Education and self-management for people newly diagnosed with type 2 diabetes: a qualitative study of patients' views.

OObjectives: We explored the perceptions, views and experiences of diabetes education in people with type 2 diabetes who were participating in a UK randomized controlled trial of methods of education. The intervention arm of the trial was based on DESMOND, a structured programme of group education sessions aimed at enabling self-management of diabetes, while the standard arm was usual care from general practices. Methods: Individual semi-structured interviews were conducted with 36 adult patients, of whom 19 had attended DESMOND education sessions and 17 had been randomized to receive usual care. Data analysis was based on the constant comparative method. Results: Four principal orientations towards diabetes and its management were identified: `resisters', `identity resisters, consequence accepters', `identity accepters, consequence resisters' and `accepters'. Participants offered varying accounts of the degree of personal responsibility that needed to be assumed in response to the diagnosis. Preferences for different styles of education were also expressed, with many reporting that they enjoyed and benefited from group education, although some reported ambivalence or disappointment with their experiences of education. It was difficult to identify striking thematic differences between accounts of people on different arms of the trial, although there was some very tentative evidence that those who attended DESMOND were more accepting of a changed identity and its implications for their management of diabetes. Discussion: No one single approach to education is likely to suit all people newly diagnosed with diabetes, although structured group education may suit many. This paper identifies varying orientations and preferences of people with diabetes towards forms of both education and self-management, which should be taken into account when planning approaches to education.

An examination of the UK community pharmacist's role in facilitating patient self-management of cardiovascular disease through lifestyle behaviours

The progression of cardiovascular disease (CVD) is largely modifiable through lifestyle behaviours. UK pharmacists are contractually obliged to facilitate patient self-management of chronic conditions such as CVD. Pharmacists are easily accessible health professionals who are well placed to identify “at risk” patients through medication regimes. Research has identified varying attitudes towards and levels of involvement in pharmacist-led health promotion activity. Given the diverse and exploratory nature of the work, a pragmatic, mixed methods approach was used to explore community pharmacists’ role in facilitating patient self-management of CVD. The thesis presents four studies: a qualitative study with pharmacists; a cross sectional questionnaire of community pharmacists; a systematic review and a qualitative study with patients with CVD. The qualitative study with pharmacists gave an insight into pharmacists’ experiences of giving patients with CVD lifestyle advice and the factors underpinning commonly cited barriers to providing public health services. This informed the development of the cross-sectional questionnaire which identified the predictors of pharmacists’ intentions to give two different types of advice to facilitate patient self-management. The systematic review identified a small number of interventions to prepare pharmacists to facilitate patient lifestyle behaviour change and evaluated the theories and behaviour change techniques used in successful interventions; however due to poor study quality and poor reporting of the interventions limited conclusions about the efficacy of the interventions could reliably be drawn. Finally, the qualitative study gave an insight into the experiences of patients with CVD using community pharmacy services and their expectations of the service they receive from community pharmacists. Recommendations about changes to pharmacy policy and practice in order to support pharmacists’ provision of CVD self-management advice are made.

Barriers and facilitators to asthma self-management in adolescents:a systematic review of qualitative and quantitative studies

BACKGROUND: Many adolescents have poor asthma control and impaired quality of life despite the availability of modern pharmacotherapy. Research suggests that poor adherence to treatment and limited engagement in self-management could be contributing factors. OBJECTIVE: To conduct a systematic review of the barriers and facilitators to self-management of asthma reported by adolescents using a narrative synthesis approach to integrate the findings. DESIGN: MEDLINE, EMBASE, CINAHL, and PsycINFO were searched for all types of study design. Full papers were retrieved for study abstracts that included data from participants aged 12-18 years referring to barriers or facilitators of asthma self-management behaviors. RESULTS: Sixteen studies (5 quantitative and 11 qualitative) underwent data extraction, quality appraisal, and thematic analysis. Six key themes were generated that encompassed barriers and/or facilitators to self-management of asthma in adolescents: Knowledge, Lifestyle, Beliefs and Attitudes, Relationships, Intrapersonal Characteristics, and Communication. CONCLUSIONS: There is a pressing need to prepare adolescents for self-management, using age-appropriate strategies that draw on the evidence we have synthesized. Current clinical practice should focus on ensuring adolescents have the correct knowledge, beliefs, and positive attitude to self-manage their illness. This needs to be delivered in a supportive environment that facilitates two-way communication, fosters adolescents' self-efficacy to manage their disease, and considers the wider social influences that impinge on self-management. Pediatr Pulmonol. 2016; 9999:XX-XX. © 2016 Wiley Periodicals, Inc.

