Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations.

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Reimagining care for young adults living with type 1 diabetes.

Young adults living with type 1 diabetes often struggle to achieve what clinicians consider to be optimal levels of metabolic control. Despite the impact that this can have on a young person's future risk of complications, there are relatively few studies reporting new ways of organizing or delivering care to this cohort. In this article, we explore some of the reasons why young adult diabetes care is challenging, and describe approaches to "re-imagining" how care might be improved. The work is informed by the 'Making Care Fit' collaborative and by a program of research, entitled D1 Now, involving co-design of a complex person-centered intervention with young adults.

The use of postal audit and feedback among Irish General Practitioners for the self - management of antimicrobial prescribing: a qualitative study.

OBJECTIVE: Inappropriate use of antibiotics has been acknowledged as a significant contributor to the proliferation of antimicrobial resistance worldwide. Physician prescribing of antibiotics has been identified as a factor in the inappropriate use of antibiotics. One methodology that is used in an attempt to alter physician prescribing behaviours is audit and feedback. This study aimed to explore the perceptions of Irish General Practitioners (GPs) towards the national introduction of postal feedback on their antibiotic prescribing behaviours beginning in 2019. DESIGN: A qualitative descriptive methodology was used. Semi-structured interviews were conducted with GPs in receipt of postal audit and feedback. METHOD: GPs working in Ireland and in receipt of postal audit and feedback on their antibiotic prescribing behaviours participated in phone-based interviews. The interviews were recorded and transcribed verbatim. The collected data was then analysed using an inductive thematic analysis. RESULTS: Twelve GPs participated in the study (female = 5). Three themes were identified from the analysis. The themes identified were the reliability and validity of the feedback received, feedback on antibiotic prescribing is useful but limited and feedback needs to be easily digestible. CONCLUSION: While the postal audit and feedback were broadly welcomed by the participants, the themes identified a perceived limitation in the quality of the feedback data, the perception of a likely low public health impact of the feedback and difficulties with efficiently processing the audit and feedback information. These findings can help refine future audit and feedback interventions on antibiotic prescribing.

Improving outcomes among young adults with type 1 diabetes: the D1 Now pilot cluster randomised controlled trial.

BACKGROUND: The D1 Now intervention is designed to improve outcomes in young adults living with type 1 diabetes. It consists of three components: an agenda-setting tool, an interactive messaging system and a support worker. The aim of the D1 Now pilot cluster randomised controlled trial (RCT) was to gather and analyse acceptability and feasibility data to allow (1) further refinement of the D1 Now intervention, and (2) determination of the feasibility of evaluating the D1 Now intervention in a future definitive RCT. METHODS: A pilot cluster RCT with two intervention arms and a control arm was conducted over 12 months. Quantitative data collection was based on a core outcome set and took place at baseline and 12 months. Semi-structured interviews with participants took place at 6, 9 and 12 months. Fidelity and health economic costings were also assessed. RESULTS: Four diabetes centres and 57 young adults living with type 1 diabetes took part. 50% of eligible young adults were recruited and total loss to follow-up was 12%. Fidelity, as measured on a study delivery checklist, was good but there were three minor processes that were not delivered as intended in the protocol. Overall, the qualitative data demonstrated that the intervention was considered acceptable and feasible, though this differed across intervention components. The agenda-setting tool and support worker intervention components were acceptable to both young adults and staff, but views on the interactive messaging system were mixed. CONCLUSIONS: Some modifications are required to the D1 Now intervention components and research processes but with these in place progression to a definitive RCT is considered feasible. TRIAL REGISTRATION: ISRCTN (ref: ISRCTN74114336 ).

Supporting self-management and clinic attendance in young adults with type 1 diabetes: development of the D1 Now intervention.

