User Retention and Engagement in the Digital-Based Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (myDESMOND) Program: Descriptive Longitudinal Study.

BACKGROUND: Digital health interventions have the potential to improve the physical and psychosocial health of people living with type 2 diabetes. However, research investigating the long-term (≥1 year) retention and engagement of users within these programs is limited. OBJECTIVE: The aim of this study was to evaluate long-term user retention and engagement in the digital-based Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (myDESMOND) program, using real-world data. METHODS: Anonymized data from all myDESMOND users who registered with the program on or before November 16, 2020, were included in the analyses. User retention was defined as the period between the day a user registered with the myDESMOND program and their last day of access. The primary engagement outcome was defined as the total number of log-ins to the program per user. The associations between retention, engagement, and sociodemographic factors (age, sex, and ethnicity) were tested using Cox regression models and Wilcoxon rank sum tests. RESULTS: A total of 9522 myDESMOND users were included in this analysis. Of the 9522 users, 5360 (56.29%) remained on the program for at least a month, whereas 1676 (17.6%) remained on the program for at least 1 year. Retention was significantly higher among older users; the adjusted hazard ratio (representing the risk of users leaving the program within the first year) among users aged ≥50 years, compared with those aged <50 years, was 0.79 (95% CI 0.75-0.84; P<.001). The median number of myDESMOND log-ins per user was 8 (IQR 4-8); however, this was significantly lower among users aged <50 years (P<.001). Engagement metrics also differed according to sociodemographic characteristics; the estimated time spent per log-in was 5.35 (IQR 2.22-11.80) minutes among all users; however, this was significantly higher among female users (P<.001), users aged ≥50 years (P<.001), and users of White ethnicity (P=.02). CONCLUSIONS: Although retention and engagement of users within myDESMOND were found to be high, these findings highlight the need for age- and culture-specific implementation strategies and content adaptations to improve retention and engagement among all users of self-management programs.

Cultural adaptation of a diabetes self-management education and support (DSMES) programme for two low resource urban settings in Ghana, during the COVID-19 era.

BACKGROUND: Type 2 diabetes is a significant public health problem globally and associated with significant morbidity and mortality. Diabetes self-management education and support (DSMES) programmes are associated with improved psychological and clinical outcomes. There are currently no structured DSMES available in Ghana. We sought to adapt an evidence-based DSMES intervention for the Ghanaian population in collaboration with the local Ghanaian people. METHODS: We used virtual engagements with UK-based DSMES trainers, produced locally culturally and linguistically appropriate content and modified the logistics needed for the delivery of the self-management programme to suit people with low literacy and low health literacy levels. CONCLUSIONS: A respectful understanding of the socio-cultural belief systems in Ghana as well as the peculiar challenges of low resources settings and low health literacy is necessary for adaptation of any DSMES programme for Ghana. We identified key cultural, linguistic, and logistic considerations to incorporate into a DSMES programme for Ghanaians, guided by the Ecological Validity Model. These insights can be used further to scale up availability of structured DSMES in Ghana and other low- middle- income countries.

EXTending availability of self-management structured EducatioN programmes for people with type 2 Diabetes in low-to-middle income countries (EXTEND)-a feasibility study in Mozambique and Malawi.

BACKGROUND: Globally, there are estimated 425 million people with type 2 diabetes (T2D) with 80% from low-middle income countries (LMIC). Diabetes self-management education (DSME) programmes are a vital and core component of the treatment pathway for T2D. Despite LMIC being disproportionally affected by T2D, there are no DSME available that meet international diabetes federation criterion. METHODS: The aims were to test the feasibility of delivering a proven effective and cost-effective approach used in a UK population in two urban settings in Malawi and Mozambique by; (1) developing a culturally, contextually and linguistically adapted DSME, the EXTending availability of self-management structured EducatioN programmes for people with type 2 Diabetes in low-to-middle income countries (EXTEND) programme; (2) using a mixed-method approach to evaluate the delivery of training and the EXTEND programme to patients with T2D. RESULTS: Twelve healthcare professionals were trained. Ninety-eight participants received the DSME. Retention was high (100% in Mozambique and 94% in Malawi). At 6 months HbA1c (-0.9%), cholesterol (-0.3 mmol/L), blood pressure (-5.9 mm Hg systolic and -6.1 mm Hg diastolic) improved in addition to indicators of well-being (problem areas in diabetes and self-efficacy in diabetes). CONCLUSION: It is feasible to deliver and evaluate the effectiveness of a culturally, contextually and linguistically adapted EXTEND programme in two LMIC. The DSME was acceptable with positive biomedical and psychological outcomes but requires formal testing with cost-effectiveness. Challenges exist in scaling up such an approach in health systems that do not have resources to address the challenge of diabetes.

