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

Effectiveness of resilience-promoting interventions in adolescents with diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

This study aimed to analyze the efficacy of resilience-promoting interventions among adolescents and youth aged 10-24 years with any type of diabetes.

METHODS

A systematic literature search was performed using the PubMed, Web of Science, Embase, Cochrane Library, CINAHL, and PsycINFO databases from inception to May 25, 2022. The Cochrane risk of bias tool (version 2) was used to assess the quality of the included studies. A meta-analysis was performed to calculate the pooled effects of resilience-promoting interventions.

RESULTS

Nineteen articles were included covering an overall sample of 2048 adolescents with diabetes. When analyzing the effectiveness of resilience-promoting interventions, hemoglobin A1c (HbA1c) at six months [mean difference = - 0.47, 95% confidence interval (CI) = - 0.83 to - 0.12, P = 0.009] after the intervention was improved. However, long-term (≥ 12 months) improvement in HbA1c was not significant. In addition, comparing the control group, there were significant differences in the effect size for stress [standardized mean difference (SMD) = - 0.87, 95% CI = - 1.25 to -0.48, P < 0.05], self-efficacy (SMD = 0.50, 95% CI = 0.02-0.98, P = 0.04) and quality of life (SMD = 0.27, 95% CI = 0.03-0.51, P = 0.03).

CONCLUSIONS

Resilience-promoting intervention is a promising way for adolescent diabetes management to improve HbA1c, stress, self-efficacy, and quality of life. Incorporating resilience-promoting components into diabetes education and re-enforcing these contents every six months are recommended for implementation in clinical practice.

Effects of mobile health interventions on improving glycemic stability and quality of life in patients with type 1 diabetes: A meta-analysis

This meta-analysis aimed to examine the effects of mobile-health-based (mHealth) interventions on improving glycemic stability and quality of life (QOL) in patients with type 1 diabetes (T1D). Various databases, including PubMed, Embase, CINAHL, Cochrane Library, ProQuest, Chinese Electronic Periodical Services, and China Knowledge Resource Integrated, were used to search for relevant articles. A fixed-effects model or random-effects model was used to examine the overall effect. Various methods, including Egger's test, Begg's test, and trim-and-fill, were adopted to examine publication bias. In total, 26 studies were recruited. Results of the random-effects model showed that the use of mHealth-based interventions significantly decreased glycated hemoglobin (HbA1c) (mean difference = -0.37, 95% confidence interval (CI) = -0.53 to -0.22, p < .001), and improved life satisfaction (Hedges' g = 0.30, 95% CI = 0.10 to 0.50, p = .003), worry of diabetes (Hedges' g = -0.25, 95% CI = -0.41 to 0.08, p = .004), and mental health (Hedges' g = 0.36, 95% CI = 0.08 to 0.64, p = .012). Both adults and youths with T1D can benefit from mHealth-based interventions to improve HbA1c (Hedges' g = -0.44, p = .002 vs. -0.30, p = .003). The effect of mHealth-based interventions on improving QOL in both adults and youths could not be examined due to only one study published in adults with T1D. Moreover, those studies that included the function of feedback from professionals showed a significant effect of decreasing HbA1c compared to those without that function (Hedges' g = -0.48 vs. -0.16, p = .019). Mobile devices are convenient, instantaneous, and easy to use to communicate. Applying mHealth-based interventions with the function of feedback from professionals can be considered an alternative healthcare service to achieve optimal glycemic stability in adults and youths with T1D.

Understanding adolescent and parent acceptability and feasibility experience in a large Type 1 diabetes mellitus behavioural trial

AIMS

Using an 18-month, multisite randomized control trial as an exemplar, the aim of this study was to identify themes related to adolescent and parental feasibility and acceptability for participation in large behavioural trials designed to improve adolescents' Type 1 diabetes self-management.

METHODS

Thematic analysis methodology was used to develop themes describing factors related to acceptability and feasibility.

RESULTS

Based on a sample of interviews (N = 72), factors contributing to intervention acceptability and feasibility were identified. Aspects of acceptability included: a framework for goal-setting, the coach as a non-judgemental listener, perception of an ongoing benefit to participation and the delivery mode. Aspects of feasibility included: participants' altruism to help adolescents with Type 1 diabetes; pre-enrolment preparation for intervention content and duration; and the option of remote intervention delivery via telephone or video, which minimized travel time and costs. In addition, participants described positive outcomes including improvements in behaviour, Type 1 diabetes self-management behaviours and parent-adolescent communication, and emotion-attitude changes. Participants also described potential revisions that may inform future trials.

CONCLUSIONS

Acceptability and feasibility of behavioural interventions with adolescents with chronic illness have multifactorial dimensions. While empowering adolescent self-management, parental support is also an under-appreciated aspect to consider. Potential revisions were identified for subsequent behavioural trials.

A Quality Improvement Initiative to Reduce Hospitalizations for Low-risk Diabetic Ketoacidosis

BACKGROUND AND OBJECTIVES

Children with established type 1 diabetes (T1D) who present to the emergency department (ED) with mild diabetic ketoacidosis (DKA) are often hospitalized, although outpatient management may be appropriate. Our aim was to reduce hospitalization rates for children with established T1D presenting to our ED with mild DKA who were considered low risk for progression of illness.

METHODS

We conducted a quality improvement initiative between January 1, 2012, and December 31, 2018 among children and young adults ≤21 years of age with established T1D presenting to our tertiary care ED with low-risk DKA. Children transferred to our institution were excluded. DKA severity was classified as low, medium, or high risk on the basis of laboratory and clinical criteria. Our quality improvement initiative consisted of development and implementation of an evidence-based treatment guideline after review by a multidisciplinary team. Our primary outcome was hospitalization rate, and our balancing measure was 3-day ED revisits. Statistical process control methods were used to evaluate outcome changes.

RESULTS

We identified 165 patients presenting with low-risk DKA. The baseline preimplementation hospitalization rate was 74% (95% confidence interval 64%-82%), and after implementation, this decreased to 55% (95% confidence interval 42%-67%) (-19%; P = .011). The postimplementation hospitalization rate revealed special cause variation. One patient in the postimplementation period returned to the ED within 3 days but did not have DKA and was not hospitalized.

CONCLUSIONS

Hospitalization rates for children and young adults presenting to the ED with low-risk DKA can be safely reduced without an increase in ED revisits.

