Diabetes care provision: barriers, enablers and service needs of young adults with Type 1 diabetes from a region of social disadvantage

Transition between paediatric and adult diabetes healthcare services: An online global survey of healthcare professionals' experiences and perceptions

INTRODUCTION

Youth with diabetes should transition from paediatric to adult diabetes services in a deliberate, organized and cooperative way. We sought to identify healthcare professionals' (HCPs) experiences and perceptions around transition readiness planning, policies and procedures, and the actual transfer to adult services.

METHODS

Data were collected via an online global survey (seven language options), broadly advertised by the International Society for Pediatric and Adolescent Diabetes (ISPAD), European Association for the Study of Diabetes (EASD), team members and partners, via newsletters, websites, e-mails and social media.

RESULTS

Respondents (n = 372) were mainly physicians (74.5 %), practicing in government funded (59.4 %), paediatric (54.0 %), metropolitan settings (85.8 %) in Europe (44.9 %); 37.1 % in low and middle-income countries (LMICs). Few centers used a transition readiness checklist (32.8 %), provided written transition information (29.6 %), or had a dedicated staff member (23.7 %). Similarly, few involved a psychologist (25.8 %), had combined (35.2 %) or transition/young person-only clinics (34.9 %), or a structured transition education program (22.6 %); 49.8 % advised youth to use technology to assist the transfer. Most (91.9 %) respondents reported barriers in offering a good transition experience. Proportionally, more respondents from LMICs prioritised more funding (p = 0.01), a structured protocol (p < 0.001) and education (p < 0.001).

CONCLUSION

HCPs' experiences and perceptions related to transition vary widely. There is a pressing need for an international consensus transition guideline.

COVID-19 pandemic-related healthcare interruptions and diabetes distress: a national study of US adults with diabetes

BACKGROUND

Early COVID-19 pandemic research found changes in health care and diabetes management, as well as increased diabetes distress. This study aims to determine the association between COVID-19 pandemic-related healthcare interruptions and diabetes distress among adults with Type 1 and Type 2 diabetes in the US in 2021.

METHODS

Multinomial logistic regression was used to analyze moderate and high levels of diabetes distress (reference = no diabetes distress) in 228 individuals with Type 1 diabetes and 2534 individuals with Type 2 diabetes interviewed in the National Health Interview Survey in 2021.

RESULTS

Among adults with Type 1 diabetes, 41.2% experienced moderate diabetes distress and 19.1% experienced high diabetes distress, and among adults with Type 2 diabetes, 40.8% experienced moderate diabetes distress and 10.0% experienced high diabetes distress. In adults with Type 1 diabetes, experiencing delayed medical care was associated with an adjusted odds ratio (aOR) of 4.31 (95% CI: 1.91-9.72) for moderate diabetes distress and 3.69 (95% CI: 1.20-11.30) for high diabetes distress. In adults with Type 2 diabetes, experiencing delayed medical care was associated with an aOR of 1.61 (95% CI: 1.25-2.07) for moderate diabetes distress and 2.27 (95% CI: 1.48-3.49) for high diabetes distress. Similar associations were observed between not receiving medical care due to the pandemic and diabetes distress.

CONCLUSION

Among people with diabetes, experiencing delayed medical care and not receiving care due to the pandemic were associated with higher reports of diabetes distress.

A randomized controlled clinical trial to improve health outcomes in youth with type 1 diabetes: Study design and baseline characteristics

Most adolescents with T1D do not meet glycemic recommendations or consistently perform the required self-management behaviors to prevent acute- and long-term deleterious health outcomes. In addition, most youth with T1D do not have access to behavioral health services to address T1D management barriers. Thus, delivering behavioral interventions during routine medical appointments may hold promise for improving T1D outcomes in adolescents. The overall objective of this study was to examine the effect of behavioral interventions, either a Personalized T1D Self-Management Behaviors Feedback Report or Problem-Solving Skills, delivered by a T1D behavioral health provider and a T1D medical provider during a joint, fully integrated appointment to improve health outcomes in youth with T1D. This paper describes the study rationale, design, and baseline characteristics for the 109 adolescent-caregiver dyads who participated. Primary and secondary outcomes include hemoglobin A1c (A1C), T1D self-management behaviors, and biological indicators of complications.

Health Care Transition to Adult Care in Type 1 Diabetes: Associations With Student and Employment Status-The SEARCH for Diabetes in Youth Study

Successful transition from a pediatric to adult diabetes care provider is associated with reduced ambulatory diabetes care visits and increased acute complications. This study aimed to determine whether the degree of independence in diabetes care and the rate of acute complications after transition to adult diabetes care were associated with individuals' student or employment status. Nonstudents were found to be less likely than students to be independent with diabetes care, and employed nonstudents were at lower risk of diabetic ketoacidosis than unemployed nonstudents. Additional support may be needed for young adults who are not students or are unemployed to improve independence and reduce the risk for acute complications.

Emerging Adults with Diabetes in Safety-Net Care: Self-Management Influences and Patient-Provider Interactions

Emerging adults with diabetes, particularly in underserved communities, represent a growing but less studied population whose needs may differ from older adults. This study investigated perspectives of underserved emerging adults regarding diabetes self-management influences and provider interactions. Focus groups and interviews with emerging adults in a safety-net health care setting were conducted to identify perspectives regarding self-management influences and patient-provider interactions. Diabetes was perceived as a psychological burden complicated by busy lifestyles and competing responsibilities. Lack of resources, especially financial barriers, also limited self-management. Participants often perceived diabetes visits as standardized encounters providing access to diabetes supplies but desired additional guidance appropriate to their needs and life-stage. Participants valued encouragement and positive ongoing provider relationships for tailored informational and emotional support and support from family and peers. Providers and health care systems adapting to provide or facilitate this support will be better able to optimize diabetes management at and between visits.

