Diabetes NewsJuly 2010
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An Internet-Based Program to Improve Self-Management in Adolescents with Type 1 Diabetes
Diabetes Care • March 2010
Young people with type 1 diabetes typically experience a decline in glycemic control (A1C) through adolescence. Risk factors associated with increasing A1C include hormonal changes and barriers to self-management such as competing demands, inadequate planning and communication, peers and social situations and negative emotions. Problem-solving and coping with diabetes barriers are skills that have been positively related to diabetes outcomes and are recommended as part of diabetes education. Previous studies have not used the Internet as a modality to teach problem solving with this population. The results of a small randomized trial examining YourWay, and Internet-based program to improve adolescent problem solving and self-management skills and glycemic control. The hypothesis of this study is that problem solving and self-management skills would improve the intervention group.
Objective - To report the results from YourWay, an Internet-based, self management intervention for adolescents with type 1 diabetes.
Research Design and Methods - Adolescents with type 1 diabetes were randomly assigned to receive usual care or usual care plus Internet-based problem-solving self-management support. Eligible participants within the Vanderbilt Eskind Pediatric Diabetes Clinic were 13-17 years of age, had Internet access, were diagnosed with type 1 diabetes for at least six months, spoke English and had no disabilities that precluded understanding of website content.
Intervention components were designed based on learning, social cognitive, and self-determination theories. A multidisciplinary team of diabetes professionals and young patients wrote and edited website content. During eleven weeks, six multimedia stories depicted psychosocial barriers to self-management (e.g.: time, pressure, competing demands and embarrassment) and approaches to coping and problem solving. Participants were prompted twice to complete problem-solving cycles for personal barriers to self-management. Other activities included: 1) a personalized homepage 2) multimedia presentations on steps of problem solving and how to use the website 3) social networking via a peer forum 4) social comparison of their responses compared with other adolescents 5) help from a problem-solving expert and 6) weekly emails that encouraged participation. Participants had no interactions with diabetes clinicians or parents through YourWay website.
A1C corresponding to baseline visit and the most recent A1C after the intervention period and were collected from medical records. Behavioral measures were administered at baseline and twelve weeks. Adherence was assessed using the Diabetes Behavior Rating Scale. Problem solving was measured by the Diabetes Problem Solving Behaviors scale, a novel 27-item self-report scale that assesses frequencies of problem-solving behaviors associated with self-management. Internal consistency of this scale was adequate within this study.
Results - No statistically significant differences between the groups existed at baseline. When data were analyzed using an as-treated approach, the same patterns were seen for average group characteristics at baseline; however, problem solving improved by 0.30 SDs for the intervention group. Self management adherence improved compared with the control group. The intervention group A1C remained constant but showed improvement relative to the control condition, which showed worsening values. Although lower than the intervention group at post-study, the change between the first and second A1c measurements for the control group was +0.33% and for the intervention group was -0.01%.
Conclusions - Previous research has indicated a general trend of increasing A1C during adolescence. A brief Internet-based self-management intervention was rated highly by participants and was effective at improving problem solving and self-management and appeared to offset the typical adolescent increase in A1C. To the author’s knowledge, this is the first trial of an Internet program to improve problem solving in adolescent patients with type 1 diabetes and the first intervention in this area that does not require additional clinician effort. The study is limited by a brief intervention period, small sample, and lack of randomization on A1C values. The range of effect sizes observed within this short term study is consistent with other longer duration, problem solving, and coping intervention studies using a face-to-face modality and suggests that an Internet-based intervention is a feasible and accessible means of improving diabetes care. Further research is necessary to establish efficacy with a larger randomization trial, integrate parents and clinicians, fully validate the problem-solving measure and identify issues in sustainability.
Reprinted with permission from the American Diabetes Association