This model outlines the challenges participants encounter in maintaining diabetes self-management practice s after attending structured education , and describes how participants try to address these barriers by adapting , simplifying or personalising the self-management approaches they have learned .
Conclusions This meta-ethnography highlights how providing skills training using structured education to people with type 1 diabetes does not necessarily result in participants adopting and sustaining recommended changes in behaviour .
Background People with type 1 diabetes who attend structured education training in self-management using flexible intensive therapy achieve improved blood glucose control and experience fewer episodes of severe hypoglycaemia .
However , many struggle to sustain these improvements over time .
To inform the design of more effective follow-up support we undertook a review of qualitative studies which have identified factors that influence and inform participants ’ self-management behaviours after attending structured education  and their need for support to sustain improvements in glycaemic control .
Intensified insulin therapy and the risk of severe hypoglycaemia
Summary The objectives of the present analyses were to assess the association between HbA1 c levels and severe hypoglycaemia ( SH , treatment with glucose i. v. or glucagon injection ) and to identify predictors of SH in a prospect i ve multicentre trial . The study population consisted of 636 insulin-dependent diabetic patients who had participated in a structured 5-day in-patient group treatment and teaching programme for intensification of insulin therapy ( ITTP ) in one of 10 hospitals and who were re-examined after 1 , 2 , 3 , and 6 years including assessment of demographic , disease and treatment related parameters , diabetes-related knowledge , behaviour , and emotional coping . At baseline , age ( mean ± SD ) was 27 ± 7 years , diabetes duration 9 ± 7 years and HbA1 c 8.3 ± 1.9 % . During the 6-year follow-up , the mean HbA1 c value improved to 7.6 % , and in patients with a diabetes duration of more than 1 year at entry into the study ( n = 538 ) the incidence of SH decreased from 0.28 cases/patient/year during the year preceding the ITTP to 0.17 cases/patient/year . The patient group was divided into decile groups according to mean follow-up HbA1 c values . In each group more than 230 patient years could be analysed . Groups with mean HbA1 c values of 5.7 , 7.0 , 7.4 , 7.7 and 8.9 % had comparable risks of SH ( 0.15–0.19 cases/patient/year ) . In a logistic regression analysis , mean HbA1 c during follow-up , a history of SH during the year preceding the ITTP , C-peptide level , emotional coping , carrying emergency carbohydrates ( as assessed at the 1-year follow-up ) , and age at onset of diabetes were significant independent predictors of SH . The incidence of SH between centres varied between 0.05 and 0.27 cases/patient/year . In conclusion , in the present analyses no linear or exponential relationship between HbA1 c and severe hypoglycaemia could be identified by using simple group comparisons . Applying complex regression analyses , various patient-related predictors of severe hypoglycaemia were identified . [ Diabetologia ( 1997 ) 40 : 926–932
This model outlines the challenges participants encounter in maintaining diabetes self-management practice s after attending structured education , and describes how participants try to address these barriers by adapting , simplifying or personalising the self-management approaches they have learned .
Conclusions This meta-ethnography highlights how providing skills training using structured education to people with type 1 diabetes does not necessarily result in participants adopting and sustaining recommended changes in behaviour .
Background People with type 1 diabetes who attend structured education training in self-management using flexible intensive therapy achieve improved blood glucose control and experience fewer episodes of severe hypoglycaemia .
However , many struggle to sustain these improvements over time .
To inform the design of more effective follow-up support we undertook a review of qualitative studies which have identified factors that influence and inform participants ’ self-management behaviours after attending structured education  and their need for support to sustain improvements in glycaemic control .