Feasibility and acceptability of an online guided self-determination program to improve diabetes self-management in young adults

Objective

Evaluate the feasibility and acceptability of an online guided self-determination (GSD) program to improve diabetes self-management skills among young adults with type 1 diabetes (YAD).

Methods

An online program comprising seven structured interactive conversations was designed. A pre- and post- interventional study used a sequential, two-phase multiple method design. Phase one comprised a training program for diabetes educators (DEs). In Phase two YAD participated in program and completed pre- and post-surveys assessing motivation to self-manage, perceived competence in diabetes and communication with DEs. Both YAD and DEs provided a program evaluation.

Results

The online GSD program was acceptable, feasible and effective in improving autonomous motivation in self-management and communication with DEs. Easy access and program flexibility were highly appreciated by both participant groups and perceived to assist YAD to stay motivated.

Conclusion

The program had a significant impact on the diabetes self-management of YAD and was a feasible and acceptable way to engage and communicate with DEs. The GSD platform contributes to age appropriate and person-centred diabetes self-management. It can potentially reach geographically distanced populations, or with social circumstances or other barriers impeding in-person service provision.

Implementation and delivery of group consultations for young people with diabetes in socioeconomically deprived, ethnically diverse settings

BACKGROUND

Young people with diabetes experience poor clinical and psychosocial outcomes, and consider the health service ill-equipped in meeting their needs. Improvements, including alternative consulting approaches, are required to improve care quality and patient engagement. We examined how group-based, outpatient diabetes consultations might be delivered to support young people (16-25 years old) in socio-economically deprived, ethnically diverse settings.

METHODS

This multi-method, comparative study recruited a total of 135 young people with diabetes across two implementation and two comparison sites (2017-2019). Informed by a 'researcher-in-residence' approach and complexity theory, we used a combination of methods: (a) 31 qualitative interviews with young people and staff and ethnographic observation in group and individual clinics, (b) quantitative analysis of sociodemographic, clinical, service use, and patient enablement data, and (c) micro-costing analysis.

RESULTS

Implementation sites delivered 29 group consultations in total. Overall mean attendance per session was low, but a core group of young people attended repeatedly. They reported feeling better understood and supported, gaining new learning from peers and clinicians, and being better prepared to normalise diabetes self-care. Yet, there were also instances where peer comparison proved difficult to manage. Group consultations challenged deeply embedded ways of thinking about care provision and required staff to work flexibly to achieve local tailoring, sustain continuity, and safely manage complex interdependencies with other care processes. Set-up and delivery were time-consuming and required in-depth clinical and relational knowledge of patients. Facilitation by an experienced youth worker was instrumental. There was indication that economic value could derive from preventing at least one unscheduled consultation annually.

CONCLUSIONS

Group consulting can provide added value when tailored to meet local needs rather than following standardised approaches. This study illustrates the importance of adaptive capability and self-organisation when integrating new models of care, with young people as active partners in shaping service provision.

TRIAL REGISTRATION

ISRCTN reference 27989430.

A Questionnaire Survey on the Prevalence and Parents' Perceptions of Respiratory Allergies in a 3- to 16-Year-Old Population in Wuhan, China

(1) Background: The prevalence of allergic rhinitis (AR) and asthma has increased rapidly in China. However, perceptions of respiratory allergies and barriers to their management have not attracted enough attention. (2) Objective: To investigate the prevalence of, parents’ perceptions of and their unmet needs for information concerning respiratory allergies in a 3- to 16-year-old children population. (3) Methods: A cross-sectional survey was conducted from June to July 2021 in three schools in Wuhan, China. A total of 1963 participants were recruited through cluster sampling for their parents to complete an online questionnaire regarding respiratory allergic symptoms. The diagnosis of respiratory allergies was based on self-reported symptoms and face-to-face physician evaluation. All the participants with respiratory allergies were asked to complete the Brief Illness Perception Questionnaire (B-IPQ), the Asthma Knowledge Questionnaire (AKQ) and a questionnaire regarding their unmet needs for disease management. (4) Results: The prevalence of respiratory allergies was 29.3% (576/1963) in the 3- to 16-year-old population, among whom AR accounted for 25.7%; asthma, 1.8% and AR-complicated asthma (AR&Asthma), 1.9%. The total B-IPQ score was 40.2 ± 10.9 in the participants with respiratory allergies, and there were no differences among the AR, asthma and AR&Asthma groups (all p > 0.05). The B-IPQ score correlated significantly with symptom onset time and a history of atopic dermatitis (p < 0.01). Nearly one fifth, 18.9%, of the participants with respiratory allergies never went to hospital for treatment, but those with higher B-IPQ scores were more likely to seek professional treatment (p < 0.001). The accuracy rates of AKQ were 72.5% in the participants with asthma and 76.7% in those without asthma (p = 0.147). Among the 576 participants with respiratory allergies, 568 (98.6%) had tried to obtain disease-management information from online platforms, and 55.5% (315/568) were dissatisfied with current platforms; the reasons included incomprehensive contents of illness (45.7%), lack of voice from leading experts (40.3%), too many advertisements (37.5%) and similar contents on different platforms (36.8%). (5) Conclusions: The prevalence of respiratory allergies is high in the 3- to 16-years old population in Wuhan, China. Yet the parents’ perceptions of respiratory allergies and knowledge of asthma are insufficient. It is crucial to increase parents’ awareness of the illness and facilitate their access to truly informative and professional platforms.

Vision-related quality of life in patients with glaucoma: the role of illness perceptions

Purpose

To explore the predictive effects of illness perceptions on vision-related quality of life (VRQoL) in Chinese glaucoma patients.

