Running head: SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 1

The Effects of Support-Based Interventions for Adolescents Living with Type One Diabetes:

A Systematic Review of Literature

Jodi Koplitz, RN, BSN

University of Wisconsin Oshkosh College of Nursing

Nursing 701 Translational Scholarship

SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 2

Abstract

Adolescents living with type 1 diabetes (T1D) are at an increased risk for poor glycemic control

due to developmental factors, mental health disorders associated with chronic disease, and

increased self-management. The purpose of this systematic review of literature (SROL) is to

share evidence from current research surrounding adolescents living with T1D and the effects of

support-based interventions on diabetic self-management. In order to understand this

relationship, a SROL referencing 18 articles was conducted. Acceptable study designs included

literature reviews, evidence from qualitative and quantitative studies, clinical expertise, and

research reviews. Keywords were used to search scholarly databases including Cochrane

Database of Systematic Reviews, CINAHL, Cochrane Central Register of Controlled Trials,

Academic Search Complete, and MEDLINE. This evidence-based review contributes to the

understanding of the adolescent experience in transitioning to self-management of T1D and how

nurses may facilitate support-based interventions. Attendance at peer-based support groups and

skills-based interventions to acquire new knowledge and gain effective coping skills proves to

have a positive impact on diabetes self-management. Current research indicates that health care

for adolescents living with T1D must be holistic and individualized to meet the unique needs

specific to developmental stage. Nurses may advocate for mental health screening and encourage

attendance at peer-based support groups and other educational programs addressing transitions in

diabetic self-management. After review of the literature, there is evidence to show the

relationship between adolescent support and improved diabetes self-management. Further

quantitative research would help explain the direct effects of skills-based interventions on

diabetes management.
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 3

The Effects of Support-based Interventions for Adolescents Living with Type One Diabetes:

A Systematic Review of Literature

Adolescence is a unique time. This transitional time from childhood to adulthood

presents a myriad of challenges and opportunities. Adolescents juggle peer relationships,

academic demands, extracurricular activities, social pressure, family problems, and increasing

independence (Smith & Storch, 2011). For adolescents living with type one diabetes (T1D),

managing this serious, chronic condition adds to the pressure causing significant stress.

Healthcare providers are left with the task of bridging the gap between parental management of

their child’s diabetic regimen to adolescent autonomy. Decision-making, long-term glycemic

control, daily blood sugar management, insulin administration, and self-advocacy are

cornerstones in helping adolescents living with T1D thrive in their self-management endeavors.

Effective chronic care management for adolescents and their families includes finding and

maintaining motivation (Christie, Romano, Thompson, Viner, & Hindmarsh, 2008). Research

shows that a supportive network incorporating shared peer experiences and skill-based

interventions leads to better self-management of diabetes for adolescents. In this systematic

review of literature (SROL), the PICOT question guiding the population, intervention, and

outcome of interest is: Does diabetes self-management improve in adolescents diagnosed with

type one diabetes after participating in support-based interventions over a one year period?

Background Review

Adolescents are developing their sense of self, gaining independence, and working

towards widening their focus from prominent childhood tasks (friendships, academics,

extracurricular activities) to include the evolving tasks of adulthood (jobs, intimate relationships,

planning life goals) (Dovey-Pearce, Hurrell, May, Walker, and Doherty, 2005). More than 85%
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 4

of young people living with T1D are not achieving the recommended target glycosylated

hemoglobin A1c (HbA1c) (<7.5%), putting them at risk of developing long-term complications

(Kime, 2013). Equally important, this population is at increased risk of developing mental health

disorders including depression, anxiety, eating disorders, and substance abuse disorders

(Kakleas, Kandyla, Karayianni, & Karavanaki, 2009). Current research indicates that emotional

disorders are associated with poor glycemic control in adolescents, leading to frequent hospital

admissions secondary to diabetic ketoacidosis or severe hypoglycemic events (Kakleas, et al.,

2009). Adolescents living with chronic disease experience social isolation secondary to increased

absence from school and other social activities (Lewis, Klineberg, Towns, Moore, & Steinbeck,

2016). As a result, adolescents living with T1D need additional support in managing their

chronic disease. Support systems are key in ensuring optimal functioning (Oris, et al., 2016).

