strategies to educate young people with type 1 …
TRANSCRIPT
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Literature Review
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
HOW CITED: La Banca RO, Sparapani VC, Bueno M, Costa T, Carvalho EC, Nascimento LC. Strategies to educate young people with type 1 diabetes mellitus on insulin therapy: systematic review. Texto Contexto Enferm [Internet]. 2020 [cited YEAR MONTH DAY]; 29:e20180338. Available from: https://doi.org/10.1590/1980-265X-TCE-2018-0338
STRATEGIES TO EDUCATE YOUNG PEOPLE WITH TYPE 1 DIABETES MELLITUS ON INSULIN THERAPY: SYSTEMATIC REVIEW
Rebecca Ortiz La Banca1
Valéria de Cássia Sparapani2
Mariana Bueno3
Taine Costa4
Emilia Campos de Carvalho5
Lucila Castanheira Nascimento6
1Joslin Diabetes Center, Harvard Medical School. Boston, Massachusetts, Estados Unidos da América.2Universidade Federal de Santa Catarina, Departamento de Enfermagem. Florianópolis, Santa Catarina, Brasil.
3Hospital for Sick Children. Toronto, Ontário, Canadá.4Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Programa Interunidades de Doutoramento em Enfermagem.
Ribeirão Preto, São Paulo, Brasil.5Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Geral e Especializada.
Ribeirão Preto, São Paulo, Brasil.6Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno Infantil e Saúde
Pública. Ribeirão Preto, São Paulo, Brasil.
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.
DESCRIPTORS: Type 1 Diabetes Mellitus. Health Education. Insulin. Review. Child. Adolescent. Pediatric Nursing.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
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ESTRATÉGIAS PARA EDUCAR JOVENS COM DIABETES MELLITUS TIPO 1 SOBRE INSULINOTERAPIA: REVISÃO SISTEMÁTICA
RESUMO
Objetivo: identificar evidências disponíveis na literatura sobre estratégias educativas utilizadas no ensino da insulinoterapia às crianças e adolescentes com diabetes mellitus tipo 1.Método: revisão sistemática, realizada em cinco bases de dados, com os descritores Insulin/therapeutic use, Patient education as topic, Diabetes mellitus type 1, Child, Infant, Adolescent e palavras-chave, sem delimitação de período. Incluídos estudos primários acerca do ensino da insulinoterapia e excluídas pesquisas sobre bomba de insulina.Resultados: identificados 243 estudos, dos quais foram incluídos 13. Os resultados apresentam estratégias educativas direcionadas às crianças, adolescentes e jovens de até 24 anos de idade, aplicadas de forma individual ou em grupos; por contato telefônico ou mensagens de texto por celular; dramatização e acampamentos educativos; por um único profissional ou equipe multidisciplinar. As estratégias descritas nos estudos analisados abordaram ajuste da insulina em situações cotidianas e educação para manejo da insulina, associados com a estratégia nutricional de contagem de carboidratos, educação em diabetes com módulo específico sobre insulinoterapia e uso da insulina de forma intensiva. Os estudos analisaram o efeito da intervenção educativa sobre diversos desfechos clínicos e comportamentais, como a hemoglobina glicada e autoeficácia.Conclusão: não foi possível determinar uma única estratégia sobre a insulinoterapia capaz de melhorar o controle metabólico e psicossocial. O desenvolvimento de estratégias educativas voltadas à insulinoterapia de crianças e adolescentes com diabetes, independentemente do contexto em que serão implementadas, tem, em sua maioria, o enfermeiro como profissional responsável, o que reafirma seu papel educador.
DESCRITORES: Diabetes Mellitus Tipo 1. Educação em saúde. Insulina. Revisão. Criança. Adolescente. Enfermagem pediátrica.
ESTRATEGIAS PARA EDUCAR A LOS JÓVENES CON DIABETES MELITUS TIPO 1 SOBRE LA INSULINOTERAPIA: UNA REVISIÓN SISTEMÁTICA
RESUMEN
Objetivo: identificar la evidencia disponible en la literatura sobre las estrategias educativas utilizadas para enseñar la terapia con insulina a niños y adolescentes con diabetes mellitus tipo 1.Método: revisión sistemática, realizada en cinco bases de datos, con los descriptores Insulina / uso terapéutico, Educación del paciente como tema, Diabetes mellitus tipo 1, Niño, Lactante, Adolescente y palabras clave, sin delimitación de períodos. Se incluyeron estudios primarios sobre la enseñanza de la terapia con insulina y se excluyó la investigación sobre la bomba de insulina.Resultados: se identificaron 243 estudios, de los cuales se incluyeron 13. Los resultados presentan estrategias educativas dirigidas a niños, adolescentes y jóvenes hasta los 24 años, aplicadas individualmente o en grupos; por contacto telefónico o mensajes de texto por teléfono celular; juegos de rol y campamentos educativos; por un solo equipo profesional o multidisciplinar. Las estrategias descritas en los estudios analizados abordaron el ajuste de la insulina en situaciones cotidianas y la educación para el manejo de la insulina, asociadas a la estrategia nutricional de conteo de carbohidratos, educación en diabetes con módulo específico sobre terapia insulínica y uso intensivo de insulina. Los estudios analizaron el efecto de la intervención educativa sobre varios resultados clínicos y conductuales, como la hemoglobina glucosilada y la autoeficacia. Conclusión: no fue posible determinar una única estrategia sobre la terapia con insulina capaz de mejorar el control metabólico y psicosocial. El desarrollo de estrategias educativas orientadas a la terapia con insulina para niños y adolescentes con diabetes, independientemente del contexto en el que se implementen, tiene, en su mayor parte, al enfermero como profesional responsable, lo que reafirma su rol educativo.
DESCRIPTORES: Diabetes Mellitus Tipo 1. Educación para la salud. Insulina. Revisión. Niño. Adolescente. Enfermería pediátrica.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
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INTRODUCTION
According to the International Diabetes Federation, more than 88 thousand Brazilian children and adolescents have Type 1 diabetes mellitus (T1D) and Brazil is the third country with the highest number of cases.1 From the start of the T1D diagnosis, children, adolescents, and their families need to develop skills and acquire knowledge to perform self-care tasks. The process that leads to the acquisition of new behaviors, including the incorporation of tools that contribute to the achievement of the treatment goals, is called diabetes education.2
The American Association of Diabetes Educators recommends seven self-care behaviors that should be developed in the educational process3. One of them involves adherence to the medication regimen, which is a challenge for those working with the pediatric age group. Intensive T1D treatment, with three or more daily doses of insulin, aims to reduce the incidence of acute and chronic complications, in addition to offering flexibility to adjust doses according to the physical activity performed and to the diet.4–5
In order to encourage young people and family members to comply with intensive multi-dose insulin therapy, diabetes education should range from the types of insulin available on the market, including their respective action profiles, concentration, peak and duration of therapeutic effect, to aspects of safe practices of the injection technique. Thus, guidelines on storage, application sites and absorption rate, syringe or pen handling, needle selection, insertion angle, indication of skin fold, combination of two types of insulin in the same syringe and disposal of waste materials are essential for proper adherence to the medication regimen.2
Despite the obvious benefits of intensive treatment, most Brazilians with T1D do not adhere to the intensive insulin regimen. It is known that 40% of newly diagnosed pediatric patients mention fear or pain during the application.6,7 Based on these findings, the intensive insulin treatment is considered a highly complex topic, requiring planning and an appropriate approach to the age group, especially when analyzing children and adolescents, so that they can gain practical skills essential for autonomy in insulin therapy.
In order to contribute to the construction of knowledge about the best practices for teaching this behavior in pediatric diabetes education, this study aimed to identify evidence available in the literature on educational strategies used in the teaching of insulin therapy to children and adolescents with T1D.