Methods

In this cross-sectional study, 97 patients with glaucoma completed the brief illness perception questionnaire (BIPQ), the glaucoma quality of life-15 (GQL-15) questionnaire, and a questionnaire regarding sociodemographic and clinical information. A correlation analysis and hierarchical linear regression analysis were performed.

Results

The BIPQ total score was positively correlated with the total score of the GQL-15 questionnaire and the scores of its four dimensions. Chronic comorbidities, the type of glaucoma, the best-corrected visual acuity (BCVA), the mean defect (MD) of visual field in the better eye, and identity in the BIPQ were critical predictors of VRQoL. Illness perceptions independently accounted for 7.8% of the variance in the VRQoL of glaucoma patients.

Conclusions

Patients with stronger illness perceptions and those who perceive themselves as having more glaucoma symptoms are likely to experience worse VRQoL. Illness perceptions in glaucoma patients deserve clinical attention, and further studies are needed to examine whether cognitive interventions targeting illness perceptions can improve VRQoL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01979-x.

Diabetes Care Provider Perceptions Regarding Emerging Adults' Diabetes Self-Management Influences and Patient-Provider Visit Interactions Within a Safety-Net Hospital

The increasing number of emerging adults with diabetes (EAWD) being cared for in adult health care settings requires a better understanding of the needs of EAWD and their interactions with adult health care providers (HCPs). This article describes findings from interviews with endocrinologists and diabetes nurses from a safety-net health care system to investigate HCPs' perspectives regarding influences on EAWD self-management and HCP interactions with EAWD. HCPs frequently perceived lower EAWD engagement in diabetes management, which was complicated by barriers such as the emotional burden of diabetes, busy lives and multiple responsibilities, and limited access to resources; however, HCPs valued the role of information and communication at visits in tailoring care for EAWD. Measures to tailor care should address the psychosocial burden related to the life stage goals and priorities of EAWD, identification of resources for EAWD and HCPs, and further elucidation of effective self-management guidance and communication strategies to support EAWD in safety-net settings.

Patients' illness perception before and after non-surgical periodontal therapy. A pre-post quasi-experimental study

BACKGROUND

Patient's illness perception, assessed through the Brief-Illness Perception Questionnaire (Brief-IPQ), plays a decisive role in the treatment effectiveness of a wide range of chronic diseases; nonetheless, evidence is still lacking regarding periodontitis. The aim of the present pre-post quasi-experimental study was to evaluate the change in the Brief-IPQ before and after non-surgical periodontal treatment (NST) and to evaluate its ability to foresee the efficacy of NST.

METHODS

A total of 126 periodontitis participants starting NST were asked to participate in the study. The nine-item Brief-IPQ together with a full periodontal chart were recorded at baseline and at the 3-month follow up (reevaluation) after NST. Pre-post comparisons of psychometric and periodontal variables were carried out through the Wilcoxon signed-rank test (α = 0.05). A predictive model was built to test the ability of the Brief-IPQ items to foresee the efficacy of NST.

RESULTS

NST led to a significant reduction in all periodontal parameters (P < 0.001); the proportion of pockets closed was 64.18%. Although the overall sum score of the Brief-IPQ remained fairly stable (P = 0.0673), significant changes occurred for items seven ("understanding") (P < 0.001) and 8 ("emotional response") (P < 0.05). The best model (R²  = 0.068, F = 2.15, P = 0.033) obtained from the multivariate linear regression analysis demonstrated that item five ("identity") (β = 2.340, P = 0.017) and item eight ("emotional response") (β = -2.569, P = 0.008) significantly predict the efficacy of NST (i.e., the proportion of pockets closed at reevaluation).

CONCLUSIONS

NST significantly ameliorates patient's understanding and emotional burden related to periodontitis. Baseline values of perceived symptoms and emotional response are predictive for the short-term efficacy of NST.

Our language matters: Improving communication with and about people with diabetes. A position statement by Diabetes Australia

The words used about diabetes affect the physical and emotional health of people living with diabetes. They also affect how individuals and society view people living with, or at risk of, diabetes. People with diabetes, their families, and people at risk of diabetes, need and deserve communications that are clear and accurate, respectful and inclusive, and free from judgement and bias. The aim of this position statement is to help bring about positive change in the language used about diabetes. It is based on 30+ years of research into the experiences of people with diabetes. Changing thelanguage of diabetes can make a powerful and positive difference to the emotional well-being, self-care and health outcomes of people affected by diabetes. It also affects community and government support for funding diabetes care, prevention and research. Diabetes Australia encourages everyone communicating about diabetes, or about people affected by diabetes, to choose and use their words carefully to support all people affected by diabetes. This position statement is intended as a guide for people working in healthcare, the media, government and policy, academia, industry, as well as employers and the community. It may also be helpful for the family and friends of people with diabetes.

A Digital Health Intervention (SweetGoals) for Young Adults With Type 1 Diabetes: Protocol for a Factorial Randomized Trial

BACKGROUND

Many young adults with type 1 diabetes (T1D) struggle with the complex daily demands of adherence to their medical regimen and fail to achieve target range glycemic control. Few interventions, however, have been developed specifically for this age group.

OBJECTIVE

In this randomized trial, we will provide a mobile app (SweetGoals) to all participants as a "core" intervention. The app prompts participants to upload data from their diabetes devices weekly to a device-agnostic uploader (Glooko), automatically retrieves uploaded data, assesses daily and weekly self-management goals, and generates feedback messages about goal attainment. Further, the trial will test two unique intervention components: (1) incentives to promote consistent daily adherence to goals, and (2) web health coaching to teach effective problem solving focused on personalized barriers to self-management. We will use a novel digital direct-to-patient recruitment method and intervention delivery model that transcends the clinic.

