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Aims To present the ADKnowl measure of diabetes-related knowledge and evaluate its use in identifying the nature and extent of patient and health professional knowledge deficits. Method The ADKnowl was used in a large-scale study of 789 patients (451 treated with insulin and 338 treated with tablets and/or diet) attending for annual review at one of two hospital out-patient diabetes clinics Results Knowledge deficits were apparent in the patients. For example, 57% did not recognize the inaccuracy of the statement ‘fresh fruit can be eaten freely with little effect on blood glucose levels’. Seventy-five percent of patients did not know that it is advisable to trim toenails to the shape of the toe. Knowledge deficits were identified for many other areas of diabetes management, e.g. prevention of hypoglycaemia, avoidance of ketoacidosis. Sixteen health professionals at the clinics answered the same items. Contrary to recommendations, 25% of health professionals thought that fresh fruit could be eaten freely. Seventy-five percent of health professionals did not know the current recommendations for trimming toenails. As expected, HbA1c did correlate with scores from two specific items, while HbA1c did not correlate with summed ADKnowl score. Conclusions Patient knowledge deficits were identified. Some specific knowledge deficits among health professionals may be the cause of some patient knowledge deficits. The ADKnowl is a useful tool in assessing both patient and health professional knowledge deficits and is available for use in a context of continuing evaluation. Diabet. Med. 18, 626–633 (2001)

Aims To assess satisfaction with treatment and psychological well-being associated with insulin glargine and Neutral Protamine Hagedorn (NPH). Insulin glargine, a new long-acting insulin analogue, provides constant, peakless insulin release following once-daily administration and is associated with fewer hypoglycaemic episodes, despite metabolic control equivalent to that achieved with NPH human basal insulin. Methods The Diabetes Treatment Satisfaction Questionnaire (DTSQ) and Well-being Questionnaire (W-BQ) were completed at baseline and at weeks 8, 20 or 28 by 517 patients with Type 1 diabetes participating in a randomized, controlled European trial comparing insulin glargine and NPH. Analysis of covariance was performed on change from baseline scores (main effects: treatment and pooled site; covariate: baseline scores). Results Treatment satisfaction improved with insulin glargine at all time points, including endpoint, but deteriorated slightly with NPH. These differences were significant throughout the study (change from baseline to endpoint: +1.27 vs. −0.56; P = 0.0001). Outcomes were better with insulin glargine for the DTSQ items, Perceived Frequency of Hyperglycaemia and Hypoglycaemia, with statistically significant differences at week 28 and endpoint for hyperglycaemia (P = 0.0373 and 0.0379) and at week 20 for hypoglycaemia (P = 0.0024). There was no difference in psychological well-being between the treatment groups, with mean scores increasing in both. Conclusions Study participants had treatment-independent improvements in General Well-being. Advantages for insulin glargine were seen in significantly improved Treatment Satisfaction throughout the study, together with lower Perceived Frequency of Hyperglycaemia than for patients on NPH, without a significant increase in Perceived Frequency of Hypoglycaemia.

Summary Aims The study aimed to explore the beliefs and concerns of people with Type 2 diabetes mellitus (DM) about their children’s risk of developing the disease and the possibilities for prevention. Methods Questionnaires were posted to all patients with Type 2 DM in four randomly selected general practices in South London. Two hundred and thirteen (73%) responded. The main outcome measures were: estimated risk of Type 2 DM in their offspring; worry about diabetes in their offspring; knowledge about the possibilities for prevention of Type 2 DM and its complications. Results Of the 159 respondents with children, at least 35% and perhaps as many as 64% underestimated the risk of their offspring developing Type 2 DM; 44% thought it possible to reduce the risk of Type 2 DM and its complications; 28% thought altering diet and 6% taking exercise might be useful preventive strategies; 49% worried about their children developing diabetes. Conclusions Although risk of Type 2 DM was underestimated for their children and little was known about prevention, about half of the respondents worried about their children developing diabetes. Education and counselling about risk and prevention are needed. This is important in view of growing interest in and opportunities for both the primary and secondary prevention of Type 2 DM. Diabet. Med. 16, 431–436 (1999)

Scales to measure perceived control of tablet-treated diabetes were adapted from a measure designed previously for insulin users. Development of the new scale is described and the psychometric properties are examined with responses from 187 tablet-treated patients. The scales consist of seven subscales which may be combined to provide three composite scores indicating the extent to which respondents perceive Personal Control, Medical Control, and Situational Control over their diabetes. Relationships between subscales and composite scores were similar to those found previously for insulin users. Patients were significantly more likely (p less than 0.001) to make attributions to Personal Control for their diabetes management rather than to Medical or Situational Control. As before, predictable biases were found in attributions to positive and negative outcomes. Correlations with medical and other psychological variables indicated that, as expected, stronger perceptions of Personal Control were associated with lower HbA1 levels (r = -0.14; p less than 0.05), lower percent ideal body weight (r = -0.24; p less than 0.01), less Anxiety (r = -0.15; p less than 0.05), greater Positive Well-being (r = 0.21; p less than 0.01) and greater Satisfaction with treatment (r = 0.34; p less than 0.001). Complementary relationships were found with the measure of Situational Control. Wallston and Wallston's speculative Locus of Control typology was investigated using the new measures, and the findings provided support for the value of this approach.