METHOD
Systematic literature review, described in accordance with the PRISMA Statement, with the following guiding question: “which strategies are used to teach insulin therapy to children and adolescents with T1D?”, elaborated according to the PICO strategy.8–9
The inclusion criteria were primary studies, without delimitation of language and year of publication, published in full, focused on strategies for teaching insulin therapy to children and adolescents with T1D. Studies that only discussed insulin therapy using continuous subcutaneous insulin infusion systems were excluded, as the particularities of teaching this technology differ from conventional insulin therapy. Experience reports, case studies, editorials, response letters, reviews and research that did not present the data of the educational strategy for the pediatric population separately from the other results were also excluded. Studies whose full texts could not be obtained even after sending requests to the journal in which they were published and to the authors were classified as unobtainable.
The searches in PubMed, EMBASE, CINAHL, LILACS/BDENF, and ERIC were carried out in December 2017 and, as already mentioned, without setting time limits. The descriptors were selected
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
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in the Medical Subject Headings (MeSH) and in the Health Sciences Descriptors (DeCS). The search strategy in PubMed, exemplified in Chart 1, shows the use of the boolean operators AND and OR.
Chart 1 – Search strategy in PubMed. Ribeirão Preto, SP, Brazil, 2018.
Database Search strategy
PubMed
(“Insulin/therapeutic use”[Mesh]) AND “Patient Education as Topic”[Mesh]) AND “Diabetes Mellitus, Type 1”[Mesh]) AND (child* AND (Humans[Mesh] AND (infant[MeSH] OR child[MeSH] OR adolescent[MeSH]) NOT (“pump * AND (Humans[Mesh] AND (infant[MeSH] OR child[MeSH] OR adolescent[MeSH]) Filters: Humans, Child: birth-18 month, Infant: birth-23 months.
Two reviewers independently evaluated the titles and abstracts of all citations identified in the databases and eliminated duplicates. The eligible studies were consulted in full when the study was relevant or when the title and abstract were insufficient for inclusion. To obtain a consensus, a third reviewer’s opinion was requested in case of disagreement. In addition, the researchers performed a manual search for primary studies. After identifying the citations in the databases, they searched the reference lists for other potential titles that suggested studies on educational strategies for insulin therapy.
For extraction and synthesis, the reviewers developed a chart in Microsoft Excel®, composed of the following items: authors, country, year of publication, study design, sample detail, type of educational and professional intervention involved, content of the intervention and duration, clinical and behavioral results and limitations. Two reviewers completed the chart separately with the data from the selected articles, and a third researcher judged divergent results to reach a consensus.
To judge the risk of bias, the tool developed by the Cochrane Collaboration was used, as the identified studies were randomized clinical trials and quasi-experiments.10
RESULTS
The results identified 243 citations: 18 from CINAHL, 15 from EMBASE, one from ERIC, 34 from LILACS / BDENF, 169 from PubMed, and six studies retrieved through a manual search. After removing duplicates and reading abstracts and titles, 17 studies were read in full, 13 of which reported educational strategies for the pediatric population and discussed aspects of insulin therapy, as shown in the flow chart in Figure 1.
Of the 13 articles included in the synthesis, seven were randomized clinical trials11–17 (RCT) and six quasi-experiments,18–23 as the same study generated two publications.12–13 The studies were published between 1991 and 2016 and developed in the following countries: Germany,21
Canada,15,20 Scotland,14,16 United States,12–13 Finland,11 Northern Ireland,17 Pakistan,22 United Kingdom,18 Tanzania23 and Turkey.19 The contexts in which the educational strategies took place were educational camps,19 pediatric diabetes clinics,12,13,22 medical centers,18 diabetes centers,20 hospitals11,17,21,23 and at a distance, by telephone14,15 and texting by mobile phone.16
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
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Figure 1 – database search flowchart.
In total,1,219 children, adolescents and young adults between five and 24 years of age participated in the analyzed studies. The inclusion of young people up to 24 years old in three studies14,19–20 is justified by the fact that it is common to include those over 18 years old in pediatric clinics. Consequently, the educational programs developed in these pediatric settings also target these young people. In two other studies, it was impossible to determine the minimum age of the participants, because the authors presented the age of the participants in age groups from zero to four years old.11,23 The detailed summary of the studies included is shown in Chart 2.
In this review, the following educational strategies were evidenced: group lectures18,20–21; individual education11,17,20,22–23 including the donation of care kits22 and dinners;17 dramatization,12–13 educational camp,19 telephone contact with the health care team14–15 and texting by mobile phone.16–17 The following themes were addressed: insulin dosage adjustment in daily situations12–15,19,21,23 and insulin management education associated with the nutritional strategy of carbohydrate counting,17–18,20
diabetes education with a specific module on insulin therapy16,22 and intensive insulin use, that is, three or more doses per day.11
In most studies, the pediatric nurse specialist or diabetes educator was part of the team responsible for the intervention, including pediatricians, diabetologists, pediatric endocrinologists, dieticians, psychologists and social workers. The category of the health care professional responsible for elaborating the educational intervention was not highlighted in a single study.16
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
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Cha
rt 2
– S
tudi
es in
clud
ed in
the
synt
hesi
s.
Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Sim
ell e
t al
, Fin
land
(1
991)
11
To re
port
the
effec
ts
on m
etab
olic
con
trol
of a
n ed
ucat
iona
l in
terv
entio
n de
velo
ped
durin
g ho
spita
lizat
ion.
RC
T.61
chi
ldre
n an
d ad
oles
cent
s, 0
to
14 y
ears
, new
ly
diag
nose
d w
ith T
1D.
Them
e: in
tens
ive
use
of in
sulin
Gro
up 1
(G1)
: dai
ly e
duca
tiona
l pro
gram
from
the
2nd to
the
7th
day
of h
ospi
taliz
atio
n. O
utpa
tient
fo
llow
-up
for t
hree
wee
ks, w
ith 3
-4 v
isits
.G
roup
2 (G
2): e
duca
tiona
l pro
gram
sta
rted
on th
e 7th
day
of h
ospi
taliz
atio
n, c
ontin
ued
two
times
a
wee
k un
til d
isch
arge
in th
e 4t
h w
eek.
Prof
essi
onal
s in
volv
ed: p
edia
trici
an, d
ietic
ian,
so
cial
wor
ker,
psyc
holo
gist
, hos
pita
l nur
se w
ith
diab
etes
trai
ning
and
nur
se fr
om th
e ou
tpat
ient
cl
inic
spe
cial
ized
in d
iabe
tes.
Both
gro
ups:
ava
ilabi
lity
of te
leph
one
appo
intm
ents
w
ith a
sen
ior p
edia
trici
an d
urin
g th
e tw
o ye
ars
of
the
stud
y. M
onth
ly a
nd q
uarte
rly fo
llow
-up.
Afte
r tw
o ye
ars,
the
parti
cipa
nts
wer
e ev
alua
ted
for t
wo
days
, lo
okin
g at
the
circ
adia
n va
riatio
n in
dia
bete
s co
ntro
l an
d en
doge
nous
insu
lin s
ecre
tion.
Clin
ical
out
com
es o
nly:
HbA
1c: i
mpr
ovem
ent a
fter o
ne m
onth
in G
1 (p
=.01
). Af
ter
two
mon
ths,
bot
h gr
oups
reac
hed
mea
n va
lues
com
para
ble
to h
ealth
y in
divi
dual
s. In
two
year
s, th
ere
was
an
incr
ease
in
HbA
1c fr
om 7
.4%
at 3
mon
ths
to 9
% in
the
21st
mon
th o
f tre
atm
ent i
n G
1; in
crea
se fr
om 7
.8%
to 8
.8%
at 1
8 m
onth
s in
G
2. S
igni
fican
t cor
rela
tion
betw
een
the
time
of d
iagn
osis
of
the
dise
ase
and
incr
ease
in H
bA1c
(p=.
004)
, con
stan
t in
the
two
year
s of
stu
dy.
C p
eptid
e: u
ndet
ecta
ble
afte
r 6 m
onth
s in
G1
and
afte
r 12
mon
ths
in G
2, o
ccur
ring
first
in c
hild
ren
aged
7 to
10
year
s an
d, la
st, i
n ad
oles
cent
s. T
here
was
no
corre
latio
n be
twee
n H
bA1c
and
C p
eptid
e af
ter t
wo
year
s of
stu
dy.