STRATEGIES TO EDUCATE YOUNG PEOPLE WITH TYPE 1 DIABETES MELLITUS ON INSULIN THERAPY: SYSTEMATIC REVIEW

ABSTRACT Objective: to identify evidence available in the literature on educational strategies used in the teaching of insulin therapy to children and adolescents with Type 1 diabetes mellitus. Method: systematic review undertaken in five databases, using the descriptors Insulin/therapeutic use, Patient education as topic, Diabetes mellitus type 1, Child, Infant, Adolescent and keywords, without any time limit. Primary studies on insulin therapy teaching were included, while research on insulin pumps was excluded. Results: 243 studies were identified, 13 of which were included. The results present educational strategies focused on children, adolescents and young people of up to 24 years of age, applied individually or in groups; by telephone contact or text messages by mobile phone; dramatization and educational camps; by a single professional or a multidisciplinary team. The strategies described in the analyzed studies addressed the adjustment of insulin dosages in everyday situations and education for insulin management, associated with the nutritional strategy of carbohydrate counting, diabetes education with a specific module on insulin therapy and intensive insulin use. The studies analyzed the effect of the educational intervention on several clinical and behavioral outcomes, such as glycated hemoglobin and self-efficacy. Conclusion: this review could not identify a single educational strategy able to improve metabolic and psychosocial outcomes. In most cases, nurses are the professionals responsible for the development of educational strategies focused on insulin therapy in children and adolescents with diabetes, regardless of the context in which they will be deployed. This confirms their role as educators.

Efficacy of the Flexible Lifestyles Empowering Change intervention on metabolic and psychosocial outcomes in adolescents with type 1 diabetes (FLEX): a randomised controlled trial

BACKGROUND

Adolescents with type 1 diabetes commonly have poor glycaemic control. We aimed to test the efficacy of a newly developed adaptive behavioral intervention (Flexible Lifestyles Empowering Change; FLEX) on metabolic and psychosocial outcomes in adolescents with type 1 diabetes.

METHODS

Young people (13-16 years, type 1 diabetes duration >1 year, HbA1c of 64-119 mmol/mol [8·0-13·0%], and without other serious medical conditions or pregnancy) from two clinical sites (Colorado and Ohio, USA) were eligible for enrolment. One caregiver was required to participate actively in the study. Adolescent participants were randomly assigned to the FLEX intervention, which used motivational interviewing and problem-solving skills training to enhance patients' self-management, or usual care control. Intervention fidelity was assessed by a behavioral psychologist with specific expertise in motivational interviewing and who was not otherwise involved in the study via audiotaped sessions. The primary outcome was measurement of glycated haemoglobin A1c (HbA1c) at 18 months. Secondary outcomes included motivation and intention, problem solving skills, self-management behaviors, symptoms of depression, health related quality of life, fear of hypoglycemia, diabetes family conflict, risk factors for T1D complications (BMI, blood pressure, and plasma lipids), and hypoglycemia derived from continuous glucose monitoring (percent time below 3·0 and 3·9 mmol/l [54 and 70 mg/dl]). Intention-to-treat analyses used mixed effects models, with fixed effects including site, timepoint, intervention group, intervention by timepoint, and baseline level of primary (HbA1c) or secondary outcomes (α=0·05). FLEX is registered on clinicaltrials.gov, number NCT01286350.

FINDINGS

Young people recruited from May 1, 2014 to April 4, 2016 were randomly assigned to FLEX (n=130) or usual care control (n=128). Mean diabetes duration was 6·4 (SD 3·8) years, and 71% (181 out of 256) of patients used insulin pump therapy. Retention was 93%, with 241 out of 258 completing the 18-month assessment. The intervention fidelity score was 4·40 of 5·00 for motivational interviewing and 97% for session content. At 18 months, HbA1c was not significantly different between intervention (83 [13] mmol/mol at baseline; 84 [19] mmol/mol at follow-up); and control (80 [14] mmol/mol at baseline; 82 [17] mmol/mol at follow-up); change in intervention versus control was -0·7 mmol/mol (95% CI -4·7 to 3·4, p=0·75). The intervention was associated with improved scores for motivation (p=0·011), problem solving (p=0·024), diabetes self-management profile (p=0·013), youth report of overall quality of life (p=0·0089), selected domains related to fear of hypoglycaemia (p=0·036 for youth's helplessness or worry; p=0·0051 for parent's efforts to maintain high blood glucose), parent report of diabetes family conflict (p=0·0001), total cholesterol (p=0·038), and diastolic blood pressure (p=0·015). A total of 54 serious adverse events were identified; 34 of these were diabetes-related, including low blood glucose requiring assistance (n=3) and high blood glucose with diabetic ketoacidosis and emergency response (n=25).

INTERPRETATION

The FLEX intervention did not significantly change HbA1c among these adolescents with elevated HbA1c, but did positively affect several psychosocial outcomes over 18 months. Further analyses will provide information regarding drivers of positive response to the intervention and will point to future directions for improvement in the approach.

FUNDING

National Institutes of Health and National Institute of Diabetes Digestive Diseases and Kidney and the Helmsley Charitable Trust.

The role of telenursing in the management of Diabetes Type 1: A randomized controlled trial

BACKGROUND

Diabetes Mellitus type 1 (T1DM) is a chronic disease that requires patients' self-monitoring and self-management to achieve glucose targets and prevent complications. Telenursing implicates technology in the interaction of a specialized nurse with patients with chronic diseases in order to provide personalized care and support.

OBJECTIVE

To evaluate the effect of telenursing on T1DM patients' compliance with glucose self-monitoring and glycemic control.

DESIGN

Randomized controlled study.

SETTINGS

Outpatient Department of Diabetes, Endocrinology and Metabolism of a University Hospital in Northern Greece.

METHODS

Ninety-four T1DM patients were recruited and randomized in two groups by a random number generator. The intervention group (N = 48) was provided with telenursing services. A specialized nurse made a weekly contact via telephone motivating patients to frequently measure blood glucose and adopt a healthy lifestyle. The control group (N = 46) received standard diabetes advice and care in the clinic. The primary outcome was the effect of the intervention in glucose control and glucose variability. The secondary outcome was the effect on frequency of self-monitoring. SPSS 20.0 was used for data analysis.

RESULTS

The two groups did not differ in age, sex, physical activity or initial HbA1c. In the intervention group, blood glucose significantly decreased at the end of the study in all predefined measurements, compared to control group: morning (93.18 ± 13.30 mg/dl vs. 105.17 ± 13.74 mg/dl, p < 0.005), pre-prandial (114.76 ± 9.54 mg/dl vs. 120.84 ± 4.05 mg/dl, p < 0.005), post-prandial (193.35 ± 25.36 mg/dl vs. 207.84 ± 18.80 mg/dl, p < 0.005), and HbA1c decreased significantly over time in the intervention group (8.3 ± 0.6% at the beginning of the study vs. 7.8 ± 1% at the end of the study, p = 0.03). In the intervention group there were also fewer omitted glucose measurements than in the control group.

