Friends or foes? A review of peer influence on self-care and glycemic control in adolescents with type 1 diabetes

Evaluating Diabetes Educational Interventions With a Skill Development Component in Adolescents With Type 1 Diabetes: A Systematic Review Focusing on Quality of Life

PURPOSE

Adolescents with type 1 diabetes mellitus (T1DM) may have reduced quality of life (QOL) when compared with their peers. This systematic review evaluated the effectiveness of diabetes self-management education (DSME) interventions with a skills development component on the QOL of adolescents with T1DM.

METHODS

Six databases were systematically searched for studies on the QOL outcomes of DSME interventions for adolescents with T1DM. Fourteen studies published between 1994 and 2014 met the inclusion criteria.

RESULTS

Of the 14 studies, only 4 had significant QOL outcomes for the intervention participants. Successful DSME interventions had indirect behavioral skills foci or a combination of indirect and direct behavioral skills foci and a duration ≥2 months.

CONCLUSION

This review provides evidence that educational interventions with an indirect behavioral skills development that facilitates diabetes management may improve QOL among adolescents with T1DM. Structured interventions targeting adolescents' QOL are needed to determine which are most effective in improving QOL. Adolescents with T1DM should be routinely screened and monitored for low QOL and referred to QOL-improving interventions.

Emotional intelligence and glycemic management among type I diabetes patients

Type 1 diabetes is a lifelong physical and emotional challenge. The concept of emotional intelligence may offer better understanding of personal resources facilitating management of such challenges. We therefore hypothesized that emotional intelligence will negatively associate with two measures of diabetic management: HA1c and blood sugar levels. A total of 78 young adults with type 1 diabetes mellitus reported their last HA1c test result and their blood sugar level, as well as demographics and took the audio-visual test of emotional intelligence. The results showed a negative association between emotional intelligence and HA1c and marginal results in the same direction with blood sugar levels even when controlling for demographics.

An analysis of the relationships between peer support and diabetes outcomes in adolescents with type 1 diabetes

This study explores the relationships between the various subtypes of global and diabetes-specific peer support and health outcomes in adolescents with type 1 diabetes. Global peer support significantly predicted self-care and glycated haemoglobin, although no associations were identified for diabetes-specific support overall, nor its factors. When comparing participants with above or below average glycaemic control, significantly greater diabetes-specific support was reported in those with poorer control. It is suggested that this may be related to feelings of nagging, in which diabetes-specific support is perceived as harassment.

A qualitative comparison of needles and insulin pump use in children with type 1 diabetes

Managing type 1 diabetes mellitus is an ongoing and challenging process; we investigated children’s experience of different treatment regimens. Interviews with 17 children (7–15 years) at two time points were analysed using the grounded theory approach. Illness phase and treatment regimen shaped how bodily cues were interpreted. Insulin pump therapy allowed children to listen to and trust their bodily cues rather than override. Shame was a barrier to support engagement. Different internalised and externalised views of type 1 diabetes mellitus emerged. Overall, children were insightful experts of their own experiences. Recommendations for psychological interventions would benefit from empirical testing.

A review of adolescent adherence in type 1 diabetes and the untapped potential of diabetes providers to improve outcomes

Only 21 % of adolescents with type 1 diabetes (T1D) meet glycemic goals set forth by the American Diabetes Association. Adherence to therapy is a particular concern in this population, and the association between poor adherence and worsening glycemic control indicates that there is a critical need to improve adherence to therapy in adolescents with T1D. In this article, we review barriers to adherence in adolescents with T1D and discuss interventions aimed at improving adherence to therapy and glycemic control. Interventions include technology-based applications, family-based therapies, motivational interviewing, and others. Notably, less than 10 % of the interventions reviewed are provider-led, clinic-based interventions, and few have focused on regimen-related aspects of adherence. This article also outlines the importance of provider communication and the role of providers in facilitating adherence behaviors in adolescents with T1D. Finally, we suggest future directions of research to improve adherence to therapy in adolescents with T1D.

Early adolescent relationship predictors of emerging adult outcomes: youth with and without type 1 diabetes

BACKGROUND

Emerging adulthood is a high-risk period for mental health problems and risk behaviors for youth generally and for physical health problems among those with type 1 diabetes.

PURPOSE

The purpose of this study was to examine whether adolescents' relationships with parents and friends predict health and risk behaviors during emerging adulthood.

METHOD

Youth with and without diabetes were enrolled at average age 12 and followed for 7 years. Parent and friend relationship variables, measured during adolescence, were used to predict emerging adulthood outcomes: depression, risk behavior, and, for those with diabetes, diabetes outcomes.