Use of complementary and alternative medicine and self-tests by coronary heart disease patients

Background: Coronary heart disease patients have to learn to manage their condition to maximise quality of life and prevent recurrence or deterioration. They may develop their own informal methods of self-management in addition to the advice they receive as part of formal cardiac rehabilitation programmes. This study aimed to explore the use of complementary and alternative medicines and therapies (CAM), self-test kits and attitudes towards health of UK patients one year after referral to cardiac rehabilitation. Method: Questionnaire given to 463 patients attending an assessment clinic for 12 month follow up in four West Midlands hospitals. Results: 91.1% completed a questionnaire. 29.1% of patients used CAM and/or self-test kits for self-management but few (8.9%) used both methods. CAM was more often used for treating other illnesses than for CHD management. Self-test kit use (77.2%,) was more common than CAM (31.7%,) with BP monitors being the most prevalent (80.0%). Patients obtained self-test kits from a wide range of sources, for the most part (89.5%) purchased entirely on their own initiative. Predictors of self-management were post revascularisation status and higher scores on 'holism', 'rejection of authority' and 'individual responsibility'. Predictors of self-test kit use were higher `holism' and 'individual responsibility' scores. Conclusion: Patients are independently using new technologies to monitor their cardiovascular health, a role formerly carried out only by healthcare practitioners. Post-rehabilitation patients reported using CAM for self-management less frequently than they reported using self-test kits. Reports of CAM use were less frequent than in previous surveys of similar patient groups. Automatic assumptions cannot be made by clinicians about which CHD patients are most likely to self-manage. In order to increase trust and compliance it is important for doctors to encourage all CHD patients to disclose their self-management practices and to continue to address this in follow up consultations.

Blood glucose self-monitoring in non-insulin-treated type 2 diabetes:a qualitative study of patients' perspectives

Background: Self-monitoring of blood glucose is controversial in the management of type 2 diabetes. Some research suggests that self-monitoring improves glycaemic control, whereas other research is sceptical about its value for people with type 2 diabetes who are not on insulin. Although blood glucose meters are widely available and used by this group, patients' own views are absent from the debate. Aim: To explore the pros and cons of glucose monitoring from the patients' perspectives. Design of study: Qualitative repeat-interview study. Setting: Patients were recruited from 16 general practices and three hospital clinics within four local healthcare cooperatives in Lothian, Scotland. Method: Interview data from 40 patients diagnosed with type 2 diabetes within the previous 6 months were analysed using thematic analysis informed by grounded theory. We report findings from round 1 and round 2 interviews. Results: Glucose monitoring can heighten patients' awareness of the impact of lifestyle; for example, dietary choices, on blood glucose levels. Glucose monitoring amplifies a sense of 'success' or 'failure' about self-management, often resulting in anxiety and self-blame if glucose readings remain consistently high. Moreover, monitoring can negatively effect patients' self-management when readings are counter-intuitive. Conclusion: Our analysis highlights the importance of understanding the meanings that newly diagnosed patients attach to glucose self-monitoring. To maximise the positive effects of self-monitoring, health professionals should ensure that patients understand the purpose of monitoring and should clarify with patients how readings should be interpreted. © British Journal of General Practice.

What are the practical implications for treating diabetes in light of recent evidence? Updated recommendations from the Global Partnership for Effective Diabetes Management

The Global Partnership for Effective Diabetes Management was established in 2004 to provide practical guidance to improving glycaemic control for people with type 2 diabetes. Those recommendations have been updated to take account of recent trials assessing the effects of intensive glucose control. We continue to emphasis the importance of early and sustained glycaemic control, aiming for HbA( 1c) 6.5-7% wherever safe and appropriate. Individualisation of targets and the management process is strongly encouraged to accommodate patient circumstances and to avoid hypoglycaemia. Prompt introduction of combinations of agents is suggested when monotherapy is inadequate.Treatments will preferably address the underlying pathophysiology of type 2 diabetes and integrate within a wider programme of care which also aims to reduce modifiable cardiovascular risk factors and better equip patients in the self-management of their condition.

