Participants' perceptions of the factors that influence diabetes self-management following a structured education (DAFNE) programme

Exploring type 2 diabetes self-management practices in rural Bangladesh: facilitators, barriers and expectations-a qualitative study protocol

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a global public health crisis impacting low-income and middle-income countries such as Bangladesh. While self-management is encouraged for individuals with T2DM, there is a significant lack of knowledge regarding the factors of facilitators, barriers and expectations associated with T2DM self-management in Bangladesh. This research aims to investigate the potential elements that support, impede and are anticipated in the effective practice of self-management for T2DM in rural areas of Bangladesh.

METHODS AND ANALYSIS

This study will use an exploratory qualitative approach. 16 focus group discussions, 13 in-depth interviews and 9 key informant interviews will be conducted among multilevel stakeholders, including people with T2DM, their caregivers, healthcare providers, health managers/administrators and policy planners. Interviews will be audio-recorded, transcribed, translated and analysed using thematic analysis.

ETHICS AND DISSEMINATION

This research project has been approved by the Monash University Human Research Ethics Committee (project reference number: 39483) and the Ethical Review Committee of the Centre for Injury Prevention and Research, Bangladesh (Memo: CIPRB/ERC/2023/14). Research findings will be disseminated in peer-reviewed journals and conference presentations. Published reports will include group data. Individual data privacy will be strictly maintained.

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.

Exploring facilitators and barriers to self-management engagement of Chinese people with type 2 diabetes mellitus and poor blood glucose control: a descriptive qualitative study

AIMS

To explore facilitators and barriers to self-management engagement of Chinese people with poorly controlled type 2 diabetes.

METHODS

Purposive sampling method was used for recruitment. Semi-structured interview and thematic analysis was used for data collection and analysis.

RESULTS

Twenty-six semi-structured interviews were conducted. Poor blood glucose control introduced awareness of susceptibility to complications, while mental disorders could be concomitant. General knowledge about healthy lifestyle and unhealthy habits impeded lifestyle management. Temporary remission of hyperglycemia and no perceived symptoms interfered engagement of medication therapy and regular blood glucose monitoring. Family and work environments could impact self-management engagement. Accessibility to reliable diabetes-related information influenced self-management engagement.

CONCLUSIONS

Awareness of susceptibility to complications motivated self-management engagement, while the awareness could cause mental disorders that need to be addressed. Customized lifestyle plans and behavior change technologies were crucial for lifestyle management. The progression of diabetes, importance of continuity of medication therapy, and the value of blood glucose monitoring should be clarified in diabetes education. Building diabetes-friendly social environments and providing reliable diabetes-related information were essential.

Exploring the impact of cultural beliefs in the self-management of type 2 diabetes among Black sub-Saharan Africans in the UK - a qualitative study informed by the PEN-3 cultural model

OBJECTIVE

The purpose of this study was to examine cultural beliefs, attitudes, and practices of Black sub-Saharan Africans (BsSAs) in the UK regarding their type 2 diabetes (T2D) self-management using the concepts of the PEN-3 cultural model.

METHOD

A qualitative study involved 36 semi-structured interviews with BsSAs living with T2D in the UK to examine relevant cultural practices and beliefs that have contributed to the uneven burden of self-management behaviours. A narrative thematic analysis of the data was then conducted for the study using NVivo software and guided by the PEN-3 cultural model, which moves beyond individualistic health behaviour models of diabetes but centralises culture in understanding health behaviours.

RESULTS

Cultural perceptions and self-management behaviours of T2D varied among the BsSAs. Systems of self-management and treatment practices that were congruent with their cultural beliefs and personal priorities were seen as essential in the positive response to self-managing T2D. Knowledge and perceptions of non-conventional and alternative remedies linked to cultural beliefs reflected the existential health-seeking behaviours, and the significance attached to BsSAs negotiated cultural identities and collective practices within the communities. Social network supports were seen as enablers while advice and regimens from healthcare professionals (HCPs) were presented as medicalised and devoid of cultural sensitivities to respondents.

CONCLUSION

The study findings highlight the need to be not only aware of the negative impact of diabetes perceptions and health behaviours among the BsSA communities, but also be aware of the enabling factors and collective practices within the communities that are equally critical in influencing the self-management and health-seeking decisions of BsSAs living with T2D. PEN-3 model was significant with exploring not only how cultural context shapes health beliefs and practices, but also how social networks and systems play a critical role in enabling or nurturing positive health behaviours and health outcomes.