Effective diabetes self-management may be defined as maintaining targeted glycemic

control via regular blood glucose checks, insulin administration, dietary monitoring, and a

consistent exercise routine (Céspedes-Knadle & Muñoz, 2011). Diabetes management programs

are intensive and complex, making adherence especially difficult for adolescents as puberty

causes hormonal and metabolic changes that affect insulin sensitivity (Céspedes-Knadle &

Muñoz, 2011). Similarly, psychosocial changes and an increasing need for independence,

increased peer pressure, and a tendency to make poor lifestyle decisions makes a strong case for

nurses to advocate for supportive interventions for adolescents living with T1D (Céspedes-

Knadle & Muñoz, 2011).

There is current qualitative research to show the relationship between support-based

interventions and effective diabetic management. This evidence-based review will contribute to
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 5

the understanding of the adolescent experience of transition to self-management of T1D and how

nurses may facilitate holistic, support-based interventions among this population.

Purpose/Aim

The purpose of this SROL is to share evidence from current research surrounding

adolescents living with T1D and the effects of support-based interventions on diabetic self-

management. Adolescents endure a transitional shift from parental control to independence.

Nurses and other healthcare providers may identify strategies to facilitate support-based

interventions in order to encourage effective diabetic self-management among adolescents.

Method

In order to conduct an unbiased and comprehensive search for this SROL, a PICOT

question was first developed as follows: Does diabetes self-management improve in adolescents

diagnosed with type one diabetes after participating in support-based interventions over a one

year period?

Search Strategy, Components, and Procedure

Keywords used to conduct the search included ‘support groups,’ ‘diabetes,’ ‘chronic

disease,’ ‘diabetes education,’ ‘management,’ ‘self-management,’ ‘transition,’ ‘adolescents,’

‘teenagers,’ and ‘young adults.’ The Boolean operator ‘or’ was used to combine keywords

‘adolescents,’ ‘teenagers,’ and ‘young adults’ in order to search for either of those descriptors of

age. These keywords were used to search several databases including Cochrane Database of

Systematic Reviews, CINAHL, Cochrane Central Register of Controlled Trials, Academic

Search Complete, and MEDLINE. Reference lists from key published articles were hand

searched to find more pertinent research.

SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 6

Literature was reviewed and refined by searching for common themes. In addition to

searching scholarly databases, professional websites including the American Diabetes

Association (ADA) and Diabetes Pro (Professionals Resources Online by the ADA) were

searched using the same keywords for additional information on adolescent-specific self-

management research. Literature search yielded several primary qualitative articles and

secondary systematic literature reviews by clinical experts in the field.

Inclusion/Exclusion Criteria and Data Extraction

Randomized control trials were sought out initially, but limited experimental studies have

been conducted in this topic area. Due to the nature of the PICOT question, acceptable study

designs were broadened to literature reviews of qualitative studies, evidence from qualitative and

other quantitative studies, clinical expertise, and research review (Melynk & Fineout-Overholt,

2015). Initial publication date criteria was set for five years. Articles not published or updated

within the last 5 years were still included due to limited research and the applicability to the

proposed PICOT question. Literature published within ten years was considered acceptable, with

one qualitative study published eleven years ago. Published works in English were exclusively

accepted.

Demographic characteristics for the population included any gender, race, and

educational status. Key words ‘adolescents,’ ‘teenagers,’ and ‘young adults’ were searched as

they all may describe the period of transition from childhood to adulthood. For the purposes of

this literature review, the term ‘adolescents’ is selected to describe the targeted population.

