HED-LINE

This paper 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. 

This paper 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.
   

This paper 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
   

The aim of this paper 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. 
   

• Scientific Summary (June 2020)
• Plain Language Summary (June 2020)

• HED-LINE Protocol v1.7 (October 2023)

• Benton JS, Cotterill S, Hawkes RE, Miles LM, French DP., (2022). Changes in a Digital Type 2 Diabetes Self-management Intervention During National Rollout: Mixed Methods Study of Fidelity. Journal of Medical Internet Research
• Hawkes RE, Benton JS, Cotterill S, Sanders C, French DP. Service Users’ Experiences of a Nationwide Digital Type 2 Diabetes Self-Management Intervention (Healthy Living): Qualitative Interview Study. JMIR Diabetes 2024. 
• Brunton L, Cotterill S, Wilson P. Evaluating the National Rollout of a Type 2 Diabetes Self-Management Intervention: Qualitative Interview Study With Local National Health Service Leads Responsible for Implementation. J Med Internet Res. 2024 Sep 25.

• Experiences of attending an NHS behaviour change programme and working with two independently funded evalution teams - Eric Lowndes (Nov 2020)