Development and validation of the self-management Barriers and Supports Evaluation for working-aged adults with type 1 diabetes mellitus

INTRODUCTION

To optimize type 1 diabetes mellitus self-management, experts recommend a person-centered approach, in which care is tailored to meet people's needs and preferences. Existing tools for tailoring type 1 diabetes mellitus education and support are limited by narrow focus, lack of strong association with meaningful outcomes like A1c, or having been developed before widespread use of modern diabetes technology. To facilitate comprehensive, effective tailoring for today's working-aged adults with type 1 diabetes mellitus, we developed and validated the Barriers and Supports Evaluation (BASES).

RESEARCH DESIGN AND METHODS

Participants 25-64 years of age with type 1 diabetes mellitus were recruited from clinics and a population-based registry. Content analysis of semistructured interviews (n=33) yielded a pool of 136 items, further refined to 70 candidate items on a 5-point Likert scale through cognitive interviewing and piloting. To develop and validate the tool, factor analyses were applied to responses to candidate items (n=392). Additional survey data included demographics and the Diabetes-Specific Quality of Life (QOL) Scale-Revised. To evaluate concurrent validity, hemoglobin A1c (HbA1c) values and QOL scores were regressed on domain scores.

RESULTS

Factor analyses yielded 5 domains encompassing 30 items: Learning Opportunities, Costs and Insurance, Family and Friends, Coping and Behavioral Skills, and Diabetes Provider Interactions. Models exhibited good to adequate fit (Comparative Fit Index >0.88 and Root Mean Squared Error of Approximation <0.06). All domains demonstrated significant associations with HbA1c and QOL in the expected direction, except Family and Friends. Coping and Behavioral Skills had the strongest associations with both HbA1c and QOL.

CONCLUSIONS

The BASES is a valid, comprehensive, person-centered tool that can tailor diabetes support and education to individuals' needs in a modern practice environment, improving effectiveness and uptake of services. Clinicians could use the tool to uncover patient-specific barriers that limit success in achieving HbA1c goals and optimal QOL.

Innovating the Iowa Congregate Nutrition Program: A Needs and Preference Assessment

Participation in the Congregate Nutrition Program (CNP) is declining. This study examined CNP participation motivators, barriers, menu preferences, desired facility attributes, and educational programming to help identify strategies to increase participation. Four focus groups were held (3 = CNP participants only, n = 21; 1 = non-CNP participants, n = 11). They were audio-recorded, transcribed, and analyzed for common themes. All participants were White and food secure (93.8%). The majority were educated (75.8%), female (72.2%), and aged 71-80 years old (53.1%). CNP participation motivators were affordability, healthy meals, socialization, and location convenience. CNP participation barriers were limited awareness, the low perceived need for attending the CNP, and transportation. Ideal CNP characteristics were menu choice, variety of activities, and a welcoming ambiance. Preferred marketing strategies were print advertising and word of mouth. These findings provide insight as to how the CNP may be modified to be more appealing for the older adult population.

Type 2 diabetes patients' views on prevention of hypoglycaemia - a mixed methods study investigating self-management issues and self-identified causes of hypoglycaemia

Background

Hypoglycaemia is a common and potentially avoidable adverse event in people with type 2 diabetes (T2D). It can reduce quality of life, increase healthcare costs, and reduce treatment success. We investigated self-management issues associated with hypoglycaemia and self-identified causes of hypoglycaemia in these patients.

Methods

In this mixed methods study qualitative semi-structured interviews were performed, which informed a subsequent quantitative survey in T2D patients. All interviews were audio recorded, transcribed verbatim and coded independently by two coders using directed content analysis, guided by the Theoretical Domains Framework. Descriptive statistics were used to quantify the self-management issues and causes of hypoglycaemia collected in the survey for the respondents that had experienced at least one hypoglycaemic event in the past.

Results

Sixteen participants were interviewed, aged 59–84 years. Participants perceived difficulties in managing deviations from routine, and they sometimes lacked procedural knowledge to adjust medication, nutrition or physical activity to manage their glucose levels. Grief and loss of support due to the loss of a partner interfered with self-management and lead to hypoglycaemic events. Work ethic lead some participant to overexerting themselves, which in turn lead to hypoglycaemic events. The participants had difficulties preventing hypoglycaemic events, because they did not know the cause, suffered from impaired hypoglycaemia awareness and/or did not want to regularly measure their blood glucose. When they did recognise a cause, they identified issues with nutrition, physical activity, stress or medication. In total, 40% of respondents reported regular stress as an issue, 24% reported that they regularly overestimated their physical abilities, and 22% indicated they did not always know how to adjust their medication. Around 16% of patients could not always remember whether they took their medication, and 42% always took their medication at regular times. Among the 83 respondents with at least one hypoglycaemic event, common causes for hypoglycaemia mentioned were related to physical activity (67%), low food intake (52%), deviations from routine (35%) and emotional burden (28%). Accidental overuse of medication was reported by 10%.

