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Table 1 The origins and development of the DAFNEplus research programme

From: Mobilising knowledge between practitioners and researchers to iteratively refine a complex intervention (DAFNEplus) pre-trial: protocol for a structured, collaborative working group process

The DAFNEplus programme originates from the DAFNE (Dose Adjustment for Normal Eating) 5-day structured education programme for people with type 1 diabetes, which is widely delivered as part of routine clinical care in the UK and other countries [15, 16]. The current DAFNE programme is delivered by diabetes specialist nurses, dietitians and physicians and provides adults with type 1 diabetes training in flexible intensive insulin therapy to enable them to adjust their insulin doses and improve blood glucose control. People attending DAFNE courses are:
(1) Taught how to count carbohydrates and, using ratios, to calculate mealtime insulin dose requirements relative to the amounts of carbohydrate ingested;
(2) Advised to undertake regular review of blood glucose data and how to interpret patterns or changes in readings to inform adjustments to mealtime ratios and basal insulin doses to ensure readings are maintained within clinically recommended ranges; and
(3) Instructed how to calculate and use corrective doses of insulin or additional carbohydrate to maintain blood glucose readings within recommended target ranges.
Following their courses, participants are invited to attend an optional group follow-up session 6–8 weeks later before returning to attend routine clinical appointments every 6–12 months.
An RCT to evaluate DAFNE established the importance of providing structured education to teach diabetes self-management skills to enable people with type 1 diabetes to better manage the disease [17]. However, although DAFNE has been shown to help people initially improve their glycaemic control, many are unable to sustain these improvements and control their blood glucose levels consistently over time [18]. A programme of research funded by the National Institute for Health Research (NIHR) was undertaken to investigate why people struggle over time and identified that DAFNE courses often fail to help participants sustain using new skills as part of their everyday lives. This research also highlighted a need to integrate within the DAFNE curriculum both support for behaviour change and structured health professional support, utilising new technologies to assist self-care [15].
In response, a multi-disciplinary research group was established and awarded funding by the NIHR for a new programme grant to develop the DAFNEplus intervention and enhance support provided to participants. This group used findings from the previous DAFNE studies, undertook a systematic review of the literature on structured education programmes and sought input from clinical and health psychologists with expertise in behaviour change to establish three inter-linked work packages to:
(1) Modify the existing DAFNE curriculum and incorporate techniques for initiating and sustaining behaviour changes;
(2) Develop structured follow-up support; and
(3) Develop and assess how digital information communication technologies can be incorporated within the revised intervention to support health behaviours needed to optimise self-management of type 1 diabetes.
The outputs from these projects have been combined and comprise the DAFNEplus intervention which aims to support and motivate participants to manage type 1 diabetes as part of their everyday lives in the longer term. The DAFNEplus pilot study is currently underway to refine each element of the intervention (curriculum, follow-up support and new technologies). This will be followed by a definitive pragmatic cluster RCT of DAFNEplus versus standard DAFNE in 14 DAFNE centres across the UK, due to commence in Autumn 2018.