This paper is in the following e-collection/theme issue:

mHealth for Symptom and Disease Monitoring, Chronic Disease Management (1269) mHealth for Wellness, Behavior Change and Prevention (2681) Design and Formative Evaluation of Mobile Apps (653) Usability of Apps and User Perceptions of mHealth (866) mHealth for Treatment Adherence (375) Diabetes Self-Management (453) Chronic Disease Self-Management in Childhood and Adolescence (115) Glucose Tracking and Self-Monitoring of Blood Glucose (148) Diabetes Education and Self-Management in Childhood and Adolescence (28)

Published on in Vol 9, No 9 (2021): September

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/23916, first published .
An mHealth-Based Intervention for Adolescents With Type 1 Diabetes and Their Parents: Pilot Feasibility and Efficacy Single-Arm Study

An mHealth-Based Intervention for Adolescents With Type 1 Diabetes and Their Parents: Pilot Feasibility and Efficacy Single-Arm Study

An mHealth-Based Intervention for Adolescents With Type 1 Diabetes and Their Parents: Pilot Feasibility and Efficacy Single-Arm Study

Authors of this article:

Bree Holtz1 Author Orcid Image ;   Katharine M Mitchell1 Author Orcid Image ;   Amanda J Holmstrom2 Author Orcid Image ;   Shelia R Cotten3 Author Orcid Image ;   Julie K Dunneback4 Author Orcid Image ;   Jose Jimenez-Vega5 Author Orcid Image ;   Deborah A Ellis6 Author Orcid Image ;   Michael A Wood7 Author Orcid Image
Article Authors Cited by (8) Tweetations (3) Metrics

    Original Paper

    1Department of Advertising and Public Relations, Michigan State University, East Lansing, MI, United States

    2Department of Communication, Michigan State University, East Lansing, MI, United States

    3Office of Research Development, Clemson University, Clemson, SC, United States

    4Sparrow Health System, Lansing, MI, United States

    5DeVos Children’s Hospital, Grand Rapids, MI, United States

    6Department of Family Medicine, Wayne State University, Detroit, MI, United States

    7Pediatric Endocrinology, University of Michigan Medical School, Ann Arbor, MI, United States

    Corresponding Author:

    Bree Holtz, PhD

    Department of Advertising and Public Relations

    Michigan State University

    404 Wilson Road

    Room 309

    East Lansing, MI, 48824

    United States

    Phone: 1 5178844537

    Email: bholtz@msu.edu


    Background: Type 1 diabetes (T1D) affects more than 165,000 individuals younger than 20 years in the United States of America. The transition from parent management to parent-child team management, with the child taking on increased levels of self-care, can be stressful and is associated with a deterioration in self-management behaviors. Therefore, a mobile app intervention, MyT1DHero, was designed to facilitate diabetes-specific positive parent-adolescent communication and improve diabetes-related outcomes. The MyT1DHero intervention links an adolescent with T1D and their parent through 2 separate app interfaces and is designed to promote positive communication regarding T1D management.

    Objective: The aim of this pilot study was to determine (1) the initial efficacy of the MyT1DHero intervention in improving diabetes outcomes in adolescents, specifically the hemoglobin A1c (HbA1c) levels, diabetes care adherence, and quality of life, and (2) the adolescents’ overall satisfaction with this intervention.

    Methods: This pilot study included 30 adolescent-parent pairs who used the MyT1DHero app in a 12-week single-arm clinical trial. Participants were recruited from the local pediatric endocrinology subspecialty clinic via snowball sampling. HbA1c levels, diabetes care adherence, quality of life, family conflict, and satisfaction levels were measured and analyzed using paired sample two-sided t tests and linear regression analyses.

    Results: The final analysis included 25 families. The mean age of the adolescents was 12.28 (SD 1.62) years. Half of the participants (13/25) reported a diabetes diagnosis of less than 5 years. After 12 weeks of the intervention, diabetes care adherence significantly improved (before the study: mean 3.87 [SD 0.59]; after the study: mean 4.19 [SD 0.65]; t21=–2.52, P=.02, d=0.52) as did quality of life (before the study: mean 4.02 [SD 0.84]; after the study: mean 4.27 [SD 0.73]; t24=2.48, P=.01, d=0.32). HbA1c levels (before the study: mean 8.94 [SD 1.46]; after the study: mean 8.87 [SD 1.29]; t24=0.67, P=.51, d=0.04) and family conflict (before the study: mean 2.45 [SD 0.55]; after the study: mean 2.61 [SD 0.45]; t23=0.55, P=.14, d=0.32) changed in the hypothesized direction, but the change was not significant. However, higher use of the mobile app was associated with more improvement in HbA1c levels (F1,20=9.74, P<.005; R2=0.33). Overall, the adolescents were satisfied with the app intervention.

    Conclusions: In a 12-week pilot study of the mobile app intervention designed to facilitate parent-adolescent communication for improving diabetes outcomes, significant benefits were demonstrated in self-care adherence and quality of life. A randomized controlled trial with a longer intervention is needed to replicate these findings and to determine the stability of the intervention effects.

