Outcomes of a Community-Based Rehabilitation Programme for People with Diabetes/Prediabetes

Abstract

Aim Diabetes is a chronic condition that requires ongoing healthcare management and is increasing in prevalence. Exercise is known to be effective in diabetes management as well as ongoing patient education and support. The aim of this study was to investigate the qualitative and quantitative outcome data of an existing 12-week community-based rehabilitation programme for people with diabetes/prediabetes. The data were interpreted to determine possible clinical benefits at programme completion and 3-month follow-up, as well as participant acceptability, adherence and attrition from the programme. Design A prospective observational study of mixed method design. Participants Thirty six adult volunteers of mixed ethnicity, who were diagnosed with diabetes or had recognised pre-diabetes risk factors, were assessed at the beginning of the programme. Intervention The 12-week programme included twice-weekly sessions comprised of 45 minutes of self-management education followed by 45 minutes of aerobic and resistance exercise. The programme was run in a community gymnasium and participants were supervised by a physiotherapist, physiotherapy students and a nurse. Ongoing supervised exercise was offered to participants following completion of the programme. Outcome measures The six-minute walk test (6MWT) was used as primary outcome measure to indicate the level of cardiorespiratory fitness. Waist circumference, resting blood pressure and grip strength were secondary outcome measures used to assess health-related physical fitness. Self-efficacy and exercise behaviour questionnaires were also used to assess clinical benefit. An evaluation form comprising open-ended questions was used to assess programme acceptability. Adherence was measured by programme attendance and participants were invited to provide reasons for attrition. Results Participants were overweight/obese and had multimorbidity. Of the 36 participants assessed at baseline, 25 completed the programme and 20 returned at 3-months post programme for further assessment, an overall attrition rate of 44%. Of the 16 participants lost to follow up, 10 were due to medical reasons not related to the programme, and six were related to cost of transport and work commitments. There were no adverse medical or acute injury events reported during the programme. In those that completed the 12-week programme there was a 70% adherence rate. The proportion of participant with Māori/Pacific Island ethnicity measured at baseline (33%) remained consistent throughout the programme. Clinical improvements were observed both at programme completion and 3 months post programme completion respectively in cardiorespiratory fitness (6MWT) (87 m (95%CI 65-109; p≤0.00; d=1.02), 60 m (95%CI 21-100; p≤0.01; d=0.76)), diastolic blood pressure (-3 mmHg (95%CI -7 to 2), -5 mmHg (95%CI -9 to -1; p≤0.05)), waist circumference (-3cm (95%CI –6 to –1), -3cm (95%CI –6 to 1)), self-efficacy (0.7 (95%CI -0.2 to 1.6; d=0.45), 0.8 (95%CI 0.04 to 1.5; d=0.67)) and exercise behaviour (aerobic exercise 53 min/wk (95%CI 26 to 81; p≤0.01), 71 min/wk (95%CI 25 to 118; p≤0.01); stretching/strengthening exercise 29 min/wk (95%CI 12 to 47; p≤0.01), 59 min/wk (95%CI 30 to 89; p≤0.01)). The qualitative data suggested two key themes determined programme acceptability: “social support” and “self-management”. “Social support” developed from the relationships made between staff, students and participants. “Self-management” developed from the increased motivation, confidence, safety and empowerment provided by the programme. Conclusions This study demonstrated that a community rehabilitation programme for people with diabetes/prediabetes is safe, culturally accepted, feasible and provides benefit to participants. These benefits were observed both quantitatively in measures of health-related physical fitness and qualitatively in reports of increased social support and confidence in their ability to independently manage their diabetes/prediabetes. The results should be interpreted with a degree of caution due to the high attrition rate, however this represents the clinical reality of working with a multimorbid population. The programme aligns with current health priorities supporting streamlined management of people with complex health conditions and warrants further research into a scaling up of such a programme into a randomised control trial (RCT) to investigate both clinical and cost effectiveness.