X-PERT Programme Structured Education for people with Diabetes

Intended Audience

Health care professionals and people with diabetes

Health Area

Organisations throughout the UK and Republic of Ireland

Background

X-PERT was devised for people who have Type 2 diabetes. The programme was also developed for the Urdu speaking South Asian community, with 3 out of the 10 programmes run for this community. The sessions attracted a mixture of people from different educational and economic backgrounds.

The programme was delivered at several community venues within Burnley, Pendle and Rossendale, Lancashire. These were easily accessible e.g. local health and community centres or rooms provided by social services.

The work began in November 2000 and the evaluation, including a randomised control trial of 314 participants was completed in November 2003. As a result the programme is now being rolled out throughout the UK and the Republic of Ireland to people with type 1 and type 2 diabetes. 

The role of disease-specific education to support self-management is outlined in a wide range of national policy documents, highlighting the need for patient education to be a key part of any diabetes service: 

National Service Framework (NSF) for Diabetes

Standard 3 of the NSF states that all people with diabetes will receive a service that encourages partnership and decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. Structured education is one of the key interventions needed to achieve Standard 3.

Structured Patient Education in Diabetes June 2005

The joint report from the Department of Health and Diabetes UK details what structured education programmes must do in order to meet the structured education criteria. The document also details current gaps in education provision. 

Choosing Health - Making Healthy Choices Easier

The White Paper aims to develop health as a way of life for the general population, where people are supported to make the right decisions about their health, and then carry them out in practice. The general ethos of the X-PERT Programme supports this vision.

NICE (2008)

The NICE guidance on the use of patient education models for diabetes recommends that structured education is offered to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review. It is also recommend that people and their carer’s are informed that structured education is an integral part of diabetes care.

How this service improves

To deliver a service of excellence, which is patient-centred, developed in partnership, equitable, integrated and focused on structured education leading to increased skills, knowledge and confidence in the prevention and self-management of long-term medical conditions

Objectives

Philosophy and aims of the programme:

1. Develop, monitor and evaluate a community-based, health professional-led, structured education programme for adults with Type1 and Type 2 diabetes
   
2. Deliver the programme in a manner that allows participants to develop the skills, knowledge and confidence to identify their own problems and possible solutions concerning lifestyle and self-management of diabetes
   
3. Improve quality of life, diabetes control and reduce the risk of developing secondary complications

Service Provided

Six, weekly, sessions are run, each lasting two and a half hours. Each topic is delivered according to the group's identified felt needs. All sessions are based on patient activation, discovery learning and empowerment.

Week 1: What is diabetes, basic digestion, self-monitoring of diabetes, possible symptoms, treatments and health results through a process of discovery learning that also explores feelings, dispels myths and uses visual educational materials developed for the programme.

 Week 2:  Weight management: energy balance, the’ Eatwell Plate’ with food pictures to inform about sensible eating whilst exploring barriers in doing so,  a fat attack DVD that clearly demonstrates in an educational but humorous way that crash diets don't work. Strategies for weight loss explored using innovative energy deficit cards, practical examples and local exercise-on-prescription schemes.  Participants supported in performing dietary self-assessment and setting goals to suit individual need.

Week 3:  Carbohydrate awareness: an interactive group task using glucose, sugar [sucrose] & starch [low and high glycaemic index] models and life-sized food pictures to demonstrate that the quantity [amount] of carbohydrate consumed is the key strategy for optimal glycaemic control whilst the quality [type] of carbohydrate may have modest additional benefits.

 Week 4:  Reading and Understanding Food Labels: an option of a supermarket tour or an in-house session using food labelling demonstration cards to reduce confusion and develop skills, knowledge and confidence in reading and understanding food labels. The session encourages a nutritional intake that is enjoyable, variable and balanced whilst dispelling the notion that good and bad foods exist.

Week 5: Possible Shot and Longer-Term Complications:  discovery learning using visual educational tools to explore the possible complications of diabetes and explain conditions such as nephropathy, retinopathy, arteriosclerosis and blood pressure in layman’s terms. Emphasis is placed on self-management, prevention, annual review and special considerations such as travel, driving, mood and sick day rules.

Week 6:  Are you an X-PERT: a fun and interactive board game to reinforce the main messages from the X-PERT Programme and build confidence that learning has taken place. Also an opportunity for participants to taste and share experiences from adapting recipes considering  type and amount of fat, carbohydrate and fibre.  Information about the annual update session provided.

The discovery learning sessions (weekly topics) have been shown to develop skills and knowledge and the Lifestyle Experiment (final 20-30 minutes each week) encourages participants to implement new skills/knowledge leading to increased confidence and experience in diabetes self-management.  Participants are encouraged to complete their diabetes health profile, identify concerns and possible solutions. The lifestyle experiment session is not didactic in nature and it is intended to enable people to make informed decisions regarding diabetes self-care.

