A Web-Delivered Multicomponent Intervention for Adolescents with Poorly Controlled Type 1 Diabetes: A Pilot Randomized Controlled Trial

Abstract

Background Type 1 diabetes is associated with significant mortality and economic cost. Management of type 1 diabetes involves completing multiple daily adherence behaviors, and many adolescents struggle with self-management and show poor glycemic control. Purpose The purpose was to conduct an unblinded pilot randomized controlled parallel-group study of a web-delivered multi-component intervention targeting self-monitoring of blood glucose, working memory, and parent supervision of diabetes care among adolescents with type 1 diabetes. Intervention components included high magnitude incentives for adolescents and parents, motivational and cognitive behavioral therapy and working memory training for adolescents, and training in contingency contracting for parents. Methods Adolescents (N=114) with poorly controlled type 1 diabetes were screened and N=61 were randomized using minimum likelihood allocation to usual care (usual care, N=31) or to a 25-week/15 session web-delivered intervention (WebRx, N=30). Results At the end of treatment, adolescents in WebRx had higher self-monitoring of blood glucose (d=0.58) (primary outcome), better visual spatial working memory (d=0.48) and inhibition (d=0.98), and lower HbA1c (d=0.45) than those in usual care. WebRx parents reported more frequent review of the adolescent’s glucometer (d=1.30), and reduced family conflict (d=0.56). Between-condition differences were maintained 6 months later in self-monitoring of blood glucose (d=0.42), visual spatial working memory (d=0.76), family conflict (d=0.50), and HbA1c (d=0.44). Conclusions Results showing sustained effects on self-monitoring of blood glucose and HbA1c support moving forward with a larger trial to test this innovative web-delivered and multicomponent intervention. (ClinicalTrials.gov number NCT01722643).

Adolescent Emotional Control Moderates Benefits of a Multicomponent Intervention to Improve Type 1 Diabetes Adherence: A Pilot Randomized Controlled Trial

“…Sixty-one participants and their parents completed the study's intake assessment. There were not significant differences in clinical indicators (e.g., HbA1c and type of insurance) between those who participated and declined to participate (see Stanger et al, 2018). This sample size was selected for 80% power to detect a mean difference of 1.5 average daily glucose checks at 6-month follow-up, the primary outcome of the trial.…”

“…self-regulation, the ability to modulate cognitions, emotions, and behaviors toward long-term goals, is a key individual difference that has been associated with adherence behaviors, including SMBG, and glycemic control (Lansing, Crochiere, Cueto, Wiebe, & Berg, 2017;McNally, Rohan, Pendley, Delamater, & Drotar, 2010;Perez et al, 2016). A multicomponent, web-delivered intervention designed to target biopsychosocial processes in the self-regulation of SMBG in adolescents with above-target glycemic control was developed and tested, showing improvements in SMBG and HbA1c at 6-and 12-month follow-ups (Stanger, Lansing, Scherer, Budney, Christiano, & Casella, 2018). To target psychological, biological, and social processes associated with self-regulation for chronic illness self-management (Lansing & Berg, 2014), this intervention combined incentives for SMBG and brief web counseling (psychological) with working memory training (biological) for adolescents as well as parental contingency contracting training (focused on adolescent SMBG; social).…”

“…Among children and adolescents with type 1 diabetes, problems in working memory have been associated with poorer adherence and glycemic control (McNally et al, 2010;Ohmann et al, 2010;Perez et al, 2016). In pilot studies of working memory training in adolescents with type 1 diabetes, evidence has suggested that working memory training may be beneficial for improving executive functioning and SMBG (Lansing, Stanger, et al, 2016;Stanger et al, 2018). Third, increased parental monitoring has also been identified as an important intervention target to improve adherence in adolescents with type 1 diabetes (Ellis et al, 2007;Horton, Berg, Butner, & Wiebe, 2009).…”

Adolescent and parent perspectives on the acceptability of financial incentives to promote self‐care in adolescents with type 1 diabetes

“…This is reinforced by the perspectives of adolescents in pilot FI programs stating that extrinsic financial rewards aided them in realizing the intrinsic value of self‐care . While some trial programs incorporating FI have led to sustained improvements in participant HbA1c, others had non‐significant effects on glycemic control . This heterogeneity highlights the need for future work to optimize the structure of FI to appeal to adolescent preferences and address the multifactorial nature of glycemic control.…”

“…FI programs for adolescents with T1D led to improvements in the frequency of incentivized self‐care behaviors . Further, in some studies, but not all, increased engagement in self‐care persisted after the discontinuation of incentives and was associated with durable reductions in HbA1c . This suggests that FI not only has the potential to improve clinical outcomes but may lead to long‐term cost savings due to the relatively low cost of incentives as well as the preventative value of improved glycemic control.…”