• Background
• Development
• Pilot
• KICk-OFF RCT

Patient
School
Health Care
Professional
Clinic
Setting
Peter Hindmarsh
Hours spent with diabetes over 3 months
2160
480
12
0.25 - 0.50

• DAFNE study group
• Good outcomes in diabetes control and quality of life from cross over study in adults
British Medical Journal 2002;325(7367):746.
• 2001 – Diabetes UK met with several UK paediatric centres
• Sheffield given task of taking forward paediatric DAFNE

Research question:
What is the effect of an intensive, structured education course on glycaemic control and quality of life in children with Type 1 diabetes?
Medical Research Council – A framework for development and evaluation of RCTs for complex interventions to improve health
( www.mrc.ac.uk April 2000, updated 2008)
4 phase approach
1. Theoretical “ Modelling” phase
2. Development phase
3. Pilot evaluation
4. Randomised controlled trial

• DAFNE is based on model of therapeutic patient education developed in Germany ( Dusseldorf model)
• DAFNE trial in UK demonstrated benefit in 150 adults – improved blood sugar control, improved quality of life, less hypos
• Social learning theory – Bandura

Social Learning Theory – A. Bandura 1977
People learn from one another via:
• observation of behaviour and attitudes
• imitation and adaptation
Requires :
• attention – affected by complexity, functional value
• retention – affected by imagery, organisation
• reproduction - physical capability, self observation
• motivation - reinforced by past and promised incentives

Aim: to produce an education course for children with type 1 diabetes, that - was age appropriate
- was acceptable to children and families
- used recognised educational techniques

Julie Knowles - Research nurse, Helen Waller - Psychologist
 PDSN survey (Autumn 2002)
Journal Of Diabetes Nursing 2005;9:332-339.

Focus groups (Jan. 2003)
Child: Care, Health and Development 2005;31(3):283-289.
 Lubeck, Germany (Jan. 2004)

• Understand how children learn
Educational Theories
• Understand how to teach
Learning styles
• Develop a curriculum

How do you learn?

• Adults are autonomous and self-directed
• Adults have a wealth of life experiences and knowledge
• Adults are goal orientated
• Adults are relevancy orientated
• Adults are practical
• Adults demand respect from instructors
The adult learner a neglected species. Malcolm Knowles 1994

How do children learn?
“
Theories
• Behaviourism
Learning from external stimuli. It can be conditioned by giving rewards and punishments
• Piaget – 4 stages of child development.
Focused on maturation. Growing up does not mean knowing more but it changes how we think.
• Vygotsky – Learning is a social process
Language development and learning through interaction with others of same age and older .
• IQ – Focused on the concept of a general intelligence
• Gardener – “multiple intelligences” allowing different learning styles
Muijs et al (2005). Effective Teaching

Working with teachers and educationalists
• Presentation
• Reading age
• Lesson planning
• Specific teaching skills
• Style of teaching (observation)
King Edward V11 Secondary School
• Setting boundaries/learning environment

A step by step guide to the education session to allow replication by others and achievement of goals
Office For Standards in Education (OFSTED)
• Is it clear what the purpose of the lesson is?
• Has the lesson taken into account the learners needs?

KICk-OFF course
5 day out patient course for 11-16 yr olds
• 8 per group
• Age banded 11-13 years and 14-16 years
• Modular structure,
• Involves parents and friends
• Variety of teaching styles – very practical and interactive

Modules from the Paediatric
KICk-OFF Curriculum
What is diabetes?
Food and diabetes
Insulin management Sick day rules
Hypoglycaemia Monitoring
Living with diabetes School and Diabetes
Transition of care

KICk-OFF curriculum – day 2
Tuesday
Learning objectives

Individual insulin adjustment practice
 Continue with carbohydrate and insulin ratios

Further skills in counting grams of carbohydrate
 Hypoglycaemia – signs and symptoms, treatment and prevention

Feedback to carers
 Continue with school packs
Today’s programme
Session 1 9.00am-10.30am
Discussion about individual blood glucose levels
Hypoglycaemia
BREAK
Session 2 10.45am-12.15pm
Hypoglycaemia
CP/insulin ratio
Work out CP’s for lunch
PACKED LUNCH
Session 3 1.00pm-2.15pm
Practical session [cooking] on counting grams of carbohydrate
BREAK
Session 4 2.30pm-4.00pm
Prepare food for parents to practice CHO estimation
Quiz
Parents invited to listen.
Recap days objectives
Plan evening insulin dose

