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.

Severe hypoglycaemia in type 1 diabetes mellitus: underlying drivers and potential strategies for successful prevention

Hypoglycaemia remains an over-riding factor limiting optimal glycaemic control in type 1 diabetes. Severe hypoglycaemia is prevalent in almost half of those with long-duration diabetes and is one of the most feared diabetes-related complications. In this review, we present an overview of the increasing body of literature seeking to elucidate the underlying pathophysiology of severe hypoglycaemia and the limited evidence behind the strategies employed to prevent episodes. Drivers of severe hypoglycaemia including impaired counter-regulation, hypoglycaemia-associated autonomic failure, psychosocial and behavioural factors and neuroimaging correlates are discussed. Treatment strategies encompassing structured education, insulin analogue regimens, continuous subcutaneous insulin infusion pumps, continuous glucose sensing and beta-cell replacement therapies have been employed, yet there is little randomized controlled trial evidence demonstrating effectiveness of new technologies in reducing severe hypoglycaemia. Optimally designed interventional trials evaluating these existing technologies and using modern methods of teaching patients flexible insulin use within structured education programmes with the specific goal of preventing severe hypoglycaemia are required. Individuals at high risk need to be monitored with meticulous collection of data on awareness, as well as frequency and severity of all hypoglycaemic episodes.

Patient experience of hypoglycaemia unawareness in Type 1 diabetes: are patients appropriately concerned?

OBJECTIVE

Risk of severe hypoglycaemia is increased by absence of subjective awareness of hypoglycaemia and reduced by avoidance of minor hypoglycaemia. For many, problems persist despite educational strategies that work for others. We explored psychological factors that might inhibit the efforts of an individual in hypoglycaemia avoidance.

METHODS

People with Type 1 diabetes and hypoglycaemia unawareness gave semi-structured interviews exploring their perceptions and experiences of their condition. Identified factors were grouped into categories and analysed to establish links and form a grounded theory in a constant comparative analysis. A questionnaire was devised from the qualitative analysis to identify patients with problematic beliefs about their hypoglycaemia.

RESULTS

Saturation (no new themes emerging) was reached with 17 patients. Responses fell into two groups: high concern and low concern regarding hypoglycaemia unawareness. Those in the first group described severe hypoglycaemia as aversive and wanted to regain awareness. The second group included three patients in whom unawareness was not associated with severe hypoglycaemia, nevertheless unhelpful attitudes which inhibited hypoglycaemia avoidance were expressed. Responses from this group fell into categories: (1) normalizing the presence of unawareness; (2) underestimating its consequences; (3) wanting to avoiding the 'sick role'; and (4) overestimating the consequences of hyperglycaemia.

CONCLUSIONS

A qualitative analysis of patient interviews identified deficits in education, technology and motivation in hypoglycaemia unawareness. Interventions can therefore be tailored to target underlying problems that prevent individual patients from regaining awareness. A brief assessment tool was devised to categorize patients' hypoglycaemia unawareness accordingly. Psychological interventions should be developed to address the problems of 'low concern' regarding hypoglycaemia unawareness.

Are depot antipsychotics more coercive than tablets? The patient's perspective

Some clinicians consider depot antipsychotics to be stigmatising, coercive and unacceptable to patients. This cross-sectional study investigated patients' perspectives of coercion for depot and oral antipsychotics. In all, 72 participants with chronic mental illness on voluntary maintenance antipsychotic medication were interviewed for their views on oral and depot medication and experiences of coercion. The MacArthur Admission Experience (short form) was adapted to explore coercion regarding medication. Mean total coercion levels were higher for those on depot (depot: mean 4.39; oral: 2.80, P = 0.027), as were perceived coercion (2.52 vs 1.73, P = 0.041) and negative pressures subscales (1.17 vs 0.33, P = 0.009). No significant differences were found for the 'voice' subscale and affective reactions. Specifically, more participants on depot felt that people try to force them to take medication (30% vs 2%, P< 0.001). Depots were perceived as more coercive than oral antipsychotics. Greater perceived coercion may explain why some consider depots to be a more stigmatising form of treatment. Although forced medication is sometimes required, the experience of coercion should be minimised by giving patients a fair say in treatment decisions, regardless of formulation.