Conclusion

People with T2D experience various issues with self-managing their glucose levels. This study underlines the importance of daily routine and being able to adjust medication in relation to more physical activity or less food intake as well as the ability to reduce and manage stress to prevent hypoglycaemic events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01466-0.

Qualitative analysis of reasons for hospitalization for severe hypoglycemia among older adults with diabetes

BACKGROUND

Hospital admissions for severe hypoglycemia are associated with significant healthcare costs, decreased quality of life, and increased morbidity and mortality, especially for older adults with diabetes. Understanding the reasons for hypoglycemia hospitalization is essential for the development of effective interventions; yet, the causes and precipitants of hypoglycemia are not well understood.

METHODS

We conducted a qualitative study of non-nursing home patients aged 65 years or older without cognitive dysfunction admitted to a single tertiary-referral hospital with diabetes-related hypoglycemia. During the hospitalization, we conducted one-on-one, in-depth, semi-structured interviews to explore: (1) experiences with diabetes management among patients hospitalized for severe hypoglycemia; and (2) factors contributing and leading to the hypoglycemic event. Major themes and sub-themes were extracted using the constant comparative method by 3 study authors.

RESULTS

Among the 17 participants interviewed, the mean age was 78.9 years of age, 76.5% were female, 64.7% African American, 64.7% on insulin, and patients had an average of 13 chronic conditions. Patients reported: (1) surprise at hypoglycemia despite living with diabetes for many years; (2) adequate support, knowledge, and preparedness for hypoglycemia; (3) challenges balancing a diet that minimizes hyperglycemia and prevents hypoglycemia; (4) the belief that hyperglycemia necessitates medical intervention, but hypoglycemia does not; and (5) tension between clinician-prescribed treatment plans and self-management based on patients' experience. Notably, participants did not report the previously cited reasons for hypoglycemia, such as food insecurity, lack of support or knowledge, or treatment errors.

CONCLUSIONS

Our findings suggest that some hypoglycemic events may not be preventable, but in order to reduce the risk of hypoglycemia in older individuals at risk: (1) healthcare systems need to shift from their general emphasis on the avoidance of hyperglycemia towards the prevention of hypoglycemia; and (2) clinicians and patients need to work together to design treatment regimens that fit within patient capacity and are flexible enough to accommodate life's demands.

Knowledge, Perceptions and Concerns of Diabetes -Associated Complications Among Individuals Living with Type 1 and Type 2 Diabetes Mellitus

The purpose of this study was to investigate the knowledge, perceptions and concerns of individuals living with diabetes mellitus regarding the disorder and its associated long-term health complications. Individuals living with type 1 (N = 110) and type 2 (N = 100) diabetes were surveyed at the Diabetes Centre at University Hospital Galway (Ireland). A questionnaire was used to record respondent's perceptions and concerns about living with diabetes and developing associated long-term health complications, especially diabetes-induced osteopathy. Participants' responses revealed a variety of perspectives. Individuals with type 1 diabetes had a deeper understanding of the aetiology of diabetes and were more concerned about its complications than individuals with type 2 diabetes. The most recognized complications identified by the participants were retinopathy (92% type 1; 83% type 2), amputations (80% type 1; 70% type 2) and nephropathy (83% type 1; 63% type 2). Diabetes-related osteopathy was under-recognized, with 37% (type 1) and 23% (type 2) of respondents identifying bone fractures as a diabetes-related complication. Enhancing the patient awareness of this under-recognized diabetes-associated complication and ensuring that preventative measures are incorporated within health care programmes may offer methodologies to address this complication clinically.

Exploring patient empowerment

Purpose

The purpose of this paper is to develop a research framework for exploring and improving patient empowerment through the analysis of the effects produced by a satisfying physician relationship on patient involvement in the healthcare process.

Design/methodology/approach

The authors begin with a literature review of patient empowerment in healthcare, useful to highlight the importance of relational aspects. Then, the authors tested the hypotheses of the research through the analysis of 450 questionnaires. The results are analyzed through covariance-based structural equation modeling.

Findings

This paper highlights how empowerment is a more complex phenomenon, needing many dimensions to be investigated. The hypotheses were tested, and correlations computed, highlighting a medium-strong positive correlation between physician relationship and patient involvement determining satisfying patient empowerment.

Research limitations/implications

The considerations conducted in the paper are restricted to physician relationship and needs further research aimed to analyze and evaluate the changes in the patient behaviors influenced by empowerment.

