How do structured education programmes work? An ethnographic investigation of the dose adjustment for normal eating (DAFNE) programme for type 1 diabetes patients in the UK

Structured education programmes (SEPs) for patients with diabetes and other chronic diseases are being widely adopted across the UK and elsewhere. Trials suggest they are more efficacious than didactic approaches, with patients showing improvements in learning, blood glucose control and quality of life. However, the reasons for these improvements are not well understood. To establish how, and why, SEPs work, we undertook a qualitative investigation of the Dose Adjustment for Normal Eating (DAFNE) programme. DAFNE is a well-established SEP for type 1 diabetes patients in the UK, which teaches them to alter their insulin doses in order to improve dietary freedom and blood glucose control. Six five-day courses were observed and in-depth interviews conducted with 30 patients aged 18-59 years on completion of the courses. Prior to their courses, many patients had developed protective behaviours and risk-avoiding strategies, such as running blood glucose levels high to avoid hypoglycaemia, or low to avoid developing complications. Implementing the insulin dose adjustments recommended on the course often required patients to move out of comfort zones and take what they had perceived, initially at least, as risks. In order to understand and explain course dynamics and outcomes, we draw upon Adams' concept of the risk-thermostat - which presupposes that all individuals are equipped with an internal instrument by which they gauge and respond to risk - and add a corporeal dimension to it. In doing so, we highlight the dynamic ways in which (embodied) group interactions and experiences, and their enmeshment with other aspects of course delivery, such as educator surveillance and employment of course rules, helped to enhance learning and promote patients' transformations into insulin dose adjusting subjects. This included inter-corporeal processes through which patients recalibrated their risk thermostats in light of the insulin dose adjustment experiences of others.