Adolescence was defined by various ages according to authors. In this SROL, adolescence may

be defined as a child aged 11 to 19 years of age based on the average ages presented in the

literature (Dovey-Pearce, et al., 2005). Literature describing young adults as children aged 16 to
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 7

25 is also included in this review (Dovey-Pearce, et al., 2005). Literature addressing T1D was

exclusively included. Any literature addressing type two diabetes and prediabetes was excluded.

All settings were considered.

In order to holistically answer the PICOT question, interventions of interest included

attendance at peer support groups, participation in skills-based interventions to build knowledge

of T1D, and the acquisition of new skills to cope with and manage chronic illness. Outcomes of

interest included adolescent perceptions on the importance of self-management, effective

diabetic management (HbA1c levels, decision-making, glycemic control), and demonstration of

effective coping skills.

Using the search strategy outlined above, initial results generated 833 potential sources.

After screening potential sources using inclusion and exclusion criteria, 769 sources were

eliminated. The remaining 65 records were screened, 25 full-text articles were assessed for

eligibility, and as a final product, eight qualitative evidence articles and four quantitative

evidence articles were included. There are 18 cited references to include the above-mentioned

qualitative and quantitative evidence, literature reviews, clinical expertise articles, informational

texts, and research reviews. (See Appendix A for the identification, screening, eligibility, and

inclusion summary).

Research in this SROL included levels II, III, and V. Level II evidence included

quantitative studies (quasi-experimental and proof of concept), level III evidence included

quantitative research studies and literature reviews, and level V evidence include clinical

expertise, and research review. No level I or IV evidence was included. The majority of findings

are rated as high or good quality according to the research and non-research evidence appraisal

tools by John Hopkins Hospital and University (Dearholt & Dang, 2012). Most of the research
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 8

may be considered high or good quality due to professional sponsorship, thorough systematic

search strategy, consistency, clear conclusions, evaluation of strengths and limitations of studies,

and recent publication within the last 5 years (Dearholt & Dang, 2012).

Results

Literature review of level II, III, and V evidence of good or high quality yielded two

major themes in diabetic adolescent self-management in relationship to the participation in

support-based interventions. These themes include the (1) participation in peer-based support

groups and (2) skills-based supportive interventions to facilitate successful transition in self-

management, including the acquisition of effective coping skills (See Appendices G and H for

the individual evidence summary and synthesis and recommendation).

Peer-Based Support Groups

Céspedes-Knadle and Muñoz (2011) identify that peer-based group interventions yield

positive outcomes in achieving effective diabetes management. Support groups that address

patient education, health-promoting behaviors, and medical adherence are associated with

improved glycemic control (Céspedes-Knadle & Muñoz, 2011). Peer-based support groups offer

adolescents the unique opportunity to join with peers who are going through similar life changes,

but who also understand the challenges of managing T1D on a daily basis. Support groups help

adolescents understand that they are not alone (Lewis, et al., 2016). Additionally, parents find

peer-based support groups to helpful in addressing both short and long-term concerns and a way

to share experiences and gain new knowledge (Christie, et al., 2008).

According to Christie and colleagues, support groups are attractive to adolescents living

with chronic illness as they often have limited opportunity to converse with peers who

experiencing similar restraints on social and extracurricular activities caused by disease

SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 9

management (Christie, et al., 2008). Researchers have conducted qualitative studies on the

content of peer support groups and discussion topics including fears, difficulties, and daily life

have proven to be beneficial (Konradsdottir, & Svavarsdottir, 2011). Few quantitative studies

have associated support group participation with improved HbA1c and an increase in self-care

behaviors (Markowitz & Laffel, 2012; Park, et al., 2015).

