Research Development

Staff Publications

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Find out what your colleagues have been writing. This section features articles published by staff working for St Helens and Knowsley Teaching Hospitals and Halton, Knowsley and St Helens community staff.

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All publications by 'Cardwell J'



Mersey and West Lancashire Teaching Hospitals NHS Trust – St Helens & Knowsley Staff

Mortality from diabetic kidney disease before and during the COVID pandemic

Background and aims We have previously published 5-and 10-year audits from our UK diabetes kidney clinic reporting outcomes comparable to those in landmark trials of diabetic kidney disease in broadly similar patients. This 2023 (20-year) audit again showed practice consistent with NICE, ADA and Kidney Disease Improving Global Outcomes guidelines, but..

Published: 04/09/2023
Authors: Lewis GA, Cardwell J, Hardy KJ

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A62 (P227) Risk of 12-month mortality following a severe inpatient hypoglycaemic event...

Aims At our Trust, all severe inpatient hypoglycaemic episodes in individuals with diabetes (defined as a hypoglycaemic episode requiring injectable treatment) are reported to NaDIA-Harms (National Diabetes Inpatient Audit). We conducted a detailed review of the care of all these events to improve patient safety. In this study, we assessed..

Published: 25/04/2023
Authors: Taylor J, Michaels S, Hatton DA, Caton K, Cardwell J, Hardy KJ, Strong AJ, Bujawansa S

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P303 Explicit glycated haemoglobin goals improve subsequent HbA1c levels with no impact on health-related quality of life

Background National guidelines recognise the importance of individualising HbA1c targets. Many people with diabetes agree to have their targets re-evaluated in consultations in response to specific characteristics. Aims We aimed to evaluate the impact of relaxed or stretch HbA1c goals on subsequent HbA1c levels and health-related quality..

Published: 25/04/2023
Authors: McNulty S, Westall S, Narayanan RP, Irving G, Furlong NJ, Bujawansa S, Cardwell J, Hardy KJ

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P302 Glycated haemoglobin targets: The experiences and views of people with diabetes and diabetes healthcare professionals

Background National guidelines highlight the importance of individualising HbA1c targets. Little is known about the experiences of people with diabetes and diabetes healthcare professionals (HCPs) on the use of HbA1c targets. We explored the experiences of adults with diabetes and diabetes HCPs on the use of glycated haemoglobin..

Published: 25/04/2023
Authors: Westall S, Narayanan RP, Irving G, Furlong NJ, McNulty SJ, Bujawansa S, Cardwell J, Hardy KJ

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P300 Setting explicit glycated haemoglobin goals improves diabetes-related distress, self-efficacy and wellbeing

Background High levels of diabetes-related distress and low levels of self-efficacy and wellbeing are associated with poorer outcomes in people with diabetes. Aims We evaluated the impact of relaxed or stretch HbA1c targets on diabetes-related distress, self-efficacy and wellbeing in adults with type 1 or type 2 diabetes. Methods We randomised 50..

Published: 25/04/2023
Authors: Westall S, Narayanan RP, Irving G, Furlong NJ, McNulty S, Bujawansa S, Balafshan T, Cardwell J, Hardy KJ

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P244 Planning services for people with type 2 diabetes: Is incidence still increasing

Aims Government plans for integrated care systems and integrated care boards are a welcome move towards more joined-up diabetes care between the NHS and local authorities, between health and social care and between specialist, community and primary care services. To plan effectively, for example, structured education for all newly diagnosed..

Published: 23/03/2022
Authors: Westall S, Mitchell L, Cardwell J, Furlong NJ, Narayanan RP, Bujawansa S, Balafshan T, Hardy KJ, McNulty S

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P124 Covid-19 pandemic associated with three-fold increase in demand for diabetes specialist advice

Aims The covid-19 pandemic was associated with legally restricted public movement (lockdowns) and reduced access to face-to-face consultation for diabetes in primary and specialist care. The aim of this study was to assess the impact of the pandemic on requests for specialist telephone support. Methods Retrospective analysis of calls for..

