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• W2053609864 abstract "A report from a joint meeting of Diabetes UK and the Royal College of Psychiatrists (Liaison Section), 27–28 November 2003, Nottingham, UK This 2003 psychosocial conference – the 10th such meeting – took place in Nottingham and the theme was ‘new ways of working in diabetes’. Opening the conference, Peter Trigwell (Leeds University and Chair of the Organising Committee) said that the meeting would focus on working in groups and psychological and therapeutic working in diabetes. It is not possible in a paper this length to cover all the excellent presentations and posters at the meeting so this report summarises samples from the various topics discussed. Joan Everett, Bournemouth Diabetes and Endocrine Centre Joan Everett discussed the pros and cons of group education as opposed to one-to-one situations. Ms Everett described the experiences of a number of studies from different parts of the world. Some studies showed no differences between groups and individuals, but one Cuban study comparing interactive groups with individual education found that the former consistently scored higher in knowledge, skills and behaviours, and treatment responsibility, self-confidence and autonomy. Furthermore, there was a lower HbA1c, fewer emergencies and less complications in the groups. Groups appeared to be successful because there was a common interest and participants used the experience of others. Group members focused on personal issues, confronted difficult issues, developed skills of reflection and learned to give and receive support. The advantage of individual education was that it fitted more readily into medical services and personal expectation. It allowed flexibility in appointments, and interventions could be tailored according to the state of change. It also took more account of differences between individuals. Therefore, it could be asked which was the most important: the quality of the education or the method of delivery? Ms Everett described structured type 1 education from her unit in Bournemouth. There had been 90 participants and the programme was offered to anyone who wanted to improve self-management skills and to the newly diagnosed. Experience showed that those recently diagnosed or who had poor glycaemic control and who attended intensive training received benefit (Figures 1 and 2). Group education in Bournemouth focused on conversion to insulin, carbohydrate counting training and insulin pump therapy. Change in HbA1c in those with poor glycaemic control at baseline (HbA1c >8%). (J Everett, Bournemouth Diabetes and Endocrine Centre) Change in HbA1c in recently diagnosed subjects who attended intensive education compared with those who did not. (J Everett, Bournemouth Diabetes and Endocrine Centre) Rosie Walker, In Balance Healthcare UK Continuing the theme of working in groups, Rosie Walker said that diabetes education was more than knowledge alone. Group education was not a new idea and its benefits had been recognised for many years. The literature had grown more recently with the epidemic predicted and the need for more insulin use in type 2 diabetes. In Balance Healthcare had UK experience of running group work skills workshops. The workshops used activities to explore the nature of groups, difficulties and their possible solutions. Lesley Hitchman and Gayle Richards, Great Western Hospital, Swindon Lesley Hitchman and Gayle Richards described a group-based pilot study for those who identified themselves as struggling to cope with diabetes. The intervention was not intended to be information-giving but to teach psychological strategies to help people regain a sense of control over their lives. Recruitment was from hospital clinics and GP surgeries and during the two-hour evening meetings the participants – predominantly type 2 females – worked together in twos and threes. The five-week programme covered the impact of diabetes on life, beliefs about diabetes (myths, fears and facts), coping (what helps and what hinders), diabetes (the unwelcome guest in the family) and making the most of consultations. Measures were PAIDS (Problem Areas In Diabetes Scale), HADS (Hospital Anxiety and Depression Scale) and GHQ (General Health Questionnaire). The results regarding eight participants are shown in Table 1. The organisers felt that there had been too few sessions, that the course needed to include an information-giving session, that a separate group was needed for young people with type 1 diabetes and that self-efficacy should be measured next time. Participants felt that the course met their needs well or extremely well and that meeting and talking to others, learning how they coped and listening to their problems and solutions were important. A second course is now in progress (for six weeks including an information session) and it is aimed to hold a group for young people with type 1 diabetes in 2004. Helen Waller, University of Sheffield Helen Waller reported a study in which 24 children with type 1 diabetes and 29 parents attended one of four focus group sessions designed to seek their views regarding the feasibility and course design of a new structured education programme, based on an existing adult course. Both children and parents felt that the proposed intervention was feasible. Potential problems included self-management during school time and parental anxiety relating to their child's coping skills and switching to a more intensive insulin regimen. In terms of the design and delivery of the education, participants focused on maximising the enjoyment and interest of the course and encouraging effective learning and adherence to the regimen. Gail Dovey-Pearce, Northumbria Healthcare NHS Trust Gail Dovey-Pearce presented initial findings from a user-involvement study, using the framework approach, to inform diabetes care for people aged 16–25. The aim was to identify, describe and understand the views of young adults with diabetes, regarding the organisation and ethos of service delivery. Questions asked were: ‘What services could health professionals offer to facilitate young adults' coping, adjustment and self-care?’ and ‘How should these services be organised and delivered to be maximally accessible, effective and acceptable to service users?’