CONCLUSIONS

Patients in the intervention group achieved better glucose control and more frequent self-monitoring than patients in routine care in the clinic. The findings of our study indicate that telenursing can motivate T1DM patients to better control their disease.

Design and development of a stepped-care behavioral intervention to support parents of young children newly diagnosed with type 1 diabetes

One of the most common chronic conditions of childhood, the prevalence of type 1 diabetes (T1D) in young children is increasing. Early childhood development complicates optimal T1D management and glycemic outcomes. Parents are at risk for elevated psychological distress, especially immediately following diagnosis. Few empirically supported interventions are available to support parents and promote optimal T1D management during this vulnerable period. This paper reports on the development and study design of First STEPS: Study of Type 1 in Early childhood and Parenting Support. The aim of this trial is to evaluate the efficacy of a stepped care behavioral intervention for parents of young children over the first year following a new T1D diagnosis. The stepped care design provides participants with up to three intensity levels, or steps, of clinical behavioral intervention support based on need, compared to usual care. Intervention steps include peer parent coaching, telephone-based behavioral support, personalized psychological assessment and recommendations, and intensive assessment of T1D glycemic management with recommendations. Primary outcomes include children's glycemic control and parents' psychosocial functioning. Secondary outcomes include children's behavioral and psychosocial functioning. Exploratory analyses will evaluate demographic, disease-specific, and psychosocial factors related to progression in and response to each step of the intervention.

Psycho-educational interventions for children and young people with Type 1 Diabetes in the UK: How effective are they? A systematic review and meta-analysis

Aims

To synthesise evidence from UK-based randomised trials of psycho-educational interventions in children and young people (CYP) with Type 1 Diabetes (T1D) to inform the evidence-base for adoption of such interventions into the NHS.

Methods

We searched Medline, Embase, Cochrane, PsycINFO, CINAHL, and Web of Science up to March 2016. Two reviewers independently selected UK-based randomised trials comparing psycho-educational interventions for improving management of T1D for CYP with a control group of usual care or attention control. The main outcome was glycaemic control measured by percentage of glycated haemoglobin (HbA_1c); secondary outcomes included psychosocial functioning, diabetes knowledge, adverse and other clinical outcomes. A narrative synthesis and meta-analysis were conducted. Pooled effect sizes of standardised mean difference (SMD) were calculated.

Results

Ten eligible trials of three educational and seven psycho-educational interventions were identified. Most interventions were delivered by non-psychologists and targeted adolescents with more than one year duration of diabetes. Meta-analysis of nine of these trials (N = 1,838 participants) showed a non-significant reduction in HbA_1c attributable to the intervention (pooled SMD = -0.06, 95% CI: -0.21 to 0.09). Psycho-educational interventions aiming to increase children’s self-efficacy had a moderate, beneficial effect (SMD = 0.50, 95% CI: 0.13 to 0.87). No benefits on diabetes knowledge and other indicators of psychosocial functioning were identified.

Conclusions

There is insufficient evidence to recommend the use of particular psycho-educational programme for CYP with T1D in the UK. Further trials with sufficient power and reporting standards are needed. Future trials could consider active involvement of psychological specialists in the delivery of psychologically informed interventions and implementation of psycho-educational interventions earlier in the course of the disease.

Systematic review registration

PROSPERO CRD42015010701

Telemedicine for the Management of Glycemic Control and Clinical Outcomes of Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Importance: Telemedicine has been shown to be an efficient and effective means of providing care to patients with chronic disease especially in remote and undeserved regions, by improving access to care and reduce healthcare cost. However, the evidence surrounding its applicability in type 1 diabetes remains scarce and conflicting.

Objective: To synthesize evidence and quantify the effectiveness of telemedicine interventions for the management of glycemic and clinical outcomes in type 1 diabetes patients, relative to comparator conditions.

Data Sources: MEDLINE, EMBASE, Cochrane Library, Web of Science, PsycINFO, and CINAHL were searched for published articles since inception until December 2016.

Study Selection: Original articles reporting the results of randomized controlled studies on the effectiveness of telemedicine in people with type 1 diabetes were included.

Data Extraction and Synthesis: Two reviewers independently extracted data, assessed quality, and strength of evidence. Interventions were categorized based upon the telemedicine focus (monitoring, education, consultation, case-management, and peer mentoring).

Main Outcome and Measure: Absolute change in glycosylated hemoglobin A1c (HbA1c) from baseline to follow-up assessment.

Results: A total of 38 studies described in 41 articles were identified. Positive effects on glycemic control were noted with studies examining telemedicine, with a mean reduction of 0.18% at the end of intervention. Studies with longer duration (>6 months) who had recruited patients with a higher baseline HbA1c (≥9%) were associated with larger effects. Telemedicine interventions that involve individualized assessments, audit with feedback and skill building were also more effective in improving glycemic control. However, no benefits were observed on blood pressure, lipids, weight, quality of life, and adverse events.

Conclusions and Relevance: There is insufficient evidence to support telemedicine use for glycemic control and other clinically relevant outcome among patients with type 1 diabetes.

Barriers and facilitators associated with attendance at hospital diabetes clinics among young adults (15-30 years) with type 1 diabetes mellitus: a systematic review

Regular clinic attendance is recommended to facilitate self-management of diabetes. Poor attendance is common among young adults with type 1 diabetes mellitus (DM). This systematic review aimed to produce a narrative synthesis of the evidence regarding factors which promote or impede regular attendance at adult diabetes clinics among young adults (15-30 years) with type 1 DM. Studies reporting facilitators and barriers to clinic attendance were identified by searching four electronic databases, checking reference lists, and contacting diabetes research networks. A total of 12 studies (8 quantitative and 4 qualitative) met the inclusion criteria. Young adult's experiences transitioning from paediatric to adult diabetes care can influence attendance at the adult clinic positively if there is a comprehensive transition programme in place, or negatively if the two clinics do not communicate and provide adequate support. Post-transition, relationship development and perceptions of the value of attending the clinic are important for regular attendance. Controlled research is required to better understand decisions to attend or not attend outpatient services among people with chronic conditions. Service delivery must be sensitive to the developmental characteristics of young adults and tailored support may be required by young adults at greatest risk of non-attendance.

Does telemedicine improve treatment outcomes for diabetes? A meta-analysis of results from 55 randomized controlled trials

AIMS

To assess the overall effect of telemedicine on diabetes management and to identify features of telemedicine interventions that are associated with better diabetes management outcomes.