Published: 23/03/2022
Authors: Archer N, Westall S, Cardwell J, Furlong NJ, Narayanan RP, Bujawansa S, Balafshan T, Hardy KJ, McNulty S

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P243 Digital diabetes care: How well equipped are patients and what do they think about it

Aims Covid-19 precipitated an abrupt shift to non-face-to-face (digital) consultation. Some believe that this was overdue and that digital is better for many patients. Our aim was to establish the extent to which people with diabetes were equipped to manage digital consultation and what they felt about it. Methods We..

Published: 23/03/2022
Authors: Westall S, Mitchell L, Cardwell J, Furlong NJ, Narayanan RP, Bujawansa S, Balafshan T, Hardy KJ, McNulty S

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P147 Quick reference insulin safety medicine binder: A change in practice in St Helens & Knowsley Teaching Hospitals NHS Trust

Aim Despite national initiatives to improve practice, the National Diabetes Inpatient Audit (NADIA) 2019 still reported high levels of medication and insulin errors. A quick reference insulin safety binder was produced to promote insulin safety and support registered nurses whilst undertaking medication rounds. The binder is an eye catching, easy to..

Published: 23/03/2022
Authors: Strong AJ, Michaels S, Cardwell J, Bujawansa S

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P143 Non-attendance at structured type 2 diabetes education increases with deprivation

Aims Inequalities exacerbate poor health outcomes in diabetes. Structured education in type 2 diabetes is the cornerstone of supported self-management, but many people with newly diagnosed type 2 diabetes in the UK are not offered structured education and non-attendance in those accepting an offer of structured education is high. The aim of..

Published: 23/03/2022
Authors: Cardwell J, Mitchell L, Westall S, McNulty S, Furlong NJ, Narayanan RP, Bujawansa S, Balafshan T, Hardy KJ

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P193 Therapeutic inertia: Do patients get to target dose after glucagon-like peptide-1 receptor agonist (GLP-1-RA) initiation

Aims A recent primary care database study (J Rachman, Eli Lilly & Co) suggests that only about half of UK patients initiated on subcutaneous semaglutide (Ozempic) reach target maintenance dose. To assess the extent to which these data represent UK practice, we audited semaglutide dose optimisation and metabolic outcomes in our..

Published: 23/03/2022
Authors: Cardwell J, Edon E, Westall S, McNulty S, Furlong NJ, Narayanan RP, Bujawansa S, Balafshan T, Hardy KJ

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A5 (P240) Reduced exercise activity is associated with increased anxiety in type 1 but not type 2 diabetes

Aims Increased physical activity and a healthy lifestyle underpin efforts to prevent type 2 diabetes and are cornerstones in managing type 1 and type 2 diabetes. Not only is reduced activity associated with risk of weight gain and adverse metabolism, but it is also mooted to be associated with impaired psychological wellbeing. We..

Published: 14/04/2021
Authors: Westall S, Narayanan RP, Sullivan H, Bujawansa S, Furlong NJ, McNulty S, Cardwell J, Mitchell L, Jackson J, Hardy KJ

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P166 The impact of local, validated structured education programmes on self-care activities in people with diabetes

Background Better glycaemic control is exhibited in patients with higher self-care abilities. The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire measures diabetes self-care activities. As part of a local, validated structured education programme, we measure the SDSCA scores before and after completing structured education. Scores are outputted as ‘number of..

Published: 14/04/2021
Authors: Furlong NJ, Westall S, Cardwell J, Jackson J, Cairns J, Mitchell L, Bujawansa S, McNulty S, Narayanan RP, Hardy KJ

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P252 The impact of a validated structured education programme on diabetes-related distress in patients with type 1 diabetes

Background and Aim People with type 1 diabetes experience varying degrees of the emotional burden of diabetes and its treatments. The Problem Areas in Diabetes (PAID) questionnaire can be used to evaluate this domain. As part of a local, validated structured education programme for people with type 1 diabetes, baseline and endpoint..

