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

A qualitative evaluation of the effectiveness of behaviour change techniques used in the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention

BACKGROUND

Type 2 diabetes (T2D) is up to three times more common in people of Black African and Black Caribbean heritage living in the UK, compared to their White British counterparts. Structured education is the cornerstone of care but is less successful for people from minority ethnic groups. Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) was developed to support diabetes self-management in people of Black African and Caribbean heritage living with T2D in the UK. The intervention was designed using COM-B/behaviour change wheel methodology to specify the theory of change. In a process evaluation study, we explored how the selected behaviour change techniques (BCTs) supported behaviour change in the intervention.

METHODS

Focus groups and interviews were conducted with participants who were randomised to receive the HEAL-D intervention in a feasibility trial. A topic guide directed discussions to explore experiences of HEAL-D, key learnings and impact, and behaviour change; the interviews gave the opportunity to probe further the focus group themes and areas requiring clarification. Sessions were audio-recorded and transcribed. Framework analysis was used to explore how the selected BCTs supported behaviour change in those attending HEAL-D.

RESULTS

Thirty-six participants took part in one or both activities (44% Black African, 50% Black Caribbean, 6% Mixed race; 61% female, 83% first-generation; mean age 59.5 years, SD 10.02). Participants reported increased physical activity, reduced carbohydrate portion size and engagement in weight monitoring behaviour. BCTs to increase social opportunity (social comparison, social support) and overcome motivational barriers (credible sources and modelling) were effective in addressing cultural barriers relating to diet, stigma and health beliefs. BCTs to develop capability (demonstration, instruction, information on health consequences) were effective because of the cultural salience of the developed components. Less impactful BCTs were problem solving, graded tasks, goal setting, and feedback on outcomes.

CONCLUSIONS

BCTs in the HEAL-D intervention were effective in supporting behaviour change, particularly those promoting social opportunity, as normative cultural habits and beliefs can conflict with diabetes self-management guidance. In addition, lifestyle interventions should include opportunity for experiential learning alongside culturally salient information provision.

TRIAL REGISTRATION

number: NCT03531177, May 18th 2018.

The collaborative working group method for pre-trial knowledge mobilisation: a qualitative evaluation of a structured process for iteratively refining a complex intervention (DAFNEplus)

BACKGROUND

There is a lack of practical guidance about how to effectively mobilise knowledge at the pre-trial stage. Despite increased guidance on developing complex interventions in recent years, much of this focuses on the theory and principles behind high-quality intervention development, rather than the practical aspects of how this should be achieved. This paper shares the findings from an embedded, qualitative evaluation of the Collaborative Working Group (CWG) process, a structured approach we developed to iteratively refine a complex intervention prior to a randomised controlled trial.

METHODS

The CWG was designed and delivered to support iterative refinements to a complex intervention pre-trial as part of the DAFNEplus research programme, a large intervention development study to refine and pilot a self-management education programme for people with type 1 diabetes. The CWG comprised monthly teleconferences and four strategically timed face-to-face meetings throughout the pre-trial period to support knowledge sharing between the practitioners delivering the pilot intervention and the researchers evaluating it. We conducted an embedded qualitative study to elicit CWG members' experiences and to hear their views of the acceptability, feasibility and effectiveness of the approach. Data were generated through two focus groups with CWG members, four individual interviews with CWG facilitators and documentary analysis of meeting materials.

RESULTS

This qualitative evaluation shows that participants generally found the CWG to be an acceptable, feasible and useful approach to supporting complex intervention refinement pre-trial. The qualitative findings highlight five critical elements that shape the success and acceptability of the CWG approach: funnelling knowledge over time, negotiating trust, balancing practicalities, making epistemic compromises and managing power and hierarchy in decision-making. The findings highlight the need to build in adequate time and resources to support trust-building and knowledge sharing throughout each stage in the research process, in addition to the benefits of creating boundary-spanning roles.

CONCLUSIONS

This paper showcases a practical approach to operationalising collaborative intervention refinement and development pre-trial, with tangible lessons and recommendations for future research teams. The paper adds new insights and practical guidance to the intervention development and knowledge mobilisation fields.