METHODS

Hedges's g was estimated as the summary measure of mean difference in HbA1c between patients with diabetes who went through telemedicine care and those who went through conventional, non-telemedicine care using a random-effects model. Q statistics were calculated to assess if the effect of telemedicine on diabetes management differs by types of diabetes, age groups of patients, duration of intervention, and primary telemedicine approaches used.

RESULTS

The analysis included 55 randomized controlled trials with a total of 9258 patients with diabetes, out of which 4607 were randomized to telemedicine groups and 4651 to conventional, non-telemedicine care groups. The results favored telemedicine over conventional care (Hedges's g=-0.48, p<0.001) in diabetes management. The beneficial effect of telemedicine were more pronounced among patients with type 2 diabetes (Hedges's g=-0.63, p<0.001) than among those with type 1 diabetes (Hedges's g=-0.27, p=0.027) (Q=4.25, p=0.04).

CONCLUSIONS

Compared to conventional care, telemedicine is more effective in improving treatment outcomes for diabetes patients, especially for those with type 2 diabetes.

Impact of phone call intervention on glycemic control in diabetes patients: a systematic review and meta-analysis of randomized, controlled trials

Background

Telephone-delivered intervention can provide many supports in diabetes self-management to improve glycemic control. Several trials showed that telephone intervention was positively associated with glycemic outcomes in diabetes. The objective of this meta-analysis was to assess the impact of telephone contact intervention (intervention group) on glycemic control compared with standard clinical care (control group).

Methods

Randomized control studies of telephone intervention in diabetes were searched on Medline (Pubmed), the Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science (ISI), and Scopus. Electronic search was done from inception to April 2013. The following MeSH terms were used: diabetes mellitus, randomized control trials and telemedicine, together with keywords including phone intervention, diabetes, and glycemic control. Historical search was also conducted on the references of relevant articles. The quality of the trials was assessed using Maastricht-Amsterdam scale. Treatment effect was estimated with mean difference in the change of hemoglobin A1c (HbA1c) from baseline between the intervention and control groups.

Results

A total of 203 articles were examined. Five trials involving 953 patients met the inclusion criteria and contributed to the meta-analysis. Telephone contact intervention was no more effective than standard clinical care in improving glycemic control (pooled mean difference in HbA1c −0.38%, 95%CI −0.91 to 0.16%).

Conclusions

This meta-analysis showed that the phone contact intervention was no more effective than standard clinical care in improving glycemic control in diabetes. However, telephone intervention may still have potential benefits especially for low-and middle-income countries; thus further large sample size and well-controlled studies are needed to evaluate the impact of the intervention.

Diabetes self-management education patterns in a US population-based cohort of youth with type 1 diabetes

PURPOSE

The purpose of this study is to describe (1) the receipt of diabetes self-management education (DSME) in a large, diverse cohort of US youth with type 1 diabetes (T1DM), (2) the segregation of self-reported DSME variables into domains, and (3) the demographic and clinical characteristics of youth who receive DSME.

METHODS

Data are from the US population-based cohort SEARCH for Diabetes in Youth. A cross-sectional analysis was employed using data from 1273 youth <20 years of age at the time of diagnosis of T1DM. Clusters of 19 self-reported DSME variables were derived using factor analysis, and their associations with demographic and clinical characteristics were evaluated using polytomous logistic regression.

RESULTS

Nearly all participants reported receiving DSME content consistent with "survival skills" (eg, target blood glucose and what to do for low or high blood glucose), yet gaps in continuing education were identified (eg, fewer than half of the participants reported receiving specific medical nutrition therapy recommendations). Five DSME clusters were explored: receipt of specific MNT recommendations, receipt of diabetes information resources, receipt of clinic visit information, receipt of specific diabetes information, and met with educator or nutritionist. Factor scores were significantly associated with demographic and clinical characteristics, including race/ethnicity, socioeconomic status, and diabetes self-management practices.

CONCLUSIONS

Health care providers should work together to address reported gaps in DSME to improve patient care.

Diabetes self-management smartphone application for adults with type 1 diabetes: randomized controlled trial

Background

Persistently poor glycemic control in adult type 1 diabetes patients is a common, complex, and serious problem initiating significant damage to the cardiovascular, renal, neural, and visual systems. Currently, there is a plethora of low-cost and free diabetes self-management smartphone applications available in online stores.

Objective

The aim of this study was to examine the effectiveness of a freely available smartphone application combined with text-message feedback from a certified diabetes educator to improve glycemic control and other diabetes-related outcomes in adult patients with type 1 diabetes in a two-group randomized controlled trial.

Methods

Patients were recruited through an online type 1 diabetes support group and letters mailed to adults with type 1 diabetes throughout Australia. In a 6-month intervention, followed by a three-month follow-up, patients (n=72) were randomized to usual care (control group) or usual care and the use of a smartphone application (Glucose Buddy) with weekly text-message feedback from a Certified Diabetes Educator (intervention group). All outcome measures were collected at baseline and every three months over the study period. Patients’ glycosylated hemoglobin levels (HbA1c) were measured with a blood test and diabetes-related self-efficacy, self-care activities, and quality of life were measured with online questionnaires.

Results

The mean age of patients was 35.20 years (SD 10.43) (28 male, 44 female), 39% (28/72) were male, and patients had been diagnosed with type 1 diabetes for a mean of 18.94 years (SD 9.66). Of the initial 72 patients, 53 completed the study (25 intervention, 28 control group). The intervention group significantly improved glycemic control (HbA1c) from baseline (mean 9.08%, SD 1.18) to 9-month follow-up (mean 7.80%, SD 0.75), compared to the control group (baseline: mean 8.47%, SD 0.86, follow-up: mean 8.58%, SD 1.16). No significant change over time was found in either group in relation to self-efficacy, self-care activities, and quality of life.

Conclusions

In adjunct to usual care, the use of a diabetes-related smartphone application combined with weekly text-message support from a health care professional can significantly improve glycemic control in adults with type 1 diabetes.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12612000132842; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612000132842 (Archived by WebCite at http://www.webcitation.org/6Kl4jqn5u).

The in vivo adherence intervention for at risk adolescents with asthma: report of a randomized pilot trial

OBJECTIVE

Low-income and minority adolescents are at high risk for poor asthma outcomes, due in part to adherence. We tested acceptability, feasibility, and effect sizes of an adherence intervention for low socioeconomic status (SES) minority youth with moderate- and severe-persistent asthma. Design and Methods Single-site randomized pilot trial: intervention (n = 12; asthma education, motivational interviewing, problem-solving skills training, 1 month cell-phone with tailored text messaging) versus control (n = 14; asthma education; cell-phone without tailored messaging). Calculated effect-sizes of relative change from baseline (1 and 3 months).