Insu
lin u
se: l
ower
mea
n fo
r G1
in th
e tw
o ye
ars
of s
tudy
. C
hang
es re
late
d to
the
time
of d
iagn
osis
and
not
to th
e pe
riod
of h
ospi
taliz
atio
n.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
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Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Gre
y et
al
, Uni
ted
Stat
es
(199
8)*, 1
2
To d
eter
min
e w
heth
er
Cop
ing
Skills
Tra
inin
g (C
ST) c
ombi
ned
with
in
tens
ive
diab
etes
tre
atm
ent i
mpr
oves
m
etab
olic
con
trol (
MC
) an
d qu
ality
of l
ife (Q
oL)
of a
dole
scen
ts s
tarti
ng
inte
nsiv
e th
erap
y re
gim
ens.
RC
T.65
ado
lesc
ents
, 13
to
18 y
ears
old
, on
insu
lin
ther
apy
for a
t lea
st o
ne
year
.
Them
e: c
opin
g sk
ills in
the
man
agem
ent o
f in
tens
ive
insu
lin th
erap
y.C
ontro
l gro
up (C
G):
inte
nsiv
e tre
atm
ent (
mul
tiple
-do
se in
sulin
ther
apy)
.Ex
perim
enta
l gro
up (E
G):
inte
nsiv
e tre
atm
ent a
nd
CST
, whi
ch c
onsi
sted
of d
ram
atiz
atio
n of
eve
ryda
y si
tuat
ions
(foo
d ch
oice
s, c
onfli
cts,
dec
isio
n m
akin
g), t
o tra
in c
opin
g sk
ills. P
artic
ipan
ts w
ere
eval
uate
d an
d th
e sc
ene
was
repe
ated
unt
il th
e ex
pect
ed b
ehav
ior w
as id
entifi
ed.
Gro
ups
of 2
-3 a
dole
scen
ts; a
vera
ge d
urat
ion
1-1.
5 ho
urs.
The
ado
lesc
ents
par
ticip
ated
in a
n av
erag
e of
six
wee
kly
sess
ions
, fol
low
ed b
y m
onth
ly
cons
ulta
tions
at t
he p
edia
tric
diab
etes
clin
ic fo
r th
ree
mon
ths.
Clin
ical
:de
crea
se in
HbA
1c a
fter t
hree
m
onth
s, fa
ster
and
gre
ater
one
m
onth
afte
r the
sta
rt of
inte
nsiv
e tre
atm
ent,
mai
ntai
ned
until
the
end
of th
e st
udy
in th
e EG
.In
bot
h gr
oups
, int
ensi
ve th
erap
y as
soci
ated
with
a h
ighe
r num
ber o
f m
onth
ly v
isits
led
to a
dec
reas
e in
H
bA1c
at t
hree
mon
ths
(p<.
01).
The
resu
lts s
ugge
st th
at in
tens
ive
treat
men
t im
prov
es M
C, w
hich
can
be
inte
nsifi
ed th
roug
h th
e C
ST.
CST
has
an
imm
edia
te b
enefi
cial
eff
ect o
n th
e ad
oles
cent
’s a
bilit
y to
ob
tain
MC
in th
e sh
ort t
erm
.Th
ere
was
no
diffe
renc
e be
twee
n th
e gr
oups
in te
rms
of in
sulin
do
ses
or n
umbe
r of b
lood
glu
cose
m
onito
ring
chec
ks p
erfo
rmed
per
da
y.Th
e in
terv
entio
n di
d no
t affe
ct th
e de
crea
se in
acu
te c
ompl
icat
ions
.BM
I inc
reas
ed in
the
over
wei
ght
parti
cipa
nts
in b
oth
grou
ps.
Beh
avio
ral:
impr
oved
sel
f-effi
cacy
(S
elf-E
ffica
cy fo
r D
iabe
tes
scal
e),
depr
essi
on (C
hild
ren’
s D
epre
ssio
n In
vent
ory)
, Q
oL (D
iabe
tes
Qua
lity
of L
ife Y
outh
sca
le),
and
copi
ng w
ith T
1D (I
ssue
s in
cop
ing
with
IDD
M)
durin
g th
e th
ree
mon
ths
of s
tudy
in E
G.
Cha
rt 2
– C
ont.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
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Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Gre
y et
al
, Uni
ted
Stat
es
(200
0)*13
To d
eter
min
e if
the
initi
al e
ffect
of C
ST
on M
C a
nd Q
oL,
com
bine
d w
ith
inte
nsiv
e ca
re, c
an b
e m
aint
aine
d in
you
ng
peop
le w
ho a
re s
tarti
ng
treat
men
t. R
CT.
77 a
dole
scen
ts, 1
2 to
17
yea
rs o
ld, o
n in
sulin
th
erap
y fo
r at l
east
one
ye
ar.
Them
e: c
opin
g sk
ills in
the
man
agem
ent o
f in
tens
ive
insu
lin th
erap
y.C
ontro
l gro
up (C
G):
inte
nsiv
e tre
atm
ent (
mul
tiple
-do
se in
sulin
ther
apy)
.Ex
perim
enta
l gro
up (E
G):
inte
nsiv
e tre
atm
ent a
nd
CST
, whi
ch c
onsi
sted
of d
ram
atiz
atio
n of
eve
ryda
y si
tuat
ions
to tr
ain
copi
ng s
kills
. Par
ticip
ants
wer
e ev
alua
ted
and
the
scen
e w
as re
peat
ed u
ntil
the
expe
cted
beh
avio
r was
iden
tified
.G
roup
s of
2-3
ado
lesc
ents
: ave
rage
dur
atio
n of
1-1
.5 h
ours
. The
ado
lesc
ents
par
ticip
ated
in
an a
vera
ge o
f six
wee
kly
sess
ions
, fol
low
ed b
y m
onth
ly a
ppoi
ntm
ents
at t
he P
edia
tric
Dia
bete
s C
linic
for 1
2 m
onth
s.
Clin
ical
:de
crea
se in
HbA
1c a
fter 1
2 m
onth
s in
EG
.Be
tter M
C in
EG
with
bet
ter s
elf-
effica
cy re
late
d to
dia
bete
s an
d m
edic
al tr
eatm
ent (
Sel
f-Effi
cacy
fo
r Dia
bete
s sc
ale)
, with
sta
tistic
al
sign
ifica
nce
durin
g th
e si
x m
onth
s.
Beh
avio
ral:
less
neg
ativ
e im
pact
on
QoL
(Dia
bete
s Q
ualit
y of
Life
You
th s
cale
) afte
r 12
mon
ths,
with
the
best
re
sults
obs
erve
d in
the
first
thre
e m
onth
s of
in
terv
entio
n.
How
ells
et
al, S
cotla
nd
(200
2)14
To e
valu
ate
the
chan
ges
in s
elf-e
ffica
cy
of y
oung
peo
ple
with
T1
D w
ho p
artic
ipat
ed
in th
e N
egot
iate
d Te
leph
one
Supp
ort
(NTS
) int
erve
ntio
n.R
CT.
79 y
oung
peo
ple,
12
to 2
4 ye
ars
old,
on
conv
entio
nal i
nsul
in
ther
apy.
Them
e: p
robl
em-s
olvi
ng c
once
rnin
g T1
D.
Gro
up 1
(G1)
: con
vent
iona
l tre
atm
ent (
quar
terly
co
nsul
tatio
n at
the
diab
etes
cen
ter).
Gro
up 2
(G2)
: con
vent
iona
l tre
atm
ent a
nd N
TS,
cons
istin
g of
a p
hone
cal
l by
a di
etic
ian
spec
ializ
ed
in p
edia
trics
and
dia
bete
s ov
er a
one
-yea
r per
iod.
