Successful Diabetes Self-management Research Articles

The Self-Management-Based care interventions on quality of life in type 2 Diabetes Mellitus patients: An integrative review

Type 2 Diabetes Mellitus (T2DM) is caused by the disruption of insulin secretion and resistance. One aspect that plays an important role in this disease is self-management education. Good self-care behavior facilitates controlled diabetes management and prevents complications as well as ensures a better life quality. It is necessary to review the up-to-date, evidence-based literature to understand the diabetes self-management based care interventions to improve the quality of life. A literature search was performed on Scopus, PubMed, ProQuest, and Science Direct to find articles published during 2017-2022. The search for the article used different combinations of keywords with Boolean operators, including “type 2 diabetes mellitus”, “diabetes self-management” and “quality of life”. Studies were selected based on inclusion criteria, with a focus on full test articles discussing self-management of diabetes, T2DM, and quality of life with research designs such as randomized controlled trials (RCT). Eight articles met the criteria and were used in the review. Based on the review, eight articles showed that self-management interventions provide significant effectiveness for quality of life and self-care for type 2 diabetes mellitus patients. Almost all the articles stated an increase in self-care behaviors and quality of life after receiving self-management interventions. Successful diabetes self-management depends on individual self-care activities to control symptoms presented. Furthermore, regular self-management activities prevent complications from arising. Therefore, patients’ compliance with diabetes self-management is needed to improve their life quality.

Is integrating video into tech-based patient education effective for improving medication adherence? – A review

Abstract Patient education is a crucial part of the efforts to improve the level of medication adherence. Successful diabetes self-management will be achieved if health practitioners (doctors, pharmacists, nurses, and other health-related professionals) provide education to their patients. One of the multimedia platforms that are now popular in patient education and health promotion is video. This study primarily aimed to review published research examining integration of video-based digital interventions into tech-based patient education methods to promote medication adherence in diabetic patients. All of the articles presented in this review were collected from the PubMed, Science Direct, and Sage Publication databases. This review compared study samples, intervention characteristics (length of intervention and learning media), and adherence outcomes, as well as additional outcomes across the studies. Of the 304 articles reviewed, seven studies that met the criteria were found and included in the review. Overall, 57.14% of the integrated video-based interventions demonstrated improved medication adherence and 42.86% demonstrated improvement in other related health outcomes. The interventions were 7 weeks to 6 months in length and were in the form of storytelling with videos, smartphone apps, educational programs, or web-based education. It can be concluded that video-based digital interventions aimed to improve medication adherence in diabetic patients are promising. For optimum outcomes, this study highly suggests that a combination of video (synchronous and asynchronous) and a good patient education program is an ideal form of intervention for patients with type 2 diabetes. Regarding the education platform, the intervention could be humanoid robots, storytelling, mobile health (mHealth) apps, websites, robot-enhanced diabetes care, and other related tech-based programs or even conventional models.

Blood glucose estimation based on ECG signal.

Successful self-management of diabetes requires Continuous Glucose Monitors (CGMs). These CGMs have several limitations such as being invasive, expensive and limited in terms of use. Many techniques, in vain, have been proposed to overcome these limitations. Nowadays, with the help of the Internet of Medical Things (IoMT) technologies, researchers are working to find alternative solutions. They succeed to predict hypoglycemia and hyperglycemia peaks using Electrocardiogram (ECG) signals. However, they failed to use it to estimate the Blood Glucose Concentration (BGC) directly and in real time. Three patients with 08days of measurements from the D1namo dataset contributed to the study. A new technique has been proposed to estimate the BGC curves based on ECG signals. We used a convolutional neural network to segment the different regions of ECG signals as well as we extracted ECG features that were required for the next step. Then, five regression models have been employed to estimate BGC using as input sixth ECG parameters. We were able to segment the ECG signals with an accuracy of 94% using the convolutional neural network algorithm. The best performance among all simulated models was provided by Exponential Gaussian Process Regression (GPR) with Root Mean Squared Error (RMSE) values of 0.32, 0.41, 0.67 and R-squared (R2) values of 98%, 80%, and 70% for patients 01, 02 and 03 respectively. The method indicates the potential use of ECG wearable devices as non-invasive for continuous blood glucose monitoring, which is affordable and durable.