RESULTS

Intervention was judged acceptable and feasible by participants. Participants (12-18 years, mean = 15.1, SD = 1.67) were 76.9% African-American, 80.7% public/no insurance. At 1 and 3 months, asthma symptoms (Cohen's d's = 0.40, 0.96) and HRQOL (PedsQL™; Cohen's d's = 0.23, 1.25) had clinically meaningful medium to large effect sizes.

CONCLUSIONS

This intervention appears promising for at-risk youth with moderate- and severe-persistent asthma.

Patients' experience of a telephone booster intervention to support weight management in Type 2 diabetes and its acceptability

We studied the patient experience of a telephone booster intervention, i.e. weekly reinforcement of the clinic advice regarding lifestyle modification advice to support weight loss. Forty six adults with Type 2 diabetes and a body mass index >28 kg/m(2) were randomised into either intervention (n = 25) or control (n = 21) groups. Semi-structured interviews were conducted with the intervention group participants to explore their views and experiences. The patients were satisfied or very satisfied with the telephone calls and most would recommend the intervention to others in a similar situation. The content of the telephone follow-up met their need for on-going support. The benefits arising from the telephone calls included: being reminded to comply with their regimen; prompting and motivating adherence to diabetes self-care behaviours; improved self-esteem; and feeling 'worthy of interest'. The convenience and low cost of telephone support has much potential in chronic disease management.

A Controlled Pre-Post Evaluation of a Computer-based HIV/AIDS Education on Students' Sexual Behaviors, Knowledge and Attitudes

Unlike traditional approaches to sexuality and HIV education which can be constrained by the sensitive nature of the subject, Information Technology (IT) can be an innovative teaching tool that can be used to educate people about HIV. This is especially relevant to interventions targeting young people; the population group fond of using IT, and the same group that is more vulnerable to HIV/AIDS. Yet, there are significantly few empirical studies that rigorously evaluated computer-assisted school-based HIV/AIDS interventions in developing countries. The modest studies conducted in this area have largely been conducted in developed countries, leaving little known about the effectiveness of such interventions in low resource settings, which moreover host the majority of HIV/AIDS infections.

This research addresses this gap by conducting a controlled pre-post intervention evaluation of the impacts of the World Starts With Me (WSWM), a computer-assisted HIV/AIDS intervention implemented in schools in Uganda. The research question was: did the WSWM intervention significantly influence students’ sexual behaviors, HIV/AIDS knowledge, attitudes and self-efficacy? To address this question, questionnaires were simultaneously administering to 146 students in an intervention group (the group receiving the WSWM intervention) and 146 students in a comparison group (the group who did not receive the WSWM intervention), before (February 2009) and after the intervention (December 2009).

Findings indicate that the intervention significantly improved students’ HIV/AIDS knowledge, attitudes self-efficacy, sex abstinence and fidelity, but had no significant impact on condom use. The major reason for non-use of condoms was lack of knowledge about condom use which can be attributed to teachers’ failure and inabilities to demonstrate condom use in class. To address this challenge, intervention teachers should be continuously trained in skills-based and interactive sexuality education. This training will equip them with self-confidence and interactive teaching skills, including tactics for emphasizing building students’ skills through role plays and interactive assignments. In addition, the HIV interventions themselves should include interactive virtual condom use demonstrations that can be accessed by students themselves.

Contextual Mediators influencing the Effectiveness of Behavioural Change Interventions: A Case of HIV/AIDS Prevention Behaviours

Background:

Although Uganda had recorded declines in HIV infection rates around 1990’s, it is argued that HIV/AIDS risk sexual behaviour, especially among the youth, started increasing again from early 2000. School-based computer-assisted HIV interventions can provide interactive ways of improving the youth’s HIV knowledge, attitudes and skills. However, these interventions have long been reported to have limited success in improving the youth’s sexual behaviours, which is always the major aim of implementing such interventions. This could be because the commonly used health promotion theories employed by these interventions have limited application in HIV prevention. These theories tend to lack sufficient attention to contextual mediators that influence ones sexual behaviours. Moreover, literature increasingly expresses dissatisfaction with the dominant prevailing descriptive survey-type HIV/AIDS-related research.

Objective and Methods:

The objective of this research was to identify contextual mediators that influence the youth’s decision to adopt and maintain the HIV/AIDS preventive behaviour advocated by a computer-assisted intervention. To achieve this objective, this research employed qualitative method, which provided in-depth understanding of how different contexts interact to influence the effectiveness of HIV/AIDS interventions. The research question was: What contextual mediators are influencing the youth’s decision to adopt and maintain the HIV/AIDS preventive behaviour advocated by a computer-assisted intervention? To answer this research question, 20 youth who had previously completed the WSWM intervention when they were still in secondary schools were telephone interviewed between Sept.08 and Dec.08. The collected data was then analysed, based on grounded theory’s coding scheme.

Results:

Findings demonstrate that although often ignored by HIV interventionists and researchers, variety of contextual mediators influence individual uptake of HIV preventives. These include relationship characteristics, familial mediators, peer influence, gender-based social norms, economic factors and religious beliefs.

Conclusion:

To generate concomitant mutual efforts, rather than exclusively focusing on individual level mediators, there is an urgent need to shift to integrative approaches, which combine individual level change strategies with contextual level change approaches in the design and implementation of interventional strategies to fight against HIV/AIDS.

Metabolic control in children and adolescents with insulin-dependent diabetes mellitus at King Abdul-Aziz University Hospital

OBJECTIVE

Preventing long-term diabetic complications requires good metabolic control, especially in type 1 diabetes mellitus (T1DM). We describe the metabolic control of T1DM and the factors affecting it among children and adolescents attending the Pediatric Clinic at King Abdul-Aziz University Hospital.

METHODS

A retrospective cross-sectional study was conducted on T1DM children and adolescents who had attended the Pediatric Clinic at King Abdul-Aziz University Hospital from 2006 to 2010. Both clinical and laboratory data were reviewed for the enrolled cases. The mean age of the patients was 12.5 ± 4.1 years. Ages ranged from 1 to 18 years (n = 484: male = 213, female = 271). 38.6% of the patients were pre-pubertal and 61.4%-- pubertal. The patients were categorized into 3 age groups as 1-6 years (10.3%), 7-12 years (33.5%) and 13-18 years (56.2%).

