Identifying Core Components of
Structured Education Courses for
Type 1 Diabetes
Laura Grant1, Julia Lawton2, David Hopkins3,
Jackie Elliott4, Suzanne Lucas5, Marie Clark6, Ian
MacLellan7, Mark Davies8, Simon Heller4 &
Debbie Cooke9
1Adelphi Values, Manchester 2University of Edinburgh;
3King’s College Hospital, 4University of Sheffield,
5Diabetes Modernisation Initiative, London, 6University
College London, 7Ian MacLellan, DAFNE User Action
Group (DUAG), 8Belfast City Hospital, 9University of
Surrey
Introduction
From multiple fixed doses of insulin to more complex insulin adjustment
Reduced risk of severe hypoglycaemia & improvements in overall
HbA1c
Developed in Dusseldorf, Germany
Structured education programmes, DAFNE & BERTIE
Existing measures did not capture the current approach to type 1
diabetes management
Aims
Describe and compare the way structured education courses
for type 1 diabetes have evolved in the UK, so that we could
Develop, pilot and validate a questionnaire assessment tool
of diabetes-specific self-care behaviours, for adults with type
1 diabetes.
Methods
83 courses on Diabetes Education Network
28 met NICE criteria + 1 from manual internet searching
Reason for exclusion
No reply
Course in development
Based directly on DAFNE or BERTIE
Education for both type 1 and type 2
Course too specific e.g. newly diagnosed
Not enough information
Missing data on QA and audit
Number of courses
3 courses
4 courses
6 courses
2 courses
2 courses
2 courses
2 courses
Methods
Educators from 5 courses were interviewed
(April-June 2011)
DAFNE, BERTIE, ICE, SELECT
& DAISY
Consensus meeting with 15 key stakeholders
Core Components of Courses
Core Components from
Interviews
Carbohydrate counting and insulin
dose adjustment
Hypoglycaemia management
Group work
Goal setting
Challenges
Empowerment
Summary of Process
Identified the core components of diabetes structured education
Related these components to self-care behaviours
Develop a questionnaire tool to assess the extent to which people
carry out these behaviours
Example Questionnaire Items
Routine BG Monitoring (6 items)
- I check my blood glucose when I am physically active e.g. walking,
gardening
- On average, over the last 2 weeks, how many times have you
checked your blood glucose each day?
- I carried my blood glucose meter with me
Recording & Reflecting on BG Monitoring (3 items)
- I recorded my blood glucose results e.g. in a diary, on a computer
- I recorded information that could affect my blood glucose levels
e.g. carbohydrate intake, insulin dose, exercise
- I looked for trends or patterns in my recorded blood glucose levels
and used this to adjust my quick-acting insulin
Example Questionnaire Items
Checking Ketones (2 items)
[when ill] I check my ketone levels when my blood glucose is higher than
normal
Timing of Quick-Acting Insulin with Meals (2 items)
- I took my quick-acting insulin before meals
- I took my quick-acting insulin after meals
Adjusting Quick-Acting Insulin to Carbohydrate Intake (2 items)
- I adjusted my QA insulin according to the carbohydrate I was eating
- I counted the carbohydrates I ate
I take less insulin than recommended (5 items)
- to try to avoid putting on weight
- because I am fed up with my diabetes
Response Format
5-point Likert Scale ‘never’ to ‘always’ for majority of items
611 adults with type 1 from 16 hospitals
N
Min
Max
Mean
Std
Dev
HbA1c (mmol/mol)
584
5.4
15.1
8.2
1.4
IFCC
584
35
141
67
15.2
Age
610
18
86
47
14.8
Duration
600
6 mth
73
25
15.5
Total N
N
%
Yes
376
62
No
232
38
Male
272
45
Female
338
55
Below degree level
375
61
Undergraduate degree and
higher
234
38
Yes
296
48
No
395
52
Attended structured educ
Gender
Educational level
Diabetes complications
608
610
609
611
Example Items: How did people respond?
