Primary And Secondary Prevention Strategies For Type 2 Diabetes Mellitus: Nursing Staff And General Practitioners Perspective Essay.

What primary and secondary prevention strategies can be implemented for type 2 diabetes mellitus, a chronic disorder: perspective of nursing staff and general practitioners?

Background- Early prevention of the chronic disease diabetes is possible with the implementation of appropriate pharmacological and lifestyle interventions among individuals, who are considered to be at an increased likelihood of suffering from the condition. Hence, primary care would be the valid setting for the research to be conducted.

Hypothesis- General Practitioners and nurses can help in early prevention of type 2 diabetes by implementing pharmacological and lifestyle interventions.

Aim- To determine the perceptions of general practitioners and nurses on the identification and management of type 2 diabetes among people who are at risk

Research design- Qualitative study will comprise of focus groups as the data collection method, followed by analysis of responses into themes.

Statistical reports suggest that an estimated 6% Australians that accounts for 1.2 million people, aged more than 18 years suffered from diabetes in 2014-2015. There wereapproximately 16,400 deaths in Australia in 2015 due to diabetes mellitus, with more than half of them (55%) occurring due to type 2 diabetes (Australian Government, 2018). Furthermore, death due to type 2 diabetes and rates of hospitalisation have been found to be twice as great in rural regions, when compared to theurban areas. There is mounting evidence that has associated socioeconomic disadvantage with an increase in vulnerability to develop diabetes, its prevalence, hospitalisation, and subsequent death rates (Saydah, Imperatore & Beckles, 2013). Furthermore, there were approximately 1 million hospitalisations in the year 2015-2016 due to diabetes alone. This provides adequate evidence for justifying the rationale behind focusing the research question on early detection and prevention of the chronic disorder.

In the words of Yates et al. (2014) impaired tolerance of glucose and problems in fasting glycaemia have been identified as major precursors that act as indicators for people who are assumed to be at an augmented risk of acquiring type 2 diabetes mellitus.This impairment in glucose tolerance (IGT) is usually defined in the form of a transition phase that fluctuates between normal tolerance of glucose and diabetes mellitus, and is commonly referred to as pre-diabetes. There is mounting evidence from clinical trials that focus on lifestyle interventions that obese persons having impaired glucose tolerance have reported successful prevention of their transition to type 2 diabetes mellitus, or a delay in the development of their symptoms (Yoon, Kwok & Magkidis, 2013). This early management of the chronic condition has usually been brought about by increased adherence to physical activity, and dietary modifications that have resulted a subsequent weight loss. Furthermore, scholarly literature by Yang et al. (2014) has also elaborated on the benefits exerted by pharmacological intervention such as, acarbose and/or metformin.

Hypothesis

The findings were further supported by the Diabetes Prevention Program that was successful in establishing a correlation between amplified physical activity, metformin therapy and a momentous lessening in the number of people who had impaired glucose tolerance (Diabetes Prevention Program Research Group, 2015). Other evidences are also in accordance to the fact that multifaceted lifestyle interventions that comprise of exercise, dietary alterations, smoking cessation, counselling, and behavioural modifications have proved beneficial in averting or delaying the onset of diabetes among people who have been detected to be at an increased risk for the chronic disorder (Gong et al., 2015). Lifestyle interventions have also been found to exert direct benefits in neuropathy and severe nephropathy (Dunkley et al., 2014).

People with diabetes have also been benefited from diabetes education that promotes awareness on the disease, and its treatment regimen. It has also been found that good nutritional intake and regular exercise will help in achieving a healthy body weight, thus facilitating the management of the blood glucose levels in permissible limits. The long term sustainability of the diabetes prevention procedures have also been found beneficial in controlling high blood pressure, a risk factor for type 2 diabetes (Look AHEAD Research Group, 2013).