RESULTS

The overall mean HbA1c was 9.4 ± 2.4% and the duration of patient follow-up was 26 ± 17 months. 10.3% of the patients were on conventional insulin regimens and 89.7%--on intensive insulin therapy. 31.4% had satisfactory HbA1c according to the American Diabetes Association guidelines. The duration of T1DM was 2.9 ± 1.4 years. The patients with diabetes duration ≤ 2 years (45%) had a mean HbA1c of 8.7 ± 1.8% and those with diabetes duration > 2 years (55%) had a mean HbA1c value of 9.8 ± 2.3% (p < 0.001).

CONCLUSIONS

The metabolic control of T1DM children in our cohort was less satisfactory than in other studies. We recommend the promotion of physical exercise and family educational programs to improve the metabolic control of T1DM pediatric patients in our population.

The development and testing of an instrument for perceived self-efficacy for fatigue self-management

BACKGROUND

Persons with chronic illness commonly report fatigue. Measurement of perceived self-efficacy for fatigue self-management (PSEFSM) is essential if fatigue is to be monitored and enhanced to improve physical functional status.

OBJECTIVE

The objective of the study was to describe the development and testing of the PSEFSM instrument.

METHODS

The PSEFSM instrument was incorporated into 2 randomized controlled trials for secondary analysis (N=298): 63 persons with lung cancer and 235 persons with other cancer diagnoses undergoing a course of chemotherapy.

RESULT

: Evidence for construct validity and generalizability was supported through hypotheses testing of the mediation pathway from fatigue to physical functional status through PSEFSM, with results indicating support for partial mediation. Structural modeling indicated a good model fit that further supported the construct validity of the PSEFSM instrument.

CONCLUSIONS

The instrument provides a reliable and valid measure of PSEFSM that could be used in research to facilitate the development of interventions to increase perceived self-efficacy to achieve optimal symptom self-management.

IMPLICATIONS FOR PRACTICE

The PSEFSM instrument is brief and easy to complete, which results in a low response burden for persons who are already fatigued, providing for regular use in transdisciplinary research and practice settings. This is important because the use of this instrument can impact how we partner with our patients to better understand how to manage this troublesome symptom, fatigue.

A pilot project for improving paediatric diabetes outcomes using a website: the Pediatric Diabetes Education Portal

We created a website for patients and families that allowed them to review clinic test results, review educational materials related to these results and post questions to their diabetes educator. Fingerstick haemoglobin A(1c) (HbA(1c)) testing and periodic use of a continuous glucose monitoring system (CGMS) were offered to all patients. The HbA(1c) and CGMS results were posted to the website after each clinic visit. A total of 52 patients with type 1 diabetes were enrolled in the study. There were 16 patients with HbA(1c) values within ADA guidelines and 16 with HbA(1c) values above guidelines; 20 patients were excluded for various reasons. Users of the website were defined as families who logged in four or more times over the six-month study period. For patients whose HbA(1c) started above ADA guidelines, the mean HbA(1c) for website users decreased from 10.5% (SD 2.2) at baseline to 9.1% (SD 1.2) after six months. In the non-users, the mean HbA(1c) increased from 9.5% (SD 1.5) at baseline to 10.4% (SD 2.5). However, these changes were not significant. A between groups comparison (users versus non-users) showed a significant improvement in HbA(1c) for website users (P = 0.03). This change in HbA(1c) was clinically relevant. Further studies with more patients are needed to see if these improvements can be sustained over a longer period.

Healthy coping: issues and implications in diabetes education and care

Psychological, emotional, and social factors not only impact quality of life, but also often play a role in chronic illness outcomes. Diabetes care, in particular, is greatly influenced by psychosocial factors when they hinder a person's ability to manage the disease and achieve metabolic control. Healthy coping, defined as responding to a psychological and physical challenge by recruiting available resources to increase the probability of favorable outcomes in the future, is essential to effective self-management by people with diabetes. In June 2009, the American Association of Diabetes Educators convened a multidisciplinary expert panel to discuss healthy coping in diabetes. The panel included diabetes educators and behavioral science and mental health professionals. Drawing on their knowledge and experiences, as well as information presented at the symposium, the panel probed several aspects of healthy coping including what it entails, common barriers, assessment, population diversity, and clinical applications. A team approach to addressing the patient's coping is critical. Team involvement relieves the diabetes educator of the entire burden of supporting the patient in this regard. The team should be broadly defined and include those who are formally and informally involved. Healthy coping is a complex, qualitative behavior that cannot be easily quantified. Future efforts to address the issue of healthy coping should add to the body of literature regarding diabetes self-management at the individual and population-based levels.

Systematic review of communication technologies to promote access and engagement of young people with diabetes into healthcare

BACKGROUND

Research has investigated whether communication technologies (e.g. mobile telephony, forums, email) can be used to transfer digital information between healthcare professionals and young people who live with diabetes. The systematic review evaluates the effectiveness and impact of these technologies on communication.

METHODS

Nine electronic databases were searched. Technologies were described and a narrative synthesis of all studies was undertaken.

RESULTS

Of 20,925 publications identified, 19 met the inclusion criteria, with 18 technologies assessed. Five categories of communication technologies were identified: video-and tele-conferencing (n = 2); mobile telephony (n = 3); telephone support (n = 3); novel electronic communication devices for transferring clinical information (n = 10); and web-based discussion boards (n = 1). Ten studies showed a positive improvement in HbA1c following the intervention with four studies reporting detrimental increases in HbA1c levels. In fifteen studies communication technologies increased the frequency of contact between patient and healthcare professional. Findings were inconsistent of an association between improvements in HbA1c and increased contact. Limited evidence was available concerning behavioural and care coordination outcomes, although improvement in quality of life, patient-caregiver interaction, self-care and metabolic transmission were reported for some communication technologies.

CONCLUSIONS

The breadth of study design and types of technologies reported make the magnitude of benefit and their effects on health difficult to determine. While communication technologies may increase the frequency of contact between patient and health care professional, it remains unclear whether this results in improved outcomes and is often the basis of the intervention itself. Further research is needed to explore the effectiveness and cost effectiveness of increasing the use of communication technologies between young people and healthcare professionals.

Helping high-risk youth move through high-risk periods: personally controlled health records for improving social and health care transitions

BACKGROUND

New patient-centered information technologies are needed to address risks associated with health care transitions for adolescents and young adults with diabetes, including systems that support individual and structural impediments to self- and clinical-care.

METHODS

We describe the personally controlled health record (PCHR) system platform and its key structural capabilities and assess its alignment with tenets of the chronic care model (CCM) and the social-behavioral and health care ecologies within which adolescents and young adults with diabetes mature.