    Trial Registration: ClinicalTrials.gov NCT03436628; https://clinicaltrials.gov/ct2/show/NCT03436628

    JMIR Mhealth Uhealth 2021;9(9):e23916

    doi:10.2196/23916

    Keywords

    mobile health (mHealth); adolescents; type 1 diabetes; mobile phone; parent-adolescent; chronic disease; feasibility; diabetes management 


    Background

    Type 1 diabetes (T1D) affects more than 165,000 individuals younger than 20 years in the United States [1,2]. If the child is young at diagnosis, parents initially take over the responsibility for the management of T1D owing to the complexity of the disease and its management to prevent acute and long-term health complications. However, during adolescence, the child begins to take on more responsibility for diabetes self-management. While they are learning the skills needed for self-management, it is vital that parents remain engaged in the process, but they should also prepare their adolescents for independence [3,4].

    Transition of T1D Care

    The transition from parent management to a parent-adolescent team management—with the adolescent taking on increased responsibilities of self-care and parents learning to relinquish control—can be stressful and is associated with a deterioration in diabetes self-management adherence behaviors [5]. Diabetes management requires monitoring the blood glucose levels multiple times per day, counting the carbohydrates for meals and snacks, calculating and administering insulin doses by injection or pump, and adjusting the insulin levels or food depending on the glucose readings during a physical activity or illness [6-9]. The transition period, which begins when the child is an adolescent, generally lasts until early adulthood. However, during adolescence, there is often a decrease in the frequency of blood glucose monitoring, an increase in hemoglobin A1c (HbA1c) levels, and an increased risk for hospitalization associated with diabetic ketoacidosis. Such deterioration in management can result in poorer glycemic control and potentially lifelong complications [10]. Therefore, it is important to develop interventions to assist in the transition from parent to parent-adolescent team management in order to improve the health-related outcomes for the adolescent.

    Parent and Adolescent Communication

    Communication between parents and adolescents is critical at this juncture but is often fraught with difficulty and conflict that is further aggravated by adolescents’ deteriorating adherence to their diabetes management and metabolic control [5,11,12]. Additionally, parents often report feeling worried about their child’s health and feel compelled to check on them frequently [13]. In turn, many adolescents feel that their parents are frequently nagging them about their diabetes care [14]. Reducing parent-adolescent conflict around diabetes management and creating an open and trusting relationship during this tumultuous time is imperative, as a review of the literature found that parent-adolescent diabetes-related conflict is associated with poorer diabetic outcomes [15]. Studies have demonstrated that increased positive reciprocity, problem-solving, and positive communication between parents and adolescents, including optimistic communication, parental social support, and shared decision-making, are associated with positive T1D outcomes [16-19]. Reducing conflict and improving parent engagement during this transition may be possible though the use of technology (ie, mobile phones) to improve communication around diabetes care, thereby improving diabetes outcomes.

    Mobile Health Apps

    Mobile health (mHealth) apps have been rated as highly desirable by adolescents with T1D [20]. mHealth enables the use of more engaging strategies such as gamification and customization that have been shown to improve the frequency of blood glucose monitoring in adolescents with T1D [21], and in some cases, improve HbA1c levels when compared to standard care [22,23]. Therefore, an mHealth intervention, MyT1DHero, was developed to help support and improve parent-adolescent communication related to diabetes management. The focus of MyT1DHero’s is to improve positive communication regarding T1D in an effort to reduce “blood sugar nagging” by parents [24]. These improvements in family communication were, in turn, expected to reduce family conflict, improve adolescents’ adherence to blood glucose monitoring, and thus improve HbA1c levels and quality of life.

    MyT1DHero Intervention

    The MyT1DHero intervention links the adolescent with T1D and their parent through 2 separate app interfaces—one for the adolescent and one for the parent. This app is designed to promote positive communication regarding T1D management. In order to frame the communication in that way, we asked that parents and adolescents establish a blood glucose testing schedule on the app, which will create time-specific reminders for the adolescent to test and enter their blood glucose readings. The app intervention also provides adolescents with tips on how to address out-of-range blood glucose values. For example, when an adolescent enters a low blood glucose reading, the app provides a list of possible snacks (both standard and family-entered). When the child successfully measures and enters the blood glucose values into the app, points are awarded that the adolescents can use to “purchase” accessories for their “hero” avatar on the app. These accessories include capes, boots, logos, masks, and different hair colors and styles. The parents receive notifications about each blood glucose value their child enters. Additionally, parents and adolescents may send each other preprogrammed messages within the app that act as conversation prompts to facilitate positive communication about management, which also earns the adolescent points. In addition to the main functions of the intervention described above, there are also links to videos of other adolescents with T1D telling their stories and providing affirming messages. The reinforcement of diabetes behaviors has been found to help in supporting the adolescents to be more independent, while still keeping the parent aware. See Figure 1 for the screenshots of the app. This intervention is currently only available on an Android platform. Those without a phone or with a phone that was not compatible with MyT1DHero were provided a mobile phone for this study. The literature on the development and usability testing of MyT1DHero can be found elsewhere [14,25]. The objective of this pilot test was to determine (1) the initial efficacy of the MyT1DHero intervention in improving diabetes outcomes, specifically the HbA1c levels, diabetes care adherence, and quality of life, and (2) the adolescents’ overall satisfaction with the MyT1DHero intervention.

