Use of Diabetes Technology in Children: Role of Structured Education for Young People with Diabetes and Families

A Serious Game (MyDiabetic) to Support Children's Education in Type 1 Diabetes Mellitus: Iterative Participatory Co-Design and Feasibility Study

BACKGROUND

Serious games, which are gaming applications used for purposes beyond entertainment to educate users on, and address, specific issues, may present a timely approach to promote healthy diabetes management behaviors among children with type 1 diabetes mellitus (T1DM). The lasting benefits associated with these serious games encompass improved patient education; enhanced glycemic control; the reinforcement of bonds within the community of people with diabetes; the facilitation of meaningful dialogues with caregivers, especially within the familial setting; and a significant reduction in the economic burdens associated with subsequent complications.

OBJECTIVE

This paper primarily aims to provide a detailed overview of the iterative design process and the associated evaluation methods used in the development of the educational game. Furthermore, this study aims to enhance motivation for sustained and extended engagement with the game over time. The MyDiabetic game design aims to educate children on various aspects, including the connections among food, insulin, and physical activity. Furthermore, it seeks to impart knowledge related to the operation of a glucometer and an insulin pen, as well as more advanced technologies such as administering glucagon, measuring ketoacidosis, and continuous glucose monitoring.

METHODS

The co-design methodology was applied, involving interviews, design workshops, and prototype feedback sessions. A combination of several approaches, such as tailoring, observational learning, social and family support, decision-making practice, and reward systems, was used to support children's compliance. Moreover, incorporating the literature, guidelines, and current practices into the design ensured that the game was aligned with established health care pathways and included relevant information and best practices for diabetes management.

RESULTS

The game was tested on 32 children in 3 iterations. Positive responses were received from children who tested the game as well as their parents. The game was also presented to 5 schoolmates of children with T1DM who appreciated a better understanding of the disease and the opportunity to support their friends more efficiently in T1DM compensation. The involvement of children and clinicians in participatory co-design contributed to to the game's high acceptance. With regard to the game's impact on education, 1 week of testing revealed an enhancement in educational outcomes.

CONCLUSIONS

The game is especially suitable for children newly diagnosed with T1DM because it acquaints them in a fun way with new terminology; for example, they can try to measure glycemia levels in an interactive way. The game also caters to children who still need to develop reading skills by including an audio guide. The guide ensures that children of all literacy levels can benefit from the game's educational content and interactive experiences. The game is available for download on Google Play and the Apple App Store.

Use of diabetes technologies in the primary school environment: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to map the literature on the use of diabetes technologies in the primary school environment by children with type 1 diabetes (T1D) and/or their parents.

INTRODUCTION

T1D is a complex chronic disorder that is one of the fastest growing diseases in childhood. Technological advances in recent times have seen a growth in the use of diabetes technologies. Despite these advances, having T1D still creates challenges for parents' and children's school experiences. Furthermore, the literature on the use of diabetes technologies during the primary school day is under-investigated.

INCLUSION CRITERIA

This review will consider peer-reviewed primary research studies or systematic reviews that include children with T1D aged 6 to 12 years who use diabetes technologies in the primary school environment and/or their parents.

METHODS

This review will be conducted in accordance with JBI methodology for scoping reviews and will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Following an initial limited search, a full search strategy was developed using index terms and key text words. This strategy will be used across relevant databases, including Embase, MEDLINE (Ovid), CINAHL (EBSCOhost), and Web of Science Core Collection for the full scoping review. There will be no limitations on language or year. Two reviewers will independently screen titles, abstracts, and full-text articles and extract relevant data using the JBI data extraction instrument. Data will be presented in a descriptive manner, supported by tables and charts, and accompanied by a narrative summary.

Evaluation of the DigiBete App, a Self-Management App for Type 1 Diabetes: Experiences of Young People, Families, and Healthcare Professionals

Type 1 diabetes (T1DM) is a public health issue for children, young people, and families (CYPF) and requires innovative interventions. The DigiBete app is a self-management and educational app to help CYPF and healthcare professionals (HCPs) manage T1DM, featuring educational advice and resources such as guidance, quizzes, and educational and instructional videos on how to manage T1DM. To assess the impact and implementation of the app, the service-level evaluation deployed a mixed-methods design. App data were captured via the DigiBete platform and an online survey with a non-probability sample of HCPs (N = 178) and CYPF (N = 1165) = 1343. Overall, 55.7% (n = 512/919) of app users were female, and 4855 videos were viewed across the participating areas, with an average of 1213 videos per site (range 776-1679) and 4.4 videos per app user. The most popular videos were how to give a glucagon injection and "My Sick Day Rules", which showed what to do when CYPF were unwell due to T1DM. Interviews (n = 63) were undertaken with 38 CYPF and 25 HCPs. The findings indicate that CYPF and HCPs found the app an essential tool in the management of T1DM. CYPF and HCPs felt the app provided a valuable educational resource in a central location that was invaluable in an emergency or unknown situation. The app was a trusted and bona-fide source of information that could be accessed at any time. HCPs validated DigiBete in helping CYPF to manage their T1DM. At the same time, the app saved HCPs' service time and money and helped CYPF take back some of the control in managing their diabetes.

