Improving communication and recall of information in paediatric diabetes consultations: a qualitative study of parents' experiences and views

Adolescents, parents, and providers' experiences of triadic encounters in paediatric diabetes clinics: A qualitative study

INTRODUCTION

Adolescents with Type 1 diabetes are a cohort whose self-management of their diabetes care often declines during adolescence which can lead to adverse health outcomes. Research indicates that providers find it challenging to engage adolescents in communication exchanges during triadic encounters in diabetes clinics. Our study aimed to explore adolescents, parents, and providers' experiences of clinic encounters.

METHODS

A qualitative study was conducted with a convenience sample of 13 adolescents with Type 1 diabetes (aged 11-17), 14 parents, and seven providers. Participants were recruited from two outpatient diabetes clinics in two urban children's hospitals, Ireland. Data were obtained using a combination of interviews and focus groups. Data were analysed thematically.

RESULTS

Adolescents and their parents appeared to hold both positive and negative experiences of diabetes clinic encounters. Providers reported challenges associated with engaging adolescents in communication exchanges. The structure, focus and style of clinic encounters created barriers that potentially led to suboptimal adolescent participation and impaired provider-adolescent communication during clinic visits.

CONCLUSIONS

The findings provide insights into the challenges associated with adolescents' engagement in communication encounters in diabetes clinics. Healthcare providers could encourage adolescents to be more actively involved in their diabetes management, by taking an adolescent-centred approach and creating a nonjudgemental milieu. Focusing on adolescent's agenda could lead to more meaningful and relevant discussions between providers and adolescents and ensure more tailored education in the time available. Adolescence is a risky period for nonadherence and adverse health complications; therefore, it is critical that providers make every contact count in diabetes clinic encounters.

PATIENT OR PUBLIC INVOLVEMENT

The study's design and delivery were guided by two advisory groups, comprising (1) five adolescents living with Type 1 diabetes (T1D) and (2) five parents of an adolescent with T1D.

Transition from parents to caregivers of a child with type 1 Diabetes Mellitus: a scoping review

OBJECTIVES

to map and summarize the existing scientific evidence on parents' transition experience to exercise the caregiver role of a child with 1DM, identifying gaps in knowledge of this experience.

METHODS

a scoping review was carried out based on JBI methodology, in two databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

RESULTS

we included 31 articles. From the studies, constitutive elements of parents' transition experience to caregiver role of a child with 1DM were found, which focused on the nature of the experience, the feelings and emotions experienced, the hindering conditions, the facilitating conditions, the strategies used by parents and the results or effects obtained.

FINAL CONSIDERATIONS

the transition process' characterizing elements were identified, but not a theoretical explanation of it. Additional research should be carried out in order to allow a deeper understanding of this process.

Transição de pais para cuidadores de um filho com Diabetes Mellitus tipo 1: scoping review

RESUMO Objetivos: mapear e resumir a evidência científica existente sobre a experiência de transição dos pais para o exercício do papel de cuidador de um filho com DM1, identificando lacunas existentes no conhecimento dessa experiência. Métodos: efetuada revisão scoping baseada na metodologia do JBI, em duas bases de dados, seguindo a checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Resultados: foram incluídos 31 artigos. A partir dos estudos, foram encontrados elementos constitutivos da experiência de transição dos pais para o papel de cuidador de um filho com DM1, que se centraram na natureza da experiência, nos sentimentos e emoções experimentadas, nas condições dificultadoras, nas condições facilitadoras, nas estratégias utilizadas pelos pais e nos resultados ou efeitos obtidos. Considerações finais: identificaram-se elementos caracterizadores do processo de transição, mas não uma explicação teórica do mesmo. Investigação adicional deverá ser realizada, a fim de permitir compreender aprofundadamente este processo.