    ‎
    Figure 1. Screenshots of the MyT1DHero app.
    View this figure

    Study Participants

    Eligible adolescents were 10-15 years of age, had a T1D diagnosis for at least 6 months, with HbA1c levels ≥7.0%, fluent in English, had a parent/guardian willing to participate, and allowed to use a mobile phone for this study. Participants were recruited from the local pediatric endocrinology subspecialty clinic through the Southeast Michigan JDRF (formerly Juvenile Diabetes Research Foundation) groups, as well as Facebook, Twitter, word-of-mouth, and snowball sampling. Recruitment to this study took place from September 2017 to December 2017. Thirty adolescent-parent pairs were enrolled in this study. This study was approved by the institutional review board at the Michigan State University and Sparrow Health System.

    Study Design

    This pilot study was a single-arm preclinical/postclinical trial without a control group. The intervention was tested over a 12-week period. At the initial visit, informed consent (parent) and assent (adolescent) were obtained. Additionally, venipuncture for determining baseline HbA1c levels was performed at a laboratory (specifically for this study), and pretest survey measures were collected from both the adolescents and the parents.

    Measures

    The surveys included questions from the Diabetes Behavior Rating Scale [26], which assesses how well the adolescent is managing diabetes care, and the survey was given to both the adolescent and the parent (see Textbox 1 for example questions, α=.64-.65; all reliabilities reported are based on this study’s sample). This scale has been tested in this population as a measure of adherence several times and includes daily and long-term adherence items [26,27]. This scale has 5 response categories ranging from 1 (Never) to 5 (Always). A higher score indicates a greater level of adherence.

    Survey for the assessment of diabetes care.

    Examples of questions in the survey for adolescents

    How often…

    • was the amount of insulin that your doctor prescribed (including adjustments for diet or blood glucose level) actually taken?
    • were your blood sugar numbers written in your log, diary, or chart?
    • is insulin correctly adjusted for meals you eat away from home (eg, at restaurants, parties)?
    • are clinic or doctor’s appointments kept?
    • is your doctor/nurse called for changes in insulin dose if you get frequent “high” or “low” blood sugar levels?
    • is your doctor/nurse called if you have severe diabetic symptoms that you cannot correct (eg, drinking a lot, needing fast sugar a lot)?

    Examples of questions in the survey for parents

    How often…

    • was the amount of insulin that your child’s doctor prescribed (including adjustments for diet or blood glucose level) actually taken?
    • were your child’s blood sugar numbers written in their log, diary, or chart?
    • is insulin correctly adjusted for your child’s meals that they eat away from home (eg, at restaurants, parties)?
    • are clinic or doctor’s appointments kept?
    • is your child’s doctor/nurse called for changes in insulin dose if you get frequent “high” or “low” blood sugar levels?
    • is your child’s doctor/nurse called if you have severe diabetic symptoms that you cannot correct (eg, drinking a lot, needing fast sugar a lot)?
    Textbox 1. Survey for the assessment of diabetes care.

    Quality of life [28] was self-reported by the adolescent using the PedsQL generic scale (α=.96). This 23-item scale contained 5 response categories ranging from 1 (Never) to 5 (Almost Always); a lower score indicates higher perception of quality of life.

    Family conflict was measured using the Revised Diabetes Family Conflict Scale [29] given to both the adolescent and parent. Reliability ranged from α=.94 to α=.95. This 12-item scale has 3 response categories ranging from 1 (Almost Always) to 3 (Never), with a higher score indicating a lower level of conflict.

    Satisfaction with the app was measured at the end of the study by using 8 questions from the Poststudy System Usability Questionnaire [30] (α=.84-.85). Satisfaction was measured by asking participants about the different aspects of the app, for example, “I found the MyT1DHero app easy to use.” Response options ranged from 1 (Strongly Agree) to 7 (Strongly Disagree), with a lower score indicating higher satisfaction.

    Usage was measured in multiple ways. For the number of days used, a day of usage was counted if the child entered the app. The number of days used was grouped as low, medium, and high usage. The low category indicated entering the readings in the app once or less per day for the month, the medium category indicated twice or less per day for the month, and the high category indicated at least 3 times per day. The “high” category indicates proper use of the app as we asked for at least 4 blood sugar entries per day. In addition, the number of blood sugar entries per day and the number of messages sent per day were also considered, and these data were stored by the server. Finally, changes in app usage across the 90-day study period were measured.

