Experiences and perspectives of the parents of emerging adults living with type 1 diabetes

Diabetes care in the pandemic era in the Midwestern USA: a semi-structured interview study of the patient perspective

OBJECTIVES

To understand patients' experiences with diabetes care during the COVID-19 pandemic, with an emphasis on rural, medically underserved, and/or minoritised racial and ethnic groups in the Midwestern USA.

DESIGN

Community-engaged, semi-structured interviews were conducted by medical student researchers trained in qualitative interviewing. Transcripts were prepared and coded in the language in which the interview was conducted (English or Spanish). Thematic analysis was conducted, and data saturation was achieved.

SETTING

The study was conducted in communities in Eastern and Western Iowa.

PARTICIPANTS

Adults with diabetes (n=20) who were fluent in conversational English or Spanish were interviewed. One-third of participants were residents of areas designated as federal primary healthcare professional shortage areas and/or medically underserved areas, and more than half were recruited from medical clinics that offer care at no cost.

RESULTS

Themes across both English and Spanish transcripts included: (1) perspectives of diabetes, care providers and care management; (2) challenges and barriers affecting diabetes care; and (3) participant feedback and recommendations. Participants reported major constraints related to provider availability, costs of care, access to nutrition counselling and mental health concerns associated with diabetes care during the pandemic. Participants also reported a lack of shared decision-making regarding some aspects of care, including amputation. Finally, participants recognised systems-level challenges that affected both patients and providers and expressed a preference for proactive collaboration with healthcare teams.

CONCLUSIONS

These findings support enhanced engagement of rural, medically underserved and minoritised groups as stakeholders in diabetes care, diabetes research and diabetes provider education.

Adolescents' Experiences of Transition to Self-Management of Type 1 Diabetes: Systematic Review and Future Directions

PURPOSE

The purpose of this systematic literature review was to explore studies that report the experiences of adolescents, their families, and health care professionals of adolescents' transition to self-management of type 1 diabetes (T1DM).

METHODS

SocINDEX, PsycInfo, APA PsycArticles, and MEDLINE electronic databases were searched. Studies reporting on experiences of transition to self-management of T1DM for adolescents, their parents, siblings, and health care professionals published between January 2010 amd December 2021 were included. The Mixed Methods Appraisal Tool guided trustworthiness and relevance of selected studies.

RESULTS

A total of 29 studies met the inclusion criteria. Findings indicate that adolescents' experiences of transitioning to self-management of T1DM are interconnected with the supports provided by others (eg, family, teachers, friends). Considering interdependence and collective lived experiences is essential to developing effective and personalized family, peer, and social interventions to facilitate transition and to avoid negative outcomes in later life. The renegotiation of roles within the network of supports that impact adolescents' transition and adolescents' self-negotiation have been neglected.

CONCLUSION

Transition to self-management of T1DM is a dynamic and iterative process comprising of continuous shifts between interdependence and independence, making it challenging for all involved. A number of research gaps and avenues for future research are outlined.

Sustained Improvement in Glycemic Control in Emerging Adults with Type 1 Diabetes 2 Years After the Start of the COVID-19 Pandemic

INTRODUCTION

Although there were initial concerns that the public health response to the COVID-19 pandemic would adversely affect glycemic control in people with type 1 diabetes, several early continuous glucose monitor (CGM) studies reported an unexpected slight improvement in glucose metrics. Early emerging adulthood (roughly spanning the ages of 18-24 years) is often a vulnerable time in the life of a person with type 1 diabetes. Here, we set out to determine how the care and glucose management of emerging adults with type 1 diabetes changed over a period of approximately 2 years from the start of the COVID-19 pandemic.

METHODS

This was a retrospective study of a tertiary referral, multidisciplinary young adult diabetes clinic, spanning before and after the 777-day state of emergency in the City of Toronto.

RESULTS

Of 130 emerging adults with type 1 diabetes (80 male, 50 female; mean age 21.0 ± 2.1 years), baseline pre-pandemic HbA_1c values were available for 120 individuals. During 24.9 ± 5.4 months of follow-up before and after the start of the COVID-19 pandemic, HbA_1c fell from 8.5 ± 1.7% (69.3 ± 18.8 mmol/mol) to 8.1 ± 1.9% (65.2 ± 20.5 mmol/mol) (P < 0.05), with change in HbA_1c from pre-lockdown levels being sustained throughout the second year of the pandemic. Over the same period, CGM use rose from 43% to 83%, primarily through increased uptake of intermittently scanned CGM, which is covered through the Ontario Drug Benefit program. Change in HbA_1c was most evident in Dexcom G6 real-time CGM users - 0.7 ± 1.2% (- 9.8 ± 17.1 mmol/mol) (P < 0.01 vs. self-monitoring of blood glucose).