Published: 14/04/2021
Authors: Narayanan RP, Westall S, Sullivan H, Cardwell J, Langan E, Gallagher CG, Bujawansa S, McNulty S, Furlong NJ, Hardy KJ

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P164 The impact of a local, validated structured education programme on anxiety and depression in people with diabetes

Background People with type 1 and type 2 diabetes experience greater degrees of anxiety and depression than the general population. The Hospital Anxiety Depression Scale (HADS) can evaluate this. Scores ≥8 on HADS-A (anxiety) or HADS-D (depression) indicate potential cases of anxiety or depression. Methods As part of a validated structured education programme,..

Published: 14/04/2021
Authors: Narayanan RP, Westall S, Sullivan H, Cardwell J, Cairns J, Gallagher CG, Bujawansa S, McNulty S, Furlong NJ, Hardy KJ

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A mixed-methods evaluation of the impact of a pharmacist-led feedback pilot intervention on insulin prescribing in a hospital setting

Aims To explore the impact of a prescribing feedback intervention on insulin prescribing. Methods This was a mixed-methods study in a hospital setting. An insulin prescribing feedback intervention was delivered verbally and in writing to twelve doctors. Insulin prescribing error frequency was compared to ten doctors who had not received..

Published: 13/03/2021
Authors: Lloyd M, Bennett N, Wilkinson A, Furlong NJ, Cardwell J, Michaels S

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The development of a diabetes screening service for the homeless population in St Helens

Aim To screen members of the homeless community in St. Helens for diabetes, and offer advice, support, diabetic eye screening and diabetic foot screening for those with diabetes, following two diabetes-related deaths in this population in 2018. Method(s) The Teardrops Hub staff promoted the drop in service to their service..

Published: 07/10/2020
Authors: Pendlebury H, Bujawansa S, Cardwell J

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Evaluating the views of doctors and nurses on the delivery of a safe insulin tips (SIPS) educational programme

Aim To evaluate the views of doctors and nurses on the delivery and use of a safe insulin tips (SIPS) educational programme. Methods Twelve SIPS were developed covering key areas of safe insulin use by a multi‐professional collaboration of patients and healthcare professionals. Individual SIPs were emailed weekly over 12..

Published: 07/10/2020
Authors: Lloyd M, Michaels S, Cardwell J, Furlong NJ

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The impact of local, validated structured education programmes on self-care activities in people with diabetes

Background and Aim Better glycaemic control is exhibited in patients with higher self‐care abilities. The Summary of Diabetes Self‐Care Activities (SDSCA) questionnaire measures diabetes self‐care activities. As part of a local, validated structured education programme, we measure the SDSCA scores before and after completing structured education. Scores..

Published: 07/10/2020
Authors: Furlong NJ, Westall S, Cardwell J, Jackson J, Cairns J, Mitchell L, Bujawansa S, McNulty S, Narayanan RP, Hardy KJ

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The impact of a validated structured education programme diabetes-related distress in patients with type 2 diabetes

Background and Aim Patients with type 2 diabetes experience varying degrees of the emotional burden of diabetes and its treatments. The Problem Areas in Diabetes (PAID) questionnaire can be used to evaluate this domain. As part of a local, validated structured education programme for people with type 2 diabetes, baseline and endpoint..

Published: 07/10/2020
Authors: Cardwell J, Bujawansa S, McNulty S, Furlong NJ, Narayanan RP, Jackson J, Mitchell L, Westall S, Hardy KJ

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The impact of a validated structured education programme on diabetes-related distress in patients with type 1 diabetes

Background and Aim People with type 1 diabetes experience varying degrees of the emotional burden of diabetes and its treatments. The Problem Areas in Diabetes (PAID) questionnaire can be used to evaluate this domain. As part of a local, validated structured education programme for people with type 1 diabetes, baseline and endpoint..

