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Keywords:

  • diabetes;
  • peer advisors;
  • expert patients;
  • training programme

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

The primary objective was to train people with diabetes and carers to be effective trainers, committee members, campaigners and peer advisors. The secondary objective was to assess the impact of the course on the individuals.

Sixty-six volunteers were enrolled in the programmes, each of which comprised 18 separate weekly sessions, each lasting 90 minutes. Questionnaires pertaining to knowledge, well-being, Michigan Care Profile, and behaviour were carried out at the start, and three and 12 months post course. Each volunteer underwent a 40-minute oral assessment at the end.

Fifty-one (77%) people, of whom 44 were individuals with diabetes, completed the courses; 50 (98%) were successful in the final assessment. Significant improvement in knowledge was demonstrated (72.5% vs 82.2%, p<0.001). Twenty-one (41%) lectured at subsequent courses, eight (16%) lectured at national conferences, and all campaigned within the community. They were represented in all major committees. The number of participants with diabetes who joined Diabetes UK increased from 20 (45%) to 31 (70%).

The effect on the individuals (values are at the start, three months and one year of the courses) showed significant improvements in their understanding (68.6 vs 84, p<0.001, and 87.8, p<0.001), self-care ability (72.4 vs 73.3, p=0.350, and 77.8, p=0.044), self-care adherence (73.9 vs 76.9, p=0.108, and 83, p<0.001), and importance of self-care (90 vs 95.5, p=0.028, and 97.8, p=0.007), and reduction in negative attitude (41.9 vs 37.3, p=0.023, and 34.0, p=0.017). No significant changes were noted in the other parameters although they showed continuing improvements.

In conclusion, despite the wide range in the backgrounds of the individuals, the programmes were understandable and effective. They fulfilled the primary objectives, and have enhanced the voice and choice of people with diabetes within the health service. This paper describes the impact of the first three courses. Copyright © 2005 John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

Diabetes is a chronic condition which requires the constant attention of the person concerned and that of many health professionals involved in the delivery of diabetes care. To achieve good control of diabetes and related conditions, it is important that people with diabetes are trained to look after their condition. Encouraging self-management in diabetes care is well recognised by the World Health Organization1 and this is also emphasised in the National Service Framework for Diabetes2 published by the Department of Health of the United Kingdom. In recent years, as stated in the NHS Plan,3 it has been acknowledged that patients need to be involved in the planning and delivery of services. The document on the ‘Expert Patient’4 emphasises the relevance of self-management, and it places a strong emphasis on the concept of trained patients leading self-management courses for fellow patients. It also recognises that such courses will enable trained patients to be advocates for others and play a significant role in advising health authorities on the provision of health care. Health care professionals have traditionally delivered self-management training programmes for diabetes, and it is important to recognise that such programmes are usually tailored to the specific requirements of individuals. However, the roles of the expert patient call for a more detailed training of individuals if they are to lead self-management courses for others, and be able to deal with all types of diabetes. To be effective members of health care committees they will require a wide factual knowledge. Such individuals will also be useful members of self-help groups and patient organisations. A programme to develop lay advisors in diabetes to fulfil the above functions was launched in 19805 but the exercise was not acknowledged by society, perhaps because of the prevalent doctor orientated culture at the time.

In the light of the Government's recent emphasis on the relevance of user-led self-management courses this paper describes a training programme for peer advisors in diabetes (PADs), and compares it with the ‘The Expert Patients Programme’ (EPP). The paper describes the impact of three courses; the fourth is in progress. The establishment of this training programme was in addition to the current structured programme of education routinely offered to people with diabetes.

This paper also discusses issues pertaining to clinical governance of PADs, and a formal role in delivering courses in self-management.

Objectives

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References
  • Primary objective. The primary objective was to establish a training programme for people with diabetes and their carers which would impart a high degree of understanding of diabetes, and enable them to fulfil a number of functions (Table 1).

  • Secondary objective. The secondary objective was to assess the effect of the training on the attitudes and behaviour of the participants.