METHODS

A 2x2 factorial randomized trial will be conducted with 300 young adults ages 19-25 with type 1 diabetes and (Hb)A_1c ≥ 8.0%. All participants will receive the SweetGoals app that tracks and provides feedback about two adherence targets: (a) daily glucose monitoring; and (b) mealtime behaviors. Participants will be randomized to the factorial combination of incentives and health coaching. The intervention will last 6 months. The primary outcome will be reduction in A_1c. Secondary outcomes include self-regulation mechanisms in longitudinal mediation models and engagement metrics as a predictor of outcomes. Participants will complete 6- and 12-month follow-up assessments. We hypothesize greater sustained A_1c improvements in participants who receive coaching and who receive incentives compared to those who do not receive those components.

RESULTS

Data collection is expected to be complete by February 2025. Analyses of primary and secondary outcomes are expected by December 2025.

CONCLUSIONS

Successful completion of these aims will support dissemination and effectiveness studies of this intervention that seeks to improve glycemic control in this high-risk and understudied population of young adults with T1D.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04646473; https://clinicaltrials.gov/ct2/show/NCT04646473.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/27109.

Facilitating participation in cardiovascular preventive initiatives among people with diabetes: a qualitative study

Background

Type 2 diabetes (T2D) is associated with a significantly increased risk of cardiovascular disease (CVD). The DIAbetic CArdioVAscular Screening and intervention trial (DIACAVAS) was designed to clarify whether advanced imaging for subclinical atherosclerosis combined with medical treatment is an effective strategy to develop individualised treatment algorithms for Danish men and women with T2D aged 40–60. But in the DIACAVAS pilot study, the uptake was only 41%. Consequently, we explored how people experienced living with T2D to understand how to improve the uptake in initiatives targeting the prevention of CVD.

Methods

We used semi-structured interviews to obtain information on how the respondents experienced having T2D. For supplementary information, we used structured interviews on e.g. socioeconomic factors. From April to October 2019, 17 participants aged 40–60 years were recruited from general practices and diabetes outpatient clinics in Denmark. Several levels of analysis were involved consistent with inductive content analysis.

Results

The participants’ experiences of living with T2D fell along two continuums, from an emotional to a cognitive expression and from reactive to proactive disease management. This led to identification of four archetypal characteristics: (I) powerlessness, (II) empowerment, (III) health literacy, and (IV) self-efficacy. These characteristics indicated the importance of using different approaches to facilitate participation in cardiovascular preventive initiatives. Additionally, findings inspired us to develop a model for facilitating participation in future preventive initiatives.

Conclusion

Encouraging people with T2D to participate in cardiovascular preventive initiatives may necessitate a tailored invitation strategy. We propose a model for an invitational process that takes into consideration invitees’ characteristics, including powerlessness, empowerment, health literacy and self-efficacy. This model may enhance participation in such initiatives. However, participation is a general concern, not only in relation to cardiovascular prevention. Our proposed model may be applicable in preventive services for people with T2D in general.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10172-6.

Prevalence and management of diabetes among the uninsured: A multicenter study in Tampa Bay, FL

AIMS

This study describes the prevalence and management of uninsured patients with diabetes in free clinics around the Tampa Bay area.

METHODS

A retrospective chart review collected data from uninsured patients who visited nine free clinics from January 2016 to December 2017. The data included sociodemographics, chronic disease diagnoses and treatments, and social history. Statistical analysis including chi-square tests and logistic regression were used to describe patients with diabetes.

RESULTS

With a prevalence of 19.41% among 6815 uninsured patients and a mean HbA1c of 7.9% (63 mmol/mol), patients with diabetes were more likely to be White, women, obese, unemployed, and have hypertension and depression compared to patients without diabetes. There were no significant differences in sociodemographic variables between those with controlled and uncontrolled diabetes. Among the variables studied by logistic regression, unemployment was found to be a significant predictor of poor glycemic control among men.

CONCLUSIONS

Diabetes is a challenging chronic disease among the uninsured of Tampa Bay due to its prevalence and suboptimal glycemic control. Obesity and unemployment represent significant challenges that increase the burden of diabetes among the uninsured. Free clinics may benefit from additional resources and intervention programs, with future research assessing their effects on care outcomes.

A discussion of healthcare support for adolescents and young adults with long-term conditions: Current policy and practice and future opportunities

BACKGROUND

Adolescence and young adulthood can be a period of significant and unique life changes in which competing demands and challenges distract from disease self-management. Specific challenges related to the way individual services are configured can also limit the support available. This paper presents a discussion of healthcare service support for adolescents and young adults, using type 1 diabetes as an exemplar.

DESIGN

Discussion paper.

RESULTS

A wide variety of issues at the biopsychosocial level of the individual, health services policy and practice pose challenges to effective health support for adolescents and young adults. Intersectoral, multilevel and multicomponent opportunities are available to engage and empower young people to be part of change and accountability mechanisms and to transform the support available and outcomes achievable. A priority research agenda can benefit patients, families and their communities.

CONCLUSION

Future policy and practice development may assist clinicians, service providers and managers, policymakers, non-governmental organizations and community groups to deliver more effective and efficient support to vulnerable adolescent and young adult populations.

Effectiveness of the Freestyle Libre Flash Glucose Monitoring System on Diabetes Distress Among Individuals with Type 1 Diabetes: A Prospective Study

AIM

To study and explore the intervention of the flash glucose monitoring system (FGMS) on diabetes-related distress (DRD) in children and adolescents with type 1 diabetes (T1D).