Self-Management of Diabetes in Black Men: The Flint MANUP Intervention Study

The story of John Henry, the “steel-drivin’ man”, is well known to Black men in the United States. John Henry is considered a hero because he demonstrated tremendous strength and self-determination. The MANUP diabetes program used the John Henryism, defined as high-effort active coping in the face of adversity, as the basis of a diabetes intervention for Black men. MANUP conducted four community-based focus groups identifying topics of concern to Black men with type 2 diabetes (T2D). Interestingly, the men reported that high-effort active coping was crucial for successful diabetes self-management. MANUP then developed and implemented a longitudinal culturally targeted self-management program for 33 Black men with T2D in Flint, Michigan. MANUP included discussion groups, physical activity, and an app incorporating text-messaging, group-chat, and a blood glucose monitoring dashboard to improve glycemic control (A1c). This single-group, repeated measures intervention assessed A1c three times over a six-month period. Improvements in A1c were observed at: baseline – time 2: 8.9% vs 8.6%, p=0.14; time 2 – time 3: 8.6% vs 8.1%, p=0.21; and baseline – time 3: 8.9% vs 8.1%, p=0.005. After controlling for age and insulin use, the significant reduction in A1c over 6 months remained (p=0.01). These findings demonstrate that combining mobile health technology and moderate physical activity with culturally targeted discussion topics can improve T2D self-management and reduce A1c in Black men. More community-driven longitudinal intervention studies that improve diabetes self-management among Black men are needed to achieve gender and racial health equity..

Determinants of successful diabetes self-management behaviors among women of Arab descent with Type 2 Diabetes

BackgroundType 2 Diabetes (T2D) continues to be an escalating public health problem contributes to increased morbidity and mortality. Although the complications of T2D is a major threat to the health of women of Arab descent, there is lack of information about their health practices and diabetes self-management behaviors. AimsThe purpose is to examine the impact of diabetes knowledge, social/family support, acculturation, and diabetes-related emotional distress on DSM behaviors and glycemic control among women of Arab descent utilizing the Roy Adaptation Model. MethodA non-experimental correlational descriptive design. ResultsThe BMI, Diabetes knowledge, diabetes-related emotional distress, and the level of HbA1C explained 28% of the variance in DSM behaviors. DSM behaviors were negatively related to diabetes-related emotional distress. DSM behaviors were positively related to diabetes knowledge and HbA1C. ConclusionsThe findings of this work provided a foundation for further advanced research design including experimental designs to expand the knowledge of this phenomenon and how to manage this disease successfully yet a culturally appropriate method.

Sleep, self-management, neurocognitive function, and glycemia in emerging adults with Type 1 diabetes mellitus: A research protocol.

Type 1 Diabetes (T1D) affects 1.6 million Americans, and only 14% of emerging adults ages 18-25 years achieve targets for glycemic control (A1C < 7.0%). Sleep deficiency, including habitual short sleep duration (<6.5 hr total sleep time and high within-person variability in total sleep time), is associated with poorer glycemic control. Emerging adults with T1D have a more pronounced sleep extension on weekends compared with matched controls, consistent with sleep deficiency; however, associations among sleep variability and glycemic control have not been explored in this population. Sleep deficiency may affect the complex higher-order neurocognitive functioning needed for successful diabetes self-management (DSM). We report the protocol for an ongoing study designed to characterize sleep and the associations among sleep deficiency, neurocognitive function, DSM, diabetes quality of life, and glycemia among a sample of 40 emerging adults with T1D. We monitor sleep via wrist-worn actigraphy and glucose via continuous glucose monitoring concurrently over 14 days. We are collecting data on self-report and objective sleep, a 10-min psychomotor vigilance test on a PVT-192 device, a 3-min Trail Making Test on paper, and questionnaires, including twice-daily Pittsburgh sleep diaries using Research Electronic Data Capture (REDCap)TM . Results from this study will be used to support the development and testing of the efficacy of a tailored sleep self-management intervention that may improve total sleep time, sleep variability, neurocognitive function, DSM, glycemic control, and glucose variability among emerging adults with T1D.