Practical implications

The research points offer new insight into patient empowerment and allow the healthcare provider to create new opportunities for promoting patient empowerment through the development of quality relationship for effective patient involvement.

Originality/value

The study developed contributes new insight about patient empowerment in the healthcare management literature, proving the key role of satisfying physician relationship useful for future researches.

The Diabetes Self-Care Calendar for people with type 2 diabetes mellitus in rural Indonesia: a pilot study

Background

Diabetes self-care reminders are widely applied to improve self-care among diabetes patients. Unfortunately, there is a lack of self-care reminders for diabetes patients who live in rural areas of developing countries with limited resources.

Aims

The study evaluated the feasibility of the Diabetes Self-Care Calendar as a reminder tool for self-care.

Methods

The study was conducted in a community health centre in Pekalongan Regency, Indonesia. The Diabetes Self-Care Calendar was developed as a reminder tool following the American Association of Diabetes Educator self-care guidelines. The feasibility of the calendar was evaluated using the quality assessment questionnaire that assessed accessibility, acceptability, effectiveness, efficiency and appropriateness. The participants' qualitative feedback was organised into themes.

Results

A total of 10 patients with type 2 diabetes mellitus participated in the study. The quality of the calendar was evaluated in terms of accessibility (m = 9.5; range = 0 - 10), acceptability (m = 9.7; range = 0 - 10), effectiveness (m = 9.3; range = 0 - 10), efficiency (m = 9; range = 0 - 10) and appropriateness (m = 9; range = 0 - 10). The feasibility of the calendar was m = 9.3 (range = 9 to 9.7). Three themes emerged based on the participants' qualitative feedback included family involvement, calendar portability and calendar design.

Conclusions

The findings suggest the Diabetes Self-Care Calendar is feasible as a reminder tool for type 2 diabetes mellitus patients who live in rural areas.

Self-Management education for adults with poorly controlled epILEpsy [SMILE (UK)]: a randomised controlled trial

BACKGROUND

Epilepsy is a common neurological condition resulting in recurrent seizures. Research evidence in long-term conditions suggests that patients benefit from self-management education and that this may improve quality of life (QoL). Epilepsy self-management education has yet to be tested in a UK setting.

OBJECTIVES

To determine the effectiveness and cost-effectiveness of Self-Management education for people with poorly controlled epILEpsy [SMILE (UK)].

DESIGN

A parallel pragmatic randomised controlled trial.

SETTING

Participants were recruited from eight hospitals in London and south-east England.

PARTICIPANTS

Adults aged ≥ 16 years with epilepsy and two or more epileptic seizures in the past year, who were currently being prescribed antiepileptic drugs.

INTERVENTION

A 2-day group self-management course alongside treatment as usual (TAU). The control group received TAU.

MAIN OUTCOME MEASURES

The primary outcome is QoL in people with epilepsy at 12-month follow-up using the Quality Of Life In Epilepsy 31-P (QOLIE-31-P) scale. Other outcomes were seizure control, impact of epilepsy, medication adverse effects, psychological distress, perceived stigma, self-mastery and medication adherence. Cost-effectiveness analyses and a process evaluation were undertaken.

RANDOMISATION

A 1 : 1 ratio between trial arms using fixed block sizes of two.

BLINDING

Participants were not blinded to their group allocation because of the nature of the study. Researchers involved in data collection and analysis remained blinded throughout.

RESULTS

The trial completed successfully. A total of 404 participants were enrolled in the study [SMILE (UK), n = 205; TAU, n = 199] with 331 completing the final follow-up at 12 months [SMILE (UK), n = 163; TAU, n = 168]. In the intervention group, 61.5% completed all sessions of the course. No adverse events were found to be related to the intervention. At baseline, participants had a mean age of 41.7 years [standard deviation (SD) 14.1 years], and had epilepsy for a median of 18 years. The mean QOLIE-31-P score for the whole group at baseline was 66.0 out of 100.0 (SD 14.2). Clinically relevant levels of anxiety symptoms were reported in 53.6% of the group and depression symptoms in 28.0%. The results following an intention-to-treat analysis showed no change in any measures at the 12-month follow-up [QOLIE-31-P: SMILE (UK) mean: 67.4, SD 13.5; TAU mean: 69.5, SD 14.8]. The cost-effectiveness study showed that SMILE (UK) was possibly cost-effective but was also associated with lower QoL. The process evaluation with 20 participants revealed that a group course increased confidence by sharing with others and improved self-management behaviours.

