Background: There is recognition of an urgent need for clinic-based interventions for young
people with type 1 diabetes mellitus that improve glycemic control and quality of life. The Child
and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) is a
structured educational group program, using psychological techniques, delivered primarily by
diabetes nurses. Composed of four modules, it is designed for children with poor diabetic
control and their parents. A mixed methods process evaluation, embedded within a cluster
randomized control trial, aimed to assess the feasibility, acceptability, fidelity, and perceived
impact of CASCADE.

Methods: 28 pediatric diabetes clinics across England participated and 362 children aged 8–16
years, with type 1 diabetes and a mean glycosylated hemoglobin (HbA1c) of 8.5 or above, took
part. The process evaluation used a wide range of research methods.

Results: Of the 180 families in the intervention group, only 55 (30%) received the full program
with 53% attending at least one module. Only 68% of possible groups were run. Staff found
organizing the groups burdensome in terms of arranging suitable dates/times and satisfactory
group composition. Some staff also reported difficulties in mastering the psychological
techniques. Uptake, by families, was influenced by the number of groups run and by school,
work and other commitments. Attendees described improved: family relationships; knowledge
and understanding; confidence; motivation to manage the disease. The results of the trial
showed that the intervention did not significantly improve HbA1c at 12 or 24 months.

Conclusions: Clinic-based structured group education delivered by staff using psychological
techniques had perceived benefits for parents and young people. Staff and families considered
it a valuable intervention, yet uptake was poor and the burden on staff was high.
Recommendations are made to inform issues related to organization, design, and delivery in
order to potentially enhance the impact of CASCADE and future programs.


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