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Development of a supported self-management intervention for adults with type 2 diabetes and a learning disability

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Pilot and Feasibility Studies20184:106

  • Received: 3 November 2017
  • Accepted: 9 May 2018
  • Published:
Open Peer Review reports



Although supported self-management is a well-recognised part of chronic disease management, it has not been routinely used as part of healthcare for adults with a learning disability. We developed an intervention for adults with a mild or moderate learning disability and type 2 diabetes, building on the principles of supported self-management with reasonable adjustments made for the target population.


In five steps, we:
  1. 1.

    Clarified the principles of supported self-management as reported in the published literature

  2. 2.

    Identified the barriers to effective self-management of type 2 diabetes in adults with a learning disability

  3. 3.

    Reviewed existing materials that aim to support self-management of diabetes for people with a learning disability

  4. 4.

    Synthesised the outputs from the first three phases and identified elements of supported self-management that were (a) most relevant to the needs of our target population and (b) most likely to be acceptable and useful to them

  5. 5.

    Implemented and field tested the intervention



The final intervention had four standardised components: (1) establishing the participant’s daily routines and lifestyle, (2) identifying supporters and their roles, (3) using this information to inform setting realistic goals and providing materials to the patient and supporter to help them be achieved and (4) monitoring progress against goals.

Of 41 people randomised in a feasibility RCT, thirty five (85%) completed the intervention sessions, with over three quarters of all participants (78%) attending at least three sessions.

Twenty-three out of 40 (58%) participants were deemed to be very engaged with the sessions and 12/40 (30%) with the materials; 30 (73%) participants had another person present with them during at least one of their sessions; 15/41 (37%) were reported to have a very engaged main supporter, and 18/41 (44%) had a different person who was not their main supporter but who was engaged in the intervention implementation.


The intervention was feasible to deliver and, as judged by participation and engagement, acceptable to participants and those who supported them.

Trial registration

Current Controlled Trials ISRCTN41897033 (registered 21/01/2013)


  • Type 2 diabetes
  • Supported self-management
  • Learning disability


In UK practice, the terms learning disability and intellectually disability are used interchangeably. It is estimated that 2% of the population has a learning disability, with about 1.5% having a mild or moderate disability. Diabetes in people with a learning disability has been estimated to be more common than in the general population [1, 2], with a cited prevalence of 9–11% [3, 4]. People with learning disabilities also have higher rates of hospital admissions from diabetes-related ambulatory care-sensitive conditions [4]. There are a number of possible explanations for high rates of type 2 diabetes mellitus (T2DM) in adults with a learning disability including high prevalence of obesity [5, 6], prescription medications that increase diabetes risk and more limited self-management skills [7].

Supported self-help or self-management with health problems is now well established in that the principles are clear in terms of core elements, although the intensity with which it is delivered and its specific content have varied considerably between studies [810]. In relation to intensity, the main variation is in amount of contact with the support/therapist, which ranges from regular face-to-face meetings to limited telephone contact. The usual pattern is that a professional (or trained peer) acts as a ‘therapist’ to help and encourage the nominated patient in using self-management materials.

As regards the content, all programmes contain an educational and an instructional component, the variation residing mainly in the degree of use of formal techniques for supporting change in behaviour and the degree to which they are theory-based. Typical elements [11] include:
  • Helping people to understand the short-, medium- and longer term consequences of health-related behaviour

  • Helping people to feel positive about the benefits of changing their behaviour

  • Building the person’s confidence in their ability to make and sustain changes

  • Recognising how social contexts and relationships may affect a person’s behaviour

  • Helping plan changes in terms of easy steps over time

  • Identifying and planning for situations that might undermine the changes people are trying to make (including planning explicit ‘if–then’ coping strategies to prevent relapse)

  • Encouraging people to make a personal commitment to adopt health-enhancing behaviours by setting (and recording) achievable goals in particular contexts, over a specified time

  • Helping people to use self-regulation techniques (such as self-monitoring, progress review, relapse management and goal revision) to encourage learning from experience

  • Encouraging people to engage the support of others to help them to achieve their behaviour-change goals

Current recommendations for diabetes self-management focus largely on educational and didactic approaches [12]. Development of self-management material for adults with a learning disability has tended to take the same approach [13]. In these programmes, there is typically less emphasis on more autonomous aspects of self-management such as advice about self-monitoring. There is also little on the interaction between the person with diabetes and others supporting their care. Many adults with a learning disability do not live entirely independently even when living in the community—that is, not living in a hospital setting. Family members and other informal or formal carers often provide support in the form of help with shopping, cooking, monitoring and prompting about medication and so on. Living and support arrangements are diverse [14, 15]; some adults with a learning disability remain in the parental home; some live with a sibling or other relative; some live alone or in shared accommodation with non-resident support or peer support from those with whom they share, and some are married or cohabiting with somebody who may or may not themselves have a learning disability. Since many of the positive and negative influences on good diabetes management reside in the immediate social network [1620], self-management needs to involve not just the person with diabetes but their supporter, and flexibility is needed in negotiating and implementing an intervention.

There is a clear need to improve on this state of affairs. The Equality Act 2010 sets out the legal requirement for public services to provide reasonable adjustments at both service level and individual level for people with a disability, and that should include provision of accessible therapeutic support. This will require modification of even well-established interventions since people with a learning disability have by definition a significantly reduced ability to understand new or complex information and manage independently [21]; many also have communication difficulties. It will involve finding a form of communication that matches the person’s needs and may well involve a supporter who is familiar with helping that person make decisions [22, 23].

We have recently completed a feasibility RCT of a supported self-management intervention for evaluation in a feasibility RCT, the OK Diabetes trial. The protocol for the OK Diabetes RCT [24] and the results for the trial [25, 26] have been reported elsewhere. The present paper reports on our work in developing and field testing the intervention for use in the trial.

The approach we adopted in developing the intervention lies somewhere between the creation of a new therapy on the one hand and standardising (for example in a manual) an existing one. It involved using the principles of an existing therapy in developing the form and content of the intervention, with reasonable adjustments made so that it was suitable for use with our target population. This approach responds to the need to make reasonable adjustments to healthcare interventions for those with a learning disability [27] without sacrificing the effective components of a complex intervention that has been developed and evaluated in the general population.


Supported self-management is an approach to chronic disease management in which the underlying theory and the basic principles of implementation are already established. Development work in the current project did not therefore need to start from the early phases of intervention development (Fig. 1) as recommended by, for example, the UK’s Medical Research Council [28]—elaborating theory and undertaking early phase proof of concept and efficacy studies. Instead we planned our development work in five phases:
  1. 1.