CONCLUSION

Among emerging adults with type 1 diabetes attending a multidisciplinary clinic in a high-income country, glycated hemoglobin levels are on average 0.4% (4.1 mmol/mol) lower than they were before the pandemic. This reduction in HbA_1c is unlikely to be a consequence of early strict lockdowns given the length of time of follow-up. Rather, improved glycemic control coincided with increased utilization of wearable diabetes devices.

Moving up: Healthcare transition experiences of adolescents and young adults with cystic fibrosis

PURPOSE

The experience of healthcare transition from pediatric to adult care in cystic fibrosis (CF) remains poorly understood, particularly among racially and ethnically diverse adolescents and young adults (AYAs) with CF. The objective of this qualitative study was to explore the perspectives of a diverse sample of AYAs with CF at one urban academic medical center regarding healthcare transition.

DESIGN AND METHODS

Guided by qualitative descriptive methodology, we purposively selected AYAs who represented the pre and post transition experience: some AYAs had experienced the transition preparation program CF R.I.S.E. Demographic information and responsibility for self-management behaviors were collected using an online survey. Semi-structured video interviews were conducted following an iterative interview guide. A codebook directed inductive coding. QSR NVivo Version 12 software was used to organize the data.

RESULTS

12 AYAs with CF were enrolled (25% female, 25% Black AYA, 33% Hispanic/Latina/o AYA, 50% White AYA; mean age 20.8 years). Three themes were identified: independent care of the whole self, preparing for change and the unknown and transition experiences vary.

CONCLUSIONS

Not all participants experienced a smooth transition. Participants identified suggestions for the development of transition preparation interventions, specifically around involving AYAs in transition decisions and beginning transition preparation early in adolescence.

PRACTICE IMPLICATIONS

Participants expressed uncertainty about transition when they felt little control over the process or lacked sufficient information about adult care. Therefore, comprehensive early transition preparation for all AYAs with CF with a focus on involving AYAs in transition decisions is recommended.

Toward a better understanding of transition from paediatric to adult care in type 1 diabetes: A qualitative study of adolescents

AIMS

Type 1 diabetes is associated with significant morbidity, with an increasing risk of acute diabetes-related complications in adolescence and emerging adulthood. Purposeful transition from paediatric to adult-oriented care could mitigate this risk but is often lacking. Detailed understanding of the perspectives of adolescents in their final year of paediatric care is essential to inform delivery of transition care programs.

METHODS

We conducted semi-structured interviews with adolescents (aged 17 years) with type 1 diabetes at an academic institution from April 2017 to May 2018. Participants were recruited through convenience sampling. Sixty-one interviews were transcribed for analysis. Coding followed the principles of thematic analysis.

RESULTS

Thirty-six percent of participants were male, and participants were from diverse socioeconomic backgrounds. We found three overarching themes in our analysis: first, difficulties navigating changing relationships with parents and healthcare teams; second, the need to increase type 1 diabetes self-management and differing comfort levels based on age of diagnosis; and third, perceived responsibilities for transition care preparation (for both the paediatric team and adolescents themselves) focused not only on type 1 diabetes-specific skills but also on healthcare system structures.

CONCLUSIONS

Our findings suggest that novel transition programs addressing changing inter-personal relationships, disease-specific self-management (adapted for age of diagnosis), and healthcare system navigation, supported by parents and peers, may be needed to improve transition care for adolescents with type 1 diabetes.

Cutting the cord? Parenting emerging adults with chronic pain

The role of parent factors, such as distress and protective behaviors, on pain and functional outcomes of emerging adults living with chronic pain has been largely unexplored. The effects of helicopter parenting and developmental changes occurring during this transition period between adolescence and adulthood (commonly defined as the ages between 18 and 30 years) may exacerbate the pain experience and have the potential to influence chronic pain management. Clinical practice, with an additional focus on supporting the parent(s), may aid in meeting the needs of this population. In this paper, we review the available literature on (a) the socio-cultural shift in parenting over the past decade with a focus on helicopter parenting; (b) the impact of this parenting style on the pain experience and outcomes of emerging adults living with chronic pain; (c) provide recommendations for chronic pain management with a focus on the parent-emerging adult dyad; and (d) conclude with future research recommendations. This narrative review is the first to consider the impacts and outcomes of helicopter parenting on emerging adults with chronic pain.