Establishing a framework for dynamic risk management in 'intelligent' aero-engine control

The behaviour of control functions in safety critical software systems is typically bounded to prevent the occurrence of known system level hazards. These bounds are typically derived through safety analyses and can be implemented through the use of necessary design features. However, the unpredictability of real world problems can result in changes in the operating context that may invalidate the behavioural bounds themselves, for example, unexpected hazardous operating contexts as a result of failures or degradation. For highly complex problems it may be infeasible to determine the precise desired behavioural bounds of a function that addresses or minimises risk for hazardous operation cases prior to deployment. This paper presents an overview of the safety challenges associated with such a problem and how such problems might be addressed. A self-management framework is proposed that performs on-line risk management. The features of the framework are shown in context of employing intelligent adaptive controllers operating within complex and highly dynamic problem domains such as Gas-Turbine Aero Engine control. Safety assurance arguments enabled by the framework necessary for certification are also outlined.

Description and preliminary results from a structured specialist behavioural weight management group intervention:Specialist Lifestyle Management (SLiM) programme

Background -  Specialist Lifestyle Management (SLiM) is a structured patient education and self-management group weight management programme. Each session is run monthly over a 6-month period providing a less intensive long-term approach. The groups are patient-centred incorporating educational, motivational, behavioural and cognitive elements. The theoretical background, programme structure and preliminary results of SLiM are presented. Subjects/methods - The study was a pragmatic service evaluation of obese patients with a body mass index (BMI) ≥35 kg/m2 with comorbidity or ≥40 kg/m2 without comorbidity referred to a specialist weight management service in the West Midlands, UK. 828 patients were enrolled within SLiM over a 48-month period. Trained facilitators delivered the programme. Preliminary anonymised data were analysed using the intention-to-treat principle. The primary outcome measure was weight loss at 3 and 6 months with comparisons between completers and non-completers performed. The last observation carried forward was used for missing data. Results - Of the 828 enrolled within SLiM, 464 completed the programme (56%). The mean baseline weight was 135 kg (BMI=49.1 kg/m2) with 87.2% of patients having a BMI≥40 kg/m2 and 12.4% with BMI≥60 kg/m2. The mean weight change of all patients enrolled was −4.1 kg (95% CI −3.6 to −4.6 kg, p=0.0001) at the end of SLiM, with completers (n=464) achieving −5.5 kg (95% CI −4.2 to −6.2 kg, p=0.0001) and non-completers achieving −2.3 kg (p=0.0001). The majority (78.6%) who attended the 6-month programme achieved weight loss with 32.3% achieving a ≥5% weight loss. Conclusions - The SLiM programme is an effective group intervention for the management of severe and complex obesity.

Self-monitoring of blood glucose in Black Caribbean and South Asian Canadians with non-insulin treated Type 2 diabetes mellitus:a qualitative study of patients' perspectives

Background: To examine the views and current practice of SMBG among Black Caribbean and South Asian individuals with non-insulin treated Type 2 diabetes mellitus. Methods: Twelve participants completed semi-structured interviews that were guided by the Health Belief Model and analyzed using thematic network analysis. Results: The frequency of monitoring among participants varied from several times a day to once per week. Most participants expressed similar experiences regarding their views and practices of SMBG. Minor differences across gender and culture were observed. All participants understood the benefits, but not all viewed SMBG as beneficial to their personal diabetes management. SMBG can facilitate a better understanding and maintenance of self-care behaviours. However, it can trigger both positive and negative emotional responses, such as a sense of disappointment when high readings are not anticipated, resulting in emotional distress. Health care professionals play a key role in the way SMBG is perceived and used by patients. Conclusion: While the majority of participants value SMBG as a self-management tool, barriers exist that impede its practice, particularly its cost. How individuals cope with these barriers is integral to understanding why some patients adopt SMBG more than others. © 2013 Gucciardi et al.; licensee BioMed Central Ltd.

