'Is Insulin Right for Me?': Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes-A randomised controlled trial.

AIMS: To test 'Is Insulin Right for Me?', a theory-informed, self-directed, web-based intervention designed to reduce psychological barriers to insulin therapy among adults with type 2 diabetes. Further, to examine resource engagement and associations between minimum engagement and outcomes. METHODS: Double-blind, two-arm randomised controlled trial (1:1), comparing the intervention with freely available online information (control). Eligible participants were Australian adults with type 2 diabetes, taking oral diabetes medications, recruited primarily via national diabetes registry. EXCLUSION CRITERIA: prior use of injectable medicines; being 'very willing' to commence insulin. Data collections were completed online at baseline, 2-week and 6-month follow-up. PRIMARY OUTCOME: negative insulin treatment appraisal scale (ITAS) scores; secondary outcomes: positive ITAS scores and hypothetical willingness to start insulin. ANALYSES: intention-to-treat (ITT); per-protocol (PP) examination of outcomes by engagement. TRIAL REGISTRATION: ACTRN12621000191897. RESULTS: No significant ITT between-arm (intervention: n = 233; control: n = 243) differences were observed in primary (2 weeks: Mdiff [95% CI]: -1.0 [-2.9 to 0.9]; 6 months: -0.01 [-1.9 to 1.9]), or secondary outcomes at either follow-up. There was evidence of lower Negative ITAS scores at 2-week, but not 6-month, follow-up among those with minimum intervention engagement (achieved by 44%) compared to no engagement (-2.7 [-5.1 to -0.3]). CONCLUSIONS: Compared to existing information, 'Is insulin right for me?' did not improve outcomes at either timepoint. Small intervention engagement effects suggest it has potential. Further research is warranted to examine whether effectiveness would be greater in a clinical setting, following timely referral among those for whom insulin is clinically indicated.

'We're all on the same team'. Perspectives on the future of artificial pancreas systems by adults in Australia with type 1 diabetes using open-source technologies: A qualitative study.

AIMS: An emerging group of people with type 1 diabetes are not waiting for commercial solutions, choosing to manage their condition with open-source artificial pancreas systems (APS). Our aim was to explore their perspectives on the future of APS. METHODS: Semi-structured telephone interviews were conducted (in Australia, October 2018 to January 2019) with 23 adults with type 1 diabetes currently using open-source APS. Interviews were recorded, transcribed and analysed thematically. RESULTS: Participants described five key features of open-source APS they value: compatibility, user-led design, customisability, ability to evolve faster and community-driven. They attributed the success of the open-source APS movement to benefits they derive from these features: choice, solutions that meet their needs, ownership, staying one step ahead and real-time support. They expressed hope that future commercial products and healthcare would benefit from their learnings and from collaboration with the open-source APS community. CONCLUSIONS: Participants believed that there will always be a place for the open-source community. It will continue to build on and advance commercial products, respond to user needs, offering a higher degree of control and customisation than afforded by commercial products and generating optimism for the future. Participants desired that future commercial diabetes technologies would be inspired by the open-source community and developed collaboratively with people with diabetes.

'Is insulin right for me?': Feasibility of a pilot randomised controlled trial and acceptability of a web-based intervention to reduce psychological barriers to insulin therapy among adults with type 2 diabetes.

AIMS: Acceptable and accessible interventions are needed to address 'psychological insulin resistance', which is a common barrier to insulin uptake among adults with type 2 diabetes (T2D). Our aim was to test the feasibility of a randomised controlled trial (RCT) study design and acceptability of a theoretically grounded, psycho-educational, web-based resource to reduce negative insulin appraisals among adults with T2D. METHODS: A double-blinded, parallel group, two-arm pilot RCT (1:1), comparing intervention with active control (existing online information about insulin). Eligible participants were Australian adults with T2D, taking oral diabetes medications. EXCLUSION CRITERIA: prior use of injectable medicines; being 'very willing' to commence insulin. Primary outcomes: study feasibility (recruitment ease, protocol fulfilment, attrition, data completeness); secondary outcomes: intervention acceptability (intervention engagement, user feedback) and likely efficacy (negative Insulin Treatment Appraisal Scale [ITAS] scores at follow-up). Online surveys completed at baseline and 2 weeks. RESULTS: During 4-week recruitment, 76 people expressed interest: 51 eligible and 35 enrolled (intervention = 17, control = 18; median[interquartile range] age = 62[53, 69] years; 17 women). Protocol fulfilment achieved by 26 (74%) participants (n = 13 per arm), with low participant attrition (n = 6, 17%). Intervention acceptability was high (>80% endorsement, except format preference = 60%). ITAS negative scores differed between-groups at follow-up (M diff = -6.5, 95% confidence interval: -10.7 to -2.4), favouring the intervention. CONCLUSIONS: This novel web-based resource ("Is insulin right for me?") is acceptable and associated with a likely reduction in negative insulin appraisals, relative to existing resources. This pilot shows the study design is feasible and supports conduct of a fully powered RCT.