On the other hand, there is enough evidence to explain the mechanism of action of the anti-diabetic medications on the blood glucose levels. These pharmacological interventions have been found to keep the blood sugar levels in normal ranges by increasing the uptake of glucose from the peripheral cells, including the skeletal muscles (Pernicova & Korbonits, 2014). According to Rojas and Gomes (2013) metformin has also been established as the mainstay treatment for type 2 diabetes where its initial prescription, along with compliance to lifestyle interventions have been found to reduce the blood glucose levels, thus preventing impaired glucose tolerance. Research evidences have also suggested that general practitioners, although aware of the impaired glucose tolerance, often demonstrate a failure in understandingtheimplication, in relation to risks for coronary heart illness and following diabetes. This formed the basis for the research design.

To determine the steps that can be taken for preventing type 2 diabetes mellitus, a chronic disorder, by taking into account the perspective of nursing staff and general practitioners.

The PICO framework refers to a technique that is primarily used in evidence based practice for framing and answering a clinical question. However, in this research, since there was no particular intervention, the PICO framework was not used. Hence, the PS format that examines questions associated to understanding an issue was used in this regard.

P (Population)	Nursing staff and general practitioners
S (Situation)	Early detection and prevention of type 2 diabetes

Aim

Table 1- Research question

• Research objectives

• What do nursing staff and general practitioners know about early detection of individuals who are at an increased risk of type 2 diabetes onset?
• What resources and guidance must be provided for helping nursing staff and general practitioners play their role in primary prevention of the condition?

The research will be based on a qualitative approach that will be mainly exploratory in nature and will allow gaining a sound understanding of the underlying opinions, reasons, and motivations behind the phenomenon that is being investigated (Lewis, 2015). Hence, this research design will facilitate gaining a deeper insight into the problem of early detection and prevention of type 2 diabetes. A total of 30 nursing staff and general practitioners, working across three hospitals in the district will be asked to participate in the focus group. They will be sent sealed envelope that will contain detailed information on the purpose and potential benefits of the research that is intended to be conducted.

The sample selection will be based on convenience sampling, followed by selection of a location that can be easily accessed by all participants. Financial reimbursement of approximate will be paid to each participant 150 AUD, for attending the focus group, in place of caring for the patients. Focus groups will form the primary data collection method, where each team will be comprised of five members. The focus group will allow collection of responses from a planned discussion that will elicit the thoughts and perceptions of the participants on the research question, and will be conducted over two months.

Primary reason for using focus group as the data collection procedure is for discovering how the respondents feel and think about the topic, and adding a certain human dimension to the associated impersonal data (Cleary, Horsfall & Hayter, 2014). This will also offer broader range of information and create provisions for seeking clarification. The lead facilitator will be involved in directing the questions and prompting the participants to provide responses (Fusch & Ness, 2015). This will be followed by recording the responses, and taking notes on the verbal and non-verbal cues such as, emotive elements and body language. The responses will be transcribed verbatim, and the emergent patterns of responses will be categorised into themes and sub-themes.

Ethical approval will be taken from the university Human Research Ethics Committee. Informed consent will be taken from all participants, prior to beginning the data collection procedure. They will also be allowed to withdraw or refuse participation at any point of time.

Research timeline

Nov 18

Dec 18

Jan 19

Feb 19

Mar 19

Apr 19

May 19

Jun 19

Jul 19

Aug 19

Sep 19

Oct 19

Nov 19

Dec 19

Background reading

Developing research question

Deciding the background aims and objective

Obtaining ethical approval

Focus group

Analysis

Drawing conclusion

Writing the findings

Dissemination

Table 2- Timeline for research

Contrasting views might be prevalent among the nurses and the general practitioners regarding the steps that they should take for early detection and prevention of type 2 diabetes. Although the participants are expected to emphasise on the benefits that administration of lifestyle interventions, in combination with pharmacological therapies might exert on the at-risk population, they might cite lack of available resources as a major barrier that prevents them from adorning their role in primary care facilities. Low patient motivation and need for diabetes education campaigns are also expected to be discussed in the responses.

