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Annemarie Reinhardt Varming,1 Rikke Torenholt,1 Tue Helms Andersen,2 Birgitte Lund Møller,3 Ingrid Willaing1 1Diabetes Management Research, Health Promotion, Steno Diabetes Center Copenhagen, The Capital Region of Denmark, 2Danish Diabetes Association, 3Department of Intersectoral Collaboration, Region of Southern Denmark, Denmark Background: Self-management education is critical to the development of successful health behavior changes related to chronic illness. However, people in high-risk groups attend less frequently or benefit less from patient education programs than do people with more socioeconomic advantages.Aim: The aim was to test the feasibility of a participatory person-centered education approach and tool-kit targeting self-management of chronic illness in hardly reached people.Methods: After participating in a training program, educators (n=77) tested the approach in practice. Data collection included online questionnaires for educators (n=65), observations of education sessions (n=7), and interviews with educators (n=11) and participants (n=22). Descriptive statistics were calculated. Transcripts of interviews and observations were analyzed using systematic text condensation. Feasibility was examined in terms of practicality, integration, suitability, and efficacy.Results: Educators had a positive response to the approach and found that the tools supported involving participants in education and support. Participant satisfaction varied, depending on the ability of educators to integrate the tools into programs in a meaningful way. The tools provided time for reflection in the education process that benefited participants and educators alike. Educators found it challenging to allow participants to help set the agenda and to exchange experiences without educator control. Barriers to use reported by educators included lack of time for both training and preparation.Limitations: The testing included varied groups of participants, some groups included members of hardly reached populations and others did not. Also, some tools were only tried in practice by a few educators.Conclusion: The approach was feasible in terms of practicality, integration, acceptability, and efficacy and perceived by educators as suitable for both hardly reached participants and those who are less disadvantaged. Implementation of the approach requires time for training and preparation. Keywords: health care educators, professional development, skills, vulnerable patients, support, participatory, dialogue tools, tool kit

Lene Eide Joensen,1 Merete Meldgaard Andersen,2 Sabrina Jensen,1 Kirsten Nørgaard,2 Ingrid Willaing1 1Diabetes Management Research, Steno Diabetes Center Copenhagen, Gentofte, 2Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark Aim: The aim of this study was to explore the effects of a flexible and participatory peer support intervention in a clinical setting for adults with type 1 diabetes treated with an insulin pump, focusing on enhancing diabetes-specific social capital. The key questions were as follows: 1) what effects are appropriate to expect, according to participants? and 2) to what extent did these effects occur? Methods: Two peer support intervention programs were conducted in a diabetes specialist clinic (N=30). A participatory and adaptable approach allowed flexibility in the content of peer support meetings, which were facilitated by a diabetes nurse. Individual interviews explored participants’ perception of effects of the intervention. Interview data were analyzed qualitatively. Participants (n=27) completed a baseline and postintervention questionnaire that included items assessing diabetes empowerment, diabetes distress, diabetes-specific social support, and diabetes loneliness. HbA1c levels were compared before and after the intervention. Results: Participants experienced enhanced diabetes-specific social capital, diabetes motivation, awareness of personal diabetes practices, and serenity and openness in life with diabetes. They also became more aware of treatment and support possibilities. Negative effects included feeling sad or upset after the meetings or feeling different than and not as well-controlled as other participants. Quantitative analyses showed enhanced social support, decreased eating distress and trends toward enhanced diabetes empowerment, decreased diabetes loneliness, and decreased diabetes distress (powerlessness). We found fewer positive and/or negative outcomes among participants who felt no need for peer support or felt that the group was not a unit or that important issues were not addressed. Conclusion: The study indicated that flexible and participatory peer support can strengthen diabetes-specific social capital and improve participants’ well-being and diabetes empowerment. Awareness of participants’ incentives for attending peer support, as well as the risk of people feeling isolated within peer support groups, is essential to creating effective diabetes-specific social support. Keywords: type 1 diabetes mellitus, insulin pump therapy, psychosocial support, psychological well-being, empowerment, exploratory research

