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

An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents

Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.

Protocol for the Promoting Resilience in Stress Management (PRISM) intervention: A multi-site randomized controlled trial for adolescents with type 1 diabetes

BACKGROUND

Adolescents with type 1 diabetes (T1D) are at high risk for elevated diabetes distress, which greatly impacts diabetes management, glycemic outcomes and overall quality of life. Developing protective skills and "resilience resources" to navigate adversity and manage diabetes distress has high potential to help adolescents with T1D achieve optimal behavioral, psychological, and health outcomes. The "Promoting Resilience in Stress Management" (PRISM) program is a manualized, brief, skills-based intervention delivered over 6 months via two 45-60 min one-on-one sessions and a family meeting with a PRISM coach, and supplemented by booster calls and a digital app. This trial (PRISM versus usual care)is designed to:: (1) assess PRISM's impact on glycemic outcomes and diabetes distress among adolescents with T1D, and (2) explor PRISM's impact on resilience, self-reported adherence, and quality of life.

METHODS

We describe the protocol for a multi-site randomized controlled trial designed for adolescents ages 13-18 with elevated diabetes distress. The primary trial outcomes are glycemic outcomes and diabetes distress 6 months post-randomization. Secondary outcomes include resilience, self-reported adherence, and QOL 6 months post-randomization. Our hypothesis is that youth in the PRISM group will demonstrate better glycemic outcomes and improved diabetes distress, adherence, resilience, and QOL compared to usual care.

CONCLUSIONS

This study will provide methodologically rigorous data and evidence regarding a novel intervention to promote resilience among adolescents with T1D and elevated diabetes distress. This research has the potential to offer a practical, skills-based curriculum designed to improve outcomes for this high-risk group.

TRIAL REGISTRATION

Prospectively registered at Clinicaltrials.gov (NCT03847194).

Quantitative and qualitative analysis of the quality of life of Type 1 diabetes patients using insulin pumps and of those receiving multiple daily insulin injections

Introduction

Insulin pump therapy represents an alternative to multiple daily injections and can improve glycemic control and quality of life (QoL) in Type 1 diabetes mellitus (T1DM) patients. We aimed to explore the differences and factors related to the T1DM-specific QoL of such patients in Latvia.

Design and methods

A mixed-method cross-sectional study on 87 adult T1DM patients included 20 pump users and 67 users of injections who participated in the quantitative part of the study; 8 pump users and 13 injection users participated in the qualitative part. Patients were invited to participate using a dedicated digital platform. Their QoL and self-management habits were assessed using specially developed questionnaires adapted to Latvian conditions. Multiple logistic regression models were built to investigate the association between social and self-management factors and patients’ QoL. In addition, qualitative analysis of answers was performed.

Results

Insulin pump users were younger, had higher incomes, and reported higher T1DM expenses than users of multiple daily injections. There were no differences in self-management between the groups; Total QoL differed at the 0.1 significance level. In fully adjusted multiple logistic regression models, the most important factor that increased Total QoL was lower T1DM-related expenses (odds ratio, OR 7.02 [95% confidence interval 1.29; 38.0]). Men and those with more years of living with T1DM had better QoL (OR 9.62 [2.20; 42.1] and OR 1.16 [1.05; 1.29], respectively), but the method of administration was not significantly associated with QoL (OR 7.38 [0.87; 62.9]). Qualitative data supported the results of quantitative analysis.

Conclusions

QoL was the main reason to use an insulin pump, while the expense was the main reason to avoid the use of it or to stop using it. Reimbursement policies thus should be considered to enable patients to choose the more convenient method for themselves.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02029-2.

Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review

BACKGROUND

For people with diabetes mellitus to achieve optimal glycaemic control, motivation to perform self-management is important. The research team wanted to determine whether or not psychological interventions are clinically effective and cost-effective in increasing self-management and improving glycaemic control.

OBJECTIVES

The first objective was to determine the clinical effectiveness of psychological interventions for people with type 1 diabetes mellitus and people with type 2 diabetes mellitus so that they have improved (1) glycated haemoglobin levels, (2) diabetes self-management and (3) quality of life, and fewer depressive symptoms. The second objective was to determine the cost-effectiveness of psychological interventions.