'For me, it didn't seem as drastic a step as being controlled by insulin': A qualitative investigation of expectations and experiences of non-insulin injectable therapy among adults with type 2 diabetes.

AIMS: This qualitative study aims to explore beliefs, attitudes and experiences of injectable glucagon-like-peptide-1 receptor agonists (GLP-1RAs) use and discontinuation, as well as attitudes to further injectable treatment intensification, among adults with type 2 diabetes (T2D). METHODS: Nineteen in-depth semi-structured interviews lasting (mean ± standard deviation) 45 ± 18 min were conducted, face-to-face (n = 14) or via telephone (n = 5). Transcripts were analysed using inductive template analyses. Eligible participants were English-speaking adults with T2D who had recently initiated (≤3 years) GLP-1RA treatment. RESULTS: Participants were aged 28-72 years, who predominantly lived in metropolitan areas (n = 15), and had an experience of daily (n = 11) and/or once-weekly (n = 13) GLP-1RA formulations. Six participants had discontinued treatment and seven had trialled two or more formulations. Expectations and experiences of GLP-1RA were related to the perceived: (1) symbolism and stigma of injectable diabetes treatment; (2) ease of injectable administration and device preferences; (3) treatment convenience and social impact; (4) treatment efficacy and benefits, and; (5) negative treatment side effects. Some participants reported increased receptiveness to insulin therapy following their GLP-1RA experience, others emphasised unique concerns about insulin beyond injectable administration. CONCLUSIONS: This study provides a novel understanding of expectations and experience of non-insulin injectables among Australian adults with T2D. Our data suggest expectations may be informed by attitudes to insulin therapy, while perceived treatment benefits (e.g. weight-related benefits, administration frequency) may motivate uptake and ongoing use despite concerns. Experience of GLP-1RA injections may impact receptiveness to future insulin use.

High vision-related quality of life indices reduce the odds of depressive symptoms in aged care facilities.

Objective: To examine the association between vision-related quality of life (VRQoL) and depressive symptoms in residents with vision impairment (VI) in aged care facilities.Methods: In this cross-sectional study using baseline data from a cluster-randomized controlled trial (ACTRN12615000587505) assessing the effectiveness of a novel eye care model, 186 English-speaking residents (mean age 84 years, SD[standard deviation] = 8.7; 33.9% male) with VI and moderate cognitive functioning or better were recruited from 38 facilities across Victoria, Australia. VRQoL was measured using Rasch-transformed scores from the 'Reading'; 'Mobility', and 'Emotional' scales of the Impact of Vision Impairment for Residential Care (IVI-RC) questionnaire. Outcomes were presence of depressive symptoms (binary score: Cornell Scale for Depression in Dementia [CSDD] > 0 vs. CSDD = 0) and severity of depressive symptoms (continuous CSDD score; sample range 1-21). Independent associations with presence and severity of depressive symptoms were examined using zero-inflated logistic and linear multivariable models, respectively.Results: Of the 186 participants, n = 79 (42.5%), n = 94 (50.5%) and n = 13 (7%) reported no, mild (scores 1-7), and clinically significant depressive symptoms (score ≥8), respectively. Better vision-related Mobility (OR = 0.64; 95% CI: 0.44, 0.95, p = 0.02) was associated with reduced odds of depressive symptoms. With every unit improvement in vision-related Reading (ß=-0.48; 95% CI: -0.94, -0.01, p = 0.04) and Emotional (ß=-0.56; 95% CI: -1.09, -0.02, p = 0.04), severity of depressive symptoms reduced, independent of sociodemographic and medical issues.Conclusion: Better VRQoL was independently associated with reduced depressive symptoms. Supporting older people in aged care to maintain optimal levels of vision-specific functioning, independence, and emotional well-being may protect their mental health.

