A Social Ecological Perspective On Diabetes Care: Supporting Adolescents And Caregivers

The diabetes illness management regimen is complex and demanding, requiring daily motivation and self-control. Adolescents with diabetes face unique risks for which social support may be one protective factor. The importance of social support from family and friends is well documented in the literature. Support for the caregiver and support from the health care provider, conversely, are understudied. These four sources of social support, considered together, span the adolescent\u27s micro-, meso-, and exosystems constituting a social ecological model of social support for diabetes. The primary aim of this study was to test this model. The hypotheses were that each source of social support would independently and positively contribute to illness management when evaluated simultaneously, after controlling for adolescent and caregiver demographics and that illness management behavior would mediate the relationship between social support and diabetes health. A secondary data analysis of adolescents with chronically poorly managed diabetes was undertaken. Structural equation modeling was used to test the study hypotheses. A total of 146 adolescents and their primary caregivers participated in the study. Participants were primarily African American, low-income single-parent families. Results from the analysis did not support the model as hypothesized but did support an alternative model. In the alternative model, exosystem, but not mesosystem, support was positively associated with microsystem support. Microsystem support was directly related to adolescents\u27 illness management behavior and indirectly related to adolescents\u27 health status. Findings from this study introduce an innovative model of social support for adolescents with diabetes. Supporting the caregiver of adolescents with diabetes may have a beneficial impact on the social support environment in which adolescents perform their daily illness care. A more supportive daily care environment, in turn, may translate to better illness management and better illness health. Social support intervention may be an important strategy for medical social workers, as members of multidisciplinary medical treatment teams, treating adolescents with diabetes and their families

The Relationship Among Depression, Motivational Factors, and Diabetes Management In Emerging Adults with Type 1 Diabetes

Self-determination theory (SDT) posits intrinsic motivation arises from fulfilling three psychological needs – autonomy, self-efficacy, and relatedness. SDT is useful for understanding the challenges emerging adults (EA, age 18-30) living with a chronic illness, like type 1 diabetes (T1D), face including developing independence, autonomy and new relationships while parental support and involvement decrease. This places EAs at risk for sub-optimal health. Depression can further decrease motivation. The aim of this study is to test the hypothesis that depressive symptoms are associated with motivation (autonomy and self-efficacy) which are associated with diabetes management (DM) in EAs with T1D. Participants (N=52) were from a larger randomized clinical trial testing an intervention to improve DM. At study entry, EAs endorsing higher depression levels also reported statistically significantly lower self-efficacy on the Perceived Health Competency Scale (PHCS; r=-0.350, p=0.011). Self-efficacy assessed by the Diabetes Empowerment Scale (DES; r=-0.217,p=0.123) was not associated with depression, nor was autonomy assessed, using the Treatment Self-Regulation Scale (TSRQ; r=-0.157,p=0.267), although both were in the hypothesized direction. EAs reports of self-efficacy (rPHCS=0.123,p=0.206; rDES=0.055,p=0.701) and autonomy (r=0.178,p=0.206) were not correlated with DM, although responses were in the intended direction. Therefore, t in this sample, there was partial support for the hypothesis that depression reduces motivation was partially supported, but there was not enough support for the relationship between motivation and –DM link

Technology-delivered adaptations of motivational interviewing for the prevention and management of chronic diseases: Scoping review

BACKGROUND: Motivational interviewing (MI) can increase health-promoting behaviors and decrease health-damaging behaviors. However, MI is often resource intensive, precluding its use with people with limited financial or time resources. Mobile health-based versions of MI interventions or technology-delivered adaptations of MI (TAMIs) might increase reach. OBJECTIVE: We aimed to understand the characteristics of existing TAMIs. We were particularly interested in the inclusion of people from marginalized sociodemographic groups, whether the TAMI addressed sociocontextual factors, and how behavioral and health outcomes were reported. METHODS: We employed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews to conduct our scoping review. We searched PubMed, CINAHL, and PsycInfo from January 1, 1996, to April 6, 2022, to identify studies that described interventions incorporating MI into a mobile or electronic health platform. For inclusion, the study was required to (1) describe methods/outcomes of an MI intervention, (2) feature an intervention delivered automatically via a mobile or electronic health platform, and (3) report a behavioral or health outcome. The exclusion criteria were (1) publication in a language other than English and (2) description of only in-person intervention delivery (ie, no TAMI). We charted results using Excel (Microsoft Corp). RESULTS: Thirty-four studies reported the use of TAMIs. Sample sizes ranged from 10 to 2069 participants aged 13 to 70 years. Most studies (n=27) directed interventions toward individuals engaging in behaviors that increased chronic disease risk. Most studies (n=22) oversampled individuals from marginalized sociodemographic groups, but few (n=3) were designed specifically with marginalized groups in mind. TAMIs used text messaging (n=8), web-based intervention (n=22), app + text messaging (n=1), and web-based intervention + text messaging (n=3) as delivery platforms. Of the 34 studies, 30 (88%) were randomized controlled trials reporting behavioral and health-related outcomes, 23 of which reported statistically significant improvements in targeted behaviors with TAMI use. TAMIs improved targeted health behaviors in the remaining 4 studies. Moreover, 11 (32%) studies assessed TAMI feasibility, acceptability, or satisfaction, and all rated TAMIs highly in this regard. Among 20 studies with a disproportionately high number of people from marginalized racial or ethnic groups compared with the general US population, 16 (80%) reported increased engagement in health behaviors or better health outcomes. However, no TAMIs included elements that addressed sociocontextual influences on behavior or health outcomes. CONCLUSIONS: Our findings suggest that TAMIs may improve some health promotion and disease management behaviors. However, few TAMIs were designed specifically for people from marginalized sociodemographic groups, and none included elements to help address sociocontextual challenges. Research is needed to determine how TAMIs affect individual health outcomes and how to incorporate elements that address sociocontextual factors, and to identify the best practices for implementing TAMIs into clinical practice