More information can be found on the X-PERT website www.xperthealth.org.uk

Accountability

Accountability The project is accountable to Dr. Trudi Deakin (contact details given at the end of the document)

Project Aims

What will success look like? X-PERT is a tried and tested model that has been shown to result in the following:

1. People with diabetes developing the skills, knowledge and confidence to make informed decisions and self-manage their diabetes (increased self-empowerment).
2. Improved patient experience and quality of life.
3. Improved clinical outcomes and reduced risk of developing diabetes-related complications.
4. Reduced requirement for diabetes medication.
5. Increased patient and public involvement (PPI) in future design and delivery of diabetes services.

A Randomised Control Trial involving 314 participants was conducted. Ten X-Pert programmes were delivered as well as a control group who received routine treatment ie, individual appointments with the GP, Practice Nurse and Dietitian.

Evaluation

Process evaluation has shown that the participants enjoyed the programme and this was reinforced by the excellent attendance rate (95%). People with diabetes and carers found it useful and perceived that it would have a positive impact on their health. The majority (91%) stated that the knowledge gained equipped them with the skills to help other people with diabetes. Psychosocial, lifestyle and clinical outcomes were collected at baseline, four and 14 months. Statistically significant differences were seen between the participants attending the X-PERT Programme and those receiving routine treatment although there was no continued support and follow-up after attendance on the six-week X-PERT Programme indicating that improvement in health and wellbeing resulted from increased self-management of diabetes.

The X-PERT Programme has been shown to improve:

Self-empowerment

Self-empowerment and knowledge of diabetes, scores showed there were significant statistical differences between the X-PERT patients and controls for total empowerment score (difference 0.3; P=0.006), psychosocial adjustment (difference 0.3; P=0.005), readiness to change (difference 0.2; P=0.001) and goal setting (difference 0.2; P=0.03).

Food intake and quality of life in respect of food and drink

The food frequency questionnaire indicated that the X-PERT patients were consuming two extra portions of fruit and vegetables each day (difference 2.2 portions; P<0.001) compared to controls at 14 months post education programme. Furthermore, the X-PERT patients showed significant improvements, compared with controls, in the negative impact of diabetes on freedom to eat (difference 1.1; P=0.04); freedom to drink (difference 1.5; P=0.01); enjoyment of food (difference 1.1; P=0.05). 

Clinical outcomes

The mean HbA1c was lower in the X-PERT Patients compared to the individual appointments group (0.7%; Repeated measures ANOVA P<0.001), there were also improvements in the X-PERT patients compared to the control group for total cholesterol (0.1 mmol/l; P=0.01); body weight (1.2 Kg; P<0.001) BMI (0.4 Kg/m2, P<0.001) and waist circumference (3 cm; P<0.001). 

Reduction in the requirement for diabetes medication

The number needed to treat (NNT) for preventing diabetes medication increase was 4 (95% CI: 3 to 7) and NNT for reducing diabetes medication was 7 (95% CI: 5 to 11).

Lifestyle

Diabetes knowledge scores improved more in the X-PERT patients than in those receiving individual appointments (+1.8 versus +0.8, P<0.001). 

At four months there was a significant difference in physical activity with X-PERT patients exercising an extra day per week (difference 0.9 day; 95% CI: 0.3 to 1.6), performing foot care self-management (difference 0.7 day; 95% CI: 0.4 to 1.1) and self-monitoring blood glucose levels (difference 0.9 day; 95% CI: 0.2 to 1.6) compared to those participants receiving individual appointments. That increase remained significant in respect of exercise and foot care at 14 months (difference 0.9 day; 95% CI: 0.1 to 1.6; difference 0.6 day; 95% CI: 0.2 to 1.0, respectively).

Audit

Regular audits involving thousands of people with diabetes in the UK and Republic of Ireland who have attended the X-PERT Programme since the randomised controlled trail have shown that Regular audits involving thousands of people with diabetes in the UK and Republic of Ireland who have attended the X-PERT Programme since the randomised controlled trail have shown that the audit standards have been met. National implementation of the X-PERT Programme increases skills, knowledge and confidence for diabetes self-management resulting in increased health and wellbeing.

References

Deakin TA. Expert Patient Education versus Routine Treatment (X-PERT). PhD Thesis: 1-346; 2004. Nuffield Institute for Health, University of Leeds.

Deakin TA. Self-managing diabetes the X-PERT way. Nursing in Practice, September/October 2005.

Deakin TA. (2006).Structured Patient Education: Who are the X-PERTs? Journal of Diabetes Nursing 2006: 10 (10); 375-379.

Deakin TA, Cade JE, Williams R and Greenwood DC (2006) Glycaemic Control: The Diabetes X-PERT Programme makes a Difference. Diabetic Medicine: 23; 944-954. 

Deakin TA, Whitham C. (2009) National Audit of the X-PERT Programme. Diabetic Medicine:26 (Suppl. 1);33.