Individuals' Perspectives on Coping with Vision Loss from Diabetic Retinopathy.

SIGNIFICANCE: People with vision loss from diabetic retinopathy (DR) and diabetic macular edema (DME) use problem-focused and emotion-regulation strategies that may influence their short- and longer-term adaptation and psychological outcomes. Our findings can assist the development of models of adjustment to DR/DME-related vision loss and treatments focused on adaptation. PURPOSE: To qualitatively determine the coping strategies used by participants with vision loss resulting from DR/DME. METHODS: Fifty-seven participants with DR/DME engaged in one of eight focus groups or one of 18 semistructured interviews. Participants were mostly older than 55 years (mean, 58.7 years) and male (68%) and had type 2 diabetes (74%; median duration, 17 years). Almost 50% had proliferative DR, 95% had undergone laser treatment, and 42% had DME; 68%, 14% and 14% had none, mild (<0.3 logarithm of the minimum angle of resolution ≤ 0.48), and moderate-severe vision impairment (>0.48 logarithm of the minimum angle of resolution) in the better eye. Focus groups/interviews were transcribed verbatim and iteratively analyzed using the constant comparative method. Qualitative software NVivo 2008 was used to sort/store the data. Our top-down and bottom-up approach to conceptualize the data was informed by the Transactional Model of Stress and Coping. RESULTS: Coping efforts were mostly problem focused (64%) with seven subthemes: problem solving, passive coping, changing activities to suit a new ability level, active coping, rehearsing alternative outcomes, maintaining independence, and information seeking. Emotion-regulation strategies were distraction, acceptance, alternative adaptive thinking, avoidance, expressing emotions, denial, and changing emotions. Meaning-based coping strategies included mindfulness and engaging in meaningful activities. Themes relating to adaptation and moderators to coping (e.g., dispositional optimism) are outlined. CONCLUSIONS: Participants described a variety of ways to cope. Some strategies are likely to improve functioning and decrease distress, whereas others are expected to reduce immediate distress while perpetuating this in the longer term. Our findings may assist researchers to develop models of adjustment to DR/DME-related vision loss and psychosocial/educational interventions focused on adaptation.

Assessment of the psychometric properties of the Chinese Impact of Vision Impairment questionnaire in a population-based study: findings from the Singapore Chinese Eye Study.

PURPOSE: We investigated whether the Chinese impact of vision impairment (IVI) questionnaire is valid to generate reliable person estimates in a population-based sample. METHODS: VRQoL was measured using the 32-item Chinese version of the IVI questionnaire in the Singapore Chinese Eye Study (2009-2011), a population-based study of the prevalence and risk factors for VI and eye diseases in Chinese Singaporeans. Rasch analysis was used to assess the Chinese IVI's response category functioning, precision, unidimensionality, targeting and differential item functioning. The ability of the Chinese IVI to discriminate participants along the spectrum of VI demonstrated criterion validity. RESULTS: Of the 3353 participants, 27.2 % (n = 912) had VI (presenting visual acuity <6/12, better eye). Response categories were collapsed from six to four to resolve disordered thresholds. The Chinese IVI initially demonstrated multidimensionality and was split into three scales: 'Reading and Accessing Information'; 'Mobility and Independence'; and 'Emotional Well-being'. All three scales were unidimensional and demonstrated excellent range-based precision (all reliability coefficients 0.97), following removal of three misfitting items. Mean person measures decreased with worsening VI (e.g. Reading: none (7.50 logits); mild (6.99 logits); moderate (6.44 logits); and severe (3.01 logits) VI; p < 0.001). CONCLUSIONS: A three-dimensional 29-item Chinese IVI is a valid tool to assess the impact of VI on VRQoL in a large population-based sample, comprising over a quarter of participants with VI. The 28-item English IVI is also likely to be valid for use in population-based studies; however, this must be demonstrated empirically in future studies.