Ad
oles
cent
s de
cide
d on
the
them
e of
the
call,
w
hich
took
pla
ce e
very
two
to th
ree
wee
ks, w
ith
the
optio
n of
ext
ra c
alls
upo
n th
e yo
uth’
s in
itiat
ive.
H
ome
visi
ts b
y on
e cl
inic
al p
sych
olog
ist f
or a
ctiv
e in
stru
ctio
n an
d de
liver
y of
a le
aflet
on
prob
lem
-so
lvin
g.G
roup
3 (G
3): N
TS a
nd c
onsu
ltatio
n at
the
diab
etes
ce
nter
onc
e/ye
ar, H
bA1c
eve
ry th
ree
mon
ths
(at
hom
e or
col
lect
ion
at th
e ce
nter
).M
ost c
hose
n th
emes
in N
TS: d
iabe
tes
(gen
eral
), pe
rform
ance
at w
ork,
frie
ndsh
ip, r
elat
ions
hip
with
pa
rent
s an
d si
blin
gs, h
ealth
, soc
ial l
ife a
nd le
isur
e,
scho
ol/u
nive
rsity
, and
oth
ers.
On
aver
age,
eac
h pa
rtici
pant
rece
ived
16
calls
, la
stin
g ni
ne m
inut
es e
ach,
at t
hree
-wee
k in
terv
als.
Clin
ical
:th
e N
TS d
id n
ot im
prov
e gl
ycem
ic
cont
rol i
n G
2 an
d G
3.G
1, G
2 an
d G
3 sh
owed
an
incr
ease
in B
MI d
urin
g th
e st
udy.
Ther
e w
as a
sta
tistic
ally
sig
nific
ant
corre
latio
n (p
<.01
) bet
wee
n th
e pa
rtici
pant
’s a
ge a
nd th
e av
erag
e du
ratio
n of
the
tele
phon
e co
ntac
t in
G2
and
G3.
Few
er c
onsu
ltatio
ns a
t the
di
abet
es c
ente
r in
G3.
G1,
G2,
and
G3
show
ed n
o st
atis
tical
ly s
igni
fican
t diff
eren
ces
(p=.
84) i
n th
e nu
mbe
r of
emer
genc
y ho
spita
lizat
ions
due
to
diab
etes
com
plic
atio
ns d
urin
g th
e st
udy.
Beh
avio
ral:
ther
e w
as n
o st
atis
tical
ly
sign
ifica
nt d
iffer
ence
be
twee
n th
e gr
oups
in
the
self-
effica
cy
scor
es (S
elf-E
ffica
cy
for D
iabe
tes)
, tre
atm
ent
adhe
renc
e ba
rrier
s (E
nviro
nmen
tal
barri
ers
to A
dher
ence
Q
uest
ionn
aire
) pro
blem
so
lvin
g (S
ocia
l Pro
blem
So
lvin
g In
vent
ory)
, and
di
abet
es k
now
ledg
e (D
iabe
tes
Know
ledg
e Sc
ale)
.Se
lf-effi
cacy
incr
ease
d si
gnifi
cant
ly in
the
com
bine
d in
terv
entio
n an
d in
indi
vidu
als
with
H
bA1c
und
er 8
%.
Cha
rt 2
– C
ont.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
9/21
Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Law
son
et
al, C
anad
a (2
005)
15
To d
eter
min
e th
e eff
ect
of te
leph
one
cont
act
on M
C, t
reat
men
t co
mpl
ianc
e, a
nd Q
oL
of a
dole
scen
ts w
ith
T1D
.R
CT.
43 a
dole
scen
ts, 1
3 to
17
yea
rs o
ld. T
1D fo
r at
leas
t 1 y
ear,
insu
lin
ther
apy
2-3
times
/da
y an
d in
appr
opria
te
glyc
emic
con
trol i
n th
e la
st 6
mon
ths.
Them
e: a
djus
tmen
ts to
insu
lin d
osag
es.
Con
trol g
roup
(CG
): st
anda
rd c
are
(two
or th
ree
dose
s of
NPH
and
regu
lar i
nsul
in, o
r gly
cem
ic
corre
ctio
ns w
ith u
ltraf
ast i
nsul
in; m
eal p
lan
with
a
diet
icia
n on
ce p
er y
ear;
quar
terly
med
ical
retu
rn
with
dia
beto
logi
st a
nd H
bA1c
).Ex
perim
enta
l gro
up (E
G):
stan
dard
car
e an
d te
leph
one
cont
act f
or s
ix m
onth
s. T
wo
diab
etes
nu
rse
educ
ator
s ea
ch c
onta
cted
abo
ut 1
1-12
ad
oles
cent
s w
eekl
y, to
dis
cuss
the
bloo
d gl
ucos
e di
ary
of th
e pr
evio
us w
eek
and
nece
ssar
y ad
just
men
ts in
insu
lin d
osag
es.
Clin
ical
:de
crea
se in
HbA
1c in
29%
of
parti
cipa
nts
in E
G a
nd in
crea
se in
19
% (p
=.01
5) o
f the
par
ticip
ants
in
EG. I
ncre
ased
HbA
1c in
CG
.In
crea
sed
BMI i
n EG
. Th
ere
wer
e no
cha
nges
in in
sulin
do
sage
s or
sev
ere
hypo
glyc
emic
ep
isod
es in
bot
h gr
oups
.
Beh
avio
ral:
Impr
ovem
ent o
f QoL
(D
iabe
tes
Qua
lity
of
Life
You
th s
cale
) and
fa
mily
func
tioni
ng
(Fam
ily E
nviro
nmen
t Sc
ale)
sco
res
of th
e ex
perim
enta
l gro
up a
t th
ree
mon
ths.
The
inte
rven
tion
show
ed
gaps
in th
e kn
owle
dge
abou
t T1D
.
Fran
klin
et
al, S
cotla
nd
(200
6)16
To d
escr
ibe
the
Swee
t Ta
lk
RC
T.92
you
ng p
eopl
e, 8
to
18 y
ears
old
, with
T1D
fo
r at l
east
one
yea
r.
Them
e: T
1D s
elf-c
are
task
s.G
roup
1 (G
1): s
tand
ard
care
(2-3
dos
es o
f pr
emix
ed in
sulin
).G
roup
2 (G
2): s
tand
ard
care
and
Sw
eet T
alk
Gro
up 3
(G3)
: bas
al th
erap
y-bo
lus
and
Sw
eet
Talk
. (au
tom
ated
sys
tem
that
sto
res
and
send
s,
acco
rdin
g to
a p
revi
ous
sche
dule
, abo
ut 4
00 te
xt
mes
sage
s by
mob
ile p
hone
, gui
ded
by b
ehav
iora
l th
eorie
s). I
t inc
lude
s: a
wee
kly
rem
inde
r of
the
succ
essf
ul g
oals
agr
eed
at th
e cl
inic
; dai
ly
mes
sage
s w
ith ti
ps, i
nfor
mat
ion,
or r
emin
ders
to
rein
forc
e th
e go
als
agre
ed u
pon
with
the
heal
th
care
team
con
cern
ing
insu
lin a
pplic
atio
n, b
lood
gl
ucos
e se
lf-m
onito
ring,
hea
lthy
eatin
g, a
nd
exer
cise
.
Clin
ical
:im
prov
emen
t of H
bA1c
in G
3 (p
<.00
1).
No
sign
ifica
nt c
hang
es w
ere
iden
tified
in D
KA a
nd s
ever
e hy
pogl
ycem
ia e
piso
des.
The
BMI i
ncre
ased
in G
3.Th
e us
e of
the
heal
th s
ervi
ce w
as
grea
ter i
n G
2 an
d G
3 (p
=.01
6).
Emer
genc
y co
ntac
ts w
ith th
e he
alth
car
e te
am w
ere
mor
e fre
quen
t in
G3
than
G2
(p=.
02).
Beh
avio
ral:
impr
oved
sel
f-effi
cacy
(S
elf-E
ffica
cy fo
r D
iabe
tes
scor
e) in
G2
whe
n co
mpa
red
to G
1 (p
=.00
3); i
ncre
ased
ad
here
nce
to th
e tre
atm
ent,
mea
sure
d us
ing
a vi
sual
ana
log
scal
e (p
=.04
2).
