Psycho-educational interventions for children and young people with Type 1 diabetes

BACKGROUND

A systematic review of the literature in 2000 revealed numerous methodological shortcomings in education research, but in recent years progress has been made in the quantity and quality of psycho-educational intervention studies.

SUMMARY OF CONTENTS

This review focuses on diabetes education programmes developed for children, young people and their families in the past 5 years. A comprehensive review of the literature identified 27 articles describing the evaluation of 24 psycho-educational interventions. Data summary tables compare the key features of these, and comparisons are made between individual, group and family-based interventions. Effect sizes are calculated for nine of the randomized studies. Three research questions are posed: firstly has the recent literature addressed the problems highlighted in the previous review; secondly is there sufficient evidence to recommend adaptation of a particular programme; and, finally, what do we still need to do?

CONCLUSIONS

Progress in the quality and quantity of educational research has not resulted in improved effectiveness of interventions. There is still insufficient evidence to recommend adaptation of a particular educational programme and no programme that has been proven effective in randomized studies for those with poor glycaemic control. To develop a range of effective educational interventions, further research involving larger sample sizes with multicentre collaboration is required.

The prevalence of co-morbid depression in adults with Type 1 diabetes: systematic literature review

AIM

To review the literature estimating the cross-sectional prevalence of clinical depression in adults with Type 1 diabetes.

METHODS

Electronic databases and published references were used to identify studies published between January 2000 and June 2004, with a previous meta-analysis used to identify studies before 1 January 2000.

RESULTS

Between January 2000 and June 2004, a further five eligible studies were identified. Only one was a controlled study using diagnostic interviewing to determine rates of depression. Taking all of the eligible studies identified by the previous meta-analysis and this search, the prevalence of clinical depression in controlled studies was 12.0% for people with diabetes compared with 3.2% for control subjects. In studies with no control group, the prevalence of clinical depression was 13.4%.

CONCLUSION

There are wide-ranging differences reported in the various studies on the prevalence of depression in Type 1 diabetes. In view of the differing methods of diagnosis and small participant numbers, the results should be viewed with caution. A controlled study using diagnostic interviewing techniques to determine levels of depression is recommended to provide a clearer picture of both the prevalence and characteristics of that depression.

A short form of the Diabetes Quality of Life for Youth questionnaire: exploratory and confirmatory analysis in a sample of 2,077 young people with type 1 diabetes mellitus

AIMS/HYPOTHESIS

The aim of this study was to test the construct validity of the Diabetes Quality of Life for Youth (DQOLY) questionnaire in a large representative sample of young people with type 1 diabetes mellitus.

METHODS

The 52-item DQOLY questionnaire was completed by 2,077 adolescent individuals (aged 10-18 years) with type 1 diabetes. Participants were recruited from 22 paediatric diabetes centres in 18 countries across Europe, Asia and North America. HbA(1c) levels were determined once and analysed centrally.

RESULTS

Exploratory factor analysis generated three possible measurement models of a revised questionnaire, two with four factors and one with six factors with all models indicating the presence of one satisfaction scale, but with many of the impact and worry scale items either double loading or not loading on any factors. Subsequent confirmatory analysis indicated that compared with the original DQOLY scales, the six-factor solution was the best-fitting model.

CONCLUSIONS/INTERPRETATION

The DQOLY factor structure does not show construct validity in a large, diverse representative sample of young people with type 1 diabetes. However, a revised (short-form) version of the DQOLY is proposed that has improved construct validity, adequate internal consistency, and more precise and hypothesised association with HbA(1c). It is anticipated that this shorter version will enhance the acceptability and clinical utility of the measure, making it more feasible to introduce as part of routine care.

Diabetes screening anxiety and beliefs

AIMS

This study assesses the impact of screening for diabetes on anxiety levels in an ethnically mixed population in the UK, and explores whether beliefs about Type 2 diabetes account for these anxiety levels.

METHODS

This cross-sectional study recruited individuals who were identified at high risk of developing diabetes through general practitioners' (GPs) lists or through public media recruitment. Participants completed an oral glucose tolerance test (OGTT). Between blood tests, participants completed the Spielberger State Anxiety Scale Short Form, the Emotional Stability Scale of the Big Five Inventory 44 and three scales from the Diabetes Illness Representations Questionnaire, revised for this study.