A Systematic Review of Fatigue in Type 2 Diabetes

Introduction: Fatigue is often found in people with type 2 diabetes and it is known as Diabetes Fatigue Syndrome. Fatigue is a widespread clinical complaint among people with type 2 diabetes (T2DM). It has been directly related to poor self-reported health and it is likely a key barrier to the successful self-management of diabetes. The aim of this study was to identify fatigue in type 2 diabetes.Methods: The databases used to identify suitable articles were Scopus, Science Direct and PubMed limited articles published between 2012 and 2019 in English with the full text available. The search utilized the keywords of “diabetes, fatigue, diabetes fatigue syndrome, and type 2 diabetes”. Searching for the articles also used “AND”. Following the search, 7 articles met the inclusion criteria.Results: The studies were classified into 3 groups based on the causes of fatigue. The causes of fatigue involve physiological factors, psychological factors and lifestyle factors.Conclusion: Diabetes fatigue syndrome is defined as a multifactor syndrome of fatigue or easy fatigability occurring in persons with diabetes caused by a variety of lifestyle, nutritional, medical, psychological, glycemia/diabetes-related, endocrine, and iatrogenic factors.

\u2018Learning to shape life\u2019 \u2013 a qualitative study on the challenges posed by a diagnosis of diabetes mellitus type 2

BackgroundDiabetes mellitus type 2 is a central challenge for health policy and healthcare in all advanced countries. For the affected persons, living with a diagnosis of type 2 diabetes is difficult because the disease and its treatment have a considerable effect on daily life. The aim of this study was to investigate the challenges associated with a diagnosis of type 2 diabetes for those affected and the range, depth and complexities of the subjective perspectives of the patients under the conditions of the German healthcare system.MethodsA cross-sectional qualitative study was conducted using a sample of 19 adult patients with type 2 diabetes mellitus. Patients were recruited successively from two specialized diabetological practices, three general practitioner’s offices, and two hospitals. The patients were interviewed once in person using semi-structured interviews. All interviews were recorded, transcribed, and analysed based on grounded theory.ResultsPersons affected by diabetes mellitus type 2 seem to feel responsible for managing their disease. Two strategies of action could be identified: 1) patients strictly followed the recommendations of the physicians, or 2) they showed that they are knowledgably managing their diabetes mellitus type 2. The action strategy to address the disease seemed to be influenced by patients’ confidence in themselves, the effectiveness of the interventions, or the patients’ locus of control. Minor differences in educational status could be discovered, and patients who were less educated tended to follow the recommendations of the physicians very strictly and seemed to place more emphasis on being compliant, which goes hand in hand with a life with prohibitions and restrictions. In contrast, being perceived as competent patients who make their own rules to manage the disease in daily life appeared to be more important for people with higher education levels.ConclusionPatient education and self-management programmes for diabetes mellitus type 2 should take different types of learners into account. Giving less-educated patients specific recommendations for successful diabetes self-management is particularly important.Trial registrationGerman clinical trial register (DRKS-ID: DRKS00007847).

Living with painful diabetic neuropathy: insights from focus groups into fears and coping strategies

Objective: Painful diabetic neuropathy (PDN) is known to negatively affect quality of life. Being physically active is a crucial part of successful diabetes self-management, but regimen adherence is often low. Coping strategies and fears have shown to be related to less physical activity (PA). The aim of the present study was to obtain more in-depth information on psychological risk factors leading to less PA in persons with PDN.Design: Three semi-structured focus group interviews were conducted with a representative sample of persons with PDN (N = 12). Data were transcribed verbatim and analysed using a hybrid method of thematic analyses and a grounded theory approach.Main Outcome Measures: Fears and coping strategies related to PA in persons with PDN.Results: Several specific fears were identified; fear of hypoglycaemia, fear of pain increase, fear of total exhaustion, fear of physical injury, fear of falling, fear of loss of identity, and fear of negative evaluation by others. To cope with these fears, avoidance, remaining active, cognitive distraction, and acceptance strategies were described.Conclusion: In persons with PDN, diabetes-related fears and pain-related fears play a role in less engagement in PA, indicating the need for new methods for improving self-management in persons with PDN.