    Procedures

    At enrollment, participants received a detailed explanation of the MyT1DHero app intervention. The parents and adolescents were asked to use the app for 12 weeks, with specific instructions for adolescents to enter their blood glucose readings at least 4 times per day. At the conclusion of the intervention, a repeat venipuncture for HbA1c levels was performed at a laboratory, and posttest surveys were conducted (either online or in-person). Participants were compensated US $50 (US $25 for parents and US $25 for adolescents) after completing the tasks at the initial enrollment meeting. Participants received an additional US $50 (US $25 for parents and US $25 for adolescents) after completing the repeat venipuncture. Finally, an additional US $100 (US $50 for parents and US $50 for adolescents) was given to the participants after completing the posttest surveys and returning phones, if applicable.

    Statistical Analysis

    Statistical analyses were performed using SPSS (v.25, IBM Corp). Descriptive statistics were conducted to summarize the sample characteristics and study variables. Paired-sample two-sided t tests were conducted to determine if there were statistical differences in HbA1c levels and the other study outcomes from preintervention to postintervention. Additionally, linear regression analysis was conducted to evaluate the association between the adolescents’ usage of the app (high usage, 70-90 days; low usage, 69 days or less) and change in HbA1c levels (pre-HbA1c subtracted from post-HbA1c). We also tested the correlations between the adolescent and parent measures, as well as between the age of the adolescent and the satisfaction of the intervention.


    Participant Characteristics

    From September 2017 to December 2017, 30 families were screened and enrolled in this study. The final analysis included 25 families (5 never completed posttest assessments, Figure 2). The majority of the adolescents were Whites (22/25, 88%). The mean age of the adolescents was 12.28 (SD 1.62) years and the majority of the parents was in the age range of 35-44 years (n=10) (see Table 1). Comparing the participants who dropped out, there were no differences in the demographics, except in the length of diagnosis. All the participants who dropped out (n=5) reported that they had been diagnosed for 5 or more years. Of those who completed the study, 12 reported that they had been diagnosed for 5 or more years, 11 had been diagnosed for 1 to 5 years, and 2 had been diagnosed that year (t22=1.73, P<.001).

    ‎
    Figure 2. Participant recruitment flowchart.
    View this figure
    Table 1. Demographics of the participants and outcomes (N=25).
    DemographicsValues, n (%)
    Adolescent age (years)

    		104 (16)

    		114 (16)

    		127 (28)

    		135 (20)

    		141 (4)

    		154 (16)
    Adolescent gender

    		Female12 (48)

    		Male13 (52)
    Length of diagnosis

    		6 months to less than 1 year2 (8)

    		1 year to less than 5 years11 (44)

    		5 years or more12 (48)
    Ethnicity/race

    		White22 (88)

    		Black or African American2 (8)

    		Hispanic or Latino1 (4)
    Parent relationship to adolescent

    		Biological mother22 (88)

    		Biological father1 (4)

    		Adoptive mother1 (4)

    		Adoptive father1 (4)
    Parent age (years)

    		25-341 (4)

    		35-4410 (40)

    		45-548 (32)

    		55-643 (12)
    Income (US $)

    		Less than $25,0002 (8)

    		$25,000-$49,9994 (16)

    		$50,000-$74,9995 (20)

    		$75,000-$99,9994 (16)

    		$100,000 or more10 (40)
    Insurance

    		Employer provided18 (72)

    		Medicaid2 (8)

    		Medicare1 (4)

    		Self-insured, non-Medicare, or Medicaid1 (4)

    		Other3 (12)
    Treatmenta

    		Pump21 (84)

    		Continuous glucose monitor12 (45)

    		Multiple daily injections4 (16)

    aThe participants in this category were on multiple treatments, which is reflected in the percentages in the subcategories.

    Study Outcomes

    HbA1c levels

    After 12 weeks, there were no significant changes (Table 2) in the HbA1c levels (before the study: mean 8.94 [SD 1.46]; after the study: mean 8.87 [SD 1.29]; t24=0.67, P=.51, d=0.04).

    Table 2. Results of the outcome variables.
    Group, outcome variablesPretest values, mean (SD)Posttest values, mean (SD)P value
    Adolescents

    		Hemoglobin A1c levels8.94 (1.46)8.87 (1.29).51

    		Diabetes behavior rating scale (1=Never to 5=Always)3.87 (0.59)4.19 (0.65).02

    		Quality of life scale (1=Never to 5=Almost Always)4.02 (0.84)4.27 (0.73).01

    		Revised diabetes family conflict scale (1=Almost Always to 3=Never)2.45 (0.55)2.61 (0.45).14
    Parents

    		Diabetes behavior rating scale (1=Never to 5=Always)4.04 (0.50)4.34 (0.47).02

    		Revised diabetes family conflict scale (1=Almost Always to 3=Never)2.47 (0.78)2.51 (0.85).78
    Diabetes Care Adherence and Quality of Life