X-PERT is an award winning programme

• Diabetes UK Diabetes Education Award (March 2003)
• National Obesity Forum Weight Management in Diabetes Care Award (October 2003)
• Health Service Journal Patient-Centred Care Award (November 2004)
• The Secretary of State’s Excellence in Healthcare Management Award (November 2004)
• Public Servants Innovation, Breaking New Ground Award (Finalist, May 2006)
• TrusTECH Innovation in Service Delivery Award (3rd Prize, July 2006)
• The HSE Overall National Achievement Award, Republic of Ireland (April 2008)

Quality Assurance:

The X-PERT programme meets all the Quality Assurance standards with mechanisms in place to monitor the environment, structure, process, delivery and outcomes of the programme.

Participants Comments:

"This is the first time in 10 years of being a diabetic that anybody has told me these things"

"I am certain that I would not have gained more than 20% of the knowledge I have about diabetes had I not attended this course. I believe that diabetics will respond better to education delivered in this way, rather than the ad hoc information handed out by busy Consultants/GPs/Practice Nurses. This course should be essential after-care for all newly diagnosed diabetics"

"I think that these sessions should be attended by all diabetics & their families. The content was extremely helpful & I feel more confident about my condition" "I feel I have gained a lot more knowledge about diabetes, which I can use for myself and at the hospital, with elderly patients. I will show my file to the boss"

"Enjoyable and informative sessions. Would welcome chance of update sessions later in the year  even twice each year"

"I think some sessions should be at night for people who have to work" "Don't feel as frightened as I did.....feel more confident in myself - things explained so that anybody & everybody can understand"

"This course was really helpful in helping me understand diabetes as all demonstrations were in laymen's language - programme should have been implemented years ago"

"Very glad to be offered the course, much appreciated (Thank you NHS!). Feel much encouraged in dealing with myself and more understanding with latest knowledge"

"Enjoyed every session & learnt a lot to improve my health & my husband thought it was a great help for partners who should know just as much"

Resources

Educational Visual aids

The X-PERT Pack includes: 

• X-PERT Handbooks x 20. This is an 80 page comprehensive summary of the X-PERT Programme along with additional information about self-management of diabetes.
• Three-panel, six-sided table top magnetic display boards with printed visuals on four sides.
• ‘What is diabetes’ panel plus 48 fully magnetic matt finished labels
• ‘Balance of Good Health/Eatwell Plate’ display with 10 food group/portion magnetic labels plus 72 magnetic foods pictures
• Body Story ‘Fat Attack’ DVD
• Energy balance model with Basal Metabolic Rate card, 20 food pictures and 15 activity pictures
• Weight loss support - set of 21 magnetic labels: 500 Kcal energy deficit cards; 1lb & 5lb weight loss; small steps label
• Fat models: 1lb & 5lb rolls/blobs of fat
• Carbohydrate models: glucose, sucrose, high & low glycaemic index
• Set of 35 carbohydrate awareness magnetic labels
• Carbohydrate awareness quiz: 97 life-size matt finished food pictures
• Glycated haemoglobin models: 4% [20 mmol/mol] & 10% [86mmol/mol]
• Blood pressure model to explain systolic & diastolic blood pressure
• Longer-term complications interactive panel plus 42 complication/medication magnetic labels
• Death of the Artery model: four sections of artery showing different levels of blockage
• Occluded Artery: showing a constricted passage clogged with plaque
• Eye model with cut-away portion to show inner anatomy including retina and blood vessels
• Kidney model to explain the function of a healthy kidney, microalbuminuria and nephropathy
• Are you an X-PERT? Magnetic game with 90 A5 quiz cards, 18 fully magnetic matt finished counters & six dice
• Carry case with X-PERT logo and shoulder strap for the magnetic board and trolley case for educational models.

For more information and to order via the online shop please visit www.xperthealth.org.uk and access the healthcare professional pages.

Additional Information

Updates and the future

Between September 2005 and May 2009, 813 healthcare professionals have been trained to deliver the X-PERT Programme. X-PERT is currently being implemented by approximately 92 organisations throughout the UK and Republic of Ireland. 

A national database has been developed for audit and quality assurance. The current national audit results (>6,000 people with diabetes) meet the audit standards identified by the randomised controlled trial.  This demonstrates that results are reproducible with different educators and with different populations.

X-PERT insulin has now been developed and the first 2-day health professional train the trainer course is to be held in July 2009 (please see “Training Courses” on the “Healthcare Professional” pages of the X-PERT website for more details). A self-directed learning kit, consisting of a set of six DVDs, handbook and X-PERT game is available for those people who are housebound or who are unable to attend group sessions.  

Future developments will include X-PERT Junior, X-PERT Weight, X-PERT Heart, X-PERT Health and e-learning.

Contact

X-PERT Team

Dr Trudi Deakin BSc (Hons) Ad Dip PGCE PhD RD

Claire Whitham: Diabetes Specialist Dietitian

Pam Tetlow: Diabetes Specialist Nurse

Laura Rosthorn: Administration Manager