    Clarifying the principles of supported self-management—as summarised in review articles and educational pieces and as identifiable from the protocols and final reports of individual studies of self-management in diabetes

  2. 2.

    Identifying from published literature the reported barriers to effective self-management of type 2 diabetes in adults with a learning disability

  3. 3.

    Collaborating with services that provide health support to adults with a learning disability to review existing materials that aim to support self-management of diabetes for people with a learning disability for examples of good practice

  4. 4.

    Synthesising the outputs from the first three phases to decide on those elements of supported self-management that are most relevant to the needs of our target population (that is, will overcome likely barriers) and most likely to be acceptable and useful (that is, match identified good practices). This phase involved a series of problem structuring and consensus meetings in the research team, at each step checking interim outputs against guidelines on reasonable adjustments and consulting with experts and service users

  5. 5.

    Implementation and field testing of early versions—modifying the intervention materials in the light of feedback from research diabetes nurses supporting the intervention (see later)

Fig. 1
Fig. 1

The intervention development process

At each stage, there were regular consultation meetings involving members of the research team, people with a learning disability and their representatives in local third sector organisations and expert clinicians experience working in learning disability.

We worked with two local third sector organisations with a special interest in supporting people with a learning disability: Tenfold ( and People in Action ( and with easy on the i, ( an organisation with special expertise in preparing accessible materials for people with a learning disability. Each group had established relationships with adults with a mild or moderate learning disability, with whom they worked to review materials and policies. Over 12 months, we were introduced to service users who could advise us, by the organisations for which they worked; we met two to three times for each part of the project. Exchanges were not formalised, and we did not record the meetings for research purposes, except to record the advice received.

Phases 1 + 2: literature reviews

At the time of our study, there were no relevant RCTs in the area of diabetes self-management in learning disability and therefore we did not undertake a formal systematic review of effectiveness studies.

We aimed to use the published literature to identify (a) the principles of self-management that we would hope to embody in our own intervention and (b) those influences on self-management potential in our population that should inform the form or content of a supported self-management programme.

To help identify published information relevant to our intervention, an information scientist (JW) undertook initial searches in four main areas:
  • Supported self-management in chronic disease;

  • Self-care in diabetes, including barriers to effective self-care;

  • Diabetes and a learning disability—a broad search to identify factors that might be specific to the target population;

  • Descriptions of specific interventions aimed at improving diabetes control in adults with a learning disability.

Searches were refined in a series of iterative discussions based upon outputs from preliminary searches. We also checked the reference lists of two relevant NICE Guidelines, [11, 29], two Cochrane Reviews, [30, 31], a guideline on supported self-management published by Diabetes UK, [32], and outlines of national standards in diabetes management from the US [33] and the UK [34].

On the basis of these searches, run in MEDLINE, EMBASE, CINAHL and PsychINFO, we identified and reviewed 707 titles and abstracts on the topics of self-management of chronic disease including diabetes, and 350 titles and abstracts on the topic of diabetes in adults with a learning disability.

The searches are available in the full report of the study [26].

Titles and abstracts were reviewed by two of the applicants (AH and GL), and full versions of relevant papers were obtained. We categorised retrieved papers as follows:
  • Reviews of self-management and diabetes (N = 10) [9, 10, 3542]

  • Individual self-management programmes or interventions (N = 22) [4364]

  • Research protocols describing individual self-management interventions (N = 8) [6572]

  • Observational studies reporting influences on self-management—barriers and enablers (N = 31) [1620, 7399]

We extracted data that described the form or content of self-management using an initial framework derived from reviewing the two NICE Guidelines, two Cochrane Reviews and the guideline on supported self-management published by Diabetes UK. We then refined this framework by reference to six individual studies for which reasonably comprehensive descriptions of the intervention were contained in the reports [51, 58, 100103]. The remaining studies were reviewed against this framework to identify any missing themes, using a modified best-fit framework analysis [104].

Next, we reviewed papers describing barriers to effective self-management, influences on interventions or outcomes that were specific to adults with a learning disability. In a series of review meetings, we organised the identified influences into a descriptive framework. We did not apply a quality assessment to papers, as long as they contained a usable account of intervention components.

Finally, we combined the two frameworks in a synthesis that allowed us to identify the general principles to be adhered to in implementing a pragmatic and sustainable programme of supported self-management, and the form and content of the specific intervention for this project.

Phase 3: scoping existing resources

For existing self-care resources, a scoping exercise was conducted in which examples of good practice in interventions around health in people with a learning disability were sought from services in the UK. Sources included charities including Diabetes UK, local NHS Trusts and patient groups, NHS Choices and Easyhealth.

We identified 18 examples of resources developed in the UK to support self-management of diabetes for people with a learning disability. The resources were all in leaflet or booklet form, using more-or-less easy-read language, illustrated with photographs or cartoons and covering topics like foods to eat and avoid, exercise, foot care and what to do if ill.

Resources were reviewed by a panel consisting of members of the research team, a dietician in learning disability services and service user representatives. Panel members rated each resource from 1 to 10 on a Likert scale. In informal group discussions that reviewed each resource in turn, members identified which aspects they liked and disliked about each resource (for example, information complexity, font size, use of images) and noted any implications for the new intervention. Results were recorded on a structured proforma.

Phase 4: problem structuring and priority setting

Using the general approach of problem structuring and priority setting [105], preliminary versions of the supported self-management package—including not just format and content but tailoring (for easy reading, visibility for those with poor acuity and so on)—were discussed in the research team. Finally, we considered guidance on reasonable adjustments to healthcare designed to ensure access for people with a disability, to check that we were meeting these obligations.

A further round of more focused (purposive) reviewing of literature was used to clarify which were the key principles for this population. We generated two checklists derived from the literature and our discussions (see Tables 1 and 2 below) to ensure that all relevant topics were covered, that all components of the intervention could be linked to principles of self-management, and to help frame final decisions (Table 3).
Table 1

Elements of supported self-management for type 2 diabetes

What self-management of diabetes involves

Food—buying, preparing, eating

Weight control or weight loss

Physical activity or exercise

Looking after your body—foot care, dental care

Healthy living—alcohol, smoking

Taking tablets

Visiting professionals—dental care, medical care, eye checks

Maintaining emotional wellbeing

Components of self-management programmes

Education—about diabetes and what it is; what self-management involves

Problem solving

Goal setting, planning

Monitoring and feedback, e.g. blood glucose, weight, dietary intake, tablets take

Skills development—foot care, self-monitoring of blood glucose, preparing food, use of IT

Effective use of other people and resources, e.g. company when going swimming/walking

Managing emotions and building confidence

Format: what does ‘supported’ mean?