Implementation Science Research Examining the Integration of Evidence-Based Practices Into HIV Prevention and Clinical Care: Protocol for a Mixed-Methods Study Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Model

BACKGROUND: The Exploration, Preparation, Implementation, and Sustainment (EPIS) model is an implementation framework for studying the integration of evidence-based practices (EBPs) into real-world settings. The EPIS model conceptualizes implementation as a process starting with the earliest stages of problem recognition (Exploration) through the continued use of an EBP in a given clinical context (Sustainment). This is the first implementation science (IS) study of the integration of EBPs into adolescent HIV prevention and care settings. OBJECTIVE: This protocol (ATN 153 EPIS) is part of the Scale It Up program, a research program administered by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), described in this issue by Naar et al. The EPIS study is a descriptive study of the uptake of 4 EBPs within the Scale It Up program. The goal of EPIS is to understand the barriers and facilitators associated with the Preparation, Implementation, and Sustainment of EBPs into HIV prevention and clinical care settings. METHODS: The EPIS study is a convergent parallel mixed-methods IS study. Key implementation stakeholders, that is, clinical care providers and leaders, located within 13 ATN sites across the United States will complete a qualitative interview conducted by telephone and Web-based surveys at 3 key implementation stages. The Preparation assessment occurs before EBP implementation, Implementation occurs immediately after sites finish implementation activities and prepare for sustainment, and Sustainment occurs 1 year postimplementation. Assessments will examine stakeholders\u27 perceptions of the barriers and facilitators to EBP implementation within their clinical site as outlined by the EPIS framework. RESULTS: The EPIS baseline period began in June 2017 and concluded in May 2018; analysis of the baseline data is underway. To date, 153 stakeholders have completed qualitative interviews, and 91.5% (140/153) completed the quantitative survey. CONCLUSIONS: The knowledge gained from the EPIS study will strengthen the implementation and sustainment of EBPs in adolescent prevention and clinical care contexts by offering insights into the barriers and facilitators of successful EBP implementation and sustainment in real-world clinical contexts

Provider Communication Behaviors that Predict Motivation to Change in Black Adolescents with Obesity

Objective: The goal of this research was to identify communication behaviors used by weight loss counselors that mostly strongly predicted black adolescents\u27 motivational statements. Three types of motivational statements were of interest: change talk (CT; statements describing their own desires, abilities, reasons, and need for adhering to weight loss recommendations), commitment language (CML; statements about their intentions or plans for adhering), and counterchange talk (CCT; amotivational statements against change and commitment). Methods: Thirty-seven black adolescents with obesity received a single motivational interviewing session targeting weight-related behaviors. The video-recorded transcribed sessions were coded using the Minority Youth Sequential Coding for Observing Process Exchanges generating a sequential chain of communication. Data were then subjected to sequential analysis to determine causal relationships between counselor and adolescent communication. Results: Asking open-ended questions to elicit adolescent CT and emphasizing adolescents\u27 autonomy most often led to CT. Open-ended questions to elicit CML, reflecting adolescent CML, and emphasizing autonomy most often led to CML. In contrast, open-ended questions to elicit CCT, reflecting CCT, reflecting ambivalence, and neutral open-ended questions about the target behavior led to CCT. Conclusions: This study provides clinicians with insight into the most effective way to communicate with black adolescents with obesity about weight loss. Specifically, reflective statements and open questions focusing on their own desires, abilities, reasons, need, and commitment to weight loss recommendations are more likely to increase motivational statements, whereas other types of reflections and questions may be counterproductive. Finally, because adolescents have a strong need for autonomous decision making, emphasizing their autonomy may be particularly effective in evoking motivational statements