Table 1. Functions of peer advisors
• To assist health professionals in the provision of diabetes education for people with diabetes and their carers
• To be effective participants in committees of the health service and voluntary organisations, and to be campaigners
• To be able to play a role in monitoring equity, accessibility and quality of diabetes service within the district
• To be able to listen and provide support to the person with diabetes and their carers, on a one-to-one basis

Process

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

Volunteers were invited to participate in the programme through advertisements placed in Sweet Pea, a local patient magazine produced and controlled entirely by people with diabetes, as well as at all clinics for diabetes.

Each programme comprised 18 separate weekly sessions, each lasting for 90 minutes. Pre-session refreshments and three social evenings during each course were provided to promote camaraderie.

The style of teaching was interactive combined with lectures and workshops. The subjects discussed at each course are shown in Table 2. Volunteers agreed to participate fully in the training schedule and to appear for a formal assessment at the conclusion of the sessions.

Table 2. Course contents
• Structure of the body related to functions
• Nature of diabetes
• Lowering blood glucose—effect of exercise, diet and therapeutic interventions
• Nutrition and meal plans
• Monitoring techniques and interpretation of results
• Short-term complications
• Long-term complications
• Evidence favouring good control of glucose, blood pressure and lipids
• Listening and communication skills (two sessions)
• Structure of the NHS—decision making, how to influence committees
• Current priorities in diabetes
• PADs—functions, governance rules and expectations, and Diabetes UK
• Revision session

Assessment

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

Before the commencement of the programme, participants completed a number of questionnaires for demographic data in order to test knowledge,6 to assess the Michigan Care Profile7 and WHO Well-Being Index,8 as well to ascertain changes in behaviour. The level of glycosylated haemoglobin (HbA1c) was assessed.

The above assessments were repeated three and 12 months after the completion of each course (the knowledge questionnaire was not re-assessed at 12 months).

At the completion of the teaching sessions of each course, all participants underwent a 40-minute oral assessment by eight independent clinicians, divided into four groups. Each group was housed in a separate and private room. Candidates spent 20 minutes with each of two pairs of examiners. During this, factual knowledge (the results of written knowledge questionnaires were made available), understanding, insight, application of knowledge, and candidates' perception of their limitations were assessed. After each candidate, the four assessors conferred to determine the outcome of the exercise for the individual.

At the conclusion of the above, each successful PAD was assigned a health professional as a mentor.

The first course was delivered entirely by health professionals. In subsequent courses, volunteering PADs were gradually introduced as lecturers, as an on-going training for those who would undertake teaching commitments in the future. Before each lecture, PADs rehearsed the lectures with their mentors. At the end of each session conducted by them, and with the full consent of each lecturer, student participants were invited to criticise the content and the delivery of the session and, after that, the consultant in charge made observations on how to improve future sessions.

Statistical analysis

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

The data were normally distributed. Student t-test was used to compare pre- and post-course assessments. A p value of less than 0.05 was deemed significant.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

Sixty-six volunteers commenced the programme and 51 (77%; seven carers and 44 people with diabetes) completed the course and undertook the final assessment; one was advised to undertake further training.

The results reported in this paper pertain to the 44 people with diabetes; the majority of the questions asked were not applicable to carers.

The reasons given for dropping out were ill health (eight) and change of shift at work (four) and three did not disclose a reason.

Demographic data are shown in Table 3.

Table 3. Demographic data
Type 1: number27
Two injections daily 1
Multiple injections17
Insulin pump 9
Type 2: number17
Diet only 3
Tablets 9
Insulin 5
Male: number25
Female: number19
Age (years) at diagnosis: median (range)33 (1–67)
Duration (years) of diabetes: median (range) 9.5 (1–41)
Age (years) at end of formal education 
≤1615
≤1910
>2019

Qualifying assessment

The assessors' report stated: ‘It should be remembered that this process must have been something of an ordeal for some people who had, perhaps, not taken an examination for many years. Two 20-minute sessions were quite hard work for the candidate.’

‘The assessors were mindful of the fact that the candidates were in no way medically qualified, and were on the whole patients with diabetes wishing to help fellow sufferers.’