Comparison of weight loss outcomes between obese patients with and without Type 2 diabetes attending a weight management focused structured educational group

Aims: Specialist lifestyle management (SLiM) is a medically supported dietetically led structured group education and self-management programme focusing on weight management. Obese patients with Type 2 diabetes are perceived to find it more difficult to lose weight compared with those without diabetes. We aimed to compare the weight loss achieved by obese patients with or without Type 2 diabetes completing the SLiM programme. Methods: A prospective analysis of patients attending SLiM between 2009 and 2013 was conducted. Results: There were 454 obese patients (mean age 49.1 ± 11.6years, women 72.5%, body mass index 49.8 ± 9.3kg/m2, weight137.3 ± 28kg). 152/454 patients (33%) had Type 2 diabetes of which 31 (20.4%) were insulin treated. Patients with Type 2diabetes were older (52.4 ± 11.3 vs 47.5 ± 11.4 years, p < 0.001). SLiM resulted in significant weight loss in patients with (136.5 ± 27 vs 130.2 ± 25.3, p < 0.001) or without (137.6 ± 29 vs 132.6 ± 28.4, p < 0.001) Type 2 diabetes. Weight loss was comparable between patients with and without Type 2 diabetes (6.1 ± 7.9 vs5.1 ± 7kg, p = 0.2). The proportion of patients achieving ≥ 10%weight loss was similar between patients with and without Type 2diabetes (10.5% vs 9.9%, p = 0.4). Insulin-treated patients lost similar weight to those not treated with insulin (6.3 ± 9.4 vs 6.1 ± 7.6kg, p = 0.9). After adjustment for age, sex, referral weight and medications, Type 2 diabetes did not predict weight change during the SLiM programme (b = 0.3, p = 0.5). Conclusions: Attending the SLiM groups produces a significant weight loss in patients with Type 2 diabetes which is comparable to those without Type 2 diabetes. Insulin-treated patients lost similar weight to those not on insulin. Weight gain with Type 2 diabetes and insulin treatment is not ‘unavoidable’ if patients receive the appropriate support and education.

Diabetes management in care homes:steps in the right direction?

Aims: Previous research has identified several inadequacies in management of diabetes within care homes many of which were highlighted in Diabetes UK’s report Diabetes in care homes:awareness, screening, training. The aim of this study was to see if this was still the case and to identify specific areas for improvement. Methods: Thirty care homes in Birmingham were invited to participate in the study. Data were collected using a standard questionnaire based on the Diabetes UK national survey of care homes comprising questions relating to screening, self-management, care planning and local authority support. All returned responses were analysed. Results: Responses were received from 20 of the 30 care homes approached. The mean percentage of residents with diabetes in the care homes sampled was 13.7%. None of the homes screened for diabetes on admission and only 5% screened residents annually.80% of homes acknowledged providing diabetes-specific training to staff. Residents in 95% of homes had a medical review in the last 12 months: 70% with a GP, 20% with a diabetes specialist nurse/nurse. 65% of homes provided support for self-management.45% of care homes did not have individualised care plans for residents with diabetes. 35% of managers reported poor support and guidance from their local authority.Conclusions: Improvements were noted in the care provided to individuals with diabetes living in care homes in Birmingham. Aspects relating to screening, individualised care plans and support to care home staff still need attention.

Attitudes of young people with diabetes to an Internet-based virtual clinic

We assessed the feasibility of developing a virtual diabetes clinic for young people, using the Internet. The proposed content of the site would be based on self-efficacy theory, aiming to develop confidence in self-management of diabetes. A questionnaire about the proposed Website was delivered to 72 patients who attended a young person’s outpatient clinic in a district hospital. Thirty-nine replies were received, a response rate of 54%. The mean age of the respondents was 13 years. A positive attitude to the potential clinic was reported by 95% of respondents. The items rated as most useful were: quick and easy access to up-todate information about diabetes; the opportunity to ask an expert; good graphics; easy navigation; interactivity. Responses to open questions indicated that 24-hour access and anonymity in asking questions were also valued. A virtual clinic appears to be a possible method of health-care delivery to young people with diabetes.