Increasing uptake of structured self-management education programmes for type 2 diabetes in a primary care setting: a feasibility study.

BACKGROUND: Structured self-management education (SSME) for people with type 2 diabetes mellitus (T2DM) improves biomedical and psychological outcomes, whilst being cost-effective. Yet uptake in the UK remains low. An 'Embedding Package' addressing barriers and enablers to uptake at patient, health care professional and organisational levels has been developed. The aim of this study was to test the feasibility of conducting a subsequent randomised controlled trial (RCT) to evaluate the Embedding Package in primary care, using a mixed methods approach. METHODS: A concurrent mixed methods approach was adopted. Six general practices in the UK were recruited and received the intervention (the Embedding Package). Pseudonymised demographic, biomedical and SSME data were extracted from primary care medical records for patients recorded as having a diagnosis of T2DM. Descriptive statistics assessed quantitative data completeness and accuracy. Quantitative data were supplemented and validated by a patient questionnaire, for which two recruitment methods were trialled. Where consent was given, the questionnaire and primary care data were linked and compared. The cost of the intervention was estimated. An integrated qualitative study comprising ethnography and stakeholder and patient interviews explored the process of implementation, sustainability of change and 'fit' of the intervention. Qualitative data were analysed using a thematic framework guided by the Normalisation Process Theory (NPT). RESULTS: Primary care data were extracted for 2877 patients. The primary outcome for the RCT, HbA1c, was over 90% complete. Questionnaires were received from 423 (14.7%) participants, with postal invitations yielding more participants than general practitioner (GP) prompts. Ninety-one percent of questionnaire participants consented to data linkage. The mean cost per patient for the Embedding Package was £8.94, over a median follow-up of 162.5 days. Removing the development cost, this reduces to £5.47 per patient. Adoption of ethnographic and interview methods in the collection of data was appropriate, and the use of NPT, whilst challenging, enhanced the understanding of the implementation process. The need to delay the collection of patient interview data to enable the intervention to inform patient care was highlighted. CONCLUSIONS: It is feasible to collect data with reasonable completeness and accuracy for the subsequent RCT, although refinement to improve the quality of the data collected will be undertaken. Based on resource use data collected, it was feasible to produce cost estimates for each individual component of the Embedding Package. The methods chosen to generate, collect and analyse qualitative data were satisfactory, keeping participant burden low and providing insight into potential refinements of the Embedding Package and customisation of the methods for the RCT. TRIAL REGISTRATION: ISRCTN, ISRCTN21321635, Registered 07/07/2017-retrospectively registered.

Using Intervention Mapping to Develop a Digital Self-Management Program for People With Type 2 Diabetes: Tutorial on MyDESMOND.

Digital health interventions (DHIs) are increasingly becoming integrated into diabetes self-management to improve behavior. Despite DHIs becoming available to people with chronic conditions, the development strategies and processes undertaken are often not well described. With theoretical frameworks available in current literature, it is vital that DHIs follow a shared language and communicate a robust development process in a comprehensive way. This paper aims to bring a unique perspective to digital development, as it describes the systematic process of developing a digital self-management program for people with type 2 diabetes, MyDESMOND. We provide a step-by-step guide, based on the intervention mapping (IM) framework to illustrate the process of adapting an existing face-to-face self-management program (diabetes education and self- management for ongoing and newly diagnosed, DESMOND) and translating it to a digital platform (MyDESMOND). Overall, this paper describes the 4 IM steps that were followed to develop MyDESMOND-step 1 to establish a planning group and a patient and public involvement group to describe the context of the intervention and program goals, step 2 to identify objectives and determinants at early design stages to maintain a focus on the strategies adopted, step 3 to generate the program components underpinned by appropriate psychological theories and models, and step 4 to develop the program content and describe the iterative process of refining the content and format of the digital program for implementation. This paper concludes with a number of key learnings collated throughout our development process, which we hope other researchers may find useful when developing DHIs for chronic conditions.

