title: Implementing a structured education program for children with diabetes: lessons learnt from an integrated process evaluation.
abstract: 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.
  ISRCTN52537669.
authors.affiliation: Social Science Research Unit , UCL Institute of Education , London , UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Sawtell
authors.affiliation: Department of Practice and Policy , UCL School of Pharmacy , London , UK.
authors.forename: Liz
authors.initials: L
authors.lastname: Jamieson
authors.affiliation: Social Science Research Unit , Institute of Education , London , UK.
authors.forename: Meg
authors.initials: M
authors.lastname: Wiggins
authors.affiliation: Department of Practice and Policy , UCL School of Pharmacy , London , UK.
authors.forename: Felicity
authors.initials: F
authors.lastname: Smith
authors.affiliation: Social Science Research Unit , Institute of Education , London , UK.
authors.forename: Anne
authors.initials: A
authors.lastname: Ingold
authors.affiliation: Social Science Research Unit , Institute of Education , London , UK.
authors.forename: Katrina
authors.initials: K
authors.lastname: Hargreaves
authors.affiliation: Social Science Research Unit , Institute of Education , London , UK.
authors.forename: Meena
authors.initials: M
authors.lastname: Khatwa
authors.affiliation: Medical Statistics Department , London School of Hygiene and Tropical Medicine , London , UK.
authors.forename: Lucy
authors.initials: L
authors.lastname: Brooks
authors.affiliation: University College London Hospitals NHS Foundation Trust , London , UK.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Thompson
authors.affiliation: University College London Hospitals NHS Foundation Trust , London , UK.
authors.forename: Deborah
authors.initials: D
authors.lastname: Christie
keywords: Education; Pediatric Diabetes; Randomized Controlled Trial; Research Methodologies