    Significant improvements were found in the diabetes behavior and quality of life of the adolescents. Posttest measurements (mean 4.19 [SD 0.65]) of diabetes behavior demonstrated improvement compared to the pretest measurements (mean 3.87 [SD 0.59]; t21=–2.52, P=.02, d=0.52). The parents’ perceptions of diabetes behavior also improved from before the study (mean 4.04 [SD 0.50]) to after the study (mean 4.34 [SD 0.47]; t21=–2.58, P=.02, d=0.62). Additionally, the scores of the child and the parent Diabetes Behavior Rating Scale were significantly correlated (r24=0.46, P=.04). The quality of life significantly improved after the intervention for the adolescents (mean 4.27 [SD 0.73]) compared to that before the intervention (mean 4.02 [SD 0.84]; t24=2.48, P=.01, d=0.32). Although there was an improvement in the family conflict for the adolescents from before the intervention (mean 2.45 [SD 0.55]) to after the intervention (mean 2.61 [SD 0.45]; t23=0.55, P=.14, d=0.32), the improvement was not significant. The results of the parents’ perception of conflict did not change significantly from before the intervention (mean 2.47 [SD 0.78]) to after the intervention (mean 2.51 [SD 0.85]; t21=–0.28, P=.78, d=0.28). The scores of the child and the parent Revised Diabetes Family Conflict Scale were significantly correlated (r22=0.47, P=.03).

    Satisfaction With the Intervention

    Satisfaction with the intervention was measured through 8 questions. Overall, both the adolescents (mean 2.19 [SD 0.94]) and the parents (mean 2.26 [SD 1.29]) rated the intervention as satisfactory. The results of Pearson correlation indicated that there was no association between the age of the child and the satisfaction level (r24=–0.02, P=.92). Each satisfaction item with the descriptive statistics can be found in Table 3.

    Table 3. Satisfaction of the participants with the MyT1DHero app measured using the poststudy system usability questionnaire.a
    Variables (scored on a scale of 1-7)AdolescentsParents

    		Mean (SD)RangeMean (SD)Range
    Overall, I’m satisfied with how easy it is to use this app.2.70 (1.59)1-72.10 (1.62)1-7
    Learning to use this app was easy.1.74 (0.94)1-52.00 (1.77)1-7
    The characters on the screen were easy to see.1.63 (0.79)1-31.48 (0.68)1-3
    The app is understandable.2.15 (1.13)1-51.97 (1.60)1-7
    It was easy to become skilled using this app.2.11 (1.25)1-62.00 (1.55)1-7
    I found the app easy to use.2.30 (1.68)1-71.87 (1.59)1-7
    I think using this app is a good idea.2.93 (1.94)1-72.19 (1.76)1-7
    Proper type 1 diabetes terms were used throughout the app.2.04 (1.13)1-52.45 (1.79)1-7
    All satisfaction items2.19 (0.94)1-72.56 (1.29)1-7

    aResponse categories: 1=strongly agree, 4=neutral, 7=strongly disagree.

    App Usage

    The average number of days the app was used was 63 (SD 27.70) days. The majority of the participants had usage in the medium or high use categories (21/25, 84%). In addition, participants entered their blood sugar readings an average of less than 3 times per day (mean 2.70 [SD 2.01]) and sent less than 1 message on average per day (mean 0.20 [SD 0.24]) or an average of approximately 23 messages over the course of the entire study period (mean 22.60 [SD 22.38]). Over the 90-day study period, daily use varied. At the start of the study (days 1-5), participants used the app the most times per day (mean 24.54 [SD 9.36]). In the following 60 days, participants used the app on average 7 times per day (mean 7.46 [SD 2.36]). The average use per day then fell further during the final 25 days of the study (mean 4.45 [SD 1.39]). However, linear regression analysis indicated a significant effect between the overall use of the app (high/medium/low) and improvement in HbA1c levels (F1,20=9.74, P<.005; R2=0.33), demonstrating that the adolescents who used MyT1DHero more had greater improvements in their HbA1c levels. We then conducted a separate linear regression to examine if there were any specific functions that predicted the change in HbA1c levels (F5,7=–5.681, P=.21; R2=0.80). The data demonstrated that the more the adolescents logged their blood glucose readings and the more messages they sent to their parents, the more their HbA1c levels improved (Table 4).

    Table 4. Linear regression of the types of usage predicting the change in the hemoglobin A1c levels.
    FunctionUnstandardized βSEβt(df)P value
    Constant–1.3560.332N/Aa–4.089 (24).005
    Glucose logging (child only).0040.0011.0984.798 (24).002
    Messaging (child)–.0690.020–1.168–3.492 (24).01
    Messaging (parent).0420.014.9453.024 (24).02
    Glucose-specific messaging (child).0660.044.6481.494 (24).18
    Glucose-specific messaging (parent)–.0130.012–.470–1.091 (24).31

    aN/A: not applicable.

    Further, participants who used a continuous glucose monitor (CGM) were asked to enter their calibration blood glucose values 1-2 times per day but were allowed to use their CGM number for the other entries. Importantly, there were no significant differences between CGM users and non-CGM users in the usage of the app by category (t24=0.561, P=.58) nor in the days used (t24=0.092, P=.93).