Lene E Joensen,1 Tine Filges,2 Ingrid Willaing1 1Health Promotion Research, Steno Diabetes Center, Gentofte, 2Filges Analysis, Hellerup, Denmark Aim: To explore the function of peer support from the perspective of adults with type 1 diabetes in Denmark. Methods: The study population consisted of 20 adults with type 1 diabetes. The sample was diverse in relation to educational background, age, sex, and cohabitation status. Inspired by action research, several methods and perspectives on peer support were explored and tested. Workshops and group and individual interviews were performed. Systematic text condensation was used to analyze data, supplemented with theory-based interpretive analysis. Results: Adults with type 1 diabetes found peer support highly relevant to reduce a burdensome feeling of diabetes-specific loneliness. Peer support showed potential to create diabetes-specific social capital not only by creating reciprocal social support between peers but also, more importantly, by creating space for genuine trust and a feeling of communality. There was a widespread feeling of the pervasive impact of diabetes on daily life and thus the relevance of discussing all aspects of life. However, participants perceived peer support as particularly relevant in relation to big changes in life, for example, in family life, at work, or through treatment events such as getting an insulin pump. Conclusion: Peer support programs focusing on creating and establishing diabetes-specific social capital using participatory approaches seem highly relevant among adults with type 1 diabetes. Content, methods, and effects of peer support need further exploration in collaboration with adults with type 1 diabetes. Keywords: type 1 diabetes mellitus, adult, psychosocial support systems, patient preferences, peer support, diabetes-specific social capital, diabetes-specific loneliness

Rikke Torenholt,1 Annemarie Varming,1 Gitte Engelund,1 Susanne Vestergaard,2 Birgitte Lund Møller,3 Regitze Anne Saurbrey Pals,1 Ingrid Willaing1 1Health Promotion Research, Steno Diabetes Center A/S, Gentofte, 2Danish Diabetes Association, Copenhagen, 3Region of Southern Denmark, Vejle, Denmark Abstract: Individuals with lower income and less education are two to four times more likely to develop diabetes than more advantaged individuals. In response to this, there is a need for developing health promotion activities targeting hardly reached populations. The aim of this study was to examine the perspectives of hardly reached people with type 2 diabetes on patient education, focusing on their wishes and needs regarding format and approach. Data were collected through qualitative interviews with nine individuals with type 2 diabetes with little or no education and characterized as hardly reached patients by health professionals. Interviews were transcribed verbatim and analyzed according to systematic text condensation. We identified four main categories of preferences for patient education: 1) flexibility related to start time, duration, and intensity; 2) simple and concrete education tools, with regard to design and extent; 3) being together, related to meeting people in a similar situation; and 4) respectful educators, related to constructive patient–educator relationships. Insights into the preferences of hardly reached people with diabetes can contribute to the development of appropriately tailored patient education for this patient group.Keywords: patient education, type 2 diabetes, hardly reached people, preferences

Annemarie Reinhardt Varming,1 Ulla Møller Hansen,1 Gudbjörg Andrésdóttir,2 Gitte Reventlov Husted,1 Ingrid Willaing1 1Patient Education Research, 2Complications Research, Steno Diabetes Center, Gentofte, Denmark Purpose: To explore the feasibility of a research-based program for patient-centered consultations to improve medical adherence and blood glucose control in patients with type 2 diabetes. Patients and methods: The patient-centered empowerment, motivation, and medical adherence (EMMA) consultation program consisted of three individual consultations and one phone call with a single health care professional (HCP). Nineteen patients with type 2 diabetes completed the feasibility study. Feasibility was assessed by a questionnaire-based interview with patients 2 months after the final consultation and interviews with HCPs. Patient participation was measured by 10-second event coding based on digital recordings and observations of the consultations. Results: HCPs reported that EMMA supported patient-centered consultations by facilitating dialogue, reflection, and patient activity. Patients reported that they experienced valuable learning during the consultations, felt understood, and listened to and felt a trusting relationship with HCPs. Consultations became more person-specific, which helped patients and HCPs to discover inadequate diabetes self-management through shared decision-making. Compared with routine consultations, HCPs talked less and patients talked more. Seven of ten dialogue tools were used by all patients. It was difficult to complete the EMMA consultations within the scheduled time. Conclusion: The EMMA program was feasible, usable, and acceptable to patients and HCPs. The use of tools elicited patients’ perspectives and facilitated patient participation and shared decision-making. Keywords: type 2 diabetes, adherence, participation, dialogue, health education, self-management

Nana F Hempler,1 Sara Nicic,1 Bettina Ewers,2 Ingrid Willaing1 1Health Promotion Research, Steno Diabetes Center, Gentofte, Denmark; 2Nutrition and Food Services Department, Steno Diabetes Center, Gentofte, Denmark Background: The high prevalence of diabetes among South Asian populations in European countries partially derives from unhealthy changes in dietary patterns. Limited studies address perspectives of South Asian populations with respect to utility of diabetes education in everyday life. This study explores perspectives on dietary diabetes education and healthy food choices of people living in Denmark who have a Pakistani background and type 2 diabetes. Methods: In-depth interviews were conducted between October 2012 and December 2013 with 12 participants with type 2 diabetes who had received dietary diabetes education. Data analysis was systematic and was based on grounded theory principles. Results: Participants described the process of integrating and utilizing dietary education in everyday life as challenging. Perceived barriers of the integration and utilization included a lack of a connection between the content of the education and life conditions, a lack of support from their social networks for dietary change, difficulty integrating the education into everyday life, and failure to include the participants’ taste preferences in the educational setting. Conclusion: Dietary education that is sensitive to the attitudes, wishes, and preferences of the participants and that aims at establishing a connection to the everyday life of the participants might facilitate successful changes in dietary practices among people with a Pakistani background and type 2 diabetes. The findings suggest that more focus should be placed on collaborative processes in the dietary educational setting in order to achieve appropriate education and to improve communication between this population and health care professionals. Keywords: dietary diabetes education, healthy food choices, Pakistani background, type 2 diabetes, patient perspectives, preferences

