Summary
DWELL (Diabetes and WELLbeing) is a patient education programme for people with type 2 diabetes, a staff training programme and an ambassador training programme for people who attended the DWELL programme and want to support continued delivery by becoming a DWELL ambassador. The DWELL project brought together a range of organisations, professionals and people living with type 2 diabetes to co-design, deliver and evaluate its effectiveness.
Innovation
Most diabetes education programmes for people with type 2 diabetes are targeted at the newly diagnosed, but there are many people diagnosed before education programmes were routinely offered who have not instigated behaviour change. Often, they have low motivation and the depression associated with living with a long-term condition and may feel isolated and unsupported. The DWELL project investigated developing and evaluating an innovative education programme for this group. It was funded by the EU Interreg 2 Seas programme 2014-2020 and co-funded by the European Regional Development Fund and participating partners. It started in 2016, when funding was approved, and continued to March 2023. An extension and additional funding were provided as the project was suspended during the COVID-19 pandemic. Partners from the UK, France, Belgium and the Netherlands and people living with type 2 diabetes, co-designed the programme. Professor Eleni Hatzidimitriadou from Canterbury Christ Church University led the evaluation, ethical approval to conduct the project as formal research was gained, and it was adopted by the NIHR as a portfolio study. DWELL focused on creating a learning environment that allowed people time to bond with the other participants and space to share issues. This was achieved by having a maximum of eight participants per programme, with groups lasting 2.5 hours. The philosophy was for the diabetes professional facilitator to travel alongside the participants on their journey. The programme included 1-2-1 motivational conversations at weeks one and 11 to help people identify motivators and set smart goals. Activities included guided relaxation, support to help overcome hurdles and information sessions about type 2 diabetes, presented using a conversational approach.
Equality, Diversity and Variation
The DWELL programme was open to all adults with type 2 diabetes free of charge. Programmes were offered at different times of the day to allow access for all. The locations were selected to be non-clinical, with good transport links and disabled access, parking etc. Sign-up was encouraged via a wide range of sources. Participating partners used their local contacts and knowledge to advertise the DWELL programme widely. Participants could self-refer or were signposted to the project and had to commit to attending for 12 weeks. The content was adapted to take account of cultural and dietary aspects. Variations in the outcomes achieved were on a par, regardless of ethnicity or cultural background. Small groups and long contact time enabled participants to gain the most from attendance. The safe and supportive environment allowed them to disclose problems and issues they had not shared before, thereby improving outcomes.
Results
Self-management is essential for people with diabetes. Literature searches highlighted a paucity of evidence around psychological and motivational support and an emphasis on need for research into impact and/or cost-effectiveness. DWELL assessed participant outcomes and programme impact in terms of quality of life, empowerment, physical activity and self-care, as well as attitudes and behaviours regarding self-management, experience with the programme from participants/staff/ambassadors’ perspectives and analysis of cost benefits. A quasi-experimental design adopted a longitudinal, mixed methods approach across five sites, including two in the UK (Medway and Maidstone in Kent). The MRC Process Evaluation framework was adopted. Data collection was via an online survey tool, focus groups and interviews, plus secondary analysis of other sources. A total of 593 people with type 2 diabetes took part in the study, across four countries. Significant positive changes were noted, which were sustained at 6 and 12 months post programme. Statistically significant changes in metabolic health and self-reported attitudinal and behavioural benefits were reported by the end of the programme, including average weight loss of 3.55 kg, average waist circumference reduction of 2.7cm, average BMI reduction of 2.62, average HbA1c reduction of 20.5 mmol/mol, enhanced empowerment and self-efficacy, improved diabetes management, greater perceived personal control and understanding of diabetes, decreased negative feelings associated with diabetes, increased optimism for treatment and long-term prognosis, decreased eating in response to emotions and external cues, increased restrained eating, improvements in self-care attitudes and adherence to professional advice.
User Feedback
Feedback from participants was positive and collected in the focus groups as part of the evaluation process. In order to reduce bias, these were undertaken by an experienced researcher who had not been involved in delivering the programme. Participants expressed their belief in the course by becoming DWELL ambassadors. They helped to recruit to the project and spoke at events.
Dissemination and Sustainability
For the purposes of this award only the UK sites are discussed. When the EU funding ended in March 2023, the results helped secure funding from the Medway and Swale ICB to continue for a further year, to March 2024. A business case is being made to continue the DWELL programme as a commissioned service in the Medway and Swale region and as an option for people with type 2 diabetes. As part of this process the programme is going through QISMET accreditation. The DWELL project team is keen for the programme to continue, having seen the difference it makes to the lives of people living with type 2 diabetes, not just in terms of metabolic health, but also in terms of improved wellbeing, self esteem and motivation. Participants report that HCP consultations are more meaningful and constructive, that they have an increased knowledge and understanding of their condition, what to do to get back on track and when to seek help. Quality of life is improved and additional skills have been gained. The resources developed could be used by other groups in the UK and the current DWELL team would support this.
