Background
The importance of people with diabetes self-managing their condition effectively on a daily basis is paramount. Although the effectiveness of structured education has been demonstrated for those with type 1 diabetes a recent National (UK) Paediatric Diabetes Audit 2013/14 reported less than 40% of children and young people were recorded as having received some form of such education [1]. Despite evidence of the effectiveness of education and self-management support it is declined by a significant proportion of those invited to attend [2]. 
Aim
To identify factors that influence lack of engagement of young people with type 1 diabetes (aged 13-21 years) with structured diabetes education to inform and broaden the reach of future SDE from a sound evidence base.
Method
Phase 1: A quantitative, cross sectional survey of 227 young people with Type 1 diabetes drawn from 11 health trusts across Northern Ireland (NI) and England, (United Kingdom) deemed representative of the wider population, was undertaken. A questionnaire exploring non-attendance, health and diabetes specific variables was completed and HbA1c results collected. 
Phase 2: From this original cohort 72.3% of the young adults and 56% of their parents consented to be contacted again and a subset of n = 20 young people, 10 from NI and 10 from England was purposefully selected based on length of time diagnosed, gender, location and HbA1c level. We also selected n = 17 parents (10 from NI and 7 from England). The young adults and their parents participated in semi-structured interviews conducted either face to face in their own home or via telephone. Health care professionals (HCP), n = 16, from NI and England who work with young adults with diabetes took part in focus group interviews in their place of work. Each interview lasted 30-40 minutes and focus groups lasted 45-60 minutes, exploring in depth the reasons non-attendance at SDE.
Results
Phase 1: Young adults
The five most commonly cited reasons for non-attendance were ‘Had other things to do’ (68.3%); ‘No time’ (62.2%), ‘Could not get time off school/college or work’ (60.8%), ‘Learnt about diabetes from other sources’ (55.5%) and ‘Feel able to cope on own’ (52.9%). The mean HbA1c of the entire sample was 76.7 (±SD 20.0) mmol/mol (9.2%).
Phase 2
Young adults and parents 
The main reasons for non-attendance at diabetes education given by both the young people and parents were very similar and centred on three main themes: 
•	timing of courses.
•	access issues relating to travel distance and financial implications of taking public transport and missing work.
•	lack of communication and understanding by the referrer about the benefits of attending.
Health Care Professionals 
The main themes arising from the HCP focus groups on their thoughts as to why adolescents chose not to attend SDE were very similar to both the parents and the young adults. The HCPs were not unsympathetic to the adolescents who they feel are already dealing with a challenging period of their life independent of the issues around diabetes, and accompanied by a high level of life-demands in which those of diabetes management often took second place. 
Discussion
This study, spanning both quantitative and qualitative approaches provided the opportunity to gather data that can be genenralised (the survey) and also to probe and gain direct information from these three cohorts (the interviews). The combined findings demonstrate that greater emphasis is required on communication with young people about the benefits of structured diabetes education. In addition, efforts need to be directed to making diabetes education more accessible without losing the quality of structured programmes. Discussion with those adolescents, their parents and HCPs revealed that online modes of education should be explored alongside consideration being given to tailored approaches to individuals with specific needs. Bearing in mind that many of the young adults involved in this study had sub-optimal glycaemic control, placing themselves at risk of long term complications, solutions to non-attendance are urgently required. Further investigation is required into preferred, effective modes of delivery of diabetes education in type 1 diabetes. To date the development and provision of structured diabetes education appears to have been curriculum focussed and standardised at the expense of ‘person centeredness’. 

References
1. http://www.rcpch.ac.uk/sites/default/files/page/NPDA%20Report%202014-15%20v5.2%20sent%20to%20HQIP%2025.05.2016.pdf
2. http://onlinelibrary.wiley.com/doi/10.1111/dme.13120/abstract

Declining diabetes education: the views of young people with type 1 diabetes, parents and health professionals