Implementation of Person-Centered Methods in Group-Based Diabetes Education

Healthcare professionals’ (HCPs) skills in person-centeredness are pivotal for delivering successful diabetes self-management education and support (DSMES). Many HCPs favor person-centered methods as a concept but implementation in practice remains challenging. The main focus is on information about diabetes, complications, medications, diet and exercise. This study explored how HCPs implement new methods to facilitate person-centered DSMES in groups. The study was guided by action research and divided into three phases (investigation, action, and pilot) using a variety of qualitative methods. In step one, observations were conducted across five educational settings including 49 persons with T2DM and 13 HCPs to explore HCPs’ person-centered skills. In step two, 14 HCPs collaborated in two workshops to develop new methods e.g., exercises and dialog tools to prompt discussions about psychosocial aspects of diabetes and to fit educational needs to both the individual and the group. In step three, we pilot-tested the methods using observations in three settings and interviewed 5 HCPs and 27 participants with T2DM. A final workshop was conducted to evaluate the methods. Systematic text condensation and hermeneutic analysis were used to analyze data. Implementation of the methods was characterized by three categories. Some HCPs chose not to implement the methods because they conflicted with their usual practice relying on the biomedical model. Other HCPs agreed with the concept but was unable to structure the process, leaving participants uncertain about the aim. Finally, some HCPs succeeded with implementation promoting participants’ needs, reflections and discussions in groups. Implementing methods to deliver person-centeredness is complex and requires systematic training of HCPs. The training should be structured stepwise incorporating techniques directed towards existing skills including ample time to train and reiterate skills. Disclosure V. Stenov: None. G. Wind: None. M. Vallis: Speaker's Bureau; Self; Novo Nordisk A/S. Advisory Panel; Self; Novo Nordisk Inc.. Speaker''s Bureau; Self; AbbVie Inc.. Advisory Panel; Self; Valeant Pharmaceuticals International, Inc.. Speaker's Bureau; Self; Merck &amp; Co., Inc.. Advisory Panel; Self; Sanofi. Speaker's Bureau; Self; Sanofi. S. Reventlow: None. N.F. Hempler: None.

Adolescent Perceptions of Peer Responses to Diabetes Self-Management: A Qualitative Study.

Type 1 diabetes (T1D) is more prevalent in adolescents than in adults, and the self-management of insulin-dependent diabetes is complex. T1D requires injections of insulin, self-management of blood testing, regular physical activity, and diet monitoring, which are challenging for growing and developing adolescents. Adolescents are often more concerned with how they are perceived by their peers than how they perceive themselves. Positive peer responses influence the self-care management of adolescents with T1D in school settings. By contrast, negative peer responses and avoidance behaviors threaten to negatively affect the health outcomes of adolescents with T1D. Evidence indicates that peer influence is crucial to the successful self-management of diabetes in adolescents. However, very few studies have investigated the effect of peer influence on adolescents with T1D. This article describes how adolescents with T1D perceive the responses of their peers to their diabetes self-management in school settings. Ten 12- to 17-year-old adolescents with diabetes were recruited from a pediatric endocrinology clinic at a university hospital in Taiwan. Audio-recorded interview data were transcribed verbatim and reviewed for accuracy. A thematic analysis approach was used to analyze the narrative content of semistructured interviews with participants. The rigor of the data collection and analysis was emphasized. Analysis of peer responses to the diabetes care practices of the participants revealed six themes: knowledge seeking, curiosity, enthusiasm, empathy, fearfulness, and isolation and bullying. Subthemes were categorized to illustrate how adolescents with T1D balance the challenge of diabetes self-care regimens and normal peer interactions. They were coping with the requirements of their T1D regimen and hoping to determine the perceptions of their peers toward this regimen and themselves. Understanding the perception of peer identity for adolescents with T1D provides information for diabetes education and assists school nurses to facilitate successful T1D management in adolescents.

Correlations Between A1C and Diabetes Knowledge, Diabetes Numeracy, and Food Security in a Vulnerable Type 2 Diabetes Population.

Type 2 diabetes is over-represented in vulnerable populations. Vulnerable patients managing diabetes are challenged with less-than-optimal processes and outcomes of care; thus, Healthy People 2020 and the American Diabetes Association have renewed the focus on social determinants of health with regard to the management of chronic diseases such as diabetes. This study explored the correlations between A1C and social and personal factors, including diabetes knowledge, diabetes numeracy, and food security. The Diabetes Numeracy Test-15, the Spoken Knowledge in Low Literacy Diabetes Scale, and the U.S. Department of Agriculture Food Security Questionnaire were administered to a Caucasian study population (n = 96) receiving diabetes care at a federally qualified health center. Although the correlation coefficients generated by the results obtained from the three questionnaires and A1C levels were generally small, a correlation coefficient of 0.46 was found between food security and A1C. An improved understanding of factors that contribute to the successful self-management of diabetes is necessary to improve diabetes outcomes in vulnerable populations.