RESULTS

Configured as Web-based platforms, PCHRs can support a new class of patient-facing applications that serve as monitoring and support systems for adolescents navigating complex social, developmental, and health care transitions. The approach can enable supportive interventions tailored to individual patient needs to boost adherence, self-management, and monitoring.

CONCLUSIONS

The PCHR platform is a paradigm shift for the organization of health information systems and is consistent with the CCM and conceptualizations of patient- and family-centered care for diabetes. Advancing the approach augers well for improvement around health care transitions for youth and also requires that we address (i) structural barriers impacting diabetes care for maturing youth; (ii) challenges around health and technology literacy; (iii) privacy and confidentiality issues, including sharing of health information within family and institutional systems; and (iv) needs for evaluation around uptake, impacts, and outcomes.

Preventing poor psychological and health outcomes in pediatric type 1 diabetes

Youth with type 1 diabetes are at high risk for psychosocial morbidities. These include depression, disturbed eating behavior, family conflict, poor health-related quality of life, low self-efficacy, and difficulty with medical adherence and metabolic control. A number of prevention interventions have been studied in this group, with the overall goal of improving adaptation and coping skills. This paper reviews the current research aimed at preventing poor outcomes in youth with type 1 diabetes and recommends simple interventions that can be added to clinical encounters. Recommendations for future psychosocial prevention studies are also discussed.

The impact of telemedicine interventions involving routine transmission of blood glucose data with clinician feedback on metabolic control in youth with type 1 diabetes: a systematic review and meta-analysis

Our objective was to determine the impact of telemedicine (TM) interventions on the management of type 1 diabetes (T1DM) in youth. We performed a systematic review of randomized trials that evaluated TM interventions involving transmission of blood glucose data followed by unsolicited scheduled clinician feedback. We found no apparent effect of the TM interventions on hemoglobin A1c (HbA1c), severe hypoglycemia, or diabetic ketoacidosis. The limited data available on patient satisfaction, quality of life, and cost also suggested no differences between groups. It is unlikely that TM interventions, as performed in the assessed studies, had a substantial effect on glycemic control or acute complications. However, it remains possible that there are other benefits of TM not adequately reported, that newer TM strategies may be more effective and that interventions may benefit subgroups of youth, such as those with the poor glycemic control, adolescents, or those living in remote areas.

Adherence challenges in the management of type 1 diabetes in adolescents: prevention and intervention

PURPOSE OF REVIEW

Despite the availability of effective therapies, adolescents with type 1 diabetes demonstrate poorer adherence to treatment regimens compared with other pediatric age groups. Nonadherence is tightly linked to suboptimal glycemic control, increasing morbidity, and risk for premature mortality. This article will review barriers to adherence and discuss interventions that have shown promise in improving outcomes for this population.

RECENT FINDINGS

Adolescents face numerous obstacles to adherence, including developmental behaviors, flux in family dynamics, and perceived social pressures, which compound the relative insulin resistance brought on by pubertal physiology. Some successful interventions have relied on encouraging nonjudgmental family support in the daily tasks of blood glucose monitoring and insulin administration. Other interventions overcome these barriers through the use of motivational interviewing and problem-solving techniques, flexibility in dietary recommendations, and extending provider outreach and support with technology.

SUMMARY

Effective interventions build on teens' internal and external supports (family, technology, and internal motivation) in order to simplify their management of diabetes and provide opportunities for the teens to share the burdens of care. Although such strategies help to minimize the demands placed upon teens with diabetes, suboptimal glycemic control will likely persist for the majority of adolescents until technological breakthroughs allow for automated insulin delivery in closed loop systems.

Improving glycaemic control in children and adolescents: which aspects of therapy really matter?

In paediatric diabetes, the concept of intensive therapy in the post-Diabetes Control and Complications Trial period has become subverted by a pharmaco-technological paradigm at the expense of other aspects of care such as goal-setting and psychosocial support. This review examines which patients benefit most from intensive therapy in terms of glycaemic control (HbA1c). It also reviews published controlled trial and observational data relating to the impact of various insulin types and delivery systems on glycaemic control and canvasses the literature dealing with the impact of patient support, philosophy of care, goal setting and treating team dynamic on HbA1c. Taking into account the characteristics of those patients who benefit most from intensive therapy, the quantum of HbA1c change and the persistence of changes that have been reported in selected and non-selected patient groups, it appears that there is a clear hierarchy in aspects of therapy that improve glycaemic control for children and adolescents with Type 1 diabetes. Prime issues appear to be patient support, team cohesion and goal setting. The reported glycaemic benefits achieved by an isolated emphasis upon a pharmaco-technological paradigm are limited in children and adolescents. It appears that only after the prime issues have been first considered will the potential benefits of the insulin types and regimens then be realized.

Telehealth behavior therapy for the management of type 1 diabetes in adolescents

BACKGROUND

Poor management of type 1 diabetes mellitus (T1DM) may result in serious medical complications. Psychological intervention may improve adherence to medical regimens; however, access to trained professionals is limited, particularly in rural communities. Telehealth interventions may address this by allowing families to access services at home; however, little is known about the efficacy of such services.

METHOD

This study presents results from a pilot trial of a randomized waitlist controlled trial of Telehealth Behavioral Therapy (TBT) for youths with T1DM. Primary outcome measures were adherence to the diabetes regimen, glycemic control, and level of family discord. Thirty-two youths (23 female) with T1DM (aged 9 to 17 years) and one parent or caregiver participated. Telehealth Behavioral Therapy sessions were conducted thrice weekly for 12 weeks by phone and lasted an average of 15 min each.

RESULTS

Results indicated that youths in treatment decreased their hemoglobin A1c by 0.74 compared to 0.09 in the waitlist, though this was not statistically significant. Youths in treatment reported increased unsupportive and decreased caring parental behaviors.

CONCLUSION

Telehealth Behavioral Therapy improves access to knowledgeable providers and results in a clinically significant improvement in glycemic control. Despite some youths experiencing an increase in unsupportive parental behaviors, TBT is a promising method of service delivery that warrants further investigation.