Experience with burdens of diabetes device use that affect uptake and optimal use in people with type 1 diabetes

Diabetes technology continues to advance, with more individuals with type 1 diabetes (T1D) adopting insulin pumps, continuous glucose monitoring (CGM), and automated insulin delivery (AID) systems that integrate real-time glucose data with an algorithm to assist with insulin dosing decisions. These technologies are linked with benefits to glycemic outcomes (e.g. increased time in target range), diabetes management behaviors, and quality of life. However, current devices and systems are not without barriers and hassles for the user. The intent of this review is to describe the personal challenges and reactions that users experience when interacting with current diabetes technologies, which can affect their acceptance and motivation to engage with their devices. This review will discuss user experiences and strategies to address three main areas: (i) the emotional burden of utilizing a wearable device; (ii) the perceived and experienced negative social consequences of device use; and (iii) the practical challenges of wearing devices.

Designing a Collaborative Patient-Centered Digital Health Platform for Pediatric Diabetes Care in British Columbia: Formative Needs Assessment by Caregivers of Children and Youths Living With Type 1 Diabetes and Health Care Providers

BACKGROUND

Digital health apps are becoming increasingly available for people living with diabetes, yet data silos continue to exist. This requires health care providers (HCPs) and patients to use multiple digital platforms to access health data.

OBJECTIVE

In this study, we gathered the perspectives of caregivers of children and youths living with type 1 diabetes (T1D) and pediatric diabetes HCPs in the user-centered design of TrustSphere, a secure, single-point-of-access, integrative digital health platform.

METHODS

We distributed web-based surveys to caregivers of children and youths living with T1D and pediatric diabetes HCPs in British Columbia, Canada. Surveys were designed using ordinal scales and had free-text questions. Survey items assessed key challenges, perceptions about digital trust and security, and potential desirable features for a digital diabetes platform.

RESULTS

Similar challenges were identified between caregivers of children and youths living with T1D (n=99) and HCPs (n=49), including access to mental health support, integration of diabetes technology and device data, and the ability to collaborate on care plans with their diabetes team. Caregivers and HCPs identified potential features that directly addressed their challenges, such as more accessible diabetes data and diabetes care plans. Caregivers had more trust in sharing their child's data digitally than HCPs. Most caregivers and HCPs stated that an integrative platform for T1D would support collaborative patient care.

CONCLUSIONS

Caregiver and HCP perspectives gathered in this study will inform the early prototype of an integrative digital health platform. This prototype will be presented and iterated upon through a series of usability testing sessions with caregivers and HCPs to ensure the platform meets end users' needs.

School Nurse Confidence with Diabetes Devices in Relation to Diabetes Knowledge and Prior Training: A Study of Convergent Validity

Objective

The Diabetes Device Confidence Scale (DDCS) is a new scale designed to evaluate school nurse confidence with diabetes devices. We hypothesized that DDCS score would be associated with related constructs of school nurse diabetes knowledge, experience, and training.

Research Design and Methods

In a cross-sectional study, we co-administered the DDCS and Diabetes Knowledge Test 2 (DKT2) questionnaires to school nurses in Pennsylvania. We summarized DDCS scores (range 1-5) descriptively. We evaluated the relationship between DKT2 percent score and DDCS mean score with the Spearman correlation coefficient. Simple linear regression examined school nurse characteristics as predictors of DDCS score.

Results

A total of 271 completed surveys were received. Mean DDCS score was 3.16±0.94, indicating moderate confidence with devices overall. School nurses frequently reported low confidence in items representing specific skills, including suspending insulin delivery (40%), giving a manual bolus (42%), knowing when to calibrate a continuous glucose monitor (48%), changing an insulin pump site (54%), and setting a temporary basal rate (58%). Mean DKT2 score was 89.5±0.1%, which was weakly but not significantly correlated with DDCS score (r=0.12, p=0.06). Formal device training (p<0.001), assisting ≥5 students with diabetes devices in the past 5 years (p<0.01), and a student caseload between 1000-1500 students (p<0.001) were associated with higher mean DDCS score.

Conclusions

DDCS score is related to prior training and experience, providing evidence for the scale's convergent validity. The DDCS may be a useful tool for assessing school nurse readiness to use devices and identify areas to enhance knowledge and practical skills.

Digital technology and its effects on knowledge improvement for diabetes management: An integrative review

AIM

To evaluate the effectiveness of educational digital technology in improving patients' and health professionals' knowledge about diabetes management.