Ther
e w
as n
o ch
ange
in
kno
wle
dge
leve
ls
(Dia
bete
s Kn
owle
dge
Scor
e).
The
soci
al s
uppo
rt (D
iabe
tes
Soci
al S
uppo
rt In
terv
iew
) pro
vide
d by
th
e he
alth
car
e te
am
incr
ease
d w
hen
Sw
eet
Talk
was
use
d in
G2
and
G3
(p<.
05).
Cha
rt 2
– C
ont.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
10/21
Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Coa
tes
et
al, N
orth
ern
Irela
nd
(201
3)17
To e
valu
ate
the
impa
ct o
f a d
iabe
tes
educ
atio
n pr
ogra
m fo
r ad
oles
cent
s w
ith T
1D
(CH
OIC
E): H
bA1c
, BM
I, hy
pogl
ycem
ia
and
hype
rgly
cem
ia
epis
odes
, and
ad
here
nce
to th
e di
et.
RC
T.13
5 ad
oles
cent
s, 1
3 to
16
yea
rs o
ld. T
1D fo
r at
leas
t one
yea
r.
Them
es: i
nter
actio
n be
twee
n ca
rboh
ydra
te
cons
umpt
ion
and
insu
lin re
quire
men
t; m
eal t
imes
an
d eff
ects
of p
hysi
cal e
xerc
ise
on b
lood
glu
cose
an
d in
sulin
.C
ontro
l-gro
up (C
G):
stan
dard
car
e ev
ery
thre
e m
onth
s, w
ith th
e pr
ofes
sion
al fr
om th
e cl
inic
, to
solv
e pr
oble
ms.
Expe
rimen
tal g
roup
(EG
): C
HO
ICE,
con
sist
ing
of fo
ur w
eekl
y ed
ucat
iona
l ses
sion
s, in
volv
ing
one
nurs
e an
d tw
o di
etic
ians
with
exp
erie
nce
in
diab
etes
at s
even
hos
pita
ls. T
he d
urat
ion
of th
e se
ssio
ns w
as th
ree
hour
s, p
lus
one
dinn
er to
pr
actic
e ca
rboh
ydra
te c
ount
ing.
The
se in
clud
ed a
cu
rricu
lar g
uide
, pla
tes
to s
tand
ardi
ze th
e m
eals
, im
ages
of i
ndiv
idua
l por
tions
to b
uild
cus
tom
mea
ls
and
card
s to
pro
mot
e th
e di
alog
ue. D
urin
g th
e br
eaks
bet
wee
n th
e se
ssio
ns a
nd a
t tw
o, fo
ur a
nd
five
mon
ths
afte
r the
inte
rven
tion,
text
mes
sage
s w
ere
sent
to a
sses
s th
e pr
ogre
ss a
nd e
ncou
rage
co
mm
unic
atio
n.
Clin
ical
:im
prov
ed H
bA1c
in E
G a
fter 2
4 m
onth
s.G
reat
er v
aria
tion
in B
MI i
n C
G a
t 12
mon
ths.
Aver
age
of s
ix d
ays
of
hype
rgly
cem
ia in
the
24-m
onth
pe
riod,
with
out D
KA e
piso
des,
in
both
gro
ups.
No
diffe
renc
e be
twee
n th
e gr
oups
in
the
num
ber o
f hyp
ogly
cem
ic
epis
odes
.
Beh
avio
ral:
grea
ter a
dher
ence
to
the
diet
(Dia
bete
s C
are
Profi
le) a
fter o
ne, t
hree
, an
d si
x m
onth
s in
EG
.
Cha
rt 2
– C
ont.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
11/21
Cha
rt 2
– C
ont.
Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Pric
e et
al
, Uni
ted
King
dom
(2
016)
18
To a
naly
ze th
e eff
ect
of K
ids
in C
ontro
l of
Foo
d: K
ICk-
OFF
on
the
biom
edic
al
and
psyc
holo
gica
l ou
tcom
es o
f you
ng
peop
le w
ith T
1D.
RC
T.37
0 ad
oles
cent
s, 1
1 to
16
yea
rs o
ld, T
1D fo
r at
leas
t 1 y
ear.
Them
es: c
arbo
hydr
ate
coun
ting
and
adju
stm
ent
of in
sulin
dos
es in
dai
ly li
fe; m
anag
emen
t of
hyp
ogly
cem
ia, k
eton
es, a
nd lo
ng-te
rm
com
plic
atio
ns.
Con
trol-g
roup
(CG
): st
anda
rd c
are.
Expe
rimen
tal g
roup
(EG
): KI
CK-
OFF
(five
-day
co
urse
taug
ht a
t 17
med
ical
cen
ters
). G
roup
ed
ucat
ion
stra
tegy
, inc
ludi
ng w
ritte
n m
ater
ial,
supp
ort q
uest
ionn
aire
and
eva
luat
ion.
Dev
elop
ed
by a
dia
bete
s nu
rse
and
a di
etic
ian
with
exp
ertis
e in
dia
bete
s, a
nd b
y a
mem
ber o
f the
loca
l tea
m.
The
prof
essi
onal
s w
ere
train
ed d
urin
g a
five-
day
cour
se o
n te
achi
ng s
kills
, dev
elop
ed d
urin
g th
e pi
lot s
tudy
.
Clin
ical
:H
bA1c
leve
ls w
ithou
t sta
tistic
ally
si
gnifi
cant
diff
eren
ces
betw
een
the
grou
ps o
ver t
he 2
4 m
onth
s (p
=.38
).EG
par
ticip
ants
with
hig
h H
bA1c
at
the
begi
nnin
g of
the
stud
y sh
owed
be
tter r
esul
ts a
fter t
wo
year
s w
hen
com
pare
d to
the
CG
(p=.
03).
Afte
r 24
mon
ths,
the
CG
pre
sent
ed
wor
seni
ng o
f HbA
1c le
vels
co
mpa
red
to th
e EG
, in
whi
ch th
e de
crea
se c
ontin
ued.
Ther
e w
as n
o si
gnifi
cant
cha
nge
in th
e ra
tes
of D
KA a
nd s
ever
e hy
pogl
ycem
ia.
Beh
avio
ral:
impr
oved
gen
eral
QoL
sc
ores
(Ped
sQL-
G) i
n th
e ex
perim
enta
l gro
up
at s
ix- a
nd tw
elve
-m
onth
s po
st-in
terv
entio
n (p
=.04
) and
impr
oved
sc
ores
in p
hysi
cal a
nd
psyc
hoso
cial
dom
ains
at
six
mon
ths
(p=.
04).
Ther
e w
as a
dec
reas
e in
dis
ease
sym
ptom
s (P
edsQ
L-D
) at s
ix
mon
ths
(p=.
008)
.Af
ter 1
2 an
d 24
mon
ths,
th
e C
G p
rese
nted
hig
h tre
atm
ent a
dher
ence
sc
ores
(p=.
02) a
nd, a
t six
an
d 12
mon
ths,
hig
h se
lf-effi
cacy
sco
res
(p=.
01
and
p=.0
2).
Sem
iz e
t al
, Tur
key
(200
0)19
To e
valu
ate
the
effec
tiven
ess
of
cam
ps fo
r chi
ldre
n w
ith d
iabe
tes,
usi
ng
obje
ctiv
e pa
ram
eter
s.Q
uasi
-exp
erim
ent.
Youn
g pe
ople
from
8 to
20
yea
rs o
ld, T
1D fo
r at
leas
t 1 y
ear.
28 p
artic
ipan
ts
in C
amp
1; 2
9 pa
rtici
pant
s in
Cam
p 2;
14
par
ticip
ated
in b
oth.