METHODS

A 12-week prospective study was performed from March 2019 to July 2019 involving 187 children and adolescents (age range 13-19 years; 56.7% female) with T1D who were self-testing their glucose levels using the conventional fingerprick method. At the time of the baseline visit, FGMS sensors were fixed by a trained diabetes educator onto each patient in the study population. A trained interviewer also administered the 28-item T1-Diabetes Distress Scale (T1-DDS) questionnaire to each participant at the baseline visit and again after 12 weeks to determine the T1-DDS score.

RESULTS

Comparison of the baseline (fingerprick) data with data collected at 12 weeks after the patients had switched to the FGMS revealed a significant decrease in the subdomains of the T1-DDS as follows: powerlessness (p = 0.0001); management distress (p = 0.0001); hypoglycemia distress (p = 0.0001); negative social perceptions (p = 0.0001); eating (p = 0.0001); physician distress (p = 0.0001); friend/family distress (p = 0.0001); and total T1-DDS score (p = 0.0001). Similarly, analysis of the data revealed that there was also a substantial drop from baseline to 12 weeks after initiation of the intervention in the clinical variables assessed, such as glycosylated hemoglobin; specifically, there was a considerable decrease after 12 weeks in the frequency of hypoglycemia. Interestingly, the frequency of glucose monitoring also showed an upswing among users of the FGMS.

CONCLUSION

The outcomes of this study clearly demonstrate that once the patients had been switched from the fingerprick method to FGMS, the DRD and related clinical parameters showed remarkable improvement. However, further studies are necessary to determine whether the continued and consistent use of the FGMS will achieve better results.

A mHealth Support Program for Australian Young Adults with Type 1 Diabetes: A Mixed Methods Study

Aims and Objectives

Young adulthood is a life stage comprised of many turning points. For young adults with type 1 diabetes (T1DM), diabetes self-management support is crucial during this period. There is a lack of diabetes education programs and services tailored to this population. This paper presents the findings, according to the STROBE guidelines, on the usability and acceptability of a patient-informed mHealth support program (Diabetes YES) that was developed for young adults with T1DM.

Methods

A total of 34 young adults aged 18-35 years with T1DM participated in the Diabetes YES program over 12 weeks. Google analytics was used to tracked website use, while a website usability survey measured ease of use. Facebook analytics was used to measure peer support engagement. Evaluation of the program was completed using Likert scales and open-ended questions.

Results

Participants rated the website favourably for its ease of navigation and easy to understand information. Web page visits declined sharply while peer support group engagement through Facebook remained consistent throughout the intervention period. Participants utilised weekly discussion topics to generate conversation within the peer support group. Emotional support from peers was the highest regarded benefit reported by participants.

Conclusions

Diabetes YES is an example of an mHealth support program that was readily accepted by young adults living with T1DM. Feasibility studies are an important formative step in the implementation of mHealth programs within mainstream healthcare. Future work should focus on the adaptability of such programs to fit within larger consumer or healthcare organisations.

The effect of psychological distress on self-care intention and behaviour in young adults with type 1 diabetes

An extended theory of planned behaviour including psychological distress was used to predict blood glucose monitoring in young adults with type 1 diabetes. Participants completed two surveys, a week apart (n = 167). Attitudes and perceived behavioural control were significantly associated with intention but subjective norm was not. Intention predicted blood glucose monitoring at T2. Higher scores in psychological distress significantly predicted poorer blood glucose monitoring at T2 but did not moderate the intention-behaviour relationship. Findings demonstrate some concerns with the theory of planned behaviour to predict self-care behaviour, yet highlight the importance of addressing psychological distress in diabetes self-management.

"I kind of gave up on it after a while, became too hard, closed my eyes, didn't want to know about it"-adults with type 1 diabetes mellitus describe defeat in the context of low social support

Background

Type 1 diabetes mellitus (T1DM) is a lifelong condition that requires diligent self‐management to avoid complications. Living with T1DM is a considerable challenge and the inability to follow a prescribed regimen is often termed non‐compliance. However, this fails to acknowledge that for some people the barriers to glycaemic control may be insurmountable.

Objective

This qualitative study explores the structural determinants, social context and lived experience of T1DM with 17 adults to understand influences on patterns of self‐care, engagement with and trust in health‐care services, and health outcomes.

Results

Their stories tell us that strong social support is vital to disease adaptation and ongoing management. When social support is absent, the story is one of struggling with intensive diabetes management alone and difficulty controlling blood glucose levels. When confronted with suboptimal glycaemic control, participants isolated from social support developed combative relationships with health‐care providers and disengaged from health care. Their subsequent slide to chronic comorbid illness is steep and this study reveals the heartache and loss experienced when difficult life circumstances and low levels of social support have led to irreparable kidney damage.

Conclusion

Patterns of poor glycaemic control viewed in the health‐care encounter without an understanding of the context or life circumstances in which they are occurring can lead to an inability to engage with health‐care services. Disengagement from services and the absence of specialist care further isolates people, leaving them managing their diabetes alone with limited success.

Differences between the perspectives of physicians and patients on the potential barriers to optimal diabetes control in China: a multicenter study

BACKGROUND

To investigate the potential barriers to optimal diabetes control by evaluating the different perspectives of physicians and patients on such matters in China.

METHODS

This multi-center survey was conducted from December 2015 to March 2016. A multi-stage stratified random sampling method was used to sample representative diabetes physicians and patients in 18 hospitals in Shaanxi province, China. A self-designed questionnaire was used. The questionnaire mainly consisted of 2 questions for physicians and 1 question for patients of which the participants were required to rank in priority of 3 (for physicians) and 2 (for patients) choices from a list of barriers. The strategies to improve diabetes control were only in the questionnaire for physicians.