DATA SOURCES

The following databases were accessed (searches took place between 2003 and 2016): MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsycINFO, EMBASE, Cochrane Controlled Trials Register, Web of Science, and Dissertation Abstracts International. Diabetes conference abstracts, reference lists of included studies and Clinicaltrials.gov trial registry were also searched.

REVIEW METHODS

Systematic review, aggregate meta-analysis, network meta-analysis, individual patient data meta-analysis and cost-effectiveness modelling were all used. Risk of bias of randomised and non-randomised controlled trials was assessed using the Cochrane Handbook (Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928).

DESIGN

Systematic review, meta-analysis, cost-effectiveness analysis and patient and public consultation were all used.

SETTING

Settings in primary or secondary care were included.

PARTICIPANTS

Adolescents and children with type 1 diabetes mellitus and adults with types 1 and 2 diabetes mellitus were included.

INTERVENTIONS

The interventions used were psychological treatments, including and not restricted to cognitive-behavioural therapy, counselling, family therapy and psychotherapy.

MAIN OUTCOME MEASURES

Glycated haemoglobin levels, self-management behaviours, body mass index, blood pressure levels, depressive symptoms and quality of life were all used as outcome measures.

RESULTS

A total of 96 studies were included in the systematic review (n = 18,659 participants). In random-effects meta-analysis, data on glycated haemoglobin levels were available for seven studies conducted in adults with type 1 diabetes mellitus (n = 851 participants) that demonstrated a pooled mean difference of -0.13 (95% confidence interval -0.33 to 0.07), a non-significant decrease in favour of psychological treatment; 18 studies conducted in adolescents/children with type 1 diabetes mellitus (n = 2583 participants) that demonstrated a pooled mean difference of 0.00 (95% confidence interval -0.18 to 0.18), indicating no change; and 49 studies conducted in adults with type 2 diabetes mellitus (n = 12,009 participants) that demonstrated a pooled mean difference of -0.21 (95% confidence interval -0.31 to -0.10), equivalent to reduction in glycated haemoglobin levels of -0.33% or ≈3.5 mmol/mol. For type 2 diabetes mellitus, there was evidence that psychological interventions improved dietary behaviour and quality of life but not blood pressure, body mass index or depressive symptoms. The results of the network meta-analysis, which considers direct and indirect effects of multiple treatment comparisons, suggest that, for adults with type 1 diabetes mellitus (7 studies; 968 participants), attention control and cognitive-behavioural therapy are clinically effective and cognitive-behavioural therapy is cost-effective. For adults with type 2 diabetes mellitus (49 studies; 12,409 participants), cognitive-behavioural therapy and counselling are effective and cognitive-behavioural therapy is potentially cost-effective. The results of the individual patient data meta-analysis for adolescents/children with type 1 diabetes mellitus (9 studies; 1392 participants) suggest that there were main effects for age and diabetes duration. For adults with type 2 diabetes mellitus (19 studies; 3639 participants), baseline glycated haemoglobin levels moderated treatment outcome.

LIMITATIONS

Aggregate meta-analysis was limited to glycaemic control for type 1 diabetes mellitus. It was not possible to model cost-effectiveness for adolescents/children with type 1 diabetes mellitus and modelling for type 2 diabetes mellitus involved substantial uncertainty. The individual patient data meta-analysis included only 40-50% of studies.

CONCLUSIONS

This review suggests that psychological treatments offer minimal clinical benefit in improving glycated haemoglobin levels for adults with type 2 diabetes mellitus. However, there was no evidence of benefit compared with control interventions in improving glycated haemoglobin levels for people with type 1 diabetes mellitus.

FUTURE WORK

Future work should consider the competency of the interventionists delivering a therapy and psychological approaches that are matched to a person and their life course.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016033619.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 28. See the NIHR Journals Library website for further project information.