‘Whilst not wishing to be too harsh on candidates, the assessment board was determined to ensure that the candidates were safe to be let loose on the public and the qualification gained was one worth having.’

Results pertaining to the primary objective

There was a highly significant improvement in knowledge (Table 4). Twenty-one (41%) were lecturers at the courses, and eight (16%) lectured at national conferences. Four were elected as members of the Local Diabetes Service Advisory Group, now known as the Managed Network Group; one was elected as the Honorary Secretary of this Group. Eight served on the Primary Care Trust's working parties on the standards of the National Service Framework for Diabetes. Two are members of the Joint Implementation Committee of the Isle of Wight. Following a formal interview, two were selected as members of the Patient Involvement Unit of the Royal College of Physicians of London. The number of PADs who were members of Diabetes UK increased from 20 (45%) to 31 (70%). The entire membership of the local committee of Diabetes UK, except the post of chairman, now consists of PADs. The latter also form the entire editorial board of Sweet Pea which is published by the local Diabetes UK and which is, as stated above, controlled by people with diabetes.

Table 4. Knowledge, WHO Well-Being, Michigan Care Profile scores, HbA1c. Values are expressed as per cent. Results are mean (Standard Deviation). Significance stated as p1 (three months after), p2 (one year after)
 Before3 months after1 year afterp1p2
Knowledge72.5 (11.6)82.2 (8.5) <0.001 
WHO Well-Being62.8 (19.3)66.6 (20.1)70.6 (19.3)0.1400.068 Index
Michigan Diabetes Care Profile: 
 Understanding68.6 (14.0)84.0 (10.8)87.8 (12.7)<0.001<0.001
 Positive attitude71.4 (11.8)71.6 (13.8)76.6 (15.8)0.4720.127
 Negative attitude41.9 (15.9)37.3 (14.2)34 (13.1)0.0230.017
 Self-care ability72.4 (14.2)73.3 (14.4)77.8 (12.3)0.3500.044
 Importance of care90 (17.7)95.5 (7.2)97.8 (6.2)0.0280.007
 Self-care adherence73.9 (14.6)76.9 (11.9)83.0 (10.9)0.108<0.001
 HbA1c 7.8 (1.6) 7.6 (1.3) 7.6 (1.1)0.1900.273

At the conclusion of the first course, the participants enacted a constitution for their group, which is mainly responsible for the campaigning and its various activities. In agreement with health professionals, they formulated rules of clinical governance applicable to all their members (Appendix 1 [see journal online at www.interscience.wiley.com]).

The group independently published leaflets and posters pertaining to peer advisors, which were then delivered by them to all primary care outlets and pharmacies. All have personally visited their doctors' surgeries to introduce themselves. In addition, they organised a meeting for primary care health professionals and managers to explain their functions and how they may be used as a resource. They have established a rota of individuals to attend the open meetings of the Primary Care Trust and the hospital Trust.

With the assistance of the Clinical Governance Unit, PADS have embarked on an audit programme to monitor the quality of annual reviews.

Within the first two years, PADs responded to 25 requests for consultation; 10 patients (40%) responded to a questionnaire. The views of the patients who consulted PADs are shown in Table 5.

Table 5. Views of patients who consulted PADs
 Strongly agreeAgreeNot certainDisagree stronglyDisagree
‘I found the advice given by the peer advisor to be useful’5 (50%)3 (30%)1 (10%)1 (10%)Nil
‘The attitude of the peer advisor was reassuring’5 (50%)3 (30%)1 (10%)1 (10%)Nil
‘The peer advisor enabled me to express my concerns fully’ [90% responded]5 (50%)2 (20%)1 (10%)1 (10%)Nil
‘I would recommend consultation with a peer advisor to people with diabetes and their carers’5 (50%)4 (40%)Nil1 (10%)Nil