RESULTS

A total of 85 physicians and 584 patients completed the questionnaire. Physicians and patients differed regarding the patients' awareness of the risk of diabetes: over 70% of the physicians believed that the patients had no sufficient understanding of the harm and risk of diabetes, whereas the patients believed otherwise. Both physicians and patients considered self-monitoring of blood glucose to be an important link of glucose control; unfortunately, most of the patients failed to do so in practice. In addition, physicians considered "improving health insurance coverage for diabetes" as the first important measure and "providing more and easy-to-use diabetes brochures or educational materials for patients" as the second important measure to improve diabetes control.

CONCLUSION

The survey revealed differences between the perspectives of physicians and patients on the potential barriers to optimal diabetes control. The main potential barriers to optimal diabetes control were patient's poor lifestyle interventions, limited understanding of the danger of diabetes, and poor self-monitoring of blood glucose. From the physicians' perspective, China's primary focus about diabetes control in the future should still be put on diabetes education, particular the importance of lifestyle interventions.

Weight loss, adverse events, and loss to follow-up after gastric bypass in young versus older adults: A Scandinavian Obesity Surgery Registry study

BACKGROUND

Young adults display particularly poor weight loss in behavioral obesity treatment; nonetheless, they have seldom been included in bariatric research.

OBJECTIVES

To compare weight loss, adverse events, and loss to follow-up in young (18-25 yr) versus older (≥26 yr) adults up to 5 years after Roux-en-Y gastric bypass.

SETTING

Nationwide, register-based study, Sweden.

METHODS

Prospective registry data (Scandinavian Obesity Surgery Register) were analyzed in young (22.2 yr [standard deviation (SD): 2.1], 81.6% women, mean body mass index 43.7 kg/m² [SD: 5.4]) and older (42.6 years [SD: 9.6], 82.0% women, mean body mass index 43.4 kg/m² [SD: 5.0]) adults undergoing Roux-en-Y gastric bypass. Groups were matched for body mass index, sex, and year of surgery. Regression analyses and mixed models were used to compare outcomes between groups.

RESULTS

A total of 369 young (37.0% of eligible) and 2210 older (46.1%) adults attended the 5-year follow-up. At this time, weight loss was 31.8% in young and 28.2% in older adults (P < .001), with a serious adverse event (Clavien-Dindo ≥3b) being reported in 52 (14.1%) young and 153 (6.9%) older adults (odds ratio = 2.06, 95% confidence interval: 1.45-2.92, P < .001). Loss to follow-up was higher in young versus older adults throughout the study period (range of relative risk = 1.16-1.89, P < .001).

CONCLUSIONS

While young adults displayed at least equal weight loss as older adults, rates of adverse events were approximately doubled, and loss to follow-up rates were higher. Future studies on the significance of and the etiology behind the higher incidence of serious adverse events are needed. Intensified clinical contact post Roux-en-Y gastric bypass should have the potential to further improve outcomes in young adults.

Occupational Therapy Intervention Improves Glycemic Control and Quality of Life Among Young Adults With Diabetes: the Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of a manualized occupational therapy (OT) intervention (Resilient, Empowered, Active Living with Diabetes [REAL Diabetes]) to improve glycemic control and psychosocial well-being among ethnically diverse young adults with low socioeconomic status (SES) who have type 1 or type 2 diabetes.

RESEARCH DESIGN AND METHODS

Eighty-one young adults (age 22.6 ± 3.5 years; hemoglobin A_1c [HbA_1c] = 10.8%/95 mmol/mol ± 1.9%/20.8 mmol/mol) were randomly assigned to the REAL Diabetes intervention group (IG) or an attention control group (CG) over 6 months. IG participants received biweekly sessions guided by a manual composed of seven content modules; CG participants received standardized educational materials and biweekly phone calls. Blinded assessors collected data at baseline and 6 months. The primary outcome was HbA_1c; secondary outcomes included diabetes self-care, diabetes-related quality of life (QOL), diabetes distress, depressive symptoms, and life satisfaction. Change scores were analyzed using Wilcoxon rank sum tests.

RESULTS

Intent-to-treat analyses showed that IG participants showed significant improvement in HbA_1c (-0.57%/6.2 mmol/mol vs. +0.36%/3.9 mmol/mol, P = 0.01), diabetes-related QOL (+0.7 vs. +0.15, P = 0.04), and habit strength for checking blood glucose (+3.9 vs. +1.7, P = 0.05) as compared with CG participants. There was no statistically significant effect modification by sex, ethnicity, diabetes type, recruitment site, or SES. No study-related serious adverse events were reported.

CONCLUSIONS

The REAL Diabetes intervention improved blood glucose control and diabetes-related QOL among a typically hard-to-reach population, thus providing evidence that a structured OT intervention may be beneficial in improving both clinical and psychosocial outcomes among individuals with diabetes.

Psychosocial barriers to healthcare use among individuals with diabetes mellitus: A systematic review

PURPOSE

To conduct a systematic review regarding psychosocial barriers to healthcare use in individuals with diabetes mellitus, using a well-established model of health-service use as a theoretical framework.

METHODS

We used database-specific controlled vocabularies and additional free text terms, and conducted searches via MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, OVID Journals. Included studies were rated according to the UK National Institute for Health and Care Excellence (NICE) criteria. A narrative data synthesis was conducted, using the Andersen model and developing categories from the included studies.

PRINCIPAL RESULTS

In total, 2923 studies were identified, and 15 finally included. We identified barriers according to the main categories "population characteristics", "norms and values", and "healthcare services" on a contextual and individual level, as well as "health status". Frequently reported barriers were "socioeconomic status", and "physician characteristics". Ethnic minorities were frequently analysed and may have specific barriers, e.g. "cultural beliefs" and "language".