Written materials

Charts—fridge door charts, ‘plan your plate’, diaries


Web-based programmes—static or interactive/moderated

Telephone or SMS contact—prompts or interactive

IT—beeping fridges, watches, tablet boxes, smart phones, etc.

Groups, e.g. nurse-led, third sector, exercise group, group education

Professional contact—nurse, diabetes educator, GP,

Peer support—informal, trained peer support, family, couples work

Tailoring of content and format

Literacy and other intellectual attainment

Sensory impairments

Language difficulties—non English, comprehension or speech problems

Self-nominated goals or problems

Professionally identified priorities

Living arrangements

Supporter’s priorities

Table 2

Checklist of possible needs and barriers to good healthcare requiring adjustment

Example of impairment or deficit

Example of adjustment (enabler of good healthcare)

 Intellectual disability/reduced mental capacity

 Staff training in capacity assessment and inclusive practice

 Memory problems

 Prompts, support for appointments

 Literacy/reading skills deficit

 Accessible materials, communication skills

 Vision/hearing impairment

 Visual aids

 Speech problems

 Time, trained staff

 Mobility difficulties, physical symptoms or restrictions

 May need OT/physio assessment/mobility aids

Attitudinal barriers


 History of lack of dignity/respect in services

 Staff training

 Threat to safety including bullying

 Safeguarding protocols

 Overcoming stigma


 Instrumental barriers


 Transport to services

 Funding, safe provision


 Personal budget

 Lack of access to personal pleasure/R+R activities

 Planning meeting with supporter

 Treatment burden—timing, side-effects

 Support with adherence, modified regime

Social barriers


 Lack of social support/networks

 Identify, train and support carers; advocacy; third sector

 Talking with professionals

 Staff training + supervision

 Communicating needs

 LD register; Health Action Plan

 Understanding—health risks, necessary actions

 Accessible information

 Low self confidence

 Social engagement activities

Mental Health


 Challenging behaviour

 Pacing of change; staff training

 Distress + mental disorder

 Mental health review with learning disability team

Table 3

Links between components of OK Diabetes intervention and principles of self-management

Behaviour change: the principles of effective interventions [29]


Place in intervention programme (see Additional files 12 and 3)

Helping people to understand the short-, medium- and longer term consequences of health-related behaviour

Review with participants—‘Looking after my diabetes’

Helping people to feel positive about the benefits of changing their behaviour

Discuss plan for change in general terms—‘I am going to…’

Building the person’s confidence in their ability to make and sustain changes

Encourage positive action planning

Recognising how social contexts and relationships may affect a person’s behaviour

Review participant’s life—social network, named supporter and helpers

Helping plan changes in terms of easy steps over time

Make a weekly plan

Identifying and planning for situations that might undermine the changes people are trying to make (including planning explicit ‘if–then’ coping strategies to prevent relapse)

Build ‘if–then’ thinking into action plan

Encouraging people to make a personal commitment to adopt health-enhancing behaviours by setting (and recording) achievable goals in particular contexts, over a specified time

Write goals on visible board

Helping people to use self-regulation techniques (such as self-monitoring, progress review, relapse management and goal revision) to encourage learning from experience

Identify personal rewards for success

Encouraging people to engage the support of others to help them to maintain their behaviour-change goals

Supporter pack and flash cards

Principles for priority setting were:
  • The intervention should respond to known barriers to self-management reported by people with a disability—including practical problems such as transport, likely attrition from drop out when multiple attendances are expected, inability to accommodate the presence of a supporter;

  • The format of the intervention should be likely to encourage self-maintained change beyond an early supported element; in our target population, this meant especially that the intervention should involve supporters involved with any aspect of lifestyle (shopping, food choice, physical activity, medication monitoring and so on) relevant to diabetes;

  • The intervention should be designed to be readily integrated into usual healthcare provision in the NHS, to ensure sustainability.

Based upon all the advice we received from those working with our target group, we wanted to give particular salience to:
  • Practical aspects of self-care—buying and preparing food. changes aiming for a healthier balanced diet, increasing physical activity

  • Use of simple (accessible) written materials and charts

  • Supportive contact both with a professional and with a supporter if one could be identified

  • Use of practical goal setting, planning to meet goals and self-monitoring

By contrast, we decided that less helpful aspects would be:
  • Education of a more theoretical sort about the nature of diabetes, food values and so on. All participants received factual information about managing their diabetes in a booklet as part of the Treatment As Usual arm of the RCT (

  • IT-based interventions, web, DVD, mobile phone etc., because this is usually not readily accessible by our participants

  • Group-based interventions—attendance is typically poor and meeting the specific individual needs arising in a heterogeneous population is harder

Phase 5: implementation and field testing an early version

We decided that professional support would be provided by diabetes nurses with experience in primary care rather than learning disability nurses, the rationale being that (i) very few of the target population would be in contact with (or taken on by) specialist learning disability services; (ii) in routine NHS practice where 20–25% of diabetes patients would be using insulin, diabetes nurses would have more relevant experience; (iii) for our population (not all of whom would have been told they had, or would self-describe as having, a learning disability), the diabetes background was considered to be more acceptable; and (iv) the intervention would be more readily easily used by staff in mainstream services. We planned for the sessions to be delivered in people’s homes to ensure adherence and to allow assessment of the person’s everyday environment, since we did not think the participants would be able to give a good account in a clinic of the influences on their diet, physical activity and self-care.

We developed a training plan for the nurses delivering the intervention covering the underlying principles of mental capacity and of self-management, the individualised elements specific to learning disability, trouble-shooting and dealing with potential problems and the details of the programme and the materials provided with it.

Explicit links were made between the practicalities of the intervention and its rationale in self-management principles (Table 3). We interviewed two general practitioners, a consultant physician in diabetes and a diabetes nurse manager, about any challenges in fitting the intervention into routine care.

The training programme was delivered by two of the researchers (AH, GL) over three sessions of face-to-face contact with the nurses. Both trainers were clinicians (liaison psychiatrist, AH, clinical psychologist GL) with experience of NHS practice in the management of long-term physical illness and previous experience in applied health research and supervision of therapies. We did not involve service users in the training. An additional session on mental capacity assessment was delivered by AS to the nurses and all research interviewers.