RESULTS

Of the 1339 who completed the OGTT and questionnaire booklet, 54% were female, with 21% from an Asian background. Forty-five per cent of participants reported little to moderate amounts of anxiety at screening (mean 35.2; sd = 11.6). There was no significant effect of family history of diabetes, ethnic group or recruitment method on anxiety. The only variable significantly associated (negatively) with anxiety was the personality trait of emotional stability. Of responders, 64% and 61% agreed that diabetes was caused by diet or hereditary factors, respectively. Only 155 individuals (12%) agreed that diabetes was serious, shortens life and causes complications.

CONCLUSIONS

The results of this study replicate that of previous studies, indicating that screening for diabetes does not induce significant anxiety. Bivariate analysis indicated that individuals who perceived diabetes to be serious, life shortening and resulting in complications had higher anxiety scores, the personality trait of emotional stability being the strongest predictor of anxiety.

The value of empathy in dietetic consultations. A pilot study to investigate its effect on satisfaction, autonomy and agreement

Forty individuals with diabetes and three dietitians completed a questionnaire concerning their consultation. Empathy was examined using the Empathic Communication Coding System (ECCS) (Bylund & Makoul, 2002). The more empathic the professionals' response to emotional opportunities, the more satisfied patients were with their consultations (r = 0.41, d.f. = 15, P = 0.05). There was a nonsignificant trend that the more empathic opportunities that arise during a consultation, the higher the agreement between patient and dietitian on what was discussed (r = 0.28, P = 0.07). The data also suggest that patients reported more autonomy support when they created more empathic opportunities during their consultation (r = -0.29, P = 0.07). This preliminary study suggests that professionals' responses to empathic opportunities may be a useful component of dietetic consultations.

Psychological barriers

Type 2 diabetes treatment outcomes ultimately depend on patients and their ability to make long-term behavioural changes that support good self-care and metabolic control. Patients' perceptions about diabetes and diabetes-related complications can have a strong influence on their emotional well-being, as well as day-to-day self-care and the quality of metabolic control. The gravity of diabetes is often underestimated, and many patients do not understand the link between poor glycaemic control and long-term complications of the disease. Similarly, people with diabetes commonly undervalue the role of lifestyle changes and pharmacological therapy in preventing future complications. Negative emotions and preconceptions about treatment can also discourage adherence to treatment plans. 'Psychological insulin resistance' caused by fear and concerns about insulin and daily insulin injections can discourage many patients from starting insulin therapy, even if oral agents have failed. Depression, stress and anxiety represent further obstacles to optimum self-care and the attainment of glucose goals. Healthcare professionals should endeavour to understand and accommodate these issues when setting personal treatment goals and developing plans to achieve them. Importantly, the advice and support they provide should be tailored to the unique needs of each patient. There is scope to improve outpatient consultations to ensure agreement between patients and professionals concerning issues discussed and decisions made, and this may help to improve recall and motivation to manage diabetes. Engaging patients in the goal-setting process can help to overcome potential barriers to good self-care and may increase the probability that treatment goals are achieved.

Discrepancies between patient and professionals recall and perception of an outpatient consultation

AIMS

To explore the degree of agreement between patient and health care professional's perceptions of consultations.

METHODS

Immediately after 141 dietitian/nurse specialist consultations, patients and professional's completed the Health Care Climate questionnaire (HCC), Medical Interview Satisfaction Scale (MISS) and the Treatment Self-Regulation Questionnaire (TSRQ) In addition, both parties were asked about any key points or issues discussed in the consultation; any decisions that were made about their diabetes treatment today; any goals that were set as a result of today's consultation.

RESULTS

Patient and professional's scores on the HCC and MISS were not correlated (r=0.3 and 0.16). Patient and professionals disagreed on the issues discussed 19.6% of the time, on the decisions made 20.7% of the time and goals set 44.3% of the time. More autonomy support in the consultation was associated with greater autonomous motivation for self-care (r=0.31; P<0.001) more controlled motivation was associated with less agreement on issues discussed and goals set (r=-0.20; r= -0.24; P<0.05).