MAJOR CONCLUSIONS

We identified a broad range of barriers to healthcare use in individuals with diabetes mellitus. However, the number of studies is low. Further research is needed to analyse barriers in more detail considering special subgroups.

Transitional Needs of Australian Young Adults With Type 1 Diabetes: Mixed Methods Study

BACKGROUND

Young adulthood is marked by transitions that impact diabetes self-management behaviors, which require ongoing diabetes education and support. Traditional diabetes education programs and services currently do not meet the needs of many young adults with type 1 diabetes mellitus (T1DM) as they continue to fall through the cracks of clinical services. Age-centered diabetes education programs and services present an opportunity for young adults to meet in a supportive environment and gain a better understanding about diabetes management.

OBJECTIVE

The aim of the study was to identify the health and well-being needs of Australian young adults aged between 18 and 35 years with T1DM to develop appropriate solutions to keep them engaged with diabetes self-management.

METHODS

In total, 13 semistructured individual interviews and self-reported surveys were obtained to understand participants' experiences with diabetes education programs and services. Together with survey data, transcribed interviews were analyzed into themes and categories using comparative analysis to identify the health and well-being needs of young adults with T1DM during young adulthood.

RESULTS

Diabetes education and service needs for young adults with T1DM related to improving access to existing diabetes education programs and services, having credible informational resources, as well as having personalized diabetes management advice. Participants especially valued relevant and real-time information and opportunities for peer support, mostly sourced from Web-based platforms.

CONCLUSIONS

There is a need for diabetes education programs and services to be age-appropriate and easily accessible, to provide relevant and credible information, and to provide opportunities for peer support to better support young adults with T1DM. These findings also support the use of diabetes education programs or services delivered online through mHealth systems in this population.

Cut Points for Identifying Clinically Significant Diabetes Distress in Adolescents With Type 1 Diabetes Using the PAID-T: Results From Diabetes MILES Youth-Australia

OBJECTIVE

To establish cut point(s) for the Problem Areas in Diabetes-teen version (PAID-T) scale to identify adolescents with clinically meaningful, elevated diabetes distress.

RESEARCH DESIGN AND METHODS

Data were available from the Diabetes Management and Impact for Long-term Empowerment and Success (MILES) Youth-Australia Study, a national survey assessing various psychosocial indicators among self-selected National Diabetes Services Scheme registrants. Participants in the current study (n = 537) were (mean ± SD) 16 ± 2 years old, had type 1 diabetes for 6 ± 4 years, and 62% (n = 334) were girls. They completed measures of diabetes distress (PAID-T) and depressive symptoms (Patient Health Questionnaire for Adolescents) and self-reported their most recent HbA_1c and frequency of self-monitoring of blood glucose (SMBG). Relationships between the PAID-T and the psychological and clinical variables were examined to identify a clinically meaningful threshold for elevated diabetes distress. ANOVA was used to test whether these variables differed by levels of distress.

RESULTS

Two cut points distinguished none-to-mild (<70), moderate (70-90), and high (>90) diabetes distress. Moderate distress was experienced by 18% of adolescents and high distress by 36%. Mean depressive symptoms, self-reported HbA_1c, and SMBG differed significantly across the three levels of diabetes distress (all P < 0.001), with moderate-to-large effect sizes.

CONCLUSIONS

Using the PAID-T, this study defined two clinically meaningful cut points to distinguish none-to-mild, moderate, and high diabetes distress in adolescents (aged 13-19). Based on these cut points, most respondents experienced at least moderate diabetes distress, which was clinically significant. Establishing thresholds for elevated diabetes distress will aid clinicians and researchers to interpret PAID-T scores, prompt discussion and intervention for those with unmet needs, and enable the effectiveness of interventions to be evaluated.

Group clinics for young adults with diabetes in an ethnically diverse, socioeconomically deprived setting (TOGETHER study): protocol for a realist review, co-design and mixed methods, participatory evaluation of a new care model

INTRODUCTION

Young adults with diabetes often report dissatisfaction with care and have poor diabetes-related health outcomes. As diabetes prevalence continues to rise, group-based care could provide a sustainable alternative to traditional one-to-one consultations, by engaging young people through life stage-, context- and culturally-sensitive approaches. In this study, we will co-design and evaluate a group-based care model for young adults with diabetes and complex health and social needs in socioeconomically deprived areas.

METHODS AND ANALYSIS

This participatory study will include three phases. In phase 1, we will carry out a realist review to synthesise the literature on group-based care for young adults with diabetes. This theory-driven understanding will provide the basis for phase 2, where we will draw on experience-based co-design methodologies to develop a new, group-based care model for young adults (aged <25 years, under the care of adult diabetes services). In phase 3, we will use a researcher-in-residence approach to implement and evaluate the co-designed group clinic model and compare with traditional care. We will employ qualitative (observations in clinics, patient and staff interviews and document analysis) and quantitative methods (eg, biological markers, patient enablement instrument and diabetes distress scale), including a cost analysis.

ETHICS AND DISSEMINATION

National Health Service ethics approval has been granted (reference 17/NI/0019). The project will directly inform service redesign to better meet the needs of young adults with diabetes in socioeconomically deprived areas and may guide a possible cluster-randomised trial, powered to clinical and cost-effectiveness outcomes. Findings from this study may be transferable to other long-term conditions and/or age groups. Project outputs will include briefing statements, summaries and academic papers, tailored for different audiences, including people living with diabetes, clinicians, policy makers and strategic decision makers.

REGISTRATION DETAILS

PROSPERO (CRD42017058726).

Socioeconomic inequalities in mortality, morbidity and diabetes management for adults with type 1 diabetes: A systematic review

Aims

To systematically review the evidence of socioeconomic inequalities for adults with type 1 diabetes in relation to mortality, morbidity and diabetes management.

