Insights into optimising education for patients living with diabetes mellitus: A model for the post-pandemic era, informed by survey data

Background: Patient education represents the key element in the management of diabetes mellitus (DM) and has changed dramatically during the last 3 years. Uptake of structured education is poor, and patient perception of received education varies greatly. The purpose of this study was to assess patients’ perception of adequacy of delivered education, barriers to attending structured courses and preferences for ongoing DM-related education. Methods: Patients living with Type 2 DM attending diabetes clinics were invited to complete a questionnaire about their understanding of DM, adequacy of offered education and desired features of future courses, following their clinic appointment at University Hospitals Coventry and Warwickshire (UHCW). Those interested ( n = 146) completed this


Conclusion:
The provision of DM-related education pre-pandemic did not meet patients' needs. Gaining insight and understanding into the gaps within current DMrelated educational provision and patient preferences for its delivery are key strategies in the development of reformed DM-related education that will ultimately equip patients with improved self-management skills.

K E Y W O R D S
diabetes, diabetes education, mindfulness

INTRODUCTION
Living with diabetes mellitus (DM), perhaps more than any other 21st Century chronic disease, requires focus, diligence, drive and poise.
Even with extensive input from healthcare professionals and spe- The DESMOND course consists of a 6-h structured selfmanagement educational programme. DESMOND targets patient understanding of DM and provides lifestyle advice including that related to food choices and physical activity. 4 Based on current published evidence, clinical effectiveness of DESMOND is mixed.
Although early improvements in both weight and smoking cessation occur at 1-year following attendance at a DESMOND course, 5

Research design
This was a cross sectional study, using a bespoke questionnaire.
Power calculation was not done; however we aimed to get a minimum of 100 responses. Following informed consent, we requested

Statistical analysis
IBM SPSS 26 was used for all statistical testing. All available data were used for individual analysis. Data were displayed using excel. Data on satisfaction with received education were non-parametric. Therefore, we used the Mann-Whitney U test for comparisons between data.
The chi-squared test was used to analyse preference of future mode of education delivery based on patients' age. We report descriptive data as mean, median, interquartile range (IQR) and standard deviation (SD). A p value <0.05 was considered significant. Some participants did not complete all the questions in the questionnaire and as a result the total number of responses can differ between individual questions.
Percentages were rounded to the nearest percentage.

Research objectives
To identify the number of patients attending secondary care diabetes service who have not had any formal diabetes education and to explore preferred methods of delivery for future diabetes self-management courses.

Participant cohort demographics
We report on data generated from self-completion of a standard ques-

Adequacy of DM-related education provision
One reported more than one deficiency, such as dietary education, general diabetes education and timeliness combined (data shown in Figure 5).

Preference for accessibility and format of DM-related education
A majority of the cohort (n = 109) specified a preferred method of ongoing DM-related education. Overall, the cohort was roughly split regarding preference for a face-to-face versus remote delivery of DMrelated education, with 51% expressing a preference for the former.

F I G U R E 4 Understanding and interest in HbA1c
For the remainder, 33% preferred remote delivery, and 16% preferred a combined approach of face-to-face and remote delivery. One variable chi-squared (X 2 ) analysis (with a cut off X 2 value of 5.99 for 2 degrees of freedom and alpha of 0.05), demonstrated that face-toface delivery of DM-related education was preferred overall (X 2 (2) = 18.8, p < 0.005), in the 51-64 years (X 2 (2) = 17.1, p < 0.005) and ≥65 years age groups (X 2 (2) = 6.7, p = 0.05). However, there was no difference in the preferred educational delivery method in the younger ≤50 years age group, (X 2 (2) = 2.4, p = 0.76), although most wanted remote options (14, 45% remote; 7, 23% hybrid) (data shown in Figure 6).

Participant feedback
There was expression of interest in options for skype contact, more accessible courses and support with eating behaviours and impulses.
The main barriers to attending courses were mobility issues, language problems and learning difficulties. Patients would like healthcare professionals to 'help with mental health issues', create 'smaller modules allowing disabled patients to attend' and 'apps/short articles/interactive'.
Patients also wanted help with increasing their self-compassion and return to normality: 'Don't make the patient feel like a failure: We need to know how a normal life can be achieved'.

DISCUSSION
The data outlined from our audit reveal serious deficiencies in the adequacy of existing DM-related educational provision for our patients.
This represents an important unmet need, and one that is well overdue. Unfortunately, the insights gained from our local audit are reflected nationally: the inadequacy of DM-related patient education is a national problem. 12 It follows that tackling this problem requires a national solution. It is important to highlight here that the problems with DM-related educational provision are not necessarily related to the adequacy of the educational programmes on offer. Indeed, the existing DAFNE and DESMOND courses appear in many cases excellent. Rather, the main issue (as identified from our survey) is that although such traditional courses exist and are offered to patients, the courses themselves are poorly attended, with only a small minority of patients offered the course who attend it. Therefore, reformation of DM education needs to properly address its accessibility and other barriers to its successful implementation. Although patients from our survey expressing a preference wanted face to face education as an option, as many wanted remote or hybrid, so all three should be included in future programmes to maximise accessibility.
Our study had several limitations. It was done in one diabetes centre only and assessed people living with T2D accessing secondary care.
Whilst we collected data on >100 patients, we would need to repeat the survey on larger numbers of patients, in different settings and localities to get a broader insight into the problem. Additionally, the survey relied entirely on patient self-recall, and therefore there was potential for lack of accuracy from reduced memory of educational provision that may have occurred at diagnosis for example (especially as some of them were diagnosed in 1979: it is entirely feasible that not all patients can remember what happened that far back). Also, there may be potential for recall bias. It is known that one's memory of the past is influenced by one's current emotional status. If a patient is feeling distressed currently, then their outlook on the past (and future) will tend to be more negative, and their recollection of the utility of educational provision may be influenced in that way as well.
We used HcA1c as a proxy measure of diabetes understanding, but of course to properly assess this would have required far greater questioning into many aspects of DM, which would not have been feasible

