider-generated 'red flags' and participant-generated 'frequently asked questions') were analysed to identify and synthesise modifiable barriers and enablers to sustained self-management. These were characterised according to the Capability-Opportunity-Motivation-Behaviour (COM-B) model.

RESULTS

150 distinct behaviours were identified and organised into three self-regulatory behavioural cycles, reflecting different temporal and situational aspects of diabetes self-management: Routine (e.g. checking blood glucose), Reactive (e.g. treating hypoglycaemia) and Reflective (e.g. reviewing blood glucose data to identify patterns). Thirty-four barriers and five enablers were identified: 10 relating to Capability, 20 to Opportunity and nine to Motivation.

CONCLUSIONS

Multiple behaviours within three self-management cycles are involved in sustained type 1 diabetes self-management. There are a wide range of barriers and enablers that should be addressed to support self-management behaviours and improve clinical outcomes. The present study provides an evidence base for refining and developing type 1 diabetes self-management programmes.

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.

A Facilitated Web-Based Self-Management Tool for People With Type 1 Diabetes Using an Insulin Pump: Intervention Development Using the Behavior Change Wheel and Theoretical Domains Framework

BACKGROUND

Type 1 diabetes (T1D) requires intensive self-management (SM). An insulin pump is designed to better support personal T1D management, but at the same time, it exacerbates the complexity and requirements of SM. Research shows that people with diabetes are likely to benefit from navigating and connecting to local means of social support and resources through web-based interventions that offer flexible, innovative, and accessible SM. However, questions remain as to which behavior change mechanisms within such resources benefit patients most and how to foster engagement with and endorsement of SM interventions.

OBJECTIVE

The aim of this study was to evaluate the perspectives and experiences of people with T1D using an insulin pump and specialist health care professionals (HCPs) and determine what behavior change characteristics and strategies are required to inform the optimization of an existing web-based social network (SN) intervention to support SM.

METHODS

Focus groups with insulin pump users (n=19) and specialist HCPs (n=20) in 6 National Health Service (NHS) trusts across the south of England examined the barriers and enablers to incorporating and self-managing an insulin pump. An analysis was undertaken using the Behavior Change Wheel and Theoretical Domains Framework, followed by a taxonomy of behavior change techniques (BCTs) to identify the contents of and strategies for the implementation of a complex health intervention.

RESULTS

A total of 4 themes represent the SM perspectives and experiences of stakeholders: (1) a desire for access to tailored and appropriate resources and information-the support and information required for successful SM are situational and contextual, and these vary according to time and life circumstances, and therefore, these need to be tailored and appropriate; (2) specific social support preferences-taking away isolation as well as providing shared learnings and practical tips, but limitations included the fear of judgment from others and self-pity from peers; (3) the environmental context, that is, capacity and knowledge of pump clinic HCPs-HCPs acknowledge the patient's need for holistic support but lack confidence in providing it; and (4) professional responsibility and associated risks and dangers, whereas HCPs are fearful of the consequences of promoting non-NHSSM support, and they question whether SM support fits into their role. BCTs were identified to address these issues.

CONCLUSIONS

The use of behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers and enablers of self-managing T1D with an insulin pump. A web-based SN intervention appears to offer additional forms of SM support while complementing NHS services. However, for intervention implementation, HCPs' apprehensions about responsibility when signposting to non-NHS SM support would need to be addressed, and opportunistic features would need to be added, through which pump users could actively engage with other people living with T1D.

What are the characteristics of the best type 1 diabetes patient education programmes (from diagnosis to long-term care), do they improve outcomes and what is required to make them more effective?

The last 20 years have witnessed a marked change in approaches to the management of type 1 diabetes in the UK. This is exemplified by National Institute of Health and Care Excellence (NICE) guidance which acknowledges that reaching and maintaining target glucose depends on people with type 1 diabetes effectively implementing flexible intensive insulin therapy. The guidance emphasizes that successful self-management requires the acquisition of complex skills and is best achieved by participation in high-quality structured education. Controlled trials and other research have shown that programmes teaching self-management can lower glucose levels while reducing hypoglycaemia, improve psychological outcomes and are highly cost-effective. An important principle of successful programmes is therapeutic education in which learning becomes a partnership between the professional and the person with diabetes who learns to fit diabetes into his/her everyday life. Other recommended elements of programmes include a written curriculum, group teaching by a professional multidisciplinary team and quality assurance. Yet many participants struggle post-course to implement and maintain skills, and overall HbA_1c levels, particularly in the UK, remain far from target. Recent studies have identified the barriers to sustained effective self-management and concluded that even high-quality programmes generally lack critical components. These include incorporating evidence from behaviour change research, exploiting the promise of new technologies in reducing the burden of self-management, and providing structured professional support once people have completed the training. Studies are currently underway to evaluate structured training courses which have added these elements and examine whether they can lower glucose to levels closer to target without impairing quality of life.

Establishment of a type 1 diabetes structured education programme suitable for Chinese patients: type 1 diabetes education in lifestyle and self adjustment (TELSA)

BACKGROUND

Various guidelines recommend that all adults diagnosed with type 1 diabetes (T1D) should be offered an evidence based, structured education programme (SEP) to optimize self-management care. China has a 13,000 annual increase in newly diagnosed T1D cases, of which 65% are adults. However, there is yet no validated SEP targeted to T1D patients in China. The purpose of this study is to establish a structured T1D self-management education programme-'Type 1 Diabetes Education in Lifestyle and Self Adjustment' (TELSA) that is adapted to medical and cultural practices in China.

METHODS

TELSA programme was developed based on the ADDIE model, following three steps: i) Semi-structured interviews were administered to 10 healthcare professionals (HCPs) and 13 T1D patients. Different topic guides, focusing on 4 dimensions including goals, contents, format of delivery, and quality assurance, were designed for either HCPs or patients. The interviews were recorded and analysed with thematic analysis. ii) Extracted themes were modified according to Delphi consultation. iii) Preliminary courses were conducted as pilot study to evaluate the effects of TELSA and optimization of the curriculum was finalized accordingly.

RESULTS

A total of 18 themes in 4 dimensions of the programme design were identified in the final version: i) goals: 'behaviour modification' and 'outcome improvement'; ii) contents: 'living with T1D', 'self-monitoring of blood glucose', 'knowing insulin', 'insulin dose adjustment', 'carbohydrates and carbohydrate counting', 'hypoglycaemia', 'complications of diabetes', 'managing psychological issues', 'physical activity', and 'question-and-answer'; iii) format: 'multidisciplinary team combined with peer support', 'face-to-face education followed by remote learning', and '2-day programme held on weekends'; and iv) quality assurance: 'after-class quiz', 'patients' feedback', and 'long-term evaluation on effectiveness'.

CONCLUSIONS

A type 1 diabetes structured education programme in China was set up and shown to be applicable under local medical, social, and cultural environment.

TRIAL REGISTRATION

NCT03610984. Date of registration: August 2, 2018.