Choosing and Using Theories in Diabetes Education Research

Randomized Trial of Long-Acting Insulin Glargine Titration Web Tool (LTHome) Versus Enhanced Usual Therapy of Glargine Titration (INNOVATE Trial)

BACKGROUND

Basal insulin titration in the real world is often unsuccessful. LTHome, a web tool, applies a rules engine-based algorithm providing insulin titration advice directly to the patient.

METHODS

This pilot, randomized trial evaluates basal insulin glargine titration by LTHome compared to enhanced usual therapy ([EUT]-diabetes education program) over 12 weeks. Important inclusion criteria: 18-75 years, type 2 diabetes, computer literacy, and HbA1c >7.0%. Trial protocol was approved by ethics board.

RESULTS

We randomized 139 subjects. The achievement of primary composite outcome (four out of seven fasting plasma glucose [FPG] within 5-7.2 mmol/L + mean for three consecutive FPG within 5-7.2 mmol/L + no severe hypoglycemia) was 15% in LTHome versus 41% in EUT (noninferiority not met, P-value = 0.92). Other outcomes were similar between the LTHome and EUT arms: alternate composite outcome achievement (last five FPG mean within the range of 5-7.2 mmol/L + no hypoglycemia, 47% and 51%, P = 0.73); A1c reduction (-1.0% and -1.1%, P = 0.66); proportion achieving A1c ≤7% (14% and 20%, P = 0.36); and hypoglycemia incidence (31% and 37%, P = 0.4), respectively. Patient satisfaction score improvements were greater in LTHome versus EUT (change in fear of hypoglycemia score P = 0.04 and change in diabetes distress score P = 0.04). The mean number of additional healthcare provider visits was 0.13 for LTHome and 1.22 for EUT (P < 0.01).

CONCLUSION

INNOVATE trial suggests clinical utility of LTHome compared to EUT in real-life settings. Further research is needed to evaluate the efficacy and safety of automated insulin titration algorithms.

Understanding physical activity in adults with type 2 diabetes after completing an exercise intervention trial: A mediation model of self-efficacy and autonomous motivation

This study was set out to test if autonomous motivation mediated the relationship between self-efficacy and 12-month physical activity (PA) in adults with type 2 diabetes involved in a randomized exercise trial. Participants (n = 234) completed questionnaires measuring barrier self-efficacy at 3 months, autonomous motivation at 6 months, and PA at 12 months. A mediational analysis of longitudinal data revealed that autonomous motivation mediated the relationship between barrier-self-efficacy and PA. High barrier self-efficacy can therefore help predict 12-month PA in adults with type 2 diabetes, although this effect is attenuated by autonomous motivation. Hence, participating in PA for autonomous reasons such as by choice and/or for fun further explains PA at 12 months in this population. Results of this study extend our understanding of the motivational constructs involved in PA in the maintenance phase. This study has important theoretical implications in that it helps to organize and consolidate well-known correlates of PA by proposing a temporal relationship between them that could be tailored in interventions.

Web-based guided insulin self-titration in patients with type 2 diabetes: the Di@log study. Design of a cluster randomised controlled trial [TC1316]

BACKGROUND

Many patients with type 2 diabetes (T2DM) are not able to reach the glycaemic target level of HbA1c < 7.0%, and therefore are at increased risk of developing severe complications. Transition to insulin therapy is one of the obstacles in diabetes management, because of barriers of both patient and health care providers. Patient empowerment, a patient-centred approach, is vital for improving diabetes management. We developed a web-based self-management programme for insulin titration in T2DM patients. The aim of our study is to investigate if this internet programme helps to improve glycaemic control more effectively than usual care.

METHODS/DESIGN

T2DM patients (n = 248), aged 35-75 years, with an HbA1c > or = 7.0%, eligible for treatment with insulin and able to use the internet will be selected from general practices in two different regions in the Netherlands. Cluster randomisation will be performed at the level of general practices. Patients in the intervention group will use a self-developed internet programme to assist them in self-titrating insulin. The control group will receive usual care.Primary outcome is the difference in change in HbA1c between intervention and control group. Secondary outcome measures are quality of life, treatment satisfaction, diabetes self-efficacy and frequency of hypoglycaemic episodes. Results will be analysed according to the intention-to-treat principle.