Pre-pandemic landscape for patient DM-related education in the UK
Traditionally, there were three levels of DM-related educational delivery: (i) one-to-one advice; (ii) informal ongoing learning; (iii) structured health care professional directed education that meets nationallyagreed criteria, as defined by the National Institute for Health and Care Excellence. 13 These criteria state that any educational course requires a foundational evidence-based with specific aims and objectives, driven by theory, resource effective, delivery by trained educators and regular auditing. 14 However, the criteria do not specify what content is required.
The Department of Health and Diabetes UK provides guidance on the specific content of such DM-related courses, with information about day-to-day management of DM, the nature of DM, living with DM and sick day rules. 15 The American Association of Diabetes Educators also created a framework for any patient centred DMeducation, which allows the evaluation and creation of new courses and programmes. 16 The framework has seven key behaviours, including healthy eating, physical activity, DM monitoring, taking medication, reducing the risk of DM-related complications, problem solving and healthy coping. These criteria provide a focus on overall healthier lifestyle, including metabolic health parameters, such as weight, blood pressure, lipids and mental health.
All level three educational programmes in the UK have to be Quality Institute for Self-Management Education and Training approved. Examples of some of the level three courses are DAFNE, X-PERT Diabetes Programme and DESMOND.

Digitally enabled structured patient education
One of the first technology-enabled DM-related structured educational courses took place at Stanford University in California in 2010.
Following this 6-week web-based programme, patients had improved self-efficacy, confidence in managing their condition and glycaemic control. 17 By 2017, there were at least 25 high quality studies that reported assessment of digitally enabled DM-related structured education.
Review of these studies identified four key elements of a successful remote educational course: (i) two-way communication; (ii) patientgenerated health data; (iii) tailored education and (iv) individualised feedback. Accordingly, all of these factors should be integrated into the design of any self-management education and support courses for patients with DM. 18 Interestingly, healthy coping strategies (including stress management and peer support, which often have direct implications on other self-management behaviours such as healthy eating behaviours and physical activity) were under-represented in digitally enabled DM-related structured education. 18 However, previous qualitative study found that patients felt digital health interventions could help address some of the unmet needs, such as placing an emphasis on emotional management, having up-to-date evidence-based guidance for patients and providing access to peer-generated and professional advice. 19 In the current pandemic, the way we deliver clinical care and

Mindfulness and DM-related education
Mindfulness is a state of moment-to-moment, non-judgmental, non-reactive attending and awareness and has historical origins. 21 Mindfulness has become more widely recognised in the Western world following the introduction of mindfulness-based stress reduction in 1979 and now is an increasingly popular concept, applicable to any discipline and everyday life. In short, mindfulness-based educational courses can teach patients healthy coping strategies and particularly improve their emotional regulation, self-awareness and attentional control, all of which are missing from the traditional DM-related educational courses.

A new era in DM-related education
A key feature of any future DM-related patient education is its accessibility to not just a small minority but to all patients. For this ideal to be realised, it is likely that future DM educational programmes are implemented via hybrid mode, through multiple formats and platforms, which includes for example remote access via Teams or Zoom, as well as online learning platforms and face-to-face learning.
Timing of courses is key, and offer of both in and out of working hours courses is crucial to reduce barriers such as childcare responsibilities and work commitments. Newly diagnosed patients may benefit from a health care professional delivered structured course (either remotely or in-person), which will also enable more interaction with other people living with T2D. Evidence shows that substantive educational value can be delivered in group consultations for diabetes, both in person and virtually. 33 Furthermore, educational programmes should also be designed in a way that is malleable and can be moulded and tailored to individual groups of patients (to include, for example, multiple options for languages and culturally specific advice on dietary needs). Patients in primary care will have different needs to those attending secondary care. Involving patients in shaping education about their condition empowers as well as engages them and facilitates the attainment of healthcare's quintuple aim: better-quality education as well as care for the same or lower cost, enjoyable for patients, students and teaching staff. 34 Ongoing education can be provided by a platform enabling a mixture of online learning and self-monitoring that includes the option for two-way communication between the patient and a health care professional. There should also be an option for individualised feedback and for patients to gain insights from their own health data (such as levels of physical activity levels, food intake and blood sugar monitoring). The tailored educational components should include advice skills to improve self-regulation to enable patients to truly self-manage their condition. Finally, we believe that future DM-related educational programmes should incorporate evidence-based mindfulness strategies in a truly patient centred holistic manner. Through such a renewed approach to DM education, there will likely be increased interest and uptake amongst patients, and ultimately better self-management, healthier lifestyles, reduced distress and improved overall wellbeing.