Wednesday, 1 May 2013

Spreading the word at the Diabetes UK Professionals Conference

Today is a writing day - preparing my share of an article for publication. The article will tell the story of the original research for this project which was undertaken in Glasgow and Bradford and the interventions that have been developed as a result. See

 It has reminded me to post these photos of our poster which was displayed at the Diabetes UK Professionals Conference in mid-March.

I spent one day at this impressive three day gathering of hundreds of people who are working on diabetes. 

The physical presence of various drug companies (all serving lovely coffee) brought home the fact that the huge rise in numbers of people with diabetes means a huge rise in cost to the NHS - and provides a correspondingly great rise in business opportunities! It is an ill wind..........

I enjoyed a range of presentations especially the lunchtime one about the Diabetes Year of Care. There were three fascinating presentations on the different psychological approaches that can be taken to supporting people with diabetes. That session was imaginatively titled 'Oranges are not the only fruit'!

The conference was a showcase for all aspects of the work being carried out in relation to diabetes. The sheer scale of the conference put our relatively small experiment into context. It would have been easy to feel that our efforts seemed so simplistic amongst a great deal of visible complexity.

 And yet the truth is that success in managing diabetes and achieving the best outcomes lies for the most part in the hands of the people who have the disease. They are the key actors. All efforts to discover from people what supports and enables them to take positive action are worth making.

Tuesday, 30 April 2013

When less could be more

Below is an extract from a Wall Street Journal article about 'minimally disruptive medicine'. The whole article can be read at: It was published in early April.
I was reminded of the article when in conversation with a nurse about self-care management. She cited the example of an older man now living alone. His one contact with other people is at the pub. His consequent regular drinking was posing a problem for managing his diabetes. Simply telling him that his drinking was damaging his health wasn't changing anything. Nor was the evidence of his test results. His desire to combat his loneliness in the only way he knew how was outweighing what his test results were saying.
The Wall Street article describes reframing or changing the conversation between the clinician and patient. Diabetes is a complex, often frightening disease for people. To remain well, they are told about all the changes they are expected to make to the way they live. It can sound like a lot of demands with which people are expected to comply.
Doctor Montori starts from a different place. He starts with the question to the patient: 'What are your goals, hopes and dreams?' The focus then is on a conversation which identifies what help/intervention is needed to help the person achieve what they want to achieve. It isn't just about quality of care checks and results. 

' With Chronic Care, Less Can Be More

Victor Montori at the Mayo Clinic says that 'minimally disruptive medicine' can lead to better health—and lower costs

'As an endocrinologist, Dr. Montori specializes in diabetes, one of the most prevalent and costly of chronic diseases. But as director of the Health Care Delivery Research Program at the Mayo Clinic in Rochester, Minn., he focuses on innovative ways to improve care for all chronic illness, which taken together represents the leading cause of death and disability in the U.S.
Care for such diseases is often so complex, Dr. Montori says, it overwhelms patients and makes it hard for them to follow their regimens. His solution—minimally disruptive medicine—is gaining interest among health-care quality groups and policy makers. Here are edited excerpts from an interview with The Wall Street Journal:
Patients' Capacity
WSJ: What is minimally disruptive medicine?
Mayo Clinic
Victor Montori says care for chronic diseases is often so complex that it overwhelms patients.
DR. MONTORI: It is health care designed to achieve the goals of patients while imposing the smallest possible footprint on their lives. Patients and clinicians can work together in deciding which treatments to take, prioritizing those most likely to help our patients achieve their goals and dreams. Then, we need to deliver these treatments in a way that is mindful of the work required and patients's capacity to get this work done.

For now, it is a four-pronged approach to the care of patients with many chronic conditions.
Like everyone else, we are working actively on care coordination.
We are also working to ensure we know what matters to patients. What patients really want is often not to have better blood pressure or lower cholesterol. What they usually want is to feel better, not die before their time, and be able to do what they need to do to fulfill their obligations and pursue their dreams. We must commit to work toward our patients' goals.
Then, we are implementing shared decision-making, using point-of-care tools that help with issues such as which medicine to take for diabetes or whether to take statins or aspirin to reduce the risk of heart attack.
Finally, we are working hard to understand patients' capacity. We are testing an approach to uncover patient's health literacy and resilience; their mental, physical, and financial health; the quality of their support network and of the environment in which they live. We want to know what resources they have which can be optimized to face the complexity of caring for their conditions.
Enhancing capacity and reducing workload can help patients access, use, and enact the care they need and want. This care will not be wasted.'

Monday, 16 July 2012

More than a leaflet

The final version of our 5 Key Messages. It is intended to provide a focus for a conversation between practitioner and patient/client.
Message 1 - Diabetes can cause blindness
This was in response to the women's group who asked us to be clear about consequences. Not to be afraid to stat the facts.
Message 2 - Save your sight
There is good news, you can take action to save your sight.

Message 3 - Go to all your appointments
In terms of looking after your eyes this is the most important action. Even people who do everything right, can get bleeding in their eyes. This can be treated if picked up early. Especially important is going for 'retinal screening', known by many people as the 'eye photo'.
Message 4 - Look after your blood 
As well as good blood glucose, the opticians tell us that good blood pressure and good blood cholesterol are important for keeping your eyes healthy

Message 5 - Find out more
The women's group said that we shouldn't just talk about eyes and diabetes. They argued that there are still a lot of people who don't understand that diabetes affects the whole body. So message 5 tells people that taking the action outlined in the leaflet will help other parts of the body. People are encouraged to find out more about this from their health practitioners.

Wednesday, 11 July 2012

What's all this about a camel?

Images by artist Sarah Jane Mason
The use of this Sufi story is aimed at building understanding about prevention and self-care in the Pakistani origin community. The South Asian origin communities have a significantly higher risk of developing Type 2 diabetes.

