ARC GM | (HED-LINE) Healthy Living Diabetes: Long-term Independent National Evaluation

The HED-LINE research project (2020-2024) was funded by the National Institute for Health and Care Research Policy Research programme to evaluate the early roll-out of Healthy Living across England.

What was the HED-LINE study about?

Find out more about the Healthy Living service, the HED-LINE evaluation and its findings in this animation:

Healthy Living for Type 2 Diabetes

Healthy Living is a free online NHS service to help people self-manage type 2 diabetes. It is available across England to support people in making some changes such as being more active, eating healthily and stopping smoking.

Diabetes Self-Management Education and Support programmes can support people with type 2 diabetes to develop the knowledge and skills to make changes in their diet and exercise behaviour and better manage their diabetes.

NHS face-to-face group services are available, but an online service may be a suitable option for some people and may reduce pressure on clinical services. Healthy Living was created as an online alternative for people with type 2 diabetes in England.

What we did

The aim of the HED-LINE research study was to consider whether Healthy Living works and whether it is a good use of NHS resources. We studied anonymised data from Healthy Living and general practice records, looked closely at the website content, analysed the costs and benefits, and interviewed website users and NHS staff.

We reported on:

Uptake: Who uses the Healthy Living platform and whether engagement varies by patient populations.
Effectiveness: Whether it’s effective in changing health outcomes for people.

Implementation of Healthy Living: What the key barriers and facilitators are to implementing this national programme.
Service delivery and fidelity: Whether people are receiving a high quality Healthy Living service.
Cost-effectiveness: If the programme is delivering value for money.

During the research we regularly reported back to the people at NHS England who run Healthy Living, making suggestions about what could be improved, so they could make changes as they went along. People with experience of diabetes played an important role in this research and helped us to identify the benefits to patients and the NHS.

Why this research was needed

Healthy Living is based on HeLP Diabetes, an online intervention that is evidence-based, theoretically informed, acceptable to patients and which was found to be effective in reducing blood glucose in a clinical trial.

What remained uncertain was how Healthy Living would perform when offered nationally in real-world conditions. Therefore, it was important to have an independent evaluation of the national roll-out of Healthy Living.

Who we worked with

NIHR Policy Research Programme

NHS England

HED-LINE Patient and Public Involvement Group

NIHR Research for the Future

Findings

Uptake

The 'Uptake' work package aimed to understand how many people started, and continued to use, the Healthy Living platform.

Paper: Changes in a Digital Type 2 Diabetes Self-management Intervention During National Rollout: Mixed Methods Study of Fidelity
Changes in a Digital Type 2 Diabetes Self-management Intervention During National Rollout: Mixed Methods Study of Fidelity described the main content and features of Healthy Living. It compared how Healthy Living was used when it was introduced into routine practice in the NHS with how it was designed in the original Randomised Controlled Trial (when it was called HeLP-Diabetes). It also aimed to explain the reasons for any differences in use when it was introduced in routine practice.

The main findings were:
- Healthy Living included the majority of behaviour change techniques (BCTs) that were originally designed in HeLP-Diabetes.
- Healthy Living addressed the same areas of self-management as HeLP-Diabetes, including medical management (e.g., adopting healthy behaviours, taking medicines), emotional management (e.g., managing emotions including anger, guilt, shame, despair), and role management (e.g., managing changes in relationships and day-to-day activities).
- Two main changes were identified when Healthy Living was introduced into routine practice:
- 1. Healthcare professionals did not help patients to access the Healthy Living website, as they do not have enough available time.
- 2. Healthy Living included an additional structured education section of web-based learning that HeLP-Diabetes did not have. This was because of changes to NHS policy since HeLP-Diabetes was originally developed that encouraged the use of structured education for patients.
- The content of the original HeLP-Diabetes website was made easier to use and more accessible to meet NHS digital standards.

Paper: Service Users’ Experiences of a Nationwide Digital Type 2 Diabetes Self-Management Intervention (Healthy Living): Qualitative Interview Study
Service Users’ Experiences of a Nationwide Digital Type 2 Diabetes Self-Management Intervention (Healthy Living): Qualitative Interview Study described the main findings from interviews with 19 people who had used Healthy Living. The interviews took place early in the national rollout of Healthy Living in the NHS.