RESULTS

Parent relationship quality predicted decreased depressive symptoms and, for those with diabetes, decreased alcohol use. Parent control predicted increased smoking, reduced college attendance, and, for control participants, increased depressive symptoms. For those with diabetes, parent control predicted decreased depressive symptoms and better self-care. Friend relationship variables predicted few outcomes.

CONCLUSIONS

Adolescent parent relationships remain an important influence on emerging adults' lives.

Differentiating peer and friend social information-processing effects on stress and glycemic control among youth with type 1 diabetes

OBJECTIVE

Many adolescents with Type 1 diabetes (T1D) find adherence difficult in social situations because they fear negative evaluations by others. These negative reaction attributions are associated with anticipated adherence difficulties, stress, and glycemic control. It is unclear whether peer versus friend attributions are distinct constructs, or whether there is a differential impact on glycemic control moderated by youth characteristics.

METHOD

Youth with T1D (n = 142; 58% female; 84% Caucasian, mean = 13.79 years, standard deviation = 2.10) completed the Peer Attribution and Diabetes Stress Questionnaires. HbA1cs were obtained from medical records.

RESULTS

Negative peer versus friend attributions appear distinct and were differentially related to anticipated adherence difficulties, stress, and glycemic control, with peer attributions having the strongest effect. Grade, age, and sex were not moderators for these relationships.

CONCLUSION

Peer-related attributions may be a particularly salient target for interventions to improve adherence and distress among youth with T1D.

Conceptions of diabetes and diabetes care in young people with minority backgrounds

Adolescents with type 1 diabetes (T1DM) need stable self-care routines for good metabolic control to minimize future cardiovascular health complications. These routines are demanding, and might be particularly challenging in underprivileged groups. The aim of this study was to gain in-depth knowledge on the experience of adolescents with T1DM and a non-Swedish background regarding factors that might influence their ability to take care of themselves; in particular, factors that might influence diabetes management routines, their social situation, and the support they receive from caregivers. We interviewed 12 adolescents with T1DM and minority backgrounds. The results indicated resources and constraints in the adolescents' social context and in the health care organization. The adolescents developed conceptions that helped to explain and excuse their self-care failures, and their successes. These findings highlight the importance of integrating T1DM as part of the individual's personal prerequisites. We discuss implications for the organization of diabetes care for adolescents.

Developmental changes in the roles of patients and families in type 1 diabetes management

Developmentally-tailored diabetes self-care education and support are integral parts of contemporary multidisciplinary T1D care. The patient with T1D must have the support of the family and the diabetes team to maintain the rigors of diabetes management, but the specific roles of patients and families with regard to daily diabetes tasks change considerably throughout the developmental span of early childhood, middle childhood/school-age years, and adolescence. This review provides a framework of key normative developmental issues for each of these developmental stages. Within this context, ideal family diabetes management is reviewed within each developmental stage and anticipated challenges that can arise during these stages and that can adversely impact diabetes management are presented. This paper also summarizes empirical evidence for specific intervention and care strategies to support optimal diabetes management across these stages in order to maximize opportunities for a successful transfer of diabetes management tasks from parents to maturing youth. Finally, the review provides an emphasis on approaches to promote family teamwork and adolescent diabetes self-care adherence as well as opportunities to use novel technology platforms as a means to support optimal diabetes management.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

Background

Despite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.

Aim

To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.

Methods

Self-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.

Results

We included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.

Conclusions

Supporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.

Study registration

This study is registered as PROSPERO CRD42012002898.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient perspectives on peer mentoring: type 1 diabetes management in adolescents and young adults

PURPOSE

The purpose of the study was to identify attitudes and topics relevant to peer mentoring as an adherence-promoting intervention for adolescents and young adults (YAs) with type 1 diabetes (T1D).

METHODS

Self-administered survey data were collected in 2 diabetes clinics from a convenience sample of adolescents as prospective mentees (ages 13-18) and YAs as prospective mentors (ages 19-25) with T1D. Survey topics included demographics, disease history, glycemic control, adherence, depression, barriers to disease management, social support, and interest in peer mentoring. Descriptive statistical analyses, thematic coding, and stepwise multivariate logistic regression were performed.

RESULTS

A majority of the 54 adolescents and 46 YAs expressed interest in a peer mentoring program. Having supportive friends and living in a large household positively predicted adolescent interest in having a peer mentor. Approximately one-third of all participants experienced social barriers to diabetes management. For adolescents, barriers included inflexible schedules, unfamiliar foods, and the embarrassment of checking blood glucose in front of others. Young adults reported barriers in tracking food consumption and remembering to check blood glucose. Various diabetes management skills were in high demand by adolescents, who especially desired to learn about managing T1D on their own and in college. Participants were open to multiple communication modes, including in-person meetings, phone, text messaging, and social media.