. In a three-stage approach, semi-structured interviews (stage 1) were conducted with 19 participants covering the impact of diabetes, coping with diabetes and suggestions for service improvement. Stage 2 consisted of a focus group of eight participants, which reflected on the stage 1 findings and explored further options for service provision. Stage 3 was a Delphi survey of all 16–25s in the Northumbria Service area and a national sample of diabetes staff. The qualitative data obtained were analysed using the Framework Approach to qualitative data analysis. The analysis showed that the impact of diabetes on the young adults' thinking included wishing diabetes away, vulnerability and uncertainty, unpredictability and perceptions of control. This unpredictability and lack of perceived control could lead to frustration, self-blame, an over-estimated perception of control, feelings of fatalism or luck, a black and white view of control and a ‘yo-yo’ pattern of self-care. Suggested service approaches that could be linked to the impact of unpredictability and controllability included the wish for staff understanding of what's going on in the patient's life, staff encouragement to use own expertise, staff being sensitive when people are upset and ‘staff being interested in me as well as my diabetes’. Suggestions for improving diabetes information included relevance to an individual, week-long course at diagnosis, a newsletter, phone/e-mail and text contact with staff, information booklets and videos for family members. Suggestions for extra services included a diabetes ‘counsellor’, anonymous clinic feedback forms, Q & A sessions with staff and a mentor system. Dr Dovey-Pearce concluded that young adult service users could participate in service development, have practical ideas and also understand the complexities of change and development. Julie Charman, Royal Bournemouth Hospital Some people find it easier to lose weight with the support and motivation offered in a group setting, noted Julie Charman who reported on a local, dietitian-led weight loss support group for people with type 2 diabetes and obesity. The aim was to achieve and maintain a minimum 10% weight loss over one year for those attending the sessions. Sixty-nine obese people with type 2 diabetes were identified from a primary care register and invited. The results to date showed that mean weight and BMI fell over the first four months of the programme – the average weight loss being 3.3%. Mean HbA1c, total cholesterol and HDL cholesterol had remained stable. And at the one-month review, 100% of attendees said they had made at least one lifestyle change since the initial group session. Based on results, long-term plans for this work involved ‘rolling out’ the programme to enable health care professionals working in primary care to undertake the education with support and guidance. David Shaw, Buckingham Chilterns University College David Shaw explained the technique and value of motivational interviewing (MI) and explained how it had worked in a sample of South Asian people with type 2 diabetes. Setting the scene he reminded us that non-compliance in diabetes was a major problem and that British Asians particularly were prone to diabetes. In particular with this group, the traditional biomedical approach had appeared to have failed, as it did not take into account the individual's perspective. MI – which had been used with problem drinking and other forms of substance abuse – had shown some good results. The nature of MI was that it was a client-centred directive therapy aimed at making patients experts in their own problems, able to take individual responsibility and to live with consequences. The role of the professional was as facilitator, neutral supporter and stimulator of decision making, whilst avoiding confrontation and persuasion. Clients were approached initially by letter with a telephone follow-up by a dietician (trained in MI). There was then an assessment meeting (T1) and six fortnightly MI sessions over three months with a follow-up assessment (T2) and debriefing interview. This was audio-taped and transcribed and the content analysed using the 1-Pass System & MISC 2. Biomedical measures included HbA1c, BMI and waist measurement. Psychosocial assessments were by the Diabetes Management Self Efficacy Scale and the Diabetes Impact Measurement Scale. The results had been mixed: there were some significant findings (at T2 decreased weight and HbA1c) but many non-significant findings. Some of these results may have been due to limited therapist competence, lack of participant-centredness and an absence of specific target setting. Whilst Dr Shaw stressed the suitability of MI for British South Asians he suggested that further validation of methods and instruments was needed. Wendy Fairhurst, University of Manchester Further insights into MI were given by Wendy Fairhurst who provided a systematic review of the effectiveness of the technique in promoting lifestyle change associated with the development and management of chronic disease. Ms Fairhurst suggested that a triangulated approach may be most appropriate in facilitating an evaluation of short and long-term outcomes and of process, and that this was more consistent with the philosophical underpinning of both MI and health promotion generally. Andrea Docherty, University of Warwick Continuing the same theme, Andrea Docherty described a study on the enhancement of psychosocial well being and self-management in diabetes care through the provision of telecare MI. The feasibility data highlighted the long-term psychological and management difficulties encountered by diabetes patients. These related in particular to the acceptance of the chronic nature of the disease, subsequent treatment changes and the need for lifestyle alteration, particularly in relation to diet and exercise. Medication adherence and change were highlighted by both patients and