Module 4: living with diabetes

Guidelines on exercise²⁵ are provided with a set of training slides from the workshop to explain the principles of exercise and management of insulin and carbohydrates. Families identify the effect that low and high blood glucose levels have on performance and concentration and discuss strategies they already use to bring BG levels into target range before starting activity.

Family groups identify how different activities affect BG levels and discuss the timing of insulin injections in relation to activity. Young people discuss the advantages of using carbohydrate before, during and after exercise (to keep their BG stable during different kinds of activity).

At the end of module 4, young people and families complete a ‘blueprint for success’. This marks the end of the sessions and acknowledges the steps into the future the young person has already made. It creates an opportunity to review the programme and strengthens long-term motivation to change by reviewing previous successful goals.

The two main psychological approaches used in the delivery of CASCADE are MI and SF. Specific components of each approach were incorporated into each module to enhance engagement and develop confidence and motivation to change. The following techniques were integrated throughout each module. Communication skills: focusing on positive solutions: identifying skills abilities and strengths;²⁶ encouraging families and children to identify previous successes; describing ongoing positive developments; focusing on the future; scaling; considering the pros and cons of behavior change; establishing the importance and confidence of change;²⁷ using ‘scaffolding’ to help individuals discover information for themselves.²⁸ Additional learning is a collaborative effort between individuals and trainers reducing the sense of an expert imposing knowledge and moving toward a shared venture. This active rather than passive approach has been shown to be effective in eliciting behavior change in other areas.²⁹ The manual also included training on running groups that was presented in the workshops.

Two members (DC and RT) taught eight 2-day workshops that included MI and SF principles as well as the content and delivery of the four modules to a minimum of two educators per intervention site. Each site sent the required minimum of one pediatric clinical nurse specialist plus another member of the diabetes team with some sites sending more than two. A total of 43 staff attended over a number of weeks. Staff from a minimum of one clinic and a maximum of three were trained together in each workshop. A few sites found it challenging to ‘free up’ staff to attend. A detailed intervention manual and resources were provided.³⁰ The training was designed to increase daily use of behavior change techniques and improve communication in healthcare encounters with patients as well as greater consideration of emotional as well as physical needs of young people and the social constraints of family life.

The intervention groups could be offered during standard clinic times or at different times of the day or week depending on what resources were available to the clinical teams. The educators were encouraged to be as flexible as possible within the remit of their job plans. Advice on organizing groups was also available from the research team. Most groups were offered in the clinic during normal clinic hours with a small number offered in a community space out of hours. Further details on the issues and challenges faced by clinic staff in intervention delivery are described in Christie et al.³⁰