Shelagh A. Mulvaney

An Internet-Based Program to Improve Self-Management in Adolescents With Type 1 Diabetes

OBJECTIVE To report results from YourWay, an Internet-based self-management intervention for adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS A total of 72 adolescents with type 1 diabetes, ages 13–17 years, were randomized to a usual-care-plus-Internet support or a usual-care group. The intervention was designed to enhance problem-solving barriers to self-management. A1C was obtained from medical records, and problem-solving and self-management were obtained via adolescent report. RESULTS Group differences were not statistically significant using intent-to-treat analyses. Using as-treated analyses, adolescents in the treatment condition showed statistically significant improvement in self-management (d = 0.64; P = 0.02) and important improvements in problem-solving (d = 0.30; P = 0.23) and A1C (d = −0.28; P = 0.27). Mean A1C for the intervention group remained constant (−0.01%), while the control group increased (0.33%). CONCLUSIONS This brief trial suggests that self-management support delivered through a secure website may improve self-management and offset typical decreases in adolescent glycemic control.

Patient Web Portals to Improve Diabetes Outcomes: A Systematic Review

Patient web portals (PWPs), defined as the integration of electronic medical records and patient health records, have been related to enhanced patient outcomes. A literature review was conducted to characterize the design and evaluation of PWPs to improve health care processes and outcomes in diabetes. A summary of 26 articles revealed the positive impact PWPs have on patient outcomes, patient-provider communication, disease management, and access to and patient satisfaction with health care. Innovative and useful approaches included the evaluation of specific components of the PWPs, assessing the impact of PWPs on mediators of health behaviors, such as patient distress, identification of barriers to use, and patient willingness to pay for access. Future research should focus on relevant processes that mediate patient and provider use, impact on health care utilization, and a patient-centered approach to the design and integration of educational opportunities afforded through PWPs.

Self-Management Behaviors, Racial Disparities, and Glycemic Control Among Adolescents With Type 2 Diabetes

OBJECTIVE. Type 2 diabetes is a growing problem among adolescents, but little is known about self-management behaviors in this population. Our aim was to examine self-management behaviors and glycemic control among adolescents with type 2 diabetes. METHODS. From 2003 to 2005, a telephone survey of adolescents with type 2 diabetes was performed. Chart review obtained most recent glycated hemoglobin and clinical characteristics. Analyses compared patient characteristics and self-management behaviors to recent glycated hemoglobin levels. RESULTS. Of 139 patients contacted, 103 (74%) completed the study. The mean age was 15.4 years: 69% were girls, 47% were white, and 46% were black. Mean glycated hemoglobin was 7.7%, and the average duration of diabetes was 2.0 years. More than 80% of patients reported ≥75% medication compliance, and 59% monitored blood glucose >2 times daily. However, patients reported frequent episodes of overeating, drinking sugary drinks, and eating fast food. More than 70% of patients reported exercising ≥2 times a week, but 68% reported watching ≥2 hours of television daily. Nonwhite patients had higher glycated hemoglobin and hospitalizations per year compared with white patients. In multivariable analyses, nonwhite race remained significantly associated with higher glycated hemoglobin even after adjusting for age, gender, BMI, insurance status, and other factors. Nonwhite patients were more likely to watch ≥2 hours of television per day (78% vs 56%), to report exercising ≤1 time per week (35% vs 21%), and to drink ≥1 sugary drink daily (27% vs 13%). CONCLUSION. Although patients reported good medication and monitoring adherence, they also reported poor diet and exercise habits and multiple barriers. Nonwhite race was significantly associated with poorer glycemic control even after adjusting for covariates. This may, in part, be related to disparities in lifestyle behaviors. Additional studies are indicated to further assess self-management behaviors and potential racial disparities in adolescents with type 2 diabetes.