    Overview of This Study

    The purpose of this study was to conduct a preliminary evaluation of the efficacy of the MyT1DHero mobile app intervention. The goal of the MyT1DHero intervention is to facilitate positive diabetes-related communication between adolescents with T1D and their parents to improve diabetes outcomes and help in the transition of diabetes management responsibilities. As the adolescent transitions to more self-care, they need to perform these management behaviors independently, such as monitoring blood glucose levels and taking the appropriate actions if these values are out of range.

    Adherence Improvements in Diabetes Care

    The results from this preliminary evaluation demonstrate that diabetes care adherence as reported by both the adolescents and the parents and the quality of life as reported by adolescents improved after using the MyT1DHero app. Demonstrating improvement in diabetes management behaviors is critical for this population, especially in this age group, as these behaviors need to be learned and integrated into everyday life for the rest of the adolescents’ life. Studies have demonstrated that perceptions of quality of life significantly affect adherence to medical recommendations and overall health outcomes [30-33]. These findings suggest that participating in this type of intervention could improve primary clinical outcomes such as glycemic control; however, additional studies with longer follow-up periods are needed to see if improvements in diabetes care would be manifested in improved blood glucose levels.

    HbA1c Improvements

    Although there was no overall significant effect on the HbA1c levels, the results of our study demonstrate that those who used the app more had more improvements in their HbA1c levels. This indicates the importance of creating an engaging intervention that is tailored to individual families in order to encourage long-term engagement [34]. Moreover, improvements in diabetes behavior and quality of life through long-term use of the MyT1DHero app intervention could also positively affect clinical diabetes outcomes; however, further research is needed.

    Adolescent App Satisfaction

    This study shows promise for interventions delivered via mobile phones. Past research has shown that mobile phones and apps are perceived by adolescents as a more acceptable way to communicate with a parent, particularly in social contexts in which adolescents may be reluctant to engage in diabetes management, for example, when they are with their peers [35]. Furthermore, while our sample spans 2 developmental stages, this study was conducted to understand the acceptability of the intervention. However, there was no relationship between age and satisfaction of the app intervention, indicating that more qualitative work should be done in this area to determine the acceptability and appropriateness for different ages.

    Communication Between Parents and Adolescents

    Future research should include not only assessments of the intervention’s effect on negative communication patterns between parents and adolescents but also the positive interactions. For example, although the use of the intervention did not result in a significant drop in family conflict, it is possible that positive communication behaviors such as self-disclosure, expressions of affection, and social support did increase throughout the length of the intervention. Further, our data demonstrate that when parents initiate the messaging that is perceived to be negative for the child, it can be considered as “nagging” by the parents. However, when the child reached out, there was more positive impact [24]. Future studies should also measure different types of communication—both positive and negative.

    Limitations of This Study

    This research has the following limitations. The small sample size was fairly homogenous. The sample reported relatively low levels of baseline family conflict, which may also have limited the study’s ability to show significant reductions in conflict at the 12-week follow-up. This study used self-report measures, which should be noted as a limitation. Providing a mobile phone might have also affected the results. We had to provide phones to participants who had an Apple phone; therefore, these participants ended up carrying 2 phones. Additionally, although we asked families to provide us with the blood glucose trends via a meter download at baseline and at study end, the majority of the families failed to do this. Therefore, an objective measure of blood glucose checking was not available for use in the analyses. Finally, we cannot know for sure if the adolescents entered their blood glucose values accurately and honestly in the app. Further studies are necessary to determine the intervention efficacy in promoting positive communication around T1D management.

    Conclusion

    The strengths of this study demonstrate a positive impact on adolescents’ diabetes behaviors and quality of life through the use of an app focused on fostering positive communication with their parents. Mobile phone apps provide a promising avenue for improving parental involvement in the transition of diabetes management from children to adolescents. Using a family-based app intervention provides parents access to their child’s health care treatment and allows adolescents to easily ask for help even when the family is not together. More work regarding the use of similar app interventions is needed to further demonstrate their positive and long-term effectiveness for adolescents with T1D. This study provides preliminary support for the feasibility and efficacy of the MyT1DHero intervention for improving health outcomes in adolescents with T1D. mHealth interventions developed to improve the communication between adolescents and their parents during the transition to adolescent self-care could be a promising method to improve health outcomes in this population.

    Acknowledgments

    This work was supported by the American Diabetes Association (#1-16-ICTS-045). All authors have read and approved the final manuscript.

    Conflicts of Interest

    None declared.