health professionals as a potential area of difficulty, providing support for the target group within the current intervention. In general, telecare support was perceived as a useful intervention, which could be successfully provided by either nurse or lay advisor. This was connected with a range of advantages including greater understanding, enhanced support, improved disease management and improved relations between GP and patient. Clear and comprehensive training was desired in order to ensure that the potential pitfalls of inadequate lay knowledge and the provision of incorrect information were avoided. A proposal for a randomised controlled trial comparing nurse and lay advisor delivery of telecare MI for diabetes patient education and support in a primary care setting has recently succeeded in acquiring funding from the BUPA Foundation. The trial was to commence in March 2004. Jackie Fosbury, St Thomas' Diabetes Centre, London In an illuminating presentation, Jackie Fosbury explained that all poorly controlled diabetic patients referred for psychotherapy had complex psychological and mental health difficulties and were neglectful or self-sabotaging in relation to their lives and their diabetic management. Their early formative experiences revealed pre-diagnosis difficulties which later affected self-care. The causes and mechanisms were different in each individual case. Treatment therefore needed to demonstrate the underlying and wide ranging aspects of a person's life as opposed to aiming for specific behavioural change in respect to detailed management techniques. Ms Fosbury explained that there were different types of psychotherapy ranging from action (behavioural), educational (learning), insight (analytical) and integrated approaches such as Cognitive Analytic Therapy. Ms Fosbury focused on insight/psycho-analytical approaches to improving self-care in people with poorly controlled diabetes. The central principle of psychotherapy was that distressed or disordered emotions, thoughts and negative behaviour occurred unconsciously and were the residue of conflicts from long ago. Thus, the initial focus of psychotherapy was often not on the presenting problem but on the unconscious driving forces creating these difficulties from childhood. Consequently, one aim of psychotherapy was to make the unconscious conscious. An example of early negative experiences could include critical and controlling ‘care’ which has led to a criticised, controlled and not good enough child (adult/patient). This internalisation of these child-derived feelings was often referred to as the patient's core pain. As we developed, however, it emerged that we had actually internalised an understanding of two roles: (1) child-derived (2) parent derived. So in due course individuals could re-enact both roles in subsequent relationships that repeated their early negative experiences. (Table 2). The re-enactment was also confirmed around diabetes self-care and the elicitation of poor care from others, e.g. frequency of being rejected and neglected by others (nurses, psychologists etc). This was often unconscious and needed to be made conscious during the therapy. The re-enactment was referred to as the transference. Understanding and working with the transference were central to psychotherapy. It referred to the venting of positive and negative past experiences projected on to the therapist. The therapist's job was to recognise the transference once it arose, accept it uncritically then interpret it and feed its origins back to the patient. Resistance was a defence mechanism, was usually unconscious and was derived from the need to repress threatening or painful feelings. Examples of resistance were forgetting or blanking out appointments and use of insulin. Ruth Allen, University of Bristol Ruth Allen investigated the acceptability – to type 1 adolescents – of cognitive behavioural therapy (CBT) or counselling. The youngsters were randomised to attend individual sessions of CBT or counselling. Both psychological interventions were acceptable to the majority of the patients recruited. CBT sessions were designed specifically to focus on diabetes-related issues whilst counselling sessions were non-directive. This was reflected in the themes discussed by the patients in the two groups. Jackie Stuart and Hilary Hearnshaw, University of Warwick As part of the International Partnership for Self-management and Empowerment (IPSE) research, Jackie Stuart and Hilary Hearnshaw validated the UK use of the type 2 Diabetes Management Self-Efficacy Scale (DMSES) and the Perceived Therapeutic Efficacy Scale (PTES). The DMSES measures a person's confidence in 20 self-management activities and the PTES measures how much a person believes the treatment will give desired outcomes. The scales both showed internal consistency and reliability over time. The researchers concluded that both have value for new ways of working in both clinical practice and research in diabetes. Kirsty Winkley London Kirsty Winkley presented preliminary cross-sectional results of the South London Diabetic Foot Project. As she reminded us, patients with diabetes and foot ulcers have high levels of morbidity and mortality and a poorer quality of life; they also tend to use health service resources heavily. The aim of the prospective study in 253 patients with their first presentation of a diabetic foot ulcer was to test whether depression and other psychological factors were risk factors for the recurrence of foot ulcers at 18 months follow-up. The preliminary cross-sectional findings indicated that there was a 25% prevalence of depressive disorder and that reporting more depressive symptoms and less personal control is significantly associated with the severity of the baseline ulcer. Report by Charles D Wroe, Medical Correspondent" @default.
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• W2053609864 date "2004-05-01" @default.
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• W2053609864 title "Psychosocial conference: new ways of working in diabetes" @default.
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