CONCLUSIONS

For people with epilepsy and persistent seizures, a 2-day self-management education course is cost-saving, but does not improve QoL after 12-months or reduce anxiety or depression symptoms. A psychological intervention may help with anxiety and depression. Interviewed participants reported attending a group course increased their confidence and helped them improve their self-management.

FUTURE WORK

More research is needed on self-management courses, with psychological components and integration with routine monitoring.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN57937389.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 21. See the NIHR Journals Library website for further project information.

Factors influencing self-management in patients with type 2 diabetes in general practice: a qualitative study

Many Australian adults with type 2 diabetes mellitus (T2DM) do not follow recommended self-management behaviours that could prevent or delay complications. This exploratory study aimed to investigate the factors influencing self-management of T2DM in general practice. Semi-structured qualitative interviews were conducted with patients with T2DM (n = 10) and their GPs (n = 4) and practice nurses (n = 3) in a low socioeconomic area of Sydney, New South Wales, Australia. The interviews were analysed thematically using the socio-ecological model as a framework for coding. Additional themes were derived inductively based on the explicitly stated meaning of the text. Factors influencing self-management occurred on four levels of the socio-ecological model: individual (e-health literacy, motivation, time constraints); interpersonal (family and friends, T2DM education, patient-provider relationship); organisational (affordability, multidisciplinary care); and community levels (culture, self-management resources). Multi-level strategies are needed to address this wide range of factors that are beyond the scope of single services or organisations. These could include tailoring health education and resources to e-health literacy and culture; attention to social networks and the patient–provider relationship; and facilitating access to affordable on-site allied health services.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

PROSPERO registration: CRD42017067961.

Electronic supplementary material

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

Structured education using Dose Adjustment for Normal Eating (DAFNE) reduces long-term HbA1c and HbA1c variability

AIMS

Previous evidence has demonstrated that participation in the Dose Adjustment for Normal Eating (DAFNE) education programme can reduce HbA_1c and severe hypoglycaemia in people with Type 1 diabetes. In a number of studies, increased HbA_1c variability has been associated with higher diabetic morbidity and mortality. No studies have examined the impact of structured education on HbA_1c variability in Type 1 diabetes.

METHODS

People with Type 1 diabetes who had attended DAFNE were identified for inclusion from the Scottish Care Information-Diabetes dataset. HbA_1c median and variability, expressed as coefficient of variation (CV) before and after DAFNE was calculated.

RESULTS

Some 1061 individuals participated in DAFNE education and 687 met the inclusion criteria. A significant median reduction in HbA_1c [-3.5 mmol/mol (-0.3%)] was seen at 12 months with a significant reduction [-1.5 mmol/mol (-0.1%)] still seen at 60 months of follow-up. HbA_1c variability as measured by CV was significantly lower during the post-DAFNE period: 0.08 (IQR 0.05-0.12) reduced to 0.07 (IQR 0.05-0.10); P = 0.002.

CONCLUSION

The data confirm that DAFNE participation improves glycaemic control in Type 1 diabetes with benefits being sustained for 5 years. This study is the first to demonstrate reduced HbA_1c variability after completion of structured education. This is new evidence of the beneficial impact of DAFNE on glycaemic profile.

Older adults’ self-reported barriers to adherence to dietary guidelines and strategies to overcome them

Once an older adult develops type 2 diabetes, they often need to change their diet as part of the treatment. We report differences in dietary barriers and strategies to overcome them in 17 older adults without type 2. Data were gathered through 24-hour diet recalls, collected barriers and strategies in changing diet, and the health locus of control scales. Differences in barriers and strategies were partially explained by health locus of control subscales. People who believed that others (e.g. doctors) controlled their health were less likely to identify barriers or strategies to overcome them. The results contribute to training materials and decision aids.

The potential of critical social theory as an educational framework for people with epilepsy

Effective education can support people with epilepsy to develop the attributes and skills required to function as equal partners with clinical service providers, make informed decisions, and competently self-manage their healthcare. However, despite knowledge deficits, unmet information needs, and a poor sense of empowerment, the study of education for people with epilepsy is often neglected and is a poorly understood component of holistic practice within epilepsy healthcare. Historically, the only debate with regard to education and people with epilepsy has been guided either within a positivist or within a constructivist philosophy. We argue that new pedagogies are warranted, recognizing the views of people with epilepsy regarding their illness. Therefore, this paper explores the potential of an educational framework for people with epilepsy based upon critical social theory (CST). By utilizing a CST approach for education, people with epilepsy are engaged with as active 'participants'. This is a key difference that distinguishes CST from other metatheoretical frameworks. It has the potential to support people with epilepsy to acquire the skills and confidence to manage the biopsychosocial challenges associated with their condition.