Outcomes of a multidisciplinary transition clinic for youth with type 1 diabetes

BACKGROUND

Emerging adults with type 1 diabetes (T1D) have several challenges regarding diabetes management and care transition from pediatric to adult services. In this study we aimed to assess the effectiveness of the newly established transition clinic for emerging adults with T1D.

METHODS

We conducted an observational study of emerging adults with T1D treated in a transition clinic jointly operated by a pediatric and adult multidisciplinary care team during 2019-2021. A retrospective chart review of hemoglobin A1c (HbA1c), frequency of clinic attendance, acute diabetes-related complications, assessment of gaps in knowledge and behavior, and psychosocial outcomes was analyzed.

RESULTS

A total of 21 patients with T1D were included. Median age at the transfer to the transition clinic was 24 years (range 21-34). Fifteen patients (71%) were successfully transferred to adult services; mean duration of follow-up at the transition clinic was 9.2 months (SD 3.9). None of the patients was lost to follow-up or experienced serious diabetes related complications. Mean (95% confidence interval) HbA1c levels decreased from 8.97% (7.87-10.07) at baseline to 8.25% (7.45-9.05) at the most recent visit (p = 0.01). A proportion of patients achieving the glycemic target (HbA1c < 7.5%) was increased from 24% at the first visit to 38% at the most recent visits. Patients' HbA1c levels at the adult clinic continued a favorable trend. Seven patients (33%) were identified as having symptoms of depression. Knowledge and behavioral gaps were identified and counselled by clinical care team.

CONCLUSION

The multidisciplinary transition clinic has shown to be beneficial in terms of improving glycemic control, maintaining continuity of care and clinic attendance.

Effect of hospital discharge plan for children with type 1 diabetes on discharge readiness, discharge education quality, and blood glucose control

BACKGROUND

Type 1 diabetes is one of the most common chronic diseases in childhood. The number of type 1 diabetes patients in China still ranks fourth in the world. Therefore, children with type 1 diabetes in China are a group that needs attention. The management of type 1 diabetes mellitus (T1DM) involves many aspects of daily life. It is extremely challenging for children and their families. T1DM children have complex medical care needs. Despite the continuous development of therapeutic medicine and treatment technologies, blood glucose control in children with T1DM is still not ideal. They and their parents need to acquire more knowledge and skills before being discharged.

AIM

To explore the influence of hospital discharge plan based on parental care needs of children with T1DM on discharge readiness, quality of discharge education and blood glucose control level.

METHODS

In total, 102 parents of children with type 1 diabetes were divided into control group and intervention group according to admission time. Fifty cases from February to June 2019 were selected as the control group, and 52 cases from July to October 2019 were selected as the intervention group to implement the discharge plan. The Readiness for Hospital Discharge Scale, Hospital Discharged Education Quality Scale and children's blood glucose metabolism indicators were used to compare the differences in discharge preparation, discharge education quality and blood glucose control between the two groups of children and their parents.

RESULTS

On the day of discharge, the two groups of children had the following scores of readiness for discharge: The intervention group score was 225.34 ± 32.47, and the control group score was 208.68 ± 29.31. The P value was 0.007, and the difference was statistically significant. The discharge education quality scores were as follows: The intervention group score was 135.11 ± 19.86, the control group score was 124.13 ± 15.56, the P value was 0.002 and the difference was statistically significant. Three months after discharge, the blood glucose metabolism indicator showed that the glycosylated hemoglobin value of the two groups was (7.45% ± 1.04%), and that of the control group was (8.04% ± 1.27%), P = 0.012. Therefore, the improvement of parents' readiness for discharge, quality of discharge education and blood glucose metabolism indicators (glycosylated hemoglobin, fasting blood glucose and postprandial blood glucose) in the intervention group were better than those in the control group (P < 0.05), and the difference was statistically significant.

CONCLUSION

The discharge plan for children with T1DM can help the children and their families realize the transition from hospital care to home self-management and improve the parents' readiness for discharge, thereby improving children’s blood glucose control levels.