A comparative effectiveness study of two culturally competent models of diabetes self-management programming for Latinos from low-income households

BackgroundDiabetes risk is extremely high for Latinos from low-income households. Health guidelines recommend that individuals learn strategies to self-manage their diabetes, but getting people to adopt required lifestyle changes is challenging and many people are not able to prevent their pre-diabetes from escalating or effectively control their diabetes. Systematic reviews show that culturally competent self-management programs can significantly improve diabetes outcomes and different models for culturally competent programming have been developed.MethodsThis patient-engaged study will compare the effectiveness of two distinct evidence-based models for culturally competent diabetes health promotion at two sites that serve a large Latino patient population from low-income households: 1) The Diabetes Self-Management Support Empowerment Model, an educational session approach, and 2) The Chronic Care Model, a holistic community-based program. Data collection will involve interviews, focus groups, surveys and assessments of each program; and testing of patient participants for A1c, depression, Body Mass Index (BMI), and chronic stress with hair cortisol levels. We will recruit a total of 240 patient-social support pairs: Patients will be adults (men and women over the age of 18) who: 1.) Enter one of the two diabetes programs during the study; 2.) Self-identify as “Latino;” 3.) Are able to identify a social support person or key member of their social network who also agrees to participate with them; 4.) Are not pregnant (participants who become pregnant during the study will be excluded); and 5.) Have household income 250% of the Federal Poverty Level (FPL) or below. Social supports will be adults who are identified by the patient participants. PRIMARY OUTCOME: Improved capacity for diabetes self-management measured through improvements in diabetes knowledge and diabetes-related patient activation. SECONDARY OUTCOME: Successful diabetes self-management as measured by improvements in A1c, depression scale scores, BMI, and circulating levels of cortisol to determine chronic stress.DiscussionOur hypothesis is that the program model that interfaces most synergistically with patients’ culture and everyday life circumstances will have the best diabetes health outcomes.Trial registrationThis study was registered with ClinicalTrials.gov on December 16, 2016 (Registration #NCT03004664).

The Experiences of Older Italian Migrants With Type 2 Diabetes: A Qualitative Study.

Older Italian migrants in Australia are a vulnerable group, with high rates of type 2 diabetes and low levels of English language proficiency. The project explored the experience of living with diabetes and factors that facilitated or inhibited access to diabetes services. Focus groups were conducted in Italian with 13 participants with type 2 diabetes, aged 68 to 85 years. Findings indicate five main themes, including (a) the value of health, (b) the impact of diabetes, (c) making changes, (d) managing diabetes, and (e) access to information and services. The social context of food, presented the greatest impediment to successful diabetes self-management for this group of older Italian migrants. Participants identified a need for greater community engagement and education. A need for greater access to interpreters and information in Italian was identified. Counselling services may be necessary for this group.

Mobile Applications for Control and Self Management of Diabetes: A Systematic Review.

Mobile applications (apps) can be very useful software on smartphones for all aspects of people's lives. Chronic diseases, such as diabetes, can be made manageable with the support of mobile apps. Applications on smartphones can also help people with diabetes to control their fitness and health. A systematic review of free apps in the English language for smartphones in three of the most popular mobile app stores: Google Play (Android), App Store (iOS) and Windows Phone Store, was performed from November to December 2015. The review of freely available mobile apps for self-management of diabetes was conducted based on the criteria for promoting diabetes self-management as defined by Goyal and Cafazzo (monitoring blood glucose level and medication, nutrition, physical exercise and body weight). The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) was followed. Three independent experts in the field of healthcare-related mobile apps were included in the assessment for eligibility and testing phase. We tested and evaluated 65 apps (21 from Google Play Store, 31 from App Store and 13 from Windows Phone Store). Fifty-six of these apps did not meet even minimal requirements or did not work properly. While a wide selection of mobile applications is available for self-management of diabetes, current results show that there are only nine (5 from Google Play Store, 3 from App Store and 1 from Windows Phone Store) out of 65 reviewed mobile apps that can be versatile and useful for successful self-management of diabetes based on selection criteria. The levels of inclusion of features based on selection criteria in selected mobile apps can be very different. The results of the study can be used as a basis to prvide app developers with certain recommendations. There is a need for mobile apps for self-management of diabetes with more features in order to increase the number of long-term users and thus influence better self-management of the disease.