Them
es: t
each
ing
the
insu
lin in
ject
ion
tech
niqu
e;
reco
gniti
on a
nd m
anag
emen
t of h
yper
glyc
emia
an
d D
KA; a
djus
tmen
t of i
nsul
in d
oses
bas
ed o
n di
et a
nd a
ctiv
ities
; im
porta
nce
of c
ontro
l and
new
th
erap
ies.
Cam
ps: 1
0 da
ys lo
ng, a
hea
lth c
are
team
co
mpr
isin
g pe
diat
ric e
ndoc
rinol
ogis
ts, d
iabe
tes
nurs
es a
nd d
ietic
ians
.As
sess
men
t bef
ore/
afte
r the
inte
rven
tion:
pa
rtici
pant
s co
mpl
eted
a k
now
ledg
e qu
estio
nnai
re
on d
iabe
tes
and
nutri
tion
befo
re, i
mm
edia
tely
afte
r an
d si
x m
onth
s af
ter b
oth
cam
ps.
Clin
ical
:th
ere
was
no
diffe
renc
e in
the
mea
n an
nual
HbA
1c le
vel b
efor
e an
d af
ter t
he fi
rst c
amp
in a
ll pa
rtici
pant
s (p
>.05
).N
o di
ffere
nce
in th
e H
bA1c
leve
l be
fore
the
first
and
afte
r bot
h ca
mps
(p>.
05).
Afte
r the
firs
t cam
p: W
eigh
t gai
n of
1.2
kg
in 1
8 ch
ildre
n co
nsid
ered
un
derw
eigh
t, an
d w
eigh
t los
s of
0.
9 kg
in 8
chi
ldre
n w
ho w
ere
over
wei
ght.
Beh
avio
ral:
incr
ease
d kn
owle
dge,
m
ore
note
wor
thy
afte
r the
se
cond
cam
p (p
<.05
).Kn
owle
dge
decr
ease
d af
ter s
ix m
onth
s w
hen
com
pare
d to
imm
edia
tely
af
ter t
he c
amps
. N
ever
thel
ess,
the
leve
ls
still
rem
aine
d hi
gher
th
an th
e kn
owle
dge
leve
ls b
efor
e th
e ca
mps
(p
<.05
).
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
12/21
Cha
rt 2
– C
ont.
Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Law
son
et
al, C
anad
a (2
000)
20
To c
ompa
re th
e sh
ort-t
erm
resu
lts o
f th
e In
tens
e D
iabe
tes
Man
agem
ent P
rogr
am
(IDM
).Q
uasi
-exp
erim
ent.
28 y
oung
peo
ple,
11
to 2
0 ye
ars
old,
w
ith n
ephr
omeg
aly
dete
cted
by
ultra
soun
d.
Them
es: a
ctio
n an
d ad
just
men
t of i
nsul
in d
oses
; da
ily g
luco
se m
onito
ring
and
on d
ays
of il
lnes
s;
caus
es, t
reat
men
t, an
d pr
even
tion
of h
ypog
lyce
mia
ep
isod
es; f
ood
plan
and
car
bohy
drat
e co
untin
g.G
roup
1: c
usto
miz
ed e
duca
tion
on ID
M +
inte
nse
clin
ical
follo
w-u
p fo
r thr
ee m
onth
s; s
ix-e
ight
hou
rs
of e
duca
tiona
l int
erve
ntio
n, d
istri
bute
d in
thre
e-fo
ur s
essi
ons
cond
ucte
d at
a d
iabe
tes
cent
er b
y a
diab
etes
nur
se, a
die
ticia
n an
d a
rese
arch
er.
Wee
kly
tele
phon
e co
ntac
t ini
tiate
d by
the
rese
arch
er.
Gro
up 2
: ID
M a
s pa
rt of
the
diab
etes
car
e ro
utin
e,
educ
atio
nal s
essi
ons
in g
roup
s of
up
to 2
0 pe
ople
, con
duct
ed b
y a
diab
etes
nur
se s
peci
alis
t, a
diet
icia
n, a
nd a
dia
beto
logi
st. E
ncou
rage
d te
leph
one
cont
act (
patie
nt’s
initi
ativ
e).
IDM
: mul
tiple
-dos
e re
gim
en o
f reg
ular
(IR
) or
ultra
fast
insu
lin b
efor
e m
eals
and
NPH
bef
ore
bedt
ime.
IR d
oses
wer
e ad
just
ed a
ccor
ding
to
the
pre-
pran
dial
glu
cose
leve
l, am
ount
of
carb
ohyd
rate
s in
gest
ed a
nd p
lann
ed p
hysi
cal
exer
cise
afte
r the
mea
l. Al
l par
ticip
ants
wer
e in
stru
cted
to m
onito
r blo
od g
luco
se le
vels
four
tim
es a
day
.
Clin
ical
out
com
es o
nly:
Gro
up 1
: mea
n de
crea
se in
HbA
1c o
f 2.5
% in
the
first
th
ree
mon
ths
(p<.
0001
). Ep
isod
es o
f sev
ere
hypo
glyc
emia
oc
curre
d.G
roup
2: m
ean
HbA
1c d
ecre
ased
by
0.9%
in th
e fir
st
thre
e m
onth
s (p
=.05
). Th
ere
wer
e no
epi
sode
s of
sev
ere
hypo
glyc
emia
.C
onsi
dera
ble
incr
ease
in H
bA1c
in b
oth
grou
ps o
ne y
ear a
fter
the
inte
rven
tion.
Ther
e w
as n
o di
ffere
nce
betw
een
the
mea
n H
bA1c
in b
oth
grou
ps a
t 15
mon
ths
afte
r the
beg
inni
ng o
f ID
M (p
=.8)
. N
o ep
isod
es o
f DKA
wer
e ob
serv
ed in
bot
h gr
oups
.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
13/21
Cha
rt 2
– C
ont.
Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Von
Seng
busc
h et
al,
Ger
man
y (2
005)
21
To e
valu
ate
the
effec
tiven
ess
of
stan
dard
ized
and
st
ruct
ured
dia
bete
s ed
ucat
ion,
dev
elop
ed
by a
rem
ote
team
.Q
uasi
-exp
erim
ent.
107
child
ren
with
mea
n ag
e 11
.1 ±
2.5
yea
rs
old
and
T1D
for a
t lea
st
six
mon
ths.
Them
e: fu
nctio
n of
insu
lin a
nd p
aren
t em
pow
erm
ent t
o ad
just
dos
es a
ccor
ding
to d
aily
ev
ents
and
cha
lleng
es.
Five
-day
cou
rse
(Mon
day
to F
riday
), w
hich
thre
e re
sear
cher
s co
nduc
ted
at e
ight
sta
te h
ospi
tals
in
coop
erat
ion
with
the
loca
l hea
lth te
am.
Gro
up e
duca
tion,
incl
udin
g fo
ur to
six
chi
ldre
n of
th
e sa
me
age
grou
p. In
divi
dual
or g
roup
edu
catio
n fo
r par
ents
, one
to tw
o tim
es a
wee
k.D
ata
colle
cted
bef
ore
(t0),
at s
ix w
eeks
(t1)
, and
at
six
mon
ths
(t2) a
fter t
he in
terv
entio
n.
Clin
ical
:ch
ildre
n w
ith H
bA1c
> 8
% b
efor
e th
e in
terv
entio
n si
gnifi
cant
ly
impr
oved
MC
bet
wee
n t0
and
t1
, and
t0 a
nd t2
, reg
ardl
ess
of
chan
ges
in in
sulin
ther
apy
and
the
num
ber o
f glu
cose
mon
itorin
g ch
ecks
per
day
(p<.
01).
Chi
ldre
n w
ith H
bA1c
<6.
8%
incr
ease
d th
e le
vel b
etw
een
t0 a
nd
t1(p
>.05
), an
d be
twee
n t0
and
t2
(p<.
05).
Ther
e w
as n
o si
gnifi
cant
di
ffere
nce
in H
bA1c
at t
he th
ree
mea
sure
men
t tim
es (P
>.05
), no
r in
the
num
ber o
f sev
ere
hypo
glyc
emia
epi
sode
s (p
>.05
), bu
t the
re w
as a
sig
nific
ant
redu
ctio
n in
the
num
ber o
f hos
pita
l ad
mis
sion
s (p
<.05
).