Communication and Social Relations: A Qualitative Study of Families’ Experience with Their Outpatient Pediatric Diabetes Visits

Clinical outpatient visits comprise a relatively small part of the lives of children with diabetes and their families, but there is evidence that these visits have a strong impact on the long-term management of diabetes. Because children with diabetes are looking at frequent hospital visits for the rest of their lives, it is important to explore their experiences to ensure visits meet their needs. This study aimed to investigate families’ experiences with outpatient visits at a pediatric diabetes clinic. Thirteen semi-structured family interviews were conducted. Systematic text condensation was used to analyze the data. With an analytical focus on communication and social relations, nine themes were identified: 1. Discrepancies in perception of diabetes tasks, 2. Talking about adult things, but the children listen, 3. The importance of spoken and written words, 4. Confusion about division of responsibilities, 5. Relief when someone eases the burden, 6. Courtesy when visiting the clinic, 7. Understanding of the family context, 8. Importance of continuous personal relations, and 9. Need for a facilitated peer network. The findings encourage reflection on how to improve communication and underline the importance of establishing a continuous and personal relation between families and health care professionals to improve families’ experience with pediatric outpatient visits.

Socioeconomic and Racial Disparities in Diabetic Ketoacidosis Admissions in Youth With Type 1 Diabetes

OBJECTIVE

We sought to determine whether census tract poverty, race, and insurance status were associated with the likelihood and severity of diabetic ketoacidosis (DKA) hospitalization among youth with type 1 diabetes (T1D).

METHODS

We conducted a retrospective population-based cohort study using Cincinnati Children's Hospital electronic medical record (EMR) data from January 1, 2011, to December 31, 2017, for T1D patients ≤18 years old. The primary outcome was admission for DKA. Secondary outcomes included DKA severity, defined by initial pH and bicarbonate, and length of stay. Exposures were the poverty rate for the youth's home census tract, parent-reported race, and insurance status. We used multivariable logistic regression to analyze effects on odds of admission.

RESULTS

We identified 439 patients with T1D; 152 were hospitalized. The cohort was 48% female, 25% Black, and 36% publicly insured; the median age was 14 years. For every 10% increase in a youth's census tract poverty rate, the adjusted odds of admission increased by 22% (95% CI, 1.03-1.47). Public insurance status was associated with DKA admission (adjusted odds ratio [AOR], 2.71, 95% CI, 1.62-4.55) while race was not. There were no clinically meaningful differences in pH or bicarbonate by census tract poverty, race, or insurance status; however, Black patients experienced differences in care (eg, longer length of stay).

CONCLUSION

Youth with T1D living in high poverty areas and on public insurance were significantly more likely to be admitted for DKA. Severity upon presentation was similar across exposures. Understanding contextual mechanisms by which disparities emerge will inform changes aimed at equitably improving care.

Parents' experiences of caring for a young child with type 1 diabetes: a systematic review and synthesis of qualitative evidence

AIMS

To synthesise the qualitative evidence on parents' experiences of caring for a child aged ≤8 years with type 1 diabetes to identify: the challenges they encounter; their views about support received; ways in which support could be improved; and, directions for future research.

METHODS

We searched Medline, EMBASE, CINAHL, PsycINFO and Web of Science databases to identify qualitative studies reporting parents' views and experiences of caring for a child with type 1 diabetes aged ≤8 years. Key analytical themes were identified using thematic synthesis.

RESULTS

Fourteen studies were included. The synthesis resulted in the generation of two overarching themes. Monopolisation of life describes the all-encompassing impact diabetes could have on parents due to the constant worry they experienced and the perceived need for vigilance. It describes how parents' caring responsibilities could affect their wellbeing, relationships and finances, and how a lack of trusted sources of childcare and a desire to enable a 'normal' childhood constrained personal choices and activities. However, use of diabetes technologies could lessen some of these burdens. Experiences of professional and informal support describes how encounters with healthcare professionals, while generally perceived as helpful, could lead to frustration and anxiety, and how connecting with other parents caring for a child with type 1 diabetes provided valued emotional and practical support.

CONCLUSIONS

This synthesis outlines the challenges parents encounter, their views about support received and ways in which support might be improved. It also highlights significant limitations in the current literature and points to important areas for future research, including how sociodemographic factors and use of newer diabetes technologies influence parents' diabetes management practices and experiences. PROSPERO: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128710.

The Challenges of Being Physically Active: A Qualitative Study of Young People With Type 1 Diabetes and Their Parents

BACKGROUND

Benefits of physical activity are well recognized for youth with type 1 diabetes mellitus (T1DM), but being active is challenging. In this study, we aimed to investigate the challenges experienced by adolescents, their parents and young adults with T1DM when they are physically active.