The effect of the course on individuals

The effect on the individuals showed significant improvements in their understanding (68.6 vs 84, p<0.001, and 87.8 at one year, p<0.001), in self-care ability (72.4 vs 73.3, p=0.350 and 77.8 at one year, p=0.044), self-care adherence (73.9 vs 76.9, p=0.108, and 83 at one year, p<0.001, importance of self-care (90 vs 95.5, p=0.028, and 97.8 at one year, p=0.007), and a reduction in their negative attitude (41.9 vs 37.3, p=0.023, and 34 at one year, p=0.017). No significant changes were noted in the other parameters although they showed continuing improvements. Details are shown in Table 4.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

It is encouraging to note that a number of the primary objectives have been fulfilled. As anticipated, there was a significant improvement in the factual knowledge of the participants. The independent assessors had paid particular attention to the participants' ability in the application of knowledge and their understanding of the subject, in addition to their ability to listen and to communicate. The assessors had found the standard to be remarkably high. This was despite the wide range of the educational, occupational and social backgrounds of the individuals.

None of the participants had any previous experience of teaching and, yet, 21 of them effectively participated as teachers in successive courses. The course also enabled some of them to lecture at national conferences for health care professionals—a remarkable achievement.

Important primary objectives of the programme were to enable PADs to participate effectively in National Health Service committees and to play an active role within the local branch of Diabetes UK, and these were achieved.

People with diabetes experience varying degrees of emotions; health care professionals often do not have the time to explore these feelings. Explanations given by doctors and nurses are often not fully understood. PADs are ideally placed to reinforce advice and to provide reassurance and support to the person with diabetes. And yet, despite the wide publicity throughout the community and in all primary care units, the number of patient requests for consultation with PADs has been small. This may well have been due to the current procedure for requests to be made. In the interest of protecting confidentiality, patients are given the telephone number of an appropriate PAD and are asked to make the first contact. Patients or their carers may well have been reluctant to call a stranger. Application has therefore been made to alter the governance rules. In future, patients will be asked to give written consent for their names and telephone numbers to be passed on to an appropriate PAD; the onus will then be on the latter to make the initial contact. This method will also enable the Diabetes Centre to track consultations and to monitor the consultations more accurately. Initially, PADs were known as ‘Peer Counsellors’. The use of the word ‘Counsellor’ may well have played a role: people have their own perceptions about counselling and counsellors, and it was therefore decided by the PADs group to change their nomenclature to ‘Peer Advisors’. The speed with which this activity increases will depend on the enthusiasm of health care professionals in utilising this valuable resource, as well as on the attitude of society to consult trained lay people rather than health care professionals. A significant development will be for primary care to use PADs within the practice, and for health authorities actively to promote the concept. A larger pool of trained individuals will no doubt add to the increasing awareness within society.

The lack of a significant improvement in HbA1c may well be due to reasonable levels before the start of the course. The significant improvements in understanding, self-care ability, importance of care, and self-care adherence, and a reduction in negative attitudes reflect the effects on the individuals. Well-Being Index and changes in positive attitudes were not significant but showed an improving trend over a year. It is worth noting, however, that these improvements were sustained over a year.

Imparting information, and the promotion of self-management, should not be the only features of a training programme. Volunteers are from varying backgrounds, and will not have known each other before joining the course. The promotion of camaraderie amongst them is vital if they are to function effectively as a group. The inclusion of social evenings as integral to the programme was most effective: the PADs have become good friends and colleagues.

The duties undertaken by PADs are very responsible. It is therefore important for them to undertake regular updating, and for their activities to be monitored carefully. They will need to follow certain rules of conduct when undertaking consultations. Each consultation must be recorded, giving details of what the problems were and what advice was given. The role of the mentor in this activity is important; consultation records are therefore returned to the mentor before a copy is sent to the appropriate general practitioner. It is gratifying that all PADs have acknowledged and accepted the clinical governance rules and codes of conduct.

If patients are to be effective advocates and members of committees, they will need to understand the medical terminology and reasoning often used during discussions. It will be important for them to understand the evidence in support of what care people with diabetes should receive. They will require an understanding of the audit process, and the ability to interpret and critically analyse audit reports presented at committees. The programme described equips PADs to fulfil these roles.