Beh
avio
ral:
diab
etes
kno
wle
dge
incr
ease
d at
t1 a
nd t2
co
mpa
red
to t0
(p<.
05).
Adol
esce
nts
who
live
d w
ith a
sin
gle
pare
nt
obta
ined
a h
ighe
r kn
owle
dge
scor
e w
hen
com
pare
d to
thos
e w
ho
lived
with
bot
h pa
rent
s (p
<.05
).Im
prov
ed Q
oL (G
erm
an
KIN
DL
R q
ualit
y-of
-life
qu
estio
nnai
re) a
t t1
(p<.
05) a
nd t2
(p<.
01).
Satis
fact
ion
with
the
inte
rven
tion
(Ger
man
C
SQ-8
Clie
nt S
atis
fact
ion
Que
stio
nnai
re) w
as h
igh:
57
.4%
of c
hild
ren
rate
d it
as ‘v
ery
good
’ at t
1.
Texto & Contexto Enfermagem 2020, v. 29: e20180338ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2018-0338
14/21
Cha
rt 2
– C
ont.
Aut
hors
hip,
co
untr
y an
d ye
ar
Obj
ectiv
e, ty
pe
of s
tudy
and
pa
rtic
ipan
tsEd
ucat
iona
l int
erve
ntio
nC
linic
al a
nd b
ehav
iora
l out
com
es
Qay
yum
et
al, P
akis
tan
(201
0)22
To e
valu
ate
the
effec
tiven
ess
of
Dia
bete
s Se
lf-M
anag
emen
t Ed
ucat
ion
(DSM
E) in
gl
ycem
ic c
ontro
l of
Paki
stan
i chi
ldre
n w
ith
T1D
.Q
uasi
-exp
erim
ent.
50 c
hild
ren,
mea
n ag
e 10
yea
rs, a
nd a
ge o
f di
agno
sis
8.15
±3.0
2 ye
ars.
Them
e: s
peci
fic m
odul
e on
insu
lin th
erap
y th
at
addr
esse
d ty
pes
of in
sulin
, pre
para
tion
of th
e in
ject
ion,
app
licat
ion
site
s an
d fo
rms,
whe
re/h
ow/
for h
ow lo
ng in
sulin
can
be
stor
ed.
DSM
E: e
duca
tiona
l pro
gram
of a
ped
iatri
c di
abet
es
clin
ic, o
rgan
ized
in fo
ur m
odul
es c
onsi
stin
g of
1.5
-ho
ur le
ctur
es, o
ffere
d fo
r gro
ups
of 1
0 ch
ildre
n an
d th
eir p
aren
ts/c
areg
iver
s. A
t the
end
, the
par
ticip
ants
re
ceiv
ed a
glu
cose
met
er w
ith re
agen
t stri
ps, a
bl
ood
gluc
ose
diar
y, e
duca
tiona
l lea
flets
, nut
ritio
nal
diar
y, a
nd a
n id
entifi
catio
n ca
rd a
nd b
race
let,
as
wel
l as
a do
ll w
ith h
ighl
ight
ed a
pplic
atio
n si
tes.
Mon
thly
follo
w-u
p w
ith a
ped
iatri
c en
docr
inol
ogis
t, a
pedi
atric
ian,
a d
ietic
ian,
a d
iabe
tes
nurs
e af
ter t
he
inte
rven
tion,
with
tele
phon
e re
min
ders
one
wee
k be
fore
the
appo
intm
ent.
Clin
ical
out
com
es o
nly:
no d
iffer
ence
s w
ere
iden
tified
in th
e in
sulin
regi
men
or m
ean
insu
lin d
osag
e du
ring
the
stud
y.D
ecre
ase
in H
bA1c
afte
r par
ticip
atio
n in
the
DSM
E (p
<.00
1).
Muk
ama
et
al, T
anza
nia
(201
3)23
To a
naly
ze th
e im
pact
of
a d
iabe
tes
educ
atio
n an
d m
anag
emen
t pr
ogra
m: g
lyce
mic
co
ntro
l and
chr
onic
co
mpl
icat
ions
of
chi
ldre
n an
d ad
oles
cent
s in
Ta
nzan
ia.
Qua
si-e
xper
imen
t.81
par
ticip
ants
, 0 to
17
year
s ol
d, w
ith T
1D fo
r at
leas
t six
mon
ths.
Them
es: p
reve
ntio
n an
d tre
atm
ent o
f hy
pogl
ycem
ia; p
reve
ntio
n of
hyp
ogly
cem
ia d
ue to
in
corre
ct in
sulin
app
licat
ion;
cau
tion
with
exc
essi
ve
phys
ical
act
ivity
and
ski
ppin
g m
eals
; cal
cula
tions
of
insu
lin d
osag
es a
nd s
tora
ge m
etho
ds; r
ecog
nitio
n an
d pr
even
tion
of D
KA.
Indi
vidu
al e
duca
tiona
l int
erve
ntio
n de
velo
ped
in a
ho
spita
l by
two
pedi
atric
end
ocrin
olog
ists
, nur
ses,
di
etic
ians
and
psy
chol
ogis
ts. D
urat
ion
of th
e st
udy:
si
x m
onth
s.
Clin
ical
out
com
es o
nly:
ther
e w
as n
o im
prov
emen
t in
HbA
1c a
t six
mon
ths
afte
r the
in
terv
entio
n (p
=.1)
.Th
ere
was
no
stat
istic
ally
sig
nific
ant a
ssoc
iatio
n be
twee
n th
e re
sults
of H
bA1c
and
gen
der (
p=.0
6), n
or w
ith m
edic
al re
turn
s (p
=.89
) or i
nsul
in d
osag
e (p
=.17
).Th
e nu
mbe
r of h
ypog
lyce
mia
epi
sode
s dr
oppe
d by
2/3
at s
ix
mon
ths
(p=.
65).
DKA
epi
sode
s w
ere
asso
ciat
ed w
ith th
e la
ck o
f ins
ulin
dos
es
(p<.
05) a
nd b
lood
glu
cose
mon
itorin
g at
hom
e.
*The
arti
cles
Gre
y et
al (
1998
) and
Gre
y et
al (
2000
) are
resu
lts fr
om th
e sa
me
stud
y.
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All studies examined the effect of the educational intervention on glycated hemoglobin (HbA1c), but other outcomes of interest were the effects of the intervention on the Body Mass Index (BMI);12,14–17,19 number of injections and insulin dose per day;12–13,15,17,23 episodes of hyperglycemia with ketoacidosis (DKA), and severe hypoglycemia;11,15–16,23 number of blood glucose monitoring checks at home;11 number of emergency contacts with the health care team by telephone;15–16 and attendance at medical appointments.11,16
Self-efficacy, depression, coping difficulty, barriers to treatment adherence, quality of life, social support, family dynamics, knowledge about diabetes, adherence to diet and medical return visits, and satisfaction with the intervention were measured in ten studies,11–19, 21 using specific scales to evaluate these constructs. However, only seven of them mentioned the validation processes of the scales in the contexts in which they were used.12–16,18 The verification of endpoints varied among the studies. In the majority, the endpoints were three, six, and twelve months after the intervention.