Reducing medicines waste in the community

There is increasing concern at the amount and cost of prescribed medicines that are unused or wasted and then have to be disposed of. Previous studies have used health promotion and Dispose Unwanted Medicines Properly campaigns targeted at the patient to describe and quantify the annual cost of waste. The reasons patients return unused drugs to pharmacies have also been explored. The paper focuses on patient explanations for not needing medication; categorized as: over-collection in the past, self-management strategies, changes in medical condition, other changes in patient circumstances, or the repeat medicines policy at the surgery. The aim of the original study was to make a measurable change in prescribed medicines with a reduction in medicines wastage, whilst at the same time achieving improved standards of pharmaceutical care. Information on patient needs and behaviour came from consultation in the pharmacy monitoring forms and interview. The study was based on two medical practices in the West Midlands, UK, comparing an outer city and an inner city population. The participants were general practitioners, pharmacists and 350 repeat prescription patients. Prescriptions were issued for two three-month periods. The outcome was that 23.8% of the prescribed items were not dispensed, at a value of £13.1K, 58% of the medications that would be expected to be regularly supplied were collected. The study suggests that closer professional management at the point of dispensing and an understanding of patient experiences can help reduce the amount of unwanted medication collected by patients.

An investigation of managerial skills:Implications for personnel policy

This research explores the conceptual basis in adopting a skills approach to management development. The literature reveals a number of development approaches but only a limited appreciation of how the manager does his job i.e. of the skills that he needs. An investigation of managerial skills was conducted with 10 manager s mainly occupying middle and senior positions. The principal source of evidence was the manager's thoughts on what he did and how he did it, although the interviews were supplemented by formal and informal observation. There was also a dialectic value from discussions with other analysts/managers and empathy between analyst and practitioner also played a part. Each manager was invited to comment upon his own skills analysis as a check upon validity. The study supports the view that the manager similar to other skilled practitioners, is conceptually a model builder and operationally a navigator (Singleton 1978b) . The manager variously holds enactive, pictorial, symbolic and hybrid models that enable him to understand his world and act in it. The universal managerial function is decision making and the study presents a preliminary nomenclature in classifying decision processes or perceptual skills. Managerial skills are also reflected in interpersonal interaction where the hallmark is mutual construction and attribution and in 'self-management’ where the requirement is to cope with the inner rather than the outer world. Differences between the managers are most evident in perceptual skills, the more senior manager requiring increasing ability to process abstract information and take account of environmental uncertainty. He will also make greater use of 'off- line’ information. The practical purpose in studying managerial skills is to facilitate the improvement of managerial performance and the implications of the research for training, selection and appraisal are explored.

Diabetic patient education and motivation. Available in 2 volumes.

Diabetes mellitus is a condition which requires a high degree of patient cooperation in self-management to achieve optimal glycaemic control. The concept of patient education, to enhance the treatment and management of diabetes, is well recognised. Several diabetes education programmes have already been described, but increased knowledge of diabetes did not necessarily result in improved self-mangement or glycaemic control. Other factors, such as attitudes and motivations, may therefore be particuarly important. The aims of the present study were to investigate the influence of patients' attitudes to diabetes, and to develop motivational aspects which enable the application of knowledge to enhance self-management and compliance with treatment. Thirty-one insulin-dependent diabetic (IDD) patients entered into a 12 month educational programme, particularly designed to increase motivation. Patients' attitudes to diabetes, their knowledge and self-management skills were assessed using questionnaires and practical tests, and parameters of glycaemic control were measured. The progress of these patients was compared at intervals with a close matched group of 25 control IFF patients who continued to receive routine clinic care. Patients completing the educational programme achieved better glycaemic control (p< 0.05), greater knowledge (p< 0.001), more favourable attitudes (p< 0.03) and increased competence in management skills (p< 0.02) compared with the control group. Evaluation procedures indicated that the programme was acceptable to the patients, and was successful in terms of increasing patient motivation. Six months after completion of the programme, glycaemic control deteriorated, although knowledge, attitudes and management skills were unchanged. This might reflect the withdrawal of extrinsic motivation, attention and supervision provided during the programme. It is recommended that consideration be given to the development of patients' intrinsic motivation to achieve maximum benefit from diabetes education programmes.