Effects of a Life Skills-Based Intervention on Mental Health of Adolescents and Young Adults With Type 1 Diabetes

The current study examined the effectiveness of a life skills training intervention on the psychological health of adolescents and young adults with type 1 diabetes. This quasi-randomized controlled trial recruited 80 individuals from the West Azerbaijan Diabetes Community in Urmia, Iran. Participants were randomly allocated to intervention (n = 40) or control (n = 40) groups. The intervention group received nine sessions of life skills training, and the control group received routine care only. Data collection tools included a demographics questionnaire and the Depression, Anxiety, and Stress Scale. Compared to the control group, intervention group participants achieved statistically significant improvements in their physiological health, including stress (p < 0.04), anxiety (p < 0.04), and depression (p < 0.03). Nurses, including diabetes educators, should assess patients with diabetes for psychological complications and consider empowering adolescents and young adults with diabetes through life skills training, which can be incorporated into diabetes management plans to promote health and well-being. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Adaptation of an Evidence-Based Diabetes Management Intervention for Delivery in Community Settings: Findings From a Pilot Randomized Effectiveness Trial

Objective

To adapt an evidence-based intervention targeting diabetes management in adolescents with poorly controlled type 1 diabetes for use in a community setting by community health workers (CHWs) and to conduct pilot testing of the new intervention, REACH for Control (RFC). The study was conducted as a collaboration between university researchers and a federally qualified health center. Methods In a pilot effectiveness trial, feasibility and acceptability of RFC were evaluated based on participant enrollment, treatment dose, and consumer satisfaction. RFC effects on adolescent adherence, health outcomes, and quality of life were also assessed. The trial used a parallel group design. Families were randomized to 6 months of RFC plus standard medical care (n = 26) or standard care (SC) only (n = 24). Data were collected at baseline and 7-month posttest. A mixed-methods approach was used to analyze data.

Results

Qualitative analyses suggested that caregivers viewed RFC and delivery of a home-based intervention by CHWs positively. Furthermore, adolescents who received RFC had statistically significant (p = .05) and clinically meaningful improvements in hemoglobin A1c (HbA1c) (0.7%) and reported significant improvements in quality of life from baseline to follow-up (p = .001). No significant changes were found for adolescents in standard medical care. However, while dose of primary intervention session delivered was acceptable, dose of follow-up sessions used for skills practice was low.

Conclusions

Results provide preliminary support for RFC's acceptability and effectiveness to improve health status and quality of life when used in community settings serving high-risk, low-income families. Additional testing in a full-scale effectiveness trial appears warranted.

Psychosocial Interventions for Emergent Adults With Type 1 Diabetes: Near-Empty Systematic Review and Exploratory Meta-Analysis

Risk for developing mental health concerns is increased for people with diabetes. Coupled with stressors related to the transition from adolescence to adulthood, emergent adults may be in greater need of psychosocial interventions to help them cope. This review summarizes the literature on interventions used with people with diabetes aged 15-30 years on psychosocial and biological (A1C) outcomes. Core databases were searched for both published and grey research. Studies completed between January 1985 and October 2018 using any psychosocial intervention and meeting age and diabetes type requirements were selected if they included a control or comparison group and findings reported in such a way that effect size was calculable. Two authors independently extracted relevant data using standard data extraction templates. Six studies with 450 participants met the broad inclusion criteria. Sample-weighted pooling of 12 outcomes, six each on glycemic control and psychosocial status, suggested the preventive potential (d = 0.31, 95% CI 0.17-0.45) and homogeneity (χ² [11] = 11.15, P = 0.43) of studied interventions. This preliminary meta-analysis provides some suggestion that psychosocial interventions, including telephone-based case management, individualized treatment modules, and small-group counseling interventions, may diminish burden, depression, and anxiety and enhance glycemic control among emerging adults with type 1 diabetes as they transition from adolescence to adulthood.

Implementation of an educational intervention to optimize self-management and transition readiness in young adults with sickle cell disease

BACKGROUND

The transition from the pediatric setting to adult care is a well-described period of morbidity and mortality for persons with sickle cell disease (SCD). We sought to measure the feasibility and effectiveness of providing skill-based educational handouts on improving self-management and transition readiness in adolescents with SCD.