METHODS

Six focus groups involving adolescents (13 to 18 years old, n=14) and young adults (19 to 25 years old, n=7) and 4 focus groups with parents (n=14) of the adolescents (13 to 18 years) were established. Data were analyzed using content analysis.

RESULTS

Adolescents and young adults with T1DM identified challenges of unpredictability, knowledge, trust and stigma when they were physically active. Parent challenges were specifically unpredictability and trust.

CONCLUSIONS

Interventions are needed that provide adolescents and young adults with T1DM and parents of adolescents with T1DM more in-depth information about managing physical activity in a manner that enhances their perceived competence and builds autonomy. Interventions can also target peer and community support.

Health professionals' perspectives on delivering home and hospital management at diagnosis for children with type 1 diabetes: A qualitative study from the Delivering Early Care in Diabetes Evaluation trial

OBJECTIVE

To explore the delivery of home and hospital management at diagnosis of type 1 diabetes in childhood and any impact this had on health professionals delivering care.

METHODS

This qualitative study was undertaken as part of the Delivering Early Care in Diabetes Evaluation randomized controlled trial where participants were individually randomized to receive initiation of management at diagnosis, to home or hospital. Semi-structured telephone interviews were planned with a purposive sample of health professionals involved with the delivery of home and hospital management, to include consultants, diabetes and research nurses, and dieticians from the eight UK centres taking part. The interview schedule focused on their experiences of delivering the two models of care; preferences, impact, and future plans. Data were subject to thematic analysis.

RESULTS

Twenty-two health professionals participated, represented by consultants, diabetes and research nurses, and dieticians. Overall, nurses preferred home management and perceived it to be beneficial in terms of facilitating a unique opportunity to understand family life and provide education to extended family members. Nurses described a special bond and lasting relationship that they developed with the home managed children and families. Consultants expressed concern that it jeopardized their relationship with families. Dieticians reported being unable to deliver short bursts of education to families in the home managed arm. All health professionals were equally divided over which was logistically easier to deliver.

CONCLUSIONS

A hybrid approach, of a brief stay in hospital and early home management, offers a pragmatic solution to the advantages and challenges presented by both systems.

Education makes people take their medication: myth or maxim?

Education on its own doesn't make people take their treatment as intended. However, when it follows shared decision making, in which patient and doctor together agree on the best course of therapeutic action, education helps patients take their treatment. http://bit.ly/2G2XswD.

Online survey to assess parents' experience and preferences for follow-up visits for children living with type 1 diabetes in Quebec, Canada: a study protocol

INTRODUCTION

It is accepted that although patients may initiate a visit to a healthcare provider, follow-up visits are often based on recommendations from providers. This suggests that follow-up care, since not initiated by patients, may not reflect patients' perception of a need for care. However, few studies have examined the burden of regular follow-up care and patients' perceived value of such care. For parents of children with type 1 diabetes (T1D), follow-up visits are scheduled regardless of how well controlled the diabetes is. Our study examines how benefits and burden from the parents' perspective could affect their preferences in regard to the frequency of regular follow-up care.

METHODS

We aim to develop an online patient survey to be distributed to parents of children living with T1D in the province of Quebec, Canada. The survey will be available in French and English, and distributed through diabetes clinics, on social media groups and forums for parents of children with T1D. The survey will be developed in collaboration with parents of children with T1D to ensure that it appropriately reflects the services in regular follow-up care and that the language is understandable and clear.

ETHICS AND DISSEMINATION

All participants will be informed of the requirements and objectives of the survey at the beginning of the questionnaire and that the data collected will remain anonymous and confidential. Ethics approval for the study was obtained from the research ethics committee of the CHU de Québec-Université Laval. Results of the study will be shared with relevant stakeholders with the aim of improving practices and better meeting patients' and families' needs.

Experiences of self-management among young adults with Type 1 diabetes in the context of a structured education programme: a qualitative study

AIMS

To explore the experiences of young adults with regard to self-management of Type 1 diabetes in the context of a structured education programme.

METHODS

Qualitative interviews and focus groups were conducted with young adults attending a structured education course promoting a flexible and self-directed format. Participants attending the structured education courses were recruited using purposive sampling to acquire a broad mix of participants based on age and equal numbers of young men and women. Fifteen interviews were conducted 12 weeks after each course, whilst seven focus groups and observations of the course delivery were conducted at two course sites and were led by nurse/dietitian educators representing two different diabetes centres (paediatric and adult). The interview and focus group data were audio recorded and transcribed, coded, and analysed thematically to identify similarities and differences.