Published: 07/10/2020
Authors: Narayanan RP, Westall S, Sullivan H, Cardwell J, Langan E, Gallagher CG, Bujawansa S, McNulty S, Furlong NJ, Hardy KJ

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Perceived problem areas in diabetes do not correlate with levels of anxiety and depression

Background and Aim Diabetes‐related distress, anxiety and depression are all highly prevalent in people with diabetes. The Problem Areas In Diabetes (PAID) and Hospital Anxiety and Depression Score (HADS) questionnaires can be used to measure these domains. We evaluated the impact of structured education on each of these. Methods..

Published: 07/10/2020
Authors: Westall S, Narayanan RP, Langan E, Gallagher CG, Bujawansa S, McNulty S, Furlong NJ, Cardwell J, Hardy KJ

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The impact of a validated structured education programme on anxiety and depression in patients with type 1 diabetes

Background and Aim People with type 1 diabetes experience greater degrees of anxiety and depression than the general population. The Hospital Anxiety and Depression Scale (HADS) questionnaire can evaluate this. As part of a local, validated structured education programme for people with type 1 diabetes, baseline and endpoint measurements of anxiety and..

Published: 07/10/2020
Authors: Sullivan H, Westall S, Jackson J, Cairns J, Cardwell J, Bujawansa S, McNulty S, Furlong NJ, Narayanan RP, Hardy KJ

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The impact of seven-day working by a diabetes specialist nurse (DSN) team within an acute hospital trust

Aim Inpatient Diabetes Specialist Nurse Cover nationally is varied. Post a successful NHS England Transformation funding bid the aim was to provide greater support for ward areas, reduce error rates and increase satisfaction rates through the implementation of seven‐day working and an emergency advice line led by a diabetes..

Published: 07/10/2020
Authors: Michaels S, Bujawansa S, Hardy KJ, Cardwell J, Milne R, Strong AJ, Lee C, Smith R

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Reviewing current type 1 diabetes education provision across Merseyside

Aims NICE guideline NG17 recommend individual care plans agreed with the person with type 1 diabetes (PWT1D), reviewed annually and to include diabetes education provision. Where and how this education should be delivered is up for debate. A group was established in Merseyside to look at education offered to PWT1..

Published: 07/10/2020
Authors: Strong AJ, Cardwell J

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Measuring inpatient diabetes related staff satisfaction using a SurveyMonkey questionnaire

Background We introduced seven‐day working and increased support for inpatients from the diabetes specialist nursing (DSN) Team in 2017. Previous surveys using hand‐delivered or postal questionnaires had resulted in low response rates. This year we used an online survey via SurveyMonkey® to measure inpatient diabetes related staff satisfaction. Aim..

Published: 07/10/2020
Authors: Milne R, Bujawansa S, Hardy KJ, Cardwell J, Michaels S, Smith R, Lee C

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Financial impact of improving diabetes‐related clinical outcomes

Background Our Trust received funding through the NHS Diabetes Transformation Programme to improve inpatient care and foot care. The monies received for inpatient care was used to increase the number of diabetes inpatient nurses by fivefold. We introduced extended weekday coverage (0,800–2,200), weekend cover and an emergency support line. The funding..

Published: 07/10/2020
Authors: Bujawansa S, Furlong NJ, Narayanan RP, Westall S, Cardwell J, Mitchell L, Michaels S, Hardy KJ

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Improved structured education uptake by systematising the offer

Aims In the UK, attendance at diabetes‐structured education is poor. Indeed, even evidence of a formal offer of structured education is sometimes lacking. Our aim was to improve education update by mailing a validated letter offering structured education to every person registered with diabetes in our borough. Methods With..