Psychological outcome measures of Well-being and Treatment Satisfaction have been designed and developed for people with tablet-treated Type 2 diabetes. The Well-being scale includes three six-item sub-scales to measure Depression, Anxiety, and Positive Well-being. A prime consideration when selecting items for the psychological well-being measures was to minimize the confounding of diabetic symptomatology with the somatic symptoms of depression and anxiety. Cronbach's alpha indicated that each of the Well-being sub-scales and the Treatment Satisfaction scale was internally reliable (alphas ranged from 0.70 to 0.88) and evidence for construct validity was provided by predicted associations with other variables collected at the time of the study. For example, lower Well-being scores were associated with being overweight (Depression: p less than 0.05; Anxiety: p less than 0.001) while greater Satisfaction with Treatment was associated with lower HbA1 levels (p less than 0.001) and lower percent ideal body weight (p less than 0.01). These scales should prove particularly useful where measures of quality of life are required to complement metabolic variables when evaluating new treatments, education programmes, and other interventions, or in the routine auditing of established methods of treatment.

The design and development of scales to measure diabetes-specific health beliefs of patients treated with oral hypoglycaemic agents and diet are described. The scales, which were developed from the responses of 187 tablet-treated patients, measure perceived Benefits of, and Barriers to Treatment, and perceived Severity of, and Vulnerability to Complications of diabetes and other disorders unrelated to diabetes. Cronbach's alpha indicated that each scale was internally reliable (alpha = 0.67 to 0.89) and construct validity was indicated by expected correlations between the scales and other variables including measures of blood glucose control, body weight, and psychological well-being. Thus, patients who were overweight and/or had higher glycosylated haemoglobin (HbA1) levels perceived their treatment to be less 'Cost-effective' (Benefits less Barriers), rated Complications as being more severe, and reported greater Vulnerability for themselves and the 'average person' with diabetes to these Complications (p less than 0.05 to p less than 0.01). Furthermore, respondents with higher Depression and Anxiety scores and lower Positive Well-being and Treatment Satisfaction scores reported greater Vulnerability to Complications for themselves and the 'average person', and also felt that their treatment was less 'Cost-effective' (p less than 0.01 to p less than 0.001). The measures are likely to be particularly useful in studies which assess the efficacy of interventions in modifying health beliefs with a view to achieving desired behaviours. They may also be useful as an instrument of audit if indicators about the suitability of possible interventions are sought.

We welcome Speight et al.’s review of quality of life measurement in adults with diabetes [1]. The discussion of the importance of differentiating quality of life from constructs such as health status, well-being and treatment satisfaction is useful in addressing a continuing confusion in the literature. Also we are pleased to see the positive reviews of the Audit of Diabetes-Dependent Quality of Life (ADDQoL), Diabetes Treatment Satisfaction Questionnaire (DTSQ) and Well-Being Questionnaire (W-BQ12). However, we would like to comment on remarks about the ADDQoL and provide updates on all three measures. Speight et al. cited the Food and Drug Administration (FDA) 2006 draft guidelines on Patient Reported Outcome measures which advised against questions requiring judgements about hypothetical situations. While this advice is sound in some instances, there are major benefits of the design of ADDQoL items which ask respondents how aspects of their life would change if they did not have diabetes (see response to FDA draft guidance by Clare Bradley published at http://www.fda.gov/ohrms/dockets/dockets/06d0044/06d-0044-EC18-Attach-1.pdf. A direct question about the impact of diabetes often elicits optimistic coping responses suggesting little or no impact while asking ‘but what if you didn’t have diabetes?’ would elicit a more realistic response.

A series of scales was designed to measure perceived control of diabetes and diabetes-related health beliefs with a view to predicting treatment preferences and individual differences in response to the treatments. Scale development is described and the psychometric properties examined with responses from 286 insulin requiring adult diabetic patients. Patients were significantly more likely (p less than 0.001) to attribute responsibility for their diabetes control to themselves rather than to their medical advisors or to other factors. For most of the patients the benefits of treatment were perceived substantially to outweight any barriers (p less than 0.001). Compared with their perceptions of vulnerability to disorders unrelated to diabetes, patients thought that they were more vulnerable to such diabetes related complications as eye, kidney and foot problems (p less than 0.001) but not to heart disease.

Insulin-treated diabetic patients attending a busy diabetic clinic were approached to determine their interest in using continuous subcutaneous insulin infusion (CSII) via a portable pump. Three hundred and eighty-two patients were offered the choice of CSII, intensified conventional therapy (ICT) or continuation of less intensified treatment. One hundred and sixteen patients (30.4%) chose CSII, 169 (44.2%) chose ICT, 97 (25.4%) chose the less intensive regimen. Those choosing CSII represented a broad cross section of the clinic population, though older patients with a longer duration of diabetes tended to continue with less intensified therapy. There were no differences between groups in the level of blood glucose control or the prevalence of complications at the outset of the study. Of 104 patients not previously using CSII, 86 have so far commenced the therapy. Twenty-seven (32.6%) of these discontinued within one year, 23 doing so in the first three months of treatment. Metabolic control, assessed by glycosylated haemoglobin, was significantly improved in the CSII group after three months and in the other treatment groups by six months. Glycosylated haemoglobin levels achieved with CSII were significantly lower at three and six months when compared with the other treatments.