BACKGROUND: Self-management of type 1 diabetes (T1D) is complex and can be particularly challenging for young adults. This is reflected in the high blood glucose values and rates of clinic non-attendance in this group. There is a gap for a theory-based intervention informed by key stakeholder opinions to support and improve self-management in young adults with T1D. PURPOSE: The aim of the work was to systematically co-develop an evidence-based and stakeholder-led intervention to support self-management and clinic engagement in young adults living with T1D in Ireland. Co-development was led by the Young Adult Panel. METHODS: The Behaviour Change Wheel was used to guide the development. Five evidence sources were used to inform the process. An iterative co-design process was used with the Young Adult Panel. Initial intervention components were refined and feasibility tested using qualitative methods. RESULTS: Environmental restructuring, education and training were selected as appropriate intervention functions. The co-design process, along with qualitative refinement and feasibility work, led to the final intervention content which consisted of 17 behaviour change techniques. The final D1 Now intervention consists of three components: a support worker, an agenda setting tool and an interactive messaging service. CONCLUSIONS: The D1 Now intervention is now at pilot evaluation stage. Its transparent and systematic development will facilitate evaluation and future replications.

Piloting an Intervention to Improve Outcomes in Young Adults Living With Type 1 Diabetes: The Experience of the D1 Now Support Worker.

Introduction: D1 Now is a novel intervention which aims to support self-management and clinic engagement and improve outcomes in young adults (18-25 years) living with type 1 diabetes in Ireland. It has been developed using a systematic, theoretical, user-centred approach. The specific role of the Support Worker, one of three components of the D1 Now intervention, was developed to provide continuity and build relationships between young adults and their diabetes team. Methods: A Support Worker - an Occupational Therapist, who had a background in youth mental health - was hired as part of the D1 Now pilot randomised controlled trial and was based in one intervention site to join the existing diabetes team. Discussion: The Support Worker aimed to provide an accessible and consistent point of contact for young adults, facilitated conversations about distress, and encouraged graded goal setting and collaborative problem solving. The role afforded her with a unique window into the lived experiences of young adults with type 1 diabetes where she observed the ongoing negotiation of life and living alongside diabetes care and management. The prevalence of diabetes distress was high in the study cohort with particular challenges associated with 'all or nothing' thinking patterns as well as disordered eating behaviours. The Support Worker also played an advocacy role in supporting the diabetes team's awareness of young adults' needs and explored current barriers to care. Preliminary findings from the D1 Now pilot have identified that the role of the Support Worker was viewed positively from the perspective of young adults with type 1 diabetes.

Patients' Experiences of Using Smartphone Apps to Support Self-Management and Improve Medication Adherence in Hypertension: Qualitative Study.

BACKGROUND: Worldwide, hypertension control rates remain suboptimal despite clinically effective antihypertensive drug therapy. Patient failure to take medication as prescribed (ie, nonadherence) is the most important factor contributing to poor control. Smartphone apps can facilitate the delivery of evidence-based behavior change techniques to improve adherence and may provide a scalable, usable, and feasible method to deliver self-management support. OBJECTIVE: The aim of this study is to explore patients' experiences of the usability and feasibility of smartphone apps to support self-management and improve medication adherence in hypertension. METHODS: A qualitative descriptive study was conducted. A total of 11 people living with hypertension from the West of Ireland were sampled purposively and interviewed about their experience of using a self-management app for a 4-week period, which included two key functionalities: self-monitoring of blood pressure (BP) and medication reminders. Thematic analysis was carried out on the semistructured interview data. RESULTS: Participants' age ranged from 43 to 74 years (mean 62 years, SD 9.13). Three themes were identified: digital empowerment of self-management, human versus digital systems, and digital sustainability. Although patients' experience of using the technology to self-monitor BP was one of empowerment, characterized by an enhanced insight and understanding into their condition, control, and personal responsibility, the reminder function was only feasible for patients who reported unintentional nonadherence to treatment. Patients experienced the app as a sustainable tool to support self-management and found it easy to use, including those with limited technological competence. CONCLUSIONS: The study's findings provide new insights into the experience of using apps to support medication adherence in hypertension. Overall, the data support apps as a usable and feasible method to aid self-management of hypertension and highlight the need for personalized functionality, particularly with regard to medication adherence reminder strategies. The study's findings challenge the perspective that the use of these technologies to support self-management can inevitably add to the burden of treatment experienced by patients.