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.

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.

Improving retrospective intervention descriptions: Lessons learned from research on type 2 diabetes programmes in the United Kingdom and the Republic of Ireland

In recent years, multiple countries worldwide have implemented behavioural interventions within national healthcare systems. Describing the content of these interventions is critical to improve their implementation, replication, and effectiveness, as well as to advance behavioural science. Tools, such as the Behaviour Change Technique Taxonomy, can enhance the quality of intervention description and reporting. As interventions are frequently developed without the use of such tools, retrospective coding of existing interventions to accurately characterise their content is becoming more common. However, the use of these tools for retrospective coding poses various challenges, the discussion of which has been neglected to date. This commentary discusses the challenges encountered when retrospectively describing the content of five nationally implemented programmes for type 2 diabetes in the United Kingdom and the Republic of Ireland and suggests recommendations to tackle these challenges. We present important methodological, practical, and ethical considerations for researchers to reflect on, relevant to the retrospective description of existing interventions. Specifically, we discuss (i) the importance of positive relationships and collaboration with intervention stakeholders, (ii) the practical and ethical considerations when analysing the content of implemented interventions, (iii) the independence of research teams and the potential for misclassification of intervention content, and (iv) the challenges associated with the analysis of intervention content using behavioural science tools. There is a growing demand for more robust approaches to address the methodological, practical, and ethical challenges associated with such studies. The present commentary describes key issues to be considered by research teams, as well as concrete recommendations to improve the retrospective characterisation of intervention content.

Promoting planting in front gardens: a systematic approach to intervention development

Planting in front gardens is associated with a range of human and environmental health benefits. Effective interventions aimed at cultivating this practice are, however, hampered by the paucity of theory- and evidence-based behavioural research in this context. This study aims to systematically determine a set of behaviour change interventions likely to be effective at promoting planting in front gardens amongst UK householders. The Behaviour Change Wheel framework was applied. Behavioural systems mapping was used to identify community actors relevant to front gardening. Potential behavioural influences on householders' front gardening were identified using the Capability, Opportunity, Motivation, Behaviour model. Using peer-reviewed scientific findings as evidence, behavioural influences were systematically linked to potential intervention strategies, behaviour change techniques and real-world implementation options. Finally, intervention recommendations were refined through expert evaluations and local councillor and public stakeholder feedback, evaluating them against the Acceptability, Practicability, Effectiveness, Affordability, Side effects and Equity criteria in a UK implementation context. This study formulated 12 intervention recommendations, implementable at a community level, to promote front gardening. Stakeholder feedback revealed a preference for educational and supportive (social and practical) strategies (e.g., community gardening workshops, front gardening 'starter kits') over persuasive and motivational approaches (e.g., social marketing, motivational letters from the council to householders). Householders' front gardening behaviour is complex and influenced by the behaviour of many other community actors. It also needs to be understood as a step in a continuum of other behaviours (e.g., clearing land, gardening, waste disposal). This study demonstrates the application of behavioural science to an understudied implementation context, that is, front gardening promotion, drawing on a rigorous development process promoting a transparent approach to intervention design. Stakeholder consultation allowed relevance, feasibility and practical issues to be considered. These improve the likely effectiveness of interventions in practice. The next steps include evaluating the proposed interventions in practice.

Acceptability of community health worker and peer supported interventions for ethnic minorities with type 2 diabetes: a qualitative systematic review

Objective

Ethnic minority groups in high income countries in North America, Europe, and elsewhere are disproportionately affected by T2DM with a higher risk of mortality and morbidity. The use of community health workers and peer supporters offer a way of ensuring the benefits of self-management support observed in the general population are shared by those in minoritized communities.

Materials and methods

The major databases were searched for existing qualitative evidence of participants' experiences and perspectives of self-management support for type 2 diabetes delivered by community health workers and peer supporters (CHWPs) in ethnically minoritized populations. The data were analysed using Sekhon's Theoretical Framework of Acceptability.