Educator
Preparation
Dietitian and nurse
Transport children to school cookery room. Set up the work stations with foods needed for recipes.
TIM
E
EDUCATOR
ACTIVITY
2pm
Explain:-
This session is a practical session to learn how to work out how much CHO is in the food you prepare.
Group to split into pairs and they are each given a recipe



STUDENT
ACTIVITY
Response:
Split into pairs but not the same pairs as the morning
Follow recipes
Tidy up after the food is prepared
MATERIALS
4 recipes for fruit muffins fruit scones jam and butter scales
Paper plates ingredients utensils
Calculators
Pens
Flip charts
Worksheet for estimating CP’s in rice, pasta, potato, cereals.

Complete work sheet

Day 2, session 4. Counting grams of carbohydrate
Learning Objectives TUESDAY
Session 4:-

Counting grams of carbohydrate

Practical session

Continue with carbohydrate and insulin ratios

Continuing with learning the skills for counting grams of carbohydrate
Materials

Scales

Food ingredients

Recipes

Flip chart

Pens

Diaries

Work sheets

Calculators

Plates

Kitchen equipment

Digital scales

Pots and pans

Baking tins

Washing up materials

(tea towels, cloths, washing up liquid)

Carbohydrate counting in snacks and recipes
Chocolate Chip Muffins
Ingredients
150g/5oz self-raising flour
150g/5oz margarine
150g/5oz sugar
2 eggs
75g/3oz chocolate chips
100g/3½oz drinking chocolate powder
Session 4 2.30pm-4.00pm
Prepare food for parents to practice CHO estimation
Quiz

December 2003 - 2004 :
6 courses – 48 young people, age 11-16 yrs from 3 centres
Outcomes over 6 months
Educational evaluation
Process evaluation
Interviews with psychologist
Results
Good evaluation – some changes to programme
More parent teaching
Biomedical – HbA1c, Hypos, BMI
Psychological – quality of life, self efficacy, family conflict etc
HbA1c – unchanged overall
Improved in those with poor control
Improved in younger age group
QOL – improved
Self efficacy, coping with diabetes etc improved

Hands on Learning …
Social Support…

Cooking and Counting Carbs …
Eating Out and Bowling Exercising in the Gym

Improve presentation :
Cell energy

In 11-16 year olds on intensive insulin therapy : -
Does the KICk-OFF structured education course affect outcomes, measured over 2 years?
Primary outcome measures:
• Biomedical – blood sugar control (HbA1c), hypoglycaemia
• Psychological – quality of life, fear of hypoglycaemia, self efficacy
Secondary outcomes
• Process evaluation, sustainability of education
• Weight, diet
• Is it cost effective ?
• Website support

5 day Educator Training course – Sheffield Hallam University
How do we ensure uniformity of teaching in all centres?
Does the curriculum allow key learning points to be achieved?
Can there be flexibility within a curriculum?
How do we support the learning needs of educators?

Trial Design
• Risk of “ contamination of control group in clinic trained to deliver the course – cluster randomisation
• The intervention will be delivered to groups rather than individuals
• Variation between centres –in HbA1c, staffing levels, ethnic & social mix of patients, current educational practise – stratification

30 centres
Each recruit 16-32
N=560
Centre stratification
15 Control n= 280
15 Intervention n= 280
Usual care
KICk-OFF courses
Follow up 6,12 & 24 months
KICk-OFF courses
5 days
3 educators (2 research staff, 1 local)
8 participants 11-13 or 14-16 yrs

• 4 year project from Sept 08
• Martin Fox – project coordinator
• Julie Knowles- lead educator
• Project group –
Educationalists - Jerry Wellington, Grace Hoskins 1
Health Economics – Alan Brennan, Katherine Stephens 1
Psychology – Chris Eiser 1
Clinical – Simon Heller, Jerry Wales 1
Statistician – Jenny Freeman 1
Website development and evaluation – Amy McPherson 2
1 = University of Sheffield, 2 = University of Nottingham

Current priorities
• local R&D/ ethics approval and centre stratification
• recruitment of participants then centre randomisation
• 6 educator posts start Sept 09
• educational material – printing, purchase etc
• website – to support learning of those in KICk-OFF groups www.kick-off.org.uk

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