Video calls for reducing social isolation and loneliness in older people: a rapid review.

BACKGROUND: The current COVID-19 pandemic has been identified as a possible trigger for increases in loneliness and social isolation among older people due to the restrictions on movement that many countries have put in place. Loneliness and social isolation are consistently identified as risk factors for poor mental and physical health in older people. Video calls may help older people stay connected during the current crisis by widening the participant's social circle or by increasing the frequency of contact with existing acquaintances. OBJECTIVES: The primary objective of this rapid review is to assess the effectiveness of video calls for reducing social isolation and loneliness in older adults. The review also sought to address the effectiveness of video calls on reducing symptoms of depression and improving quality of life. SEARCH METHODS: We searched CENTRAL, MEDLINE, PsycINFO and CINAHL from 1 January 2004 to 7 April 2020. We also searched the references of relevant systematic reviews. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs (including cluster designs) were eligible for inclusion. We excluded all other study designs. The samples in included studies needed to have a mean age of at least 65 years. We included studies that included participants whether or not they were experiencing symptoms of loneliness or social isolation at baseline. Any intervention in which a core component involved the use of the internet to facilitate video calls or video conferencing through computers, smartphones or tablets with the intention of reducing loneliness or social isolation, or both, in older adults was eligible for inclusion. We included studies in the review if they reported self-report measures of loneliness, social isolation, symptoms of depression or quality of life.  Two review authors screened 25% of abstracts; a third review author resolved conflicts. A single review author screened the remaining abstracts. The second review author screened all excluded abstracts and we resolved conflicts by consensus or by involving a third review author. We followed the same process for full-text articles. DATA COLLECTION AND ANALYSIS: One review author extracted data, which another review author checked. The primary outcomes were loneliness and social isolation and the secondary outcomes were symptoms of depression and quality of life. One review author rated the certainty of evidence for the primary outcomes according to the GRADE approach and another review author checked the ratings. We conducted fixed-effect meta-analyses for the primary outcome, loneliness, and the secondary outcome, symptoms of depression. MAIN RESULTS: We identified three cluster quasi-randomised trials, which together included 201 participants. The included studies compared video call interventions to usual care in nursing homes. None of these studies were conducted during the COVID-19 pandemic.  Each study measured loneliness using the UCLA Loneliness Scale. Total scores range from 20 (least lonely) to 80 (most lonely). The evidence was very uncertain and suggests that video calls may result in little to no difference in scores on the UCLA Loneliness Scale compared to usual care at three months (mean difference (MD) -0.44, 95% confidence interval (CI) -3.28 to 2.41; 3 studies; 201 participants), at six months (MD -0.34, 95% CI -3.41 to 2.72; 2 studies; 152 participants) and at 12 months (MD -2.40, 95% CI -7.20 to 2.40; 1 study; 90 participants). We downgraded the certainty of this evidence by three levels for study limitations, imprecision and indirectness. None of the included studies reported social isolation as an outcome. Each study measured symptoms of depression using the Geriatric Depression Scale. Total scores range from 0 (better) to 30 (worse). The evidence was very uncertain and suggests that video calls may result in little to no difference in scores on the Geriatric Depression Scale compared to usual care at three months' follow-up (MD 0.41, 95% CI -0.90 to 1.72; 3 studies; 201 participants) or six months' follow-up (MD -0.83, 95% CI -2.43 to 0.76; 2 studies, 152 participants). The evidence suggests that video calls may have a small effect on symptoms of depression at one-year follow-up, though this finding is imprecise (MD -2.04, 95% CI -3.98 to -0.10; 1 study; 90 participants). We downgraded the certainty of this evidence by three levels for study limitations, imprecision and indirectness. Only one study, with 62 participants, reported quality of life. The study measured quality of life using a Taiwanese adaptation of the Short-Form 36-question health survey (SF-36), which consists of eight subscales that measure different aspects of quality of life: physical function; physical role; emotional role; social function; pain: vitality; mental health; and physical health. Each subscale is scored from 0 (poor health) to 100 (good health). The evidence is very uncertain and suggests that there may be little to no difference between people allocated to usual care and those allocated to video calls in three-month scores in physical function (MD 2.88, 95% CI -5.01 to 10.77), physical role (MD -7.66, 95% CI -24.08 to 8.76), emotional role (MD -7.18, 95% CI -16.23 to 1.87), social function (MD 2.77, 95% CI -8.87 to 14.41), pain scores (MD -3.25, 95% CI -15.11 to 8.61), vitality scores (MD -3.60, 95% CI -9.01 to 1.81), mental health (MD 9.19, 95% CI 0.36 to 18.02) and physical health (MD 5.16, 95% CI -2.48 to 12.80). We downgraded the certainty of this evidence by three levels for study limitations, imprecision and indirectness. AUTHORS' CONCLUSIONS: Based on this review there is currently very uncertain evidence on the effectiveness of video call interventions to reduce loneliness in older adults. The review did not include any studies that reported evidence of the effectiveness of video call interventions to address social isolation in older adults. The evidence regarding the effectiveness of video calls for outcomes of symptoms of depression was very uncertain. Future research in this area needs to use more rigorous methods and more diverse and representative participants. Specifically, future studies should target older adults, who are demonstrably lonely or socially isolated, or both, across a range of settings to determine whether video call interventions are effective in a population in which these outcomes are in need of improvement.

