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Implementing a structured education program for children with diabetes: lessons learnt from an integrated process
Mary Sawtell1, Liz Jamieson2, Meg Wiggins3
1Social Science Research Unit , UCL Institute of Education , London , UK.
Insights
The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) program showed perceived benefits for families managing type 1 diabetes, but faced low uptake and high staff burden. Further program improvements are recommended.
Area of Science:
- Pediatric Endocrinology
- Clinical Psychology
- Health Services Research
Background:
- Type 1 diabetes in youth requires interventions to improve glycemic control and quality of life.
- The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) is a structured group program using psychological techniques for children with type 1 diabetes and their parents.
- A mixed-methods process evaluation assessed CASCADE's feasibility, acceptability, fidelity, and perceived impact within a cluster randomized control trial.
Purpose of the Study:
- To evaluate the feasibility, acceptability, fidelity, and perceived impact of the CASCADE program.
- To identify barriers and facilitators to the uptake and delivery of CASCADE.
- To inform future improvements for clinic-based diabetes education programs.
Main Methods:
- A cluster randomized control trial involving 28 pediatric diabetes clinics and 362 children (aged 8-16) with type 1 diabetes (mean HbA1c ≥8.5%).
- A mixed-methods process evaluation utilizing diverse research methods.
- Data collection included program delivery metrics, staff feedback, and family experiences.
Main Results:
- Only 30% of families received the full CASCADE program, with 53% attending at least one module; 68% of planned groups were delivered.
- Staff reported burdens related to organization and mastering psychological techniques; family uptake was affected by scheduling and other commitments.
- Attendees reported improved family relationships, knowledge, confidence, and motivation, but the trial did not significantly improve HbA1c at 12 or 24 months.
Conclusions:
- The CASCADE program was perceived as valuable by staff and families, offering benefits in relationships and self-management knowledge.
- Despite perceived benefits, poor uptake and high staff burden limit the program's effectiveness.
- Recommendations focus on optimizing organization, design, and delivery to enhance the impact of CASCADE and similar future interventions.
Background:
There is recognition of an urgent need for clinic-based interventions for young people with type 1 diabetes mellitus that improve glycemic control and quality of life. The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) is a structured educational group program, using psychological techniques, delivered primarily by diabetes nurses. Composed of four modules, it is designed for children with poor diabetic control and their parents. A mixed methods process evaluation, embedded within a cluster randomized control trial, aimed to assess the feasibility, acceptability, fidelity, and perceived impact of CASCADE.
Methods:
28 pediatric diabetes clinics across England participated and 362 children aged 8-16 years, with type 1 diabetes and a mean glycosylated hemoglobin (HbA1c) of 8.5 or above, took part. The process evaluation used a wide range of research methods.
Results:
Of the 180 families in the intervention group, only 55 (30%) received the full program with 53% attending at least one module. Only 68% of possible groups were run. Staff found organizing the groups burdensome in terms of arranging suitable dates/times and satisfactory group composition. Some staff also reported difficulties in mastering the psychological techniques. Uptake, by families, was influenced by the number of groups run and by school, work and other commitments. Attendees described improved: family relationships; knowledge and understanding; confidence; motivation to manage the disease. The results of the trial showed that the intervention did not significantly improve HbA1c at 12 or 24 months.
Conclusions:
Clinic-based structured group education delivered by staff using psychological techniques had perceived benefits for parents and young people. Staff and families considered it a valuable intervention, yet uptake was poor and the burden on staff was high. Recommendations are made to inform issues related to organization, design, and delivery in order to potentially enhance the impact of CASCADE and future programs.
Current Controlled Trials:
ISRCTN52537669.
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