Supervised use of the intervention with three initial cases was also arranged. In each case, the whole intervention was delivered over a maximum of four visits and the nurses met together with AH and GL after each visit, to discuss any challenges with implementation. On the basis of this experience, early versions of the intervention were modified in format to make them easier to use. In particular, the forms for keeping notes on each contact were found to be over-structured by the nurses and intrusive for use in the field. Once they had familiarised themselves with the principles of self-management and the nature of each contact, the nurses preferred to make free-form notes during contact and then check afterwards that they had recorded all the necessary information and completed the essential standardised forms (CRF) for the trial.

Both nurses involved in the field-testing reported during case supervision finding the materials easy to use and the nature of the intervention easy to understand.

Results (see Additional files 12 and 3)

The final intervention had four standardised components with associated materials. How they were delivered depended on participant and supporter characteristics and preferences:
  1. 1.

    Establishing the participant’s daily routines and lifestyle: This included current diet and activity routines, participation in daytime social activities or work, shopping and food preparation, current self-reported health and self-management. The main aim of this component was to identify the social and personal influences in the life of the person with diabetes that would limit their ability to self-manage or that might be mobilised as a resource in supporting self-management.

  2. 2.

    Identifying all supporters and helpers and their roles: A key supporter and other helpers were identified where possible. Key supporters and other helpers were given written information about the project, and if they agreed to support a goal set by the participant, they were given a written reminder of their role. The main aim was to identify people who might be a useful resource in supporting self-management and to ensure any changes were embedded in the social network for longer term maintenance of change.

  3. 3.

    Setting realistic goals for change: The main aim was to avoid prescribing change in the way of good dietary practice or other lifestyle change, but to support goals suggested by the person with diabetes that were specific, simple and achievable given the person’s current routines and social support, and consonant with their willingness to make change. The intention was to encourage engagement in a population usually thought of as having little agency and to introduce the idea of selectable elements in a repertoire of self-management options.

  4. 4.

    Monitoring progress against agreed upon goals: We devised a simple system that did not depend on high levels of functional literacy, using tear-off calendar sheets on which participants noted goal attainment in a Yes/No format. The main aim was to encourage active participation in an activity that is a core feature of self-management.

We prepared materials to accompany these activities:
  • For the nurses—templates for a weekly timetable, a chart to record friends and family and other helpers, charts to be completed in collaboration with the person with diabetes (‘my life’, ‘my likes and don’t likes’, ‘looking after my diabetes’)

  • For the person with diabetes—an OK Diabetes board to place in a prominent position at home with visible record of goals including pictorial prompts, e.g. ‘snack swaps’, a written action plan in multiple formats and tear-off slips to record daily actions

  • For supporters and helpers—an information sheet explaining the study and a card summarising what their role was in helping to support the person with diabetes in meeting their chosen goals

The research nurse worked through the elements of supported self-management with the participant, explaining how to use materials and suggesting initial actions and activities. Further contact was negotiated with the person with diabetes. We anticipated that a total of three to four meetings of 30 to 60 min over 6 to 8 weeks would be provided, followed by telephone support and advice.

We took steps to ensure consistency in the use of the supported self-management: (i) training and supervision sessions with research nurses, (ii) annotation of the intervention materials by research nurses and (iii) ensuring nurses had other experience and training in diabetes or learning disability care prior to the RCT.


In developing the intervention, we were mindful of the need to assess fidelity (how much the intervention was delivered as planned) and adherence (how successfully the intervention was taken up by participants). We developed a simple approach to collecting intervention materials that could then be used to assess these aspects of intervention performance, the details of which have been reported elsewhere [25, 106].


Although not described in the same detail, similar approaches have been used previously in adapting established and effective therapies to develop brief psychological interventions for depression in people with a learning disability [107, 108].

Our approach to intervention development was based upon the principle of making reasonable adjustments to an existing approach and has a number of advantages. Firstly, because it involved considerable service user and expert input, it proved acceptable to participants. Secondly, its flexibility, which includes when, where and by whom is it delivered, makes our findings transferable to other settings.

As others have noted however [109], even extensively documented and theory-driven approaches to intervention development will entail a degree of personal judgement and will depend upon the particular perspective of the service users and third sector organisations consulted. We are aware for example, that while we privileged an understanding of the individual’s lifestyle and relationship with supporters over psychological characteristics like motivation or knowledge, others have chosen to adapt existing educational programmes for use with this population [110].


Existing evidence-based interventions can be successfully modified for use with adults who have a learning disability, using literature reviews, service user and expert input to decide upon principle focus and upon desirable form and content of the eventual package. Services can be delivered by healthcare staff with limited experience of LD with relatively little training. Flexibility will always be needed to respond to the differing living and personal arrangements of participants (for example the nature and involvement of a supporter) and variable cognitive abilities.



Other members of the OK Diabetes team were as follows: Professor Amanda Farrin, Dr. Alexandra Wright-Hughes, and Dr. Rebecca Walwyn (Leeds Clinical Trial Research Unit); Professor Claire Hulme and Mr. John O’Dwyer (Academic Unit of Health Economics).

We received valuable support and input from two local third sector organisations and would like to acknowledge especially Kath Lindley at Tenfold and Aqila Choudhury at People in Action ‘easy on the i’ is the information design service within the Learning Disability Service at Leeds and York Partnership NHS Foundation Trust . They contributed greatly at each stage of development and in generating the materials to support the intervention.


The study was funded by the National Institute for Health Research Health Technology Assessment programme NIHR HTA project 10/102/03.

Availability of data and materials

The dataset used during the current study will be made available to the scientific community with as few restrictions as feasible while retaining exclusive use until the publication of major outputs. Enquiries should be directed to the corresponding author.