Effective Patient-Provider Communication in Pediatric Obesity

Effective patient-provider communication, although acknowledged as a key clinical skill and linked to better outcomes for patients, providers, and society as a whole, is not a primary focus of many medical schools’ curricula. Motivational Interviewing, or MI, is a patient-centered, directive communication framework appropriate for the health care setting with an ever growing empirical evidence base. Research on MI’s causal mechanisms has previously established patient change talk (motivational statements about behavior change) to be a mediator of behavior change. Current MI research is focused on identifying which provider communication skills are responsible for evoking change talk. MI recommends three core communication skills – informing, asking, and listening. A consistent evidence base is emerging for providers’ use of reflections (an active listening strategy). Our research provides evidence that asking for and reflecting patient change talk are effective communication strategies, but cautions providers to inform judiciously. In addition, our research indicates that supporting a patient's decision making autonomy is an important strategy to promote health behaviors

Asthma and Technology in Emerging African American Adults (The ATHENA Project): Protocol for a Trial Using the Multiphase Optimization Strategy Framework

BackgroundAsthma causes substantial morbidity and mortality in the United States, particularly among African American emerging adults (AAEAs; aged 18-30 years), but very few asthma programs have targeted this population. Interventions that provide education and address underlying motivation for managing asthma may be the most effective. However, intensive face-to-face interventions are often difficult to implement in this population. ObjectiveThe purpose of this study is to develop an effective mobile asthma management intervention to improve control among AAEAs. MethodsWe will assess the ability of multiple technologic components to assist and improve traditional asthma education. The first component is the Motivational Enhancement System for asthma management. It is a mobile 4-session intervention using supported self-regulation and motivational interviewing. Personalized content is based on each participant’s activity level, daily experiences, and goals. The second component is supportive accountability. It is administered by asthma nurses using targeted mobile support (Skype/voice calls) to provide education, promote self-efficacy, and overcome barriers through a motivational interviewing–based framework. The third component is SMS text messaging. It provides reminders for asthma education, medication adherence, and physical activity. The fourth component is physical activity tracking. It uses wearable technology to help meet user-defined physical activity goals. Using a multiphase optimization strategy (MOST) framework, we will test intervention components and combinations of components to identify the most effective mobile intervention. The MOST framework is an innovative, and cost- and time-effective framework that uses engineering principles to produce effective behavioral interventions. We will conduct a component selection experiment using a factorial research design to build an intervention that has been optimized for maximum efficacy, using a clinically significant improvement in asthma. Participants (N=180) will be randomized to 1 of 6 intervention arms. Participants will be recruited from multiple sites of the American Lung Association-Airway Clinical Research Centers network and ambulatory care clinics at the Detroit Medical Center. Data collections will occur at baseline, and 3, 6, and 12 months. ResultsAt study completion, we will have an empirically supported optimized mobile asthma management intervention to improve asthma control for AAEAs. We hypothesize that postintervention (3, 6, and 12 months), participants with uncontrolled asthma will show a clinically significant improvement in asthma control. We also hypothesize that improvements in asthma management behaviors (including physical activity), quality of life, symptoms, adherence, and exacerbation (secondary outcomes) will be observed. ConclusionsAAEAs are disproportionately impacted by asthma, but have been underrepresented in research. Mobile asthma management interventions may help improve asthma control and allow people to live healthier lives. During this project, we will use an innovative strategy to develop an optimized mobile asthma management intervention using the most effective combination of nurse-delivered asthma education, a smartphone app, and text messaging. International Registered Report Identifier (IRRID)PRR1-10.2196/3794

Influence of provider openness and leadership behaviors on adherence to motivational interviewing training implementation strategies: Considerations for evidence-based practice delivery