A clinic-based pilot intervention to enhance diabetes management for elderly Hispanic patients.

Successful diabetes self-management requires behavioral and lifestyle changes. However, low-income patients may face challenges related to poverty that make it difficult to engage in lifestyle changes. We piloted an intervention designed to help older, low-income, Hispanic, patients with diabetes access free or low-cost community resources to enhance diabetes self-management. Results from this pilot intervention are reported. Patients were recruited at baseline to complete surveys assessing diabetes self-care activities, diabetes self-efficacy, and general self-efficacy. Volunteers were trained by a clinic social worker to help patients identify needs and make referrals to local community resources (e.g., housing, transportation, food, clothing, dental and prescription services, employment, or family social services). Identical surveys were administered at 3-month follow-up. 28 patients were recruited at baseline and 18 patients completed the follow-up assessment. No significant changes in diabetes care and self-efficacy were detected. All patients requested at least one referral to a community resource. The most common requests were for low-cost dental clinics, food assistance, and housing support. At follow-up, nine (50%) patients contacted their given referrals. The need for assistance with basic social services is high in this population. The rate of referral uptake (50%) is high for a relatively low intensity intervention. Since the completion of the pilot, the program has trained 21 volunteers and helped over 220 patients in a primary care clinic. Using a volunteer model and creating connections to existing community resources is a cost-conscious way to deliver needed services to patients.

Moving the Journey Towards Independence: Adolescents Transitioning to Successful Diabetes Self-Management

To gain a greater understanding of adolescent's experiences living with Type 1 diabetes mellitus (T1DM) and create a theoretical paradigm. Grounded theory as described by Glaser was used. Fifteen in-depth interviews were conducted with adolescent's ages 11-15 with T1DM. Symbolic interactionism is the theoretical framework for grounded theory. Data were collected; transcribed, coded, and analyzed simultaneously using constant comparative analysis and findings were grounded in the words of participants. A theoretical model was created with the concept of "normalizing". Normalizing was defined as the ability to integrate diabetes into one's daily life to make diabetes 'part of me'. Phase four of the model, and the focus of this manuscript was "Moving the Journey towards Independence" and included: 1) taking over care, 2) experiencing conflict with parents, and 3) realizing diabetes is hard. The major task for adolescents in this phase was separating from parents to independently manage diabetes. The normalizing task for this phase was: "taking on the burden of care". Adolescents described challenges with independent care and increased parental conflict including: fearing needles, forgetting insulin, feeling embarrassed and believing that diabetes was a burden in their life. Additionally, juggling the multiple responsibilities of home, school and work along with managing a chronic illness during adolescence is challenging. Transitioning to diabetes self-management is a challenge for adolescents. This model advances understanding of the moving processes in adolescents transitioning; additionally, hypotheses are presented that may be used for developing interventions to promote success in self-management.

Issues that impact type-2 diabetes self-management in rural communities.

To evaluate and synthesize the evidence related to issues that impact type-2 diabetes self-management in rural communities. A systematic review of the literature from 2008 to 2013 was conducted using the following health science databases: CINAHL, PubMed, Cochrane Library, and OVID. Other databases searched included the clearinghouses of the Centers for Disease Control (CDC); National Rural Health Association (NRHA), State Offices of Rural Health (SORH), and Rural Health Research & Policy Centers (RHRPC). Keywords used to obtain relevant articles included rural, type-2 diabetes self-management, health disparities, and nursing. Three themes emerged from the literature examined: barriers to type-2 diabetes self-management, provider tools and education enhance type-2 diabetes self-management, and recommendations and guidelines for diabetes self-management efficacy. The information presented here will support healthcare providers in improving preventative care, providing optimal disease management, and assisting with successful type-2 diabetes self-management in rural populations.

Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional

BackgroundMany adults with type 1 diabetes cannot self-manage their diabetes effectively and die prematurely with diabetic complications as a result of poor glucose control. Following the positive results obtained from a randomised controlled trial (RCT) by the Dose Adjustment For Normal Eating (DAFNE) group, published in 2002, structured training is recommended for all adults with type 1 diabetes in the UK.AimWith evidence that blood glucose control is not always improved or sustained, we sought to determine factors explaining why some patients benefit from training more than other patients, identifying barriers to successful self-management, while developing other models to make skills training more accessible and effective.FindingsWe confirmed that glycaemic outcomes are not always improved or sustained when the DAFNE programme is delivered routinely, although improvements in psychosocial outcomes are maintained. DAFNE courses and follow-up support is needed to help participants instil and habituate key self-management practices such as regular diary/record keeping. DAFNE graduates need structured professional support following training. This is currently either unavailable or provided ad hoc without a supporting evidence base. Demographic and psychosocial characteristics had minimal explanatory power in predicting glycaemic control but good explanatory power in predicting diabetes-specific quality of life over the following year. We developed a DAFNE course delivered for 1 day per week over 5 weeks. There were no major differences in outcomes between this and a standard 1-week DAFNE course; in both arms of a RCT, glycaemic control improved by less than in the original DAFNE trial. We piloted a course delivering both the DAFNE programme and pump training. The pilot demonstrated the feasibility of a full multicentre RCT and resulted in us obtaining subsequent Health Technology Assessment programme funding. In collaboration with the National Institute for Health Research (NIHR) Diabetes Research Programme at King’s College Hospital (RG-PG-0606-1142), London, an intervention for patients with hypoglycaemic problems, DAFNE HART (Dose Adjustment for Normal Eating Hypoglycaemia Awareness Restoration Training), improved impaired hypoglycaemia awareness and is worthy of a formal trial. The health economic work developed a new type 1 diabetes model and confirmed that the DAFNE programme is cost-effective compared with no structured education; indeed, it is cost-saving in the majority of our analyses despite limited glycated haemoglobin benefit. Users made important contributions but this could have been maximised by involving them with grant writing, delaying training until the group was established and funding users’ time off work to maximise attendance. Collecting routine clinical data to conduct continuing evaluated roll-out is possible but to do this effectively requires additional administrator support and/or routine electronic data capture.ConclusionsWe propose that, in future work, we should modify the current DAFNE curricula to incorporate emerging understanding of behaviour change principles to instil and habituate key self-management behaviours that include key DAFNE competencies. An assessment of numeracy, critical for insulin dose adjustment, may help to determine whether or not additional input/support is required both before and after training. Models of structured support involving professionals should be developed and evaluated, incorporating technological interventions to help overcome the barriers identified above and enable participants to build effective self-management behaviours into their everyday lives.Trial registrationClinicalTrials.gov NCT01069393.FundingThe NIHR Programme Grants for Applied Research programme.

Barriers and opportunities: a community-based participatory research study of health beliefs related to diabetes in a US Marshallese community.

This study investigates the beliefs and perceptions related to type 2 diabetes that influence diabetes self-management behaviors for Marshallese in the United States. Using the health belief model as a theoretical framework, the researchers seek to better understand the underlying beliefs that motivate or impede diabetes self-management behaviors. The community-based participatory research (CBPR) collaborative engaged in 14 months of preliminary fieldwork and conducted 2 tiers of focus groups for this project as part of the long-term commitment to reducing health inequalities in the Marshallese community. The CBPR team conducted an initial round of 2 exploratory focus groups (n = 15). Based on the knowledge gained, researchers held a second round of focus groups (n = 13) on health beliefs regarding diabetes. All participants were Marshallese, aged 18 years and older, and included men and women. Participants either had a diagnosis of diabetes or were a caretaker of someone with diabetes. The findings elucidate the structural and nonstructural barriers to successful diabetes self-management for Marshallese in the United States. Barriers include eating differently from the rest of the family, social stigma of diabetes, transportation, cost, lack of access to health care, and cultural and language barriers. While there are significant barriers to improving diabetes self-management, there are also areas of opportunity, including family and peer reinforcement to encourage proper diabetes management behaviors and a growing community desire to lift the stigma of diabetes. The CBPR team offers recommendations to make diabetes management interventions more culturally appropriate and effective for the Marshallese population.