Results

The results are described within five domains of the framework of acceptability collapsed from seven for reasons of clarity and concision: Affective attitude described participants' satisfaction with CHWPs delivering the intervention including the open, trusting relationships that developed in contrast to those with clinical providers. In considering Burden and Opportunity Costs, participants reflected on the impact of health, transport, and the responsibilities of work and childcare on their attendance, alongside a lack of resources necessary to maintain healthy diets and active lifestyles. In relation to Cultural Sensitivity participants appreciated the greater understanding of the specific cultural needs and challenges exhibited by CHWPs. The evidence related to Intervention Coherence indicated that participants responded positively to the practical and applied content, the range of teaching materials, and interactive practical sessions. Finally, in examining the impact of Effectiveness and Self-efficacy participants described how they changed a range of health-related behaviours, had more confidence in dealing with their condition and interacting with senior clinicians and benefitted from the social support of fellow participants and CHWPs.

Conclusion

Many of the same barriers around attendance and engagement with usual self-management support interventions delivered to general populations were observed, including lack of time and resource. However, the insight of CHWPs, their culturally-sensitive and specific strategies for self-management and their development of trusting relationships presented considerable advantages.

New advances in type 1 diabetes

Type 1 diabetes is an autoimmune condition resulting in insulin deficiency and eventual loss of pancreatic β cell function requiring lifelong insulin therapy. Since the discovery of insulin more than 100 years ago, vast advances in treatments have improved care for many people with type 1 diabetes. Ongoing research on the genetics and immunology of type 1 diabetes and on interventions to modify disease course and preserve β cell function have expanded our broad understanding of this condition. Biomarkers of type 1 diabetes are detectable months to years before development of overt disease, and three stages of diabetes are now recognized. The advent of continuous glucose monitoring and the newer automated insulin delivery systems have changed the landscape of type 1 diabetes management and are associated with improved glycated hemoglobin and decreased hypoglycemia. Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and glucagon-like peptide 1 receptor agonists may find use in management in the future. Despite these rapid advances in the field, people living in under-resourced parts of the world struggle to obtain necessities such as insulin, syringes, and blood glucose monitoring essential for managing this condition. This review covers recent developments in diagnosis and treatment and future directions in the broad field of type 1 diabetes.

6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

6. Glycemic Targets: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Development of a behavior change intervention to improve physical activity adherence in individuals with metabolic syndrome using the behavior change wheel

Background

Adherence to physical activity is inadequate in adults with metabolic syndrome. Adherence to physical activity recommendations is crucial and can result in improved health outcomes and reduced medical burdens. A comprehensive behavior change intervention, including identifying determinants of adherence to physical activity recommendations, intervention options, intervention content and implementation options, was imperative for enhancing physical activity adherence. The aim of the study is to develop an intervention to increase physical activity adherence among individuals with metabolic syndrome.

Methods

The study followed the eight steps of the Behavior Change Wheel guide, including defining the problem in behavioral terms (Step 1), selecting target behavior (Step 2), specifying target behavior (Step 3), identifying what needs to change (Step 4), identifying intervention functions (Step 5), identifying policy categories (Step 6), identifying behavior change techniques (Step 7), and determining model of delivery (Step 8). The semi-structured, in-depth interviews were employed to identify the determinants of adherence to physical activity among twenty-eight individuals with metabolic syndrome based on capability, opportunity, motivation and behavior model. Next, the intervention functions and policy categories were chosen to address these determinants. Finally, behavior change techniques were selected to assist in the delivery of the intervention functions and be translated into intervention content.

Results

Our study identified eighteen facilitators and fifteen barriers to physical activity adherence. It resulted in the selection of seven intervention functions and nineteen behavior change techniques for the intervention program. Then, the current study identified an app as the delivery mode. Finally, a behavioral change intervention was generated for individuals with metabolic syndrome to increase physical activity recommendation adherence.