The ‘Expert Patient’ document recommends the development of a core programme for user-led self-management training in chronic diseases like arthritis, multiple sclerosis, epilepsy and diabetes. The paper suggests that the model to be used is based on the chronic disease self-management programme developed by Stanford University.4 This course is run over six consecutive weeks, each session lasting for 150 minutes. In view of the fact that this programme is now being rolled out nationwide, it is relevant to consider the differences between it and the programme described in this paper. The EPP is a generic programme, intended for all patients with chronic disease, but the programme described in this paper is specific for diabetes and it is not designed for all patients with diabetes. The PADs programme is for only those who volunteer to serve diabetes and are prepared to undertake the specific training and assessment. It concentrates on methods of coping with pain, cognitive symptom management and relaxation although it does deal with nutrition. Pain is usually not a prominent feature for most people with diabetes. The information imparted by the EPP is neither specific nor sufficient to enable people with diabetes to self-manage their diabetes after attending the EPP. A major difference between the two programmes is that the EPP does not conclude with a formal assessment whereas the PADs programme insists on this. The Government has funded the EPP to be rolled out throughout the country but in its current generic structure; despite the reservations expressed, people with diabetes and their carers should be encouraged to enrol for the programme.

Perhaps there is a place to create a disease specific arm to the EPP for those who would wish to undertake further training in order to fulfil the functions of PADs; this would then enable the PADs programme to be funded on a national basis.

Should PADs be known as expert patients? All those who complete the EPP are automatically classed as expert patients. There is no doubt that PADs are clearly well informed and empowered patients, having undertaken an intensive training programme and having been rigorously assessed by independent examiners. It is interesting to record that PADs unanimously concluded that it would be unwise to use the word ‘expert’ in their title.

Self-management training is considered to be an important part of disease management in diabetes. Such training is traditionally delivered during working hours but it will need to be done after working hours if we wish to involve those at work and those who look after children during the day. This limitation makes PADs ideally placed to deliver training in self-management, both in terms of the timing of such programmes and in the choice of localities. Twenty-one PADs have already indicated their interest in teaching and they have gained experience in teaching as part of the on-going course. The supportive structure and assessment processes described have been important in encouraging their continued interest. A programme to assess the feasibility and effectiveness of training on self-management delivered by PADs, in a group setting, has now been agreed. Should this study show a positive result, the case for creating more PADs will become compelling.

In conclusion, despite the wide variation in the educational, occupational and social backgrounds of the participants, the training programme described is understandable and effective.

This programme is not designed for all people with diabetes but only for those who wish to serve society in addition to self-managing their condition. It is also recognised that not all PADs will either be interested in or effective in all the functions described.

Whilst we may encourage people with diabetes and their carers to join the EPP, there is a case for developing a disease specific arm for diabetes, incorporating the course described in this paper. The authors recognise that the use of the term ‘expert patient’ is here to stay—at least for those who enrol for the EPP. The decision of the PADs not to use the term ‘expert’ in their description is commended.

A seminar to discuss the experiences of patients who have undergone such training in chronic disease, and to address issues pertaining to the training programme, clinical governance and other practical points, would be most helpful.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

We wish to warmly thank our patients for their participation and their continued enthusiasm. We also thank the following, whose continued support made the exercise possible and for it to continue: members of the external assessment board—A Brooks, A Felton, RD Hill (Chairman), A Krentz, M MacKinnon, P Singhal, S Sexton, L Worral; G Elderfield, S Paul and T Walsh for taking part in the teaching sessions; and, for the education grants from Abbot Laboratories, Bristol Myers Squibb, GlaxoSmithKline, Novo Nordisk, Roche, Takeda, Vectasearch, Clinic and the Voluntary Group of Isle of Wight. A particular thanks to Carol Lockyer for providing much needed administration.