DISCUSSION

An internet intervention supporting self-titration of insulin therapy in T2DM patients is an innovative patient-centred intervention. The programme provides guided self-monitoring and evaluation of health and self-care behaviours through tailored feedback on input of glucose values. This is expected to result in a better performance of self-titration of insulin and consequently in the improvement of glycaemic control. The patient will be enabled to 'discover and use his or her own ability to gain mastery over his/her diabetes' and therefore patient empowerment will increase. Based on the self-regulation theory of Leventhal, we hypothesize that additional benefits will be achieved in terms of increases in treatment satisfaction, quality of life and self-efficacy.

TRIAL REGISTRATION

Dutch Trial Register TC1316.

Determinants of the use of a diabetes risk-screening test

A study was designed to investigate why people do or do not make use of a diabetes risk test developed to facilitate the timely diagnosis of diabetes. Data were collected using a web-based questionnaire, which was based on the Health Belief Model, the Theory of Planned Behavior, and the Threatening Medical Situations Inventory. People who had and had not used the risk test were recruited to complete the survey. The sample consisted of 205 respondents: 44% who had used the test and 56% who had not. The hypothesized relationships between the dependent variable (diabetes risk test use) and the determinants used in this study were tested using logistic regression analysis. Only two significant predictors of diabetes risk test use were found: gender and barriers. More women than men use the test. Furthermore, people who experience more barriers will be less inclined to use the test. The contribution of diabetes screening tests fully depends on people's willingness to use them. To optimize the usage of such test, it is especially important to address the barriers as perceived by the public. Two types of barriers must be addressed: practical barriers (time to take the test, fear of complexity of the test), and consequential barriers (fear of the disease and treatment, uncertainties about where to go in the case of an increased risk of diabetes).

A cross-cultural comparison of the developmental evolution of expertise in diabetes self-management

AIMS

The authors compare the findings of two research studies, one conducted in Japan and the other in Canada, about the developmental evolution of self-management of diabetes. In this article, the authors identify the similarities and differences that exist in the research data, proposing that the differences are situated in the different cultural perspectives of self-management that exist in both countries.

BACKGROUND

Researchers have acknowledged that self-management has cultural dimensions. Despite this, however, there are few studies that have provided a cross-cultural comparison of the experience of self-management among different cultural groups.

DESIGN

The authors conducted a critical comparative analysis of two models of developing expertise in diabetes self-management. The review included an analysis of the cultural meanings of the various terms and the underlying assumptions of both models.

CONCLUSIONS

The models shared many similarities; however, their differences were identified, such as the meaning and interpretation of various words or experiences, and shaped by the culturally bound perspectives of self and health.

RELEVANCE TO CLINICAL PRACTICE

The findings serve as a caution to imposing ethnocentric views and interpretations in diabetes care. In addition, they remind us about the importance of asking people with diabetes about what they understand, desire and understand. The findings challenge nurses to reflect on how the development of self-management of diabetes in various national contexts is influenced by health care practices that focus on control or harmony.

Designing a research study

Diabetes educators and advanced-practice nurses in diabetes care often participate in clinical research. The purpose of this article is to provide a broad overview of important decisions in planning a research study. The research process is reviewed, including the conceptual phase, the design and planning phase, the empirical phase, the analytic phase, and the dissemination phase. Issues unique to diabetes education research are highlighted.

Diabetes and education in the elderly

Diabetes mellitus (DM) in the elderly is a chronic disease where self management is a key aspect. This includes lifestyle modification (diet and exercise), medication compliance and hypoglycaemia management. Education is an important part of this process and the specific needs of the older population with DM have been underlined. The literature has shown that education through a multidisciplinary approach may improve the glycaemic control in selected elderly patients with DM. This article will focus on the evidences from the medical literature and the multiple challenges of teaching in this population.