Patients have unwritten duties: experiences of patients with type 1 diabetes in health care

AIM

To describe the perceptions and experiences of patients with type 1 diabetes, examine their duties and responsibilities for their own care and increase our understanding of the value-based role of patients in the changing healthcare environment.

BACKGROUND

Current type 1 diabetes care highlights the importance of self-care and of patient involvement, which implies the need to evaluate the patients' role. Little is known about patients' views about their own role, and related responsibilities and duties for their own care. This is essential if we are to promote efficient patient involvement.

DESIGN

This study had a qualitative descriptive design.

METHODS

We conducted one-to-one themed interviews with 20 patients with type 1 diabetes during summer 2013 at a diabetes polyclinic in Finland. Data were analysed using inductive content analysis.

FINDINGS

Patients with type 1 diabetes believed that their well-being and self-care required them to consider their own responsibilities and their duties towards themselves, family members, society and healthcare professionals. These duties were seen to have implications for care outcomes, quality of life, and effectiveness and economy in health care. However, patients' background, motivation, relationships with healthcare staff and patient counselling influenced whether they fulfilled those duties, which are all crucial elements in type 1 diabetes care.

CONCLUSION

Patient duties are significant for the well-being of patients with type 1 diabetes, but also for their successful involvement in their care. This study can be used to inform the development of individual care planning and support of patient involvement.

Factors influencing the adoption of self-management solutions: an interpretive synthesis of the literature on stakeholder experiences

Background

In a research context, self-management solutions, which may range from simple book diaries to complex telehealth packages, designed to facilitate patients in managing their long-term conditions, have often shown cost-effectiveness, but their implementation in practice has frequently been challenging.

Methods

We conducted an interpretive qualitative synthesis of relevant articles identified through systematic searches of bibliographic databases in July 2014. We searched PubMed (Medline/NLM), Web of Science, LISTA (EBSCO), CINAHL, Embase and PsycINFO. Coding and analysis was inductive, using the framework method to code and to categorise themes. We took a sensemaking approach to the interpretation of findings.

Results

Fifty-eight articles were selected for synthesis. Results showed that during adoption, factors identified as facilitators by some were experienced as barriers by others, and facilitators could change to barriers for the same adopter, depending on how adopters rationalise the solutions within their context when making decisions about (retaining) adoption. Sometimes, when adopters saw and experienced benefits of a solution, they continued using the solution but changed their minds when they could no longer see the benefits. Thus, adopters placed a positive value on the solution if they could constructively rationalise it (which increased adoption) and attached a negative rationale (decreasing adoption) if the solution did not meet their expectations. Key factors that influenced the way adopters rationalised the solutions consisted of costs and the added value of the solution to them and moral, social, motivational and cultural factors.

Conclusions

Considering ‘barriers’ and ‘facilitators’ for implementation may be too simplistic. Implementers could instead iteratively re-evaluate how potential facilitators and barriers are being experienced by adopters throughout the implementation process, to help adopters to retain constructive evaluations of the solution. Implementers need to pay attention to factors including (a) cost: how much resource will the intervention cost the patient or professional; (b) moral: to what extent will people adhere because they want to be ‘good’ patients and professionals; (c) social: the expectations of patients and professionals regarding the interactive support they will receive; (d) motivational: motivations to engage with the intervention and (e) cultural: how patients and professionals learn and integrate new skills into their daily routines, practices and cultures.

Self-Management and Self-Management Support Outcomes: A Systematic Review and Mixed Research Synthesis of Stakeholder Views

INTRODUCTION

Self-management has received growing attention as an effective approach for long-term condition management. Little is known about which outcomes of supported self-management are valued by patients, their families, health professionals and those who commission self-management services. This study systematically reviewed published empirical evidence in accordance with PRISMA guidelines to determine the outcomes of self-management valued by these key stakeholder groups, using three prominent exemplar conditions: colorectal cancer, diabetes and stroke.

AIM

To systematically review the literature to identify which generic outcomes of self-management have been targeted and are considered important using three exemplar conditions (colorectal cancer, diabetes and stroke), which collectively have a range of features that are likely to be representative of generic self-management issues.

METHODS

Systematic searching of nine electronic databases was conducted in addition to hand searches of review articles. Abstracts were identified against inclusion criteria and appraised independently by two reviewers, using a critical appraisal tool. Synthesis of findings was conducted using mixed research synthesis.