As for the risk of bias, in five of the clinical trials, the randomization method was properly reported,14–18 while four studies mentioned concealing the participants’ group allocation.14–15,17–18 The masking of participants and professionals is liable to bias, as both know who will be included or not in the group that will receive the education, except for the texting intervention (Sweet Talk)16, in which professionals do not know which adolescents will receive the messages. All clinical trials reported masking of the participants, which did not occur in the quasi-experiments. Regarding the masking of the outcome evaluators, only four reported measures to hide the results from the researchers involved in the data analysis.11–14
Seven studies mentioned data losses and exclusion, such as participants’ withdrawal or incompleteness of data for the analysis of HbA1C, characterizing a low risk of bias for incomplete outcomes.12–16,18–19 Only three of the clinical trials showed the intervention protocol or correctly included the publication of the desired outcomes in its description.15,18,21
DISCUSSION
This study identified several educational strategies for the teaching of insulin therapy to children and adolescents with T1D, developed in different contexts, such as pediatric clinics, diabetes centers, hospital environments, educational camps and distance education. The diversity of contexts shows that diabetes education does not take place only in hospitals or at the time of diagnosis in health care settings but positively helps in the treatment as, like the educational camps, the environment favors the promotion of autonomy, which leads to the internalization of self-care behaviors.24 The design of the strategies in these contexts should be appropriate to their clients’ educational needs and, in the case of children and adolescents, the school setting deserves attention in future research.25
The literature recommends that diabetes education aimed at the pediatric clientele must be planned in such way that age, developmental stage and socio-cultural issues are taken into account.25 Resources such as dramatization,12–13 development of educational14 and illustrative22 leaflets were used in some studies in this review. In only one study, a doll that highlighted the insulin application sites was used in the strategy.22 The remaining educational programs did not mention how the information was given to the participants, highlighting a gap in the studies concerning how the educational programs have been developed.
Despite the efforts the health care professionals have made, three out of four young people with T1D report at least one factor that inhibits their treatment adherence and that may be associated with improper glycemic control, i.e., HbA1c levels superior to 7.5%.26 Aspects such as fear and pain are barriers to the achievement of intensive treatment, but can be overcome by implementing effective educational strategies. The team should be attentive to the educational diagnosis of the pediatric population and define whether the strategies implemented consider these individual aspects.25
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Beyond encouraging adherence to insulin therapy, the nurse’s role is to empower the young person with T1D for self-care in a planned manner, so that the transition from childhood to adult life takes place without negatively affecting the follow-up care. The health care team should conduct the treatment of young people until the transition to adulthood, as some studies have pointed out.27–28 Aware of these clients’ preferences, researchers have used technology as a diabetes education resource. The telephone contacts with the health care team and the text messages sent to the patients by mobile phone are examples found in this review.14,16
These interventions do not depend on family involvement, as they focus on the adolescent’s learning needs. In younger children, however, family-centered care is more appropriate.29 A review on the use of video games and virtual environments in diabetes education for self-care highlighted that studies on medication adherence are still numerically scarce and, as highlighted in the findings of this review, strategies need to be better outlined in order to objectively measure their effect.30
Although the implementation of recreational strategies such as Therapeutic Play and interactive technologies are based on the guidelines for diabetes education, aiming to influence the educational particularities of the young clients2, these were not addressed in the articles retrieved in this review. Only two studies evidenced appropriate strategies for younger children, an age group in which the number of new cases of T1D has grown exponentially,1 which is another gap that needs attention in the future.
Due to the wide range of educational strategies evaluated in the articles included in this study, no single strategy could be determined that is capable of improving knowledge about insulin therapy, combined with a psychosocial or metabolic improvement. These findings are consistent with those described in a review on psychosocial interventions for children and young people in the UK.31
The use of validated instruments to assess the proposed constructs is the first step to ensure the methodological rigor of these interventions. The risk of bias assessment of the experimental and quasi-experimental studies in this review highlights the need for a thorough description of the study protocols. In 2014, in a study of the available instruments to assess self-care behaviors in diabetes, different weaknesses were demonstrated in the validation process.32
Evidencing validated instruments for the pediatric population is one of the knowledge gaps that needs to be reviewed, as in a study published in 201133. Investments are also needed in the assessment of other extremely important aspects of education involving insulin therapy, such as recognizing a possible increase in the number of injections after participating in an educational strategy, assessing the occurrence of less hypo- and hyperglycemia episodes related to intensive medication, increased frequency of capillary glucose tests or decrease in the number of contacts with the health care team. Although mentioned in some studies, these have not been assessed as outcomes of interest among the studies included in this review. HbA1C, a biological marker evaluated in all investigations, is a parameter that reveals glycemic control, but that, alone, does not show the necessary skills adjustments that support insulin therapy.
The engagement of different professionals in the educational strategies described was also observed, including nurses, pediatricians, diabetologists, pediatric endocrinologists, dieticians, psychologists, and social workers. The presence of the multiprofessional team in teaching children and adolescents with T1D is paramount. The team should be responsible for monitoring educational interventions in order to ensure the quality of the care provided.25
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The training of professionals with expertise in diabetes education is a reality in countries like the United States and Brazil, guaranteeing the career development of leaderships for the multiprofessional teams that assist children and adolescents with T1D.25,34 Nurses were present in most of the studies listed in this research, highlighting their role as health care educators and promoters of self-care in young people with T1D. Regardless the time of T1D onset the children or the adolescents are in, this professional play an important role in the disease management.35
The approach of different topics, such as the adjustment of insulin dosage in daily situations, 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, allowed important outcomes: improved HbA1c results, even if modest, especially in the long term11–13,15,17–18,22, better self-efficacy results12–15, better treatment adherence16,18, increased knowledge on the disease19,21 and its coping12, as well as a better quality of life12–13,15,18,21, but not maintained over time.15 No decrease was observed in most studies concerning the number of acute complications.12,14–18,21
Important aspects related to insulin therapy, such as the presence of lipohypertrophy, rotation of the application sites and reuse of needles were not mentioned as issues evaluated after the educational interventions, although they are fundamental for the achievement of proper metabolic control and reduction of complications in the short and long terms.36
Maintaining the behavioral change related to insulin therapy also depends on the quality of the educational programs. These should prioritize not only strategies that take into account the needs and particularities of the target population, but also ongoing support37–38 to develop and maintain self-care behaviors, progressively achieving better outcomes.
As a limitation of this review, we identify the possibility that the choice of the descriptors to perform the search strategy was not comprehensive enough to capture all the studies produced. In addition, ten studies were classified as unobtainable, published between 1978 and 1990, whose full texts could not be accessed, even after contact with the respective authors.
CONCLUSION
The systematic review evidenced the use of the following education strategies: group lectures; individual education with donation of care kits and dinners; dramatization; educational camp; telephone contact with the health care team and texting by mobile phone.
The strategies implemented for the child and youth audience and the focus on insulin therapy education took place in multiple health care contexts, developed by a single professional or multidisciplinary team. Nurses served as the leaders in most of the studies analyzed. These studies investigated clinical and behavioral outcomes, and all educational strategies measured glycemic control through HbA1C. No single strategy could be identified that managed to improve metabolic control and promote behavioral changes with regard to the insulin therapy of youth with T1D.
Methodological weaknesses were found in fundamental stages for the design of experimental studies, such as bias in planning phases of the intervention and in evaluation of its outcomes. Outlining educational strategies focused on insulin therapy for children and adolescents with diabetes has shown a gap that, once filled, will contribute to evidence-based practice and the improvement of pediatric diabetes education.
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NOTES
CONTRIBUTION OF AUTHORSHIP Study design: La Banca RO, Nascimento LC.Data collection: La Banca RO, Sparapani VC, Costa T.Data analysis and interpretation: La Banca RO, Sparapani VC, Costa T, Bueno M, Nascimento LC.Discussion of results: La Banca RO, Sparapani VC, Bueno M, Nascimento LC.Writing and/or critical content review: La Banca RO, Sparapani VC, Bueno M, Carvalho EC, Nascimento LC.Review and final approval of final version: La Banca RO, Sparapani VC, Bueno M, Costa T, Carvalho EC, Nascimento LC.
FUNDING INFORMATIONThis study was carried out with the support of the Coordination for the Improvement of Higher Education Personnel-Brazil (CAPES) - Funding Code 001, and the The Brazilian National Council for Scientific and Technological Development (CNPq) – Process number 312339/2017-8.
CONFLICT OF INTERESTSNo conflicts of interest
HISTORICAL Received: September 19, 2018.Approved: March 01, 2019.
CORRESPONDING AUTHORRebecca Ortiz La [email protected]