What's the point? Understanding why people with Type 2 diabetes decline structured diabetes education

Background
Structured diabetes education (SDE) is one of the priorities for diabetes management in the UK. It improves health outcomes and reduces the onset of diabetic complications for people with Type 2 diabetes. National guidance recommends people with diabetes are offered education programmes as soon as possible after diagnosis and thereafter on a regular basis. National diabetes audit data for England and Northern Ireland demonstrates attendance to SDE programmes is disappointingly low.
Aim
Given the evidence of psychological and physical benefits of SDE, this qualitative research study sought to understand the personal experiences of people living with Type 2 diabetes that led to them declining invitations to attend education programmes.
Method
Twenty adults (10 from Northern Ireland, 10 from England) were selected using purposive sampling from Phase 1 of a larger investigation into why people with Type 2 diabetes declined attending SDE. 
A topic guide developed by the Steering Group and informed by results from the Phase 1 of a larger study was used to carry out in-depth interviews either face to face or by telephone. Interviews averaged 30-90 minutes, were digitally recorded and transcribed verbatim. Relevant areas explored in the topic guide included; experience of living with diabetes; difficulties or otherwise with self-management; reasons for non-attendance at SDE. Interviews were analysed using a Thematic Framework
Results
Ethnicity was white in NI and mainly white in England. Age range was 32-79 years. Duration of Type 2 diabetes was from 1-28 years. 
There were 6 themes; 
•	  ‘What’s the Point?’;
•	  ‘Avoidance- ‘What I don’t know will not annoy me’’;
•	  ‘Make It Real’;
•	   ‘Relationships with health care professionals; disease focused versus patient focused’; 
•	  ‘Practical barriers’
•	  ‘Finding a Way to Self-Manage’.
Discussion
None of those interviewed had any real understanding that preventing complications requiring action prior to these developing and many thought that attending education might be something they would do if complications were to develop. The sub-theme ‘Feeling well – must be well’ compounded this flawed state of knowledge.  The theme ‘Make It Real’ highlighted the difficulty many felt about taking Type 2 diabetes seriously and related to this was a fatalistic attitude by some, who felt that their health had a pre-determined path that they were unable to influence.
 Relationships with health care professionals were reported as either unsatisfactory causing negativity about SDE, or as supportive, and which may have already provided an educational component. Subsequently this contributed to some participants questioning why they needed more education, or to ‘repeat’ education. In addition, where relationships with HCPs were viewed as person focused, ease of contact meant that some participants felt they could access knowledge and support when needed, again diminishing the perceived need for SDE.  
Perceptions of SDE included attending lectures, given rules and ‘being talked down to’. Many suggested sharing and learning from others’ experiences would be a preferred option. Understanding what to expect during the programme in terms of educational style could also be an important factor in encouraging attendance.
 Declining SDE is less about practical barriers to attendance such as timing and venue, and more related to psychological barriers including adjustment to the diagnosis. Taking Type 2 diabetes seriously and understanding about the importance of attending SDE over and above initial one to one education was a major gap. Key recommendations include;
1         HCPs should have a working knowledge of their local SDE programmes to be able to promote them successfully and optimise attendance. Most of these participants clearly voiced a desire to become educated and had already sought information from a variety of sources. Many described as appealing, the kind of person-centred interactive educational programmes that are already available to them
2          Health care professionals involved in diabetes care should also be aware of the internal and external circumstances and barriers for individuals, as described above, that get in the way of attending structured diabetes education.

‘What’s the Point?’ Understanding why people with type 2 diabetes decline structured diabetes education