CONCLUSION

There is significant disagreement between patients and professionals perceptions and recollection of the content of consultations. Professional's communications skills need to be developed to ensure these discrepancies are minimized. Skills to provide greater autonomy support in the consultation would help to enhance this process and improve outcomes.

Illness representations and coping as predictors of emotional well-being in adolescents with type 1 diabetes

OBJECTIVES

To test whether coping acts to mediate the relationships between illness representations and emotional well-being in adolescents with diabetes.

METHODS

Seventy adolescents between 11 and 18 years of age were asked to complete the Diabetes Illness Representations Questionnaire (DIRQ), the Well-being Questionnaire, and the Kidcope.

RESULTS

Perceived impact, identity, and cognitive restructuring were significant independent predictors for depressive symptomatology. For anxiety, perceived impact and identity were significant predictors, and for positive emotional well-being, treatment effectiveness to control diabetes was the only significant predictor. Multiple regression analyses indicated that coping did not mediate the association between illness representations and positive emotional well-being.

CONCLUSIONS

Perceived impact was consistently associated with participants' indices of negative emotional well-being. Contrary to the hypothesized model, coping did not mediate the association between illness representations and emotional well-being in this sample.

Development, reliability and validity of the Diabetes Illness Representations Questionnaire: four studies with adolescents

AIMS

This article reports on the development and validity of a Diabetes-specific Illness Representations Questionnaire (DIRQ) to assess all five dimensions of an individual's perception of diabetes, for adolescents with Type 1 diabetes mellitus.

METHODS

There were two development studies. Study 1: participants (n = 115) completed a questionnaire assessing perceptions of the consequences of diabetes and the effectiveness of treatment, along with a questionnaire assessing self-care. Study 2: participants (n = 79) completed a questionnaire assessing their identity, timeline and causal beliefs, along with a diabetes self-efficacy and barriers to adherence questionnaire. Subsequently there were two validation studies. Study 3: participants (n = 44 adolescents and 28 parents) completed the DIRQ and questionnaires assessing their self-care and psychological well-being. Glycaemic control was assessed through retrieval of routine assay results. Study 4: participants (n = 70) completed the DIRQ and questionnaires to assess their psychological well-being, with glycaemic control assessed through retrieval of routine assay results.

RESULTS

The development studies suggest that the perceived consequences of diabetes consist of two subscales, perceived threat and perceived impact, and provide further support for the distinction between treatment effectiveness to control diabetes and treatment effectiveness to prevent complications. Along with the validation studies, the results indicate that the questionnaire scales showed good internal consistency and construct validity through their associations with measures of self-care and psychological well-being.

CONCLUSION

The data reported here suggest that the DIRQ has the potential to be a useful tool for clinical assessment and evaluating the impact of psycho-educational and medical interventions.

Diabetes services in the UK: third national survey confirms continuing deficiencies

AIMS

To determine the current level of diabetes services and to compare the results with previous national surveys.

METHODS

A questionnaire was mailed to all paediatricians in the UK identified as providing care for children with diabetes aged under 16 years. Information was sought on staffing, personnel, clinic size, facilities, and patterns of care. Responses were compared with results of two previous national surveys.

RESULTS

Replies were received from 244 consultant paediatricians caring for an estimated 17 192 children. A further 2234 children were identified as being cared for by other consultants who did not contribute to the survey. Of 244 consultants, 78% expressed a special interest in diabetes and 91% saw children in a designated diabetic clinic. In 93% of the clinics there was a specialist nurse (44% were not trained to care for children; 47% had nurse:patient ratio >1:100), 65% a paediatric dietitian, and in 25% some form of specialist psychology or counselling available. Glycated haemoglobin was measured routinely at clinics in 88%, retinopathy screening was performed in 87%, and microalbuminuria measured in 66%. Only 34% consultants used a computer database. There were significant differences between the services provided by paediatricians expressing a special interest in diabetes compared with "non-specialists", the latter describing less frequent clinic attendance of dietitians or psychologists, less usage of glycated haemoglobin measurements, and less screening for vascular complications. Non-specialist clinics met significantly fewer of the recommendations of good practice described by Diabetes UK.