Authors’ contributions

AH contributed to the design analysis and write up of the project and was the chief investigator overseeing the project implementation and corresponding author for the report. LB contributed to the design, conduct and analysis of the report, with lead role on the research in adults with learning disability, deputised for Professor House. AM was the project co-ordinator, responsible for the design of materials, recruitment and data collection, and JW designed and undertook all literature searches. GL contributed to the design and implementation of the SSM intervention, including supervision of nurses. AS lead the role in advising on involving adults with learning disability, training researchers in practice related to mental capacity. RA advised on all clinical aspects of the treatment and assessment of type 2 diabetes. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethical approval was granted for the study by the Yorkshire and Humber Research Ethics Committee (Reference: 12/ YH/0304). All participants gave written or independently witnessed verbal consent.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK
Leeds Institute of Clinical Trials Research, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK
Leeds York Partnership NHS Foundation Trust, Leeds, UK
Division of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK


  1. Straetmans JM, van Schrojenstein Lantman-de HM, Schellevis FG, Dinant G-J. Health problems of people with intellectual disabilities: the impact for general practice. Br J Gen Pract. 2007;57(534):64–6.PubMedPubMed CentralGoogle Scholar
  2. Emerson E, Baines S, Allerton L, Welch V. Health inequalities and people with learning disabilities in the UK: 2010. Durham: Improving Health & Lives: Learning Disabilities Observatory. p. 2010.Google Scholar
  3. Emerson E. Health status and health risks of the ‘hidden majority’ of adults with intellectual disability. Intellect Dev Disabil. 2011;49Google Scholar
  4. Glover G, Emerson E, Eccles R: Using local data to monitor the health needs of people with learning disabilities. Durham: Lives: Learning Disabilities Public Health Observatory; 2012.Google Scholar
  5. Hsieh K, Rimmer JH, Heller T. Obesity and associated factors in adults with intellectual disability. J Intellect Disabil Res. 2014;58(9):851–63.View ArticlePubMedGoogle Scholar
  6. Melville C, Hamilton S, Hankey C, Miller S, Boyle S. The prevalence and determinants of obesity in adults with intellectual disabilities. Obes Rev. 2007;8Google Scholar
  7. Hert M, Correll CU, Bobes J, Cetkovick-Bakmas M, Cohen D, Asai I, Detraux J, Gautam S, Moller HJ, Ndetei DM. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52–77.View ArticleGoogle Scholar
  8. Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet. 2004;364(9444):1523–37.View ArticlePubMedGoogle Scholar
  9. Heinrich E, Schaper NC, de Vries NK. Self-management interventions for type 2 diabetes: a systematic review. Eur Diabetes Nurs. 2010;7(2):71–6.View ArticleGoogle Scholar
  10. Radhakrishnan K. The efficacy of tailored interventions for self-management outcomes of type 2 diabetes, hypertension or heart disease: a systematic review. J Adv Nurs. 2012;68(3):496–510.View ArticlePubMedGoogle Scholar
  11. Type 2 diabetes: prevention in people at high risk []. Accessed 21 May 2018.
  12. National Institute for Health and Clinical Excellence: Type 2 diabetes in adults: management. NICE guideline NG28. In.: National Institute for Health and Care Excellence; 2015.Google Scholar
  13. Taggart L, Coates V, Clarke M, Truesdale-Kennedy M, Bunting B. Piloting a structured education programme for the self-management of type 2 diabetes for adults with intellectual disabilities: study protocol for a pilot randomised controlled trial. Trials. 2015;16(148):1–8.Google Scholar
  14. Braddock D, Emerson E, Felce D, Stancliffe RJ. Living circumstances of children and adults with mental retardation or developmental disabilities in the United States, Canada, England and Wales, and Australia. Dev Disabil Res Rev. 2001;7(2):115–21.Google Scholar
  15. Forrester-Jones R, Carpenter J, Coolen-Schrijner P, Cambridge P, Tate A, Beecham J, Hallam A, Knapp M, Wooff D. The social networks of people with intellectual disability living in the community 12 years after resettlement from long-stay hospitals. J Appl Res Intellect Disabil. 2006;19(4):285–95.View ArticleGoogle Scholar
  16. Cardol M, Rijken M, van Schrojenstein Lantman-de Valk H. Attitudes and dilemmas of caregivers supporting people with intellectual disabilities who have diabetes. Patient Educ Couns. 2012;87(3):383–8.View ArticlePubMedGoogle Scholar
  17. Hale LA, Trip HT, Whitehead L, Conder J. Self-management abilities of diabetes in people with an intellectual disability living in New Zealand. J Policy Pract Intellect Disabil. 2011;8(4):223–30.View ArticleGoogle Scholar
  18. Rintala T-M, Jaatinen P, Paavilainen E, Åstedt-Kurki P. Interrelation between adult persons with diabetes and their family a systematic review of the literature. J Fam Nurs. 2013;19(1):3–28.View ArticlePubMedGoogle Scholar
  19. Stopford R, Winkley K, Ismail K. Social support and glycemic control in type 2 diabetes: a systematic review of observational studies. Patient Educ Couns. 2013;93(3):549–58.View ArticlePubMedGoogle Scholar
  20. Chesla CA, Bartz RJ, Gilliss C, Skaff MA, Sabogal F, Kanter RA, Lutz CP. The family and type 2 diabetes: a framework for intervention. Diabetes Educ. 1998;24(5):599–607.View ArticlePubMedGoogle Scholar
  21. Department of Health. Valuing people: a new strategy for learning disability for the 21st century. London: HM Government; 2001.Google Scholar
  22. Iacono T. Ethical challenges and complexities of including people with intellectual disability as participants in research. J Intellect Dev Disabil. 2006;31(3):173–9.View ArticlePubMedGoogle Scholar
  23. Iacono T, Murray V. Issues of informed consent in conducting medical research involving people with intellectual disability. J Appl Res Intellect Disabil. 2003;16(1):41–51.View ArticleGoogle Scholar
  24. Walwyn RE, Russell AM, Bryant LD, Farrin AJ, Wright-Hughes AM, Graham EH, Hulme C, O’Dwyer JL, Latchford GJ, Stansfield AJ. Supported self-management for adults with type 2 diabetes and a learning disability (OK-Diabetes): study protocol for a randomised controlled feasibility trial. Trials. 2015;16(1):342.View ArticlePubMedPubMed CentralGoogle Scholar