Aims: To explore perceptions of useful routine consultations with diabetologists from the perspective of adults with type 1 diabetes, including preferences for discussing psychosocial issues. Methods: We conducted semi‐structured interviews in 2018/2019 with 33 people with type 1 diabetes (age 22–75 years, 20 men and 13 women, median diabetes duration 25 years) recruited from two diabetes clinics in the capital region of Denmark. Interviews were audio recorded, transcribed verbatim and analysed using thematic text condensation. Results: Achieving a useful consultation was perceived as a shared responsibility between people with diabetes and diabetologists. Participants' perspectives of what constitutes a useful consultation and expectations for both consultation and diabetologist varied in relation to perceptions of (1) the interaction between the person with diabetes and diabetologist, including being prepared, being honest, experiencing good rapport and preferring a partnership with the diabetologist or 'keeping it clinical' and (2) the diabetologist's approach to diabetes care, including providing up‐to‐date knowledge and listening and showing understanding. Conclusions: Both content and style of diabetes consultations need to be adapted to the individual person with type 1 diabetes. People with diabetes have an important role in expressing their needs and preferences related to both content and style. Diabetologists need to be aware of and attentive to the many individual needs and expectations among people with diabetes, including the desire and need to discuss psychosocial issues. Dialogue tools for preparation and in consultations may enable people with diabetes to voice their needs and expectations and diabetologists to juggle these diversities. [ABSTRACT FROM AUTHOR]

Aims: To identify currently available studies on the association between psychosocial factors and HbA1c in adults with insulin pump‐treated type 1 diabetes, by performing a systematic review of the literature. Methods: MEDLINE, Embase, CINAHL and PsycINFO were searched for original studies on the association between psychosocial factors and HbA1c in ≥ 50 adult, non‐pregnant, insulin pump users with type 1 diabetes. Results: The search resulted in 1777 unique records, of which eight were eligible for inclusion. All identified studies were observational, with sample sizes ranging from 51 to 214. Seven different psychosocial factors were investigated in the eight studies. Study analysis suggested that HbA1c may be associated with diabetes numeracy and quality of life. There were no indications of associations between HbA1c and fear of hypoglycaemia or self‐efficacy. Results regarding associations between HbA1c and coping style, diabetes distress and locus of control were inconsistent. Conclusions: This systematic review summarizes the currently limited information on the association between psychosocial factors and HbA1c during insulin pump therapy. The evidence base of the included studies was weak, and this review highlights the need for more research in these areas, with improved methodological and theoretical frameworks, including exploration of a broader spectrum of psychosocial variables and their potential association with HbA1c and other metabolic outcomes. (PROSPERO International prospective register of systematic reviews registration no: CRD42020145705). What's new?: The glycaemic benefits of insulin pump therapy vary among individuals, and the reasons for this are not fully clarified.This systematic review synthesizes the literature—eight observational studies in total—on the association between psychosocial factors and HbA1c in adult insulin pump users.Despite the importance of the topic for society as well as for the individual insulin pump wearer, research within this field is still limited in scope.More research is needed to fully elucidate what influences HbA1c during insulin pump therapy and what actions should be taken for more people to reach glycaemic goals. [ABSTRACT FROM AUTHOR]

Aims: To identify challenges and solutions to integrating psychosocial support into routine diabetes care from the perspective of stakeholders with expertise in diabetes self‐management education and support. Methods: Ninety‐four people attended the annual international Diabetes Self‐Management Alliance meeting in 2016, which included plenary sessions and workshops on self‐management education, support and prevention. One workshop focused on how to integrate psychosocial support into routine diabetes care; this was run four times consecutively, allowing all conference participants to attend the workshops in groups of 20–25 people. Results: Challenges and solutions associated with integrating psychosocial support into routine diabetes care concern the patient–provider relationship, the healthcare system and the community. Challenges identified were: lack of time, skills and resources to deal with psychological well‐being; a culture of patient blame and care expectations; the complexity of person‐centred assessment of psychological issues; and the substantial healthcare system focus on productivity and biomedical indicators. Lack of involvement of local communities and of inclusion of social determinants of health were also highlighted as challenging. Solutions identified were more patient–provider dialogue; more training and better skills among care providers; system incentives for psychosocial outcomes; and targeting social determinants of health and involvement of family and peers. Conclusions: From the perspective of international stakeholders with an expertise in diabetes self‐management and support attending the conference in Denmark, substantial new incentives and systematic cultural changes are needed in healthcare systems to integrate psychosocial support into routine diabetes care, as recommended in international guidelines. What's new?: Few other studies have focused on exploring potential solutions to implementing psychosocial support in routine clinical practice.This article identifies challenges in addressing the psychosocial aspects of diabetes in routine diabetes care and the solutions to mitigate them, from the perspective of international stakeholders with expertise in diabetes self‐management education and support.One of the most substantial challenges identified is the healthcare system's focus on productivity and biomedical indicators.Solutions point to required changes at the levels of the patient–provider relationship and the organization and healthcare system. [ABSTRACT FROM AUTHOR]