BACKGROUND

The use of digital technologies has been expanding in recent years in several areas of healthcare and education.

DESIGN

Integrative literature review.

DATA SOURCES

The following databases were searched: PubMed, Lilacs, BDENF, Web of Science and SciELO (1 January 2016 and 31 December 2020).

REVIEW METHODS

Titles and abstracts were screened and selected by independent reviewers based on eligibility criteria. A consensus was drawn on which articles should be included. Data were extracted using an instrument created by the authors, and the synthesis of knowledge was made by compiling the results in a table and identifying thematic axes.

RESULTS

Seventy-one articles were retrieved, and after the final analysis, a total of 11 were included. Most studies have pointed out benefits from the use of digital technologies in diabetes education, with two thematic categories emerging: 'Digital technologies in the education of patients with diabetes' and 'Digital technologies in continuing professional education in diabetes'.

CONCLUSION

The use of digital technologies is beneficial and effective both for continuing professional education and educating patients about diabetes management.

Barriers and Facilitators to Diabetes Device Adoption for People with Type 1 Diabetes

PURPOSE OF REVIEW

Diabetes technology (insulin pumps, continuous glucose monitoring, automated insulin delivery systems) has advanced significantly and provides benefits to the user. This article reviews the current barriers to diabetes device adoption and sustained use, and outlines the known and potential facilitators for increasing and sustaining device adoption.

RECENT FINDINGS

Barriers to diabetes device adoption continue to exist at the system-, provider-, and individual-level. Known facilitators to promote sustained adoption include consistent insurance coverage, support for providers and clinics, structured education and support for technology users, and device user access to support as needed (e.g., through online resources). Systemic barriers to diabetes device adoption persist while growing evidence demonstrates the increasing benefits of newest devices and systems. There are ongoing efforts to develop evidence-based structured education programs to support device adoption and sustained use.

Young Children with Type 1 Diabetes: Recent Advances in Behavioral Research

PURPOSE OF REVIEW

This review provides a recent update of behavioral research pertinent to young children with T1D and addresses current priorities and future directions.

RECENT FINDINGS

Rates of type 1 diabetes (T1D) in young children (ages 1-7) are continuing to rise. Since 2014, changes to diabetes care and management have impacted young children and reinforced the need for increased attention and interventions to support diabetes management, especially in caregivers who are primarily responsible for their young child's diabetes management. T1D is associated with unique physiologic challenges in young children, with constant management demands elevating parental diabetes-related stress and fear of hypoglycemia. Diabetes technology use has significantly increased in young children, contributing to improvements in glycemic levels and parent and child psychosocial functioning. Yet despite the positive outcomes demonstrated in select clinical behavioral interventions, research with this young child age group remains limited in scope and quantity.

Use of continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes mellitus: a systematic mapping review

BACKGROUND

Among the treatments for type 1 diabetes mellitus (T1DM), Continuous Subcutaneous Insulin Infusion (CSII) is a device that infuses insulin through the subcutaneous tissue in an uninterrupted manner and that comes closest to the physiological secretion of insulin. The use of CSII can provide the family with greater security and children and adolescents have more autonomy in relation to the treatment of T1DM. There is a lack of reviews that systematically gather the mounting evidence about the use of CSII in children and adolescents with T1DM. Therefore, the aim of this review was to group and describe primary and secondary studies on the use of CSII in children and adolescents with T1DM.

METHODS

A systematic mapping review was performed based on searches in the following databases: PubMed, Embase, CINAHL, Lilacs and PsycINFO, using a combination of descriptors and keywords. The screening of the studies was carried out with the aid of the Rayyan software and reading in full was conducted independently by two reviewers. The data extraction of the studies was performed using an extraction tool adapted and validated by researchers specialized in diabetes. The data were analyzed according to the content analysis technique. The map from geocoding of the studies was produced using the ArcGis 10.5 software.

RESULTS

A total of 113 studies were included in the review, including primary studies, literature reviews and gray literature publications. The content analysis of the results of the studies allowed for the identification of four categories: 1) metabolic control; 2) support networks; 3) benefits of using CSII; and 4) challenges of using CSII, each category having its respective subcategories. The review also made it possible to conduct a rigorous mapping of the literature on the use of CSII considering the location of development and the design of the studies.

CONCLUSIONS

The use of CSII should be indicated by health professionals able to prepare children, adolescents, and their families for the treatment of T1DM, and, despite being a technological device, it may not be suitable for the entire pediatric population.