Comparative efficacy of exercise and anti-hypertensive pharmacological interventions in reducing blood pressure in people with hypertension: A network meta-analysis.

AIMS: This analysis aims to estimate the comparative efficacy of anti-hypertensive medications and exercise interventions on systolic and diastolic blood pressure reduction in people with hypertension. METHODS: A systematic review was conducted focusing on randomised controlled trials (RCTs) of exercise interventions and first-line anti-hypertensives where blood pressure reduction was the primary outcome in those with hypertension. Network meta-analyses were conducted to generate estimates of comparative efficacy. RESULTS: We identified 93 RCTs (N = 32,404, mean age in RCTs: 39-70 years) which compared placebo or usual care with first-line antihypertensives including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers and thiazide-like diuretics and exercise interventions including aerobic training and dynamic resistance training. Of these, there were 81 (87%) trials related to medications (n = 31,347, 97%) and 12 (13%) trials related to exercise (n = 1057, 3%). The point estimates suggested that antihypertensive medications were more effective than exercise but there was insufficient evidence to suggest that first-line medications significantly reduced blood pressure to a greater extent than did the exercise interventions. Of the first-line treatments, angiotensin receptor blockers and calcium channel blockers had the highest treatment ranking, while exercise had the second lowest treatment ranking, followed by control conditions. CONCLUSION: The current evidence base with a bias towards medication research may partly explain the circumspection around the efficacy of exercise in guidelines and practice. Clinicians may justifiably consider exercise for low risk hypertension patients who confirm a preference for such an approach.

Smartphone apps for improving medication adherence in hypertension: patients' perspectives.

PURPOSE: Digital interventions, such as smartphone applications (apps), are becoming an increasingly common way to support medication adherence and self-management in chronic conditions. It is important to investigate how patients feel about and engage with these technologies. The aim of this study was to explore patients' perspectives on smartphone apps to improve medication adherence in hypertension. METHODS: This was a qualitative study based in the West of Ireland. Twenty-four patients with hypertension were purposively sampled and engaged in focus groups. Thematic analysis on the data was carried out. RESULTS: Participants ranged in age from 50 to 83 years (M=65 years) with an equal split between men and women. Three major themes were identified in relation to patients' perspectives on smartphone apps to improve medication adherence in hypertension: "development of digital competence," "rules of engagement," and "sustainability" of these technologies. CONCLUSION: These data showed that patients can identify the benefits of a medication reminder and recognize that self-monitoring their blood pressure could be empowering in terms of their understanding of the condition and interactions with their general practitioners. However, the data also revealed that there are concerns about increasing health-related anxiety and doubts about the sustainability of this technology over time. This suggests that the current patient perspective of smartphone apps might be best characterized by "ambivalence."