    1. Pettitt DJ, Talton J, Dabelea D, Divers J, Imperatore G, Lawrence JM, SEARCH for Diabetes in Youth Study Group. Prevalence of diabetes in U.S. youth in 2009: the SEARCH for diabetes in youth study. Diabetes Care 2014 Mar;37(2):402-408 [FREE Full text] [CrossRef] [Medline]
    2. Majumder E, Cogen FR, Monaghan M. Self-Management Strategies in Emerging Adults With Type 1 Diabetes. J Pediatr Health Care 2017;31(1):29-36 [FREE Full text] [CrossRef] [Medline]
    3. Nordfeldt S, Ängarne-Lindberg T, Nordwall M, Krevers B. Parents of adolescents with type 1 diabetes--their views on information and communication needs and internet use. A qualitative study. PLoS One 2013;8(4):e62096 [FREE Full text] [CrossRef] [Medline]
    4. Palmer DL, Berg CA, Butler J, Fortenberry K, Murray M, Lindsay R, et al. Mothers', fathers', and children's perceptions of parental diabetes responsibility in adolescence: examining the roles of age, pubertal status, and efficacy. J Pediatr Psychol 2009 Mar;34(2):195-204 [FREE Full text] [CrossRef] [Medline]
    5. Ellis DA, Podolski C, Frey M, Naar-King S, Wang B, Moltz K. The role of parental monitoring in adolescent health outcomes: impact on regimen adherence in youth with type 1 diabetes. J Pediatr Psychol 2007 Oct;32(8):907-917. [CrossRef] [Medline]
    6. Downing J, Gleeson HK, Clayton PE, Davis JRE, Wales JK, Callery P. Transition in endocrinology: the challenge of maintaining continuity. Clin Endocrinol (Oxf) 2013 Jan;78(1):29-35. [CrossRef] [Medline]
    7. Herbert L, Owen V, Pascarella L, Streisand R. Text message interventions for children and adolescents with type 1 diabetes: a systematic review. Diabetes Technol Ther 2013 May;15(5):362-370. [CrossRef] [Medline]
    8. Timms N, Lowes L. Autonomy or non-compliance in adolescent diabetes? Br J Nurs 1999;8(12):794-7, 800. [CrossRef] [Medline]
    9. Weissberg-Benchell J, Wolpert H, Anderson BJ. Transitioning from pediatric to adult care: a new approach to the post-adolescent young person with type 1 diabetes. Diabetes Care 2007 Oct;30(10):2441-2446. [CrossRef] [Medline]
    10. Morrison S, Dashiff C, Abdullatif H, Moreland E. Parental separation anxiety and diabetes self-management of older adolescents: a pilot study. Pediatric Nursing 2012;38(2):88-95 ISSN: 0097-9805 [FREE Full text]
    11. Gustafsson PA, Cederblad M, Ludvigsson J, Lundin B. Family interaction and metabolic balance in juvenile diabetes mellitus. A prospective study. Diabetes Res Clin Pract 1987 Nov;4(1):7-14. [CrossRef] [Medline]
    12. Hauser ST, Jacobson AM, Lavori P, Wolfsdorf JI, Herskowitz RD, Milley JE, et al. Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: II. Immediate and long-term linkages with the family milieu. J Pediatr Psychol 1990 Aug;15(4):527-542. [CrossRef] [Medline]
    13. Holtz BE, Mitchell KM, Nuttall AK, Cotten SR, Hershey DD, Dunneback JK, et al. Using User-Feedback to Develop a Website: MyT1DHope, for Parents of Children with T1D. Health Commun 2020 Mar;35(3):281-288. [CrossRef] [Medline]
    14. Holtz BE, Murray KM, Hershey DD, Dunneback JK, Cotten SR, Holmstrom AJ, et al. Developing a Patient-Centered mHealth App: A Tool for Adolescents With Type 1 Diabetes and Their Parents. JMIR Mhealth Uhealth 2017 May 19;5(4):e53 [FREE Full text] [CrossRef] [Medline]
    15. Tsiouli E, Alexopoulos EC, Stefanaki C, Darviri C, Chrousos GP. Effects of diabetes-related family stress on glycemic control in young patients with type 1 diabetes: Systematic review. Can Fam Physician 2013 Mar;59(2):143-149 [FREE Full text] [Medline]
    16. Wysocki T, Greco P, Harris MA, Bubb J, White NH. Behavior therapy for families of adolescents with diabetes: maintenance of treatment effects. Diabetes Care 2001 Mar;24(3):441-446. [CrossRef] [Medline]
    17. Hanson CL, Henggeler SW, Burghen GA. Social competence and parental support as mediators of the link between stress and metabolic control in adolescents with insulin-dependent diabetes mellitus. Journal of Consulting and Clinical Psychology 1987;55(4):529-533. [CrossRef]
    18. Wysocki T, Lochrie A, Antal H, Buckloh LM. Youth and parent knowledge and communication about major complications of type 1 diabetes: associations with diabetes outcomes. Diabetes Care 2011 Aug;34(8):1701-1705 [FREE Full text] [CrossRef] [Medline]
    19. Katz ML, Volkening LK, Butler DA, Anderson BJ, Laffel LM. Family-based psychoeducation and Care Ambassador intervention to improve glycemic control in youth with type 1 diabetes: a randomized trial. Pediatr Diabetes 2014 Mar;15(2):142-150 [FREE Full text] [CrossRef] [Medline]