Home telemanagement for patients with ulcerative colitis (UC HAT)

Effective therapies exist to treat ulcerative colitis (UC); nonadherence, inadequate monitoring, and side-effects result in suboptimal outcomes. Novel methods for monitoring are needed. Our objectives were to assess acceptance of home automated telemanagement in ulcerative colitis (UC HAT). The UC HAT system consists of a laptop connected to a scale, a decision support server, and a web-based clinician portal. The UC HAT system facilitates self-care in UC patients by monitoring patient symptoms, side-effects, and adherence, and helping patients in following their individualized treatment plans. Ten adult patients with UC were trained to use UC HAT. Attitudinal surveys and qualitative interviews were performed. The results showed that all patients reported that use of the computer was not complicated. 90% reported that the symptom diary and side-effect questions were not difficult. All patients reported that the training was adequate and 70% reported that testing took little time. Seventy percent would feel safer using the system, and 90% would agree to use UC HAT in the future. Patients felt UC HAT would keep the patient and provider up to date on changes in symptoms. Self-testing appeared to make patients accountable for managing the disease. It was discussed that improved monitoring is needed for UC. Patients with UC can be easily trained to use HAT, and patient acceptance of the UC HAT system is high. Home automated telemanagement has potential to improve clinical outcomes and patient satisfaction in UC.

An automated telemedicine system improves patient-reported well-being

BACKGROUND

Control of serum glucose levels is essential for the reduction of complications of diabetes. Telemedicine is one strategy through which serum glucose control can be improved.

METHODS

A total of 35 adult, insulin-treated patients with diabetes (type 1 and type 2) were enrolled in the present study (63.0 +/- 10 years of age, 63% female) and randomized to telemedicine monitoring (including cordless, remote glucose monitor, and transmitter, n = 17), or conventional follow-up (n = 18). Metabolic parameters were evaluated, and a quality of life questionnaire was administered both pre- and post-treatment.

RESULTS

Groups were similar at baseline in terms of demographic, quality of life, and metabolic parameters. Significant differences in post-treatment metabolic parameters were not observed, although serum glucose was marginally elevated in the control group compared to the telemedicine group (214 +/- 65 mg/dL vs. 171 +/- 77 mg/dL, P = 0.09). On the other hand, being clinically symptom-free (71% vs. 11%, P = 0.003), having no hypoglycemic events (82% vs. 17%, P = 0.0001), and having no hyperglycemic events (65% vs. 17%, P = 0.004) were all significantly more frequently reported in the telemedicine group compared to the control group. Compared to the control group, the telemedicine group reported experiencing significantly less anxiety, treatment difficulty, depression, disease-associated life complications, and feelings of impotence or ineptitude and significantly greater improvement in personal control over glucose, weight, and overall diabetes.

CONCLUSIONS

Though post-treatment metabolic differences were not observed between treatment groups, the telemedicine group reported significantly greater post-treatment experiences of improved quality of life and sense of control over the disease. Thus patient satisfaction can be enhanced through the use of telemedicine.

Patients' engagement with "Sweet Talk" - a text messaging support system for young people with diabetes

Background

Guidelines for optimizing type 1 diabetes in young people advocate intensive insulin therapy coupled with personal support from the health care team. “Sweet Talk” is a novel intervention designed to support patients between clinic visits using text messages sent to a mobile phone. Scheduled messages are tailored to patient profiles and diabetes self-management goals, and generic messages include topical “newsletters” and anonymized tips from other participants. The system also allows patients to submit data and questions to the diabetes care team.

Objectives

The aim was to explore how patients with type 1 diabetes interact with the Sweet Talk system in order to understand its utility to this user group.

Methods

Subjects were 64 young people with diabetes who were participating in the intervention arms of a randomized controlled trial. All text messages submitted to Sweet Talk during a 12-month period were recorded. Messaging patterns and content were analyzed using mixed quantitative and qualitative methods.

Results

Patients submitted 1180 messages during the observation period (mean 18.4, median 6). Messaging frequency ranged widely between participants (0-240) with a subset of 5 high users contributing 52% of the total. Patients’ clinical and sociodemographic characteristics were not associated with total messaging frequency, although girls sent significantly more messages unrelated to diabetes than did boys (P = .002). The content of patients’ messages fell into 8 main categories: blood glucose readings, diabetes questions, diabetes information, personal health administration, social messages, technical messages, message errors, and message responses. Unprompted submission of blood glucose values was the most frequent incoming message type (35% of total). Responses to requests for personal experiences and tips generated 40% of all the incoming messages, while topical news items also generated good responses. Patients also used the service to ask questions, submit information about their self-management, and order supplies. No patients nominated supporters to receive text messages about their self-management goals. Another option that was not used was the birthday reminder service.

Conclusions

Automated, scheduled text messaging successfully engaged young people with diabetes. While the system was primarily designed to provide “push” support to patients, submission of clinical data and queries illustrates that it was seen as a trusted medium for communicating with care providers. Responses to the newsletters and submission of personal experiences and tips for circulation to other participants also illustrate the potential value of such interventions for establishing a sense of community. Although participants submitted relatively few messages, positive responses to the system suggest that most derived passive support from reading the messages. The Sweet Talk system could be readily adapted to suit other chronic disease models and age groups, and the results of this study may help to inform the design of future text message support interventions.

Problem solving in diabetes self-management and control: a systematic review of the literature

PURPOSE

The purpose of this systematic review is to assess the published literature on problem solving and its associations with diabetes self-management and control, as the state of evidence exists.

DATA SOURCES

PubMed, PsychINFO, and ERIC electronic databases were searched for the years 1990 to the present and for English-language articles, and reference lists from included studies were reviewed to capture additional studies.

STUDY SELECTION

Quantitative and qualitative studies that addressed problem solving as a process or strategy for diabetes self-management were included. Fifty-two studies met the criteria for inclusion.

DATA EXTRACTION

Study design, sample characteristics, measures, and results were reviewed.

DATA SYNTHESIS

Thirty-six studies were quantitative; 16 were conceptual or qualitative. Studies were classified as addressing the problem-solving definition/framework, assessment, intervention, or health care professional issues.

CONCLUSIONS

Problem solving is a multidimensional construct encompassing verbal reasoning/rational problem solving, quantitative problem solving, and coping. Aspects of problem solving can be assessed using newly developed diabetes-specific problem-solving measures for children/adolescents and adults. Cross-sectional studies in adults, but not children/adolescents, provide consistent evidence of associations between problem solving and A1C level. Only 25% of problem-solving intervention studies with children/adolescents and 50% of interventions with adults reported improvement in A1C. Most intervention studies reported an improvement in behaviors, most commonly global adherence in children/adolescents and dietary behavior in adults. Methodological limitations (noninclusion of problem-solving measures, inadequate descriptions of problem-solving interventions, homogenous samples) need to be addressed in future research to clarify the effect of problem solving on diabetes outcomes, identify characteristics of effective interventions, and determine the utility across age and racial/ethnic groups.