Published: 07/10/2020
Authors: Mitchell L, Cardwell J, Bujawansa S, Hardy KJ

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Exploring the impact of a pharmacist‐led feedback intervention on insulin prescribing error frequency

Aims The aim of this research was to explore the impact of pharmacist‐led feedback on insulin prescribing. Methods This study was undertaken in a large UK teaching hospital. Ward pharmacists were trained in the delivery of prescribing feedback. Definitions of insulin prescribing errors were based on the National Diabetes..

Published: 26/06/2019
Authors: Bennett N, Cardwell J, Furlong NJ, Hart A, Lloyd M, Michaels S

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Simulation-based training to support healthcare staff in the management of hypoglycaemia

Aims To evaluate the use of multiprofessional high‐fidelity simulation to educate nurses and healthcare assistants on the management of hypoglycaemia and diabetic ketoacidosis. Methods A simulation‐based training event was developed by a multidisciplinary team. Nurses and healthcare assistants on two hospital wards were invited to participate. Effectiveness of..

Published: 26/06/2019
Authors: Cardwell J, Furlong NJ, Hart A, Lloyd M, Michaels S, Rowson M

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Exploring the impact of a feedback intervention on insulin prescribing behaviour

Aims The aim of this research was to explore the impact of feedback on insulin prescribing behaviour. Method(s) Doctors that had received feedback on their insulin prescribing were invited to participate in the study. Semi-structured interviews were used to explore the potential impact of feedback on their insulin prescribing...

Published: 26/06/2019
Authors: Bennett N, Cardwell J, Furlong NJ, Hart A, Lloyd M, Michaels S

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Assessment of diabetes knowledge

​ Abstract In the UK, approximately 12–25% of all hospital inpatients have diabetes, although most are admitted for other health problems. People with diabetes often have a prolonged hospital stay compared to people without the condition, often as a result of suboptimal inpatient management of their diabetes. During in-depth interviews conducted in..

Published: 19/07/2016
Authors: Cardwell J, Hardy KJ

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Diabetes education through adult learning

​ Abstract Patient education is acknowledged to be the cornerstone of effective self-management in people with chronic conditions such as diabetes. While the effects of patient education in terms of biophysical endpoints such as HbA1c are well studied, its effects on quality of life (QOL) and other non-biophysical outcomes are..

Published: 19/07/2016
Authors: Cardwell J, Hardy KJ, O'Brien S

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Inpatients with Diabetes

​ Aim:  UK management of inpatients with diabetes is suboptimal. Previously, we found diabetes knowledge to be lacking amongst ward staff nurses. We hypothesised that final year student nurses should know about diabetes management and our aim was to test diabetes knowledge in such students to determine whether low knowledge amongst..

Published: 19/07/2016
Authors: O'Brien S, , Cardwell J, Hardy KJ

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Healthcare Assistants Lack the Knowledge

​ Aim:  Much healthcare for people with diabetes is delivered by healthcare assistants (HCAs). We interviewed inpatients with diabetes following discharge from hospital and they raised concerns about HCAs’ understanding of diabetes.Given the enhanced role of HCAs in recent years it is essential they know how to manage inpatients with..

Published: 19/07/2016
Authors: , Cardwell J, Hardy KJ, O'Brien S

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Inpatient Diabetes Care

​ Aim:  Inpatient diabetes care is a burden on NHS resources. National inpatient audits identify areas of poor management but do not provide insight into underlying causes to fix the problems. Our aim was to explore the experiences of inpatients with diabetes, identify reasons for mismanagement and investigate these further. Methods: ..

Published: 19/07/2016
Authors: O'Brien S, , Cardwell J, Hardy KJ

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Guidelines and Inpatient Diabetes Nurse Specialists

​ Aim:  Diabetes specialist nurses (DSNs) have a vital role in enabling people to self-manage and in supporting non-specialist staff. Our research has identified low diabetes knowledge amongst ward nurses and students, but this may not be problematic if DSNs bridge the gap. Here, we surveyed ward nurses to determine their ..