New self-management technologies for the treatment of hypertension: general practitioners' perspectives.

Background: Digital health interventions, such as those that can be delivered via smartphone applications (apps) or wireless blood pressure monitors, offer a new, scalable and potentially cost-effective way to improve hypertension self-management. In Ireland, as is common in the UK, the majority of hypertension management occurs in general practice. Therefore, it is crucial to investigate how general practitioners (GPs) feel about and engage with the growth of these new methods of self-management of blood pressure. Aim: To explore GPs' perspectives of self-management technology to support medication adherence and blood pressure control in patients with hypertension. Design and setting: This was a qualitative interview study based in the West of Ireland. Ten GPs who were purposively sampled participated in semi-structured interviews. Thematic analysis was carried out on the data. Results: Three major themes were identified: current reach and future potential, empowerment and responsibility. Conclusions: GPs could see the benefit of using these technologies, such as more accurate blood pressure data and potential to engage patients in self-management. Concerns relating to the increased workload associated with a potentially unmanageable quantity of information and an increase in healthcare use among the 'worried well' also emerged strongly from the data.

Medication adherence among patients with apparent treatment-resistant hypertension: systematic review and meta-analysis.

OBJECTIVES: Medication nonadherence is a known behavioural contributor to poor blood pressure (BP) control that puts patients with hypertension at elevated cardiovascular risk. Studies of medication adherence for apparent treatment-resistant hypertension (aTRH) vary significantly with respect to design, methods, and setting, and, as a result, have produced highly variable figures describing the prevalence of nonadherence. This review aimed to describe the prevalence and potential moderators of medication nonadherence estimates for aTRH. METHODS: Systematic review and random effects meta-analysis. RESULTS: From an initial discovery of 921 studies, we identified 24 studies that measured medication adherence for patients with uncontrolled BP despite being prescribed three or more antihypertensive medications of different classes. By using a random effects model, the pooled prevalence of nonadherence was 31.2% (95% confidence interval = 20.2-44.7, I = 99.50) with nonadherence rates ranging from 3.3 to 86.1%. The strongest contributor to variance in nonadherence rates was the method of adherence assessment used. Studies that relied on self-report measures of adherence and/or pharmacy data reported lower levels of nonadherence than studies using more objective methods, such as liquid chromatography-mass spectrometry in single time-point bioassays or directly observed therapy. CONCLUSION: Findings indicate that medication nonadherence is a significant problem among aTRH patients. Identifying the most accurate and clinically feasible adherence assessment methods is necessary to reduce BP and cardiovascular morbidity, facilitate early behavioural intervention, prevent unnecessary diagnostic testing, and limit sometimes unnecessary and expensive BP lowering procedures. REGISTRATION NUMBER: CRD42016028121.

Effectiveness and content analysis of interventions to enhance medication adherence and blood pressure control in hypertension: A systematic review and meta-analysis.