Conclusions

The Behavior Change Wheel provided a systematic approach to designing a behavior change intervention, which helped improve the health outcomes and reduce medical burdens and economic burdens among individuals with metabolic syndrome. The findings suggested that potential intervention should pay special attention to increasing knowledge in metabolic syndrome, imparting skills of physical activity, offering a supportive environment, and providing suggestions on regular physical activity using the appropriate behavior change techniques. A feasibility study will be undertaken to assess the acceptability and effectiveness of the intervention program in the future.

Supporting Behavior Change After AECOPD - Development of a Hospital-Initiated Intervention Using the Behavior Change Wheel

After hospitalization due to acute COPD exacerbations, patient-manageable behaviors influence rehospitalization frequency. This study's aim was to develop a hospital-ward-initiated Behaviour-Change-Wheel (BCW)-based intervention targeting patients' key health behaviors, with the aim to increase quality of life and reduce rehospitalization frequency. Intervention development was performed by University Hospital Zurich working groups and followed the three BCW stages for each of the three key literature-identified problems: insufficient exacerbation management, lack of physical activity and ongoing smoking. In stage one, by analyzing published evidence - including but not limited to patients' perspective - and health professionals' perspectives regarding these problems, we identified six target behaviors. In stage two, we identified six corresponding intervention functions. As our policy category, we chose developing guidelines and service provision. For stage three, we defined eighteen basic intervention packages using 46 Behaviour Change Techniques in our basic intervention. The delivery modes will be face-to-face and telephone contact. In the inpatient setting, this behavioral intervention will be delivered by a multi-professional team. For at least 3 months following discharge, an advanced nursing practice team will continue and coordinate the necessary care package via telephone. The intervention is embedded in a broader self-management intervention complemented by integrated care components. The BCW is a promising foundation upon which to develop our COPD intervention. In future, the interaction between the therapeutic care team-patient relationships and the delivery of the behavioral intervention will also be evaluated.

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.

A Focus Group Study of Self-Management in Patients With Glomerular Disease

INTRODUCTION

Patients with glomerular disease experience symptoms that impair their physical and mental health while managing their treatments, diet, appointments and monitoring general and specific indicators of health and their illness. We sought to describe the perspectives of patients and their care partners on self-management in glomerular disease.

METHODS

We conducted 16 focus groups involving adult patients with glomerular disease (n = 101) and their care partners (n = 34) in Australia, Hong Kong, the United Kingdom, and United States. Transcripts were analyzed thematically.

RESULTS

We identified the following 4 themes: empowered in autonomy (gaining confidence through understanding, taking ownership of disease and treatment, learning a positive health approach); overwhelmed by compounding treatment burdens (financially undermined and depleted, demoralized by side effects and harms, frustrated by fragmented and inflexible care, fear of possible drug harms); striving for stability and normalcy (making personal sacrifices, maximizing life participation, attentiveness to bodily signs, avoiding precarious health states, integrating medicines into routines); and necessity of health-sustaining relationships (buoyed by social support, fulfilling meaningful responsibilities, sharing and normalizing experiences, seeking a trusting and respectful alliance).

CONCLUSION

Patients with glomerular disease and their care partners value their capacity for autonomy and disease ownership, stability of their health, and relationships that support self-management. Strategies directed at strengthening these factors may increase self-efficacy and improve the care and outcomes for patients with glomerular disease.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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.

Perceived barriers and enablers to the provision of diabetic retinopathy screening for young adults: a cross-sectional survey of healthcare professionals working in the UK National Diabetic Eye Screening Programme

INTRODUCTION

Diabetic retinopathy screening (DRS) attendance in young adults is consistently below recommended levels. The aim of this study was to conduct a survey of screening providers in the UK Diabetic Eye Screening Programme (DESP) to identify perceived barriers and enablers to DRS attendance in young adults and elicit views on the effectiveness of strategies to improve screening uptake in this population.

RESEARCH DESIGN AND METHODS

Members of the British Association of Retinal Screening (n=580) were invited to complete an anonymous online survey in July 2020 assessing agreement with 37 belief statements, informed by the Theoretical Domains Framework (TDF) of behavior change, describing potential barrier/enablers to delivering DRS for young adults and further survey items exploring effectiveness of strategies to improve uptake of DRS.