Research Design

• The findings will be disseminated via podcasts, blogs, conferences, leaflets and pamphlets.
• The primary healthcare workers and target population that has been identified at an increased risk of type 2 diabetes onset will be disseminated the findings.
• The hospital authorities and local government officials will also be made aware on the results since they play an important role in making resources available that are necessary for disease prevention and early management.

Research gaps:

The objective designed for the research proposal had focused entirely on the perspectives of the care providers or the health care professionals for the prevention strategies. The patient perspective on the feasible primary and secondary prevention strategies were not included in the focus of the research which can be considered a huge gap for the research to be inclusive. Although, due to time and resource availability restrain, for this research we are will only be focusing on the perspectives of the nurses and the general practitioners.

References

Australian Government. (2018). Diabetes snapshot. Retrieved from https://www.aihw.gov.au/reports/diabetes/diabetes-snapshot/contents/how-many-australians-have-diabetes.

Cleary, M., Horsfall, J., & Hayter, M. (2014). Data collection and sampling in qualitative research: does size matter?. Journal of advanced nursing, 70(3), 473-475.

Diabetes Prevention Program Research Group. (2015). Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study. The lancet Diabetes & endocrinology, 3(11), 866-875.

Dunkley, A. J., Bodicoat, D. H., Greaves, C. J., Russell, C., Yates, T., Davies, M. J., & Khunti, K. (2014). Diabetes prevention in the real world: effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes and of the impact of adherence to guideline recommendations: a systematic review and meta-analysis. Diabetes care, 37(4), 922-933.

Fusch, P. I., & Ness, L. R. (2015). Are we there yet? Data saturation in qualitative research. The qualitative report, 20(9), 1408-1416.

Gong, Q. H., Kang, J. F., Ying, Y. Y., Li, H., Zhang, X. H., Wu, Y. H., & Xu, G. Z. (2015). Lifestyle interventions for adults with impaired glucose tolerance: a systematic review and meta-analysis of the effects on glycemic control. Internal Medicine, 54(3), 303-310.

Lewis, S. (2015). Qualitative inquiry and research design: Choosing among five approaches. Health promotion practice, 16(4), 473-475.

Look AHEAD Research Group. (2013). Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. New England journal of medicine, 369(2), 145-154.

Pernicova, I., & Korbonits, M. (2014). Metformin—mode of action and clinical implications for diabetes and cancer. Nature Reviews Endocrinology, 10(3), 143.

Racgp.org.au (2018). RACGP – Obesity Prevention guidelines. [Online]. Retrieved from https://www.racgp.org.au/publications/goodpractice/201703/overweight-and-obesity [Accessed on 4th Nov].

Rojas, L. B. A., & Gomes, M. B. (2013). Metformin: an old but still the best treatment for type 2 diabetes. Diabetology & metabolic syndrome, 5(1), 6.

Saydah, S. H., Imperatore, G., & Beckles, G. L. (2013). Socioeconomic status and mortality: contribution of health care access and psychological distress among US adults with diagnosed diabetes. Diabetes care, 36(1), 49-55.

Yang, W., Liu, J., Shan, Z., Tian, H., Zhou, Z., Ji, Q., ... & Xu, Y. (2014). Acarbose compared with metformin as initial therapy in patients with newly diagnosed type 2 diabetes: an open-label, non-inferiority randomised trial. The Lancet Diabetes & Endocrinology, 2(1), 46-55.

Yates, T., Haffner, S. M., Schulte, P. J., Thomas, L., Huffman, K. M., Bales, C. W., ... & Tuomilehto, J. (2014). Association between change in daily ambulatory activity and cardiovascular events in people with impaired glucose tolerance (NAVIGATOR trial): a cohort analysis. The Lancet, 383(9922), 1059-1066.

Yoon, U., Kwok, L. L., & Magkidis, A. (2013). Efficacy of lifestyle interventions in reducing diabetes incidence in patients with impaired glucose tolerance: a systematic review of randomized controlled trials. Metabolism, 62(2), 303-314.