Estimating Utility Weights for the Vision Related Quality of Life Index.

PURPOSE: The VisQoL instrument was constructed as a vision-specific addition to the AQoL-6D multi-attribute utility instrument. The composite instrument, the AQoL-7D, was assigned utility scores that are the basis for now estimating VisQoL utilities when it is used as a stand-alone instrument. This study aimed to construct mapping functions that allow utility scores to be assigned to the Vision Related Quality of Life (VisQoL) instrument, a stand-alone vision-specific quality-of-life measure. METHODS: A sample of 164 patients completed the AQoL-7D, which includes the VisQoL. Mapping algorithms between VisQoL and AQoL-7D were then derived using two econometric methods, ordinary least squares estimator and generalized linear model (GLM). Two model specifications were considered with either six VisQoL raw item values or VisQoL overall dimension value as the key independent variables. The predictive performance of each method on each model specification was assessed using the mean absolute error (MAE) and intraclass correlation coefficient (ICC). Both internal and external validation tests (using a second, independent sample of 164 patients) were performed. RESULTS: The mapping algorithms derived from the GLM had superior properties to the ordinary least squares-based algorithms in both internal and external validation tests. The ICC values ranged from 0.851 to 0.913, and the MAE ranged from 0.043 to 0.052 for two model specifications, based on two econometric methods. However, predicted utilities tend to over-predict/under-predict the lowest/highest observed utility. CONCLUSIONS: Mapping algorithms predicting AQoL-7D utility based on six VisQoL items or VisQoL dimension value have been developed. The algorithm can be used to estimate quality adjusted life years. This allows the VisQoL to be used in cost utility analyses.

Help seeking among vision-impaired adults referred to their GP for depressive symptoms: patient characteristics and outcomes associated with referral uptake.

Adults with vision impairment commonly experience depression; however, depression often remains undetected and therefore untreated in this group. Using a prospective longitudinal design, the aim of this study was to determine the rate of uptake for a referral to a general practitioner (GP), in vision-impaired adults, who were screened for depression in low vision rehabilitation and eye-care settings. Fifty-seven vision-impaired adults (aged ≥ 18 years) were recruited from low vision rehabilitation centres across Australia and the Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, between June 2010 and May 2012. Participants screened positive for depressive symptoms and were referred to their GP for follow up. Telephone assessments took place at baseline, 3 and 6 months to determine uptake of a GP referral and changes in depressive symptoms over 6 months. Forty-six per cent of participants followed through with the GP referral. A desire for emotional support and stigma towards seeking support from a psychologist were significantly associated with uptake (both P < 0.05). GPs were more likely to recommend anti-depressant medication compared with a psychologist consultation (69% v. 54%) and patients themselves were more likely to take anti-depressant medication (94% v. 14% who saw a psychologist). Depressive symptoms decreased significantly over 6 months for those who followed through with a GP referral (baseline M = 10.04, s.d. = 5.76 v. 6-months M = 6.20, s.d. = 3.38; z = -2.26, P = 0.02) but not for those who did not use the GP referral (z = -1.92, P = 0.55). This method of referral to a GP following depression screening may provide an effective pathway to detect and manage depression in vision-impaired adults.

Feasibility and acceptability of 'low-intensity mental health support via a telehealth-enabled network' for adults with type 1 and type 2 diabetes: the LISTEN pilot study.