RESULTS

Over 20,536 abstracts were screened. 41 studies which met the review criteria were fully retrieved and appraised. The majority of evidence related to diabetes. Few studies directly focussed on stakeholders' views concerning desired self-management outcomes; the majority of evidence was derived from studies focusing upon the experience of self-management. The views of health care commissioners were absent from the literature. We identified that self-management outcomes embrace a range of indicators, from knowledge, skills, and bio-psychosocial markers of health through to positive social networks.

CONCLUSIONS

Patients', families', health professionals' and commissioners' views regarding which outcomes of self-management are important have not been clearly elicited. The extent to which bio-psychosocial indicators relate to successful self-management from the perspectives of all groups of stakeholders is unknown. Further investigation regarding which self-management outcomes are considered important by all stakeholders is necessary to guide the commissioning and design of future self-management services.

Proceedings of the 5th International DAWN Summit 2014: Acting together to make person-centred diabetes care a reality

Almost 250 stakeholders from across the world, representing all aspects of diabetes, attended the 5th International DAWN Summit. The summit focussed on the issues raised by the recently published DAWN2 study, placing particular emphasis on promoting the concept of person-centred diabetes care. Discussions between the delegates took place throughout a variety of sessions, with presentations, interactive exchanges and workshops providing a platform for clarification of common global priorities and opportunities for joint action. Following the summit, these ideas were developed further, leading to the creation of a Global Action Framework. The framework aims to support the ongoing local implementation of change in response to the DAWN2 results, while helping enable person-centred diabetes care to become a reality at all levels.

Type 1 diabetes patients' experiences of, and need for, social support after attending a structured education programme: a qualitative longitudinal investigation

AIMS AND OBJECTIVES

To explore patients' experiences of, views about and need for, social support after attending a structured education programme for type 1 diabetes.

BACKGROUND

Patients who attend structured education programmes attain short-term improvements in biomedical and quality-of-life measures but require support to sustain self-management principles over the longer term. Social support can influence patients' self-management practices; however, little is known about how programme graduates use other people's help.

DESIGN

This study was informed by the principles of grounded theory and involved concurrent data collection and analysis. Data were analysed using an inductive, thematic approach.

METHODS

In-depth interviews were undertaken postcourse, six and 12 months later, with 30 adult patients with type 1 diabetes recruited from Dose Adjustment for Normal Eating courses in the United Kingdom.

RESULTS

Patients' preferences for social support from other people ranged from wanting minimal involvement, to benefiting from auxiliary forms of assistance, to regular monitoring and policing. New self-management skills learnt on their courses prompted and facilitated patients to seek and obtain more social support. Support received/expected from parents varied according to when patients were diagnosed, but parents' use of outdated knowledge could act as a barrier to effective support. Support sought from others, including friends/colleagues, was informed by patients' domestic/employment circumstances.

CONCLUSION

This study responds to calls for deeper understanding of the social context in which chronic illness self-management occurs. It highlights how patients can solicit and receive more social support from family members and friends after implementing self-care practices taught on education programmes.

RELEVANCE TO CLINICAL PRACTICE

Health professionals including diabetes specialist nurses and dietitians should explore: patients' access to and preferences for social support; how patients might be encouraged to capitalise on social support postcourse; and new ways to inform/educate people within patients' social networks.

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

SETTING

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

RESULTS

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

CONCLUSIONS

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

Coping with SLE: just in case vs. just in time: nurse's perspective

This paper considers the experiences of people with lupus in comparison with those with diabetes, and discusses the impact of lupus specialist nurses in information-giving and education under the guise of 'just in case' vs. 'just in time'. Now recognized as a difficult condition to diagnose, lupus can lead to significant worry and distress especially during delays to diagnosis and times of high disease activity. Providing appropriate, individualized information to people with lupus is embedded in specialist nursing practice and enables individuals to use the tools of self-management approaches in gaining control over everyday symptoms.

Diabetes Attitudes, Wishes and Needs second study (DAWN2™): cross-national comparisons on barriers and resources for optimal care--healthcare professional perspective

AIMS

The second Diabetes Attitudes, Wishes and Needs (DAWN2) study sought cross-national comparisons of perceptions on healthcare provision for benchmarking and sharing of clinical practices to improve diabetes care.

METHODS

In total, 4785 healthcare professionals caring for people with diabetes across 17 countries participated in an online survey designed to assess diabetes healthcare provision, self-management and training.