A pilot test of a tailored mobile and web-based diabetes messaging system for adolescents

We conducted a pilot trial of a new mobile and web-based intervention to improve diabetes adherence. The text messaging system was designed to motivate and remind adolescents about diabetes self-care tasks. Text messages were tailored according to individually-reported barriers to diabetes self-care. A total of 23 adolescents with type 1 diabetes used the system for a period of three months. On average, they received 10 text messages per week (range 8–12). A matched historical control group from the same clinic was used for comparison. After three months, system users rated the content, usability and experiences with the system, which were very favourable. Comparison of the intervention and control groups indicated a significant interaction between group and time. Both groups had similar HbA1c levels at baseline. After three months, the mean HbA1c level in the intervention group was unchanged (8.8%), but the mean level in the control group was significantly higher (9.9%), P = 0.006. The results demonstrate the feasibility of the messaging system, user acceptance and a promising effect on glycaemic control. Integrating this type of messaging system with online educational programming could prove to be beneficial.

Using Mobile Phones to Measure Adolescent Diabetes Adherence

OBJECTIVES 1) describe and determine the feasibility of using cell-phone-based ecological momentary assessment (EMA) to measure blood glucose monitoring and insulin administration in adolescent Type 1 diabetes, 2) relate EMA to traditional self-report and glycemic control, and 3) identify patterns of adherence by time of day and over time using EMA. METHOD Adolescents with Type 1 diabetes (n = 96) completed baseline measures of cell phone use and adherence. Glycemic control (measured by levels of HbA1c) was obtained from medical records. A subgroup of adolescents (n = 50) completed 10 days of EMA to assess blood glucose monitoring frequency, timing of glucose monitoring, insulin administration, and insulin dosing. One third of adolescents were not allowed to use their cell phones for diabetes at school. Parental restrictions on cell phone use at home were not prevalent. RESULTS The EMA response rate (59%) remained stable over the 10-day calling period. Morning time was associated with worse monitoring and insulin administration, accounting for 59-74% of missed self-care tasks. EMA-reported missed glucose checks and missed insulin doses were correlated to traditional self-report data, but not to HbA1c levels. Trajectory analyses identified two subgroups: one with consistently adequate adherence, and one with more variable, and worse, adherence. The latter adherence style showed worse glycemic control. CONCLUSION Mobile phones provide a feasible method to measure glucose monitoring and insulin administration in adolescents, given a limited assessment duration. The method provided novel insights regarding patterns of adherence and should be explored in clinical settings for targeting or tailoring interventions.

Mobile Intervention Design in Diabetes: Review and Recommendations

Mobile technology enhances the potential to assess, prompt, educate, and engage individuals with diabetes. The near-ubiquitous presence of mobile phones allows real-time contextually relevant support for diabetes self-care. We review the design of mobile interventions included in a recent meta-analysis. Although mobile programs can lead to improvements in glycemic control, many aspects, such as the role of the diabetes clinician, real-time features, and patient engagement have not been documented. Studies with the greatest impact on hemoglobin A1c integrated patient feedback and a role for clinicians. Research is needed regarding feasible and efficacious roles for clinical support in mobile interventions. Recommendations for design and research include the following: consideration of patient and clinician burden; identification of patterns and metrics for patient treatment adherence and engagement; integration of goal setting and problem solving; enhancing patient education; a greater focus on patient-centered motivational strategies; and utilization of study designs that relate intervention design elements to outcomes.

Health literacy and quality: focus on chronic illness care and patient safety.

Despite a heightened focus on improving quality, recent studies have suggested that children only receive half of the indicated preventive, acute, or chronic care. Two major areas in need of improvement are chronic illness care and prevention of medical errors. Recently, health literacy has been identified as an important and potentially ameliorable factor for improving quality of care. Studies of adults have documented that lower health literacy is independently associated with poorer understanding of prescriptions and other medical information and worse chronic disease knowledge, self-management behaviors, and clinical outcomes. There is also growing evidence to suggest that health literacy is important in pediatric safety and chronic illness care. Adult studies have suggested that addressing literacy can lead to improved patient knowledge, behaviors, and outcomes. Early studies in the field of pediatrics have shown similar promise. There are significant opportunities to evaluate and demonstrate the importance of health literacy in improving pediatric quality of care. Efforts to address health literacy should be made to apply the 6 Institute of Medicine aims for quality-care that is safe, effective, patient centered, timely, efficient, and equitable. Efforts should also be made to consider the distinct nature of pediatric care and address the “4 Ds” unique to child health: the developmental change of children over time; dependency on parents or adults; differential epidemiology of child health; and the different demographic patterns of children and their families.