Adolescent reasons to attend include knowledge acquisition, sharing a common reality,

gaining confidence, social opportunity, convenient service, positive experience, and freedom of

expression (Christie, et al., 2008). Lewis and colleagues found that attendance at support groups

yield outcomes including an increased sense of independence, self-confidence, and resilience

(Lewis, et al., 2016). Barriers to support group attendance include willingness to attend,

scheduling conflicts, school demands, and the belief that good management already exist so

additional support is unwarranted (Christie, et al., 2008; Lewis, et al., 2016).

Skills-Based Interventions for Transition and Coping

Jameson (2011) describes healthcare transition as the meaningful, planned movement of

adolescents with chronic conditions from child-centered to adult-focused health care systems.

The process should be responsive to individualized needs and must be participatory, flexible, and

supportive (Kime, 2013). Current research shows that transitional care is inadequate and focused

on service transfer, rather than the holistic needs of the individual (Kime, 2013).

In a qualitative study by Rasmussen and colleagues, adolescents described transition as a

significant life event that creates permanent change on life and diabetic self-management

perspective (Rasmussen, Ward, Jenkins, King, & Dunning, 2011). These life changes including

entering new relationships, the workforce, relocating, and progressing through the educational

system are considered stressful with the potential to negatively affect glycemic control
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 10

(Rasmussen, et al., 2011). In order to offset these external stressors caused by the developmental

stage of adulthood and to enhance diabetic self-management, adolescents describe skills-based

knowledge acquisition to be helpful (Sansom-Daly, Wakefield, Peate, & Bryant, 2012). Life

transitions are more manageable when adolescents have control of their diabetes and feel

motivated to set goals and plan for self-management (Rasmussen, et al., 2011).

Learning how to navigate the developmental stage of adolescence causes its own set of

emotional upheaval, but when paired with figuring out how to self-manage a chronic disease,

mental health and the acquisition of effective coping skills must be addressed. Adams (2012)

describes “the desire to fit in and be normal may cause adolescents to become erratic with their

blood glucose monitoring or insulin administration, causing poor, inconsistent blood glucose

levels” (p. 20). Adolescent students experience significant stressors due to the restrictive

demands of diabetes management in addition to major life stressors of adolescence that can

include divorce, family issues, academic struggles, and bullying (Smith & Storch, 2011).

Depression and other mental health disorders are associated with poor glycemic control, which

may lead to a lack of compliance with diet, exercise, and medication management (Kakleas, et

al., 2009). Similarly, apathy and a lack of self-care, which is commonly witnessed alongside

depression and anxiety disorders, leads to poor lifestyle habits that negatively impact effective

self-management (Kakleas, et al., 2009).

Céspedes-Knadle and Muñoz (2011) state that adolescents perceive themselves as more

knowledgeable and autonomous than their parents perceive them to be. Such differences in

perception are linked with poor diabetes outcomes for adolescents and poor emotional

adjustment for parents (Céspedes-Knadle & Muñoz, 2011). With this in mind, self-management

programs designed to address the unique balance between parental control and adolescent
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 11

independence are ideal. Additionally, studies show that independent decision-making about daily

diabetes management is positively correlated with metabolic control and that parental support

that is not needed may hinder the development towards adolescent independence in decision-

making and self-management (Viklund & Wikblad, 2009). One key tool is a diabetes-specific

transition curriculum that outlines the essentials of diabetes self-management to include topics

such as, ‘managing your own health care,’ ‘roommates/ living alone,’ ‘meal planning,’ ‘coping

skills,’ ‘hypoglycemia,’ ‘social risk-taking,’ ‘sick days,’ and ‘changing diabetes care teams”

(Jameson, 2011).

Discussion and Implications for Practice, Education, and Research

Current research tells us that health care for adolescents living with T1D must be holistic

and individualized to meet the unique needs of their developmental stage. Key issues to address

when creating services for adolescents include staff consistency, civility, age-specific

information, and support-based interventions in health, emotional, social, and developmental

needs (Dovey-Pearce, et al., 2005). Nurses and other healthcare providers may model healthy

relationships, facilitate the acquisition of new skills, identify barriers and strategize ways to

overcome obstacles in order for the adolescent to become a full participant in their care (Dovey-

Pearce, et al., 2005). Nurses may encourage attendance at peer-based support groups and

educational programs that address transitions in diabetic self-management.