I recorded my blood glucose results e.g. in a diary, on a
computer
Missing
Total
Never
N
163
%
26.7
Rarely
65
10.6
Sometimes
48
7.9
Often
63
10.3
Always
266
43.5
Total
605
99.0
999
6
1.0
611
100.0
Example Items: How did people respond?
[when ill] I check my ketone levels when my blood glucose is higher
than normal
Missing
Total
Never
Rarely
Sometimes
Often
Always
Total
999
System
Total
N
%
233
82
73
82
83
553
7
51
58
611
38.1
13.4
11.9
13.4
13.6
90.5
1.1
8.3
9.5
100.0
Example Items: How did people respond?
Taking less insulin than recommended
• 111 participants (18%) took less insulin than
recommended for one or more of the reasons listed:
-
To try to avoid putting on weight
Fed up with diabetes
Do not like injecting
Do not like thinking about diabetes
Comparing behaviours: structured
education vs. none
Routine BG
monitoring
Recording &
reflection
Monitoring ketones
Checking long-acting
dose
Educ
N
Mean (sd)
Score t
Range
df
Sig.
Yes
358
25.9 (4.6)
6-31
3.6
575
.000
No
219
24.4 (4.9)
Yes
373
9.4 (4.1)
3-15
3.0
598
.003
No
227
8.4 (3.9)
Yes
342
4.6 (2.6)
2-10
3.5
544
.000
No
204
3.8 (2.5)
Yes
310
3.6 (0.7)
2-10
-3.1
503
.002
No
195
3.8 (0.5)
Comparing behaviours: structured
education vs. none
Routine BG
monitoring
Educ
N
Mean (sd)
Score t
Range
df
Sig.
Yes
358
25.9 (4.6)
6-31
575
.000
No
219
24.4 (4.9)
1
.03
%
Do not always attend
diabetes appts
Yes
374
9
No
231
15
3.6
Chi
n/a
4.6
No significant differences: Timing of QA with meals, Dose
correction, Adjusting QA insulin in specific situations, Rotating
injection/infusion sites, Carrying appropriate hypo treatments,
Changing BG levels before showing nurse/Dr, Avoiding checking
BG when high
Model
B
Std.
Error
Beta
t
Sig.
Educational level
-.31
.12
-.11
-2.50
.013
Diabetes duration
-.01
.00
-.07
-1.45
.147
Insulin pump/MDI
.19
.15
.06
1.30
.195
Attended structured education
-.00
.13
.00
-.01
.996
Routine BG monitoring
-.03
.01
-.09
-1.87
.062
Recording & reflection
-.01
.02
-.03
-.68
.499
Monitoring ketones
.12
.03
.22
4.92
.000
Timing of QA with meals
-.05
.02
-.09
-2.04
.042
Adjusting insulin to carb intake
-.09
.04
-.13
-2.62
.009
Insulin omission
-.24
.18
-.06
-1.36
.175
Carrying hypo treatments
-.20
.16
.06
1.27
.205
Over-treating hypos
-.16
.06
-.12
-2.71
.007
Changing BG levels for dr/nurse
.69
.24
.13
2.85
.005
Avoiding testing when high
.11
.15
.03
.71
.480
Rotating injection/infusion sites
-.07
.08
-.04
-.88
.380
Attending clinic appointments
.31
.21
.07
1.45
.148
Summary
• Developed questionnaire to measure self-care behaviours
in type 1 diabetes that reflect current approaches to
management
• Examined differences in self-care behaviours between
those who have and haven’t done structured education
• Explained 23% of variance in HbA1c using some of these
behavioural variables. Why only 23%?
d.cooke@surrey.ac.uk
Laura.grant@adelphivalues.com
Acknowledgments: Thank you to all the participants
and DEN
Funder: NIHR Research for Patient Benefit Programme