OBJECTIVE: The objective of this systematic review is to evaluate the effectiveness of medication adherence interventions on blood pressure control in hypertensive patients. In addition, we aim to explore what barriers and facilitators in the interventions may have been targeted and how these might be related to the effect size on blood pressure (BP). DESIGN: This review is a hypertension-specific update to the previous Cochrane Review by Nieuwlaat et al. ( 2014 ) on interventions to enhance medication adherence. A systematic literature search was carried out and two authors independently screened titles and abstracts for their eligibility for inclusion and independently extracted data from the selected studies and assessed the methodological quality using the Cochrane Collaboration Risk of Bias Tool. A meta-analysis was conducted and additionally, theoretical factors in interventions were identified using the Theoretical Domains Framework. RESULTS: The meta-analysis found a modest main effect of adherence interventions on SBP (MD -2.71 mm Hg, 95% CI -4.17 to -1.26) and DBP (MD -1.25 mm Hg, 95% CI -1.72 to -.79). However, there was substantial significant heterogeneity across both outcomes. A narrative review on adherence outcomes was conducted. In terms of the theoretical analysis, the relationship between the total number of times the domains were coded within an intervention and change of SBP (r  =  -.234, p = .335) and DBP was not significant (r  =  -.080, p = .732). Similarly, the relationship between the total number of times different domains were coded within an intervention and change of SBP (r  =  .080, p = .746) and DBP was not significant (r  =  -.188, p = .415). DISCUSSION: This review and meta-analysis of interventions documented significant but modest post-intervention improvements in BP outcomes among hypertensive patients. However, this is a tentative finding as substantial heterogeneity and potential biases were present. One of the greatest challenges of this review was assessing risk of bias, extracting sufficient data to calculate effect size and coding interventions with the amount of information provided in papers. It is imperative that future adherence research comprehensively reports methodology.

Effectiveness and content analysis of interventions to enhance medication adherence in hypertension: a systematic review and meta-analysis protocol.

BACKGROUND: Hypertension control through pharmacological treatment has led to substantial benefits in the prevention of morbidity and mortality from cardiovascular diseases. However, evidence from a number of studies suggests that as many as 50 to 80 % of patients treated for hypertension have low adherence to their treatment regimen. The objective of this systematic review is to evaluate the effectiveness of medication adherence interventions for hypertension. In addition, we aim to explore what barriers and facilitators in the interventions may have been targeted and how these might be related to the effect size on blood pressure (BP). METHODS: This review is a hypertension-specific update to the previous Cochrane Review by Nieuwlaat et al. (2014) on interventions to enhance medication adherence. A systematic literature search will be carried out, and two authors will independently screen titles and abstracts for their eligibility for inclusion and independently extract data from the selected studies and assess the methodological quality using the Cochrane Collaboration Risk of Bias Tool. A meta-analysis will be conducted, and additionally, theoretical factors in interventions will be identified using the Theoretical Domains Framework. DISCUSSION: This review will generate new information by quantitatively evaluating the effectiveness of adherence interventions for hypertension and potentially identify which theoretical domains are associated with more effective interventions and which domains have not been the subject of intervention development. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016033358.

Behavior Change Techniques in Apps for Medication Adherence: A Content Analysis.

INTRODUCTION: There are a vast number of smartphone applications (apps) aimed at promoting medication adherence on the market; however, the theory and evidence base in terms of applying established health behavior change techniques underpinning these apps remains unclear. This study aimed to code these apps using the Behavior Change Technique Taxonomy (v1) for the presence or absence of established behavior change techniques. METHODS: The sample of apps was identified through systematic searches in both the Google Play Store and Apple App Store in February 2015. All apps that fell into the search categories were downloaded for analysis. The downloaded apps were screened with exclusion criteria, and suitable apps were reviewed and coded for behavior change techniques in March 2015. Two researchers performed coding independently. RESULTS: In total, 166 medication adherence apps were identified and coded. The number of behavior change techniques contained in an app ranged from zero to seven (mean=2.77). A total of 12 of a possible 96 behavior change techniques were found to be present across apps. The most commonly included behavior change techniques were "action planning" and "prompt/cues," which were included in 96% of apps, followed by "self-monitoring" (37%) and "feedback on behavior" (36%). CONCLUSIONS: The current extent to which established behavior change techniques are used in medication adherence apps is limited. The development of medication adherence apps may not have benefited from advances in the theory and practice of health behavior change.