Aim: To explore the experiences of adults with newly diagnosed Type 1 diabetes in order to understand the adaptive processes that occur in the early phase of the condition. Methods: We conducted longitudinal semi‐structured interviews with 30 adults newly diagnosed with Type 1 diabetes (age range 20–67 years; 16 men; median diabetes duration 23.5 months), recruited from hospitals in Denmark and the UK. The data were analysed using a narrative approach. Results: The narratives could be grouped into three thematic areas: the diagnosis; learning about diabetes; and learning to live with diabetes. Diabetes was characterized as a major disruptor to the established and future life plans of participants, causing significant emotional distress. The narratives showed how early experiences triggered the development of ongoing psychological problems (fear of complications or hypoglycaemia) and diabetes distress, and that navigating different social scenarios (relationships and employment) could be challenging, leading to suboptimal self‐management behaviours. The narratives also showed that health professionals often did not attend effectively to participants' emotional needs after diagnosis, and that the language used frequently triggered negative feelings, such as fear or a sense of failure. Conclusions: Many of the common psychosocial problems associated with Type 1 diabetes seem to gestate in the early phase of life with the condition. There appear to be opportunities to enhance the support provided in this phase to minimize these problems. What's new?: We currently know little about the early experiences of adults newly diagnosed with Type 1 diabetes or how they adapt to a life with diabetes.This study shows that, after the diagnosis of diabetes, adults experience significant emotional distress and can quickly develop ongoing psychosocial problems that affect their self‐management behaviours.After diagnosis, adults need much more support in adapting to the condition emotionally, psychologically and socially. Such support may reduce or prevent the development of negative psychosocial reactions that can impede self‐management behaviours and reduce well‐being. [ABSTRACT FROM AUTHOR]

Aims The aim of this study was to investigate associations between HbA1c recall by patients with Type 2 diabetes and self-management behaviours, patient activation, perception of care and diabetes distress. Methods In a cross-sectional survey, 993 patients with Type 2 diabetes reported their latest HbA1c. Validated scales measured self-management behaviours, patient activation, perception of care and diabetes distress. Self-reported HbA1c was compared with latest measured HbA1c. Using logistic regressions, associations between HbA1c recall and the variables of interest were investigated. Results Sixty-four per cent of patients recalled their latest HbA1c. Poor HbA1c recall was significantly associated with unhealthy eating behaviour, low level of exercise, low level of patient activation, poor glycaemic control, not knowing target HbA1c level, low educational level and being female. There were no associations between recall of HbA1c and diabetes distress or perceived care. Conclusions Recall of HbA1c level may increase patient activation and health-promoting behaviours. However, low educational level may be a barrier for using HbA1c as a motivator for health-promoting behaviours. This study indicates a need for studies of causal relationships, as well as mechanisms and challenges in using patient awareness of HbA1c as a driver for health-promoting behaviours. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine preferences among patients with type 2 diabetes for content and format of patient education. METHODS: Using discrete choice methods, we surveyed patients about their preferences for patient education. We investigated preferred content and format regarding education on living well with diabetes, preventing complications, healthy eating, exercising, and psychosocial issues related to diabetes. RESULTS: We obtained usable responses from 2187 patients with type 2 diabetes. Acquiring competencies to live a fulfilling life with diabetes, adjust diet and exercise habits, and prevent complications was significantly more highly valued than was simply being informed about these topics. Patients preferred to be involved in the planning of their diabetes care and valued individually tailored content higher than prescheduled content. Women and younger patients found diet and exercise significantly more important than did men, and patients with poorly controlled diabetes valued all education and support more highly than did patients in better control. CONCLUSION: Patients with type 2 diabetes prefer to be actively involved in educational activities, to develop competencies to prevent and manage complications, and to involve their social network in supporting them. PRACTICE IMPLICATIONS: Future patient education should enhance participation and competence development and include relatives. [ABSTRACT FROM AUTHOR]