Title: Collaborative communitY based education program to reduce Inequalities in the uptake of diabetes screening among Minority Ethnic peopLe in WaLes: A Phase I feasibility study (CYMELL)
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Background: The prevalence of diabetes is increasing: 3.9 million people across the UK (5.7% of the population); and 199,000 in Wales (8.0% of the population – highest prevalence in the UK nations). People from ethnic minorities (14% of UK population) are disproportionately prone to Type 2 Diabetes Mellitus (T2DM) with prevalence three to five times higher than in Caucasians; and younger onset, with 40% of those diagnosed by age 40. To prevent complications from diabetes, the NHS recommends monitoring, or screening for, nine indicants: glycated haemoglobin (HbA1c); blood pressure; cholesterol; Body Mass Index (BMI); smoking status; retina; feet; urine albumin; and serum creatinine. The National Diabetes Audit (NDA) showed that in 2019-20 only 42% of people with T2DM in Wales received such monitoring. Though those from ethnic minorities are at greater risk of developing diabetic complications, they are much less likely to attend screening. Data shows that 22% of ethnic minorities miss retinopathy screening and there are 70% more foot amputations compared with the white population. Aim: To increase uptake of screening for retinopathy (eyes), neuropathy (feet) and nephropathy (kidney) among ethnic minorities with diabetes in Wales. Plan of investigation: With diabetes care providers (diabetes nurse, podiatrist, and retinal photographer), patients and ethnic community leaders, we will co-design and deliver ‘One-stop diabetes shops’ and educational materials (infographics and GIF images). Participating general practices will invite people from ethnic minorities with diabetes whose primary care records show they have previously missed screening. We will ask community leaders and Third Sector organisations to publicise these one-stop shops and encourage those invited to attend. We aim to recruit about 12 participants to attend each one-stop shop. We will collect data using baseline and post six month questionnaires and focus groups to assess change in motivation and behaviour and acceptability of the intervention. We will develop a logic model to define the essential elements of the intervention, to identify key outcomes and explore ways to achieve those outcomes. We will use a stepped wedge cluster trial to pilot and test the feasibility and initial effectiveness of the intervention. Each of the three steps will use two general practices who have collaborated with the health services research teams in Swansea, Cardiff and Wrexham (Welsh Local Authorities with high proportions of ethnic minorities). We will use the published Acceptance Checklist for Clinical Effectiveness Pilot Trials (ACCEPT) to assess the feasibility of extending this intervention and research design across Wales. Potential benefits: We will develop a linguistically appropriate and culturally sensitive educational and screening intervention. If our pilot trial shows this to be feasible and potentially effective, we will apply to the National Institute for Health Research (NIHR) for a grant to test this intervention across Wales in a full stepped wedge randomised cluster trial. The ultimate benefits would include increasing access to screening services in ethnic minorities, thus reducing rates of blindness, amputations and kidney disease in this high-risk population. If we find supporting evidence, there would be considerable potential to adapt this approach to other screening programmes and disease areas in this population and other marginalised groups.

Lay abstract: Aim of the research: To develop a ‘One-stop diabetes shop’ to meet the educational needs of people from ethnic minorities with diabetes in Wales and to increase their uptake of screening for complications in their eyes, feet and kidneys. Background: The number of people diagnosed with diabetes is increasing worldwide. Unfortunately, people from ethnic minorities are at greater risk – up to five times more likely to develop diabetes than those who are ‘white’; and they develop diabetes at a younger age. The complications of diabetes are harmful and costly to treat. To prevent these complications, the NHS has nine ways of testing and screening people with diabetes: three are blood tests; another is whether they smoke; and the other five check their weight, blood pressure, eyes, feet and urine. In 2019-2020, only 42% of people in Wales with Type 2 diabetes had received all these tests. Moreover, people from ethnic minorities are especially unlikely to get these checks. So, finding new ways of encouraging them to attend for these checks would reduce the risk of complications, especially blindness, amputations and needing kidney dialysis. What we hope to achieve: Working with people with diabetes and their health workers, and leaders in ethnic communities, we will co-design ‘One-stop diabetes shop’ with educational materials appropriate to ethnic communities and available in a wide range of languages along with short animations known as GIFs (Graphics Interchange Formats). We will find settings for these one-stop shops that are familiar to ethnic minorities, and easily accessible by them. We will assemble teams including a diabetes nurse, a podiatrist, a retinal photographer, and ethnic community leaders and workers, to run these one-stop shops which will include checks for eyes, feet and kidneys. We aim to show that this patient-friendly approach has real potential to increase the number who attend for screening and possibly improve their health. Research methods: We will pilot, 'One-stop diabetes shops' in six practices in Swansea, Cardiff and Wrexham (Welsh Local Authorities with high proportions of ethnic minorities) who have collaborated with applicants in successful previous trials. This will enable us to test the feasibility of, and plan for, a future all - Wales trial (which might include up to 30 general practices in 10 Local Authorities) to evaluate rigorously whether one-stop shops do indeed improve the care of diabetes in ethnic minorities. Public involvement: We will involve people with diabetes from ethnic minorities and people with experience of engaging with ethnic minorities from start to finish of the project. They have helped us to design this proposal and will help us develop educational materials, design the one-stop shop, and publicise the potentially influential findings. We will involve ethnic community leaders in these tasks, especially in encouraging patients to attend the one-stop shops. Dissemination: Once our findings are clear, we will share them with all organisations committed to the health and welfare of ethnic minorities and similar marginalised groups, notably asylum seekers and refugees. Our patient and public members will lead dissemination to the wider public through open events to enhance understanding. We will also seek early scientific validation through publication in peer reviewed open access journals that recognise the importance of pilot studies in developing new approaches

Research activity codes: 4.3 INFLUENCES AND IMPACT;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: METABOLIC AND ENDOCRINE