The main findings were:
- Having a source of trustworthy and easy-to-access information was valued by participants.
- Some participants were unaware of the link between their diabetes diagnosis and low mood. After completing the emotional management content, this prompted some participants to book an appointment with their GP to discuss low mood.
- More interactivity was required to encourage continued use of the website. This included interactivity:
- 1. between the website, other resources and devices
- 2. between health professionals and services
- 3. with other people living with Type 2 Diabetes
- The website was viewed as particularly useful for people who are newly diagnosed with Type 2 Diabetes.

Implementation of Healthy Living

This work package explored how implementation of Healthy Living differed across the country.

Paper: Evaluating the National Rollout of a Type 2 Diabetes Self-Management Intervention: Qualitative Interview Study With Local National Health Service Leads Responsible for Implementation
The aim of the paper 'Evaluating the National Rollout of a Type 2 Diabetes Self-Management Intervention: Qualitative Interview Study With Local National Health Service Leads Responsible for Implementation' was to understand what made introducing and using Healthy Living in existing T2DM care pathways across England easier or more difficult.

The main findings were:
- Most sites that were sampled (14 out of 16) were implementing Healthy Living across their area, but this was limited to ‘light touch’ implementation, which mainly involved one-way communications to general practices to inform them about offering Healthy Living.
- Local leads were positive about offering Healthy Living as an additional educational intervention for people with type 2 diabetes. However, because Healthy Living is a self-directed, web-based programme without health professional support, some felt it was more geared towards people who were well-educated and motivated to self-learn. They thought it was less geared towards patients with the greatest need.
- Early-engagement areas received funds from NHS England to support implementation, and these were used to do more intensive implementation activities. 2 out of the 4 early-engagement areas chose to provide financial incentives to general practices for referring patients to Health Living.
- The main barrier to doing longer, more targeted implementation activities included not receiving data on the types of patients who registered for Healthy Living and the use of Healthy Living not being compulsory.

Service delivery and fidelity

This work package checked what was being delivered and how it compared to expectations.

Paper: Exposure to behaviour change techniques and self-management tasks in a nationally-implemented digital intervention for type 2 diabetes self-management: Analysis of usage data
Exposure to behaviour change techniques and self-management tasks in a nationally-implemented digital intervention for type 2 diabetes self-management: Analysis of usage data was the first analysis to measure engagement with behaviour change techniques (BCTs) and self-management tasks in a ‘real-world’ digital Type 2 Diabetes self-management programme. We collected anonymous data relating to over 42 thousand people registered on Healthy Living from May 2020 to September 2023 and analysed which parts of the online information they accessed and how many BCTs and self-management tasks they were exposed to.

The main findings showed:
- 19,137 (almost 70% of) people registered accessed some of the Healthy Living content.
- Fewer than 30% of people progressed past the first section of the structured education, so were not exposed to BCTs included in the intervention after that point.
- This meant that service users were exposed to BCTs such as ‘providing information about the health consequences of a behaviour’ and ‘social support’ in the first section of the structured education, but many were not exposed to BCTs to help them self-regulate their health behaviours such as ‘goal setting’.
- The average number of times users were exposed to tasks was:
- 1. medical self-management tasks (for example, adopting healthy behaviours, seeking medical support, taking medication) = 11 times
- 2. emotional self-management tasks (for example, meditation, identifying triggers for stress, seeking support from friends or loved ones) = 4 times
- 3. role self-management tasks (for example, managing changes in work and day-to-day activities) = 0 times

Downloadable Resources

More information

For more information about this work, please contact:

Dr Sarah Cotterill
Principal Investigator

Mike Spence
Senior Programme Lead

This project was independent research funded by the National Institute for Health and Care Research (Policy Research Programme, Healthy Living Diabetes - Long-term Independent National Evaluation (HED-LINE), NIHR200933).

The views expressed in this project are those of the authors and not necessarily those of the National Institute for Health and Care Research, the Department of Health and Social Care or NHS England.