Appendix

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References

Appendix 1. Regulation and clinical governance of peer advisors in diabetes

  1. Who are entitled to be peer advisors?

  2. People who have attended a recognised course and appeared for an examination at the end of that course

  3. Each peer advisor will have a health care professional as a mentor. The mentor will provide advice and support, and will monitor the activities of their charge. The mentor will be a health care professional within the specialist field

  4. Consultations

    • A
      All consultations will be recorded on a form, noting at least the following:
      • a
        Names and contact details of peer advisor and the person with diabetes
      • b
        How and when contact was made
      • c
        Where and when the consultation took place
      • d
        What were the problems and what advice was given
      • e
        Any follow-up arrangements
  5. The completed form will be sent to the Diabetes Centre, which will ensure that copies are sent to the mentor and the appropriate general practitioner

  6. Details of the consultation will remain confidential other than through the distribution of the recorded report

  7. Any health care professional concerned with the management of the person with diabetes will have the right to discuss issues with the advisor

  8. The cases encountered will be discussed at the quarterly meetings of peer advisors, ensuring that patient confidentiality is protected

  9. Peer advisors will accept that they will be required to attend quarterly meetings of continuing education. At such meetings, they will also be informed of service changes, Government notices and feedback from meetings attended by peer advisors

  10. If, for any reason, conduct of a peer advisor is questioned, that person should be accountable to a committee, which will consist of an equal number of health care professionals and peer advisors

  11. The peer advisors shall formally elect a committee to ensure that regular educational meetings are held, and to monitor the activities of its members. The committee will also undertake activities that are decided by its members

  12. Code of conduct—this will be the same as the rules which apply to health care professionals. Peer advisors are urged to ensure that, when they consult in a private environment, there is present a member of the family or a chaperone

  13. How to contact peer advisors?

  14. It is recognised that peer advisors should not be given patient details

    1. For one-to-one consultation

    2. Health professionals who wish to seek the involvement of peer advisors would need to contact the Diabetes Centre. The Diabetes Centre will hold details about peer advisors, and it will be responsible for the allocation of the appropriate peer advisor. Alternatively, health professionals may wish to invite a peer advisor personally known to them. Peer advisors will seek to introduce themselves to their family doctors and nurses

    3. A person with diabetes or a carer or members of the family will have the right to contact the Diabetes Centre directly

    4. The person with diabetes will be given the name and contact details of the appropriate peer advisor. In the interest of protecting patient confidentiality it is appropriate that the person seeking the help of a peer advisor should make the first contact

    5. The choice of a particular peer advisor will depend on the type of diabetes and on geographical convenience

    6. For committee work

    7. The peer advisor group should elect peer advisors invited to be members of committees. Requests for such members should be made to the chairmen of Diabetes UK and the Peer Advisor Group

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Objectives
  5. Process
  6. Assessment
  7. Statistical analysis
  8. Results
  9. Discussion
  10. Acknowledgements
  11. Conflict of interest statement
  12. Appendix
  13. References
  • 1
    Report of a WHO Working Group: Therapeutic Patient Education. Copenhagen: World Health Organization, 1998.
  • 2
    Department of Health. National Service Framework for Diabetes. London: Department of Health, 2001; http://www.doh.gov.uk/nsf/diabetes/index.htm
  • 3
    Department of Health. The NHS Plan. London: Department of Health, 2000; http://www.nhs.uk/ nationalplan/npch 10.htm
  • 4
    Department of Health. The Expert Patient. London: Department of Health, 2001; http://www.doh. gov.uk/cmo/ep-report.pdf
  • 5
    Backhouse M, Baksi AK. Diabetic education: the use of formal lectures. In Diabetes Education. BaksiAK, HideDW, GilesG (eds). Chichester: John Wiley & Sons, 1984; 111114.
  • 6
    International Diabetes Federation. Your guide to diabetes and cardiovascular health. Brussels: International Diabetes Federation, 2001.
  • 7
    Michigan Diabetes Research and Training Center (2002;). Survey Instruments. http://www.med.umich. edu/mdrtc/survey/index.html
  • 8
    Bonsignora M, Barkow K, Jessen F, et al. Validity of the five-item WHO Well-Being Index (WHO 5) in an elderly population. Eur Arch Psychiatry Clin Neurosci 2001; (Suppl 2): 11271131.