It is important for nurses to understand the emotional, social, and cognitive factors that

are going on during transitions to assist adolescents living with T1D in achieving positive health

outcomes through making individualized goals and providing flexible and sensitive treatment

(Rasmussen, et al., 2011). Nurses may advocate for regular assessment of mental health

disorders and referral to psychiatric services as needed (Kakleas, et al., 2009). Moreover, nurses
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 12

can nurture the changing relationships between parents and adolescents during times of transition

by setting realistic goals for diabetic control and encouraging adolescent independence while

being mindful of parental expectations and feelings (Kakleas, et al., 2009).

Further research is needed in order to increase the likelihood of adolescent involvement

in peer-based support groups and to more adequately quantify the impact of peer-based support

group attendance on effective diabetes self-management (Lewis, et al., 2016). Additionally,

further quantitative research would help explain the effects of structured skills-based

interventions on effective diabetes management. Specific directives for new research should

include the direct relationship between support-based interventions and the lowering of HbA1c

levels, incidence of mental health issues, effective coping skills, dietary control, exercise

programs, and insulin management.

Conclusion and Recommendations

After review of the current literature on support-based interventions for adolescents

living with T1D, there is evidence to show the relationship between adolescent support and

improved diabetes self-management. Adolescents require a holistic approach to meet their

development needs. This includes chronic disease management education, skills-based training,

social support networks, and mental health monitoring. Nurses must continue to advocate for the

individualized needs within the adolescent population and work with primary care providers and

families to facilitate effective self-management.

SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 13

References

Adams, J. (2012). Life experience for an adolescent with type 1 diabetes: nursing strategies to

support a healthy lifestyle. Whitireia Nursing Journal, (19), 18-26.

Céspedes-Knadle, Y. M., & Muñoz, C. E. (2011). Development of a Group Intervention for

Teens With Type 1 Diabetes. Journal For Specialists In Group Work, 36(4), 278-295.

doi:10.1080/01933922.2011.613898

Christie, D., Romano, G., Thompson, R., Viner, R., & Hindmarsh, P. (2008). Attitudes to

psychological groups in a paediatric and adolescent diabetes service -- implications for

service delivery. Pediatric Diabetes, 9(4pt2), 388-392.

Dearholt, S., Dang, D. (2012). Johns Hopkins Nursing Evidence-based Practice: Models and

Guidelines. Indianapolis, IN: Sigma Theta Tau International.

Dovey-Pearce, G., Hurrell, R., May, C., Walker, C., & Doherty, Y. (2005). Young adults' (16-

25 years) suggestions for providing developmentally appropriate diabetes services: a

qualitative study. Health & Social Care In The Community, 13(5), 409-419.

Jameson, P. L. (2011). Adolescent transition: Challenges and resources for the diabetes team.

Diabetes Spectrum. 24 (1) 18-21. doi:10.2337/diaspect.24.1.18

Kakleas, K., Kandyla, B., Karayianni, C., & Karavanaki, K. (2009). Psychosocial problems in

adolescents with type 1 diabetes mellitus. Diabetes & Metabolism, 35(5), 339-350.

doi:10.1016/j.diabet.2009.05.002

Kime, N. (2013). Young people with type 1 diabetes and their transition to adult services. British

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Konradsdottir, E., & Svavarsdottir, E. K. (2011). How effective is a short-term educational and

support intervention for families of an adolescent with type 1 diabetes?. Journal For
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Specialists In Pediatric Nursing, 16(4), 295-304. doi:10.1111/j.1744-6155.2011.00297.x

Lewis, P., Klineberg, E., Towns, S., Moore, K., & Steinbeck, K. (2016). The Effects of

Introducing Peer Support to Young People with a Chronic Illness. Journal Of Child &

Family Studies, 25(8), 2541-2553. doi:10.1007/s10826-016-0427-4

Markowitz, J. T., & Laffel, L. B. (2012). Transitions in care: support group for young adults with

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29(4), 522-525. doi:10.1111/j.1464-5491.2011.03537.x

Melnyk, B., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing & Healthcare:

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Oris, L., Seiffge-Krenke, I., Moons, P., Goubert, L., Rassart, J., Goossens, E., & Luyckx, K.