Methods

We carried out a systematic search across six relevant databases and included all studies reporting associations between socioeconomic indicators and mortality, morbidity, or diabetes management for adults with type 1 diabetes. Data extraction and quality assessment was undertaken for all included studies. A narrative synthesis was conducted.

Results

A total of 33 studies were identified. Twelve cohort, 19 cross sectional and 2 case control studies met the inclusion criteria. Regardless of healthcare system, low socioeconomic status was associated with poorer outcomes. Following adjustments for other risk factors, socioeconomic status was a statistically significant independent predictor of mortality in 9/10 studies and morbidity in 8/10 studies for adults with type 1 diabetes. There appeared to be an association between low socioeconomic status and some aspects of diabetes management. Although only 3 of 16 studies made adjustments for confounders and other risk factors, poor diabetes management was associated with lower socioeconomic status in 3/3 of these studies.

Conclusions

Low socioeconomic status is associated with higher levels of mortality and morbidity for adults with type 1 diabetes even amongst those with access to a universal healthcare system. The association between low socioeconomic status and diabetes management requires further research given the paucity of evidence and the potential for diabetes management to mitigate the adverse effects of low socioeconomic status.

Access to Transportation and Health Care Visits for Medicaid Enrollees With Diabetes

PURPOSE

Diabetes is a chronic condition that requires frequent health care visits for its management. Individuals without nonemergency medical transportation often miss appointments and do not receive optimal care. This study aims to evaluate the association between Medicaid-provided nonemergency medical transportation and diabetes care visits.

METHODS

A retrospective analysis was conducted of demographic and claims data obtained from the Oklahoma Medicaid program. Participants consisted of Medicaid enrollees with diabetes who made at least 1 visit for diabetes care in a year. The sample was predominantly female and white, with an average age of 46.38 years. Two zero-truncated Poisson regression models were estimated to assess the independent effect of transportation use on number of diabetes care visits.

FINDINGS

Use of nonemergency medical transportation is a significant predictor of diabetes care visits. Zero-truncated Poisson regression coefficients showed a positive association between the use of transportation and number of visits (0.6563, P < .001). Age, gender, race/ethnicity, area of residence, and presence of additional chronic conditions had independent associations with number of visits. Older enrollees were likely to make more visits than younger enrollees with diabetes (0.02382); controlling for all other factors in the model, rural residents made more visits than urban; women made fewer visits than men (-0.09312; P < .001); and minorities made fewer visits than whites, with pronounced differences for Hispanics and Asians compared to whites.

CONCLUSIONS

Findings underscore the importance of ensuring transportation to Medicaid populations with diabetes, particularly in the rural areas where the prevalence of diabetes and complications are higher and the availability of medical resources lower than in the urban areas.

Diabetes Distress Among Adolescents with Type 1 Diabetes: a Systematic Review

Diabetes distress (DD) refers to the negative emotions arising from living with diabetes and the burden of self-management. Among adults, the prevalence and significance of DD are well established, but this is not the case among adolescents. This systematic review investigated among adolescents with type 1 diabetes: the prevalence of DD; demographic, clinical, behavioral and psychosocial correlates of DD and interventions that reduce DD. Consistent with adult studies, around one third of adolescents experience elevated DD and this is frequently associated with suboptimal glycemic control, low self-efficacy and reduced self-care. Three measures of DD have been developed specifically for adolescents, as those designed for adults may not be sufficiently sensitive to adolescent concerns. Interventions reducing DD in the short term include strategies such as cognitive restructuring, goal setting and problem solving. Further work is needed to investigate sustainability of effect. Rigorous research is needed to progress this field among adolescents.

The detection and management of diabetes distress in people with type 1 diabetes

Diabetes distress (DD) represents a significant clinical burden in which levels of DD are related to both glycated haemoglobin (HbA1c) and some self-management behaviours. DD is related to, but different from, depression. Differences in DD experienced in people with type 1 and type 2 diabetes have been observed. Commonly measured using the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS), rates of elevated DD in research study participants range from 20 to 30 %. Risk factors for elevated DD in type 1 diabetes are longer duration of diabetes, severe hypoglycaemia, younger age and being female. A systematic review of intervention studies assessing DD identified eight randomised controlled trials (RCTs) and nine pre-post design studies. Only three studies targeted DD with the intervention. Intervention types were diabetes self-management education (DSME), psychologically informed self-management and devices. DSME pre-post studies, namely the Dose Adjustment For Normal Eating (DAFNE) programme, produced more consistent improvements in DD and HbA1c at follow-up. Psychologically informed self-management was more heterogeneous, but several RCTs were effective in reducing DD. Group interventions offered the greatest benefits across intervention designs.

Type 1 diabetes in young adulthood

Type 1 diabetes has traditionally been studied as a chronic illness of childhood. However, young adulthood is a critical time for the development and integration of lifelong diabetes management skills, and research is starting to identify unique challenges faced by youth with diabetes as they age into adulthood. Most young adults experience multiple transitions during this unstable developmental period, including changes in lifestyle (e.g., education, occupation, living situation), changes in health care, and shifting relationships with family members, friends, and intimate others. Young adults with type 1 diabetes must navigate these transitions while also assuming increasing responsibility for their diabetes care and overall health. Despite these critical health and psychosocial concerns, there is a notable lack of evidence-based clinical services and supports for young adults with type 1 diabetes. We review relevant evolving concerns for young adults with type 1 diabetes, including lifestyle considerations, health care transitions, psychosocial needs, and changes in supportive networks, and how type 1 diabetes impacts and is impacted by these key developmental considerations. Specific avenues for intervention and future research are offered.