BACKGROUND: This study examined the feasibility and acceptability of the low-intensity mental health support via telehealth-enabled network (LISTEN) intervention, for adults with diabetes, facilitated by diabetes health professionals (HPs). METHODS: LISTEN training. Three HPs participated in three half-day online workshops and applied their learnings during training cases (maximum four). Competency was assessed with a validated tool and achieved 'satisfactory' ratings for three consecutive sessions. LISTEN pilot. A single-group, pre-post study (up to four LISTEN sessions) with online assessments at baseline, post-intervention, and 4-week follow-up. Eligible participants were adults with type 1 or type 2 diabetes, with diabetes distress, but excluded if they had moderate/severe depressive and/or anxiety symptoms. Feasibility was assessed via recruitment and session completion rates. Acceptability was assessed with post-intervention self-report data. Changes in diabetes distress and general emotional well-being from baseline (T1) were explored at post-intervention (T2) and at 4-week follow-up (T3). RESULTS: Two HPs achieved competency (median training case sessions required: 7) and progressed to deliver LISTEN in the pilot study. In the pilot, N = 16 adults (Med [IQR] age: 60 [37-73] years; 13 women) with diabetes participated (median sessions per participant: 2). Twelve participants (75%) completed the post-intervention assessment (T2): 92% endorsed the number of sessions offered as 'just right', 75% felt comfortable talking with the HP, and 67% were satisfied with LISTEN. Perceived limitations were the structured format and narrow scope of problems addressed. Diabetes distress scores were lower post-intervention. CONCLUSIONS: This pilot demonstrates the feasibility of training HPs to deliver LISTEN, and the acceptability and potential benefits of LISTEN for adults with diabetes. The findings highlight adaptations that may enhance the delivery of, and satisfaction with, LISTEN that will be tested in a hybrid type 1 effectiveness-implementation trial.

Discussing depression in patients with visual impairment differs across countries: Validation of a prediction model in healthcare providers.

PURPOSE: Healthcare providers often experience difficulties in discussing depression with adults with visual impairment (VI), obstructing timely referral. The purpose of this study was to examine predictors of routine discussions of depression with adults with VI from the perspective of different healthcare providers from different countries. METHODS: Cross-sectional survey data from Welsh (N = 122), Australian (N = 94) and Dutch (N = 100) healthcare providers, that is eye care practitioners (ECPs) and low-vision care providers (LVCPs), were analysed. Multivariable logistic regression analysis was performed in the Welsh sample to determine predictors for discussing depression. Internal validation was conducted by using a bootstrap method, and the recalibrated model was externally validated in the Australian and Dutch sample. RESULTS: Work experience in eye care services (OR 0.95; 95% confidence interval (CI) 0.92 to 0.99) and perceived barriers (OR 0.95; 95% CI 0.92 to 0.98) was found to predict discussing depression with patients. The area under the curve (AUC) of 0.73 reflected good discrimination of the model. The model showed a slightly better fit in the Australian sample (AUC = 0.77), but a poor fit in the Dutch sample. CONCLUSION: The final prediction model was not generalizable to Dutch healthcare providers. They perceived less barriers in depression management than Welsh and Australian healthcare providers. This could be explained by differences in ECPs and LVCPs roles and responsibilities, increased attention on mental health and differences in organizing health care. Differences between healthcare providers' responsibilities and support needs should be taken into account while creating a facilitating environment to discuss depression.

Low-Intensity mental health Support via a Telehealth Enabled Network for adults with diabetes (LISTEN): protocol for a hybrid type 1 effectiveness implementation trial.

BACKGROUND: Mental health problems are common among people with diabetes. However, evidence-based strategies for the prevention and early intervention of emotional problems in people with diabetes are lacking. Our aim is to assess the real-world effectiveness, cost-effectiveness, and implementation of a Low-Intensity mental health Support via a Telehealth Enabled Network (LISTEN), facilitated by diabetes health professionals (HPs). METHODS: A hybrid type I effectiveness-implementation trial, including a two-arm parallel randomised controlled trial, alongside mixed methods process evaluation. Recruited primarily via the National Diabetes Services Scheme, Australian adults with diabetes (N = 454) will be eligible if they are experiencing elevated diabetes distress. Participants are randomised (1:1 ratio) to LISTEN-a brief, low-intensity mental health support program based on a problem-solving therapy framework and delivered via telehealth (intervention) or usual care (web-based resources about diabetes and emotional health). Data are collected via online assessments at baseline (T0), 8 weeks (T1) and 6 months (T2, primary endpoint) follow-up. The primary outcome is between-group differences in diabetes distress at T2. Secondary outcomes include the immediate (T1) and longer-term (T2) effect of the intervention on psychological distress, general emotional well-being, and coping self-efficacy. A within-trial economic evaluation will be conducted. Implementation outcomes will be assessed using mixed methods, according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Data collection will include qualitative interviews and field notes. DISCUSSION: It is anticipated that LISTEN will reduce diabetes distress among adults with diabetes. The pragmatic trial results will determine whether LISTEN is effective, cost-effective, and should be implemented at scale. Qualitative findings will be used to refine the intervention and implementation strategies as required. TRIAL REGISTRATION: This trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN: ACTRN12622000168752) on 1 February, 2022.