RESULTS

In total, 140 (24%) responses were received mostly from screener/graders (67.1%). There was a high level of agreement that the DESP had a role in improving attendance in young adults (96.4%) and that more could be done to improve attendance (90.0%). The most commonly reported barriers related to TDF domains Social influences and Environmental context and resources including lack of integration of DRS with other processes of diabetes care, which limited the ability to discuss diabetes self-management. Other barriers included access to screening services and difficulties with scheduling appointments. Less than half (46.4%) of respondents reported having a dedicated strategy to improve screening uptake in young adults. Strategies perceived to be effective included: screening within the community; prompts/reminders and integrating eye screening with other diabetes services.

CONCLUSIONS

Screening providers were concerned about screening uptake in young adults, although many programs lacked a dedicated strategy to improve attendance. Problems associated with a lack of integration between DRS with other diabetes care processes were identified as a major barrier to providing holistic care to young adults and supporting diabetes self-management.

Staying 'Covid-safe': Proposals for embedding behaviours that protect against Covid-19 transmission in the UK

OBJECTIVES

The Scientific Pandemic Insights group on Behaviours (SPI-B) as part of England's Scientific Advisory Group on Emergencies (SAGE), were commissioned by the UK Cabinet Office to identify strategies to embed infection control behaviours to minimize Covid-19 transmission in the long term.

METHODS

With minimal direct evidence available, three sources of information were used to develop a set of proposals: (1) a scoping review of literature on sustaining behaviour change, (2) a review of key principles used in risk and safety management, and (3) prior reports and reviews on behaviour change from SPI-B. The information was collated and refined through discussion with SPI-B and SAGE colleagues to finalize the proposals.

RESULTS

Embedding infection control behaviours in the long-term will require changes to the financial, social, and physical infrastructure so that people in all sections of society have the capability, opportunity, and motivation needed to underpin those behaviours. This will involve building Covid-safe educational programmes, regulating to ensure minimum standards of safety in public spaces and workspaces, using communications and social marketing to develop a Covid-safe culture and identity, and providing resources so that all sections of society can build Covid-safe behaviours into their daily lives.

CONCLUSIONS

Embedding 'Covid-safe' behaviours into people's everyday routines will require a co-ordinated programme to shape the financial, physical, and social infrastructure in the United Kingdom. Education, regulation, communications, and social marketing, and provision of resources will be required to ensure that all sections of society have the capability, opportunity, and motivation to enact the behaviours long term.

Staying 'Covid-safe': Proposals for embedding behaviours that protect against Covid-19 transmission in the UK

Objectives

The Scientific Pandemic Insights group on Behaviours (SPI‐B) as part of England’s Scientific Advisory Group on Emergencies (SAGE), were commissioned by the UK Cabinet Office to identify strategies to embed infection control behaviours to minimize Covid‐19 transmission in the long term.

Methods

With minimal direct evidence available, three sources of information were used to develop a set of proposals: (1) a scoping review of literature on sustaining behaviour change, (2) a review of key principles used in risk and safety management, and (3) prior reports and reviews on behaviour change from SPI‐B. The information was collated and refined through discussion with SPI‐B and SAGE colleagues to finalize the proposals.

Results

Embedding infection control behaviours in the long‐term will require changes to the financial, social, and physical infrastructure so that people in all sections of society have the capability, opportunity, and motivation needed to underpin those behaviours. This will involve building Covid‐safe educational programmes, regulating to ensure minimum standards of safety in public spaces and workspaces, using communications and social marketing to develop a Covid‐safe culture and identity, and providing resources so that all sections of society can build Covid‐safe behaviours into their daily lives.

Conclusions

Embedding ‘Covid‐safe’ behaviours into people’s everyday routines will require a co‐ordinated programme to shape the financial, physical, and social infrastructure in the United Kingdom. Education, regulation, communications, and social marketing, and provision of resources will be required to ensure that all sections of society have the capability, opportunity, and motivation to enact the behaviours long term.