Our research showed that people do not always understand the idea of prevention. They feel that what happens to them is 'Allah's will' or just a bi-product of growing old.

Community members have a great respect for professionals and they are not always persuaded that  they have an important part to play in self-care. 

The use of this story with community groups and Expert Diabetes groups, makes a direct link with people's deeply held faith. I have written in an earlier blog about the importance of understanding the communities that we serve. 

This story (pasted below in English and Urdu) is proving a light hearted way to get messages across and spark great discussions. 

Each discussion pack has the colour version of the story with text and a black and white copy for each participant, a copy of the story in Urdu and a set of our 5 Key Messages leaflet. 

A Teacher was travelling with one of his disciples. They had had a long day journeying across the hot desert. The disciple, a young man, was in charge of taking care of the camel.

They came in the night, tired, to an Oasis. The Teacher said to the disciple
‘I am very tired, I am going to bed. Before you go to bed, just make sure that you tie up the camel.

The disciple thought to himself: ‘I am very tired as well. I can’t be bothered to tie up the camel. I know, I will ask Allah to look after the camel. So he prayed, “Allah, take care of the camel,” and the young man fell asleep.

In the morning the camel was gone. The Master asked the young man, “What happened to the camel? Where is the camel?”

And the disciple said, “I don’t know. Don’t blame me. You ask Allah. I asked Allah to take care of the camel. I asked him very clearly! There was no miss- ing the point. Not only once in fact, I asked Him three times. And you go on teaching ‘Trust Allah’, so I trusted. Now don’t look at me like that.”

The Teacher gave a big sigh. He said: “Allah has no other hands than yours. Tying up the camel would not have stopped it from being stolen, but it would have stopped it from wandering off .Yes trust in Allah but tie up your camel first!”

For Discussion
1. What do you think this story is saying to us?
2. In what ways can we ‘tie up our camel’ by looking after our bodies and our health? 

Monday, 21 May 2012

The psychology of persuasion in behaviour change

 Thanks to @stuartberry1 and Steve Wardle, @desirableUX for finding this short video. 

It shows BJ Fogg talking about the psychology of persuasion in behaviour change.

Fogg talks about the importance of aligning three things:

- Trigger (the trigger for action)
- Ability (the person's ability to take the action)
- Motivation (enough reason to bother taking any action)

If any of these are missing, then a change in behaviour is unlikely to occur.

Fogg's formula fits with what our groups of people with diabetes told us when asked to tell stories about when they had changed their behaviour.

Triggers - the most common triggers for action and change described by our groups were experiencing symptoms, or having some other tangible evidence that something was wrong e.g. test results.

We want to change those triggers, so that people are taking action before there are any tangible problems i.e. so that they are preventing or limiting the negative impact of diabetes on their bodies.

So what triggers could we use that would become what Fogg calls 'hot' triggers? The suggestions that came from the groups centred around knowledge and understanding. When people were taking action to change their behaviour in order to prevent problems, they did so because they were clear about the benefits of acting or the consequences of not acting. 

For example amongst people with diabetes who go regularly for retinal screening (eye photos), the 100% motivation was their fear of losing their sight. They knew that diabetes can cause bleeding in their eyes and that that, left untreated, can cause blindness. So the message from the groups is 'be straight with us about the consequences of not changing our behaviour.' That knowledge and understanding provides both a trigger and a motivation.

Ability - The two groups were also clear about the importance of taking ability into account, when asking people to take action. It calls on health practitioners to have a good knowledge of the realities of life in the communities they serve; to have the humility to ask the person with diabetes what might work best for them and to listen carefully to their reply.

Motivation- This is one of the biggest challenges for people as they manage this disease. Diabetes is for the most part a long-term, chronic condition. People with diabetes describe the struggle they have over a long period of time to keep their motivation with regard to diet, exercise, taking medication and keeping all their health appointments. It would be good to know of any studies about what works.

Fogg's formula and the way it chimes with what was said by our two groups of people with diabetes, underlines once again just how much we can trust the contributions that patients/clients make to service design. 

This is especially true when that contribution has been made through a focused, deliberative process. As people deliberate together, their own views are changed and shaped by what they hear from others. Listening to others also sparks ideas and thoughts that otherwise would have remained undiscovered and undisclosed. 

Thursday, 10 May 2012

Creating a self-care document

It is an exciting week, as we test the prototypes of a self-care document. The prototypes were created at a workshop held in March. 

Eleven health and social care practitioners developed the prototypes based on the findings of research with people with diabetes and members of the wider community.

This is what they came up with:

Working with an artist and creative practitioner, these instant prototypes were mocked up into proper documents. We are now taking them round health practitioners and patient focus groups for feedback. From that feedback we will create the final version.

Initial responses have been very positive.

Wednesday, 25 April 2012

Appreciative way to spread the 5 key messages

Yesterday, thirteen people met together to design a programme of activities to spread the 5 Key Messages about diabetes eye care. The different perspectives in the room included: health practitioners, health research, optometrists, health trainers, the community, and voluntary sector. 

We used Appreciative Inquiry (AI) to help us to think about what would need to happen to spread the messages successfully.

Appreciative Inquiry asks us to notice the very best of what works in relation to a particular issue - in this case spreading health messages across a community; and to explore what else might be needed to do this even more successfully. Then using the very best examples and the additional ideas, a picture can be developed of what success would look like. When we know what we are aiming for, then we can design the right steps to take us in that direction. 

Our workshop gathered the very best examples of spreading health messages through:
- community venues and networks; 
- GPs, Opticians, Pharmacists, and Hospital Outpatients; 

To these each participant added their own ideas.

Three pictures were created showing what needs to be done to spread the messages successfully. The video below shows the final presentations.