CONCLUSIONS

The survey shows improvements in services provided for children with diabetes, but serious deficiencies remain. There is a shortage of diabetes specialist nurses trained to care for children and paediatric dietitians, and a major shortfall in the provision of psychology/counselling services. The services described confirm the need for more consultant paediatricians to receive specialist training and to develop expertise and experience in childhood diabetes.

A randomized control trial of the effect of negotiated telephone support on glycaemic control in young people with Type 1 diabetes

AIM

To evaluate changes in self-efficacy for self-management in young people with Type 1 diabetes participating in a "Negotiated Telephone Support" (NTS) intervention developed using the principles of problem solving and social learning theory.

METHODS

One-year RCT with 79 young people (male 39; mean age +/- sd 16.5 +/- 3.2 years, duration 6.7 +/- 4.4 years, HbA(1c) 8.6 +/- 1.5%) randomized into: Group 1 (control group), continued routine management, n = 28; Group 2, continued routine management with NTS, n = 25; Group 3, annual clinic with NTS, n = 26.

OUTCOME MEASURES

HbA(1c), self-efficacy, barriers to adherence, problem solving, and diabetes knowledge.

RESULTS

There were no differences between the groups at baseline. Participants in Groups 2 and 3 received an average of 16 telephone calls/year (range 5-19), median duration 9 min (2-30), with a median interval of 3 weeks (1-24) between calls. Significant correlations were found between age and average length of call (r = 0.44, P < 0.01) and frequency of contact (r = 0.36, P < 0.05). Social and school topics were discussed frequently. After 1 year, while the participants in the two intervention groups showed significant improvements in self-efficacy (P = 0.035), there was no difference in glycaemic control in the three groups. Barriers to insulin use adherence were a significant predictor of HbA(1c) (P < 0.001) after controlling for baseline.

CONCLUSIONS

NTS is an effective medium to deliver a simple theory-based psychological intervention to enhance self-efficacy for diabetes self-management. Reduced clinic attendance, combined with NTS, did not result in a deterioration of HbA(1c). Intensive personal support needs to be combined with intensive diabetes therapy to improve glycaemic control in this age group.

Psychological counselling in problematic diabetes: does it help?

BACKGROUND

In past decades clinicians have increasingly recognized the importance of psychological support for people with diabetes and their families, and many have recommended integrating psychological counselling into routine diabetes care. It is therefore important to consider whether psychological interventions in diabetes are effective in improving clinical outcomes.

METHODS

This review was limited to the literature reporting on the treatment of five common psychological problems known to complicate diabetes management: depression, eating disorders, anxiety/stress, self-destructive behaviour and interpersonal/family conflicts. A literature search was undertaken using MedLine and PsychInfo, including studies published in English peer-reviewed journals between 1990 and 2001, reporting on the effects of psychological interventions in the areas mentioned. Case studies were excluded from the review.

RESULTS

In line with earlier reviews, relatively little empirical research was found to substantiate the effect of psychological counselling in complicated diabetes. Most studies are uncontrolled, and involve small samples. In total only 11 randomized controlled trials were identified. Results indicate that cognitive behaviour therapy (CBT) is effective in the treatment of depression in Type 2 diabetes patients, both in reducing depressive symptoms and HbA1c. Favourable effects have been observed in pilot studies applying CBT in the field of stress management, eating disorders and self-destructive behaviour, but future research should substantiate these preliminary findings. Behaviour family therapy proved beneficial in terms of resolving family conflicts, but did not impact glycaemic control.

CONCLUSIONS

Evidence to support the effect of psychological treatment in problematic diabetes is still scarce, due to limited research in this area. Suggestions are made to further develop psychotherapeutic research in diabetes care. We conclude that future research should gain from a behavioural medicine approach to diabetes, with close collaboration between diabetologists and psychologists.

Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: a systematic review

BACKGROUND

Insulin-dependent diabetes mellitus, also known as type 1 diabetes, is a life-threatening condition and is the third most common chronic illness among young people. As a result of minimal or non-existent insulin production, people with diabetes must take over the normally automatic task of regulation of blood glucose levels. This is achieved by a complex regimen involving multiple, daily administrations of insulin coordinated with dietary intake and energy expenditure and monitored by blood glucose testing.