METHODS

This was a single-center study in which participants completed a self-assessment, the Adolescent Autonomy Checklist (AAC), to assess transition readiness and self-management skills at baseline. After results were reviewed by the study coordinator, participants were provided with skill-based handouts on noted areas of deficit. The AAC was subsequently completed at a follow-up visit. All data were stored electronically and transferred into SAS for statistical analyses.

RESULTS

Sixty-one patients completed the AAC at baseline and postintervention. At baseline, patients reported needing the most help with skills in money management, living arrangements, vocational skills, and emergency and healthcare skills. Postintervention, statistically significant improvements (P < 0.05) occurred in skills related to laundry, housekeeping, healthcare, and sexual development. A regression model exploring the time to follow-up showed that most improvements could not be attributed to maturation alone.

CONCLUSION

This study showed that educational handouts are a readily implementable and well-accepted intervention among adolescents with SCD who identify challenges with skills necessary to successfully transition to adult care. Distinguishing which transition needs are best improved with this type of intervention will help to strengthen the multidisciplinary approach necessary to support adolescents and young adults with SCD as they matriculate to adult care.

The psychosocial self-efficacy in adolescents with type 1 diabetes

AIM

To analyse psychosocial self-efficacy in adolescents with type 1 diabetes, evaluate associations between self-efficacy and metabolic control and background variables and determine psychometric properties of the Finnish Diabetes Empowerment Scale (Fin-DES-28).

DESIGN

A descriptive correlational survey.

METHODS

The data were collected with the Finnish Diabetes Empowerment Scale from 13-16-year-old adolescents with type 1 diabetes (N = 189, 34%) in one university hospital district area in 2014.

RESULTS

The level of psychosocial self-efficacy was quite good. The highest scores were in managing the psychosocial aspects of diabetes, followed by assessing dissatisfaction and readiness to change and setting and achieving diabetes goals. The self-efficacy did not correlate with metabolic control or background variables. A positive association was found between self-efficacy and understanding of diabetes and its treatment, adjustment of diabetes to life and the relationship with the doctor and the nurse. The internal consistency of the Finnish Diabetes Empowerment Scale was adequate. The low response rate limits generalization.

Self-rated health among American adolescents with type 1 diabetes in the T1D Exchange Clinic Registry

BACKGROUND

The goal of this study was to examine the self-rated health (SRH) of adolescents with type 1 diabetes (T1D).

METHODS

A logistic regression analysis of baseline data from adolescents in the United States included in the T1D Exchange Clinic Registry in 2010-2012 was conducted. Participants were 13-18years old at the time of enrollment in the registry and had been diagnosed with T1D at least one year before enrollment (n=5799).

RESULTS

Half (49.0%) of the participants were female, 46.3% were ages 16-18years, 22.5% were non-white, 35.7% did not have private/military health insurance, and 78.8% had HbA1c levels >7.5%, indicating poor T1D management, 20.7% reported having diabetes-related stress often or very often, and 46.4% used insulin injections or pens rather than a pump. In total, 10.3% (n=600) of the participants rated their health as poor or fair and 59.3% (n=3439) rated their health as very good or excellent. Participants with poor or fair SRH were more likely than those with very good or excellent SRH to be female (adjusted OR=1.7(1.4, 2.1)), 16 to 18years old (OR=2.1(1.7, 2.5)), and non-white (OR=2.7(2.2, 3.4)), to be without private or military insurance (OR=2.4(2.1, 3.0)), to have HbA1c levels >7.5% (OR=3.3(2.4, 4.7)), to report having diabetes-related stress often or very often (OR=6.1(5.1, 7.2)), and to use an injection or pen rather than a pump (OR=2.1(1.6, 2.4)).

CONCLUSIONS

Because adolescents with T1D who report lower SRH are more likely to have uncontrolled blood glucose and frequent diabetes-related stress, use of pumps and stress-reduction strategies may improve SRH among adolescents with T1D.