Screening for depression: integrating training into the professional development programme for low vision rehabilitation staff.

BACKGROUND: To describe the integration of depression screening training into the professional development programme for low vision rehabilitation staff and report on staff evaluation of this training. DESIGN: Pre-post intervention study, in a single population of low vision rehabilitation staff. PARTICIPANTS: Three hundred and thirty-six staff from Australia's largest low vision rehabilitation organization, Vision Australia. METHODS: Staff completed the depression screening and referral training as part of a wider professional development programme. A pre-post-training questionnaire was administered to all staff. MAIN OUTCOME MEASURES: Descriptive and non-parametric statistics were used to determine differences in self-reported knowledge, confidence, barriers to recognition and management of depression between baseline and post training. RESULTS: One hundred and seventy-two participants completed both questionnaires. Following training, participants reported an increased knowledge of depression, were more likely to respond to depression in their clients and reported to be more confident in managing depression (P < 0.05). A range of barriers were identified including issues related to the client (e.g. acceptance of referrals); practitioners (e.g. skill, role); availability and accessibility of psychological services; time and contact constraints; and environmental barriers (e.g. lack of privacy). Additional training incorporating more active and 'hands-on' sessions are likely to be required. CONCLUSIONS: This training is a promising first step in integrating a depression screening tool into low vision rehabilitation practice. Further work is needed to determine the barriers and facilitators to implementation in practice and to assess clients' acceptability and outcomes.

Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes: study protocol for a two-armed randomised controlled trial of 'Is insulin right for me?'.

INTRODUCTION: Psychological barriers to insulin therapy are associated with the delay of clinically indicated treatment intensification for people with type 2 diabetes (T2D), yet few evidence-based interventions exist to address these barriers. We describe the protocol for a randomised controlled trial (RCT) examining the efficacy of a novel, theoretically grounded, psychoeducational, web-based resource designed to reduce psychological barriers to insulin among adults with non-insulin treated T2D: 'Is insulin right for me?'. METHODS AND ANALYSIS: Double-blind, parallel group RCT. A target sample of N=392 participants (n=196/arm) will be randomised (1:1) to 'Is insulin right for me?' (intervention) or widely available online resources (control). Eligible participants include adults (18-75 years), residing in Australia, currently taking oral hypoglycaemic agents to manage T2D. They will be primarily recruited via invitations and reminders from the national diabetes registry (from a purposefully selected sample of N≥12 000). EXCLUSION CRITERIA: experience of self-administered injectable; previously enrolled in pilot RCT; 'very willing' to start insulin as baseline. Outcomes will be assessed via online survey at 2 weeks and 6 months. Primary outcome between-group: difference in mean negative Insulin Treatment Appraisal Scores (ITAS negative) at 2-week and 6-month follow-up. SECONDARY OUTCOMES: between-group differences in mean positive insulin appraisals (ITAS positive) and percentage difference in intention to commence insulin at follow-up time points. All data analyses will be conducted according to the intention-to-treat principle. ETHICS AND DISSEMINATION: Deakin University Human Research Ethics Committee (2020-073). Dissemination via peer-reviewed journals, conferences and a plain-language summary. TRIAL REGISTRATION NUMBER: ACTRN12621000191897; Australian and New Zealand Clinical Trials Registry.

Diabetes Distress During COVID-19: Three Brief 'Snapshot' Surveys of Adults With Diabetes Calling the Australian National Diabetes Services Scheme Helpline.