OBJECTIVES

To examine the effectiveness of educational and psychosocial interventions for adolescents with type 1 diabetes designed to improve their diabetes management. Specifically, it addressed the following research questions: (1) Do educational and psychosocial interventions for adolescents with type 1 diabetes have beneficial effects on biological and psychosocial outcomes? (2) Are there types or features of interventions that have been shown to be more effective than others? (3) What evidence is there of the cost-effectiveness of interventions?

METHODS

A search strategy was formulated, piloted and refined. Three journals were handsearched, 11 electronic databases were searched and personal contacts, flyers, conferences and websites were used to notify the research community of the review to access further literature. This process generated 10,535 abstracts, which, after screening, resulted in 367 articles identified for retrieval. This number was augmented by hand-searching, personal contact and exploding references, and a final total of 457 articles were scrutinised. Of these, 64 reports describing 62 studies were identified as empirical papers evaluating educational or psychosocial interventions. The relevant data were extracted from the papers and summary tables for each study were prepared. Where possible, effect sizes were computed for outcomes from studies that included a randomised control group (CG) and other relevant information.

RESULTS

A descriptive analysis of the 62 studies was undertaken. Most studies (67.7%) were conducted in the USA and 41% were randomised controlled trials (RCTs), none of which were UK-based. Only 48% of the reports provided an explicit theoretical rationale for the intervention. The mean number of participants was 53.8. The studies took place in various settings, evaluated a variety of interventions, involved various interventionists, addressed various components and assessed the effects by a range of outcomes, including measures of metabolic control and psychological and behavioural outcomes. Follow-up assessments were relatively rare. RESULTS - THE EFFECTIVENESS OF INTERVENTIONS: The 25 RCTs were examined in more detail and three of the most effective were described in depth. Effect sizes could be calculated for 14 studies. The mean (pooled) effect size for psychosocial outcomes was 0.37 and 0.33 for glycated haemoglobin with outliers (0.08 without outliers), indicating that these interventions have small to medium beneficial effects on diabetes management outcomes. A narrative review of the 21 pre-post studies with no CG was performed, including evaluations of interventions conducted at summer camps, interventions for poorly controlled patients and educational interventions. All studies reported beneficial effects. RESULTS - COST-EFFECTIVENESS: Few studies addressed economic considerations associated with interventions, and the lack of information on costs and the diversity of outcomes included by investigators impeded cost- effectiveness comparisons. Shorter hospitalisation at diagnosis is at least as effective in achieving control and avoiding complications in adolescence as longer stays. Home care may result in improved outcomes but may not be cheaper than hospital care at diagnosis. Targeting poorly controlled subjects may reduce adverse events and hospitalisations and may be more cost-effective than generic interventions. There is a need for rigorous cost-effectiveness studies of educational and psychosocial interventions for adolescents with type 1 diabetes that include longer-term considerations.

CONCLUSIONS

The following conclusions were drawn from this review: (1) Educational and psychosocial interventions have small to medium beneficial effects on various diabetes management outcomes. (2) Well-designed trials of such interventions are needed in the UK (no completed RCTs of educational or psychosocial interventions for adolescents with type 1 diabetes conducted in the UK were found). (3) The evidence, arising primarily from studies in the USA, provides a starting point for the design of interventions in the UK. (4) Quantitative and narrative analysis of the evidence suggested that interventions are more likely to be effective if they demonstrate the inter-relatedness of the various aspects of diabetes management. (ABSTRACT TRUNCATED)

Personal models of diabetes in relation to self-care, well-being, and glycemic control. A prospective study in adolescence

OBJECTIVE

Personal models of diabetes have been shown to be proximal determinants of self-care behavior in adults with diabetes, both cross-sectionally and prospectively. This study set out to test the predictive utility of this approach in adolescents with diabetes.

RESEARCH DESIGN AND METHODS

Participants were recruited from four regional hospitals in southern England (n = 54). They completed questionnaires assessing diabetes self-care, well-being, and personal models of diabetes (perceived impact, perceived seriousness, and short- and long-term treatment effectiveness) at baseline and 1-year follow-up. GHb assays performed as part of the patients' usual diabetes care were used to assess glycemic control.