(2016). Parental and peer support in adolescents with a chronic condition: a typological

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Nursing, 20(13/14), 1981-1992. doi:10.1111/j.1365-2702.2010.03657.x

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Smith, L. B., & Storch, E. A. (2011). Stress, coping, and diabetes support groups. National

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 SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 16

Appendix A
Data Extraction Summary

Records identified through Additional records identified

Identification

database searching through other sources

(n = 833) (n = 23)

Records after duplicates removed

(n = 856)
Screening

Records screened Records excluded

(n = 65) Records
(n =excluded
40)
(n = 40)

Full-text articles
Full-text articles
assessed for eligibility
excluded, with reasons
Eligibility

(n = 25)
(n = 7)

Studies included in
qualitative synthesis
(n = 8)
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n=2)
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 17

Appendix G
Individual Evidence Summary Tool

Article Author Evidence Sample, Sample Study findings that help Limitations Evidence
Number and Date Type Size, and Setting answer the EBP question Level and
Quality
1 Adams, 2012 Clinical N/A Describes nurse role in None identified. Level V
Expertise supporting adolescent self- B
management of T1D
2 Céspedes- Qualitative Discussion of The Teen Power intervention Data on the effects of Level III
Knadle & implementation of offered specific activities and the curriculum on B
Muñoz, 2011 support group workshops, as well as an HbA1c levels,
curriculum designed opportunity to learn from depression, and
for adolescents their peers. It supported caregiver stress have
living with T1D social networking. not yet been collected
at the time of
publication.
3 Christie, et al., Qualitative 64 parents of Parents agree that peer Only asked parents Level III
2008 children living with support groups would help their preferences, B
T1D interviewed via their child living with T1D which can be quite
phone gain confidence and different from what
knowledge. Groups would children would want.
give children the chance to
feel connected to others.
4 Dovey-Pearce, Qualitative 23 adolescent Adolescents expressed the None identified. Level III
et al., 2005 diabetics aged 16-25 need for support in relation B
diagnosed within six to health, emotional, social,
months interviewed and developmental needs due
via surveys to their developmental stage.
5 Jameson, 2011 Clinical N/A Strategies to assist None identified. Level V
Expertise adolescents in making the B
transition to self-
management.
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 18

6 Kakleas, et al., Literature N/A Mental health disorders are None identified. Level III
2009 Review common in adolescents with A
T1D and show difficulty
coping with their disease.
Poor glycemic control is
common in adolescents as
they become increasingly
independent. They are often
referred to mental health
services, including therapy.
7 Kime, 2013 Research 300 participants in a The transition to Does not specifically Level V
Review three-year multi-site independence in self-care for address support B
research study adolescents affects the ability groups. Suggests the
to achieve the recommended need for more support
target HbA1c. A supportive, during transitional
multidisciplinary approach care and the use of a
will ensure adequate support. community nurse.
8 Konradsdottir, Quasi- 23 families A piloted support group for Small sample size Level II
& experimental completed mailed adolescents gave them a that focused on B
Svavarsdottir, (Quantitative) questionnaire twice chance to give one another differences in coping
2011 in a six month support and reflect of their between mothers and
period shared experiences. fathers, not students.
9 Lewis, et al., Qualitative 14 members of a Students who participated in Small sample size. Level III
2016 hospital-based peer support group program Participation in a B
support program described an increasing sense support group is
completed of independence, self- dependent on student
questionnaires confidence, and resilience. willingness and
The group provided a social parent availability.
connection. Short time
measurement yielded
little change in
evaluation tool
responses.
10 Markowitz & Qualitative 15 young adults Participation in support Small sample size. Level III
Laffel, 2012 aged 18-30 group associated with B
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 19