The aim of this study was to take 'snapshots' of how people with diabetes are feeling emotionally during the coronavirus disease 2019 (COVID-19) pandemic. Three 'snapshot' surveys were conducted during May 2020, August 2020 and April 2021, each over a two-week period. Adults (≥18 years) with diabetes calling the Australian Government's National Diabetes Services Scheme Helpline (NDSS) were invited to participate. Those who accepted were asked three questions sourced/adapted from the Problem Areas in Diabetes scale. Responses were recorded on a 5-point scale (0='not a problem', 4='serious problem'). Of interest were scores ≥2, indicating this was at least a 'moderate problem'. The survey was administered by NDSS Helpline staff via telephone. Basic demographic and clinical data were collected. In total, 1,278 surveys were completed over the three 'snapshots' (1st N=449; 2nd N=414; 3rd N=415). Participants were aged (median[IQR]) 62[47,72] years, 56% were women, and 57% had type 2 diabetes. At the 3rd 'snapshot', 21% had received a COVID-19 vaccine. Our findings show that feeling at least moderately 'burned out' by the constant effort needed to manage diabetes is salient, and consistently experienced by adults with diabetes calling the NDSS Helpline at three timepoints during the coronavirus pandemic. Those who participated in the 3rd 'snapshot' survey were less likely to report that feeling 'alone with their diabetes' or 'worrying about their diabetes because of the COVID-19 pandemic' were moderate or serious problems for them. Except for younger adults, findings indicate that the easing of restrictions may mitigate some of the effects of the pandemic on diabetes-specific emotional problems, including feeling 'burned out', 'alone' with diabetes, and/or worried about diabetes due to COVID-19. Prospective data are needed to improve our understanding of the emotional impact of COVID-19 on people with diabetes and to inform when and how to target support for those who need it most.

How Adults with Type 1 Diabetes Are Navigating the Challenges of Open-Source Artificial Pancreas Systems: A Qualitative Study.

Objective: An emerging group of people with type 1 diabetes are building and using their own artificial pancreas systems (APS). Currently, these "user-led," open-source systems are not endorsed by regulatory bodies. People face multiple challenges when building and using open-source APS (e.g., lacking required technical knowledge, difficulties sourcing hardware). We explored the experiences of adults with type 1 diabetes using open-source APS to understand how they are navigating these challenges. Research Design and Methods: We conducted semistructured telephone interviews (October 2018 to January 2019) with Australian adults about their experiences using an open-source APS. Interviews were recorded, transcribed, and analyzed thematically. Results: Participants included 23 adults with type 1 diabetes, aged 25-64 years, 10 (43%) women, with 1-34 months of experience of open-source APS. Participants used four key strategies to navigate challenges: (1) peer support, (2) self-sufficiency, (3) risk management, and (4) trade-offs. Participants relied on peer support and self-sufficiency to fill perceived gaps in professional and industry support. They felt that using an open-source solution was no riskier than previous management and demonstrated a conscious weighing-up of risks. Overall, participants felt that the experienced benefits for their physical health and quality of life outweighed the challenges and potential risks. Conclusions: Adults with type 1 diabetes are applying several interweaving psychosocial and practical strategies to navigate the challenges of building and using open-source APS. The findings highlight the importance of health professionals' showing support and understanding for those choosing to use an open-source APS.

'Is Insulin Right for Me?' Development of a theory-informed, web-based resource for reducing psychological barriers to insulin therapy in type 2 diabetes.

OBJECTIVE: To develop a theory and evidence-based web intervention to reduce psychological barriers towards insulin therapy among adults with non-insulin-treated type 2 diabetes (T2D). METHODS: Salient psychological barriers towards insulin were identified from the literature and classified using the Theoretical Domains Framework (TDF). Relevant TDF domains were mapped to evidence-based behaviour change techniques (BCTs), which informed the content for each barrier. Acceptability was explored using cognitive debriefing interviews (n=6 adults with T2D). RESULTS: 'Is Insulin Right for Me' addresses eight barriers, phrased as common questions: Does insulin mean my diabetes is more serious? Do insulin injections cause complications? Is it my fault I need to inject insulin? Will I gain weight? Will injecting hurt? What about hypos? Will injecting insulin be a burden? What will others think of me? BCTs, including persuasive communication and modelling/demonstration, were delivered using appropriate methods (eg, demonstration of the injection process). Participant suggestions for improvement included clear and direct messages, normalising insulin and avoiding confronting images. CONCLUSIONS: 'Is Insulin Right for Me' is the first theory and evidence-based, web intervention designed to reduce psychological barriers towards insulin therapy for adults with T2D. Evaluation is needed to determine its impact on negative appraisals and receptiveness towards insulin.