  25. House A, Bryant L, Russell AM, Wright-Hughes A, Graham L, Walwyn R, Wright JM, Hulme C, O'Dwyer JL, Latchford G, et al. Randomized controlled feasibility trial of supported self-management in adults with type 2 diabetes mellitus and an intellectual disability: OK Diabetes. Diabet Med. 2018;35(6):776–88.Google Scholar
  26. House A, Bryant L, Russell AM, Wright-Hughes AM, Graham EH, Walwyn R, Wright J, Hulme CT, O'Dwyer J, Latchford GJ et al. Managing with learning disability and diabetes—OK-DIABETES: a case finding study and feasibility randomised controlled trial. In: NIHR Library. Edited by NIHR. London; 2018. in pressGoogle Scholar
  27. Equality Act, 2010. HM Government Equalities Office.
  28. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.View ArticlePubMedPubMed CentralGoogle Scholar
  29. National Institute of Health and Care Excellence: Behaviour change: general approaches. Public Health Guideline PH6 2007.Google Scholar
  30. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2005;18Google Scholar
  31. Duke SA, Colagiuri S, Colagiuri R. Individual patient education for people with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2009;(1):CD005268.Google Scholar
  32. Improving supported self-management for people with diabetes []. Accessed 21 May 2018.
  33. Funnell MM, Brown TL, Childs BP, Haas LB, Hosey GM, Jensen B, Maryniuk M, Peyrot M, Piette JD, Reader D, Siminerio LM. National standards for diabetes self-management education. Diabetes Care. 2009;32(Supplement 1):S87–94. Google Scholar
  34. National Diabetes Audit - 2013-2014 and 2014-2015: Report 1, Care Processes and Treatment Targets. []. Accessed 21 May 2018.
  35. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Education. 2016;99(6):26-43.Google Scholar
  36. Clark M. Diabetes self-management education: a review of published studies. Primary Care Diabetes. 2008;2(3):113–20.View ArticlePubMedGoogle Scholar
  37. Gucciardi E, Chan VW-S, Manuel L, Sidani S. A systematic literature review of diabetes self-management education features to improve diabetes education in women of Black African/Caribbean and Hispanic/Latin American ethnicity. Patient Educ Couns. 2013;92(2):235–45.View ArticlePubMedGoogle Scholar
  38. Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet. 2004;363(9421):1589–97.View ArticlePubMedGoogle Scholar
  39. Jarvis J, Skinner T, Carey M, Davies M. How can structured self-management patient education improve outcomes in people with type 2 diabetes? Diabetes Obes Metab. 2010;12(1):12–9.View ArticlePubMedGoogle Scholar
  40. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care. 2002;25(7):1159–71.View ArticlePubMedGoogle Scholar
  41. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord. 2013;12(1):14.View ArticlePubMedPubMed CentralGoogle Scholar
  42. Steinsbekk A, Rygg L, Lisulo M, Rise MB, Fretheim A. Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Serv Res. 2012;12(1):213.View ArticlePubMedPubMed CentralGoogle Scholar
  43. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. British medical Journal. 2002;325:746-9.Google Scholar
  44. Deakin TA, Cade JE, Williams R, Greenwood DC. Structured patient education: the diabetes X-PERT Programme makes a difference. Diabet Med. 2006;8Google Scholar
  45. Glasgow R, Toobert D, Hampson S. Effects of a brief office-based intervention to facilitate diabetes dietary self-management. Diabetes Care. 1996;19(8):835–42.View ArticlePubMedGoogle Scholar
  46. Jansink R, Braspenning J, Keizer E, van der Weijden T, Elwyn G, Grol R. No identifiable Hb1Ac or lifestyle change after a comprehensive diabetes programme including motivational interviewing: a cluster randomised trial. Scand J Prim Health Care. 2013;31(2):119–27.View ArticlePubMedPubMed CentralGoogle Scholar
  47. Khunti K, Gray LJ, Skinner T, Carey ME, Realf K, Dallosso H, Fisher H, Campbell M, Heller S, Davies MJ. Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. BMJ. 2012;344Google Scholar
  48. Klug C, Toobert DJ, Fogerty M. Healthy changes for living with diabetes: an evidence-based community diabetes self-management program. Diabetes Educ. 2008;34(6):1053–61.View ArticlePubMedPubMed CentralGoogle Scholar
  49. Lennox N, Edie G, Taylor M, Rey-Conde T, McPhee J. Diabetes, to the point: designing a website about diabetes for adults with intellectual disability and carers. Technol Disabil. 2009;21(1-2):11–8.Google Scholar
  50. Lennox NG, Rey-Conde TF, McPhee JH, Taylor M. The development and evaluation of resources about diabetes management for people with intellectual disability and their care providers. J Dev Disabil. 2009;15(2):77–80.Google Scholar
  51. Liu S, Bi A, Fu D, Fu H, Luo W, Ma X, Zhuang L. Effectiveness of using group visit model to support diabetes patient self-management in rural communities of Shanghai: a randomized controlled trial. BMC Public Health. 2012;12(1):1043.View ArticlePubMedPubMed CentralGoogle Scholar
  52. Lorig K, Sobel D, Stewart A, Brown BW, Bandura A, Ritter P, Gonzalez VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37Google Scholar
  53. McGowan PT. Self-management education and support in chronic disease management. Primary care. 2012;39(2):307–25.View ArticlePubMedGoogle Scholar
  54. McMahon GT, Fonda SJ, Gomes HE, Alexis G, Conlin PR. A randomized comparison of online- and telephone-based care management with internet training alone in adult patients with poorly controlled type 2 diabetes. Diabetes Technol Ther. 2012;14(11):1060–7.View ArticlePubMedPubMed CentralGoogle Scholar
  55. Mitchell B, Armour C, Lee M, Song YJ, Stewart K, Peterson G, Hughes J, Smith L, Krass I. Diabetes Medication Assistance Service: the pharmacist’s role in supporting patient self-management of type 2 diabetes (T2DM) in Australia. Patient Educ Couns. 2011;83(3):288–94.View ArticlePubMedGoogle Scholar
  56. Molsted S, Tribler J, Poulsen PB, Snorgaard O. The effects and costs of a group-based education programme for self-management of patients with type 2 diabetes. A community-based study. Health Educ Res. 2012;27(5):804–13.View ArticlePubMedGoogle Scholar