Published: 19/07/2016
Authors: Cardwell J, , Hardy KJ, O'Brien S

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Pump Advanced Carbohydrate Education programme

​ Abstract Enabling patients to have a say in the design and delivery of local health services is a key priority in the NHS. The St Helens and Knowsley Teaching Hospitals NHS Trust diabetes team aimed to set up a peer support group for people with type 1 diabetes to aid in..

Published: 19/07/2016
Authors: Cardwell J, Furlong NJ, Hardy KJ, Wessels L, O'Brien S

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St Helens Community Staff

P303 Explicit glycated haemoglobin goals improve subsequent HbA1c levels with no impact on health-related quality of life

Background National guidelines recognise the importance of individualising HbA1c targets. Many people with diabetes agree to have their targets re-evaluated in consultations in response to specific characteristics. Aims We aimed to evaluate the impact of relaxed or stretch HbA1c goals on subsequent HbA1c levels and health-related quality..

Published: 25/04/2023
Authors: McNulty S, Westall S, Narayanan RP, Irving G, Furlong NJ, Bujawansa S, Cardwell J, Hardy KJ

Read More

P302 Glycated haemoglobin targets: The experiences and views of people with diabetes and diabetes healthcare professionals

Background National guidelines highlight the importance of individualising HbA1c targets. Little is known about the experiences of people with diabetes and diabetes healthcare professionals (HCPs) on the use of HbA1c targets. We explored the experiences of adults with diabetes and diabetes HCPs on the use of glycated haemoglobin..

Published: 25/04/2023
Authors: Westall S, Narayanan RP, Irving G, Furlong NJ, McNulty SJ, Bujawansa S, Cardwell J, Hardy KJ

Read More

P300 Setting explicit glycated haemoglobin goals improves diabetes-related distress, self-efficacy and wellbeing

Background High levels of diabetes-related distress and low levels of self-efficacy and wellbeing are associated with poorer outcomes in people with diabetes. Aims We evaluated the impact of relaxed or stretch HbA1c targets on diabetes-related distress, self-efficacy and wellbeing in adults with type 1 or type 2 diabetes. Methods We randomised 50..

Published: 25/04/2023
Authors: Westall S, Narayanan RP, Irving G, Furlong NJ, McNulty S, Bujawansa S, Balafshan T, Cardwell J, Hardy KJ

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Knowsley Community Staff

Halton Community Staff

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North West Boroughs Community Health Staff

The development of a diabetes screening service for the homeless population in St Helens

Aim To screen members of the homeless community in St. Helens for diabetes, and offer advice, support, diabetic eye screening and diabetic foot screening for those with diabetes, following two diabetes-related deaths in this population in 2018. Method(s) The Teardrops Hub staff promoted the drop in service to their service..

Published: 07/10/2020
Authors: Pendlebury H, Bujawansa S, Cardwell J

Read More

The impact of a validated structured education programme on diabetes-related distress in patients with type 1 diabetes

Background and Aim People with type 1 diabetes experience varying degrees of the emotional burden of diabetes and its treatments. The Problem Areas in Diabetes (PAID) questionnaire can be used to evaluate this domain. As part of a local, validated structured education programme for people with type 1 diabetes, baseline and endpoint..

Published: 07/10/2020
Authors: Narayanan RP, Westall S, Sullivan H, Cardwell J, Langan E, Gallagher CG, Bujawansa S, McNulty S, Furlong NJ, Hardy KJ

Read More

Perceived problem areas in diabetes do not correlate with levels of anxiety and depression

Background and Aim Diabetes‐related distress, anxiety and depression are all highly prevalent in people with diabetes. The Problem Areas In Diabetes (PAID) and Hospital Anxiety and Depression Score (HADS) questionnaires can be used to measure these domains. We evaluated the impact of structured education on each of these. Methods..

Published: 07/10/2020
Authors: Westall S, Narayanan RP, Langan E, Gallagher CG, Bujawansa S, McNulty S, Furlong NJ, Cardwell J, Hardy KJ

Read More