completed pre- and improved HbA1c levels

post-questionnaires decreased burden, and an
when attending a increase in self-care.
support group
11 Oris, et al., Qualitative 109 adolescents Adolescents depend more on Assessed general Level III
2016 living with TID peers than parents for support and not A
were compared to emotional support. Peer diabetes-specific
119 healthy support in adolescents with support, so social
adolescents via chronic illness is related to a support was not
questionnaire better quality of life. identified as being
related to glycemic
control. An indirect
relationship may be
inferred from data.
12 Park, et al., Quantitative 148 adults with T1D After six months, HbA1c Studied with a group Level II
2015 Proof of and type 2 diabetes levels improved (average of adults and T1D and A
Concept participated in a 9.6% to 8.7%). type 2 diabetes.
peer-led support
group
13 Rasmussen, et Qualitative 20 young adults Strategies to assist young Small sample size. Level III
al., 2011 with T1D adults with transitions in self- B
participated in semi- management.
structured
interviews
14 Sansom-Daly, Literature N/A Skills-based interventions Diabetes requires Level III
et al., 2012 Review yield positive results in long-term follow-up, A
adolescents living with which may inhibit the
chronic illness. These include publication of studies
coping skills and mental that show the positive
health. impact of diabetic
interventions.
15 Smith & Clinical N/A Students find comfort in None identified. Level V
Storch, 2011 Expertise shared experiences. Diabetic B
support groups may be hard
to find, but participation can
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 20

help students cope with the

day-to-day demands of
diabetes.
16 Viklund & Qualitative 31 adolescents Adolescents need a Small sample size. Level III
Wikblad, 2009 living with T1D supportive network in order B
aged 12-17 were to improve their decision-
interviewed after making competence with
participating in a T1D. In order to compensate
two-week for the deficiencies in their
educational program competence in adolescence, a
social network is essential.
SUPPORT-BASED INTERVENTIONS FOR ADOLESCENT DIABETICS 21

Appendix H
Synthesis and Recommendations Tool
Total Overall
Synthesis of Findings
Category (Level Type) Number of Quality
Evidence that Answers the EBP Question
Sources/Level Rating
Level I
-Experimental study
-Randomized Controlled Trial (RCT) 0 - N/A
-Systematic review of RCTs with or without meta-analysis
Level II HbA1c levels improved after participating in peer-led
-Quasi-experimental studies
-Systematic review of a combination of RCTs and quasi- support group. Adolescents view supportive
2 A/B
experimental studies, or quasi experimental studies only, interventions with peers to be helpful in T1D self-
with or without meta-analysis management.
Level III There is a unique relationship between parents and
-Non-experimental study
-Systematic review of a combination of RCTs, quasi- adolescents during times of transition. Mental health
experimental, and non-experimental studies only, with or disorders are common in adolescents living with T1D.
with-out meta-analysis Adolescents show difficulty coping with disease and
-Qualitative study or systematic review of qualitative studies 10 B
with or without meta-analysis need supportive interventions for mental health.
Participation is support-based interventions encourage
adolescents to be more independence and confident in
their self-management.
Level IV
-Opinion of respected authorities and/or reports of
nationally recognized expert committees/consensus panels 0 - N/A
based on scientific evidence

Level V Nurses are important advocates for transitions in

-Evidence obtained from literature reviews, quality
improvement, program evaluation, financial evaluation, or adolescent self-management. Adolescents are in a
case reports
4 B unique developmental stage that requires
-Opinion of national recognized expert(s) based on individualized strategies. Adolescents find comfort in
experiential evidence
shared experiences with peers.