RESULTS

The analysis revealed three themes, 'we're in it together', 'tacit benefits' and 'transitions beyond the structured education programme'. The findings show that structured education programmes can facilitate reflective critical thinking and greater engagement with diabetes self-management if they: a) foster maximal learning from fellow participants to decrease feelings of isolation, b) maximize engagement during the course by delivering the content in a flexible manner, and c) recognize the social and emotional needs of young adults.

CONCLUSION

Structured education courses can result in improved critical thinking and engagement with diabetes self-management by empowering young adults through a flexible and self-directed learning style that encourages peer group discussion.

Parent experiences of diabetes care questionnaire (PEQ-DC): reliability and validity following a national survey in Norway

BACKGROUND

Patient experiences are acknowledged as an important aspect of health care quality but no validated instruments have been identified for the measurement of either parent or patient experiences with outpatient paediatric diabetes care. The aim of the current study was to assess the psychometric properties of a new instrument developed to measure parent experiences of paediatric diabetes care at hospital outpatient departments in Norway.

METHODS

The development of the questionnaire was based on a literature review of existing questionnaires, qualitative interviews with both parents and children/adolescents, expert-group consultations, pretesting of the questionnaire and a pilot study. The national pilot study included parents of 2606 children/adolescents aged 0-17 years with Type 1 Diabetes registered in The Norwegian Childhood Diabetes Registry, a nationwide, population-based registry. Levels of missing data, ceiling effects, factor structure, internal consistency, item discriminant validity and construct validity were assessed.

RESULTS

A total of 2606 patients were included in the survey, but 80 were excluded due to incorrect addresses. 1399 (55%) parents responded to the questionnaire. Low levels of missing or "not applicable" responses were found for 31 of the 35 items (< 10%), and 27 of 35 items were below the ceiling-effect criterion. Psychometric testing and theoretical considerations identified six scales: Consultation (six items), organisation (five items), equipment (three items), nurse contact (four items), doctor contact (four items) and outcome (five items). All six scales met the 0.7 criterion for Cronbach's alpha (range: 0.71-0.90). As expected, each item had a higher correlation with its hypothesised scale than with any of the other five scales. The construct validity of the Parent Experiences of Diabetes Care Questionnaire (PEQ-DC) was supported by 17 out of 18 associations with variables expected to be related to parent experiences.

CONCLUSION

The psychometric testing of the PEQ-DC showed good evidence for data quality, internal consistency and construct validity. The instrument includes important aspects of diabetes care at paediatric outpatient departments from the perspective of the parent. The content validity of the PEQ-DC was secured by a rigorous development process, and the instrument was tested following a national survey in Norway, securing generalisability across Norway.

Can we trust what parents tell us? A systematic review

Taking a history is a key diagnostic instrument in paediatric consultations. Numerous issues potentially reduce the history's reliability. Therefore, paediatricians have always expressed ambivalence regarding history taking from parents, both valuing and distrusting it. In this review, we describe how parents build and present a description of their child's health issues in the conceptual framework of self-regulation theory. We performed a systematic review on the literature on the reliability of history taking. No studies examined the reliability of history taking from parents, but there is a considerable body of evidence on the issue of mutual trust in relationships between health care professionals and patients. Because trust is a dynamic relational phenomenon, taking a patient centred approach in consultations is likely to increase the patients' and parents' trust in the health care professional, and their willingness to follow the health care professional's treatment proposals. We provide evidence based recommendations on how to build and maintain trust in paediatric consultations by taking a patient centred approach in such consultations.

Effective strategies for encouraging behavior change in people with diabetes

Behavioral management of diabetes leads to better health outcomes. This paper reviews the available literature on facilitators of behavior change in people with diabetes and highlights approaches and strategies diabetes care providers can utilize. The research and clinical evidence points to the critical nature of considering the content and structure of recommendations, and utilizing problem solving and teamwork approaches. Furthermore, close attention to individual and community factors will optimize behavior change. These factors include health literacy, community infrastructure, support within the family, and whether there are co-occurring eating and mood issues. Recommendations are provided to optimize communication and embed behavior change approaches in clinical and community encounters.