CONCLUSIONS

Many adolescents and young adults with T1D are interested in peer mentoring as a way to facilitate learning and sharing essential diabetes management skills and experiences.

Friendship and romantic relationships among emerging adults with and without type 1 diabetes

OBJECTIVE

To examine whether friendship and romantic relationships of emerging adults with type 1 diabetes differed from those of a comparison group, and to determine whether these relationships were associated with psychological and diabetes health outcomes.

METHODS

High school seniors with (n = 122) and without (n = 118) type 1 diabetes were assessed annually for 3 years. Friend and romantic relationship variables, psychological distress, life satisfaction, eating disturbances, and, for those with diabetes, diabetes outcomes were assessed.

RESULTS

Those with diabetes reported less friend support but similar friend conflict compared with controls. Aspects of romantic relationships and friend relationships were associated with health outcomes, but there were more effects involving romantic relationships. On some indices, romantic support was more beneficial for controls and romantic conflict was more troublesome for those with diabetes.

CONCLUSIONS

Both friendship and romantic relationships were associated with psychological and diabetes outcomes among emerging adults.

Teaming up: feasibility of an online treatment environment for adolescents with type 1 diabetes

OBJECTIVE

To evaluate the feasibility of an online interactive treatment environment for adolescents with type 1 diabetes, called Sugarsquare, to supplement usual care.

RESEARCH DESIGN AND METHODS

Sugarsquare provides easily accessible contact with the diabetes team, peer support, and treatment overview. Of 120 eligible patients, 62 adolescents aged 11-21 (M = 15.23, SD = 2.00) were assigned to a usual-care group (n = 31) or a usual-care + intervention group (n = 31). Feasibility was assessed in terms of acceptability, demand, practicability, integration, and efficacy in a 9-month study-period.

RESULTS

Assessment of acceptability and demand revealed that 20 adolescents in the intervention group (65%) logged in at least once; 16 adolescents (52%) logged in repeatedly. Usage resulted in 5795 page-views, 3580 chat-messages, 427 forum-messages, and in 40 private interactions between 11 adolescents (35%) and professionals. Assessment of practicability revealed that all 13 professionals (100%) accessed the intervention. Slow processing speed and security procedures formed obstacles for usage. Assessment of integration showed that international standards for diabetes care (International Diabetes Federation/International Society for Pediatric and Adolescent Diabetes/American Diabetes Association) were met. Assessment of efficacy revealed improvement in the intervention group in evaluation of care (Patients' Evaluation of Quality of Diabetes), F(1,30) = 5.35, p < 0.05, and quality of life, communication (PedsQL), F(1,30) = 11.65, p <0.05. The latter was correlated with posted chat-messages (r = 0.42, p < 0.05). No between-group differences were found.

CONCLUSIONS

This study shows that Sugarsquare is feasible in adolescents with type 1 diabetes. It meets a demand in adolescents and can support professionals when organizing on-going care according to international standards. Results are promising and next steps are a full-scale randomized controlled trial and subsequent implementation in daily care.

Features of online health communities for adolescents with type 1 diabetes

The aim of this exploratory study was to examine diabetes online health communities (OHCs) available to adolescents with type 1 diabetes (T1D). We sought to identify and classify site features and relate them to evidence-based processes for improving self-management. We reviewed 18 OHCs and identified the following five feature categories: social learning and networking, information, guidance, engagement, and personal health data sharing. While features that have been associated with improved self-management were present, such as social learning, results suggest that more guidance or structure would be helpful to ensure that those processes were focused on promoting positive beliefs and behaviors. Enhancing guidance-related features and structure to existing OHCs could provide greater opportunity for effective diabetes self-management support. To support clinical recommendations, more research is needed to quantitatively relate features and participation in OHCs to patient outcomes.

How adolescents with diabetes experience social support from friends: two qualitative studies

Self-management of diabetes is challenging, especially for adolescents who face multiple changes, including closer peer relationships. Few studies have explored how friends can provide constructive support in this effort. The present research investigated, in two qualitative studies, the perceptions of adolescents with diabetes and their friends with respect to the positive social support that friends can offer. In study 1, 28 adolescents aged 12-15 with type 1 diabetes participated in online focus groups. In study 2, 11 of these adolescents were interviewed in person together with their best friends. The data were analysed by means of content analysis. In study 1, the adolescents with diabetes identified various supportive behaviours of friends, particularly concerning emotional support: treating them normally, showing interest, having fun, providing a distraction, and taking their diabetes into account. They differed in their attitude towards support, and this influenced which behaviours they perceived as supportive. Study 2 showed that the adolescents with diabetes and their friends often had similar opinions on the desired degree of support. Fear of stigmatization and sense of autonomy withheld some adolescents with diabetes from soliciting more support. These insights can be useful in patient education aiming to promote social support.