  57. Müller N, Stengel D, Kloos C, Ristow M, Wolf G, Müller UA. Improvement of HbA(1c) and stable weight loss 2 years after an outpatient treatment and teaching program for patients with type 2 diabetes without insulin therapy based on urine glucose self-monitoring. Int J Gen Med. 2012;5:241–7.View ArticlePubMedPubMed CentralGoogle Scholar
  58. Naik AD, Palmer N, Petersen NJ, Street RL Jr, Rao R, Suarez-Almazor M, Haidet P. Comparative effectiveness of goal setting in diabetes mellitus group clinics: randomized clinical trial. Arch Intern Med. 2011;171(5):453–9.View ArticlePubMedPubMed CentralGoogle Scholar
  59. Song MS, Kim HS. Intensive management program to improve glycosylated hemoglobin levels and adherence to diet in patients with type 2 diabetes. Appl Nurs Res. 2009;22(1):42–7.View ArticlePubMedGoogle Scholar
  60. Thoolen BJ, de Ridder D, Bensing J, Gorter K, Rutten G. Beyond good intentions: the role of proactive coping in achieving sustained behavioural change in the context of diabetes management. Psychol Health. 2009;24(3):237–54.View ArticlePubMedGoogle Scholar
  61. Trento M, Passera P, Borgo E, Tomalino M, Bajardi M, Cavallo F, Porta M. A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care. 2004;27(3):670–5.View ArticlePubMedGoogle Scholar
  62. van der Wulp I, de Leeuw JR, Gorter KJ, Rutten GE. Effectiveness of peer-led self-management coaching for patients recently diagnosed with type 2 diabetes mellitus in primary care: a randomized controlled trial. Diabet Med. 2012;29(10):e390–7.View ArticlePubMedGoogle Scholar
  63. Zanetti ML, Otero LM, Peres DS, MAd S, FPdM G, MCF F. Progress of the patients with diabetes mellitus who were managed with the staged diabetes management framework. Acta Paulista de Enfermagem. 2007;20:338–44.View ArticleGoogle Scholar
  64. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;2002(346):393–403.Google Scholar
  65. Christie D, Strange V, Allen E, Oliver S, Wong ICK, Smith F, Cairns J, Thompson R, Hindmarsh P, O'Neill S, et al. Maximising engagement, motivation and long term change in a Structured Intensive Education Programme in Diabetes for children, young people and their families: Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE). BMC Pediatr. 2009;9(1):57.View ArticlePubMedPubMed CentralGoogle Scholar
  66. Debussche X, Collin F, Fianu A, Balcou-Debussche M, Fouet-Rosiers I, Koleck M, Favier F. Structured self-management education maintained over two years in insufficiently controlled type 2 diabetes patients: the ERMIES randomised trial in Reunion Island. Cardiovasc Diabetol. 2012;11:91.View ArticlePubMedPubMed CentralGoogle Scholar
  67. Gray LJ, Khunti K, Williams S, Goldby S, Troughton J, Yates T, Gray A, Davies MJ. Let’s prevent diabetes: study protocol for a cluster randomised controlled trial of an educational intervention in a multi-ethnic UK population with screen detected impaired glucose regulation. Cardiovasc Diabetol. 2012;11(1):56.View ArticlePubMedPubMed CentralGoogle Scholar
  68. Johnson ST, Mundt C, Soprovich A, Wozniak L, Plotnikoff RC, Johnson JA. Healthy eating and active living for diabetes in primary care networks (HEALD-PCN): rationale, design, and evaluation of a pragmatic controlled trial for adults with type 2 diabetes. BMC Public Health. 2012;12:455.View ArticlePubMedPubMed CentralGoogle Scholar
  69. Lascar N, Kennedy A, Jackson N, Daley A, Dowswell G, Thompson D, Stokes K, Greenfield S, Holder R, Andrews R et al: Exercise to preserve beta cell function in recent-onset type 1 diabetes mellitus (EXTOD)—a study protocol for a pilot randomized controlled trial. Trials 2013, 14:180-180.Google Scholar
  70. Ma J, King AC, Wilson SR, Xiao L, Stafford RS. Evaluation of lifestyle interventions to treat elevated cardiometabolic risk in primary care (E-LITE): a randomized controlled trial. BMC Fam Pract. 2009;10:71.View ArticlePubMedPubMed CentralGoogle Scholar
  71. Murray E, Dack C, Barnard M, Farmer A, Li J, Michie S, Pal K, Parrott S, Ross J, Sweeting M. HeLP-Diabetes: randomised controlled trial protocol. BMC Health Serv Res. 2015;15(1):578.View ArticlePubMedPubMed CentralGoogle Scholar
  72. Simmons D, Cohn S, Bunn C, Birch K, Donald S, Paddison C, Ward C, Robins P, Prevost AT, Graffy J. Testing a peer support intervention for people with type 2 diabetes: a pilot for a randomised controlled trial. BMC family practice. 2013;14(1):5.
  73. Baker RM. Economic rationality and health and lifestyle choices for people with diabetes. Soc Sci Med. 2006;63(9):2341–53.View ArticlePubMedGoogle Scholar
  74. Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med. 2003;1(1):15–21.View ArticlePubMedPubMed CentralGoogle Scholar
  75. Beverly EA, Miller CK, Wray LA. Spousal support and food-related behavior change in middle-aged and older adults living with type 2 diabetes. Health Educ Behav. 2007;Google Scholar
  76. Cardol M, Rijken M, van Schrojenstein Lantman-de Valk H. People with mild to moderate intellectual disability talking about their diabetes and how they manage. J Intellect Disabil Res. 2012;56(4):351–60.View ArticlePubMedGoogle Scholar
  77. Cartwright L, Reid M, Hammersley R, Blackburn C, Glover L. Food choice by people with intellectual disabilities at day centres: a qualitative study. J Intellect Disabil. 2014;19(2):103-15.Google Scholar
  78. Caton S, Chadwick D, Chapman M, Turnbull S, Mitchell D, Stansfield J. Healthy lifestyles for adults with intellectual disability: knowledge, barriers, and facilitators. J Intellect Dev Disabil. 2012;37(3):248–59.View ArticlePubMedGoogle Scholar
  79. Chlebowy DO, Hood S, LaJoie AS. Facilitators and barriers to self-management of type 2 diabetes among urban African American adults focus group findings. Diabetes Educ. 2010;36(6):897–905.View ArticlePubMedGoogle Scholar
  80. Dagnan D. Psychosocial interventions for people with intellectual disabilities and mental ill-health. Curr Opin Psychiatry. 2007;20(5):456–60.View ArticlePubMedGoogle Scholar
  81. Ding EL, Prescott MR, Watson KT, Bui N, Makarechi L, Zoughbie DE: Abstract 009: Microclinic social network lifestyle intervention for weight loss and obesity management: a 10-month randomized controlled trial. Circulation 2013, 127(Suppl 12):A009-A009.Google Scholar
  82. Dysch C, Chung MC, Fox J. How do people with intellectual disabilities and diabetes experience and perceive their illness? J Appl Res Intellect Disabil. 2012;25(1):39–49.View ArticlePubMedGoogle Scholar