Real-world artificial intelligence-based opportunistic screening for diabetic retinopathy in endocrinology and indigenous healthcare settings in Australia.

This study investigated the diagnostic performance, feasibility, and end-user experiences of an artificial intelligence (AI)-assisted diabetic retinopathy (DR) screening model in real-world Australian healthcare settings. The study consisted of two components: (1) DR screening of patients using an AI-assisted system and (2) in-depth interviews with health professionals involved in implementing screening. Participants with type 1 or type 2 diabetes mellitus attending two endocrinology outpatient and three Aboriginal Medical Services clinics between March 2018 and May 2019 were invited to a prospective observational study. A single 45-degree (macula centred), non-stereoscopic, colour retinal image was taken of each eye from participants and were instantly screened for referable DR using a custom offline automated AI system. A total of 236 participants, including 174 from endocrinology and 62 from Aboriginal Medical Services clinics, provided informed consent and 203 (86.0%) were included in the analysis. A total of 33 consenting participants (14%) were excluded from the primary analysis due to ungradable or missing images from small pupils (n = 21, 63.6%), cataract (n = 7, 21.2%), poor fixation (n = 2, 6.1%), technical issues (n = 2, 6.1%), and corneal scarring (n = 1, 3%). The area under the curve, sensitivity, and specificity of the AI system for referable DR were 0.92, 96.9% and 87.7%, respectively. There were 51 disagreements between the reference standard and index test diagnoses, including 29 which were manually graded as ungradable, 21 false positives, and one false negative. A total of 28 participants (11.9%) were referred for follow-up based on new ocular findings, among whom, 15 (53.6%) were able to be contacted and 9 (60%) adhered to referral. Of 207 participants who completed a satisfaction questionnaire, 93.7% specified they were either satisfied or extremely satisfied, and 93.2% specified they would be likely or extremely likely to use this service again. Clinical staff involved in screening most frequently noted that the AI system was easy to use, and the real-time diagnostic report was useful. Our study indicates that AI-assisted DR screening model is accurate and well-accepted by patients and clinicians in endocrinology and indigenous healthcare settings. Future deployments of AI-assisted screening models would require consideration of downstream referral pathways.

Effectiveness of an innovative and comprehensive eye care model for individuals in residential care facilities: results of the residential ocular care (ROC) multicentred randomised controlled trial.

BACKGROUND: To assess the clinical and patient-centred effectiveness of a novel residential ocular care (ROC) model in Australian individuals residing in residential care. METHODS: In this prospective, multicentred, randomised controlled trial conducted in 38 Australian aged-care facilities (2015-2017), 178 visually impaired individuals living in residential care facilities (mean age ±SD: 83.9±8.6 years; 65.7% women) were cluster randomised to ROC (n=95) or usual care (n=83) pathways. The ROC arm comprised a tailored and comprehensive within-site eye examination and care rehabilitation pathway, while usual care participants were given a referral to an external eyecare provider. Outcomes included presenting distance and near visual acuity (PNVA); Rasch-transformed Reading, Emotional and Mobility scores from the Impact of Vision Impairment questionnaire; quality of vision (QoV comprising Rasch-transformed Frequency, Severity and Bother domains) scores; Euroqol-5-Dimensions (raw scores); Cornell Scale for Depression (raw scores) and 6-month falls frequency, assessed at baseline and 6 months post intervention. Within-group and between-group comparisons were conducted using linear mixed models, adjusted for baseline differences in characteristics between the two arms. RESULTS: At 6 months, intention-to-treat analyses showed significant between-group improvements in ROC residents compared with usual care for PNVA, Emotional and QoV scores (all p<0.05) These significant findings were retained in per-protocol analyses. No other between-group changes were observed. CONCLUSION: Our ROC model was effective in improving near vision, emotional well-being and perceived burden of vision-related symptoms in residential care dwellers in Australia with vision impairment. Future studies to evaluate the cost effectiveness and implementation of ROC in Australia are warranted.