Development and Initial Validation of the Barriers to Diabetes Adherence Measure for Adolescents

AIMS The purpose of this study was to develop a measure of psychosocial barriers to adherence in adolescents with type 1 diabetes (T1D) and examine relationships to patient characteristics, adherence, and hemoglobin A1C (A1C). METHODS Barriers to diabetes adherence (BDA) items were generated by researchers, clinicians, and patients. Adolescents aged 12-17 with T1D completed the BDA and an adherence measure. Hemoglobin A1C was obtained through medical chart review. RESULTS Factor analysis from 123 adolescents resulted in a 21-item, five-component solution that accounted for 64.5% of the variance. The components were stress and burnout, time pressure and planning, social support, parental autonomy support, and stigma. The BDA total and subscales were internally consistent. The BDA total and some components were associated with adherence and A1C. The BDA was the only predictor of A1C compared to demographic, clinical, and adherence variables (F 6.17, p<.05). Subjects with higher A1C (>8.5) showed a higher level of barriers (F 15.20, p<.001) and a differential profile of barriers (F 5.75, p<.05). CONCLUSIONS The BDA may be useful in research and clinical settings as a compliment to adherence measures and to tailor educational programs. Additional research is necessary to establish test-retest reliability and discriminant validity.

Assessing Adolescent Asthma Symptoms and Adherence Using Mobile Phones

Background Self-report is the most common method of measuring medication adherence but is influenced by recall error and response bias, and it typically does not provide insight into the causes of poor adherence. Ecological momentary assessment (EMA) of health behaviors using mobile phones offers a promising alternative to assessing adherence and collecting related data that can be clinically useful for adherence problem solving. Objective To determine the feasibility of using EMA via mobile phones to assess adolescent asthma medication adherence and identify contextual characteristics of adherence decision making. Methods We utilized a descriptive and correlational study design to explore a mobile method of symptom and adherence assessment using an interactive voice response system. Adolescents aged 12-18 years with a diagnosis of asthma and prescribed inhalers were recruited from an academic medical center. A survey including barriers to mobile phone use, the Illness Management Survey, and the Pediatric Asthma Quality of Life Questionnaire were administered at baseline. Quantitative and qualitative assessment of asthma symptoms and adherence were conducted with daily calls to mobile phones for 1 month. The Asthma Control Test (ACT) was administered at 2 study time points: baseline and 1 month after baseline. Results The sample consisted of 53 adolescents who were primarily African American (34/53, 64%) and female (31/53, 58%) with incomes US

Self-management problem solving for adolescents with type 1 diabetes: Intervention processes associated with an Internet program

40K/year or lower (29/53, 55%). The majority of adolescents (37/53, 70%) reported that they carried their phones with them everywhere, but only 47% (25/53) were able to use their mobile phone at school. Adolescents responded to an average of 20.1 (SD 8.1) of the 30 daily calls received (67%). Response frequency declined during the last week of the month (b=-0.29, P<.001) and was related to EMA-reported levels of rescue inhaler adherence (r= 0.33, P=.035). Using EMA, adolescents reported an average of 0.63 (SD 1.2) asthma symptoms per day and used a rescue inhaler an average of 70% of the time (SD 35%) when they experienced symptoms. About half (26/49, 53%) of the instances of nonadherence took place in the presence of friends. The EMA-measured adherence to rescue inhaler use correlated appropriately with asthma control as measured by the ACT (r=-0.33, P=.034). Conclusions Mobile phones provided a feasible method to assess asthma symptoms and adherence in adolescents. The EMA method was consistent with the ACT, a widely established measure of asthma control, and results provided valuable insights regarding the context of adherence decision making that could be used clinically for problem solving or as feedback to adolescents in a mobile or Web-based support system.