    20. Markowitz JT, Cousineau T, Franko DL, Schultz AT, Trant M, Rodgers R, et al. Text messaging intervention for teens and young adults with diabetes. J Diabetes Sci Technol 2014 Oct;8(5):1029-1034 [FREE Full text] [CrossRef] [Medline]
    21. Cafazzo JA, Casselman M, Hamming N, Katzman DK, Palmert MR. Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res 2012 May 08;14(3):e70 [FREE Full text] [CrossRef] [Medline]
    22. Kitsiou S, Paré G, Jaana M, Gerber B. Effectiveness of mHealth interventions for patients with diabetes: An overview of systematic reviews. PLoS One 2017;12(3):e0173160 [FREE Full text] [CrossRef] [Medline]
    23. Holtz B, Lauckner C. Diabetes management via mobile phones: a systematic review. Telemed J E Health 2012 May;18(3):175-184. [CrossRef] [Medline]
    24. Holtz BE, Mitchell KM, Holmstrom AJ, Cotten SR, Hershey DD, Dunneback JK, et al. Teen and parental perspectives regarding transition of care in type 1 diabetes. Children and Youth Services Review 2020 Mar;110:104800. [CrossRef]
    25. Holtz BE, Murray KM, Hershey DD, Richman J, Dunneback JK, Vyas A, et al. The design and development of MyT1DHero: A mobile app for adolescents with type 1 diabetes and their parents. J Telemed Telecare 2017 Dec 11;25(3):172-180. [CrossRef]
    26. Iannotti RJ, Nansel TR, Schneider S, Haynie DL, Simons-Morton B, Sobel DO, et al. Assessing regimen adherence of adolescents with type 1 diabetes. Diabetes Care 2006 Oct 26;29(10):2263-2267. [CrossRef] [Medline]
    27. Hood KK, Peterson CM, Rohan JM, Drotar D. Association between adherence and glycemic control in pediatric type 1 diabetes: a meta-analysis. Pediatrics 2009 Dec;124(6):e1171-e1179. [CrossRef] [Medline]
    28. Varni JW, Burwinkle TM, Jacobs JR, Gottschalk M, Kaufman F, Jones KL. The PedsQL in type 1 and type 2 diabetes: reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales and type 1 Diabetes Module. Diabetes Care 2003 Mar;26(3):631-637. [CrossRef] [Medline]
    29. Hood KK, Butler DA, Anderson BJ, Laffel LM. Updated and revised Diabetes Family Conflict Scale. Diabetes Care 2007 Jul;30(7):1764-1769 [FREE Full text] [CrossRef] [Medline]
    30. Lewis JR. IBM computer usability satisfaction questionnaires: Psychometric evaluation and instructions for use. International Journal of Human-Computer Interaction 1995 Jan;7(1):57-78. [CrossRef]
    31. Graue M, Wentzel-Larsen T, Hanestad BR, Søvik O. Health-related quality of life and metabolic control in adolescents with diabetes: the role of parental care, control, and involvement. J Pediatr Nurs 2005 Oct;20(5):373-382. [CrossRef] [Medline]
    32. Nansel T, Weisberg-Benchell J, Wysocki T, Laffel L, Anderson B, Steering Committee of the Family Management of Diabetes Study. Quality of life in children with Type 1 diabetes: a comparison of general and diabetes-specific measures and support for a unitary diabetes quality-of-life construct. Diabet Med 2008 Dec;25(11):1316-1323 [FREE Full text] [CrossRef] [Medline]
    33. Nardi L, Zucchini S, D'Alberton F, Salardi S, Maltoni G, Bisacchi N, et al. Quality of life, psychological adjustment and metabolic control in youths with type 1 diabetes: a study with self- and parent-report questionnaires. Pediatr Diabetes 2008 Oct;9(5):496-503. [CrossRef] [Medline]
    34. Mitchell KM, Holtz BE, McCarroll A. Patient-Centered Methods for Designing and Developing Health Information Communication Technologies: A Systematic Review. Telemed J E Health 2019 Nov;25(11):1012-1021. [CrossRef] [Medline]
    35. Davie R, Panting C, Charlton T. Mobile phone ownership and usage among pre-adolescents. Telematics and Informatics 2004 Nov;21(4):359-373. [CrossRef]

    ‎
    CGM: continuous glucose monitor
    HbA1c: hemoglobin A1c
    mHealth: mobile health
    T1D: type 1 diabetes

    Edited by L Buis; submitted 27.08.20; peer-reviewed by SHM Guo; comments to author 02.11.20; revised version received 16.12.20; accepted 23.08.21; published 14.09.21

    Copyright

    ©Bree Holtz, Katharine M Mitchell, Amanda J Holmstrom, Shelia R Cotten, Julie K Dunneback, Jose Jimenez-Vega, Deborah A Ellis, Michael A Wood. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 14.09.2021.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on https://mhealth.jmir.org/, as well as this copyright and license information must be included.