RESULTS

After controlling for baseline anxiety, change in perceived impact of diabetes prospectively predicted adolescents' anxiety (beta = -0.21; t = -2.65; P < 0.01). After controlling for baseline dietary self-care, change in perceived effectiveness of the diabetes treatment regimen to control diabetes predicted dietary self-care (beta = -0.39; t = -3.28; P < 0.0005). Poorer dietary self-care and being female were predictive of poorer glycemic control (r2 = 0.29; F = 2.74; P < 0.005).

CONCLUSIONS

This study provides further support for the role of personal models of illness in determining responses to illness. As adolescents take responsibility for the management of their diabetes, parents, clinicians, educators, and interventionists should consider these adolescents' beliefs about their diabetes and its treatment as key factors influencing self-care, emotional well-being. and glycemic control.

Behavioral interventions for adolescents with type 1 diabetes: how effective are they?

OBJECTIVE

To evaluate the effectiveness of behavioral interventions for adolescents with type 1 diabetes based on a systematic review of the literature.

RESEARCH DESIGN AND METHODS

The literature was identified by searching 11 electronic databases, hand-searching 3 journals from their start dates, and contacting individual researchers. Only articles that reported evaluations of behavioral (including educational and psychosocial) interventions for adolescents (age range 9-21 years) with type 1 diabetes that included a control group were included in the present review. Data summarizing the key features of the interventions and their effects were extracted from each article. Where possible, effect sizes for the randomized control trials (RCTs) were calculated.

RESULTS

The search process identified 64 reports of empirical studies. Of these, 35 studies included a control group, and 24 were RCTs. Effect sizes could be calculated for 18 interventions. The overall mean effect size calculated across all outcomes was 0.33 (median 0.21), indicating that these interventions have a small- to medium-sized beneficial effect on diabetes management. Interventions that were theoretically based were significantly more effective than those that were not (P<0.05, 1-tailed).

CONCLUSIONS

Research to date indicates that these interventions are moderately effective. Several methodological weaknesses to be avoided in future studies are noted. It is also recommended that investigators use the reach, efficacy, adoption, implementation, and maintenance (RE-AIM) framework to guide the design of future studies, which should result in more disseminable interventions. RE-AIM assesses the intervention's reach, or percent or representativeness of patients willing to participate; efficacy across a range of outcomes; adoption, or the percent and representativeness of settings willing to implement the intervention; implementation, or the consistency of the delivery of the intervention as intended; and maintenance, or the extent to which delivery of the intervention becomes a routine part of health care in the medical setting.

Social support and personal models of diabetes as predictors of self-care and well-being: a longitudinal study of adolescents with diabetes

OBJECTIVES

To examine whether peer support and illness representation mediate the link between family support, self-management and well-being.

METHOD

Fifty-two adolescents (12-18 years old) with Type I diabetes were recruited and followed over 6 months, completing assessments of self-management, well-being, and social support.

RESULTS

Perceived impact of diabetes and supportive family and friends were prospectively predictive of participants' well-being measures. Although support from family and friends was predictive of better dietary self-care, this relationship was mediated by personal model beliefs. In particular, beliefs about the effectiveness of the diabetes treatment regimen to control diabetes was predictive of better dietary self-care.

CONCLUSIONS

Both friends and family are important to support adolescents as they live with and manage their diabetes. Personal models of diabetes are important determinants of both dietary self-care and well-being. In addition, personal models may serve to mediate the relationship between social support and dietary behavior.

Social support and personal models of diabetesin relation to self-care and well-being inadolescents with type I diabetes mellitus

This study set out to examine whether peer support and illness representation mediates the link between family support, self-management and well-being. Seventy-four participants (12-18-years-old) with type I diabetes mellitus completed questionnaires assessing their self-management, depression, anxiety, perceived social support and personal models of diabetes. Perceived impact of diabetes, but not perceived seriousness, and peer support were significant predictors of depression. Family support was a significant predictor of all self-management measures. However, for dietary self-management this relationship was partially mediated by the perceived efficacy of treatment to control diabetes, but not efficacy of treatment to prevent complications.