RESULTS

Between 61.4 and 92.9% of healthcare professionals felt that people with diabetes needed to improve various self-management activities; glucose monitoring (range, 29.3-92.1%) had the biggest country difference, with a between-country variance of 20%. The need for a major improvement in diabetes self-management education was reported by 60% (26.4-81.4%) of healthcare professionals, with a 12% between-country variance. Provision of diabetes services differed among countries, with many healthcare professionals indicating that major improvements were needed across a range of areas, including healthcare organization [30.6% (7.4-67.1%)], resources for diabetes prevention [78.8% (60.4-90.5%)], earlier diagnosis and treatment [67.9% (45.0-85.5%)], communication between team members and people with diabetes [56.1% (22.3-85.4%)], specialist nurse availability [63.8% (27.9-90.7%)] and psychological support [62.7% (40.6-79.6%)]. In some countries, up to one third of healthcare professionals reported not having received any formal diabetes training. Societal discrimination against people with diabetes was reported by 32.8% (11.4-79.6%) of participants.

CONCLUSIONS

This survey has highlighted concerns of healthcare professionals relating to diabetes healthcare provision, self-management and training. Identifying between-country differences in several areas will allow benchmarking and sharing of clinical practices.

Barriers to self-management of diabetes

People with diabetes hold major responsibility for the day-to-day management of their chronic condition. The management that, amongst others, includes blood glucose monitoring, medication taking, diet and physical activity, aims at normalizing blood glucose levels. In many individuals, the level of glycaemia, however, frequently exceeds the recommendations. This observation, together with patients' and practitioners' reports, suggests that active self-management is suboptimal. Various reasons, both individual and environment related, contribute to the suboptimal concordance with treatment regimen. The aim of this review is to discuss some of the barriers to optimal diabetes self-management.

"This does my head in". Ethnographic study of self-management by people with diabetes

Background

Self-management is rarely studied 'in the wild'. We sought to produce a richer understanding of how people live with diabetes and why self-management is challenging for some.

Method

Ethnographic study supplemented with background documents on social context. We studied a socio-economically and ethnically diverse UK population. We sampled 30 people with diabetes (15 type 1, 15 type 2) by snowballing from patient groups, community contacts and NHS clinics. Participants (aged 5-88, from a range of ethnic and socio-economic groups) were shadowed at home and in the community for 2-4 periods of several hours (total 88 visits, 230 hours); interviewed (sometimes with a family member or carer) about their self-management efforts and support needs; and taken out for a meal. Detailed field notes were made and annotated. Data analysis was informed by structuration theory, which assumes that individuals' actions and choices depend on their dispositions and capabilities, which in turn are shaped and constrained (though not entirely determined) by wider social structures.

Results

Self-management comprised both practical and cognitive tasks (e.g. self-monitoring, menu planning, medication adjustment) and socio-emotional ones (e.g. coping with illness, managing relatives' input, negotiating access to services or resources). Self-management was hard work, and was enabled or constrained by economic, material and socio-cultural conditions within the family, workplace and community. Some people managed their diabetes skilfully and flexibly, drawing on personal capabilities, family and social networks and the healthcare system. For others, capacity to self-manage (including overcoming economic and socio-cultural constraints) was limited by co-morbidity, cognitive ability, psychological factors (e.g. under-confidence, denial) and social capital. The consequences of self-management efforts strongly influenced people's capacity and motivation to continue them.

Conclusion

Self-management of diabetes is physically, intellectually, emotionally and socially demanding. Non-engagement with self-management may make sense in the context of low personal resources (e.g. health literacy, resilience) and overwhelming personal, family and social circumstances. Success of self-management as a policy solution will be affected by interacting influences at three levels: [a] at micro level by individuals' dispositions and capabilities; [b] at meso level by roles, relationships and material conditions within the family and in the workplace, school and healthcare organisation; and [c] at macro level by prevailing economic conditions, cultural norms and expectations, and the underpinning logic of the healthcare system. We propose that the research agenda on living with diabetes be extended and the political economy of self-management systematically studied.

Perceptions of Caribbean type 2 diabetes patients on self-monitoring of blood glucose

CONTEXT

The views of type 2 diabetes (T2DM) patients have not been considered in the debate on the role of self-monitoring of blood glucose (SMBG) in the management of T2DM.

OBJECTIVE

To assess the views of T2DM patients on SMBG.

METHODS

Two previously trained research assistants used a structured pre-tested questionnaire to interview 416 T2DM patients practising SMBG in out-patient clinics in the privacy of the patients after they have consented to be interviewed.

RESULTS

79% of patients were unemployed with mean duration of diabetes of 11.8 ± 0.5 year. 94% of patients did not have health insurance policies while 86% did not belong to any diabetes support group. Although 70% of the patients identified SMBG as expensive, 94% believed it assists glycaemic control, while 89% thought it was worth the expense.

CONCLUSION

Caribbean T2DM patients believe SMBG was beneficial for the management of their diabetes and empowering them may reduce diabetes complications.