Use and Trends of Diabetes Self-Management Technologies: A Correlation-Based Study

Applications and systems for diabetes self-management are growing and involve a vast majority of factors to consider. This study was aimed at examining the integration of portable technologies for diabetes self-management, as well as benefits and issues arising of its use. From a web-based study on several groups of people with diabetes, most of them accustomed to the daily use of devices and applications for self-control, a deeper analysis based on correlations and inference was conducted considering information about the disease, technology knowledge and devices handling, use of technologies for diabetes control and management, and training with devices from a clinical and educational viewpoint. In this study, more than 70% of participants use Continuous Glucose Systems and additional devices (41.85% also use insulin pumps) which impacts positively on the knowledge of incoming technologies. The "easy to use" factor of current apps for diabetes self-management is the most valuable feature. Also, 88.98% of participants did not use gamification-based methods during the initial training sessions, although gamification is a useful technique in learning stages. An inference analysis shows how specific characteristics of diabetes devices and apps should improve. On the basis of the results, we discuss about benefits, shortcomings, and the state of these technologies and patient needs for the future.

Optimizing the use of technology to support people with diabetes: research recommendations from Diabetes UK's 2019 diabetes and technology workshop

AIMS

To identify key gaps in the research evidence base that could help improve how technology supports people with diabetes, and provide recommendations to researchers and research funders on how best to address them.

METHODS

A research workshop was conducted, bringing together research experts in diabetes, research experts in technology, people living with diabetes and healthcare professionals.

RESULTS

The following key areas within this field were identified, and research recommendations for each were developed: Matching the pace of research with that of technology development Time in range as a measure Health inequalities and high-risk groups How to train people to use technology most effectively Impact of technology usage on mental health CONCLUSIONS: This position statement outlines recommendations through which research could improve how technology is employed to care for and support people living with diabetes, and calls on the research community and funders to address them in future research programmes and strategies.

Executive function mediates the link between externalizing behavior and HbA1c in children and adolescents with type 1 diabetes: A cross-national investigation

OBJECTIVE

Externalizing behavior (i.e., conduct problems, hyperactivity) and executive function (EF) problems in children and adolescents with type 1 diabetes (T1D) have been associated with worse diabetes-related and psychosocial outcomes but have not been examined in relationship to each other. We aimed to examine whether externalizing behavior is associated with HbA1c and whether this relationship is mediated by EF problems, specifically metacognition (i.e., ability to initiate, plan, organize and monitor behavior) and behavioral regulation (i.e., impulse control, regulation of emotion and behavior).

RESEARCH DESIGN AND METHODS

Cohorts of Belgian and Dutch parents of children and adolescents (6-18 years) with T1D filled out questionnaires on externalizing behavior (Strengths and Difficulties Questionnaire; SDQ) and EF (Behavior Rating Inventory of Executive Function; BRIEF) composite scales. Treating physicians collected HbA1c values. Mediation analyses were performed separately for the BRIEF composite Metacognition and Behavior Regulation scales, correcting for age, sex and diabetes duration.

RESULTS

The 335 parents of children and adolescents with T1D (mean age 12.3 ± 2.8 SD; mean HbA1c 7.6% ± 1.1 SD [60 mmol/mol ± 12.0 SD]; mean diabetes duration 5.3 ± 3.6 SD; 49.6% female) participated. Analyses showed that the association between externalizing behavior and HbA1c is mediated by metacognition (ab path Point estimate = 0.05 BCa CI 95% 0.02-0.08), and not behavioral regulation.

CONCLUSIONS

Results uncovered the influence externalizing behavior may have on EF problems in the metacognition domain, which in turn seem to influence HbA1c. Clinicians should be mindful of these EF problems when working with children and adolescents displaying externalizing behavior, and not only target behavioral but also cognitive processes.

Diabetes education in pediatrics: How to survive diabetes

Diabetes mellitus is the most common abnormal carbohydrate metabolism disorder affecting millions of people worldwide. It is characterized by hyperglycemia as a result of ß-cell destruction or dysfunction by both genetic and environmental factors. Over time chronic hyperglycemia leads to microvascular (i.e., retinopathy, nephropathy and neuropathy) and macrovascular (i.e., ischemic heart disease, peripheral vascular disease, and cerebrovascular disease) complications of diabetes. Diabetes complication trials showed the importance of achieving near-normal glycemic control to prevent and/or reduce diabetes-related morbidity and mortality. There is a staggering rate of increased incidence of diabetes in youth, raising concerns for future generations' health, quality of life and its enormous economic burden. Despite advancements in the technology, diabetes management remains cumbersome. Training individuals with diabetes to gain life-long survival skills requires a comprehensive and ongoing diabetes education by a multidisciplinary team. Diabetes education and training start at the time of diagnosis of diabetes and should be continuous throughout the course of disease. The goal is to empower the individuals and families to gain diabetes self-management skills. Diabetes education must be individualized depending on the individual's age, education, family dynamics, and support. In this article, we review the history of diabetes, etiopathogenesis and clinical presentation of both type 1 and type 2 diabetes in children as well as adolescents. We then focus on diabetes management with education methods and materials.