Adolescents, parents and physicians: a comparison of perspectives on type 1 diabetes self-care

OBJECTIVE

No research to date has compared the beliefs of adolescents, parents and physicians with respect to type 1 diabetes mellitus self-care perceptions and barriers. This study examined how adolescents with type 1 diabetes, their parents and physicians perceive 4 key diabetes self-care behaviours (testing blood glucose, taking insulin, exercise and diet) and what influences those behaviours.

METHOD

Forty-eight adolescent/parent dyads and 21 pediatric endocrinologists rated importance, difficulty and proficiency for 4 self-care behaviours, and provided up to 5 perceived influences on these behaviours. We compared adolescents to parents and families to physicians.

RESULTS

Groups rated all self-care behaviours as important, with taking insulin as most important. Families rated behaviours as relatively easy compared to physicians. All groups agreed that diet was both the most difficult self-care behaviour and the behaviour at which adolescents were least proficient. Although families rated teens as proficient overall, physicians disagreed. Adolescent and parent perception of diet difficulty was related to poorer glycemic control, and blood glucose testing and insulin administration proficiency were linked to better glycemic control. Compared to other groups, teens were especially likely to mention internal and hindering influences, and more likely to mention other people as negative influences.

CONCLUSIONS

Although all groups agreed that all self-care behaviours are important, there are key areas of discrepancy in perceptions, particularly between families and physicians. Further research should connect the beliefs examined in this study to actual self-care behaviours.

Relationships and health among emerging adults with and without Type 1 diabetes

OBJECTIVE

The study's goal was to examine the impact of parent and peer relationships on health behaviors and psychological well-being of those with and without Type 1 diabetes over the transition to emerging adulthood. Emerging adulthood is an understudied developmental period and a high-risk period--especially for those with Type 1 diabetes.

METHOD

Youth with (n = 117) and without Type 1 diabetes (n = 122) completed questionnaires during their senior year of high school and 1 year later. Measures included supportive and problematic aspects of parent and peer relationships, health behaviors, psychological well-being, and, for those with diabetes, self-care behavior and glycemic control.

RESULTS

Prospective multiple and logistic regression analysis revealed that friend conflict was a more potent predictor than friend support of changes in health behaviors and psychological well-being. Parent support was associated with positive changes in psychological well-being and decreases in smoking, whereas parent control was related to increases in smoking and depressive symptoms. There was some evidence of cross-domain buffering such that supportive relationships in one domain buffered adverse effects of problematic relationships in the other domain on health outcomes.

CONCLUSIONS

This longitudinal study showed that parent relationships remain an important influence on, and peer relationships continue to influence, the health behaviors and psychological well-being of emerging adults with and without Type 1 diabetes. Parent relationships also have the potential to buffer the adverse effects of difficulties with peers.

Ser diabético na família e na sociedade: a avaliação do adolescente em Itajubá, Minas Gerais, Brasil

Objetivo: Investigar a realidade de adolescentes com diabetes mellitus tipo 1 no convívio familiar e social na cidade de Itajubá, Minas Gerais. Métodos: O presente estudo utiliza uma abordagem qualitativa e transversal. Para a coleta dos dados foi realizada uma entrevista semiestruturada com 20 adolescentes, de 11 a 20 anos de idade, de ambos os gêneros, entre os meses de julho e setembro de 2011. Resultados: Identificamos uma diversidade de ideias em relação a como os adolescentes convivem com a doença no contexto familiar, as quais variam entre “difícil”, “ruim”, “complicado”, “normal”, “bom”, “acostumado” e “fácil”. Em relação à doença e ao convívio social, os resultados variam entre “difícil”, “normal”, “acostumado”, “complicado”, “ruim” e “depende”. Tanto para o contexto familiar como para o contexto social, a ideia mais citada foi “difícil”. Conclusões: Os resultados destacam que, na família, tais dificuldades são superadas quando comparadas às dificuldades no contexto social. Concluindo que o suporte do ambiente familiar é fundamental para um bom desenvolvimento do adolescente com diabetes frente aos problemas da doença.