BackgroundAdherence to intervention training implementation strategies is at the foundation of fidelity; however, few studies have linked training adherence to trainee attitudes and leadership behaviors to identify what practically matters for the adoption and dissemination of evidence-based practices. Through the conduct of this hybrid type 3 effectiveness-implementation cluster randomized controlled trial, we collected Exploration, Preparation, Implementation, and Sustainment (EPIS) data and merged it with tailored motivational interviewing training adherence data, to elucidate the relationship between provider attitudes toward evidence-based practices, leadership behaviors, and training implementation strategy (e.g., workshop attendance and participation in one-on-one coaching) adherence.MethodOur sample included data from providers who completed baseline (pre-intervention) surveys that captured inner and outer contexts affecting implementation and participated in tailored motivational interviewing training, producing a dataset that included training implementation strategies adherence and barriers and facilitators to implementation (N = 77). Leadership was assessed by two scales: the director leadership scale and implementation leadership scale. Attitudes were measured with the evidence-based practice attitude scale (EBPAS-50). Adherence to training implementation strategies was modeled as a continuous outcome with a Gaussian distribution. Analyses were conducted in SPSS.ResultsOf the nine general attitudes toward evidence-based practice, openness was associated with training adherence (estimate [EST] = 0.096, p < .001; 95% CI = [0.040, 0.151]). Provider general (EST = 0.054, 95% CI = [0.007, 0.102]) and motivational interviewing-specific (EST = 0.044, 95% CI = [0.002, 0.086]) leadership behaviors were positively associated with training adherence (p < .05). Of the four motivational interviewing-specific leadership domains, knowledge and perseverant were associated with training adherence (p < .05). As these leadership behaviors increased, knowledge (EST = 0.042, 95% CI = [0.001, 0.083]) and perseverant (EST = 0.039, 95% CI = [0.004, 0.075]), so did provider adherence to training implementation strategies.ConclusionsAs implementation science places more emphasis on assessing readiness prior to delivering evidence-based practices by evaluating organizational climate, funding streams, and change culture, consideration should also be given to metrics of leadership. A potential mechanism to overcome resistance is via the implementation of training strategies focused on addressing leadership prior to conducting training for the evidence-based practice of interest

Developing Machine Learning Models for Behavioral Coding

Objective: The goal of this research is to develop a machine learning supervised classification model to automatically code clinical encounter transcripts using a behavioral code scheme. Methods: We first evaluated the efficacy of eight state-of-the-art machine learning classification models to recognize patient-provider communication behaviors operationalized by the motivational interviewing framework. Data were collected during the course of a single weight loss intervention session with 37 African American adolescents and their caregivers. We then tested the transferability of the model to a novel treatment context, 80 patient-provider interactions during routine human immunodeficiency virus (HIV) clinic visits. Results: Of the eight models tested, the support vector machine model demonstrated the best performance, achieving a .680 F1-score (a function of model precision and recall) in adolescent and .639 in caregiver sessions. Adding semantic and contextual features improved accuracy with 75.1% of utterances in adolescent and 73.8% in caregiver sessions correctly coded. With no modification, the model correctly classified 72.0% of patient-provider utterances in HIV clinical encounters with reliability comparable to human coders (k = .639). Conclusions: The development of a validated approach for automatic behavioral coding offers an efficient alternative to traditional, resource-intensive methods with the potential to dramatically accelerate the pace of outcomes-oriented behavioral research. The knowledge gained from computer-driven behavioral research can inform clinical practice by providing clinicians with empirically supported communication strategies to tailor their conversations with patients. Lastly, automatic behavioral coding is a critical first step toward fully automated eHealth/mHealth (electronic/mobile Health) behavioral interventions

Moderating Effect of Depression on Glycemic Control in an eHealth Intervention Among Black Youth With Type 1 Diabetes: Findings From a Multicenter Randomized Controlled Trial

Background: Black adolescents with type 1 diabetes (T1D) are at increased risk for suboptimal diabetes health outcomes; however, evidence-based interventions for this population are lacking. Depression affects a high percentage of youth with T1D and increases the likelihood of health problems associated with diabetes. Objective: Our aim was to test whether baseline levels of depression moderate the effects of a brief eHealth parenting intervention delivered to caregivers of young Black adolescents with T1D on youths' glycemic control. Methods: We conducted a multicenter randomized controlled trial at 7 pediatric diabetes clinics located in 2 large US cities. Participants (N=149) were allocated to either the intervention group or a standard medical care control group. Up to 3 intervention sessions were delivered on a tablet computer during diabetes clinic visits over a 12-month period. Results: In a linear mixed effects regression model, planned contrasts did not show significant reductions in hemoglobin A1c (HbA1c) for intervention adolescents compared to controls. However, adolescents with higher baseline levels of depressive symptoms who received the intervention had significantly greater improvements in HbA1c levels at 6-month follow-up (0.94%; P=.01) and 18-month follow-up (1.42%; P=.002) than those with lower levels of depression. Within the intervention group, adolescents had a statistically significant reduction in HbA1c levels from baseline at 6-month and 18-month follow-up. Conclusions: A brief, culturally tailored eHealth parenting intervention improved health outcomes among Black adolescents with T1D and depressive symptoms. Trial registration: ClinicalTrials.gov NCT03168867; https://clinicaltrials.gov/study/NCT03168867.</p