  83. Gill JM, Mainous AG, Diamond JJ, Lenhard MJ. Impact of provider continuity on quality of care for persons with diabetes mellitus. Ann Fam Med. 2003;1(3):162–70.View ArticlePubMedPubMed CentralGoogle Scholar
  84. Glasgow R, Nelson C, Strycker L, King D. Using RE-AIM metrics to evaluate diabetes self-management support interventions. Am J Prev Med. 2006;30(1):67–73.View ArticlePubMedGoogle Scholar
  85. Glasgow RE, Toobert DJ, Gillette CD. Psychosocial barriers to diabetes self-management and quality of life. Diabetes Spectrum. 2001;14(1):33–41.View ArticleGoogle Scholar
  86. Gomersall T, Madill A, Summers LKM. Getting one’s thoughts straight: a dialogical analysis of women's accounts of poorly controlled type 2 diabetes. Psychol Health. 2012;27(3):378–93.View ArticlePubMedGoogle Scholar
  87. Harvey JN, Lawson VL. The importance of health belief models in determining self-care behaviour in diabetes. Diabet Med. 2009;26(1):5–13.View ArticlePubMedGoogle Scholar
  88. Hawkins A, Look R. Levels of engagement and barriers to physical activity in a population of adults with learning disabilities. Br J Learn Disabil. 2006;34(4):220–6.View ArticleGoogle Scholar
  89. Majeed-Ariss R, Jackson C, Knapp P, Cheater FM. British-Pakistani women’s perspectives of diabetes self-management: the role of identity. J Clin Nurs. 2015;24(17-18):2571–80.View ArticlePubMedGoogle Scholar
  90. Nagelkerk J, Reick K, Meengs L. Perceived barriers and effective strategies to diabetes self-management. J Adv Nurs. 2006;54(2):151–8.View ArticlePubMedGoogle Scholar
  91. Nam S, Chesla C, Stotts NA, Kroon L, Janson SL. Barriers to diabetes management: patient and provider factors. Diabetes Res Clin Pract. 2011;93(1):1–9.View ArticlePubMedGoogle Scholar
  92. Nath C. Literacy and diabetes self-management. Am J Nurs. 2007;107(6):43–9.View ArticlePubMedGoogle Scholar
  93. Perri MG, Sears SF, Clark JE. Strategies for improving maintenance of weight loss: toward a continuous care model of obesity management. Diabetes Care. 1993;16(1):200–9.View ArticlePubMedGoogle Scholar
  94. Rouse L, Finlay WM. Repertoires of responsibility for diabetes management by adults with intellectual disabilities and those who support them. Sociol Health Illness. 2016;38(8):1243–57.View ArticleGoogle Scholar
  95. Skovlund SE, Peyrot M. The Diabetes Attitudes, Wishes, and Needs (DAWN) program: a new approach to improving outcomes of diabetes care. Diabetes Spectrum. 2005;18(3):136–42.View ArticleGoogle Scholar
  96. Trief P, Sandberg JG, Ploutz-Snyder R, Brittain R, Cibula D, Scales K, Weinstock RS. Promoting couples collaboration in type 2 diabetes: the diabetes support project pilot data. Fam Syst Health. 2011;29(3):253.View ArticlePubMedGoogle Scholar
  97. Whitehead LC, Trip HT, Hale LA, Conder J. Negotiated autonomy in diabetes self-management: the experiences of adults with intellectual disability and their support workers. J Intellect Disabil Res. 2016;60(4):389–97.View ArticleGoogle Scholar
  98. Winkley K, Evwierhoma C, Amiel S, Lempp H, Ismail K, Forbes A. Patient explanations for non-attendance at structured diabetes education sessions for newly diagnosed type 2 diabetes: a qualitative study. Diabet Med. 2015;32(1):120–8.View ArticlePubMedGoogle Scholar
  99. Zulman DM, Rosland AM, Choi H, Langa KM, Heisler M. The influence of diabetes psychosocial attributes and self-management practices on change in diabetes status. Patient Educ Couns. 2012;87(1):74–80.View ArticlePubMedGoogle Scholar
  100. Deakin TA, Cade JE, Williams R, Greenwood DC. Structured patient education: the diabetes X-PERT Programme makes a difference. Diabet Med. 2006;23(9):944–54.View ArticlePubMedGoogle Scholar
  101. Funnell MM, Anderson RM. Empowerment and self-Management of Diabetes. Clin Diabetes. 2004;22(3):123–7.View ArticleGoogle Scholar
  102. Group DPPR. The diabetes prevention program (DPP). Diabetes Care. 2002;25(12):2165–71.View ArticleGoogle Scholar
  103. Skinner TC, Carey ME, Cradock S, Daly H, Davies MJ, Doherty Y, Heller S, Khunti K, Oliver L. Diabetes education and self-management for ongoing and newly diagnosed (DESMOND): process modelling of pilot study. Patient Educ Couns. 2006;64(1):369–77.View ArticlePubMedGoogle Scholar
  104. Carroll C, Booth A, Cooper K. A worked example of" best fit" framework synthesis: a systematic review of views concerning the taking of some potential chemopreventive agents. BMC Med Res Methodol. 2011;11(1):29.View ArticlePubMedPubMed CentralGoogle Scholar
  105. Mingers J, Rosenhead J. Problem structuring methods in action. Eur J Oper Res. 2004;152(3):530–54.View ArticleGoogle Scholar
  106. Graham L, Wright J, Walwyn R, Russell AM, Bryant L, Farrin A, House A. Measurement of adherence in a randomised controlled trial of a complex intervention: supported self-management for adults with learning disability and type 2 diabetes. BMC Med Res Methodol. 2016;16(1):132.View ArticlePubMedPubMed CentralGoogle Scholar
  107. Jahoda A, Melville C, Cooper S-A, Hastings R, Briggs A, Dagnan D, Hatton C, McConnachie A, Williams C, Jones RP. BEAT-IT: a randomised controlled trial comparing a behavioural activation treatment for depression in adults with intellectual disabilities with an attention control: summary of study protocol. Trials. 2015;16Google Scholar
  108. Jahoda A, Melville C, Pert C, Cooper SA, Lynn H, Williams C, Davidson C. A feasibility study of behavioural activation for depressive symptoms in adults with intellectual disabilities. J Intellect Disabil Res. 2015;59(11):1010–21.View ArticlePubMedGoogle Scholar
  109. Greaves CJ, Wingham J, Deighan C, Doherty P, Elliott J, Armitage W, Clark M, Austin J, Abraham C, Frost J. Optimising self-care support for people with heart failure and their caregivers: development of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention using intervention mapping. Pilot and feasibility studies. 2016;2(1):37.View ArticlePubMedPubMed CentralGoogle Scholar
  110. Taggart L, Coates V, Clarke M, Bunting B, Davies M, Carey M, Northway R, Brown M, Truesdale-Kennedy M, Martin-Stacey L. A study protocol for a pilot randomised trial of a structured education programme for the self-management of type 2 diabetes for adults with intellectual disabilities. Trials. 2015;16(1):148.View ArticlePubMedPubMed CentralGoogle Scholar


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