The impact of an intervention to increase uptake to structured self-management education for people with type 2 diabetes mellitus in primary care (the embedding package), compared to usual care, on glycaemic control: study protocol for a mixed methods study incorporating a wait-list cluster randomised controlled trial.

BACKGROUND: Approximately 425 million people globally have diabetes, with ~ 90% of these having Type 2 Diabetes Mellitus (T2DM). This is a condition that leads to a poor quality of life and increased risk of serious health complications. Structured self-management education (SSME) has been shown to be effective in improving glycaemic control and patient related outcome measures and to be cost-effective. However, despite the demonstrated benefits, attendance at SSME remains low. An intervention has been developed to embed SSME called the 'Embedding Package'. The intervention aims to address barriers and enhance enablers to uptake of SSME at patient, healthcare professional and organisational levels. It comprises a marketing strategy, user friendly and effective referral pathways, new roles to champion SSME and a toolkit of resources. METHODS: A mixed methods study incorporating a wait-list cluster randomised trial and ethnographic study, including 66 UK general practices, will be conducted with two intervention start times (at 0 and 9 months), each followed by an active delivery phase. At 18 months, the intervention will cease to be actively delivered and a 12 month observational follow-up phase will begin. The intervention, the Embedding Package, aims to increase SSME uptake and subsequent improvements in health outcomes, through a clear marketing strategy, user friendly and effective referral pathways, a local clinical champion and an 'Embedder' and a toolkit of resources for patients, healthcare professionals and other key stakeholders. The primary aim is, through increasing uptake to and attendance at SSME, to reduce HbA1c in people with T2DM compared with usual care. Secondary objectives include: assessing whether there is an increase in referral to and uptake of SSME and improvements in biomedical and psychosocial outcomes; an assessment of the sustainability of the Embedding Package; contextualising the process of implementation, sustainability of change and the 'fit' of the Embedding Package; and an assessment of the cost-effectiveness of the Embedding Package. DISCUSSION: This study will assess the effectiveness, cost-effectiveness and sustainability of the Embedding Package, an intervention which aims to improve biomedical and psychosocial outcomes of people with T2DM, through increased referral to and uptake of SSME. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number ISRCTN23474120. Assigned 05/04/2018. The study was prospectively registered. On submission of this manuscript practice recruitment is complete, participant recruitment is ongoing and expected to be completed by the end of 2019.

Automated estimated GFR reporting: A new tool to promote safer prescribing in patients with chronic kidney disease?

A number of drugs rely on the kidney for excretion and thus require their dose to be modified in any patients where there is renal impairment. Others are nephrotoxic and should be avoided completely in patients with renal disease. Traditionally clinicians have had to rely on serum creatinine to assess renal function but this may not accurately reflect the kidney function of an individual since its level also depends on muscle mass. In particular elderly females may have significant impairment of renal function despite a normal or near normal serum creatinine. The advent of automated reporting of estimated glomerular filtration rate (eGFR) provides the clinician with simple, easily understood and readily available measurement which more accurately reflects a patient's renal function. In particular eGFR allows the clinician to readily identify and stratify patients with chronic kidney disease (CKD) and can allow a more rational and safer approach to prescribing in this group of high risk patients. This commentary suggests that national prescribing formularies should use eGFR to provide consistent advice about the appropriate dose adjustment and avoidance of potentially toxic drugs at various stages of CKD. Such an approach may prove invaluable in improving prescribing in CKD and avoiding drug toxicity in this group of patients.